Definition

An epidural hematoma is bleeding that occurs inside the head, located between the skull and the outer layer of the brain (dura mater). Epidural hematomas occur in 2% of all head injury cases and up to 15% of all fatal head injuries. Annually, there are approximately 40,000 cases of epidural hematoma. Epidural hematomas can also occur in the spinal column, though this is very rare, about 1 in 1,000,000 people.

Causes

The main cause of an epidural hematoma is head injury. Most of these injuries are due to traffic accidents, physical violence, and falls. In addition to head trauma, epidural hematomas can also result from brain infections, blood clotting disorders, bleeding tumors, and vascular malformations in the surrounding tissues.

In children, epidural hematomas often occur due to skull fractures. At that age, the outer layer of the brain is not tightly attached to the skull, making bleeding more likely. Vascular abnormalities can cause blood vessels to rupture easily, filling the space between the skull and the brain's outer layer with blood.

Risk factor

Males are at a higher risk for epidural hematomas than females. This is likely because men are more engaged in activities involving movement and motor vehicles. The highest incidence of epidural hematomas occurs in teenagers and young adults, with an average age of 20-30 years. As people age, the dura mater adheres more firmly to the skull, reducing the risk of bleeding in that area.

Symptoms

The main symptom of an epidural hematoma is losing consciousness right after the injury, then waking up, and subsequently losing consciousness again hours later. The period when the person is awake between the two episodes of unconsciousness is known as a lucid interval. However, it's important to note that not all cases of epidural hematoma exhibit this pattern. Other symptoms of an epidural hematoma include:

• Confusion
• Dizziness or severe headache
• Drowsiness or decreased consciousness
• Unequal pupil size in both eyes
• Nausea and vomiting
• Weakness in limbs, often on the opposite side of the injury
• Seizures immediately after the injury

Generally, these symptoms appear within minutes to hours after a head injury.

Diagnosis

Several physical signs can indicate an epidural hematoma, including decreased pulse rate and blood pressure, skull fractures, scalp wounds, leakage of cerebrospinal fluid (indicated by clear fluid from the nose or ears post-injury), decreased consciousness, asymmetrical pupil size, and weakness on one side of the body post-injury. Neurological examinations may also be conducted to detect nervous system dysfunctions.

A CT scan is performed if an epidural hematoma is suspected. CT scans are preferred for initial assessment as they are quick and provide detailed information. An epidural hematoma on a CT scan appears as a convex lens-shaped mass compressing the brain.

Laboratory tests may be performed to assess blood and platelet levels, evaluate the risk of further bleeding, and determine blood type for possible transfusions. Coagulation tests can indicate the risk of further bleeding. Blood chemistry tests can identify factors complicating treatment, and toxicology tests for illegal substances and alcohol levels can determine potential causes of the head injury.

Management

The treatment of epidural hematomas aims to reduce the risk of death from brain compression. Initial assessment includes securing the airway, breathing, and circulation. A tube may be inserted into the throat to ensure adequate air exchange in the lungs.

Once stabilized, the patient may be referred for surgery, especially if the epidural hematoma is acute, has a volume greater than 30 mL, or if consciousness decreases along with asymmetrical pupil size. The surgery, called a craniotomy, aims to reduce intracranial pressure by removing the hematoma.

If surgery is not needed, medication may be used. The patient's head is elevated about 30 degrees, and if intubated, deep and rapid breathing can help reduce brain pressure. Blood clotting disorders may be treated with medications like vitamin K and transfusions of fresh frozen plasma or platelets.

Diet and activity must be carefully managed. Initially, feeding may be via IV, but nasogastric feeding may be an option if the patient is intubated. Excessive activity should be avoided, and bed rest is recommended in the initial days, usually requiring hospitalization. During hospitalization, the patient's condition is monitored, and medications are given to prevent stomach ulcers and blood clots from immobility.

In severe cases, long-term physical therapy may be necessary to restore limb function, and speech therapy may be needed if there are speech difficulties.

Complications

Complications of epidural hematomas vary in severity. Seizures can occur from immediately after the injury up to three months later. Paralysis or decreased sensation in limbs may occur, and severe cases may lead to brain stem compression and death.

Prevention

Preventing epidural hematomas involves wearing head protection when cycling or motorbiking and during activities that risk falls or head injuries. Following safety rules during recreation or sports and avoiding alcohol or illegal substances before driving can prevent traffic accidents.

When to see a doctor?

Remember to seek immediate medical attention if you or a family member experiences a head injury followed by fainting and then regaining consciousness. This period of alertness is characteristic of an epidural hematoma. Getting prompt medical help can stop the bleeding and prevent increased pressure inside the skull.

After treatment, consult a doctor if you experience memory loss, dizziness, headaches, anxiety, speech difficulties, or limb paralysis. Go to the nearest emergency room if you or someone nearby has difficulty breathing, seizures, unequal pupil size, unresponsiveness to calls or touch, or decreased consciousness.

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