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You are watching: Difference between epidural and subdural hematoma

StatPearls . Sweetheart Island (FL): StatPearls Publishing; 2021 Jan-.


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Continuing education and learning Activity

Intracranial hemorrhage incorporates four broad types of hemorrhage: epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and also intraparenchymal hemorrhage. Each kind of hemorrhage outcomes from various etiologies and the clinical findings, prognosis, and also outcomes space variable. This activity provides a broad overview the the types of intracranial hemorrhage and also the role of the interprofessional team in managing influenced patients.

Objectives:
Describe the common presentation the epidural, subdural, subarachnoid, and also intraparenchymal intracranial hemorrhage.
Summarize the testimonial of epidural, subdural, subarachnoid, and intraparenchymal intracranial hemorrhage.
Outline the monitoring approaches for epidural, subdural, subarachnoid, and also intraparenchymal intracranial hemorrhage.
Review the role of interprofessional team members in optimizing collaboration and also communication to ensure patients with intracranial hemorrhage receive high-quality care, which will lead to enhanced outcomes.

Introduction

Intracranial hemorrhage encompasses four broad types that hemorrhage: epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and intraparenchymal hemorrhage.<1><2><3> Each form of hemorrhage is different worrying etiology, findings, prognosis, and also outcome. This post provides a large overview of the species of intracranial hemorrhage.


Etiology

Epidural Hematoma

An epidural hematoma can either it is in arterial or venous in origin. The classical arterial epidural hematoma wake up after blunt trauma to the head, typically the temporal region. Castle may likewise occur after ~ a penetrating head injury. There is typically a skull fracture with damage to the middle meningeal artery leading to arterial bleeding right into the potential epidural space. Back the middle meningeal artery is the classically defined artery, any meningeal artery have the right to lead to arterial epidural hematoma.<4>

A venous epidural hematoma occurs as soon as there is a skull fracture, and also the venous bleeding from the skull fracture filling the epidural space. Venous epidural hematomas are typical in pediatric patients. 

Subdural Hematoma 

Subdural hemorrhage occurs when blood enters the subdural space which is anatomically the arachnoid space. Typically subdural hemorrhage occurs after a courage traversing between the brain and skull is stretched, broken, or torn and begins to bleed into the subdural space. These most typically occur ~ a blunt head injury yet may also occur after penetrating head injuries or spontaneously.<5><6>

Subarachnoid Hemorrhage

A subarachnoid hemorrhage is bleeding right into the subarachnoid.  Subarachnoid hemorrhage is split into traumatic versus non-traumatic subarachnoid hemorrhage. A second categorization scheme divides subarachnoid hemorrhage into an aneurysmal and non-aneurysmal subarachnoid hemorrhage. Aneurysmal subarachnoid hemorrhage occurs after the rupture that a cerebral aneurysm enabling for bleeding right into the subarachnoid space. Non-aneurysmal subarachnoid hemorrhage is bleeding into the subarachnoid space without i can identify aneurysms. Non-aneurysmal subarachnoid hemorrhage most generally occurs after trauma v a dull head injury v or without penetrating trauma or suddenly acceleration transforms to the head.<7>

Intraparenchymal Hemorrhage

Intraparenchymal hemorrhage is bleeding right into the brain parenchyma proper. Over there is a wide range of reasons because of which hemorrhage can happen including, yet not minimal to, hypertension, arteriovenous malformation, amyloid angiopathy, aneurysm rupture, tumor, coagulopathy, infection, vasculitis, and trauma.


Epidemiology

Epidural Hematoma 

Epidural hematomas are present in approximately 2% of head injury patients and account for 5% come 15% of deadly head injuries. Approximately 85% come 95% of epidural hematomas have actually an overlying skull fracture. 

Subdural Hematoma

The incidence the subdural hematoma is approximated to be in between 5% come 25% the patients through a significant head injury.  there is an yearly incidence the one to five cases per 100,000 populace per year v a masculine to female ratio of 2:1. The incidence the subdural hematomas increases throughout life.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage accounts for approximately 5% of every strokes and also has an incidence of approximately two come 25 per 100,000 person-years because that those end the period of 35. The incidence patterns up progressively as patient age and may be really slightly an ext frequent in females 보다 males (1.15:1 for the female to male ratio).

