Intracranial Injuries

Question 1

Layers of the Meninges

Answer 1

Epidural Space (potential space)
Dura Mater (Outer and Inner)
Subdural Space
Arachnoid Mater
Arachnoid Space
Pia Mater

Question 2

Usual cause of epidural bleeds

Answer 2

Arterial bleeds secondary to trauma

Question 3

Usual cause of subdural bleeds

Answer 3

Cortical Bridging Veins secondary to trauma, usually acceleration/deceleration, or rotational injuries

Alcoholics, elderly, and atrophied brains are more suspectable as their brains are smaller and have more room to move to sever these veins

Question 4

Usual cause of subarachnoid bleeds

Answer 4

Cerebral Arteries aneurism rupture

Blunt trauma, acceleration/deceleration, or rotational injuries

Question 5

Usual symptoms of subarachnoid bleeds

Answer 5

Thunderclap HA (worst of their life)
Focal Changes based on location
Seizures
ALOC
N/V
Photophobia
Vision changes

Question 6

Extra-axial bleed types

Answer 6

Epidural
Subdural
Subarachnoid

Question 7

Intra-axial Bleed types

Answer 7

Cerebral Contusion
Intracerebral bleed
Cerebellar Bleed
Intraventricular bleed

Question 8

Symptomatic Progression for Epidural Hematoma

Answer 8

Brief LOC, lucid period, then Rapid Deterioration

HA
Progressive obtundation
Contralateral Hemiparesis
Ipsilateral Fixed/Dilated Pupil

Question 9

CT Presentation of Epidural Hematoma

Answer 9

Won’t cross suture lines
Presents as rapidly progressing bleed
Bi-convex concave lens shape

Question 10

Acronym to remember CT shapes of bleeds in order of D.A.P. (Dura, Arachnoid, Pia)

Answer 10

ICP

I - “Eye” shaped
C - ‘C’ looks like a moon
P - Pitting into the sulci

Question 11

Symptomatic Progression for Epidural Hematoma

Answer 11

Won’t cross Dural reflections
Presents as slowly progressing bleed
shape

Question 12

Symptomatic Progression for Subdural Hematoma

Answer 12

Most often non-localizing, but may have focal signs
Slow progression usually

HA
Disorientation gradually increasing
Contralateral Hemiparesis
Ipsilateral Fixed/Dilated Pupil

Question 13

CT Presentation of Subdural Hematoma

Answer 13

Midline Shift
Bleed can encompass the entire side border of the head
Shape is almost moon-like as it fills up the length of the skull pushing it to the side

Question 14

TX of subarachnoid bleeds

Answer 14

No surgical options

Reduce secondary brain injury

Manage ICP

Question 15

Usual causes of intraventricular bleeds

Answer 15

Typically associated with traumatic subarachnoid hemorrhage or

Around 30% are PRIMARY…result from…
- Tearing of subeperdymal veins
- Diffuse Axonal Injury
- Brain Stem Contusions

Question 16

Symptomatic presentation of intraventricular bleeds

Answer 16

HA
Seizures
ALOC
N/V
Minimal or absent focal signs

Question 17

CT presentation of intraventricular bleeds

Answer 17

Obvious blood in the ventricles

Question 18

CT presentation of Subarachnoid bleeds

Answer 18

Pits / fingers of bleeding in the sulci

Question 19

Symptomatic presentation of cerebral contusion

Answer 19

HA
Confusion
Sleepiness
Dizziness
LOC
N/V
Seizures
Focal Changes

Question 20

Most common type of inner head bleed

Answer 20

Cerebral Contusion

Question 21

Causes of cerebral contusion

Answer 21

Most commonly coup-contra-coup

Question 22

CT scan presentation of cerebral contusion

Answer 22

Small ill-defined dense focci areas of isolated bleeding, can progress into more rounded hematomas 24-48 hours later

Question 23

TX for cerebral contusion

Answer 23

No surgery
Can use an EVD to release pressure
Treat ICP
Prevent secondary brain injury

Question 24

What is an EVD and what is it used for?

Answer 24

External Ventricular Drain …

A burr hole is used to penetrate the skull, after which a catheter is blindly advanced into the lateral ventricle using anatomic landmarks. Among critically ill patients, the procedure is usually performed at the bedside.

An EVD is the gold standard approach to measurement of intracranial pressure, because it allows for rezeroing of the pressure transducer as needed. (Some other devices don’t allow rezeroing, which may cause the pressure to “drift” out of calibration over time.)

(1) Accurate measurement of the intracranial pressure (ICP).
(2) Therapeutic drainage of cerebrospinal fluid may be performed (especially in hydrocephalus).
(3) Diagnostic sampling of CSF may be performed.
(4) Intrathecal administration of medications is possible (e.g., chemotherapeutics or antibiotics).

Question 25

Intracerebral Hemorrhage causes

Answer 25

Typically penetrating, but can also be blunt

Usually never acceleration / decceleration

Question 26

Primary vs Secondary Brain Injury

Answer 26

Primary - occurs at time of impact and results in either focal or diffuse injury

Secondary - continuation of damage to the brain as a result of physiological effects from the primary injury (ischemia, penumbra, infarction, ICP, changes as cascade progresses)

Question 27

Intracerebral Hemorrhage location

Answer 27

bleeding in parenchymal brain tissue

Question 28

Diffuse Injury types

Answer 28

Concussion — mild-moderate

Diffuse Axonal Injury — worst
- Diffuse shearing of axons
- LOC
- Posturing

Question 29

How will diffuse injuries present on a CT scan?

Answer 29

Typically normal aside from whatever minor diffuse edema is present