Neuroradiology

Traumatic Hemorrhage
By: Luke Aldo, MSIV
LECOM
Erie, Pennsylvania
Layers of the Meninges
 Epidural Hematoma

• Accumulation of blood in the potential

space between dura mater and bone
• EDH is considered to be the most serious
complication of head injury, requiring
immediate diagnosis and surgical
intervention (mortality rate associated
with epidural hematoma has been
estimated to be 5-50%)
 Pathophysiology
• Usually results from a brief linear contact force
to the calvaria that causes separation of the
periosteal dura from bone and disruption of
interposed vessels due to shearing stress
• Skull fractures occur in 85-95% of adult cases
• Extension of the hematoma usually is limited by
suture lines owing to the tight attachment of the
dura at these locations.
• The temporoparietal region and the middle
meningeal artery are involved most commonly
(66%)
 Frequency
• Epidural hematoma complicates 2% of cases of head
trauma (approximately 40,000 cases per year)
• Alcohol and other forms of intoxication have been
associated with a higher incidence of epidural hematoma
• Sex
– more frequent in men, with a male-to-female ratio of 4:1
• Age
– rare in individuals younger than 2 years
– rare in individuals older than 60 years because the dura is tightly
adherent to the calvaria
 History
• Head trauma
• Lucid interval between the initial loss of
consciousness at the time of impact and a
delayed decline in mental status (10-33% of
cases)
• Headache
• Nausea/vomiting
• Seizures
• Focal neurological deficits (eg, visual field cuts,
aphasia, weakness, numbness)
 Diagnostic Imaging
• Noncontrast CT scanning of the head (imaging
study of choice for intracranial EDH) not only
visualizes skull fractures, but also directly images
an epidural hematoma
• It appears as a hyperdense biconvex or
lenticular-shaped mass situated between the
brain and the skull, though regions of
hypodensity may be seen with serum or fresh
blood
• MRI also demonstrates the evolution of an
epidural hematoma, though this imaging
modality may not be appropriate for patients in
unstable condition
 Subdural Hematoma
• Rapidly clotting blood collection below the inner
layer of the dura but external to the brain and
arachnoid membrane
• Typically, low-pressure venous bleeding of
bridging veins (between the cortex and venous
sinuses) dissects the arachnoid away from the
dura and layers out along the cerebral convexity
• It conforms to the shape of the brain and the
cranial vault, exhibiting concave inner margins
and convex outer margins (crescent shape)
• Frequency is related directly to the incidence of
blunt head trauma
• It’s the most common type of intracranial mass
lesion, occurring in about a third of those with
severe head injuries
 Mortality/Age
• Mortality
– Simple SDH (no parenchymal injury) is associated with a
mortality rate of about 20%
– Complicated SDH (parenchymal injury) is associated with a
mortality rate of about 50%
• Age
– It’s associated with age factors related to the risk of blunt head
trauma
– More common in people older than 60 years (bridging veins are
more easily damaged/falls are more common)
– Bilateral SDHs are more common in infants since adhesions
existing in the subdural space are absent at birth
– Interhemispheric SDHs are often associate with child abuse
 History
• Usually involves moderately severe to severe blunt head
trauma
• Acute deceleration injury from a fall or motor vehicle
accident, but rarely associated with skull fracture
• Generally loss of consciousness
• Any degree or type of coagulopathy should heighten
suspicion of SDH
• Commonly seen in alcoholics because they’re prone to
thrombocytopenia, prolonged bleeding times, and blunt
head trauma
• Patients on anticoagulants can develop SDH with
minimal trauma and warrant a lowered threshold for
obtaining a head CT scan
 Diagnostic Imaging
• MRI is superior for demonstrating the size of an acute
SDH and its effect on the brain, however noncontrast
head CT is the primary means of making a diagnosis and
suffice for immediate management purposes
• Noncontrast head CT scan (imaging study of choice for
acute SDH)
– The SDH appears as a hyperdense (white) crescentic mass along
the inner table of the skull, most commonly over the cerebral
convexity in the parietal region. The second most common area
is above the tentorium cerebelli
• Contrast-enhanced CT or MRI is widely recommended
for imaging 48-72 hours after head injury because the
lesion becomes isodense in the subacute phase
• In the chronic phase, the lesion becomes hypodense and
is easy to appreciate on a noncontrast head CT scan
 Summary
• Epidural Hematoma • Subdural Hematoma
– Potential space between – Between the dura mater
the dura in the inner table and the arachnoid mater
of the skull – Can cross sutures
– Can’t cross sutures – Cortical bridging veins
– Skull fractures in – Crescent shape
temporoparietal region – Loss of consciousness
– Middle meningeal artery
– Common in elderly
– Lenticular or biconvex – Common in alcoholics
shape
– Lucid interval – Medical emergency
– Common in alcoholics – CT without contrast
– Medical emergency – Evacuate via burr holes
– CT without contrast
– Evacuate via burr holes
 Bibliography

• Abramson, Nina, MD. Subdural Hematoma.

Brigham Radiology: 1994 Nov.
• Azmoun, Leyla, MD. Epidural Hematoma.
Brigham Radiology: 1995 Nov.
• Liebeskine, David, MD. Epidural Hematoma.
Emedicine.com: 2006 Apr; 1-10.
• Scaletta, Tom, MD. Subdural Hematoma.
Emedicine.com: 2006 May; 1-10.