Epidural hematoma differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

Epidural hematoma must be differentiated from other diseases that cause severe headache such as subarachnoid hemorrhage, meningitis, intracranial mass, cerebral hemorrhage, cerebral infarction, intracranial venous thrombosis, migraine, pituitary apoplexy, and lymphocytic hypophysitis.

Differentiating epidural hematoma from other diseases

Epidural hematoma should be differentiated from other diseases causing severe headache for example:

Onset	Disease	Symptoms		Gold Standard Test	CT/MRI Findings	Other Investigation Findings
		Headache Characteristics	Associated Features
Sudden	Pituitary apoplexy	Severe headache	Nausea and vomiting Paralysis of eye muscles (diplopia) Changes in vision	MRI	CT scan without contrast is the initial test of choice. Pituitary hemorrhage on CT presents as a hyper-dense lesion. MRI is done in cases of inconclusive CT. An MRI is more sensitive in identifying intrasellar mass and soft tissue changes.	Blood tests may be done to check: PT/INR and aPTT Pituitary hormonal assay
	Subarachnoid hemorrhage	Severe headache Thunderclap Described as the worst headache of life	Double vision Nausea and vomiting Symptoms of meningeal irritation Sudden decreased level of consciousness	Digital subtraction angiography	The modality of choice for diagnosis of subarachnoid hemorrhage is non-contrast head computed tomography (CT), with or without lumbar puncture.[1] CT shows hyperattenuating material filling the subarachnoid space.	Lumbar puncture (LP) is necessary when there is a strong suspicion of subarachnoid hemorrhage. LP will show: Elevated opening pressure Elevated red blood cell (RBC) Xanthochromia
	Meningitis	Headache is associated with: Fever Neck stiffness	Photophobia    Phonophobia  Irritability Altered mental status	Lumbar puncture for CSF	CT scan of the head may be performed before LP to determine the risk of herniation.	Diagnosis is based on clinical presentation in combination with CSF analysis. CSF analysis is the investigation of choice. For more information on CSF analysis in meningitis please click here.
	Cerebral hemorrhage	Rapidly progressing headache	Symptoms of increased intracranial pressure (ICP) Focal neurological deficits	CT without contrast (differentiates ischemic stroke from hemorrhagic stroke)	CT is highly sensitive for identifying acute hemorrhage which appears as a hyperattenuating clot. Gradient echo and T2 susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.	PT/INR and aPTT should be checked to rule out coagulopathy.
	Migraine	Severe to moderate headache One-sided Pulsating Lasts between several hours to three days.	Nausea and vomiting Preceding aura Photophobia Phonophobia	---	CT and MRI may be needed to rule out other suspected possible causes of headache.	Migraine is a clinical diagnosis that does not require any laboratory tests. Laboratory tests may be ordered to rule out any suspected coexistent metabolic problems.
	Head injury (Epidural hematoma)	Dull Throbbing One sided or all around	Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness Lucid interval	CT scan without contrast	CT scan is the first test performed and identifies cerebral hemorrhage (appears as a hyperattenuating clot) following head injury. MRI is more sensitive, takes more time, and is done in patients with symptoms unexplained by CT scan.	The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
	Lymphocytic hypophysitis	Generalized headache Retro-orbital or Bitemporal pain	Most often seen in late pregnancy or the postpartum period Mass lesion effect such as visual field defects Hypopituitarism	Pituitary biopsy	CT & MRI typically reveal features of a pituitary mass.	The most accurate test is a pituitary biopsy which will show lymphocytic infiltration.
Gradual	Intracranial mass	Morning headache	Nausea Vomiting Change in mental status Seizures Focal neurological deficits	MRI	CT or MRI is the initial test to detect intracranial lesions (ring enhancing lesions). These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.	Biopsy of the lesion may be done to identify the nature of the lesion such as: Tumor Abscess X-ray of the skull is a non specific test, but useful if any of the lesions are calcified
	Intracranial venous thrombosis	Diffuse headache Headache can be the only symptom of cerebral venous thrombosis	Focal neurological deficits Seizures Depressed level of consciousness	Digital subtraction angiography	The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus. CT and MRI may identify Cerebral edema and venous infarction may be apparent.	CT venography detects the thrombus, computed tomography with radiocontrast in the venous phase (CT venography or CTV) has a detection rate that in some regards exceeds that of MRI. Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance."

Epidural hematoma in the spine

Bleeding into the epidural space in the spine may also cause epidural hematoma. These may arise spontaneously (e.g. during childbirth, or as a rare complication of anaesthesia (such as epidural anaesthesia) or surgery (such as laminectomy).

The anatomy of the epidural space means that spinal epidural hematoma has a different profile from cranial epidural hematoma. In the spine, the epidural space contains loose fatty tissue, and the epidural venous plexus, a network of large, thin-walled veins. This means that bleeding is likely to be venous. Anatomical abnormalities and bleeding disorders make these lesions more likely.

They may cause pressure on the spinal cord or cauda equina, which may present as pain, muscle weakness, or bladder and bowel dysfunction.

The diagnosis may be made on clinical appearance and time course of symptoms. It usually requires MRI scanning to confirm.

The treatment is surgical decompression.

The incidence of epidural hematoma following epidural anaesthesia is extremely difficult to quantify; estimates vary from 1 per 10,000 to 1 per 100,000 epidural anaesthetics. This means that a typical anaesthetist or anesthesiologist is statistically unlikely to cause one in a whole career.

Other Differential diagnosis

• Intracranial hematoma

• Extra-axial hematoma

• Subdural hematoma
• Subarachnoid hemorrhage

• Intra-axial hematoma

• Diffuse axonal injury
• Concussion
• Brain contusion