TRAUMA 14.1 Epidural Hematoma Patient 1: A 35-year-old woman was hit in the head during a fight. Though the patient was initially unconscious, she soon seemed to be fine and was able to talk and act normally. She returned home and about 3 hours later was taken to a local hospital after complaining of a headache. She was transferred from there by ambulance in critical condition and was admitted about 7 hours after the fall. She died the next day. Patient 2: A 55-year-old man arrived unconscious after a car accident. Patient 3: A 23-year-old man arrived unconscious after he was hit in the head with a blunt object. Images 14.1A and 14.1B: Axial and coronal CT images demonstrate a large, “lens-shaped” left epidural hematoma with midline shift and subfalcine herniation visible on the coronal image. Image 14.1C: Axial CT image demonstrates a large, right epidural hematoma with midline shift and hemorrhagic contusions in the left frontal lobe. Image 14.1D: Axial CT image demonstrates a left epidural hematoma with a skull fracture. Image 14.1E: Catheter angiogram demonstrating the location of the middle meningeal artery. 1. Araujo JL, Aguiar Udo P, Todeschini AB, Saade N, Veiga JC. Epidemiological analysis of 210 cases of surgically treated traumatic extradural hematoma. Rev Col Bras Cir. July–August 2012;39(4):268–271. 2. Zink BJ. Traumatic brain injury outcome: concepts for emergency care. Ann Emerg Med. March 2001;37(3):318–332. 3. Graham DI, Gennareli TA. Pathology of brain damage after head injury. In: Cooper P, Golfinos G, eds. Head Injury. 4th ed. New York, NY: Morgan Hill; 2000:133–154. 14.2 Subdural Hematoma An 80-year-old man presented to the hospital after falling down at home. He was discharged, but returned 21 days later with confusion and headaches. Image 14.2A: Axial CT image demonstrates a very small right subdural hematoma (red arrow). Image 14.2B: Axial CT image, taken 3 days later, demonstrates marked expansion of the hematoma. It is crescent-shaped. Image 14.2C: Axial CT image, taken 21 days later, demonstrates the evolution of the hematoma. As there is no longer acute blood, the appearance is isodense to brain parenchyma. Image 14.2D: Gross pathology of a subdural hematoma. Image 14.2E: Axial CT scan demonstrates large right subdural hematoma with both acute blood and chronic fluid collection. There is a large amount of mass effect with midline shift. Image 14.2F: Axial CT scan, taken after neurosurgical evacuation reveals a decrease in the mass effect and pneumocephalus. 1. Iliescu IA. Current diagnosis and treatment of chronic subdural haematomas. J Med Life. July–September 2015;8(3):278–284. 2. Iliescu IA, Constantinescu AI. Clinical evolutional aspects of chronic subdural haematomas—literature review. J Med Life. 2015;8:26–33. 3. Adhiyaman V, Asghar M, Ganeshram KN, Bhowmick BK. Chronic subdural haematoma in the elderly. Postgrad Med J. February 2002;78(916):71–75. Unless otherwise stated, all pathology images in this chapter are from the website http://medicine.stonybrookmedicine.edu/pathology/neuropathology and are reproduced with permission of the author, Roberta J. Seidman, MD, Associate Professor. Unauthorized reproduction is prohibited. 14.3 Hemorrhagic Contusions A 43-year-old man arrived unconscious after a motor vehicle accident. Images 14.3A and 14.3B: Axial CT images demonstrate hemorrhagic contusions in the temporal and frontal lobes bilaterally. Image 14.3C: Axial fluid-attenuated inversion recovery (FLAIR) image demonstrates hemorrhagic contusions in the frontal lobes. Image 14.3D: Hemorrhagic contusions are visible frontal lobes on gross pathology (red arrows). 1. Torbic H, Forni AA, Anger KE, Degrado JR, Greenwood BC. Use of antiepileptics for seizure prophylaxis after traumatic brain injury. Am J Health Syst Pharm. May 2013;70(9):759–766. Unless otherwise stated, all pathology images in this chapter are from the website http://medicine.stonybrookmedicine.edu/pathology/neuropathology and are reproduced with permission of the author, Roberta J. Seidman, MD, Associate Professor. Unauthorized reproduction is prohibited. 