A busy night in casualtyA busy night in casualty

Case 1Case 1

An 18yr old rugby player received a blow An 18yr old rugby player received a blow to the head during a tackle with brief loss to the head during a tackle with brief loss of consciousness. He recovered but was of consciousness. He recovered but was substituted for a rest. Whilst sitting on the substituted for a rest. Whilst sitting on the bench 5 minutes later he collapsed with bench 5 minutes later he collapsed with sustained loss on consciousness. He is sustained loss on consciousness. He is brought in by blue light ambulance.brought in by blue light ambulance.

What are the possible causes?What are the possible causes? What is the investigation of choice?What is the investigation of choice? Why did he initially recover and then what Why did he initially recover and then what

happened?happened?

Patient Normal scan

Middle meningeal artery is a branch of maxillary arteryIt enters the foraman spinosum to supply the bones of vault of skullIts branches cause grooves which can be seen on inside of skullIt is vunerable to injury in fracture of temporal bone producing an extradural haematoma

Case 2Case 2

An elderly man fell at home. He was An elderly man fell at home. He was brought to A/E, assessed as minor head brought to A/E, assessed as minor head injury and allowed home. A few weeks injury and allowed home. A few weeks later he was brought back with increasing later he was brought back with increasing confusion and some mild left sided confusion and some mild left sided weakness.weakness.

What could cause a left sided weakness What could cause a left sided weakness (hemiparesis) and why?(hemiparesis) and why?

What investigations would you request?What investigations would you request?

Patient Normal CT scan

Subdural haematomaSubdural haematoma

Blood accumulates in subdural space following Blood accumulates in subdural space following rupture of veinrupture of vein

More common in elderly where cerebral atrophy More common in elderly where cerebral atrophy can increase vunerability of bridging veins to can increase vunerability of bridging veins to tearing as cross subdural spacetearing as cross subdural space

Symptoms often indolent and fluctuateSymptoms often indolent and fluctuate Does not have to show focal signsDoes not have to show focal signs

Case 3Case 3

A 35 yr old business man was driving A 35 yr old business man was driving along the road when his female passenger along the road when his female passenger says he developed a sudden pain in the says he developed a sudden pain in the back of his head and briefly lost back of his head and briefly lost consciousness. She fortunately guided the consciousness. She fortunately guided the car to the side of the road without incident. car to the side of the road without incident. He is brought to A/E drowsy having He is brought to A/E drowsy having vomited in the ambulance.vomited in the ambulance.

What are the possible diagnoses?What are the possible diagnoses?

What investigations could you perform and What investigations could you perform and do any of these carry any risks?do any of these carry any risks?

“circle of Willis”

Berry aneurysm

Subarachnoid haemorrhageSubarachnoid haemorrhage

Account for 10% of cerebrovascular diseaseAccount for 10% of cerebrovascular disease Commonest cause is saccular “berry” aneurysmCommonest cause is saccular “berry” aneurysm Most common on “circle of Willis”Most common on “circle of Willis” Blood clot in subarachnoid space can lead to obstruction Blood clot in subarachnoid space can lead to obstruction

of CSF flow and hydrocephalusof CSF flow and hydrocephalus 50% dead or moribund before reach hospital, further 10-50% dead or moribund before reach hospital, further 10-

20% die in early weeks from further bleeding20% die in early weeks from further bleeding Refer to neurosurgeons for surgery etc.Refer to neurosurgeons for surgery etc.

Case 4Case 4

An 25 yr old medical student is brought An 25 yr old medical student is brought into A/E after celebrating the end of his into A/E after celebrating the end of his exams with history from ambulance staff exams with history from ambulance staff that he had been found vomiting, suffered that he had been found vomiting, suffered a cut to his head when he fell over but was a cut to his head when he fell over but was becoming more drowsy. Neurological becoming more drowsy. Neurological examination revealed no focal abnormality examination revealed no focal abnormality and an emergency CT scan of his head is and an emergency CT scan of his head is normal.normal.

How do assess drowsiness?How do assess drowsiness? What are the possible causes of his What are the possible causes of his

illness?illness? What additional investigations might be What additional investigations might be

needed?needed?

Glasgow Coma scaleGlasgow Coma scale

Causes of comaCauses of coma

Altered consciousness is produced by three types of Altered consciousness is produced by three types of

process affecting the brain stem, reticularprocess affecting the brain stem, reticular formation and formation and the cerebral cortex the cerebral cortex

Diffuse brain dysfunctionDiffuse brain dysfunction• Generalized metabolic or toxic (e.g. septicaemia) disordersGeneralized metabolic or toxic (e.g. septicaemia) disorders

Direct effect on brain stemDirect effect on brain stem Indirect effect on brain stemIndirect effect on brain stem

• lesions above the tentorium cerebellilesions above the tentorium cerebelli

Diffuse brain dysfunctionDiffuse brain dysfunction

Drug overdose, alcoholDrug overdose, alcohol CO poisoningCO poisoning Anaesthetic gasesAnaesthetic gases Hypo / HyperglycaemiaHypo / Hyperglycaemia HypoxiaHypoxia Renal failureRenal failure Hepatic failureHepatic failure Hypo / hypernatraemiaHypo / hypernatraemia HypothermiaHypothermia Cerebral malariaCerebral malaria EncephalopathyEncephalopathy

and so onand so on