| To understand epidural and subdural
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| | head-injured patients who arrived at an
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| hematomas -- two serious consequences of
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| | emergency department in coma, but they
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| head injuries -- we need to know the
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| | can also be seen in conscious patients.
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| basic anatomy of the brain and its
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| | Epidural hematomas usually occur in
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| coverings. Imagine an evil carpenter with
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| | conjunction with skull fractures, and
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| an electric drill intent on drilling into
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| | this is no coincidence, as the ruptured
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| a person's brain. What layers would the
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| | blood vessel often lies beneath the
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| drill encounter in its passage from the
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| | fracture. The presence of an epidural
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| outside of the head to its
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| | hematoma signifies a highly dangerous
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| destination?The drill would pass through
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| | condition. Between 5 and 43% of people
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| the skin and then the skull (braincase)
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| | who have them die. Emergency surgery to
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| before penetrating a series of three
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| | remove the clot is the usual
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| membranes comprising the meninges. In
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| | treatment.When considering subdural
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| sequence, the three membranes are the
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| | hematomas, it is useful to divide them
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| dura mater (Latin for "tough mother"),
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| | into acute and chronic varieties, with
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| the arachnoid mater (cobwebby mother) and
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| | "acute" meaning the hematoma is new, and
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| the pia mater (tender mother) and then
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| | "chronic" meaning it has been present for
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| finally the brain itself.Epidural and
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| | at least three weeks. (The hematoma can
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| subdural hematomas are alike in that they
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| | also pass through a "subacute" phase,
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| are masses of clotted blood (hematomas)
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| | meaning that it has been present for 3
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| caused by head trauma and deposited
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| | days to 3 weeks.) By the time an acute
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| outside the brain but inside the skull.
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| | subdural hematoma has become chronic, it
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| However, they differ in their locations
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| | is a thick liquid instead of a solid
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| relative to the dura mater. An epidural
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| | blood clot, and also appears darker on CT
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| hematoma lies outside (on top of) the
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| | scans.Acute subdural hematomas usually
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| dura mater, while a subdural hematoma
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| | occur in people with obvious and
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| lies inside (beneath) the dura mater and
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| | significant blows to the head. In one
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| outside the arachnoid mater. Thus, the
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| | study they were present in 24% of the
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| locations of the two kinds of hematoma
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| | patients who arrived at an emergency
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| are encoded in their names -- "epi" is
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| | department in coma, but can be present in
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| Greek for "upon" and "sub" is Latin for
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| | non-comatose patients as well. Acute
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| "below." A third kind of hematoma caused
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| | subdural hematomas are associated with a
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| by head injuries is traumatic
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| | death rate between 30 and 90%, with a
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| intracerebral hemorrhage. These occur
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| | figure of 60% typically cited. Emergency
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| within the brain tissue itself and are no
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| | surgery is the usual treatment, though
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| less serious than those outside the
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| | studies have shown that alert patients
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| brain, but are not the subject of the
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| | with small subdural hematomas can do as
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| current essay.Epidural and subdural
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| | well without surgery if monitored closely
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| hematomas are produced by ruptures of
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| | for signs of worsening.Infants are also
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| different blood vessels. Epidural
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| | vulnerable to acute subdural hematomas.
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| hematomas are usually caused by bleeding
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| | Neurosurgeons at the Kaohsiung Medical
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| from an artery that nourishes the
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| | University in Taiwan reviewed records on
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| meninges known as the middle meningeal
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| | 21 children, ages 6 days to 12 months,
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| artery, while subdural hematomas are
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| | who had acute subdural hematomas. In this
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| usually due to bleeding from veins that
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| | case series, "shaken baby syndrome" was
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| drain blood away from the surface of the
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| | the most common cause. Eight of the
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| brain.Yet another difference between
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| | infants underwent an immediate operation,
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| epidural and subdural hematomas is what
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| | and another 11 required delayed surgery.
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| they look like on computed tomographic
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| | While most of the children did well, one
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| (CT) scans. When the bleeding was recent,
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| | baby died and another 7 sustained
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| both show up as intensely bright objects
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| | moderate to severe disabilities from
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| on the scan, but the shapes of the blood
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| | their injuries.Chronic subdural hematomas
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| clots are different. In epidural
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| | often show up in patients over 60 years
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| hematomas the blood is more limited in
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| | of age in whom the head injuries that
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| its spread because it has to push harder
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| | caused them might have seemed trivial
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| to move outward in the tight space
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| | when they occurred, or might even have
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| between the inner surface of the skull
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| | been forgotten. Older people are
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| and the outer surface of the dura mater.
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| | especially vulnerable due to the fact
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| In contrast, the bleeding that produces
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| | that their brains have atrophied (shrunk)
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| subdural hematomas is more free to spread
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| | and the veins draining the surface of the
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| in the looser space beneath the dura
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| | brain are stretched and fragile, easily
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| mater and typically runs from the front
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| | disrupted by glancing blows. Risk of
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| of the head to the rear.One issue that
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| | subdural hematoma rises still higher if
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| applies to both kinds of hematomas is
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| | the individual falls a lot, drinks
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| that they occupy space -- sometimes a lot
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| | alcohol a lot or takes blood-thinning
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| of it -- within the braincase where there
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| | medication.Subdural hematomas can expand
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| isn't a lot of extra space to go around.
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| | progressively to the point of causing
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| As they expand they compress the brain
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| | symptoms like headache, slurred speech,
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| tissue next to them and additionally
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| | confusion, lethargy, unsteadiness or even
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| raise the pressure within the skull which
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| | a seizure. Surgery to remove the hematoma
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| can damage the rest of the brain.
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| | and stop the bleeding is the typical
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| Moreover, the hematoma is not necessarily
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| | treatment, and 93 to 97% of patients
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| the only problem caused by the head
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| | survive to 30 days after surgery. Most
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| injury. The blow to the head that caused
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| | regain their pre-injury level of
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| the bleed can also damage the brain
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| | function. Milder cases of chronic
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| tissue directly.Who gets epidural
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| | subdural hematoma can be monitored
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| hematomas? They usually occur in people
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| | without surgery.(C) 2006 by Gary
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| with obvious and significant blows to the
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| | CordingleyGary Cordingley, MD, PhD, is a
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| head, as from motor vehicle accidents. In
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| | clinical neurologist, teacher and
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| one study they were present in 10% of
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| | researcher who works in Athens, Ohio.
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