epidural hematoma

epidural hematoma, a type of head injury involving bleeding into the space between the skull and the dura mater, the outermost layer of the protective structures surrounding the brain. It can occur when a traumatic force applied to the head is sufficient to cause a deformity of the skull and damage to the underlying middle meningeal artery. The high pressure of the blood coming from the arterial circulation causes the dura mater to separate from the skull, creating the classic lens-shaped hematoma that can expand quickly, placing significant pressure on the brain. It is a relatively rare type of head injury but is very serious and can lead to significant disability or death. Early recognition of the warning signs and quick medical attention are paramount for a good outcome.

Anatomy

The brain is protected inside the skull by three separate layers of tissue (meninges). The innermost layer, the pia mater, is a thin and delicate membrane that lies on the surface of the brain. The second layer, the arachnoid mater, covers the brain and pia mater but does not follow the contour of the involutions of the brain. The outermost layer, the dura mater, provides a thicker and tougher layer of protection.

These layers define three potential spaces for blood to collect. The epidural space, between the skull and the dura mater, the subdural space, between the dura mater and arachnoid layers, and the subarachnoid space, between the arachnoid and pia layers, each have their own potential sources of hemorrhage. The pia mater is too closely adhered to the brain and too fragile to act as a barrier for blood, and, therefore, there is no potential space between the pia and the brain for a hemorrhage to form.

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The epidural space is prone to blood collection due to the presence of a series of arteries that supply blood to the meninges, the meningeal arteries. The largest meningeal artery, the middle meningeal artery, is the source of most epidural hematomas because of its location near the temporal skull. Although the majority of epidural hematomas are the result of arterial injury, they may also develop following injury to a meningeal vein or dural sinus, vascular structures that are also located in or near the epidural space.

Mechanism of injury

An epidural hematoma can occur as the result of an impact to the head. An epidural hematoma forms when the head impact is of sufficient force to either pull the meninges away from the inner table of the skull or cause a skull fracture. The vascular structures mentioned above, especially the middle meningeal artery, can be compromised in this setting, leading to bleeding and hematoma formation.

Given that the blood in the meningeal arteries is coming from the arterial side of the circulatory system and is, therefore, under high pressure, epidural hematomas typically expand at a much faster rate than hematomas that are formed from venous blood, such as subdural hematomas. The quickly expanding epidural hematoma increases intracranial pressure and can lead to damage of the underlying brain, brain herniation, or death.

Signs and symptoms

The first sign of injury occurs shortly after the head impact and typically involves a change in consciousness. This change can span the spectrum from mild confusion to complete loss of consciousness. If the injured person remains conscious, he or she often has many of the signs and symptoms that are typically seen in concussion, such as headache, nausea, dizziness, and lack of coordination. The classic presentation of an epidural hematoma, however, involves what is known as the lucid interval. After the initial decrease in consciousness, which can last for several minutes, the injured person can improve significantly or even completely. During this time, the physical examination can be completely normal, and the injured person may appear unaffected. At this stage, the epidural hematoma is still small enough to be asymptomatic. As it expands, however, the increasing pressure inside the skull puts the brain at risk, leading to a quick return of symptoms. Continued expansion of the hematoma can then lead to rapidly progressive symptoms, coma, and even death.

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It should be noted that the presenting signs and symptoms of epidural hematoma are similar to those of other head injuries, including concussion. Often, the main difference is in the time course of symptoms. If any injured person develops new symptoms several minutes after a witnessed impact or if there is any perceived clinical worsening, emergency medical services should be notified immediately.

Diagnostic tests

The presence of an epidural hematoma is usually confirmed with a computed tomography (CT) scan of the head. Magnetic resonance imaging (MRI) of the brain can also be used. While the MRI may provide more information regarding damage to the brain itself, it is more expensive, requires more time, and is not available at every medical facility. The initial diagnosis, therefore, is typically made with a CT scan. Acutely, epidural hematomas appear hyperdense (bright) on CT scan, are classically lens shaped, and are typically located in the temporal area.

Once the hematoma is confirmed, the patient should be evaluated for surgical intervention. Surgery includes evacuation of the hematoma as well as repair of the vascular structures and skull, as needed.