Epidural Hemorrhage

Epidural hemorrhage (EDH) is a life-threatening type of traumatic brain injury where blood accumulates between the skull and the protective covering of the brain (dura mater). Most commonly caused by head trauma that tears an artery, it creates increasing pressure on the brain. The hallmark feature is the "lucid interval" - a period of apparent recovery followed by rapid deterioration. Emergency surgical intervention is crucial for survival and preventing permanent brain damage.

Overview

Epidural hemorrhage, also known as epidural hematoma (EDH) or extradural hemorrhage, is a serious medical emergency involving bleeding between the skull and the outermost membrane covering the brain (dura mater). This condition typically results from traumatic head injury and accounts for approximately 1-2% of all head trauma cases. Despite its relative rarity, EDH carries significant morbidity and mortality if not promptly recognized and treated.

The epidural space is normally a potential space, meaning it doesn't exist unless pathologically created by blood accumulation. When bleeding occurs in this space, it creates a lens-shaped (biconvex) collection of blood that compresses the brain tissue. The bleeding is usually arterial in origin, most commonly from the middle meningeal artery, though venous bleeding can also occur, particularly in children and with posterior fossa hematomas.

What makes epidural hemorrhage particularly dangerous is its characteristic clinical presentation known as the "lucid interval." After initial head trauma, a patient may lose consciousness briefly, then regain consciousness and appear relatively normal for minutes to hours before rapidly deteriorating as the hematoma expands. This deceptive pattern can lead to delayed diagnosis and treatment. However, it's important to note that not all patients experience this classic presentation - some may remain unconscious from the initial injury, while others may never lose consciousness until late in the course.

Symptoms

The symptoms of epidural hemorrhage can evolve rapidly and vary depending on the location, size, and rate of bleeding. Understanding the progression of symptoms is crucial for early recognition and intervention.

Classic Presentation - The Lucid Interval

The classic presentation occurs in about 20-50% of cases:

  1. Initial impact: Brief loss of consciousness at time of injury
  2. Lucid interval: Patient regains consciousness, may seem normal
  3. Deterioration: Progressive decline as hematoma expands

Early Symptoms

  • Severe headache, often progressively worsening
  • Dizziness and confusion
  • Nausea and vomiting
  • Drowsiness or altered consciousness
  • Visual disturbances or blurred vision
  • Weakness on one side of the body

Progressive Symptoms

  • Deteriorating level of consciousness
  • Pupillary changes (dilated pupil on affected side)
  • Hemiparesis or hemiplegia (weakness/paralysis on opposite side)
  • Speech difficulties
  • Seizures
  • Irregular breathing patterns

Late/Severe Symptoms

  • Coma
  • Decerebrate or decorticate posturing
  • Cushing's triad (hypertension, bradycardia, irregular respirations)
  • Fixed and dilated pupils
  • Respiratory arrest

Associated Symptoms

Pediatric Presentation

Children may present differently:

  • Irritability and inconsolable crying
  • Bulging fontanelle in infants
  • Poor feeding
  • Lethargy
  • Seizures more common than in adults

Causes

Epidural hemorrhage is almost always caused by traumatic injury to the head. Understanding the mechanisms and anatomical factors helps explain why certain injuries lead to this condition.

Primary Causes

  • Skull fractures: 85-95% of EDH cases involve temporal bone fractures
  • Direct trauma: Blunt force injury to the temporal region
  • Falls: Common in elderly and children
  • Motor vehicle accidents: High-impact collisions
  • Sports injuries: Contact sports, cycling without helmets
  • Assault: Blows to the head
  • Penetrating injuries: Less common but possible

Vascular Sources of Bleeding

  • Middle meningeal artery: Most common source (70-80%)
  • Middle meningeal vein: More common in elderly
  • Diploic veins: Within skull bone
  • Venous sinuses: Posterior fossa hematomas
  • Anterior meningeal artery: Frontal EDH

Anatomical Considerations

Factors that influence EDH development:

  • Pterion region: Thin skull area where vessels are vulnerable
  • Dural attachments: Stronger in children, limiting hematoma size
  • Skull thickness: Varies by location and age
  • Vessel location: Grooves in skull bone house arteries

Pathophysiology

The sequence of events leading to clinical symptoms:

  1. Trauma causes vessel tear
  2. Blood accumulates in epidural space
  3. Hematoma strips dura from skull
  4. Mass effect compresses brain tissue
  5. Increased intracranial pressure develops
  6. Brain herniation occurs if untreated

Rare Non-traumatic Causes

  • Coagulopathy or bleeding disorders
  • Vascular malformations
  • Infection with skull erosion
  • Tumor hemorrhage
  • Post-surgical complication

Risk Factors

While anyone can develop an epidural hemorrhage following head trauma, certain factors increase the risk and severity of this condition.

