Epidural Hematoma: Symptoms, Types, Causes and Treatment

Epidural hematoma (EDH) is a critical medical condition involving bleeding between the dura mater and the skull or spinal canal. While often associated with traumatic head or spine injury, EDH may also result from surgery, vascular disorders, or occur spontaneously. Prompt recognition and management are essential to prevent lasting neurological damage or death. In this comprehensive guide, we’ll explore the symptoms, types, causes, and treatments for epidural hematoma, synthesizing the latest research and clinical findings.

Symptoms of Epidural Hematoma

Recognizing the symptoms of an epidural hematoma is crucial for rapid intervention and improved outcomes. Symptoms can vary widely depending on the location (cranial or spinal), the rate of bleeding, and the patient’s age.

Symptom	Description	Onset	Source
Headache	Intense, often sudden	Acute/Delayed	4 7 12
Vomiting	Nausea, emesis, can be early sign	Acute	4 12
Lethargy	Drowsiness, reduced alertness	Acute/Progress	4 12
Neurological Deficits	Weakness, paralysis, sensory loss	Acute/Progress	2 3 4 5 9 10
Back Pain	Sharp, severe, may radiate to extremities	Acute	1 2 5 8
Seizures	Involuntary movements, rare in spinal EDH	Acute	4
Saddle Anesthesia	Numbness in groin/perianal area	Acute	3 10

Table 1: Key Symptoms

Understanding the Symptom Spectrum

Symptoms of epidural hematoma can be dramatic and life-threatening, but sometimes may initially be subtle.

Cranial Epidural Hematoma

• Classic Presentation: After a head injury, patients may have a brief loss of consciousness, a lucid interval, then rapid deterioration with headache, vomiting, confusion, and neurological deficits such as hemiparesis or abnormal pupil responses. In children, vomiting, headache, and lethargy are especially common, even after minor trauma 4.
• Delayed Symptoms: Some patients, including children, may initially appear well and then rapidly deteriorate. Alertness at diagnosis is not always reassuring; close observation is vital 4 12.
• Seizures: While not a primary symptom, seizures can occur, particularly in children 4.

Spinal Epidural Hematoma

• Pain: Sudden, severe back or neck pain is almost universal. This may radiate to the arms or legs 1 2 5 8.
• Neurological Deterioration: Rapidly evolving weakness, sensory loss, bladder/bowel dysfunction, and in severe cases, paralysis can occur 2 3 5 9 10.
• Saddle Anesthesia: Loss of sensation in the perineal region is a classic sign of cauda equina syndrome, often due to lumbar hematoma 3 10.

Symptom Progression and Monitoring

• Acute vs. Delayed: While most symptoms are acute, some (particularly in spinal or chronic hematomas) may develop over days 1 3 7.
• Importance of Early Recognition: Persistent severe pain followed by neurological symptoms is a red flag for possible epidural hematoma 1 5. A normal neurological exam does not exclude risk—especially in the presence of risk factors or trauma 4 12.

Types of Epidural Hematoma

Epidural hematomas can be classified based on their location, cause, and the speed at which they develop. Understanding these distinctions is important for diagnosis and treatment.

Type	Location	Onset	Source
Cranial Acute	Brain	Hours	4 7 12 13 16
Cranial Chronic	Brain	Days–Weeks	7
Spinal Acute	Spine	Hours	1 2 3 5 10
Spinal Chronic	Spine	Days–Weeks	7 14
Traumatic	Brain/Spine	Acute	4 7 8 16
Spontaneous	Brain/Spine	Acute	2 6 8 15
Postoperative	Brain/Spine	Acute/Delayed	1 3 6 9 11

Table 2: Types of Epidural Hematoma

Location-Based Types

Cranial Epidural Hematoma

• Acute Cranial EDH: Most often results from head trauma. Blood accumulates rapidly between the skull and dura, often over the temporal region 4 7 12 13.
• Chronic Cranial EDH: Less common, develops over days or weeks, often after mild or unrecognized trauma 7.

Spinal Epidural Hematoma

• Acute Spinal EDH: Presents with sudden back pain and rapid neurological compromise. Can be spontaneous, postoperative, or related to trauma 1 2 3 5 10.
• Chronic Spinal EDH: Rare, progresses over a longer period and may be mistaken for other spinal pathologies 7 14.

Etiology-Based Types

Traumatic Epidural Hematoma

• Cranial: Typically caused by skull fracture traversing a meningeal vessel, especially the middle meningeal artery 4 7 12 16.
• Spinal: Less common, may result from vertebral fractures, high-impact injuries, or underlying disc herniation 8.

Spontaneous Epidural Hematoma

• Occurs without evident trauma; often associated with coagulopathies, vascular malformations, or even minor movements 2 6 8 15.

Postoperative Epidural Hematoma

• Cranial and Spinal: May occur after neurosurgical or spinal procedures, with symptoms emerging immediately or even days later 1 3 6 9 11.

Acute vs. Chronic

• Acute: Rapid symptom onset and progression, higher risk of severe outcomes if not treated promptly.
• Chronic: Slower progression, sometimes with stable or incomplete deficits, but still requires careful monitoring and often surgical intervention 7 14.

Causes of Epidural Hematoma

Identifying the underlying cause is essential for both prevention and management. Causes vary by age, location, and individual risk factors.

