Syndromes of Extracranial Hematomas

SUBDURAL HEMATOMA

Subdural hematomas can be acute, subacute, or chronic. Acute subdural hematomas occur within 24 to 48 hours

Figure 22-10 A, Nonenhanced axial CT shows subarachnoid hemorrhage in the left sylvian fissure and adjacent intraparenchymal hemorrhage in the temporaB, AP left common carotid arteriogram shows a lobulated left middle cerebral artery trifurcation aneurysm. (Courtesy of Karen S. Caldemeyer, M.D.)

after an injury. They can be secondary to arterial or venous bleeding into the subdural space. The usual cause is a blow to the head by falling or being struck. The neurological symptoms depend on the area of the brain involved. There can be rapidly evolving focal signs that produce aphasia, memory disturbances, hemiparesis and hemisensory deficits, and altered consciousness. Signs of increased intracranial pressure may be present. Diagnosis is made by CT scan. Chronic subdural hematomas present at weeks to months after the injury. Patients presenting with this type of hematoma include the elderly with cerebral atrophy, patients with epilepsy, patients with alcohol dependence, and persons with coagulation defects. These hematomas may become quite large without producing symptoms. The neurological findings may vary from no or minimal deficit, to focal neurological symptoms that may be transient or progressive. In some, there may be florid symptoms of increased intracranial pressure with headaches, nausea, vomiting, and papilledema. There may be accompanying seizures. Diagnosis of a chronic subdural hematoma may require a CT scan without and with contrast due to the possibility of isodensity of the hematoma with the surrounding brain at some point in its evolution (see Chapter.23 ).

EPIDURAL HEMATOMA

The most important type of epidural hematoma to be acquainted with is the acute epidural hematoma usually due to arterial bleeding from damage to the middle meningeal artery. Patients with this condition may have a history of trauma with a lucid interval followed by rapid development of focal neurological signs and deterioration in consciousness. The deterioration is due to high-pressure arterial bleeding with increased intracranial pressure. Like subdural hematomas, epidural hematomas can present subacutely or chronically, with the same time frame and similar symptoms. A CT scan classically shows a lens-shaped density that does not follow sulcal margins. Skull roentgenograms may show an associated skull fracture. Prompt diagnosis is important because a craniotomy with evacuation of the clot is often needed.

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