Traumatic Brain Injury Epidural Hematoma

8/12/2019 Traumatic Brain Injury Epidural Hematoma

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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009

Traumatic Brain InjuryTraumatic Brain InjuryJames G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.

Professor of Radiology, Neurology, and Biomedical InformaticsProfessor of Radiology, Neurology, and Biomedical Informatics

Chair, Department of Radiology and Radiological SciencesChair, Department of Radiology and Radiological Sciences

Uniformed Services UniversityUniformed Services University

Bethesda, MDBethesda, MD

http://http://rad.usuhs.milrad.usuhs.mil


TBI Educational ObjectivesTBI Educational Objectives

Who needs brain imaging?Who needs brain imaging?

What type of imaging is needed?What type of imaging is needed?

Intraaxial LesionsIntraaxial Lesions Primary LesionsPrimary Lesions

Contusion, Shearing InjuryContusion, Shearing Injury

Immediate Neurological EffectsImmediate Neurological Effects

Extraaxial LesionsExtraaxial Lesions Secondary LesionsSecondary Lesions

Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid

Delayed Neurological EffectsDelayed Neurological Effects


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Membrane HematomaMembrane Hematoma

EpiduralEpidural

AcuteAcute

BiconvexBiconvex

UnilateralUnilateral

Skull fractureSkull fracture

Limited by suturesLimited by sutures

SubduralSubdural

Acute to ChronicAcute to Chronic

Concave layerConcave layer

BilateralBilateral

Fracture +/Fracture +/--

Cross suturesCross sutures


Membrane HematomaMembrane Hematoma

EpiduralEpidural SubduralSubdural


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CENTRIPETAL APPROACHCENTRIPETAL APPROACH(outside to inside)(outside to inside)

ScalpScalp

CalvariumCalvarium

EpiduralEpidural

SubduralSubdural

SubarachnoidSubarachnoid

IntraIntra--parenchymalparenchymalIntraIntra--ventricularventricular


Traumatic Hemorrhage:Traumatic Hemorrhage:

SubgalealSubgaleal

CephalohematomaCephalohematoma

Subperiosteal Outer TableSubperiosteal Outer Table

Epidural (Extradural)Epidural (Extradural)

Subperiosteal Inner TableSubperiosteal Inner Table

SubduralSubdural

EpiEpi--arachnoidarachnoid

SubarachnoidSubarachnoid

Parenchymal HemorrhageParenchymal Hemorrhage

IntraIntra--ventricularventricular


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22 y.oy.o. with dilated pupil. with dilated pupil

Midline Herniation: Subfalcial and Downward Transtentorial


CNS TRAUMA EPIDURALCNS TRAUMA EPIDURALHEMATOMAHEMATOMA

Young Men (20Young Men (20--40's)40's)

Head Trauma frequentHead Trauma frequent

Also, dura (periosteum) more adherent inAlso, dura (periosteum) more adherent in

older peopleolder people

Acute presentationAcute presentation

Skull fracture (90%)Skull fracture (90%) BiBi--convex, hyperdenseconvex, hyperdense-- limited by sutureslimited by sutures


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EPIDURAL HEMATOMAEPIDURAL HEMATOMA

Source of BleedingSource of Bleeding MENINGEAL VESSELSMENINGEAL VESSELS

Arterial (high pressure)Arterial (high pressure)

Venous (low pressure)Venous (low pressure)

DURAL SINUSDURAL SINUS High flow, low pressureHigh flow, low pressure

OTHEROTHER Diploic veins (Fx)Diploic veins (Fx)

Marrow sinusoidsMarrow sinusoids


EPIDURAL HEMATOMAEPIDURAL HEMATOMA

Significant traumaSignificant trauma

Fracture & concussion (l.o.c.)Fracture & concussion (l.o.c.)

Lucid IntervalLucid Interval

pt Wakes Uppt Wakes Up

40% pts.40% pts. Delayed neurologic Sx (hrs. Later)Delayed neurologic Sx (hrs. Later)

Herniation, coma and deathHerniation, coma and death


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Epidural Hematoma: Lens ShapeEpidural Hematoma: Lens Shape

Scalp & Skull

Dura & Arachnoid

Pia and Brain

Ventricle and CSF


Epidural HematomaEpidural Hematoma


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EPIDURAL HEMATOMAEPIDURAL HEMATOMATraumaTrauma --> fracture & concussion> fracture & concussion

Tearing/stripping of both layersTearing/stripping of both layersfrom inner tablefrom inner table

Laceration of outer periostealLaceration of outer periosteallayerlayer

Laceration of meningeal vesselsLaceration of meningeal vessels

Inner (meningeal dura) intactInner (meningeal dura) intact

Blood between naked bone andBlood between naked bone andduradura

NORMAL arterial pressureNORMAL arterial pressurecontinues to dissectcontinues to dissect




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Brain Herniation SyndromesBrain Herniation Syndromes


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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009Epidural HematomaEpidural Hematoma


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Epidural HematomaEpidural Hematoma -- TreatmentTreatment

Craniotomy

Drain clot

Repair the Artery!


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Small EDHSmall EDH Conservative TxConservative Tx

Smile of the Quadrigeminal Cistern


Everyone deserves a smile!Everyone deserves a smile!Quadrigeminal plate cistern

Corpora quadrigemini2 pairs of colliculi

SuperiorInferior

Perimesencephalic cisternAmbient cistern

Courtesy Frank Brennan, CDR, USN (ret.)


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Progressive EDHProgressive EDH

8 PM10 AM


SUBPERIOSTEAL HEMATOMASUBPERIOSTEAL HEMATOMA

CEPHALOHEMATOMACEPHALOHEMATOMA (Birth trauma)(Birth trauma)

(outer table, sub(outer table, sub--periosteal)periosteal)

EPIDURAL HEMATOMAEPIDURAL HEMATOMA (Inner table, "sub(Inner table, "sub--periosteal")periosteal")


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CephalohematomaCephalohematoma

Birth TraumaBirth Trauma


CephalohematomaCephalohematoma -- CalcifiedCalcified


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Documents

Traumatic Brain Injury Epidural Hematoma