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 ESSENTIALS OF

Anne G. Osborn
ii
 iii

A Fundamental Guide for Residents and Fellows

Anne G. Osborn, MD, FACR

University Distinguished Professor and
Professor of Radiology and Imaging Sciences
William H. and Patricia W. Child Presidential Endowed Chair in Radiology
University of Utah School of Medicine
Salt Lake City, Utah
 ESSENTIALS OF OSBORN’S BRAIN: A FUNDAMENTAL GUIDE
iv
FOR RESIDENTS AND FELLOWS ISBN: 978-0-323-71320-7

Copyright © 2020 by Elsevier. All rights reserved.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices
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Contributing Authors v

Gary L. Hedlund, DO
Adjunct Professor of Radiology
University of Utah School of Medicine
Salt Lake City, Utah

Karen L. Salzman, MD
Professor of Radiology and Imaging Sciences
Neuroradiology Section Chief and Fellowship Director
Leslie W. Davis Endowed Chair in Neuroradiology
University of Utah School of Medicine
Salt Lake City, Utah
vi
 Introduction vii

Welcome to Essentials of Osborn’s Brain! When I wrote the first edition of

Osborn’s Brain in 2013, it was written as a curriculum in neuroradiology with
the “must know—now!” topics, such as brain trauma, strokes, and hemorrhage
covered in the first few chapters of the text. At nearly 1,300 pages, the 2018
updated second edition was a comprehensive and very detailed delineation of
brain pathology and imaging…more than even the most dedicated residents
and fellows could absorb.

Hence the idea to edit and consolidate the most important concepts of Osborn’s
Brain, second edition into a shorter, more “digestible” text aimed at residents
and fellows in radiology, neurology, and neurosurgery. We have constructed a
year-by-year (or rotation-by-rotation) study guide that takes a trainee through
the essentials but also enhances learning with complementary assignments
from STATdx and RadPrimer, invaluable resources that are available through
many institutional training programs. We’ve also scoured the web for free,
universally accessible programs that supplement reading assignments and
provide active links to the websites.

So let me be your guide to exploring the wonderful, fascinating world of brain

anatomy, pathology, and imaging.

Anne G. Osborn, MD, FACR

University Distinguished Professor and Professor of Radiology and Imaging Sciences
William H. and Patricia W. Child Presidential Endowed Chair in Radiology
University of Utah School of Medicine
Salt Lake City, Utah
viii
 Image Contributors ix

AFIP Archives H. R. Harnsberger, MD K. K. Oguz, MD

D. P. Agamanolis, MD B. Hart, MD J. P. O’Malley, MD
N. Agarwal, MD E. T. Hedley-White, MD N. Omar, MD
J. Ardyn, MD G. Hedlund, DO J. Paltan, MD
M. Ayadi, MD R. Hewlett, MD G. Parker, MD
S. Aydin, MD P. Hildenbrand, MD T. Poussaint, MD
D. Bertholdo, MD C. Y. Ho, MD R. Ramakantan, MD
S. Blaser, MD B. Horten, MD C. Rambaud, MD
J. Boxerman, MD C. Hsu, MD M. L. Rivera-Zengotita, MD
M. Brant-Zawadski, MD M. Huckman, MD C. Robson, MBChB
P. Burger, MD P. Hudgins, MD F. J. Rodriguez, MD
S. Candy, MD A. Illner, MD P. Rodriguez, MD
M. Castillo, MD B. Jones, MD A. Rosenberg, MD
P. Chapman, MD J. A. Junker, MD E. Ross, MD
L. Chimelli, MD E. C. Klatt, MD A. Rossi, MD
S. Chung, MD D. Kremens, MD L. Rourke, MD
M. Colombo, MD W. Kucharczyk, MD Rubinstein Collection, AFIP
J. Comstock, MD P. Lasjaunias, MD Archives
J. Curé, MD S. Lincoff, MD E. Rushing, MD
B. Czerniak, MD T. Markel, MD M. Sage, MD
A. Datir, MD M. Martin, MD B. Scheithauer, MD
B. N. Delman, MD A. Maydell, MD P. Shannon, MD
B. K. DeMasters, MD S. McNally, MD A. Sillag, MD
K. Digre, MD T. Mentzel, MD E. T. Tali, MD
H. D. Dorfman, MD C. Merrow, MD M. Thurnher, MD
M. Edwards-Brown, MD M. Michel, MD T. Tihan, MD
D. Ellison, MD K. Moore, MD K. Tong, MD
H. Els, MD S. Nagi, MD J. Townsend, MD
A. Ersen, MD T. P. Naidich, MD U. of Utah Dept. of Dermatology
W. Fang, MD N. Nakase, MD S. van der Westhuizen, MD
N. Foster, MD S. Narendra, MD M. Warmuth-Metz, MD
C. E. Fuller, MD K. Nelson, MD T. Winters, MD
S. Galetta, MD R. Nguyen, MD A. T. Yachnis, MD
C. Glastonbury, MBBS G. P. Nielsen, MD S. Yashar, MD
S. Harder, MD M. Nielsen, MS
x
Acknowledgments xi

EDITOR IN CHIEF
Rebecca L. Bluth, BA

TEX T EDITORS
Arthur G. Gelsinger, MA
Nina I. Bennett, BA
Terry W. Ferrell, MS
Megg Morin, BA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

ILLUSTR ATIONS
Richard Coombs, MS
Lane R. Bennion, MS
Laura C. Wissler, MA

ART DIREC TION AND DESIGN

Tom M. Olson, BA

PRODUC TION COORDINATORS

Emily C. Fassett, BA
John Pecorelli, BS
 Table of Contents
xii

Section 1: Section 2: Section 3:

Trauma Nontraumatic Hemorrhage Infection, Inflammation, and
and Vascular Lesions Demyelinating Diseases
CHAPTER 1: Trauma Overview. . . . 5
Anne G. Osborn, MD, FACR CHAPTER 4: Approach to CHAPTER 11: Approach to
Nontraumatic Hemorrhage Infection, Inflammation, and
CHAPTER 2: Primary Effects and Vascular Lesions. . . . . . . . . . . 63 Demyelination. . . . . . . . . . . . . . . . 199
of CNS Trauma . . . . . . . . . . . . . . . . . 11 Anne G. Osborn, MD, FACR Anne G. Osborn, MD, FACR
Anne G. Osborn, MD, FACR and
Gary L. Hedlund, DO CHAPTER 5: Spontaneous CHAPTER 12: Congenital, Acquired
Parenchymal Hemorrhage. . . . . . . 73 Pyogenic, and Acquired Viral
CHAPTER 3: Secondary Effects Anne G. Osborn, MD, FACR Infections . . . . . . . . . . . . . . . . . . . . 203
and Sequelae of CNS Trauma. . . . 47 Anne G. Osborn, MD, FACR and
Anne G. Osborn, MD, FACR CHAPTER 6: Subarachnoid Gary L. Hedlund, DO
Hemorrhage and Aneurysms . . . . 93
Anne G. Osborn, MD, FACR CHAPTER 13: Tuberculosis and
Fungal, Parasitic, and Other
CHAPTER 7: Vascular Infections . . . . . . . . . . . . . . . . . . . . 225
Malformations . . . . . . . . . . . . . . . . 113 Anne G. Osborn, MD, FACR
Anne G. Osborn, MD, FACR
CHAPTER 14: HIV/AIDS . . . . . . . 243
CHAPTER 8: Arterial Anatomy Anne G. Osborn, MD, FACR
and Strokes . . . . . . . . . . . . . . . . . . . 135
Anne G. Osborn, MD, FACR CHAPTER 15: Demyelinating and
Inflammatory Diseases . . . . . . . . 257
CHAPTER 9: Venous Anatomy Anne G. Osborn, MD, FACR
and Occlusions . . . . . . . . . . . . . . . . 157
Anne G. Osborn, MD, FACR

CHAPTER 10: Vasculopathy . . . . 173

Anne G. Osborn, MD, FACR
 Table of Contents
xiii

Section 4: Section 5: Section 6:

Neoplasms, Cysts, and Toxic, Metabolic, Congenital Malformations of
Tumor-Like Lesions Degenerative, and CSF the Skull and Brain
Disorders
CHAPTER 16: Introduction to CHAPTER 35: Embryology and
Neoplasms, Cysts, and CHAPTER 29: Approach to Toxic, Approach to Congenital
Tumor-Like Lesions . . . . . . . . . . . . 281 Metabolic, Degenerative, and Malformations . . . . . . . . . . . . . . . . . . 583
Anne G. Osborn, MD, FACR CSF Disorders . . . . . . . . . . . . . . . . . 475 Anne G. Osborn, MD, FACR and
Anne G. Osborn, MD, FACR Gary L. Hedlund, DO
CHAPTER 17: Astrocytomas . . . . 291
Anne G. Osborn, MD, FACR CHAPTER 30: Toxic CHAPTER 36: Posterior Fossa
Encephalopathy . . . . . . . . . . . . . . . 483 Malformations . . . . . . . . . . . . . . . . . . 589
CHAPTER 18: Nonastrocytic Anne G. Osborn, MD, FACR Anne G. Osborn, MD, FACR and
Glial Neoplasms . . . . . . . . . . . . . . . 313 Gary L. Hedlund, DO
Anne G. Osborn, MD, FACR CHAPTER 31: Inherited
Metabolic Disorders . . . . . . . . . . . 499 CHAPTER 37: Commissural and
CHAPTER 19: Neuronal and Gary L. Hedlund, DO Cortical Maldevelopment . . . . . . . . 601
Glioneuronal Tumors. . . . . . . . . . . 327 Anne G. Osborn, MD, FACR and
Anne G. Osborn, MD, FACR CHAPTER 32: Acquired Metabolic Gary L. Hedlund, DO
and Systemic Disorders . . . . . . . . 521
CHAPTER 20: Pineal and Germ Anne G. Osborn, MD, FACR CHAPTER 38: Holoprosencephalies,
Cell Tumors . . . . . . . . . . . . . . . . . . . 341 Related Disorders, and Mimics. . . . 611
Anne G. Osborn, MD, FACR CHAPTER 33: Dementias and Anne G. Osborn, MD, FACR and
Brain Degenerations . . . . . . . . . . 545 Gary L. Hedlund, DO
CHAPTER 21: Embryonal Anne G. Osborn, MD, FACR
Neoplasms. . . . . . . . . . . . . . . . . . . . 351 CHAPTER 39: Familial Cancer
Anne G. Osborn, MD, FACR CHAPTER 34: Hydrocephalus Predisposition Syndromes . . . . . . . 617
and CSF Disorders . . . . . . . . . . . . . 565 Anne G. Osborn, MD, FACR and
CHAPTER 22: Tumors of the Anne G. Osborn, MD, FACR and Gary L. Hedlund, DO
Meninges . . . . . . . . . . . . . . . . . . . . . 363 Gary L. Hedlund, DO
Anne G. Osborn, MD, FACR CHAPTER 40: Vascular
Neurocutaneous Syndromes . . . . . 633
CHAPTER 23: Nerve Sheath
Anne G. Osborn, MD, FACR and
Tumors . . . . . . . . . . . . . . . . . . . . . . . 385
Gary L. Hedlund, DO
Anne G. Osborn, MD, FACR
CHAPTER 41: Anomalies of the
CHAPTER 24: Lymphomas and
Skull and Meninges . . . . . . . . . . . . . . 641
Hematopoietic and Histiocytic
Anne G. Osborn, MD, FACR and
Tumors . . . . . . . . . . . . . . . . . . . . . . . 399
Gary L. Hedlund, DO
Anne G. Osborn, MD, FACR

CHAPTER 25: Sellar Neoplasms

and Tumor-Like Lesions . . . . . . . . 411
Karen L. Salzman, MD and
Anne G. Osborn, MD, FACR

CHAPTER 26: Miscellaneous Tumors

and Tumor-Like Conditions . . . . . 431
Anne G. Osborn, MD, FACR

CHAPTER 27: Metastases and

Paraneoplastic Syndromes . . . . . 439
Anne G. Osborn, MD, FACR

CHAPTER 28: Nonneoplastic

Cysts . . . . . . . . . . . . . . . . . . . . . . . . . 451
Anne G. Osborn, MD, FACR
 ESSENTIALS OF

Anne G. Osborn
Section 1
Section 1
Trauma
 Chapter 1
5

Trauma Overview
Trauma is one of the most frequent indications for Introduction 5
emergent neuroimaging. Because imaging plays such Epidemiology of Head Trauma 5
a key role in patient triage and management, we Etiology and Mechanisms of Injury 5
Classification of Head Trauma 6
begin this book by discussing skull and brain trauma.
Imaging Acute Head Trauma 6
How To Image 6
We start with a brief consideration of epidemiology. Traumatic brain injury Who and When To Image 6
(TBI) is a critical public health and socioeconomic problem throughout the
world. The direct medical costs of caring for acutely traumatized patients are Trauma Imaging: Keys to Analysis 7
huge. The indirect costs of lost productivity and long-term care for TBI Scout Image 7
survivors are even larger than the short-term direct costs. Brain Windows 7
Subdural Windows 8
We then briefly discuss the etiology and mechanisms of head trauma. Bone CT 8
Understanding the different ways in which the skull and brain can be injured CTA 9
provides the context for understanding the spectrum of findings that can be
identified on imaging studies.

