Epidural Hemorrhage Clinical Overview
Alright, listen up. You will see this on-call, usually after a nasty Mat Rempit accident comes in. Pay attention, because missing an extradural hemorrhage (EDH) is one of the fastest ways to kill a patient who could have walked out of the hospital.
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a classic neurosurgical emergency, frequently seen in our Emergency Departments following road traffic accidents, particularly motorcycle collisions and assaults.
High-Yield Definition: An EDH is an accumulation of blood in the potential space between the inner surface of the skull and the dura mater.
Clinical One-Liner: Think of it as an arterial bleed in the head after trauma. It's fast, it's dangerous, and it needs the neurosurgeons yesterday.
II. Etiology & Risk Factors
Etiology:
Almost always traumatic.
The classic mechanism is a skull fracture (especially of the temporal bone) that tears the underlying middle meningeal artery. Venous EDH can occur but is less common and slower to expand.
Risk Factors:
Young Age: More common in adolescents and young adults. The dura is less adherent to the skull, making it easier for a hematoma to form.
Male Gender: Due to higher rates of risk-taking behaviour leading to trauma.
High-Impact Head Trauma: Motorcycle accidents, falls from height, assault with a blunt object.
III. Quick Pathophysiology
It's simple cause and effect. A direct blow fractures the skull and tears the middle meningeal artery. High-pressure arterial blood pumps into the epidural space, rapidly stripping the dura from the skull. This expanding hematoma acts as a space-occupying lesion, compressing the brain parenchyma. If not evacuated, this leads to a rapid rise in intracranial pressure (ICP), causing brainstem herniation and death.
IV. Clinical Assessment
Red Flags & Immediate Actions:
Deteriorating GCS: A drop of >2 points on the Glasgow Coma Scale (GCS). → Action: Alert your senior/Neurosurgery registrar immediately. Prepare for intubation.
Anisocoria (Unequal Pupils): A fixed and dilated pupil on one side is a sign of uncal herniation (compression of Cranial Nerve III). → Action: This is a dire emergency. Inform the neurosurgeon on-call for immediate review for surgery. Start medical management for raised ICP.
Cushing's Triad (Late Sign): Bradycardia, irregular breathing, and a widened pulse pressure (high systolic BP). → Action: The patient is herniating. Intubate, hyperventilate as a bridge to surgery, and give IV Mannitol. This is a last resort.
History:
The Lucid Interval (Classic, but only seen in ~30% of cases): The patient suffers a brief loss of consciousness at the time of impact, followed by a period where they are awake and alert (the "lucid interval"). They then experience a rapid neurological decline as the hematoma expands.
Common Symptoms: Severe headache, nausea/vomiting, dizziness, confusion.
Pertinent Negatives: Ask about anticoagulant use (to rule out other bleeds), history of seizures, and previous neurosurgery.
Physical Examination:
GCS: This is your most important tool. Assess it, document it, and repeat it every 15-30 minutes.
Pupils: Check size, symmetry, and reactivity to light. A sluggish or non-reactive pupil is a major warning sign.
Focal Neurology: Look for contralateral hemiparesis (weakness on the opposite side of the body from the bleed) due to compression of the corticospinal tracts.
Clinical Pearl: Don't be falsely reassured by a high GCS on arrival. The "lucid interval" is a trap. Any patient with a significant head injury mechanism and a temporal bone fracture needs a CT scan and close observation, even if they look well initially.
V. Diagnostic Workflow
Differential Diagnosis:
Subdural Hemorrhage (SDH):
Points For: Traumatic head injury, altered mental status.
Points Against: Usually a venous bleed (tearing of bridging veins), so onset is slower. More common in the elderly and alcoholics.
How to Differentiate: CT Brain will show a crescent-shaped (crescenteric) hematoma that crosses suture lines.
Subarachnoid Hemorrhage (SAH):
Points For: Sudden severe headache, altered GCS.
Points Against: Often non-traumatic ("thunderclap headache" from a ruptured aneurysm). Patients often have signs of meningism (neck stiffness, photophobia).
How to Differentiate: CT Brain shows blood in the basal cisterns and sulci.
Investigations Plan:
Bedside / Initial (First 5 Mins):
GCS & Pupil Check: Essential first step.
C-spine clearance: Assume a C-spine injury in any trauma patient until proven otherwise.
Blood Glucose: Rule out hypoglycemia as a cause for altered mental status.
First-Line Labs & Imaging:
Non-Contrast CT Brain: This is the gold standard and should be done immediately in any patient with suspected EDH.
Expected Finding: A hyperdense (bright), biconvex (lens-shaped) collection of blood that does not cross suture lines. Look for associated skull fractures. Note any midline shift.
