SUPERFICIAL LOBAR HEMORRHAGES. ‘he pamen, the most common se of prtmany ICH is eof fur Toeatios in the cerebral cores. The pata tal frei area are mot quently involved. In gener hyper oto i a8 enporea rik factor forall ICH regan of fn, but whether Hol presse ply 4 kes role in the ution of lobar vers eubcoralhernorshage remain onclesve Primary ampli angiopahy rently unerties hypertensive intacerebral lobar hemorhage, Other less omuon case inca vascular malformation, pits and Incntic malignancies, sympathomimetic deg antcnagae Tans ireverable ancpicce nd Hbrinaytic agers and Sins thromlosis with venous infetion and Heed Tatar emorshages oien present wth headaches ad vomit- ing Seizures tthe onetofloir hemorhage ate commen, Iovtislsly those within the posterior pra oot ae. Fencionaly, paints with lobar hemorrhage may hve better funeuncs than chose with deep humorshages. However, prog sis depends on ernatona se, evel of eonciosncs ore Senation, and presence of inaventcilr blood Morality fares range fom 12 to 30% in sper Toa heonhages ompared to 25-42% in decp bas gungioc and thalanic Iemchages and upc 97% i pontine hemorhage. + Frontal hematomas Inesranil hemorrhages in the supe ‘or apect ofthe frontal fe are arly sll and cause ‘wees inthe eontalateral ley. Inferior fowl heme: hoger are lage, casing 4 depresed level af consi ths, hemiplegia, hemseary des, and horizon {ue pares Language outpt can also he aft. Apathy Su abla occur ith soperior mei lesions an my be prominent + Parietal hematomas, With ght hemispheric hemorshages, fea the most sting ei preentaon is corte hegact syndrome, while lf hemiphenc hemorrhages prodace vanous degrees of phasis, Extension int subcori= SSL areas often occurs with wesknes, and herianopds frequently sen. More medial herorsages esa in own trad presse onthe upper brainer and can eauseobtnde. + Occipital hematomas. Although headaches are prominent in many lobar hemorrhages, those ocertng with oe emomhage are parcuby severe. The mt lias erologe defi & homonymous bemianopis bat some Patent present wit other val change, incing Dashes Fgh igs and palinogiaGffermage). Other dite inate of more aneeriory located hemorrhage iacade visml extinction, dgraphia, and dls. Oeepitalhemato- sys are the least kel to be related to hypertension, + Temporal hematomas. Newologie daft so temporal hematomas difer depending on the side involved. Fient tudai, offenasocited with paaphasia and poor compre hawion, ithe most prominent deft from iol Teh. ‘emporal lobe hemorage fa conc, ight temporal hem cnages are often esaciaed with eae min probes, ‘mort commonly confusion, Other news symptoms ‘pend on whether there extension ito the siroaing ‘abort areas or aan rom lobe Infratentorial Hemorrhages CCEREBELLAR HEMORRHAGE Clinical Vignette ‘A Stearold woman with sextant! hsory of arterial hypertension presented to the ED with @ hour duration of acutvonet headache. gat unseainss, and lft am Incoranation. On examination, the potent wae et ad Cente bu had sided dysmevi gat aan, and ft eu and CHM! poser. Her BP was 200/110 mi ig lrgene head CT showed a em cerebalor hemorrhage ith sah compression ofthe fourth ventric Athy fanavetrectmon aiming fra AP of 100-120 mm Hawa Win 30 mints afte the CF sen the patent eel of oncousness deterred, necessitating intubation She ‘nes brought immeditly 0 te aperating ram for eae laion of the Nematome end responded wl. One month oer, er examination mos remarkable fr ony lms res of the eft arm anda sgh wide sed gat. Asin che preceding viet, patients with ecb hemor tages candetericest rapidly crn in ont of one eye” Bat 8 sill respond exceptionally well wth expetious sgl Ireerention. Mose cerbele hemorrhages are asc with hypertension. However approximately 10% of primary cersbel Jae hemorrhages ae eased by AVM, trons, bod dyersias and the we of warria