Epidural Hematoma



  • Direct skull trauma
  • Inward bending of calvarium causes bleeding when dura separates from skull:
    • Middle meningeal artery is involved in bleed >50% of time
    • Meningeal vein is involved in 1/3
  • Skull fracture is associated in 75% of cases, less commonly in children
  • >50% have epidural hematoma (EDH) as isolated head injury:
    • Most commonly associated with subdural hematoma (SDH) and cerebral contusion
  • Classic CT finding is lenticular, unilateral convexity, usually in temporal region
  • It usually does not cross suture lines, but may cross midline


  • Accounts for 1.5% of traumatic brain injury (TBI)
  • Male/female incidence is 3:1
  • Peak incidence is from second to third decades of life
  • Motor vehicle accidents (MVAs), assault, and falls are most common causes:
    • Of all blunt mechanisms, assault has highest association with intracranial injury requiring neurosurgical intervention
  • Uncommon in very young (<5 yr) or elderly patients
  • Mortality is 10% for adults, lower for children and is related to preoperative condition
  • Worse prognosis for low presenting GCS score, abnormal pupil, older patients, increased ICP preoperatively, midline shift >10 mm on CT, mixed density lesion, presence of concomitant intracranial lesion, volume of bleed >30 cc

Pediatric Considerations
  • Head injury is the most common cause of death and acquired disability in childhood
  • PECARN rules may be used to help stratify risk:
    • Children with one of the following variables are at low risk and do not require head CT:
      • LOC ≥5 s
      • Vomiting (in age ≥2)
      • Severe headache (in age ≥2)
      • Acting abnormally to parents
      • Severe mechanism
      • Abnormal mental status
      • Skull fracture
      • GCS <15
      • Scalp hematoma; nonfrontal
  • Falls, pedestrian-struck bicycle accidents are most common causes:
    • Most severe head injuries in children are from MVA
    • Always consider possibility of nonaccidental trauma
  • <50% have altered level of consciousness (LOC):
    • If EDH in differential diagnosis (DD), CT should be obtained
  • Bleeding is more likely to be venous
  • Good outcome in 95% of children <5 yr

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