Brain Haemorrhages and Fractures

Question 1

what does TBI stand for

Answer 1

traumatic brain injury

Question 2

what is a common cause of brain haemorrhage

Answer 2

Trauma - Head Injury - RTA = one of the most severe causes, assault, accident trips and falls, sports-related injuries, industrial accidents

Question 3

facts and figures involving head injuries

Answer 3

each year, around 700,000 people attend A&E with a head injury
more than 80% only have a minor injury
around 3/4 of those with head injuries are male
nearly half the people with head injuries are children

Question 4

how has risk of head injuries been reduced

Answer 4

legislative measures - seatbelt in cars, anti-drink drive campaigns, bicycle/sports helmets
reducing hazards in the home that may cause a fall
childproofing the home
using correct safety equipment for work and DIY

Question 5

what is a ‘head injury’ defined by the NICE guidelines

Answer 5

‘any trauma or the head or superficial injuries to the face’ caused when an external mechanical force causes an insult to the brain

Question 6

what 2 categories can brain injuries fall into - explain

Answer 6

primary - occurring at time of injury - cannot be altered/reversed
secondary - occurring later - often amenable to prevention/reversal

Question 7

how to decrease a secondary brain injury

Answer 7

early diagnosis and rapid appropriate treatment

Question 8

causes of secondary brain injury - 5 points

Answer 8

hypoxia 
hypovolaemia 
intracranial haematoma causing pressure effects
cerebral oedema 
infection

Question 9

signs and symptoms of head injury - 13 points

Answer 9

Headache
Reduced or loss of consciousness
Acute neurological deficit (motor/sensory)
Reduced GCS
Confusion
Agitation
Decreased alertness
Nausea/Vomiting
Seizures
Diplopia
Seizures
Rhinorrhoea
Otorrhoea

Question 10

describe the Glasgow coma scale

Answer 10

a practical method for assessment of impairment of conscious level in response to defined stimuli
1974
easily repeatable measure of conscious state and neurological ability

Question 11

what is the primary investigation of choice for head injury and what do the guidelines advise

Answer 11

CT

advises who gets a CT scan and the time scale

Question 12

which modality is not the imaging modality of choice and why

Answer 12

MRI
accessibility - not for the patient in the acute scenario, contraindicated due to its magnetic field
inability to screen the unconscious patient - requires a number of staff who are unaware of the magnetic field hazard
staff would have to go through safety screening - time consuming
CT provides similar information for most clinical purposes

Question 13

what is the criteria for an ‘immediate’ scan and a ‘delayed’ scan

Answer 13

immediate = < 1hr
delayed = within 8 hrs

Question 14

when else should a CT scan be carried out within 8 hours

Answer 14

patients on warfarin presenting with a head injury in the absence of other indications
or immediately if 8 hrs has already elapsed

Question 15

what are the 6 types of haemorrhage

Answer 15

extradural haemorrhage - trauma
subdural haemorrhage - trauma
contusion - trauma
diffuse axonal injury- trauma, complex (MRI)
subarachnoid haemorrhage - trauma, spontaneous
intracerebral haemorrhage - trauma, spontaneous

Question 16

describe extradural haemorrhage

Answer 16

occurs between dura mater and skull
requires trauma to draw dura from bone, skull in 80% of cases
stripping of dura from bone = laceration of the arteries - usually the middle meningeal artery
arterial bleed = confined by limits of dura where its torn away or by the sutures

Question 17

radiographic appearance of extradural haemorrhage

Answer 17

typically bi-convex/lentiform hyperdensity

Question 18

who is mainly affected?

how can it present

Answer 18

typically affects young patients involved in a clearly defined blow (assault/fall/sports-injury etc)
newborns - due to abnormal/difficult labour or forceps delivery

severe headache - due to ripping of the dura from skull
?LOC - depends on force of impact
classic lucid interval after concussive force of blow
patient regains consciousness but the EDH continues to expand = mass effect = increased intracranial pressure = decreased level of consciousness and possible coning

Question 19

describe subdural haemorrhage

Answer 19

severe or minor head injury causes rapid acceleration/deceleration of the brain tissue
bridging veins tear = low pressure venous bleeding
large haematomas can form before clinical signs appear
associated with cerebral atrophy - common in elderly and alcoholics
bridging veins under greater tension as the brain gradually shrinks from skull
easily ruptured - with only minor trauma

Question 20

radiographic appearance of subdural haemorrhage

Answer 20

between dura mater and arachnoid mater
crescent, concave, sickle shape
time of presentation since injury is important because radiographic density of blood alters with age

ACUTE - hyper dense
SUBACUTE - isotense (4-21 days after)
CHRONIC - hypodense (21 days or more after)

Question 21

who does it affect?

Answer 21

> 60yrs, more common in men than women
puts with clotting disorders including alcoholics
associated with NAI - shaken baby syndrome

Question 22

how is acute usually presented and chronic usually presented

Answer 22

ACUTE
usually younger patients/alcoholics due to the way they present
rates of mortality and morbidity = high
emergency management = critical
CHRONIC
usually seen in elderly
often slow deterioration seen in patient as haematoma expands
gradual onset of confusion, decreased level of consciousness, headache, difficulty with gait or balance, memory loss

Question 23

describe contusion

Answer 23

bruise on the brain
often occurs in frontal and temporal regions due to brain colliding with the brain protuberances within the skull
blood vessels are damaged and haemorrhage due to direct trauma

Question 24

radiographic appearance of contusion

Answer 24

often multiple small haemorrhages at grey/white matter interface
delayed scan demonstrates oedema and atrophy

Question 25

how is contusion usually presented and who’s affected

Answer 25

associated with young males due to mechanism
can be minor with few symptoms and little/no damage to brain
severe contusions = extended period of unconsciousness
patients aware confused, tired, agitated, emotional
other symptoms = memory loss, attention problems, difficulty with motor coordination, loss of ability to understand or express speech
more severe contusions = increased intracranial pressure, coning, possibly coma and death

Question 26

what are the pharmocological options for brain haemorrhage

Answer 26

painkillers
corticosteroids/diuretics to reduce swelling
anticonvulsants - control seizures
ACE inhibitors to lower blood pressure

Question 27

what are the surgical intervention for brain haemorrhage

Answer 27

craniotomy and evacuation of haemorrhage to alleviate swelling
neurological clipping of aneurysm
endovascular coiling of aneurysm

Question 28

conservative options for brain haemorrhage

Answer 28

close clinical observation

follow up CT scans to assess - decline in neurological status, extent of clot evacuation, anyone haematoma formation

Question 29

what is the prognosis for a brain haemorrhage

Answer 29

depends on size and location of haemorrhage

initial presentation (GCS) significantly correlates to outcome of patients who survive

Question 30

describe skull #s

Answer 30

not always seen but can see fluid in sinuses and pneumocephalus in the skull vault, intracranial air - leaked in via #

Question 31

describe base of skull #s

Answer 31

s diagnosed clinically from these signs

may involve the foramen though which cranial nerves pass - dysfunction in these may lead to loss of smell, hearing, imbalance, weakness in the facial muscles

may also tear the dura resulting in a leakage of CSF into the ear (otorrhea) or nose (rhiorrhea)
or cause blood to leak behind the ear (Battle’s sign) or around the eyes (Racoon eyes)

Question 32

treatment for skull #s

Answer 32

patient given antibiotic cover to prevent infection/meningitis and surgical intervention may be required