Extradural haematoma and base of skull fracture

Case contributed by Dr Dayu Gai

Presentation

This 30 year old male was involved in an accident where the back of his car was rear-ended. There was bleeding noted from his left ear. A CT trauma series was performed.

Patient Data

Age: 30
Gender: Male

Conclusion:

  • Left temporoparietal and petrous temporal fractures with underlying extradural haematoma causing local mass effect but no midline shift.
    • Underlying the left calvarial fracture is a temporoparietal extraaxial haemorrhage, containing gas locules, which has a biconvex contour and maximal depth 13 mm. The extraaxial collection is limited posteriorly by the lambdoid suture and is consistent with extradural haematoma. Mixed density of this collection raises the possibility of ongoing active bleeding.
  • Skull base fracture involves the left carotid canal, and CT angiogram is recommended to exclude carotid injury.
  • Mild rotation of C1 on C2 is likely positional.

Case Discussion

Base of skull fractures are commonly seen in craniofacial trauma. Up to 24% of patients with blunt head trauma sustain a skull base fracture1

Base of skull fractures are clinically relevant due to the possibility of endangerment of nearby structures including:

  • Cranial nerves
  • Internal carotid artery
  • Cavernous sinus

Definitive management for skull base fracture depends on the degree of fracture and the clinical state of the patient. Indications for operative management include:

  • Neurological deficits - facial nerve paralysis, hearing loss or blindness
  • CSF fistula - manifests as rinorrhea and otorrhea
  • Temporal bone fracture

Operative management includes a subtotal petrosectomy. This involves exenteration of the temporal bone air cell tracts and obliteration of the eustachian tube. Once the injured structures are repaired, the remaining cavity is obliterated with an endogenous fat graft and temporalis muscle flap. 

In the absence of the above features, conservative, expectant management is carried out. This includes a 5 day course of intravenous antibiotics.

Another point to note, is that nasogastric tube placement is to be avoided in patients with confirmed or suspected base of skull fracture. This is due to the risk of intracranial nasogastric tube placement, whereby the tube traverses into the cranium via a fractured cribriform plate2.

This patient has a petrous temporal bone fracture. He underwent operative management as described above.

Extradural haematoma (EDH) has a reported incidence of 2.7-4% of traumatic brain injuries3. In particular, blunt trauma due to traffic accidents, falls and assaults account for over 90% of causes.
Pathologically, extradural haematoma has traditionally been reported due to middle meningeal artery haemorrhage - a branch of the maxillary artery.

Clinically, the characteristic 'lucid interval' where a patient becomes unconscious after the initial insult, then wakes up and then deteroriates again was found in 47% of patients. Other clinical changes noted include pupillary abnormalities, focal deficits and seizures.

CT is the imaging modality of choice for diagnosis of extradural haematoma. The characteristic appearance of EDH is a hyperdense, lentiform lesion which represents acute haemorrhage building up between the dura and the skull. In particular, the following factors are associated with a poor outcome:

  • Haematoma volume greater than 30cm3
  • Midline shift (MLS) greater than 5mm
  • Clot thickness greater than 15mm on initial CT

Management is invariably with urgent decompressive craniectomy. That being said, there has been one study where the authors treated a subset of EDH cases conservatively4.

Case contributed by A/Prof. Pramit Phal.

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Case information

rID: 32049
Case created: 11th Nov 2014
Last edited: 3rd May 2017
Inclusion in quiz mode: Included

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