Traumatic Brain Injury

James G. Smirniotopoulos, M.D.

Professor of Radiology, Neurology, and Biomedical Informatics
Chair, Department of Radiology and Radiological Sciences
Uniformed Services University
Bethesda, MD
http://rad.usuhs.mil
http://rad.usuhs.mil
USUHS Smirniotopoulos - 2009

TBI Educational Objectives

Who needs brain imaging?
What type of imaging is needed?
Intraaxial Lesions Primary Lesions
Contusion, Shearing Injury
Immediate Neurological Effects

Extraaxial Lesions Secondary Lesions

Epidural, Subdural, Subarachnoid
Delayed Neurological Effects
USUHS Smirniotopoulos - 2009

Membrane Hematoma
Epidural

Subdural

Acute
Biconvex
Unilateral
Skull fracture
Limited by sutures

Acute to Chronic
Concave layer
Bilateral
Fracture +/+/Cross sutures

USUHS Smirniotopoulos - 2009

Membrane Hematoma
Epidural

Subdural

USUHS Smirniotopoulos - 2009

CENTRIPETAL APPROACH
(outside to inside)

Scalp
Calvarium
Epidural
Subdural
Subarachnoid
Intra-parenchymal
Intra-ventricular
USUHS Smirniotopoulos - 2009

Traumatic Hemorrhage:
Subgaleal
Cephalohematoma
Subperiosteal Outer Table
Epidural (Extradural)
Subperiosteal Inner Table
Subdural
Epi-arachnoid
Subarachnoid
Parenchymal Hemorrhage
Intra-ventricular
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2 y.o. with dilated pupil

Midline Herniation: Subfalcial and Downward Transtentorial

USUHS Smirniotopoulos - 2009

CNS TRAUMA EPIDURAL

HEMATOMA
Young Men (20-40's)
Head Trauma frequent
Also, dura (periosteum) more adherent in
older people

Acute presentation
Skull fracture (90%)
Bi-convex, hyperdense- limited by sutures

USUHS Smirniotopoulos - 2009

EPIDURAL HEMATOMA
Source of Bleeding
MENINGEAL VESSELS
Arterial (high pressure)
Venous (low pressure)

DURAL SINUS
High flow, low pressure

OTHER
Diploic veins (Fx)
Marrow sinusoids

USUHS Smirniotopoulos - 2009

EPIDURAL HEMATOMA
Significant trauma
Fracture & concussion (l.o.c.)

Lucid Interval
pt Wakes Up
40% pts.
Delayed neurologic Sx (hrs. Later)
Herniation, coma and death
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Epidural Hematoma: Lens Shape

Scalp & Skull

Dura & Arachnoid
Pia and Brain
Ventricle and CSF
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Epidural Hematoma

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EPIDURAL HEMATOMA
Trauma -> fracture & concussion
Tearing/stripping of both layers
from inner table
Laceration of outer periosteal
layer
Laceration of meningeal vessels
Inner (meningeal dura) intact
Blood between naked bone and
dura
NORMAL arterial pressure
continues to dissect
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Epidural Hematoma

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Epidural Hematoma

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Brain Herniation Syndromes

f

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Brain Herniation Syndromes

f
C

Blown Pupil:
Oculomotor
nerve
T
ipsilateral to the
mass lesion

USUHS Smirniotopoulos - 2009

Brain Herniation Syndromes

f
C

t
Kernohans Notch:
Cerebral peduncle
contralateral to the
mass lesion

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USUHS Smirniotopoulos - 2009

Epidural Hematoma
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Epidural Hematoma

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Epidural Hematoma

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Epidural Hematoma

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Epidural Hematoma - Treatment

Craniotomy
Drain clot
Repair the Artery!

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Small EDH Conservative Tx

Smile of the Quadrigeminal Cistern

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Everyone deserves a smile!

Quadrigeminal plate cistern
Corpora quadrigemini
2 pairs of colliculi
Superior
Inferior
Perimesencephalic cistern
Ambient cistern

Courtesy Frank Brennan, CDR, USN (ret.)

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Progressive EDH

10 AM

8 PM
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SUBPERIOSTEAL HEMATOMA
CEPHALOHEMATOMA
(Birth trauma)
(outer table, subsub-periosteal)

EPIDURAL HEMATOMA
(Inner table, "sub"sub-periosteal")

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Cephalohematoma
Birth Trauma

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Cephalohematoma - Calcified

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Membrane Hematoma
Epidural

Subdural

Acute
Biconvex
Unilateral
Skull fracture
Limited by sutures

Acute to Chronic
Concave layer
Bilateral
Fracture +/+/Cross sutures

USUHS Smirniotopoulos - 2009

Membrane Hematoma
Epidural

Subdural

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Subdural Hematoma: Concave

Splits Arachnoid from the Dura

Scalp & Skull

Dura
Arachnoid
Pia and Brain
Ventricle and CSF
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