Head Trauma:
Cerebral Contusions and
Epidural Hematomas

• subarachnoid hemorrhage (SAH)
• subdural hemorrhage (SDH)
• epidural hemorrhage (EDH)
• intraparenchymal hemorrhage (IPH)
• diffuse axonal injury (DAI)

Approximately 1.4 million people per year suffer traumatic brain injury (TBI). Of these patients, approximately 1.1 million are treated and released, 240,000 are hospitalized, and 50,000 die. TBI has a bimodal age distribution with the greatest risk in 0–4 and 15- to 19-year-olds. Males have 1.5 times the risk of females.

Raccoon’s eyes (periorbital ecchymosis), Battle’s sign (postauricular ecchymosis), and otorrhea/rhinorrhea suggest a basilar skull fracture.

Assessment by Glasgow Coma Scale, 15 points, based on motor (6 points), best verbalization (5 points), and best eye opening (4 points). Other aspects include cranial nerve exam (pupil reactivity to light, visual fields/acuity, facial asymmetry), fundascopic exam for papilledema, and reflexes.

CT scan indicated if post-traumatic GCS ≤14, focal deficit, amnesia for the injury, signs of basilar skull fracture. MRI not recommended in trauma since limited availability, slower image acquisition time and increased cost for no greater information.

Cerebral Contusion: Contusion can occur from an external force causing the skull/skull fragments to strike the brain (sledge hammer) or through deceleration injury, where the brain continues to move toward the rapidly decelerating skull (ie, MVA).

“Coup” lesions are ipsilateral to the impact site and can be associated with adjacent skull fractures. “Contrecoup” lesions are opposite the coup lesion due to the rebounding brain striking the inner table of the skull.

Contusions:
50% temporal lobes,
30% frontal lobes,
25% parasaggital
but 90% with multiple or bilateral locations.

On CT scans, contusions are patchy, hyperdense lesions with a hypodense background. Often associated with intraparenchymal hemorrhage.

Epidural Hemorrhage: Blood collects in the space between the dura and inner table of the skull. It is seen in 1% of all head trauma admissions and in 5–15% of patients with fatal head injuries. Ninety percent are due to arterial bleeding following a fracture at the middle meningeal artery groove, and 10% are due to venous bleeding, usually associated with violation of a venous sinus by an occipital, parietal, or sphenoid wing fracture.

EDHs are usually located at the site of impact over the lateral convexity of a cerebral hemisphere (70%), frontal (5–10%), parieto-occipital (5–10%), or posterior fossa locations (5–10%). On CT scan, EDHs usually appear as a hyperdense, biconvex (lenticular) mass adjacent to the inner table of the skull.

1) a brief post-traumatic loss of consciousness (LOC) followed by
2) a lucid interval, of varying duration,
3) proceeding to obtundation, contralateral hemiparesis, and ipsilateral pupillary dilatation.

Surgical evacuation should be performed if >30 cm2, comatose, or anisocoria.

FIGURE 1

Source: Mattox KL, Moore EE, Feliciano DV: Trauma, 7th Edition: www.accesspharmacy.com