Makindo Medical Notes

Related Subjects: |Subdural haematoma |Extradural haematoma

The characteristic presentation of an extradural hematoma (EDH) includes a head injury followed by a brief period of unconsciousness, a subsequent lucid interval, and then a decline in consciousness as measured by the Glasgow Coma Scale (GCS). This is a medical emergency requiring urgent CT imaging and neurosurgical consultation.

About

• Extradural hematoma occurs due to bleeding outside the dura mater, contained within the periosteal suture lines of the skull.
• Often arterial in origin, typically involving the middle meningeal artery, making the condition severe and potentially life-threatening.
• If left untreated, EDH can lead to significant brain injury and rapid deterioration, potentially resulting in death.

Aetiology

• Usually associated with a head injury leading to bleeding from the middle meningeal artery.
• Bleeding occurs outside the dura mater, constrained by the skull’s periosteal suture lines.
• May also involve the middle meningeal vein.
• Frequently accompanied by a temporal or parietal skull fracture.
• Most common in males aged 20-30 years, often due to high-energy impacts.

Causes

• Falls, physical assaults, and sports-related injuries.
• Traumatic events, such as skiing accidents or birth trauma, especially in neonates.

Clinical Features

• Initial head injury often with visible superficial trauma.
• A lucid interval, during which the patient appears alert, followed by worsening symptoms as the hematoma expands.
• Progressive reduction in GCS, leading to eventual unconsciousness.
• Cheyne-Stokes respiration may develop as intracranial pressure increases.

Investigations

• Blood Tests: Full blood count (FBC), Urea & Electrolytes (U&E), and Liver Function Tests (LFT) to assess overall health and guide treatment.
• Non-contrast CT Scan: The primary diagnostic tool. Shows a biconvex (lens-shaped) hyperdensity confined by periosteal suture lines, often accompanied by midline shift and skull fracture. Additional signs of traumatic brain injury, such as cerebral contusions, may also be present.

Management

• Initial Stabilization: Ensure airway, breathing, and circulation (ABC). Intubate if GCS < 8. Administer IV fluids and arrange an urgent CT head scan.
• Neurosurgical Consultation: Essential for all EDH cases to assess the need for surgical intervention.
• Coagulopathy Management: Reverse any anticoagulant effects if the patient is on blood thinners.
• Surgical Clot Evacuation: Immediate evacuation is often life-saving. If a craniotomy is delayed, burr hole drainage may be necessary.
• Surgical Indications: Surgery is recommended for hematomas larger than 30 cm³ irrespective of GCS. Craniotomy is performed at the area of maximum hematoma thickness.
• Postoperative Care: Intensive care monitoring, including intracranial pressure (ICP) and neuro-monitoring. Neurorehabilitation may be required following recovery.