anticoagulation. Headache, sinning ‘ertgo, nase, vomiting, anc most commonly, ste it ‘acter the pica presentation, Some esdaches are acp= al, but many involve the orbital and supesori ares, The ‘moscrelable ymptons of hemispheric ereelarhemortage include headache, vomiting, stages, ptr ib sia vith, times, pater peripheral CNV and CNV plies {ed horionlnystages "The lex common verian hemorhages often resemble & pontine hemorrhage and can progres rapidly to coma, aking Fetal o identify speci ery inal sigs that can di ferenate one fom the eter Cranial nerve ples ae related to volvement of ajcent pontine tractors or stretching o- ‘ondary to incresed cerebellar presen hypertensive Mees invohing the verso the cerebellar hemispheres, the sperior cerebellar ary is most ofen involve Unlike supatenaia leds, which sal hemorrhage often well tert, infetenterial ICH within the poxeior few often leas wo rapid nearlogc deterioration and death, (Close monitoring in am TCU for 36-48 hour, whe the so deterioration ix ati highest, therefore recommenda for ‘most patients. Rebleeding apareint the outs venti nd Acelerated hemoahagi ems, alone on combination, en lead to 4 devastating ostenme. Hemorrhage lager than 3c smay end ito the fourth vested Ted t the deel ‘ment fact yc nd equ enrcostomy pace ‘ment. The threshold for surgical evacuation ofthe heaton ‘how be low atl considera at the ears ign of deteriory Sion The msjoe gai i decompresion ofthe perio fo prevent blockage ofthe fourth ventrile and compression ofS542 SECTION + Carsbrovacular Dienses the aducentbrintern. Forums, i impending besntem ‘ompeenion is receeined early, dete ae fen ony inal fella dec afer surgery, ven with ecndve cerebellar ‘rsvaton an decompresion. The potentially postive recor fy from cerebellar hemorrhges and decompressive surgery rele thatthe dep cerebele mul erucl for gait coordin "iw and flan, ate ote spared fom dvece damage FONTINE/IMIDBRAIN HEMORRHAGE Pontine and midbrain hemorthages ae relatively uncommon burt hase the mose devastating utcome compare with ether sie of primary inuacanial hemorthages The distin vase ler estore cat the eine prestation, The parsedan penetra, aeing dry from the anlar trunk, are the ‘Primary rere upping the midline pons or midbrain. ICH Inthislocaton causes lateral damage ad is ofen fat- Soden ‘nse of deep eons, quadsgaesi, ophthalmoplegia, and bt ‘apply sbmoraaie ar the presenting sg ‘Ancher proup of snail tre, the sho Crewnerentel enetator, curses Ira sopping the Iteral basis pont ‘wherea hemorrhage may predominaey case unilateral ular Symptoms wich profound dysphagia ‘The died important ‘roup of rel, the long ceufrenia ares, aes fm ie enrtoinfro coral ery nd pearly spies the Tora tegmentun. ICH within thi segment lads to Felatvely sino sympeoms, incaing facial nabs and ataxia second "rytoinvolementof the pial rigeninal nd vestibular uc However, valent ofthe ineiaie pontine nll, suc as the cohlae se fail mile ar alo aed, which lend #9 Pantin hemorshages often have relatively gad clinial resentation evolving over hours Neurologic defining Foraont gaze pase, ite slgyshl eave pops, quale press, an coms aed capectd iia sigs. Cerin unig 5 findings, ncdingceular bobbing andthe one-and-a-half Syndrome, provide excellent dagnoste es to pontine hemor- ‘ages: Some patents slo exhib witching 0 the band ‘ace and vippling of rso muscles. Dysutonomia with ieeglar pe, erate rething pater, and an increase i boy t= perature hase ls been asersed Vii, sometines Fighting, Focmed hallnaons, called pedncule halleinoss, occur relatively olen in parents wth involvement ofthe midbrain ‘egnencun. SECONDARY INTRACEREBRAL HEMORRHAGE ICH nor directly cased by hypertension i encountered wih vascular malforadons, hemortiagie transformation of Come stroke, ancoagulants, a6 well sp eine agents or Severe ampatler therapy (Bor 8-1). Pinay ald ‘ngtopathy is ofen the undeying cause of nonhypertensive fofar hemorrhage. Less common eauss include primary and metastatic malignancies, sins thrombosis with’ venous Infrcions and Hees, acquired or inherited eamguopatic, indeed or stcimemne vasalider and syste granulo rmatous dordery ental infections prone, and trauma (Bor 58-2, {Box 56-1 Common Causes of Intracerebral Hemorshage 1. Primary iracorbelhemorhage 2. vaseaar malformations 3. embolic inte {Box 56-2 Uncommon Causes of Inuracerebral Hemorrhage! ndocard ‘enous trombout Sade ca ven 5. Other homolog dsoréers,parcualy coaguopathis ‘fbcragenema| 6 vacates Systemic ius eybematosus ‘Megene raufortesis Tasayas ater Primary cs vaseulis Symosthomiretisfmphetamine, cocaine, Phernpropanoline) 7. systemic dserders ‘rcldoi Bett syrome ENS inetons, patty herpes zoster “26, damiated mad cng oat Tnmost ses oFICH, expel when hypertension sas fellowop ireging sedis are emi! to ergs Gi posites of underlying predisposing pathology. Conta Enhanced ain AIR scanning performed about 3 tons ate ser exuavaied blood has been allowed to reason, tnciner an underying lon intly cured by the ses pean (Osu ascler me were ponably the so underdagnoned cases of lobar hemorrhages prior to CT a MR seanning and were frequen mised by earl angiography due to the presence of ot and mas eet on he bin. Tey were dagnoned nly dang urgieal or pathologie specime {Rejection afer hematora ener The mot common ocel ‘ascot Ions inl small AVMs and ever snglonss (ig. 834-0).snc Here Sodio AVAL Xe icc Neha Hanaraton With ravens PA Ther. | £ - Hemarrbage bain ifort (BD, in comcast © primary F inmscenilhemorhaye, Ix a secondary phenomenon that Bcecry or reat of wcncmic darmge to bath the bain pare yma and the vessel wal ital the ste of occasion The ‘secu all endricbiam and the blood brain hare re sb quent damaged and kes with repetsion a they no longer erate normal anerial pres. Petechial beeing sv Sines, grom hemorrhage Uvough dhe damaged vessel into the Inne aren maybe seen (Fig S8-3ESF) Tes estimated hae _ [Box 58° Tumors Causing Inuiacrebral Hemorthage™ Patary adenoma DStgodendogtoma ney ptecial bleding develops in more than SO% of patients with bolic ince Although ticoten pied that eardioembobe SHroes are more likely to be anointed wth development of HD, some invsigatrssogest that any age inte, ean les of mechanism is predispose to sch bleeding. The we of IV heperin or Repaid for secondary stroke prevention slo promotes the derelgment of HBL However, the presence of Petechil hemorrhage without frank hematoma formation does ot seem to worsen neurologic outcome ‘Along with pica suluachnold hemorthage, anemryemal pear cin, 4 tes, cae ieaparenchyeal heaton With fro nearologc signs (Fig. S8-1AKB). ‘The Iocan oF the Doo often inst these ofthe anes. Later temporal Tobe hemromas suggest MCA aneurysmal rapeare while metiblly Tossed bless ate stocaed wih cated artery heurysns Frontal hematomas inde anterior communica ing artery ancarym. Prmeror communicating artery ane ‘pum case thalamic hemorrhages, fen with arent Primacy or metas ban tnmors cn lead to ICH (Box 5-3, Fig. S#-ACKCD), A single small hemorbage fom met {10 leon, cn bo seen with eanemes oe bypernepi rns maybe difiel to disingish fom primary ICH ass ‘rience of ether Iesions identified. Other ces, sich a typical coral or subcortical latin of the Heed, relat ‘margin, an uneypeted conus enhancement ofthe lesion mont prompt further ivesigatons wo exdade temic disor des A decile dennatlogt eramination sey reveal itep lly pigmented lesion, svgestingmcanoma, and wlrasound ‘orbody CT san may uncovers real tsmoe Antithrombotic- and Anticoagulant Induced ICH Tequeston of whether apirn promotes ICH remains nce, butthe Physician’ Health Seu srindomize, doable bided,S544 SECTION + Cersbrovascla eases (A.C wihttond in ivin fu O witness presage