Case Report VI

Epidural Hematoma

Compiled by:
DHITA KEMALA RATU 1102009075
NABILA TODA 1102009169

Supervisor:
Dr.. Herry Setya Yudha Utama, Sp.B, MHKes, Finacs

DEPARTMENT OF SURGERY
Arjawinangun Hospital
Oktober 2013

CASE PRESENTATION
I.

IDENTITY

Name

: Tn. Syahroni

Age

: years

Sex

: Man

Religion

: Islam

Address

: Klangenan

II.

HISTORY TAKING (Autoanamnesis and Alloanamnesis)

Main complaint

Additional complaints :

difficult to communicate since 6 hours SMRs

headache, dizziness, nausea, reduced visibility

Right Now History of Disease

Patients come to hospitals with complaints Arjawinangun difficult to

communicate since 6 hours SMRs. 7 hours before admission to hospital, patients had a
single accident with a motor bike. When an accident occurs, the patient is not using a
helmet. After the accident, the patient had suffered a fainting for 10 minutes. Once
aware, patients have difficulty communicating, slurred speech, and as people
sleepy. Patients also complain of headache right side, dizziness, nausea, and reduced
visibility. Complaint denied vomiting, complaints of weakness on the side of the body is
also denied.
Past history of disease

History have had the same complaints previously denied

Family history of disease

No family member who suffers from the same disease as the patient

III.

PHYSICAL EXAMINATION

General state

Moderate sick

Awareness

Apathetic

Vital signs

TD

: 140/90 mmHg
N

: 96 x / min

RR

: 18 x / min

: 36.5 C

Head

Normocephal., swallow a/r temporal dextra

Eye

Conjunctiva anemis
Sclera jaundice

(- / -)
(- / -)

Hematoma of the conjunctiva OD

OD lid hematoma superior and inferior
Thoracic
Cor

Pulmo

Inspection

: Cardiac Iktus not visible

Palpation

: Iktus apex was not palpable

Percussion

: Dim, normal heart borders

Auscultation

: I-II regular BJ, BJ additional (-)

Inspection

: Symmetrical, in static and dynamic conditions.

Palpation

Vocal fremitus on the right and left hemithorax

symmetrical palpable.

Abdomen

Extremity

Percussion

: Sonor on both hemithorax.

Auscultation

: Vesicular + / + N, crackles - / -, wheezing - / -

Inspection

: Flat

Palpation

: Supple, NT / NK / NL -/-/-, liver and spleen not enlarge

Percussion

: Tympanic abdomen around the field

Auscultation

: peristaltic normal

Above

: Edema - / -, cyanosis - / -

Under

: Edema - / -, cyanosis - / -

Localist Status a / r temporal dextra

Inspection

: Blisters appear along dextra temporal hematoma in the region of the

measuring 4x3 cm, looks hyperemia, pus (-), blood (-)

Palpation : Palpable lump with soft consistency, tenderness (+), pain (+), crepitation not
exemnined

IV. SUPORTIVE EXAMINATION

Full Blood Lab

Leukocyte

: 15,100 mm

Hb

: 12.3% g / dl

Ht

: 36.7% g / dl

Plt

: 277,000 mm

CT scan of the head

Impression

: Epidural Hematoma temporal dextra

VI. DIAGNOSTIC
Moderate Head Injury with epidural hematoma

VII. Differential Diagnostic

Subdural hematoma

VIII. THERAPY

Medikamentosa:

IVFD RL 20 TPM
Cefotaxime 2x1 gr
Piracetam 3x1 gr
Neurobat 2x1 ampoule
Kalnex 3x500 mg

Operative: craniotomy

IX. Prognosis
- Quo ad Vitam
- Quo functionam ad

: dubia
: dubia

Epidural Hematoma
Epidural hematoma is a type of intracranial bleeding most often occurs due to
fracture of the skull. Olek cover the brain in the skull is rigid and hard. The brain is also
surrounded by something that is useful as a wrapper which is called the dura. Its function
is to protect the brain, covering the venous sinuses, and forming periosteum tabula
interna.

