Head Injury- Clinical
Manifestations, Diagnosis and
Management
-Dr. Vibha A P
Emergency Response Care Physician
GVK-EMRI, ...
Head Injury
• Any degree of traumatic brain injury
ranging from scalp laceration to LOC to
focal neurological deficits
Head Injury
• Causes
– Motor vehicle accidents
– Falls
– Assaults
– Sports-related injuries
– Firearm-related injuries
Head Injury
• High potential for poor outcome
• Deaths occur at three points in time after
injury:
– Immediately after the...
Head Injury
TYPES:
• Scalp laceration
• Skull Fractures
• Minor Head Trauma
Concussion and post-concussion syndrome
• Majo...
Head Injury
• Scalp lacerations
– The most minor type of head trauma
– Scalp is highly vascular → profuse
bleeding
– Major...
Head Injury
• Skull fractures
– Linear Skull Fracture
– Depressed Skull Fracture
– Diastatic Skull Fracture
– Basal Skull ...
Head Injury
• Skull fractures
– Location of fracture alters the
presentation of the manifestations
– Facial paralysis
– Co...
Battle’s SignBattle’s Sign
Fig. 55-13
Head Injury
• Basal Skull fractures
– CSF leak (extravasation)
into ear (Otorrhea) or
nose (Rhinorrhea)
– High risk infect...
Investigations
 X-ray
 CT scan: standard modality
 MRI
 Bleeding from the ear or nose in cases of suspected CSF
leak -...
Management
Pre-hospital care:
• Patients with severe head injuries should be assumed to
have a cervical spine (C-spine) in...
Head Injury
• Minor head trauma
– Concussion : head injury with a temporary
loss of brain function concussion can cause a
...
Head Injury
Types of Head Injuries
Concussion
Presentation:
Physical-headache, LOC, Amnesia, s/s of ↑
ICP(Cushing’s triad)...
Head Injury
• Minor head trauma
– Postconcussion syndrome
• 2 weeks to 2 months
• Persistent headache
• Lethargy
• Persona...
Head Injury
• Major head trauma
– Includes cerebral contusions and
lacerations
– Both injuries represent severe trauma
to ...
Head Injury
• Major head trauma
– Contusion
• The bruising of brain tissue within a focal
area that maintains the integrit...
Head Injury
Cerebral Contusion Cerebral Laceration
Head Injury
Pathophysiology
• Diffuse axonal injury (DAI)
– Widespread axonal damage occurring
after a mild, moderate, or ...
Head Injury
Pathophysiology
• Diffuse axonal injury (DAI)
– Clinical signs:
∀↓ Level of Consciousness
∀↑ ICP
• Decerebrati...
Intracranial Hemorrhage
Extra- axial hemorrhage
• Epidural hematoma
• Subdural hematoma-
Acute
Chronic
• Subarachnoid hemo...
Epidural hematoma
– Results from bleeding between the dura and
the inner surface of the skull
– MC type of traumatic Intra...
Epidural hematoma
Source of Bleed :
Temperoparietal locus (most likely) - Middle
meningeal artery
Frontal locus - anterior...
Subdural hematoma
– Occurs from bleeding between the dura mater and
arachnoid layer of the meningeal covering of the
brain...
Subdural hematoma
– Acute subdural hematoma(<72hrs)
• High mortality
• Associated with major direct trauma (Shearing
Force...
Subdural hematoma
– Subacute subdural hematoma
• Occurs within 4-21 days of the injury
• Failure to regain consciousness m...
Epidural and Subdural HematomasEpidural and Subdural Hematomas
Fig. 55-15
Epidural Hematoma
Subdural Hematoma
Epidural and Subdural HematomasEpidural and Subdural Hematomas
Hematoma type Epidural Subdural
Location Between the skull ...
Subarachnoid Hemorrhage
Causes:
• Rupture of Berry aneurism(MCC)
• Trauma (fracture at the base of the skull leading to
in...
Intracerebral Hemorrhage
(ICH)
Intracranial hemorrhage is hemorrhage that occurs
within the brain tissue itself; an intra-...
