EPIDURAL

HEMATOMA
SUBDURAL
HEMATOMA
Rupak Raj Ghimire
HEAD TRAUMA
1-Skull fractures.
2-Epidural ,subdural & subarachnoid
hematoma
3-Cerebral contusion& intraventricular
Hemorrhage
4-Diffuse Axonal Injury (DAI).
5-Related Brain edema & herniation.
EPIDURAL HEMATOMA
usually associated with a skull fracture.

often occurs when a direct impact

fractures the calvarium .
fractured bone lacerates a dural artery
(middle meningeal artery) or a venous
sinus.
On CT, the hematoma forms a
hyperdense biconvex mass.
usually uniformly high density but may
contain hypodense foci due to active
bleeding.
The shift can cause tiny tears in nearby arteries

Middle
meningeal
artery
The artery
that runs
between the
dura and the
skull inferior to
a thin portion
of temporal
bone.
 and the result is bleeding inside
the brain cavity.

HEMORRHAGE FROM THIS ARTERY CAUSES RAPID

PRESSURE ON THE BRAIN.
 The epidural hematoma that
builds inside the brain leaves no
room for the brain, so it begins
to shift and push against the
brain-stem. It affects speech,
movement, breathing, and even
results in the loss of
consciousness.
CT SCAN RESULTS OF EPIDURAL HEMATOMA
Momentary loss of consciousness at the time
of injury, followed by an interval of apparent
recovery (lucid interval)

During the lucid interval, compensation for the

expanding hematoma takes place by rapid absorption
of CSF and decreased intravascular volume, both of
which help maintain a normal ICP. When these
mechanisms can no longer compensate, even a small
increase in the volume of the blood clot produces a
marked elevation in ICP.
 An epidural hematoma is considered an extreme emergency,
marked neurologic deficit or even respiratory arrest can
occur within minutes.
Treatment consists of making openings through the
skull (burr holes) to decrease ICP emergently, remove
the clot, and control the bleeding. A craniotomy may be
required to remove the clot and control the bleeding. A
drain is usually inserted after creation of burr holes or a
craniotomy to prevent reaccumulation of blood.
 SUBDURAL HEMATOMA
Deceleration and acceleration or rotational
forces that tear bridging veins can cause an
acute subdural hematoma
Causes :
minimal trauma in old age,
child abuse
ventricular decompression,
may occur in patients receiving anticoagulants or
patients with a coagulopathy condition.
blood collects in the space between the
arachnoid matter and the dura matter,
Because the subdural space is not limited by
the cranial sutures, blood can spread along the
entire hemisphere and into the hemispheric
fissure, limited only by the dural reflections .
3 major types :Acute, subacute & chronic
 subdural hemorrhages may cause an increase in intracranial
pressure (ICP), which can cause compression of and
damage to delicate brain tissue. Subdural hematomas are
often life-threatening when acute, but chronic subdural
hematomas are usually not deadly if treated.
In contrast, epidural hematomas are usually caused by tears
in arteries, resulting in a buildup of blood between the dura
and the skull.
CLASSIFICATION

Subdural hematomas are divided into

(depending on their speed of onset )

acute

chronic,
 ACUTE SDH
Acute subdural hematomas that
are due to trauma are the lethal of
all head injuries and have a high
mortality rate if they are not rapidly
treated with surgical
decompression.
ETIOLOGY OF ACUTE SDH

Head trauma
Coagulopathy or medical anticoagulation
(eg, warfarin [Coumadin], heparin,
hemophilia, liver disease,
thrombocytopenia)
Nontraumatic intracranial hemorrhage
due to cerebral aneurysm, arteriovenous
malformation, or tumor (meningioma or
dural metastases)
Postsurgical (craniotomy, CSF shunting)
Intracranial hypotension (eg, after lumbar puncture,
lumbar CSF leak, lumboperitoneal shunt, spinal
epidural anesthesia

Child abuse or shaken baby syndrome (in the

pediatric age group)

Spontaneous or unknown (rare)

 Acute bleeds develop after high speed
acceleration or deceleration injuries and
are increasingly severe with larger
hematomas.
 They are most severe if associated with
cerebral contusions.

Though much faster than chronic subdural

bleeds, acute subdural bleeding is usually
venous and therefore slower than the
usually arterial bleeding of an epidural
hemorrhage.
 Acute subdural bleeds have a high
mortality rate, higher even than diffuse
brain injuries, because the force
(acceleration/deceleration) required to
cause them cause other severe injuries as
well.

