Diagnostics

• Follow trauma protocols for patients with traumatic EDH

  • Immediate initiation of neuroprotective measures takes precedence over diagnostics.

  • Diagnostics should not delay transfer to a neurocritical care unit if needed.

  • See “Initial management of TBI” for details.

• CT head without IV contrast is the first-line imaging modality for all patients with suspected EDH.

• Imaging should not delay transfer for neurosurgical care in patients who already meet the criteria for intervention.

• In cases of rapidly declining neurological status or evidence of brain herniation, consider emergency temporizing surgery even in the absence of confirmatory imaging

• Indications: first-line imaging in patients with suspected acute EDH

• Characteristic findings

  • Biconvex (lenticular shaped), sharply demarcated extraaxial lesion

  • Typically hyperdense in appearance

  • Limited by suture lines

  • Common locations

    • Arterial EDH: temporal or temporoparietal region

    • Venous EDH: posterior cranial fossa

  • Evidence of skull fracture, if present

  • Initial CT scan may be normal in patients with delayed EDH and small lesions can quickly expand in size

The initial CT scan may be normal if the bleed is slow (e.g., small arterial EDH in the middle cranial fossa, venous EDH). Neuroimaging should be repeated if there are any signs of clinical deterioration in patients with neuroimaging that is initially normal.

• Indications

  • Stable patients with suspected small EDH (i.e., normal or near-normal initial CT scan)

  • Follow-up neuroimaging in stable patients with neurological deterioration not explained by CT findings.

  • Difficulty distinguishing EDH from SDH on CT scan

• Characteristic findings

  • Similar to those on CT scan

  • Lesion would appear hypointense on a T2-weighted scan

• Traumatic EDH: See “Diagnostics in TBI.”

• Nontraumatic EDH: Consider angiography if a dural vascular malformation is suspected.

• Suspected associated cerebral venous sinus thrombosis: Consider venography.

• Traumatic EDH: See “Diagnostics in TBI” for routine laboratory studies that should be obtained in all patients with TBI.

• Nontraumatic EDH: coagulation panel and additional studies for coagulopathy, if suspected

• Epidural hematoma

• Subdural hematoma

• Subarachnoid hemorrhage

• Intracerebral hemorrhage