The management of Traumatic Brain Injury (TBI) presents some of the most urgent diagnostic and therapeutic challenges in modern medicine. Among these, Epidural Hemorrhage (EDH), also known as an epidural hematoma, stands out as a condition where rapid intervention is paramount to patient survival and neurological outcome.
Case Presentation: A Textbook Example of EDH
The case involves an 18-year-old male who was intoxicated and assaulted with a glass bottle, sustaining a blow to the left temporoparietal region of the scalp. He experienced a brief loss of consciousness for 5 minutes.
The patient was initially discharged. However, two hours after the injury, he presented to a nearby emergency department complaining of severe headache, nausea, and vomiting.
Upon physical examination, his Glasgow Coma Scale (GCS) score was 15 (The GCS score range is 3–15, with 15 indicating a normal level of consciousness) . His pupils were equal and reactive bilaterally, and a small contusion was noted on the scalp. Given the history of trauma and worsening symptoms , a Computed Tomography (CT) scan of the head was performed.
1. Understanding Epidural Hemorrhage (EDH)
1.1. Pathophysiology
Epidural hemorrhage (EDH) is a type of traumatic brain injury characterized by bleeding between the skull and the dura mater (the outermost membrane covering the brain). It is typically caused by a severe head injury, such as a skull fracture, which tears a meningeal artery. This results in a rapid accumulation of blood in the potential space between the skull and the dura. This rapid expansion causes a swift and dangerous rise in Intracranial Pressure (ICP), which can lead to potentially fatal complications.
EDH is most common in young adults and is frequently associated with trauma such as motor vehicle accidents, falls, or, as in this case, assault.
1.3. Clinical Presentation
The symptoms of EDH can vary , but they are often characterized by a period of unconsciousness followed by a short period of lucidity before neurological deterioration worsens.
Initial Unconsciousness: 5 minutes following the assault.
Secondary Deterioration: Severe headache, nausea, and vomiting 2 hours later.
Physical Findings: A GCS score of 15 , with equal and reactive pupils and a small scalp contusion.
Other potential symptoms include confusion, weakness, and seizures.
2. Imaging Features: Diagnosis is Key
Diagnosis is typically based on clinical signs and imaging studies such as CT or MRI scans.
Imaging Findings
Imaging Feature Summary
The characteristic finding for EDH on imaging is a lens-shaped clot that does not cross the suture lines. This finding, along with the patient's history of trauma and subsequent symptom deterioration, confirms the diagnosis of Epidural Hemorrhage (EDH).
The primary differential diagnosis for EDH following trauma is Subdural Hemorrhage (SDH).
| Feature | Epidural Hemorrhage (EDH) | Subdural Hemorrhage (SDH) |
| Shape on CT | Biconvex (Lens-shaped) | Crescent-shaped |
| Suture Line | Does not cross sutures | Crosses sutures (but not falx or tentorium) |
| Vascular Source | Typically Arterial (Middle Meningeal Artery) | Typically Venous (Bridging Veins) |
| Location | Between Skull and Dura | Between Dura and Arachnoid Mater |
3. Management and Prognosis
3.1. Treatment
The treatment for EDH typically involves emergency surgery. Prompt intervention is critical to prevent further brain injury and potentially fatal complications.
Surgical Management: This generally requires an emergency craniotomy to evacuate the hematoma (clot) and repair the damaged vessel. This is the standard of care for most symptomatic or large EDHs.
Conservative Management: Small, asymptomatic EDHs (typically <30 ml, <15 mm thickness, with minimal midline shift) in neurologically stable patients may be managed conservatively with strict monitoring and serial CT scans. However, due to the high risk of rapid deterioration, most EDH cases warrant surgical evacuation.
3.2. Prognosis
The prognosis for EDH depends on several factors:
The size and location of the hemorrhage.
The severity of associated brain injury.
The timeliness of medical intervention.
Many patients can achieve full recovery with prompt treatment. However, delayed diagnosis and treatment can lead to severe disability or death. Prevention involves raising awareness of the importance of seeking immediate medical attention after a head injury.
Quiz
Question 1 (Diagnosis) An 18-year-old male presents with severe headache and vomiting two hours after sustaining a blow to the head, having briefly lost consciousness initially. CT scan (Figures 1-4) reveals a biconvex, hyperdense collection in the left temporoparietal region that does not cross the suture lines but causes a significant midline shift. What is the most likely diagnosis?
Subdural Hematoma (SDH)
Epidural Hemorrhage (EDH)
Glioblastoma Multiforme (GBM)
Subarachnoid Hemorrhage (SAH)
Meningioma
Answer and Explanation:
Answer: 2. Epidural Hemorrhage (EDH)
Explanation: The combination of trauma, a possible lucid interval (initial loss of consciousness followed by subsequent deterioration), and the classic CT finding of a biconvex (lens-shaped) hematoma that is constrained by the cranial sutures strongly points to an Epidural Hemorrhage. SDH is typically crescent-shaped.
Bridging Veins
Superior Sagittal Sinus
Anterior Cerebral Artery
Middle Meningeal Artery (MMA)
Basilar Artery
Answer and Explanation:
Answer: 4. Middle Meningeal Artery (MMA)
Explanation: EDH is overwhelmingly caused by an arterial tear, specifically the rupture of the Middle Meningeal Artery, often associated with an overlying skull fracture (Figure 3). This arterial source explains the rapid accumulation of blood and quick progression of symptoms. Bridging veins are the typical source of Subdural Hematomas.
Question 3 (Treatment) Given the large size and significant midline shift shown in the CT images (Figures 1 and 4), what is the most appropriate immediate definitive management for this patient?
Initiate supportive care and observe the GCS score every hour.
Start osmotic therapy (e.g., Mannitol) and obtain a follow-up CT in 12 hours.
Emergency Craniotomy for Hematoma Evacuation and Hemostasis.
Administer prophylactic anticonvulsants and transfer to a specialized rehabilitation center.
Consult with an interventional radiologist for endovascular embolization.
Answer and Explanation:
Answer: 3. Emergency Craniotomy for Hematoma Evacuation and Hemostasis.
Explanation: A large EDH causing a midline shift constitutes a neurosurgical emergency requiring immediate decompression. The goal is to relieve the rapidly increasing ICP and prevent imminent brain herniation. Emergency craniotomy for clot evacuation and vessel repair is the definitive treatment to prevent fatal complications60.
References
Smith, S. W., et al. (2007). Case 13-2007: An 18-Year-Old Man with Epidural Hemorrhage after an Assault. New England Journal of Medicine, 356(19), 1987-1994. (Source DOI: 10.1056/NEJMicm0706764
61 )Bullock, M. R., Chesnut, R. M., Ghajar, S., et al. (2006). Guidelines for the management of severe traumatic brain injury. Journal of Neurotrauma, 23(3-4), 1-285.
Bhardwaj, R., & Wani, M. A. (2018). The management of acute epidural haematoma: a review. Journal of Neurosciences in Rural Practice, 9(4), 589–594.
Mendelow, A. D., Karmi, A., & Massi, A. (2010). Epidural hematoma: a review. Neurosurgery Clinics of North America, 21(3), 513-524.
Koivunen, J., et al. (2002). Outcome of acute epidural hematoma. Neurosurgical Review, 25(3), 196-200.
Lee, M. C., et al. (2019). Clinical and radiologic predictors of outcome in patients with traumatic brain injury: a single-center experience. World Neurosurgery, 129, e538-e546.
Servadei, F., et al. (2002). The role of the timing of surgery in the outcome of patients with acute subdural hematoma: a prospective study. Neurosurgery, 51(5), 1146-1151.
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