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Epidural Hematoma (Extradural Haematoma)

by Carlo Raj, MD
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    00:01 Let’s begin by looking at epidural.

    00:03 I’m going to let you take a look at the CT.

    00:05 A beautiful CT of a biconvex structure.

    00:10 Obviously, that huge structure over -- Well, that the left side of the brain.

    00:14 And on the left side of the skull, you will then notice what? It looks like the lens of the eye.

    00:20 But obviously, it is not the lens.

    00:22 It is actually accumulation of blood.

    00:23 Hence, this is called hematoma.

    00:25 This is epidural.

    00:28 So what happened? It’s the fact that upon injury to the brain, you have the middle meningeal artery, which then ruptured, resulting in accumulation of blood.

    00:36 Hema-, -toma.

    00:39 What does lucid interval mean? This is sad.

    00:42 It really is sad.

    00:44 The child gets hit by a ball and the father rushes out onto the field and says, “Son, son, son, are you okay?” The child gets up and says, “Yeah, daddy. I’m great! Let’s go get some ice cream.

    00:53 Lucid.

    00:55 Clear.

    00:56 What happens next? They go get some Italian ice.

    01:00 Next time the child falls, the child never gets back up.

    01:04 The child is dead.

    01:06 This is epidural hematoma.

    01:08 This is called walk and die syndrome.

    01:10 Literally, everything’s lucid.

    01:13 And then, next time the child or the patient falls, dead.

    01:17 Now, you’d think that you get hit by whatever, trauma, and if there’s such trauma that’s been sustained resulting in epidural hematoma, do you not think that this hematoma is then compressing upon the brain? Of course it is.

    01:32 So what do you think happens to intracranial pressure? It is going to increase.

    01:36 What else may occur? Well, depending as to the site of the hematoma, there’s every possibility that you might then be pushing the brain tissue to the wrong spot.

    01:47 Remember that description? “Wrong spot.” Herniation.

    01:52 And depending as to where, what if it was by the temporal lobe, which could occur? And then you have the uncus, which is then pressing upon the brainstem.

    02:01 What is this called? Transtentorial herniation.

    02:04 You see as to how you must be able to put everything together.

    02:08 And it’s a very possible that all of this is occurring at the same time.

    02:12 Why wouldn’t it? Deficit: Where do you find issues? Contralateral hemiparesis.

    02:19 Ipsilateral pupillary dilation.

    02:21 The words, we’re talking about your cranial type of issues.

    02:25 Contralateral hemiparesis, motor Ipsilateral, cranial nerve, pupillary dilation.

    02:31 Why do think? Why do think this is occurring? Well, in this picture actually, the epidural hematoma is then causing herniation of your temporal lobe or the uncus against the third cranial nerve, resulting in the loss of your parasympathetic pupillary constriction.

    02:50 And therefore, resulting in ipsilateral pupillary dilation.

    02:54 Don’t memorize that.

    02:56 You already know this, but I’m expecting you to go through the entire story.

    03:00 Integration.

    03:02 Integration.

    03:05 Let’s do subdural hematoma.

    03:07 First, with subdural hematoma, this would be the most common of the hematomas, okay? And here, in this case, maybe the child is shaken unbeknownst to the father, okay? So happy, shaken the baby.

    03:22 Or maybe you have a patient that fell down the stairs.

    03:25 Or as we get older, what happens to the size of the brain? It gets smaller.

    03:31 Just call it senile atrophy.

    03:33 As the brain gets smaller and smaller and smaller, Or shaking the baby, not good, huh? You’re shaking the baby or the brain gets smaller, what happens? You’re going to pull on what? Bridging veins.

    03:48 You pull the bridging veins enough, what happens? Rupture.

    03:51 Now, what do you end up resulting in please? A subdural hematoma.

    03:56 I need you to be careful with this picture here.

