Epidemiology

Frequency

Epidural hematoma complicates 2% of cases of head trauma (approximately 40,000 cases per year).
Spinal epidural hematoma affects 1 per 1,000,000 people annually. Alcohol and other forms of
intoxication have been associated with a higher incidence of epidural hematoma. The incidence has
remained stable over many years. [3]

International frequency is unknown, though it is likely to parallel the frequency in the United States.

Mortality/Morbidity

Mortality rate associated with epidural hematoma has been estimated to be 5–50%.

The level of consciousness prior to surgery has been correlated with mortality rate: 0% for awake
patients, 9% for obtunded patients, and 20% for comatose patients.

Bilateral intracranial epidural hematoma has a mortality rate of 15–20%.

Posterior fossa epidural hematoma has a mortality rate of 26%.

Race, sex, and age-related demographics

No racial predilection has been reported.

Intracranial and spinal epidural hematomas are more frequent in men, with a male-to-female ratio of
4:1.

Intracranial epidural hematoma is rare in individuals younger than 2 years.

Intracranial epidural hematoma is also rare in individuals older than 60 years because the dura is
tightly adherent to the calvaria.

Spinal epidural hematoma has a bimodal distribution with peaks during childhood and during the fifth
and sixth decades of life. Increasing age has been noted as a risk factor for postoperative spinal
epidural hematoma.

Pathophysiology

Epidural hematoma usually results from a brief linear contact force to the calvaria that causes
separation of the periosteal dura from bone and disruption of interposed vessels due to shearing stress.
Skull fractures occur in 85–95% of adult cases, but they are much less common in children because of
the plasticity of the immature calvaria. Arterial or venous structures may be compromised, causing
rapid expansion of the hematoma; however, chronic or delayed manifestations may occur when
venous sources are involved. Extension of the hematoma usually is limited by suture lines owing to
the tight attachment of the dura at these locations. Recent analyses have revealed that epidural
hematomas may actually traverse suture lines in a minority of cases. [2]

The temporoparietal region and the middle meningeal artery are involved most commonly (66%),
although the anterior ethmoidal artery may be involved in frontal injuries, the transverse or sigmoid
sinus in occipital injuries, and the superior sagittal sinus in trauma to the vertex. Bilateral epidural
hematomas account for 2–10% of all acute epidural hematomas in adults but are exceedingly rare in
children. Posterior fossa epidural hematomas represent 5% of all cases of epidural hematomas.

Spinal epidural hematoma may be spontaneous or may follow minor trauma, such as lumbar puncture
or epidural anesthesia. Spontaneous spinal epidural hematoma may be associated with
anticoagulation, thrombolysis, blood dyscrasias, coagulopathies, thrombocytopenia, neoplasms, or
vascular malformations. The peridural venous plexus usually is involved, though arterial sources of
hemorrhage also occur. The dorsal aspect of the thoracic or lumbar region is involved most
commonly, with expansion limited to a few vertebral levels.