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Head Injury + Brain Haemorrhage Flashcards

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1
Q

What are RF for brain injury and what type

A

Focal - contusion / haematoma
Diffuse - diffuse axonal injury

RF
Head injury
Hypertension
Aneurysm
Ischaemic stroke
Brain tumour
Anti-coagulate
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2
Q

How does basal skull fracture present

A

Panda eyes
Battle sign (bruised mastoid)
CSF leakage ears or nose

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3
Q

What does a 3rd CN palsy secondary to tentorial herniation present with

A

Unilateral dilated + fixed pupils or sluggish

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4
Q

What does bilateral suggest

A

Bilateral CN 3 palsy from herniation or poor CNS perfusion

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5
Q

What does optic nerve injury cause

A

Unilateral dilated pupil

May be equal and cross reactive

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6
Q

What causes bilateral constricted pupils

A

Opiates
Pontine lesion
Metabolic encephalopathy

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7
Q

What causes unilateral constricted but light responsive

A

Sympathetic pathway disruption

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8
Q

What gets immediate CT

A 
GCS <13 initial
GCS <15 2 hours post
Suspected open or depressed skull fracture
Basal skull
Post traumatic seizure
Focal neuro deficit
\+1 vomit
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9
Q

Who gets CT within 8 hours

A

Anyone on warfarin
If LOC / amnesia
>65
Hx bleeding / clotting issues
Dangerous mechanism
30 mins retrograde amnesia of immediately before
CT cervical spine if neck pain / reduced rotation

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10
Q

Who gets ICP monitoring

A

If GCS 3-8 even if CT normal as ICP may begin to rise

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11
Q

What do you want for ICP monitoring

A

Minimal CPP
70 in adults
40-70 in children

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12
Q

How do you treat

A 
ATLS principles
Stabilise cervical spine
ABCDE
FBC, clotting 
Intubate if GCS <8 - urgent airway 
IV mannitol if rising ICP
Immediate head CT 
Depression craniotomy may be needed
If depressed skull fracture =surgical reduction + debridement
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13
Q

Electroylyte complication of head injury

A

Hyponatraemia due to inappropriate ADH secretion

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14
Q

What is extradural haemorrhage

A

Blood between skull and dura as dura peeled off skull

Nothing normally present

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15
Q

What causes extradural

A

Head injury
Often low impact
90% associated skull fracture which damages middle meningeal artery splitting dura

Usually temporal region / temporal bone fracture
Pterion = area that encompasses
- Parietal bone
- Temporal bone
- Greater wing of sphenoid
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16
Q

What are the symptoms of extra-dural

A

Classic lucid interval
LOC, briefly regain then lost again due to expanding haematoma
Headache
Vomit
Confusion
Seizures
Hemiparesis / hyperreflexia / upgoing plantar

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17
Q

What cane extra-dural lead too

A

Uncal herniation
3 CN palsy - fixed/. dilated pupil
CUshing’s = late
Death by res arrest

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18
Q

How do you Dx extra-dural haemorrhage

A

CT / MRI
Shows biconvex shape limited by sutures as blood pushes on brain (skull can’t move)
Hyperdense

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19
Q

What is CI

A

LP

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20
Q

How do you Rx extra-dural

A 
Craniotomy
May do Burr hole if unable
Evacuation
Airway protection
Intubation, ventilation and mannitol
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21
Q

What are the layers of the SCALP

A 
Skin
Connective tissue
Aponeurosis
Loose connective tissue
Periosteum (skull)
Dura -> arachnoid -> pia
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22
Q