Intraparenchymal Hemorrhage 

Intraparenchymal hemorrhage accounts because that 10% to 20% of all strokes.  Intraparenchymal hemorrhage incidence rises for those aged 55 and also older with an increasing incidence as age increases. Over there is part controversy regarding gender differences, however there might be a slight male predominance.


Pathophysiology

Epidural Hematoma

Epidural hematomas take place when blood dissects right into the potential space between the dura and also inner table the the skull. Most typically this wake up after a skull fracture (85% to 95% that cases). There have the right to be damages to an arterial or venous vessel which allows blood to dissect into the potential epidural space resulting in the epidural hematoma. The most usual vessel damaged is the center meningeal artery underlying the temporoparietal region the the skull.

Subdural Hematoma

Subdural hematoma has multiple causes including head trauma, coagulopathy, vascular abnormality rupture, and also spontaneous. Most typically head trauma causes motion the the mind relative to the skull which can stretch and also break blood vessels traversing from the mind to the skull. If the blood vessels room damaged, castle bleed into the subdural space.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage most generally occurs after trauma whereby cortical surface vessels are injured and also bleed into the subarachnoid space. Non-traumatic subarachnoid hemorrhage is most frequently due come the rupture the a cerebral aneurysm. Once aneurysm ruptures, blood can circulation into the subarachnoid space. Other causes that subarachnoid hemorrhage encompass arteriovenous malformations (AVM), usage of blood thinners, trauma, or idiopathic causes.

Intraparenchymal Hemorrhage 

Non-traumatic intraparenchymal hemorrhage most frequently occurs an additional to hypertensive damage to cerebral blood vessels which eventually burst and bleed into the brain. Other reasons include rupture of an arteriovenous malformation, rupture of an aneurysm, arteriopathy, tumor, infection, or venous outflow obstruction. Penetrating and non-penetrating trauma may also cause intraparenchymal hemorrhage.


History and also Physical

Epidural Hematoma

Patients with epidural hematoma report a history that a focal length head injury such as blunt trauma indigenous a hammer or baseball bat, fall, or engine vehicle collision. The standard presentation of one epidural hematoma is a ns of consciousness after the injury, followed by a lucid interval then neurologic deterioration. This classic presentation just occurs in less than 20% of patients. Other symptoms the are common include major headache, nausea, vomiting, lethargy, and seizure.

Subdural Hematoma

A background of either major or minor head injury can frequently be discovered in cases of subdural hematoma. In larger patients, a subdural hematoma can take place after trivial head injuries including bumping that the head top top a cabinet or running right into a door or wall. One acute subdural deserve to present with recent trauma, headache, nausea, vomiting, transformed mental status, seizure, and/or lethargy. A chronic subdural hematoma can current with a headache, nausea, vomiting, confusion, diminished consciousness, lethargy, engine deficits, aphasia, seizure, or personality changes. A physical exam may show a focal motor deficit, neurologic deficits, lethargy, or altered consciousness.

Subarachnoid Hemorrhage

A thunderclap headache (sudden severe headache or worst headache the life) is the classic presentation of subarachnoid hemorrhage. Other symptoms encompass dizziness, nausea, vomiting, diplopia, seizures, ns of consciousness, or nuchal rigidity. Physical exam findings may encompass focal neurologic deficits, cranial nerve palsies, nuchal rigidity, or diminished or altered consciousness. 

Intraparenchymal Hemorrhage

Non-traumatic intraparenchymal hemorrhages frequently present through a history of suddenly onset of hit symptoms consisting of a headache, nausea, vomiting, focal neurologic deficits, lethargy, weakness, slurred speech, syncope, vertigo, or transforms in sensation.