14.4 Diffuse Axonal Injury A 35-year-old woman developed significant cognitive impairment after a motor vehicle accident. Images 14.4A–14.4C: Axial-diffusion-weighted images demonstrate areas of restricted diffusion, with several lesions in the corpus callosum and the grey–white junction, and midbrain characteristic of diffuse axonal injury. Images 14.4D and 14.4E: Axial gradient echo images demonstrate foci of susceptibility secondary to prior microhemorrhages. The red arrows point to microhemorrhage in the corpus callosum, a typical location for such hemorrhages. Image 14.4F: Axial CT image demonstrates intraparenchymal hemorrhage in the right frontal lobe. Images 14.4G and 14.4H: Axial gradient echo images demonstrate foci of susceptibility in the corpus callous, brainstem, and cerebellum in a patient with severe head trauma. Soft tissue swelling is evident over the right calvarium. Images 14.4I and 14.4J: Axial FLAIR and CT image demonstrate acute blood products (red arrow) in the cerebellum and edema throughout the cerebellum and pons. 14.5 Gunshot Wound A 45-year-old woman developed personality changes after being shot in the head. A 25-year-old woman developed paraplegia after being shot in the back. Images 14.5A and 14.5B: Axial CT scans demonstrate encephalomalacia in the frontal lobes bilaterally with residual bone fragments in the right frontal lobe in a patient who suffered a gunshot wound. Image 14.5C: Gross pathology of gunshot wounds in two different patients (image credit Roberta J. Seidman, MD). Images 14.5D and 14.5E: Sagittal and axial CT scans of the lumbar spine demonstrate a bullet in the upper lumbar spine, at the level of the conus medullaris. 1. Martins RS, Siqueira MG, Santos MT, Zanon-Collange N, Moraes OJ. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. August 2003;60(2):98–104. 2. Hofbauer M, Kdolsky R, Figl M, et al. Predictive factors influencing the outcome after gunshot injuries to the head-a retrospective cohort study. J Trauma. October 2010;69(4):770–775. 3. Kim TW, Lee JK, Moon KS, et al. Penetrating gunshot injuries to the brain. J Trauma. June 2007;62(6):1446–1451.
Case History
Diagnosis: Epidural Hematoma
Introduction
Epidural hematomas occur when there is damage to the middle meningeal artery, a branch of the external carotid artery found in the epidural space.
Clinical Presentation
Patients present after head trauma or neurosurgical procedures. The degree of trauma required to produce an epidural hematoma causes a concussion severe enough to render the patient unconscious. After the patient awakens from this initial blow, there is a lucid period of several hours, after which there may be rapid neurological deterioration due to expansion of the hematoma.
The rapidity of the decline occurs as the expanding hematoma is from an arterial source, in contrast to subdural hematomas (SDHs), which originate from the lower pressure venous system. Additionally, the dura is firmly adherent to the skull at suture lines. As the hematoma expands, it cannot cross these suture lines, causing compression of the underlying brain.
Radiographic Appearance and Diagnosis
CTs are the imaging modality of choice for patients with head trauma. Epidural hematomas have a lens-shaped appearance. Depending on the size and location of the hematoma, there may be mass effect and brain herniation.
Treatment
The treatment for expanding epidural hematomas is immediate neurosurgical evacuation. Without treatment, large bleeds may be fatal in several hours.
References
Case History
Diagnosis: Subdural Hematoma
Introduction
SDHs are due to tearing of the bridging veins, which course through the dura and drain the underlying brain into the dural sinuses. Movement of the brain within the skull can tear the bridging veins and cause bleeding into the potential space between the dura and arachnoid layer.
Clinical Presentation
SDH presents with a headache, cognitive dysfunction, or progressive focal neurological deficits. Since the bleeding is under venous pressure, the hematoma can present quite slowly and grow to a large size before patients develop symptoms.
Elderly patients and alcoholics are especially vulnerable to SDHs as brain atrophy leads to stretching of the bridging veins. In this population, they are sometimes found incidentally, and large SDHs can accumulate with minor trauma or even without a known history of trauma.
Radiographic Appearance and Diagnosis
CT is the imaging modality of choice to investigate SDHs. Acute SDHs present with a crescent-shaped hyperdensity representing acute blood products. There may be significant mass effect and compression of the underlying brain depending on its size. Over the next few weeks to months, the blood is replaced by cerebrospinal fluid (CSF), and the fluid collection has a density similar to CSF. Patients may suffer recurrent bleeding, with both chronic and acute blood products.
Treatment
Small SDHs may be monitored clinically and radiographically. Surgical evacuation is required to treat larger, symptomatic SDHs.
References
Case History
Diagnosis: Hemorrhagic Contusions
Introduction
Trauma is one of the leading causes of intraparenchymal hemorrhage and cerebral contusion. The orbitofrontal cortex and anterior temporal lobes are especially vulnerable in acceleration–deceleration injuries, when the brain crashes into and is lacerated by bone at the base of the skull. The surface of the brain is most commonly affected.
