Head Trauma

Question 1

Indications for EDH surgery:

Answer 1

Level:
1. EDH volume > 30cm3 should be evacuated regardless of GCS.

2. EDH with all of the following characteristics can be managed nonsurgically with serial CT scans and close neurological observation in a neurosurgical centre:
   a) volume < 30cm3
   b) and thickness < 15mm
   c) and midline shift (MLS) < 5mm (p.1110)
   d) and GCS > 8
   e) and no focal neurologic deficit

*The estimated volume of a lens = (1.6 to 2) × r2t = (0.4 to 0.5) × d2t ≈ (H × AP × T)/2 (that is 1/2 the products of the height times the length in the AP dimension times the thickness T).

Question 2

EDH - general information:

Answer 2

Incidence: 1% of head trauma admissions (which is ≈ 50% of the incidence of acute subdural).
- male: female = 4:1
- 85% = arterial bleeding - middle meningeal artery
- 70% occur laterally over the hemispheres with their epicentre at the pterion

Question 3

EDH - presentation:

Answer 3

“Textbook” presentation (< 10%-27%)
● brief posttraumatic loss of consciousness (LOC);
● followed by a “lucid interval” for several hours;
● obtundation, contralateral hemiparesis and ipsilateral pupillary dilatation;

60% of patients with EDH have a dilated pupil, 85% of which are ipsilateral

Question 4

EDH - “PEDS”:

Answer 4

In peds, EDH should be suspected if there is a 10% drop in hematocrit after admission.

Question 5

EDH - Kernohan’s phenomenon:

Answer 5

Shift of the brainstem away from the mass may produce compression of the opposite cerebral peduncle on tentorial notch which can produce ipsilateral hemiparesis (so called Kernohan’s phenomenon or Kernohan’s notch phenomenon

Question 6

EDH - mortality:

Answer 6

Overall: 20–55%
Optimal diagnosis and treatment: 5–10% (12% in a recent CT era series)

Question 7

Delayed epidural hematoma (DEDH) - definition:

Answer 7

EDH that is not present on the initial CT scan, but is found on subsequent CT.

9–10% of all EDHs

Question 8

Posterior fossa epidural hematoma - characteristics:

Answer 8

• 5% of EDH
• More common in 1st two decades of life
• 84% have occipital skull fractures, only ≈ 3% of children with occipital skull fractures develop p-fossa EDH.
• Cerebellar signs are surprisingly lacking or subtle in most.
• Overall mortality is ≈ 26%

Question 9

ASDH - receiving anticoagulation therapy - risk:

Answer 9

Receiving anticoagulation therapy increases the risk of ASDH 7-fold in males and 26-fold in females.

Question 10

SDH - density changes on CT:

Answer 10

acute (1-3 days) - hyperdense
subacute (3 days to 2-3 weeks) - isodense
chronic (> 3 wks and < 3–4 mos) - hypodense

Question 11

ASDH - indications for surgery:

Answer 11

1. > 10mm or midline shift (MLS) > 5mm (on CT) => regardless of GCS
2. < 10mm and MLS < 5mm:
   a) GCS drops by ≥ 2 points from injury to admission
   b) and/or the pupils are asymmetric or fixed and dilated
   c) and/or ICP is > 20mm Hg
3. monitor ICP in all patients with ASDH and GCS < 9

Question 12

ASDH - mortality range:

Answer 12

Mortality range: 50–90%
- 90–100% in patients on anticoagulants

Question 13

Interhemispheric subdural hematoma - characteristics:

Answer 13

Subdural hematoma along the falx between the two cerebral hemispheres.
- may occur in children (possible child abuse)
- Spontaneous cases should be investigated for possible underlying aneurysm.
- Reported mortality: 25–42%.

Question 14

Interhemispheric subdural hematoma - treatment:

Answer 14

Controversial. Small asymptomatic cases may be managed expectantly. Surgery should be considered
for progressive neurological deterioration with larger lesions. Approached through a parasagittal
craniotomy.

✖ Surgery for these lesions can be treacherous—there is risk of venous infarction and one often finds they are dealing with a superior sagittal sinus injury.

Question 15

Infantile acute subdural hematoma - definition:

Answer 15

Def.: acute SDH in an infant due to minor head trauma without initial loss of consciousness
or cerebral contusion, possibly due to rupture of a bridging vein. The most common trauma is a fall
backwards from sitting or standing.

Question 16

Infantile acute subdural hematoma - presentation:

Answer 16

The infants will often cry immediately and then (usually within minutes to 1 hour) develop a generalized seizure. Patients are usually < 2 yrs old (most are 6–12 mos, the age when they first begin to pull themselves up or walk).

Question 17

Infantile acute subdural hematoma - treatment:

Answer 17

Minimally symptomatic cases (vomiting, irritability, no altered level of consciousness and no motor disturbance) with liquefied hematoma may be treated with percutaneous subdural tap, which may be repeated several times as needed.

Chronically persistent cases may require a subduroperitoneal shunt.

More symptomatic cases with high-density clot on CT require craniotomy.

Question 18

Infantile acute subdural hematoma - mortality:

Answer 18

8% morbidity and mortality rate in one series.