Traumatic Intracranial

Hemorrhage
Amber Bucker, Henriette Westerlaan, Aryan
Mazuri, Maarten Uyttenboogaart and Robin
Smithuis
University Medical Center Groningen and Alrijne Hospital in
Leiderdorp, the Netherlands

Any type of bleeding inside the skull or brain is a medical

emergency.
The most common causes of hemorrhage are trauma,
haemorrhagic stroke and subarachnoid haemorrhage due
to a ruptured aneurysm.
Complications are increased intracerebral pressure as a re-
sult of the hemorrhage itself, surrounding edema or hydro-
cephalus due to obstruction of CSF.

In this article we will discuss traumatic hemorrhages.

Non-traumatic hemorrhages are discussed here.

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Localization of hemorrhage
Anatomy of the meninges
Traumatic hemorrhage
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
DiPuse Axonal Injury
Duret hemorrhage

Localization of hemorrhage

Extra-axial hemorrhage - Intracranial extracerebral

Subarachnoid hemorrhage is acute bleeding under
the arachnoid. Most commonly seen in rupture of an
aneurysm or as a result of trauma.
Subdural hematoma is a bleeding between the inner
layer of the dura mater and the arachnoid mater of
the meninges. It usually results from traumatic tearing
of the bridging veins that cross the subdural space in
patients with anticoagulantia therapy.
Epidural hematoma is bleeding in the virtual space
between the dura mater and the skull. Seen in fracture
of the temporal bone with rupture of the middle
meningeal artery.
Intra-axial hemorrhage - intracerebral
Cerebral hemorrhagic contusion small post-
traumatic hemorrhages located near the skull in the
area of the coupe and contre-coup, most commonly
frontobasal and anterior in the temporal lobes.
Sometimes in combination with a subdural hematoma
or subarachnoid hemorrhage.
DiCuse axonal injury (DAI). DiPuse injury at the level
of the gray-white matter junction seen in high velocity
injuries. CT has low sensitivity. Better seen on MRI.

Anatomy of the meninges

Meninges are the three membranes that envelop

the brain and spinal cord: the dura mater, the arachnoid
mater, and the pia mater.
Cerebrospinal Uuid is located in the subarachnoid space be-
tween the arachnoid mater and the pia mater.

Dura mater is the outermost meningeal layer that covers

the brain and spinal cord.
It consists of two layers: the inner meningeal layer and the
outer periosteal layer.

Arachnoid is a layer with delicate Vbres which extend down

through the subarachnoid space and attach to the pia
mater.
Arachnoid granulations - also called Pacchionian granula-
tions - are small protrusions of the arachnoid mater
through the outer membrane of the dura mater into
the dural venous sinuses of the brain, and allow cere-
brospinal Uuid to exit the subarachnoid space and enter
the blood stream.

Pia mater is the innermost layer covering the brain.

The pia mater allows blood vessels to pass through and
nourish the brain.
The arachnoid and pia mater together are sometimes called
the leptomeninges.

Traumatic hemorrhage

Epidural hematoma

An epidural hematoma is a bleeding that occurs between

the dura and the skull.
It is mostly seen in children who have a head injury with
fracture of the temporal bone resulting in tearing of the
middle meningeal artery.

In theory an epidural hematoma can cross the midline be-

cause it is located between the dura and the skull.
However since the dura is tightly adherent to the adjacent
skull near suture lines, an epidural hematoma usual-
ly does not cross suture lines.

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A 11 year-old boy fell oP his bike probably due to an epilep-

tic convulsion.
He hit the curb with his head.
His level of consciousness was lowered and his EMV score
was 2-4-3.
He presented with bradycardia, hypertension, abnormal
posturing and a non-reactive dilated right pupil, which are
all signs of brain herniation and raised intracranial pres-
sure.

CT Vndings
Lentiform temporoparietal hemorrhage is shown
The hemorrhage is limited in its extent by the cranial
sutures.
Associated skull fracture
Swirl sign indicating extravasation of blood into the
hematoma. It represents unclotted fresh blood, which
is of lower attenuation than the clotted blood which
surrounds it.
Horizontal subfalcine and uncal herniation.
A craniotomy was performed subsequently and the torn
middle meningeal artery was coagulated.

Clinical outcome was good.

Subdural hematoma

A subdural hematoma is a collection of blood between the

inner layer of the dura and the arachnoid.
It cannot cross the midline, but can be located near dural
folds like the falx or the tentorium.

It usually results from rupture of the cortical bridging veins.

It usually occurs in head trauma and especially in patients
who are treated with antcoagulantia.

It is most common in elderly and alcoholics with atrophy.

In brain atrophy the venous subdural structures are less
well “packed” against the skull, which give them more space
to move and possibility to torn.

This patient has an acute subdural hematoma.

