CASE 44

A 15-year-old boy was the pitcher for his little league baseball team when
he was hit by a line drive to the right temple area. He lost consciousness
briefly but woke up after about 45 seconds and had no neurological
deficits. He was taken to the emergency room and seemed to be in good
condition. Four hours later, while being observed, he complained of an
increasing headache and had a seizure. On examination, the patients
right pupil appeared dilated and reacted sluggishly to light. The
emergency physician is concerned about increased intracranial pressure.
What is the most likely diagnosis?
What is the anatomical explanation for this condition?

ANSWERS TO CASE 44: EPIDURAL HEMATOMA

Summary: A 15-year-old boy was hit by a baseball to the right temple
area. He lost consciousness briefly and had a lucid interval. Four hours
later, he developed an increasing headache, a dilated and sluggish right
pupil, and had a seizure, consistent with increased intracranial pressure.
Most likely diagnosis: Epidural hematoma resulting in increased
intracranial pressure
Anatomical explanation for this condition: Disruption of a branch of the
middle meningeal artery, which causes a growing hematoma between
the dura and cranium and puts pressure on the underlying brain

CLINICAL CORRELATION
This 15-year-old baseball player underwent significant blunt trauma to the
right temple area by a baseball. He had a brief loss of consciousness, likely
due to the concussion of the baseball. After waking up, he had no
neurological deficits; however, after 4 hours, there were signs of increased
intracranial pressure. The most likely explanation is disruption of the middle
meningeal artery, which underlies the temporal bone. Over time, the
hematoma formed, putting pressure on the underlying brain tissue. The
ipsilateral pupil was affected due to compression of the oculomotor nerve
(CN III) by the temporal lobe of the brain. This scenario of a loss of
consciousness followed by a lucid interval and a second loss of
consciousness is very typical for epidural hematoma. Because this is
arterial bleeding, rapid expansion of the hematoma is typical. Emergent
cerebral decompression and surgical control of the bleeding is
paramount.

APPROACH TO MENINGES AND ARTERIAL

SUPPLY TO BRAIN
Objectives
1. Be able to list the meningeal layers.
2. Be able to identify the dural folds and associated dural sinuses.
3. Be able to describe the vascular supplies to the meninges and
underlying brain.
Definitions
Pachymeninx: The thick meningeal layer, that is, the dura mater.
Leptomeninx: The thin meningeal layers, that is, the arachnoid and pia
maters together.
Dural sinus: Cavity filled with venous blood formed by a split in the two
layers of dura mater, the periosteal and meningeal layers. Blood drains
from the system of sinuses into the internal jugular vein.
Pterion: A landmark on the lateral surface of the skull formed by the
junction of the frontal, parietal, temporal, and sphenoid bones. It usually
has an H-shaped appearance.

DISCUSSION
As in the spinal cord, there are three meningeal layers that cover the brain:
the dura mater, arachnoid mater, and pia mater. The dura mater is a thick,
strong membrane (pachymeninx) that is closely apposed to the deep
surface of the cranium. Immediately deep to the dura is the arachnoid
layer, a thin, nearly transparent membrane that adheres to the deep
surface of the dura. The arachnoid layer is separated from the brain by
the subarachnoid space, which is filled with CSF. The pia mater is a thin
layer attached to the surface of the brain itself. The arachnoid and pia
layers together may be referred to as the leptomeninges.
The dura mater that covers the external surface of the brain consists of two
layers, an external periosteal layer attached to the bone and an internal
meningeal layer. The internal layer forms folds that separate the major
lobes of the brain. The falx cerebri courses along the midline and
separates the left and right cerebral hemispheres. Running at right angles,
the tentorium cerebelli separates the two lobes of the cerebrum from the
cerebellum. On the inferior surface of the tentorium is attached the small
falx cerebelli, which also runs along the midline and partially separates
the cerebellum into lobes. Another important dural infolding covers the
pituitary fossa and is the called the diaphragma sellae.
Normally, the two dural layers are tightly apposed, but they may split to
form the dural sinuses (Figure 44-1). The major dural sinuses are the
superior sagittal sinus, which courses along the superior edge of the falx
cerebri, and the transverse sinus, which courses along the posterior border
of the tentorium cerebelli. The transverse sinus continues laterally as the
sigmoid sinus and empties into the internal jugular vein. On the inferior
surface of the falx cerebri, the inferior sagittal sinus continues as the
straight sinus after joining the great vein of Galen, which drains the brain.
The superior, straight, and transverse sinuses come together at the
confluence of sinuses, a landmark on the internal surface of the occipital
bone. Other important sinuses are the superior and inferior petrosal sinuses
and the cavernous sinus.
The vessels that supply the dura mater are branches of the middle
meningeal artery. This artery arises in the infratemporal fossa from the first
part of the maxillary artery and enters the cranial cavity through the
foramen spinosum. The artery runs within the dura mater and separates
into anterior and posterior divisions. An external landmark for the middle
meningeal artery is the pterion, where the frontal, parietal, temporal, and
sphenoid bones converge.

