QuestionSBA
QuestionChoice
Asking the family if they want the death to be referred to the coroner is inappropriate, as referral to the coroner is a legal requirement in certain circumstances, including this case involving trauma and injury. The family should be kept informed of the events.
10038614
e
Ask the family if they want the death to be referred to the coroner
QuestionChoice
In England and Wales, certain deaths must be referred to the coroner, including those likely due to trauma or injury, whether accidental or not. This case involves a head injury from a fall, leading to an intracranial haemorrhage, which qualifies for referral. Other examples of deaths that should be referred to the coroner include deaths due to unknown causes, deaths during surgical procedures, deaths under suspicious circumstances, and deaths in custody.
10038610
a
Refer to coroner
QuestionChoice
Completing the death certificate with intracranial haemorrhage as the cause is not appropriate in this case. The death must be referred to the coroner due to the traumatic nature of the injury.
10038611
b
Complete death certificate with intracranial haemorrhage as the cause
QuestionChoice
Completing the death certificate with a fall as the cause is not appropriate. The death must be referred to the coroner due to the traumatic injury and subsequent intracranial haemorrhage.
10038612
c
Complete death certificate with fall as the cause
QuestionChoice
Completing the death certificate with atrial fibrillation as the cause is incorrect because the primary cause of death was the intracranial haemorrhage resulting from the fall. This death needs to be referred to the coroner. A phrase along the lines of "atrial fibrillation (treated)" will be likely to ultimately go in part 2 of the certificate, reflecting that the anticoagulation contributed to the death but was not part of the direct sequence of events.
10038613
d
Complete death certificate with atrial fibrillation as the cause
Concept
Chapter
# Summary
 
An extradural haematoma is a type of intracranial haemorrhage where blood accumulates between the dura mater and the skull. The condition typically results from blunt trauma, usually leading to fracture of the pterion bone damaging the middle meningeal artery. The classic presentation of an extradural haematomas is a history of trauma or a fall, followed by a transient loss of consciousness, then a lucid interval with ongoing headache before subsequent deterioration of consciousness. A CT scan is the usual diagnostic investigation, looking for a biconvex hyperdense lesion with or without associated overlying skull fracture. Management may be conservative with monitoring and observation, or surgical with a craniotomy or Burr hole formation. This depends on the size of the haematoma, the patient's clinical condition and whether mass effect is present.
 
# Definition
 
An extradural haematoma occurs when a collection of blood forms between the dura mater, the outermost meningeal layer, and the inner surface of the skull. This commonly results from a traumatic arterial bleed, with the middle meningeal artery implicated in the majority of cases.
 

# Epidemiology

Approximately 2% of head injuries presenting to emergency services are found to have caused extradural haematomas. Most of these are acute but subacute and chronic presentations also occur. 

The most common age group affected is 20-30 year olds, with men making up the majority of cases (linked to high risk activities in this demographic such as contact sports and violence).

# Aetiology
 
Extradural haematomas are almost always secondary to traumatic head injury, most commonly with a fracture of the temporal or parietal bone which damages underlying vessels.

The most common vessel damaged is the middle meningeal artery, however extradural haematomas can also result from a venous bleed.
 
# Signs and Symptoms
 
The classic clinical course seen in extradural haematomas is as follows:

 - Brief loss of consciousness following the initial traumatic head injury
 - A period of regained consciousness and apparent recovery (the lucid interval)
 	- There may be ongoing headache during this time 
 - Subsequent deterioration with worsening symptoms and signs

Symptoms may include:

- Headache
- Nausea and vomiting
- Seizures
- Limb weakness, numbness or other neurological symptoms
- Confusion
 
Signs may include:

- External injuries e.g. signs of skull fractures, haematomas or lacerations on the head
- Reduced level of consciousness
- Seizures
- Cushings Triad: Bradycardia, hypertension and irregular breathing (sign of raised intracranial pressure)
- 6th nerve palsy (a false localising sign secondary to raised intracranial pressure
- Cerebrospinal fluid otorrhea or rhinorhoea (sign of dural tearing)
- Unequal pupils
- Focal neurological signs e.g. visual field defects, ataxia

