EPIDURAL HEMATOMA (EDH)
Definition
- Collection of blood between skull and dura mater
- Classically due to arterial bleed
Etiology & Pathophysiology
- Middle meningeal artery rupture
- Almost always associated with skull fracture
- High-pressure arterial bleeding → rapid expansion
- Dura is tightly adherent at sutures → blood cannot cross sutures
Typical Patient
- Young adults
- High-velocity trauma (RTA, assault, fall)
Classical Clinical Course
Lucid interval:
- Initial loss of consciousness
- Temporary recovery (lucid phase)
- Rapid neurological deterioration
Clinical Features
- Severe headache
- Vomiting
- Ipsilateral fixed dilated pupil (CN III compression)
- Contralateral hemiparesis
- Rapid fall in GCS
CT Scan Features
- Biconvex (lentiform), hyperdense
- Does NOT cross sutures
- Often associated with skull fracture
- Mass effect with midline shift
Management
Neurosurgical emergency
- Immediate craniotomy if:
- Volume >30 mL
- Thickness >15 mm
- Midline shift >5 mm
- GCS <9 with pupillary abnormality
Medical (only if small & stable):
- ICU monitoring
- ICP control
Prognosis
- Excellent if treated early
- High mortality if delayed intervention
SUBDURAL HEMATOMA (SDH)
Definition
- Collection of blood between dura and arachnoid mater
- Usually due to venous bleed
Etiology & Pathophysiology
- Tearing of bridging veins
- Slower accumulation than EDH
- Blood spreads widely as dura is not tightly adherent
Risk Groups
- Elderly
- Alcoholics
- Anticoagulated patients
- Cerebral atrophy
Types of SDH
|
Type |
Time |
CT Density |
|
Acute |
<72 hours |
Hyperdense |
|
Subacute |
3–21 days |
Isodense |
|
Chronic |
>3 weeks |
Hypodense |
Clinical Features
- Altered sensorium
- Headache
- Focal neurological deficits
- Seizures
- No lucid interval (usually)
CT Scan Features
- Crescent-shaped
- Crosses sutures
- Does NOT cross falx or tentorium
- Variable density depending on age of bleed
Management
- Acute SDH:
- Often requires urgent craniotomy
- Worse prognosis than EDH
- Chronic SDH:
- Burr-hole drainage
- Excellent outcomes
Prognosis
- Worse than EDH
- Depends on:
- Age
- Initial GCS
- Associated brain injury
EDH vs SDH (COMPARISON)
|
Feature |
EDH |
SDH |
|
Location |
Skull–dura |
Dura–arachnoid |
|
Vessel |
Artery (MMA) |
Vein (bridging veins) |
|
Onset |
Rapid |
Slow |
|
Lucid interval |
Common |
Rare |
|
CT shape |
Biconvex (lentiform) |
Crescent |
|
Cross sutures |
No |
Yes |
|
Skull fracture |
Common |
Uncommon |
|
Age group |
Young |
Elderly |
|
Prognosis |
Better if early |
Worse overall |
EXAM PEARLS
- Lucid interval = EDH
- Crescent shape crossing sutures = SDH
- Rapid deterioration + fixed pupil = EDH
- Elderly on anticoagulants = SDH
- EDH is a neurosurgical race against time
- SDH mortality > EDH mortality
ICU & ANESTHESIA RELEVANCE
- Aggressive ICP control
- Avoid hypotension & hypoxia
- Rapid airway protection
- Reversal of anticoagulation in SDH
- Hyperosmolar therapy as bridge to surgery