Introduction
Epidemiology of Head Trauma
At least 10 million people worldwide sustain TBI each year. Approximately
10% sustain fatal brain injury. Lifelong disability is common in those who
survive. Between 5% and 10% of TBI survivors have serious permanent
neurologic deficits, and an additional 20-40% have moderate disability. Even
more have subtle deficits ("minimal brain trauma").

Etiology and Mechanisms of Injury

Trauma can be caused by missile or nonmissile injury. Nonmissile closed head
injury (CHI) is a much more common cause of neurotrauma than missile
injury. Falls have now surpassed road traffic incidents as the leading cause of
TBI.

So-called "ground-level falls" (GLFs) are a common indication for

neuroimaging in young children and older adults. In such cases, brain injury
can be significant. With a GLF, a six-foot-tall adult's head impacts the ground
at 20 MPH. Anticoagulated older adults are especially at risk for intracranial
hemorrhages, even with minor head trauma.

Motor vehicle collisions occurring at high speed exert significant

acceleration/deceleration forces, causing the brain to move suddenly within
the skull. Forcible impaction of the brain against the unyielding calvarium
and hard, knife-like dura results in gyral contusion. Rotation and sudden
changes in angular momentum may deform, stretch, and damage long
vulnerable axons, resulting in axonal injury.
 Trauma
6
Classification of Head Trauma
The most widely used clinical classification of brain trauma,
the Glasgow Coma Scale (GCS), depends on the assessment of
three features: Best eye, verbal, and motor responses. With
the use of the GCS, TBI can be designated as a mild, moderate,
or severe injury.
TBI can also be divided chronologically and pathoetiologically
into primary and secondary injury, the system used in this text.
Primary injuries occur at the time of initial trauma. Skull
fractures, epi- and subdural hematomas, contusions, axonal
injury, and brain lacerations are examples of primary injuries.
Secondary injuries occur later and include cerebral edema,
perfusion alterations, brain herniations, and CSF leaks.
Although vascular injury can be immediate (blunt impact) or
secondary (vessel laceration from fractures, occlusion
secondary to brain herniation), for purposes of discussion, it is
included in the chapter on secondary injuries.
CLASSIFICATION OF HEAD TRAUMA
Primary Effects
• Scalp and skull injuries
• Extraaxial hemorrhage/hematomas
• Parenchymal injuries
• Miscellaneous injuries
Secondary Effects
• Herniation syndromes
• Cerebral edema
• Cerebral ischemia
• Vascular injury (can be primary or secondary)
Imaging Acute Head
Trauma
Imaging is absolutely critical to the diagnosis and
management of the patient with acute TBI. The goal of
emergent neuroimaging is twofold: (1) Identify treatable
injuries, especially emergent ones, and (2) detect and
delineate the presence of secondary injuries, such as
herniation syndromes and vascular injury.
How To Image
NECT
CT is now accepted as the "workhorse" screening tool for
imaging acute head trauma. The reasons are simple: CT
depicts both bone and soft tissue injuries. It is also widely
accessible, fast, effective, and comparatively inexpensive.
Nonenhanced CT (NECT) scans (4 or 5 mm thick) from just
below the foramen magnum through the vertex should be
performed. Two sets of images should be obtained: One using
brain and one with bone reconstruction algorithms. Viewing
the brain images with a wider window width (150-200 HU, the
so-called "subdural window") should be performed on PACS.
The scout view should always be displayed as part of the
study.
MDCT is now routine in trauma triage. Coronal and sagittal
reformatted images using the axial source data improve the
detection rate of acute traumatic subdural hematomas.
Three-dimensional shaded surface displays are helpful in
depicting skull and facial fractures. If facial bone CT is also
requested, a single MDCT acquisition can be obtained without
overlapping radiation exposure to the eye and lower 1/2 of
the brain.
Head trauma patients with acute intracranial lesions on CT
have a higher risk for cervical spine fractures compared with
patients with a CT-negative head injury. Because up to 1/3 of
patients with moderate to severe head injury as determined
by the GCS have concomitant spine injury, MDCT of the
cervical spine is often obtained together with brain imaging.
Soft tissue and bone algorithm reconstructions with
multiplanar reformatted images of the cervical spine should
be obtained.
CTA
CT angiography (CTA) is often obtained as part of a whole-
body trauma CT protocol. Craniocervical CTA should also
specifically be considered (1) in the setting of penetrating
neck injury, (2) if a fractured foramen transversarium or facet
subluxation is identified on cervical spine CT, or (3) if a skull
base fracture traverses the carotid canal or a dural venous
sinus. Arterial laceration or dissection, traumatic
pseudoaneurysm, carotid-cavernous fistula, or dural venous
sinus injury are nicely depicted on high-resolution CTA.
MR
Although MR can detect traumatic complications without
radiation and is more sensitive for abnormalities, such as
contusions and axonal injuries, there is general agreement
that NECT is the procedure of choice in the initial evaluation of
brain trauma. Limitations of MR include acquisition time,
access, patient monitoring and instability, motion degradation
of images, and cost.
With one important exception—suspected child abuse—using
MR as a routine screening procedure in the setting of acute
brain trauma is uncommon. Standard MR together with
susceptibility-weighted imaging and DTI is most useful in the
subacute and chronic stages of TBI. Other modalities, such as
fMRI, are playing an increasingly important role in detecting
subtle abnormalities, especially in patients with mild cognitive
deficits following minor TBI.
Who and When To Image
Who to image and when to do it are paradoxically both well
established and controversial. Patients with a GCS score
indicating moderate (GCS = 9-12) or severe (GCS ≤ 8)
neurologic impairment are invariably imaged. The real debate
is about how best to manage patients with GCS scores of 13-
15. In places with high malpractice rates, many emergency
 Trauma Overview
7

(1-1A) Scout view in a 66-year-old woman with a CT head (1-1B) Head CT in the same case (not shown) was normal.
requested to evaluate ground-level fall shows a posteriorly Cervical spine CT was then performed. The sagittal image
angulated C1-odontoid complex ﬈. reformatted from the axial scan data shows a comminuted,
posteriorly angulated dens fracture ſt.

physicians routinely order NECT scans on every patient with

head trauma regardless of GCS score or clinical findings. Trauma Imaging: Keys to
GLASGOW COMA SCALE Analysis
Best Eye Response (Maximum = 4) Four components are essential to the accurate interpretation
• 1 = no eye opening of CT scans in patients with head injury: The scout image plus
• 2 = eye opening to pain brain, bone, and subdural views of the NECT dataset. Critical
• 3 = eyes open to verbal command information may be present on just one of these four
• 4 = eyes open spontaneously components.
Best Verbal Response (Maximum = 5)
Suggestions on how to analyze NECT images in patients with
• 1 = none
acute head injury are delineated below.
• 2 = incomprehensible sounds
• 3 = inappropriate words
• 4 = confused Scout Image
• 5 = oriented Before you look at the NECT scan, examine the digital scout
Best Motor Response (Maximum = 6) image! Look for cervical spine abnormalities, such as fractures
• 1 = none or dislocations, jaw &/or facial trauma, and the presence of
• 2 = extension to pain foreign objects (1-1A). If there is a suggestion of cervical spine
• 3 = flexion to pain fracture or malalignment, MDCT of the cervical spine should
• 4 = withdrawal to pain be performed before the patient is removed from the scanner
• 5 = localizing to pain (1-1B).
• 6 = obedience to commands
Sum = "Coma Score" and Clinical Grading Brain Windows
• 13-15 = mild brain injury
Methodically and meticulously work your way from the
• 9-12 = moderate brain injury
outside in. First, evaluate the soft tissue images, beginning
• ≤ 8 = severe brain injury
with the scalp. Look for scalp swelling, which usually indicates
the impact point. Carefully examine the periorbital soft
tissues.

Next, look for extraaxial blood. The most common extraaxial

hemorrhage is traumatic subarachnoid hemorrhage (tSAH)
followed by sub- and epidural hematomas. The prevalence of
 Trauma
8
(1-2A) Axial NECT in an 18-year-old man who fell
off his skateboard shows a small right epidural
hematoma that also contains air st.
(1-2B) Bone algorithm reconstruction shows a
nondisplaced linear fracture ſt adjacent to the
epidural blood and air st.
(1-2C) Reconstructed coronal (L) and sagittal (R)
bone CTs show the fracture ſt comminuted and
crosses the mastoid st and middle ear ﬇.
tSAH in moderate to severe TBI approaches 100%. tSAH is usually found in
the sulci adjacent to cortical contusions, along the sylvian fissures, and
around the anteroinferior frontal and temporal lobes. The best place to look
for subtle tSAH is the interpeduncular cistern, where blood collects when
the patient is supine.
Any hypodensity within an extraaxial collection should raise suspicion of
rapid hemorrhage with accumulation of unclotted blood or (especially in
alcoholics or older patients) an underlying coagulopathy. This is an urgent
finding that mandates immediate notification of the responsible clinician.
Look for intracranial air ("pneumocephalus"). Intracranial air is always
abnormal and indicates the presence of a fracture that traverses either the
paranasal sinuses or mastoid.
Now, move on to the brain itself. Carefully examine the cortex, especially the
"high-yield" areas for cortical contusions (anteroinferior frontal and temporal
lobes). If there is a scalp hematoma due to impact (a "coup" injury), look 180°
in the opposite direction for a classic "contre-coup" injury. Hypodense areas
around the hyperdense hemorrhagic foci indicate early edema and severe
contusion.
Move inward from the cortex to the subcortical white and deep gray matter.
Petechial hemorrhages often accompany axonal injury. If you see subcortical
hemorrhages on the initial NECT scan, this is merely the "tip of the iceberg."
There is usually a lot more damage than what is apparent on the first scan. A
general rule: The deeper the lesion, the more severe the injury.
Finally, look inside the ventricles for blood-CSF levels and hemorrhage due to
choroid plexus shearing injury.
Subdural Windows
Look at the soft tissue image with both narrow ("brain") and intermediate
("subdural") windows. Small, subtle subdural hematomas can sometimes be
overlooked on standard narrow window widths (75-100 HU) yet are readily
apparent when wider windows (150-200 HU) are used.
Bone CT
Bone CT refers to bone algorithm reconstruction viewed with wide (bone)
windows. If you cannot do bone algorithm reconstruction from your dataset,
widen the windows and use an edge-enhancement feature to sharpen the
image. Three-dimensional shaded surface displays (3D SSDs) are especially
helpful in depicting complex or subtle fractures (1-2).
Even though standard head scans are 4-5 mm thick, it is often possible to
detect fractures on bone CT. Look for basisphenoid fractures with
involvement of the carotid canal, temporal bone fractures (with or without
ossicular dislocation), mandibular dislocation ("empty" condylar fossa), and
calvarial fractures. Remember: Nondisplaced linear skull fractures that do
not cross vascular structures (such as a dural venous sinus or middle
meningeal artery) are in and of themselves basically meaningless. The brain
and blood vessels are what matter!
The most difficult dilemma is deciding whether an observed lucency is a
fracture or a normal structure (e.g., suture line or vascular channel). Keep in
mind: It is virtually unheard of for a calvarial fracture to occur in the absence
of overlying soft tissue injury. If there is no scalp "bump," it is unlikely that the
lucency represents a nondisplaced linear fracture.
Bone CT images are also very helpful in distinguishing low density from air vs.
fat. Although most PACS stations have a region of interest (ROI) function
 Trauma Overview
9
that can measure attenuation, fat fades away on bone CT images, and air
remains very hypodense.

CTA
CTA is generally indicated if (1) basilar skull fractures cross the carotid canal
or a dural venous sinus (1-3); (2) if a cervical spine fracture-dislocation is
present, especially if the transverse foramina are involved; or (3) if the
patient has stroke-like symptoms or unexplained clinical deterioration. Both
the cervical and intracranial vasculature should be visualized.

Although it is important to scrutinize both the arterial and venous sides of

the circulation, a CTA is generally sufficient. Standard CTAs typically show
both the arteries and the dural venous sinuses well, whereas a CT venogram
(CTV) often misses the arterial phase.

Examine the source images as well as the multiplanar reconstructions and

maximum-intensity projection (MIP) reformatted scans. Traumatic
dissection, vessel lacerations, intimal flaps, pseudoaneurysms, carotid-
cavernous fistulas, and dural sinus occlusions can generally be identified on
CTA.
(1-3A) NECT shows pneumocephalus st, base of
skull fractures ſt adjacent to air, which seems to
outline a displaced sigmoid sinus ﬇.

HEAD TRAUMA: CT CHECKLIST

Scout Image
• Evaluate for
○ Cervical spine fracture-dislocation
○ Jaw dislocation, facial fractures
○ Foreign object
Brain Windows
• Scalp swelling (impact point)
• Extraaxial blood (focal hypodensity in clot suggests rapid bleeding)
○ Epidural hematoma
○ Subdural hematoma (SDH)
○ tSAH
• Pneumocephalus
• Cortical contusion
○ Anteroinferior frontal, temporal lobes
○ Opposite scalp laceration/skull fracture (1-3B) NECT in the same case shows diffuse brain
• Hemorrhagic axonal injury swelling, pneumocephalus st, and traumatic
• Intraventricular hemorrhage subarachnoid hemorrhage ﬇.

