epidural hematom

1. Epidural Hematoma
Dr. Vandy Ikra
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

2. • an extra-axial collection of blood within the
potential space between the outer layer of the dura
mater and the inner table of the skull
• It is a life-threatening condition, which may require
immediate intervention and can be associated with
significant morbidity and mortality if left untreated
• Rapid diagnosis and evacuation are important for a
good outcome
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

3. Etiology
Traumatic
• Trauma Brain Injury
• Mechanisme
• Motor vehicle collisions
• Physical assaults
• Acidental falls
Non traumatic
• Mechanism
• Infection/Abscess
• Coagulopathy
• Hemorrhagic Tumors
• Vascular Malformations
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

4. • occurs in 2% of all head injuries and up to 15% of
all fatal head traumas
• Males are more often affected than are females
• the incidence is higher among adolescents and
young adults
• The mean age of affected patients is 20 to 30 years
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Epidemiology
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

5. • Arterial Injury
85% of all bleeding
Branch of the middle meningeal artery
Anterior meningeal artery or dural
arteriovenosus fistula at the vertex maybe
involved
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Pathophysiology
refference : Greenberg, M.S., 2016. Handbook of neurosurgery. 8th edn New
York.

6. • Venous Injury
Up to 10% are due to venous bleeding following
the laceration of dural venous sinus
In adults, 75% EDHs occur in the temporal region
In children, they occur with similar frequency in
the temporal, occipital, frontal, and posterior
fossa regions.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

7. • An initial loss of consciousness
• a complete transient recovery (“often termed as a
lucid interval”)
• rapid progression of neurological deterioration
• Cushing Reflex
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
History and Physical
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

8. • Subdural hematoma
• A posttraumatic disorder described by Denny-
Brown consisting of a “lucid interval” followed by
bradycardia, brief periods of restlessness and
vomiting, without intracranial hypertension or
mass
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Differential Diagnosis
refference : Greenberg, M.S., 2016. Handbook of neurosurgery. 8th edn New
York.

9. • CT Scan
• biconvex or lens-shaped mass on brain CT scan
• estimating the amount of blood present in an EDH :
ABC/2
• A: The maximum hemorrhage diameter on the CT slice with the
largest area of hemorrhage
• B: The maximum diameter 90 degrees to A on the same CT
slice
• C: The number of CT slices with hemorrhage multiplied by the
slice thickness in centimeters
• Swirl sign
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Evaluation
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

10. • MRI
• Assessing for EDH in the vertex and spinal EDH
• Angiogrhapy
• Assessing for EDH in the vertex
• Laboratory test : INR, PTT, PT, LFT
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Evaluation
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

11. • Neurosurgical Consultation & stabilize the patient -> ABCs
• Operative Management
• Craniotomy and Hematoma Evacuation
• Non Operative Management
• close observation with repeated neurological examinations and
continuous surveillance with brain imaging
• follow-up head CT scan within 6 to 8 hours following brain injury.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Treatment/Management
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

12. Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
• Indications for surgery
Level III*
1. EDH volume > 30 cm3 should be evacuated regardless of GCS
2. EDH with the all of the following characteristics can be managed
nonsurgically with serial CT scans and close neurological
observation in a neurological center
a) Volume < 30 cm3
b) and thickness < 15 mm
c) and with midline shift (MLS) < 5 mm
d) and GCS > 8
e) and no focal neurologic deficit
*Level III : its is strongly recommended that patients with an acute EDH
and GCS <9 and anisocoria undergo surgical evacuation ASAP
refference : Greenberg, M.S., 2016. Handbook of neurosurgery. 8th edn New
York.

13. Treatment/Management
• Indications Operative
Management
• Acute EDH
• Hematoma volume
greater than 30 ml
regardless of Glasgow
coma scale score (GCS)
• GCS less than 9 with
pupillary abnormalities
like anisocoria
• Indication NonOperative
Management
• EDH volume of less than 30 ml
• Clot diameter of less than 15
mm
• Midline shift of less than 5 mm
• GCS greater than 8 and on
physical examination, shows no
focal neurological symptoms.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
refference : https://www.ncbi.nlm.nih.gov/books/NBK518982/

14. Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
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