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bill Way saying, Yeah, we're live, however unwelcome. Teo a another urology. But after mind oblique, uh, this is our pen ultimate webinar for this of literation off sort of webinars today is gonna have a neurosurgical spin really big on traumatic brain injury, and he likes to introduce them. Doctor Done. Um, yeah, Belgium. Oh, ski. All right. Very loose here. Yes, before that. The justice court press. That button is one of the nearest surgery. Academic trainees at the hospital in the Southwest. Inclement in the talks about traumatic brain injuries, As always, there will be feedback available for that at the end. If you fill out, you can get certificates. Prove that you attended the teaching S o W Off you go. Okay. Can can you see the slide? Alex? Yeah, Yeah. Can you still see me? Yeah. Okay. Great. Well, I'll be speaking about from a brain injury. Let me tell you what I hope we can cover during this talk. I think we should go over some definitions because we should. We'll have a shared language where said, understanding of the language of near surgery on your radiology. When we discussed these cases, we'll go over. Some of the key and atomical concepts are relevant, understanding patients that come in with TB. I will briefly go over the CT head scan, which is the workhorse scan of your surgery. We'll talk about basic physiological principles of raised intracranial pressure and how to manage raises, raises intracranial pressure, and then we'll go over five cases. I think I want to stress that this topic is very broad. It it's also very detailed on my plan is to give you an oversight of some of the key principles on scenarios that you might find yourself as a foundation doctor, medical student or another healthcare professional, whether you work in a me in acute specialty hospital or in general practice on. But I also hope to direct you towards a resource is that you can access to get more information on for some of the cases I've also built. I've also given some relevant research studies that have defined the practice in that field soon. The Glasgow coma scale is the first concept need to understand. It was developed by Green Tea's Teasdale in his colleagues and Glasgow in the 19 seventies. It ranges from 3 to 15 on. There are two important things to always remember when calculating GCS. The first is that it is the patients best response to a stimulus on. Secondly, it can change over time. So this means that, uh, even with a map within a matter of 10 minutes, the patient's GCS can change. It doesn't necessarily mean it was Erin. It's recorded by the person before. It may just mean that the patient has improved or deteriorated. I'd like to draw your attention to this link here, which I'll leave on for the next 15 20 seconds. It's a link to a true story, abi, on your surgery training in Glasgow, which brilliantly explains the GCS on the physiological principles that underlie why patients have a, for example, motive, posturing response. We can see here that it's split into three components. The patients visual response of their eyes, response to pain to speech spontaneously. Their verbal response from no response to being fully orientated on their motor response, which is which range is from new response to pain have normal extension, abnormal flexion deflection, withdrawal from pain on localizing to pain and then the last one was being cut months an important thing to know about the murder compound is that, firstly, what is the difference between somebody who has a an abnormal flexion onda flexion withdrawal from pain? The difference is that abnormal flexion is a very stereotype to response, whereas affection, withdrawal from paying means that they're trying to to go towards the painful stimulus that they can't quite reach it. That means that in order for the patient to localized pain, they should be able to raise their hand above the above the shoulder region. If we're applying, see probable pressure. There are many ways to assess to stimulate the patient and applies painful stimulus. It could be either pressure on the nail bed or trapezius squeeze or or super orbital pressure, which on these techniques work quite effectively. So traumatic Brain injury has two distinct faces, which are essential in which is it is essential to understand when we're managing patients. There is the primary traumatic brain injury, which occurs when the patient has has the head Andrew and that can result in lacerations or contusions, and then the secondary brain injury occurs afterwards on. That is really what we're trying to prevent or reduce. The incidence off as conditions. We can't really. Once the primary injuries happened, we can't really reverse that. But the secondary injury is what we can reverse on. That's what the remainder of this talk wall will focus on. We can also classify traumatic brain injury. This is a very simple classifications based on the GCS on more complex classifications exist. Her conclusive five is mild, with the GCS of 14 to 15 moderate with a GCS of 9 to 13 on severe, which is GCS of, uh, eight or less you might remember there is an ammonic for how we can memorize the layers of the scalp, the scalp pneumonic, which is shown here. So we have the skin and we have the dense connective tissue, the upper neurosis. This is also known as the Galia, and it's the layer that we suture when we're closing uh, craniotomy. And there is also the loose connective tissue and finally, the periosteum. We also have the skull, and here we have the