Ch. 5 - Traumatic intracranial hematomas Flashcards
Most common site of extradural hematoma?
Temporal region > frontal; uncommonly posterior fossa and parasagittal
Vessel most likely torn in extradural hematoma
Middle meningeal artery
Uncommonly extradural veins, superior sagittal sinus, transverse sinus, posterior meningeal
How often does a fracture overly an extradural hematoma?
95% of adults; 75% of children
Population most likely to have extradural hematoma
Children and adults <20 years because dura strips off more readily
Extradural hematoma presentation
Severe head injury followed by deterioration of neurological state (esp. CN3 palsy and hemiparesis), HA, possibly transient LOC, Cushing’s reflex
Most important neurological sign of extradural hematoma
Deteriorating conscious state after lucid interval
CT appearance of extradural hematoma
Hyperdense biconvex hematoma with compression of underlying brain and distortion of lateral ventricle
Tx of extradural hematoma
Craniotomy and evacuation, mannitol or furosemide infusion, hyperventilation
Burr hole locations for extradural hematoma tx
Temporal first, then frontal and parietal
If extradural hematoma location is unknown, which side do you burr hole
Side of fracture
Underlying boggy swelling of skull
Same side as dilated pupil if present
85% of cases on contralateral side of hemiparesis
Why open dura during extradural hematoma evacuation?
To exclude coexisting subdural hematoma
Prognosis of extradural hematoma
Potentially reversible, full recovery expected if evacuated early enough
Define 3 types of subdural hematomas
Acute - less than 3 days
Subacute - 4-21 days
Chronic - 21+ days
Causes of acute subdural hematoma
Severe trauma and cortical lacerations OR
Less severe trauma and rupture of bridging veins (esp. if anticoagulated or cortical atrophy)
Appearance of subdural hematoma on CT
Concave towards brain:
Acute - hyperdense
Subacute - isodense with adjacent brain
Chronic- hypodense
How often are acute subdural hematomas bilateral?
1/3 of cases
Presentation of acute subdural hematoma
Severe head injury with deteriorating neuro state or failure to improve
Commonly associated fracture with acute subdural hematoma
80% have fracture of cranial vault or base of skull
Treatment of acute subdural hematoma
Craniotomy to evacuate
Two major groups of chronic subdural hematomas
Severe head injury OR
No history of head trauma (1/3 of cases) - 2/2 rupture of bridging veins in cortical atrophy
Presentation of chronic subdural hematoma
- Deterioration after head injury
- Increased ICP without localizing signs
- Fluctuating drowsiness
- Progressive dementia (more rapid than Alzheimer’s) with possible focal neurological signs esp. hemiparesis
How often are chronic subdural hematomas bilateral?
25% of cases
Tx of chronic subdural hematomas
Burr holes vs. craniotomy but do not attempt to excise hematoma membrane (may be multiloculated)
Post-op management of chronic subdural hematoma evacuation
Lie patient flat + adequate hydration to encourage brain to swell and expand into hematoma space (watch for hyponatremia)
Causes of chronic subdural hematoma in infancy
Birth trauma, abuse (10% of battered children)
How often are subdural hematomas bilateral in infants?
85% of cases
Earliest finding of chronic subdural hematoma in infants
Excessive cranial enlargement; nonspecific findings (failure to thrive, irritability)
Tx of chronic subdural hematoma in infant
Aspirate fluid; shunt if repeated aspirations unsuccessful
Causes of intracerebral hematoma
Penetrating injury, depressed skull fracture, severe head trauma
What other type of hemorrhage is commonly associated with subdural hematoma?
Intracerebral hemorrhage
CT findings of intracerebral hematoma
Multiple hematomas in contre-coup distribution
Why repeat CT in patient with a head injury but previously negative scan?
Intracerebral hematomas frequently evolve more than 24 hrs after trauma
Tx of large intracerebral hematoma? Small?
Large - evacuation unless neurological state is improving; small - observation
Identify the lesion
Extradural hematoma
Identify the lesion
Chronic subdural hematoma
Identify the lesion
Acute subdural hematoma
