NAME ;UMENZEKWE C

TOPIC;SUBDURAL/EPIDURAL HAEMATOMA

ANATOMY OF THE MENINGES

ANATOMY OF EPIDURAL SPACE

– The epidural space is the space between the dura (the outermost membrane covering the brain and spinal cord) and skull, or the bony vertebrae that form the spinal canal. In the spine, the epidural space contains lymphatics, small arteries, and the epidural venous plexus. In the brain the epidural space is a potential space, meaning that the space does not exist under normal conditions.

ANATOMY OF SUBDURAL SPACE

– The subdural space: – The space between the dura mater and the

arachnoid mater, this is a potential space in both the skull and the spine.

SUB DURAL HAEMATOMA

• It is the collection of blood in the subdural space.

• It is the most common form of traumatic intracranial mass leision.

• Could present as acute,sub acute or chronic forms.

• A reversible cause of demential

ACUTE SUBDURAL HEMATOMA

• Common in young persons• Symptoms usually present within 48hr• Results from high velocity skull trama with rapid

acceleration/deceleration of brain tissues as against fixed dura mater and the skull leading to tearing of bridging veins.

• Has high mortality rate if asso with cerebra contusion or if not rapidly treated by surgical decompression.

CHRONIC SUBDURAL HEMATOMA

• Common in elderly persons.

• Often due to minor unrecorgnised injury.

• Presents after several weeks or month.

• It is a treatable cause of demential

• The bleeding is gradual with characteristic repeated bleeds.

RISK FACTORS

• Age• Male sex• Coagulopathy or medical

anticoagulation;heparin,haemophilia,liver disease and thrombocytopenia.

• Alcoholism.• NB bilateral subdural hematomas are present in

infants bcos of absence of adhesions in the subdural space.Also is interhemispheric subdural hematomas

AETIOLOGY

1) Usually traumatic.in abt 75% of cases. -trauma may be trivial and unrecorgnised especialy in the elderly.

-the most common cause2) Undetermined/spontaneous in 25% of cases.this

is asso with;- anticoagulant and antiplatelet therapy.- Cerebral aneurysm- Arteriovenous malformation- Tumor (meningioma or dural metastasis)

PATHOGENESIS

• For traumatic aetiology,foliowing high speed impact on the skull.

• This causes brain tissue to accelerate/decelerate relatively to the fixed dural structure,tearing blood vessel majorly veins.

• These are veins running from cerebral cortex to the dural venous sinuses.these are called the bridging vein.

Pathogenesis contn

• In elderly persons,the bridging veins may already be stretched because of brain atrophy making them more susceptible to trauma.

• Damage can also come from laceration or direct injury

pathophysiology

• Following the haematoma,there wil be rise in intracranial pressure.

• This causes herniation;subfalcial(cyngulate gyrus) and transtentorial.

• Subfalcial herniation may cause a cerebral infarct via compression of anterior cerebral artery

• Transtentorial herniation wil cause infarction via the compression of posterior cerebral artery.it can also cause pressure on the 3rd cranial nerve resulting ipsilateral pupilary dilatation.

progressive transtentorial herniation,pressure on the brain stem tears blood vessels that supply the brain stem resulting in duret haemorhage and dealth.

CLINICAL FEATURES• HISTORYHISTORY• Usually involves moderately severe to severe blunt Usually involves moderately severe to severe blunt head traumahead trauma • Acute deceleration injury from a fall or motor vehicle accident, but Acute deceleration injury from a fall or motor vehicle accident, but

rarely associated with skull fracturerarely associated with skull fracture• Generally Generally loss of consciousnessloss of consciousness• Any degree or type of coagulopathy should heighten suspicion of Any degree or type of coagulopathy should heighten suspicion of

SDHSDH• Commonly seen in alcoholics because they’re prone to Commonly seen in alcoholics because they’re prone to

thrombocytopenia, prolonged bleeding times, and blunt head traumathrombocytopenia, prolonged bleeding times, and blunt head trauma• Patients on anticoagulants can develop SDH with minimal trauma Patients on anticoagulants can develop SDH with minimal trauma

and warrant a lowered threshold for obtaining a head CT scanand warrant a lowered threshold for obtaining a head CT scan

CF CONTN

• Other symptoms includes headaches,altered mental status,hemiparesis,gait disturbances and aphasia.

• Chronic subdural haematoma is a cause of reversible demential

EPIDURAL HAEMATOMA

• Accumulation of blood in the potential Accumulation of blood in the potential space between dura mater and bonespace between dura mater and bone

• Aetiology is principally traumatic;mild or Aetiology is principally traumatic;mild or severe.severe.

• It is usually from arterial bleeding into the It is usually from arterial bleeding into the epidura space.epidura space.

• When at the level of the spinal cord, it is When at the level of the spinal cord, it is mainly venousmainly venous

Involved blood vessels

• Temperoparietal locus-middle meningeal atery.(65%)

• Frontal locus-anterior ethmoidal artery(10%).