Intracerebral Hemorrhage
(ICH)
Clinical presentation: Rapidly progressive severe headache,
building over several minutes, ...
Complications
• Neurological deficits or death
• Seizures
• Obstructive Hydrocephalus
• Spasticity
• Urinary complications...
Cerbral Herniation
Brain herniation is a deadly side effect of very
high intracranial pressure that occurs when a part of
...
Cerbral Herniation
Supratentorial herniation
1. Uncal
2. Central (transtentorial)
3. Cingulate (subfalcine)
4. Transcalvar...
Cingulate Herniation
The most common type, the innermost part of the frontal
lobe is scraped under part of the falx cerebr...
Uncal Herniation
common subtype of cerebral herniation following raised ICP
Innermost part of the temporal lobe, the uncus...
Diagnostic Studies
CT scan –
• A GCS score less than 15 after blunt
head trauma warrants a patient with no
intoxicating co...
CT findingsCT findings
Fig. 55-15
Epidural Hematoma Subdural Hematoma
CT findingsCT findings
Fig. 55-15
Subarachnoid hemorrhage Intracerebral hematoma
Diagnostic Studies
• MRI – superior for demonstrating the size of
an acute subdural hematoma.
• Cerebral angiogram if hemo...
Management
1) Supportive Measures:
• Endotracheal intubation for patients with decreased level of
consciousness and poor a...
Management
2) Decrease cerebral edema:
• Modest passive hyperventilation to reduce PaCO2
• Mannitol, 0.5-1.0 gm/kg slow iv...
Management
3) Surgical Evacuation of hematoma:
• No surgical intervention if collection <10ml
Indication of surgical decom...
Management
Sugical Decompression contd..
Types:
• Burr-hole
• Craniotomy- bone flap is temporarily removed from
the skull ...
Management
4) Medical therapy:
• Antihypertensives - reduce blood pressure to prevent exacerbation
of intracerebral hemorr...
Preventive Measures
Health Promotion
• Prevent car and motorcycle
accidents
• To Wear safety helmets
Rehabilitation
Ambulatory and Home Care
• Nutrition
• Bowel and bladder management
• Spasticity
• Dysphagia
• Seizure diso...
References:
• Harrison's Principles of Internal Medicine
• Medscape Reference http://emedicine.medscape.com
• US National ...
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Head injury types, clinical manifestations, diagnosis and management

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I prepared this presentation for CME at 108 Emergency Services GVK-EMRI, Bangalore in January 2013. I kept it simple and concise as the CME was attended by EMTs too. Hope its of help to any medical professional out there.

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  • A  skull fracture  is a break in one or more of the eight bones that form the cranial portion of the  skull , usually occurring as a result of  blunt force trauma . Linear skull fractures are breaks in the bone that transverse the full thickness of the skull from the outer to inner table, are usually fairly straight and involve no displacement of the bone A depressed skull fracture is a type of fracture usually resulting from blunt force trauma, such as getting struck with a hammer, rock or getting kicked in the head. These types of fractures, which occur in 11% of severe head injuries, are comminuted fractures in which broken bones are displaced inward. Diastatic fractures occur when the fracture line transverses one or more sutures of the skull causing a widening of the suture Basilar skull fractures , are basically linear fractures that occur in the floor of the cranial vault (skull base), which require more force to cause than other areas of the neurocranium. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients. A fracture which occurs in conjunction with an overlying  laceration  which tears the epidermis and the  meninges  or runs through the  paranasal sinuses and the  middle ear  structures, resulting in the outside environment being in contact with the cranial cavity is termed a compound fracture. A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull A growing skull fracture (GSF) also known as a craniocerebral erosion or leptomeningeal cyst [14]  due to the usual development of a cystic mass filled with cerebrospinal fluid is a rare complication of head injury usually associated with linear skull fractures of the parietal bone in children under 3.
