- Epidural hematomas occur when an artery is injured and arterial blood accumulates between the dura and the calvarium.
- Do not cross suture lines because of the tight adherence of the dura to the calvarium and thus have a biconvex or elliptical appearance.
- The middle meningeal artery is classically involved, especially with a skull fracture.
- Associated with a "lucid interval", which means that a patient can be conscious and appear "normal" right after an injury, but as the blood accumulates the headache will worsen and mental status will decline as the intracranial pressure rises.
- Tearing of bridging veins during rapid or sudden changes in velocity thereby causing an accumulation of venous blood below the dura but above the arachnoid membrane (i.e., the "subural space").
- Cross suture lines since bleeding is below the dura, which is tightly attached to the calvarium, thus giving the "crescent shape" appearance on head CT.
- Can result in mass effect leading to uncal and/or tonsillar herniation if left untreated.
- Occur more frequently in elderly patients due to reduced brain volume and "stretched" bridging veins.
- General Info: Caused by increased intracranial pressure (ICP) which can lead to 4 types of herniation: central, subfalcine, tonsillar, and uncal (or transtenorial) herniation
- Pathophysiology: As the ICP increases, the CSF is initially forced to move down into the spinal canal and then the ventricles and cisterns begin to collapse. It is at this point that the ICP can rise rapidly resulting in a shift of the brain parenchyma away from the accumulating blood. If swelling progresses, the parenchyma will have to shift through several different spaces with the final movement being through the foramen magnum causing compression of the brainstem and death.
- If no contraindications exist (such as thoracic or lumbar spine injury without stabilization), raise the head of the bed to 30 degrees, keep head and neck midline, and avoid tight fitting cervical collars unless medically necessary
- If the head of the bed is contraindicated due to other injuries, place patient in reverse Trendelenburg (i.e., elevate the entire the bed up higher from the ground and then lower portion of the bed where the legs are so that the head is higher than the level of the heart).
- Note: Do not use if patient is hypotensive and/or hypovolemic as it can decrease blood pressure and thus reduce cerebral perfusion pressure (CPP).
- 0.5 - 1.0 mg/kg IV over 15 minutes
- Works to reduce cerebral edema by creating an osmotic gradient between the vascular space and the extracellular fluid of the brain, thereby causing water to shift out of the brain into the vascular space to reduce brain volume and ICP.
- 3% NaCl = 200 mL IV over 20 min
- 7.2% - 7.5% NaCl = 1.5 - 2 mL/kg IV over 15-20 minutes, respectively
- 23.4% NaCl = 30 mL IV over 2 min or over 30 min when the ICP is > 20 mm Hg
- Note! Only for short-term use in patients with evidence of brain herniation to prepare for surgical intervention as reducing the PCO2 to≤ 25 mm Hg can significantly reduce cerebral blood flow and oxygen delivery.
- Moderate short-term hyperventilation to PCO2 of no less than 30 - 35 mm Hg
- Pentobarbital = Loading dose of 10 mg/kg IV over 30 min, followed by 5 mg/kg/hr IV x 3 hrs, then 1 mg/kg/hr and adjust dose to maintain suppression of bursts on continuous EEG
- Etomidate = 0.2 mg/kg IV x 1 then 0.05 mg/kg every 3-5 min as needed (can decrease ICP without affecting cardiac output or blood pressure, but has potential to suppress adrenal function)
- Fosphenytoin (Cerebyx) = Loading dose of 10 - 20 PE/kg IV x 1 (administer at max rate of 150 mg/min IV push), then 4 - 6 mg/kg/day in 2 - 3 divided doses x 7 days
- Phenytoin (Dilantin) = Loading dose of 10 - 20 mg/kg IV x 1 (give at max rate of no more than 50 mg/min IV push due to risk of bradydysrhythmias and hypotension), then 100 mg IV every 8 hrs x 7 days
- Levetiracetam (Keppra) = 1000 mg (or 20 mg/kg rounded to the nearest 250 mg) IV over 15 min, then 1000 - 2000 mg IV every 12 hrs x 7 days
- Invasive removal of CSF by a neurosurgeonis one of the most effective treatments for lowering ICP
- Maintain normovolemia so that the patient does not develop hypotension which can reduce cerebral perfusion pressure. Note: avoid use of hypotonic fluids as this will encourage movement of free water into the brain tissue and worsen swelling.
