NEUROSURGERY- DR.AKIF A.B

EXTRADURAL HEMORRHAGE- Site = between skull and outer layer of Dura

EXTRADURAL HEMORRHAGE-Source of bleed = Middle meningeal Vessels mostly Artery

- Mostly associated with skull fracture

- Presentation: Injury – Lucid Interval – unconsciousness

- Most common site : Temporo-Parietal Region

- Lucid interval is a temporary improvement in a patient's condition after a traumatic brain injury, after which the condition deteriorates.

A lucid interval is especially indicative of an epidural hematoma.

EXTRADURAL HEMORRHAGECT SCAN

Lens/Biconvex shaped hyperdense lesion is seen between brain and skull

EXTRADURAL HEMORRHAGEManagement

Immediate Surgical Evacuation is the treatment of choice

Q. A patient of Head injury comes to you with rapidly deteriorating sensorium and with fixed and undilated pupil. Neurosurgeon and CT scan machine is not available. You decide to make a burr hole to relieve intracranial pressure. Which site will you chose ??

Ans. Burr Hole Surgery CriteriaAssess Pupil

If one pupil is dilated If both pupil is dilated

Put a temporal burr hole in ipsilateral site of pupillary dilatation

Assess which side of pupil was dilated first

Known Not Known

Look for site of trauma

If site of injury visible

If site of injury not visible

Put on left side to relieve dominant hemisphere first

Put a temporal burr hole in ipsilateral site of Pupil which was dilated first

Put a temporal burr hole in ipsilateral site of injury

SUB-DURAL HEMORRHAGESite = Between dura and arachnoid

1) Source of bleed = Bridging plexus vein

2) Presentation: impaired consciousness at time of injury and later may worsen due to enlargement of hematoma

3) CT : Concavo- convex hyperdense lesion

4) Treatment : Surgical evacuation

5) Mortality is much higher than EDH

SUB-DURAL HEMORRHAGE

SUB-DURAL HEMORRHAGECLASSIFICATION

Acute : SDH <3days

Sub-Acute : SDH 3-21days

Chronic : SDH>21days

CHRONIC SUB-DURAL HEMORRHAGE

-2-3WEEKS OLD

- any patient with head injury comes to you with symptoms 3weeks later, always suspect CHRONIC SUB DURAL HEMORRHAGE

-Most can be treated by Burr hole evacuation

- For Non responsive cases Craniotomy should be done

CUSHING’S TRIAD

-Indicative of Head Injury

- So in head injuries B.P will be high and which is absolutely normal and we shouldn’t try to reduce it much unless it is peaking to very high B.P

SUB- ARACHNOID HEMORRHAGE

-MC Cause = Trauma > Rupture of Berry Aneurysm

- Sudden transient loss of consciousness

- Severe headache mentioned as Thunderclap headache, considered worst headache of one’s life

-Vomitings +

- No focal neurological deficits

- HESS & HUNT scale is used for it.(need not remember grading)

SUB- ARACHNOID HEMORRHAGE

Diagnosis

1) Investigation of choice = Non Contrast CT Scan ( IOC for all head Injuries)

2) CSF = Shows blood in CSF (Xanthochromic spinal fluid )

Note : Lumbar puncture shouldn’t be done before imaging or before excluding hydrocephalus

SUB-ARACHNOID HEMORRHAGE

TRIPLE ‘H’ THERAPY"Triple-H" therapy is given to prevent cerebral vasospasm following subarachnoid hemorrhage.

- Maintain hypertension, hypervolemia and hemodilution.

SKULL BASE FRACTURESAnterior cranial fossa # Middle cranial fossa #Sub conjunctival hemorrhage CSF Rhinorrhoea/otorrhea

Raccoon Eyes(peri-orbital ecchymosis)

Hemotympanum

CSF rhinorrhoea Battle sign: Bruising behind ear

Carotico-cavernous fistula 7th and 8th nerve palsy

In anterior cranial fossa #, all features are present at anterior part of face like eyes/nose

In middle cranial fossa#, all features are in middle / posterior of face : ear/nose

SKULL BASE #Raccoon Eyes Battle sign

HemotympanumSub conjunctival hemorrhage

GLASGOW COMA SCALE

Score: 6-8 = Indicates Coma

3-4 : 85% of dying

Maximum score = 15 Minimum score= 3

Management Of Raised ICPHEMORRHAGE

CHRONIC SUB-DURAL HEMORRHAGE

CHRONIC SUB-DURAL HEMORRHAGE