Cerebral compression can be the result of bleeding in three places.
Bleeding outside the dura only occurs in about 2% of all head injuries. Some of these patients have a lucid interval (Patient D in Fig. 63-5) which is usually only a few hours, but it may be a week or more. Others have steadily deepening coma from time of the injury (Patient F). If they do have a lucid interval, their important first symptom is increasing headache, so take a complaint of headache very seriously in any patient with a recent head injury. If he also has giddiness, mental confusion, or drowsiness, he is may be bleeding extradurally. As this gets worse his unconsciousness deepens, and he develops pyramidal signs on the opposite side.
Bleeding under the dura occurs in about 8% of head injuries, and can follow any of the patterns D, E, and F, in Fig. 63-5. Unfortunately, removing the clot is less dramatically beneficial than it is in extradural haemorrhage. In acute subdural haemorrhage the patient’s unconsciousness deepens in a few hours, in the subacute form in a few days, but in the chronic form he may not become unconscious for months. The lucid interval before symptoms develop can thus be much longer than in extradural haemorrhage. In the chronic form the patient, who is usually elderly, suffers from repeated or increasingly severe headaches, drowsiness, apathy, or mental changes. The typical picture is that of a slowly developing cerebral crisis some time after a complete or partial recovery from a head injury, perhaps a very minor one, which the patient may not even remember. Unfortunately, you can seldom diagnose whether bleeding is subdural or extradural until you operate. The only clue is the short lucid interval and rapid progression of extradural haemorrhage.
Sometimes, when you open a patient’s skull expecting to find a subdural haemorrhage, you find that his brain is swollen and discoloured, due to bleeding inside it or to cerebral oedema.