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