:Acta

Acta Neurochir (Wien) (1991) 113:121-124

.

uroch rurgica

9 Springer-Verlag 1991 Printed in Austria

Delayed Intracranial Haemorrhage in Patients with Multiple Trauma and Shock-related Hypotension S. T. Lee 1 a n d T. N. Lui 2 1Division of Neurosurgery, Department of Surgery, Taipei Municipal Chung Hsiao Hospital 2Chang Gung Medical College & Chang Gung Memorial Hospital Taipei, Taiwan, R.O.C.

Summary During an 11 year period, 10 cases of delayed traumatic intracranial haematomas, following the correction of shock, were discovered. The intracranial haematomas were not present on initial computerized tomography (CT) scans after stabilization of the vital signs. Skull fractures were found in six patients; five of them had epidural haematomas at the site of their skull fracture. Four patients developed intracranial haematomas during general anaesthesia for extracranial surgery. All the delayed intracranial haemorrhages (seven epidural haematomas and three delayed intracranial haematomas) occurred within 12 hours after initial resuscitation. Seven out of eight patients made a good recovery after surgical removal of their intracranial haematoma. The initial hypotension may have acted as a protective mechanism, obscuring the intracranial haemorrhage. Awareness of this possibility, and a high degree of suspicion in those patients who deteriorate following correction of their shock, is important. We suggest that, even with a negative initial CT scan the duration of extracranial surgery in the acute period should be as short as possible in patients with suspected head injury. If these patients fail to wake up as expected following anaesthesia or new neurologic deficits develop, an urgent follow up CT scan should be performed.

Keywords: Head injury; shock; intracranial haemorrhage.

Introduction H e a d t r a u m a a s s o c i a t e d with m u l t i p l e injuries is n o t u n c o m m o n < ~4. S h o c k a s s o c i a t e d with m u l t i p l e t r a u m a is a l m o s t always the result o f b l o o d loss f r o m an ext r a c r a n i a l injury, r a t h e r t h a n the h e a d injury I~. R e s u s c i t a t i o n o f such p a t i e n t s r e m a i n s a m a j o r challenge to the p e r s o n n e l i n v o l v e d in their acute care. It is well k n o w n t h a t an initial negative c r a n i a l c o m p u t e r i z e d t o m o g r a p h y (CT) scan m a y n o t g u a r a n t e e an u n c o m plicated i n t r a c r a n i a l course 1 3, 9, 11, 15-18. Occult intrac r a n i a l h a e m o r r h a g e m a y n o t be evident d u r i n g the h y p o t e n s i v e stage in patients with m u l t i p l e injuries.

Once the s h o c k has been c o r r e c t e d the p o t e n t i a l for d e v e l o p i n g an i n t r a c r a n i a l h a e m o r r h a g e increases. F a i l u r e to detect a n d p r o p e r l y t r e a t the e x p a n d i n g haem a t o m a can cause d i s a s t r o u s results.

Material and Method The records of 10,095 consecutive head injury patients who were admitted to Chang Gung Memorial Hospital from 1977 to 1987 were reviewed. There were 2,292 patients who had at least one associated injury. Among them, 237 patients presented with shock. All patients were initially resuscitated with blood and crystalloid transfusions. An initial CT scan was performed in 158 patients after the vital signs had stabilized. Ten of these developed intracranial haematomas after the correction of shock, proved by follow up CT scan. The case records of these 10 patients were reviewed for age and sex, cause of injury, type of associated injury, skull X-ray, initial subsequent follow up CT scan, management and outcome of the treatment.

Results T h e r e were eight males a n d two females, r a n g i n g f r o m 5 to 56 years o f age. A l l o f the p a t i e n t s p r e s e n t e d with m u l t i p l e injuries a n d shock. F o u r p a t i e n t s presented as an a p p a r e n t m i n o r h e a d injury with a G l a s gow C o m a scale ( G C S ) o f 13-15, three seemed to have m o d e r a t e h e a d injuries with a G C S o f 9-12. T h r e e patients p r e s e n t e d with severe h e a d injuries with G C S < 8. Three p a t i e n t s with severe h e a d injuries were int u b a t e d d u r i n g resuscitation. N o n e o f the initial C T scans s h o w e d an i n t r a c r a n i a l h a e m a t o m a . Skull fractures were f o u n d in six patients. F o u r p a t i e n t s h a d p r i m a r y surgery for e x t r a c r a n i a l systemic injury. The d u r a t i o n o f e x t r a c r a n i a l surgery in these patients r a n g e d f r o m 4 to 6 hours. A l l f o u r p a t i e n t s failed to w a k e u p a n d d e t e r i o r a t e d n e u r o l o g i c a l l y a f t e r the anaesthetic. Seven patients h a d d e l a y e d e p i d u r a l hae-

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S.T. Lee and T. N. Lui: Delayed Iutracranial Haemorrhage in Patients with Multiple Trauma and Shock-related Hypotension

Table 1. Summary of 10 Multiple Trauma Patients Who Developed Delayed Haemorrhage After Correction of Shock

No.