Age-Related Factors

  • Young adults (20-30 years): Highest incidence due to risk-taking behaviors
  • Children: Falls and sports injuries common
  • Elderly: Falls with increased frailty
  • Infants: Non-accidental trauma risk

Activity-Related Risks

  • Contact sports (football, hockey, boxing)
  • Cycling or skateboarding without helmets
  • Motorcycling
  • High-risk occupations (construction, military)
  • Alcohol or substance use impairing judgment

Medical Conditions

  • Bleeding disorders or coagulopathies
  • Anticoagulant therapy
  • Previous head injuries
  • Osteoporosis (increased fracture risk)
  • Seizure disorders (fall risk)
  • Balance or gait disorders

Environmental Factors

  • Lack of safety equipment use
  • Unsafe living conditions
  • Occupational hazards
  • Geographic areas with high trauma rates
  • Limited access to emergency care

Factors Affecting Outcome

  • Time to treatment: Crucial prognostic factor
  • Initial Glasgow Coma Scale: Lower scores worse prognosis
  • Hematoma size: Larger volume worse outcome
  • Associated injuries: Multiple trauma complicates care
  • Age: Extremes of age have worse outcomes

Diagnosis

Rapid and accurate diagnosis of epidural hemorrhage is critical for patient survival. The diagnostic process combines clinical assessment with neuroimaging studies.

Clinical Assessment

  • History: Mechanism of injury, timing, loss of consciousness
  • Glasgow Coma Scale (GCS): Assess consciousness level
  • Neurological examination: Pupillary response, motor function
  • Vital signs: Look for Cushing's triad
  • Head examination: Scalp lacerations, skull fractures

Imaging Studies

Non-contrast CT scan - Gold standard:

  • Shows characteristic lens-shaped (biconvex) hyperdense mass
  • Does not cross suture lines (unlike subdural)
  • May show associated skull fracture
  • Identifies midline shift and mass effect
  • Quick and readily available

MRI (when available):

  • Better for posterior fossa hematomas
  • Identifies small hematomas
  • Shows associated brain injury
  • Not first-line due to time constraints

Laboratory Tests

  • Complete blood count: Baseline hemoglobin
  • Coagulation studies: PT, PTT, INR
  • Blood type and crossmatch: Prepare for surgery
  • Electrolytes: Correct imbalances
  • Toxicology screen: If indicated

Differential Diagnosis

Conditions to distinguish from EDH:

  • Subdural hematoma (crescent-shaped on CT)
  • Subarachnoid hemorrhage
  • Intracerebral hemorrhage
  • Diffuse axonal injury
  • Brain contusion
  • Post-concussion syndrome

Monitoring

  • Frequent neurological assessments
  • Intracranial pressure monitoring (if indicated)
  • Continuous vital sign monitoring
  • Serial imaging for non-operative cases

Treatment Options

Treatment of epidural hemorrhage depends on the size, location, and clinical status of the patient. Most cases require urgent surgical intervention, though small hematomas in stable patients may be managed conservatively.

Emergency Management

  • Airway protection: Intubation if GCS <8
  • Cervical spine stabilization: Assume injury until cleared
  • Blood pressure control: Avoid hypotension
  • Seizure prophylaxis: Consider anticonvulsants
  • Reverse anticoagulation: If applicable
  • Osmotic therapy: Mannitol for herniation

Surgical Treatment

Indications for surgery:

  • Hematoma >30 mL volume
  • Clot thickness >15 mm
  • Midline shift >5 mm
  • GCS <9 with pupillary abnormalities
  • Clinical deterioration

Surgical procedures:

  • Craniotomy: Standard approach for evacuation
  • Burr hole drainage: For liquid hematomas
  • Craniectomy: If severe brain swelling
  • Control bleeding source: Coagulation or ligation
  • Duraplasty: Repair dural tears if present

Conservative Management

For selected patients with:

  • Small hematomas (<30 mL)
  • Minimal symptoms (GCS 15)
  • No midline shift
  • Stable neurological exam

Includes:

  • Neurological ICU monitoring
  • Serial CT scans
  • Blood pressure management
  • Prevention of secondary injury
  • Ready access to operating room

Post-operative Care

  • ICU monitoring
  • ICP monitoring if indicated
  • Seizure prophylaxis
  • DVT prophylaxis
  • Early mobilization when stable
  • Nutritional support

Rehabilitation

  • Physical therapy
  • Occupational therapy
  • Speech therapy if needed
  • Cognitive rehabilitation
  • Psychological support

Prevention

While not all cases of epidural hemorrhage can be prevented, many injuries leading to this condition are preventable through safety measures and lifestyle modifications.

