Extradural hematoma; Epidural hematoma

Last reviewed: June 29, 2010.

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

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 consciousnessor 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, a 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.

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 asseizures) 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. Epidural or extradural hematoma (haematoma) is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura mater (the tough outer membrane of thecentral nervous system) and the skull. The dura mater also covers the spine, so epidural bleeds may also occur in the spinal column. Often due to trauma, the condition is potentially deadly because the buildup of blood may increase pressure in the intracranial space and compress delicate brain tissue. The condition is present in one to three percent of head injuries.[1]Between 15 and 20% of epidural hematomas are fatal.[2]

Signs and symptoms

Epidural bleeds, like subdural and subarachnoid hemorrhages, are extra-axial bleeds, occurring outside of the brain tissue, while intra-axial hemorrhages, including intraparenchymal andintraventricular hemorrhages, occur within it. After the epidural hematoma begins collecting, it starts to compress intracranial structures which may impinge on the CN III. This can be seen in the physical exam as a fixed and dilated pupil on

the side of the injury. The eye will be positioned down and out, due to unopposed CN VI innervation. Other manifestations will include weakness of the extremities on the same side as the lesion, due to compression of the crus on the opposite side of the lesion, and a loss of visual field opposite to the side of the lesion, due to compression of the posterior cerebral artery on the side of the lesion. The most feared event that takes place is the transtentorial, or uncal herniation which results in respiratory arrest since the medullary structures are compromised. The trigeminal nerve (CN V) may be involved late in the process as the pons becomes compressed, but this is not a significant clinical presentation, since by that time the patient may already be dead.[3] Epidural bleeding is rapid because it is usually from arteries, which are high pressure. Epidural bleeds from arteries can grow until they reach their peak size at six to eight hours post injury, spilling from 25 to 75 cubic centimeters of blood into the intracranial space.[4] As the hematoma expands, it strips the dura from the inside of the skull, causing an intense headache. Epidural bleeds can become large and raiseintracranial pressure, causing the brain to shift, lose blood supply, or be crushed against the skull. Larger hematomas cause more damage. Epidural bleeds can quickly expand and compress the brain stem, causing unconsciousness, abnormal posturing, and abnormal pupilresponses to light.[5]

Causes

The interior of the skull has sharp ridges by which a moving brain can be injured

The most common cause of intracranial epidural hematoma is traumatic, although spontaneous hemorrhage is known to occur. Hemorrhages commonly result from acceleration-deceleration trauma and transverse forces.[4][9] 10% of epidural bleeds may be venous,[6] due to shearing injury from rotational forces. Epidural hematoma commonly results from a blow to the side of the head. The pterion region which overlies the middle meningeal artery is relatively weak and prone to injury.[6] Thus only 20 to 30% of epidural hematomas occur outside the region of the temporal bone.[10] The brain may be injured by prominences on the inside of the skull as it scrapes past them. Epidural hematoma is usually found on the same side of the brain that was impacted by the blow, but on very rare occasions it can be due to a contrecoup injury.[1]

Treatment
As with other types of intracranial hematomas, the blood may be removed surgically to remove the mass and reduce the pressure it puts on the brain. [9] The hematoma is evacuated through a burr hole or craniotomy. If transfer to a facility with neurosurgery is prolonged trephination may be performed in the emergency department.[11] A bruise, also called a contusion, is a type of relatively minor hematoma of tissue[1] in whichcapillaries and sometimes venules are damaged by trauma, allowing blood to seep into the surrounding interstitial tissues. Bruises can involve capillaries at the level of skin, subcutaneous tissue, muscle, or bone. A bruise may be named by the length of its diameter as an petechia(less than 3 mm), purpura (3 mm to 1 cm) or ecchymosis (1 to 3 cm), although these terms can also refer to internal bleeding not caused by trauma. As a type of hematoma, a bruise is always caused by internal bleeding into the interstitial tissues, usually initiated by blunt trauma, which causes damage through physical compressionand deceleration forces. Trauma sufficient to cause bruising can occur from a wide variety of situations including accidents, falls, and surgeries. Disease states such as insufficient or malfunctioning platelets, other coagulation deficiencies, or vascular disorders, such as venous blockage associated with severe allergies[2] can lead to the formation of bruises in situations in which they would not normally occur and with only minimal trauma. If the trauma is sufficient to break the skin and allow blood to escape the interstitial tissues, the injury is not a bruise but instead a different variety of hemorrhage called bleeding, although such injuries may be accompanied by bruising elsewhere.[3] Bruises often induce pain, but small bruises are not normally dangerous alone. Sometimes bruises can be serious, leading to other more life-threatening forms of hematoma, such as when associated with serious injuries, including fractures and more severe internal bleeding. The likelihood and severity of bruising depends on many factors, including type and healthiness of affected tissues. Minor bruises may be easily recognized in people with

light skin color by characteristic blue or purple appearance (idiomatically described as "black and blue") in the days following the injury.

