Epidural hemorrhage is bleeding between the skull and dura mater, typically resulting from head trauma and arterial rupture. It is a medical emergency requiring rapid recognition and treatment.
Clinical signs include severe headache, vomiting, unequal pupils, and loss of consciousness. A characteristic “lucid interval” may precede rapid neurological deterioration.
CT imaging is the gold standard for diagnosis, revealing a biconvex hematoma compressing the brain. Immediate surgical evaluation is critical to prevent irreversible damage.
Emergency craniotomy or burr hole surgery relieves pressure and controls bleeding. Prompt intervention significantly improves outcomes, making early detection crucial.
| Disease Name | Epidural Hemorrhage |
| Definition | A serious type of bleeding that occurs between the skull and dura mater (the brain’s outermost membrane), usually as a result of head trauma. |
| Symptoms | Brief loss of consciousness after head injury, followed by a “lucid interval” (temporary return of consciousness), headache, nausea, vomiting, drowsiness, neurological deficits, unilateral dilated pupil, and in severe cases, rapid loss of consciousness and coma. |
| Causes | Usually due to head trauma resulting in skull fracture and rupture of the middle meningeal artery; in rare cases, vascular abnormalities or bleeding disorders. |
| Risk Factors | Falls from height, traffic accidents, sports injuries, childhood and adolescence (due to softer skull bones). |
| Diagnostic Methods | Emergency brain CT (computed tomography); MRI is rarely used and primarily for determining the size of the bleeding and hematoma. |
| Treatment Methods | Emergency surgical intervention (craniotomy or hematoma evacuation), intensive care monitoring, blood pressure control, neurological stabilization, ventilatory support as needed. |
| Complications | Increased pressure on brain tissue, brain herniation, permanent neurological damage, coma, death. |
| Surgical Requirement | Epidural hemorrhage is a surgical emergency; craniotomy or burr hole (small hole) procedure is usually required for rapid hematoma evacuation. |
| Recovery Time | Varies depending on the intervention and severity of injury; usually takes weeks or months, and in some cases, permanent neurological sequelae may remain. |
| Prevention Methods | Use of protective equipment such as helmets, safe driving and compliance with traffic rules, and taking precautions to reduce head trauma risk, especially in children. |
Prof. Dr. Özgür KILIÇKESMEZ Prof. Dr. Kılıçkesmez holds the Turkish Radiology Competency Certificate, the Turkish Interventional Radiology Competency Certificate, Stroke Treatment Certification, and the European Board of Interventional Radiology (EBIR). In his academic career, he won the Siemens Radiology First Prize in 2008.
Interventional Radiology / Interventional Neuroradiology
What is Epidural Hemorrhage?
Epidural hemorrhage is a dangerous accumulation of blood between the skull and the dura mater. It most often develops as a result of head trauma and is usually caused by rupture of the middle meningeal artery. The bleeding increases intracranial pressure and leads to brain compression, resulting in serious health issues. Epidural hemorrhage presents with severe headache, brief loss of consciousness, and neurological deficits. Symptoms can worsen rapidly and may become life-threatening. If not controlled, the effects of the hemorrhage can cause permanent brain damage and even death. Therefore, epidural hemorrhage is a medical emergency requiring urgent evaluation.
What Are the Causes of Epidural Hemorrhage?
Causes of epidural hemorrhage include trauma, skull fractures, and factors such as anticoagulant therapy. It most commonly occurs due to blunt head trauma resulting in traumatic brain injury. Falls, vehicle accidents, or sports injuries can cause tearing of the vessels in the epidural space, leading to rapid blood accumulation. Such trauma often affects the middle meningeal artery and accelerates bleeding.
Skull fractures can also trigger epidural hemorrhage, as the type and location of the fracture directly affect this risk. Children are particularly susceptible due to the structure of their skulls, which allows more movement of the meninges. Anticoagulant therapy increases the risk of EDH, especially when drugs such as enoxaparin or warfarin are used alongside spinal procedures or epidural anesthesia.
