Skip to content

Epidural Haematoma

Summary

fleuron

  • Acute accumulation of blood between the dura mater and inner table of the skull
  • Typically caused by arterial bleeding, often from the middle meningeal artery
  • Classically presents with a "lucid interval" followed by rapid neurological deterioration1

Pathophysiology

  • Arterial bleeding, usually from middle meningeal artery rupture
  • Less commonly caused by venous bleeding from dural sinuses
  • Blood accumulates between dura and skull, causing increased intracranial pressure
  • Rapid expansion due to arterial pressure can lead to brain herniation

Demographics

  • Most common in young adults and adolescents (20-30 years old)
  • More frequent in males (3:1 male to female ratio)
  • Often associated with traumatic brain injury, especially temporal bone fractures
  • Rare in elderly due to increased dural adherence to skull

Diagnosis

  • Clinical presentation:
    • Initial loss of consciousness, followed by a lucid interval
    • Rapid neurological deterioration
    • Ipsilateral pupillary dilation
    • Contralateral hemiparesis
  • Glasgow Coma Scale assessment
  • Neurological examination
  • Immediate neuroimaging (CT or MRI)

Imaging

  • CT scan (non-contrast):
    • Hyperdense, biconvex (lenticular) extra-axial collection
    • Does not cross suture lines
    • May show associated skull fracture
    • "Swirl sign" in active bleeding
  • MRI:
    • T1: isointense to brain in acute phase, hyperintense in subacute phase
    • T2: heterogeneous signal intensity
    • Susceptibility-weighted imaging (SWI): useful for detecting small haematomas

panels-1

  • 60-year-old patient presented after a head injury sustained after falling down a flight of stairs.
  • CT showed a lentiform hyperdensity deep to a parietal bone fracture.

Treatment

  • Emergent neurosurgical evaluation
  • Surgical evacuation for:
    • Haematoma volume > 30 mL
    • Midline shift > 5 mm
    • Thickness > 15 mm
  • Burr hole or craniotomy depending on size and location
  • Conservative management for small, asymptomatic haematomas:
    • Close neurological monitoring
    • Serial imaging
    • Osmotic diuretics to control intracranial pressure
  • Prognosis generally good with prompt diagnosis and treatment

Differential diagnosis

Imaging differential Differentiating feature
Subdural haematoma Crescentic and crosses sutures but not the midline; epidural is biconvex and bounded by sutures
Epidural empyema Rim-enhancing collection with restricted diffusion; infective context rather than acute trauma
Dural-based tumour (e.g. meningioma) Enhancing soft-tissue mass, not hyperdense clot; no fracture

  1. Berker et al. Traumatic epidural haematoma of the posterior fossa in childhood: 16 new cases and a review of the literature. 2003. British journal of neurosurgery - Open in new tab. ↩