• Continuous blood flow of oxygen and glucose.
• Normal cerebral blood flow (CBF) is about 55mL/min per 100g
of brain tissue.
• Rate below 20mL/min can result into ischemia and infarction.
• CPP = MAP – ICP
• MAP (90-110mmHg)
• ICP (5-15mmHg)
Cerebral Perfusion PressureCerebral Perfusion Pressure
• Net pressure of blood delivery to the brain.
• In a normal adult, CPP is generally regulated between 75 and 105
mmHg (can be more or less).
• Cerebral autoregulation.
• Most common pathophysiologic pathway is elevated ICP.
Monro Kellie DoctrineMonro Kellie Doctrine
• The brain is protected by a rigid case, within which there is no
• Skull (holds three things)
Cerebro-Spinal Fluid (CSF)
• An increase in any one of these three “compartments” displaces
the other two.
• Only small volume increases can be tolerated before intracranial
pressure (ICP) begins to rise.
• 3-4% of ER attendances
• 1500 cases per 100,000 population per year in UK.
• Leading cause of death and disability from childhood to early
Mechanisms of InjuryMechanisms of Injury
• Motor vehicle crashes
• Sports Injuries
• Penetrating trauma
Categories of injuryCategories of injury
• Coup injury
• Countrecoup injury
• Diffuse Axonal injury
• Focal injury
• A 29-year-old woman was an unbelted passenger in a motor
vehicle accident. On arrival to the hospital, the paramedics
inform you that she opens her eyes in response to verbal stimuli.
She is incoherent and withdraws from painful stimuli. Which of
the following is the patient’s calculated Glasgow Coma Scale
Primary InjuryPrimary Injury
• Induced by mechanical force and occurs at the moment of injury
• Causes: Impact, Mechanical disruption of cells, Vascular
permeability or disruption,
Head InjuriesHead Injuries
• Subgaleal hematoma
Case ScenarioCase Scenario
• A 15 year old boy was hit with a baseball on his head and he
became unconscious. After about ten minutes, he regained
consciousness, but he soon became lethargic, and over the next
two hours, he was stuporous. His pupils were unequal. He was
shifted to the radiology department for an urgent CT scan, which
Extradural hematomaExtradural hematoma
• Neurosurgical emergency
• Young population
• Rupture of middle meningeal artery
• Lucid interval with headache
• Ipsilateral pupillary dilatation and reduced consciousness
• Stabilize acute life-threatening conditions and initiate supportive
therapy. Airway control and blood pressure support are the most
• Establish IV access, administer oxygen, and monitor.
• Administer IV crystalloids to maintain adequate blood pressure.
• Intubation, sedation, and neuromuscular blockade per protocol. There
is some suggestion of increased mortality with prehospital intubation in
retrospective reviews of trauma patients with moderate-to-severe head
injury compared with patients intubated in the ED. Bag-valve-mask
ventilation with good technique may be of more benefit to brain
injured patients than prehospital intubation.
Acute Subdural HematomaAcute Subdural Hematoma
• High energy Injury mechanism
• Conscious level impaired
• CT scan
Chronic Subdural HematomaChronic Subdural Hematoma
• antiplatelet and anticoagulant medications
• Cerebral atrophy in elderly stretch the bridging veins.
• Rupture after only minor trauma
• Degradation of clot leads to osmotic expansion
• Mass effect
• Expanding intracranial mass
• Pressure symptoms i.e headache, drowsiness, neurological deficit,
• Electrolyte imbalance and infections may be contributory
• Burrhole procedure under local LA
• If clinically stable, a delay of 7-10
days to allow platelet function to
normalize after withdrawal of aspirin
• Anticoagulation should be reversed by administration of Vit K
Aneurysmal SubarachnoidAneurysmal Subarachnoid
• Berry Aneurysms develop at the branch points.
• Incidence of 10-15 per 100,000 population per year.
• Risk Factors, Age, Female gender, Hypertension, Smoking,
Cocaine abuse and Family history of two first degree relatives.
• Genetic disorders.
Clinical featuresClinical features
• Neck pain or stiffness
• Loss of consciousness
• Onset of headache during exertion
• Thunderclap headache
• Limited neck flexion