Emergency Neurosurgery Pharmacy Surgery Trauma

Extradural Haematoma | Neurosurgery | Geeky Medics

Extradural Haematoma

Background

Extradural haematoma (EDH) is outlined as an acute bleed between the dura mater and the inside floor of the cranium. This then causes elevated intracranial strain, which places very important mind buildings in danger.

Sufferers mostly affected by extradural haematomas (EDH) are grownup males between 20-30 years previous. It’s because they’re extra more likely to expertise a traumatic damage.

 


Aetiology

An extradural haematoma is mostly brought on by cranium trauma within the temporoparietal space, often following falls, assaults or sporting accidents. An EDH is discovered with a cranium fracture in 75% of instances.

The pterion, an anatomical landmark, is situated on this space. It’s weak to trauma as it’s the fusion level between the parietal, frontal, sphenoid and temporal bones.

The center meningeal artery is concerned in 75% of EDH because it lies beneath the pterion, which results in a excessive danger of arterial rupture.

EDH can even happen secondary to the rupture of a vein, notably if the center meningeal vein or dural sinuses are concerned.

Not often, EDH can happen secondary to arteriovenous abnormalities or different systemic bleeding issues.

Determine 1: A diagram displaying the bones of the cranium with the pterion marked in purple 2


Pathophysiology

As the quantity of blood leaking from the broken blood vessel into the extradural area will increase, it begins to strip the outer layer of the meninges, the dura mater, away from the cranium.

This typically results in the “lemon” shaped-bleed, which is seen on CT and MRI imaging.

If the extradural haematoma continues to extend in measurement, the strain contained in the skull (intracranial strain) additionally will increase.

With out remedy, this elevated strain may cause injury to the mind by means of a midline shift (displacement of the mind) and tentorial herniation (see determine 2).

A rising degree of intracranial strain (ICP) will ultimately result in brainstem dying.

Diagram showing the different types of brain herniation

Determine 2: Diagram displaying the several types of mind herniation 5

 


Medical presentation

This part has been cut up into totally different sections: first, a abstract of the standard historical past of EDH after which a extra detailed stage-by-stage take a look at a typical affected person presentation.

Historical past overview

  • Historical past of head trauma
  • Quick fluctuating degree of consciousness following the trauma earlier than showing lucid (i.e. acutely aware)
  • Speedy deterioration a while following regaining consciousness

 

Stage-by-stage presentation

Early indicators

Extreme headache:

  • Happens after the preliminary impression and may persist

 

Preliminary loss or fluctuance in consciousness:

  • Might current vaguely as tiredness or confusion

 

Interval of lucidity after preliminary lack of consciousness:

  • Often lasts between 6 and eight hours
  • Might final for days relying on the velocity of the haematoma progress

 

Late indicators

Speedy deterioration and lack of consciousness:

  • GCS rating will start to drop as intracranial strain rises and the brainstem begins to herniate

 

Eyes:

  • Focal neurological deficits turn into obvious within the eyes
  • This is because of compression of the cranial nerves
  • For instance, CNIII (oculomotor nerve) palsy might end in fastened dilation of the ipsilateral pupil. That is colloquially often known as a “blown pupil”.

 

Muscle weak spot:

  • Hemiparesis sometimes begins on the contralateral aspect to the EDH resulting from compression of the ipsilateral motor cortex.
  • Hemiparesis might turn into bilateral because the ICP will increase and the brainstem turns into compressed.
  • Ipsilateral hemiparesis can even happen by means of Kernohan’s phenomenon (in depth midline shift of the mind resulting from mass impact from the rising extradural haematoma). 7

 

Higher motor neuron indicators:

  • Constructive Babinski’s signal (upgoing toes), hyperreflexia and spasticity (hypertonia).
  • These indicators aren’t particular to EDH, which is why taking a very good historical past is essential!