    03:58 What I want you to focus upon is where that arrow you see there, that is not a biconvex structure, okay? In fact, with the subdural hematoma, what you want to do here I need you to go back and refer to epidural hematoma, where you find that huge biconvex, lens-like accumulation of blood versus here, it’s that entire structure over -- that’s the left side of the brain and it is where you’re looking at the entire area, which more or less has a concave type of appearance.

    04:32 Here, brain atrophy as we get older, ripping and tearing of the bridging vein and coagulopathy.

    04:39 It all may result in what’s known as subdural type of hematoma.

    04:43 It’s the most common type of traumatic brain injury.

    04:46 It can present subacutely or chronically.

    04:50 And to say that here, you don’t have that lucid interval that we talked about quite dramatically in that child in epidural hematoma.

    05:02 Fast facts of hematoma or summary.

    05:04 Epidural, trauma.

    05:06 Almost always with focal deficit.

    05:08 Contralateral hemiparesis.

    05:11 Ipsilateral type of pupillary issues, always requiring drainage.

    05:16 You need to get in there and you do burr hole to decompress because the pressure is so incredibly high.

    05:24 Subdural.

    05:25 Alcoholics, elderly, why? The brain is getting smaller.

    05:29 What’s it doing? It is pulling upon the bridging veins.

    05:33 Acceleration-deceleration injury.

    05:35 We’ve seen this twice.

    05:38 The first time we saw it, acceleration-deceleration, I told you about rollercoaster rides or accidents causing diffuse axonal injury or twisting and swelling of the axon, or you shake a baby, and what may happen? Tearing of the bridging veins.

    05:54 Both could occur at the same time, you can’t say that it’s just one.

    05:59 Subtle signs, possible.

    06:01 Drainage, not always necessary.

    06:04 Why? Because the amount of blood that’s accumulating here is not going to be as extensive as what we saw with epidural.

    06:12 This is a beautiful little concept picture here so that you can quickly, quickly compare and contrast epidural and subdural.


    About the Lecture

    The lecture Epidural Hematoma (Extradural Haematoma) by Carlo Raj, MD is from the course Trauma. It contains the following chapters:

    • Epidural Hematoma
    • Subdural Hematoma
    • Hematoma: Summary

    Included Quiz Questions

    1. Patient presents with ipsilateral pupillary dilatation and contralateral hemiparesis.
    2. The presence of permanent memory loss.
    3. Occurs due to tear of bridging veins.
    4. Most common intracerebral lesion in traumatic brain injury.
    5. The anterior cerebral artery is the most commonly affected artery.
    1. Elder alcoholics are at risk of developing subdural hematoma.
    2. Lucid interval is associated with subdural hematoma.
    3. Drainage of the hematoma is not often required for epidural hematoma.
    4. A biconcave lens shaped collection of blood is usually seen on MRI in patients with an epidural hematoma.
    5. Epidural hematoma can be of chronic onset.
    1. Right eye pupillary dilatation
    2. Right hemiparesis
    3. Right eye pupillary constriction
    4. Left eye pupillary constriction
    5. Left eye pupillary dilatation
    1. Uncal herniation due to epidural hematoma
    2. Subfalcine herniation due to epidural hematoma
    3. Central herniation due to subdural hematoma
    4. Subfalcine herniation due to subdural hematoma

    Author of lecture Epidural Hematoma (Extradural Haematoma)

     Carlo Raj, MD

    Carlo Raj, MD


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    Well described but omission of Chronic Subdural haematoma
    By Hamed S. on 21. March 2017 for Epidural Hematoma (Extradural Haematoma)

    Good talk on the topic but could be improved by discussion management and when you may consider surgical evacuation vs watch and wait. Also no mention of chronic subdural haematoma.

     
    Nicely done
    By Della R. on 08. February 2017 for Epidural Hematoma (Extradural Haematoma)

    I really liked this lecture and learned a lot. He broke it down and explained things simply without being condescending, and I found his examples to be easy to remember.