Haemorrhagic Stroke: Extradural (epidural)

Question 1

Defintion

Answer 1

An extradural haemorrhage is bleeding into the potential space between the skull and the dura mater. The blood then collects in this space and is referred to as an extradural haematoma (EDH)

Question 2

Epidemiology

Answer 2

Male
20-30 years of age as patients gets older the dura becomes more adherent to the skull, making EDH less likely

Question 3

Risk factors

Answer 3

Anticoagulant usage: patients on anticoagulants who sustain head injury are at an increased risk of developing a haemorrhage
Head Trauma

Question 4

Aetiology

Answer 4

Trauma to middle meningeal artery due to damage to lateral pterygoid bone
Rarely, EDH can be due to non-traumatic events such as:
- Haemorrhagic tumour
- Coagulopathy
- Infection
- Vascular malformation

Question 5

Classical presentation

Answer 5

Initial loss of consciousness
LUCID interval: regains consciousness as there is venous shunting directing blood out of the epidural space
Continued expansion of haematoma: leads to local compression of the temporal lobe and eventual cerebral herniation e.g uncal herniation
Further compression will lead to brain stem compression, Cushings reflex, tonsillar hernation, and eventual death

Question 6

Signs of worsening neurological status

Answer 6

AFTER LUCID INTERVAL
Reduced GCS
Uncal herniation: ipsilateral, fixed dilated pupil and contralateral hemiparesis
Cushing’s reflex: hypertension and bradycardia
Breathing becomes deep and irregular = sign of brain stem compression
Headache
Drowsiness
Nausea and vomiting

Question 7

Diagnosis

Answer 7

FIRST LINE + GOLD STANDARD = CT scan
- hyperdense
- bleeding limited to suture lines
- compression of the brain = midline shift
- skull fracture may be evident

Question 8

Treatment

Answer 8

ABCDE emergency management
Non surgical - IV MANNITOL
Surgical - Clot evacuation +/- ligation of bleeding vessels