Symposium Traumatic 2017 Intracranial Hemorrhage3, Trauma Aaron C. Sigler, DO, MS OaksNeurosurgery November Tulane Neurosciences North Friday, Disclosures
■ None
Symposium 2017 3, Trauma
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North Friday, Outline
■ Overview
■ Anatomy Symposium ■ Epidural hematoma 2017 3, ■ Subdural hematoma Trauma ■ Cerebral contusions Oaks November
North Friday, Traumatic ICH Overview ■ Hemorrhage within cranium from traumatic injury – Epidural – Subdural – Cerebral contusions: Symposium ▪ Subarachnoid 2017 ▪ Intraparenchymal 3, ▪ Intraventricular Trauma
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Friday, http://www.cohyperbarics.com/tbi-therapy/ Cerebral Vascular Anatomy ■ Common Carotid – Anterior Circulation – ECA (External) – ICA (Internal) ▪ C1 – cervical segment ▪ C2 – Petrous segment Symposium – Caroticotympanic, Vidian artery 2017 ▪ C3 – Lacerum segment ▪ C4 – Cavernous segment 3, – Meningohyposeal trunk, Capsular branches, Inferolateral trunk ▪ C5 – Clinoid segmentTrauma ▪ C6 – Ophthalmic segment – Ophthalmic artery, superior hypophyseal artery ▪ C7 – CommunicatingOaks segment – Posterior communicatingNovember artery (PCOMM), anterior choroidal artery – Terminal branches: Anterior Cerebral Artery (ACA), Middle Cerebral NorthArtery (MCA) Friday, Vascular Anatomy
■ Posterior circulation – Vertebral arteries ▪ Posterior inferior cerebellarSymposium artery (PICA) ▪ Basilar artery 2017 – Anterior inferior cerebellar artery3, (AICA) – Pontine branchesTrauma – Superior cerebellar artery (SCA) – Terminal branches: Posterior Cerebral Artery (PCA) Oaks November
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North Friday, Vascular Anatomy
Symposium 2017 3, Trauma
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North Friday, https://sites.google.com/a/wisc.edu/neuroradiology/anatomy/under-spin/vascular-anatomy Vascular territories
Symposium 2017 3, Trauma
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North https://sites.google.com/a/wisc.edu/neuroradiology/anatomy/under-spin/vascular-anatomy Friday, Symposium 2017 3, Trauma
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North Friday, Epidural Hematoma (EDH)
Let’s play, ■ Epidural space Where’s the Lesion?? ■ Arterial Symposium ■ Direct head trauma 2017 3, ■ Neurosurgical Emergency! Trauma ■ “Lucid Period” ■ Oaks Iatrogenic (postNovember surgery) – not usually an emergency North Friday, https://www.mypacs.net/cases/70817609.html Lucid Period
■ Patient sustains injury
■ Brief LOC Symposium ■ Regains consciousness 2017 3, ■ later lapses into unconsciousness Trauma ■ “talked and died” ■ Oaks Arterial injury, rapidNovember build up of ICP, brain compression, potential herniation North Friday, Exam Findings
■ AMS
■ Focal weakness Symposium ■ Focal numbness/tingling 2017 3, ■ GCS lowered Trauma ■ Cushing’s Triad Oaks November
North Friday, Glasgow Coma Scale ■ Maximum 15, Minimum 3 ■ 3 Parts: – Eyes (4) Symposium 2017 ▪ 4 spontaneous, 3 to speech, 2 to pain, 1 none 3, – Verbal (5) ▪ 5 oriented, 4 confused,Trauma 3 inappropriate, 2 incomprehensible, 1 none – Motor (6) Oaks ▪ 6 commands, 5November localizing to pain, 4 withdrawals, 3 flexor posturing, 2 Extensor posturing, 1 none North Friday, Teasdale G, Jennett B: Assessment of coma and impaired consciousness: A practical scale. Lancet 2:81-4, 1974. “Cushing’s Triad”
■ Brain compression causes: – HYPERTENSION – REFLEX BRADYCARDIA Symposium 2017 – RESPIRATORY INSTABILITY3, ■ Terminal sign of lethalTrauma intracranial pressure ■ Herniation imminent or in process Oaks November
North Friday, Imaging
■ CT head without contrast: – Hyperdense lens-shaped lesion with smooth inner margin underlying skullSymposium not crossing 2017 sutures (generally) 3, ■ CT C-spine withoutTrauma ■ MRI Oaks November
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North Friday, Management
■ ABCs stabilization ■ Cervical collar until cleared ■ GCS ≤8 INTUBATE Symposium ■ Correction of underlying coagulopathy 2017 ■ Correction of underlying thrombocytopenia3, ■ ICP control: Mannitol, Traumaetc ■ SURGERY!!! Oaks ■ Postop: ICP monitoring,November seizure prevention, DVT/PE prevention, stress ulcer prevention, PT/OT North Friday, Subdural Hematoma (SDH)
■ Subdural space Symposium ■ Venous 2017 ■ Traumatic, spontaneous, iatrogenic3, ■ Acute versus ChronicTrauma
■ Typically collateralOaks intracerebral injuries (contusions/concussions)November ■ PredisposingNorth factors: age, ataxia, coagulopathy,Friday, and anti-coagulation Acute SDH
Symposium 2017 3, Where’s the lesion? Trauma
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North Friday, Anatomy of EDH versus SDH
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North Friday, https://www.quora.com/Why-is-it-that-for-an-epidural-hematoma-they-do-not-cross-the-suture-lines Exam Findings
■ Focal weakness/numbness/tingling
■ Focal neurologic deficits Symposium(speech difficulties, confusion, visual2017 changes, etc) 3, ■ AMS Trauma ■ Seizure activity or GTC ■ GCS decreasedOaks November ■ Cushing’s Triad North Friday, SDH
■ Kernohan’s notch phenomenon – Unilateral pupillary dilation coupled with Ipsilateral hemiparesis/hemiplegiaSymposium 2017 – Uncal herniation 3, Trauma
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North Friday, Imaging
■ CT head without contrast: – Sickle shaped area underlying – Acute, subacute, chronic Symposium 2017 ■ CT C-spine without contrast3, ■ MRI Trauma – Less useful acutely – Axonal injuryOaks November – Structural causes North Friday, Where’s the lesion?