- This controversial with conflicting data and thus is not universally recommended. It is important however to prevent and/or treat fevers.
- EBM Topic: The Evidence for the HINTS Exam in the Bedside Diagnosis of Central Causes of Dizziness
- EBM Topic: The Evidence for Endovascular Therapy in Acute Stroke
- EBM Topic: The Evidence for Nimodipine Use for Subarachnoid Hemorrhage
- Anatomy Image: Bells Palsy vs Stroke
- Anatomy Image: Dermatomes - Full Body
- Anatomy Image: Dermatomes - Face
- Anatomy Image: Dermatomes - Hands
- Procedure: Lumbar Puncture
- Schwartz ML, et al. The University of Toronto head injury treatment study: A prospective randomised comparison of pentobarbital and mannitol. Can J Neurol Sci 1984;11:434-440.
- Muizelaar JP, et al. Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head injured patients. J Neurosurg 1984;61:700-706.
- Mendelow AD, et al. Effect of mannitol on cerebral blood flow and cerebral perfusion pressure in human head injury. J Neurosurg 1985;63:43-48.
- Smith HP, et al. Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg 1986;65:820-824.
- Rosner MJ, et al. Cerebral perfusion pressure: a hemodynamic mechanism of mannitol and the pre-mannitol hemogram. Neurosurg 1987;21:147-156.
- Cruz J, et al. Continuous monitoring of cerebral oxygenation in acute brain injury: injection of mannitol during hyperventilation. J Neurosurg 1990;73:725-730.
- Cruz J et al. Improving clinical outcomes from acute subdural hematomas with emergency preoperative administration of high doses of mannitol: a randomized trial. Neurosurgery 2001;49(4):864-71.
- Cruz J et al. Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial. Neurosurgery 2002;51(3):628-38.
- Cruz J et al. Successful use of the new high-dose mannitol treatment in patients with Glascow Coma Scale Scores of 3 and bilateral abnormal pupillary widening: a randomized trial. J Neurosurg 2004;100(3):376-83.
- Wisner JD, et al. Hypertonic saline resuscitation of head injury: effects on cerebral water content. J Trauma 1990;30:75-78.
- Vassar MJ, et al. 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg 1991;126:1065-1072.
- Mattox KL, et al. Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. Ann Surg 1991;213:482-491.
- Schmoker JD, et al. Hypertonic fluid resuscitation improves cerebral oxygen delivery and reduces intracranial pressure after hemorrhagic shock. J Trauma 1991;31:1607-1613.
- Prough DS, et al. Rebound intracranial hypertension in dogs after resuscitation with hypertonic solutions from hemorrhagic shock accompanied by an intracranial mass lesion. J Neurosurg Anesthesiol 1999;11:102-11.
- Munar F et al. Cerebral hemodynamic effects of 7.2% hypertonic saline in patients with head injury and raised intracranial pressure. J Neurotrauma 2000;17(1):41-51.
- Vialet R et al. Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 ml/kg 7.5% saline is more effective than 2 ml/kg 20% mannitol. Crit Care Med 2003;31(6):1683-7.
- Huang SJ et al. Efficacy and safety of hypertonic saline solutions in the treatment of severe head injury. Surg Neurol 2006;65(6):539-46.
- Kerwin AJ et al. The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study. J Trauma 2009;67(2):277-82.
- Paul RL, et al. Intracranial pressure responses to alterations in arterial carbon dioxide pressure in patients with head injuries. J Neurosurg 1972;36:714-720.
- Obrist WD, et al. Cerebral blood flow and metabolism in comatose patients with acute head injury. J Neurosurg 1984;61:241-253.
- Muizelaar JP, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: A randomized clinical trial. J Neurosurg 1991;75:731-739.
- Sheinberg M, et al. Continuous monitoring of jugular venous oxygen saturation in head injured patients. J Neurosurg 1992;76:212-217.
- Gopinath SP, et al. Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psych 1994;57:717-723.