Vascular abnormalities are also among the factors that increase the risk of bleeding. Conditions like arteriovenous malformations and cerebral aneurysms make individuals more vulnerable to epidural hemorrhage by increasing the likelihood of vessel rupture.
Other contributing risk factors include:
- High blood pressure
- Bleeding disorders
- History of head trauma
Finally, invasive medical procedures such as spinal anesthesia or lumbar puncture may damage blood vessels and cause epidural hemorrhage.
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How Common Is Epidural Hemorrhage?
Epidural hemorrhage (EDH) constitutes a significant portion of traumatic brain injuries and varies in prevalence among demographic groups. EDH accounts for about 2.7% to 4% of all traumatic brain injuries and is most commonly seen in younger individuals. The highest incidence occurs between the second and fourth decades of life, with the average age ranging from 20 to 45. Males are at higher risk, comprising 79% to 93% of cases.
Most cases are associated with head injuries and trauma. The most frequent causes of EDH are:
- Traffic accidents
- Falls
- Sports injuries
Clinically, EDH patients present with various symptoms, most notably:
- Headache (53.2%)
- Loss of consciousness (28.1%)
- Neurological deficits
According to Glasgow Coma Scale (GCS) scores, patients with EDH generally present with mild to moderate brain injuries. There are regional differences in EDH incidence. For example, more cases are reported in areas with high rates of traffic accidents, and demographic characteristics vary according to population risk behaviors and access to local healthcare. Geographic factors thus play a significant role in EDH incidence.
How Does Epidural Hemorrhage Develop?
The development process of epidural hemorrhage usually begins with traumatic head injury. This type of injury can result in skull fracture and accumulation of blood in the space between the dura mater and skull. This process develops especially in young individuals because the dura mater is less tightly attached to the skull.
- Traumatic Impact: The main cause of epidural hematoma is direct impact to the head. Severe trauma usually leads to serious injury, but even minor blows can initiate bleeding, especially in young people, where skull fracture and bleeding risk is higher.
- Vessel Injury: Skull fracture can tear blood vessels such as the meningeal artery under the dura mater. This tear leads to rapid blood accumulation and hematoma formation. The rupture occurs suddenly, and arterial bleeding can cause the hematoma to grow, compressing the brain.
- Expansion of the Hematoma: As bleeding continues, blood accumulates between the dura mater and skull, rapidly increasing intracranial pressure. This process leads to brain compression and impaired brain function. Hematoma expansion usually occurs within the first hours after injury and may result in further brain damage.
What Are the Symptoms of Epidural Hemorrhage?
The symptoms of epidural hemorrhage vary depending on the location and severity of the bleeding. In cranial epidural hemorrhage, increased intracranial pressure and brain compression cause distinct symptoms, such as:
- Severe headache: One of the earliest and most intense symptoms.
- Loss of consciousness: May occur immediately after trauma, followed by a lucid interval (temporary recovery of consciousness).
- Mental status changes: If untreated, can rapidly progress from confusion to coma.
- Pupil abnormalities: One pupil may be dilated or unreactive (anisocoria).
- Focal neurological deficits: Weakness or paralysis on one side of the body, depending on the affected brain region.
- Seizures: May occur due to brain irritation.
- Nausea and vomiting: Triggered by increased intracranial pressure.
- Spinal epidural hemorrhage symptoms are related to spinal cord compression and differ as follows:
- Severe back pain: Localized to the site of bleeding.
- Weakness or paralysis: Loss of motor function below the level of bleeding.
- Sensory deficits: Numbness or tingling in the limbs.
- Bladder or bowel dysfunction: Compression at certain spinal cord levels can cause these issues.
Epidural hemorrhage requires prompt diagnosis and intervention, as untreated cases may cause permanent neurological damage.
How Is Epidural Hemorrhage Diagnosed?
