Extra dural haematoma

Question 1

A patient is tackled and strikes his head, he loses consciousness temporarily, but wakes up and recovers. 1 hour later he becomes confused and progressively becomes less responsive… differential diagnosis???

Answer 1

TIA, extra or subdural haematoma, subarachnoid haemorrhage, traumatic brain injury, intracranial abscess

Question 2

patient has a GCS of 8, what is your next step in assessing them

Answer 2

ABCDE

Question 3

patients with a GCS less than 8 should be? why is this

Answer 3

intubated - they are considered at risk

may lack protective airway reflexes and require a definitive airway

Question 4

scan for extradural haematoma

Answer 4

non -contrast CT

Question 5

What will you often seen on a CT

Answer 5

left or ride sided extradural haematoma with a midline shift and effacement of ventricles, may also see a bone fracture

Question 6

what shape to extradural haematomas give and why

Answer 6

biconvex/lentiform shape

they are extra-axial collections

Question 7

what doe extra-axial collections mean

Answer 7

they are external to the brain parenchyma and collect between the suture lines of the cranium

Question 8

Where do EDH form

Answer 8

between the skull and dura matter

Question 9

what is the outer most layer of the meninges

Answer 9

the dura - thick tough and inextensible - lies directly underneath the bones of the skull

Question 10

the dura consists of 2 connective tissue sheets, what are they

Answer 10

periosteal - lines inner surface of cranium bones

meningeal - lies deep to periosteal layer in the cranial cavity

Question 11

what vessel is commonly involved in an extradural haematoma

Answer 11

middle meningeal artery - tears often occur during trauma to the lateral aspect of the skull

Question 12

the middle meningeal artery is a branch of what

Answer 12

the maxillary artery which is a terminal branch of the ECA

Question 13

most of the time, EDH are associated with

Answer 13

skull fractures

Question 14

what part of the skull does the MMA lie over

Answer 14

pterion - joins frontal, temporal, parietal and sphenoid at junction

Question 15

Difficult to treat EDH often from injury to what

Answer 15

diploic veins or venous sinuses

Question 16

How do EDH’s normally present?

Answer 16

initial loss of consciousness following trauma, complete transient recovery (lucid interval) - followed by rapid neurological deterioration

Question 17

EDH’s are often a neurosurgical emergency - why is this

Answer 17

arterial bleeding results in a rapid accumulation of blood in the extradural space.
The enlarging haematoma leads to an elevation in the ICP.
Progression to brain herniation can occur rapidly

Question 18

what herniation syndromes can occur?

Answer 18

uncal and brainstem

Question 19

What does uncal herniation result in

Answer 19

fixed dilated pupil from IIIn compression

Question 20

what does brain stem herniation result in

Answer 20

hypertension, bradycardia and irregular breathing (cushing’s reflex from raised ICP)

Question 21

what factors determine the outcome of EDH

Answer 21

GCS, age, pupillary abnormalities, associated intracranial lesions, ICP

Question 22

how do you treat EDH, non-surgical and surgical

Answer 22

non- serial CT’s and close neuro obsservation

surgical - burr holes and craniotomy to evacuate the clot

Question 23

surgical criteria?

Answer 23

volume of EDH >30
midline shift >5mm
haematoma thickness >15mm

Question 24

complications from a craniotomy

Answer 24

intra and post -operative bleeding, seizure, hydrocephalus, meningitis, coma, death

Question 25

advice patient to

Answer 25

contact the DVLA - head injury often requires 6-12 months off driving