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Neurology > Head injury - Intracerebral, Subdural and Extradural Haemorrhage, and diffuse axonal injury > Flashcards

Head injury - Intracerebral, Subdural and Extradural Haemorrhage, and diffuse axonal injury Flashcards

1
Q

What is an extradural haemorrhage?

A

A collection of blood that forms between the inner surface of the skull and outer layer of the dura, which is called the endosteal layer. EDH typically follows a linear skull vault fracture tearing a branch of the middle meningeal artery. Extradural blood accumulates rapidly over minutes or hours.

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2
Q

Which artery is most commonly implicated in an extradural haemorrhage?

A

Middle meningeal artery

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3
Q

When might you suspect an extradural haemorrhage?

A

After any skull fracture - especially temporal/parietal bone. Typically after trauma to the eye

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4
Q

Where does blood accumulate in an extradural haemorrhage?

A

Between bone and Dura

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5
Q

What are symptoms of an extradural haemorrhage?

A
  • Lucid interval following trauma, then progressively decreasing GCS
  • Increasingly severe headache
  • Vomiting
  • Confusion
  • Seizures
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6
Q

What are signs of an extradural haemorrhage?

A

Raised ICP signs (in sequence)

  1. Lucid progressing to Decreased GCS
  2. Ipsilateral myadriasis (hutchison’s pupil), with Contralateral Hemiparesis + Brisk reflexes + Upgoing plantars
  3. Tetraplegia + Bilateral fixed dilated pupils
  4. Late signs - Bradycardia, Increased BP, Respiratory depression (cushings triad)
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7
Q

What is the general progression of extradural haemorrhage from initial insult?

A

Lucid period -> decreased GCS, signs of rasied ICP -> hemiparesis, brisk reflexes, hutchison’s pupil, coma, bilateral limb weakness, resp depression

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8
Q

What would differentials be for someone who you suspected might have an extradural haemorrhage?

A
  • Epilepsy
  • Carotid dissection
  • Carbon monoxide poisoning
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9
Q

Why do individuals with an extradural haemorrhage get a hutchison’s pupil?

A

Caused by herniation of the uncus impinging on the occulomotor nerve

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10
Q

Why do individuals with extradural haemorrhage develop bradycardia as a late sign?

A

As part of Cushing’s Triad/Reflex:

  • Increase in systolic and pulse pressure
  • Bradycardia
  • Irregular respiration

Baroreceptors in the aortic arch detect the initial increase in blood pressure and trigger a parasympathetic response - induces bradycardia, which signifies the second stage of the reflex

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11
Q

Why do those with extradural haemorrhage develop Hypertension as a late sign?

A

As part of Cushing’s Reflex

  • Disturbed repiratory pattern
  • Bradycardia
  • Hypertension

In response to raised ICP, the body attempt to restore adequate perfusion to the ischaemic brain, as raised ICP reduces flow of blood into the brain

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12
Q

Why can those with an extradural haemorrhage develop irregular/depressed breathing?

A

As part of Cushing’s Reflex

  • Disturbed repiratory pattern
  • Bradycardia
  • Hypertension

Distortion and/or increased pressure on the brainstem causes an irregular respiratory pattern and/or apnea

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13
Q

How would you investigate a suspected extradural haemorrhage?

A
  • Imaging - CT Scan
  • Skull X-ray - shows fracture line
  • DON’T DO AN LP!!!
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14
Q

What is the following diagnosis?

A

Extradural haemorrhage

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15
Q

Why do extradural haemorrhage show up as a biconcave hyperattenuated area on CT?

A

Due to the insertion points of the dura to the suture lines of the skull

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16
Q

How would you manage someone with an extradural haemorrhage?

A
  • Stabilise and transfer to neurosurgery
  • Surgery - clot evacuation and ligation
  • May require intubation/ventilation
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17
Q

What is a subdural haematoma?

A

A type of hematoma, usually associated with traumatic brain injury. Blood gathers between the inner layer of the dura mater and the arachnoid mater.