FBC, Coagulation Profile, GXM: For baseline and pre-operative preparation.
VI. Staging & Severity Assessment
Severity and the need for surgery are determined by clinical status and CT findings. There's no complex staging system; it's a practical decision.
Indications for Surgical Evacuation:
Symptomatic EDH: Any patient with focal neurology or decreased GCS.
Asymptomatic EDH based on CT:
Hematoma volume > 30 mL.
Hematoma thickness > 15 mm.
Midline shift > 5 mm.
Management is guided by these parameters. A small, asymptomatic EDH might be managed conservatively with close observation in a high-dependency setting, but the threshold for surgery is low.
VII. Management Plan
Immediate Stabilisation (ATLS - ABCDE Plan):
A - Airway with C-spine control: Intubate if GCS ≤ 8, or if the patient cannot protect their airway.
B - Breathing: Ensure adequate oxygenation (SPO2 > 94%).
C - Circulation: Secure two large-bore IV lines. Maintain a Mean Arterial Pressure (MAP) of > 80 mmHg to ensure adequate Cerebral Perfusion Pressure (CPP). Avoid hypotension.
D - Disability: Perform GCS and pupil exam.
E - Exposure: Log-roll the patient to check for other injuries.
Medical Management of Raised ICP (as a bridge to surgery):
Elevate head of bed to 30 degrees.
IV Mannitol 20%: Give 1 g/kg bolus. This is an osmotic diuretic that draws fluid out of the brain parenchyma.
Hypertonic Saline: An alternative to mannitol.
Ensure normocapnia (PaCO2 35-40 mmHg).
Definitive Treatment (The Ward Round Plan):
Surgical Evacuation: The definitive treatment is a craniotomy to evacuate the hematoma and ligate the bleeding vessel. This is done by the neurosurgery team. Your job is to get the patient to them in time.
Conservative Management: Only for very select, small, asymptomatic cases with immediate access to neurosurgical intervention if they deteriorate. This requires frequent neurological observation and repeat CT imaging.
Long-Term & Discharge Plan:
Post-operative care in ICU/Neurosurgical HDU.
Seizure prophylaxis (e.g., Levetiracetam) is sometimes considered, especially with cortical irritation.
Physiotherapy and occupational therapy for any residual neurological deficits.
Follow-up in the Neurosurgery clinic.
VIII. Complications
Immediate:
Cerebral Herniation: Can be fatal within hours. Management: Immediate surgical decompression.
Short-Term (Days to Weeks):
Seizures: Due to cortical irritation. Management: Load with anti-epileptic drugs (e.g., IV Levetiracetam).
Re-bleeding/Hematoma Expansion: Management: Requires repeat CT and possibly a return to the operating theatre.
Infection (Meningitis/Abscess): Especially with open fractures. Management: Broad-spectrum antibiotics.
Long-Term (Months to Years):
Post-traumatic epilepsy.
Neurocognitive deficits (memory problems, personality changes).
IX. Prognosis
Prognosis is generally excellent if diagnosed and treated promptly. It's one of the most survivable intracranial hemorrhages because the underlying brain is often not severely injured.
Key Prognostic Factors:
Pre-operative GCS: The single most important factor.
Pupillary abnormalities: A fixed, dilated pupil is a poor prognostic sign.
Time from injury to surgery: The faster the evacuation, the better the outcome.
X. How to Present to Your Senior
Use the SBAR format. Be clear and concise.
"Dr., for review please, a trauma call patient in Red Zone.
This is a 22-year-old gentleman, unknown name, brought in by ambulance after a motorcycle accident.
His initial GCS at the scene was 13, but on arrival it has dropped to 10 (E2V3M5). He has a fixed and dilated right pupil. There is a boggy swelling over the right temporal region.
My main differential is an extradural hemorrhage with uncal herniation.
I have already intubated him, sent bloods including GXM, and booked an urgent CT Brain. I am calling to update you and request your presence. I have also informed the Neurosurgery registrar on-call."
XI. Summary & Further Reading
Top 3 Takeaways:
Think EDH in any young patient with head trauma, especially with a temporal bone fracture.
The "Lucid Interval" is a trap. A normal GCS on arrival does not rule out an evolving catastrophe.
Time is brain. Your role is rapid assessment, stabilisation (ABC), and getting an urgent Non-Contrast CT Brain. Escalate to Neurosurgery early.
Key Resources:
UpToDate: Search for "Traumatic brain injury: Epidemiology, classification, and pathophysiology" and "Intracranial epidural hematoma in adults".
AMBOSS: Epidural Hematoma
Guidelines: Refer to the Brain Trauma Foundation (BTF) guidelines for management of severe TBI. They are the international standard.
