Epidural Hematoma (EDH) 

 Definition

  Epidural hematoma (EDH) = accumulation of blood between inner table of skull and dura mater.

  • Extra-axial hemorrhage
  • Typically arterial bleed → rapid expansion
  • Most commonly due to trauma

 Etiology & Source of Bleeding

 Most common cause:

  • Skull fracture → laceration of
     Middle meningeal artery

Other sources:

  • Middle meningeal vein
  • Diploic veins
  • Dural venous sinus (rare but severe)


 Common Site

  • Temporal region (thin bone + MMA groove)
  • Also:
    • Temporoparietal
    • Posterior fossa (dangerous → brainstem compression)

 Pathophysiology

Key concept:

  • Blood accumulates rapidly under high arterial pressure
  • Dura is tightly adherent → hematoma cannot cross sutures

Sequence:

  1. Trauma → skull fracture
  2. Vessel tear (usually MMA)
  3. Rapid hematoma expansion
  4. ↑ ICP + mass effect
  5. Brain herniation if untreated

 Classic Clinical Features 

 Lucid Interval (hallmark)

  • Initial loss of consciousness
  • Temporary recovery (lucid phase)
  • Rapid deterioration

 But remember:

  • Present in <50% cases (not mandatory)

 Symptoms:

  • Severe headache
  • Vomiting
  • Altered sensorium
  • Seizures (less common vs SDH)

 Signs of rising ICP:

  • Bradycardia + hypertension → Cushing reflex
  • Papilledema (late)


 Focal deficits:

  • Contralateral hemiparesis


 Uncal Herniation (classic EDH finding):

  • Ipsilateral dilated pupil
    → compression of
    Oculomotor nerve

 Imaging – CT Scan (Gold Standard)

Classical finding:

  • Biconvex (lentiform) hyperdense lesion

Key features:

  • Does NOT cross sutures
  • May cross midline (rarely limited by falx)
  • Mass effect → midline shift

 EDH vs SDH 

Feature

EDH

SDH

Shape

Biconvex

Crescent

Source

Arterial

Venous

Cross sutures

 No

 Yes

Onset

Rapid

Slower

Lucid interval

Classic

Rare

 Severity & Prognostic Factors

Poor prognosis:

  • GCS < 8
  • Pupillary abnormalities
  • Large hematoma (>30 mL)
  • Midline shift >5 mm
  • Delayed surgery

 Management

 1. Initial Stabilization (ATLS based)

  • Airway, breathing, circulation
  • Maintain:
    • SpO₂ > 94%
    • SBP ≥ 100–110 mmHg
  • Avoid hypotension & hypoxia (worst prognostic factors)

 2. Definitive Management

 Surgical evacuation 

Indications 

 Operate if ANY of the following:

  • Hematoma volume >30 mL
  • Thickness >15 mm
  • Midline shift >5 mm
  • GCS drop ≥ 2 points
  • Pupillary asymmetry
  • Signs of herniation

Procedure:

  • Craniotomy + evacuation


 Conservative management (selected cases):

ONLY if ALL present:

  • Volume <30 mL
  • Thickness <15 mm
  • Midline shift <5 mm
  • GCS >8 and stable

 Requires:

  • ICU monitoring
  • Serial CT scans


 3. ICP Management

  • Head elevation (30°)
  • Sedation + analgesia
  • Osmotherapy:
    • Mannitol
    • Hypertonic saline
  • Avoid:
    • Hypercapnia
    • Hypoxia

 4. Seizure Prophylaxis

  • Consider:
    • Levetiracetam / phenytoin

 5. Ventilation Targets

  • PaCO₂: 35–40 mmHg
  • Temporary hyperventilation ONLY in impending herniation

 Complications

  • Brain herniation (most feared)
  • Rebleeding
  • Seizures
  • Neurological deficits
  • Death (if untreated)

 Prognosis

  • Best among intracranial hemorrhages IF treated early
  • Mortality:
    • Early surgery → <10%
    • Delayed → up to 50%