Diagnosis of epidural hematoma is primarily made using clinical findings and neuroimaging techniques. CT scans are considered the most effective method for diagnosis, revealing a biconvex, hyperdense mass on one side of the brain. These masses usually do not cross suture lines and are limited along dural attachments. CT also detects skull fractures and the effect of the hematoma on brain structures. Findings such as midline shift are critical for assessing severity.
Clinically, the lucid interval following brief loss of consciousness after head trauma is characteristic. However, as the hematoma expands, neurological condition can rapidly deteriorate. Common symptoms include:
- Severe headache
- Nausea and vomiting
- Drowsiness and extreme fatigue
- Seizures
- Weakness and abnormal pupil responses
In severe cases, brainstem compression may cause coma or respiratory failure. MRI is less commonly used in the acute phase but may be helpful in chronic or complex cases for distinguishing between lesions. The Glasgow Coma Scale (GCS) is used to assess consciousness, and a low GCS score indicates more severe brain injury.
How Is Epidural Hemorrhage Treated?
Endovascular embolization has recently emerged as a noteworthy method in the treatment of epidural hemorrhage. It is especially preferred when urgent surgical intervention is not required or when conservative treatment is inadequate. Endovascular therapy usually targets embolization of the middle meningeal artery, the source of bleeding. During the procedure, the active bleeding site is identified by angiography, and embolic agents are injected through a catheter to stop the bleeding. This technique is effective particularly if the patient’s neurological status is stable or the hematoma is small.
According to some studies, early embolization can successfully control hematoma growth. Follow-up imaging has shown significant reduction or complete resolution of the hemorrhage in many cases. Endovascular methods also offer the advantage of reducing the need for surgery, positively affecting the recovery process. Compared to conventional surgery, it is less invasive and generally has a shorter recovery period.
Endovascular techniques are particularly recommended in the following situations:
- The hematoma is relatively small
- The patient’s general neurological status is stable
- Surgical evacuation is not immediately required
However, for large hematomas or cases of rapid neurological deterioration, surgical evacuation remains the gold standard. Thus, patient selection is critical for determining the success of endovascular embolization.
What Are the Risk Factors for Epidural Hemorrhage?
Risk factors for epidural hemorrhage include both personal characteristics and trauma-related factors. These can directly affect the severity of bleeding and recovery process, such as:
- Skull fractures: Especially temporal bone fractures, which are a major risk factor for epidural hemorrhage. Cranial vault fractures can cause injury to the middle meningeal artery, leading to blood accumulation in the epidural space.
- Trauma: The most common cause of EDH is traumatic injury. Traffic accidents, assaults, or falls can damage the skull and vessels, increasing risk. Blows to the head often cause vessel tears along with linear fractures.
- Bleeding disorders: Individuals with bleeding disorders, especially those on anticoagulant therapy or with thrombocytopenia, are at risk. In these individuals, excessive bleeding occurs more easily.
- Age: Both young children and elderly adults are at higher risk for epidural hematoma. In young people, the dura mater is less firmly attached to the skull, while in the elderly, vessel fragility is increased.
- Neurological status and lesion size: Low Glasgow Coma Scale scores or large lesions may indicate more severe consequences of epidural hemorrhage.
- Hypertension and comorbidities: High blood pressure and other vascular diseases play a significant role due to increased vessel pressure.
When Can Epidural Hemorrhage Be Treated?
Treatment of epidural hemorrhage can sometimes be managed with interventional radiology options if immediate surgery is not possible. Endovascular embolization is especially important in cases involving the middle meningeal artery. Indications for embolization include:
- Active arterial bleeding
- Seeking a minimally invasive alternative for patients at high surgical risk
- Small vascular lesions with potential for progression
Embolization reduces the risks compared to open surgery and stabilizes the patient’s general condition. This approach is particularly beneficial for patients unsuitable for surgery, offering a lower-risk option and positively affecting recovery. Thus, treatment can be managed in the safest and most effective way possible.
