The Dreaded Epidural

History and Physical

A 16-year-old male fell while skateboarding and lost consciousness for an unknown period of time, with concern for subsequent tonic seizure. He was taken to the nearest emergency room. Initial GCS was 14/15.

Diagnostic Workup

Head CT showed right squamous temporal bone fracture with epidural hematoma and midline shift ( Fig. 66.1 ). He was taken immediately to the operating room for decompression, as his mental status deteriorated overnight.

An axial C T slice presents a circular skull outline with brain sulci and a straight arrow marking an illuminated pocket beneath the right frontal bone. — Fig. 66.1

Clinical Differential Diagnoses

Severe headaches can be seen with various conditions including intracranial hemorrhage, infection, tumors, stroke, seizure, migraine, and autoimmune conditions.

Imaging Differential Diagnoses

Extra-axial hyperdensities with mass effect include epidural and subdural hematoma, tumors, and infection.

Final Diagnosis

Epidural hematoma.

Discussion

Epidural hematomas usually occur in the setting of skull fractures with injury to the middle meningeal artery. This condition occurs in 1% to 4% of head injuries and is more common in young male adults. Occasionally, hemorrhage can occur spontaneously or with minor trauma due to a bleeding disorder or vascular malformation. Treatment involves urgent decompressive craniotomy or burr hole to prevent fatal brain herniation.

Clinical Red Flags

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Focal head trauma and skull fracture.
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History of brief loss of consciousness followed by a lucid interval, usually lasting between 30 minutes and several hours, before becoming somnolent again.
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Abnormal neurological findings include altered mental status, coma, seizures, anisocoria, hemiparesis, hyperreflexia, and Babinski sign.
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Cushing triad: hypertension, bradycardia, and respiratory abnormalities are signs of increased ICP.