Updated: 6/25/2021

Head Trauma

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  • Epidemiology
    • Incidence
      • 1.5 million in the US each year
    • Mechanisms
      • 41% in falls
      • 14% in motor vehicle accidents
      • 11% in assults
    • Death after head injury (bimodal distribution)
      • 10-30 year olds
      • > 70 years of age
    • Demographics
      • males affected 2x more than females
  • Etiology
    • Conditions include
      • epidural hematoma (below)
      • subdural hematoma (below)
      • subarachnoid hemorrhage (below)
      • intraparenchymal hemorrhage (below)
      • stroke
      • transient ischemic attack
      • concussion (mild traumatic brain injury)
  • Epidural Hematoma
    • Introduction
      • a traumatic intracranial hemorrhage which can follow a temporal bone skull fracture resulting in tearing of the middle meningeal artery
        • the middle meningeal artery passes through the foramen spinosum of the sphenoid bone
        • resultant rapid expansion of the hematoma with high arterial pressure can lead to transtentorial herniation
      • prognosis
        • better than for subdurals
    • Presentation
      • symptoms
        • momentary loss of consciousness
        • lucid period up to 48 hours
        • headache, nausea, hemiparesis
      • physical exam
        • CN III palsy (if tentorial herniation present)
    • Imaging
      • CT
        • lens-shaped, biconvex hyperdensity not crossing sutures
    • Treatment
      • nonoperative
        • medical management of increased intracerebral pressure
          • mannitol
          • hyperventilate
          • steroids/ventricular shunt
      • operative
        • evacuate hematoma
  • Subdural Hematoma
    • Introduction
      • occurs with head trauma + / - coagulopathy
      • results from rupture of cortical bridging veins
      • especially common in elderly and alchoholics
      • prognosis
        • worse than epidurals due to concurrent brain damage.
    • Presentation
      • symptoms
        • may begin immediately, or from days to weeks after trauma.
        • headache
        • contralateral hemiparesis
      • may look like a chronic change, with a past history of a fall
        • can be easily confused with dementia.
      • other focal changes.
    • Imaging
      • CT shows crescent shaped, concave hyperdensity that can extend across suture line
    • Treatment
      • nonoperative
        • medical management for increased ICP
          • mannitol
          • hyperventilate
          • steroids/ventricular shunt
      • operative
        • evacuation via burr holes
          • indications
            • increased ICP
            • clinical neuro decline
  • Subarachnoid Hemorrhage
    • Introduction
      • commonly caused by
        • ruputred aneurysm (Berry Aneurysm)
          • most common site of berry aneurysm development is the anterior communicating artery
        • stroke
        • AVM
        • trauma
      • blood accumulates between arachnoid and pia mater
    • Presentation
      • symptoms
        • intense headache
        • neck stiffness
        • fever
        • nausea
        • vomiting
        • fluctuating level of conciousness
        • possible seizure activity
        • can resemble meningitis because both cause menigeal irritation
      • physical exam
        • berry aneurysm presents with severe, sudden headache and CN III palsy
    • Imaging
      • immediate head CT without contrast
        • look for blood in the subarachnoid space
      • if CT is negative and there is no papilledema or focal signs, proceed with an LP
        • RBC in CSF
        • CSF xanthoma (CSF protein > 150 mg/dL or serum bilirubin > 6 mg/dL)
      • once an SAH has been confirmed, move to four vessel angiography
    • Treatment
      • nonoperative
        • medical management to prevent elevation of ICP
          • raise the head of bed
          • limit fluids
          • treat HTN
          • giving calcium channel blockers (nimodipine)
            • prevent vasospasms
          • prophylax with anti-seizure medications (phenytoin)
      • surgical
        • clipping or coiling of aneurysm or AVM
  • Intraparenchymal Haemorrhage
    • Introduction
      • a hemorrhage within the brain parenchyma
      • common bleeding sites include:
        • basal ganglia
        • internal capsule
        • thalamus
        • cerebellum
      • causes include:
        • HTN
          • leads to hemorrhage in the basal ganglia, thalamus, cerebellum, and pons.
        • trauma
        • AVM
        • coagulopathy
        • tumors
        • amyloid angiopathy in the elderly
          • leads to lobar hemorrhage
    • Presentation
      • symptoms
        • lethargy
        • headache
        • obtundation
      • physical exam
        • focal motor and sensory deficits
    • Imaging
      • immediate head CT/MRI without contrast
        • hypodensity
        • look for mass effect or focal edema that may predict a herniation
    • Treatment
      • nonoperative
        • prevent elevation of ICP
          • raise the head of the bed
          • limit IV fluids
          • treat HTN
          • give calcium channel blockers (Nimodipine)
        • if ICP increased
          • mannitol
          • hyperventilate
          • steroids
          • ventricular shunt
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