Session 10 L2: Head Trauma and Acute Intracranial Events Flashcards
What is Cerebral Contusion?
Bruising” of brain whereby blood mixes with cortical tissue due to micro-haemorrhages and small blood vessel leaks.
What is the pathophysiology of a Cerebral contusion?
Trauma to micro-haemorrhages to cerebral contusion to cerebral oedema/intracerebral bleed to raised intracranial pressure to coma
What is the definition of a concussion?
Head injury with temporary loss of brain function
What is the pathophysiology of a concussion?
- Trauma
- Stretching and injury of axons
- Impaired neurotransmission, and loss of ion regulation and a reduction in cerebral blood flow.
- This can all lead to temporary brain dysfunction
What is are the different factors involved in Post concussion syndrome?
- Thinking/Remembering
- Physical
- Emotional/Mood
- Sleep disturbance
What is involved in the thinking/remembering aspect of post concussion syndrome?
- Difficult thinking clearly
- Feeling slowed down
- Difficult concentrating
- Difficulty remembering new information
What is involved in the physical aspect of post concussion syndrome?
- Headache
- Nausea or vomiting (early on)
- Balance problems
- Dizziness
- Fuzzy or blurry vision
- Feeling tired, having no energy
- Sensitivity to noise or light
What is involved in the emotion/mood aspect of post concussion syndrome?
- Irritability
- Sadness
- More emotional
- Nervousness or anxiety
What is involved in the sleep disturbance aspect of post concussion syndrome?
- Sleeping more than usual
- Sleeping less than usual
- Trouble falling asleep
What is the definition of diffuse axonal injury?
Shearing of interface between grey and white matter following traumatic acceleration/deceleration or rotational injuries to the brain damaging the intra-cerebral axons and dendritic connections
What is the pathophysiology a diffuse axonal injury?
- Trauma
- Shearing of grey and white matter interface
- Axonal death leading to cerebral oedema
- Raised intracranial pressure
- This can lead to a coma
What is the definition of a basilar skull fracture?
Bony fracture within the base of skull (temporal, occipital, sphenoid, or ethmoid bone)
What is the pathophysiology of a basilar skull fracture?
Trauma leads to tears in the meninges which can cause CSF to leak
What are the clinical signs of basilar skull fractures?
- Raccoon eyes
- CSF rhinorrhoea
- CSF otorrhea
- Battle signs
- Haemotympanum
- Bump
What is the management of Basilar skull fractures?
- Traumatic brain injury management (including ICP control)
- Seek and treat complications
- Elevation of depressed skull fractures
- Persistent CSF leak management requires surgery
What is an extradural haemorrhage?
Collection of blood between INNER SURFACE of skull and PERIOSTEAL DURA MATER
What is the common mechanism of an extradural haemorrhage?
- Nearly always secondary to trauma and/or skull fracture typically in younger patients
- Most cases (90%) involve a severed artery – most commonly middle meningeal artery
- Supratentorial in most cases
- If its venous involvement, then torn venous sinus
What is the presentation of an extradural haemorrhage?
- Loss of consciousness due to impact of initial injury
- Followed by transient recovery with ongoing headache known as a lucid interval in 40% of patients
- As haematoma enlarges, ICP will increase causing compression of the brain and rapidly deteriorating level of consciousness
- Cranial nerve palsies may be found on examination as the brain structures herniate
What is the management of Extradural haemorrhages?
- Prognosis generally good with early intervention
- Small EDH can be observed and managed conservatively with neurological follow up
- Large EDH require referral to neurosurgery for craniotomy and clot evacuation
What are the complications of Extradural haemorrhages?
- Permanent brain damage
- Coma
- Seizures
- Weakness
- Psuedo-aneurysm
- Arteriovenous fistula
What is a subdural haemorrhage?
-Collection of blood between MENINGEAL DURA MATER and ARACHNOID MATER
What is the common mechanism of action of Subdural haemorrhage?
- Can occur in all age groups and could be ACUTE, SUBACUTE, CHRONIC (more common in elderly)
- Bleeding occurs due to shearing forces on cortical bridging veins
- Most often associated with trauma but can be spontaneous.
- Cerebral atrophy increases the risk of rupture
What is the presentation of Subdural Haemorrhages?
- ACUTE Sub-Dural Haemorrhage usually present in the setting of head trauma
- Neurological abnormalities in up to 80%
- May present with insidious onset of confusion and general cognitive decline similar to dementia
- Acute bleeds generally appear hyper dense i.e. brighter than brain tissue on CT.
- Haematoma will become progressively hypodense over time i.e. darker than brain tissue
What is the management of Sub-dural haemorrhages?
- Small CHRONIC haematomas can be evaluated with serial imaging
- ACUTE collections need immediate neurosurgical intervention to relieve raised ICP
- Symptomatic SUBACUTE/CHRONIC SDH are often treated via one or more burr holes
What is the prognosis of a subdural haemorrhage?
- Mortality in acute subdural haematomas requiring surgery intervention may exceed 50%. Full recovery may only be achieved in 20% of patients. Worse outcomes in patients who are anticoagulated
- Worse prognosis compared t Extradural haemorrhage
What is a subarachnoid haemorrhage?
Collection of blood between ARACHNOID MATER and PIA MATER
What are the features of a subarachnoid haemorrhage?
- Usually occur in middle aged patients <60
- Vast majority of SAH occur spontaneously secondary to ruptured berry aneurysm but may also be traumatic
How does a subarachnoid haemorrhage present?
- Sudden onset ‘thunderclap’ headache
- Meningism – symptoms caused by irritation of meninges
- Nausea and Vomiting
- Fever
- Focal neurological deficits
- LOC
What is a berry aneurysm?
- Largely asymptomatic but symptoms may arise if compressing on nearby structures or during early stages of rupture
- Around 3% of population may have one or more aneurysm
How can a berry aneurysm be controlled?
-Surgical clipping and endovascular coiling can be performed if risk of rupture is high
What are the risk factors of a berry aneurysm?
- Family history
- Hypertension
- Heavy alcohol consumption
- Abnormal connective tissue (Autosomal Dominant Polycystic Kidney Disease, Ehlers-Danlos, Neurofibromatosis, Marfan’s Disease)
How is a sub arachnoid haemorrhage investigated?
Lumbar puncture
• Presence of RBCs
• Xanthochromia
What is the prognosis of a subarachnoid haemorrhage?
Prognosis depends on GCS, degree of neurological deficit at the time of presentation and comorbidities
-Mortality between 30% and 90%
What are the complication of a sub arachnoid haemorrhage?
- Hydrocephalus
- Focal neurological deficits, coma
- Seizures
- Cognitive decline
- Frequent headaches
- Hypopituitarism
How are patients with a sub-arachnoid haemorrhage managed?
- Stabilise the patient
- Prevent re-bleeding
- Treat cerebral vasospasm
- Correct Hyponatraemia
- Neurosurgical intervention if large bleed
