Neuroradiology

Traumatic
By: Luke Aldo, MSIV
Hemorrhage
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
Its 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

Its 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 theyre
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 the dura in the
inner table of the skull
Cant cross sutures
Skull fractures in
temporoparietal region
Middle meningeal
artery
Lenticular or biconvex
shape
Lucid interval
Common in alcoholics
Medical emergency
CT without contrast

Between the dura mater

and the arachnoid mater
Can cross sutures
Cortical bridging veins
Crescent shape
Loss of consciousness
Common in elderly
Common in alcoholics
Medical emergency
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; 110.
Scaletta, Tom, MD. Subdural Hematoma.
Emedicine.com: 2006 May; 1-10.