Contusions that occur directly below the site of impact are referred to as coup injuries, while those that are on the opposite side of the skull are called contrecoup injuries. The impact accelerates first the skull (at this point the brain immediately subjacent to the point of impact may be damaged—so-called coup injury) and then its content away from it. As the skull stops, the brain then impacts on the internal surface of the skull, resulting in damage, called the contrecoup injury. Often, the contrecoup injury is larger than the coup injury.
Clinical Presentation
Patients with severe hemorrhagic contusions are always rendered unconscious by the trauma. Those with damage to the orbitofrontal cortex are frequently disinhibited and demonstrate poor executive function as a result of their injuries. Patients with damage to the temporal lobes have difficulty with memory consolidation and develop seizures as a result. Aphasia is commonly seen with left-sided lesions.
Radiographic Appearance and Diagnosis
CT scans are used initially in head trauma patients to visualize the blood. Their sensitivity approaches 100% in detected hemorrhagic contusions, though blood may appear isodense in patients with severe anemia. MRI is not often performed in such patients, but is more sensitive for contusions.
Treatment
Treatment is supportive. There is evidence that prophylactic anticonvulsants decrease the rate of seizures in the short term, but not in the long term.
Reference
Case History
Diagnosis: Diffuse Axonal Injury
Introduction
Diffuse axonal injury (DAI) occurs due to shear forces in patients with head injuries that involve angular rotation and acceleration–deceleration injuries, most commonly motor vehicle accidents.
In such injuries, the cerebral hemispheres rotate around the upper brainstem. The tentorium cerebelli prevents movement of the cerebellum, and swinging motion of the cerebrum is prevented by the falx cerebri. As a result, axons are stretched, though not torn.
Clinical Presentation
Patients with injuries severe enough to produce DAI uniformly suffer immediate loss of consciousness. Many remain comatose or in a persistent vegetative state. The extent of the injury might not be appreciated until patients fail to improve as expected. Those who regain consciousness are left with severe cognitive deficits.
There is no treatment beyond supportive care.
Radiographic Appearance and Diagnosis
The lesions are typically oblong and located at the grey–white junction. They may also be seen in the corpus callosum and, in severe cases, the brainstem.
The initial imaging modality in trauma patients is a noncontrast CT. However, only large hemorrhages will be seen, and most DAIs are too small to be seen on CT. MRI is much more sensitive, and often multiple small microhemorrhages can be seen best on gradient echo imaging. Diffusion-weighted imaging is also very sensitive for revealing the DAI.
A grading system exists for DAI as follows:
Grade I: Involves the grey–white matter junction, primarily of the frontal and temporal lobes.
Grade II: Involves the corpus callosum, most commonly the splenium and posterior body.
Grade III: Involves the brainstem or cerebellum.
Treatment
Treatment is supportive.
Case History
Diagnosis: Gunshot Wound
Introduction
Trauma remains the leading cause of neurological disability in young people, and unfortunately, gunshot wounds are common in the United States. There are approximately 130,000 people shot annually in the United States, and over 30,000 deaths.
Approximately 62% of gun deaths are suicides. With homicides, African American men between the ages of 15 and 40 are by far most likely to be victims.
Clinical Presentation
The injury suffered by the patient depends on the type of weapon used, the bullet used, and the location of the injury. The brain and spinal cord are particularly vulnerable to gunshot wounds. Bullets fired from rifles have the greatest velocity, and encased bullets that rotate around their short axes or deform upon impact cause more local tissue damage. Not surprisingly, many gunshot wounds to the head are instantly fatal.
Radiographic Appearance and Diagnosis
CT is the modality of choice when imaging gunshot victims, though most bullets are safe to use with MRIs.
Imaging is useful in gunshot injuries to determine the course of the bullet and assess for hemorrhage and air. The final location of the bullet may be quite distant from its entry point as internal structures alter its course. It the bullet is not found, the exit wound must be located.
Treatment
In studies by Moraes et al and Vècsei V. et al, patients with lower admission scores on the Glasgow Coma Scale (GCS), a unilateral dilated pupil or medium fixed pupil, a transventricular or bihemispheric bullet trajectory, intraventricular hemorrhage, and bilobar or multilobar wounds were strong factors in predicting morbidity and mortality. In such patients, surgical treatment was only suggested in the presence of a hematoma with mass effect and the outcome is poor. In contrast, patients with a GCS score above 8, normal pupils, and injury to a single brain lobe may benefit from aggressive treatment.
References
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