three meninges Soothe your amata, the Iraq noid layer on the P Amata. The PM matters adherent to the to the surface of the brain. The blood vessels, the arteries run in the arachnoid there, that's we have subarachnoid hemorrhage. And then Germont has the's bridging veins that go into the jewels in the Sinuses. We also need to be familiar with some of the common for nations in dreams that we see either radiologically people. Clinically, it's not uncommon to see some fell seen herniation like this on a CT scan. There may also be uncle herniation. The uncle's is the most medial part of the temporal lobe on if there is mass effect from a hematuria or a tumor that can actually cause movement of the Uncle Medially over the tentorium cerebellar on that can compress the brain stem structures. In particular, it it can compress the third nerve. The ocular motor nerve on that can result in a dilated people with a down and out appearance. But the dilate people occurs first because the parasympathetic fibers run on the outside of the nerve. You've also heard of Kuningan that refers to dissent of the cerebellum tonsils as soon here, and this is the this is the posterior fossa and this is the supratentorial. So the CT had scan Is the workforce the work workhorse? A scan of near surgery in your ideology, especially in the acute phase, where as MRI scans and more useful in following the acute face, the CT scan works by taking a sequential X rays, which were then analyzed by the computer. It generates these images which we can see. This is from the bottom of the skull, moving upwards with CT scans. When were describing the appearances of illusion. Talk about density. So whether a lesion is hypo I Sue or hyperdense compared to the adjacent brain brain come out, we'll sculpt. For example, we always compared to something else. It's also measured by hounsfield units, which tells us what the density of the lesion iss there are. There is a nice pneumonic for remembering how to systematically interpret a CT head scan. So we look first, look at the blood. If there is a presence of blood in the Brinkema in the subdural extradural spaces, perhaps in the systems going the ventricles. We didn't look at the systems, So these are the systems here. You can see my custody of these assistance around the brainstem. We also have the the frontal lobes here, the temporal loops. We can see the posterior fossa with the cerebellum in the brain stem and the other as we move up, you can see the prior lubes on the occipital loops you see here the lateral ventricles you can see on this slice the third ventricle and then has been moved down. We can see the fourth ventricle. We also want to look at the bones, but it's easier to look at the bones if they're reformatted with that, uh, with that type of sequence and we're looking for fractures because fractures can indicate an underlying can indicate both the severity of the injury. On that, there may be an underlying parenchymal injury. So if we're if we're working in a knee, we need to be aware the nice CT head guidelines on these here. I have the guidelines for adults that they're also separate pediatric guidelines on these skin. Tell us for which patients we should be performing a CT head scan within one hour of the risk factor being identified on here with an eight houses of the head injury. I will I will leave you to access these guidelines in your in time because, as you can see, they're quite detailed that important things are the initial GCS, the GCS in any the presence of any fractures. Any signs of basic skull fractures, such a zoo battle sign or hand eyes seizures, focal deficits on vomiting. These are slightly different for Children on. Then we need to be very conscious of patients. You have anticoagulants? Yeah, I will. I will touch upon intracranial pressure. I will read. Got three different concepts which I think a very relevant Teo traumatic brain injury on how we manage patients with with trying to create injury. The first is cerebral Walter Regulation. You may be familiar with this craft. This craft really has has cerebral blood flew on the Y axis on be noted, really pressure on the X axis. What what it shows is through brought a regulation and three rule of regulation is the ability of the brain to maintain cerebral blood. Flew across the room angel mean arterial pressure. We can see that the brain is able to maintain a steady serial blood flow of around 50 mils per 100 g of brain per minute between amino teary, a pressure of 15 to 150 millimeters of mercury. We can also see that the cerebral perfusion pressure can be calculated by the mean arterial pressure minus the intracranial pressure. So this is an important concept. Understand? Because if there is anything which makes the which impairs the cerebral artery kelation, the brain will not be able to maintain that cerebral blood flow, and that can result in brain injury. The second concept is the Monitor Kelly hypothesis, which I'm sure you've heard off the monarch. Any hypothesis states that Calvary more. This skull has a fixed volume, and it contains three breast spinal fluid, blood and brain. And so if there is any increase in one of those components, or if there is a new component, such a hematoma humor, then one of the other components has to decrease in volume. And that usually happens through through, for example, herniation or a reduction in the interest ruble. Since cerebrospinal fluid volume the monarch, any hypothesis is very nicely demonstrated on this graph off intracranial pressure on the Y axis on the