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Understanding Stroke and Head Trauma: Causes, Symptoms, and Management

This comprehensive overview explores the syndromes of stroke and head trauma, focusing on rapid onset cerebral deficits. It discusses risk factors, differentiating between non-modifiable and modifiable elements. Various types of strokes, including ischemic and hemorrhagic, are examined alongside their causes. The document outlines key symptoms, assessment techniques, acute interventions, and the critical role of diagnosis through imaging. Additionally, it touches on complications and recovery challenges, emphasizing the need for immediate treatment and secondary prevention strategies.

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Understanding Stroke and Head Trauma: Causes, Symptoms, and Management

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  1. Stroke, Head Trauma and conciousness Amy Wood, Haddy Cosh, Vishal Chauhan, AsfandBaig, Stewart O’Conner

  2. Definition

  3. Definition • a syndrome of rapid onset of cerebral deficit (usually focal) • Lasting > 24 hours or leading to death and no cause apparent other than a vascular one

  4. Stroke Risk Factors • Non Modifiable • Modifiable

  5. Stroke Risk Factors • Non Modifiable • Age • Male • FHx • Race – black/ hispanic • Modifiable • HT • IHD • AF • DM • Hypercholesterolaemia • Smoking • Alcohol

  6. Types

  7. Types • Ischaemia/ embolism causing cerebral infarct – 80% • Intracebral Haemorrhagic – 15%

  8. Causes -Haemorrhagic

  9. Causes -Haemorrhagic • Ruptured aneurysm • Trauma (subarachnoid/intracerebral) • Dissection (carotid/vertebral)

  10. Causes - Ischaemic

  11. Causes - Ischaemic • Cerebral Thrombosis • Cerebral Emboli • Give examples • Lacunar

  12. Symptoms - General

  13. Symptoms - General • Weakness/Paralysis or numbness on contralateral side • Vertigo/dizziness • Headache • Visual loss/blurred vision • Faintness • Confusion • Speech problems • Difficulty swallowing • Cognitive problems • Memory problems • Consciousness alterations • BUT…DEPENDS ON SITE

  14. Stroke Syndromes

  15. Stroke Syndromes • TACS - Total Anterior Circulation Syndrome • PACS - Partial Anterior Circulation Syndrome • LACS - Lacunar Syndrome • POCS - Posterior Circulation Syndrome

  16. What are the differences between them?

  17. Extras - watersheds • Susceptibility to ischaemia: • Systemic BP drop • ACA-MCA occlusion of carotid

  18. TIA

  19. TIA • Sudden focal deficit – usually only a few seconds • Presentation very similar to stroke • Amaurosis fugax?? • <24 hours with complete recovery • Issue: after 1 hour ischaemic damage has already occurred • High risk of recurrence and full stroke

  20. Causes- TIA

  21. Causes- TIA Carotid artery insufficiency – 80% Veterbrobasilar Insufficiency – 20% Circle of Willis – collateral supplies

  22. Management • Assessment/ diagnosis • Location • Subtype • Cause • Acute intervention • Secondary prevention • Reduce risk factors

  23. Assessment and Diagnosis

  24. Assessment: Diagnosis • Clinically usually • FAST • Imaging - <3hrs • CT • Available • Exclude haemorrhage • MRI • If brainstem or cerebellar symptoms

  25. Urgent CT required

  26. Acute intervention

  27. Acute intervention • Admit to Acute Stroke Unit for assessment • Iscahaemic – Thrombolysis rTPA within 3 hrs of symptoms • Haemorragic – emergency surgery

  28. Acute intervention • Antiplatelet drugs (Aspirin 150-300mg) if infarct • Contraindicated if haemorrhage!! • Monitor/prevent complications • Physiological monitoring for first 72 hours to maintain CO and supply to brain • HR, Temperature, BP, O2 sats, Blood sugar, ECG

  29. Complications

  30. Complications • Post-stroke pain/thalamic pain • 1 week- 6 months after stroke • Anywhere in spinothalamic system • Contralateral side referral of pain • Burning + sharp • Hyperalgesia & Allodynia • Treat as for neuropathic pain • TCAs

  31. Layers of the brain a) Pia mater b) Arachnoid mater  c) Dura mater  d) Superior sagittal venous sinus  e) Skull  f) Falxcelebri g) Subarachnoid space

  32. Pia • Arachnoid • Dura Subarachnoid – arteries Subdural – Bridging veins Epidural – Meningeal arteries

  33. Normal CT • Usually going to be symmetrical • Ventricles symmetrical and equally full

  34. Midline Shift • Coup injury – injury on same side of force • Contra coup– injury on the opposite side on injury • If you see midline shift, you have a high pressure situation

  35. Case 1 • Young lady hit on the side of head by a glass at a gig, seemed to recover , Found slumped 50 minutes later • Ix? • CT/MRI, x-ray if fracture • Where may she have been hit? • Pterion • What bones converge here? • frontal, parietal, sphenoid, temporal • What does this area cover? • Middle meningeal artery • Type of intracranial haemorrhage? • extradural (epi) • Type of blood characterises this? • Arterial • Why passed out? • raised ICP • Rx • surgical

  36. Extraduralhaematoma: • Midline shift • Lenticular shape • This can be middle meningeal artery – pterion bone breaks • Cerebral perfusion pressure = mean arterial pressure – ICP • Extraduralhaematoma you give Mannitol – 100mL at 20% • Diuretic

  37. Case 2 • Old alcoholic man had a fall in the park now noticed to be very drowsy with low consciousness • Ix: • CT/MRI • Likely haematoma? • Subdural • Other symptoms? • Headache, confusion, N/V, tinnitus, speech and visual problems, dizziness, weakness • Where is the bleed likely to be? • bridging veins • Type of blood? • venous • Rx depends on size + growth rate: often conservative (body reabsorbs), sometimes burr-hole drainage • Acute or Chronic

  38. Subdural Haematoma: • Runs along the surface of the brain, underneath the dura • Depending on the GCS score of the patient you may need to remove it • Midline shift

  39. Subarachnoid Haemorrhage • Sudden onset severe headache, often at the back of the head, Neck stiffness, Impaired consciousness (drowsiness / coma), Cranial nerve signs, Hemiplegia • The bleeding occurs as the result of rupture of aneurysm (80%) and AV malformations (15%) or trauma

  40. Contusion (bruise) • Intra- axial • As bruise swells, pressure goes up – all features of raised ICP (coma) • If you remove them you need to do a craniotomy

  41. Diffuse Axonal InjuryRTAs / shaken baby syndrome • If a rotational force is applied, the axons are damaged and you can have damage very far away from the original injury – diffuse axonal injury • Small contusions all over the brain • The worse it looks on the CT scan, the worse the injury in the patient – especially if you see an injury in the brainstem • DAI doesn’t look as bad on CT as some of the other ones, but can be much worse

  42. Le fort Fractures

  43. Blow-Out Fractures

  44. With a mass lesion why do you not get an immediate loss of consciousness?

  45. Due to an ability to Compensate! Intra cranial vol = vol CSF + vol Brain + vol blood + vol Mass lesion Skull can’t expand Compensation – 10-20 ml CSF in to lumbar cisterns Compensation exceeded  Increase in ICP  herniation

  46. What are the 3 key symptoms of raised ICP? Papilloedema Headache Nausea and Vomiting

  47. Label diagram

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