14. Head Trauma And Acute Intracranial Events Flashcards
What is cerebral contusion?
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.
What is concussion?
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.
What is post concussion syndrome?
A mixture of emotional and psychological symptoms that can occur after concussion for weeks to years.
What is diffuse atonal injury?
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.
Racoon eyes, CSF rhinorrhea, CSF otorrhea, battle sign, heamotympanum and a bump is a sign of what type of head injury?
Basilar skull fracture.
What is a basilar skull fracture?
Bony fracture within the base of the skull of the temporal, occipital, sphenoid or ethmoid bone. Tears the meninges causing CSF leakage.
How would you manage a patient with a basilar skull fracture?
Traumatic brain injury management including ICP control.
Seek and treat complications.
Elevation of depressed skull fractures.
Persistent CSF leak needs surgery.
What is an extradural haemorrhage?
A collection of blood between the inner surface of the skull and periosteal dura matter. Usually supratentorial.
What is the main cause of an extradural haemorrhage?
Usually severed middle meningeal artery secondary to trauma and/or skull fracture.
Venous involvement causing an extradural haemorrhage is rare, but if it does occur, what veins are usually torn?
Venous sinus.
What signs/symptoms are seen in a patient with an extradural haemorrhage?
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.
How is a small extradural haemorrhage managed?
Observes and managed conservatively with neurological follow up.
How is a large extradural haemorrhage managed?
Referral to neurosurgery for craniotomy and clot evacuation.
What is the prognosis of a patient with an extradural haemorrhage?
Prognosis is generally good with early intervention.
How does an extradural haemorrhage appear on a scan?
Lemon shaped (lentiform/biconvex).
Name 3 complications that can arise from an extradural haemorrhage?
Permanent brain damage. Coma. Seizures. Weakness. Psuedoaneurysm. Arteriovenous fistula.
What is a subdural haemorrhage?
A collection of blood between the meningeal dura mater and arachnoid mater.
What is the main cause of a subdural haemorrhage?
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.
What increases the risk of cortical bridging vein rupture and therefore subdural haemorrhage?
Cerebral atrophy.
What signs/symptoms does a patient with a subacute/chronic subdural haemorrhage tend to present with?
Elderly.
Insidious onset of confusion and general cognitive decline similar to dementia.
How would you manage a patient with an acute subdural haemorrhage?
Immediate neurosurgical intervention to relieve raised ICP via craniotomy.
What is the prognosis of a patient with a subdural haemorrhage?
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.
How would you manage a patient with a subacute/chronic subdural haemorrhage?
Neurosurgical intervention to create one or more burr hole.
What is a subarachnoid haemorrhage?
Collection of blood between the arachnoid mater and pia mater.
What is the main cause of a subarachnoid haemorrhage?
Spontaneously secondary to a ruptured berry aneurysm (can also be traumatic).
What signs/symptoms does a patient wit a subarachnoid haemorrhage tend to present with?
Middle aged. Largely asymptomatic. Sudden onset ‘thunderclap’ headache. Meningioma. Nausea and vomiting. Fever. Focal neurological deficits. Loss of consciousness.
What signs/symptoms does a patient with a berry aneurysm tend to present with and when do symptoms arise in a berry aneurysm?
Largely asymptomatic.
Symptoms arise if the aneurysm is compressing on nearby structures or during early stages of rupture.
How would you manage a patient with a berry aneurysm?
If risk of rupture is high then treat with surgical clipping and endovascular coiling.
Name 2 risk factors that can predispose a patient to berry aneurysms
Family history.
Hypertension.
Heavy alcohol consumption.
Abnormal connective tissue eg autosomal dominant polycystic kidney disease, Ehlers-Danlos, neurofibromatosis, marfan’s disease.
How does a subarachnoid haemorrhage appear on a scan?
Focal, blood can appear anywhere where CSF normally is eg in ventricles.
What procedure would you use to aid diagnosis of a subarachnoid haemorrhage? What would it show?
Lumbar puncture - presence of RBCs (the same number in 3 bottles) and Xanthochromia (within 12 hours after symptom onset).
What is the prognosis of a patient with a subarachnoid haemorrhage?
Depends on GCS, degree of neurological deficit at the time of presentation, and comorbidities. Mortality is between 30 and 90%.
Name 3 complications of a subarachnoid haemorrhage.
Hydrocephalus. Focal neurological deficits. Coma. Seizures. Cognitive decline. Frequent headaches. Hypopituitarism.
How would you manage a patient with a subarachnoid haemorrhage?
Stabilise the patient, prevent rebleeding, treat cerebral vasospasm, correct hyponatraemia, and neurosurgical intervention if large bleed.
How does a subdural haemorrhage appear on a scan?
Banana shaped (crescent/sickle).
Acute - hyperdense (more white).
Subacute/chronic - hypotenuse (dark).
