What clinical signs and symptoms should prompt me to suspect an extradural haematoma in a patient following head trauma?

Clinical signs and symptoms that should prompt suspicion of an extradural haematoma (EDH) following head trauma include:

• An initial loss of consciousness followed by a lucid interval, then deterioration in consciousness or coma, reflecting the classic presentation of EDH due to arterial bleeding causing expanding intracranial pressure NICE NG232.
• Persistent or worsening headache since the injury, which may indicate increasing intracranial pressure from the haematoma NICE NG232.
• Vomiting episodes after the injury, which can be a sign of raised intracranial pressure NICE NG232.
• Focal neurological deficits such as weakness, numbness, or cranial nerve palsies developing after the injury, indicating localized brain compression by the haematoma NICE NG232.
• Seizures occurring after the injury, which may be caused by cortical irritation from the haematoma NICE NG232.
• Signs of skull fracture, especially temporal bone fractures, including bruising behind the ears (Battle’s sign), bleeding from the ears or nose, or clear fluid leakage (cerebrospinal fluid rhinorrhea or otorrhea), which increase suspicion of an underlying EDH NICE NG232.
• Altered behaviour or irritability, particularly in children, which may reflect evolving brain injury NICE NG232.
• Progressive deterioration in Glasgow Coma Scale (GCS) score, especially a drop in motor response, indicating worsening brain injury NICE NG232.
• Symptoms of raised intracranial pressure such as drowsiness, confusion, or pupillary changes (e.g., unilateral dilated pupil) due to transtentorial herniation from the expanding haematoma NICE NG232.

From the literature, posterior fossa extradural haematomas may present more subtly but can include headache, vomiting, and cerebellar signs such as ataxia or cranial nerve deficits, emphasizing the need for high suspicion in head trauma with these symptoms Malik et al. 2007. Early diagnosis is critical as rapid deterioration can occur Ayaz et al. 2019. CT imaging remains the investigation of choice to confirm diagnosis NICE NG232.