I. INTRODUCTION
Epidural hematoma is a type of intracranial bleeding most often occurs due to
fracture of the skull. Olek cover the brain in the skull is rigid and hard. The brain is also
surrounded by something that is useful as a wrapper which is called the dura. Its function
is to protect the brain, covering the venous sinuses, and forming periosteum tabula interna
.. When one gets a great impact to the head is likely to form a hole, the movement of the
brain may cause erosion or tearing of the blood vessels that surround the brain and the
dura, when the blood vessels tear, blood accumulates in the space between the dura and
the skull, the state inlah known by a butane epidural hematoma.
Epidural hematoma as a neurological condition that is usually associated with the
emergency and linear fracture that decides larger arteries, causing bleeding. Venous
epidural hematoma associated with vein tearing and progresses slowly. Arterial hematoma
occurred in the middle meningeal artery located beneath the temporal bone. Bleeding into
the epidural space, then if there is bleeding artery hematoma will happen quickly.

II. INCIDENCE AND EPIDEMIOLOGY

In the United States, 2% of cases of head trauma resulting in epidural hematoma
and approximately 10% resulting in a coma. International is the frequency of occurrence

of epidural hematoma is similar to the incidence in the United States are at risk
Serikat.Orang EDH is the parents who have problems walking da n frequent falls.
60% of patients with epidural hematoma is under 20 years of age, and rarely
occurs in less than 2 years of age and above 60 years. Increased mortality rate in patients
aged less than 5 years and more than 55 years.More common in males than in peremp uan
with 4:1 ratio.
Types:
1. Ut ak epidural hematoma (58%) bleeding from an artery
2. Subacute hematoma (31%)
3. Cronic hematoma (11%) of venous bleeding

III. Etiology
Epidural hematoma can happen to anyone and any age, some circumstances that
can cause an epidural hematoma is as clashes in head-on motorcycle crash. Epidural
hematoma caused by trauma to the head, which is usually associated with a skull fracture
d an artery laceration.

IV. ANATOMY OF THE BRAIN

The brain is protected from injury by the hair, skin and bones wrapped, without
this protection, soft brain that makes us like it is, will be susceptible to injury and
damage. In addition, once damaged neurons, can not be repaired anymore. Head injuries
can result in big disaster for someone. Most problems are the direct result of a head
injury. These effects should be avoided and is found as soon as possible from the medical
team to avoid a series of events that lead to mental disorders da n physical and even death.
Right at the top of the skull located aponeurotika galea, a fibrous tissue, dense can
move freely, which memebantu absorb the force of external trauma. In between the skin
and galea there is a layer of fat and membrane layer in which mngandung-pembuluih large
vessels. When the tear is difficult to hold a vessel vasoconstriction and can cause
significant blood loss in patients with lacerations of the scalp. Just below the galea are
subaponeurotik space containing veins and diploika emisaria. These vessels can emmbawa

infection of the scalp all the way into the skull, which clearly shows the importance of
cleansing and debridement of the scalp galea s eksama when torn.
In adults, the skull is a tough room that is not possible intracranial
extension. Bone is actually composed of two walls or a tabula separated by a hollow
bone. Outside wall SEBIT tabula externa, and the inner wall called the tabula
interna. Structure and thus allows a force greater isolation, with a lighter weight. tabula
interna containing grooves berisiskan anterior meningeal artery, media, and p0osterior. If
the skull fracture caused tekopyaknya one of these artery-artery, arterial bleeding in
akibatkannya, who were buried in the epidural space, can manimbulkan fatal
consequences unless in tem ukan and treated promptly.
Another patron was meninges lining the brain. The third layer of the meninges is
the dura mate r, arachnoid, and pia mater:
1. Cranial dura mater, the outer layer is thick and strong. Consists of two layers:
- Endosteal layer (periosteal) outer periosteu m is formed by wrapping in Calvary
- Inner meningeal layer is a strong fibrous membrane that goes on in the foramen
magnum with the dura mater spinalis y ang spinal cord wrap
2. Arachnoidea cranial mater, a layer between y ang resembles a spider's web
3. Cranial pia mater, the innermost layer containing many fine blood vessels.

