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Epidural bleeding often manifests itself as a brief fainting condition followed by headache.

At a epidural bleeding in the head blood pours into the space between Skull bones and the extreme Meninges, the dura mater. It can also be used as a Epidural hematoma because it is a bruise (Hematoma) in the epidural space. The epidural space also exists in the Spine, between the vertebral canal and the dura mater, however, epidural bleeding occurs much more frequently intracranial (in the head) as spinal (in the Spine) on.

The meninges are made up of three layers: the Pia mater lies directly on the brain tissue and also encloses it in its furrows (sulcus), the Arachnoid mater is in the middle and lies superficially on the brain as a whole and the Dura mater is solid with that Skull bones connected and forms the outer shell.

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Located in the spine Adipose tissue in the Epidural space - The dura mater is only fused with bones in a few places. The tasks of the meninges consist in the protection and stabilization of the brain, as well as the delimitation of the Cerebral water (Liquor) from the neural tissue. Bleeding is caused, whether arterial or venous, in most cases traumatic, that is, by an accident. Any bleeding in the head is an injury that needs urgent attention as life-threatening conditions can develop.

Causes of Epidural Bleeding

A epidural bleeding mostly depends on one traumatic brain injury together, which is usually caused by an accident. The most common circumstances are car accidents, as the impact often injures the head and the skull bone can break.

In the Bleeding origin two different types can be distinguished: arterial and venous bleeding. The arterial bleeding mostly pours out of the artery that supplies the meninges - the Meningeal artery media (from the maxillary artery, a branch of the external carotid artery). It is more common than venous bleeding and is associated with one increased blood flow connected. Most of the time it arises Epidural hematoma in the area of Temporal lobe, on the side of the brain. In the case of a venous hematoma, the blood seeps into the resulting fracture gap. This is more likely to be observed in children and the clinical picture develops only very slowly, since torn veins do not bleed as much.

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A spinal epidural hemorrhage can have causes other than traumatic events. Malformations of the vascular system in or around the Spinal cord, Tumors or problems with the coagulation system can lead to an epidural hematoma. The coagulation system can be caused, for example, by genetic defects or diseases, but also by treatment with Blood thinners (Anticoagulants, anticoagulants).

Symptoms

Typical of acute arterial epidural hemorrhage in the brain is the appearance of symptoms after a brief period Faint (syncope). After regaining consciousness, a phase of symptomlessness can follow in which the patient clears up and only about a headache complains. These worsen dramatically in the course and are caused by and possibly due to the patient's psychological restlessness nausea and Vomit accompanied.
In the course of the development of the symptoms, it comes back to Clouding of consciousness, the patient becomes drowsy and less responsive. Within the first two hours after the injury, the bleeding will progressively expand increasing compression of parts of the brain and nerves.

The pressure on the oculomotor nerve and the pupil on the bleeding side enlarges (homolateral mydriasis). This is how it comes to Movement disorders or Paralysis on the opposite side of the body (contralateral hemiparesis). Seldom also occur chronic epidural bleeding on. The symptoms develop very slowly and can creep in over weeks to months. Patients report constant headaches and Attacks of dizziness, often appear confused, unoriented and dazed.

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In elderly patients this can also be signs of an emerging dementia This leads the doctor to take the wrong diagnostic path and sometimes allows the correct diagnosis of epidural bleeding to be made late.

There are special symptoms to be observed in small children. Epidural hematomas are not uncommon at a young age, even after falling from a small height. However, the skull bone is sometimes relatively flexible because of the Fontanelles the children are not yet locked. The first disturbances of consciousness therefore only set in 6 to 12 hours after the accident. Due to the relatively large head of children, the blood loss in the epidural space can take on relevant proportions. It can too Anemia (Anemia) and related Drop in blood pressure come.

For more information, also read: Cerebral hemorrhage symptoms

If the bleeding does not occur intracranially, but in the area of ​​the spine, the clinical picture changes fundamentally.
The awareness is here unaffected and the patient is usually clear if there is no additional impairment of the brain (which may be possible in the event of an accident or the like).
Mostly it comes to Pain at the site of the bleeding and in the further course to corresponding failures below the injured area.
This can lead to a complete or incomplete paraplegic syndrome in which the patient loses the ability to move, among other things.

Complications

If the brain is not relieved of pressure and the epidural bleeding continues to spread, this can happen life-threatening complications arise. So it can through the extreme space occupation to the so-called Entrapment Syndrome come. There are two possible locations. In the upper entrapment, the temporal lobe is placed under the meninges Tentorium cerebelli (in German "cerebellar tent") pressed. This is usually due to this Cerebrum (Telencephalon).

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The relocation leads to bruise of Diencephalon (Diencephalon), which controls vital processes. The impairment of this can lead to the death of the patient. Also run nearby Nerve tractsthat control the movement of the body and, in the event of impairment, one paralysis convey. The lower entrapment is just as dangerous. The pressure from above Cerebellum (Cerebelli) pushed into the foramen magnum, which is located on the underside of the skull bone.
Through this the brain is, more precisely that Medulla oblongata, connected to the spinal cord. Of the Brain stem like the diencephalon, contains vital control centers of the body, such as the respiratory center. If the medulla oblongata is compressed by the cerebellum, this is followed by the Apnea and ultimately the patient's death.

Diagnosis

When it comes to diagnostics, the treating physician actually has only two options. He can correctly interpret the clinical symptoms or use imaging techniques. Clinically, there are certain characteristics that are specific to epidural bleeding.
This includes interval symptoms, with a symptom-free pause between the first fainting (syncope). The second phase can develop into a comatose state.

