Traumatic Brain Injury Epidural Hematoma
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Transcript of Traumatic Brain Injury Epidural Hematoma
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Traumatic Brain InjuryTraumatic Brain InjuryJames G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.
Professor of Radiology, Neurology, and Biomedical InformaticsProfessor of Radiology, Neurology, and Biomedical Informatics
Chair, Department of Radiology and Radiological SciencesChair, Department of Radiology and Radiological Sciences
Uniformed Services UniversityUniformed Services University
Bethesda, MDBethesda, MD
http://http://rad.usuhs.milrad.usuhs.mil
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
TBI Educational ObjectivesTBI Educational Objectives
Who needs brain imaging?Who needs brain imaging?
What type of imaging is needed?What type of imaging is needed?
Intraaxial LesionsIntraaxial Lesions Primary LesionsPrimary Lesions
Contusion, Shearing InjuryContusion, Shearing Injury
Immediate Neurological EffectsImmediate Neurological Effects
Extraaxial LesionsExtraaxial Lesions Secondary LesionsSecondary Lesions
Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid
Delayed Neurological EffectsDelayed Neurological Effects
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Membrane HematomaMembrane Hematoma
EpiduralEpidural
AcuteAcute
BiconvexBiconvex
UnilateralUnilateral
Skull fractureSkull fracture
Limited by suturesLimited by sutures
SubduralSubdural
Acute to ChronicAcute to Chronic
Concave layerConcave layer
BilateralBilateral
Fracture +/Fracture +/--
Cross suturesCross sutures
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Membrane HematomaMembrane Hematoma
EpiduralEpidural SubduralSubdural
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
CENTRIPETAL APPROACHCENTRIPETAL APPROACH(outside to inside)(outside to inside)
ScalpScalp
CalvariumCalvarium
EpiduralEpidural
SubduralSubdural
SubarachnoidSubarachnoid
IntraIntra--parenchymalparenchymalIntraIntra--ventricularventricular
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Traumatic Hemorrhage:Traumatic Hemorrhage:
SubgalealSubgaleal
CephalohematomaCephalohematoma
Subperiosteal Outer TableSubperiosteal Outer Table
Epidural (Extradural)Epidural (Extradural)
Subperiosteal Inner TableSubperiosteal Inner Table
SubduralSubdural
EpiEpi--arachnoidarachnoid
SubarachnoidSubarachnoid
Parenchymal HemorrhageParenchymal Hemorrhage
IntraIntra--ventricularventricular
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
22 y.oy.o. with dilated pupil. with dilated pupil
Midline Herniation: Subfalcial and Downward Transtentorial
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
CNS TRAUMA EPIDURALCNS TRAUMA EPIDURALHEMATOMAHEMATOMA
Young Men (20Young Men (20--40's)40's)
Head Trauma frequentHead Trauma frequent
Also, dura (periosteum) more adherent inAlso, dura (periosteum) more adherent in
older peopleolder people
Acute presentationAcute presentation
Skull fracture (90%)Skull fracture (90%) BiBi--convex, hyperdenseconvex, hyperdense-- limited by sutureslimited by sutures
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
EPIDURAL HEMATOMAEPIDURAL HEMATOMA
Source of BleedingSource of Bleeding MENINGEAL VESSELSMENINGEAL VESSELS
Arterial (high pressure)Arterial (high pressure)
Venous (low pressure)Venous (low pressure)
DURAL SINUSDURAL SINUS High flow, low pressureHigh flow, low pressure
OTHEROTHER Diploic veins (Fx)Diploic veins (Fx)
Marrow sinusoidsMarrow sinusoids
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
EPIDURAL HEMATOMAEPIDURAL HEMATOMA
Significant traumaSignificant trauma
Fracture & concussion (l.o.c.)Fracture & concussion (l.o.c.)
Lucid IntervalLucid Interval
pt Wakes Uppt Wakes Up
40% pts.40% pts. Delayed neurologic Sx (hrs. Later)Delayed neurologic Sx (hrs. Later)
Herniation, coma and deathHerniation, coma and death
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Epidural Hematoma: Lens ShapeEpidural Hematoma: Lens Shape
Scalp & Skull
Dura & Arachnoid
Pia and Brain
Ventricle and CSF
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Epidural HematomaEpidural Hematoma
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
EPIDURAL HEMATOMAEPIDURAL HEMATOMATraumaTrauma --> fracture & concussion> fracture & concussion
Tearing/stripping of both layersTearing/stripping of both layersfrom inner tablefrom inner table
Laceration of outer periostealLaceration of outer periosteallayerlayer
Laceration of meningeal vesselsLaceration of meningeal vessels
Inner (meningeal dura) intactInner (meningeal dura) intact
Blood between naked bone andBlood between naked bone andduradura
NORMAL arterial pressureNORMAL arterial pressurecontinues to dissectcontinues to dissect
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Epidural HematomaEpidural Hematoma
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Epidural HematomaEpidural Hematoma
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
tt tt
f
Brain Herniation SyndromesBrain Herniation Syndromes
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009Epidural HematomaEpidural Hematoma
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Epidural HematomaEpidural Hematoma
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Epidural HematomaEpidural Hematoma -- TreatmentTreatment
Craniotomy
Drain clot
Repair the Artery!
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Small EDHSmall EDH Conservative TxConservative Tx
Smile of the Quadrigeminal Cistern
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Everyone deserves a smile!Everyone deserves a smile!Quadrigeminal plate cistern
Corpora quadrigemini2 pairs of colliculi
SuperiorInferior
Perimesencephalic cisternAmbient cistern
Courtesy Frank Brennan, CDR, USN (ret.)
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
Progressive EDHProgressive EDH
8 PM10 AM
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
SUBPERIOSTEAL HEMATOMASUBPERIOSTEAL HEMATOMA
CEPHALOHEMATOMACEPHALOHEMATOMA (Birth trauma)(Birth trauma)
(outer table, sub(outer table, sub--periosteal)periosteal)
EPIDURAL HEMATOMAEPIDURAL HEMATOMA (Inner table, "sub(Inner table, "sub--periosteal")periosteal")
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USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
CephalohematomaCephalohematoma
Birth TraumaBirth Trauma
USUHS SmirniotopoulosUSUHS Smirniotopoulos -- 20092009
CephalohematomaCephalohematoma -- CalcifiedCalcified
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