A 45-year-old man is found unresponsive after a road traffic accident. CT head shows a biconvex hyperdense lens-shaped extradural haematoma in the temporal region with 8 mm midline shift. On examination, there is ipsilateral pupil dilation (blown pupil). The correct immediate surgical intervention and the artery most commonly injured is:

• A Burr-hole drainage; posterior communicating artery
• B Decompressive craniectomy; anterior cerebral artery
• C IV mannitol and observation; superior sagittal sinus
• D Emergency craniotomy for clot evacuation; middle meningeal artery ✓

Explanation

Extradural haematoma (EDH) is a surgical emergency requiring emergency craniotomy for clot evacuation, particularly with midline shift >5 mm, volume >30 mL, or deteriorating neurology. The most common source is rupture of the middle meningeal artery after temporal bone fracture. Ipsilateral pupil dilation (uncal herniation with CN III compression) indicates transtentorial herniation and mandates immediate decompression. Mannitol is a temporising measure, not definitive treatment. Burr holes are only used when craniotomy is unavailable.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.