Figure 1. Anatomy Head

V. Pathophysiology
On epidural hematoma, bleeding occurs between the skull and the dura
meter. Bleeding is more common in the temporal region when one branch of middle
meningeal artery was torn. This often occurs when the tear fracture te ngkorak in the area
concerned.
Hematoma can also occur in the frontal or occipital aerah d. Meningeal arteries
that go into the skull through the foramen spinosum and the road between durameter and
bones on the surface and the os temporale.Bleeding occurs causing an epidural hematoma,
hematoma will release the pressure by further durameter skull hematoma grew sehing ga.
Hematoma enlarged in the temporal region causing pressure on the brain temporal lobe
towards the bottom and inside. This pressure causes the medial lobe herniate below the
rim tentorium. This situation led to the onset of neurologic signs d apat known by the
medical team. (1)
Pressure of herniation unkus pda artery circulation which take care of the reticular
formation in the medulla oblongata causing loss of consciousness. In this place there is a
third cranial nerve nuclei (okulomotorius).Pressure on the nerves resulting in dilation of
the pupil and eyelid ptosis. Pressure on the corticospinal path that runs up in this region,
causing weakness of the contralateral motor responses, hyperactive or very fast reflexes,
and positive Babinski sign.
With the ever growing hematoma, the entire contents of the brain will be pushed
towards the opposite, causing major intracranial pressure. Arise further signs such as
increased intracranial pressure decerebrate rigidity and impaired vital signs and respiratory
function
Because this bleeding from an artery, the blood will be pumped out to continue
growing bigger and bigger. When the head of the patient may be dropped or bumped and
promptly fainted briefly regained consciousness. Within a few hours, the patient will feel
pain progersif head become heavy, then gradually decreased consciousness. The period

between the two during the patient's loss of consciousness unconscious after an accident is
called lucid interval. The phenomenon of lucid interval occurs because the primary injury
is mild epidural hematoma. If the primary injury subdural hematoma hampi r always
heavy or epidural hematoma with severe primary trauma lucid interval does not occur
because the patient is unconscious immediately and have never experienced conscious
phase.

Source of bleeding:
meningeal artery (lucid interval: 2-3 hours)
Sinus duramatis
Diploe (mengisis Kalvaria cranial hole) that contains a. diploica and venous
diploica
Epidural hematoma is the most emergency cases in neurosurgery as fast as
durameter progresifitasnya firmly attached to the suture so immediate urge to herniation of
brain parenchyma lead easily trans and infra tentorial.Karena that every patient with head
trauma who complained of head pain that lasts a long time, let alone progressively become
heavy, must be cared for carefully checked da n.

VI. CLINICAL
A very prominent symptom awareness is progressively decreased. Patients with
this condition often appears bruising around the eyes and behind the ears. Often also
seemed a discharge on the nose or ear. Such patients should be observed carefully.
Everyone has a collection of symptoms that result from a variety of head
injury. Many symptoms that appear when occuri bersaman in head injury. G ejala which
often appear:
Impairment of consciousness, can be up to coma
Confused
Blurred vision
It's hard to talk
Headache great

 discharge of blood from the nose or ears

It appears that adalam wounds or scratches on the scalp.
Nausea
Dizziness
Sweating
Pale
Pupil anisokor, the ipsilateral pupil became dilated.

Figure 2. Epidural Hematoma

At this stage of consciousness before stupor or coma, can be found hemiparese or

focal epileptic seizures. On its journey, it will reach a maximum pupil dilation and
reaction to light at the beginning is still positive to negative. This is the sign of tentorial
herniation has occurred. There is also a rise in blood pressure and bradycardia. In the final
stage, decreased consciousness to coma in, also had contralateral pupil dilation until both
pupils showed no reaction to light again which is a sign of death. Respiratory symptoms
that

could

arise

next,

reflecting

the

disfung

rostrocaudal

brainstem.

If epidural hematoma accompanied with brain injuries such as bruising of the brain, free
interval will not be visible, while other signs and symptoms become blurred.

VII. DESCRIPTION OF RADIOLOGY

By CT-scan and MRI, intracranial hemorrhage due to trauma k epala more easily
recognizable.