Subdural Windows
• 150-200 HU (for thin SDHs under skull)
Bone CT
• Bone algorithm reconstruction > bone windows
• Do any fractures cross a vascular channel?

Selected References: The complete reference list is available on the Expert

Consult™ eBook version included with purchase.

(1-3C) CTA in the same case shows that the

sigmoid sinus ﬇ is intact but displaced medially.
Note rapidly enlarging subgaleal hematoma ſt.
 Chapter 2
11

Primary Effects of CNS Trauma

Primary head injuries are defined as those that occur Scalp and Skull Injuries 11
at the time of initial trauma, even though they may Scalp Injuries 11
not be immediately apparent on initial evaluation. Skull Fractures 13
Extraaxial Hemorrhages 15
Head injury can be caused by direct or indirect trauma. Direct trauma Arterial Epidural Hematoma 16
involves a blow to the head and is usually caused by automobile collisions, Venous Epidural Hematomas 18
Acute Subdural Hematoma 21
falls, or injury inflicted by an object, such as a hammer or baseball bat. Scalp
Subacute Subdural Hematoma 23
lacerations, hematomas, and skull fractures are common. Associated Chronic/Mixed Subdural
intracranial damage ranges from none to severe. Hematoma 26
Traumatic Subarachnoid
Significant forces of acceleration/deceleration, linear translation, and
Hemorrhage 29
rotational loading can be applied to the brain without direct head blows.
Such indirect trauma is caused by angular kinematics and typically occurs in Parenchymal Injuries 31
high-speed motor vehicle collisions (MVCs). Here, the brain undergoes rapid Cerebral Contusions and
deformation and distortion. Depending on the site and direction of the force Lacerations 31
applied, significant injury to the cortex, axons, penetrating blood vessels, and Diffuse Axonal Injury 34
deep gray nuclei may occur. Severe brain injury can occur in the absence of Diffuse Vascular Injury 36
Subcortical (Deep Brain) Injury 36
skull fractures or visible scalp lesions.
Miscellaneous Injuries 38
We begin our discussion with a consideration of scalp and skull lesions as we Pneumocephalus 38
work our way from the outside to the inside of the skull. We then delineate Abusive Head Trauma (Child
the spectrum of intracranial trauma, starting with extraaxial hemorrhages. Abuse) 40
We conclude this chapter with a detailed discussion of injuries to the brain
parenchyma (e.g., cortical contusion, diffuse axonal injury, and the serious
deep subcortical injuries).

Scalp and Skull Injuries

Scalp and skull injuries are common manifestations of cranial trauma.
Although brain injury is usually the most immediate concern in managing
traumatized patients, superficial lesions, such as scalp swelling and focal
hematoma, can be helpful in identifying the location of direct head trauma.
On occasion, these initially innocent-appearing "lumps and bumps" can
become life threatening. Before turning our attention to intracranial
traumatic lesions, we therefore briefly review scalp and skull injuries,
delineating their typical imaging findings and clinical significance.

Scalp Injuries
Scalp injuries include lacerations and hematomas. Scalp lacerations can
occur in both penetrating and closed head injuries. Lacerations may extend
partially or entirely through all five layers of the scalp (skin, subcutaneous
fibrofatty tissue, galea aponeurotica, loose areolar connective tissue, and
periosteum) to the skull (2-1).

Focal discontinuity, soft tissue swelling, and subcutaneous air are commonly
identified in scalp lacerations. Scalp lacerations should be carefully evaluated
 Trauma
12
for the presence of any foreign bodies. If not removed during
wound debridement, foreign bodies can be a potential source
of substantial morbidity and are very important to identify on
initial imaging studies. Wood fragments are often hypodense,
whereas leaded glass, gravel, and metallic shards are variably
hyperdense (2-2).
Scalp lacerations may or may not be associated with scalp
hematomas. There are two distinctly different types of scalp
hematomas: Cephalohematomas and subgaleal hematomas.
The former are usually of no clinical significance, whereas the
latter can cause hypovolemia and hypotension.
Cephalohematomas are subperiosteal blood collections that
lie in the potential space between the outer surface of the
calvarium and the pericranium, which serves as the
periosteum of the skull (2-3). The pericranium continues
medially into cranial sutures and is anatomically contiguous
with the outer (periosteal) layer of the dura.
Cephalohematomas are the extracranial equivalent of an
intracranial epidural hematoma. Cephalohematomas do not
cross suture lines and are typically unilateral. Because they are
anatomically constrained by the tough fibrous periosteum and
its insertions, cephalohematomas rarely attain a large size.
Cephalohematomas occur in 1% of newborns and are more
common following instrumented delivery. They are often
diagnosed clinically but imaged only if they are unusually
prominent or if intracranial injuries are suspected. NECT scans
show a somewhat lens-shaped soft tissue mass that overlies a
single bone (usually the parietal or occipital bone) (2-4). If
more than one bone is affected, the two collections are
separated by the intervening suture lines.
Subgaleal hematomas are subaponeurotic collections and are
common findings in traumatized patients of all ages. Here,
blood collects under the aponeurosis (the "galea") of the
occipitofrontalis muscle (2-5). Because a subgaleal hematoma
lies deep to the scalp muscles and galea aponeurotica but

(2-1) Coronal graphic

depicts normal layers of
the scalp. Skin,
subcutaneous fibrofatty
tissue overlie the galea
aponeurotica ﬊, loose
areolar connective tissue.
The pericranium ﬉ is the
periosteum of the skull
and continues into and
through sutures to merge
with the periosteal layer
of the dura ﬇. (2-2) NECT
shows scalp laceration st,
hyperdense foreign bodies
ſt, and subgaleal air ﬇.

(2-3) Graphic shows the

skull of a newborn,
including the anterior
fontanelle, coronal,
metopic, sagittal sutures.
Cephalohematoma ﬈ is
subperiosteal, limited by
sutures. Subgaleal
hematoma ﬇ is under the
scalp aponeurosis, not
bounded by sutures. (2-4)
NECT scan in a newborn
shows a small right ſt
and a large left st
parietal
cephalohematoma.
Neither crosses the
sagittal suture ﬇.
 Primary Effects of CNS Trauma
13
external to the periosteum, it is not anatomically limited by 35% of severely injured patients have no identifiable fracture,
suture lines. even with thin-section bone reconstructions.

Bleeding into the subgaleal space can be very extensive.
Subgaleal hematomas are usually bilateral lesions that often
spread diffusely around the entire calvarium. NECT scans
show a heterogeneously hyperdense crescentic scalp mass
that crosses one or more suture lines (2-6). In contrast to
benign self-limited cephalohematomas, expanding subgaleal
hematomas in infants and small children can cause significant
blood loss.
Skull Fractures
Noticing a scalp "bump" or hematoma on initial imaging in
head trauma is important, as calvarial fractures rarely—if
ever—occur in the absence of overlying soft tissue swelling or
scalp laceration. Skull fractures are present on initial CT scans
in ~ 2/3 of patients with moderate head injury, although 25-
Several types of acute skull fracture can be identified on
imaging studies: Linear, depressed, and diastatic fractures (2-
7). Fractures can involve the calvarium, skull base, or both.
Linear Skull Fractures
A linear skull fracture is a sharply marginated linear defect
that typically involves both the inner and outer tables of the
calvarium (2-8).
Most linear skull fractures are caused by relatively low-energy
blunt trauma that is delivered over a relatively wide surface
area. Linear skull fractures that extend into and widen a suture
become diastatic fractures. When multiple complex fractures
are present, 3D shaded surface display (SSD) can be very
helpful in depicting their anatomy and relationships to cranial
sutures.

(2-5) Autopsy from a

traumatized infant shows
a massive biparietal
subgaleal hematoma ſt.
The galea aponeurotica
has been partially opened
﬊ to show large
biparietal hematoma that
crosses the sagittal suture
﬉. (2-6) Axial CECT in 3y
child shows massive
subgaleal hematoma ſt
surrounding entire
calvarium. Subgaleal
hematomas cross sutures
and can become life
threatening, while
cephalohematomas are
anatomically limited.

(2-7) Autopsied skull

shows fatal trauma with
exo- (L) and endocranial
views (R). A linear
fracture ﬈ extends into
the superior sagittal
suture ﬊, causing
diastasis and a subgaleal
hematoma st. (2-8) Bone
CT through the top of the
calvarium shows linear
skull fractures ſt
extending into and
widening the sagittal
suture, causing a diastatic
fracture ﬇.
 Trauma
14
Patients with an isolated linear nondisplaced skull fracture
(NDSF), no intracranial hemorrhage or pneumocephalus,
normal neurologic examination, and absence of other injuries
are at very low risk for delayed hemorrhage or other life-
threatening complication. Hospitalization is not necessary for
many children with NDSFs.
Depressed Skull Fractures
A depressed skull fracture is a fracture in which the
fragments are displaced inward (2-9). Comminution of the
fracture fragments starts at the point of maximum impact and
spreads centrifugally. Depressed fractures are most often
caused by high-energy direct blows to a small surface with a
blunt object (e.g., hammer, baseball bat, or metal pipe) (2-10).
Depressed skull fractures typically tear the underlying dura
and arachnoid and are often associated with cortical
contusions and potential leakage of CSF into the subdural
space. Fractures extending to a dural sinus or the jugular bulb
are associated with venous sinus thrombosis in 40% of cases.
Diastatic Skull Fractures
A diastatic skull fracture is a fracture that widens ("diastases"
or "splits open") a suture or synchondrosis. Diastatic skull
fractures usually occur in association with a linear skull
fracture that extends into an adjacent suture (2-11).
Imaging
General Features. Both bone and soft tissue reconstruction
algorithms should be used when evaluating patients with
head injuries. Soft tissue reconstructions should be viewed
with both narrow ("brain") and intermediate ("subdural")
windows. Coronal and sagittal reformatted images obtained
using the MDCT axial source data are helpful additions. SSDs
can be useful in depicting complex and depressed fractures.

(2-9) 3D shaded surface

display (SSD) in a patient
with multiple linear ﬈
and diastatic ﬉ skull
fractures shows utility of
SSDs in depicting complex
fracture anatomy. Note
slight depression ﬇ of
the fractured
parietooccipital
calvarium. (2-10) Axial
bone CT in a patient who
was hit in the head with a
falling ladder shows an
extensively comminuted,
depressed skull fracture
﬇.

(2-11A) Axial NECT scan

in a 20-year-old man who
had a tree fall on his head
shows a massive
subgaleal hematoma ﬇
crossing the anterior
aspect of the sagittal
suture ſt. A small
extraaxial hematoma st,
most likely a venous
epidural hematoma (EDH),
is present. (2-11B) Bone
CT in the same case shows
a diastatic fracture of the
sagittal suture ſt.
Nondisplaced linear
fractures ﬊ are also
present.
 Primary Effects of CNS Trauma
15
CT Findings. NECT scans demonstrate linear skull fractures as sharply
marginated lucent lines. Depressed fractures are typically comminuted and
show inward implosion of fracture fragments (2-10). Diastatic fractures
appear as widened sutures or synchondroses (2-11) (2-13) and are usually
associated with linear skull fractures.

MR Findings. MR is rarely used in the setting of acute head trauma because

of high cost, limited availability, and lengthy time required. Compared with
CT, bone detail is poor, although parenchymal injuries are better seen.
Adding T2* sequences, particularly SWI, is especially helpful in identifying
hemorrhagic lesions.

Angiography. If a fracture crosses the site of a major vascular structure, such

as the carotid canal or a dural venous sinus (2-12), CT angiography is
recommended. Sagittal, coronal, and MIP reconstructions help delineate the
site and extent of vascular injuries.

Clival and skull base fractures are strongly associated with neurovascular
trauma, and CTA should always be obtained in these cases (2-13). Cervical
fracture dislocations, distraction injuries, and penetrating neck trauma also
merit further investigation. Uncomplicated asymptomatic soft tissue injuries
of the neck rarely result in significant vascular injury.
(2-12) Autopsy shows multiple skull base
fractures involving clivus ſt, carotid canals ﬇, &
jugular foramina st. (E. T. Hedley-White, MD.)

SCALP AND SKULL INJURIES

Scalp Injuries
• Lacerations ± foreign bodies
• Cephalohematoma
○ Usually infants
○ Subperiosteal
○ Small, unilateral (limited by sutures)
• Subgaleal hematoma
○ Between galea, periosteum of skull
○ Circumferential, not limited by sutures
○ Can be very large, life threatening
Skull Fractures
• Linear
○ Sharp lucent line
○ Can be extensive and widespread (2-13A) Linear ſt, diastatic ﬇ fractures of the
• Depressed skull base are present crossing the jugular
○ Focal foramen st, both carotid canals ﬈.
○ Inwardly displaced fragments
○ Often lacerates dura-arachnoid
• Diastatic
○ Typically associated with severe trauma
○ Usually caused by linear fracture that extends into suture
○ Widens, spreads apart suture or synchondrosis

Extraaxial Hemorrhages
Extraaxial hemorrhages and hematomas are common manifestations of
head trauma. They can occur in any intracranial compartment, within any
space (potential or actual), and between any layers of the cranial meninges.
Only the subarachnoid spaces exist normally; all the other spaces are
potential spaces and occur only under pathologic conditions.