interest real value on the X axis. This graph really explains cerebral compliance, which is the change in pressure divided by the change in volume, and we can see that as the volume of the brain increases. The pressure is relatively steady, but there comes a point when that that balances lost on the eye and the intracranial pressure rises rapidly. And lastly, we can speak about cushions. Reflex, which was described by hardly pushing he's regarded, is one of the fathers in your surgery, and Cushing's reflects is a combination of bradycardia and increase in the systolic BP andan irregular, respectfully, right. And this is really caused by that change from, firstly, a sympathetic output to increase the immunity really pressure when there is a brain drew, followed by a subsequent parasympathetic response that results in, uh, the bradycardia on with the bradycardia and ultimate response Gery we see there are ultimate theories as to why questions reflex happens. 11 theory is that the barrel receptors are stimulated, which causes the parasympathetic response. But there is also a theory that the vagal nerve is stretched, and that may potentially contribute as well. With regards to how we manage graze intracranial pressure, it's important to remember that there are always medical and surgical options, and there's always the option of not doing anything if that is in the patients or families wishes, depending on the situation. But whatever we do, we must use a tiered, systematic approach in order. Teo, in order to treat raised intracranial pressure, we also need to identify very early on any causes. Off raised ICP are rapidly reversible. The guideline that we the main guideline, which is used internationally, is the brain Trauma Foundation guideline. But each hospital has their own local guideline, depending on local drug availability and local experience. These are the guidelines from my trust, and we can see that there is four levels off. I see management. We initially start with basic measures to try and optimize the patient's parameters. We also considered factors such as whether the patient is wearing a survival color and whether that might be compressing venous outflow from the head. We want to exclude common factors such as pain or constipation can increase intracranial pressure. We then want to perform in urgency. T had scan to rule out any change that may be accounting for the raised ICP. As we move up the ted system, we look at things like sedation on whether we can give, uh, sedatives like proof awful whether we give any um anxiolytics or muscle relaxants. We then move further on and considered hyper was low therapy, which could either be hypotonic, saline or mannitol. And following this, there are other options, such as inducing hypothermia. The last option is really either barbiturate therapy such as Bobby True therapy and burst suppression or surgical intervention, which we will cover later on. But the surgical intervention is usually a craniectomy on the craniectomy means way performer, craniotomy toe. Take the bone flap and then we leave the bone flap off the head and convey either discarded or stores in the patient's hurting him before we move on to the cases, I just want to want to show you two slides about how we should assess patients with head and drew on. I think these aeroplane kable wherever you work. If it's pre hospital, uh, in any on award or or in general practice, the most important thing is always is follow a systematic approach. We want to use an 80 approach. As per the 80 less guidelines. The first thing is throughout any catastrophic hemorrhage, as well as to immobilize the patient's vitals spine. If there is any suggestion off, uh, injury to that we don't want to work a way through airway breathing, circulation, disability and explosion. There was a major trial published recently in the past few years called the Crash three trial, and this actually showed tranexamic acid can significant, you know, reduce reduce the risk of mortality when given to patients within three hours of injury if they have mild to moderate TBI. So this is really important, and this is now entered into clinical practice. And we routinely give tranexamic acid not only two major trauma patients, but also depression with traumatic brain injury. As we're performing the 80 and work unstable izing the patient, we need to find out if they take any anti thrombotic medication. Do they take warfarin for atrial fibrillations, or are they on aspirin and clopidogrel? Do they take any novel anticoagulant drugs? Because these will significantly alter our treatment on possible complications in the future. We want to find out what comorbidities they have and what their perioperative risks are because we will be speaking with the anesthetic team, the intensive care team on. We need to tell the anesthetist if they have any comorbidities that need to be optimized, and we need to have a frank discussion with the intensive ists about what their direction of care is and whether they're suitable candidates for intensive care. We also want to know what their pre morbid, functional status is and whether they would be candidates for surgery. And by that I mean, whether they would have, uh, have a functional outcome that would be agreeable to them based on what they have previously expressed. A. What if their family know on that varies from patient to patient. We also need to constantly be thinking about preventing secondary brain injury. And we really do that by following following these parameters and making sure we're