14. Head Trauma And Acute Intracranial Events

Question 1

What is cerebral contusion?

Answer 1

Bruising of the brain (due to coup and Conroe-coup) whereby blood mixes with cortical tissue due to micro-haemorrhages and small blood vessel leaks. Causes cerebral oedema/intracerebral bleed, raised ICP and coma.

Question 2

What is concussion?

Answer 2

Head injury with a temporary loss of brain function due to the stretching and injury of axons, leading to impaired neurotransmission, loss of ion regulation, and a reduction in cerebral blood flow.

Question 3

What is post concussion syndrome?

Answer 3

A mixture of emotional and psychological symptoms that can occur after concussion for weeks to years.

Question 4

What is diffuse atonal injury?

Answer 4

Shearing of the interface between grey and white matter following traumatic acceleration/deceleration or rotational injuries to the brain damaging the intracerebral axons and dendritic connections. Leads to axonal death, cerebral oedema, raised ICP and coma.

Question 5

Racoon eyes, CSF rhinorrhea, CSF otorrhea, battle sign, heamotympanum and a bump is a sign of what type of head injury?

Answer 5

Basilar skull fracture.

Question 6

What is a basilar skull fracture?

Answer 6

Bony fracture within the base of the skull of the temporal, occipital, sphenoid or ethmoid bone. Tears the meninges causing CSF leakage.

Question 7

How would you manage a patient with a basilar skull fracture?

Answer 7

Traumatic brain injury management including ICP control.
Seek and treat complications.
Elevation of depressed skull fractures.
Persistent CSF leak needs surgery.

Question 8

What is an extradural haemorrhage?

Answer 8

A collection of blood between the inner surface of the skull and periosteal dura matter. Usually supratentorial.

Question 10

What is the main cause of an extradural haemorrhage?

Answer 10

Usually severed middle meningeal artery secondary to trauma and/or skull fracture.

Question 11

Venous involvement causing an extradural haemorrhage is rare, but if it does occur, what veins are usually torn?

Answer 11

Venous sinus.

Question 12

What signs/symptoms are seen in a patient with an extradural haemorrhage?

Answer 12

Young patient.
Presents with loss of consciousness, followed by a transient recovery known as the lucid interval (in 40% of patients). The haematoma enlarges over time, and ICP increases causing compression of the brain and so a rapidly deteriorating level of consciousness with possible cranial nerve palsies as brain structures herniate.

Question 13

How is a small extradural haemorrhage managed?

Answer 13

Observes and managed conservatively with neurological follow up.

Question 14

How is a large extradural haemorrhage managed?

Answer 14

Referral to neurosurgery for craniotomy and clot evacuation.

Question 15

What is the prognosis of a patient with an extradural haemorrhage?

Answer 15

Prognosis is generally good with early intervention.

Question 16

How does an extradural haemorrhage appear on a scan?

Answer 16

Lemon shaped (lentiform/biconvex).

Question 17

Name 3 complications that can arise from an extradural haemorrhage?

Answer 17

Permanent brain damage.
Coma.
Seizures.
Weakness.
Psuedoaneurysm.
Arteriovenous fistula.

Question 18

What is a subdural haemorrhage?

Answer 18

A collection of blood between the meningeal dura mater and arachnoid mater.

Question 20

What is the main cause of a subdural haemorrhage?

Answer 20

Acute - bleeding due to shearing forces on the cortical bridging veins secondary to trauma (but can be spontaneous).
Subacute/chronic - elderly with vague or absent history of head trauma.

Question 21

What increases the risk of cortical bridging vein rupture and therefore subdural haemorrhage?

Answer 21

Cerebral atrophy.

Question 22

What signs/symptoms does a patient with a subacute/chronic subdural haemorrhage tend to present with?

Answer 22

Elderly.

Insidious onset of confusion and general cognitive decline similar to dementia.

Question 23

How would you manage a patient with an acute subdural haemorrhage?

Answer 23

Immediate neurosurgical intervention to relieve raised ICP via craniotomy.

Question 24

What is the prognosis of a patient with a subdural haemorrhage?

Answer 24

Prognosis is poor. Mortality in acute subdural haematomas requiring surgical intervention exceeds 50%, with worse outcomes in patients who are anticoagulated, and full recovery only achieved in 20% of patients.

Question 25

How would you manage a patient with a subacute/chronic subdural haemorrhage?

Answer 25

Neurosurgical intervention to create one or more burr hole.

Question 26

What is a subarachnoid haemorrhage?

Answer 26

Collection of blood between the arachnoid mater and pia mater.

Question 27

What is the main cause of a subarachnoid haemorrhage?

Answer 27

Spontaneously secondary to a ruptured berry aneurysm (can also be traumatic).

Question 28

What signs/symptoms does a patient wit a subarachnoid haemorrhage tend to present with?

Answer 28

``` Middle aged. Largely asymptomatic. Sudden onset ‘thunderclap’ headache. Meningioma. Nausea and vomiting. Fever. Focal neurological deficits. Loss of consciousness. ```

Question 29

What signs/symptoms does a patient with a berry aneurysm tend to present with and when do symptoms arise in a berry aneurysm?

Answer 29

Largely asymptomatic. | Symptoms arise if the aneurysm is compressing on nearby structures or during early stages of rupture.

Question 30

How would you manage a patient with a berry aneurysm?

Answer 30

If risk of rupture is high then treat with surgical clipping and endovascular coiling.

Question 31

Name 2 risk factors that can predispose a patient to berry aneurysms

Answer 31

Family history. Hypertension. Heavy alcohol consumption. Abnormal connective tissue eg autosomal dominant polycystic kidney disease, Ehlers-Danlos, neurofibromatosis, marfan’s disease.

Question 32

How does a subarachnoid haemorrhage appear on a scan?

Answer 32

Focal, blood can appear anywhere where CSF normally is eg in ventricles.

Question 33

What procedure would you use to aid diagnosis of a subarachnoid haemorrhage? What would it show?

Answer 33

Lumbar puncture - presence of RBCs (the same number in 3 bottles) and Xanthochromia (within 12 hours after symptom onset).

Question 34

What is the prognosis of a patient with a subarachnoid haemorrhage?

Answer 34

Depends on GCS, degree of neurological deficit at the time of presentation, and comorbidities. Mortality is between 30 and 90%.

Question 35

Name 3 complications of a subarachnoid haemorrhage.

Answer 35

``` Hydrocephalus. Focal neurological deficits. Coma. Seizures. Cognitive decline. Frequent headaches. Hypopituitarism. ```

Question 36

How would you manage a patient with a subarachnoid haemorrhage?

Answer 36

Stabilise the patient, prevent rebleeding, treat cerebral vasospasm, correct hyponatraemia, and neurosurgical intervention if large bleed.

Question 44

How does a subdural haemorrhage appear on a scan?

Answer 44

Banana shaped (crescent/sickle). Acute - hyperdense (more white). Subacute/chronic - hypotenuse (dark).