- InabaK et al. A prospective multicenter comparison of levetiracetam vsphenytoin for early posttraumatic seizure prophylaxis. J Trauma AcuteCare Surg.2013;74(3):766-71.
- Szaflarski JP et al. Prospective, randomized,single-blinded comparative trial of intravenous levetiracetam versus phenytoinfor seizure prophylaxis. Neurocrit Care.2010;12(2):165-72.
- Jones KE et al.Levetiracetam versus phenytoin for seizure prophylaxis in severetraumatic brain injury. Neurosurg Focus.2008;25(4): E3.
- Zafar SN et al.Phenytoin versus Levetiracetam for seizure prophylaxis after braininjury - a meta analysis. BMC Neurol.2012;12:30.
The goal for considering any one or more of the following is to maintain cerebral perfusion pressure and to reduce metabolic demands by avoiding secondary injury to the CNS.
Elevation of the Head
Barbiturates or Sedatives
Mainly for patients with traumatic brain injury, especially penetrating injuries and/or depressed skull fractures.
Editors & Reviewers
Editor-in-Chief: Anthony J. Busti, MD, PharmD, FNLA, FAHA
Editor: Dylan Kellogg, MD
Last Updated: July 2015
Subdural Hematoma, Epidural Hematoma, Traumatic Brain Injury, Brain Bleed, Head Bleed
There are several differences, including: Location: An epidural hematoma (EDH) occurs between your skull and the outermost layer of meninges, the dura mater. A subdural hematoma occurs in the space between the dura mater and the second meninges layer, the arachnoid layer.What is the best imaging modality for epidural hematoma? ›
Magnetic resonance imaging (MRI)
It should be obtained when there is high clinical suspicion for EDH, accompanying a negative initial head CT scan. In the situation of a suspected spinal EDH, a spinal MRI is the preferred imaging modality, as it affords higher resolution versus a spinal CT.
In almost all cases, extradural hematomas are seen on CT scans of the brain. They are typically bi-convex (or lentiform) in shape, and most frequently beneath the squamous part of the temporal bone. EDHs are hyperdense, somewhat heterogeneous, and sharply demarcated.Why is subdural hematoma crescent shaped? ›
Because the subdural space is not restricted by the skull suture lines, subdural hematomas appear crescent-shaped on CT, with the blood collection able to cross suture lines. This is an important distinction from epidural hematomas.How do you rule out an epidural hematoma? ›
Medical personnel typically use computed tomography (CT) brain scans to diagnose an EDH, which appears as a dense mass that pushes the brain away from the skull. A magnetic resonance imaging (MRI) scan can also diagnose an EDH, although CT is faster and more commonly used for evaluating trauma patients.How do you rule out a subdural hematoma? ›
Most people with a suspected subdural haematoma will have a CT scan to confirm the diagnosis. A CT scan uses X-rays and a computer to create detailed images of the inside of your body. It can show whether any blood has collected between your skull and your brain.What is the gold standard for epidural hematoma? ›
Magnetic resonance imaging (MRI) is currently the gold standard for diagnosis of spinal epidural hematoma. Nevertheless, prior to MRI, computed tomography (CT) was the predominant imaging modality.What is the shape of a subdural hematoma? ›
The subdural hematoma generally appears as a crescent-shaped mass over the convexity adjacent to the inner table of the skull on computed tomography (CT) scans or adjacent to the dura matter on magnetic resonance images (MRI).What are the imaging characteristics of epidural hemorrhage? ›
In almost all cases, extradural hematomas are seen on CT scans of the brain. They are typically bi-convex (or lentiform) in shape, and most frequently beneath the squamous part of the temporal bone. EDHs are hyperdense, somewhat heterogeneous, and sharply demarcated.Does subdural hematoma cross suture lines? ›
Typically crescentic (crescent moon-shaped, concave, banana-shaped) and more extensive than EDH, with the internal margin paralleling the cortical margin of the adjacent brain. As these occur in the subdural space, they cross sutures.
Chronic subdural hematoma (CSDH), which generally occurs in elderly patients, is a frequently diagnosed condition in neurosurgical departments. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most preferred diagnostic modalities for CSDH assessment.What are 3 characteristics of subdural hematoma? ›
- Headache that doesn't go away. ...
