Extradural haemorrhage (A&E) Flashcards
Define extradural haemorrhage.
Bleeding between skull & dura mater
AKA epidural haemorrhage
Which demographic does extradural haemorrhage usually happen in? (2)
- M>F
- 20-30y
What usually causes extradural haemorrhage, and where?
- usually caused by ‘low-impact trauma’ - head injury (blow to the head, fall)
- most commonly an arterial bleed - rupture of middle meningeal artery
- pterion is common site of rupture - thinnest part of skull where middle meningeal artery lies
What can extradural haemorrhage lead to? (2)
- expanding haematoma
- –> uncus of temporal lobe herniates around the tentorium cerebelli and patient develops a fixed and dilated pupil due to compression of the parasympathetic fibres of CN III
- brain herniation (coning)
What is the classic presentation of extradural haemorrhage?
Presents with sudden onset soon after injury following a brief lucid interval:
- initial loss of consciousness after head injury
- temporary consciousness recovery + return to normal neurological function (lucid interval)
- neurological status declines again - due to haematoma expansion
What might we see on examination of extradural haemorrhage? (5)
- contralateral neurological deficits
- headache
- reduced GCS –> confusion
- fixed and dilated pupils (due to expanding haematoma)
- Cushing’s reflex - hypertension and bradycardia
Where are neurological deficits seen in extradural haemorrhage?
Contralaterally
What signs of raised ICP can we see in extradural haemorrhage? (2)
- headache
- confusion (decreased GCS)
What nerve can be compressed in extradural haemorrhage and what can we see?
Compression of parasympathetic fibres of CN III –> fixed, dilated pupils
What is the Cushing’s reflex in extradural haemorrhage?
Hypertension and bradycardia
What are some risk factors for extradural haemorrhage? (3)
- low-impact trauma
- assault
- sporting injury
What is the first-line investigation for extradural haemorrhage?
Non-contrast head CT
What would you see on non-contrast head CT in extradural haemorrhage?
- hyperdense (bright) biconvex lesion (lemon-shaped) limited by suture lines of skull
- think EPIdural = PIE = LEMON
- 95% of cases are supratentorial, of which 60% are in temporoparietal region
- check for secondary features of mass effect on CT scan e.g. midline shift or subfalcine/uncal herniation - may require urgent neurosurgical intervention
What are some differential diagnoses for extradural haemorrhage? (7)
- subdural haemorrhage
- subarachnoid haemorrhage
- intracerebral haemorrhage
- delirium
- meningitis
- intracranial mass
- migraine
What is the management plan for extradural haemorrhage? (6)
- conservative monitoring
- BP reduction - IV mannitol
- severe: burr holes to evacuate haematoma + craniotomy
- stop anticoagulation/antiplatelets
- can give reversal agents
- prophylactic anticonvulsants
Why is extradural haemorrhage an emergency?
Haematoma expansion can lead to brain herniation and death
What is the definitive treatment for extradural haemorrhage?
Craniotomy and haematoma evacuation (burr holes)
What do we do with extradural haemorrhage patients who have no neurological deficit?
Cautious clinical and radiological observation
What else do we need to manage alongside extradural haemorrhage?
ICP
How do we prevent haematoma expansion in extradural haemorrhage?
Anticoagulant reversal
What are some complications of extradural haemorrhage? (3)
- herniation of the brain and permanent coma
- normal pressure hydrocephalus –> weakness, headaches, incontinence, difficulty walking
- paralysis or loss of sensation (which began at time of injury)
Describe the prognosis of extradural haemorrhage.
In patients with no other associated brain injury, early decompression is associated with good neurological outcomes, including full recovery
