19. Le Fort I fracture: horizontal detachment
of maxilla at level of nasal floor
Le Fort II fracture: fracture through maxillae,
antra, nasal bones, and infraorbital rims
Le Fort III fracture: fracture through zygomatic bones
and orbits, separating facial bones from cranial vault
Craniofacial dysjunction in Le Fort III
fracture distorts facial symmetry
19
20. Longitudinal (A) and transverse (B)
fractures of petrous pyramid of temporal
bone, and anterior basal skull fracture (C)
“Panda bear” or “raccoon” sign due to leakage of blood from
anterior fossa into periorbital tissues. Absence of conjunctival
injection differentiates fracture from direct eye trauma.
Battle sign: postauricular hematomaOtorrhea
Rhinorrhea
20
25. • Epidural hematoma usually results from a brief linear contact force to the
calvaria that causes separation of the periosteal dura from bone and
disruption of interposed vessels due to shearing stress.
• they are much less common in children because of the plasticity of the
immature calvaria.
• Extension of the hematoma usually is limited by suture lines owing to the tight
attachment of the dura at these locations.
Background
25
28. • Epidural hematoma should be suspected in any individual who sustains head trauma.
• Can be associated with a lucid interval between the initial loss of consciousness at the
time of impact and a delayed decline in mental status.
• Symptoms:
Headache
Nausea/vomiting
Seizures
Focal neurologic deficits (eg, visual field cuts, aphasia, weakness, numbness)
Symptoms
28
29. • Bradycardia +/- hypertension indicative of elevated intracranial pressure
• Skull fractures, hematomas, or lacerations
• CSF otorrhea or rhinorrhea resulting from skull fracture
• Alteration in level of consciousness (ie, Glasgow Coma Scale score)
• Anisocoria (ipsilateral dilation of the pupil)
• Weakness
• Other focal neurological deficits (eg, aphasia, visual field defects, numbness, ataxia)
Signs
29
30. •CBC - To monitor for infection and assess hematocrit and platelets for further hemorrhagic risk.
•PT/ aPTT - To identify bleeding diathesis.
•Serum alcohol level - To identify associated causes of head trauma and establish need for
surveillance with regard to withdrawal symptoms.
•Blood group and cross match - To prepare for necessary transfusions needed because of blood
loss or anemia
•Non-contrast CT - hyperdense lenticular-shaped mass situated between the brain and the skull
Investigations
30
32. Craniotomy is followed by evacuation of the hematoma, coagulation of
bleeding sites, and inspection of the dura. The dura is then tented to the
bone and, occasionally, epidural drains are employed for as long as 24
hours.
CT scanning performed before and after surgical evacuation of an intracranial
epidural hematoma.
•Minimally invasive surgical procedures, including the use of burr holes and
negative pressure drainage.
Management
32
35. • The most common intracranial mass lesions
of brain injury
• It’s a collection of blood below the inner
layer of the dura but external to the brain
and arachnoid due to laceration of vessels
(especially small cerebral veins) on the
brain surface, or 'bursting' of the brain.
• Subdural hematoma occurs in patients with
severe head injury and on elderly patients
who are elderly or who are receiving
anticoagulants.
Background
35
36. high-speed impact to the skull.
the torn blood vessel is a vein that connects
the cortical surface of the brain to a dural
sinus (termed a bridging vein).
In elderly, the bridging veins may already be
stretched because of brain atrophy
(shrinkage that occurs with age)
Mechanism
36
37. Symptoms : If not comatose;
•Headache
•Nausea
•Confusion
•Personality change
•Decreased level of consciousness
•Speech difficulties
•Impaired vision or double vision
•Weakness
On Examination(Acute presentation):
•Altered level of consciousness
•A dilated or nonreactive pupil ipsilateral to the hematoma
(or earlier, a pupil with a more limited range of reaction)
•Hemiparesis contralateral to the hematoma
What about chronic?
Signs and Symptoms
37
38. •Complete blood count
•Hemoglobin or hematocrit
•Coagulation profile
•Blood group and cross match
•Non-contrast CT scan:
acute: hyperdense (white), crescent-shaped mass
between the inner suface of the skull and the surface of
the cerebral hemisphere. It’s concave toward the brain and
unlimited by suture lines
Chronic: Hypodense
Investigations
38
39. “Question mark” skin incision
(black); outline of free bone
flap and burr holes (red)
Catheter to monitor intracranial
pressure, emerging through burr
hole and stab wound
Bone and skin flaps
replaced and sutured
Jackson-Pratt drain,
emerging from
subdural space via
burr hole and
stab wound
• Surgical decompression:
if the acute subdural
hematoma is associated
with a midline shift
greater than or equal
to 5 mm. or subdural
hematomas exceeding
1 cm in thickness.
Skin flap reflected (Raney clips control
bleeding); free bone flap removed and
dura opened; clot evacuated by
irrigation, suction, and forceps
Management
39
41. extravasation of blood into the subarachnoid space
between the pia and arachnoid membranes.
It can be due to:
head trauma or spontaneous hemorrhage
Prodormal :
•Headache
•Dizziness
•Orbital pain
•Diplopia
•Visual loss
The headache +/- nausea +/-
vomiting from increased ICP +
meningeal irritation.
Focal neurologic deficits may also
occur.
Background
Sudden onset of severe
headache (thunderclap
headache), described as the
"worst headache of my life."
Symptoms
41
42. Sudden, severe,
explosive headache
Transient or persistent alteration in consciousness
ranging from disorientation to deep coma.
Fever, sweating, vomiting
and tachycardia are
frequently present.
Diplopia and/or photophobia
also common
Kernig sign: resistance to
full extension of leg at
knee when hip is flexed
Brudzinski sign: flexion of both hips and knees
when neck is passively flexed
Signs of meningeal irritation
42
43. • Fever
• Tachycardia
• Hypotension
• Papilledema
• Neurological deficit depends
There are many grading scales (WFNS, FISHER SCALE, HUNT AND HESS)
Signs
43
44. • Non-contrast CT and LP
• Serum chemistry panel - To establish a baseline for detection of future complications
• Complete blood count - For evaluation of possible infection or hematologic
abnormality
• Prothrombin time (PT) and activated partial thromboplastin time (aPTT) - For
evaluation of possible coagulopathy
• Blood group and cross match - To prepare for possible intraoperative transfusions
Investigations
44
45. The goals of treatment in patients with subarachnoid hemorrhage
(SAH) are as follows:
•Blood pressure control – antihypertensives(CCBs)
•Prevention of seizures - Phenytoin
•Treatment of nausea - Promethazine
•Management of intracranial pressure – by restriction of fluids
•Prevention of vasospasm
•Control of pain - Opiods
•Maintenance of cerebral perfusion
Management
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