Evaluation

Epidural Hematoma<8><9><10>

Initial evaluation has airway, breathing, and also circulation together patients deserve to rapidly deteriorate and require intubation. A in-depth neurologic check helps recognize neurologic deficits. With boosting intracranial push there may be a Cushing an answer (hypertension, bradycardia, and bradypnea). Emergent CT head without contrast is the imaging choice of the test because of its high sensitivity and specificity for identifying far-reaching epidural hematomas. Historically cerebral angiography might identify the transition in cerebral blood vessels, however cerebral angiography has been supplanted by CT imaging.

Laboratory researches should also be considered including a complete blood counting to examine for thrombocytopenia, coagulation studies (PTT, PT/INR) to inspect for coagulopathy, and also a simple metabolic dashboard to check for electrolyte abnormalities.

Subdural Hematoma

After ensuring the medical stability the the patient, a thorough neurologic exam can assist identify any specific neurologic deficits. Most generally a computed tomography (CT) scan that the head without contrast is the very first imaging check of choice. One acute subdural hematoma is typically hyperdense with chronic subdural being hypodense. A subacute subdural might be isodense to the mind and more daunting to identify.

Laboratory research studies should likewise be considered including a finish blood count to check for thrombocytopenia, coagulation studies (PTT, PT/INR) to check for coagulopathy, and a straightforward metabolic panel to inspect for electrolyte abnormalities.

Subarachnoid Hemorrhage

Initial evaluation contains assessing and also stabilizing the airway, breathing, and circulation (ABCs). Patients with subarachnoid hemorrhage have the right to rapidly deteriorate and also may need emergent intubation. A thoroughly neurologic examination can help identify any kind of neurologic deficits.

The early imaging for patients v subarachnoid hemorrhage is computed tomography (CT) head without contrast. If the patience is given contrast, this have the right to obscure the subarachnoid hemorrhage. Acute subarachnoid hemorrhage is typically hyperdense on CT imaging. If the CT head is negative and there is still strong suspicion because that subarachnoid hemorrhage a lumbar puncture must be considered. The outcomes of the lumbar puncture may display xanthochromia. A lumbar puncture performed before 6 hours of the subarachnoid hemorrhage may fail come show xanthochromia. Additionally, lumbar puncture results might be confounded if a traumatic tap is encountered.

Identifying the cause of non-traumatic subarachnoid hemorrhage will help guide further treatment. Common workup includes either a CT angiogram (CTA) of the head and neck, magnetic resonance angiography (MRA) that the head and neck, or diagnostic cerebral angiogram the the head and also neck done emergently to look because that an aneurysm, AVM, or another source of subarachnoid hemorrhage.

Laboratory research studies should also be thought about including a complete blood count to examine for thrombocytopenia, coagulation studies (PTT, PT/INR) to examine for coagulopathy, and a simple metabolic dashboard to examine for electrolyte abnormalities.

Intraparenchymal Hemorrhage

Once the clinical stability the the patient is ensured, CT head without contrast is the very first diagnostic check most typically performed. The imaging should be able to identify acute intraparenchymal hemorrhage as hyperdense within the parenchyma. Depending on the history, physical and imaging findings and also patient one MRI mind with and also without comparison should be thought about as tumors in ~ the brain may present as intraparenchymal hemorrhage. Various other imaging to consider include CTA, MRA, or diagnostic cerebral angiogram to look for cerebrovascular causes of the intraparenchymal hemorrhage. Review should likewise include a complete neurologic exam to identify any neurologic deficits.

Laboratory studies should also be taken into consideration including a finish blood count to examine for thrombocytopenia, coagulation studies (PTT, PT/INR) to examine for coagulopathy, and a an easy metabolic dashboard to examine for electrolyte abnormalities.


Treatment / Management

Epidural Hematoma<11><12><13>

Treatment starts with advanced trauma life support (ATLS) consisting of airway control, ensuring sufficient ventilation and circulation. Intravenous (IV) accessibility should it is in secured. If the patient has a Glasgow Coma Score (GCS) of 8 or less or worsening neurologic status, intubation should be performed. Instant neurosurgical consultation need to be obtained for patients v epidural hematomas as they may expand over time early out to ongoing bleeding. Definitive therapy is one evacuation the the hematoma and also stopping the bleeding source. Some smaller sized epidural hematomas might be managed non-surgically and also watched closely because that resolution.