hewn cen Figure 56-4 Uncommon Causes of nvacrebral Hemocrsos pbcebo-controlled trial looking a¢ asin in canionsclar ‘ines, suggested a trend toward increased ts There were 2.1% hemorrhagic stokes inthe testmen group and 11% the placebo group. This increase was aoe seen sn many eter etna wi tes the bene of asin forthe prevention of Soke. Several slewing warfarin fr stoke prevention fn Patines with aril lbilatin have demonstrated nae Feeding rites of 05-18 per year, Te highest kor Mein va scen in patents olde than age 7 years. The combination twain ad asin sagged sar rates of sytem lee Ing. appeosimatly 2-4 per year, nd no diference in rates of ICHL The we of intravenous heparin inthe sting of seu stroke his ot been syattatilly sti sto nei or com cations A few sais have sagged no rik ICH whereas ‘thers ince 2 rs of spprosinately 2%, especially when Tapa wed in the sein ofan ate stroke. The Ine Shona Seroke Tia red shortens heparin t 12,500 eve (fer te {ania peste [CP]; monitor arterial Blood gas lee (Cr eulatry sts Sear intrrenous inion of oral sine soliton, followed by blood if insted: bia Immediate aborgry work and xray amine steroid ‘nd phenytoin pls presor agen if required hock rey he to ead injury alone; seach for tse) Concomitantly he patients general evel of responsive nyse be assed sing the Glsgow Coma Seale (Fg. 57 ‘The lest pole core of} mean that india have ally to open the eye 0 moor respon to verbal oma tr direc stim and no verbal espns the physics tion ging sore of {orn or exch ofthe three components The highest possible score i 15. Sof se injures ae come tmoaly aeccted with moe tree head injuricn A comple tamination ofthe exterior orice ofthe fae ea i Blod lor can he extensive given the locaton of blood wes ‘within the dene connective tse ofthe ssl, which deeeses Fetton of cut vests and promotes bleeding SKULL FRACTURES ‘These can he loested inthe cari (wl) andor the basal sll, Frocues of the cranial wal cry #20 mes eter incidence ofntraceail emstoma in comatoe patents ad 3 400 times greater incidence in conscious patent, Bisa sal Frases ten dic oe om head Tex penn ith Juthogremonic signs including raccoon or Pands est che Fee sins feechymosis over the mastoid, and cerebrospinal fui (CSF) leakage fom the nose, throat, o ers Fig. 59252 SECTION « Trauma >) Gisele sad ca pay a. ae Pt =— Bese eee font tee ot Spice bone ‘Figure 59 Signs Suggesting Need fr Operation Mos eas resolve spontancouly: Pesitnt leas necesitate ‘operative treament Fi. 593), ‘Depressed fractures, and thos long the emporal bone are more simmons ith ijry to the brain or blood sels A fncre line ac the mide eninge artery ay prdispone tam pidaral hematoma. Open factres with thet omminicavon beeen he itacrania auleand the eternal fsvronentareastoited with higher iss of spinal Bid eas sd infecton Fig 594). EXTRA-AXIAL TRAUMATIC BRAIN INJURIES Traumatic Subarachnoid Hemorrhage "Thins the most common soca of TL and itil ase ted with her peso inracanial lesions, Subrachno hem Comme (SAH) can rage fom clinically insignificant co fal, “These SAH blood prods can obstruct CSF rebsortan, leading to increaedintscranin pres (ICP) wth hon ‘Splits. Treatment of SAH_ offen voles placement of ‘enmcolar drsine and shoring stems for secomaty Iyedeocepbalas Epidural Hematomas “These epresent an acute bloo! collection consined bere the dora and inner able ofthe all These over in appro mately % of TBs Fig 89-5) Epidral hematomas (FHS) rst mmonly develop inthe temporal and parietal regions 909% Sof EH ae associ with a sl fretre. Aerial eerason, particulary of the middle meningeal sery (Fg 39-8) oss ommonly venous injaricy initiate che formation of hema ‘nae Contiguous aeration of the dara mater allow this Boa fn the ep ace.