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 right
side of the brain.
00:14
And on the right 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
First, with subdural hematoma,
this would be the most common
of the hematomas. Okay.
03:00
And here in this case,
maybe the child was shaking
unbeknownst to the father. Okay.
03:07
So happy shaking the baby.
03:08
Or maybe you have a patient
that fell down the stairs,
Or as we get older,
what happens the size of the brain?
Gets smaller.
Just go see now atrophy.
03:20
As the brain gets
smaller, and smaller, smaller
or shaking the baby,
not good, huh.
03:26
You're shaking the baby
or the brain gets smaller,
what happens?
You're going to pull, on what?
Bridging veins.
03:34
You pull the bridging veins enough,
what happens? Rupture.
03:37
Now, what do we end up
resulting in, please?
a subdural hematoma.
03:42
I need you to be careful
with this picture here.
03:45
What I want you to focus upon is
where that arrow, you see there,
that is not a biconvex structure.
Okay.
03:54
In fact, with the subdural hematoma,
which you want to do here,
I need you to go back and
refer to epidural hematoma,
Will 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.
04:10
And it is where you're
looking at the entire area,
which more or less has a
concave type of appearance.
04:19
Here brain atrophy
as we get older,
ripping and tearing the
bridging vein, and coagulopathy.
04:26
It all may result in what's known as
subdural type of hematoma.
04:30
It's the most common can present
sub-acutely or chronically.
04:34
Meaning to say that here,
you don't have that lucid interval
that we talked about
quite dramatically in that child
in epidural hematoma.
04:46
Fast facts of hematoma or
summary epidural trauma:
Almost always with focal deficit,
contralateral hemiparesis
ipsilateral type of
pupillary issues.
04:58
Most requiring drainage.
05:00
You need to get in there, I need to
bore a hole to decompress
because the pressure
is so incredibly high.
05:07
Subdural:
Alcoholics, elderly, why?
The brain is getting smaller.
05:13
What's it doing?
It is pulling upon
the bridging vein.
05:16
Acceleration-deceleration injury.
05:19
We've seen this twice.
05:22
The first time we saw it,
acceleration deceleration.
05:25
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 now the bridging veins.
05:37
Both could occur at the same time.
Can't say that it's just one.
05:43
Subtle signs possible.
05:45
Drainage not always necessary. Why?
Because the amount of blood
that's accumulating here
is not going to be as extensive
as what we saw with epidural.