A.12 - Traumatic intracranial bleeding Flashcards

1
Q

How can traumatic intracranial bleeding occur?

A

either extradural or intradural
intradural hematomas are usually a mix of subdural and intracerebral hematomas,
although pure subdural can happen

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2
Q

what is subdural intracranial bleeding?

A
  • impact rupture bridging veins from the cortical surface to the venous sinuses
  • no underlying cortical contusion or laceration
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3
Q

what is Extradural intracranial bleeding?

A
  • a skull fracture tearing the middle meningeal vessels (occasionally damage to sagittal/transverse sinuses)
  • usually in the temporal/temporoparietal region
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4
Q

how Brain damage can be causes in traumatic intracranial bleeding?

A
  • damage is caused directly or indirectly
  • as a result of tentorial or tonsillar herniation
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5
Q

what can create a space occupying hematoma?

A

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

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6
Q

what is Burst lobe?

A

Intracerebral hematoma mixed w/ necrotic brain tissue, rupturing into the subdural space

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7
Q

Is it possible that high IC pressure alone damages neuronal tissue?

A

It is unlikely that high IC pressure alone damages neuronal tissue, but usually occurs as a result of tonsillar or tentorial herniation

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8
Q

how can tentorial herniation occur?

A

○ 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

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9
Q

how can tonsillar herniation occur?

A

Traumatic posterior fossa hematoma → tonsillar herniation

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10
Q

what to assess if suspecting intracranial bleeding?

A

figure out if its:
● Multiple injury
● Head injury
● Suspected IC hematoma → CT!

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11
Q

how to assess multiple injury?

A

airway → breathing → circulation → head/spinal injury → limb injuries

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12
Q

how to assess head injury?

A

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

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13
Q

how to examine intracranial bleeding?

A

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

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14
Q

when examining intracranial bleeding, what are the evidence of injury?

A

● 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

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15
Q

when examining intracranial bleeding, what are the sings of Basal fracture?

A

● 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

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16
Q

when examining intracranial bleeding, what is the Conscious level - GCS?

A

● Eye movement
● Verbal response
● Motor response

17
Q

when examining intracranial bleeding, what is the pupils response?

A

● 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)

18
Q

when examining intracranial bleeding, what does limb weakness indicates?

A

● 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

19
Q

when examining intracranial bleeding, what does eye movement indicates?

A

● 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

20
Q

what are the Referral criteria in traumatic intracranial bleeding?

A

● 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

21
Q

During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Extradural level?

A
  • 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
22
Q

During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Subdural level?

A

area of increased density spreading around the surface of cerebral hemisphere becomes isodense with brain (10-12 d after), then hypodense

23
Q

During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Intracerebral level?

A

burst lobe ± subdural hematoma appearing as an irregular area of increased density (blood clot) surrounded by area of low density (edematous brain)

24
Q

how is the Management of traumatic intracranial bleeding if it is Extradural?

A
  • horseshoe craniotomy flap w/ complete evacuation of the hematoma
  • burr hole and craniectomy if rapid deterioration for temporary relief
25
Q

how is the Management of traumatic intracranial bleeding if it is Subdural/intracerebral?

A

questionmark flap over temporal and/or frontal areas w/ subdural/intracerebral evacuation of hematoma and necrotic brain

26
Q

what is Chronic subdural hematoma?

A

Occurs mainly in infancy and elderly w/ trauma as the likely cause

27
Q

what are the Predisposing factors of Chronic subdural hematoma?

A
  • cerebral atrophy causing stretching of bridging veins
  • low CSF pressure (after shunt of fistula) causing stretching of bridging veins
  • alcoholism
  • coagulation disorder
28
Q

Clinical features of Chronic subdural hematoma?

A

○ Dementia
○ Deterioration of consciousness, fluctuating
○ S&S of ↑ICP
○ Focal signs, especially ipsilateral limb weakness

29
Q

Diagnosis of Chronic subdural hematoma?

A

CT:
- isodense lesions 1-3w after injury → contrast material
- hypodense after 3w
- check midline shift and shape of ventricles

30
Q

Management of Chronic subdural hematoma?

A

○ Hematoma is evacuated through burr holes and washed w/ saline

○ Conservative treatment w/ steroids if no depressed consciousness

31
Q
A