When Can Epidural Hemorrhage Not Be Treated?
Interventional radiology for epidural hemorrhage is not always applicable and depends on the patient’s clinical condition and other health factors. Major contraindications for interventional treatment include:
- Severe coagulopathy: Disorders affecting blood clotting, especially patients at risk for uncontrolled bleeding. For those on warfarin or other anticoagulants, reversal may be necessary.
- Small or non-expanding hematomas: Epidural hemorrhages that do not cause mass effect or neurological deterioration and are small and stable do not require interventional treatment; conservative management and regular observation are preferred.
- Absence of middle meningeal artery involvement: Interventions like embolization are not suitable if the bleeding source is not from the middle meningeal artery.
- Neurological stability: Interventional therapy is not preferred for patients who are clinically or radiologically stable without significant findings; conservative follow-up is more appropriate.
- Extensive parenchymal brain injury: When other types of bleeding such as subdural or subarachnoid hemorrhage are present, isolated intervention is not beneficial. In such complex cases, the general condition is evaluated and alternative treatments are considered.
What Is the Recovery Process After Epidural Hemorrhage Treatment?
The postoperative recovery process for epidural hematoma treatment focuses on stabilizing neurological status and preventing potential complications. After interventional radiology procedures like embolization and other minimally invasive interventions, patients require close monitoring. Neurological deterioration, infection, or recurrent bleeding must be watched for carefully.
During rehabilitation, early mobilization is encouraged once neurological function stabilizes, helping to prevent complications like deep vein thrombosis. Anticoagulant therapies are considered carefully to avoid increasing bleeding risk.
Patients are regularly monitored for symptoms after surgery, including:
- Neurological assessment: Monitoring for weakness, sensory changes, or increased pain
- Imaging: MRI and CT scans to rule out ongoing bleeding or clot formation
- Management of complications: Ensuring that embolization does not cause ischemic complications and monitoring blood flow
Appropriate pain relief is prescribed, and regular follow-up is conducted to prevent long-term complications. All necessary assessments are performed to prevent infection or hematoma expansion. Recovery time depends on the location and severity of the hemorrhage and the patient’s preoperative condition. Most patients recover without significant neurological deficits and eventually return to normal function.
How Can Epidural Hemorrhage Be Prevented?
Epidural hemorrhage can have serious consequences, so taking preventive measures is critically important. Early diagnosis and monitoring are vital for preventing complications. CT scans enable rapid intervention. Continuous neurological monitoring during the first 36 hours after injury is essential, as EDH expansion frequently occurs during this period.
Managing coagulopathy is also a key preventive strategy. In patients with underlying bleeding disorders, reversal agents should be used to correct coagulopathy. This also includes managing medications that affect clotting.
Blood pressure control is another important preventive measure, as hypertension may exacerbate bleeding. Maintaining optimal blood pressure levels reduces the risk of hemorrhage progression in EDH patients.
Finally, non-surgical observation protocols offer an effective management option for small hematomas. Regular neuroimaging and clinical assessment are recommended. These approaches require a structured follow-up plan.
Girişimsel Radyoloji ve Nöroradyoloji Uzmanı Prof. Dr. Özgür Kılıçkesmez, 1997 yılında Cerrahpaşa Tıp Fakültesi’nden mezun oldu. Uzmanlık eğitimini İstanbul Eğitim ve Araştırma Hastanesi’nde tamamladı. Londra’da girişimsel radyoloji ve onkoloji alanında eğitim aldı. İstanbul Çam ve Sakura Şehir Hastanesi’nde girişimsel radyoloji bölümünü kurdu ve 2020 yılında profesör oldu. Çok sayıda uluslararası ödül ve sertifikaya sahip olan Kılıçkesmez’in 150’den fazla bilimsel yayını bulunmakta ve 1500’den fazla atıf almıştır. Halen Medicana Ataköy Hastanesi’nde görev yapmaktadır.
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