A.12 - Traumatic intracranial bleeding Flashcards
How can traumatic intracranial bleeding occur?
either extradural or intradural
intradural hematomas are usually a mix of subdural and intracerebral hematomas,
although pure subdural can happen
what is subdural intracranial bleeding?
- impact rupture bridging veins from the cortical surface to the venous sinuses
- no underlying cortical contusion or laceration
what is Extradural intracranial bleeding?
- a skull fracture tearing the middle meningeal vessels (occasionally damage to sagittal/transverse sinuses)
- usually in the temporal/temporoparietal region
how Brain damage can be causes in traumatic intracranial bleeding?
- damage is caused directly or indirectly
- as a result of tentorial or tonsillar herniation
what can create a space occupying hematoma?
Bleeding that arises in multiple contusions
○ Contusion are usually multiple and can occur under or opposite (contre-coup) to the site of impact
○ most commonly in the frontal and temporal lobes
what is Burst lobe?
Intracerebral hematoma mixed w/ necrotic brain tissue, rupturing into the subdural space
Is it possible that high IC pressure alone damages neuronal tissue?
It is unlikely that high IC pressure alone damages neuronal tissue, but usually occurs as a result of tonsillar or tentorial herniation
how can tentorial herniation occur?
○ Supratentorial hematoma → midline shift → herniation of medial temporal lobe through the tentorial hiatus (lateral tentorial herniation) → midbrain compression
○ Uncontrolled lateral tentorial herniation or diffuse bilateral hemispheric swelling → central tentorial herniation → tonsillar herniation
how can tonsillar herniation occur?
Traumatic posterior fossa hematoma → tonsillar herniation
what to assess if suspecting intracranial bleeding?
figure out if its:
● Multiple injury
● Head injury
● Suspected IC hematoma → CT!
how to assess multiple injury?
airway → breathing → circulation → head/spinal injury → limb injuries
how to assess head injury?
points to determine:
○ Period of loss of consciousness: relates to severity of diffuse brain damage
○ Period of post-traumatic amnesia: reflects severity of damage
○ Period of retrograde amnesia
○ Cause and circumstances of the injury: e.g. epilepsy
○ Presence of headache and vomiting: if they persists, IC hematoma must be considered
how to examine intracranial bleeding?
Vital signs: ↑ IC pressure → ↑ BP, ↓HR, abnormal respiratory patterns
1) Evidence of injury (lacerations, bruising)
2) Basal fracture signs
3) Conscious level - GCS
4) Pupil response
5) Limb weakness
6) Eye movement
when examining intracranial bleeding, what are the evidence of injury?
● Traumatic IC hematoma can occur with no external evidence of injury!
● Always examine deep lacerations w/ a finger for a depressed fracture
● Don’t misdiagnose a scalp hematoma (soft fluctuant center w/ firm rim) as a depressed fracture
● Consider hyperextension injury to the cervical spine if frontal laceration/bruising
when examining intracranial bleeding, what are the sings of Basal fracture?
● Clinical features are very important as it may be hard to detect on imaging!
○ Anterior fossa fracture:
- CSF rhinorrhea (contains glucose)
- bilateral periorbital hematoma
- subconjunctival hemorrhage
○ Petrous fracture:
- bleeding from ext. auditory meatus or CSF otorrhea
- bruising over the mastoid (Battle’s sign)
● Potential route of infection
when examining intracranial bleeding, what is the Conscious level - GCS?
● Eye movement
● Verbal response
● Motor response
when examining intracranial bleeding, what is the pupils response?
● The pupil dilates on the side of the expanding lesion
● Light reflex: tests optic and oculomotor nerve
● Herniation of middle temporal lobe through tentorial hiatus → direct damage to CN III (most useful indicator of an expanding IC lesion)
when examining intracranial bleeding, what does limb weakness indicates?
● Hemiparesis/hemiplegia usually occur contralaterally to the lesion (decussation of pyramidal tracts)
● False localising sign = ipsilateral deficit caused by a notch in the contralateral cerebral peduncle, often seen in chronic subdural hematomas,
● Determine by comparing response to pain stimuli
when examining intracranial bleeding, what does eye movement indicates?
● Abnormal eye movement:
- brain stem dysfunction
- damage to the nerves supplying the extraocular muscles
- damage to the vestibular apparatus
● Absent eye movements → low level of responsiveness, bad prognosis
what are the Referral criteria in traumatic intracranial bleeding?
● Adults:
- GCS <13 on assessment or <15 2h from injury
- suspected open/depressed skull fracture
- signs of basal skull fracture
- post trauma seizure
- focal neurological deficit
- >1 episode of vomiting
● Children: use a lower threshold
During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Extradural level?
- increased density
- convex inwards
- pread limited by dural adhesion to skul
- midline shift w/ compression of lat. ventricle, dilated contralat. ventricle due to obstruction of foramen of
Munro
During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Subdural level?
area of increased density spreading around the surface of cerebral hemisphere becomes isodense with brain (10-12 d after), then hypodense
During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Intracerebral level?
burst lobe ± subdural hematoma appearing as an irregular area of increased density (blood clot) surrounded by area of low density (edematous brain)
how is the Management of traumatic intracranial bleeding if it is Extradural?
- horseshoe craniotomy flap w/ complete evacuation of the hematoma
- burr hole and craniectomy if rapid deterioration for temporary relief
how is the Management of traumatic intracranial bleeding if it is Subdural/intracerebral?
questionmark flap over temporal and/or frontal areas w/ subdural/intracerebral evacuation of hematoma and necrotic brain
what is Chronic subdural hematoma?
Occurs mainly in infancy and elderly w/ trauma as the likely cause
what are the Predisposing factors of Chronic subdural hematoma?
- cerebral atrophy causing stretching of bridging veins
- low CSF pressure (after shunt of fistula) causing stretching of bridging veins
- alcoholism
- coagulation disorder
Clinical features of Chronic subdural hematoma?
○ Dementia
○ Deterioration of consciousness, fluctuating
○ S&S of ↑ICP
○ Focal signs, especially ipsilateral limb weakness
Diagnosis of Chronic subdural hematoma?
CT:
- isodense lesions 1-3w after injury → contrast material
- hypodense after 3w
- check midline shift and shape of ventricles
Management of Chronic subdural hematoma?
○ Hematoma is evacuated through burr holes and washed w/ saline
○ Conservative treatment w/ steroids if no depressed consciousness
