Traumatic Epidural Hematoma G. Gallia & M. Sobotta New Engl J Med 360: 615, 2009 W. Rose

Marieb & Hoehn 7th ed. Chapter 12

Traumatic Epidural Hematoma G. Gallia & M. Sobotta (2009). NEJM 360: 615. Gallia and Sobotta, NEJM (2009) 360:615 http://content.nejm.org/content/vol360/issue6/images/large/09f1.jpeg A. CT. 2.5 cm epidural hematoma, L parietal region. Black line = anatomical midline. Arrow: 6mm line from midline to the point midway between lateral ventricles. Indicates 6 mm left-to-right soft tissue midline shift. Transverse section: patient supine, feet toward viewer. B. CT. 2.5 cm epidural hematoma, L parietal region. Compression of left ventricular system. Coronal section: patient facing viewer. C. CT. Linear non-displaced skull fracture. Transverse section: patient supine, feet toward viewer. An 18-year-old intoxicated man was assaulted with a glass bottle on the left parietal region of his head and had a 5-minute loss of consciousness. The patient went home, but 2 hours after the injury, he presented to a local emergency department with severe headache, nausea, and vomiting. On physical examination, his score on the Glasgow Coma Scale was 15 (scores range from 3 to 15, with 15 indicating a normal level of consciousness), he had equal and bilaterally reactive pupils, and there was a small contusion on the scalp in the left temporoparietal region. Computed tomography of the head revealed a 2.5-cm epidural hematoma in the left parietal region (Panels A and B) underlying a linear, nondisplaced skull fracture (Panel C, arrows). There was mass effect, effacement of the left ventricular system, and 6 mm of left-to-right midline shift (Panel A, arrow). After 30 minutes, his score on the Glasgow Coma Scale dropped to 13, and he was intubated and transported by helicopter to our hospital, where on arrival 30 minutes later, his left pupil was dilated. He was taken directly to the operating room, where he underwent a craniotomy for evacuation of the epidural hematoma. Several bleeding sites from the middle meningeal artery were identified and coagulated. He returned to work as a builder 3 months after the injury. At his last follow-up examination, 14 months after the injury, he had no physical or cognitive deficits. CT. Transverse section: patient supine, feet toward viewer. CT. Coronal section: patient facing viewer. CT. Transverse section: patient supine, feet toward viewer. See notes.

L Parietal bone, inner surface, showing grooves for Gallia and Sobotta, NEJM (2009) 360:615 http://content.nejm.org/content/vol360/issue6/images/large/09f1.jpeg A. CT. 2.5 cm epidural hematoma, L parietal region. Black line = anatomical midline. Arrow: 6mm line from midline to the point midway between lateral ventricles. Indicates 6 mm left-to-right soft tissue midline shift. Transverse section: patient supine, feet toward viewer. B. CT. 2.5 cm epidural hematoma, L parietal region. Compression of left ventricular system. Coronal section: patient facing viewer. C. CT. Linear non-displaced skull fracture. Transverse section: patient supine, feet toward viewer. An 18-year-old intoxicated man was assaulted with a glass bottle on the left parietal region of his head and had a 5-minute loss of consciousness. The patient went home, but 2 hours after the injury, he presented to a local emergency department with severe headache, nausea, and vomiting. On physical examination, his score on the Glasgow Coma Scale was 15 (scores range from 3 to 15, with 15 indicating a normal level of consciousness), he had equal and bilaterally reactive pupils, and there was a small contusion on the scalp in the left temporoparietal region. Computed tomography of the head revealed a 2.5-cm epidural hematoma in the left parietal region (Panels A and B) underlying a linear, nondisplaced skull fracture (Panel C, arrows). There was mass effect, effacement of the left ventricular system, and 6 mm of left-to-right midline shift (Panel A, arrow). After 30 minutes, his score on the Glasgow Coma Scale dropped to 13, and he was intubated and transported by helicopter to our hospital, where on arrival 30 minutes later, his left pupil was dilated. He was taken directly to the operating room, where he underwent a craniotomy for evacuation of the epidural hematoma. Several bleeding sites from the middle meningeal artery were identified and coagulated. He returned to work as a builder 3 months after the injury. At his last follow-up examination, 14 months after the injury, he had no physical or cognitive deficits. L Parietal bone, inner surface, showing grooves for branches of middle meningeal artery. Meningeal a. supplies the meninges, I,.e the surface of the brain. Middle men. A. is biggest of the 3 m.a.s. Gray’s Anatomy. http://www.bartleby.com/107/illus133.html

Bilateral Subacute Subdural Hematomas Wind and Leiphart New Engl J Med 360: e23, 2009 W. Rose

Bilateral Subacute Subdural Hematomas, Wind and Leiphart, New Engl J Med 360: e23, 2009 Wind and Leiphart, New Engl J Med 360: e23, 2009 http://content.nejm.org/cgi/content/full/360/17/e23/F1 A 43-year-old man presented to the emergency department with a 2-day history of headache; he reported being otherwise healthy. Four weeks earlier, he had been an unrestrained driver involved in a motor vehicle accident in which he lost consciousness but did not present to a hospital. He reported having no history of coagulopathy, alcohol abuse, or use of antiplatelet or anticoagulant medication. In the emergency department, his clinical course deteriorated over a period of several hours, with worsening headache, nausea, vomiting, and lethargy. Computed tomography (CT) of the brain, performed without the administration of contrast material, revealed a loss of cortical sulci but failed to show a lesion clearly. Magnetic resonance imaging (MRI) (Panels A and B) revealed large bilateral subdural hematomas. The patient underwent successful evacuation of the hematomas through four burr holes (two on each side). He did well postoperatively and was discharged home, neurologically intact, on postoperative day 4. This case shows the occasional difficulty in visualizing subacute subdural hematomas on CT if they are isodense relative to the brain parenchyma. In such cases, MRI can be useful to better visualize the hematoma. See notes.

Epidural vs. subdural bleeding Epidural bleed : arterial, above (outside) dura. Typical: brief period of unconsciousness following injury, then lucid, then quickly progresses to unconsciousness and possible coma. Meningeal artery a common site. Subdural bleed : venous, below (inside) dura. Typical: slow progression, maybe no symptoms for days. Suspect subdural bleed if patient had fall/head injury, initially okay, later unconscious. Common in alcoholics. Note two hour progression in first case, versus four weeks in second. First involves middle meningeal artery. Portions adapted from http://dearnurses.blogspot.com/2007/04/epidural-vs-subdural-bleed.html, retrieved 2009-04-23. Epidural vs. subdural bleeding An epidural bleed is an arterial bleed. The patient has a brief period of unconsciousness following injury. He then becomes lucid and quickly progresses to unconsciousness and possible coma. A common site for injury is the meningeal artery which runs close to the surface, behind the ear. A subdural bleed is venous and progresses slowly. The patient may not experience any symptoms for a few days. It may even become chronic. Suspect a subdural bleed if the patient had a fall /head injury and was initially okay and later became unconscious. Common in alcoholics. http://dearnurses.blogspot.com/2007/04/epidural-vs-subdural-bleed.html, retrieved 2009-04-23.