Traumatic Brain Injury

Question 1

What is the classification of Subdural Haematoma (SDH) based on time?

Answer 1

Acute (within 3/7), sub acute (3-20/7), chronic (at least 21/7)

SDH is often seen in the elderly, chronic alcoholics, and patients on blood thinners.

Question 2

In which patients is Subdural Haematoma (SDH) commonly seen?

Answer 2

Elderly, chronic alcoholics, those on blood thinners

Common blood thinners include aspirin and heparin.

Question 3

What shape does a Subdural Haematoma (SDH) typically take?

Answer 3

Crescent shaped

This is due to the haematoma not being limited by suture lines.

Question 4

How does Acute SDH appear on a CT scan in relation to brain tissue?

Answer 4

Hyper dense

This contrasts with sub acute (iso-dense) and chronic (hypodense) appearances.

Question 5

What is a classic presentation of an Epidural Haematoma (EDH)?

Answer 5

Lucid interval

This is often followed by a loss of consciousness.

Question 6

What is the common cause of Epidural Haematoma (EDH)?

Answer 6

Bleeding from the middle meningeal artery

Often associated with a fracture or trauma at the pterion.

Question 7

List some indications for a Non Contrast CT Brain + Cervical spine in a patient with a history of loss of consciousness.

Answer 7

• Patient above 60 years
• Neurological deficit
• Blurred or double vision
• Vertigo
• Drug or alcohol intoxication
• Dangerous mechanism
• Seizure, somnolence, > 2 episodes of vomiting
• Headache

GCS 14-15 indicates mild head injury.

Question 8

What is the Cushing’s triad?

Answer 8

Hypertension, Bradycardia, irregular respirations

This is a clinical presentation indicative of increased intracranial pressure.

Question 9

What are some clinical presentations of a skull fracture?

Answer 9

• Low GCS/Lucid interval
• Convulsions
• Features of basal skull fracture (Panda eyes, otorrhoea, rhinorrhoea, Battle sign, haemotympanum)
• Hemiparesis/Hemiplegia
• Anisocoria
• Projectile vomiting
• Decorticate/de-cerebrate rigidity
• Amnesia
• Somnolence

These signs can indicate severe head injury.

Question 10

What does the Monroe-Kellie Hypothesis state?

Answer 10

The skull is a rigid structure containing brain, cerebrospinal fluid, and blood in equilibrium

An increase or decrease in one or two components will result in a compensatory change.

Question 11

What is a common symptom of Subarachnoid Haemorrhage (SAH)?

Answer 11

Thunder clap headache

This is described as the worst headache the patient has ever experienced.

Question 12

List some complications of Subarachnoid Haemorrhage (SAH).

Answer 12

• Post traumatic vasospasms
• Hydrocephalus
• Electrolyte imbalances (Hyponatraemia)
• Fever/Seizures

These complications can worsen the patient’s prognosis.

Question 13

What is Diffuse Axon Injury (DAI) caused by?

Answer 13

Shearing force on the white matter of axons

This often occurs during rapid acceleration/deceleration.

Question 14

What diagnostic imaging is used for Diffuse Axon Injury (DAI)?

Answer 14

MRI

It shows multiple small, hyper dense, punctate lesions along the grey-white matter junction.

Question 15

What happens if pressure in the brain becomes too high?

Answer 15

Brain herniation ensues

Types include supratentorial and subtentorial herniation.

Question 16

What is the average intracranial volume in an adult?

Answer 16

Around 1700 mls

Composed of brain tissue (1400 mls), cerebrospinal fluid (150 mls), and blood (150 mls).

Question 17

What is the Glasgow Coma Scale (GCS) classification for mild head injury?

Answer 17

GCS 14-15

Moderate head injury is GCS 9-13, and severe head injury is GCS less than or equal to 8.

Question 18

What are the two classifications of head injury based on resulting pathology?

Answer 18

• Diffuse injuries
• Focal injuries

Diffuse injuries often involve alteration of mental status out of proportion to CT findings.

Question 19

What is the definition of Traumatic Brain Injury?

Answer 19

Any alteration in mental or physical functioning due to trauma to the head

This includes both temporary and permanent brain dysfunction.

Question 20

What is the formula for Cerebral Perfusion Pressure (CPP)?

Answer 20

CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)

Normal CPP is between 60-80 mmHg.

Question 21

What are some initial assessments in a patient with head injury?

Answer 21

• Resuscitation (A, B, C, D, E)
• SAMPLE/AMPLE history

This includes symptoms, allergies, medications, past medical history, last meal, and events leading to presentation.

Question 22

What are the components of the initial management algorithm in ICU for head injury?

Answer 22

• Feeding
• Analgesia
• Sedation
• Thrombo-prophylaxis
• Head up
• Ulcer prophylaxis
• Glycaemic control
• Spontaneous breathing trial

IV fluids should be hypertonic; avoid hypotonic fluids.