Intracranial Hematoma

Head injuries account for approximately 70% of traumatic accident deaths. Intracranial hematoma plays an important role in the death and disability that are associated with head injury. Intracranial hematoma is a serious and possibly a life threatening condition that often requires immediate medical attention. Many patients with intracranial hematoma harbor mass lesions that require emergency decompression. Other causes include brain tumors, liver disease, autoimmune syndromes and bleeding disorders.

The human brain floats within the skull. It is surrounded by cerebrospinal fluid which cushions the brain from the bounces of everyday movements. Sometimes it becomes impossible for the fluid to absorb the force of a sudden blow or a quick stop. Under such situations, the brain may slide forcefully against the inner wall of the skull and get bruised. An intra-cranial hematoma occurs when the blood vessel ruptures between the skull and the brain. The blood leaks between the brain and the skull. This collection of blood, hematoma, which is possibly clotted, compresses the brain tissue. Some hematomas require surgery to remove the blood clot whereas some others can be treated without surgery.

Symptoms of intracranial hematoma include headache, nausea, vomiting, lethargy and slurred speech. The pupils may appear of unequal size. Memory loss is often associated with head trauma. One may even forget that they have suffered a blow. These symptoms of intracranial hematoma may occur either immediately or several weeks or months after a blow has been received in the head.

Injury in the head is the most common cause of intracranial hematoma. Among elderly persons, even a mild head trauma is more likely to cause a hematoma in the brain. Hematoma resulting from injury in the head is classified as:

Subdural hematoma: This occurs when the blood vessels, most often the veins rupture between the brain and the dura mater which is the outermost of three membrane layers that covers the brain. The blood that leaks forms a hematoma. This compresses the brain tissue. The danger here is that if the hematoma keeps growing then there is a progressive decline in consciousness and possible death. The risk of subdural hematoma is greater in people who use aspirin or other anticoagulants regularly. Alcoholics and very young and very old people also stand to be affected by subdural hematoma. All types of subdural hematomas require medical attention as soon as the symptoms become apparent. Other wise permanent brain damage may be the result.

Epidural hematoma: This type of hematoma occurs when the blood vessel, usually the artery, ruptures between the surface of the dura mater and the skull. Morbidity and mortality from epidural hematoma is substantial unless immediate medical attention is given. The cause of epidural hematoma is most of the time road automobile accidents or any other traumatic injuries.

Intraparenchymal hematoma: When blood pools in the white matter of the brain, Intraparenchymal hematoma occurs. There may be multiple severe Intraparenchymal hematomas after a head trauma. Serious brain damage can occur, as the neurons can no longer communicate.

A physician may find it difficult to diagnose intracranial hematoma, as it may not be immediately apparent. It is better to seek medical advice after any significant blow has been received to the head and if the patient has lost consciousness or experiences symptoms such as headache, lethargy, nausea and vomiting. A CT scan or MRI scan is suggested to define the position and size of a hematoma.

After a head injury, doctors use medications such as corticosteroids and diuretics to control the edema in the brain after head injury. Often surgery is required. If the blood clot is localized and there is no excessive clotting, then perforation is made through the skull and the liquid is removed by suction. Large hematomas require opening of a section of the skull to remove blood clots.

It is essential to wear appropriate safety equipment and gadgets during sports, including helmet when riding, motorcycling, horseback riding, skating or doing any other activity that may result in injury to head. Chances of motor vehicle accidents can be minimized by wearing a seat belt.

Subdural Hematomae

Collection of blood on the surface of the brain is termed as subdural hematoma. This condition occurs from the tear of the vein that crosses the subdural space. The general cause for subdural hematoma is severe head injury and is also referred to as acute subdural hematoma in severe conditions. It is considered the most dangerous among all head injuries. The bleeding is quick and severe and fills up the entire area of the brain within seconds thus leaving barely any space for the brain. Subdural hematoma occurs even in minor head injuries and is more prominent in elders and is termed as chronic subdural hematoma. The small veins flanked by the surface of the brain and the outward covering stretch and tear and as a result blood gets collected. This condition at times may be overlooked. There are few types of subdural hematoma that occur without any reason.

