Extradural Haemorrhage

Question 1

Definition of EDH

Answer 1

Acute bleeding between the dura mater and the inner surface of the skull

Question 2

Aetiology of EDH

Answer 2

• Most commonly caused by SKULL TRAUMA
◦ Associated with a skull fracture in most cases
◦ Likely either temporal or parietal bone (Pterion) fractured, which can cause laceration of the middle meningeal artery
◦ The high arterial pressure strips the dura away from the skull
◦ Can also occur due to rupture of the middle meningeal vein or dural sinus involvement

Question 3

Pathophysiology of EDH

Answer 3

• As more blood being to leak, a lemon-shaped haematoma would form
• As the haematoma continues to increase in size, there would a rise in ICP.
◦ Without treatment, the raised ICP can cause midline shift and herniation of the brain
◦ Can then lead to brainstem death

Question 4

History and Examination of EDH

Answer 4

• Lucid interval: Typical of Extradural haemorrhage, describes a temporary improvement in patient’s condition after traumatic brain injury, then followed by sudden deterioration in state. May last a few hours to a few days
• Initial loss of consciousness: Usually immediately after injury, then likely followed by lucid interval
• Increasingly severe headache
• Nausea and/or vomiting
• Confusion
• Progressively decreasing level of consciousness

• Reduced GCS
• Hyperreflexia, spasticity, positive Babinskis sign
• Occulomotor nerve palsy
• Hemiparesis
• Cushing’s triad: Physiological response to rising ICP: Bradycardia, hypertension and deep/irregular breathing

Question 5

Investigations of EDH

Answer 5

• 1) CT Head: Gold standard, would see classic bi-convex mass (rather than banana shaped for SDH). May also see secondary changes such as midline shift and brainstem herniation if severe

• Capillary blood glucose: to rule out hypoglycaemia for dropping GCS
• ECG: check for arrhythmias
• Coagulation: baseline/ correct any coagulopathies

Lumbar puncture contraindicated due to raised ICP

Question 6

Treatment for EDH

Answer 6

• ABCDE approach: manage airway in unconscious patient
• Neurosurgical opinion: to see if surgical intervention is required. If haematoma large enough, can use trauma craniotomy (significant mass) or Burr hole. If source of bleeding located, can be controlled through ligation or cauterisation of the vessel

• Reverse and stop anticoagulation
• Temporary anti-convulsant medication: e.g Phenytoin due to increased risk of seizures post injury
• Prophylactic antibiotics: may be given if open skull fracture to reduce risk of intracranial infection
• Agents to reduce ICP: can give IV Mannitol to temporarily decrease ICP before surgery

Continue to monitor ICP and repeat CT scans for observation

Question 7

Complications of EDH

Answer 7

• Infection due to skull fracture
• Cerebral ischaemia typically next to haematoma
• Seizures
• Cognitive impairment
• Hemiparesis
• Hydrocephalus if ventricles are obstructed
• Brainstem injury

Question 8

Prognosis of EDH

Answer 8

Very good prognosis if there is early detection and evacuation of the haematoma
prognosis if there was a low GCS at presentation, pupil abnormalities, rigidity etc