Epidural hematomas (EDHs) arise between the inner table of the skull and
outer (periosteal) layer of the dura. Subdural hematomas (SDHs) are (2-13B) CT in the same case shows that carotid
located between the inner (meningeal) layer of the dura and the arachnoid. arteries ſt and sigmoid sinuses ﬊ are patent. A
small right venous EDH st is present.
 Trauma
16
(2-14) Graphic shows EDH ﬈, depressed skull
fracture ﬇ lacerating middle meningeal artery
st. Inset shows rapid bleeding, "swirl" sign ſt.
(2-15) Biconvex aEDH ſt is shown with a thin
subdural blood collection along the tentorium,
falx ﬇, and left hemisphere st.
(2-16) (L) Bone CT shows left temporal bone
fracture ſt. (R) NECT shows mixed-density EDH
with "swirl" sign ﬇, rapid bleeding.
Traumatic subarachnoid hemorrhage (tSAH) is found within the sulci and
subarachnoid cisterns, between the arachnoid and the pia.
To discuss extraaxial hemorrhages, we work our way from the outside to
inside. We therefore begin this section with a discussion of EDHs (both
classic and variant), then move deeper inside the cranium to the more
common SDHs. We conclude with a consideration of tSAH.
Arterial Epidural Hematoma
EDHs are uncommon but potentially lethal complications of head trauma. If
an EDH is promptly recognized and appropriately treated, mortality and
morbidity can be minimized.
Terminology
An EDH is a collection of blood between the calvarium and outer (periosteal)
layer of the dura.
Etiology
Most EDHs arise from direct trauma to the skull that lacerates an adjacent
blood vessel (2-14). The vast majority (90%) are caused by arterial injury,
most commonly to the middle meningeal artery. Approximately 10% of
EDHs are venous, usually secondary to a fracture that crosses a dural venous
sinus.
Pathology
Location. Over 90% of EDHs are unilateral and supratentorial. Between 90%
and 95% are found directly adjacent to a skull fracture. The squamous
portion of the temporal bone is the most common site.
Gross Pathology. EDHs are biconvex in shape. Adherence of the periosteal
dura to the inner calvarium explains this typical configuration. As EDHs
expand, they strip the dura away from the inner table of the skull, forming
the classic lens-shaped hematoma (2-14). Because the dura is especially
tightly attached to sutures, EDHs in adults rarely cross suture lines (10% of
EDHs in children do cross sutures, especially if a fracture traverses the suture
or sutural diastasis is present).
The typical gross or intraoperative appearance of an acute EDH is a dark
purple ("currant jelly") lentiform clot.
Clinical Issues
Epidemiology. EDHs are much less common than either tSAH or SDH.
Although EDHs represent up to 10% of fatal injuries in autopsy series, they
are found in only 1-4% of patients imaged for craniocerebral trauma.
Demographics. EDHs are uncommon in infants and the elderly. Most are
found in older children and young adults. The M:F ratio is 4:1.
Presentation. The prototypical "lucid interval," during which a traumatized
patient has an initial brief loss of consciousness followed by an
asymptomatic period of various length prior to onset of coma &/or
neurologic deficit, occurs in only 50% of EDH cases. Headache, nausea,
vomiting, symptoms of intracranial mass effect (e.g., pupil-involving third
cranial nerve palsy) followed by somnolence and coma are common.
Natural History. Outcome depends on size and location of the hematoma,
whether the EDH is arterial or venous, and whether there is active bleeding.
In the absence of other associated traumatic brain injuries, overall mortality
rate with prompt recognition and appropriate treatment is under 5%.
 Primary Effects of CNS Trauma
17
Delayed development or enlargement of an EDH occurs in 10-15% of cases,
usually within 24-36 hours following trauma.

Treatment Options. Many EDHs are now treated conservatively. Most

traumatic EDHs are not surgical lesions at initial presentation, and the rate of
conversion to surgery is low. Most venous and small classic hyperdense EDHs
that do not exhibit a "swirl" sign and have minimal or no mass effect are
managed conservatively with close clinical observation and follow-up
imaging (2-17). Significant clinical predictors of EDH progression requiring
conversion to surgical therapy are coagulopathy and younger age.

Imaging
General Features. EDHs, especially in adults, typically do not cross sutures
unless a fracture with sutural diastasis is present. In children, 10% of EDHs
cross suture lines, usually the coronal or sphenosquamous suture.

Look for other comorbid lesions, such as "contre-coup" injuries, tSAH, and
secondary brain herniations, all of which are common findings in patients (2-17A) Serial imaging demonstrates temporal
with EDHs. evolution of a small nonoperated EDH. Initial
NECT scan shows a hyperdense biconvex EDH ﬇.
CT Findings. NECT scan is the procedure of choice for initial imaging in
patients with head injury. Both soft tissue and bone reconstruction
algorithms should be obtained. Multiplanar reconstructions are especially
useful in identifying vertex EDHs, which may be difficult to detect if only axial
images are obtained.

The classic imaging appearance of classic (arterial) EDHs is a hyperdense

(60-90 HU) biconvex extraaxial collection (2-15). Presence of a hypodense
component ("swirl" sign) is seen in ~ 1/3 of cases and indicates active, rapid
bleeding with unretracted clot (2-14).

EDHs compress the underlying subarachnoid space and displace the cortex
medially, "buckling" the gray matter-white matter interface inward.

Air in an EDH occurs in ~ 20% of cases and is usually—but not

invariably—associated with a sinus or mastoid fracture.

Patients with mixed-density EDHs tend to present earlier than patients with
hyperdense hematomas and have lower Glasgow Coma Scores (GCSs), larger
hematoma volumes, and poorer prognosis. (2-17B) Repeat scan 10 days later reveals that
density of the EDH ﬇ has decreased
Imaging findings associated with adverse clinical outcome are thickness > 1.5 significantly.
cm, volume > 30 mL, pterional (lateral aspect of the middle cranial fossa)
location, midline shift > 5 mm, and presence of a "swirl" sign within the
hematoma on imaging.

MR Findings. Acute EDHs are typically isointense with underlying brain,

especially on T1WI. The displaced dura can be identified as a displaced "black
line" between the hematoma and the brain.

Angiography. DSA may show a lacerated middle meningeal artery with

"tram-track" fistulization of contrast from the middle meningeal artery into
the paired middle meningeal veins. Mass effect with displaced cortical
arteries and veins is seen.

(2-17C) Repeat study 6 weeks after trauma

reveals that the EDH has resolved completely.
 Trauma
18
(2-18) Graphic shows basilar skull fracture ﬈
with transverse sinus occlusion ﬊ and posterior
fossa venous EDH st.
(2-19) Autopsy shows that venous EDH ﬊ caused
by transverse sinus injury "straddles" the
tentorium ſt. (Courtesy R. Hewlett, MD.)
(2-20) (L) Coronal, (R) sagittal CTV shows venous
EDH ﬇ straddling the tentorium ſt, elevating
the left transverse sinus st.
ACUTE ARTERIAL EPIDURAL HEMATOMA
Terminology
• EDH = blood between skull, dura
Etiology
• Associated skull fracture in 90-95%
• Arterial in 90%
○ Most often middle meningeal artery
• Venous in 10%
Pathology
• Unilateral, supratentorial (> 90%)
• Dura stripped away from skull → biconvex hematoma
• Usually does not cross sutures (exception = children, 10%)
• Does cross sites of dural attachment
Clinical
• Rare (1-4% of head trauma)
• Older children, young adults most common
• M:F = 4:1
• Classic "lucid interval" in only 50%
• Delayed deterioration common
• Low mortality if recognized, treated
• Small EDHs
○ If minimal mass, no "swirl" sign often managed conservatively
Imaging
• Hyperdense, lens-shaped
• "Swirl" sign (hypodensity) = rapid bleeding
Venous Epidural Hematomas
Not all EDHs are the same! Venous EDHs are often smaller, under lower
pressure, and develop more slowly than their arterial counterparts. Most
venous EDHs are caused by a skull fracture that crosses a dural venous sinus
and therefore occur in the posterior fossa near the skull base
(transverse/sigmoid sinus) (2-18) or the vertex of the brain [superior sagittal
sinus (SSS)]. In contrast to their arterial counterparts, venous EDHs can
"straddle" intracranial compartments, crossing both sutures and lines of
dural attachment (2-19) and compressing or occluding the adjacent venous
sinuses.
Venous EDHs can be subtle and easily overlooked. Coronal and sagittal
reformatted images are key to the diagnosis and delineation of these variant
EDHs (2-20). Several anatomic subtypes of venous EDHs, each with different
treatment implications and prognosis, are recognized.
Vertex EDH
"Vertex" EDHs are rare. Usually caused by a linear or diastatic fracture that
crosses the SSS, they often accumulate over hours or even days with slow,
subtle onset of symptoms. "Vertex" hematomas can be subtle and are easily
overlooked unless coronal and sagittal reformatted images are obtained (2-
21).
Anterior Temporal EDH
Anterior temporal EDHs are a unique subgroup of hematomas that occur in
the anterior tip of the middle cranial fossa (2-22). Anterior temporal EDHs
are caused either by an isolated fracture of the adjacent greater sphenoid
wing or by an isolated zygomaticomaxillary complex ("tripod") facial fracture.
The sphenoparietal dural venous sinus is injured as it curves medially along
 Primary Effects of CNS Trauma
19
the undersurface of the lesser sphenoid wing, extravasating blood into the
epidural space. Limited anatomically by the sphenotemporal suture laterally
and the orbital fissure medially, anterior temporal EDHs remain stable in size
and do not require surgical evacuation (2-23).

Clival EDH
Clival EDHs usually develop after a hyperflexion or hyperextension injury to
the neck and are possibly caused by stripping of the tectorial membrane
from attachments to the clivus. Less commonly, they have been associated
with basilar skull fractures that lacerate the clival dural venous plexus.

Clival EDHs most often occur in children and present with multiple cranial
neuropathies. The abducens nerve is the most commonly affected followed
by the glossopharyngeal and hypoglossal nerves. They are typically limited in
size by the tight attachment of the dura to the basisphenoid and tectorial
membrane (2-24).
(2-21A) NECT shows scalp hematoma st, ill-
VENOUS EPIDURAL HEMATOMA
defined hyperdensity extending anteriorly across
the midline ſt.
Not All EDHs Are the Same!
• Different etiologies in different anatomic locations
• Prognosis, treatment vary
Venous EDHs = 10% of All EDHs
• Skull fracture crosses dural venous sinus
○ Can cross sutures, dural attachments
• Often subtle, easily overlooked
○ Coronal, sagittal reformatted images key to diagnosis
• Usually accumulate slowly
• Can be limited in size; often treated conservatively
Subtypes
• Vertex EDH
○ Skull fracture crosses SSS
○ SSS can be lacerated, compressed, thrombosed
○ Hematoma under low pressure, develops gradually
○ Slow onset of symptoms
○ May become large, cause significant mass effect
• Anterior temporal EDH
(2-21B) Coronal NECT reformatted from the axial
○ Sphenoid wing or zygomaticomaxillary fracture source data shows the ill-defined hyperdensity
○ Injures sphenoparietal venous sinus ſt crossing the midline.
○ Hematoma accumulates at anterior tip of middle cranial fossa
○ Limited anatomically (laterally by sphenotemporal suture,
medially by orbital fissure)
○ Benign clinical course
• Clival EDH
○ Most common = child with neck injury
○ May cause multiple cranial neuropathies (CNVI most common)
○ Hyperdense collection under clival dura
○ Limited by tight attachment of dura to basisphenoid, tectorial
membrane
○ Usually benign course, resolves spontaneously

Management of a clival EDH is dictated by severity and progression of the

neurologic deficits and stability of the atlantoaxial joint. In patients with
minor cranial nerve involvement, the clinical course is usually benign, and
treatment with a cervical collar is typical.

NECT scans show a hyperdense collection between the clivus and tectorial
membrane. Sagittal MR of the craniocervical junction shows the hematoma (2-21C) Coronal CTV shows a small venous vertex
elevating the clival dura and extending inferiorly between the basisphenoid EDH that displaces the superior sagittal sinus ﬇
and tectorial membrane anterior to the medulla. and cortical veins ſt inferiorly.
 Trauma
20
(2-22) Graphic depicts
benign anterior temporal
EDH. Fracture ſt disrupts
the sphenoparietal sinus
﬉. Low-pressure venous
EDH ﬊ is anatomically
limited, medially by the
orbital fissure st and
laterally by the
sphenotemporal suture
﬈. (2-23A) NECT shows a
small biconvex left
anterior middle cranial
fossa EDH ﬇.

(2-23B) Bone CT shows a

linear fracture ſt
extending across the floor
of the left middle cranial
fossa to the inferior
orbital fissure. (2-23C) 3D
SSD shows that the
fracture ﬈ extends across
the sphenotemporal
suture ﬊. The middle
fossa EDH is anatomically
limited by the orbital
fissure medially and the
sphenotemporal suture
laterally.

