Epidural Haematoma - A Blow to The Head

Head injuries can be dicey situations, as demonstrated tragically by Natasha Richardson.

It is quite sad to hear about the case of Natasha Richardson, Liam Neeson’s wife, who hit her head during a skiing mishap and was chatting and laughing for hours even after the event. But she eventually slipped into a coma from which she never woke and died. I heard this was due to an 'epidural haematoma'. What is it?

To understand what an epidural haematoma is, one must understand the anatomy of the brain. The brain is an extremely complicated organ, not least because it controls everything we do, even our breathing, eating and sleeping habits. Think of your brain as your command and control centre and your spinal cord and nerves as the communication relay.

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The brain consists of 3 parts : forebrain, midbrain and hindbrain. The forebrain has the cerebral cortex, which is further divided into 4 pairs of lobes. The frontal lobe is the largest part, and is associated with your thinking, reasoning, planning, speech, movements, emotions and problem solving. The parietal lobe also commands your movements, perception and orientation.

The occipital lobe (back portion) helps you understand what you are seeing through your eyes and the temporal lobe has to do with perception, memory and understanding what you are hearing.

There are of course right and left lobes, and the corpus callosum connects these two hemispheres of your brain. It is said that women possess more axons (connecting nerve fibres) in their corpus callosum than men, hence they are able to integrate, process and multitask better and also talk faster!

The midbrain is made out of the tectum and tegmentum. The hindbrain, which will help us understand why Natasha Richardson had to be on life support, consists of the cerebellum, pons and medulla oblongata.

The midbrain, pons and medulla oblongata are also referred to as the brainstem. The brainstem is responsible for controlling vital life functions such as breathing, heartbeat and blood pressure.

Surrounding the brain are membranes called the meninges, which protect and cloak the brain in cerebrospinal fluid. There are three layers: the dura mater, the arachnoid mater and the pia mater.

So what does 'epidural' mean?

Epidural means outside the dura mater layer, which is the space between your skull and the dura mater. When blood begins to collect within this layer, this is called an 'epidural haematoma'. The dura is laced with tiny veins that feed and drain the membranes and the brain, and when these are torn, they can bleed into the spaces between the layers.

Another potential space separates the dura mater from the arachnoid mater. (It is 'potential' because most times, these two layers are pressing close to one another, like a thin transparent cloth laid tightly on top of the one beneath.) This is called the subdural space. And yes, a hematoma that collects within this potential space is called a 'subdural haematoma'. The pia mater closely lines your brain and spinal cord.

Is it very common for people who have injured their heads to get an epidural haematoma?

It is not that common. Epidural haematomas occur in only 1 to 2% of all people with head injuries. But for people who slip into a coma after head injury, it has been found in 10 to 20% of them. If an epidural hematoma is allowed to progress untreated, as many as 50% of patients will die.

Epidural haematomas are most common in middle age. It becomes less common after you turn 40 because your dura becomes 'stickier' to the bone of your skull and resists dissection. Men are affected four times more often than women, possibly because they are potentially more exposed to head injuries.

The most common part of the brain to get an epidural haematoma is the area between the temporal and parietal lobes.

If I hit my head, how will I know if I have an epidural haematoma? If Natasha Richardson had sought treatment earlier when she was still laughing and talking after the injury, could she have been saved?

The latter question is difficult to answer as we were not there and no CT scans were immediately taken of her head as to ascertain the nature of her injuries. But bleeding may always occur later and a heamatoma may only start to accumulate to a significant size after a period of time.

The unfortunate thing is that signs and symptoms of any haematoma occurring within the brain after a blow to the head can occur from immediately to as long as several weeks later! The symptoms are those of pressure on your brain structures – such as headache, nausea, vomiting, drowsiness, dizziness, confusion, slurred speech and weakness.

As more and more blood feeds into the haematoma, you may feel very lethargic, suffer fits or slip into unconsciousness. All these symptoms are caused by portions of your brain being affected. There are even patients who are struck in the head and become unconscious immediately, only to wake up later and feel better. Then they start to deteriorate as the haematoma accumulates.

Is there any treatment for an epidural hematoma?

Yes. This requires a neurosurgeon to evacuate the haematoma surgically, by drilling a hole through your skull. You have to do this before the hematoma exerts pressure onto the rest of your brain.


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