optimizing the patient biochemically and also based on the observations. One thing which is really important is asking ourselves whether the history and the mechanism of injury correlates with the physical examination off the patient on the scans that we've performed, because if it doesn't, we need to ask ourselves important questions. So for adults, this convey vital 10 Children. I guess the before for adults mostly, I think, is whether there has been an underlying vascular event, such a zone aneurysm or arterial venous malformation, which is ruptured that led to the trauma rather than rather, for example, if a patient felt UH, felt down a flight of stairs, did they fall because they slipped? Or did they fall because they had a ruptured aneurysm with a primary bleeding event and then fell? Because, in that case, we would perform a CT angiogram of the head and neck at the same time as the trauma scans. If the patient is stable on that, management would be very different. It would be, uh, would be disastrous to take a patient to theater if there is an underlying vascular lesion, which is not known about on in four. Children were also need to think about Nonaccidental injury and whether that history and mechanism correlates with the physical examination findings. As I mentioned in the 80 approach, we need to think about the cervical spine and on for Columbus fractures as well. I think this this factor here is probably one of the most important in my in my experience off of the little experience that I have really the early discussions with patients, uh, families will the next of kin are very, very important because these decisions about whether to offer somebody surgical intervention or not are quite difficult to make because patients come in at the extremes of illness. They're critically unwell. Often the prognosis can be poor. But it's not really that the prognosis is is poor is more than the prognosis is uncertain, and so we don't know how the patient will will will say, going forward. And really, what is acceptable for each patient? What one standard of living might be acceptable for me, but it might not be acceptable to you. So this is why I really discussions early early hoping and honest discussions with the family are very, very important. Let's move on to cases. I I'm going to if you if you can go to this voxpops side, and if you can type in this number, I'll just group in the poll. I hope some of you will be able to start are connecting whilst you're connecting. I'll just read through this suit the first cases of a 25 year old horse race who fell off during the race. He injured his head. He loses consciousness that actually recovers quickly, although he does have a persistent headache. Few hours later, he was taken to a me on, he becomes gradually more drowsy and actually loses consciousness. Yeah, so for for these cases, I think what we'll do is try. And I'll ask you to give a diagnosis based on the history without doing the scans but without seeing the scans for some of the cases. Because some of these histories of quite characteristic I'll just wait 30 seconds or so because I can see some people are joining in. Alex, can you tell me if anyone can see the results? Ah, yeah. We won't be upset the results on here, but if they can people people can see it on the on the on the website. Yeah, lot. Most people have, you know, 21 responses, but I'm sure people who are not on the website are looking through the options available. I think that most people have said acute subdural hematoma, So actually, this is quite characteristic history for extradural immature weaken. Specifically, the fact that the patient has this lucid period where they initially lose consciousness with the recover. They have a headache, usually quite a severe headache, and then several hours later, when they're being transported the hospital when they're in hospital. They become drowsy and lose consciousness suit. We can see her A an axial CT head scan. And the most obvious abnormality is this by convicts Lentiform, uh, lesion, which we can describe is being hyper dense relative to the adjacent parenchyma. This is because it looks white on. If we look at the surrounding brain following that, that structure in the pneumonic, we can see that there is loss of the so kind. We can also see that there is midline shifts. If you take this point hand on this point here and you're straight line. You can see that the lateral ventricle has been shifted towards the left side. Another important observation is that there is a, uh there is a hematuria under the skin which suggests that this is the site of the injury. Now, a common common, uh, underlying injury in addition to the Extendryl. Jr to me is the skull fracture. And we can see that on the Bernie Reconstruction. This is the very construction window we can see. There is a fracture. So what is the treatment for this patient? Let me open another pole for for those of you and lot of the website. The options are conservative, which would include medical management. Off off this, the second option is behold drainage. The third option is insertion of an intracranial pressure monitor. On the fourth option is a cranial to me and evacuation. So four options, I think well, even though the 30 seconds or so and I'll just put this gown back up so that you can see and this is the history 25 year old. He loses consciousness and he's in a coma, all right, we've had about 22 responses. Most people have said that this patient needs a cranial to me and evacuation, and that's the That's the