(2-24A) Axial CTA in a

child with craniovertebral
junction trauma shows a
small clival EDH ﬈. There
was no evidence for
vascular injury. (2-24B)
Sagittal CTA reformatted
from the axial source data
nicely demonstrates the
clival EDH ﬈.
 Primary Effects of CNS Trauma
21
Acute Subdural Hematoma
Acute subdural hematomas (aSDHs) are one of the leading causes of death
and disability in patients with severe traumatic brain injury (TBI). SDHs are
much more common than EDHs. Most do not occur as isolated injuries; the
vast majority of SDHs are associated with tSAH as well as significant
parenchymal injuries, such as cortical contusions, brain lacerations, and
diffuse axonal injuries.

Terminology
An aSDH is a collection of acute blood products that lies in or between the
inner border cell layer of the dura and the arachnoid (2-25).

Etiology
Trauma is the most common cause of aSDH. Both direct blows to the head
and nonimpact injuries may result in formation of an aSDH. Tearing of
(2-25) Graphic depicts crescent-shaped acute SDH
bridging cortical veins as they cross the subdural space to enter a dural
st with contusions and "contre-coup" injuries ﬈,
venous sinus (usually the SSS) is the most common etiology. Cortical vein diffuse axonal injuries ﬉.
lacerations can occur with either a skull fracture or the sudden changes in
velocity and brain rotation that occur during nonimpact closed head injury
(CHI).

Blood from ruptured vessels spreads quickly through the potential space
between the dura and the arachnoid. Large SDHs may spread over an entire
hemisphere, extending into the interhemispheric fissure and along the
tentorium.

Tearing of cortical arteries from a skull fracture may also give rise to an aSDH.
The arachnoid itself may also tear, creating a pathway for leakage of CSF into
the subdural space, resulting in admixture of both blood and CSF.

Less common causes of aSDH include aneurysm rupture, skull/dura-

arachnoid metastases from vascular extracranial primary neoplasms, and
spontaneous hemorrhage in patients with severe coagulopathy.

Pathology
Gross Pathology. The gross appearance of an aSDH is that of a soft, purplish,
"currant jelly" clot beneath a tense bulging dura. More than 95% are
supratentorial. Most aSDHs spread diffusely over the affected hemisphere
and are therefore typically crescent-shaped.
(2-26) Acute SDH spreads over left hemisphere
ſt, along tentorium ﬇, & into interhemispheric
fissure st but does not cross midline.

Clinical Issues
Epidemiology. An aSDH is the second most common extraaxial hematoma,
exceeded only by tSAH. An aSDH is found in 10-20% of all patients with head
injury and is observed in 30% of autopsied fatal injuries.

An aSDH may occur at any age from infancy to the elderly. There is no sex
predilection.

Presentation. Even relatively minor head trauma, especially in elderly

patients who are often anticoagulated, may result in an aSDH. In such
patients, a definite history of trauma may be lacking.

Clinical findings vary from none to loss of consciousness and coma. Most
patients with aSDHs have low GCSs on admission. Delayed deterioration,
especially in elderly anticoagulated patients, is common.

Natural History. An aSDH may remain stable, grow slowly, or rapidly (2-27) NECT scan shows that a small SDH ſt is
increase in size, causing mass effect and secondary brain herniations. easier to see with wider (R) compared with
Prognosis varies with hematoma thickness, midline shift, and the presence of standard (L) windows.
 Trauma
22
(2-28) Coronal graphic depicts thin aSDH layering
along the tentorium and inferior falx cerebri ﬈.
(2-29A) Reformatted coronal NECT scan using the
axial source data shows a small right
peritentorial aSDH ſt.
(2-29B) Sagittal scans in the same case show the
right peritentorial aSDH (top) with normal left
sagittal dura (bottom) for comparison.
associated parenchymal injuries. An aSDH that is thicker than 2 cm correlates
with poor outcome (35-90% mortality). An aSDH that occupies more than
10% of the total available intracranial volume is usually lethal.
Treatment Options. The majority of patients with small SDHs are initially
treated conservatively with close clinical observation and follow-up imaging.
Small isolated falcine or tentorial SDHs typically do not increase in size and
usually do not require short-term follow-up imaging.
Patients with larger SDHs, a lesion located at the convexity, alcohol abuse,
and repetitive falls are at the greatest risk for deterioration. Surveillance with
follow-up CT scans is recommended until the SDH resolves or at least up to
five weeks following the initial trauma.
Imaging
General Features. The classic finding of an aSDH is a supratentorial crescent-
shaped extraaxial collection that displaces the gray matter-white matter
interface medially. SDHs are typically more extensive than EDHs, easily
spreading along the falx, tentorium, and around the anterior and middle
fossa floors (2-26). SDHs may cross suture lines but generally do not cross
dural attachments. Bilateral SDHs occur in 15% of cases. "Contre-coup"
injuries, such as contusion of the contralateral hemisphere, are common.
Both standard soft tissue and intermediate ("subdural") windows as well as
bone algorithm reconstructions should be used in all trauma patients, as
small, subtle aSDHs can be obscured by the density of the overlying
calvarium (2-27). Coronal and sagittal reformatted images using the axial
source data are especially helpful in visualizing small ("smear") peritentorial
and parafalcine aSDHs (2-28) (2-29).
CT Findings
NECT. Approximately 60% of aSDHs are hyperdense on NECT scans (2-26).
Mixed-attenuation lesions are found in 40% of cases. Pockets of hypodensity
within a larger hyperdense aSDH usually indicate rapid bleeding (2-30).
"Dots" or "lines" of CSF trapped within compressed, displaced sulci are often
seen underlying an SDH (2-37).
Mass effect with an aSDH is common and expected. Subfalcine herniation
should be proportionate to the size of the subdural collection. However, if
the difference between the midline shift and thickness of the hematoma
is 3 mm or more, then mortality is very high. This discrepancy occurs when
underlying cerebral edema is triggered by the traumatic event. Early
recognition and aggressive treatment for potentially catastrophic brain
swelling are essential (2-31).
In other cases, especially in patients with repeated head injury, severe brain
swelling with unilateral hemisphere vascular engorgement occurs very
quickly. Here, the mass effect is greatly disproportionate to the size of the
SDH, which may be relatively small.
Occasionally, an aSDH is nearly isodense with the underlying cortex. This
unusual appearance is found in extremely anemic patients (Hgb under 8-10
g/dL) (2-32) and sometimes occurs in patients with coagulopathy. In rare
cases, CSF leakage through a torn arachnoid may mix with—and dilute—the
acute blood that collects in the subdural space.
CECT/CTA. CECT scans are helpful in detecting small isodense aSDHs. The
normally enhancing cortical veins are displaced inward by the extraaxial fluid
collection. CTA may be useful in visualizing a cortical vessel that is actively
bleeding into the subdural space.

MR Findings. MR scans are rarely obtained in acutely brain-
injured patients. In such cases, aSDHs appear isointense on
T1WI and hypointense on T2WI. Signal intensity on FLAIR
scans is usually iso- to hyperintense compared with CSF but
hypointense compared with the adjacent brain. aSDHs are
hypointense on T2* scans.
DWI shows heterogeneous signal within the hematoma but
may show patchy foci of restricted diffusion in the cortex
underlying the aSDH.
Differential Diagnosis
In the setting of acute trauma, the major differential diagnosis
is EDH. Shape is a helpful feature, as most aSDHs are
crescentic, whereas EDHs are biconvex. EDHs are almost
always associated with skull fracture; SDHs frequently occur in
the absence of skull fracture. EDHs may cross sites of dural
attachment; SDHs do not cross the falx or tentorium.
Primary Effects of CNS Trauma
23
Subacute Subdural Hematoma
With time, SDHs undergo organization, lysis, and
neomembrane formation. Within 2-3 days, the initial soft,
loosely organized clot of an aSDH becomes organized.
Breakdown of blood products and the formation of
organizing granulation tissue change the imaging appearance
of subacute and chronic SDHs.
Terminology
A subacute subdural hematoma (sSDH) is between several
days and several weeks old.
Pathology
A collection of partially liquified clot with resorbing blood
products is surrounded on both sides by a "membrane" of
organizing granulation tissue (2-33). The outermost

(2-30A) Axial NECT in a

74-year-old
anticoagulated patient
with a ground-level fall
shows a huge, mixed-
density aSDH ſt with
severe subfalcine
herniation of the lateral
ventricles st. Low-density
foci ﬊ within the aSDH
indicate rapid bleeding
with unclotted blood. (2-
30B) Coronal NECT shows
the subfalcine herniation
st, mixed-density aSDH
with hypodense foci ﬊.
The patient expired
shortly after the scan.

(2-31) NECT shows a

mixed-density 12-mm
aSDH ﬊ with a
disproportionately large
subfalcine herniation of
the lateral ventricles (17
mm), indicating that
diffuse holohemispheric
brain swelling is present.
Subfalcine herniation ≥ 3
mm portends a poor
prognosis. (2-32) NECT
scan in a very anemic
patient shows an isodense
aSDH ﬈. The aSDH is
almost exactly the same
density as the underlying
cortex. The gray-white
interface is displaced
inward ﬇.
 Trauma
24
membrane adheres to the dura and is typically thicker than the inner
membrane, which abuts the thin, delicate arachnoid (2-34).

In some cases, repetitive hemorrhages of different ages arising from the

friable granulation tissue may be present. In others, liquefaction of the
hematoma over time produces serous blood-tinged fluid.

Clinical Issues
Epidemiology and Demographics. SDHs are common findings at imaging
and autopsy. In contrast to aSDHs, sSDHs show a distinct bimodal
distribution with children and the elderly as the most commonly affected
age groups.

Presentation. Clinical symptoms vary from asymptomatic to loss of

consciousness and hemiparesis caused by sudden rehemorrhage into an
sSDH. Headache and seizure are other common presentations.

(2-33) Graphic depicts sSDH ſt. Inset shows Natural History and Treatment Options. Many sSDHs resolve
bridging vein ﬊ and thin inner ﬉ and thick outer spontaneously. In some cases, repeated hemorrhages may cause sudden
﬈ membranes. enlargement and mass effect. Surgical drainage may be indicated if the sSDH
is enlarging or becomes symptomatic.

Imaging
General Features. Imaging findings are related to hematoma age and the
presence of encasing membranes. Evolution of an untreated, uncomplicated
SDH follows a very predictable pattern on CT. Density of an extraaxial
hematoma decreases ~ 1-2 HU each day (2-35). Therefore, an SDH will
become nearly isodense with the underlying cerebral cortex within a few
days following trauma.

CT Findings. sSDHs are typically crescent-shaped fluid collections that are

iso- to slightly hypodense compared with the underlying cortex on NECT (2-
36). Medial displacement of the gray-white interface ("buckling") is often
present, along with "dot-like" foci of CSF in the trapped, partially effaced
sulci underlying the sSDH (2-37) (2-38). Mixed-density hemorrhages are
common.

Bilateral sSDHs may be difficult to detect because of their "balanced" mass

(2-34) Autopsy shows sSDH with organized
effect (2-37). Sulcal effacement with displaced gray matter-white matter
hematoma ſt, thick outer membrane st,
deformed brain ﬇. (Courtesy R. Hewlett, MD.) interfaces is the typical appearance.

CECT scans show that the enhanced cortical veins are displaced medially. The
encasing membranes, especially the thicker superficial layer, may enhance.

MR Findings. MR can be very helpful in identifying sSDHs, especially small

lesions that are virtually isodense with underlying brain on CT scans.

Signal intensity varies with hematoma age but is less predictable than on CT,
making precise "aging" of subdural collections more problematic. In general,
early subacute SDHs are isointense with cortex on T1WI and hypointense on
T2WI but gradually become more hyperintense as extracellular
methemoglobin increases (2-39A). Most late-stage sSDHs are T1/T2 "bright-
bright." A linear T2 hypointensity representing the encasing membranes that
surround the SDH is sometimes present.

FLAIR is the most sensitive standard sequence for detecting sSDH, as the
collection is typically hyperintense (2-40). Because FLAIR signal intensity
varies depending on the relative contribution of T1 and T2 effects, early
sSDHs may initially appear hypointense due to their intrinsic T2 shortening.
(2-35) SDHs decrease ~ 1.5 HU/day. By 7-10 days,
T2* scans are also very sensitive, as sSDHs show distinct "blooming" (2-39B).
blood in hematoma is isodense with cortex. By 10
days, it is hypodense.
Primary Effects of CNS Trauma
25
(2-36) Axial NECT scan
shows right sSDH ﬇ that
is isodense with the
underlying cortex. The
right GM-WM interface is
displaced and buckled
medially ſt compared
with normal left side st.
(2-37) NECT scan in
another patient shows
bilateral "balanced"
isodense subacute SDHs
ſt. Note that both GM-
WM interfaces are
inwardly displaced. A
"dot" of CSF in the
compressed subarachnoid
space is seen under the
left sSDH ﬇.

(2-38) NECT in an elderly

patient with sSDH,
moderate cortical atrophy
shows difference between
nearly isodense SDH and
CSF in underlying
compressed subarachnoid
space, sulci ſt. (2-39A)
Axial T1WI in patient with
a late-stage aSDH shows
crescent-shaped
hyperintense collection ſt
extending over entire
surface of left
hemisphere, gyral
compression with almost
obliterated sulci
compared with normal
right hemisphere.