Furthermore, an unequal pupil size (anisocoria), clouding of consciousness with impaired attention and half-sided symptoms, i.e. a motor or sensory disorder on one half of the body, indicate epidural bleeding. It is important that the symptoms are likely to worsen progressively, as the hematoma increases in volume and restricts brain function.

In addition to these features, an abnormal finding on the physical examination, especially in the reflex status, can indicate an existing injury.
The imaging procedure of choice when epidural bleeding is suspected is computed tomography (CT). About 90% of the hematomas can be confirmed by the CT image. The bleeding is light (hyperdense = high density), sharply demarcated from the surrounding tissue and lenticular (biconvex) in width.

The midline of the brain, which lies between the left and right hemispheres, is shifted towards the healthy side because the hematoma pushes the brain tissue away. The described phenomenon can be found in most cases in the area of ​​the temporal and / or parietal lobe, that is, on the side of the brain. In addition to a CT, magnetic resonance imaging (MRI), in which the shape of the bruise has the same characteristics, can also be useful.

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The method of first choice if spinal epidural bleeding is suspected is an MRI. In addition, the coagulation values ​​and the number of platelets in the blood can be checked in order to examine the origin of a mass shown.

Local effect

brain

In adults, the human skull is no longer able to adapt to changes in pressure. The intracranial pressureDue to changes in the volume of tissue, blood or liquor, a dangerous situation can arise relatively quickly. Most stress conditions will go through Increase in tissue volume caused, whereby in mild cases a compensation by CSF displacement in the spinal canal of the spine is possible. With epidural hemorrhage, the brain does not swell, but the volume of the liquor and the vascular system remain the same, which is why the symptoms relate to the brain parenchyma (brain tissue).

Through the increased intracranial pressurethat sinks Blood circulation of the tissue progressively. Through this so-called Underperfusion, brain edema, a swelling of the brain tissue develops. In addition to the actual cause of the pressure increase, namely the epidural bleeding, there is also the increase in volume due to the formation of the edema. Will the Neurons not supplied with blood, they die off after a while. Since nerve cells in the brain cannot be reproduced in this context, irreversible damage to the brain occurs, which can manifest itself in various ways. Cerebral edema can also do that Entrapment Syndrome which has already been explained under the complications.

Spine and spinal cord

Due to the relatively tight space in the spine, bleeding into the spine results in a mass that affects the Spinal cord Pressure. This can withstand light pressure unscathed, even if the patient may be clear pain symptoms describes. Nerve tracts run in the spinal cord that are responsible for controlling a wide variety of systems.

Depending on the level at which the compression takes place, deficits also develop in the individual systems. While in the chest area, at the level of the thoracic vertebrae, the arms are also affected in the case of motor failures, the paralysis is limited in the case of bleeding at the level of the lumbar or lumbar vertebrae Sacral vertebrae in the lower back mostly just on the legs. Not only the motor skills can be affected when the spinal cord is compressed. Sensitive failures are also signs of excessive pressure. Other body functions, such as the ability to hold or urinate, can also be affected. Damage to the spine itself from epidural bleeding is unlikely, as not enough force can be exerted to damage a healthy bone. Bleeding occurs in the injured area whirl (A traumatically triggered spinal epidural hemorrhage can be accompanied by a bony injury in the same area), in the worst case further damage cannot be ruled out.

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Frequency distribution

Since that Epidural hematoma in most cases with one traumatic brain injury is related, the frequency distribution is based on the presence of this traumatic injury. Most traumatic brain injuries are caused by car accidents, and most of the car accidents are caused by the elderly. This means that the majority of patients who suffer from epidural bleeding are younger than 40 years old.

There is also one unequal gender distribution. Men are generally considered to be more willing to take risks and more aggressive in road traffic, which is also reflected in the proportion of serious car accidents caused by men. For every 5 men with epidural bleeding, there is only one woman with the same injury.

Any cerebral haemorrhage of a traumatic nature will accumulate Alcoholics observed. The permanently intoxicated state often leads to falls in which, due to lack of reflexes, they fall unprotected on the head and injure themselves. Since there is usually also a Liver disease is present, in which substances that are actually important for blood clotting should be produced, this circumstance generally aggravates bleeding and promotes its development.

therapy

Epidural bleeding is one (both intracranial and spinal) absolute emergency. If possible, you must be admitted to hospital immediately. Therapy of choice is one neurosurgical operation. The skull bone is first drilled open as quickly as possible (Trepanation), to the Pressure from brain tissue to take, which is built up by the increasingly larger bleeding.

If this does not happen, the tissue will perish with permanent damage and even death of the patient. If the brain could be relieved, the bruise is cleared - the still liquid blood is sucked off and the already clotted blood is scraped off. This is also how it is handled with spinal bleeding. The vessel causing the problem should be found and closed again in order to prevent further bleeding and reopening of the operating area. In chronic forms can be repeated Operations be necessary.

forecast

Due to the severity of the consequential damage caused by an epidural hematoma, there is a relatively high mortality rate. Despite the attempt to treat the bleeding surgically, the patient can die. About 30 to 40% of injuries are fatal. In around 20% of those affected, the bleeding has already caused such damage to the brain that a permanent disability exists, but the patient's life can be saved. On average, half of the patients can be saved without permanent consequential damage.

In contrast to the sometimes poor prognosis for deeper bleeding in the spinal cord, it is more positive for epidural bleeding. Symptoms usually go away completely with quick treatment. Cross-sectional symptoms that are already developing can also recede completely.

Read more on the topic: What are the chances of recovery after a cerebral hemorrhage?


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