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18
Q

What layers of the meninges does a subdural haemorrhage occur between?

A

Dura and arachnoid mater

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19
Q

What is the cause of a subdural haemorrhage?

A

Rupture of bridging veins, caused by:

  • Trauma (most commonly)
  • Decreased ICP
  • Dural metastases
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20
Q

What are risk factors for subdural haemorrhage?

A
  • Falls - elderly, alcoholics
  • Anticogulation
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21
Q

What are symptoms of a subdural haemorrhage?

A
  • Fluctuating level of conscioussness
  • Physical/intellectual slowing
  • Sleepiness
  • Headache
  • Personality change
  • Unsteadiness
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22
Q

What are signs of a subdural haemorrhage?

A
  • Signs of raised ICP
  • Focal deficits - hemiparesis, sensory loss
  • Seizures
  • Stupor
  • Decreased GCS
  • Late features - Hypertension, Bradycardia, Depressed resp rate
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23
Q

What investigations would you do in someone with suspected subdural haemorrhage?

A

Imaging - CT/MRI

24
Q

What might you see on CT/MRI in someone with a subdural haemorrhage?

A
  • Clot +/- midline shift
  • Crescent-shaped collection of blood oer 1 hemisphere
25
Q

How would you manage a subdural haemorrhage?

A

Refer to neurosurgery

  • Reverse clotting abnormalities
  • Surgery - if >10mm haemorrhage or >5mm midline shift
  • Address cause of trauma - falls, abuse
26
Q

What head injuries can cause focal neurological signs or seizures?

A
  • Diffuse axonal injury
  • Contusion
  • Intracerebral haematoma
  • Extra-cerebral haematoma - Extra-dural haematoma, Sub-dural haematoma
27
Q

What GCS score would you consider intrubating someone?

A

GCS < 8 - unable to maintain own airway

28
Q

Why are those who are elderly, drink alcohol or who have dementia more at risk of subdural haemorrhage?

A

Due to cerebral atrophy - stretches venous bridges, making them more prone to rupture

29
Q

How would you manage raised ICP?

A
  • Surgery to relieve pressure - Heamatoma, ventricular shunt
  • Osmotic agents - mannitol
  • Nurse with head at 30-45o (Venous return)
  • Reduce pain
  • Maintain good PO2, reduce PCO2
  • Reduce metabolism (reduce temperature, barbiturates)
30
Q

What does the extent of retorgrade amnesia correlate with in a head injury?

A

Severity of injury - never occurs without anterograde amnesia

31
Q

If someone had a head injury, when would you consider performing a CT within an hour of presentation?

A
  • GCS <13, or < 15 at 2hrs
  • Focal neurological deficit
  • Suspected open/depressed skull fracture
  • Signs of basal skull fracture
  • Post-traumatic seizure
  • Vomiting more than once
32
Q

When would you consider doing a CT within 8 hrs of admission?

A

Any LOC/amnesia, and any of

  • Age >/= 65
  • Coagulopathy
  • High-impact injury
  • Retrograde amnesia >30 mins
33
Q

When might you suspect a cervical spine injury in combination with a head injury?

A
  • GCS <13 on inial assessment
  • Clinical suspicion, plus any of:
    • 65 or older
    • High-impact injury
    • Focal neuro deficit
    • Paraesthesia of upper/lower limbs
  • Patient has to be intubated
  • Multi-region trauma
34
Q

What are early complications of head injuries?

A
  • Subdural haemorrhage
  • Extradural haemorrhage
  • Seizures
  • Uncal herniation
  • CSF leak
  • Hydrocephalus
  • Cranial nerve palsies
35
Q

What are late complications of head injury?

A
  • Subdural haemorrhage
  • Seizures
  • Diabetes insipidus
  • Parkinsonism
  • Dementia
36
Q

When is alcohol an unlikely cause of coma?

A

If blood alcohol levels <44 mmol/L

37
Q

When would you consider admitting someone with a head injury?

