#trauma #radiopaedia see: [[paediatric head trauma]], [[traumatic brain injury|TBI]] see also: - [Elevated intracranial pressure (ICP) - EMCrit Project](cubox://card?id=ff80808187f690360187f690e9570020) - [Cameron - neurotrauma](x-devonthink-item://10DC3BB1-027C-40D6-BDB3-4AF0C6B160E6?page=100) - [Rosen - Head trauma](x-devonthink-item://57B55CFE-5572-4019-B857-9D5512E8D2BD) - [[traumatic brain injury]] - [alfred TBI](https://emergencyeducation.org.au/traumatic-brain-injury-herniation-syndromes-part-one/) - [Schwartz - Emergency Radiology CT brain](x-devonthink-item://2A71AF1A-4715-4D5F-9841-03401D8E6C4E?page=434) > [!Key Points] > - Brain injury is major cause of in-hospital deaths due to trauma > - If concern for dural venous sinus thrombosis, can proceed to CT venogram > - Approximately >30% of transverse petrous temporal bone fractures have facial nerve palsies due to disruption of the fallopian canal (facial nerve canal) . > - a *subdural hygroma* is a collection of CSF without blood > [!Complications] > **Uncal herniation** > - Duret haemorrhage -- small haemorrhages that develop within the pons or medulla due to rapidly developing brain herniation. > - PCA infarct (ipsilateral) > - Kernohan's phenomenon > > **Subfalcine herniation** > - ACA infarct (ipsilateral) > - hydrocephalus (contralateral) # Monro-Kellie Doctrine - Volume of blood, CSF and brain tissue must be relatively constant. - an increase in one should cause a decease in one or both of the remaining two - If ↑ ICP, cerebral vessels are compressed resulting in reduced cerebral blood flow.  - ↑ venous pressure also causes decreased cerebral blood flow by decreasing effective perfusion pressure and compressing cerebral vessels. ![[Pasted image 20230508000740.png]] > **CPP =  MAP - ICP** > Normal ICP is 8-20 cmH2O > CPP should ideally be > 60 **Cushing triad** is increased SBP (increased [[pulse pressure]]), reflex bradycardia, and aponea * increase in ICP results in decreased cerebral blood flow --> increase in systemic blood pressure --> stimulation of baroreceptors --> stimulation of vagal outflow --> decreased HR and RR > Cerebral blood flow is affected by: > **1. Intracranial pressure > 2. Mean arterial pressure > 3. Mean venous pressure at brain level** > 4. Local factors: pH, pCO2 – constriction and dilatation of cerebral arterioles > 5. Blood viscosity # Brain Herniation types see [[pupil exam]], [[Cranial nerve palsies#CN III palsy|CN III Palsy]], [Radiopaedia - uncal herniation](https://radiopaedia.org/articles/uncal-herniation-1?lang=us), [Radiopaedia - tonsillar herniation](https://radiopaedia.org/articles/tonsillar-herniation) | type | description | | ------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | subfalcine | - cingulate gyrus slides under falx cerebri (midline shift)<br>- can comress ACA → infarction<br>- contralateral focal hydrocephalus from foramen of monro obstruction | | transtenotoral<br>(uncal) | - effacement of perimesencephalic cisterns<br>- downward transtentoral herniation tempporal lobe (**uncal herniation**), or thalamus and midbrain (**central herniation**) <br>- ipsilateral [[Cranial nerve palsies#CN III palsy\|CN III]] may be compressed → pupil dilated and down-and-out<br>- small *duret haemorrhages* in medulla or brainstem from shearing of basilar artery branches<br>- hemiparesis from compression of contralateral cerebral peduncle<br>- central herniation causes impairment of *brainstem function* → coma, breathing abnormality, and posturing | | tonsillar | - cerebellar tonsillar herniation through foramen magnum (usually mass effect rather than Chiari malformation)<br>- subsequent compression of medullary resp centres often fatal | - tonsillar herniation -- aka coning, ↑ ICP - uncal herniation -- ipsilateral oculomotor nerve compression ![[Pasted image 20241016202201.png]] *midline shift and subfalcine herniation are essentially synonyms* ![[Pasted image 20241016201907.png]] ![[Pasted image 20241016202302.png|left occulomotor (CN III) in situ to explain why uncal herniation leads to a dilated pupil]] ![[Pasted image 20241023141712.png]] ![[Pasted image 20241023142645.png]] # Normal CT Brain anatomy - black CSF sitting in all sulci - cerebral gyri coming all the way out to inner table of skull - even in older patients; if not then something is blocking it) - grey-white differentiation - symmetry of sulci and gyri - think falx, which expands at the back for the superior saggirtal sinus draining venous blood ![[Pasted image 20240307221638.png| CTB anatomy: slices correspond with next image below]] ![[Pasted image 20240307221526.png|cross-sectional anatomy of eight typical CT slices from the mid-cerebral hemispheres to the lower brainstem]] ![[Pasted image 20230509200857.png]] ^ check occpital