1) A 38-year old cricket player was hit on the temple by a cricket ball while fielding without a helmet. He initially seemed fine but later lost consciousness and was found to have a brain hemorrhage. 2) The document discusses lucid intervals which is a period of temporary consciousness that can occur between initial unconsciousness from head trauma and delayed worsening of symptoms from a brain injury like an epidural hematoma. 3) Recognizing lucid intervals is important to prevent delays in treating expanding brain injuries. The cricket player discussed experienced a lucid interval but ultimately died after surgery failed to control his brain hemorrhage.

1. LUCID INTERVAL
BY
SREYA PAUL
118

2. CASE SCENARIO
• A 38 year old cricket player ,while fielding at forward short leg was hit on the
temple by cricket ball hit by fellow batsman. He was not wearing helmet. He
was found lying on the ground. But he was well enough to get up and after
reassuring the fielders that he is okay, went back to dressing room unassisted.
after sometime the player told his teammates that he felt unwell and was
rushed to hospital.by the time he got there he had lost consciousness, and
after he suffered convulsions ,he was operated on to remove a blood clot
from left side of his brain, but there was no hope of recovery and he died
after 3 days, when his life support was turned off.

3. ANATOMY
BRAIN IS AN IMPORTANT ORGAN
• Protective coverings of brain:
1. BONY COVERING OF THE CRANIUM
2. THREE MEMBRANOUS COVERING(MENINGES)
3. CEREBROSPINAL FLUID(CSF) - acts as a water cushion

5. MENINGES
DURAMATER(PACHYMENINX)
ARCHNOID
PIAMATER
LEPTOMENINGES

6. DURAMATER
• Thick, tough , outer covering of the brain
• Consists of two layers:-
Periosteal(outer)
Meningeal(inner)
• Dura partitions
Falx cerebri
Tentorium cerebelli
Falx cerebelli
Diaphragma sellae

7. • ARACHNOID:- thin, avascular, transparent membrane that
loosely surrounds the brain without dipping into its sulcus.
• PIAMATER:- thin, vascular membrane which closely invests the
brain, dipping into various sulci and other irregularities of its surface

9. SPACES BETWEEN THE MENINGES
• Epidural space- between duramater and skull bone.
• Subdural space- between arachnoid and duramater
• Subarachnoid space- between arachnoid and piamater

12. WHAT IS LUCID INTERVAL ??
lucid interval is the short period of consciousness between initial
unconsciousness which occur immediately after accident and
unconsciousness at later stage.
• commonly seen in extradural hematoma

13. CEREBRAL BLOOD FLOW
• Brain is dependent on continuous cerebral blood flow for oxygen and glucose delivery
• CBF= 55mL/min for every 100 g of brain tissue.
• CPP= MAP-ICP
• CPP= 75-105mmHg
• MAP= 90-110mmHg
• ICP= 5-15mmHg
• INCREASED ICP AND REDUCED CPP AND CBF PRODUCES DAMAGE TO THE
BRAIN
• 20 ml /min—ischemia and < 20ml/min cause infarction

14. THE MONRO KELLIE DOCTRINE

18. HERNIATION
• there is rapid increase in ICP ,when there is exhaustion of the compensation
mechanism
• result in herniation of the brain tissue
• the uncus of temporal lobe herniate over the tentorium cerebelli---- pupil
abnormalities
• cerebellar tonsilar herniation through foramen magnum— Cushing's triad–
hypertension, bradycardia and irregular respiration

20. EXTRADURAL HAEMATOMA

21. • Neurosurgical emergency
• Caused due to rupture of an artery, vein or venous sinus, in association with a skull
fracture. There is collection of blood in extra Dural space.
• most commonly in temperoparietal region.
• Examples- road traffic accidents, fall from height, close contact sports , coup and
countercoup injury
• transient loss of consciousness is typical, and the patient may then present in lucid
interval with headache but without neurological deficit.
• as the haematoma expands ,compensation is exhausted.
• there is contra lateral hemiparesis, reduced consciousness level and ipsilateral
pupillary dilatation

22. • classical presentation occurs in only one third cases.
• Takes time to develop, usually presents within 24hrs
• Dura is stripped from site of blow, slowly developing bleed
• Mostly seen in young males... Rarely seen before 2 yrs and after 60 yrs

23. PATHOLOGY
Injury Fracture of thin temporal bone Tear of vessels Bleeding gradual
stripping of Dura from skull and collection of blood occurs in 6-12 hrs. extradural
haematoma occurs increased ICP Coning of supratentorial contents through tentorial
hiatus shift of midbrain towards opposite side injured by sharp edge of tentorial
cerebelli Corticospinal tract gets injured before decussation on opposite side
Hemiparesis, pupillary changes occur on the same side of hematoma
KERNOHAN’S NOTCH EFFECT

24. CLINICAL FEATURES
1. Bruising of scalp
2. Skull fracture across the middle meningeal artery or large venous sinuses
3. Boggy swelling over the temporal region.
4. Severe and increasing headache- distortion of pain sensitive dura
5. Deterioration of conscious level – raised ICP
6. Dilatation of pupil- severe brain stem damage. Once both pupils dilate
and gets fixed- decerebrate rigidity develops, followed by respiratory failure
and death

25. INVESTIGATION
• On CT , extra dural haematoma appear as a
lentiform ( lens shaped or biconvex) hyper
dense lesion between skull and brain,
constrained by the adherence of Dura to the
skull .
• mass effect may be evident, with compression
of surrounding brain and midline shift.
• areas of mixed density suggest active
bleeding.
• a skull fracture is usually evident

27. IMPORTANCE OF LUCID INTERVAL????
• patient is asymptomatic in this period and appears fine
• so it can be easily missed
• lucid interval precede delayed deterioration due to expanding intracranial hematoma.
• recognition of lucid interval is having a great impact on the survival of patient.

