What are the typical findings associated with epidural hematomas (EH), specifically the location and clinical presentation?

Epidural Hematoma: Clinical Presentation and Location

Epidural hematomas are most often associated with findings seen in the frontal/temporal region, with an initial loss of consciousness followed by a brief lucid period.

Characteristic Features of Epidural Hematomas

Epidural hematomas (EDH) have a distinctive clinical presentation pattern that differs from other intracranial hemorrhages:

• Location: Most commonly occur in the temporo-frontal regions (59.5-63% of cases) 1
• Classic Clinical Course: Initial trauma with brief loss of consciousness, followed by a lucid interval, then rapid neurological deterioration
• Lucid Interval: This characteristic feature occurs in approximately 20-30% of cases 2, 3
• Skull Fracture: Present in 80-88.6% of cases, typically crossing the middle meningeal artery 1, 2

Pathophysiology and Mechanism

Epidural hematomas form between the inner skull table and dura mater, with bleeding typically originating from:

• Middle meningeal artery (most common source)
• Middle meningeal vein
• Torn dural venous sinuses 1

The hematoma is restricted by dural attachments at the cranial sutures, which explains its typical biconvex or "lens-shaped" appearance on imaging.

Clinical Presentation Details

The classic presentation includes:

• Initial trauma with brief loss of consciousness
• Lucid interval where the patient regains consciousness and appears neurologically intact
• Progressive deterioration with:
  • Persistent severe headache
  • Declining level of consciousness
  • Ipsilateral pupillary dilation (seen in approximately 50% of cases) 2
  • Contralateral hemiparesis
  • Cushing's triad in late stages (hypertension, bradycardia, irregular respirations) 4

Risk Factors and Demographics

• Most common in young adults aged 10-40 years
• Male predominance (4:1 male to female ratio)
• Uncommon after age 60 due to firm dural adherence to the skull 1

Diagnostic Considerations

• Non-contrast CT is the gold standard for diagnosis 1
• CT angiography may help identify active bleeding and risk of hematoma expansion 4
• Mortality for unrecognized epidural hematoma can be as high as 40% 5

Management Priorities

Early recognition and prompt neurosurgical intervention are critical:

• Immediate neurosurgical consultation
• Blood pressure control (target systolic BP <140 mmHg)
• Correction of any coagulopathy
• Hourly neurological assessments
• Surgical evacuation for symptomatic patients or hematomas causing mass effect 4

Pitfalls to Avoid

1. Missing the diagnosis: Some patients may not demonstrate the classic lucid interval pattern, with approximately 34.2% showing primarily persistent and 45.6% showing secondarily increasing disturbances of consciousness 2

2. Delayed intervention: Mortality increases significantly with delayed treatment, especially once midbrain compression signs develop (45.5% mortality with midbrain signs, 75% if both pupils are fixed and dilated) 2

3. Inadequate monitoring: Even small epidural hematomas can expand rapidly, particularly if diagnosed within 6 hours of trauma or if a skull fracture crosses a major vessel 6

Early recognition and prompt neurosurgical intervention remain the cornerstones of management for this potentially life-threatening but highly treatable condition.