horns of lateral ventricles, where interventricular blood can collect eg from SAH ![[Pasted image 20230509200953.png]] ^ temporal horns of lateral ventricles can also be subtle signs of **hydrocephalus** if they become dilated - also review mesotemporal lobe or uncus, which can squash midbrain ![[Pasted image 20230509201229.png]] ^ review normal micky mouse midbrain with black CSF in in interpedunclar cystern (front), may have **trace subarachnoid blood** here ![[Pasted image 20230509201655.png]] ^ note that even in this old person, the gyri are still coming all the way out to the inner table of the skull; if they did not, then suspect chronic subdural # Extradural Haematoma ![[Pasted image 20230509201828.png]] ^ left frontoparietal, efacement of sulci, small midline shift. > the lower density in the middle of the lesion is the **swirl sign** which is blood coming out as the scan is performed, which is a sign of **active bleeding** > (don’t confuse with spot sign in [[haemorrhagic stroke|ICH]]) usually ==middle meningeal artery== bleeding ![[Pasted image 20230509201953.png]] ^ this patient also had small bilateral tempral subdural haematoms ![[Pasted image 20230509202024.png]] ^ with associated fracture of the tempral bone. skull fracture is present in 90% of cases. ![[Pasted image 20230509202346.png]] ^ this patient also had an associated intraparenchymal contusion (or intraaxial). can see this is interparenchymal because of the **oedema** surrounding it ## Management of extradural haematoma see also [[traumatic brain injury#Management|TBI management]] - usually operative - ​cerebral protection therapies whilst awaiting OT - conservative therapy possible in environments where very close observation and immediate access to CT available if - < 5mm midline shift - < 30 ml calculated volume - thickness < 15mm - ​GCS 15 and neurologically stable - ​however CT findings within a few hours of injury very often worsen # Subdural haematoma (extraxial) ![[Pasted image 20230509222414.png]] ^ large subdural haematoma, a lot of mass effect. measure out midline shift. temporal horn pushed over, so **uncal herniation**. cannot see CSF around midbrain. you can see the tentorial SDH slice on left side ![[Pasted image 20230509222424.png]] ^ note thickness and hyperdensity of falx ![[Pasted image 20230509223850.png]] ^ this is a very subtle bilateral subdural haematoma that is subacute and therefore it is isodense. note those the effacement, and that gyri do not extend to the edge contrast can help visualise: ![[Pasted image 20230509223956.png]] **Another example** ![[Pasted image 20230509234429.png]] ^ The subdural space extends along the dural folds of the falx cerebri and tentorium cerebelli. The falx cerebri and left tentorium cerebelli are abnormally thickened and high-density reflecting ## Management of subdural haematoma - Indications for ==surgical evacuation== include acute SDHs with a thickness **more than 10 mm** or a **midline shift of more than 5 mm** on a CT scan, regardless of the patient’s GCS score. - Other parameters for surgical evacuation include a worsening GCS score (2 points from the time of injury to hospital admission) in comatose patients, asymmetric or fixed and dilated pupils, and persistent elevation in ICP. # Traumatic Subarachnoid haemorrhage see also [[Subarachnoid haemorrhage]] ![[Pasted image 20230509224725.png]] ^ note thickened falx, so there is also subdural as well as SAH ![[Pasted image 20230509233343.png]] ^ subtle blood level in occipital horn of lateral ventricle having spread into interventricular space > if caused by **trauma** tends to follow sulcus > if caused by anneurysm, tends to exist in basal cisterns ==Note that with trauma, SAH can be chicken or egg== ![[Pasted image 20230509233231.png]] ^ can present with trauma, but caused by ruptured berry anneurysm left sylvian fissure; will be left MCA anneurysm rupture ![[Pasted image 20230509233447.png]] ^ predominance of blood in basal cisterns ## Management of traumatic SAH - In the absence of other brain injury, tSAH generally carries a favorable prognosis. The most serious complication of tSAH is worsening of cerebral vasospasm, which may be severe enough to induce cerebral ischemia - While commonly used to prevent or reduce cerebral vasospasm following aneurysmal SAH, calcium channel blockers such as nimodipine and nicardipine are of questionable benefit in tSAH and are not routinely recommended # hypoxic brain injury ![[Pasted image 20230509234002.png|pseudo-SAH]] **global hypoxic injury** : completly effaced CSF. vessels enter (MCA and vein) and CSF arround it is completely effaced, brain next to it is dark because it is globally oedemetous, and so it gives an appearance of SAH. essentially brain dead # Interparenchymal