Symptoms of Epidural Hematoma
The classic presentation of epidural hematoma includes severe headache, brief loss of consciousness followed by a lucid interval, then rapid neurological deterioration with altered mental status, focal neurological deficits, and pupillary abnormalities. 1
Clinical Presentation
Epidural hematoma presents with a variable clinical picture that can evolve rapidly. Key symptoms include:
Initial symptoms:
- Severe headache (often described as the "worst headache of life")
- Brief loss of consciousness at time of injury
- Lucid interval (temporary improvement in consciousness before deterioration)
Progressive symptoms:
- Altered mental status/decreased level of consciousness
- Confusion and disorientation
- Nausea and vomiting
- Seizures (occur in up to 20% of cases)
- Pupillary dilation (often unilateral)
- Hemiparesis (weakness on one side of the body)
- Progressive neurological deterioration
The lucid interval is particularly characteristic of epidural hematoma, though it's not present in all cases. This represents a period where the patient appears to improve temporarily before deteriorating as the hematoma expands and increases intracranial pressure 1, 2.
Risk Factors and Mechanisms
Epidural hematomas typically result from:
- Traumatic brain injury (particularly temporal bone fractures)
- Arterial bleeding (commonly from the middle meningeal artery)
- Rapid accumulation of blood between the dura mater and skull
Diagnostic Considerations
Non-contrast CT scan is the gold standard for diagnosis of epidural hematoma in the emergency setting. The classic appearance is a biconvex (lens-shaped) hyperdense collection that doesn't cross suture lines 1.
Warning Signs Requiring Immediate Action
Certain symptoms indicate a medical emergency requiring immediate intervention:
- Loss of consciousness
- Worsening headache
- Vomiting
- Altered mental status
- Seizures
- Visual changes
- Focal neurological deficits
These signs suggest increased intracranial pressure and potential herniation, requiring immediate medical attention 3.
Special Considerations
- Epidural hematomas can be difficult to recognize clinically as patients may have a normal neurological examination initially or only brief loss of consciousness 2
- The mortality rate for unrecognized epidural hematoma can be as high as 40%, highlighting the importance of early recognition 2
- Spinal epidural hematomas present differently, with sudden onset of acute spinal pain followed by various degrees of neurological deficit 4, 5
Early recognition and rapid neurosurgical intervention are critical factors in determining outcomes for patients with epidural hematoma. Any patient with head trauma presenting with the symptoms described above should be evaluated immediately with neuroimaging.