Subdural Hemorrhage - Assignment Example

Case Study: Subdural Hemorrhage Student Name: Institutional Affiliation: Image set 3 Case Study: Subdural Hematoma Question One The image in this case is a Computed Tomography (CT) scan without contrast. The hyperdense appearance of the bones and the discrete appearance of cerebral matter in the image reveal that it is a CT-scan and not an MRI scan (Osborn et al., 2015). The image is one of normal resolution and is not a multidetector CT image. Like most other CT images, the image is a transverse projection of the head and the cranial cavity. As said earlier, the anatomical region presented is the head. The absence of facial bones and other facial features in the image and the shape of the lateral ventricles as seen in the image indicate that the level of the picture is high and above the face. The size of the head and the calcified appearance of the pineal body indicate that the image is of an adult patient who is aging – probably above 60 years of age. The final diagnosis of subdural hemorrhage also hints at the advanced age of the patient. The image is a trauma image. Although subdural hemorrhage also occurs in non-traumatic setups, trauma is the most important cause of it. Moreover, trauma has is the primary cause of superimposition of a fresh acute hemorrhage on a chronic hemorrhage. Question Two The following are the anomalies as identified in the image: i. Acute-on-chronic subdural hemorrhage – the image shows a left-sided subdural hemorrhage. The presence of a hematocrit level on the lesion indicates that there is an acute hemorrhage that has been superimposed on a chronically ongoing hemorrhage (Kim and Gean, 2011). The crescent shape of the lesion and its location in the parietofrontal convexity indicate that is a subdural and not an epidural or subarachnoid hemorrhage. ii. Mid-line shift – the loss of the delineation of the falx cerebri, which separates the two cerebral hemispheres, indicates that the left hemisphere has been pushed into the space for the right hemisphere. The loss of the left ventricle also emphasizes the midline shift, which has led to compression of the left hemisphere. iii. Acute cerebral edema superimposed on senile cerebral atrophy – the obliteration of the left lateral ventricle indicates that the brain had swollen acutely. However, the narrowing of the left frontal lobe and the mild midline shift indicates chronically ongoing cerebral atrophy. The age of the patient indicates that the atrophy is senile. Question Three Trauma is the most likely mechanism of injury that could cause the acute subdural hemorrhage. However, the cause of the chronic subdural hemorrhage onto which acute hemorrhage has been superimposed cannot be demystified easily. Based on the age of the patient, the amount of trauma needed to cause subdural hemorrhage is minimal. This is because as one ages, senile cerebral atrophy sets in. the cause of senile cerebral atrophy is not known exactly but has been associated with the reduction in cerebral blood flow with advancement of age, especially in patients with atherosclerosis and associated disorders. Cerebral atrophy leaves space around the brain tissue. In case of a minor trauma, the brain movement of the brain due to inertia can lead to counter-coup phenomena where the moving brain tissue strikes the stationary skull surrounding it. That way, the atrophied brain tissue, which is pliable, tends to injure the blood vessels in the dura matter. Bleeding tends to occur into the already existing potential space hence subdural hemorrhage. The accumulation of blood follows the potential space hence the crescent shape of the lesion with the Centre at the frontopariental convexity. The accumulation of blood can. However, be severe enough for it to put pressure onto the brain tissue surrounding them. Acute pressure on cerebral tissue leads to edema as seen in the image. Moreover, the space that is occupied by the blood leads tends to push the brain away hence the midline shift. Chronic pressure on cerebral tissue together with the effects of senile atrophy has led to the atrophy of cerebral tissue as seen on the image. Question Four The following can be done to help the patient while still in the ambulance: i. Provision of oxygen by way of mask and bag – due to the pressure effects of subdural hemorrhage, such patients might have problems with breathing. In order to maintain their PO2 at sufficient levels and to ensure their pCO2 does not rise to dangerous levels, it is important to provide the patient with oxygen. ii. Endotracheal intubation and assisted ventilation – if provision of oxygen by way of bag and mask does not benefit the patient greatly, intubation in the ambulance should be considered. Although it is considered a medical procedure, paramedics should attempt intubation for patients who have had head injuries and have dangerously low pO2. iii. Elevation of the head – this is to ensure that venous outflow from the head is maintained. This ultimately reduces the rate at which it develop and the severity of cerebral edema. Increased arterial flow to the brain when the head is depressed can contribute to cerebral edema. iv. Hyperventilation – this is meant to lower the pCO2 to below 30 mmHg. A very low pCO2 is able to reverse raised intracranial pressure. It is important to lower intracranial pressure for patients who have suffered head trauma to reduce secondary brain injury. v. Intravenous mannitol – in case the patient has features of raised intracranial pressure, hyperventilation can only be used as adjunct. Definitive management of such pressures would require