28. INITIAL MANAGEMENT
ADVANCED TRAUMA LIFE SUPPORT(ATLS)
PRIMARY SURVEY

29. NEUROLOGICAL ASSESSMENT
• Level of consciousness.
• Glasgow coma scale
• Pupillary reaction
• Pulse
• Temperature
• Blood pressure
• Respiratory rate

30. • Reflexes
• Limb movements- normal/mild weakness/severe weakness/ spastic
flexion/ extension/ no response
• History
• rule out other causes of altered consciousness
• physical examination

31. GLASGOW COMA SCALE- CONSCIOUS LEVEL
Spontaneous 4
To verbal command 3
To Painful stimulus 2
Do not open 1
Eyes open

32. Normal oriented
conversation
5
Confused 4
Inappropriate / words only 3
Sounds only 2
No sounds 1
Intubated patient T
Best verbal response

33. Obeys command 6
Localises to pain 5
Withdrawal or flexion 4
Abnormal flexion 3
Extension 2
No motor response 1
Total score 3-15
Best motor

34. HEAD INJURY CLASSIFICATION
Minor GCS 15 with no loss of consciousness
Mild GCS 14 or 15 with loss of
consciousness
Moderate GCS 9-13
Severe GCS 3-8

35. NATIONAL INSTITUTE FOR HEALTH AND
CARE EXCELLENCE(NICE)
• DISCHARGE CRITERIA IN MINOR AND MILD HEAD INJURY
• GCS 15/15 with no focal deficits
• normal CT brain if indicated
• patient not under influence of alcohol or drugs
• responsible adult accompanied

36. • verbal and written head injury advice: seek medical attention if:
persistent worsening of condition
persistent vomiting
drowsiness
visual disturbance
limb weakness or numbness

37. NATIONAL INSTITUTE FOR HEALTH AND
CARE EXCELLENCE(NICE)
CT SCAN GUIDELINES

38. • CRITERIA FOT CT-SCAN IN HEAD INJURY within 1 hour
• GCS<13 AT ANY POINT
• GCS <15 at 2hrs
• Focal neurological deficit
• Suspected open , depressed or basal skull fracture
• More than one episode of vomiting
• Any patient with a mild head injury over the age 65yrs or with coagulopathy
• Dangerous mechanism of injury or retrograde amnesia >30 min warrants CT within 8hrs

39. DRUGS
• Sedation is avoided
• Analgesics and anticonvulsants- phenobarbitone or phenytoin
• Diuretics to reduce cerebral edema-either mannitol 20% 200ml IV 8th hourly or
furosemide 40mg 8th hourly
• Antibiotics- penicillin, ampicillin, to prevent meningitis

40. • IMMEDIATE SURGICAL INTERVENTION IS A MUST TO SAVE
LIFE OF THE PATIENT
• Craniotomy is done and cranial flaps are raised.
• Dura is fixed using- Hitch Stitches
• Antibiotics and anticonvulsants are given postoperatively
• Recovery is good after surgery

43. COMPLICATIONS
EARLY
• Brain stem injury- due to coning
• Compression over cerebellum and
medulla
• CSF rhinorrhea
• CSF ottorrhoea
• Meningitis
LATE
• Chronic subdural hematoma
• post-traumatic epilepsy
• Post traumatic amnesia
• Post traumatic hydrocephalous
• Post traumatic headache

44. LUCID INTERVAL IN FORENSIC MEDICINE
 this is a period occurring in the case of mental illness during which there is
complete cessation of the symptoms of mental illness, so, that person can
judge his acts normally
 this is the temporary period of resolution of symptoms in a mentally ill
person

45. MEDICO LEGAL IMPORTANCE
1) in lucid interval ,a person can judge his acts
2) during this period a person is held responsible for his criminal act
3) a person can make valid will
4) can give evidence
5) a person can make contract

46. RAMAN LAMBA
• Raman lamba was an Indian cricketer, mainly a
batsman. He died in 23 February 1998 , after slipping
into coma due to internal hemorrhage three days after
being hit on the temple by ball while fielding in
Bangladesh's league cricket. Sources reveal that
lamba was not wearing a helmet. Although he was
fine initially, his conditioned worsened later , was
hospitalized , operated for the clot but could not be
saved

47. Natasha Richardson

49. Thanku!!
No head injury is too slight to neglect, not too severe to be despaired of
-Hippocrates