Traumatic Brain Injury

Question 1

Where is the bleed in an extradural haematoma?

Answer 1

The extradural space, between the dura and the inner skull

Question 2

Extradural haematoma can also be known as what?

Answer 2

Epidural haematoma

Question 3

Which gender is more likely to be affected by extradural haematoma? In what age demographic is this usually seen?

Answer 3

Males (4:1) / Younger adults

Question 4

What is the commonest cause of an extradural haematoma?

Answer 4

A skull fracture at the pterion, leading to rupture of the MMA beneath it

Question 5

What is the major clinical feature of an extradural haematoma?

Answer 5

Transient loss of consciousness and then recovery (resulting in a lucid interval)

Question 6

During the lucid interval of an extradural haematoma there is continued bleeding, what is the result of this?

Answer 6

Bleeding overcomes the body’s ability to compensate, leading to raised ICP causing headache and nausea/vomiting

Question 7

What happens at the end of the lucid interval in extradural haematoma?

Answer 7

There is a decrease in conscious level resulting in drowsiness and reduced GCS

Question 8

Eventually in extradural haematoma, brain herniation develops. Which is the most common type?

Answer 8

Tentorial (uncal)

Question 9

What features will a tentorial/uncal herniation as a result of extradural haematoma result in?

Answer 9

Ipislateral fixed dilated pupil and contralateral hemiparesis

Question 10

What can extradural haematoma lead to if left untreated?

Answer 10

Coma, tonsillar herniation and cardiorespiratory arrest

Question 11

What is the first line investigation for suspected extradural haematoma?

Answer 11

CT

Question 12

Describe the haemorrhage seen on CT scan of an extradural haematoma?

Answer 12

Hyperdense, biconvex, limited to the suture lines of the inner surface of the skull

Question 13

What is the commonest location of an extradural haematoma on imaging?

Answer 13

The frontotemporal region

Question 14

What is the best treatment for extradural haematoma?

Answer 14

Surgical evacuation

Question 15

If a patient with extradural haematoma is in a coma, has signs of herniation and is waiting for surgical review, what are some measures that can be taken?

Answer 15

Give mannitol and hyperventilation

Question 16

Delay in treatment of an extradural haematoma can lead to what?

Answer 16

Death or severe disability

Question 17

What are the most common mechanisms of injury of an extradural haematoma?

Answer 17

Acceleration-deceleration injury, blow to the side of the head

Question 18

What are the two key features of an extradural haematoma?

Answer 18

Lucid interval and raised ICP

Question 19

Where is the bleed in a subdural haematoma?

Answer 19

In the subdural space, between the dura and arachnoid mater

Question 20

What factors differentiate subdural haematomas into acute, subacute and chronic?

Answer 20

The time (days) since the injury, and the CT appearance

Question 21

What are the two main causes of an acute subdural haematoma and who do they occur in?

Answer 21

Younger patients following an RTA, and elderly patients after a fall

Question 22

Which represents more severe trauma and damage to the brain - an extradural or subdural haematoma?

Answer 22

Subdural

Question 23

Acceleration-deceleration injuries are a common cause of subdural haematoma, what is the reason behind this?

Answer 23

Trauma causes haemorrhage by tearing bridging veins that transverse the subdural space

Question 24

What defines an acute subdural haematoma?

Answer 24

0-5 days since the injury, hyperdense appearance on CT

Question 25

How do most patients with an acute subdural haematoma present?

Answer 25

In a coma

Question 26

What are the CT features of an acute subdural haematoma?

Answer 26

Hyperdense, crescent shape, not limited by suture lines of the skull, may have signs of other intracranial injury

Question 27

When is evacuation of acute subdural haematoma recommended?

Answer 27

If there is a diameter of > 10mm or > 5mm of midline shift

Question 28

What post-operative care is often required for an acute subdural haematoma?

Answer 28

ICP monitoring and control in neuro ICU

Question 29

Acute subdural haematoma may occur with relatively minor trauma in patients on what medication?

Answer 29

Warfarin

Question 30

Where do acute subdural haematomas most commonly occur?

Answer 30

Frontal/parietal lobes

Question 31

Which has a quicker onset of symptoms - extradural or subdural haematomas?

Answer 31

Extradural

Question 32

What is a chronic subdural haematoma?

Answer 32

A subdural bleed which has liquified over weeks

Question 33

What defines a chronic subdural haematoma?

Answer 33

> 21 days since the injury, hypodense CT appearance

Question 34

Who does chronic subdural haematoma usually occur in?

Answer 34

Elderly patients

Question 35

Apart from increased age, what are some risk factors for chronic subdural haematoma?

Answer 35

Alcoholism, anti-coagulant use, coagulation disorder, frequent falls

Question 36

How do patients with chronic subdural haematoma present?

Answer 36

Features of raised ICP +/- focal neurological deficits

Question 37

What are some CT features of chronic subdural haematoma?

Answer 37

Hypodense, crescent shaped, significant mass effect and midline shift

Question 38

When is treatment indicated for chronic subdural haematoma?

Answer 38

If there is severe headache or focal neurological deficits

Question 39

How is chronic subdural haematoma treated?

Answer 39

Correction of underlying coagulopathy if indicated, followed by surgical evacuation