1) A 19 y/o male presents to ED after he’s tackled during a game of rugby. He falls and strikes his head on the ground. He loses consciousness temporarily, but wakes up and recovers on the side lines. 1hr later he becomes confused and progressively becomes less responsive #BBEDH

2) Based on the history, what are your thoughts on a differential diagnosis? #BBEDH

3) You guys are on a roll already! Extradural haematoma, subdural haematoma, subarachnoid haemorrhage, traumatic brain injury, transient ischemia attack, intracranial abscess are some ddxs to consider.. #BBEDH

4) On arrival in ED, the patient is assessed by the nursing staff. He is only able to move his left side. The patients left arm and leg withdraws from painful stimuli. His eyes are closed and only opens them in response to pain. He is making mumbling noises.. #BBEDH

5) Based on the above information, what is his GCS? #BBEDH

6) 100% correct! The patient has a GCS of  (E2 V2 M4) #BBEDH

7) So tell me, what is your next step in the assessment of this patient? #BBEDH

8) The answer to life.. ABCDE! Initial assessment begins with evaluation of airway, breathing and circulation. An organised approach ensures a complete assessment of head injury #BBEDH

9) So let's examine the patient.. the airway is patent. Respiratory rate is 18 breaths/ minute, and heart rate is 64 breaths/min. BP is 136/86 mmHg. Pupils are equal and reactive.

Is there any speciality you’d like to involve early?

#BBEDH

10) We've got them on speed-dial.. Anaesthetics! They'll help the patient with intubation and mechanical ventilation. Pts with a low conscious level may lack protective airway reflexes and require a definitive airway. GCS of <8 → are considered at risk and should be intubated

11) The anaesthetist arrives - she intubates and mechanically ventilates the patient. How would you like to investigate this head injury further, are there any imaging tests you’d like to do at this stage?

#BBEDH

12) You betcha.. CT Head! A non-contrast CT scan is the most common imaging modality to assess for intracranial bleeding. Guidelines exist to determine those who require an immediate CT or those requiring a CT within 8 hours of injury

#BBEDH

13) The results from the head CT are shown below. What do you see?

#BBEDH

14) The CT demonstrates a left sided acute extradural haematoma w/ midline shift + effacement of ventricles. On the bone window you’ll also see an associated skull fracture. Extradural haematomas give a biconvex/elliptical/lentiform shape. Does anyone know why this is? #BBEDH

15) Exactly right! Extradural haematomas (EDHs) are 'extra-axial' collections. This means they are external to the brain parenchyma
Because they collect between the suture lines of the cranium, they give this elliptical shape #BBEDH

16) So who knows where exactly extradural haematomas form? #BBEDH

17) Between the skull and the dura materThe dura mater is the outermost layer of meninges. Meninges are the membranous covering of the brain and spinal cord. The dura is thick, tough and inextensible and lies directly underneath the bones of the skull #BBEDH

18) Within the cranial cavity, the dura consists of 2 connective tissue sheets: periosteal and meningeal layer.

The periosteal layer lines the inner surface of the bones of the cranium;

The meningeal layer lies deep to the periosteal layer in the cranial cavity.

#BBEDH

19) Altogether there are 3 meningeal layers.

Who can name the other two for us and their location?

#BBEDH

20) Pia and arachanoid! The arachanoid is the middle layer, lying directly underneath the dura. The pia mater lies below the arachnoid mater and is tightly adhered to the surface of the brain #BBEDH

21) Who knows which vessel is commonly involved in an extradural haematoma?
#BBEDH

22) Middle meningeal artery! The middle meningeal artery is a branch of the maxillary artery. The maxillary artery is one of the terminal branches of the external carotid artery

#BBEDH

23) The majority of the time, EDHs are associated with skull fractures Due to the location of the middle meningeal artery, tears typically occur during trauma to the lateral aspect of the skull

Who knows which part of the skull the middle meningeal artery overlies?

#BBEDH

24) Yes! The pterion!

This is a fragile segment of bone at the junction of the frontal, temporal, parietal and sphenoid bones

#BBEDH

25) It’s also important to note that extradural haematomas can also occur from injury to the diploic veins or venous sinuses.. These are often more difficult to treat

#BBEDH

26) So how do extradural haematomas normally present then?

#EDH

27) Similar to our patient, patients typically present with an initial loss of consciousness following the trauma then as most have answered, a complete transient recovery known as the ‘lucid interval’!

This is then followed by a rapid neurological deterioration

#BBEDH

28) EDHs are often a neurosurgical emergency. This is because arterial bleeding results in a rapid accumulation of blood in the extradural space. The enlarging haematoma leads to an elevation in the ICP. Progression to brain herniation can occur rapidly #BBEDH

29) Can anyone remember any herniation syndromes which can occur?

#BBEDH

30) Uncal herniation (leading to a fixed dilated pupil from IIIn compression)

and

brainstem herniation resulting in hypertension, bradycardia and irregular breathing (Cushing’s reflex) can occur from the raised ICP

#BBEDH

31) Prognosis for EDH is usually very good.

Factors determining the outcome include: • GCS • Age • Pupillary abnormalities • Associated intracranial lesions • Time between neurological deterioration and surgery and ICP

#BBEDH

32) Therefore, it’s important to check pupillary response, monitor the patient closely and seek neurosurgical input early for immediate intracranial intervention!

#BBEDH

33) Ok so now that you have confirmed an extradural haematoma, is there any speciality you’d like to involve straight away and any other investigations would you like to do?



#BBEDH

34) Of course, let's involve... Neurosurgery! An EDH can be a neurosurgical emergency. So how do we treat extradural haematomas?

#BBEDH

35) Treatment for EDH include surgical or non-surgical management

Non-surgical management involves serial CT scans and close neurological observation

Surgical management includes burr holes or a craniotomy to evacuate the clot

#BBEDH

36) Following that.. how do we know when to operate?

Any thoughts?

#BBEDH

37) The decision is made on the patients level of consciousness (GCS), CT head findings, pupillary abnormalities and neurological deterioration. Below is some criteria

38) It is decided to take the patient to theatre for a craniotomy and evacuation of the extradural haematoma. To find out how we perform this surgery, watch our video after the CBD!

39) Who knows any complications of a craniotomy that we must look out for?

#BBEDH

40) Some complications might include bleeding intra-operatively and post-operatively, seizure, hydrocephalus, meningitis, neurological deficit related to the area of surgery, coma, death.

#BBEDH

41) The EDH is successfully evacuated and the patient is transferred to the neuro-observations ward where he is monitored. A post-operative CT shows complete evacuation of the haematoma and resolution of midline shift..

#BBEDH

42).. On day 3 post-op, the patient is mobilising well on the ward and is fit for discharge!

Before he is discharged, is there anything you might want to advise him on?

#BBEDH

43) In addition to avoiding contact sports for a while.. to Contact the DVLA!

A head injury often requires 6-12 months off driving and is dependent on a number of factors so it’s important to inform the DVLA and seek advice

#BBEDH

And that wraps up this Live Twitter CBD on EDH, folks!

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