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Introduction
  • 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
  • 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-shapedbiconvex 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 managment 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 head of bed
        • limit IV fluids
        • treat HTN
        • give calcium channel blockers (Nimodipine)
      • if ICP increased
        • mannitol
        • hyperventilate
        • steroids
        • ventricular shunt
 

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