A
  • New, clinically significant abnormalities on CT
  • GCS <15 after CT
  • Other concerns - drugs/alcohol, other injuries, CSF leak, shock etc.
38
Q

What are indicators of a bad prognosis in a head injury?

A
  • Old age
  • Decerebrate rigidity
  • Extensor spasm
  • Prlonged coma
  • Hypertension
  • Decreased PaO2
  • To > 39
39
Q

If someone presented with a head injury, what would you do as part of your initial assessment?

A

ABCDE

  • Give oxygen if sats <92%
  • Intubate and hyperventilate if necessary
  • C-spine immobilisation
  • Fluid resus/circulation support
  • Treat seizures - lorazepam +/- phenytoin
  • Assess GCS - if <8 -> manual airway
40
Q

What initial blood investigations would you consider in someone presenting with a head injury?

A
  • U+E’s
  • Glucose
  • FBC
  • Blood alcohol
  • Toxicology screen
  • ABGs
  • Clotting
41
Q

What are signs of a CSF leak caused by a head injury?

A
  • Rhinorrhoea
  • Otorrhoea
  • Blood behind ear drum
  • Basal skull fracture signs
42
Q

What is diffuse axonal injury?

A

Severe form of head injury that occurs as a result of shearing and tensile strains produced by rotational movements of the brain within the skull. It often occurs in the absence of a skull fracture and cerebral contusions. Two main components exist:

  • Small haemorrhagic lesions in the white matter - corpus callosum and dorsolateral brainstem
  • Diffuse damage to axons - eventually degenerate, resulting in a loss of fibres in the white matter.
43
Q

What are mechanisms of brain damage form a head injury?

A
  • Diffuse axonal injury
  • Neuronal and axonal damage from direct trauma
  • Brain oedema and raised ICP
  • Brain hypoxia
  • Brain ischaemia
44
Q

What is an intracerebral haemorrhage?

A

Haemorrhage within the brain tissue itself

45
Q

What are causes of intracerebral haemorrhage?

A
  • Hypertension
  • Trauma
  • Aneurysm rupture
  • Anticoagulation
  • Thombolysis
46
Q

How might you distinguish an intracerebral haemorrhage from a stroke?

A

Very difficult - may have a headache with stroke symptoms

47
Q

What is the following?

A

Intracerebral haemorrhage

48
Q

Which imaging modality is best for visualising intracranial haemorrhage?

A

CT is best and quickest option

49
Q

What are features of anterior base of skull fracture?

A

Specific

  • CSF rhinorrhoea
  • Subcutaneous haematoma around orbit - racoon eyes

General

  • Halo sign
  • Headache
  • Amnesia/confusion
  • Focal neuro signs
  • Seizures
50
Q

What is halo sign?

A

Rapidly-expanding clear ring of fluid surrounding blood on discharge

51
Q

What are features of posterior basal skull fracture?

A

Specific

  • CSF otorrhoea: leakage of CSF from the external auditory meatus
  • Subcutaneous hematoma behind the ear (Battle sign)

General

  • Headache
  • Amnesia; confusion, disorientation
  • Impaired consciousness
  • Dizziness, nausea, vomiting
  • Focal neurologic symptoms (see stroke)
  • Seizures
  • Sensory disturbances
52
Q

What is the following?

A

Racoon eyes - sign of anterior base of skull fracture

53
Q

What GCS score would indicate a mild head injury?

A

13-15

54
Q

What GCS score would indicate a moderate head injury?

A

9-12

55
Q

What GCS score would indicate a severe head injury?

A

=8

56
Q

How would you manage a mild TBI?

A
  • Monitoring - 24 hrs
  • Simple analgesia
  • Athletes
    • Refrain from contact sports for a week - then reassess
    • Monitor in A+E - 6 hours
57
Q

What would you lookfor on CT in someone with a suspected traumatic brain injury?

A
  • Midline shift
  • Hemorrhage and hematomas (see “Differential diagnoses of intracranial hemorrhages” below)
  • Diffuse axonal injury (DAI)

Neurology (34 decks)

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