  • other than a fracture at the vertex that might be missed by CT scan and picked up by a plain film, skull x-ray is of no benefit when a CT scan is obtained. CT scan is the criterion standard modality for aiding in the diagnosis of skull fractures : MRI or magnetic resonance angiography is of ancillary value for suspected ligamentous and vascular injuries.
  • Role of surgery is limited in the management of skull fractures. Infants and children with open depressed fractures require surgical intervention.   At times, craniectomy is performed if the underlying brain is damaged and swollen.
  • is the most common type of  traumatic brain injury .
  • is the most common type of  traumatic brain injury .
  • the  pia - arachnoid  membranes are torn over the site of injury in  laceration  and are not torn in  contusion . Cerebral lacerations usually accompany other brain injuries and are often found with skull fractures on both sides of the head  common in  penetrating and perforating head trauma
  • the  pia - arachnoid  membranes are torn over the site of injury in  laceration  and are not torn in  contusion . Cerebral lacerations usually accompany other brain injuries and are often found with skull fractures on both sides of the head  common in  penetrating and perforating head trauma
  • Diffuse axonal injury  (DAI) is one of the most common and devastating types of  traumatic brain injury , [1]  meaning that damage occurs over a more widespread area than in focal brain injury. DAI, which refers to extensive lesions in  white matter  tracts, is one of the major causes of unconsciousness and  persistent vegetative state  after head trauma. [2]  It occurs in about half of all cases of severe  head trauma  and also occurs in moderate and mild brain injury . [3] the major cause of damage in DAI is the disruption of  axons , the neural processes that allow one  neuron  to communicate with another.
  •   Often due to  trauma , the condition is potentially deadly because the buildup of blood may increase  pressure  in the  intracranial space , compress delicate brain tissue, and cause  brain shift . The condition is present in one to three percent of  head injuries . [1]  Between 15 and 20% of epidural hematomas are fatal .Epidural hematoma is usually found on the same side of the brain that was impacted by the blow, but on very rare occasions it can be due to a  contrecoup injury . [1]
  •   After the epidural hematoma begins collecting, it starts to compress intracranial structures which may impinge on the CN III. [3]  This can be seen in the physical exam as a fixed and dilated pupil on the side of the injury. [3]  The eye will be positioned down and out, due to unopposed CN IV and CN VI innervation. a  lucid interval  is a temporary improvement in a patient&apos;s condition after a  traumatic brain injury , after which the condition deteriorates. A lucid interval is especially indicative of an  epidural hematoma . An estimated 20 to 50% of patients with epidural hematoma experience such a lucid interval
  •   As the brain shrinks with age, the  subdural space  enlarges and the  veins  that traverse the space must travel over a wider distance, making them more vulnerable to tears.
  • Acute subdural hematomas are less than 72 hours old and are hyperdense compared with the brain on computed tomography scans. The subacute phase begins 3-7 days after acute injury; the surgical literature favors 3 days, whereas the radiological literature favors 7. Subacute subdural hematomas are isodense or hypodense compared with the brain. Chronic subdural hematomas are 21 days (3 wk) or older and are hypodense compared with the brain. However, subdural hematomas may be mixed in nature, such as when acute bleeding has occurred into a chronic subdural hematoma.