(2-39B) T2* GRE scan

shows some "blooming"
ſt in the sSDH. (2-39C)
DWI shows the classic
double-layer appearance
of an sSDH with
hypointense rim on the
inside ﬈ and mildly
hyperintense rim on the
outside ﬇ of the clot.
 Trauma
26
Signal intensity on DWI also varies with hematoma age. DWI
commonly shows a crescentic high-intensity area with a low-
intensity rim closer to the brain surface (double-layer
appearance) (2-39C). The low-intensity area corresponds to a
mixture of resolved clot and CSF, whereas the high-intensity
area correlates with solid clot.
T1 C+ scans demonstrate enhancing, thickened, encasing
membranes (2-40D). The membrane surrounding an sSDH is
usually thicker on the dural side of the collection. Delayed
scans may show gradual "filling in" and increasing
hyperintensity of the sSDH.
hygroma is typically isodense/isointense with CSF and does
not demonstrate enhancing, encapsulating membranes.
Chronic/Mixed Subdural Hematoma
Terminology
A chronic subdural hematoma (cSDH) is an encapsulated
collection of sanguineous or serosanguineous fluid confined
within the subdural space. Recurrent hemorrhage(s) into a
preexisting cSDH are common and produce a mixed-age or
"acute on chronic" SDH (mSDH).

Differential Diagnosis Etiology

The major differential diagnosis of an sSDH is an isodense
aSDH. These are typically seen only in an extremely anemic or
anticoagulated patient. A subdural effusion that follows
surgery or meningitis or that occurs as a component of
intracranial hypotension can also mimic an sSDH. A subdural
With continued degradation of blood products, an SDH
becomes progressively more liquified until it is largely serous
fluid tinged with blood products (2-41). Rehemorrhage,
either from vascularized encapsulating membranes or rupture
of stretched cortical veins crossing the expanded subdural

(2-40A) T1WI in a 59-year-

old man with seizures
shows bilateral subdural
collections ſt that are
slightly hyperintense to
CSF. (2-40B) T2WI shows
that both collections ſt
are isointense with CSF in
the underlying
subarachnoid cisterns.

(2-40C) The fluid

collections ſt do not
suppress on FLAIR and are
hyperintense to CSF in the
underlying cisterns. (2-
40D) T1 C+ shows that the
outer membrane of the
SDH enhances ſt.
Findings are consistent
with late subacute/early
chronic SDHs.
 Primary Effects of CNS Trauma
27
space, occurs in 5-10% of cSDHs and is considered "acute-on-chronic" SDH
(2-42).

Pathology
Gross Pathology. Blood within the subdural space incites tissue reaction
around its margins. Organization and resorption of the hematoma contained
within the "membranes" of surrounding granulation tissue continue. These
neomembranes have fragile, easily disrupted capillaries and easily rebleed,
creating an mSDH. Multiple hemorrhages of different ages are common in
mSDHs (2-43).

Eventually, most of the liquified clot in a cSDH is resorbed. Only a thickened

dura-arachnoid layer remains with a few scattered pockets of old blood
trapped between the inner and outer membranes.

Clinical Issues
Epidemiology. Unoperated, uncomplicated subacute SDHs eventually (2-41) Simple cSDHs contain serosanguineous
evolve into cSDHs. Approximately 5-10% will rehemorrhage, causing fluid with hematocrit effect, thin inner ﬈, thick
multiloculated mixed-age SDHs. outer ﬇ encapsulating membranes.

Demographics. cSDHs may occur at any age. Mixed-age SDHs are much
more common in elderly patients.

Presentation. Presentation varies from no/mild symptoms (e.g., headache)

to sudden neurologic deterioration if a preexisting cSDH rehemorrhages.

Natural History. In the absence of repeated hemorrhages, cSDHs gradually

resorb and largely resolve, leaving a residue of thickened dura-arachnoid that
may persist for months or even years. Older patients, especially those with
brain atrophy, are subject to repeated hemorrhages.

Treatment Options. If follow-up imaging of a subacute SDH shows

expected resorption and regression of the cSDH, no surgery may be
required. Surgical drainage with evacuation of the cSDH and resection of its
encapsulating membranes is performed if significant mass effect or
repeated hemorrhages cause neurologic complications.

Imaging
(2-42) Complicated cSDHs contain loculated
General Features. cSDHs have a spectrum of imaging appearances. pockets of old and new blood, seen as fluid-fluid
Uncomplicated cSDHs show relatively homogeneous density/signal levels ſt within septated cavities.
intensity with slight gravity-dependent gradation of their contents
("hematocrit effect").

mSDHs with acute hemorrhage into a preexisting cSDH show a hematocrit

level with distinct layering of the old (top) and new (bottom) hemorrhages.
Sometimes, septated pockets that contain hemorrhages of different ages
form. Dependent layering of blood within the loculated collections may
appear quite bizarre.

Extremely old, longstanding cSDHs with virtually complete resorption of all

liquid contents are seen as pachymeningopathies with diffuse dura-
arachnoid thickening.

CT Findings

NECT. A hypodense crescentic fluid collection extending over the surface of

one or both cerebral hemispheres is the classic finding in cSDH.
Uncomplicated cSDHs approach CSF in density (2-44). The hematocrit effect
creates a slight gradation in density that increases from top to bottom. (2-43) cSDH autopsy: 1 side has thickened dura
ſt, mixed acute, subacute, chronic hemorrhages
Trabecular or loculated cSDHs show internal septations, often with evidence on other ﬇. (From DP: Hospital Autopsy.)
of repeated hemorrhages (2-45A). With age, the encapsulating membranes
 Trauma
28
(2-44) NECT scan shows bilateral cSDHs ſt
causing mass effect on the underlying brain. A
small left parafalcine aSDH is present ﬊.
(2-45A) NECT shows mixed cSDH ſt that features
multiple loculated pockets of blood with old
blood layered on top of recent hemorrhages.
(2-45B) T2* GRE shows multiple loculated
pockets of mixed-age blood st with varying
signal intensities and fluid-fluid levels ſt.
surrounding the cSDH become thickened and may appear moderately
hyperdense. Eventually, some cSDHs show peripheral calcifications that
persist for many years. In rare cases, a cSDH may densely calcify or even
ossify, a condition aptly termed "armored brain."
CECT. The encapsulating membranes around a cSDH contain fragile
neocapillaries that lack endothelial tight junctions. Therefore, the
membranes show strong enhancement following contrast administration.
MR Findings. As with all intracranial hematomas, signal intensity of a cSDH
or mSDH is quite variable and depends on age of the blood products. On T1
scans, uncomplicated cSDHs are typically iso- to slightly hyperintense
compared with CSF. Depending on the stage of evolution, cSDHs are iso- to
hypointense compared with CSF on T2 scans.
Most cSDHs are hyperintense on FLAIR and may show "blooming" on T2*
scans if subacute-chronic blood clots are still present (2-45B). In ~ 1/4 of all
cases, superficial siderosis can be identified over the gyri underlying a cSDH.
The encapsulating membranes of a cSDH enhance following contrast
administration. Typically, the outer layer is thicker than the inner layer.
Uncomplicated cSDHs do not restrict on DWI. With cSDHs, a "double layer"
effect—a crescent of hyperintensity medial to a nonrestricting fluid
collection—indicates acute rehemorrhage.
Differential Diagnosis
An mSDH is difficult to mistake for anything else. In older patients, a small
uncomplicated cSDH may be difficult to distinguish from simple brain
atrophy with enlarged bifrontal CSF spaces. However, cSDHs exhibit mass
effect; they flatten the underlying gyri, often extending around the entire
hemisphere and into the interhemispheric fissure. The increased extraaxial
spaces in patients with cerebral atrophy are predominantly frontal and
temporal.
A traumatic subdural hygroma is an accumulation of CSF in the subdural
space after head injury, probably secondary to an arachnoid tear. Subdural
hygromas are sometimes detected within the first 24 hours after trauma;
however, the mean time for appearance is nine days after injury. A subdural
hygroma or a hematohygroma in an infant or young child should be
considered highly suspicious for abusive head trauma (child abuse; see later
discussion).
A classic uncomplicated subdural hygroma is a hypodense, CSF-like,
crescentic extraaxial collection that consists purely of CSF, has no blood
products, lacks encapsulating membranes, and shows no enhancement
following contrast administration. CSF leakage into the subdural space is also
present in the vast majority of patients with cSDH. Therefore, many—if not
most—cSDHs contain a mixture of both CSF and blood products.
A subdural effusion is an accumulation of clear fluid over the cerebral
convexities or in the interhemispheric fissure. Subdural effusions are
generally complications of meningitis; a history of prior infection, not
trauma, is typical.
A subdural empyema (SDE) is a hypodense extraaxial fluid collection that
contains pus. Most SDEs are secondary to sinusitis or mastoiditis, have
strongly enhancing membranes, and often coexist with findings of
meningitis. A typical SDE restricts strongly and uniformly on DWI. Look for
underlying sulcal/cisternal hyperintensity on FLAIR and enhancement on T1
C+.

Traumatic Subarachnoid Hemorrhage
tSAH is found in virtually all cases of moderate to severe head
trauma. Indeed, trauma—not ruptured saccular aneurysm—is
the most common cause of intracranial SAH.
Etiology
tSAH can occur with both direct trauma to the skull and
nonimpact CHI. Tearing of cortical arteries and veins, rupture
of contusions and lacerations into the contiguous
subarachnoid space, and choroid plexus bleeds with
intraventricular hemorrhage may all result in blood collecting
within the subarachnoid cisterns.
Although tSAH occasionally occurs in isolation, it is usually
accompanied by other manifestations of brain injury. Subtle
tSAH may be the only clue on initial imaging studies that more
serious injuries lurk beneath the surface.
Pathology
Location. tSAHs are predominantly found in the
anteroinferior frontal and temporal sulci, perisylvian regions,
and over the hemispheric convexities (2-46). In very severe
cases, tSAH spreads over most of the brain. In mild cases,
blood collects in a single sulcus or the dependent portion of
the interpeduncular fossa.
Gross Pathology. With the exception of location and
associated parenchymal injuries, the gross appearance of
tSAH is similar to that of aneurysmal SAH (aSAH). Curvilinear
foci of bright red blood collect in cisterns and surface sulci (2-
47).
(2-46) Graphic depicts traumatic subarachnoid hemorrhage
(tSAH). tSAH is most common around the sylvian fissures and in
the sulci adjacent to contused gyri.
Primary Effects of CNS Trauma
29
tSAH typically occurs adjacent to cortical contusions. tSAH is
also commonly identified under acute epidural and subdural
hematomas.
Clinical Issues
Epidemiology. tSAH is found in most cases of moderate
trauma and is identified in virtually 100% of fatal brain injuries
at autopsy.
Natural History. Breakdown and resorption of tSAH occurs
gradually. Patients with isolated tSAH have very low rates of
clinical or radiographic deterioration and typically do well.
Imaging
General Features. With the exception of location, the general
imaging appearance of tSAH is similar to that of aSAH, i.e.,
sulcal-cisternal hyperdensity/hyperintensity (2-48). tSAH is
typically more focal or patchy than the diffuse subarachnoid
blood indicative of aneurysmal hemorrhage.
CT Findings. Acute tSAH is typically peripheral, appearing as
linear hyperdensities in sulci adjacent to cortical contusions or
under epi- or subdural hematomas. Occasionally, isolated
tSAH is identified within the interpeduncular fossa (2-51).
MR Findings. As acute blood is isointense with brain, it may be
difficult to detect on T1WI. "Dirty" sulci with "smudging" of
the perisylvian cisterns is typical. Subarachnoid blood is
hyperintense to brain on T2WI and appears similar in signal
intensity to cisternal CSF. FLAIR scans show hyperintensity in
the affected sulci.
"Blooming" with hypointensity can be identified on T2* scans,
typically adjacent to areas of cortical contusion. tSAH is
(2-47) Low-power photomicrograph shows an autopsied brain of
a boxer who collapsed and expired after being knocked
unconscious. Typical tSAH covers the gyri and extends into the
sulci. (Courtesy J. Paltan, MD.)
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repent your zeal on this occasion. It will be much for the Mediator’s
glory, and the welfare, I hope, of thousands of souls, to have every
thing honourably discharged. I know I shall have your prayers, dear
Madam, and I am sure you have mine. O that you may know in whom
you have believed! Come, dear Madam, be not discouraged; you know
who hath said, “then shall ye know, if ye follow on to know the Lord.” I
could enlarge, but it is near six in the morning, and I must away to
preach. O that my blessed Master may never turn me out of that divine
employ! I hope my most grateful respects and acknowledgments will
find acceptance with dear Mrs. B――; and your acceptance of the
same will add to the obligations already laid on, dear Madam,

Your most ready servant for Christ’s sake,

G. W.

LETTER MCLVII.
To Mrs. B――.

London, December 30, 1756.

Dear Madam,

G RATITUDE constrains me to send you a few lines. They inform

you, that God is doing wonders at the new chapel. Hundreds
went away last Sunday morning that could not come in. On Christmas-
Day, and last Tuesday night (the first time of burning candles) the
power of the Lord was present, both to wound and to heal. A
neighbouring Doctor hath baptized the place, calling it “Whitefields’s
Soul-trap.”—Just now the following letter came to hand.

