Dural Haematomas

Extradural Haematoma

An extradural haematoma is a bleed into the “potential” space between the dura mater meningeal layer and the inner surface of the skull.

It usually occurs due to low impact trauma to the side of the head, resulting in laceration of the middle meningeal artery running deep to the pterion.

This causes the dura to peel away from the inner layer of the skull. As the bleed enlarges it compresses the brain and raises intracranial pressure causing symptoms.

Symptoms

Initial headache and loss of consciousness

Causes a lucid interval (hours to days) as the haematoma grows

This is followed by rapid deterioration with severe headache, decreasing GCS and seizures

Pressure symptoms – CN III palsy (ipsilateral pupil dilates), leg weakness, irregular breathing

Raised ICP causes Cushing’s triad – bradycardia, hypertension and deep breathing

In untreated, can lead to respiratory arrest (compression of medulla)

Key tests

Non-contrast CT is first-line – shows biconvex, high-density area or “lemon” sign which does not cross suture lines

Management

Reversal of anticoagulation, if needed

Medication involves diuretics (to reduce ICP) and prophylactic antibiotics

Surgery – craniotomy at haematoma to relieve pressure and ligation of blood vessels

Subdural Haematoma

This is a collection of blood between the dura and arachnoid mater of the brain.

It is categorised as acute (< 3 days, associated with high impact trauma), subacute (3–21 days), or chronic (> 21 days, more common in elderly and alcoholics).

Can be due to high impact trauma to head, rupturing the bridging veins in the dural venous sinuses, but also secondary to metastases and rupture of aneurysms.

Risk factors

Elderly (brain atrophy makes bridging veins vulnerable)

Alcoholism

Anticoagulation

Symptoms

Chronic headache or new onset headache (if acute)

Fluctuating level of consciousness is a key symptom

Confusion and altered mental state (irritability)

Localising neurological signs occur late, e.g., unequal pupils, loss of smell/ hearing

Key tests

Non-contrast CT shows concave “banana” shape (does cross suture lines)

Management

Reverse clotting abnormalities

Antiepileptics may be started if causing seizures

If small, can be treated conservatively and monitored for resolution

If large or symptomatic, consider surgery (decompressive craniotomy)