The epidural haematoma

These are haemorrhages that are located outside the dura, directly underneath the skull (Fig. 1). They occur as a result of a blow to the head (for example, due to a fall from a bicycle) that causes a crack in the skull. Particularly in young people, arterial bleeding can then occur between the meninges and the skull. Since this involves arterial bleeding, it can quickly become a major haemorrhage. It then presses on the underlying brain and quickly causes loss of consciousness to a coma, resulting in death in the absence of rapid intervention.

Figure 1: Situation diagram of an epidural haematoma at a drill hole. The haemorrhage lies on top of the dura and immediately underneath the skull. The skull shows a crack, which is the cause of the laceration and the bleeding of the small artery in the dura. The rapid bleeding leads to a life-threatening blood accumulation within a few hours.

If an artery in the dura is lacerated by the crack, arterial bleeding occurs that can lead to a major haemorrhage with pressure on the brain after as little as a few hours. This causes a worsening headache, followed by drowsiness, and eventually loss of consciousness due to impingement on the brain. There are often no symptoms (aside from a mild headache in some cases), giving the appearance that nothing is wrong. The diagnosis can be confirmed by a CT scan on which the haemorrhage can be seen as a lenticular patch on the outside of the brain.

Because of this, the brain is forced to the other side of the skull. For the operation, a large hole or a flap opening (craniotomy) is made over the place where the scan indicates that the haematoma exists. One immediately sees the clots that have pushed the dura and the underlying brain inwards. The clots are removed, the bleeding artery is located and the bleeding is stopped. If an epidural haematoma is operated on in time, recovery is generally good. However, the time period during which the impingement has not yet caused irreparable damage is very short. Therefore, these patients are always admitted to the Intensive Care ward for observation. If their state of consciousness deteriorates rapidly, intervention must take place immediately.

The procedure consists of a trepanation. A piece of the skull is removed over the haemorrhage, as the surgeon must be able to stop the bleeding and must remove the blood clot immediately. After this, the bone flap is usually replaced, but it is also possible for the surgeon to decide to do this on another occasion. If this involves young patients, without a long-term coma and proper care in a recognised neurosurgery centre (like the Neurosurgery Department of the Nikolaas General Hospital) the prognosis for a subdural haematoma is usually favourable.

Aftercare

Aftercare / Recovery

Recovery is primarily dependent on the size and location of the haemorrhage and any accompanying brain damage.

In order to have the recovery proceed as smoothly as possible, there are various disciplines that can be called on:

  • Physiotherapist
    The physiotherapist works mainly on re-learning normal posture and movement.
  • Speech Therapist
    The speech therapist pays attention to language, speech and swallowing.
  • Dietician
    The dietician is called in for problems with nutrition, such as inadequate food intake.
  • Occupational Therapist
    The goal of the occupational therapist is to teach people to safely perform daily activities as independently as possible.
  • Medical Social Work
    The social worker pays attention to the home situation, so that home care can be arranged, for example.
  • Rehabilitation Physician
    The rehabilitation physician is consulted about such things as follow-up care after discharge.

Which disciplines are called on during your admission to the Neurosurgery Department of the Nikolaas General Hospital depends on your personal circumstances. During the weekly multi-disciplinary meeting held by the neurosurgeon, nurses, occupational therapists, physiotherapists and the social nurse, consideration is given the type of care that is appropriate for you. In this way, a personal care plan is drawn up. If multiple disciples are involved in your treatment and recovery, we call this a multi-disciplinary team. This multi-disciplinary team, which may include the neurologist and nurses, hold a joint meeting once a week. Rehabilitation does not take place at the Neurosurgery Department itself, but at a rehabilitation centre, which may or may not be attached to our hospital.