Extradural hemorrhage

Definition

An extradural hemorrhage is bleeding between the inside of the skull and the outer covering of the brain (called the "dura").

Alternative Names

Extradural hematoma; Epidural hematoma

Causes, incidence, and risk factors

An extradural hemorrhage is often caused by a skull fracture during childhood or adolescence. This type of bleeding is more common in young people because the membrane covering the brain is not as firmly attached to the skull as it is in older people.

An extradural hemorrhage occurs when there is a rupture of a blood vessel, usually an artery, which then bleeds into the space between the "dura mater" and the skull. The affected vessels are often torn by skull fractures.

This is most often the result of a severe head injury, such as those caused by motorcycle or automobile accidents. Extradural hemorrhages can be caused by venous (from a vein) bleeding in young children.

Rapid bleeding causes a collection of blood (hematoma) that presses on the brain, causing a rapid increase of the pressure inside the head (intracranial pressure). This pressure may result in additional brain injury.

An extradural hemorrhage is an emergency because it may lead to permanent brain damage and death if left untreated. There may be a rapid worsening within minutes to hours, from drowsiness to coma and death.

Symptoms

A health care provider should be consulted for any head injury that results in even a brief loss of consciousness or if there are any other symptoms after a head injury (even without loss of consciousness).

The typical pattern of symptoms that indicate an extradural hemorrhage is loss of consciousness, followed by alertness, then loss of consciousness again. But this pattern may NOT appear in all people.

The most important symptoms of an extradural hemorrhage are:

• Confusion
• Dizziness
• Drowsiness or altered level of alertness
• Enlarged pupil in one eye
• Headache (severe)
• Head injury or trauma followed by loss of consciousness, an period of alertness, then rapid deterioration back to unconsciousness
• Nausea and/or vomiting
• Weakness of part of the body, usually on the opposite side from the side with the enlarged pupil

The symptoms usually occur within minutes to hours after a head injury and indicate an emergency situation.

Signs and tests

The neurological examination may indicate that a specific part of the brain is malfunctioning (for instance, arm weakness on one side) or may indicate increased intracranial pressure.

If there is increased intracranial pressure, emergency surgery may be needed in order to relieve the pressure and prevent further brain injury.

A head CT scan will confirm the diagnosis of an extradural hemorrhage and will pinpoint the exact location of the hematoma and any associated skull fracture.

Treatment

An extradural hemorrhage is an emergency condition! Treatment goals include taking measures to save the person's life, controlling symptoms, and minimizing or preventing permanent damage to the brain.

Life support measures may be required. Emergency surgery is almost always necessary to reduce pressure within the brain. This may include drilling a small hole in the skull to relieve pressure and allow drainage of the blood from the brain.

Large hematomas or solid blood clots may need to be removed through a larger opening in the skull (craniotomy).

Medications used in addition to surgery will vary according to the type and severity of symptoms and brain damage that occurs.

Anticonvulsant medications (such as phenytoin) may be used to control or prevent seizures. Some medications called "hyperosmotic agents" (like mannitol, glycerol, and hypertonic saline) may be used to reduce brain swelling.

Support Groups

Expectations (prognosis)

An extradural hemorrhage has a high risk of death without prompt surgical intervention. Even with prompt medical attention, a significant risk of death and disability remains.

Complications

There is a risk of permanent brain injury whether the disorder is treated or untreated. Symptoms (such as seizures) may persist for several months, even after treatment, but in time they usually become less frequent or disappear completely. Seizures may begin as many as 2 years after the injury.

In adults, most recovery occurs in the first 6 months, with some improvement over approximately 2 years. Children usually recover more quickly and completely than adults.

Incomplete recovery is the result of brain damage. Other complications include permanent symptoms (such as paralysis or loss of sensation, which began at the time of the injury), herniation of the brain (which may result in permanent coma), and normal pressure hydrocephalus (excess fluid in the cavities of the brain).

Calling your health care provider

Go to the emergency room or call 911 if symptoms of extradural hemorrhage occur.

Spinal injuries often occur with head injuries, so if you must move the person before help arrives, try to keep his or her neck still.

Call your health care provider if symptoms persist after treatment, including memory loss, difficulty maintaining attention, dizziness, headache, anxiety, speech difficulties, and complete or partial loss of movement in part of the body.

Go to the emergency room or call 911 if emergency symptoms develop after treatment, including breathing difficulties, convulsions/seizures, decreased responsiveness, loss of consciousness, enlarged pupils, and uneven pupil size.

Prevention

An extradural hemorrhage may not be preventable once a head injury has occurred.

To minimize the risk of head injury, use appropriate safety equipment (such as hard hats, bicycle or motorcycle helmets, and seat belts).

Follow general safety rules. For example, do not dive into water if the water depth is unknown or if rocks may be present. Use appropriate safety precautions in sports, recreation, and work. Drive safely.

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References

Biros MH, Heegaard WG. Head injury. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 38.