haemorrhage ![[Pasted image 20230509234946.png]] multifocal interparenchymal haemerrage / contusion with surrounding oedema (showing it is interparenchymal, rather than subarachnoid). contra-cou injury from posterior left haematoma - oedema will generally increase in first 24 hours ![[Pasted image 20230509235222.png]] ^ subtle inferior frontal lobe contusion # hypertensive intercranial haemorrhage (rare trauma) ![[Pasted image 20230509235334.png]] ^ this chap crashed his car, has basal ganglia haemorrhage. caused car crash. has small frontal contusion that is consistent with trauma Another: ![[Pasted image 20230509235526.png]] ^ bleeding glioma caused fall > - if oedema is greater in volume than the underlying haemorrhage, then think possibly due to an underlying lesion > - if haemorrhage looks too round; consider metastasis that has bled into itself # Diffuse axonal injury ![[Pasted image 20230509235933.png]] ^ note these small interparenchmal haemorrhages at grey-white junction, high frontal classic distribution for DAI. due to sheering injury . This patient was GCS 3 > if you see haemorrhage in the corpus callosum of a trauma patient, it is diffuse axonal injury. rare ![[Pasted image 20230510000131.png]] ^ focused view of haemorrhage in corpus callosum > on MRI, if their age > 30 and have lesions in substantia nigra and mesencephalic tegmentum, then poor prognosis # Base of skull fracture > [!Secondary signs on CT] > - look for **blood** within pneumatised bones > - look for **air** outside pneumatised bones ![[Pasted image 20230510000417.png]] ^ note subtle **pneumocephalus** > can switch over to bone windows, because sometimes fat is a false positive ![[Pasted image 20230510001025.png]] ![[Pasted image 20230510001046.png]] ^ haemorrhage within petrous temple bone # MRI diagnoses - often in the category of "patient not waking up after several days when weening sedation" ![[Pasted image 20230510001239.png]] # Related Questions ## ct brain - [x] 12Q: [Collapse, GCS 10](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=10) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=7) - [ ] 13Q: [Haemorrhagic Stroke](x-devonthink-item://B74AA648-7583-42CC-9AC9-1FDBD09A2750?page=2) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=2) -- [prop](x-devonthink-item://5F365535-E019-4C8D-8402-2E764B328988?page=1) ## extradural haematoma - [ ] 15Q: [Head Injury](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=34) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=14) - [ ] 16Q: [Head Injury](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=49) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=18) ## fall - [ ] 17Q: [Elderly Collapse](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=50) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=54) - [ ] 18Q: [Complex Elderly Presentation](x-devonthink-item://CA4D5561-277D-47A1-9EC2-E0DB4C59DCFD?page=6) -- [Answer](x-devonthink-item://2551B51B-0E7C-448E-9FB5-3B547E74974A?page=6) ## hanging - [x] 22Q: [Hanging](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=5) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=5) ## head injury - [ ] 23Q: [Head Injury](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=14) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=14) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=4) - [ ] 24Q: [Head injury](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=11) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=11) - [x] DUPLICATE Q: [Head Injury](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=49) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=18) - [ ] 25Q: [Head and Neck Injury](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=75) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=28) - [ ] 26Q: [Head Injury](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=1) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=11) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=7) - [ ] 27Q: [Head Injury](x-devonthink-item://F3284DF7-780A-48C2-B18F-86C7C6B2AC27?page=3) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=44) - [ ] 28Q: [Head Injury and Haemophilia](x-devonthink-item://CA4D5561-277D-47A1-9EC2-E0DB4C59DCFD?page=12) -- [Answer](x-devonthink-item://2551B51B-0E7C-448E-9FB5-3B547E74974A?page=12) -- [prop](x-devonthink-item://EC6319AD-18CC-4975-A9F1-5209E9E9CB12?page=1) - [ ] 29Q: [Unresponsive Infant](x-devonthink-item://0987D972-A221-4F8A-B7D7-B0DCC349A2B3?page=4) -- [Answer](x-devonthink-item://C7FCB01A-E668-44AF-8C95-C298A40F8D68?page=2) -- [prop](x-devonthink-item://42954006-1F26-4D23-93DB-6738A8FA6D94?page=12) - [ ] 30Q: [Fall from Horse](x-devonthink-item://6092BF31-E542-4019-8E17-0C628DD3B0F1?page=9) -- [Answer](x-devonthink-item://E15CEB64-C6A5-4A7D-84B4-E7D1DC667B0E?page=6) ## head