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North Friday, Acute SDH Management ■ ABCs stabilization ■ C-collar until cleared ■ GCS ≤ 8 INTUBATE ■ Cautious reversal of anti-coagulation Symposium ■ Seizure prophylaxis and/or treatment 2017 ■ Control of ICP: mannitol, hyperventilation,3, etc ■ Surgical indications: Treatment of symptomatic SDH >1cm at thickest pointTrauma (>0.5cm in peds) within 4 hrs of injury reduces mortality from 90% to 30% (controversial) Oaks ■ Surgical treatment variesNovember ■ AsymptomaticNorth SDH managed expectantly Friday, Subacute/Chronic SDH Management
■ Factors: – Age, infirmity – Anticoagulants? Symposium 2017 – Size, location, duration 3, – Symptoms? Trauma ■ Surgical treatment – Burr hole(s)Oaks versus craniotomy November
North Friday, What is a Membrane?
■ Forms in late subacute to chronic SDH
■ Primitive cell layer that formsSymposium to sequester SDH in its removal process2017 3, ■ Primitive and leaky capillaries Trauma ■ Pro-lytic chemical milieu creates vicious cycle that perpetuatesOaks SDH November
North Friday, Cerebral contusions
■ Subarachnoid hemorrhages (SAH)
■ Intraparenchymal hemorrhageSymposium (IPH) ■ Intraventricular hemorrhage2017 (IVH) 3, ■ Can have any combination of the above Trauma and include SDH/EDH Oaks November
North Friday,
https://radiopaedia.org/articles/cerebral-haemorrhagic-contusion Subarachnoid Hemorrhage (SAH)
■ Subarachnoid space, bleeding of small vessels (capillaries, small arterioles, etc) Symposium ■ Trauma versus spontaneous2017 3, ■ Spontaneous: – Ruptured aneurysmTrauma (arterial) or AVM – Perimesencephalic hemorrhage (venous) Oaks November
North Friday, Traumatic SAH
■ Main concern: Blossoming
■ Hold anticoagulation Symposium ■ Repeat CT head within 6 hours,2017 and again 3, at 24 hours to confirm stability Trauma ■ Conservative management ■ Surgery reservedOaks for expanding life November threatening injuries (collateral damage) North Friday, Traumatic SAH
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North Friday, https://www.researchgate.net/figure/7426978_fig4_Fig-6-Traumatic-subarachnoid- hemorrhage-Axial-non-enhanced-CT-shows-high-density Symposium 2017 3, Trauma
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North Aneurysmal SAH Friday, Symposium 2017 3, Trauma
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Cerebral NorthAngiograms showing various Friday, pathology Intraparenchymal Hemorrhage (IPH)
■ Bleed within the substance of the brain (capillaries/ arterioles) ■ Location highly variable Symposium ■ Causes: 2017 – HTN: controlled and uncontrolled3, – Trauma – Structural lesions Trauma ▪ Arteriovenous malformations (AVMs) ▪ Cavernous malformations (cavernomas) ▪ Dural venous Oakssinus thrombosis (venous clot) ▪ Dural arteriovenousNovember fistula (DAVF) ▪ Hemorrhagic tumors (mets, lymphoma, etc) ▪ Amyloid angiopathy North Friday, ICH Scoring
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North Hemphill et al: The ICH score: A simple Friday, reliable grading scale for intracerebral hemorrhage. Stroke 32 (4):891-7, 2001 Diagnostics
■ CT head without contrast: starting point
■ CT C-spine if traumatic Symposium ■ CTA with contrast (MRA) 2017 3, ■ CTV with contrast (MRV) Trauma ■ MRI brain with and without contrast ■ Oaks Diagnostic CerebralNovember Angiography (DCA)
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North Friday, Management ■ ABCs ■ C-collar if traumatic/neck pain, until cleared ■ SBP control (<140 rapidly) Symposium ■ Anticoagulation reversal* 2017 ■ Serial imaging 3, ■ Conservative therapy:Trauma – Transition to PO BP control – Re-assess needOaks for anticoagulation November – Anticoagulate?? – NeurologyNorth management for hemorrhagic stroke Friday, Management
■ Surgical intervention – Varies depending upon pathology – Craniotomy for resection Symposium 2017 3, Trauma
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North Friday, NICO BrainPath
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North Friday, Intraventricular hemorrhage
■ Hemorrhage in ventricles ■ Typically associated with other pathology Symposium ■ Rarely isolated issue 2017 ■ “Casting of the Ventricles” 3, Trauma ■ Management: – Expectant unless obstructive hydrocephalus develops, thenOaks EVD in short term possible VP November shunt long term – IntraventricularNorth tPA (tissue plasminogen activator) Friday, Questions??
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North ThankFriday, you for your attention!