Extradural haemorrhage (A&E)

Question 1

Define extradural haemorrhage.

Answer 1

Bleeding between skull & dura mater

AKA epidural haemorrhage

Question 2

Which demographic does extradural haemorrhage usually happen in? (2)

Answer 2

• M>F
• 20-30y

Question 3

What usually causes extradural haemorrhage, and where?

Answer 3

• 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

Question 4

What can extradural haemorrhage lead to? (2)

Answer 4

• 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)

Question 5

What is the classic presentation of extradural haemorrhage?

Answer 5

Presents with sudden onset soon after injury following a brief lucid interval:

1. initial loss of consciousness after head injury
2. temporary consciousness recovery + return to normal neurological function (lucid interval)
3. neurological status declines again - due to haematoma expansion

Question 6

What might we see on examination of extradural haemorrhage? (5)

Answer 6

• contralateral neurological deficits
• headache
• reduced GCS –> confusion
• fixed and dilated pupils (due to expanding haematoma)
• Cushing’s reflex - hypertension and bradycardia

Question 7

Where are neurological deficits seen in extradural haemorrhage?

Answer 7

Contralaterally

Question 8

What signs of raised ICP can we see in extradural haemorrhage? (2)

Answer 8

• headache
• confusion (decreased GCS)

Question 9

What nerve can be compressed in extradural haemorrhage and what can we see?

Answer 9

Compression of parasympathetic fibres of CN III –> fixed, dilated pupils

Question 10

What is the Cushing’s reflex in extradural haemorrhage?

Answer 10

Hypertension and bradycardia

Question 11

What are some risk factors for extradural haemorrhage? (3)

Answer 11

• low-impact trauma
• assault
• sporting injury

Question 12

What is the first-line investigation for extradural haemorrhage?

Answer 12

Non-contrast head CT

Question 13

What would you see on non-contrast head CT in extradural haemorrhage?

Answer 13

• 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

Question 14

What are some differential diagnoses for extradural haemorrhage? (7)

Answer 14

• subdural haemorrhage
• subarachnoid haemorrhage
• intracerebral haemorrhage
• delirium
• meningitis
• intracranial mass
• migraine

Question 15

What is the management plan for extradural haemorrhage? (6)

Answer 15

• conservative monitoring
• BP reduction - IV mannitol
• severe: burr holes to evacuate haematoma + craniotomy
• stop anticoagulation/antiplatelets
• can give reversal agents
• prophylactic anticonvulsants

Question 16

Why is extradural haemorrhage an emergency?

Answer 16

Haematoma expansion can lead to brain herniation and death

Question 17

What is the definitive treatment for extradural haemorrhage?

Answer 17

Craniotomy and haematoma evacuation (burr holes)

Question 18

What do we do with extradural haemorrhage patients who have no neurological deficit?

Answer 18

Cautious clinical and radiological observation

Question 19

What else do we need to manage alongside extradural haemorrhage?

Answer 19

ICP

Question 20

How do we prevent haematoma expansion in extradural haemorrhage?

Answer 20

Anticoagulant reversal

Question 21

What are some complications of extradural haemorrhage? (3)

Answer 21

• 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)

Question 22

Describe the prognosis of extradural haemorrhage.

Answer 22

In patients with no other associated brain injury, early decompression is associated with good neurological outcomes, including full recovery