HEAD TRAUMA & Intracranial Hemorrhage:
Traumatic head injuries are a major cause of death, and disabilities worldwide, especially in children and young adults. The initial injury associated with head trauma is due to forces, , applied to the skull and brain.
Any head injury resulting in a loss of conscious or altered mental status should get CT Scan WITHOUT CONTRAST.
The injury can result in Concussion, Contusion, Subdural hematoma, or Epidural hematoma. Although loss of conscious is a common complaint in any form of head injury, but is not always present, even relatively severe forms of brain injury.
Secondary effects by contrast to the initial trauma may be quite serious and include edema (brain swelling), intracranial bleeding, intracranial hypertension, and herniation.
Factors that worsen the initial insult include hyperglycemia, anemia, hypotension, hypercarbia, and hypoxia-effects that may be preventable.
Sometimes following the initial injury other serious effects may occur, such as sepsis, infection, and seizures; and these effects must be managed aggressively.
In the majority of cases, secondary events influence the clinical course of head injury patients. One particularly important event is hypotension secondary to head injury.
Post-head injury hypotension is associated with significant (70%) morbidity/mortality.
The combination of hypotension and hypoxia adds to the likelihood of adverse outcomes (frequency = 90%).
The category of primary head injury to brain tissue consists of concussion, contusion, laceration, and hematoma (Subdural &Epidural).
Concussion – No loss of consciousness not associated with focal neurological defects.
CT scan shows normal. No treatment required
Contusion – No loss of consciousness, focal neurological defects rarely seen. Head CT shows ecchymosis. Supportive treatment, hospitalization and observation is required.
Subdural Hematoma: Acute subdural hematomas may exhibit a range of clinical presentations that include limited or slight deficits to loss of consciousness with indications of mass effect lesions.
Mass lesions may present with pupillary enlargement, unilateral decrebration, and/or hemiparesis. The most likely cause of subdural hematoma is trauma leading to rupture of the bridging veins, although spontaneous events associated with neoplasms, aneurysms, or coagulopathies also occur.
Acute subdural hematoma is defined by the appearance of symptoms within three days; subacute hematoma, within 3-15 days; and chronic subdural hematoma, within two weeks.
The patient population most likely to exhibit subacute and chronic subdural hematoma is the age group > 50 years.
Subacute and chronic subdural hematomas may exhibit broad clinical presentations ranging from focal signs to reduce level of consciousness or organic brain syndrome development.
Intracranial hypertension is typically associated with acute subdural hematoma and requires aggressive intervention to reduce ICP, and manage cerebral edema and swelling. These interventions may be required before, during, and subsequent to hematoma surgical evacuation. CT scan shows Crescent shaped collection (Concave shaped).
Epidural Hematoma: Epidural hematomas are located between the dura and the skull. The tight adhesion of the dura to the skull causes the typical biconvex shape. This also accounts for the fact that epidural hematomas may cross dural attachments, but not skull sutures. Most commonly, they occur when a skull fracture lacerates the middle meningeal artery or a major dural sinus. CT scan shows LENS shaped collection (Convex shaped).
Patients presents with loss of consciousness, regain conscious and loss of conscious again (Lucid Interval).
All forms of head injuries are present with headache, amnesia, and loss of consciousness. The degree of amnesia is closely associated with the severity of the head injury, i.e. the worst the trauma and the more of memory loss. Memory loss can be anterograde or retrograde and retrograde amnesia is seen more commonly.
Treatment: Initial step in the management severe head injury or intracranial hemorrhage is secure the airway, breathing, and circulation, and lowering the intracranial pressure Lowering the ICP can be archived by raising the head of the bed, hyperventilation and by the use of osmotic diuretics (mannitol). Steroids have no role in the management of head trauma and it is always wrong answer.
Surgical Evacuation: Craniotomy is required for management of acute epidural, intracerebral and subdural hematoma, as well as for depressed skull fractures.
Evacuation using burr holes is often required for chronic subdural hematoma treatment.
Large and symptomatic hematomas are drained and small and non-symptomatic hematomas are left alone.
Stress ulcer prophylaxis – Proton pump inhibitors (other conditions need stress ulcer prophylaxis are burns, endotracheal intubation, head trauma and on steroid treatment.)
Subarachnoid Hemorrhage (SAH):
Subarachnoid Hemorrhage is a bleeding into the subarachnoid space – the area between the arachnoid membrane and the pia matter surrounding the brain. This may occur spontaneously, usually from a ruptured cerebral aneurysm or may result from head injury
Other causes of SAH are as follow
1. Bleeding from an arteriovenous malformations
2. Bleeding disorder
3. Unknown cause (idiopathic)
4. Use of thrombolytic meds.
Clinical Symptoms: Patients presents with sudden onset of “Worst headache of life”, may lead to loss of consciousness (50%), signs of meningeal irritation, and focal neurological symptoms (30%). No fever and sudden onset of symptoms differentia the condition from meningitis.
Diagnosis: CT scan without contrast is the best initial and important diagnostic test of choice, 95% sensitive. If CT is positive, no need to do LP.
If CT scan is normal and high clinical suspicious of SAH, Lumber puncture is the most accurate and alternate test of choice, which shows blood and Xanthochromia
Management: Angiogram to locate the site of the rupture blood vessel
Clipping or embolization of the aneurysm / site of bleeding. Surgical clip or embolization is must to avoid re-bleeding and to decrease the morbidity and mortality.
Prescribe NIMODIPINE (CCB) orally to prevent the stroke.