Reverend Sir,

A THOUGHT came into my mind last Sunday morning, to go to hear

you at the new tabernacle, and to see what sort of a place it was.
In one part of your discourse my heart trembled, and the terrors of the
Lord came upon me. I then concluded, that I must prepare for hell, and
that there was no hope of salvation for me. I take this method, being
assured that you will excuse the liberty I take to ask you one question,
How I can be convinced that my past sins are to be forgiven? And O,
what must I do to be saved! My sins are innumerable. God is just. I
cannot think that I have any interest in the Redeemer’s blood. My soul
is full of grief. I must conclude. Dear Sir, favour me with a line, which
will be greatly acknowledged by,

Your friend,

A. B.

I have answered my new friend, and pray the friend of sinners to

make the chapel a soul-trap indeed, to many wandering creatures.
Abundance round about, I hear are much struck. O for humility! O for
gratitude! O for faith! Wherefore should I doubt?—Surely Jesus will
carry me through, and help me to pay the workmen. Accept repeated
thanks for the help afforded by your dear Ladies, and depend on having
the poor prayers of, dear Madam,

Your most obliged and ready servant, for Christ’s sake,

G. W.

LETTER MCLVIII.
To the Reverend Mr. M――.

London, January 4, 1757.

Reverend and dear Sir,

J UST now I received and read your kind letter, and hope, God
willing, on Friday, to have the pleasure of a personal interview.
May our common Lord sanctify it to our mutual edification! Glad should
I have been to have known you before. I love the Hanoverians,
because I think they love, and would prove faithful to our dear King
George. I am sorry for the treatment they have met with, but it is not our
province to meddle with politics. Blessed be God for a kingdom that is
not of this world, which can never be removed, or so much as shaken.

Blest is faith that trusts Christ’s power,

Blest are saints that wait his hour;

Haste, great conqueror, bring it near;

Let the glorious close appear.

You see, my dear Sir, how free I write. It is because I think you are a
true minister of our glorious Emmanuel. Be pleased to remember me
when near his throne. Though a stranger, you know my name: I am the
chief of sinners, and less than the least of all saints, but for Christ’s
sake, reverend and dear Sir,

Your unworthy brother and fellow-labourer, in our Lord’s

vineyard,

G. W.

LETTER MCLIX.
To Lady H――.

London, January 12, 1757.

Honoured Madam,

W ILL your Ladyship be pleased to accept a few hasty lines? They

come with hearty wishes, that your Ladyship, and every branch
of your honourable family, may have a very happy new year.—This can
only be had in Jesus, and therefore I wish, from the very bottom of my
heart, that you all may be blessed with all spiritual blessings.—These
are blessings indeed. They are solid, they are lasting, commensurate
even with eternity itself. I hope we have some daily foretastes of this.
Indeed, honoured Madam, a wide door seems to be opening at
Tottenham-Court chapel. The word flies like lightning in it; O that it may
prove a Bethel, a house of God, a gate of heaven! I believe it will.—As
the awakening continues, I have some hopes that we are not to be
given up. Alas! alas! We are testing and contesting, while the nation is
bleeding to death. We are condemning this and that; but sin, the great
mischief-maker, lies unmolested, or rather encouraged by every
contending party. Well, the Lord reigns;—and therefore blessed be the
God of our salvation.—I hope your honoured sister, and her noble
Lord, are well. I sometimes wish that his Lordship was at the helm, but
infinite wisdom knows what is best. Happy they who can look beyond
time! The christian can; the short-sighted infidel dares not, cannot. But I
grow troublesome. I must therefore only add my most grateful
acknowledgments, and assure your Ladyship, that I am, honoured
Madam,

Your Ladyship’s most dutiful, obliged, and ready servant for

Christ’s sake,

G. W.

LETTER ♦MCLX.
To Lady M―― H――.

London, January 13, 1757.

Honoured Madam,

I WISH your Ladyship joy. What a mercy, to be made an instrument in

settling a true minister of Jesus Christ! May he be the spiritual
father to many souls! Your Ladyship’s unexpected sight of your son,
was like life from the dead. What pleasure then must be the
consequence of seeing our relations brought home to God! This be
your happy lot! The holy spirit seems to be quickening many dead souls
here. I am informed, that all are alive without the Cannon-Gate; but
such are dead whilst they live. O Scotland! Scotland! Turn us, O good
Lord, and so shall we be turned! We had need to fast and pray too.—
Your Ladyship, I doubt not, mourns in secret. The glorious Emmanuel
will put your tears into his bottle. That your consolations in him may
abound evermore, is the earnest prayer of, honoured Madam,

Your Ladyship’s most dutiful, obliged, and ready servant for

Christ’s sake,

G. W.

♦ “MLX” replaced with “MCLX”

LETTER MCLXI.
London, February 5, 1757.

Dear Mrs. C――,

I THANK you heartily for your last kind letter, and for all your works of
faith and labours of love.—Glad would I be to see America, but the
cloud doth not seem to move that way as yet.—The new chapel at the
other end of the town is made a Bethel, and the awakening increases
day by day. O that it was so at Georgia! Surely the great Shepherd and
Bishop of souls will bless you, for taking care of the lambs in that
distant wilderness.—Mr. P――’s leaving Bethesda sadly distresses me;
but my eyes are upon Him who knows all. I wrote to desire Mr. P―― to
continue the oversight of my affairs, till I can come myself. Whatever he
and you shall agree to, in respect to Mr. R――, &c. I shall acquiesce in:
only I desire that all who are capable may be put out, and the family
reduced as low as possible, till the war is over, and the institution out of
debt. I find nobody mentions I―― P――s. If I―― P――m goes to the
college, cannot he and Mr. D―― be enough for the school? Ere now,
G―― W―― I hope is put out.—Lord, remember me and all my
various concerns!—God bless and direct you in every step! He will,—
he will.—I trust you will find it so in your late determination? Now you
are free. Things that seem against us at first, afterwards prove to be
designed for us.—What is to become or us here, God only knows.—A
year perhaps may determine.—The best sign is, that the awakening
continues.—A parcel of the addresses was put up for you, but through
mistake not put into the box. All your relations are well. That you may
prosper both in body and soul, and be filled with all the fulness of God,
is the earnest prayer of, dear Mrs. C――,

Your most affectionate, obliged friend, and ready servant for

Christ’s sake,

G. W.

LETTER MCLXII.
To the Reverend Mr. M――.

London, February 17, 1757.

Reverend and very dear Sir,

Y OUR kind letter lies before me, for which, be pleased to accept my
cordial thanks. I am glad you got safe to Chatham, and heartily
pray, that the God of the sea, and the God of the dry land, may be your
convoy on the mighty waters. The continuance of your correspondence
will be quite agreeable. Who knows but Jesus may bless it to our
mutual edification? I want to be stirred up, to begin to begin to do
something for him, who hath done and suffered so much for ill and hell-
deserving me. Surely, I am a worthless worm, and therefore little
moved with whatever judgment an ill-natured, misinformed world may
form of me. The great day will discover all. Come, Lord Jesus, come
quickly.—O to be an Israelite indeed, in whom there is no guile!
Simplicity and godly sincerity is all in all. A want of this, I fear, hath led
the Count into all his mistakes. With great regret I speak or write of any
people’s weaknesses; but I did and do now think, that divine
Providence called me to publish what you mention. The Redeemer
gave it his blessing. I do not find that their fopperies are continued, and
I hear also that they have discharged many debts. You seem to have
right notions of the sermon to which you refer. It certainly speaks of a
sinless state, which is not attainable in this life. We are called to be
saints, but not angels. Strange, that after so many years, such an error
should be propagated!—but so it is. Lord, what is man? Glory be to
God, there is a time coming, when sin, root and branch, shall be
destroyed: I mean at death. Then an eternal stop will be put to the
fountain of corruption, and we shall be sinless indeed.—Till then, O
Jesus, do thou continue to wash us in thy blood, and cloathe us with
thy compleat and everlasting righteousness; and at the same time, out
of a principle of love to thee, do thou help us to follow hard after that
holiness, without which no man can see the Lord!—But whither am I
going? My very dear Sir, excuse prolixity. I write to you, as to one whom
I love in the bowels of Jesus Christ. My most cordial respects await
all that love him. My wife joins in sending you the same, with, reverend
and very dear Sir,

Yours most affectionately in our common Lord,

G. W.

LETTER MCLXIII.
To Lady H――n.

London, March 2, 1757.

Ever-honoured Madam,
 FEW days ago, I received the kind benefaction for the happy convict
A Not doubting of success, I had advanced some guineas, which
with what hath been procured from other hands, hath bought both
their liberties, and they are provided for on the other side of the water;
just now I believe they are under sail. O that he, who I suppose will now
receive a pardon, was alike favoured! But not many mighty, not many
noble are called. However, some come to hear at Tottenham-Court.
S―― the player, makes always one of the auditory, and, as I hear, is
much impressed, and brings others with him. I hope this will not find
your Ladyship ill of the gout. May the Lord Jesus bear all your
sickness, and heal all your infirmities both of body and soul! I am
sensibly touched when any thing affects your Ladyship; gratitude
constrains to this. What shall I render unto the Lord for all his mercies?
I would preach for him, if I could, a hundred times a day. Surely, such a
worthless worm was never honoured to speak for the Redeemer
before. Your Ladyship will excuse; I must away, and give a little vent to
the heart of, ever-honoured Madam,

Your Ladyship’s most dutiful, obliged, and ready servant for

Christ’s sake,

G. W.

LETTER MCLXIV.
To the Reverend Mr. B――.

London, March 10, 1757.

Reverend and very dear Sir,

P ROVIDENTIALLY, a Lady was at my house when the bearer

brought your letter, who perhaps may want just such a servant,
within the time mentioned. Thus God provides for those that love him.
He is indeed a prayer-hearing, a promise-keeping God. Satan may and
will have us, that he may sift us as wheat; but Jesus prays for us; our
faith therefore shall not fail. This is my support; this, my very dear Sir,
must be yours. Ere long we shall be tempted no more. I am a poor
soldier; I want to be discharged. Not from Christ’s service, but from
this prison of the flesh. O that I could do something for Jesus whilst
here below! my obligations increase. He vouchsafes daily (O amazing
love) to own my feeble labours. The word runs and is glorified. That it
may run and be glorified more and more, under God, through your
instrumentality, is the earnest prayer of, reverend and very dear Sir,

Your affectionate but unworthy brother, in our glorious Head,

G. W.

LETTER MCLXV.
To Lord H――.

London, April 20, 1757.

My Lord,

I MAKE bold to trouble your Lordship with the proposals about the
Georgia college; they should have been sent before, but I heard that
your Lordship was out of town. On Monday next, my business calls me
into the country. If your Lordship should have leisure immediately to run
over the memorial, I would call on Saturday morning to know your
Lordship’s mind. In the mean while, praying that your Lordship may be
a lasting blessing to your country, I subscribe myself,

Your Lordship’s most dutiful, obliged humble servant,

G. W.
 LETTER MCLXVI.
To the Reverend Mr. T――.

Edinburgh, May 31, 1757.

C ANNOT you come here for one day this week? I shall leave
Edinburgh on Monday, God willing.—Attendance upon the
assembly, and preaching, have engrossed all my time. I can scarce
send you this.—Nil mihi rescribas attamen ipse veni.—Adieu! With love
more than I express, I am, my dear Mr. T――,

Yours, &c.

G. W.

P. S. Jesus is good to us. My hearty love awaits your whole self and
family.—It is near eight at night.

LETTER MCLXVII.
To Mr. ――.

Glasgow, June 9, 1757.

My very dear Friend,

T O me, it is almost an age since I wrote to you last. But at Edinburgh

I was so taken up all day, and kept up so late at night, that writing
was almost impracticable. Surely my going thither was of God. I came
thither the twelfth of May, and left it the sixth of June, and preached just
fifty times. To what purpose, the great day will discover. I have reason
to believe to very good purpose. Being the time of the general
assembly (at which I was much pleased) many ministers attended,
perhaps a hundred at a time. Thereby prejudices were removed, and
many of their hearts were deeply impressed. About thirty of them, as a
token of respect, invited me to a public entertainment. The Lord High
Commissioner also invited me to his table, and many persons of credit
and religion did the same in a public manner. Thousands and
thousands, among whom were a great many of the best rank, daily
attended on the word preached, and the longer I staid, the more the
congregations and divine influence increased. Twice I preached in my
way to Glasgow, and last night opened my campaign here. The cloud
seems to move towards Ireland. How the Redeemer vouchsafes to deal
with me there, you shall know hereafter. In the mean while, my very
dear friend, let me entreat the continuance of your prayers. For I am
less than the least of all saints, and unworthy to be employed in the
service of so divine a Master. Lord Jesus,

If thou excuse, then work thy will,

By so unfit an instrument;

It will at once thy goodness shew,

And prove thy power omnipotent.

I hope this will find you, and your dear yoke-fellow and daughter,
enjoying thriving souls in healthy bodies. I doubt not but you are
brightening your crown, and increasing your reward, by doing good for
your blessed Master. Ere long, you shall hear him say “Well done.” That
will crown all. I can no more, I must away to my throne. My very dear
Sir, be pleased to accept ten thousand thanks for all favours, and give
me leave (after sending most cordial respects to dear Mrs. S―― and
Miss) to subscribe myself, my very dear friend,

Your most affectionate, obliged friend, and very ready servant

for Christ’s sake,

G. W.

LETTER MCLXVIII.
 To Mr. ――.