Cushing’s triad:

  • A physiological response to critically excessive ICP
  • That is characterised by bradycardia, hypertension and deep/irregular respiration

 

Persisting unconsciousness:

  • Deep coma and really low GCS

 

Dying:

  • Typically by respiratory arrest
  • The respiratory centres within the brainstem turn into so compressed that they’re unable to perform.

 


Investigations

Non-contrast CT

  • First line investigation
  • Have to be ordered urgently if an EDH is suspected
  • Will present attribute bi-convex mass inside the cranium if there’s an EDH is current (“lemon-shaped” versus the standard “banana-shape” of subdural haemorrhages)
  • This attribute lemon form happens as as a result of the dura attaches to the cranium extra tightly throughout the suture strains and the strain of the haematoma just isn’t sufficient to beat these sutures. In consequence, the haematoma expands medially.
  • Secondary options on CT head can embrace midline shift and mind stem herniation, each of that are indications for early surgical intervention.

 

Non-contrast CT Scan of an Extradural Haematoma

Determine three: Non-contrast CT Scan of an extradural haematoma, which exhibits midline shift eight

MRI

  • Has little profit over CT and isn’t most popular because it takes longer and isn’t appropriate for pressing scanning.
  • Might, nevertheless, be used post-operatively if the affected person is unexpectedly unwell as it will possibly reveal underlying mind contusions, diffuse axonal damage or ischaemia.
  • It might be helpful in differentiating between extradural and subdural haemorrhages by way of wanting on the displaced dura.

 

X-ray

  • Not a primary line investigation as a result of a CT head is extra delicate at detecting fractures.
  • Nevertheless, a cranium fracture discovered on X-ray is all the time a sign for a direct CT head.
Non-contrast CT showing an EDH with a skull fracture marked by the arrow

Determine four: A non-contrast CT displaying an EDH with a cranium fracture marked by the arrow 9

Angiography

  • Could also be carried out when assessing a non-traumatic aetiology (e.g arteriovenous malformation)
  • Used very not often

 

Lumbar punctures are completely contraindicated for extradural haematomas, as they end in a drop in CSF strain, which can velocity up mind herniation.

 


Administration

Instant administration

  • ABCDE strategy to evaluation and administration
  • If applicable, it will embrace excessive circulate oxygen, C-spine safety, and intubation/air flow
  • The above administration applies to all trauma sufferers
  • The affected person must be urgently referred to the neurosurgical group to be able to give them the perfect probability of restoration

 

Surgical administration

  • Aims of the operation are decompression, haemostasis, and prevention of a re-bleed
  • Pressing decompression/evacuation is completed to alleviate the strain on important mind buildings
  • That is carried out by way of a burr gap into the cranium on the level the place the haematoma is thickest
  • The haematoma can then be evacuated to assist relieve the strain
  • A craniectomy could also be finished to allow the surgeons to cease the reason for the bleeding. This might contain taking a bit of cranium (a bone flap) away to offer them entry to the vasculature.
  • Ligation, or cauterisation, of any bleeding vessels, can then be carried out if applicable.

 

Medical administration

  • Diuretics: mannitol is usually used to assist lower ICP, via an osmotic impact
  • Anti-convulsants: these assist to stop post-traumatic seizures
  • Prophylactic antibiotics: these are used to scale back the danger of secondary meningitis following any open cranium fracture
  • Barbiturates: these CNS depressants could also be used to assist scale back ICP and to guard the mind from anoxia (absence of oxygen) and ischaemia

 

Submit-operative administration

  • Sufferers will obtain shut remark throughout their restoration interval, with common neurological observations (together with GCS)
  • The goal is to stop any secondary insults (e.g oedema, ischaemia or an infection)
  • ICP monitoring and repeat CT scans are helpful for detecting early medical deterioration
  • Medical administration strategies talked about above are sometimes used alongside surgical administration, as soon as the first surgical procedure has been carried out

 


Prognosis

Most individuals with an extradural haematoma, even when comparatively giant, have excellent outcomes in the event that they obtain evacuation surgical procedure early.

