Extradural hemorrhage

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

Causes
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 tocoma 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, 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.

Exams 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.

Outlook (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.

Possible 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 brainand permanent coma,
and normal pressure hydrocephalus, which can lead to weakness,
headaches, incontinence, and difficulty walking.

When to Contact a Medical Professional

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.

Alternative Names
Extradural hematoma; Epidural hematoma

References
Biros MH, Heegaard WG. Head injury. In: Marx JA, ed.Rosens Emergency
Medicine: Concepts and Clinical Practice

Update Date 7/4/2012

Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Virginia Mason
Medical Center, Seattle, Washington. Also reviewed by David Zieve, MD,
MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.
http://www.nlm.nih.gov/medlineplus/ency/article/001412.htm