‘CHAPTER 59 = Touma tothe Bain 53 (rose sal ache ered tl acre Lipton wih cons. remove Bue pct mn occ» Wath ral cae Ontrl, oe (ded tote pacar facts dnton freedoms pra maybe ced ed wed ace iene fw es stain Sellinet Figure 59-4 Compound Depressed Skull Fractures ‘igure 5955 Kou! Heratoma Inumediately sir the cloned hen injury, the patient “typ coma develop within ast] hour ater the blunt eed njry Gee cally" experiences anil but relatively reflow ofconscions- ig 99-3) However this casi presentation occurs in kes than res seconday othe primary cance injury. Thi then one tint of affected individual. The actal rate of symptom followed by «faci inert with return of wakefulness, Subse- progression depends on the type of weaned rain in ‘yond asthe tor vss Teak, an epidral hematoma develops the etolog and the sabsequen recive rte of blood ar And ealures, leading to rapid aoe into coma, Sometines this lation within the epidaral spe, Ste process my trampite fom ijuns to trament loss of Cranial CT imaging osally demonstrates a hyperdense, euseigumen and to abril period of -paraexcllyresssr~ bicovex collection been the sal and bin (Fig 39-7), On ing alerenen* only vo haves deviating, ofen ireversie, oceason, the intl CT i normal a the hematoma has ye coil po a onan Echelle ry ott meningeal te im ‘se clon on Moringa ahs cng phar ey eens te access nigel ais ening benef petri th te eer ening tery mai th te) neal ai ay and meeps nk phate Midi sings any Acsey meninges ty Figure 5946 Wenge teres and Dura ster velop co sie thats definable ‘Ths when the patio sat its ese oe prepared wo repeat the CT sana he est change in clinal sais, Once the EH is Mente, cmergeny sre evatation indie. Any lar to ee. ‘ognize an epi eatona has a most significant mortality ‘pending on patient age, time of tretmen, hematoma ss, tnd asocaed ini, al ar cpt ay esr aps mening “These blood collections are lacated between the brn pach chyma and the doral membranes and are eased by thir temporal profes Bomaromes SDHs) coeur in 15% ‘of TT pans; these ae evento eight tines more coma ‘han epidural hematomas. Olr indivi ae at grater Teens as the bein ages, there i a innate trophy of teA. Nonma nC cn do esd hematoma. ‘gure 59-7 CT and Anglogram of IC. cerebral corte. Ths in seniors, asthe brn “noel” essen in volume, an icressing space develops within thi sb eomparment. In tum thir leads to ineresed eetch on the Undine veins hetmeen the sul and the cerebral surface Cs 59). When any individual sine direct head rama, the brain parenchyma accelerates and decelerstes in elation o ed dna soc. Ths leas toa tari of the now astonselly scched veins that rma "beige between the ceria core tn the sll Similarly concomitant injury to coved eis | Se engine rl pg 9, CLINICAL PRESENTATION AND DIAGNOSIS Teint every ofthe nary determines the patenlinc esenation tht varies from neurologically inact to ler ‘rental tatessubequenly asad with pupillary inequality {nd mocor weakness, and eventually Decoing comatose with ‘ens ofdecarente or decedbratepostring. The lad inter { cesal nding with epidural hematoma, abo commonly Seon with ace SDH. Brain CT isthe inl text of choice fr Alccting SDH and concemien rain ij. An acute SDH [sreengnaed by ishyperdense crescent shaped image beameen the bran and sll ce Fig 39-7), Unlike ep hematomas, SDHs sypelly ers sal acre lines, and sometimes extend Along the ae cere, Head CT sometines underestimates the ele SDH gen hearing dey ofthat . D. Aeae intraeealmato, sina e TREATMENT AND PROGNOSIS Ifthe parent as metal stats changes sigs of fol obra compromise, beginning trestnet of seate SDH arp 18 powable with medial management for increased ICP and the teointed cerebral dea wing mani very ef Soria! Intervention with + craniotomy i appropriate for inddls sthone SDHs have mas effec, ang ofa neraogie df= ‘Ste Once a significant SDIT i define, surgi eracuton af the dor most be expotconly performed. Atur-hoe wephine ‘ciation inadequate bectse