correct treatment. This patient has a an extra drill here, a tumor that you can see here. This is causing significant mass effect, and you can see there's a lot of pressure inside this man's head. So he needs to go to theater emergently for a craniotomy to evacuate the blood on on deduced that pressure. We can also see on this slide conceive quite nicely. Why this this extra Why extradural hemotomas have a lentiform appearance, and that's because they are bound by the cranial sushi is, as you can see here, but they usually do two and underlying arterial injury, or they can be venous on for on gets a common example. Westchester. But also in real life, it's usually from the middle meningeal artery as it comes from the friends by Newsome. Done can be that can be ruptured by the skull fracture, which releases that material blood contained by the soups. But this is definitely a new surgical emergency. Patients often have excellent outcomes if they're taken to theater quickly. This is a drawing from Harvey Cushing in 1986. Okay, illustrating o'clock. But we can see her more modern schematic of how we would perform this craniotomy so you can see it's in front of the year. This is the skin decision on. Then several Bergholz are placed on. This flap of Boone is taken out. Then this part of Burn, which is in the the base of the skull, is taken away as well to give you a better exposure. The middle mid middle men Gilotrif can sometimes the visualized as it comes from the firm's by Newsome. Well, it can be like gated to stop the bleeding case to we have a sorry. We have a 35 year old man who presents after a full for a bicycle high speed and he's unhelmeted at the scene. His GCS is seven, so he's no opening his eyes at all. He's opening that he's making incomprehensible sounds on. He's withdrawing or he has abnormal affection from pain. So looking at his people's left people is seven millimeters and unreactive on his right. People's two millimeters on sluggish to react. His BP is 170 over 100 and his heart rate is 50. He's otherwise fitting well, sir, what do you think is the diagnosis based on this history? I opened the polls well on the website. I can tell you it's not extra dural humor Tober because because that was case on. So it's one of the other options I would say Think about whether to think about what is the significance of left of the left people being much larger than the right and also being unreactive. Think about the, uh what I was mentioning about the uncle herniation and how blood can actually cool cause uncle herniation on the second factor is this his BP is quite high. And he's also bradycardic, which points towards Cushing's reflex and pushing is responsive reason triple renal pressure. Both of these things point towards a large unilateral lesion, so lapse that will help us decide what this is just waiting Another 15 seconds. Okay, well, let me show you the results. So just to have a half of people have gone for traumatic subarachnoid hemorrhage on the next most common answer is acute subdural hematoma. So the correct answer is an acute subdural hematoma. Because this is a mass lesion that will cause this kind of midline shift mass effect, it will compress the ocular motor nerve closing this appearance. It will also cause a lot of pressure in the head. Whereas a traumatic subarachnoid hemorrhage usually tends to be usually density quite small, and it tends to be diffuse, so it wouldn't usually be large enough to cause movement of the head from one side of the other. But this is a very this is very important because it's a lateralized future. It tells us that there is a lesion on one side on in the days before the CT scan whether to do exploratory beholds is decided by the patient's clinical exam, we can see another axial CT scan. The most obvious abnormality is this predominantly, hyper dense lesion on the left side of the brain. This is subdural because of its crescent Eric shape. You can see how it looks like a half moon and extends all the way across. Unlike an extra dural, which would be limited by the cranium suitors, we can see that this is actually exerting significant mass effect. If this is the mid If this is the midline here, we can see how the septum pellucidum has been shifted all the way to the right. So there's perhaps more than a centimeter of midline shift here. The other thing. I notice there's loss of that so called definition should be able to see this all kind of the brain quite nicely. But we can't in this situation. So what is the treatment for this acute subdural hematoma? Then you open up the pole. Just another 30 seconds. I'll show you The history against this patient is juicy, a seven, so he's less than it. He's in a coma on. He's also being intubated on ventilators with this on this response or it. Let me show you the results. We have two options which are competing. So it's the note. So we had a craniotomy and evacuation, which is now the most popular option, and the second was comparable. Option is the whole drainage. So this patient needs to go to see you to stretch away. The reason for that is that they have significant mass lesion result in your in a coma with evidence off um, Cologne a shin. If that uncle herniation progresses, then the patient will well going to call your respiratory arrest as the flu centers in the brain stem are affected. The operation for this is quite a generous craniotomy on this. This needs to be taken to fear toe straight away. So this is a new indication for taking a patient tia to stretch away. The reason that Burkle's