trauma - [ ] 31Q: [Head injury](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=1) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=1) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=4) - [ ] 32Q: [One Punch Man](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=12) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=10) -- [prop](x-devonthink-item://B892F073-9AD2-46E4-98D6-B0574CAA73A3?page=9) ## headache - [ ] 33Q: [Possible meningitis](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=34) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=36) - [ ] 34Q: [Headache](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=46) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=50) - [ ] 35Q: [VP Shunt Complication](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=28) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=9) ## hydrocephalus - [x] DUPLICATE Q: [Confused patient with VP shunt](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=1) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=1) ## hypoxic brain injury - [x] DUPLICATE Q: [Hanging](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=5) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=5) - [ ] 36Q: [Post Arrest](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=1) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=10) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=8) ## sah - [ ] 58Q: [Subarachnoid haemorrhage](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=2) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=0) - [ ] 59Q: [Headache and Collapse with Abnormal CT](x-devonthink-item://3D57C3FE-3B52-42E0-9FBD-E4034F60C5B7?page=11) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=25) -- [prop](x-devonthink-item://E34679F3-102F-4E16-AF81-9D679412EDAC?page=13) ## stroke - [ ] 70Q: [Stroke](x-devonthink-item://EE8AC47E-BE40-4377-885E-FA9C91C8C262?page=1) -- [Answer]() - [x] DUPLICATE Q: [Collapse, GCS 10](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=10) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=7) - [ ] 71Q: [Stroke](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=44) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=16) - [x] DUPLICATE Q: [Haemorrhagic Stroke](x-devonthink-item://B74AA648-7583-42CC-9AC9-1FDBD09A2750?page=2) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=2) - [ ] 72Q: [Stroke](x-devonthink-item://92A26505-5B6B-4ADD-995F-6AAA2E05C637?page=16) -- [Answer](x-devonthink-item://0808A030-AF19-4671-BE84-3E8BCBEC6124?page=17) - [ ] 73Q: [Elderly Man with Difficulty Walking](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=30) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=21) ## subarachnoid haemorrhage - [ ] 74Q: [Severe headache and confusion](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=43) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=45) - [ ] 75Q: [Subarachnoid haemorrhage](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=25) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=25) - [ ] 76Q: [Subarachnoid haemorrhage](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=4) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=4) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=2) - [x] DUPLICATE Q: [Subarachnoid haemorrhage](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=2) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=0) - [x] DUPLICATE Q: [Headache and Collapse with Abnormal CT](x-devonthink-item://3D57C3FE-3B52-42E0-9FBD-E4034F60C5B7?page=11) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=25) - [x] 77Q: [Collapse and Reduced GCS](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=19) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=12) ## subdural haematoma - [x] DUPLICATE Q: [Head Injury](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=1) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=11) - [ ] 78Q: [Confusion](x-devonthink-item://27CD16C2-557A-4CB1-B3CF-D01330708170?page=8) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=15) -- [prop](x-devonthink-item://AB9BDA6D-9CA8-4E73-9D15-B6105225A1B4?page=7) - [x] DUPLICATE Q: [Head Injury](x-devonthink-item://F3284DF7-780A-48C2-B18F-86C7C6B2AC27?page=3) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=44) - [ ] 79Q: [Subdural Haematoma](x-devonthink-item://B9F58929-18E6-4557-B393-263A6C98DFEF?page=18) -- [Answer](x-devonthink-item://DE4A2FC7-79D2-4B5D-805E-E481F1189654?page=17) -- [prop](x-devonthink-item://F8FBC1E8-52B3-47B9-8EBB-5CB6F3F81EBC?page=15) - [ ] 80Q: [Head Injury](x-devonthink-item://C88FD92C-E0CB-48A1-8D73-F20489FA4E6C?page=8) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=31) -- [prop](x-devonthink-item://093F49C6-2E32-460E-9C00-3E9F15CD417E?page=12)