There is midline shift (left image).

The patient was operated and the hematoma was evacuat-

ed (right image).

The images show a subdural hematoma.

Notice that the hematoma has both hyperdense and iso-

dense areas.

This can be seen in hyperacute bleeding, but can also be

seen in rebleeding.

There is displacement of midline structures with obstruc-

tion of CSF Uow resulting in dilatation of the temporal horn
of the right lateral ventricle (arrow).

An acute subdural hematoma is hyperdens (clotted blood),

a subacute hematoma is isodens and a chronic subdural
hematoma appears hypodens to brain parenchyma (iso-
dens to CSF).

Sign of active bleeding

In the acute setting, a subdural hematoma can appear het-
erogenous, because of the mixed components of the hem-
orrhage: fresh in Uow of non clotted blood (hypodens) and
clotted blood (hyperdens).

Subacute isodense subdural hematoma(3-21 days).

Isodense subdural hematoma

As a subdural hematoma ages, the density of the

hematoma will decrease and may be the same as the densi-
ty of the brain, which make it di_cult to detect the
hematoma.

Here a case of an isodense subdural hematoma which is

very hard to detect (arrows).

Notice that on a higher level there is a bilateral subdural

hematoma.

In rare cases an acute subdural hematoma may be isodense

to the brain.

This is seen in patients with severe anemia, disseminated

intravascular coagulation, or if the hematoma is diluted with
cerebrospinal Uuid (ref).

When a chronic subdural hematoma (> 21 days) becomes

hypodens to parenchyma and isodens to CSF, it may mimick
a hygroma.

A hygroma is the result of a traumatic torn in the arachnoid

layer which causes CSF to leak to the subdural space,.

A subdural hematoma can spread along the falx and tento-

rium as seen in this case.

Subarachnoid hemorrhage

The images show hyperdense blood in the subarachnoid

space of the Sylvian Vssure (yellow arrow).

Notice the subgaleal hemorrhage in the right occipital re-

gion (blue arrow).

This is a coupe contrecoupe type of injury.

This is another coupe contrecoupe type of injury with con-

tusional hemorrhages and a subdural hematoma in the left
frontal lobe near the skull base (red arrow).

There is a subarachnoid hemorrhage on the right with a

fracture of the parietal bone (yellow arrow).

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DiCuse Axonal Injury

High-impact trauma with acceleration-deceleration forces,

especially rotational acceleration, can lead to stretching and
deformation of the brain tissue, resulting in DAI.
CT has a low sensitivity for detecting DAI.

In closed traumatic brain injury with no traumatic subarach-

noid hemorrhage or intraventricular hemorrhage DAI is un-
likely.

A 46 year-old man had a high energy trauma with his mo-

torcycle.
The initial EMV score was 2-5-3 and his pupils were non-re-
active and dilated.

CT Hndings
Petechial hemorrhages in both frontal lobes.
Bilateral Le Fort II fractures.
Continue with the MRI images...

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MRI was requested because of persisting cognitive deVcits.

MRI Hndings
Extensive (stage 3) diPuse axonal injury (DAI)
Involvement of the subcortical areas, the corpus
callosum, the right thalamus and putamen, the brain
stem, the cerebellar peduncles and the right cerebellar
hemisphere.
Mild global atrophy.

In closed traumatic brain injury with no traumatic subarach-

noid hemorrhage or intraventricular hemorrhage a DAI is
unlikely.
DAI can be diagnosed accurately conventional MRI, includ-
ing T2*GRE or SWI.
The presence of DAI on MRI in patients with traumatic brain
injury results in a higher chance of unfavourable functional
outcome.

Three stages can be distinguished on MRI:

1. Visible lesions in the lobar white matter
2. Lesions in the corpus callosum
3. Lesions in the brainstem.
With MRI grading, the odds ratio for unfavourable function-
al outcome increases threefold with every grade.
Lesions in the corpus callosum in particular are associated
with an unfavourable functional outcome.

This patient has an intracerebral hemorrhage as a result of

a stabwound.

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Duret hemorrhage

A 54-year-old man, who was treated with anticoagulants af-

ter aortic valve replacement, developed severe headache
after being hit by a ball.
The following day his condition worsened with loss of con-
sciousness, respiratory distress and a non-reactive dilated
left pupil.
The initial CT of his head showed an acute subdural hemor-
rhage along the left convexity with subfalcine and uncal her-
niation. The hemorrhage was evacuated surgically.

Postoperatively the CT showed an acute bleeding within the

brainstem, which had a lethal outcome.

This brain stem hemorrhage is called a Duret hemorrhage.

They are small linear areas of bleeding in the midbrain and
upper pons of the brainstem caused by a traumatic down-
ward displacement of the brainstem with parahippocampal
gyrus herniation through the tentorial hiatus.

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