# Differential Diagnosis
 
- **Subdural haematoma**: Presents with fluctuating levels of consciousness, memory impairment and headache. This often presents subacutely or chronically in older patients, often with a history of minor head trauma.
- **Subarachnoid haemorrhage**: Characterised by a sudden, severe headache (often described as a 'thunderclap' headache), nausea, vomiting, and symptoms and signs of meningism such as neck stiffness.
- **Intracerebral haemorrhage**: i.e. bleeding within the brain parenchyma. Presents with a sudden onset of neurological deficits, headache and decreased consciousness levels.
- **Alcohol intoxication**: can present with overlapping symptoms of decreased levels of consciousness, ataxia, nausea and vomiting. May co-present with an extradural haematoma in patients who injure themselves whilst intoxicated.

# Investigations
 
**Bedside investigations:**

- **ECG** in bradycardic patients to rule out other causes e.g. heart block
- **Capillary blood glucose** to rule out hypoglycaemia as a cause of decreased consciousness

**Blood tests:**

- **Full blood count** looking for anaemia from blood loss (especially if other injuries)
- **U&Es and LFTs** as a baseline in case a general anaesthetic is needed for surgical management
- **Coagulation screen** looking for a bleeding diathesis
- **Group and save** in preparation for possible surgery

**Imaging:**

- **Non-contrast CT Head** is the diagnostic investigation, looking for a lentiform or biconvex hyperdense extra-axial collection 

 - Complications resulting from raised intracranial pressure such as midline shift or subfalcine/uncal herniation may necessitate urgent neurosurgical intervention
 

 [lightgallery]
 

# Management

Management depends on the size of the haematoma, the patient's clinical condition and whether there is mass effect seen on imaging. 

**Urgent neurosurgical referral** is required in all patients presenting with suspected extradural haematoma.

**Conservative management:**

- Patients with small extradural haematomas may be admitted for neurological observations and monitoring with serial imaging
- This may also be the treatment of choice in patients who are unfit for neurosurgery due to frailty or comorbidities
- Patients undergoing medical or surgical management also require conservative management with neurorehabilitation, optimisation of nutrition and multidisciplinary team involvement

**Medical management:**

- Initial A to E assessment and resuscitation (e.g. patients with a GCS < 8 may require airway support)
- Ensure other life-threatening injuries are addressed
- Reverse any anticoagulant medication or coagulopathy (may require haematology input)
- Anticonvulsants may be required for seizure prophylaxis
- Prophylactic antibiotics may be started e.g. in cases of open skull fracture
- Consider place of care - patients with raised intracranial pressure are often admitted to intensive care for intubation and ventilation
- Intracranial pressure (ICP) can be monitored and **neuroprotective measures** put in place to help normalise this:
        - Ensure sedation and paralysis are adequate
        - Maintain oxygen and carbon dioxide levels in the normal range
        - Maintain a normal temperature
        - Consider raising head to 30 degrees (if appropriate in context of other injuries)
        - Hypertonic saline or mannitol may be used to reduce ICP

**Surgical management:**

- Burr hole craniotomy may be used to evacuate the haematoma
- Trauma craniotomy is another emergency procedure that can relieve raised intracranial pressure and evacuate the haematoma 
- Vessels with ongoing bleeding should be ligated or cauterised

# NICE Guidelines

[NICE CKS - Head Injury](https://cks.nice.org.uk/topics/head-injury/)

# References
 
[Radiopaedia: Extradural haemorrhage](https://radiopaedia.org/articles/extradural-haemorrhage?lang=gb)

[Patient UK: Extradural haematoma](https://patient.info/doctor/extradural-haematoma-pro)
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An extradural haemorrhage.
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Extradural Haemorrhage
Topic
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Neurology
20075
Deaths resulting from trauma, such as intracranial haemorrhage after a fall, must be referred to the coroner for investigation.
An 85-year-old woman is admitted to the emergency department following a fall at home, resulting in a head injury. She has a past medical history of atrial fibrillation and is on apixaban. On examination, she is drowsy and confused. An urgent CT head scan shows an intracranial haemorrhage. The patient dies shortly afterwards.

Select the single most appropriate next step in management from the list below. Select one option only.
a