Epidural Hematoma

As per published data, nearly 2% of head injury cases usually result in an epidural hematoma. In case of fatal head injuries, 5-15% of cases involve the presence of an epidural or extradural hematoma. 

(Read more: First-aid for head injury)

Research suggests that 60% of cases are acute, 30% are subacute and 10% may be classified as chronic. 

In terms of gender, males to females ratio for experiencing an epidural hematoma is 4:1. Epidural hematomas are extremely rare in children as their skull is extremely compressible and has a lot of plasticity. It is also less common in the elderly population above the age of 60 as their dura mater is strongly adherent to the brain, thus reducing the size of the potential space. 

A study conducted showed that for an extradural hematoma, the peak incidence is in the age group of 12-16 years of age. Spinal extradural hematomas are most common in the age group of 40-60 years old.

Patients of an epidural hematoma usually present with a history of trauma and injury to the head that may result in loss of consciousness. Often, this is followed by an interval called the lucid interval after which the patient starts deteriorating. But this presentation is observed in only 1/3rd of the cases. Epidural hematoma that occurs in the posterior fossa can result in very rapid deterioration. 

An epidural hematoma in the skull may result in a wide variety of changes that should be looked for in any patient who experiences a severe head injury. This is extremely important especially if the patient experienced a loss of consciousness. (Read more: Fainting)

The clinical features are as follows: 

• Headache
• Nausea and vomiting
• Seizures
• Bradycardia
• Hypertension or high blood pressure
• Evidence of skull fractures 
• Evidence of any lacerations or open wounds to the head
• Leakage of cerebrospinal fluid from the nose or ears (This may occur in the case of a fracture of the skull that involves a tear in the dura) (Read more: Cerebrospinal Fluid Test)
• Pupil size may be unequal in both the eyes 
• Changes in consciousness levels with deterioration of the glasgow coma scale score (The glasgow coma scale scores indicate the level of consciousness in a patient and have three major components which involve eye opening, talking and movements)
• Injury to the facial nerve that controls the movements on the face
• Weakness of the limbs 
• Visual field defects 
• Numbness anywhere in the body 
• Balance issues 
• Aphasia (issues with understanding speech or talking) 

In case of an epidural hematoma in the spinal column, the patients will present with clinical features of spinal cord compression. The cord compression may be at a particular level on the spinal cord or the spinal cord may be completely compressed. The patients will present with the following clinical features: 

• Weakness of limbs 
• Numbness in different areas of the body 
• Changes in the various reflexes of the body such as the knee jerk or the ankle jerk 
• Urinary incontinence 
• Combination of urinary and bowel incontinence

Spinal extradural hematoma: In some cases, a spinal extradural hematoma may occur after a patient experiences an injury around his or her spinal area. This may be seen after a lumbar puncture in which a sample of cerebrospinal fluid (the fluid that surrounds the brain and the spinal cord) is withdrawn with the help of a lumbar puncture needle (this procedure helps in diagnosing a condition called meningitis). Rarely, it may occur when a patient receives an epidural anaesthetic, which is pain relief commonly given during delivery to pregnant women. A spinal extradural hematoma may also spontaneously occur in patients who take certain medications like anticoagulation treatment that results in blood thinning or in patients who have certain illnesses that result in problems with clotting of blood.

(Read more: Spinal cord injury)

Intracranial extradural hematoma: An intracranial extradural hematoma may commonly occur after a patient experiences a skull fracture as a result of a head injury. This injury is usually very severe, for example, having a road traffic accident. The blood usually accumulates very rapidly in the epidural space after the injury has occurred and patients start to demonstrate clinical features soon. 

Epidural hematoma: The causes of an epidural hematoma can be summarised as follows: 

• An epidural hematoma commonly occurs after an injury that results in the fracture of the temporal bone or the parietal bone. As a consequence, the middle meningeal artery or middle meningeal vein gets damaged and bleeding occurs between the dura and the skull. 
• It is commonly caused due to injury to the temple of the head just next to the eye. It can also occur as a result of a tear in the dural venous sinuses.
• Children with extradural hematomas are less likely to have associated skull fractures as compared to adults. 
• An extradural hematoma in the spinal column of our body may be a result of an injury occurring during an epidural anaesthesia procedure or due to anticoagulation medications. 
• Patients with platelet defects are also susceptible to developing epidural hematomas. 

(Read more: What is normal platelet count)

Some patients who experience a head injury could be intoxicated. Hence, it may be difficult to rule out whether the decrease in the consciousness levels is due to an epidural hemorrhage or due to the intoxicating effects of alcohol or drugs. 