would not be effective for this is that with Berle's, you would not be able to identify or control active points of bleeding on. That's the main advantage of do A generous cranial to me is that you want to be able to expose the brain on D. C, where where the source of bleeding is acute. Subdural hematoma is. These tend to be more lethal than extra drug hemotomas because the higher impact is usually sustained on there one of two causes. It's either a parenchymal laceration, so a tear on the brain surface itself with very severe underlying brain Andrew. Or it can be due to an acceleration deceleration, which tears the surface bridging vessels that I showed you're not. Slide with the with the with the laser of the meninges, so you can appreciate that if there are, if there is cortical bleeding that needs to be formally assessed. Intraoperatively on treated in terms of hemostasis super holes would know Achieve that. You do need to have a wide cranial to me for this. The third case is an eight year old woman whose hit her head on a door after tripping on the pavement whilst walking her dog. She does know lose consciousness, um, Ondas well afterwards, But three weeks later, she begins to experience a headache, which gradually worsens, and two weeks after that, she actually developed some weakness on the right side of her body on our family knows that she is occasionally disorientated, confused. So what do you think is the diagnosis here? That's the first question on. Secondly, you also note in your history that she takes warfarin for atrial fibrilation. So what will you be thinking about in terms of that, if any of you joined, this is the number to log on to the V box up so you can just follow this link. Well, good to see you. Folks don't happen and type in that number, and you will be able to go to the polls just waiting on a few more responses. Yes, I think this this case is more obvious than the others. This is a chronic subdural hematoma. We have this classical history off a head injury that the patient may or may not remember. Sometimes it's quite trivial. It could be someone who raises their head and hits their head on the shelf. It can really be very, very trivial. But the right circumstances, the right patient risk factors means that they develop chronic subdural hematoma. And then this is really the complicating factor here. We also need to address. So the correct answer is a chronic subdural hematoma we see here on Axial City had scan the most obvious abnormality is a left sided crescent Eric Hypodense lesion relative to the address and breathe prank. Um, a We can say that this is 2.2 centimeters in maximal uh, it's and it's causing 1.4 centimeters of midline shift. We can also see that there is so cool effacement. So if you can you appreciate that here we can very nicely see the so ch'i where is here? We can't see the sole cause this is because the not brain is being compressed. Another thing to know is that as patients' age, there is atrophy in the brain. So actually, their brain can accommodate larger and larger lesions. Which is why someone might have a very large, chronic subdural hematoma. But be urologically Well, because their brain has a lot of space. So for the chronic subdural hematoma, what would the treatment be then? You open up that pole, okay? Have you think we'll just give it 30 seconds for this one? Trying to doot. Okay, So four chronic subdural hematoma is there are actually three options for how we can manage them. The first option is conservative treatment. The second option is a whole drainage and the third option is a mini craniotomy. Now how we decide which one to do really depends on the patient's neurological status and how how much of a deficit they have, but also what their risk factors are. So in this case, we have a lady who is urologically quite impaired because she has really bad headaches she has weakness on. She's also confused. So this that tells us that this patient needs to have surgical treatment. The question is what surgical treatment, birth cold drainage is that was popular option for chronic drills. But if the patient has lots of membranes, which I'll explain the next slide than a minute, craniotomy may be needed in order to see those on actually break them up. We also need to consider the patients come abilities on their risk factors. In this case, she has atrial fibrillation's. When she takes more friends, that's really important. We need to reverse the warfarin with vitamin K on octuplets or very plaques on. We can also take the patient to be a two for behold drainage like this, and we also inserted drain, which we leave in for about 48 hours, some some centers performance CT scan before the drains removed others dirt and go by the patient's clinical status. This is actually a subperiosteal drain, but the drinking also be inside through one whole on then it can be seen him to the other other hole. So risk factors are patients that have a coagulopathy if they have a risk of falls. For example, multiple anti hypertensives on if they suffer from seizures during the operation, there is release of this dark murderer food on in terms of why they form, it's believed that they start off his acute subdural hematoma. Is that eventually chronicity i? There is an inflammatory reaction on that causes the formacion off these membranes that further aggravate the inflammatory reaction. They're too important. Studies that have been released what one quite recently, which is that would show the dexamethasone is not advisable to be used in patients with chronic