Mechanism of bruise
Increased distress to tissue causes capillaries to break under the skin, allowing blood to escape and build up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread. Nerve endings within the affected tissue detect the increased pressure, which, depending on severity and location, may be perceived as pain or pressure or be asymptomatic. The damaged capillaryendothelium releases endothelin, a hormone that causes narrowing of the blood vessel to minimize bleeding. As the endothelium is destroyed, the underlying von Willebrand factor is exposed and initiates coagulation, which creates a temporary clot to plug the wound and eventually leads to restoration of normal tissue. During this time, larger bruises may change color due to the breakdown of hemoglobin from within escaped red blood cells in the extracellular space. The striking colors of a bruise are caused by the phagocytosis and sequential degradation of hemoglobin to biliverdin to bilirubin tohemosiderin, with hemoglobin itself producing a red-blue color, biliverdin producing a green color, bilirubin producing a yellow color, and hemosiderin producing a golden-brown color.[3] As these products are cleared from the area, the bruise disappears. Often the underlying tissue damage has been repaired long before this process is complete.
Basic Anatomy and Physiology of the Human Brain This chapter contains some basic background on the anatomy and physiology of the human brain relevant to this project. The final section focuses on the neonatal brain and some common pathologies. 2.1 Anatomy of the head The human nervous system consists of the central nervous system (CNS) and peripheral nervous system (PNS). The former consists of the brain and spinal cord, while the latter composes the nerves extending to and from the brain and spinal cord. The primary functions of the nervous system are to monitor, integrate (process) and respond to information inside and outside the body. The brain consists of soft, delicate, non-replaceable neural tissue. It is supported and protected by the surrounding skin, skull, meninges and cerebrospinal fluid.

Basic Anatomy and Physiology of the Human Brain This chapter contains some basic background on the anatomy and physiology of the human brain relevant to this project. The final section focuses on the neonatal brain and some common pathologies. 2.1 Anatomy of the head The human nervous system consists of the central nervous system (CNS) and peripheral nervous system (PNS). The former consists of the brain and spinal cord, while the latter composes the nerves extending to and from the brain and spinal cord. The primary functions of the nervous system are to monitor, integrate (process) and respond to information inside and outside the body. The brain consists of soft, delicate, non-replaceable neural tissue. It is supported and protected by the surrounding skin, skull, meninges and cerebrospinal fluid. Skin The skin constitutes a protective barrier against physical damage of underlying tissues, invasion of hazardous chemical and bacterial substances and, through the activity of its sweat glands and blood vessels, it helps to maintain the body at a constant temperature. Together with the sweat and oil glands, hairs and nails it forms a set of organs called the integumentary system. Figure 21 shows a cross-section of the skin and underlying subcutaneous tissue. The skin consists of an outer, protective layer, the epidermis and an inner layer, the dermis. While the top layer of the epidermis, the stratum corneum, consists of dead cells, the dermis is composed of vascularised fibrous connective tissue. The subcutaneous tissue, located underneath the skin, is primarily composed of adipose tissue (fat). Skull Depending on their shape, bones are classified as long, short, flat or irregular. Bones of different types contain different proportions of the two types of osseous tissue: compact and

spongy bone. While the former has a smooth structure, the latter is composed of small needle-like or flat pieces of bone called trabeculae, which form a network filled with red or yellow bone marrow. Most skull bones are flat and consist of two parallel compact bone surfaces, with a layer of spongy bone sandwiched between. The spongy bone layer of flat bones (the diplo) predominantly contains red bone marrow and hence has a high concentration of blood. The skull is a highly complex structure consisting of 22 bones altogether. These can be divided into two sets, the cranial bones (or cranium) and the facial bones. While the latter form the framework of the face, the cranial bones form the cranial cavity that encloses and protects the brain. All bones of the adult skull are firmly connected by sutures. Figure 22 shows the most important bones of the skull. The frontal bone forms the forehead and contains the frontal sinuses, which are air filled cells within the bone. Most superior and lateral aspects of the skull are formed by the parietal bones while the occipital bone forms the posterior aspects. The base of the occipital bone contains the foramen magnum, whichis a large hole allowing the inferior part of the brain to connect to the spinal cord. The remaining bones of the cranium are the temporal, sphenoid and ethmoid bones. Meninges The meninges (Figure 23) are three connective tissue membranes enclosing the brain and the spinal cord. Their functions are to protect the CNS and blood vessels, enclose the venous sinuses, retain the cerebrospinal fluid, and form partitions within the skull. The outermost meninx is the dura mater, which encloses the arachnoid mater and the innermost pia mater Cerebrospinal fluid Cerebrospinal fluid (CSF) is a watery liquid similar in composition to blood plasma. It is formed in the choroid plexuses and circulates through the ventricles into the subarachnoid space, where it is returned to the dural venous sinuses by the arachnoid villi. The prime

purpose of the CSF is to support and cushion the brain and help nourish it. Figure 24 illustrates the flow of CSF through the central nervous system.