Synopsis
Recognise traumatic extradural haematoma, interpret the characteristic but non-universal clinical and CT patterns, and identify patients needing immediate evacuation or closely supervised non-operative care.
- Extradural haematoma is usually a traumatic collection between skull and dura, often associated with a fracture and classically biconvex on CT; middle meningeal arterial injury is common, but venous sinus and other sources occur.
- The lucid interval is memorable but neither sensitive nor required. Treat the trajectory: headache, vomiting, drowsiness, focal deficit, anisocoria or a falling GCS after trauma can mark rapid expansion.
- Brain Trauma Foundation surgical guidance recommends evacuation when supratentorial EDH volume exceeds 30 cm³ regardless of GCS; smaller lesions are observed only when all specified size, shift, neurological and setting criteria are satisfied.
Key red flags
Any fall in GCS, especially a motor-score decline, new confusion, agitation or failure to recover after the injury requires urgent reassessment and neurosurgical discussion.
A new dilated or poorly reactive pupil, hemiparesis, posturing or abnormal breathing suggests transtentorial herniation and demands immediate resuscitation while surgery is mobilised.
A temporal or posterior-fossa extradural haematoma can deteriorate with little reserve; clinical progression outweighs an initially reassuring appearance.
Associated open, depressed or basal skull fracture, CSF leak, penetrating injury or major extracranial trauma changes infection, vascular, transfer and operative priorities.
Anticoagulant or antiplatelet exposure, a bleeding disorder or thrombocytopenia increases expansion risk and must be identified early without postponing imaging or transfer.
A normal examination soon after injury does not make an established extradural collection safe: selected observation requires a neurosurgical centre, serial CT and close neurological monitoring.
Record eye, verbal and motor GCS components separately and repeat them. NICE requires neurosurgical discussion for persisting coma, GCS deterioration, progressive focal signs or seizure without full recovery, irrespective of whether imaging is already available.
Compare pupil size and reactivity, eye position, facial movement and limb power. New anisocoria, a poorly reactive pupil, unilateral weakness or posturing after head trauma indicates dangerous mass effect until shown otherwise.
Analgesia, oxygenation or a seizure ending may improve responsiveness without stopping the bleed. Continued observations and repeat imaging are required whenever the course or first scan warrants them.
Reasoning priorities
Confirm the extracerebral collection and identify mass effect, fracture and coexisting traumatic brain injury quickly.
A typical EDH is hyperdense and biconvex with suture-limited margins. Record estimated volume, maximal thickness, midline shift, basal cisterns and posterior-fossa involvement; mixed density can indicate active or unclotted bleeding. Imaging cannot override deterioration.
Worked reasoning
A patient with a temporal impact becomes drowsier and develops a new unilateral dilated pupil or focal weakness.
- Call trauma, anaesthetic and neurosurgical teams immediately; stabilise airway, oxygenation and circulation with cervical-spine alignment, and document GCS components, pupils and motor responses without waiting for a complete herniation triad.
- Obtain immediate non-contrast CT if this can be done without interrupting resuscitation, transmit images during the referral, and prepare for urgent transfer or theatre while blood samples and drug history guide haemostatic support.
- If CT confirms an EDH with operative features, proceed to evacuation as soon as possible; use carefully monitored temporising pressure measures only while definitive source control is being arranged.
- After evacuation, continue neurocritical observations, repeat imaging when clinically indicated and manage associated fracture, contusion, diffuse injury, seizure and extracranial trauma.