  • kinds
  • kinds
  • Central herniation In  central herniation , the  diencephalon  and parts of the  temporal lobes  of both of the  cerebral hemispheres  are squeezed through a notch in the  tentorium cerebelli . [5][7]  . [ edit ] Cingulate herniation Subfalcine herniation on CT In  cingulate  or  subfalcine herniation , the most common type, the innermost part of the  frontal lobe  is scraped under part of the  falx cerebri , the dura mater at the top of the head between the two  hemispheres of the brain . [5][8]  Cingulate herniation can be caused when one hemisphere swells and pushes the  cingulate gyrus  by the falx cerebri. [4]  This does not put as much pressure on the brainstem as the other types of herniation, but it may interfere with  blood vessels  in the frontal lobes that are close to the site of injury (anterior cerebral artery), or it may progress to central herniation. [5] Interference with the blood supply can cause dangerous increases in ICP that can lead to more dangerous forms of herniation. [9]  Symptoms for cingulate herniation are not well defined. [9]  Usually occurring in addition to uncal herniation, cingulate herniation may present with  abnormal posturing and  coma . [4]  Cingulate herniation is frequently believed to be a precursor to other types of herniation. [9] [ edit ] Transcalvarial herniation In  transcalvarial herniation , the brain squeezes through a fracture or a surgical site in the skull. [4]  Also called &quot;external herniation&quot;, this type of herniation may occur during  craniectomy , surgery in which a flap of skull is removed, preventing the piece of skull from being replaced. [1] [ edit ] Upward herniation Increased pressure in the posterior  fossa  can cause the  cerebellum  to move up through the tentorial opening in  upward , or  cerebellar herniation . [5]  The midbrain  is pushed through the tentorial notch. This also pushes the midbrain down. [ edit ] Tonsillar herniation In  tonsillar herniation , also called  downward cerebellar herniation , [4]  or &quot;coning&quot;, the cerebellar tonsils move downward through the  foramen magnum  possibly causing compression of the lower brainstem and upper cervical spinal cord as they pass through the foramen magnum. [5]  Increased pressure on the brainstem can result in dysfunction of the centers in the brain responsible for controlling respiratory and cardiac function.
  • Subfalcine herniation on CT In  cingulate  or  subfalcine herniation , the most common type, the innermost part of the  frontal lobe  is scraped under part of the  falx cerebri , the dura mater at the top of the head between the two  hemispheres of the brain . [5] [8]  Cingulate herniation can be caused when one hemisphere swells and pushes the  cingulate gyrus  by the falx cerebri. [4]  This does not put as much pressure on the brainstem as the other types of herniation, but it may interfere with  blood vessels  in the frontal lobes that are close to the site of injury (anterior cerebral artery), or it may progress to central herniation. [5] Interference with the blood supply can cause dangerous increases in ICP that can lead to more dangerous forms of herniation. [9]  Symptoms for cingulate herniation are not well defined. [9]  Usually occurring in addition to uncal herniation, cingulate herniation may present with  abnormal posturing and  coma . [4]   . [9] [ edit ] Transcalvarial herniation In  transcalvarial herniation , the brain squeezes through a fracture or a surgical site in the skull. [4]  Also called &quot;external herniation&quot;, this type of herniation may occur during  craniectomy , surgery in which a flap of skull is removed, preventing the piece of skull from being replaced. [1] [ edit ] Upward herniation Increased pressure in the posterior  fossa  can cause the  cerebellum  to move up through the tentorial opening in  upward , or  cerebellar herniation . [5]  The midbrain  is pushed through the tentorial notch. This also pushes the midbrain down. [ edit ] Tonsillar herniation In  tonsillar herniation , also called  downward cerebellar herniation , [4]  or &quot;coning&quot;, the cerebellar tonsils move downward through the  foramen magnum  possibly causing compression of the lower brainstem and upper cervical spinal cord as they pass through the foramen magnum. [5]  Increased pressure on the brainstem can result in dysfunction of the centers in the brain responsible for controlling respiratory and cardiac function.
  • Central herniation In  central herniation , the  diencephalon  and parts of the  temporal lobes  of both of the  cerebral hemispheres  are squeezed through a notch in the  tentorium cerebelli . [5] [7]  Transtentorial herniation can occur when the brain moves either up or down across the tentorium, called ascending and descending transtentorial herniation respectively; however descending herniation is much more common. [1]  Downward herniation can stretch branches of the  basilar artery  (pontine arteries), causing them to tear and bleed, known as a  Duret hemorrhage . The result is usually fatal. [7] Radiographically, downward herniation is characterized by obliteration of the  suprasellar cistern  from temporal lobe herniation into the tentorial hiatus with associated compression on the cerebral peduncles. Upwards herniation, on the other hand, can be radiographically characterized by obliteration of the quadrigeminal cistern. Intracranial hypotension syndrome has been known to mimic downwards [ edit ] Transcalvarial herniation In  transcalvarial herniation , the brain squeezes through a fracture or a surgical site in the skull. [4]  Also called &quot;external herniation&quot;, this type of herniation may occur during  craniectomy , surgery in which a flap of skull is removed, preventing the piece of skull from being replaced. [1] [ edit ] Upward herniation Increased pressure in the posterior  fossa  can cause the  cerebellum  to move up through the tentorial opening in  upward , or  cerebellar herniation . [5]  The midbrain  is pushed through the tentorial notch. This also pushes the midbrain down. [ edit ] Tonsillar herniation In  tonsillar herniation , also called  downward cerebellar herniation , [4]  or &quot;coning&quot;, the cerebellar tonsils move downward through the  foramen magnum  possibly causing compression of the lower brainstem and upper cervical spinal cord as they pass through the foramen magnum. [5]  Increased pressure on the brainstem can result in dysfunction of the centers in the brain responsible for controlling respiratory and cardiac function.
