Head Injury and Intracranial Haemorrhage

Question 1

What counts as a severe head injury?

Answer 1

GCS <8

Question 2

Management

Answer 2

DR ABCDE assessment and resuscitation whilst keeping C-spine aligned

CT scan (according to guidelines)

Refer to neurosurgery if:

• CT scan abnormal
• GCS <8
• suspected skull fracture

Question 3

What are the guidelines concerning CT scans and head injuries?

Answer 3

CT scan immediately if:

• GCS <13 on initial assessment
• GCS <15 2 hours post injury
• Any evidence of basal skull fracture (battle’s sign, panda eyes, CSF leak etc.)
• Suspected open or depressed skull fracture
• Post-trauma seizure
• Focal neurological deficit
• More than 1 episode of vomiting

CT scan within 8 hours if risk factors:

• History of clotting issue
• On anticoagulation e.g. warfarin
• Over 65 years old
• High risk mechanism of trauma e.g. pedestrian or cyclist hit

Question 4

Subdural Haemorrhage

Classic patient

Pathology

Investigation

Management

Answer 4

CLASSIC PATIENT
Elderly or alcoholic patients. These patients have more atrophy in their brains making vessels more likely to rupture.

PATHOLOGY
Rupture of the bridging veins in the outermost meningeal layer. They occur between the dura mater and arachnoid mater.

INVESTIGATION
CT scan: crescent shape and are not limited by the cranial sutures (they can cross over the sutures).

MANAGEMENT
Neurosurgery: Burr hole craniotomy

Question 5

Extradural Haemorrhage

Classic patient

Pathology

Investigation

Management

Answer 5

CLASSIC PATIENT: young patient with a traumatic head injury that has an ongoing headache with LUCID INTERVAL of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.

PATHOLOGY: Rupture of the middle meningeal artery in the temporo-parietal region. It can be associated with a fracture of the temporal bone. It occurs between the skull and dura mater.

INVESTIGATION: Non-contrast CT scan they have a bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).

MANAGEMENT
Neurosurgery: Ligation of damaged vessel

Question 6

Subarachnoid Haemorrhage

Pathology

Clinical Feature

Associations

Investigation

Management

Answer 6

PATHOLOGY

• Ruptured cerebral aneurysm bleeding into the subarachnoid space, where the cerebrospinal fluid is
• located between the pia mater and the arachnoid membrane

CLINICAL FEATURE

• sudden onset “thunderclap” occipital headache that occurs during strenuous activity
• seizures

ASSOCIATIONS:

• Cocaine use
• Sickle Cell Anaemia
• Polycycstic Kidney Disease

INVESTIGATION

• Head CT scan
• (if negative) Lumbar Puncture: xanthochromia

MANAGEMENT:

• Nimodpine (Calcium channel blocker to stop vasospasm)
• Neurosurgery: endovascular coiling

Question 7

Intracranial Haemorrhage Management

Answer 7

Immediate non-contrast CT head to establish the diagnosis

Bloods: Check FBC and clotting (correct any clotting abnormality)

REFER
Discuss with a specialist neurosurgical centre to consider surgical treatment

Consider intubation, ventilation and ICU care if they have reduced consciousness