syndrome. The tumor on the other one is that we should be inserting drains such as this in patients. So if anybody is applying for near surgery training, it's quite nice to new these two trials and be able to save them in your interviews, lost the I'll just mentioned that we can We can evaluate the A cure it to your chronicity off subject. You mature was based on their appearances. Acute humor, tumors like this, I usually within 1 to 3 days. Where is crime? Tend to be more than three weeks on less than 3 to 4 months. When they're longer than 3 to 4 months, they become high groomers on that. There are various classification systems based on house field units to help us to differentiate things. Okay, Okay, we have two more cases, and I'm going to finish in less than 10 minutes. So this is case number four. There is a 40 year old wound who fought, who falls from a ladder, and she injured her head. She temporarily loses consciousness but recovers on in a knee. Find that her eyes a spontaneous, the open. She is confused, and she's able to localize the pain. You also note that she has a laceration to afford. So if you have a look at the scan and then think about what the diagnosis is Yeah, have a scan on. See? Tell me if you can Can see what the diagnosis is. Okay. But okay. So this is actually a cerebral confusion. Is most of you correctly said we could see it. This is an actual CT scan, and there are these focal hyper dense lesions in the left frontal lobe. You can see them here. These are cerebral contusions on contusions can be thought of ours. Bruises to the brain, parenchyma focal points of bleeding. They can be usually they're usually am a Rogic on these air actually very important to spot because if it patient has these, we most likely will be admitting. We will be admitting them to hospital for a period of observation on these patients that you clues need to keep an eye on very closely because they can rapidly deteriorate. The reason for that is that there is they can be blossoming off the off the contusions. This is a lovely diagram. Bye. One of I think he's one of the creators of radio pediarix. I strongly recommend you visit for any scans, but you can see how ever a period over the first week there is so called blossoming or progression of these contusions with quite a lot of edema on this edema can cause the intracranial pressure too to be raised so much that a craniectomy is required, and that's usually a by frontal craniectomy. If it's if it's like this. So the front of the frontal bone is taken off. It's usually caused by a contract you injury, which means that if someone has that had backwards, the movement of the brain forwards causes the injury can be G two acceleration, deceleration injuries, common sites, all the temporal lobes, the frontal lobes and the occipital lives. And I'm sure you can appreciate the temporal Fosse's every small companies that route small and tight compartment. So there is not much space for expanding intraparenchymal lesion on I just I. The other thing I want to say is that in real life we see patients with a combination of these injuries so they may have an acute subdural hematoma with a contusion or contusions with traumatic subarachnoid hemorrhage. So often it's not. It's not one of one of the other. It's not one of the other. Yet these patients can also have complications such as hyponatremia, seizures and hospital acquired infections. So this is the This is the lost the last case. We have a 30 year old man who was ejected from a vehicle following a high speed collision. The patient is in a coma at the scene on the peoples are bilaterally sluggish. Don't worry about going on the pole, because for this one I'll need to show you the scan. But bilaterally sluggish. He's incubated with mental ated before being transferred to a hospital, so we don't really know what's. We don't know what this is. It could be anything, to be honest. But we need to. We need to assess the patient and do a CT scan. So when we do a CT scan, we can we can see these quite classical appearances on these are both Axial City had scans. This is from this is from lower down going up on. Then we can see the There is this focal hemorrhage here on. There's a little difficult Emerick here. This is actually a diffuse oxygen injury on. This is a very important entity because for these patients they can have a really significant head injury on if it's very severe. The prognosis is quite poor. It's caused by it. Results in these focal hemorrhage points of the junction of the white and green matter and it's caused by sharing of the axons. I'll show you on a little slight. So imagine that this patient is comatose there. Intubated. They're ventilated. What would the treatment for this be? So this is our last. This is our last question. Have a thing can see Well, this could be What? Sorry. What? The treatment. Okay, Just another 15 seconds and concludes it. Yes, and most people are selecting ICP monitor. We need to insert a nice city moment it for this patient. The reason is that they have a They're in a coma with the head injury on the CT head scan does not identify an obvious surgical target that we can we can remove with an operation because they're comatose there. Intubated. We can't reliably assess the conscious level, so we need to insert untradeable pressure monitor to be able to evaluate their pressure is whilst concurrently pursuing medical treatment off the ICP, as in the previous lights to this is Ah, these are the different different types of ways we can measure and intracranial