  • Patients with possible subdural hematoma should be examined for related injuries (using guidelines established by the American College of Surgeons Committee on Trauma), such as cervical spine fracture, spinal cord injury, or long-bone fractures. Although magnetic resonance imaging (MRI) is superior for demonstrating the size of an acute subdural hematoma and its effect on the brain, noncontrast head CT is the primary means of making a diagnosis and suffices for immediate management purposes.
  • Early treatment in patients presenting with spontaneous intracerebral hemorrhage is important as it may decrease hematoma enlargement and lead to better neurologic outcome
  • Stupor  is a state of partial or near complete unconsciousness in which the patient is lethargic, immobile, and has a reduced response to stimuli. [3] Coma  is a state in which the patient is totally unconscious and cannot be aroused even with strong stimuli. [4] Persistent vegetative state  is a condition in which awake patients are unconscious and unaware of their surroundings and the cerebral cortex is not functioning. [5]  A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. The vegetative state is considered permanent if it persists for 12 months after TBI or 3 months after causes other than trauma. [6] A  minimally conscious state  is a condition in which patients have a reduced level of arousal and may appear, on the surface, to be in a persistent vegetative state but are capable of demonstrating the ability to actively process information. Locked-in syndrome  is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body. [7]  Voluntary control of eye movements or blinking may be spared, permitting the detection of conscious awareness and enabling the establishment of functional communication. [7] Brain death  is the irreversible loss of measurable brain function, with loss of any integrated activity among distinct areas of the brain. [8]  Breathing and heart function must be maintained with assistive devices. [8] Disorders of consciousness affect a significant number of people who suffer severe TBI; of those with severe TBI discharged from a hospital, 10-15 are in a vegetative state, and of this number only half regain consciousness within one to three years. [6]
  • Head injury types, clinical manifestations, diagnosis and management

    1. 1. Head Injury- Clinical Manifestations, Diagnosis and Management -Dr. Vibha A P Emergency Response Care Physician GVK-EMRI, Bangalore
    2. 2. Head Injury • Any degree of traumatic brain injury ranging from scalp laceration to LOC to focal neurological deficits
    3. 3. Head Injury • Causes – Motor vehicle accidents – Falls – Assaults – Sports-related injuries – Firearm-related injuries
    4. 4. Head Injury • High potential for poor outcome • Deaths occur at three points in time after injury: – Immediately after the injury – Within 2 hours after injury – 3 weeks after injury
    5. 5. Head Injury TYPES: • Scalp laceration • Skull Fractures • Minor Head Trauma Concussion and post-concussion syndrome • Major Head Trauma: Cerebral contusion Laceration
    6. 6. Head Injury • Scalp lacerations – The most minor type of head trauma – Scalp is highly vascular → profuse bleeding – Major complication is infection
    7. 7. Head Injury • Skull fractures – Linear Skull Fracture – Depressed Skull Fracture – Diastatic Skull Fracture – Basal Skull Fracture – Compound Skull Fracture – Compound elevated Skull Fracture – Growing Skull Fracture
    8. 8. Head Injury • Skull fractures – Location of fracture alters the presentation of the manifestations – Facial paralysis – Conjugate deviation of gaze – Battle’s sign, Raccoon eyes
    9. 9. Battle’s SignBattle’s Sign Fig. 55-13
    10. 10. Head Injury • Basal Skull fractures – CSF leak (extravasation) into ear (Otorrhea) or nose (Rhinorrhea) – High risk infection or meningitis – “HALO Sign ” on clothes of linen – Possible injury to Internal carotid artery – Permanent CSF leaks possible
    11. 11. Investigations  X-ray  CT scan: standard modality  MRI  Bleeding from the ear or nose in cases of suspected CSF leak -"halo" or "ring" sign , when dabbed on a tissue paper  CSF leak - analyzing the glucose level and by measuring tau-transferrin.