- Confusion and drowsiness.
- Nausea and vomiting.
- Slurred speech and changes in vision.
- Dizziness, loss of balance, difficulty walking.
- Weakness on one side of the body.
Subdural hematomas are recognized by their crescent shape overlying and compressing the brain. They are arbitrarily divided into three types: acute (< 4 days), subacute (4-21 days) and chronic (> 21 days). In the acute stage, blood is bright on CT.How do you confirm an epidural? ›
Confirmation of correct placement of the catheter in the epidural space is often performed by fluoroscopic-guided injection of contrast medium during pain procedures. Contrast dye is injected to demonstrate typical epidural spread under fluoroscopy.Where is the most common site of epidural hematoma? ›
An epidural hematoma (EDH) is bleeding between the inside of the skull and the outer covering of the brain (called the dura mater).Why is epidural hematoma worse than subdural? ›
Because epidural hematomas typically involve an artery, bleeding and increased intracranial pressure may occur much more rapidly, requiring more urgent intervention. In contrast, though still serious, subdural hematomas involve veins which tend to bleed and grow more slowly.What is the gold standard for diagnosing subdural hematoma? ›
Brain CT is the gold standard in the diagnosis of traumatic brain injury. This is an easy technique to perform, which can help accurately diagnose intracranial bleeding (epidural hematoma, subdural hematoma, subarachnoid hemorrhage, cerebral hemorrhage), brain parenchymal contusion and cubital fracture.What are the red flags for subdural hematoma? ›
confusion. personality changes, such as being unusually aggressive or having rapid mood swings. feeling drowsy and finding it difficult to keep your eyes open. speech problems, such as slurred speech.What is considered a small subdural hematoma? ›
Acute subdural hematoma usually occurs after severe, high-impact injuries and is often associated with contusions of the adjacent areas of the brain. If the subdural hematoma is small (<5 mm in thickness) and the patient is stable clinically, a period of observation may be reasonable.What is the first aid for epidural hematoma? ›
First aid for an epidural hematoma is limited to taking care of any other injuries. Most importantly, pay attention if the person loses consciousness. Anybody who loses consciousness gets a ride to the hospital in an ambulance. Call 911 for anyone who gets knocked unconscious from a blow to the head.
- Acute. This most dangerous type is generally caused by a severe head injury, and signs and symptoms usually appear immediately.
- Subacute. Signs and symptoms take time to develop, sometimes days or weeks after the injury.
Delayed traumatic intracranial hemorrhage (DIH) can occur up to several weeks after trauma to the head  and was reported to occur more frequently in patients with ATT, ranging from 0.2% to 6% [14,15,16,17].Where is the bleeding in a subdural hematoma? ›
In a subdural hematoma, the blood seeps between the dura and the arachnoid layers. It collects inside the brain's tough outer lining. This bleeding often comes from a blood vessel that breaks within the space around the brain. This most often happens because of a head injury.What is the normal size of a subdural hematoma? ›
Current guidelines recommend an acute subdural hematoma (ASDH) with a thickness greater than or equal to 10 mm or a midline shift greater than or equal to 5 mm be evacuated regardless of Glasgow Coma Scale (GCS). A large craniotomy versus craniectomy is the preferred surgical treatment for ASDH.Why subdural hematoma does not cross midline? ›
Unlike epidural hematoma, SDH is not restricted by dural tethering at cranial sutures; SDH can cross suture lines and continue along the falx and the tentorium. However, it does not cross the midline because of meningeal reflections.Why can't subdural hematoma cross midline? ›
Notice on the diagram below how subdural hematomas cannot cross at the midline because they are bound by the falx. Epidural hematomas can cross at the midline because they are located above the dura.Can a CT scan miss a subdural hematoma? ›
Delayed acute subdural hematoma (SDH) is defined as an acute SDH that is not apparent on the initial computed tomography (CT) scan but appears on a repeat CT scan. Delayed acute SDH occurs is uncommon and mainly occurs in middle-aged and elderly persons who are either on anticoagulation or antiplatelet therapy.Which imaging method is best for intracranial injury? ›
A CT scan can quickly visualize fractures and uncover evidence of bleeding in the brain (hemorrhage), blood clots (hematomas), bruised brain tissue (contusions), and brain tissue swelling. Magnetic resonance imaging (MRI).What is the ideal imaging of choice for a patient with head trauma? ›
CT is the mainstay of imaging of acute TBI for both initial triage and follow-up, as it is fast and accurate in detecting both primary and secondary injuries that require neurosurgical intervention.What is the classic presentation of a subdural hematoma? ›
Chronic subdural hematoma may have a presentation similar to that of Parkinson disease. An acute presentation is also possible, as in the case of a patient who presents with a seizure. Headache and confusion appear to be the most common presenting features, occurring in as many as 90% and 56% of cases, respectively.