The mortality rate associated with acute

subdural hematoma is around 60 to 80%.
CHRONIC SDH
Chronic subdural bleeds develop over the period
of days to weeks, often after minor head trauma.
They may not be discovered until they present
clinically months or years after a head injury.
The bleeding from a chronic bleed is slow,
probably from repeated minor bleeds, and
usually stops by itself.
Since these bleeds progress slowly, they present
the chance of being stopped before they cause
significant damage.
 ETIOLOGY OF CHRONIC SDH

Head trauma (may be relatively mild, eg, in

older individuals with cerebral atrophy)
Acute SDH, with or without surgical
intervention
Spontaneous or idiopathic
Small chronic subdural hematomas, those
less than a centimeter wide, have much
better outcomes than acute subdural
bleeds.
Only 22% of patients with chronic subdural
bleeds had outcomes worse than "good" or
"complete recovery".
Chronic subdural hematomas are common
in the elderly.
SIGNS AND SYMPTOMS

Symptoms of subdural hemorrhage have a

slower onset than those of epidural hemorrhages
because the lower pressure veins bleed more
slowly than arteries.

Therefore, signs and symptoms may show up in

minutes, if not immediately but can be delayed
as much as 2 weeks
 SIGNS AND SYMPTOMS OF SUBDURAL HEMATOMA CAN INCLUDE ANY
COMBINATION OF THE FOLLOWING:

Loss of consciousness or fluctuating levels of Nausea or vomiting

consciousness
Loss of appetite
Irritability
Personality changes
Seizures
Inability to speak or slurred
Pain
speech
Numbness
Ataxia
Headache (either constant or fluctuating) Altered breathing patterns
Dizziness Hearing loss or hearing ringing
Disorientation (tinnitus)
Amnesia Blurred Vision
Weakness or lethargy Deviated gaze,
PATHOPHYSIOLOGY

Collected blood from the subdural bleed

may draw in water due to osmosis, causing
it to expand, which may compress brain
tissue and cause new bleeds by tearing
other blood vessels.

In some subdural bleeds, the arachnoid

layer of the meninges is torn, and
cerebrospinal fluid (CSF) and blood both
expand in the intracranial space, increasing
pressure
 Substances that cause vasoconstriction
may be released from the collected
material in a subdural hematoma, causing
further ischemia under the site by
restricting blood flow to the brain.

When the brain is denied adequate blood

flow, a biochemical cascade known as the
ischemic cascade is unleashed, and may
ultimately lead to brain cell death.
 DIAGNOSIS
On a CT scan, subdural hematomas are
classically crescent-shaped, with a concave
surface away from the skull. However, they
can have a convex appearance, especially
in the early stage of bleeding.

A more reliable indicator of subdural

hemorrhage is its involvement of a larger
portion of the cerebral hemisphere since it
can cross suture lines, unlike an epidural
hemorrhage
TREATMENT
 Treatment of a subdural hematoma
depends on its size and rate of growth.
Some small subdural hematomas can be
managed by careful monitoring until the
body heals itself.
Other small subdural hematomas can be
managed by inserting temporary small
catheter through a hole drilled through the
skull and sucking out the hematoma;
 Large or symptomatic
hematomas require a
craniotomy, the surgical
opening of the skull. It
involves opening the dura,
removal of the blood clot with
suction or irrigation, and
identifying and controling
sites of bleeding.
 There are many types of craniotomies, which are
named according to the area of skullto be
removed .
Typically the bone flap is replaced. If the bone flap
is not replaced, the procedure is called a
craniectomy

Craniotomies are often named

for the bone being removed.
Some common craniotomies
include frontotemporal, parietal,
temporal, and suboccipital
DIFFERENCE BETWEEN SUBDURAL AND EPIDURAL HEMATOMA
EPIDURAL HAEMORRHAGE SUBDURAL HAEMORRHAGE
1. It is hematoma between inner 1. It occurs between the dura matter,
periosteum of cranium and duramater. which adheres to the skull, and the
arachnoid mater enveloping the brain.
2. due to tearing of bridging veins of brain.
2.Mostly due to bleed from artery
especially middle meningeal. 3. Not always associated with fracture of
cranial bones, may show blunt trauma.
3. Commonly associated with laceration &
fracture of overlying cranial vault. 4. On CT: follows the anatomy of cerebral
hemisphere & is seen concave away
4.On CT: seen as biconvex hyperdense area from skull/ crescent shaped.
pushing the brain tissue away.