North Oaks Trauma Symposium Friday, November 3, 2017

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1 Traumatic Intracranial Hemorrhage Aaron C. Sigler, DO, MS Neurosurgery Tulane Neurosciences

2 None Disclosures

3 Overview Anatomy Epidural hematoma Subdural hematoma Cerebral contusions Outline

4 Traumatic ICH Overview Hemorrhage within cranium from traumatic injury Epidural Subdural Cerebral contusions: Subarachnoid Intraparenchymal Intraventricular

5 Cerebral Vascular Anatomy Common Carotid Anterior Circulation ECA (External) ICA (Internal) C1 cervical segment C2 Petrous segment Caroticotympanic, Vidian artery C3 Lacerum segment C4 Cavernous segment Meningohyposeal trunk, Capsular branches, Inferolateral trunk C5 Clinoid segment C6 Ophthalmic segment Ophthalmic artery, superior hypophyseal artery C7 Communicating segment Posterior communicating artery (PCOMM), anterior choroidal artery Terminal branches: Anterior Cerebral Artery (ACA), Middle Cerebral Artery (MCA)

6 Vascular Anatomy Posterior circulation Vertebral arteries Posterior inferior cerebellar artery (PICA) Basilar artery Anterior inferior cerebellar artery (AICA) Pontine branches Superior cerebellar artery (SCA) Terminal branches: Posterior Cerebral Artery (PCA)

7

8 Vascular Anatomy

9 Vascular territories

10

11 Epidural Hematoma (EDH) Epidural space Arterial Direct head trauma Neurosurgical Emergency! Lucid Period Let s play, Where s the Lesion?? Iatrogenic (post surgery) not usually an emergency

12 Lucid Period Patient sustains injury Brief LOC Regains consciousness later lapses into unconsciousness talked and died Arterial injury, rapid build up of ICP, brain compression, potential herniation

13 AMS Focal weakness Exam Findings Focal numbness/tingling GCS lowered Cushing s Triad

14 Glasgow Coma Scale Maximum 15, Minimum 3 3 Parts: Eyes (4) 4 spontaneous, 3 to speech, 2 to pain, 1 none Verbal (5) 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none Motor (6) 6 commands, 5 localizing to pain, 4 withdrawals, 3 flexor posturing, 2 Extensor posturing, 1 none Teasdale G, Jennett B: Assessment of coma and impaired consciousness: A practical scale. Lancet 2:81-4, 1974.

15 Cushing s Triad Brain compression causes: HYPERTENSION REFLEX BRADYCARDIA RESPIRATORY INSTABILITY Terminal sign of lethal intracranial pressure Herniation imminent or in process

16 Imaging CT head without contrast: Hyperdense lens-shaped lesion with smooth inner margin underlying skull not crossing sutures (generally) CT C-spine without MRI

17

18 Management ABCs stabilization Cervical collar until cleared GCS 8 INTUBATE Correction of underlying coagulopathy Correction of underlying thrombocytopenia ICP control: Mannitol, etc SURGERY!!! Postop: ICP monitoring, seizure prevention, DVT/PE prevention, stress ulcer prevention, PT/OT

19 Subdural Hematoma (SDH) Subdural space Venous Traumatic, spontaneous, iatrogenic Acute versus Chronic Typically collateral intracerebral injuries (contusions/concussions) Predisposing factors: age, ataxia, coagulopathy, and anti-coagulation

20 Where s the lesion? Acute SDH

21 Anatomy of EDH versus SDH

22 Exam Findings Focal weakness/numbness/tingling Focal neurologic deficits (speech difficulties, confusion, visual changes, etc) AMS Seizure activity or GTC GCS decreased Cushing s Triad

23 SDH Kernohan s notch phenomenon Unilateral pupillary dilation coupled with Ipsilateral hemiparesis/hemiplegia Uncal herniation

24 Imaging CT head without contrast: Sickle shaped area underlying Acute, subacute, chronic CT C-spine without contrast MRI Less useful acutely Axonal injury Structural causes

25 Where s the lesion?

26 Acute SDH Management ABCs stabilization C-collar until cleared GCS 8 INTUBATE Cautious reversal of anti-coagulation Seizure prophylaxis and/or treatment Control of ICP: mannitol, hyperventilation, etc Surgical indications: Treatment of symptomatic SDH >1cm at thickest point (>0.5cm in peds) within 4 hrs of injury reduces mortality from 90% to 30% (controversial) Surgical treatment varies Asymptomatic SDH managed expectantly

27 Subacute/Chronic SDH Management Factors: Age, infirmity Anticoagulants? Size, location, duration Symptoms? Surgical treatment Burr hole(s) versus craniotomy

28 What is a Membrane? Forms in late subacute to chronic SDH Primitive cell layer that forms to sequester SDH in its removal process Primitive and leaky capillaries Pro-lytic chemical milieu creates vicious cycle that perpetuates SDH

29 Cerebral contusions Subarachnoid hemorrhages (SAH) Intraparenchymal hemorrhage (IPH) Intraventricular hemorrhage (IVH) Can have any combination of the above and include SDH/EDH

30 Subarachnoid Hemorrhage (SAH) Subarachnoid space, bleeding of small vessels (capillaries, small arterioles, etc) Trauma versus spontaneous Spontaneous: Ruptured aneurysm (arterial) or AVM Perimesencephalic hemorrhage (venous)

31 Traumatic SAH Main concern: Blossoming Hold anticoagulation Repeat CT head within 6 hours, and again at 24 hours to confirm stability Conservative management Surgery reserved for expanding life threatening injuries (collateral damage)

32 Traumatic SAH

33 Aneurysmal SAH

34 Cerebral Angiograms showing various pathology

35 Intraparenchymal Hemorrhage (IPH) Bleed within the substance of the brain (capillaries/ arterioles) Location highly variable Causes: HTN: controlled and uncontrolled Trauma Structural lesions Arteriovenous malformations (AVMs) Cavernous malformations (cavernomas) Dural venous sinus thrombosis (venous clot) Dural arteriovenous fistula (DAVF) Hemorrhagic tumors (mets, lymphoma, etc) Amyloid angiopathy

36 ICH Scoring Hemphill et al: The ICH score: A simple reliable grading scale for intracerebral hemorrhage. Stroke 32 (4):891-7, 2001

37 Diagnostics CT head without contrast: starting point CT C-spine if traumatic CTA with contrast (MRA) CTV with contrast (MRV) MRI brain with and without contrast Diagnostic Cerebral Angiography (DCA)

38

39 ABCs Management C-collar if traumatic/neck pain, until cleared SBP control (<140 rapidly) Anticoagulation reversal* Serial imaging Conservative therapy: Transition to PO BP control Re-assess need for anticoagulation Anticoagulate?? Neurology management for hemorrhagic stroke

40 Management Surgical intervention Varies depending upon pathology Craniotomy for resection

41 NICO BrainPath

42 Intraventricular hemorrhage Hemorrhage in ventricles Typically associated with other pathology Rarely isolated issue Casting of the Ventricles Management: Expectant unless obstructive hydrocephalus develops, then EVD in short term possible VP shunt long term Intraventricular tpa (tissue plasminogen activator)

43 Questions?? Thank you for your attention!

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