Extradural Haematoma

extradural hematoma

The meninges are the protective lining that surround and enclose the brain within the skull, and the spinal cord within the vertebral column. There are three layers of meninges:

  1. The outermost layer that lies next to the skull or the vertebral column is called the dura mater.
  2. The middle layer is called the arachnoid mater.
  3. The inner layer that is closest to the brain or the spinal cord is called the pia mater.

There are also three 'spaces' between the layers of meninges:

  1. The epidural space is the space between the vertebral column and the dura mater.
  2. The subdural space is the space between the dura mater and the arachnoid mater.
  3. The subarachnoid space is the space between the arachnoid mater and pia mater.

What is an extradural haematoma?

An extradural haematoma is a collection of blood in the epidural space. 'Extradural' means outside the dura.

What causes an extradural haematoma?

Spinal extradural haematoma

A spinal extradural haematoma is less common than an intracranial extradural haematoma. Sometimes a spinal extradural haematoma can occur after trauma or an injury around the spinal area. For example, it can (rarely) occur after a lumbar puncture (a procedure where a sample of fluid that surrounds the brain and spinal cord is taken with a needle to help diagnose conditions such as meningitis). It may also (rarely) occur after an epidural anaesthetic (a common type of pain relief used during childbirth and for other reasons).

Intracranial extradural haematoma

An extradural haematoma usually occurs inside the head, most commonly after a fractured skull caused by a head injury. The fractured skull bone can cause separation of the dura mater from the inside of the skull and can cause damage to a blood vessel (usually an artery). The damaged blood vessel causes blood to leak and collect in the potential epidural space between the skull and the dura mater. This build up of blood can cause the pressure inside the head to rise. This can put pressure on the brain and cause injury to the brain if it is not treated quickly.

What are the symptoms of an intracranial extradural haematoma?

Classically, someone who develops an intracranial extradural haematoma loses consciousness at the time of the head injury and then has a 'lucid interval' of a few hours after the head injury where they appear relatively well and normal. Later, they deteriorate and lose consciousness again as the haematoma forms.

You may experience drowsiness or a severe headache. You may also have nausea (feeling sick) and/or vomiting. You may become confused and may develop weakness of an arm and/or leg on one side of your body and/or speech difficulties. Sometimes a seizure can occur.

How is an intracranial extradural haematoma diagnosed?

The doctors and nurses will be able to perform a full examination to look for signs of a possible intracranial extradural haematoma and also signs of any other injury that you may have. They will be able to check your level of consciousness, look for any signs of arm or leg weakness, and also examine your eyes to look for any signs of raised pressure within the skull.

Blood tests may be taken to look for other possible reasons for confusion and/or loss of consciousness. Blood tests may also show any problems with blood clotting. A CT scan of the head is good at detecting an intracranial extradural haematoma. It can also show any skull fracture that may be present.

What is the treatment for an intracranial extradural haematoma?

If you have an intracranial extradural haematoma, the priority is first to stabilise your condition. You may need treatment to stabilise your blood pressure. If you have breathing difficulties or your consciousness level is affected, you may need help with your breathing using a ventilator.

A small intracranial extradural haematoma that is not producing any symptoms (or the symptoms are not severe), can sometimes be treated just by careful monitoring and observation. The blood clot may re-absorb (clear) by itself. Repeated physical examinations are usually carried to assess your level of consciousness and look for any symptoms that may appear such as headache, arm or leg weakness, etc. Repeated CT scanning may also be used to ensure that the haematoma is not getting any bigger.

However, generally, surgery is needed to treat an intracranial extradural haematoma. This is usually carried out by a neurosurgeon and involves removal of the haematoma. Most commonly, surgery either involves making 'burr holes' in the skull or an operation called a craniotomy. Burr holes are small holes that are drilled through the skull over the area where the haematoma has formed. They allow the blood to be removed or 'sucked out' through the holes. A craniotomy is where a portion of the skull is removed so that the brain and meninges are exposed. It can relieve any raised pressure inside the skull and also means that the clotting blood in the extradural space can be removed. The section of skull that was removed is then replaced and fixed back in place, re-attaching the dura mater to the skull bone.

What is the prognosis?

Provided that quick treatment is carried out, the outlook is generally good. In those people who are conscious before they have surgery, death is extremely unlikely and surgery usually has a very good outcome. However, the outlook is not as good in those who are unconscious before they have surgery. There is a risk of permanent brain injury even if an intracranial extradural haematoma is treated.

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