Figure 44-1. The dura and meninges: 5 superior sagittal sinus, 6 inferior sagittal sinus, 18 lateral
lacuna, 19 emissary vein (connects sinuses to scalp veins), 20 arachnoid granulation (resorption of
cerebrospinal fluid). (Reproduced, with permission, from the University of Texas Health Science Center,
Houston Medical School.)

The vessels that supply the brain arise from the circle of Willis (see Case 46
for more details). This anastomotic formation originates from the internal
carotid and vertebral arteries. The major branches tend to course along
the surface of the brain and give off penetrating branches.
Head trauma can result in damage to vessels and internal bleeding. Blood
accumulates in potential spaces surrounding the brain, expanding their
volume, and putting pressure on the brain. The site of accumulation is
characteristic of the type of vessel that is damaged. For example, rupture
of the middle meningeal artery will lead to accumulation of blood in the
epidural potential space, between the external periosteal layer of the dura
and the calvaria. Blood from a cerebral artery due, for example, to a
ruptured cerebral aneurysm, will accumulate in the subarachnoid space.
Head trauma may result in rupture of veins as they enter a sinus, usually
resulting in accumulation of blood in the subdural potential space
between the dural and arachnoid layers. These veins may be cerebral
veins that drain the brain or emissary veins that drain the scalp.

COMPREHENSION QUESTIONS
[44.1] A 35-year-old man developed an intracranial hemorrhage when
one of the meningeal arteries ruptured. Anatomically, where is the
hematoma located?
A. Immediately superficial to the dura
B. Immediately deep to the dura
C. Within the subarachnoid space
D. Within the brain parenchyma
[44.2] A 1-month-old infant is seen in the emergency department due to
lethargy and seizures. After careful questioning, it was discovered that the
infant was shaken before the change in mental status. Which vessels are
most likely to be injured?
A. Meningeal arteries
B. Meningeal veins
C. Emissary veins
D. Middle cerebral arteries
[44.3] A 21-year-old man is brought into the emergency room after being
hit in the head with a baseball bat. The neurosurgeon notes that the skull
fracture and underlying hematoma seem to have occurred at the
junction of the four major bones of the skull. Which of the following
describes this region?
A. Bregma
B. Lambda
C. Pterion
D. Nasion

Answers
[44.1] A. Injuries to the meningeal arteries lead to epidural hematomas.
[44.2] C. Infants who are shaken are vulnerable to laceration of the
emissary veins that are found below the dura. Thus, they often develop
subdural hematomas.
[44.3] C. The pterion is a landmark of the skull where the four major bones
of the skull (frontal, parietal, temporal, and sphenoidal) come together. It
is also the thinnest part of the skull.

ANATOMY PEARLS
The dura mater, which covers the external surface of the brain,
consists of two layers, an external periosteal layer attached to the bone
and an internal meningeal layer.
An external landmark for the middle meningeal artery is the pterion,
where the frontal, parietal, temporal, and sphenoid bones converge.
The vessels that supply the dura mater are branches of the middle
meningeal artery, and injuries to these vessels lead to epidural
hematomas.
Blood from ruptured cerebral arteries due, for example, to a ruptured
cerebral aneurysm, will accumulate in the subarachnoid space.

REFERENCES
Moore KL, Dalley AF. Clinically Oriented Anatomy, 5th ed. Baltimore, MD:
Lippincott Williams & Wilkins, 2006:90821.
Netter FH. Atlas of Human Anatomy, 4th ed. Philadelphia, PA:
Saunders/Elsevier, 2006: plates 1002.
Snell RS. Clinical Anatomy by Regions, 8th ed. Baltimore, MD: Lippincott
Williams & Wilkins, 2008:6817.