A 21-year-old motorcyclist was brought to the emergency room after being found unconscious on the street with a head injury. He had swelling above his right ear. Initially his neurological exam was normal except for some confusion and unclear speech. Later he became stuporous and his right pupil dilated. Emergency surgery was undertaken. The document discusses the anatomy of the brain, cranial meninges, types of head injuries including epidural hematoma. It describes the signs and symptoms of epidural hematoma, methods of diagnosis including CT scan, and treatment involving craniotomy or burr hole evacuation surgery.

1. IS HE DEAD ?

2. Contents
• Introduction
• Anatomy of the brain
• Anatomy of the cranial meninges
• Types of head injury
• Hematoma & Pathophysiology
• Diagnosis
• Treatment

3. Introduction
Abdulmalik Sultan Alawam

4. Case (10) -Is he dead?
A 21-year-old motorcyclist was brought into the emergency room.
He had been found lying
unconscious, without a helmet, in the street, having apparently
slipped going around a curve. It
appeared that his head had probably hit the curb. He had facial
abrasions and a swelling above his right ear. While in the
emergency room he regained consciousness. He appeared dazed
and
complained of headache but did not speak clearly. Neurologic
examination showed no
papilledema. His pupils were equal, round, and reactive to light
(PERRL), extraocular movements were normal, and there was
questionable left facial weakness. There were no other neurologic
deficits. Other findings included a blood pressure of 120/80 mm
Hg, a pulse rate of 75/min, and a respiratory rate of 17/min. The
patient was kept for observation in the emergency room. Several
hours later the patient had become stuporous and his right pupil
was dilated. His blood pressure was 150/90 mm Hg; pulse rate,
55/min; and respiratory rate, 12/min. Emergency surgery was
undertaken.

5. A 21 years-old…
A 21-year-old
motorcyclist was
brought into the
emergency room. He
had been found lying
unconscious, without
a helmet, in the
street, having
apparently slipped
going around a curve.
It appeared that his
head had probably hit
the curb.

6. He had facial abrasions
and a swelling above his
right ear. While in the
emergency room he
regained consciousness.
He appeared dazed and
complained of headache
but did not speak clearly.

7. Neurologic
examination
showed no
papilledema. His
pupils were
equal, round,
and reactive to
light (PERRL),
extraocular
movements
were normal, and
there was
questionable left
facial weakness.
There were no
other neurologic
deficits.
( PERRL )
Pupils
Equal,
Round, and
Reactive to
Light
Assessment of cranial
nerve III + IV + VI

8. Other findings
included a blood
pressure of 120/80
mm Hg, a pulse rate
of 75/min, and a
respiratory rate of
17/min. The patient
was kept for
observation in the
emergency room.
Vital
Signs

9. Several hours later
the patient had
become stuporous
and his right pupil
was dilated. His
blood pressure
was 150/90 mm Hg;
pulse rate, 55/min;
and respiratory rate,
12/min.
Unilateral dilated pupil  CN III compression due to haematoma?
150/90 mm Hg 12/min

10. Emergency surgery was
undertaken.
Keywords to focus on:
• Recent head injury
• Loss of consciousness
• Swelling above his
right ear
• Stuporous & difficulty speaking
• Initially PERRL but then enlarged right
pupil
• Left facial weakness
• Vital signs:
• Increased blood pressure
• Decreased pulse & respiratory rate
Epidural hematoma

11. Anatomy Of The
Brain
Moath Abdullah Alkeaid

12. The Brain
The brain, a bilaterally symmetric,
soft, gelatinous structure
surrounded by its layers and
enclosed in its bony cranium, is
continuous with the spinal cord at
the foramen magnum at the base
of the skull.

13. The brain is subdivided into four major regions:
• Cerebrum:
is the largest part of the brain is composed of right and left
hemispheres.
• Diencephalon:
Is inferior to the cerebrum and superior to the midbrain and it’s
composed of epithalamus, thalamus, hypothalamus and
subthalamus.
• Cerebellum:
Is located under the cerebrum and it’s function is to coordinate
muscle movement and balance.
• Brainstem:
It’s including the midbrain, pons, and the medulla. And it’s act
as a relay center connecting the cerebrum and the cerebellum to
the spinal cord.

