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Gwen - 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

Name the types of intracranial haemorrhage

A

Intra-cerebral haemrrhage

Subarachnoid haemorrhage

Subdural haemorrhage

Extradural (epidural) haemorrhage

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2
Q

Risk factors intracranial haemorrhage

A

Hypertension

Vascular malformations - cerebral aneurysm, arterio-venous malformation, cavernous haemangioma

Infections

Intracranial tumours

Bleeding disorders

Drugs

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3
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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4
Q

Which artery is most commonly implicated in an extradural haemorrhage?

A

Middle meningeal artery (often due to fractured temporal or parietal bone)

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5
Q

Aetiology extradural haemorrhage

A

Trauma - acceleration/deceleration or blow to side of head.

Majority in temporal region

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6
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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7
Q

Where does blood accumulate in an extradural haemorrhage?

A

Between bone and Dura

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8
Q

What are symptoms of an extradural haemorrhage?

A
  • Lucid interval following trauma, then progressively decreasing GCS (because collection occurs between bone and dura)
  • Increasingly severe headache
  • Vomiting
  • Confusion
  • Seizures
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9
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. False localisint 3rd nerve palsy causing ipsilateral pupil dilatation
  4. Tetraplegia + Bilateral fixed dilated pupils
  5. Late signs - Bradycardia, Increased BP, Respiratory depression (cushings triad)
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10
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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11
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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12
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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13
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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14
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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15
Q
A
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16
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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17
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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18
Q

What is the following diagnosis?

A

Extradural haemorrhage
(Extradural, eye looking in)

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19
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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20
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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21
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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22
Q

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

A

Dura and arachnoid mater

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23
Q

What is the cause of a subdural haemorrhage?

A

Rupture of bridging veins, caused by:

  • Trauma (most commonly)
    • ​Severe head injury
    • Minor head injury (in alcoholics and elderly esp if anticoagulated)
  • Decreased ICP
  • Dural metastases
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24
Q

What are risk factors for subdural haemorrhage?

A
  • Falls - elderly, alcoholics (may not remember), epileptics
  • Anticogulation
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25
Q

Is it venous or arterial blood leakage in subdural haemorrhage?

A

Tearing of bridging veins between cortex and venous sinuses (VENOUS BLOOD), results in accumulating haematoma between dura and arachnoid matter

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26
Q

What are symptoms of a subdural haemorrhage?

A

CONSIDER IN ANWAYONE WHOSE CONSCIOUS LEVEL FLUCTUATES AND IN THOSE HAVING AN “EVOLVING STROKE” ESP. IF ON ANTICOAGULANTS

  • Fluctuating level of conscioussness (gradually rising ICP)
  • Physical/intellectual slowing
  • Sleepiness
  • Headache
  • Personality change
  • Unsteadiness
  • Weakness/numbness
  • Slurred speech
27
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
  • Localising neuro signs - unequal pupils, hemiparesis
28
Q

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

A

Imaging - CT/MRI

29
Q

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

A
  • Clot +/- midline shift
  • Crescent-shaped collection of blood over 1 hemisphere
30
Q

How would you manage a subdural haemorrhage?

A

Refer to neurosurgery

  • Osmotic diuretic - IV mannitol
  • Reverse clotting abnormalities
  • Surgery - if >10mm haemorrhage or >5mm midline shift - via burr twist drill and burr hole craniosstomy OR craniectomy
  • Address cause of trauma - falls, abuse

If untreated potential tentorial herniation and coning

31
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
32
Q

What GCS score would you consider intrubating someone?

A

GCS < 8 - unable to maintain own airway

33
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

34
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)
35
Q

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

A

Severity of injury - never occurs without anterograde amnesia

36
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
37
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
38
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
39
Q

What are early complications of head injuries?

A
  • Subdural haemorrhage
  • Extradural haemorrhage
  • Seizures
  • Uncal herniation
  • CSF leak
  • Hydrocephalus
  • Cranial nerve palsies
40
Q

What are late complications of head injury?

A
  • Subdural haemorrhage
  • Seizures
  • Diabetes insipidus
  • Parkinsonism
  • Dementia
41
Q

When is alcohol an unlikely cause of coma?

A

If blood alcohol levels <44 mmol/L

42
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.
43
Q
A
44
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
45
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
46
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
47
Q

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

A
  • Rhinorrhoea
  • Otorrhoea
  • Blood behind ear drum
  • Basal skull fracture signs
48
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.
49
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
50
Q

What is an intracerebral haemorrhage?

A

Haemorrhage within the brain tissue itself

51
Q

What are causes of intracerebral haemorrhage?

A
  • RF
    • Hypertension
    • Alcoholics
    • Smoking
    • Drugs - amphetamines, cocaine, anticoagulatns, thrombolysis
    • Trauma
  • Spontaneous
    • Aneurysm rupture
    • Haemorrhagic infarction
    • Tumours
52
Q

How might you distinguish an intracerebral haemorrhage from a stroke?

A

Very difficult - may have a headache with stroke symptoms

53
Q

What is the following?

A

Intracerebral haemorrhage

54
Q

Which imaging modality is best for visualising intracranial haemorrhage?

A

CT is best and quickest option

55
Q

What is the difference between primary and secondary head injury?

A

Primary = occur imediately after the initial trauma

Secondary = fro m the delayed effect of the primary injury eg hypoxia, hypotension, haemorrhage, intracranial hypertension

56
Q

Name the layers of the scalp

A

Skin

Connective tissue

Aponeurosis

Loose connective tissue

Pericranium

57
Q

Describe mechanisms of diffuse brain injury

A

Diffuse axonal injury - shearing forces

Diffuse hypoxic damage - common in all forms of brain injury (associated with brain swelling)

Diffuse brain swelling - hypocia/hypercapnea

Diffuse vascular injury

58
Q
A
59
Q

What does cerebral pefusion depend on?

A

Cerebral perfusion pressure (CPP)=MAP-ICP

60
Q

What is cushing’s reflex?

A

Physiological response to raised ICP - triad of hypertension, bradycardia and irregular breathing

61
Q

What is the munroe kelly doctrine?

A

Volume inside the cranium is a fixed volume (blood, brain, csf)

62
Q

Medical means of maintaining CPP

A
  • Improve cerebral venous drainage
    • Position (45 degrees)
    • Avoid pressure on jugular
  • Decrease CBF
    • Sedation, analgesia
    • avoid hyperthermia
    • Hyperventilation
    • Osmotic therapy (mannitol)
63
Q

Surgical means of maintaining CPP

A
  • CSF drainage (ventriculostomy) - using catheter
    • External ventricular drain
    • Ventriculopleural shunt
    • Ventriculoperitoneal shunt
    • Ventriculoatrial shunt
  • Decrompressive craniectomy
  • Removal of mas lesion
64
Q

Immediate management of increased ICP

A
  1. ABCDE
  2. Correct hypertension and treat seizures
  3. Elevate bed
  4. If intubated, hyperventilate to reduce PaC)2 (causing vasoconstriction and reduced ICP almost immediately) (so O2 causes vasodilation which inceases CPP)
  5. Osmotic agents (mannitol)
  6. Corticosteroids
    1. Not effective in reduceing ICP unless for oedema surrounding tumours (IV prednisolone)
  7. Fluid restriction
  8. Definitive treatment

Gwen - Neurology (38 decks)

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