Traumatic Hemorrhagic Conditions Flashcards
A patient presenting with refractory intracranial hypertension due to diffuse parenchymal injury with clinical and radiographic evidence for impending transtentorial herniation should have decompressive craniectomy. While a patient presenting with medically refractory posttraumatic cerebral edema and associated intracranial hypertension should have which of the following?
● A. Bifrontal decompressive craniectomy within 24 hours
● B. Bifrontal decompressive craniectomy within 48 hours
● C. Treatment with hyperventilation
● D. Decompressive bifrontal craniectomy within 4 hours
● E. None of the above
B. Bifrontal decompressive craniectomy within 48 hours
Nonoperative management of traumatic intracerebral hemorrhage (TICH) with intensive monitoring and serial imaging is used in patients without neurologic compromise, no significant mass effect on CT, and controlled ICP. What are the indications for surgical evacuation of TICH?
● A. Progressive neurologic deterioration referable to TICH
● B. Medically refractory intracranial hypertension or signs of mass effect on CT
● C. TICH volume more than 50 mL
● D. GCS equal to 6 to 8 with frontal or temporal TICH volume more than 20 mL with midline shift of more than 5 mm and/or compressed basal cisterns on CT
● E. All of the above
E. All of the above
Incidence of delayed traumatic intracerebral hemorrhage (DTICH) in patients with GCS less than 9 is almost 10%. When does most DTICH occur?
● A. Within 24 hours of injury
● B. Within 5 days of injury
● C. Within 72 hours of injury
● D. Within 7 days of injury
● E. Within 9 days of injury
C. Within 72 hours of injury
A patient after road traffic accident (RTA) presents with brief period of LOC followed by a lucid interval of few hours in which he remained conscious and then deteriorated suddenly. On CT of the brain, there is a biconvex hyperdense area on right parietal area with possible rupture of middle meningeal artery. The patient is also showing ipsilateral dilated pupil and contralateral hemiparesis on examination. What are the indications of surgical evacuation of this lesion?
● A. EDH volume of more than 30 mL
● B. EDH thickness of more than 15 mm
● C. Midline shift of more than 5 mm
● D. GCS less than 8
● E. Focal neurologic deficit
● F. All of the above
F. All of the above
Subdural hematoma is typically more diffuse, less uniform, usually crescentic over brain surface, often less dense as compared to extradural hematoma (EDH), and cannot cross intradural barriers like falx or tentorium whereas an EDH can.
Which of the following statements is correct regarding acute subdural hematoma (ASDH) density changes with time?
● A. Acute SDH is from 1 to 3 days and is hyperdense on CT relative to brain
● B. Subacute SDH is from 4 days to 2 or 3 weeks and it is isodense to brain
● C. Chronic SDH is from 3 weeks to 3 or 4 months and it is hypodense (approaching density of CSF)
● D. After about 1 to 2 months, it may become lenticular in shape with density more than CSF but less than fresh blood
● E. All of the above
E. All of the above
According to the 4-hour rule, patients operated within 4 hours of injury had 30% mortality compared to 90% mortality if surgery was delayed for more than 4 hours. Also, functional survival (Glasgow outcome scale more than or equal to 4) rate of 65% could be achieved with surgery within 4 hours. What are the indications of surgery for ASDH?
● A. Thickness greater than 10 mm
● B. Midline shift more than 5 mm
● C. ASDH with thickness less than 10 mm and midline shift less than 5 mm should undergo surgery if GCS drops by more than 2 points from the time of injury to admission or the pupils are asymmetric, fixed, and dilated or ICP is more than 20 mmHg
● D. A, B, and C
● E. Patient presenting after 4 hours of injury should never be evacuated
D. A, B, and C
Mortality rate of ASDH is 50 to 90%. The variables which strongly influence outcome in patients with ASDH includes mechanism of injury, age, neurologic condition on admission, and postoperative ICP. Which statement is correct regarding admission GCS, mortality, and functional survival in these patients?