Tests for epidural hematoma

Following investigations may be required in the case of a suspected epidural hematoma:

• Baseline investigations such as a complete blood count (CBC), urine routine and microscopy are usually performed. 
• Platelets and coagulation profiles should be performed in patients who are suspected of having any coagulation anomalies and present with a spontaneous hemorrhage. 
• An X-Ray of the skull should be performed to check for the presence of a fracture of the skull. 
• X-ray of the cervical spine should be performed including the odontoid peg view. This helps in excluding injuries to the spine. 
• Computed tomography scans (CT Scans) should be performed as they provide more information. A computed tomography scan may show the presence of a hematoma or any air pockets. 
• Magnetic resonance imaging scans (MRI Scans) provide better images. They are similar to CT Scans but use magnetic rays instead of X-Rays. 

It’s important to note that a lumbar puncture should not be performed, especially if the patients demonstrate signs of raised intracranial pressure. 

When a patient suffers an epidural hematoma, the doctors would make treatment recommendations depending on the individual case severity. 

• If the patient is unconscious, the basic ABC protocol should be followed to resuscitate the patient. The ABC protocol includes airway, breathing and circulation maintenance. 
• The airway should be maintained and the neck should be treated with care until a cervical spine injury has been excluded.
• Supplemental oxygen may be required if the patient’s saturation dips. (Read more: What is oxygen therapy)
• Trauma assessment should be done as patients may also have other injuries to vital organs like liver or spleen. 
• Intravenous fluids may be needed to ensure that the patient’s circulation is preserved and the brain receives adequate blood supply. (Read more: What is fluid therapy)
• Alert patients with small hematomas can be managed conservatively and should be carefully observed in case of sudden deterioration. 
• If the patient’s intracranial pressure is increased, it can be treated with osmotic diuretics like Mannitol, which is given intravenously. Hypertonic saline can also be given and is known to be safe and effective. It has the advantage of replenishing or maintaining the intravascular volume instead of increasing fluid loss in urine (as done by mannitol). 
• Ventilation with the elevation of the head of the bed to 30 degrees may be needed. Hypocapnia (low carbon dioxide) levels should be avoided as it may result in cerebral vasoconstriction. 
• Burr holes may need to be created to evacuate a hematoma. 
• For a large hematoma, intervention is necessary. In some cases, conservative management can be considered to be appropriate for large epidural hemorrhage if the Glasgow coma scale score at presentation and later on remains the same with improvement in the clinical features of the patient. Non-comatose patients with extradural hematomas less than 30 cm in volume, less than 15 mm thick and causing less than 5 mm midline shift. It is also recommended that extradural hematomas larger than 30 cubic centimetres should have a surgical evacuation in all patients. 
• Other issues that may need to be addressed include deep vein thrombosis prevention, where the patient should be given low-dose heparin along with proton pump inhibitors to prevent peptic ulcers. Anticoagulation itself in patients with extradural hematomas is potentially dangerous and compression stockings may be used. 

Epidural hematoma holds the possibility of the patient dying. Other complication are: 

• The neurological deficits in the patients can be permanent or temporary. 
• Seizures after trauma due to damage to the brain may develop after 1-3 months of suffering the injury. The risk of seizures diminishes with time and alcohol increases the risk of post-traumatic seizures. Prophylactic phenytoin can be used to prevent early post-traumatic seizures. 
• Post-concussion syndrome, where patients experience headaches, dizziness, vertigo, restlessness and inability to concentrate, may occur. 
• Spinal extradural hematomas may result in spasticity, neuropathic pain and complications such as urinary and fecal incontinence. 

Mortality rate for an epidural hematoma stands at 30% and low glasgow coma scale suggests a poor prognosis. Prognosis largely depends on early detection and treatment of epidural hematoma as they can help prevent bad outcomes. Some other factors also play a role: 

• Children have a good prognosis when they suffer an extradural hematoma. 
• Patients older than 75 years of age have a poor prognosis. These patients should be managed conservatively.
• The larger the size of the hematoma, the worse the prognosis. 
• Location of the hematoma can be a factor. For example, the temporal location has a poor prognosis. 
• Patients who worsen rapidly have a poor prognosis.
• Patients with pupillary anomalies have a poor prognosis.
• Increased intracranial pressure suggests a poor prognosis. 

Some precautions you can take to prevent an epidural hematoma are: 

• Motorcyclists should wear helmets. Helmets should also be worn by skateboarders and snowboarders as well. 
• Driving after the consumption of alcohol should be avoided to prevent road traffic accidents. 
• Boxers should know that head guards do not protect the brain. As per various health associations, boxing along with mixed martial arts should be banned. Boxing is the most common cause of head injuries.

(Read more: Brain injury)