Traumatic Brain Injury Epidural Hematoma

1
USUHS Smirniotopoulos USUHS Smirniotopoulos - - 2009 2009

Traumatic Brain Injury
Traumatic Brain Injury
J ames G. Smirniotopoulos, M.D. J ames G. Smirniotopoulos, M.D.
Professor of Radiology, Neurology, and Biomedical Informatics Professor of Radiology, Neurology, and Biomedical Informatics
Chair, Department of Radiology and Radiological Sciences Chair, Department of Radiology and Radiological Sciences
Uniformed Services University Uniformed Services University
Bethesda, MD Bethesda, MD
http:// http://rad.usuhs.mil rad.usuhs.mil
TBI Educational Objectives TBI Educational Objectives
Who needs brain imaging? Who needs brain imaging?
What type of imaging is needed? What type of imaging is needed?
Intraaxial Lesions Intraaxial Lesions Primary Lesions Primary Lesions
Contusion, Shearing Injury Contusion, Shearing Injury
Immediate Neurological Effects Immediate Neurological Effects
Extraaxial Lesions Extraaxial Lesions Secondary Lesions Secondary Lesions
Epidural, Subdural, Subarachnoid Epidural, Subdural, Subarachnoid
Delayed Neurological Effects Delayed Neurological Effects
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Membrane Hematoma Membrane Hematoma
Epidural Epidural
Acute Acute
Biconvex Biconvex
Unilateral Unilateral
Skull fracture Skull fracture
Limited by sutures Limited by sutures
Subdural Subdural
Acute to Chronic Acute to Chronic
Concave layer Concave layer
Bilateral Bilateral
Fracture +/ Fracture +/- -
Cross sutures Cross sutures
Epidural Epidural Subdural Subdural
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CENTRIPETAL APPROACH CENTRIPETAL APPROACH
(outside to inside) (outside to inside)
Scalp Scalp
Calvarium Calvarium
Epidural Epidural
Subdural Subdural
Subarachnoid Subarachnoid
Intra Intra- -parenchymal parenchymal
Intra Intra- -ventricular ventricular
Traumatic Hemorrhage: Traumatic Hemorrhage:
Subgaleal Subgaleal
Cephalohematoma Cephalohematoma
Subperiosteal Outer Table Subperiosteal Outer Table
Epidural (Extradural) Epidural (Extradural)
Subperiosteal Inner Table Subperiosteal Inner Table
Subdural Subdural
Epi Epi- -arachnoid arachnoid
Subarachnoid Subarachnoid
Parenchymal Hemorrhage Parenchymal Hemorrhage
Intra Intra- -ventricular ventricular
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2 2 y.o y.o. with dilated pupil . with dilated pupil
Midline Herniation: Subfalcial and Downward Transtentorial
CNS TRAUMA EPIDURAL CNS TRAUMA EPIDURAL
HEMATOMA HEMATOMA
Young Men (20 Young Men (20- -40's) 40's)
Head Trauma frequent Head Trauma frequent
Also, dura (periosteum) more adherent in Also, dura (periosteum) more adherent in
older people older people
Acute presentation Acute presentation
Skull fracture (90%) Skull fracture (90%)
Bi Bi- -convex, hyperdense convex, hyperdense- - limited by sutures limited by sutures
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EPIDURAL HEMATOMA EPIDURAL HEMATOMA
Source of Bleeding Source of Bleeding
MENINGEAL VESSELS MENINGEAL VESSELS
Arterial (high pressure) Arterial (high pressure)
Venous (low pressure) Venous (low pressure)
DURAL SINUS DURAL SINUS
High flow, low pressure High flow, low pressure
OTHER OTHER
Diploic veins (Fx) Diploic veins (Fx)
Marrow sinusoids Marrow sinusoids
Significant trauma Significant trauma
Fracture & concussion (l.o.c.) Fracture & concussion (l.o.c.)
Lucid I nterval Lucid I nterval
pt Wakes Up pt Wakes Up
40% pts. 40% pts.
Delayed neurologic Sx (hrs. Later) Delayed neurologic Sx (hrs. Later)
Herniation, coma and death Herniation, coma and death
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Epidural Hematoma: Lens Shape Epidural Hematoma: Lens Shape
Scalp & Skull
Dura & Arachnoid
Pia and Brain
Ventricle and CSF
Epidural Hematoma Epidural Hematoma
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Trauma Trauma - -> fracture & concussion > fracture & concussion
Tearing/stripping of both layers Tearing/stripping of both layers
from inner table from inner table
Laceration of outer periosteal Laceration of outer periosteal
layer layer
Laceration of meningeal vessels Laceration of meningeal vessels
Inner (meningeal dura) intact Inner (meningeal dura) intact
Blood between naked bone and Blood between naked bone and
dura dura
NORMAL arterial pressure NORMAL arterial pressure
continues to dissect continues to dissect
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t t
t t
f
Brain Herniation Syndromes Brain Herniation Syndromes
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C
M
U
T
T
t t
t t
f
Blown Pupil:
Oculomotor nerve
ipsilateral to the
mass lesion
C
M
U
T
T
t t
t t
f
Kernohans Notch:
Cerebral peduncle
contralateral to the
mass lesion
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11
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Epidural Hematoma Epidural Hematoma - - Treatment Treatment
Craniotomy
Drain clot
Repair the Artery!
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Small EDH Small EDH Conservative Tx Conservative Tx
Smile of the Quadrigeminal Cistern

Everyone deserves a smile! Everyone deserves a smile!
Quadrigeminal plate cistern
Corpora quadrigemini
2 pairs of colliculi
Superior
Inferior
Perimesencephalic cistern
Ambient cistern
Courtesy Frank Brennan, CDR, USN (ret.)
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Progressive EDH Progressive EDH
8 PM 10 AM
SUBPERIOSTEAL HEMATOMA SUBPERIOSTEAL HEMATOMA
CEPHALOHEMATOMA CEPHALOHEMATOMA
(Birth trauma) (Birth trauma)
(outer table, sub (outer table, sub- -periosteal) periosteal)
(Inner table, "sub (Inner table, "sub- -periosteal") periosteal")
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Cephalohematoma Cephalohematoma
Birth Trauma Birth Trauma
Cephalohematoma Cephalohematoma - - Calcified Calcified
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Epidural Epidural
Acute Acute
Biconvex Biconvex
Unilateral Unilateral
Skull fracture Skull fracture
Limited by sutures Limited by sutures
Subdural Subdural
Acute to Chronic Acute to Chronic
Concave layer Concave layer
Bilateral Bilateral
Fracture +/ Fracture +/- -
Cross sutures Cross sutures
Epidural Epidural Subdural Subdural
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Subdural Hematoma: Concave Subdural Hematoma: Concave
Splits Arachnoid from the Dura Splits Arachnoid from the Dura
Scalp & Skull
Dura
Arachnoid
Pia and Brain
Ventricle and CSF

Traumatic Brain Injury Epidural Hematoma

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USUHS Smirniotopoulos USUHS Smirniotopoulos - - 2009 2009

Smile of the Quadrigeminal Cistern

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