head injury + bleeds

Question 1

primary focal brain injuries

Answer 1

contusion or haematoma

Contusion/bruising on opposite side to primary – due to bouncing off skull
* Coup (adjacent) or contralateral (contre-coup)
o Contracoup tend to be worse

Question 2

primary diffuse brain injuries

Answer 2

diffuse axonal injury
 Severe form of traumatic brain injury due to shearing forces
 Occur where density difference is greatest (grey/white interface)
 Excitotoxicity + apoptosis
 Inflammatory mediator release

a result of mechanical shearing following deceleration, causing disruption and tearing of axons

younger patient, reduced consciousness, difficult to manage

Question 3

causes of secondary brain injuries

Answer 3

cerebral oedema
ischaemia
infection
herniation

Question 4

cushing reflex

Answer 4

hypertension + bradycardia

-> often occurs late + is usually preterminal event

a physiological nervous system response to acute elevations of intracranial pressure (ICP),

Question 5

extradural haematoma vs acute subdural

Answer 5

extradural
- injury with LOC
- recovery with lucid interval then rapid progression of neurological symtpoms

acute subdural = crescent shaped, white
chronic subdural = crescent shaped, dark

Question 6

CT within 1hr criteria

Answer 6

• GCS <13 on initial assessment
• GCS <15 at 2hrs after injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
• Post traumatic seizure
• Focal neurological deficit – weak on one side
• More than one episode of vomiting
• Suspicion of NAI
• Also if they experienced some loss of consciousness or amnesia since the injury –
  o >65yrs
  o Coagulopathy
  o Dangerous mechanism of injury

Question 7

glasgow coma scale

Answer 7

Eye opening
o Open spontaneously = 4
o To speech
o To pain
o No eye opening= 1
Verbal
o Orientated = 5
o Confused
o Inappropriate
o Incomprehensible
o No verbal = 1
Motor
o Obeying= 6
o Localizing pain
o Flexing
o Abnormal flexing
o Extending
o No motor response= 1

Severity scale
o Mild = 14, 15 of brief LOC
o Moderate = 9-13
o Severe = 3-8

Question 8

extradural haematoma

Answer 8

between dura mater + skull

lens/lemon shape on CT

causes
- acceleration-deceleration trauma
- blow to side of head

Question 9

trauma to the pterion can cause which kind of haematoma

Answer 9

extradural
- rupture of middle meningeal artery

Question 10

ypical history of extradural haematomas

Answer 10

young patient with traumatic head injury
ongoing headache
has a period of improved neurological symptoms + consciousness

followed by RAPID decline over hours

Question 11

rupture of bridging veins can cause what type of haematoma?

Answer 11

subdural
- bleeding into the outermost meningeal layer
- between dura + arachnoid mater

Question 12

acute subdural presentation

Answer 12

cresent white shape on CT
- not limited to cranial sutures - can cross
commonest arounf frontal + parietal lobes

blood is more clotted in one area - big craniotomy

Question 13

chronic subdural haematoma

Answer 13

elderly falls, assoc with brain atrophy
torn cerebral vain

when becomes chronic becomes more liquified + drain - yellow tinged blood

Question 14

intracerebral haematoma causes

Answer 14

(within brain itself)

• spontaneous, infarct, tumour
• aneurysm rupture
• vasculitis
  drugs
• hypertension, diabetes

hypertension = commonest, rupture of microaneurysms

Question 15

intracerebral presentation + CT findings

Answer 15

presents similarily to ischaemic stroke or decreased consciousness

CT shows hyperdensity (bright lesion) within substance of brain

Question 16

subarachnoid haemorrhage

Answer 16

between pia mater + arachnoid membrane
(where CSF is)

usually by ruptured cerebral aneurysm
high mortality - low suspicion

more common in black, feale ages 45-70

Question 17

commonest cause of subarachnoid haemorrhage

Answer 17

rupture of saccular aneurysm (berry aneurysm)

-> most in territory if internal carotid artery

Question 18

conditions assoc with berry aneurysms

Answer 18

polycystic kidney disease
Ehlers-Danlos
coarctation of aorta

Question 19

presentation of subarachnoid haemorrhage

Answer 19

sudden onset occipital headache that occurs during strenuous activity - weightlifting, sex
–> thunderclap headache (“hit hard on back of head”)

neck stiffness, photophobia
vision changes

Question 20

subarachnoid haemorrhage investigations

Answer 20

CT
lumbar puncture
o If CT head is negative, at least 12hrs following onset of symptoms to develop xanthochromia
o Red cell count raised – if decreasing in number of samples probs traumatic from puncture

(Xanthochromia – yellow colour caused by bilirubin, distinguishes from trauma blood)

angiography - once confirmed to locate source

Question 21

management of subarachnoid haemorrhages

Answer 21

in accordance of causative pathology
intracranial aneurysms -
- coil or craniotomy + clipping
- nimodipine -> prevents vasospasm, CCB targeting brain vasculature

Question 22

different types of brain herniation

Answer 22

subfalcine - down under falxi cerebri
uncal - part of temporal lobe moving medially

central/coning - through foramen magnum, BAD
transcalvarial - skull fracture, pushing out of skull

Question 23

effect of uncal harniation on pupils

Answer 23

compression of oculomotor nerve leads to ipsilateral dilated pupil -> blown

Question 24

brain death

Answer 24

must be done by 2 doctors
- no pupil response
- no corneal reflex
no motor respone
no vestibuloocular reflex
no gag/cough reflex
no respiration

Question 25

cause of acute spinal cord compression

Answer 25

trauma
tumours - haemorrhage or collapse
infection

spontaneous haemorrhage - more common in anti-platelet therapy

Question 26

cord transection

Answer 26

complete lesion - all motor + sensory modalities

initially a flacced areflexic paralysis - spinal shock
upper motor neuron signs appear later

Question 27

brown-sequard syndrome

Answer 27

caused by lateral hemisection of spinal cord

Question 28

brown-sequard syndrome presentation

Answer 28

• Ipsilateral motor level – weakness below lesion
• Ipsilateral dorsal column sensory level – loss of proprioception + vibration sensation
• Contralateral spinothalamic sensory level – loss of pain + temp sensation

Question 29

central cord syndrome

Answer 29

hyperflexion or extension of head injury to ALREADY STENOTIC neck or syringomyelia

predominantly bilateral upper limb weakness
cape-like spinothalamic sensory loss

Question 30

anterior cord syndrome

Answer 30

occlusion of anterior spinal artery

tracts affected
- lateral corticospinal tracts
- lateral spinothalamic tracts

presents
- bilateral paresis
- bilateral loss of pain + temp sensation

Question 31

when should excision for spinal decompression be done?

Answer 31

only if primary cancer or could walk fin an hour ago

Question 32

sudden onset thunderclap headache

Answer 32

10/10 severe – worst headache of my life
- Hit in back of the head
- Assoc with N+V

Differential – subarachnoid haemorrhage
o Immediate CT scan

***If neg – need lumbar puncture to obtain CSF sample to prove diagnosis