Extradural hemorrhage (summary)
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This is a basic article for medical students and non-radiologists
Extradural haemorrhage (EDHhaemorrhages (EDHs) is collection represent collections of blood in the extradural (epidural) space, also known as epidural space. The collection is bounded byhaemorrhage sits between the skull superficially and deeper, bythe dura which overlies the durabrain parenchyma.
Epidemiology
Patients with extradural haemorrhages are usually young and have a history of high-energy head trauma (see investigation of head injury). The aetiology of EDH explains the relationship between EDH and skull fracture.
Clinical presentation
Patients with EDH often describe headache, although this may be the result of head injury and underlying fracture.
EDH may result in mass effect which can cause localising signs (sixth cranial nerve palsy) or autonomic changes, followed by focal neurology and loss of consciousness if the mass effect is significant.
Some patients have an initial loss of consciousness followed by a return to normal conscious level which is accompanied by a persistent severe headache. This is termed the "lucid interval" 1 and is followed by subsequent drop in conscious level.
Pathophysiology
The source of haemorrhage tends to be arterial and the result of an associated skull fracture. The middle meningeal artery is particularly at risk because it sits under the thinnest part of the skull between the ears and the eyes in the squamous temporal bone.
The headache that patients experience is the result of the dura mater is stripped off the skull vault as the collection grows.
Radiographic features
Non-contrast CT is the imaging modality of choice for the investigation because it is highly sensitive for haemorrhage and fracture. Moreover, it is quick and highly available, and is the safest option for a potentially sick patient.
CT
EDH will be seen peripherally as a biconvex area of hyperdensity. This has been described as looking like a lens (lentiform) or an egg ("eggs"-tradural haemorrhage). The haemorrhage is well demarcated as it sits between the skull and brain parenchyma and does not cross the skull sutures.
While theyThey tend to be hyperdense (bright). However, active haemorrhage will be seen as an area of hypodensity (the non-clotted blood appears dark within the rest of the clotted haematoma).
CT can also illustrate underlying skullmay illustrate skull fractures or other parenchymal injuries. If the haemorrhage is of sufficient size, there mass effect may be seen, e.g. midline shift, herniation).
Treatment and prognosis
Extradural haemorrhages necessitate urgent consultation with neurosurgical services 2. Surgical treatment involves evacuation of the clot through a cranial burr hole. Smaller bleeds may be managed conservatively.
EDHs generally have a good prognosis if appropriately treated 3. In high impact trauma, morbidity and mortality may be related to other associated injuries including brain injury.
Differential diagnosis
Large extraduralsExtradurals are usually easily identified on imaging because of their shape. However, when smaller there may be other potential diagnosesare important differentials:
- other haemorrhage, e.g. subdural haemorrhage
-
extra-axial tumours, e.g. meningioma
typically
Subdurals (SDH) usually occur in older patientsconcavecross sutures
Meningiomas are limited by dural reflectionsmeningiomahyperdense but enhance following contrastmore
More information
-<h5>This is a basic article for medical students and non-radiologists</h5><p><strong>Extradural haemorrhage (EDH)</strong> is collection of blood in the <a href="/articles/extradural-space">extradural space</a>, also known as epidural space. The collection is bounded by the skull superficially and deeper, by the dura.</p><p>Patients with extradural haemorrhages are usually young and have a history of high-energy head trauma (see <a href="/articles/investigation-of-head-injury-basic">investigation of head injury</a>).</p><h4>Clinical presentation</h4><p>Patients with EDH often describe headache, although this may be the result of head injury and underlying fracture.</p><p>EDH may result in mass effect which can cause localising signs (sixth cranial nerve palsy) or autonomic changes, followed by focal neurology and loss of consciousness if the mass effect is significant.</p><p>Some patients have an initial loss of consciousness followed by a return to normal conscious level which is accompanied by a persistent severe headache. This is termed the "lucid interval" <sup>1</sup> and is followed by subsequent drop in conscious level.</p><h4>Pathophysiology</h4><p>The source of haemorrhage tends to be arterial and the result of an associated skull fracture. The <a href="/articles/middle-meningeal-artery">middle meningeal artery</a> is particularly at risk because it sits under the thinnest part of the skull between the ears and the eyes in the <a href="/articles/squamous-temporal-bone">squamous temporal bone</a>. </p><p>The headache that patients experience is the result of the <a href="/articles/dura-mater">dura mater</a> is stripped off the skull vault as the collection grows.</p><h4>Radiographic features</h4><p>Non-contrast CT is the imaging modality of choice for the investigation because it is highly sensitive for haemorrhage and fracture. Moreover, it is quick and highly available, and is the safest option for a potentially sick patient.</p><h5>CT</h5><p>EDH will be seen peripherally as a biconvex area of hyperdensity. This has been described as looking like a lens (lentiform) or an egg ("eggs"-tradural haemorrhage). The haemorrhage is well demarcated as it sits between the skull and brain parenchyma and does not cross the skull sutures.