case study abt brain hematomas

1. CASE STUDY
Dr. Umar Tauqir
PGR RADIOLOGY
AL-Noor Diagnostics

2. • 18years/male presented to us with h/o RTA 2
days back with sudden loss of consciousness
and h/o vomiting as well
• No any other associated or systemic complains
• He was in our department for CT Brain Plain

3. HU UNITS NORMAL VALUES
AIR -1000
LUNG -500
FAT -100 TO -50
WATER 0
CSF +15
KIDNEY +30
BLOOD +30 to +45
MUSCLE +10 to +40
GREY WATER +37 to +45
WHITE MATTER +20 to +30
LIVER +40 to +60
SOFT TISSUE’CONTRAST +100 to +300
BONE +700 (cancellous bone) to +3000
(cortical bone)

4. A Hyper-dense area in temporal lobe extending to parietal lobe
having value of 65 HU most likely represent a epidural Hematoma

5. A linear un-displaced fracture involving frontal bone
extending to temporal bone .

6. 3D Image CT scan
showing
LINEAR fracture
Involving fronto-
temporal region

7. HEAD INJURY
– Any degree of traumatic brain injury ranging
from scalp laceration to LOC to focal neurological
deficits
• Deaths occur at three points in time after
injury:
–Immediately after the injury
–Within 2 hours after injury
–3 weeks after injury

8. TYPES OF HEAD INJURY
• Scalp laceration
• Skull Fractures
• Minor Head Trauma
Concussion and post-concussion syndrome
• Major Head Trauma:
Cerebral contusion
Laceration

9. 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 la

11. DIFFUSE AXONAL INJURY
• 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
• (DAI) is one of the most common and devastating types of traumatic
brain injurymeaning 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.
• It occurs in about half of all cases of severe head trauma and also occurs in
moderate and mild brain injury
• the major cause of damage in DAI is the disruption of axons, the neural
processes that allow one neuron to communicate with another

12. CLINICAL SIGNS
 Level of Consciousness
•  ICP
• De-cerebration or decortication
• Global cerebral edema
• 90% regain consciousness from severe
DAI

13. INTRACEREBRAL HEMHORAGE
Extra- axial hemorrhage
Epidural hematoma
Subdural hematoma-
Subarachnoid hemorrhage
Intra-axial hemorrhage
Intra-parenchymal hemorrhage
Intra-ventricular hemorrhage

14. 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
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

15. SUB DURAL 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, Patients on anticoagulants

16. – 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

17. – 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

18. DIFFERENCE

19. SUB ARACHNOID HEMOHRAGE
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 com

20. INTRACEREBRAL HEMOHRAGE
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

22. Latest trend in Field Of NS
• A new classification of head injury based
primarily on information gleaned from the
initial computerized tomography (CT) scan is
described
It utilizes the status of the
• Mesencephalic cisterns
• The degree of midline shift in millimeters
• The presence or absence of one or more
surgical masses

23. DIFFUSE HEAD
INJURY
DIFFUSE HEAD
INJURY ONE
It includes all
head injuries
where there is
no visible
pathology
DIFFUSE HEAD
INJURY II DIFFUSE HEAD
INJURY III
DIFFUSE HEAD
INJURY IV
Swelling with
cistern absent
or compressed
with mdline
shift 0-5mm
With no high or
mixed density
lesion more
than 25cc
With midline
shift of more
than 5mm
And no high
or mixed
density lesion
of more than
25cc
Cisterns are
present, the
midline shift is
less than 5mm,
no high or mixed
density lesion
more than 25cc

24. 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

25. CEREBRAL 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. “

26. 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)

27. MANAGMENT
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.

28. 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)

29. 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

30. 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.

31. TAKE HOME MESSAGE
CT scan –
• A GCS score less than 15 after blunt head
trauma warrants a patient with no intoxicating
consideration of an urgent CT scan.