Epidural hematoma management and treatment

epidural hematoma merupakan cedera kepala ringan

1. Traumatic Epidural Hematoma Department of General Surgery Faculty of Medicine, Universitas Padjadjaran Dr. Hasan Sadikin General Hospital Bandung

2. INTRODUCTION EDH is a collection of blood between the duramater and the inner surface of the skull. Early recognition and coordinated multidisciplinary care improve outcomes and prevent neurological deterioration Often results from arterial bleeding due to traumatic brain injury ; characterized by the " lucid interval " phenomenon, requiring vigilant clinical monitoring. Delayed treatment can lead to severe complications.

3. INTRODUCTION EDH accounts for approximately 2% of all head injuries and up to 15% of fatal head traumas ; higher incidence in males , especially adolescents and young adults. Advanced imaging techniques, particularly computed tomography (CT) scans, are crucial for diagnosis and determining hematoma severit Effective management requires a multidisciplinary approach ; early surgical evacuation improves prognosis. Further investigation is needed to improve current treatment strategies, develop more advanced imaging techniques, and discover novel therapies to address the remaining challenges in epidural hematoma management.

4. EPIDEMIOLOGY

5. While epidural hematomas are a relatively infrequent type of head injury, occurring in roughly 2% of cases , they are a significant factor in fatal head trauma, representing up to 15% of such deaths . Higher incidence in males , especially adolescents and young adults ; mean age 20-30 years old Higher prevalence in younger populations is linked to increased exposure to high-energy traumas like sports injuries and vehicular accidents. EDH is less common in individuals over 50 to 60 years of age. Age-related anatomical changes, including the duramater's firmer adhesion to the skull; decreased potential space for blood accumulation; and reduced vascularity and elasticity of the dural membrane.

6. PATHOPHYSIOLOGY

7. The most common cause of EDH is bleeding from an injured artery. In most cases, the bleeding originates from the middle meningeal artery. In a smaller percentage of cases (up to 10%), EDH results from venous bleeding; typically involves lacerations of the dural venous sinuses. Location of EDH : Adults : Most frequently observed in the temporal region (approximately 75% of cases). Children : More evenly distributed across the temporal, occipital, frontal, and posterior fossa regions. This reflects differences in cranial development and injury patterns

8. EDH can be classified based on its appearance on imaging over time: Acute EDH (within 24 hours) : Characterized by a swirl of unclotted blood on imaging. Subacute EDH (days 2-4) : Presents as a solid hematoma. Chronic EDH (over 7-20 days) : Appears as a mixed or lucent lesion, possibly with contrast enhancement.

9. CLINICAL PRESENTATION

10. Observed in approximately 14% to 21% of cases, the classic presentations of EDH are : Initial loss of consciousness after the trauma. A transient lucid interval (period of apparent recovery). Not all patients experience a lucid interval. Some patients may remain unconscious , while others may exhibit no initial loss of consciousness. Subsequent neurological deterioration. Small EDHs may remain asymptomatic, while rapid hematoma growth can lead to signs of increased intracranial pressure (ICP).

11. Patients may remain conscious until late in the disease course; Sudden decompensation characterized by apnea (cessation of breathing) and coma. Ipsilateral pupil dilation Bradycardia Signs of Increased Intracranial Pressure (ICP) : Irregular respiration. Posterior fossa EDH (rare) comprises approximately 5% of all cases. Collectively termed the Cushing reflex Indicate impending brain herniation. Requires immediate surgical intervention.

12. SIGNIFICANCE OF EARLY INTERVENTION The outcome for EDH patients is strongly linked to how quickly they are diagnosed and treated. Delays in treatment increase the likelihood of irreversible brain damage and death. Surgically removing the hematoma is the main treatment, except for a few patients with small, stable hematomas who may be managed without surgery. Especially in patients with rapidly expanding hematomas or those with EDH in the posterior fossa. Advances in brain imaging, particularly CT scans , have significantly improved the ability to detect EDH early.