    12. 12. Management Pre-hospital care: • Patients with severe head injuries should be assumed to have a cervical spine (C-spine) injury and immobilized with until clinical and radiographic studies can prove otherwise • Minimize CSF leak – Bed flat – Never suction orally; never insert NG tube; never use Q-Tips in nose/ears; caution patient not to blow nose • Place sterile gauze/cotton ball around area Definitive Rx: • Measures to reduce ICP • Supportive management • Surgery
    13. 13. Head Injury • Minor head trauma – Concussion : head injury with a temporary loss of brain function concussion can cause a variety of physical, cognitive , and emotional symptoms. Cause: Sudden acceleration and deceleration injury eg: Car accident, sports injury, bicycle accident etc
    14. 14. Head Injury Types of Head Injuries Concussion Presentation: Physical-headache, LOC, Amnesia, s/s of ↑ ICP(Cushing’s triad) , convulsions Cognitive : confusion, irritability, behavioral changes
    15. 15. Head Injury • Minor head trauma – Postconcussion syndrome • 2 weeks to 2 months • Persistent headache • Lethargy • Personality and behavior changes
    16. 16. Head Injury • Major head trauma – Includes cerebral contusions and lacerations – Both injuries represent severe trauma to the brain
    17. 17. Head Injury • Major head trauma – Contusion • The bruising of brain tissue within a focal area that maintains the integrity of the pia mater and arachnoid layers associated with multiple micro-hemorrhages, small vessel bleed into brain tissue – Lacerations • Involve actual tearing of the brain tissue • Intracerebral hemorrhage is generally associated with cerebral laceration
    18. 18. Head Injury Cerebral Contusion Cerebral Laceration
    19. 19. Head Injury Pathophysiology • Diffuse axonal injury (DAI) – Widespread axonal damage occurring after a mild, moderate, or severe TBI – Seen in half the cases of head injury – Process takes approximately 12-24 hours
    20. 20. Head Injury Pathophysiology • Diffuse axonal injury (DAI) – Clinical signs: ∀↓ Level of Consciousness ∀↑ ICP • Decerebration or decortication • Global cerebral edema • 90% regain consciousness from severe DAI
    21. 21. Intracranial Hemorrhage Extra- axial hemorrhage • Epidural hematoma • Subdural hematoma- Acute Chronic • Subarachnoid hemorrhage Intra-axial hemorrhage • Intra-parenchymal hemorrhage • Intra-ventricular hemorrhage
    22. 22. Epidural hematoma – Results from bleeding between the dura and the inner surface of the skull – MC type of traumatic Intracranial bleed, rarely occurs spontaneously – A neurologic emergency – Bleed is Venous or arterial origin
    23. 23. Epidural hematoma Source of Bleed : Temperoparietal locus (most likely) - Middle meningeal artery Frontal locus - anterior ethmoidal artery Occipital locus - transverse or sigmoid sinuses Vertex locus - superior sagittal sinus Clinical Features: • LOC>>> Lucid Interval >> unconsciousness • s/s of raised ICP • Focal neurological deficit • s/s of cerebral herniation
    24. 24. Subdural hematoma – Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain – Source of bleed: Bridging veins; May be caused by an arterial hemorrhage – Much slower to develop into a mass large enough to produce symptoms. Cause: Acceleration-deceleration injury, direct trauma, Risk factors: Elderly, dementia, alcoholics, shaken baby syndrome, pts on anticoagulants
    25. 25. Subdural hematoma – Acute subdural hematoma(<72hrs) • High mortality • Associated with major direct trauma (Shearing Forces) Clinical Features: Headache, fluctuating LOC, confusion, dilated fixed pupil, deviated gaze CT scan: hyperdense
    26. 26. Subdural hematoma – Subacute subdural hematoma • Occurs within 4-21 days of the injury • Failure to regain consciousness may be an indicator CT scan: Isodense or hypodense – Chronic subdural hematoma(>3wks) • Develops over weeks or months after a seemingly minor head injury, probably from repeat minor bleeds CT scan : hypodense