Photos Plain Head

Plain on the head, we can not definitely diagnose as epidural hematoma. With
Antero-posterior projection (AP), lateral side of the traumatized on the movie to find a
bone fracture that cuts sulcus meningeal arteries.

Computed Tomography (CT-Scan)

CT-Scan examination can show the location, volume, effects, and potential for
other intracranial Cedara. At epidural usually on one part only (single) but can also occur
on both sides (bilateral), shaped bikonfeks, most often in the temporoparietal
region. Homogeneous density of blood (hiperdens), demarcated, midline pushed to the
contralateral side. There is also a fracture line in the area of epidural hematoma, which is a
high density in the acute stage (60-90 HU), characterized by the stretching of an artery.

Figure 3. CT Scan picture epidural hematoma

Magnetic Resonance Imaging (MRI)

MRI will describe the mass hiperintens bikonveks shifted dura mater, located
between the bones of the skull and the dura mater. MRI can also depict boundary fracture
occurs. MRI is one of the selected type of examination untu k diagnosis.

VIII. DIAGNOSIS

1.Hematoma subdural
Subdural hematoma caused by pooling of blood between the dura mater and the
arachnoid. Acute subdural hematoma is clinically difficult to distinguish from an epidural
hematoma that develops slowly. Can be caused by severe trauma to the head that causes
the shifting of whole brain parenchyma and damage a bone. kortikalis. Usually
accompanied by bleeding brain tissue. CT-Scan picture subdural hematoma, fluid
retention appears that hyper ekstraaksial crescent-shaped dens.

Figure 4. Subdural Hematoma

Figure 5. CT Scan picture subdural hematoma

Subarachnoid 2.Hematoma
Subarachnoid hemorrhage occurs due to rupture of blood vessels in it.

Figure 6. Intracerebral Bleeding

IX. MANAGEMENT
Emergency Handling:
Decompress with simple trepanation
Craniotomy for evacuation of hematoma

Medical treatment

30 0 elevation head of the bed after making sure there was no spinal injury or

use a reverse Trendelenburg position to reduce intracranial pressure d improved its early
venous drainage.
-

Common treatment given to the head injury is dexametason group (with a

starting dose of 10 mg followed 4 mg every 6 hours), mannitol 20% (dose of 1-3 mg / kg /

day) which aims to address the cerebral edema that occurs but it is still controversy in
choosing which one is best. It is recommended to give prophylactic therapy with
phenytoin early (first 24 hours) to prevent the onset of epileptogenic focus and for longterm use can be continued with carbamazepine.
-

Tri-hydroxymethyl-amino-methane (THAM) is a buffer that can be entered

into the central nervous system and theoretically superior to sodium bicarbonate, in this
case to reduce intracranial pressure.
-

Barbiturates are used to transform and overcome inrakranial pressure

elevated and has a protective effect against ischemic brain from anoxia and usual dosage
applied was started with 10 mg / kg in 30 minutes and followed by 5 mg / kg every 3
hours and drip 1 mg / kg / h transform and achieve serum levels of 3-4mg%. (8)
Operative therapy
Operation is done when there is:
Volume hamatom> 30 ml (another library> 44 ml)
The state of the patient deteriorates
encouragement of diameter> 3 mm
Indication of operation in the field of neurosurgery is for life saving and saving
for the functional. If the goal for both the operation becomes operative emergenci. Usually
this situation in seb emergenci lesion persisted abkan by space.
Indications for life saving is if the lesion persisted volume space:
> 25 cc = prodded supra-territorial space
> 10 cc = prodded infratentorial space
> 5 cc = prodded thalamus space

While the indications of life saving evacuation was a significant period effect:
Decrease in clinical

 mass effect with volume> 20 cc with midline shift> 5 mm with progressive

clinical enurunan p.
epidural hematoma thickness> 1 cm with midline shift> 5 mm with progressive
clinical decline.

X. Prognosis
Prognosis depends on:
The location (infratentorial more ugly)
The amount of
Awareness of when entering the operating room.

If treated quickly, the prognosis is usually good epidural hematoma, due to

overall brain damage can be limited. The mortality rate ranges from 7-15% and 5-10% in
the case of disability. Very poor prognosis in patients mengal ami coma before surgery.

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