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