What is subdural haemorrhage

A

Blood between dura and arachnoid
Not in brain
Not normally anything there

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23
Q

When should you suspect subdural

A

Fluctuating consciousness

Evolving stroke + anti-coagulant

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24
Q

What causes acute subdural

A

High energy impact
Stretches subdural emissary veins which burst

Bridging veins connect brain to sinus
Transverse sinus > sigmoid > IJV

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25
What causes chronic subdural
Rupture of bridging veins - which are friable in elderly Elderly and alcoholic at risk and anti-coagulant Shaken baby Minor trauma
26
What is the brain damage in subdural
More severe than extra-dural
27
How does acute subdural present
``` Range of presentations Fluctuating consciousness Headache Personality change Raised ICP Seizure Focal neuro Coma due to coning No meningitic Sx ```
28
How does chronic present
Progressive history of confusion, reduced consciousness or neurological deficit after head injury Headache
29
Who is at risk
On anti-coagulant
30
How do you Dx Differences between acute / chronic
``` CT = 1st line MRI Diffuse concave shape not limited by sutures - blood tricked around brain as no dura to stop Hyperdense if acute Hypodense if chronic ```
31
How do you manage
Usually conservative but contact neuro-surgery Monitor ICP Craniotomy Burr hole surgery
32
DDX
Stroke Dementia CNS Weirnecke's
33
What is SAH
Blood between arachnid and pia were CSF is located
34
What causes SAH
``` Trauma = most common Traumatic / spontaneous rupture of berry aneurysm = most common AV malformation = most common in the young Tumours Infectious - encephalitis Mycotic aneurysm Spasm Venous sinus thrombosis Vasculitis ```
35
How does SAH present
``` Sudden onset thunderclap headache Worse ever Occipital / hit on back of head N+V Menigism - stiff neck / photophobia / phonophobia Seizures Reduced GCS due to sudden rise in ICP Papilloeema due to raise ICP Visual disturbance FOcal neuro Hypertension May have sentinel headache due to warning leak ```
36
What might you see on ECG
ST elevation due to vagal stimulation but no infarction
37
What are RF for SAH
``` Previous SAH Trauma High BP Smoking Alcohol Age Cocaine use Female FH Polycystic kindey Sickle cell Coarctation Aorta Ehler's Danlos ```
38
How do you Dx
``` General + neuron exam Routine bloods FUndoscopy Non-contrast CT = 1st line Angiography once SAH confirmed to locate the source of bleeding ```
39
What does CT show
All grooves flooded Hypertense Can't see gyro
40
What do you do if CT -ve
LP post 12 hours Look for xanthochromia (breakdown of RBC) Stays +ve for 12 days
41
What can you do after 2 weeks
Angiogrphy
42
If patient presents within 6 hours of headache onset and CT normal
Discharge
43
How do you treat
Refer neurosurgery CT intracranial angio to identify lesion for surgery Coil for aneurysm = 1st line as endovascular Surgical clipping but more invasive as involves craniotomy
44
What do you do whilst awaiting Rx
Strict bed rest Control BP Nimidopine (CCB) = evidence that reduces reflex vasoconstriction / spasm after SAH as well as lowering BP (given for 21 days) - Only give if aneurysmal SAH Don't want to lower BP acutely as might be needed to perfuse brain Re-examine CNS - BP / pupils / GCS Repeat CT if deteriorating
45
What are complications of SAH
``` Vasospasm - Due to release of inflammatory cytokines - Often new onset focal neurology - Peak incidence = 6-8 days Hyponatramia due to ADH Seizures Hydrocephalus requiring stent Cardiac dysfunction Cerebral ischaemia Stroke Infection Re-bleed ```
46
What determines prognosis
LOC Age Amount of blood on CT
47
What causes hyponatraemia after SAH
Cerebral salt wasting - Fluid depletion due to urinary loss of Na and H20 follows - Patient will appear dehydrated - Rx = IV saline SIADH - Kidney retain water which dilutes Na - Concentrated urine - Rx = fluid restriction
48
What is intracerebral haemorrhage
Collection of blood within substance of brain | Form of stroke
49
What are natural causes
``` Hypertension AV anomaly Aneurysm Amyloid angiopathy Vascular tumours ```
50
What causes traumatic
Diffuse axonal injury after big decelaration in rotational force Shearing of long fibres Often = brain dead / coma May not pick up on CT / MRI
51
How does it present
Ischaemic stroke so always do CT before thrombosis as might haemorrhage More focal signs than SAH
52
How do you Dx
CT = hyperdense everywhere | APP shows hypoxic ischaemic damage present in DAI after 3 hours
53
How do you Rx
Stroke team Conservative Surgical evacuation if large / decompressive craniotomy to prevent ICP rising Skull put into abdominal to keep safe
54
Bone on CT =
HYPERDENSE | WHITE
55
Fluid / CSF on CT
HYPODENSE | BLACK
56
What is isodense
Grey
57
What causes inter ventricular haemorrhage
Premature ventricles (IVH) SAH Vascular Tumour
58
How do you Dx
CT | Hyperdense in ventricle space
59
How do you Rx
Urgent surgical diversion
60
What are complications
Obstruting hydrocephalus requiring drain
61
What is contusion
Bruising of brain
62
What causes contousin
Depressed fracture
63
What is COUP and COUNTRECOUP
``` Coup = contusion at blow Contrecoup = opposite to force ```
64
What causes laceration
Blunt force
65
What causes incision
Sharp force
66
What causes a brain aneurysm
Weakening of blood vessels
67
Where do most occur
Branch points of circle of Willis where arteries connect as most turbulent flow Berry or micro = most common
68
What are RF for developing aneurysm
``` Smoking High BP Age Women FH PCKD Ehlor danlos Certain connective tissue / vasculitis ```
69
What are symptoms
``` Only notice if burst causing SAH Sudden severe headache Decreased consciosness N+V Neck stiffness Photophobia Coma ```
70
How do you Dx
CT LP 12 hours after Angio 2 weeks after
71
How do you Rx
Monitor aneurysm | Coil or clip
72
Complications
``` Hydrocephalus Vasospasm Ischaemia SAH Stroke ```
73
How common is SAH
1 in 10 people with thunderclap headache
74
What is important to do if GCS drops
``` ABCDE Urgent airway if GCS <8 Blood sugar Pupils - PEARL Urgent CT - radiology Bleep anaesthetist ```
75
How doy ou detect diffuse axonal injury
MRI
76
Who needs urgent neurosurgical review
GCS <8
77
How do you investigate cervical spine
CT
78
What is immediate with diffuse axonal injury
Coma | Takes weeks to recover
79
How may cervical spine injury present
Pain Reduced movement Neuro soins e.g. can't feel legs
80
How do you check CSF is CSF
Glucose
81
Differences in stroke
``` Ischaemi = no headache Haemorrhagic = headache ```
82
Young adult presents with menigism and headache what are DDX
``` Ruptured AV malformation Ruptured aneurysm Menngitis Rupture mycotic aneurysm Migraine Trauma ```
83
What are the sutures in the skull
Coronal at front | Saggital down middle

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