13. EVALUATION

14. CT Scans considered the gold standard for diagnosing EDH. Typically appears as a biconvex or lens-shaped hyperdense mass. The hematoma is confined by the dura's attachment to cranial sutures, preventing spread across suture lines. Low-density areas or the "swirl sign" indicate active bleeding. International Normalized Ratio (INR) Partial Thromboplastin Time (PTT) Laboratory Tests : Prothrombin Time (PT) Liver Function Tests (LFTs) Purpose: To assess bleeding risk or detect underlying coagulopathies

15. CT SCAN IN EDH

16. ASSESSMENT OF EDH VOLUME A x B x C / 2 A = greatest hemorrhage diameter in the axial plane B = hemorrhage diameter at 90º to A in the axial plane C = originally described as the number of CT slices with hemorrhage multiplied by the slice thickness, but can simply be substituted with the craniocaudal diameter of the hemorrhage where there is access to multiplanar reformats this dimension is known as height (H) in other formulas

17. Offers superior sensitivity compared to CT scans , especially for detecting vertex EDH Recommended when there's a strong clinical suspicion of EDH but initial CT results are negative. Magnetic Resonance Imaging (MRI) Preferred modality for spinal EDH due to its high-resolution capabilities. May be necessary in cases involving vertex EDHs. Used to investigate potential dural arteriovenous (AV) fistulas originating from the middle meningeal artery. Angiography

18. TREATMENT & MANAGEMENT

19. Initial Stabilization EDH is a neurosurgical emergency requiring prompt intervention to minimize the risk of neurological deterioration and death due to hematoma expansion and herniation. The first step is stabilizing the patient's airway, breathing, and circulation (ABCs). Early surgical evacuation (within 1-2 hours of presentation) significantly improves outcomes. Once stable, patients with acute EDH are evaluated for surgical intervention. Surgery is indicated if: Hematoma exceeds 30 mL, regardless of GCS score. GCS score is less than 9 with pupillary abnormalities (e.g., anisocoria).

20. Gold Standard : Craniotomy and Hematoma Evacuation Alternative : Burr Hole Evacuation (Trephination) ; although craniotomy is still preferred when possible for complete evacuation and better outcomes. Operative Management Conservative Management Criteria : May be considered for select patients with mild symptoms who meet specific criteria: Non-Operative Management Hematoma volume < 30 mL Clot diameter < 15 mm Midline shift < 5 mm GCS > 8 without focal neurological deficits Follow-up CT : early after admission (e.g., 6 hours) and then any time the patient becomes symptomatic, or in 1-2 wks if clinically stable. Repeat in 1 – 3 mos (to document resolution).

21. Surgical management of EDH

22. Exploratory burr holes INDICATIONS : 1. clinical criteria: based on deteriorating neurologic exam. Indications in E/R (rare): patient dying of rapid transtentorial herniation (see below) or brainstem compression that does not improve or stabilize with mannitol and hyperventilation. a)  indicators of transtentorial herniation/brainstem compression: ●  sudden drop in Glasgow Coma Scale (GCS) score ●  one pupil fixes and dilates ●  paralysis or decerebration develops (usually contralateral to blown pupil) b)  recommended situations where criteria should be applied: ●  neurologically stable patient undergoes witnessed deterioration as described above ●  awake patient undergoes same process in transport, and changes are well documented by competent medical or paramedical personnel 2. other criteria a) some patients needing emergent surgery for systemic injuries (e.g., positive peritoneal lavage + hemodynamic instability) where there is not time for a brain CT

23. Exploratory burr holes I f patient fits the above criteria (emergent operation for systemic injuries or deterioration with failure to improve with mannitol and hyperventilation), and CT scan cannot be performed and interpreted immediately, then treatment should not wait for CT scan a)  in general, if the O.R. can be immediately available, burr holes are preferably done there (equipped to handle craniotomy, better lighting and sterility, dedicated scrub nurse ... ), espe - cially in older patients (> 30 yrs ) not involved in MVAs (see below). This may more rapidly diagnose and treat extraaxial hematomas in herniating patients, although no di ff erence in outcome has been proven b)  if delay in getting to the O.R. is foreseen, emergency burrholes in the E/R should be performed

24. Technique Choice of side for initial burr hole Start with a temporal burr hole on the side: ipsilateral to a blown pupil. This will be on the correct side in > 85% of epidurals and other extra-axial mass lesions if both pupils are dilated, use the side of the first dilating pupil (if known) if pupils are equal, or it is not known which side dilated first, place on side of obvious external trauma if no localizing clues, place hole on left side (to evaluate and decompress the dominant hemisphere)