• Occipital locus-transverse or sigmoid sinuses(10%)

• Vertex locus-superior sagital sinus

EPIDEMIOLOGY 1) Occurs in 1-2% of head trauma in the USA. 2) Mortality is 5-43%. It is nil for patient who were not in coma.10% for obtuded

pxt and 20% for those who were deeply comatous preoperatively.• high mortality rates are asso with; -advance age, -intradural leision. -temporal location. -increased hematoma volume. -increased ICP -low GCS -Pupilary dilation -Rapid clinical progressionM0rtality is more in under 5yrs and those above 55yrs

EPID CONT

• 3) Age; commoner in teenagers and young adult who are less than 20yrs.

-less common in elderly bcos the dura is strongly attatched to the inner surface the skull.

aetiology

• Majorly associated with skull fracture in aduit unlike in children where there is calvarium plasticity.

• Fracture is asso with laceration of the above listed vessels.can also be venous especialy in 1/3 of cases esp in parieto occipital region or the posterior fossa.

CLINICAL FEATURE

• HISTORY;

• May or may not loose consciousness

• If consciousness is lost,pxt may cont to be unconscious.

• Lucid interval occurs in about 20-35% of the cases.

• Other symptoms includes severe headache,vommitting and seisures.

ON EXAMINATION

- Cushings response;raised BP,bradycardia and bradypnoea.

- Scalp lacerations may be present- Dilated slugish pupil at the ipsilateral or bilateral

may suggest compression of CN 3 from raised ICP.

- Hemiplegia contralateral to the injury may be present.

- Classical triad of herniation are coma,fixed and dilated pupil and decerebrate posture.

Diffrerences between the two

Epidural Hematoma subdural hematomaEpidural Hematoma subdural hematoma

– Potential space between -between the dura mater and the Potential space between -between the dura mater and the the dura and the inner table arachnoid materthe dura and the inner table arachnoid mater of the skullof the skull

– Can’t cross sutures -can cross suture linesCan’t cross sutures -can cross suture lines--

-Lenticular or biconvex shape -crescent shape-Lenticular or biconvex shape -crescent shape

– Lucid interval followed by -Gradualy increasing headache’then Lucid interval followed by -Gradualy increasing headache’then unconsciousness confusionloss or unconsciousnessunconsciousness confusionloss or unconsciousness

DIAGNOSTIC IMAGING

• NON CONTRAST CT SCAN.

-IN EPIDURAL HEMATOMA;shows both skull fracture and the hematoma in the epidural space.

-epidural hematoma appears as a appears as a hyperdensehyperdense biconvex or lenticular-shapedbiconvex or lenticular-shaped mass situated between the brain and the mass situated between the brain and the skull.skull.

Epidural haematoma

Epidural haematoma

CT FINDINGS

– Noncontrast head CT scanNoncontrast head CT scan (imaging study of choice (imaging study of choice for acute SDH) for acute SDH)

– The SDH appears as a The SDH appears as a hyperdensehyperdense (white) (white) crescentic crescentic massmass along the inner table of the skull, most along the inner table of the skull, most commonly over the cerebral convexity in the parietal commonly over the cerebral convexity in the parietal region. The second most common area is above the region. The second most common area is above the tentorium cerebellitentorium cerebelli

– Contrast-enhanced CT or MRI is widely Contrast-enhanced CT or MRI is widely recommended for imaging 48-72 hours after head recommended for imaging 48-72 hours after head injury because the lesion becomes isodense in the injury because the lesion becomes isodense in the subacute phasesubacute phase

– In the chronic phase, the lesion becomes hypodense In the chronic phase, the lesion becomes hypodense and is easy to appreciate on a noncontrast head CT and is easy to appreciate on a noncontrast head CT scanscan

Acute sub dural haematoma with midline shift

subacute sub dural hematoma

• MRI is superior for demonstrating the size is superior for demonstrating the size of an acute SDH and its effect on the of an acute SDH and its effect on the brain, however noncontrast head CT is the brain, however noncontrast head CT is the primary means of making a diagnosis and primary means of making a diagnosis and suffice for immediate management suffice for immediate management purposespurposes

TREATMENT

• MEDICAL;

- Anti imflammatory such as use of steroid to modulate imflammation at the post traumatic period.

- Seisure prophylasis

- Medication to lower intracranial pressure eg mannitol,glycerol and hypertonic saline.

• SUGERY;most for epidural hematoma -indications;1) Hematoma of greater than 1cm in its thickest diameter.2) Deterioriation in brain function.3) Severe headache.4) Midline shift of greater than or equal to 5mm.5) In a comatose pxts who do not met the above criterial and have; -GCS score decrease by 2 or more pts from initial value at

presentation. - pxts who have dilated and fixed pupil -ICP greater than 20mmHg this surgery simply implies making a burr hole on the afted area of

the skull.

PROGNOSIS

• Prognosis is good for epidura hematoma with hx of lucid interval,otherwise,a marker of poor prognosis.

• For subdural hematoma,prognosis is good for the chronic form but poor for the acute subdural hematoma.acute subdural hematoma has a high mortality rate even more than the epidural hematoma.

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