The result is considerably higher when in comparison with different types of traumatic mind damage (TBI) the place prognosis is usually poor.

Nevertheless, prognosis worsens considerably if surgical intervention is delayed. For this reason it’s important that a analysis is made early.

Medical options related to a poorer prognosis:

  • Low GCS
  • Lack of lucid interval
  • Pupil abnormalities
  • Decerebrate rigidity (exaggerated extensor posture of all extremities which happens after a midbrain damage)
  • Different present kinds of mind damage

 


Problems

An infection

  • Could be related to cranium fractures

 

Ischaemia

  • Typically happens adjoining to the haematoma
  • May also come up within the areas provided by an injured/ruptured artery

 

Publish-traumatic epilepsy

  • Seizures post-trauma may cause additional mind injury
  • Epilepsy might stay long-term because of the mind injury

 

Cognitive impairment

  • Resulting from direct mind tissue insults on the time of the damage and injury occurring secondary to raised intracranial strain

 

Hemiparesis

  • Resulting from direct mind tissue insults on the time of the damage and injury occurring secondary to raised intracranial strain (e.g. motor cortex and cerebral peduncle)

 

Hydrocephalus

  • Extreme accumulation of fluid within the mind secondary to obstruction of cerebrospinal fluid drainage
  • Hydrocephalus will increase ICP, which may trigger additional injury to mind tissue

 

Brainstem damage

  • Because of elevated ICP, resulting in brainstem herniation (see Determine 2)
  • This typically leads to everlasting brainstem damage or dying

 


Edited by

Samantha Strickland

Hull York Medical Scholar

 

Reviewed by

Mr Konstantinos Lilimpakis

Neurosurgical Medical Fellow

 


References

  1. Oxford Handbook of Medical Drugs. 10th Version 2017.
  2. Edited picture initially from Mariana Ruiz Villarrea. Revealed on-line 2007 Jan four. Out there from: https://en.wikipedia.org/wiki/File:Human_skull_side_simplified_(bones).svg [Accessed 15th November 2018]
  3. Virtually a Physician. Extradural Haemorrhage. Obtainable from:

https://almostadoctor.co.uk/encyclopedia/extradural-haemorrhage [Accessed 18th June 2018]

  1. Rengachary SS (ed.), Ellenbogen RG (ed.). Rules of Neurosurgery, 2nd Version. Elsevier; 2005
  2. Picture by Richard Millard. Revealed on-line 2009 Sept 16. Obtainable from: https://commons.wikimedia.org/wiki/File:Brain_herniation_types-2.svg [Accessed 15th November 2018]
  3. Oxford Handbook of Crucial Care. 2nd Version 2005.
  4. Kernohan Phenomenon. Obtainable From: https://radiopaedia.org/cases/kernohan-phenomenon [Accessed 19th October 2018]
  5. Extradural Haemorrhage. Case courtesy of Dr Sandeep Bhuta, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/4458″>rID: 4458</a>. Obtainable from: https://radiopaedia.org/articles/extradural-haemorrhage [Accessed 18th June 2018]
  6. Picture by Hellerhoff. Revealed on-line 2009 Nov 1. Obtainable from https://commons.wikimedia.org/wiki/File:Epidurales_Haematom.jpg [Accessed 15th November 2018]
  7. Misulis KE, Head TC. Netter’s Concise Neurology, Up to date Version. Elsevier; 2017.
  8. Lindsay KW, Bone I, Fuller G. Neurology and Neurosurgery Illustrated, fifth Elsevier; 2011.
  9. Henry MM (ed.), Thompson JN (ed.). Medical Surgical procedure, third Version. Elsevier; 2012.
  10. ABC Medical Notes App. Extradural Haematoma. Out there From: http://www.abcmedicalnotes.com/ [Accessed 18th June 2018]

 

Print Friendly, PDF & Email