Extradural Haemorrhage Flashcards
What is an extradural haemorrhage (EDH)?
It is an intracranial haemorrhage within the extradural space, which is located between the dura mater and the inner surface of the skull
Describe the pathophysiological consequence of extradural haemorrhages
There is compression of local brain structures and a rise in intracranial pressure
If intracranial pressure continues to rise, midline shift and tentorial herniation may occur – leading to brainstem death
Which artery is most commonly associated with extradural haemorrhages?
Midline meningeal artery (MMA)
What is the most common cause of a middle meningeal artery rupture?
Low impact skull trauma in the temporoparietal region, specifically affecting the pterion
In most cases, a temporal skull fracture is associated
What is the pterion?
It is the anatomical landmark where the parietal, frontal, sphenoid and temporal bones fuse
Which artery underlies the pterion?
Middle meningeal artery
What are the two risk factors associated with an extradural haemorrhage?
Male Gender
Young Age, 20 – 30 Years Old
What are the eleven clinical features of extradural haemorrhage?
Immediate Consciousness Loss > Injury
Lucid Interval
Progressive Decreasing Consciousness Level
Headache
Confusion
Hemiparesis
Paraesthesia
Oculomotor Nerve Palsy
Hyperreflexia
Babinski’s Sign
Cushing’s Reflex
How long following the initial head injury do individuals experience a decreasing conscious level? Why?
It usually takes several hours
It is related to the effects of increased intracranial pressure due to the expanding haematoma and brain herniation
What is the clinical feature associated with oculomotor nerve palsy?
Fixed dilation of the ipsilateral pupil
What is Babinski’s sign?
Upgoing plantar reflex
What is Cushing’s reflex?
It is the physiological response to raised ICP, in order to improve perfusion of the body
What are the triad of clinical features associated with Cushing’s reflex?
Hypertension
Bradycardia
Irregular breathing pattern
What are the two investigations used to diagnose extradural haemorrhages?
Skull X-Ray
CT Scan
How are skull x-rays used to investigate extradural haemorrhages?
They are not used in the investigation of extradural haemorrhages
However, it is important to note that in cases where a skull fracture is identified on a skull x-ray, a CT scan should be performed urgently to assess for evidence of an extradural haemorrhage
What is the gold standard investigation used to diagnose extradural haemorrhages?
CT scan
What are the four features of extradural haemorrhages on CT scans?
Bi-Convex Lemon Hyperdense Mass
Mass Limitation To Suture Lines of Skull
Midline Shift
Brainstem Herniation
Why do extradural haemorrhages appear lemon-shaped on CT scans?
This is due to the haematoma being forced to expand medially due to inability to expand past the suture lines of the skull
What are the five initial management options of extradural haemorrhages?
ABCDE Approach
Coagulation Correction
Prophylactic Antibiotics
Anticonvulsant Medications
Intracranial Pressure Reduction Agents
What coagulation correction is recommended in extradural haemorrhages?
In cases where individuals are on anticoagulants, they should receive reversal agents to prevent further bleeding
OR
In cases where individuals have coaguloapathy, haematology advice is required to determine whether transfusions are required
Why are prophylactic antibiotics used to manage extradural haemorrhages?
They reduce the risk of intracranial infection
Why are anticonvulsants used to manage extradural haemorrhages?
They reduce the risk of seizure development
Name two anticonvulsants used to manage extradural haemorrhages
Levitracetam
Phenytoin
Name two drugs used to reduce intracranial pressure
IV mannitol
Barbiturates
When is conservative management of extradural haemorrhages recommended?
In cases of small haemorrhages with no neurological deficits
What is the conservative management option of extradural haemorrhages?
Cautious clinical and radiological observation
What are the two surgical management options of extradural haemorrhages?
Burr Hole Craniotomy
Craniotomy
What is burr hole craniotomy?
It involves formation of a small hole within the skull
This enables insertion of a suction tube to evacuate the haematoma
What is the first line surgical management option of extradural haemorrhages?
Craniotomy
What is craniotomy?
It involves surgical removal of a skull section, with evacuation of the haematoma and ligation of the ruptured blood vessel
What are the five complications of extradural haemorrhages?
Intracranial Infection
Cerebral Ischaemia
Seizures
Hydrocephalus
Brainstem Injury
