The brain is enclosed in the skull, which is a rigid, solid bone. Surrounding the brain is a tough, leathery outer covering called the dura (door-uh). The dura attaches to the brain, just beneath the skull bone. The dura normally protects the brain and keeps it nourished with blood and spinal fluid. When a person receives a severe blow to the head, the brain bounces within the cavity. This movement of the brain structures may cause shearing or tearing of the blood vessels surrounding the brain and dura. When the blood vessels tear, blood accumulates within the space between the dura and the skull. This is known as an epidural hematoma (epi-door-ul hem-a-to-ma), or blood clot at the covering of the brain.
When the blood accumulates between the dura and skull, swelling of the brain occurs. There is no extra room within the skull to allow for the brain to swell and for the blood to accumulate. The only way the brain can compensate is to shift the delicate structures out of the way. This can cause pressure on vital functions, such as eye opening, speech, level of awakeness (or consciousness) or even breathing. Generally, an epidural can cause serious problems and must be removed to prevent increased swelling of the brain. The procedure of choice for removal of an epidural hematoma is surgery to remove the blood clot.
An epidural hematoma can happen to anyone, at any age. Some common causes of epidural hematoma include:
- A blow to the head, such as in a motor vehicle crash, assault or bicycle accident
- Falling down and striking the head
People at particular risk are those who:
- Are elderly and have trouble walking or fall often
- Take a blood thinner, such as Coumadin
Signs and symptoms
The signs and symptoms of an epidural hematoma include severe headache, dizziness, vomiting, increased size of one pupil or sudden weakness in an arm or leg. As the epidural hematoma swells and the brain structures are pushed together, more visible signs can occur. A more dangerous sign of epidural hematoma is a decreased level of consciousness, such as drowsiness, confusion or inability to awaken from a very deep sleep (often called coma). Because the brain controls all functions of the human body, breathing pattern changes also can occur. Shortness of breath, gasping for air or very slow breathing can be a warning sign that the person needs help. An epidural hematoma can be life-threatening; therefore, if any of these signs or symptoms occur, the person should be taken to a medical facility immediately.
If your health-care provider suspects an epidural hematoma, the following tests may be ordered.
This is a special X-ray image of the brain. The test is performed by having the patient lie on a flat X-ray table that slides into a round, open scanner. The X-ray images are taken as the patient is lying still on the X-ray table.
The treatment for epidural hematoma depends upon the clinical signs and symptoms, as well as the size of the clot and area of the brain involved. Surgery is generally recommended to remove the clot. The surgery is performed by a neurosurgeon. The specific procedure, as well as the risks and benefits, should be discussed in detail by the neurosurgeon performing the procedure.
Questions you may want to ask
- Where will the incision be, and how much hair will need to be shaved?
- Where will the person be after recovery (in the intensive care unit or stepdown unit)?
- How soon after surgery is the patient likely to wake up?
- Will the person need to be on a breathing machine (ventilator)? And if so, for how long?
- What are the complications of this type of surgery?
Recovery after surgery
After the blood clot has been removed, the patient generally is placed in the intensive care unit (ICU), where specially trained nurses can monitor closely the level of consciousness and any signs of complications. Often a ventilator (breathing machine) is needed until the patient wakes up enough to breathe on his or her own. Frequent assessments will be needed to determine the level of consciousness. Special medications may be given to reduce brain swelling and keep the pressure inside the head down to a normal level.
Visiting the patient in the intensive care unit can be frightening at first. The unit often is noisy and filled with machines and monitors. These monitors are used to closely watch the heart, blood pressure and pressure inside the head. The ventilator is used to help the patient breathe. Often the patient has several intravenous lines that deliver fluid and nutrition through veins. A dressing may be on the head to cover the surgical area. A tube may be in the nose or mouth to keep the stomach clear or to feed the patient.
Patients who have had an epidural hematoma often appear confused or combative. Some patients may need their hands restrained to keep from pulling out vital tubes, such as the breathing tube. It is important to ask the ICU nurses any questions to help understand the equipment and condition of the patient. To make sure all questions are answered, some families write down questions while waiting to see their loved one. Don't hesitate to ask - even if the question seems silly or you have asked it before.
Depending on the severity of the injury, some patients will require a rehabilitation program to regain their abilities. A uniquely trained team of rehabilitation specialists often includes nurses, physiatrists (rehabilitation doctors), neuropsychologists, speech therapists, physical therapists and occupational therapists.
It is important to keep in mind that recovery from a traumatic brain injury can be very slow. Sometimes several days can go by without seeing any major visible change. This is not unusual, and it is best to ask the health-care providers if any changes have occurred. It is also important to try to get enough rest and nutrition while waiting for the patient to recover. It is normal to feel frustrated, overwhelmed, lonely and worried. Sometimes a friend, or support group can help. Before your stress gets out of control, tell someone who can help.
An excellent source for further information or support is
Brain Injury Association
1776 Massachusetts Ave.
NW Suite 100 Washington, DC, 20036