| An epidural hematoma is caused from bleeding between the skull and the outer membrane that covers the brain (dura mater). Rapid bleeding results in a localized accumulation of blood (hematoma) that presses on the brain tissue and leads to a rapid increase in pressure within the brain (increased intracranial pressure).
Ninety percent of all epidural hematomas are caused by head trauma due to car accidents, sports injuries, violent attacks, or falls, and are associated with a skull fracture that crosses a portion of the middle meningeal artery or vein. In 60% of cases, the middle meningeal artery is the source of bleeding.Risk: Risk factors for epidural hematoma include belonging to the male sex or to certain age groups (children and the elderly) who have an increased risk for falls. Incidence and Prevalence: Epidural hematomas represent 2% of head injuries and are much less frequent than subdural hematomas. About 10% of brain injuries are classified as moderate to severe, and are thereby capable of causing bleeding within the skull. |
Source: Medical Disability Advisor
| History: After an epidural hematoma is sustained, it is usually followed by loss of consciousness, then an alert period succeeded by deterioration and a return to an unconscious state. During the alert period, the individual may experience severe headache accompanied by nausea or vomiting, seizures, visual field cuts, difficulty speaking, weakness and numbness. Physical exam: Enlarged or uneven pupils, weakness of an arm or a leg usually on the opposite side of the enlarged pupil, and localized exam abnormalities (focal neurologic deficits) related to pressure effects from the epidural hematoma may be evident upon exam. Slowed heart rate and high blood pressure are signs of increased intracranial pressure. Skull bruises, cuts, blood behind the eardrum, an unstable vertebral column, or fractures may be seen as a result of the trauma. Tests: CT of the brain usually confirms the diagnosis of an epidural hematoma, establishes its location, and often demonstrates an associated skull fracture. Cervical spine x-rays may also provide evidence of fractures. MRI can also help identify the epidural hematoma but is not recommended if a patient is unstable. Blood count, platelet count, coagulation studies, and serum chemistries, as well as a toxicology screen and blood alcohol level are obtained to evaluate the patient. Blood type and cross matching tests are done in case any transfusions are needed. |
Source: Medical Disability Advisor
| Epidural hematoma is treated surgically by evacuation of the hematoma. First, small holes are bored through the skull (burr holes) and then the clot is removed either manually or by suction (evacuation procedure).
Medications may be used as additional therapy and vary with the kind of symptoms and extent of brain damage. Anticonvulsants may be used to control or prevent seizures. Osmotic diuretics and hyperventilation or corticosteroids can reduce swelling inside the skull. Antibiotics help control infection. Antipyretic agents help to control fever. Patients may also be treated with antidotes to reverse coagulopathies and anticoagulants to prevent blood clots from forming due to the patient's immobility. |
Source: Medical Disability Advisor
| If the diagnosis is recognized immediately and surgery is performed, the outcome is generally good. If the individual is first seen during the lucid period, a CT may not be done because an epidural hematoma is not suspected. If the diagnosis and treatment of epidural hematoma are therefore delayed, incidence of death or long-term neurologic deficits increases. The mortality rate of epidural hematomas is between 5% and 50%.
Outcome after surgical evacuation of an epidural hematoma is directly related to the level of consciousness before surgery. An outcome study on individuals with epidural hematoma suggests that 23% have a poor outcome, and 77% have good recovery to moderate disability following surgery (Bradley). |
Source: Medical Disability Advisor
| If there is only minimal damage to the brain, the overall objective for rehabilitation of individuals with epidural hematoma injury is to return them as quickly and as fully as possible to the mainstream. Rehabilitation may involve physical, occupational, and speech therapy and/or cognitive retraining to help the individual achieve functional recovery and cope with disabilities that may remain.
Rehabilitation varies for each individual because of the uniqueness of the problems that result from different areas of the brain affected. Treatment guidelines for the individual who has lost voluntary motion of his or her limbs begin with passive range of motion exercises. When unconscious, the individual may progress to becoming less comatose or sleepy to a more aware or awake state; however, he or she may still be confused and easily distracted. If memory is affected by the epidural hematoma, exercises are initiated to promote memory return as well as instructing the individual to carry out simple tasks. This can be as elementary as motivating the individual to receive an object in his or her hand or instructing the individual to go from a sitting to standing position.
The rehabilitation program sequences activities that progress from easy to more difficult such as teaching the individual to rise from a chair to instructing proper walking patterns. Once the individual regains thinking processes, rehabilitation focuses on the needs of muscular strength, endurance, and flexibility. Muscle imbalance is corrected by using traditional physical therapy methods and techniques to help make the muscular and nervous systems work together. Group activities may take place in mat classes, wheelchair classes, or in other activities such as volleyball games.
When appropriate, the final phase of rehabilitation following recovery from an epidural hematoma involves the individual's reinstatement to work. Physical and mental exercises are now directed toward the work requirements. Modifications may need to be made by the physical therapist for those individuals with various deficits after an epidural hematoma. |
Source: Medical Disability Advisor
| Without prompt surgical intervention, there is a high-risk of death. Even with prompt surgical intervention, complications such as permanent brain damage and seizures may occur. One prolonged effect of epidural hematomas is called a post-concussion syndrome, which is characterized by dizziness, headache, vertigo, poor concentration, sleepiness, and emotional lability. |
Source: Medical Disability Advisor
| Work restrictions and accommodations after an epidural hematoma are a function of the degree of brain damage that may have occurred. Patients with severe injuries may require inpatient and outpatient rehabilitation services to assist with regaining independence at home and returning to work. They may need job retraining, psychological counseling, as well as driving retraining before they can return to work. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- What are individual's vital signs? Is there fever or a slowed heart rate?
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Has individual suffered a head injury?
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Did individual lose consciousness and then have an alert period?
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Does individual complain of a severe headache? Nausea or vomiting?
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Has individual become unconscious again?
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On exam were individual's pupils enlarged or unequal?
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Does individual have weakness of an arm or leg?
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Has individual had a CT scan or MRI?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Is individual being treated with hyperventilation, antipyretics?
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Did individual have surgery to evacuate the hematoma?
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Is individual being treated with anticonvulsants, diuretics or corticosteroids?
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Is individual receiving antibiotics?
Regarding prognosis:
- Is individual active in rehabilitation?
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Is individual's employer able to accommodate any necessary restrictions?
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Does individual have any conditions that may affect ability to recover?
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Does individual have any complications such as permanent brain damage, seizures, uncal hernia, postconcussion syndrome or normal pressure hydrocephalus?
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Source: Medical Disability Advisor
| Bradley, Walter G., et al., eds. Neurology in Clinical Practice. 3rd ed. Boston: Butterworth-Heinemann, 1999. |
Source: Medical Disability Advisor
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