pressure the most common is and intraparenchymal monitor. So small burr hole was drilled. The monitor is placed in the parenchyma Other options include a ninja ventricular catheter or a bolt catheter on. All these are effective means of measuring the intracranial pressure. The Brain Trauma Foundation has these guidelines these now superseded by a new guideline. But I think this relevant in terms of helping a society who needs to have a nice sleep monitor. Diffuse axle injury causes this tearing of the axons of the great White Matter junction. And we can classify it based on where the focal lesions I They're great white matter. This is the memory scan of the same patient, and you can see why. And Emory so useful to evaluate patients that we suspect may have d A. I also use for prognostication. Secondly, visits president Corpus callosum or in the breaks down. So I think this is ah, very important classifications system. Okay, well, that finishes the presentation just under now. Thank you very much for listening. I I I'm I'm very happy to present this case for you, and I hope it was useful. We covered some key definitions on concepts. We went over the physiology off my CP and how we manage it. We also spoke about how to assess it patient with head Andrew systematically look for secondary brain injury. We went over extradural hemotomas subdural materials, Contusions on diffuse oxygen. Injury on. I've shown you some of the evidence base. So please, if you can put a graph this this date to form some feedback So it's that was done, and that was really, really rid. Um, it's definitely not condensed. Got a little sore. There's just a couple questions That's all right as well. Um, yeah. Um, say stupid is asking you correctly differentiate between chronic subdural, an acute on chronic subdural. Yes, eso chronic subdural. There might be a single head injury that happened several weeks back, but if somebody has recurrent falls every few weeks, or even in every few days, it makes you wonder whether they had an initial bleed on in subsequent bleeds that have caused this acute on chronic appearance. That's the chemical way or a geologically. We can look at the scans and see if there is any new bleeding as well as older, believing another. What shows a mixture of hyperdense and hyperdense blood. The exception is if it's hyper acute bleeding, which can actually appear as hyperdense blood and That's the I think it was called the Swelled Sign You can. There's brilliant cases in Radio Pedia, but pretty fast. You really must should. But why are TR is that right? Try and violence is actually stop you problems. Yes, the patients are risk because it's it's a number of mechanisms and actually a lot of them aren't understood very well. A friend of mine does it research Study into this looking at which is more common out of cerebral salt wasting one SIADH. But there is a general stress response which impairs the pituitary on the pituitary gland, and we see either the syndrome of inappropriate and to dairy, too common or cerebral salt wasting. Also, the patients are quite vulnerable because off being in hospital, they're often resuscitated with crystalloid fluids. Well, they they have all the forms of resuscitation, but but certainly electrolyte your insurance in particular hyponatremia. It is very common after a head injury. It's not uncommon to see somebody with the sodium of 120 or 125 after an injury, and it's absolutely vital to spot early and treated breads did it for a more seconds, then will have there yet There is no have you seen Based is a pontine mile analysis. I can never pronounce that after manager of hyponatremia off the brain injury. I have not looked after somebody myself, but I knew there was a patient in intensive care unit I worked in that had always suspected of having it. It was somebody who came in with a with a very lewd sodium around 104 105 they were in status on. They needed to be aggressively resuscitated. And I think that one of the reasons for the neurological disability was attributed to that syndrome. But I have not seen it myself. It is quite right, Um, and then DNA the corner he Hello, Dean Regular is as us. When you have met patients with contusions, how often do you really scanned them? There's often no set rule. It's often and individual decision based on the location of the contusions, their size and the number. It also depends on the patient's come abilities and risk factors. So if they have a caregiver pathy or if they take on anti platelet on anticoagulant, then you would be re scanning them sooner in terms off guidance. It's important to follow the patients GCS if their motor score drops by one point. That would be an indication to scan them. So if they grew from being confused, two only localizing pain. That's an indication to scan them in general and then a drop in the other two categories of the GCS voice and verbal in eyes by two points. That would also be a an indication Well, about the compliant to relation to the memory. Care about threats, changing volume of the brain to practice religion pressure changes. Um, it may be I may have got it the wrong way around on the grass. Uh, though we've been called for them saying the events finished, Um, I think that was it Questions. Um, the, uh, records come inside. Room we have for the weapon all Friday. Uh, have one of the neurology registrars, Um, just on neurological infections like meningitis. And careful, like this, um, etcetera. That's, um, probably eight o'clock. Definitely not be missed. So hopefully see you or them