Extradural Haemorrhage
aka Epidural Haematoma
Blood collects between the dura mater and the bone of the skull. The dura is stripped away from the skull – indicating a high pressure bleed. On CT and MRI, it has a classical lentiform (lens) shaped appearance.

Pathology

Due to a bleed in the extradural space, usually from the middle meningeal artery and/or vein. Typically the result of head trauma around the eye, resulting in fracture to the temporal or parietal bones.
The collection of blood strips the dura off the inside of the skull, and the blood collects in this area.
It is usually due to an arterial bleed – in contrast to a subdural haematoma – which s typically a venous bleed.
Normal Dura Anatomy

Normal Dura Anatomy

Extradural Haemoatoma

Extradural Haemoatoma

Presentation

  • Classically presents with neurological signs after a lucid interval after some kind of head trauma. Usually a blow to the head in the temporal region. 
  • Head trauma often results in no initial signs / symptoms, then about 24 hours later, the patient becomes drowsy
  • Head trauma causing some initial headache and drowsiness which resolves. Then hours later, drowsiness and other signs occur
  • The lucid interval can be from a few hours to a few days
  • There is often no other sign of injury or trauma
Signs and symptoms include:
  • Drowsiness
  • Pupil asymmetry – due to IIIrd cranial nerve compression
  • Impaired consciousness
  • Headache (severe)
  • Vomiting
  • Seizures
  • Confusion
  • Hemiparesis
  • Upgoing plantars
  • Coma
    • Dilation of ipsilateral pupil
    • Bilateral limb weakness
    • Bradycardia – late sign
    • ↑BP – late sign
    • Death due to respiratory arrest

Investigations

  • CT / MRI – shows a lens shaped lesion. This well circumscribed and well contained blood is due to the strong adherence of the dura mater to various structures in the skull.
  • X-ray – may show fractures of the skull. If fractures are present then you need to do a CT as there is a high risk of extradural haemorrhage
  • Lumbar puncture is CONTRAINDICATED

Management

  • Urgent decompression is required
  • Start with ABCD, and give high flow oxygen. Maintain SBP >90mmHg
  • Sit up in bed if possible
  • Call Neurosurgery!
  • Surgery – is usually the first line treatment. The blood can be evacuated, and the bleeding lesion ligated. Prognosis is excellent if early stages, but poor if coma or pupil signs.

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