Extradural Haemorrhage - Medical Negligence Lawyers
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An extradural brain haemorrhage involves bleeding outside of the outer covering of the brain, the dura, and the skull itself. It is a condition caused by a skull fracture that happens to kids in childhood or adolescence. The reason it is more common in young people is because the dura is not so firmly attached to the person’s skull as it is in people who are older.
Usually, the skull fracture ruptures an artery near the dura mater, which causes bleeding in the area described above. One or several arteries can be torn by the skull fracture.
An extradural haemorrhage is usually the result of a serious head injury—one that is caused by an automobile or motorcycle accident. In very young kids, the bleed is venous and not arterial but can still be severe bleeding.
The rapid nature of the bleeding causes a large collection of blood (known as a haematoma) which presses on the brain. This can cause further brain injury and the pressure can cause the brain to herniate through the hole at the base of the brain (the foramen magnum). This results in a lack of spontaneous breathing, cardiac arrest and death.
This is considered a medical emergency because brain damage is likely if the haemorrhage is not treated promptly. If not treated at all, the outcome is death. The person rapidly worsens over several minutes to hours. They progress from drowsiness to developing a coma to sudden death fairly rapidly.
The bleeding source is usually a ruptured meningeal artery—usually the middle meningeal artery. In about 80 percent of cases, there is an associated skull fracture. Headache is related to the stripping of the dura away from the bone and the increasing size of the haemorrhage. About 5-10 percent of cases involve a haemorrhage in the posterior fossa of the skull. The extradural haematoma is usually unilateral (in 95 percent of cases). Ninety to ninety five percent are supratentorial; 60 percent are temporoparietal; 20 percent are frontal; 20 percent are parieto-occipital; 5-10 percent are infratentorial and located in the posterior fossa.
Because of the rapidity of this disorder, a health professional should look after anyone with a head injury that involved even a brief loss of consciousness or if other symptoms occur after a head injury, even if loss of consciousness did not occur.
Usually, with an extradural haemorrhage, there is loss of consciousness and then a period of alertness followed by another loss of consciousness. This might not happen in everyone, however.
Common symptoms to pay attention to in an extradural haemorrhage include:
- Decreased level of consciousness
- Different sized pupils with one being very large
- Severe headache
- Head injury with loss of consciousness, alertness and then loss of consciousness
- Weakness of half the body
- Nausea and vomiting
These symptoms tend to occur within minutes of the injury and it is usually clear that the individual is suffering from a medical emergency.
The exams and tests used to diagnose extradural haemorrhages involve first doing a neurological exam that may show the part of the brain involved; it will also reveal evidence of increased intracranial pressure. If there is evidence of intracranial pressure increase, patient needs emergency surgery in order to relieve the pressure. This helps make sure that there is no further brain injury either.
If there is time, a head CT scan can be done, which will show the skull fracture, show that it is in fact an extradural hematoma, and will show the exact location of the bleed. A CT is the preferred test because it easily shows extradural haematomas. They are seen as convex areas of bleeding just beneath the squamous aspect of the temporal bone. There may be a secondary mass effect such as a shift of the brain from the midline, an uncal herniation or a subfalcine herniation.
If the bleeding is active when the CT scan is done, there may be hyper dense, non-clotted blood seen along with a swirl effect. Because of the type of bleed it is, it is stopped by the sutures of the skull, which differentiates it from a subdural haematoma, which is not limited by the suture lines of the skull. The extradural haematoma does cross the venous sinuses and will raise them up. The bleed can cross a suture line only if there is a fracture that causes diastasis of a nearby suture, rupturing the dura.
An MRI can be done, showing the displacement of the dura which looks hypo-dense as opposed to how it looks on a subdural haematoma. IV contrast can be done on both CT scans and MRI scans and will help define the areas of bleeding.
The treatment of extradural haemorrhage is an emergency. The hope of the emergency team is to first save the individual’s life, keep symptoms at a minimum, and minimize the long term sequelae that can happen with this kind of injury. The person may need life support measures along with emergency surgery designed to reduce the amount of pressure within the brain. In its most basic of procedures, emergency personnel can drill a burr hole into the skull to allow the blood to escape and to decrease the pressure on the brain. Sometimes large blood clots need to be removed through a larger hole called a craniotomy.
Some patients need medications like phenytoin to block seizures while others will receive medications like mannitol, which is a hyperosmotic agent that reduces swelling on the brain.
The prognosis of having an extradural haematoma is poor if the person doesn’t have prompt surgery and this means that these people generally die without intervention. The risk of disability and death remains high even if everything was done as promptly as possible.
Possible complications include permanent injury to the brain, even if the haemorrhage was appropriately treated. Seizures can last for several months but eventually fade off and disappear. There may be as many as two years past before the seizures start.
The most recovery occurs within the first six months with residual improvement lasting about two years. Children with an extradural hemorrhage tend to do better than adults.
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The author of the substantive medical writing on this website is Dr. Christine Traxler MD whose biography can be read here