● A. Patients with admission GCS 3 has 90% mortality and functional survival of only 5%
● B. Patients with admission GCS 4 has 76% mortality and functional survival of only 10%
● C. Patients with admission GCS 5 has 62% mortality and functional survival of only 18%
● D. Patients with admission GCS 6-7 has 51% mortality and functional survival of only 44%
● E. All of the above
E. All of the above
A young child presents with history of backwards fall from standing position after which the child cried and then developed a generalized seizure. On CT of the brain, ASDH is found with hyperdense blood, and the patient is diagnosed as case of infantile acute subdural hematoma. What is the most appropriate management in this patient?
● A. Percutaneous subdural tap
● B. Craniotomy and evacuation of clot
● C. Subdural peritoneal shunt
● D. Burr hole and drainage of clot
● E. None of the above
B. Craniotomy and evacuation of clot
Many chronic subdural hematoma (CSDH) start out as acute subdurals in which fibroblasts invade due to an inflammatory response. These fibroblasts form neomembranes on the inner and outer surface of the clot which is followed by neocapillaries, enzymatic fibrinolysis, and liquefaction of blood clot.
Which of the following is incorrect regarding Markwalder neurologic grading scale for CSDH?
● A. Grade 0 is neurologically intact patients
● B. Grade 1 is alert and oriented patient with mild symptoms (H/A) and no or minimal neurologic deficit
● C. Grade 2 is drowsy or disoriented and variable neurologic deficit (hemiparesis)
● D. Grade 3 is stuporous but responds appropriately to noxious stimulus and severe focal signs (hemiplegia)
● E. Grade 4 is noncomatose patient with motor response to noxious stimuli
E. Grade 4 is noncomatose patient with motor response to noxious stimuli
Management step for CSDH includes seizure prophylaxis, coagulopathies reversal, and treatment of hematoma if symptomatic (focal deficit, mental status change, seizure, and severe headache). A patient with CSDH shows improvement after ap-
proximately 20% removal of collection. Postoperatively, CT shows persistent fluid in 78% of cases on postoperative day 10 and in 15% on postoperative day 40. Hence, it is recommended
not to treat persistent fluid collections evident on CT within 20 days postoperatively. What are the surgical options in patients with CSDH?
● A. Placing two subdural burr holes
● B. Single large burr hole with irrigation and aspiration
● C. Single burr hole drainage with placement of a subdural drain
● D. Twist drill craniostomy
● E. Craniotomy with excision of subdural membrane
● F. All of the above
F. All of the above
For medically refractory IC-HTN and post-traumatic edema, bifrontal decompressive craniectomy should be done within what time?
● A. 6 hours
● B. 12 hours
● C. 24 hours
● D. 36 hours
● E. 48 hours
E. 48 hours
Which of the following is an indication for surgical evacuation of TICH?
● A. Volume > 10 cm3
● B. Volume > 20 cm3
● C. Volume > 15 cm3
● D. Volume > 30 cm3
● E. Volume > 50 cm3
E. Volume > 50 cm3
A middle-aged male presented to emergency department after roadside accident with GCS 7, right dilated pupil, and left hemiparesis. CT of brain shows left-sided traumatic lesion. What is Kernohan’s notch phenomenon?
● A. Stalk effect
● B. Talk and die syndrome
● C. Long tract sign
● D. False localizing sign
● E. Radiological error
D. False localizing sign
Mottling of density on brain CT in extradural hematoma is described in which of the following?
● A. Chronic
● B. Delayed
● C. Acute
● D. Subacute
● E. Hyperacute
E. Hyperacute
A small volume extradural hematoma was managed medically without surgery. The patient remained clinically stable and a follow-up scan was done 1 week later and the patient was discharged. If the patient remains asymptomatic, when should the next follow-up CT scan to document resolution be
performed?
● A. 2 weeks
● B. 4 weeks
● C. 6 months
● D. 1 year
● E. 5 years
B. 4 weeks
