Snapshot A 28-year-old man presents to the emergency department after a motor vehicle accident. The patient has a Glasgow score of 10. After airway, breathing, and circulation is secured, he undergoes a head CT without contrast, which demonstrates a lens-shaped hyperdensity that does not cross the suture line. There is a mild midline shift demonstrated on head imaging. Neurosurgery was consulted and plans are made for a craniotomy and hematoma evacuation. Introduction Overview an epidural hematoma is a condition characterized by arterial bleeding developing in the potential space between the dura and the skull treatment includes surgical decompression with a craniotomy Epidemiology Risk factors head injury Etiology Middle meningeal artery tear Pathoanatomy the middle meningeal artery is a branch of the maxillary artery serves to supply the skull and the dura head injury leads to a tear in the middle meningeal artery, leading to rapid filling in the epidural space, which compresses the parenchyma of the brain brain parenchymal compression can lead to transtentorial brain herniation the petrosal bone is thin, which can be easily fractured, resulting in a middle meningeal artery tear Presentation Symptoms/physical exam note that there are a spectrum of clinical presentations transient loss of conciousness "lucid interval" characterized by recovery of the patient's conciousness, followed by clinical deterioration due to expansion of the hematoma that's under arterial pressure expansion of the hematoma can result in ipsilateral dilated pupil (secondary to uncal herniation) Cushing reflex (e.g., hypertension, bradycardia, and respiratory depression) Imaging CT head without contrast indication imaging study of choice due to its rapidity in obtaining images and easy identification of the hematoma findings lens-shaped, biconvex hyperdensity that does not cross the suture lines Differential Subdural hematoma differentiating factors crescent-shaped hemorrhage seen on CT head without contrast Subarachnoid hemorrhage differentiating factors thunderclap headache hyperdensity in the subarachnoid space on CT head without contrast Treatment Operative craniotomy and hematoma exacuation indication mainstay of treatment in symptomatic acute epidural hematomas Complications Transtentorial herniation Respiratory failure and death