What does this case show?
This patient has a right-sided acute extra-dural haemorrhage (EDH) with an overlying skull fracture.
How should they be managed?
These patients require discussion with your neurosurgical team. Large clots will require evacuation (usually through "Burr holes" drilled in the skull) but smaller ones may be managed conservatively. A full assessment for any other injuries is important, especially in high-energy trauma.
If there were neurological changes as discussed before (III or VI palsy, autonomic irregularities) what can this be indicative of?
There would be concern about coning. This is where the intra-cerebral pressure builds to such a point that the brain tissue gets pushed out of the skull space by the bleed. Often the first signs can be brainstem compromise and these neurological signs are very important to watch out for.
Large right-sided bi-convex (or lenticular) collection under the skull. It is hyperdense in comparison to surrounding brain tissue/parenchyma.
On this slice, there is midline shift with compression of the lateral ventricles.
There is also marked soft tissue swelling over the skull on the right side.
Using the bony window, there is a depressed, comminuted skull fracture overlying the area we know the collection is in.