Sex

Age

1

M

5

2

M

48

3

M

28

4

F

45

5

F

16

6

M

17

7

M

16

8

M

20

9

M

27

10

M

56

Associated Injury

Haemothorax scalp avulsion Traumatic below knee amputation Haemothorax multiple fracture Liver laceration spleen rupture Liver laceration retro-peritoneal haematoma Multiplefracture Tongue laceration Perineum laceration multiple fracture Scalp laceration multiple fracture Spleenrupture Liver,kidney laceration

Skull fracture

Initial CT

GCS (before CT)

-

13

5

+

Cerebral oedema Negative

14

12

+

Negative

14

8

-

Negative "

12

7

+

Depressed fracture

7

4

+

Negative

12

6

+

Negative

13

5

+

Negative

12

-

Cerebral oedema Subarachnoid haemorrhage

-

Duration* (hrs)

Follow up

OP

Outcome

4

C

G

6

C

G

12

C

G

7

C

G

4

C

E

EDH Left F EDH Left P

10

C

G

4

C

G

10

EDH

6

C

G

6

12

4

N

E

6

6

ICH Right F ICH Bifrontal

4

N

E

CT

EDH Left T ICH Left F EDH Right P EDH Right F EDH Left T

GCS

* Duration between two CT scan. T: Temporal. C: Craniotomy. E: Expired. EDH: Epidural haematoma. F: Frontal. N: None. ICH: Intracerebral haematoma. P: Parietal. G: Good.

matomas, and three had delayed intracerebral haematomas. The time interval between the initial CT scan and the development of the delayed intracranial haem a t o m a ranged from 4 to 12 hours. Seven of eight patients made a good recovery after surgical removal of the intracranial haematoma, while three patients died due to the delayed intracranial haematoma. Discussion The priorities in the evaluation and management of patients with head injuries are as follows: respiration, circulation, and the nervous system 12. Head injuries associated with multiple trauma and shock m a y have an unfavourable outcome of not treated properly. In 1978 G o o d k i n and Zahniser reported a case of delayed epidural h a e m a t o m a after the correction of shock, demonstrated by sequential angiographic studies 1~ Since then 0nly a few cases have been reported but the mortality of these patients remains unsatisfactorily high 2' 3, 16

F o r those patients who have serious systemic injuries with massive and continuing haemorrhage, rapid fluid and blood transfusion m a y not be sufficient to stabilize

the circulation. In such a condition, rapid operative control of the haemorrhage may be necessary. Cooper suggested that patients with a focal neurological deficit or an altered level of consciousness should have a CT scan prior to the administration of a general anaesthetic for the operative management of systemic injuries 5. Although Ford and McLaurin 8 concluded in an animal study that epidural h a e m a t o m a formation probably achieves near m a x i m u m size within minutes following trauma, seven of our cases developing delayed epidural h a e m a t o m a s had negative initial CT scans. G u d e m a n etal. suggested that the CT appearance of a delayed traumatic intracerebral h a e m a t o m a is likely to represent haemorrhage into an existing traumatized area. However in three of our patients developing delayed traumatic intracerebral haematomas, no intracerebral haemorrhage was detectable on the initial CT scan. T h e hypotension m a y provide a protective mechanism to prevent the initial intracerebral haemorrhage. Once the shock has been corrected, the intracranial bleeding then becomes evident. For those patients who are continuously observed in the intensive care unit or in the emergency depart-

s. T. Lee and T. N. Lui: Delayed Intracranial Haemorrhage in Patients with Multiple Trauma and Shock-related Hypotension ment with an initial negative CT scan, the neurological deterioration will alert the neurosurgeon to do a followup CT scan. But for patients with initial negative CT scans prior to general anaesthesia required to treat extracranial injuries, a lack of continuing evaluation of the neurological condition may occur. Mann et al. reported a multiple trauma patient developing a delayed acute subdural haematoma during extracranial surgery to correct shock which went undetected during anaesthesia 16. Four of our patients also developed delayed intracranial haemorrhages during operations for systemic injuries, which were not detected during anaesthesia. Although intracranial pressure monitoring may be indicated for severe head injury patients (GCS ~< 8), for mild head injury patients this is seldom considered. Decrease in ICP induced by hyperventilation during anaesthesia, the rapid correction of hypotension through massive blood transfusions and the rapid rise in blood pressure following the control of systemic haemorrhage may all have contributed to the development of delayed intracranial haemorrhage in our cases. The mechanism of the development of delayed intracerebral haemorrhage may be due to intracranial vascular weakness and loss of autoregulation 2' 7, 1i Once the initial hypovolaemia had been corrected, the intravascular pressure increased, leading to the subsequent intracerebral haemorrhage. Bucci etal. propose that multiple trauma patients who have sustained significant head injuries and have also been hypotensive, requiring major fluid replacement, should have a CT scan when they are fully stabilized 3. In our patients the initial CT scans following the stabilization of the blood pressure were negative. The intracranial haemorrhages developed 4-12 hours after resuscitation. For patients who have initial negative CT scans undergoing general anaesthesia for extracranial surgical procedures, a follow-up CT scan after anaesthesia may help to detect delayed intracranial haemorrhages. Skull fractures detected on initial radiological examination may be helpful to determine the site of the extradural haemorrhage. In our cases, 5 of 7 epidural haematomas had skull fractures related to the site of the epidural haematoma. If an intracranial haemorrhage were suspected during operation an explorative burr hole at the skull fracture site may facilitate earlier removal of an epidural haematoma during anaesthesia. We suggest that multiple trauma patients requiring surgery to control and treat extracranial causes of shock receive a promt follow up CT scan if they fail

