FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Stroke & vascular

Extradural haemorrhage

Middle meningeal artery tear → blood between dura and skull (biconvex)

Overview

Arterial bleeding (classically the middle meningeal artery at the pterion) collecting between the skull and dura. Typically a young patient after a temporal head injury, with the classic "lucid interval" then rapid deterioration. CT shows a BICONVEX (lens) collection limited by sutures.

Recognise

  • Head trauma to the temple → brief loss of consciousness → LUCID INTERVAL → rapid decline
  • Expanding haematoma → rising ICP, then a fixed dilated pupil (CN III) from herniation
  • Young patients (dura more adherent in the elderly)

Red flags

  • Deteriorating GCS after a lucid interval, fixed dilated pupil, Cushing reflex → herniation; neurosurgical emergency

Differentials & how to tell them apart

Subdural haematomacrescent shape, crosses sutures, venous, elderly/insidious
Concussionno expanding collection on CT
Diffuse axonal injuryhigh-energy injury, CT may be near-normal, profound coma

Investigations

CT head: BICONVEX (lentiform) hyperdense collection, does NOT cross suture lines; look for the temporal bone fracture.

Management

Urgent neurosurgical clot evacuation (craniotomy); temporise raised ICP

  1. 1CT head; urgent neurosurgical referral for clot evacuation. Temporise raised ICP (head-up, osmotic therapy) while awaiting theatre.Gate: A biconvex (lens) collection limited by suture lines = extradural (arterial); a crescent crossing sutures = subdural (venous)
  2. 2Evacuation + control of the bleeding vessel; ICP and neuro-obs monitoring.
No drug — neurosurgical evacuation — urgent craniotomy/clot evacuation
Osmotic therapy (mannitol/hypertonic saline) — temporise raised ICP pending surgery

Key points

The lucid interval (talk-and-die) is the classic teaching. The pterion overlies the middle meningeal artery. Rapid surgical evacuation can be life-saving with excellent recovery.

Monitor & prognosis

GCS, pupils, repeat CT, ICP.

Excellent if evacuated early; fatal if the herniation is missed.

Source: NICE NG232 (head injury); neurosurgical guidance