Personal Safety Equipment

  • Wear helmets for cycling, motorcycling, skateboarding
  • Use appropriate sports protective gear
  • Seatbelts and proper car seats
  • Hard hats in construction zones
  • Proper fitting and certified equipment

Fall Prevention

  • Remove home hazards (loose rugs, clutter)
  • Install grab bars and handrails
  • Adequate lighting, especially stairs
  • Non-slip surfaces in bathrooms
  • Regular vision and balance checks
  • Appropriate footwear

Sports Safety

  • Follow sport-specific safety rules
  • Proper training and conditioning
  • Age-appropriate activities
  • Qualified coaching and supervision
  • Recognition of concussion symptoms
  • Gradual return to play protocols

Vehicle Safety

  • Follow traffic laws and speed limits
  • Avoid distracted driving
  • Never drive under influence
  • Regular vehicle maintenance
  • Defensive driving techniques

Medical Management

  • Manage conditions affecting balance
  • Review medications causing dizziness
  • Monitor anticoagulation therapy
  • Treat seizure disorders
  • Address substance abuse issues

Education and Awareness

  • Recognize head injury symptoms
  • Know when to seek medical care
  • First aid training
  • Community safety programs
  • Workplace safety training

When to See a Doctor

Epidural hemorrhage is a medical emergency. Any head injury with concerning symptoms requires immediate medical evaluation.

Call 911 Immediately For

  • Loss of consciousness after head injury
  • Worsening headache after head trauma
  • Confusion or disorientation
  • One pupil larger than the other
  • Weakness or numbness on one side
  • Repeated vomiting after head injury
  • Seizure following head trauma
  • Clear fluid from nose or ears
  • Difficulty staying awake
  • Slurred speech

Warning Signs of Deterioration

High-Risk Situations

Seek immediate evaluation for head injuries in:

  • Elderly individuals
  • People on blood thinners
  • Those with bleeding disorders
  • Alcohol or drug intoxication
  • Multiple trauma victims
  • High-impact mechanisms

What to Tell Emergency Services

  • Mechanism of injury
  • Time of injury
  • Initial symptoms
  • Changes in condition
  • Medical history and medications
  • Any loss of consciousness

Frequently Asked Questions

What is the "lucid interval" in epidural hemorrhage?

The lucid interval is a period of apparent normalcy between the initial head injury and the onset of serious symptoms. After the initial trauma (which may cause brief unconsciousness), the patient regains consciousness and may appear relatively well for minutes to hours. As the hematoma expands, they then rapidly deteriorate. This classic pattern occurs in only 20-50% of cases but is important to recognize as it can lead to false reassurance and delayed treatment.

How quickly does epidural hemorrhage develop?

Epidural hemorrhage typically develops more rapidly than subdural hemorrhage because it usually involves arterial bleeding. Symptoms can develop within minutes to hours after injury. The classic acute presentation occurs within 24-48 hours, though some cases may present in a delayed fashion. The speed of development depends on the source of bleeding - arterial bleeds expand quickly while venous bleeds may develop more slowly.

What is the prognosis for epidural hemorrhage?

With prompt diagnosis and treatment, the prognosis for epidural hemorrhage can be excellent. Mortality rates have decreased from 20-30% to 5-10% with modern management. Good outcomes (return to normal function) occur in 65-85% of patients who receive timely treatment. Factors affecting prognosis include initial Glasgow Coma Scale score, time to treatment, patient age, and presence of other injuries. Delayed treatment significantly worsens outcomes.

Can you have an epidural hemorrhage without losing consciousness?

Yes, not all patients with epidural hemorrhage lose consciousness. Some may have no loss of consciousness at all, particularly with smaller hematomas or venous bleeding. Others may only experience headache, dizziness, or mild confusion. This is why any significant head injury warrants medical evaluation, even if the person seems fine initially. The absence of unconsciousness doesn't rule out serious injury.

How is epidural hemorrhage different from subdural hemorrhage?

Epidural hemorrhage occurs between the skull and dura mater (outer brain covering), while subdural hemorrhage occurs between the dura and the brain itself. On CT scan, epidural hemorrhages appear lens-shaped and don't cross suture lines, while subdural hemorrhages are crescent-shaped and can cross sutures. Epidural hemorrhages typically progress more rapidly due to arterial bleeding, while subdural hemorrhages often involve slower venous bleeding and may develop over days to weeks.