EPIDURAL HEMATOMA

Epidural or extradural hematoma (haematoma), also known as an epidural hemorrhage, is a

type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura mater (the
tough outer membrane of the central nervous system) and the skull.[1] The spinal cord is also covered
by a layer of dura mater, so epidural bleeds may also occur in the spinal column. Often due
to trauma, the condition is potentially deadly because the buildup of blood may increase pressure in
the intracranial space, compress delicate brain tissue, and cause brain shift. The condition is present
in one to three percent of head injuries.[2] Around 15% - 20% of epidural hematomas are fatal.[3]

Signs and symptoms[edit]

Epidural, subdural, and subarachnoid hemorrhages are extra-axial bleeds, occurring outside of the
brain tissue, whileintra-axial hemorrhages, including intraparenchymal and intraventricular
hemorrhages, occur within it.
Epidural hematomas may present with a lucid period immediately following the trauma and a delay
before symptoms become evident. After the epidural hematoma begins collecting, it starts to
compress intracranial structures which may impinge on the CN III.[4] This can be seen in the physical
exam as a fixed and dilated pupil on the side of the injury.[4]The eye will be positioned down and out,
due to unopposed CN IV and CN VI innervation.
Other manifestations will include weakness of the extremities on the opposite side as the lesion
(except in rare cases), due to compression of the crossed pyramid pathways, and a loss of visual
field opposite to the side of the lesion, due to compression of the posterior cerebral arteryon the side
of the lesion.
The most feared event that takes place is the transtentorial, or uncal herniation which results in
respiratory arrest since the medullary structures are compromised. The trigeminal nerve (CN V) may
be involved late in the process as the pons becomes compressed, but this is not a significant clinical
presentation, since by that time the patient may already be dead.[5] In the case of epidural hematoma
in the posterior cranial fossa, the herniation is tonsillar and causes the Cushing's triad: hypertension,
bradycardia, and irregular respiration.
Epidural bleeding is rapid because it is usually from arteries, which are high pressure. Epidural
bleeds from arteries can grow until they reach their peak size at six to eight hours post injury, spilling
from 25 to 75 cubic centimeters of blood into the intracranial space.[6] As the hematoma expands, it
strips the dura from the inside of the skull, causing an intense headache. Epidural bleeds can
become large and raise intracranial pressure, causing the brain to shift, lose blood supply, or be
crushed against the skull. Larger hematomas cause more damage. Epidural bleeds can quickly
expand and compress the brain stem, causing unconsciousness,abnormal posturing, and
abnormal pupil responses to light.[7]

Cause[edit]
The interior of the skull has sharp ridges by which a moving brain can be injured

The most common cause of intracranial epidural hematoma is traumatic, although spontaneous
hemorrhage is known to occur. Hemorrhages commonly result from acceleration-deceleration
trauma and transverse forces.[6][8] The majority of bleeds originate from meningeal arteries,
particularly in the temporal region. 10% of epidural bleeds may be venous,[9] due to shearing injury
from rotational forces. Epidural hematoma commonly results from a blow to the side of the head.
The pterionregion which overlies the middle meningeal artery is relatively weak and prone to injury.
[9]

Thus only 20 to 30% of epidural hematomas occur outside the region of the temporal bone. [10] The

brain may be injured by prominences on the inside of the skull as it scrapes past them. Epidural
hematoma is usually found on the same side of the brain that was impacted by the blow, but on very
rare occasions it can be due to a contrecoup injury.[2]