Neuroradiology Traumatic Hemorrhage By: Luke Aldo, MSIV LECOM Erie, Pennsylvania Layers of the Meninges Epidural Hematoma вЂў Accumulation of blood in the potential space between dura mater and bone вЂў 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 вЂў Usually results from a brief linear contact force вЂў вЂў вЂў 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 вЂў Epidural hematoma complicates 2% of cases of head вЂў вЂў trauma (approximately 40,000 cases per year) Alcohol and other forms of intoxication have been associated with a higher incidence of epidural hematoma Sex вЂ“ more frequent in men, with a male-to-female ratio of 4:1 вЂў Age вЂ“ rare in individuals younger than 2 years вЂ“ rare in individuals older than 60 years because the dura is tightly adherent to the calvaria History вЂў Head trauma вЂў Lucid interval between the initial loss of вЂў вЂў вЂў вЂў 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 вЂў Noncontrast CT scanning of the head (imaging вЂў вЂў 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 вЂў Rapidly clotting blood collection below the inner вЂў вЂў 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) вЂў Frequency is related directly to the incidence of вЂў blunt head trauma ItвЂ™s the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries Mortality/Age вЂў Mortality вЂ“ Simple SDH (no parenchymal injury) is associated with a mortality rate of about 20% вЂ“ Complicated SDH (parenchymal injury) is associated with a mortality rate of about 50% вЂў Age вЂ“ ItвЂ™s associated with age factors related to the risk of blunt head trauma вЂ“ More common in people older than 60 years (bridging veins are more easily damaged/falls are more common) вЂ“ Bilateral SDHs are more common in infants since adhesions existing in the subdural space are absent at birth вЂ“ Interhemispheric SDHs are often associate with child abuse History вЂў Usually involves moderately severe to severe blunt head trauma вЂў Acute deceleration injury from a fall or motor vehicle вЂў вЂў вЂў вЂў 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 theyвЂ™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 вЂў MRI is superior for demonstrating the size of an acute вЂў 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) вЂ“ 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 вЂў Contrast-enhanced CT or MRI is widely recommended вЂў 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 вЂў Epidural Hematoma вЂ“ Potential space between the dura in the inner table of the skull вЂ“ CanвЂ™t cross sutures вЂ“ Skull fractures in temporoparietal region вЂ“ Middle meningeal artery вЂ“ Lenticular or biconvex shape вЂ“ Lucid interval вЂ“ Common in alcoholics вЂ“ Medical emergency вЂ“ CT without contrast вЂ“ Evacuate via burr holes вЂў Subdural Hematoma вЂ“ Between the dura mater and the arachnoid mater вЂ“ Can cross sutures вЂ“ Cortical bridging veins вЂ“ Crescent shape вЂ“ Loss of consciousness вЂ“ Common in elderly вЂ“ Common in alcoholics вЂ“ Medical emergency вЂ“ CT without contrast вЂ“ Evacuate via burr holes Bibliography вЂў Abramson, Nina, MD. Subdural Hematoma. вЂў вЂў вЂў 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.