    27. 27. Epidural and Subdural HematomasEpidural and Subdural Hematomas Fig. 55-15 Epidural Hematoma Subdural Hematoma
    28. 28. Epidural and Subdural HematomasEpidural and Subdural Hematomas Hematoma type Epidural Subdural Location Between the skull and the dura Between the dura and the arachnoid Involved vessel Temperoparietal (most likely) - Middle meningeal artery Frontal - anterior ethmoidal artery Occipital - transverse or sigmoid sinuses Vertex - superior sagittal sinus Bridging veins Symptoms Lucid interval followed by unconsciousness Gradually increasing headache and co nfusion CT appearance Biconvex lens- limited by suture lines Crescent shaped- crosses suture lines Fig. 55-15
    29. 29. Subarachnoid Hemorrhage Causes: • Rupture of Berry aneurism(MCC) • Trauma (fracture at the base of the skull leading to internal carotid aneurysm) • Amyloid angiopathy • Blood dyscrasias • Vasculitis Clinical Features: • Explosive or thunderclap headache, “worst headache of my life”, • nausea and vomiting, decreased LOC or coma. • Signs of meningeal irritation
    30. 30. Intracerebral Hemorrhage (ICH) Intracranial hemorrhage is hemorrhage that occurs within the brain tissue itself; an intra-axial hemorrhage. Two main types: 1)Intraparencymal hemorrahge- ICH extending into brain parenchyma; MCC- HTNsive vasculopathy 2)Intra-ventricular hemorrhage- ICH extending into ventricles; MCC –trauma Causes: Hypertensive vasculopathy(70-80%) Ruptured AVM Trauma Blood dyscracias
    31. 31. Intracerebral Hemorrhage (ICH) Clinical presentation: Rapidly progressive severe headache, building over several minutes, often accompanied by focal neurological deficits, nausea and vomiting, decreased level of consciousness. S/S depend site of hemorrhage: Basal ganglia/internal capsule - hemiparesis, dysphasia Cerebellum - ataxia, vertigo Pons - cranial nerve deficits, coma Cerebral cortex - hemiparesis, hemisensory loss, hemianopsia, dysphasia
    32. 32. Complications • Neurological deficits or death • Seizures • Obstructive Hydrocephalus • Spasticity • Urinary complications • Aspiration pneumonia • Cushing’s ulcer • Neuropathic pain • Deep venous thrombosis • Pulmonary emboli • Cerebral herniation
    33. 33. Cerbral Herniation Brain herniation is a deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull. “Brain herniation represents mechanical displacement of normal brain relative to another anatomic region secondary to mass effect from traumatic, neoplastic, ischemic, or infectious etiologies. “
    34. 34. Cerbral Herniation Supratentorial herniation 1. Uncal 2. Central (transtentorial) 3. Cingulate (subfalcine) 4. Transcalvarial Infratentorial herniation 5. Upward (upward cerebellar or upward transtentorial) 6. Tonsillar (downward cerebellar)
    35. 35. Cingulate Herniation The most common type, the innermost part of the frontal lobe is scraped under part of the falx cerebri, the dura mater at the top of the head between the two hemispheres of the brain. Cingulate herniation can be caused when one hemisphere swells and pushes the cingulate gyrus by the falx cerebri. Cingulate herniation is frequently believed to be a precursor to other types of herniation
    36. 36. Uncal Herniation common subtype of cerebral herniation following raised ICP Innermost part of the temporal lobe, the uncus, can be squeezed so much that it moves towards the tentorium and puts pressure on the brainstem, most notably the midbrain Clinical feature: • Compression of I/L CN III- I/L fixed dilted pupil • Compression of I/L PCA- C/L homonymous hemianopsia • Compression of C/L crus cerebri- I/L hemiparesis • Duret hemorrhage
    37. 37. Diagnostic Studies CT scan – • A GCS score less than 15 after blunt head trauma warrants a patient with no intoxicating consideration of an urgent CT scan.