the paramedics to use intravenous mannitol, which is an osmotic diuretic. vi. Reversal of anticoagulation with warfarin – the use of anticoagulants as warfarin is an important risk factor for subdural hemorrhage in the elderly. Reversal of anticoagulation by administering fresh frozen plasma has been shown to reduce the severity and improve the prognosis of subarachnoid hemorrhage (Aguillar et al., 2007). The paramedics should first ascertain that the patient used warfarin before trying to reverse its effects. Question Five The following are the diagnostic measures that can be done by paramedics, their limitations, and how these limitations can be overcome: i. History taking – a good history can help a paramedic to determine if there is head injury or not. Moreover, history can help to differentiate between the various forms of intracranial hemorrhage. However, paramedics may find patients who have suffered head injury in coma; this makes it difficult to get a good history from such patients. Familiarization with management protocols can help paramedics to provide initial care to patients even when they have no history. ii. Physical examination – this can help the paramedic to ascertain whether there is brain injury or not. Furthermore, it can help the paramedics to localize the lesion. One limitation with physical examination is, however, the lack of specificity in most of the signs elicited. Again, familiarization with management protocols can help paramedics provide best available care for patients despite the lack of specificity in physical examination findings. iii. Glasgow Coma Scale (GCS) – this can help paramedics to ascertain the severity of the injuries sustained by a patient. However, the findings of this scale can be inaccurate and do not help in localizing the lesion. To overcome this, paramedics should combine the GCS with other scales when evaluating patients. Question Six Apart from the CT scan, which has already been conducted, there are other diagnostic tests, which should be done of the patient: i. Magnetic Resonance Imaging (MRI) scan. Although a CT scan can be diagnostic of subdural hemorrhage, an MRI scan can be done as an adjunct to it. The MRI scan offers the advantage of showing the surgeon the full extent of the hemorrhagic lesion in order for them to remove it completely (Osborn et al., 2015). ii. Coagulation Profile – this will include the patients Prothrombin Time (PT), the activated Partial Thromboplastin Time (aPTT), the bleeding time, and the International Normalized Ratio (INR). This will help the doctors to determine whether the subdural hemorrhage is purely traumatic or is related to another medical phenomenon. This knowledge will aid in the definitive management of the patient. Moreover, it will help to determine the risk of bleeding during the operation. iii. Arterial Blood Gases – once the patient arrives in hospital, it is important to ascertain the partial pressures of O2 and CO2 in blood. This will help to determine the severity of the injury that the patient has suffered. Moreover, determination of this and correction of the determined abnormalities can help to prevent further hypoxic brain injury or secondary brain injury due to cerebral edema. iv. Complete Blood Count and Kidney Function Test – these two are important baseline tests that should be conducted on any patient before they undergo a surgical procedure. Moreover, these tests will aid the doctors in determining if the patient has any comorbidities and how to manage these. Moreover, the complete blood count can help the surgeon to ascertain the risk of bleeding during the surgical procedure to that is to be conducted. Question Seven Management of a patient with a subdural hematoma is primarily neurosurgical. In theatre, a neurosurgeon conducts a craniotomy on an anesthetized patient as they are guided by available images. The surgeon then identifies and evacuates the hematoma primarily by sanction (Bullock et al., 2006). This is followed by irrigation to identify the remaining bleeders. The surgeon then looks to stop the ongoing bleeding before closing up the patient and sending them to recovery. Other emergent issues like cerebral edema and elevated intracranial pressure are also managed by the neurosurgeon in collaboration with other doctors. The outlook for subdural hemorrhage is generally better than that of epidural hemorrhage. Patients who were in coma with subdural hemorrhage are likely to recover from the coma when the hematoma is evacuated promptly. Elderly patients and those on anticoagulants have worse prognosis and more likelihood of recurrence though. The outlook is generally worse for middle aged individuals since the amount of force required to cause subdural hemorrhage is immense; this means that other injuries are common is this age group. Apart from recurrence, other possible complications of subdural hemorrhage and its treatment are seizures and infection. With proper prophylaxis of infection and control of seizures, full recovery can be anticipated. References Aguilar, M. I., Hart, R. G., Kase, C. S., Freeman, W. D., Hoeben, B. J., García, R. C., ... & Steiner, T. (2007, January). Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion. In Mayo Clinic Proceedings (Vol. 82, No. 1, pp. 82-92). Elsevier. Bullock, M. R., Chesnut, R., Ghajar, J., Gordon, D., Hartl, R., Newell, D. W. & Wilberger, J. E. (2006). Surgical management of acute subdural hematomas. Neurosurgery, 58(suppl_3), S2-16. Kim, J. J., & Gean, A. D. (2011). Imaging for the diagnosis and management of traumatic brain injury. 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