A.12 - Traumatic intracranial bleeding

Question 1

How can traumatic intracranial bleeding occur?

Answer 1

either extradural or intradural
intradural hematomas are usually a mix of subdural and intracerebral hematomas,
although pure subdural can happen

Question 2

what is subdural intracranial bleeding?

Answer 2

• impact rupture bridging veins from the cortical surface to the venous sinuses
• no underlying cortical contusion or laceration

Question 3

what is Extradural intracranial bleeding?

Answer 3

• a skull fracture tearing the middle meningeal vessels (occasionally damage to sagittal/transverse sinuses)
• usually in the temporal/temporoparietal region

Question 4

how Brain damage can be causes in traumatic intracranial bleeding?

Answer 4

• damage is caused directly or indirectly
• as a result of tentorial or tonsillar herniation

Question 5

what can create a space occupying hematoma?

Answer 5

Bleeding that arises in multiple contusions

○ Contusion are usually multiple and can occur under or opposite (contre-coup) to the site of impact
○ most commonly in the frontal and temporal lobes

Question 6

what is Burst lobe?

Answer 6

Intracerebral hematoma mixed w/ necrotic brain tissue, rupturing into the subdural space

Question 7

Is it possible that high IC pressure alone damages neuronal tissue?

Answer 7

It is unlikely that high IC pressure alone damages neuronal tissue, but usually occurs as a result of tonsillar or tentorial herniation

Question 8

how can tentorial herniation occur?

Answer 8

○ Supratentorial hematoma → midline shift → herniation of medial temporal lobe through the tentorial hiatus (lateral tentorial herniation) → midbrain compression

○ Uncontrolled lateral tentorial herniation or diffuse bilateral hemispheric swelling → central tentorial herniation → tonsillar herniation

Question 9

how can tonsillar herniation occur?

Answer 9

Traumatic posterior fossa hematoma → tonsillar herniation

Question 10

what to assess if suspecting intracranial bleeding?

Answer 10

figure out if its:
● Multiple injury
● Head injury
● Suspected IC hematoma → CT!

Question 11

how to assess multiple injury?

Answer 11

airway → breathing → circulation → head/spinal injury → limb injuries

Question 12

how to assess head injury?

Answer 12

points to determine:
○ Period of loss of consciousness: relates to severity of diffuse brain damage
○ Period of post-traumatic amnesia: reflects severity of damage
○ Period of retrograde amnesia
○ Cause and circumstances of the injury: e.g. epilepsy
○ Presence of headache and vomiting: if they persists, IC hematoma must be considered

Question 13

how to examine intracranial bleeding?

Answer 13

Vital signs: ↑ IC pressure → ↑ BP, ↓HR, abnormal respiratory patterns

1) Evidence of injury (lacerations, bruising)
2) Basal fracture signs
3) Conscious level - GCS
4) Pupil response
5) Limb weakness
6) Eye movement

Question 14

when examining intracranial bleeding, what are the evidence of injury?

Answer 14

● Traumatic IC hematoma can occur with no external evidence of injury!

● Always examine deep lacerations w/ a finger for a depressed fracture

● Don’t misdiagnose a scalp hematoma (soft fluctuant center w/ firm rim) as a depressed fracture

● Consider hyperextension injury to the cervical spine if frontal laceration/bruising

Question 15

when examining intracranial bleeding, what are the sings of Basal fracture?

Answer 15

● Clinical features are very important as it may be hard to detect on imaging!

○ Anterior fossa fracture:
- CSF rhinorrhea (contains glucose)
- bilateral periorbital hematoma
- subconjunctival hemorrhage

○ Petrous fracture:
- bleeding from ext. auditory meatus or CSF otorrhea
- bruising over the mastoid (Battle’s sign)

● Potential route of infection

Question 16

when examining intracranial bleeding, what is the Conscious level - GCS?

Answer 16

● Eye movement
● Verbal response
● Motor response

Question 17

when examining intracranial bleeding, what is the pupils response?

Answer 17

● The pupil dilates on the side of the expanding lesion

● Light reflex: tests optic and oculomotor nerve

● Herniation of middle temporal lobe through tentorial hiatus → direct damage to CN III (most useful indicator of an expanding IC lesion)

Question 18

when examining intracranial bleeding, what does limb weakness indicates?

Answer 18

● Hemiparesis/hemiplegia usually occur contralaterally to the lesion (decussation of pyramidal tracts)

● False localising sign = ipsilateral deficit caused by a notch in the contralateral cerebral peduncle, often seen in chronic subdural hematomas,

● Determine by comparing response to pain stimuli

Question 19

when examining intracranial bleeding, what does eye movement indicates?

Answer 19

● Abnormal eye movement:
- brain stem dysfunction
- damage to the nerves supplying the extraocular muscles
- damage to the vestibular apparatus

● Absent eye movements → low level of responsiveness, bad prognosis

Question 20

what are the Referral criteria in traumatic intracranial bleeding?

Answer 20

● Adults:
- GCS <13 on assessment or <15 2h from injury
- suspected open/depressed skull fracture
- signs of basal skull fracture
- post trauma seizure
- focal neurological deficit
- >1 episode of vomiting

● Children: use a lower threshold

Question 21

During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Extradural level?

Answer 21

• increased density
• convex inwards
• pread limited by dural adhesion to skul
• midline shift w/ compression of lat. ventricle, dilated contralat. ventricle due to obstruction of foramen of
  Munro

Question 22

During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Subdural level?

Answer 22

area of increased density spreading around the surface of cerebral hemisphere becomes isodense with brain (10-12 d after), then hypodense

Question 23

During the Investigation (CT scan) of traumatic intracranial bleeding what you may see on the Intracerebral level?

Answer 23

burst lobe ± subdural hematoma appearing as an irregular area of increased density (blood clot) surrounded by area of low density (edematous brain)

Question 24

how is the Management of traumatic intracranial bleeding if it is Extradural?

Answer 24

• horseshoe craniotomy flap w/ complete evacuation of the hematoma
• burr hole and craniectomy if rapid deterioration for temporary relief

Question 25

how is the Management of traumatic intracranial bleeding if it is Subdural/intracerebral?

Answer 25

questionmark flap over temporal and/or frontal areas w/ subdural/intracerebral evacuation of hematoma and necrotic brain

Question 26

what is Chronic subdural hematoma?

Answer 26

Occurs mainly in infancy and elderly w/ trauma as the likely cause

Question 27

what are the Predisposing factors of Chronic subdural hematoma?

Answer 27

• cerebral atrophy causing stretching of bridging veins
• low CSF pressure (after shunt of fistula) causing stretching of bridging veins
• alcoholism
• coagulation disorder

Question 28

Clinical features of Chronic subdural hematoma?

Answer 28

○ Dementia
○ Deterioration of consciousness, fluctuating
○ S&S of ↑ICP
○ Focal signs, especially ipsilateral limb weakness

Question 29

Diagnosis of Chronic subdural hematoma?

Answer 29

CT:
- isodense lesions 1-3w after injury → contrast material
- hypodense after 3w
- check midline shift and shape of ventricles

Question 30

Management of Chronic subdural hematoma?

Answer 30

○ Hematoma is evacuated through burr holes and washed w/ saline

○ Conservative treatment w/ steroids if no depressed consciousness