BIG 3 injuries are >8 mm SDH, >8 mm EDH, >8 mm IPH, or “scattered” SAH and are managed with admission, a neurosurgery consultation and at least one scheduled repeat head CT.What are the 4 types of brain hematomas? ›
Intracranial hemorrhage encompasses four broad types of hemorrhage: epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and intraparenchymal hemorrhage.Is epidural hematoma crescent shaped? ›
Image depicts a fracture of the right frontal bone anterior to the coronal suture. Epidural hematomas can typically be distinguished from subdural hematomas by the biconvex shape of epidural hematomas, versus the crescent shape of the subdural hematoma.What does a subdural hematoma look like on CT scan? ›
Post-traumatic acute subdural hematomas generally appear hyperdense on a computed tomography scan. In the hyperacute stage, a subdural hematoma in rare cases appears heterogeneous with isodense images. This can pose a diagnostic problem and compromise patient care.Which hematoma is crescent shaped? ›
Subdural hematomas are recognized by their crescent shape overlying and compressing the brain.How to tell the difference between a hematoma and a brain bleed? ›
The most obvious difference between a hematoma and a hemorrhage is that a hemorrhage may bleed externally. Hemorrhages may also bleed internally and this would not be visible. Hematoma symptoms may include bluish or purplish discoloration of the skin (a bruise) or a lump under the skin.What are the symptoms of an epidural hematoma? ›
- Drowsiness or altered level of alertness.
- Enlarged pupil in one eye.
- Headache (severe)
- Head injury or trauma followed by loss of consciousness, a period of alertness, then rapid deterioration back to unconsciousness.
- Nausea or vomiting.
Skull radiographs may demonstrate the fracture responsible for an epidural hematoma, although vascular channels and suture lines may mimic skull fractures and make the diagnosis difficult. Furthermore, small, minimally displaced skull fractures can be difficult to diagnose.What are the symptoms of a spinal epidural hematoma? ›
The first clinical symptom of spinal epidural hematoma, in most of the cases, is sudden backpain or radicular pain, depending on the location of the bleeding. After hours to days of initiation of symptoms this insidiously progresses to a complete or partial paraplegia or even quadriplegia.How do you rule out a brain bleed? ›
CT scan. This imaging test can detect bleeding in the brain. While a CT scan is a highly effective test when performed properly, the scan may not find the bleed if you have a low red blood cell count (anemia) and only a small amount of blood is lost during the bleed.
Treating minor head injuries
You can hold a cold compress to their head – try a bag of ice or frozen peas wrapped in a tea towel. Seek immediate medical advice if symptoms such as mild dizziness and a headache get worse.
Epidural and subdural hematomas are traumatic brain injuries that both involve bleeding in the brain, but they have different locations and characteristics. Epidural hematomas are more immediate and easier to diagnose and treat. Not doing so can lead to neurological symptoms such as: Confusion.Can an MRI rule out epidural hematoma? ›
MRI can establish the presence, location and extent of the haematoma, along with cord compression and concurrent injuries. Epidural haematoma is the most common location of haematoma in the spine.What is the gold standard for diagnosing epidural hematoma? ›
Magnetic resonance imaging (MRI) is currently the gold standard for diagnosis of spinal epidural hematoma.What are 3 signs of a spinal hematoma? ›
Typically, the hematoma is asymptomatic, but in rare cases it will compress the spinal cord, with potentially devastating neurological consequences. These symptoms include sensory disruption, bowel and bladder incontinence, motor weakness, or, in severe cases, complete paralysis of the affected limbs.