25. Approach Burr holes are placed along a path that can be connected to form a “trauma flap” if a craniotomy becomes necessary The “trauma flap” is so-called because it provides wide access to most of the cerebral convexity permitting complete evacuation of acute blood clot and control of most bleeding. First outline the trauma flap with a skin marker: start at the zygomatic arch < 1 cm anterior to the tragus (spares the branch of the facial nerve to the frontalis muscle and spares the anterior branch of the superficial temporal artery (STA)) proceed superiorly and then curve posteriorly at the level of top of the pinna 4–6 cm behind the pinna it is taken superiorly 1–2 cm ipsilateral to the midline (sagittal suture) curve anteriorly to end behind the hairline

26. BURR HOLE LOCATIONS ●   temporal burr hole (1 in ▶ Fig. 60.3) ○  over middle cranial fossa typically on side of dilated pupil (if there is one) just superior to the zygomatic arch. Provides access to middle fossa (the most common site of epidural hematoma) and usually allows access to most convexity subdural hematomas, as well as proximity to middle meningeal artery in region of pterion ○  if no epidural hematoma, the dura is opened if it has bluish discoloration (suggests subdural hematoma (SDH)) or if there is a strong suspicion of a mass lesion on that side ●  if completely negative, usually perform temporal burr hole on contralateral side in the same location ●  if negative and if a CT cannot now be done and the OR immediately available from there, proceed to ○   ipsilateral frontal burr hole (2 in ▶ Fig. 60.3), if negative proceed to ○   parietal region (3 in ▶ Fig. 60.3), if negative proceed to ○   posterior fossa (4 in ▶ Fig. 60.3)

27. DIFFERENTIAL DIAGNOSIS CT scans are primary diagnostic tool, MRI and angiography provide additional sensitivity and specificity in complex cases. EDH management requires accurate diagnosis and decisive treatment Early recognition and timely intervention remain pivotal in optimizing patient outcomes and reducing morbidity and mortality associated with EDH. Intracranial Abscess Intracranial Mass Seizure Transient Ischemic Attack (TIA)

28. PROGNOSIS

29. Generally favorable for isolated EDHs when promptly diagnosed and surgically managed. Hematomas > 50 cm³ before evacuation are associated with poorer neurological outcomes and higher mortality rates. Arterial bleeding (rapid development): Allows quicker detection; while dural sinus tears (slower development): Leads to delayed recognition and intervention Factors Influencing Prognosis include: patient age, time between injury and treatment, presence of coma or lucid interval, pupillary abnormalities, Glasgow Coma Scale (GCS) or motor score at presentation

30. Low GCS score at presentation Unreactive pupils Postoperative ICP is a key prognostic indicator. Advanced age Poor Prognostic Markers Delays in surgical intervention Hematoma volumes between 30 and 150 mL Midline shifts > 10-12 mm Postoperative Intracranial Pressure "Swirl sign" indicating active bleeding Concurrent lesions (subarachnoid hemorrhages, diffuse cerebral edema)

31. Seizures can result from irritation of brain tissue by the hematoma or elevated ICP. Accumulating blood exerts pressure on the brain, causing compression and damage, increasing ICP. Outcomes of Untreated/Late-Diagnosed EDH can lead to permanent neurological impairment or death. Early recognition, imaging, and surgical evacuation are crucial. Rising ICP can lead to brain herniation , compressing critical structures like the brainstem. Complications

32. Neurosurgical and Trauma Teams should be involved as soon as an EDH is suspected. Neurosurgeons determine the need for surgical intervention and provide postoperative care. Trauma Surgeons stabilize the patient (ABCs) Timely Neurosurgical Consultation : Crucial for treatment success. Delays increase the risk of irreversible neurological damage or death Other Specialists : Neurologists (seizures), critical care teams (ICP management). Consultations

33. Roles of Emergency Providers, Pharmacists, and Nurses

34. CONCLUSION

35. Effective management of epidural hematoma (EDH) hinges on a coordinated, multidisciplinary approach involving emergency physicians, pharmacists, and nurses. The successful management of EDH highlights the critical role of collaboration and a shared commitment to patient care in emergency medicine. Prompt diagnosis, stabilization, and intervention (including safe and tailored pharmacological treatments) are essential to prevent neurological damage, reduce mortality, and improve functional recovery.

36. Thank You