• Any recent head injury and getting unconscious after a head injury.
  
• Acute headache
  
• Distorted speech and at times loss of speech and loss of memory in few patients.
  
• Nausea and vomiting and seizures
  
• Weakness and lack of sensation accompanied by lethargy.
  
• In infants, the fontanels will bulge out and there will be an increase in the circumference of the head accompanied by high-pitched crying.

With the help of a CT scan or a MRI scan, the doctor will be able to confirm the extent of the damage. This is an emergency situation and needs immediate monitoring and surgery. This surgery will help reduce the pressure exerted on the brain by the bleeding. Doctors generally drill a hole in the brain and allow the hematoma to drain. Depending on the size of the hematoma, doctors decide on the type of surgery required.

• Wear protective gear for the head while working in high raised structures.
  
• Wear helmet when traveling on two wheelers.
  
• Wear your seat belt while driving; this will help reduce the impact of any head injury during accidents.
  

Basilar skull fracture

If there is a fracture or break in the cranial or skull bones, it is called a skull fracture. When the base of the skull is involved in a head injury, it is a basilar skull fracture or basal skull fracture. It is also known as depressed skull fracture and linear skull fracture. This linear fracture is rare and occurs in only 4% of patients with severe head injury. Falls, injuries caused by penetrating external objects like knives, hammers or axe or gunshot wounds may result in skull fractures. It can also occur when the skull hits a solid object with considerable force. Basilar skull fracture can be called a linear fracture at the base of the skull. Usually, dural tear is associated with this type of fracture. This fracture occurs at specific points on the skull base. While analyzing skull fractures, it is seen that 19-221% of all skull fractures happen to be basilar skull fractures.

There may be a traumatic brain injury when the skull is fractured. The area of the brain injured and the severity of injury is diagnosed by examining the fracture. If bacteria enter inside the skull through this fracture of the skull, it will lead to infection. Sudden blow to the back of the head can also result in a basilar skull fracture.

After a head injury, if there is a leak of a clear fluid from the nose or ears, it indicates that the clear fluid is cerebrospinal fluid (CSF) that surrounds the brain. CSF drains out through the ears or nose, when the skull is fractured and the Meninges or the covering of the brain is torn. The typical nasal drainage due to allergies, cold or crying is different from this drainage of CSF. It is also an indication of a fracture of the frontal bone or the base of the skull i.e. sphenoid or temporal bone or of the ethmoid bones (bones that support the nose and sinuses).

If bleeding from the ears or nose is not due to a cut or a direct blow, it may be an indication of a fracture of the base of the skull. Determine the cause of the bleeding by washing the blood thoroughly and see if the bleeding is from a cut or not. Ascertain the source of bleeding from the ear. It is an indication of a skull fracture if a nose bleed does not stop with home treatment. If bruising or dislocation develops within 24 hours after a head injury, it also indicates a basilar skull fracture. Often bleeding within the skull may occur with a basilar skull fracture. This condition may lead to infection.

• Battle's sign-bruising behind one ear.
  
• Raccoon eyes-bruising around both eyes.
  
• Abnormalities pertaining to vision.
  
• Weakness of facial muscles.
  
• Problems in hearing.
  
• Difficulties in smelling.
  
• Nasal drip due to leaking of cerebral spinal fluid.

Diagnosis is made with laboratory check of the clear dripping fluid for the presence of CSF. A CT scan of the head with the focus on bones can reveal the extent of damage to the bones. CSF otorrhea and bruising over the mastoids commonly known as 'battle sign' is an indication of a fracture of the petrous temporal bone. Rhinorrhea and bruising around the eyes (raccoon eyes) are noticed with anterior cranial fossa fractures. Depending on an associated intracranial pathologic condition, the Glasgow Coma Score and loss of consciousness may differ from patient to patient. Temporary deafness is a possibility but it resolves in about three weeks.

Hemotympanum and mucosal edema in the middle ear fossa cause this temporary hearing loss. Basilar skull fractures sometimes leads to meningitis in some patients. If the bones around the foramen magnum are broken, there is a risk of damage to the blood vessels and nerves exiting the hole.