</p><p>While they tend to be hyperdense (bright), active haemorrhage will be seen as an area of hypodensity (the non-clotted blood appears dark within the rest of the clotted haematoma). </p><p>CT can also illustrate underlying skull fractures or other parenchymal injuries. If the haemorrhage is of sufficient size, there may be evidence of mass effect (<a title="Midline shift" href="/articles/midline-shift">midline shift</a>, <a title="Brain herniation" href="/articles/cerebral-herniation">herniation</a>).</p><h4>Treatment and prognosis</h4><p>Extradural haemorrhages necessitate urgent consultation with neurosurgical services <sup>2</sup>. Surgical treatment involves evacuation of the clot through a cranial burr hole. Smaller bleeds may be managed conservatively.</p><p>EDHs generally have a good prognosis if appropriately treated <sup>3</sup>. In high impact trauma, morbidity and mortality may be related to other associated injuries including brain injury.</p><h4>Differential diagnosis</h4><p>Large extradurals are usually easily identified on imaging. However, when smaller there may be other potential diagnoses:</p><ul>-<li>-<a href="/articles/subdural-haemorrhage-basic">subdural haemorrhage</a><ul>-<li>-<a href="/articles/subdural-haemorrhage-basic"></a>typically occur in older patients</li>-<li>concave</li>-<li>cross sutures, but are limited by dural reflections</li>-</ul>- +<h6>This is a basic article for medical students and non-radiologists</h6><p><strong>Extradural haemorrhages (EDHs)</strong> represent collections of blood in the <a href="/articles/extradural-space">extradural (epidural) space</a>. The haemorrhage sits between the skull superficially and the dura which overlies the brain parenchyma.</p><h4>Epidemiology</h4><p>Patients with extradural haemorrhages are usually young and have a history of high-energy head trauma (see <a href="/articles/investigation-of-head-injury-basic">investigation of head injury</a>). The aetiology of EDH explains the relationship between EDH and skull fracture.</p><h4>Clinical presentation</h4><p>Patients with EDH often describe headache, although this may be the result of head injury and underlying fracture.</p><p>EDH may result in mass effect which can cause localising signs (sixth cranial nerve palsy) or autonomic changes, followed by focal neurology and loss of consciousness if the mass effect is significant.</p><p>Some patients have an initial loss of consciousness followed by a return to normal conscious level which is accompanied by a persistent severe headache. This is termed the "lucid interval" <sup>1</sup> and is followed by subsequent drop in conscious level.</p><h4>Pathophysiology</h4><p>The source of haemorrhage tends to be arterial and the result of an associated skull fracture. The <a href="/articles/middle-meningeal-artery">middle meningeal artery</a> is particularly at risk because it sits under the thinnest part of the skull between the ears and the eyes in the <a href="/articles/squamous-temporal-bone">squamous temporal bone</a>. </p><p>The headache that patients experience is the result of the <a href="/articles/dura-mater">dura mater</a> is stripped off the skull vault as the collection grows.</p><h4>Radiographic features</h4><p>Non-contrast CT is the imaging modality of choice for the investigation because it is highly sensitive for haemorrhage and fracture. Moreover, it is quick and highly available, and is the safest option for a potentially sick patient.</p><h5>CT</h5><p>EDH will be seen peripherally as a biconvex area of hyperdensity. This has been described as looking like a lens (lentiform) or an egg ("eggs"-tradural haemorrhage). The haemorrhage is well demarcated as it sits between the skull and brain parenchyma and does not cross the skull sutures.</p><p>They tend to be hyperdense (bright). However, active haemorrhage will be seen as an area of hypodensity (the non-clotted blood appears dark within the rest of the clotted haematoma). </p><p>CT may illustrate skull fractures or other parenchymal injuries. If the haemorrhage is of sufficient size, mass effect may be seen, e.g. <a href="/articles/midline-shift">midline shift</a>, <a href="/articles/cerebral-herniation">herniation</a>.</p><h4>Treatment and prognosis</h4><p>Extradural haemorrhages necessitate urgent consultation with neurosurgical services <sup>2</sup>. Surgical treatment involves evacuation of the clot through a cranial burr hole. Smaller bleeds may be managed conservatively.</p><p>EDHs generally have a good prognosis if appropriately treated <sup>3</sup>. In high impact trauma, morbidity and mortality may be related to other associated injuries including brain injury.</p><h4>Differential diagnosis</h4><p>Extradurals are usually easily identified on imaging because of their shape. However, there are important differentials:</p><ul>
- +<li>other haemorrhage, e.g. <a href="/articles/subdural-haemorrhage-basic">subdural haemorrhage</a>
-<li>-<a href="/articles/brain-tumours-basic">meningioma</a><ul>-<li>hyperdense, but enhance following contrast</li>-<li>more mass-like</li>-<li>unlikely to be associated with skull fracture</li>-</ul>- +<li>extra-axial tumours, e.g. <a href="/articles/intracranial-tumours-basic">meningioma</a>
-</ul><h4>More information</h4><ul><li><a href="/articles/extradural-haemorrhage">extradural haemorrhage</a></li></ul>- +</ul><p>Subdurals (SDH) usually occur in older patients, often after minor trauma. They may be dense like EDH, but they are concave and cross sutures.</p><p>Meningiomas are extra-axial tumours that arise from the meninges and may be dense on CT imaging. They have a much more focal, mass-like appearance.</p><h4>More information</h4><ul><li><a href="/articles/extradural-haemorrhage">extradural haemorrhage</a></li></ul>
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