    38. 38. CT findingsCT findings Fig. 55-15 Epidural Hematoma Subdural Hematoma
    39. 39. CT findingsCT findings Fig. 55-15 Subarachnoid hemorrhage Intracerebral hematoma
    40. 40. Diagnostic Studies • MRI – superior for demonstrating the size of an acute subdural hematoma. • Cerebral angiogram if hemorrhage is confirmed (not necessary in case of classic hypertensive hemorrhage • Cervical spine X-ray • EEG • Lumbar Pucture
    41. 41. Management 1) Supportive Measures: • Endotracheal intubation for patients with decreased level of consciousness and poor airway protection. • Cautiously lower blood pressure to a MAP less than 130 mm Hg, but avoid excessive hypotension.[10] • Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan. • Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema • Avoid hyperthermia. • Facilitate transfer to the operating room or ICU.
    42. 42. Management 2) Decrease cerebral edema: • Modest passive hyperventilation to reduce PaCO2 • Mannitol, 0.5-1.0 gm/kg slow iv push • Furosemide 5-20 mg iv • Elevate head 20-30 degrees, avoid any neck vein compression • Sedate and paralyze if necessary with morphine and vecuronium (struggling, coughing etc will elevate intracranial pressure)
    43. 43. Management 3) Surgical Evacuation of hematoma: • No surgical intervention if collection <10ml Indication of surgical decompression: • The GCS score decreases by 2 or more points between the time of injury and hospital evaluation • The patient presents with fixed and dilated pupils • The intracranial pressure (ICP) exceeds 20 mm Hg Exception : In Subdural hematoma with GCS=15- hematoma >10mm ,or >5mm midline shift ---- requires Surgical decompression SAH: whn a cerebral aneurysm is identified on angiography, clipping and coiling is done to prevent re-bleed
    44. 44. Management Sugical Decompression contd.. Types: • Burr-hole • Craniotomy- bone flap is temporarily removed from the skull to access the brain • Craniectomy – in which the skull flap is not immediately replaced, allowing the brain to swell, thus reducing intracranial pressure • Cranioplasty - surgical repair of a defect or deformity of a skull.
    45. 45. Management 4) Medical therapy: • Antihypertensives - reduce blood pressure to prevent exacerbation of intracerebral hemorrhage in hypertensive encephalopathy. Eg Nicardipine, labetolol; CCB help relieve vasospasm in SAH and decrease further damage • Diuretics - Mannitol, CAI • Anticonvulsants – reduce frequency of seizures and prophylaxis of seizures eg: Fosphenytoin • Antipyretics- to Rx fever and pain relief eg: Acetaminophene • Antidote- VitK/FFP for warfarin overdose; protamine for heparin overdose • Antacids- prophylaxis for Cushing’s gastric ulcer eg: Famotidin • Glucorticoids may help reduce the head and neck ache caused by the irritative effect of the subarachnoid blood.
    46. 46. Preventive Measures Health Promotion • Prevent car and motorcycle accidents • To Wear safety helmets
    47. 47. Rehabilitation Ambulatory and Home Care • Nutrition • Bowel and bladder management • Spasticity • Dysphagia • Seizure disorders • Family participation and education
    48. 48. References: • Harrison's Principles of Internal Medicine • Medscape Reference http://emedicine.medscape.com • US National Library of Medicine National Institutes of Health http://www.ncbi.nlm.nih.gov

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