Epidural hematoma differential diagnosis

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, 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 sudden headache for example:

Onset	Disease	Symptoms		Gold Standard Test	CT/MRI Findings	Other Investigation Findings
		Headache Characteristics	Associated Features
Sudden	Epidural hematoma	Dull Throbbing One sided or all around	Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness	CT scan without contrast	Biconvex lens shaped hematoma which expand inward toward the brain rather than along the inside of the skull	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.
	Subdural hematoma	Gradually increasing headache and confusion	Personality change Seizures Nausea and vomiting Loss of consciousness	CT scan without contrast	Crescent-shaped hematoma with a concave surface away from the skull	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.
	Subarachnoid hemorrhage	Thunderclap headache Worst headache in life Pulsates towards the back of the head	Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness	CT scan without contrast	Hyperattenuating material is seen filling the subarachnoid space Most commonly around the circle of Willis Small amounts of blood may sometimes be appreciated pooling in the interpeduncular fossa	MRI is sensitive to subarachnoid blood and is able to visualise it well in the first 12 hours typically as a hyperintensity in the subarachnoid space on FLAIR Lumbar puncture is performed to evaluate the cerebrospinal fluid for the presence of red blood cells and xanthochromia
	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.
						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.
	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."

• Brain contusion