In addition, any enlargement of the EDH is a reasonable indication for operative evacuation. The need for prolonged hospitalization for observation and frequent scans during nonoperative approach has encouraged me to consider surgical intervention in most patients with any mass effect from an acute EDH. Nonoperative management includes serial CT scans and close neurologic observation, and must be cautiously considered. Medical (nonoperative) management (controversial).EDH >30 cm3 regardless of the patient’s Glasgow coma score (GCS).Indications for surgical or medical management of an EDH are as follows: If a posterior fossa EDH is suspected, thin-cut CT of the region is mandatory. A skull fracture at the vertex justifies acquiring coronal images because none of the common indicators, mass effect or ventricular disfigurement, will be readily visualized on an axial CT. In contrast, a venous EDH caused by a superior sagittal sinus injury expanding at the vertex may be difficult to visualize on an axial CT. The classic EDH at the pterion accumulates hematoma within the temporal fossa and is readily visible on imaging. Depending on the extent of fracture and mechanism of injury, serial CT scans are obtained to exclude an evolving hematoma not visible on the initial imaging. In such an instance, an EDH must be completely ruled out with close observation. Indeed, a CT scan soon after the injury may only depict a skull fracture over the middle meningeal artery, with limited or no blood within the epidural space. EDHs are associated with visible skull fractures in 80–90% of patients. Mass effect may be seen, causing midline shift and ventricular collapse. Cranial sutures limit the extent of hematoma because of the attachment of the dura at these locations. In a patient with an EDH, the blood appears bright white on the scan and in the shape of a convex lens. The scan should be ordered without contrast so that any blood in the epidural space can be easily visualized with no loss of pathologic signals caused by contrast-induced noise. A computed tomography (CT) scan is required as part of the diagnostic workup. An accurate history from both the patient and any observers is critical for proper assessment.Įpidural hematomas typically occur in a patient involved in a head strike (as a result of a blunt injury or even motor vehicle accident) who may or may not have lost consciousness. All health care providers should ensure timely treatment of this life-threatening condition. The physician must have a high index of suspicion when evaluating any patient who has sustained blunt trauma to the area of the pterion. Therefore, a failure to diagnose an EDH that is easily treatable can lead to very unfortunate results. Ultimately, brainstem dysfunction occurs. The expanding hematoma results in declining mental status the progressive uncal herniation leads to a blown pupil and contralateral hemiparesis. The return to previous activity, called the lucid interval, is of variable duration and has been shown to occur in roughly one-third of all patients with EDH. Upon regaining consciousness, the patient often continues with the previous activity with no regard for the gravity of the situation. Classically, an EDH occurs after a traumatic blunt blow to the lateral portion of the head provokes a short period of unconsciousness.
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