Dublin, June 30, 1757.

My very dear Sir,

Y OUR kind letter, dated the 25th instant, I just now received, for
which as well as all other favours be pleased to accept unfeigned
thanks.—What to do I cannot well tell.—As I am in the kingdom, it is
pity to leave it unvisited.—The door is open, and indeed the poor
Methodists want help.—Here in Dublin the congregations are very
large, and very much impressed. The Redeemer vouchsafes to give me
great freedom in preaching, and arrows of conviction fly and fasten.—
One of the Bishops told a nobleman, “He was glad I was come to rouse
the people”—The nobleman, with whom I sweetly conversed yesterday,
told me this again.—Lord Jesus, do thou (for it is thy doing) rouse all
ranks for thy mercy’s sake! I hope Mr. M――n will go on and prosper.—
As for Mr. J――s, I think it best for him to keep as he is.—I find he is
unsettled, and therefore would be always uneasy.—If Messrs. D――s
and D――r can serve alternately in the Summer, by the help of Jesus I
will go through the Winter work.—Alas, that so few have the ambition of
coming out to the help of the Lord against the mighty. Not one
clergyman in all Ireland yet stirred up to come out singularly for God!
Pity, Lord, for thy mercy’s sake! I think God will yet appear for the
protestant interest.—My rout now is to Athlone, Limerick, Cork, and to
return here about July 21.—Whether I shall then go to the North, and to
Scotland, or whether I shall come by way of Park-Gate, must be
determined hereafter.—I know you will pray, my very dear Sir, that the
never-failing Jesus will direct my goings in his way. I would fain be
where and what he would have me to be.—I bless him, for making you,
my very dear Sir, instrumental in strengthening my weak hands, and
earnestly pray, that great may be the reward of you and your dear
relations in the kingdom of heaven.—Assure yourselves you or they are
never forgotten by, my very dear Sir,

Yours most affectionately in our glorious Head,

G. W.
 LETTER MCLXIX.
To Mr. R―― K――n.

Dublin, July 3, 1757.

My very dear Mr. K――,

A CCEPT a few lines from a poor, feeble, but willing pilgrim.—They

bring you most amazing news. The infinitely condescending
Jesus still vouchsafes to follow the chief of sinners with his unmerited
blessing.—In Scotland, his almighty arm was most powerfully revealed;
—and, here in Dublin, many have begun to say, “What shall we do to
be saved.”—Congregations are large, and very much impressed
indeed.—A spirit of conviction and consolation seems to be sent forth.
—All sorts attend, and all sorts seem to be affected.—I should be glad
to come to London, but cannot in confidence as yet.—Not one minister
either in the church or among the dissenters in this kingdom, as far as I
can hear, appears boldly for God, even a God in Christ. To-morrow
therefore I purpose to set out for Athlone, Limerick, and Cork. God only
knows, after that, where will be the next remove.—Perhaps to London,
perhaps to the North of Ireland, which I hear lies open for the gospel.—
Winter must be the London harvest.—O for more labourers who will
account the work itself the best wages! God will bless you and yours,
for strengthening my hands. I send you and Mrs. K――n my hearty
love, and earnestly pray the Lord of all Lords to bless you. Next post,
or soon after in my circuit, I hope to write to dear Mr. and Mrs. J――.
God forbid that I should forget my old friends.—I pray for, though I
cannot write to them.—I am glad to find that dear Mr. G―― is safe
returned.—Pray remember me to him, and to all enquiring friends in the
kindest manner, and assure them of being remembered at the throne of
grace, by, very dear Mr. and Mrs. K――,

Your most obliged, affectionate friend, and ready servant in

our common Lord,

G. W.
 July 5th.

Since writing the above, I have been in the wars.—But blessed be

God am pretty well recovered, and going on my way rejoicing.—Pray
hard.

LETTER MCLXX.
To Mr. ――.

Dublin, July 9, 1757.

My dear Friend,

M ANY attacks have I had from Satan’s children, but yesterday, you
would have thought he had been permitted to have given me an
effectual parting blow. You have heard of my being in Ireland, and of
my preaching daily to large and very affected auditories, in Mr. W――’s
spacious room. When here last, I preached in a more confined place in
the week days, and once or twice ventured out to Oxminton-Green, a
large place like Moorfields, situated very near the barracks, where the
Ormond and Liberty, that is, high and low party boys, generally
assemble every Sunday, to fight with each other. The congregations
then were very numerous, the word seemed to come with power; and
no noise or disturbance ensued. This encouraged me to give notice,
that I would preach there again last Sunday afternoon. I went through
the barracks, the door of which opens into the green, and pitched my
tent near the barrack walls, not doubting of the protection, or at least
interposition of the officers and soldiery, if there should be occasion.
But how vain is the help of man! Vast was the multitude that attended;
we sang, prayed, and preached, without much molestation; only now
and then a few stones and clods of dirt were thrown at me. It being war
time, as is my usual practice, I exhorted my hearers not only to fear
God, but to honour the best of kings, and after sermon I prayed for
success to the Prusian arms. All being over, I thought to return home
the way I came; but to my great surprize access was denied, so that I
had to go near half a mile from one end of the green to the other,
through hundreds and hundreds of papists, &c. Finding me unattended,
(for a soldier and four methodist preachers, who came with me, had
forsook me and fled) I was left to their mercy; but their mercy, as you
may easily guess, was perfect cruelty. Vollies of hard stones came from
all quarters, and every step I took, a fresh stone struck, and made me
reel backwards and forwards, till I was almost breathless, and all over a
gore of blood. My strong beaver hat served me as it were for a scull
cap for a while; but at last that was knocked off, and my head left quite
defenceless. I received many blows and wounds; one was particularly
large and near my temples. I thought of Stephen, and as I believed that
I received more blows, I was in great hopes that like him I should be
dispatched, and go off in this bloody triumph to the immediate presence
of my master. But providentially, a minister’s house lay next door to the
green; with great difficulty I staggered to the door, which was kindly
opened to, and shut upon me. Some of the mob in the mean time
having broke part of the boards of the pulpit into large splinters, they
beat and wounded my servant grievously in his head and arms, and
then came and drove him from the door. For a while I continued
speechless, panting for and expelling every breath to be my last; two or
three of the hearers, my friends, by some means or other got
admission, and kindly with weeping eyes washed my bloody wounds,
and gave me something to smell to and to drink. I gradually revived, but
soon found the lady of the house desired my absence, for fear the
house should be pulled down. What to do, I knew not, being near two
miles from Mr. W――’s place; some advised one thing, and some
another. At length, a carpenter, one of the friends that came in, offered
me his wig and coat, that I might go off in disguise. I accepted of, and
put them on, but was soon ashamed of not trusting my master to
secure me in my proper habit, and threw them off with disdain. I
determined to go out (since I found my presence was so troublesome)
in my proper habit; immediately deliverance came. A methodist
preacher, with two friends, brought a coach; I leaped into it, and rid in
gospel triumph through the oaths, curses, and imprecations of whole
streets of papists unhurt, though threatened every step of the ground.
None but those who were spectators of the scene, can form an idea of
the affection with which I was received by the weeping, mourning, but
now joyful methodists. A christian surgeon was ready to dress our
wounds, which being done, I went into the preaching place, and after
giving a word of exhortation, join’d in a hymn of praise and
thanksgiving, to him who makes our extremity his opportunity, who stills
the noise of the waves, and the madness of the most malignant people.
The next morning I set out for port Arlington, and left my persecutors to
his mercy, who out of persecutors hath often made preachers. That I
may be thus revenged of them, is the hearty prayer of,

Yours, &c.

G. W.

LETTER MCLXXI.
To Mr. I――.

Cork, July 15, 1757.

My very dear Mr. I――,

A CCEPT a few loving lines, as a token that you and yours are not
entirely forgotten by me. They leave me, earnestly desirous to
know what path the God whom I serve would have me to take. Every
where (O amazing condescension!) the glorious Emmanuel so smiles
upon my feeble labours, that it is hard to get off. At Port Arlington,
Athlone, Limerick, and in this place, the word hath run and been
glorified. Arrows of conviction seem to fly, and the cup of many hath
been made to run over. I hope you have had some refreshings from the
presence of the Lord. Nothing else can carry us comfortably through
the howling wilderness of this troublesome life. I have met with some
hard blows from the Dublin rabble. But blessed be God, they have not
destroyed me. Perhaps I am to see London before my great change
comes. And who knows, but we may enjoy our Peniels and Bethels
there again? Troublous times seem to be approaching. God hide us all
under the shadow of his almighty wings! When you see dear Mr.
W――, pray remember me to him and his in the kindest manner, as
likewise to Mr. and Mrs. W――. I think of, and pray for you, and all my
dear friends, though preaching and travelling prevents my writing. O
that none of us may be parted in another world! Jesus alone can keep
us by his almighty power. To his tender and never-failing mercy do I
most earnestly commit you, and earnestly intreat the continuance of
your prayers in behalf of, my very dear friend,

Yours, &c.

G. W.
 LETTER MCLXXII.
To the Reverend Mr. G――.

Wednesbury, Staffordshire, August 7, 1757.

Reverend and very dear Sir,

T HOUGH Mr. Hopper promised to write you an ♦historical, letter

as last Thursday from Dublin, yet I cannot help dropping you a
few lines from this place. Blessed be God, we had a passage, and
last night we had a pleasant season. At Athlone, Limerick, Cork, and
especially at Dublin, where I preached near fifty times, we had
Cambuslang seasons. With the utmost difficulty I came away. O
these partings! The blows I received some time ago, were like to
send me, where all partings would have been over. But I find we are
immortal till our work is done. Lord Jesus, help me to begin in
earnest! My cordial love awaits my host and hostess. Be pleased to
desire them to send my things by the first opportunity, directed to Mr.
David Brown, at the Orphan-hospital, Edinburgh.—This morning our
Lord hath met us.—I am to preach twice more.—Ere long we shall
praise for ever. I hope dear Mr. N――’s son is better. I commend
your whole self, and all dear friends, to his never-failing mercy, and
entreat you never to forget, my very dear Sir,

Yours most affectionately in the best bonds,

G. W.

♦ “histostrical” replaced with “historical”

 LETTER MCLXXIII.
To Mrs. C――.

London, August 26, 1757.

Dear Mrs. C――,

I THINK myself quite happy, in finding that you are satisfied in your
present situation.—I have no doubt of your being called to do it by
Bethesda’s God, and heartily pray that you may be amply rewarded
by Him.—I had rather have you preside over the orphan family, than
any woman I know of in the world. I would gladly indulge Mr. B――,
but though I have sent again and again, I cannot find that his wife
hath the least inclination to come over; as this is the case, and she is
provided for, I wish he could be easy. Mr. P―― and you may agree,
as to the terms of his continuance at Bethesda. Mr. D―― seems
fixed, and I have written to Mr. P――, to let John H――y have
overseers wages for the two last years, and find himself; but perhaps
it may be best not to give up the indentures.—As he is faithful, and
the plantation flourishes, I would not part with him. I do not love
changes. Sometimes I wish for wings to fly over; but providence
detains me here. I fear a dreadful storm is at hand. Lord Jesus, be
thou our refuge! At Dublin I was like to be sent beyond the reach of
storms. But I find we are immortal till our work is done. A most
blessed influence attended the word in various parts of Ireland, and
here at London the prospect is more and more promising. We expect
some important news from America. As to outward things, all is
gloomy. Jesus can dispel every cloud. I hope Bethesda will be kept
in peace. I am glad the Governor hath been to visit the house. May
God make him a blessing to the colony! My kinsman hath met with
an early trial. May the Lord sanctify it! I am glad G―― W―― is put
out, and that you have sent the children; I pity them, but they must
blame their parents. O ingratitude! I wish you would now and then
mention B―― W――, and let me know how the English children are
disposed of. I would fain have a list of black and white from time to
time. Blessed be God for the increase of the negroes. I intirely
approve of reducing the number of orphans as low as possible; and I
am determined to take in no more than the plantation will maintain,
till I can buy more negroes. Never was I so well satisfied with my
assistants as now. God bless you! God bless you! My tender love
and respects attend you all. I would have Joseph P――n sent to the
college. I am glad Mrs. F―― is married. Continue to pray for me,
and depend on hearing as often as possible from, dear Mrs. C――,

Your affectionate, obliged friend, and ready servant in our

common Lord,

G. W.

LETTER MCLXXIV.
To Mr. H――.

Exeter, September 28, 1757.

My very dear Sir,

J UST this moment I had the pleasure of receiving your very kind
letter, and have but just time, before the post goes out, to return
you my most hearty thanks. Blessed be God, I can send you good
news from Plymouth.—The scene was like that of Bristol; only more
extraordinary, to see officers, ♦soldiers, sailors, and the dock-men,
attending with the utmost solemnity upon the word preached. Arrows
of conviction fled and fastened, and I left all God’s people upon the
wing for heaven. Blessed be the Lord Jesus for ordering me the lot
of a cast-out!