Cause	Mechanism	Prevalence	Source
Trauma	Vessel rupture from impact or fracture	Common	4 7 8 12
Surgery	Vessel injury or impaired clotting	Uncommon	1 3 6 9 11
Coagulopathy	Impaired clotting, often from medications	Significant	2 9 10 14 15
Vascular Malformation	Bleeding from abnormal vessels	Rare	2 14 15
Spontaneous	No clear antecedent, sometimes minor strain	Rare	2 8 15
Underlying Disc Disease	Tearing of epidural veins adjacent to disc	Notable	8

Table 3: Causes of Epidural Hematoma

Traumatic Causes

• Cranial: Most common cause, especially in children and young adults. Skull fractures crossing major vessels (e.g., middle meningeal artery) are a frequent source 4 7 12.
• Spinal: Less often traumatic, but may occur with vertebral fractures or forceful movements 8.

Surgical Causes

• Both cranial and spinal surgeries can result in epidural hematoma, especially if:
  • There is intraoperative vessel injury
  • Coagulopathy is present (either pre-existing or medication-induced)
  • There is impaired resorption due to scarring from previous surgeries 1 3 6 9 11

Coagulopathy and Anticoagulation

• Patients with blood clotting disorders or on anticoagulant therapy are at increased risk, even without obvious trauma 2 9 10 14 15.
• In some cases, simply discontinuing anticoagulants may not be enough; reversal with agents like vitamin K may be necessary to prevent progression 14.

Vascular Malformations

• Rare, but can cause spontaneous bleeding into the epidural space. Arteriovenous malformations or angiomas may be implicated 2 14 15.

Spontaneous and Disc-Related Causes

• Spontaneous spinal epidural hematoma can occur with minimal or no trauma, sometimes associated with underlying disc herniation or annular tears, which may damage adjacent veins 8 15.

Other Considerations

• Children: Even minor falls may result in EDH due to the pliability of the pediatric skull and vascular anatomy 4.
• Postoperative Delayed Hematoma: Scar tissue may prevent normal resorption of small bleeds, causing delayed deterioration 1.

Treatment of Epidural Hematoma

The treatment approach depends on the size, location, cause, and severity of the hematoma, as well as the patient’s neurological status.

Treatment	Indication	Approach	Source
Surgical Evacuation	Large/acute hematomas, neuro deficits	Craniotomy, laminectomy	5 7 10 13 14 16
Minimally Invasive	Select cases with surgical risk	Embolization, drainage	16
Conservative	Small, stable, asymptomatic cases	Observation, repeat imaging	12 13
Reversal of Coagulopathy	Bleeding due to anticoagulants	Vitamin K, stop meds	9 14 15
Negative Pressure Wound Therapy	Select recurrent/spinal cases	Surgical adjunct	6

Table 4: Treatment Options

Surgical Management

• Cranial EDH: For hematomas >30 cm³, or with significant mass effect or neurological decline, prompt craniotomy is standard. Surgery is especially urgent in patients with coma or unequal pupils 13.
• Spinal EDH: Surgical decompression (laminectomy) is the mainstay for most symptomatic cases, especially with acute neurological deficits 5 7 10 14.

Timing and Outcomes

• Early intervention is vital. Delays can lead to permanent deficits. However, in cases where symptoms are stable and incomplete, surgery may be less urgent 14.
• Complete recovery is most likely if intervention occurs before severe or complete neurological loss 9 10 14.

Minimally Invasive and Alternative Approaches

• Minimally Invasive Techniques: For select cranial cases, endovascular embolization combined with drainage and clot dissolution (urokinase) under local anesthesia has shown promise, particularly in elderly or high-risk surgical patients 16.
• Negative Pressure Wound Therapy: May be used in select recurrent spinal cases as an adjunct to surgery 6.

Conservative Management

• Patients with small, stable, asymptomatic hematomas—especially without vessel injury or early diagnosis—may be managed with observation and repeat imaging in a neurosurgical center 12 13.
• Careful monitoring is essential, as up to 32% may eventually require surgery if deterioration occurs 12.

Treating Underlying Causes

• Coagulopathy: Reversal of anticoagulation (e.g., with vitamin K) is critical in cases caused or worsened by blood thinners 9 14 15.
• Vascular Malformation: Requires both evacuation and addressing the vascular lesion 2 14.

Prognosis

• The outcome depends on the speed of diagnosis and treatment, the degree of neurological deficit, and the underlying cause.
• Most patients recover well if treated promptly, but delays or severe initial symptoms may result in permanent neurological issues 4 9 10 14.

Conclusion

Epidural hematoma is a potentially life-threatening condition that demands rapid identification and appropriate management. Early recognition of symptoms, understanding the various types and causes, and prompt, tailored treatment can significantly improve outcomes.

Key Points Covered in This Article:

• Symptoms: Range from headache and vomiting to severe neurological deficits; back pain and saddle anesthesia are typical in spinal cases.
• Types: Classified by location (cranial or spinal), onset (acute or chronic), cause (traumatic, spontaneous, postoperative).
• Causes: Trauma is most common, but surgery, coagulopathy, vascular malformations, and even spontaneous events are contributors.
• Treatment: Surgical evacuation is standard for large or symptomatic hematomas; conservative management may be possible for small, stable cases; minimally invasive options are emerging for select patients.

With vigilance and evidence-based care, the risks of permanent damage from epidural hematoma can be minimized, ensuring better outcomes for patients facing this serious condition.