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to waken as expected from anaesthetic or display any new neurological deficit. We also recommend the operation be as short as possible. Of major importance is the maintenance of a high degree of suspicion for the development of a delayed intracranial haemorrhage in all multiple trauma patients presenting in shock.

Acknowledgement The authors wish to thank Dr. Mickel Bullard for review and suggestions, Miss Yun Shu for secretarial assistance.

References 1. Borovich B, Braun J, Guilburd JN, Zaaroor M, Michich M, Levy L, Lemberger A, GrushkiewiczT, Feinsod M, Schachter I (1985) Delayed onset of traumatic extradural hematoma. J Neurosurg 63:30-34 2. Brown FD, Mullah S, Duda EE (1978) Delayed traumatic intracerebral hematomas. Report of three cases. J Neurosurg 48: 1019-1022 3. Bucci MN, Phillips TW, McGillicuddy JE (1986) Delayed epidural hemorrhagein hypotensivemultiple trauma patients. Neurosurgery 19:65-68 4. Clark WK (1979) Trauma to the nervous system. In: Shires GT (ed) Care of the trauma patient, 2nd ed. McGraw-Hill, New York, pp 207-258 5. Cooper PR, Maravilla K, Moody S, Clark WK (1979) Serial computerized scanning and the prognosis of severe head injury. Neurosurgery 5:566-569 6. Diaz FG, Yock DH, Larson D, Rockswold GL (1979) Early diagnosis of delayed posttraumatic intracerebral hematomas. J Neurosurg 50:217-223 7. Evans JP, Scheinker IM (1946) Histologic studies of the brain following head trauma: II. Posttraumatic petechial and massive intracerebral hemorrhage. J Neurosurg 3:101-103 8. Ford LE, McLaurin RL (1963) Mechanisms of extraduraI hematomas. J Neurosurg 20:760-769 9. French BN, Dublin AB (1979) The value of computerized tomography in the management of 1000 consecutive head injuries. Surg Neurol 12:171-183 10. Goodkin R, Zahniser J (1978) Sequential angiographic studies demonstrating delayed development of an acute epidural hematoma. J Neurosurg 48:479-482 11. Gudeman SK, Kishore PRS, Miller JD, Girevendulis AK, Lipper MH, Becker DP (1979) The genesis and significance of delayed traumatic intracerebral hematoma. Neurosurgery 5: 309-313 12. Hekmatpanch J (1973) The management of head trauma. Surg Clin North Am 53:47-57 13. Illingworth G, Jennett WB (1965) The shocked head injury. Lancet 2:511-514 14. Lee ST, Lui TN, Chang CN, Wang DJ, Heimburger RF, Fai HD (1990) Features of head injury in a developingcountry Taiwan (1977-1988). J Trauma 30:194-199 15. Lipper MH, Kishore PRS, Girevendulis AK, Miller JD, Becker DP (1979) Delayed intracranial hematoma in patients with severe head injury. Radiology 133:645-649

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S.T. Lee and T. N. Lui: Delayed Intracranial Haemorrhage in Patients with Multiple Trauma and Shock-related Hypotension

16. Mann KS, Yue CP, Ho YH, Chan FL (1985) Posttraumatic acute arterial subdural hematoma manifested during anaesthesia. Neurosurgery 16:387-390

18. Young HA, Gleave JRW, Schmidek HH (1984) Delayed traumatic intracerebral hematoma: Report of 15 cases operatively treated. Neurosurgery 14:22-25

17. Roberson FC, Kishore PRS, Miller JD, Lipper MH, Becker DP (1979) The value of serial computerized tomography in the management of severe head injury. Surg Neurol 12:161-167

Correspondence and Reprints: Shih-Tseng Lee, M.D., Department of Surgery, Taipei Municipal Chung Hsiao Hospital, 87, TungTeh Road, Nankang Taipei, 11502, Taiwan, R.O.C.

Delayed intracranial haemorrhage in patients with multiple trauma and shock-related hypotension.

During an 11 year period, 10 cases of delayed traumatic intracranial haematomas, following the correction of shock, were discovered. The intracranial ...
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