Extradural Haemorrhage

Question 1

Define extradural haemorrhage. What is it also known as?

Answer 1

Epidural hematoma is when bleeding occurs between the dura mater and the skull.

Question 2

Who is extradural haemorrhage most common in?

Answer 2

• Males
• Typically in young adults due to head trauma
• Makes up 1-4% of head injuries
• Ocassionally as a result of bleeding disorder/ vessel malformation

Question 3

Where does epidural haematoma most commonly occur and why?

Answer 3

Pterion region - overlying the middle meningeal artery , which is weak and prone to injury

Only 20-30% of epidural haematomas occur outside the region of the temporal bone

Question 4

What is the aetiology of an epidural haematoma? Which artery commonly ruptures?

Answer 4

Blood accumulates between bone and dura

• Traumatic skull fracture
• Often fractured temporal or parietal bone causing laceration of the middle meningeal artery and vein (after trauma to temple)
• Any other tear in dural venous sinus

Question 5

What is typical of extradural bleeds?

Answer 5

Lucid interval - temporary improvement in a patient’s condition after a traumatic brain injury, after which the condition deteriorates

Question 6

Describe the sequence of events following an extradural bleed.

Answer 6

• Head injury causes no loss of consciousness or initial dorwsiness that resolves quickly
• Lucid interal may last few hours to a few days
• Falling GCS and rising ICP follows
• Increasingly severe headache, vomiting, confusion, serizures, +/- hemiparesis, UML signs.
• Later if bleeding continues ipsilateral pupil dilate, coma deepens, bilateral limb weakness
• Irregular and deep breathing, hypertension, bradycardia
• Coma
• Death due to respiratory arrest

Question 7

What is Cushing’s triad?

Answer 7

This is caused by Cushing’s reflex which is a physiological neurological response to raised ICP. Seen in terminal stages of head injury.

In the case of epidural hematoma in the posterior cranial fossa, tonsillar herniation causes Cushing’s triad:

1. systolic hypertension (widening pulse pressure)
2. bradycardia,
3. and irregular breathing (due to brainstem compression)

Question 8

What would you differentials be for extradural haematoma?

Answer 8

TIA

Intracranial mass

Brain abscess

Question 9

What investigations would you do for suspected epidural haematoma? What does it look like on CT? What is contraindicated?

Answer 9

CT - shows BICONVEX/lens-shaped haematoma (a more rounded shape than subdural haematoma as the tough dural attachments to the skull keep it more localised)

Skull XR - may shows fracture lines along course of middle meningeal vessesl

LP is CONTRAINDICATED

Question 10

Summarise the signs of epidural haematoma.

Answer 10

• Brief loss of consciousness which is quickly regained after injury
• Lucid interval
• Seizures
• Compressed CNIII - fixed and dilated pupil on affected side
• Unopposed innervation of CNIV and CNVI - eye down and out
• Cushing’s triad (late)

Question 11

How do you manage epidural haematoma? (*not on Sofia)

Answer 11

Treatment is generally by urgent surgery in the form of a craniotomy or burr hole

Stabilize and transfer urgently (with skilled medical and nursing escorts) to a neurosurgical unit for clot evacuation ± ligation of the bleeding vessel.

Care of the airway in an unconscious patient and measures to ↓icp often require intubation and ventilation (+ mannitol)