15. The cerebrum is divided
into 5 lobes:
• Frontal
• Parietal
• Occipital
• Temporal
• Insula

16. Blood supply of the brain:
1- Internal carotid system:
• Anterior cerebral artery
• Middle cerebral artery
2- the vertebro-basilar system
• Posterior cerebral artery

18. Circle of willis:
The circle of Willis is a part of the
cerebral circulation and is
composed of the following arteries:
• Anterior cerebral artery
• Anterior communicating artery
• Internal carotid artery
• Posterior communicating artery
• Posterior cerebral artery

20. Anatomy Of The
Cranial Meninges
Saleh Hassan Alorainy

21. Anatomy Of The Cranial Meninges
•Three layers
• Dura mater
• Arachnoid mater
• Pia mater

23. Dura mater
Spaces • Epidural space
• Subdural space
Function • Keeps the brain intact
Clinical
significance
• Epidural hematoma
• Subdural hematoma

24. Arachnoid Mater
Spaces • Subdural space
• Subarachnoid space
Function • CSF
Clinical
significance
• Extraction of CSF

25. Pia Mater
Function • Covers the Sulci and gyri
Clinical
significance
• Meningitis

26. Types of head injury
Saleh Alorainy

27. Types of Head injury
• Hematoma
• Hemorrhage
• Skull fracture
• Concussion
• Diffuse axonal injury
• Edema

28. Skull fracture
Skull fracture
Closed Open Depressed Basal Other
Linearcomminuted

30. Concussion
• Mild traumatic brain injury
• Rupture of the axons
• caused by a blow to the head or violently shaking the head
• Post-concussion syndrome

32. Diffuse axonal injury
• Severe traumatic brain injury
• Rupture of the axons , death of the neurons
• caused by a strong blow to the head , usually by car accidents
• Can cause death.

34. Edema
Edema
Vasogenic
cerebral
BBB
Cytotoxic
cerebral
Glia or
neuron
Osmotic
cerebral
Osmolality
Interstitial
cerebral
CSF

35. Hematoma and Pathophysiology
Tariq Saleh Dabil

36. Hematoma
• Abnormal collection of blood outside blood vessels.
• Due to damage of Blood Vessel ( Wall, Arteries, vein and capillaries).

37. Intracranial Haemorrhage
• Extra-Axial Hemorrhage
• Epidural
• Subdural
• subarachnoid
• Intra-Axial Hemorrhage
• Intracerebral
• Intraventricural

38. Epidural Haemorrhage
• Accumulation of blood.
• In the potential space of Skull and
Dura mater.
• Note: Spinal epidural hematoma: a hematoma between spinal vertebrae and the outside
lining of the spinal cord.
• half as common as a subdural hematomas.
• Occurs:
• Trauma (separation of periosteal dura from bone
and, indirectly, tears (lacerates) meningeal
vessels.
• Skull Fractions (70-95%)
Source of the blood: Arterial, mostly;( Middle Meningeal artery ),
Anterior ethmoidal artery may be involved in frontal injuries,
transverse or sigmoid sinus in occipital injuries, and the
superior sagittal sinus in vertex trauma.

39. Clinical Manifestation:
• Altered consciousness.
• Headache.
• Vomiting.
• seizure.
• Aphagia.
Diagnosis
• MRI and CT scan.
Epidural hematoma as seen on CT scan with overlying skull
fracture. Note the biconvex shape hemorrhage. Also some
brain contusion with bleeding on the opposite side of the
brain.

