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Epidural Haematoma

Summary

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  • 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 deterioration

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

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  • 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

Differential Diagnosis Differentiating Feature
Subdural Haematoma Epidural haematoma is biconvex/lentiform shaped on CT, while subdural is crescent-shaped
Cerebral Contusion Epidural haematoma typically does not cross suture lines, contusions can
Subarachnoid Haemorrhage Epidural haematoma is extra-axial and does not fill sulci or cisterns
Brain Abscess Epidural haematoma has acute onset, while abscess develops over days to weeks
Acute Stroke Epidural haematoma is not confined to a vascular territory
Tumour Epidural haematoma has acute onset and often associated with skull fracture
Arachnoid Cyst Epidural haematoma has high density on CT, while arachnoid cyst is CSF density
Empyema Epidural haematoma typically has a homogeneous appearance, empyema may have air bubbles
Acute Encephalitis Epidural haematoma has a clear mass effect, encephalitis shows diffuse brain swelling
Tension Pneumocephalus Epidural haematoma is hyperdense on CT, pneumocephalus is hypodense (air density)