The characteristic picture of an extradural hematoma (EDH) includes a head injury followed by a short period of unconsciousness, then a period of regained consciousness (lucid interval), and finally a fall in Glasgow Coma Scale (GCS). This is a medical emergency requiring urgent CT and neurosurgical consultation.
About
- Extradural hematoma is caused by bleeding outside the dura mater, confined by the periosteal suture lines of the skull.
- It is often arterial in origin, making the condition clinically severe and potentially life-threatening.
- If untreated, it can result in significant brain injury and rapid death.
Aetiology
- Usually related to a head injury with bleeding from the middle meningeal artery.
- Bleeding occurs outside the dura mater and is confined by the skull’s periosteal suture lines.
- Can also involve the middle meningeal vein.
- An associated temporal or parietal skull fracture is often present.
- Most common in males aged 20-30 years.
Causes
- Falls, assaults, and sports injuries.
- Traumatic incidents such as skiing or birth trauma.
Clinical Features
- Initial head injury with visible superficial trauma.
- A lucid interval, during which the patient appears to recover, before symptoms worsen as the hematoma expands.
- Progressive reduction in GCS, leading to unconsciousness.
- Cheyne-Stokes respiration may develop as the condition deteriorates.
Investigations
- Blood tests: Full blood count (FBC), Urea & Electrolytes (U&E), Liver function tests (LFT).
- Non-contrast CT scan: The diagnostic tool of choice. It typically shows a biconvex area of hyperdensity confined by the periosteal suture lines. Midline shift and a visible skull fracture may be present. Additional signs of traumatic brain injury, such as cerebral contusions, may also be observed.
Management
- Ensure airway, breathing, and circulation (ABC). Intubation is required if GCS < 8. Administer IV fluids and obtain an urgent CT head scan. Immediate neurosurgical consultation is essential.
- Reverse any coagulopathy (e.g., if the patient is on anticoagulants).
- Urgent surgical clot evacuation is often life-saving. Burr hole drainage may be necessary if craniotomy is delayed.
- Surgical intervention is recommended for all cases where the hematoma is larger than 30 cm3, regardless of GCS. A craniotomy is performed over the area of maximum hematoma thickness.
- Post-surgery, patients may require intensive care monitoring, including intracranial pressure (ICP) and neuro-monitoring, followed by neurorehabilitation.