40. Subdural Haemorrhage • Below Dura mater.
• Between Dura mater, and
Arachnoid Membrane.
• Similar reasons to occur as epidural
• Drugs, alcoholism, Diabetics.
Note: Elderly
Source of the blood: Tearing the
bridging veins. blood drainage from
cerebral cortex into a dural venous
sinus

41. • Subdural hematomas maybe characterized by their size and
location, and classified on the basis of the amount of time elapsed
since the precipitating event (if any):
• Acute subdural hematoma occurs within 72 hours of injury.
• Subacute subdural hematoma occurs 3–7 days after injury.
• Chronic subdural hematoma occurs weeks-to-months after
trauma.
Subdural Haemorrhage

42. Clinical Manifestation:
• Lucid Interval.
• Confusion
• Headache
Note: Clinical signs are may be nonspecific,
nonlocalized, or absent, and may be stable or
rapidly progressive.
crescent-shaped (external border convex
internal border concave) collection of blood,
which rarely crosses the falx cerebri or
tentorium cerebelli

44. Subarachnoid Hematoma
• Within the subarachnoid space.
• The blood occupies the whole
area.
• Occurs due: Rapture of
saculam aneurysm
• Aneurysm of Cerebral Artery
• Other reasons:
• Nonaneurysm subarachnoid hematoma

45. Clinical Manifestation:
• Lucid Interval.
• Sudden severe headache
• Confusion
• Headache
• Meningismus (stiff neck, photophobia)
• Seizure

46. Intra-Axial Haemorrhage
• Second most common cause of
stroke
Etiology:
• Embolism
• Hypertension
• Brain tumors
• Bleeding
disorders
• Drug use
Clinical Manifestation:
• Symptoms depend on Areas.
• Headaches
• Nausea and Vomiting
Happens as a secondary situation
when
subacrachnoid/intracerebral
haemorrhage develop.

47. Diagnosis
Fahad Sulaiman Alhussainan

48. Site of Injury
• Also known as the weakest part
of the skull
• Where the frontal, parietal,
temporal, and sphenoid (greater
wing) bones articulate
• Anterior branch of the middle
meningeal artery lies just deep
to this point

49. Epidural Space
Real or Not?

50. Signs and Symptoms
• Head injury
• Loss of consciousness
o Lucid Interval
• Confusion
• Drowsiness or altered level of alertness
• Severe Headache
• Mydriasis of one eye on the side of injury
• Muscle Weakness
o usually contralateral to the injured side

51. Diagnostic Tests & Confirmation
CT Scan/ Head Scan/ Skull Scan MRI

52. How to differentiate between Epidural hematoma
from other hematomas?

53. Treatment
Suliman Sultan Abuhaimad

54. Treatment of Epidural Hematoma
• EDH is a neurologic emergency that often requires
surgical treatment to prevent irreversible brain injury and
death caused by hematoma expansion, elevated
intracranial pressure, and brain herniation.
• Small volume of EDH can be managed non-operatively
as long as the patient remain stable.

55. When to perform surgery?
• The decision to perform surgery in patients with acute EDH is
based primarily upon the patient's neurologic status, as
assessed by the Glasgow coma score (GCS) score, neurologic
examination and pupillary signs, and brain imaging findings.
• Craniotomy and hematoma evacuation is the mainstay of surgical
treatment of symptomatic acute EDH.

56. Treatment of Epidural Hematoma
Craniotomy: is a surgical operation in which a bone flap
is temporarily removed from the skull to access the brain.
Open Craniotomy affords a more complete evacuation of the
hematoma.

58. Treatment of Epidural Hematoma
Burr hole evacuation (trephination) is used for acute
EDH.
Generally, when a blood clot is moderately old (two to three weeks),
it might be drained through a small hole in the skull, and a large
craniotomy flap might be avoided.

60. Medications
Medications used in addition to surgery will vary according to the type
and severity of symptoms and brain damage that occurs.
1-Hyperosmotic agents (like mannitol, glycerol, and hypertonic saline)
may be used to reduce inflammation and swelling in the brain.
2-Anti-seizures medications (such as phenytoin) may be used to
control or prevent seizures.

61. This Seminar was done by:-
1. Abdulmalik Sultan Alawam
2. Moath Abdullah Alkeaid
3. Saleh Hassan Alorainy
4. Tariq Saleh Dabil
5. Fahad Sulaiman Alhussainan
6. Suliman Sultan Abuhaimad

62. THANK YOU!