Subdural Hematoma

Treatment starts with ensuring enough airway, breathing, and also circulation. Intubation should be considered if the patient has actually a deteriorating GCS or GCS that 8 or less. Prompt neurosurgical consultation have to be acquired as emergency surgery might be forced to evacuate the subdural hematoma. The definitive therapy for subdural hematomas is an evacuation, but depending on the size and also location some subdural hematomas might be watched because that resolution.

Non-surgical management choices include repeat imaging come ensure subdural stability, the reversal that anticoagulation, platelet transfusions for thrombocytopenia or dysfunctional platelets, monitoring with frequent neurologic assessments for deterioration, and/or controlling hypertension. Over there is controversy about whether steroids can assist stabilize the size of the subdural hematoma while offering it time come resorb or till surgical treatment.

Surgical management choices include a twist drill hole, burr hole(s), and craniotomy for evacuation. Data suggests that a twist drill hole has actually the shortest surgical complication rate with the highest recurrence rate. A craniotomy has actually the greatest surgical complication rate with the lowest recurrence price of the surgical options, and burr hole(s) evacuation falls somewhere in between a twisted drill hole and also a craniotomy because that complication rate and recurrence rate.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage might depend if it is a traumatic or non-traumatic subarachnoid hemorrhage. For traumatic subarachnoid hemorrhage, the ABCs of medication must occur first. Beforehand consultation v neurosurgery need to be considered. If the patient is top top anticoagulation or antiplatelet agents consideration need to be given to reversing their effects. Care is commonly conservative through close assessments of vitals and neurologic status. In obtunded patients, there may be a require for intracranial press (ICP) screen and/or external ventricular drainpipe (EVD). Patients should be monitored because that hydrocephalus or cerebral swelling. Repeat imaging have the right to verify the development of the traumatic subarachnoid hemorrhage. Sometimes aneurysmal rupture or incompetence of various other intracranial vascular malformations can masquerade as traumatic subarachnoid hemorrhage. If over there is no clear and also convincing background of a traumatic origin, climate a non-traumatic etiology for the subarachnoid hemorrhage must be sought.

In non-traumatic subarachnoid hemorrhage, the etiology that the hemorrhage must be ascertained and addressed. Early on consultation with neurosurgery should it is in considered. Therapy varies depending top top the etiology of the hemorrhage however can include treatment of an aneurysm or arteriovenous malformation or other etiology. Additionally, there need to be a short threshold for location of an exterior ventricular drainpipe (EVD) because of the threat of hydrocephalus.

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Intraparenchymal Hemorrhage

Intraparenchymal hemorrhage can be life-threatening and treatment starts with the ABCs of medicine and also stabilization that the patient.  Blood pressure should be controlled to decrease the danger of additional hemorrhage. Beforehand consultation through neurosurgery must be considered. The treatment the intraparenchymal hemorrhage counts on the etiology of the hemorrhage. Treatment options are variable and include aggressive surgical evacuation, craniectomy, catheter-based dissolution, or observation. Surgical evacuation is controversial because that some forms of intraparenchymal hemorrhage. Although countless intraparenchymal hemorrhages are second to cerebrovascular condition and hypertension, the surgeon have to anticipate encountering other underlying pathology consisting of an aneurysm, AVM, and/or tumor when evacuating an intraparenchymal hemorrhage. Periodically evacuation of the hematoma might be more detrimental 보다 the hematoma itself, and also a craniectomy is performed rather to enable for cerebral swelling. There room a variety of catheter-based equipment which shot to dissolve the hemorrhage. A conversation of these is beyond the limit of this article. Smaller and non-operable hemorrhages might be managed medically with regulate of blood pressure, the reversal the anticoagulation or antiplatelet agents, and also neuroprotective strategies to prevent and/or mitigate secondary cerebral injury.