Operative management of traumatic intracranial hemorrhage

1. 1. In the majority of cases of middle meningeal hemorrhage there are neurologic signs implicating the cortex on the effected side. Widely dilated pupil on the same side is seen frequently, although one case in this series had dilated pupil on the opposite side. Pupils equal in size do occur; this was true in two cases in this series.2. 2. Bloody spinal fluid of varying concentration does not rule out middle meningeal hemorrhage. In this series all punctured cases had bloody spinal fluid. To assume that the condition is one of subarachnoid hemorrhage because of the bloody spinal fluid is a grave mistake in these cases.3. 3. Lucid interval may be absent in middle meningeal hemorrhage. This was true in more than half of the cases in this series. Lucid interval may be wiped out because of (1) very rapid hemorrhage and (2) associated severe damage of the brain.4. 4. Lucid interval was seen not only in cases of middle meningeal hemorrhage but also in those with acute subdural hemorrhage, subdural collection of spinal fluid and edema of the brain.5. 5. Chronic subdural hematoma usually follows slight injury to the head, but in this series its association with severe brain injury and fracture of the skull is brought out. Seven cases had associated fracture of the skull.6. 6. The association of chronic subdural hematoma and relatively severe brain injury should be suspected in patients who remain unconscious, drowsy or disorientated for several weeks. Particularly if the spinal fluid pressure is high, an exploratory operation is justifiable.7. 7. When the question of cranial exploration arises, cases of head injury should be treated individually and if certain signs obtain operative intervention should be effected. In the presence of the proper signs exploration is justifiable even though results may not be favorable. In this clinic we are particularly impressed by a combination of all or some of the following signs as indication for exploration: 7.1. A. Dulling of the conscious state leading to unconsciousness or progressive deepening of an unconscious state already present.7.2. B. Presence and progression of localizing signs rather than neurologic signs implicating the entire nervous system.7.3. C. Increase in spinal fluid pressure.7.4. D. Low pulse rate (in some cases).Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/32606/1/0000747.pd

A comparative study of cranial, blunt trauma fractures as seen at medicolegal autopsy and by Computed Tomography

<p>Abstract</p> <p>Background</p> <p>Computed Tomography (CT) has become a widely used supplement to medico legal autopsies at several forensic institutes. Amongst other things, it has proven to be very valuable in visualising fractures of the cranium. Also CT scan data are being used to create head models for biomechanical trauma analysis by Finite Element Analysis. If CT scan data are to be used for creating individual head models for retrograde trauma analysis in the future we need to ascertain how well cranial fractures are captured by CT scan. The purpose of this study was to compare the diagnostic agreement between CT and autopsy regarding cranial fractures and especially the precision with which cranial fractures are recorded.</p> <p>Methods</p> <p>The autopsy fracture diagnosis was compared to the diagnosis of two CT readings (reconstructed with Multiplanar and Maximum Intensity Projection reconstructions) by registering the fractures on schematic drawings. The extent of the fractures was quantified by merging 3-dimensional datasets from both the autopsy as input by 3D digitizer tracing and CT scan.</p> <p>Results</p> <p>The results showed a good diagnostic agreement regarding fractures localised in the posterior fossa, while the fracture diagnosis in the medial and anterior fossa was difficult at the first CT scan reading. The fracture diagnosis improved during the second CT scan reading. Thus using two different CT reconstructions improved diagnosis in the medial fossa and at the impact points in the cranial vault. However, fracture diagnosis in the anterior and medial fossa and of hairline fractures in general still remained difficult.</p> <p>Conclusion</p> <p>The study showed that the forensically important fracture systems to a large extent were diagnosed on CT images using Multiplanar and Maximum Intensity Projection reconstructions. Difficulties remained in the minute diagnosis of hairline fractures. These inconsistencies need to be resolved in order to use CT scan data of victims for individual head modelling and trauma analysis.</p