Extradural Haemorrhage

Question 1

What is an extradural haematoma?

Answer 1

collection of blood in the extradural space (between skull + dura mater)

Question 2

Describe the aetiology of extradural haemorrhage

Answer 2

Almost always TRAUMA
typically LOW IMPACT e.g. fall/ blow to head
Collection often in temporal region as thin skull at pterion overlies the middle meningeal artery where parieto-temporal fractures cause damage (+ thus is vulnerable to injury)

Question 3

What is the pterion?

Answer 3

Anatomical landmark where the parietal, frontal, sphenoid + temporal bones fuse.
MMA lies underneath

Question 4

Describe the epidemiology of extradural haemorrhage

Answer 4

~2% of all head injuries
M>F
Most commonly seen in YOUNG ADULTS (20-30s)

Question 5

Describe the time frame of symptoms of extradural haemorrhage

Answer 5

1. Immediate brief LOC
2. Temporary recovery “lucid interval”
3. Progressive deterioration in conscious level

This pattern is not always seen

Question 6

List 3 symptoms of extradural haemorrhage

Answer 6

Headache
N+V
Progressive drowsiness

Question 7

List 6 signs of extradural haemorrhage

Answer 7

Reduced consciousness (GCS)
Focal neurological deficit e.g. weakness
Tenderness of the skull (in context of injury)
Hyperreflexia + spasticity
Upgoing plantars (Babinski’s sign)
Cushing’s triad

Question 8

What is Cushing’s triad?

Answer 8

Physiological response to raised ICP
Bradycardia
HTN
Irregular breathing.

Question 9

What sign is indicative of herniation?

Answer 9

Fixed + dilated pupil
Uncus of temporal lobe herniates around tentorium cerebelli
Causes compression of parasympathetic fibres of CN3

Question 10

What may cause ipsilateral weakness in EDH? What is this known as?

Answer 10

Compression of the contralateral cerebral peduncle
Kernohan’s phenomenon

Question 11

What bedside investigations are required in EDH?

Answer 11

Monitoring GCS
Blood glucose (r/o hypoglycaemia as cause of reduced consciousness)
ECG (r/o heart block as cause of bradycardia)

Question 12

What bloods are required in EDH?

Answer 12

FBC: detect anaemia + thrombocytopenia
U+Es: r/o electrolyte abnormalities which may contribute to low GCS
Coagulation: r/o underlying coagulopathy
G+S: if going to theatre
Cross match: for blood products

Question 13

What is the gold standard investigation to be performed for EDH?

Answer 13

Urgent CT Head

(non-contrast)

Question 14

Describe the appearance of extradural haemorrhage on CT

Answer 14

“Lemon shaped haematoma”

Hyperdense bi-convex mass: haematoma expands medially due to being unable to expand past the points at which the dura is tightly bound to the suture lines of the skull.

Question 15

Name 2 possible secondary features on a CT head in EDH

Answer 15

Midline shift
Brainstem herniation

Question 16

Give a risk factor for extradural haemorrhage

Answer 16

Bleeding tendency
E.g. haemophilia, anticoagulant therapy

Question 17

What features may allow for conservative management of EDH?

Answer 17

<30cm3 with
low thickness,
minimal midline shift +
GCS >8 w/o any focal neurological deficits

Question 18

Which feature indicates a patient should be managed surgically regardless of other factors?

Answer 18

> 30cm3

Question 19

Describe medical management of EDH

Answer 19

Neuroprotective measures
ICP Mx
Seizure Mx

Question 20

Describe conservative management of EDH

Answer 20

Serial CT imaging + close observation

Question 21

What neuroprotective measures can be employed in EDH?

Answer 21

Normoxia (maintain normal O2 sats)
Normocarbia (CO2 can be altered it ventilated)
Normothermia (maintain normal temp)
Adequate sedation + paralysis
ICP monitoring: < 22 mmHg

Question 22

What can be used for ICP management in EDH?

Answer 22

Hypertonic saline 2.7%
(Mannitol not commonly used but may still be in guidelines)

Question 23

What can be used for seizure management in EDH?

Answer 23

Levetiracetam (Keppra)

Question 24

What is definitive treatment of EDH?

Answer 24

Craniotomy + evacuation of the haematoma
(Trauma or Burr hole craniotomy)

Question 25

Describe post-op management of EDH

Answer 25

Observation on neuro-critical care or HDU with close neuro-obs + routine post-op CT scans

Question 26

What is the prognosis of EDH?

Answer 26

Good if treated rapidly
Poor if surgical Mx delayed

Question 27

List 5 complications of EDH

Answer 27

Infection
Cerebral Ischaemia
Seizures
Hemiparesis
Cognitive impairment