EM · Subdural and extradural haematoma
Subdural and extradural haematoma
Also known as Acute subdural haematoma · Chronic subdural haematoma · Extradural haematoma · Epidural haematoma
Subdural and extradural haematoma — the two extra-axial traumatic collections distinguished by anatomy, source, and tempo. Extradural (epidural) haematoma: arterial bleed from the middle meningeal artery after a temporal fracture, the lentiform biconvex shape on CT, the lucid interval, the young trauma patient, the urgent craniotomy. Acute subdural haematoma: venous bridging-vein or cortical bleed, the crescent shape crossing sutures, the elderly and anticoagulated patient, the craniotomy. Chronic subdural: the insidious cognitive decline in the atrophic elderly brain, the burr-hole evacuation. Management: ABCDE, ICP control (mannitol 0.5 g per kg, head up 30 degrees, hypertonic saline 3 per cent 250 mL), urgent neurosurgical referral, and early reversal of anticoagulation. Differential: subarachnoid, contusion, tumour. ACEM-primary, globally tagged.
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Red flags
- The lucid interval followed by a rapid fall in GCS is an expanding extradural haematoma until proven otherwise — give osmotherapy and call neurosurgery now
- A unilateral fixed dilated pupil is uncal herniation — give mannitol 0.5 g per kg or hypertonic saline 3 per cent 250 mL and call neurosurgery immediately
- Reverse the anticoagulation early in any anticoagulated patient with an intracranial bleed — the expanding haematoma is the danger
- An isodense chronic subdural can be missed on CT in the elderly patient with cognitive decline — look for the effaced sulci and the midline shift
- Never attribute a reduced GCS to alcohol, dementia, or age alone — the CT excludes the mass
Meet the patient
A 19-year-old is brought in after being struck on the side of the head in an assault. He was briefly unconscious, then walked to the ambulance talking — but an hour later he is increasingly confused, vomits twice, and his GCS has fallen from 15 to 12. His right pupil is becoming dilated.[1]
One question decides his next thirty minutes: is this the evolving extradural haematoma? The lucid interval then the falling GCS plus a unilateral dilating pupil is uncal herniation from an expanding arterial clot. Give osmotherapy now and call neurosurgery — this is the lesion where minutes decide the outcome, and the brain underneath is often uninjured.[1]
References8ShowHide
- [1]Khairat A, Waseem M. Epidural Hematoma 2026.PMID 30085524
- [2]Pierre L, Julien C, Margetis K, et al. Subdural Hematoma 2026.PMID 30422565
- [3]Hawryluk GWJ, Rubiano AM, Totten AM, et al. Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations Neurosurgery, 2020.PMID 32761068
- [4]Karcioglu O, Zengin S, Ozkaya B, et al. Direct (New) Oral Anticoagulants (DOACs): Drawbacks, Bleeding and Reversal Cardiovasc Hematol Agents Med Chem, 2022.PMID 34521332
- [5]CRASH-3 trial collaborators Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial Lancet, 2019.PMID 31623894
- [6]Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas. Neurosurgery, 2006.PMID 16710967
- [7]Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery, 2006.PMID 16710968
- [8]Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet, 2004.PMID 15474134