the clo i often tla more ‘iscons than aoral Hood Increased postoperative ICP oocars in almost 50% of SDH patient and thu the nial medial management must be continoed (Fig. 59-10). Residual and recurrent hematomas ae slo postoperative concerns ‘An aeute SDI soften asoited with poor ute, The ‘combination ofthe ematons wth che injuries, pariaarly ‘hose affecting the brain parenchyma, essed with 2 30% tonality rate OF those patients who do survive significant amber have permanent metal and piss! dss, Out= ‘omer are strongly preficed ty pati age at iil presents tion Mortalies of 20% ate retuede for indians younger than 40 years but this er neremes to 659 for tho older than thi This is «devastating lesion in senior ene a there isan 8% mors for octogenarian. The intl consaowsnese Teel alo rower» prognostic guide. Conscious patient ave morality re of esr dun 10% wherest unconscious patents fave #5-60% mortalityi 556 SECHION a « Tuma Sal ere Si of epidural hemo Scot spce item peri eee ens ving wis pata. rata sddn ro oe osgl | a ‘ Tenet cin Scalp, tll Moning nd Cb lad Vue ‘7 vr saginy Archos! eet peeing al Dolo eo cet ene sn dng vs) Fo a pet bts ‘sper empl eal pal ances ‘Spel engl ey hac gratin sao el neta np ie pt ea “lari nd npn tie ‘igure 698 Sopercal Cerebral Vins and Dinoc Ves“uma incon paar ese oe er Sraeone ssa. (CHROMIC SUBDURAL HEMATOMA ‘These sural blood collections commonly appear 2-3 weeks afr an often seemingly innocuous injury ae Mstrated in the inal vignette, The incdene 1-2 pe 100009 persons cach jean Most chronic SDI pens are oer than 30” yeas {Chronic alcohols or patients with coaglopathin, particulary Som itogene sours such a atcoagla, ae tore prone to bleeding with relatively mir wauma suchas suing one Trad on the dooefme on entering anasto, Intl, relatrely minor amounts of blond ener the sua sl sjce afer trauma or spontaneous hemorrhages. Subs ‘ely, ver er week neal these bod prot ead 2 mnembrane formation at both the inner and outer aspects of the hematoms, Evenly these membranes are prone to low trade ecg and th ead oslo enlargement of the SDH, Concomitant higher mote presre develops within the ssioral hema leading wo at osmexic gradient that po notes passge of CSF ino the inal SDH and consequently this mas Testo gradually enlarges. The lini course a= thle and not peticable I the SDH reaches aerial sie 0 Counpeoine brn Function, symp wil develop. In contrast, ‘Noumer of SDHs wil soul abr whoa ever becoming Sena ‘CHAPTER 59 + Trauma tothe rain 557 CLINICAL PRESENTATION AND DIAGNOSIS “The presentation my range frm se foc sgs of crcl compromise a deersined bythe sit of injury sich 8 aphai, focal weakness sensory fos, confsion, oe seming catty dementia wih bifonal lesions, rm thoce symptoms of the ‘arious herniation syndromes. high dial suspicion of SDH tus alas over espily wih the tr india when- ter there remote hstory of end tana. the stay of ‘hoe (ce ig. 57). Ocenia rain IRL serenity leads wo dnghoss of SDH i patients presenting with se Tike or seinretype symptoms “TREATIENT AND PROGNOSIS “Medic management and observations commended for indi- ‘vials with sobre nia symproms and signs: icontinoation ‘of anvinuguane medications cote sera in a hopital or typ rela ay and serial CT. Surgel therapy i able for any chronic SDH that casing sniicant ns fect of east with sgifeane cline! midi, Upto 45% of ‘homie SDHs reccumulate. Postural moral is apprs- nately 10%, Unlike cute SDH, mou chronic sub ptients ‘reableo rzun to their previous evel of fanctoning although ‘hut 10% may develop Seere, INTRA-AXIAL TRAUMATIC INJURIES, Cerebral Contusions “These are the second mot common ofthe TI Isons. Usually the ont and enpora fobs are afte, Basialacotasion isabse to the bain sue per se. These lesions ae compose ‘of hemorthage, infarcted tsb, and necro. Cop lesions ate thon loon der the ae of dre ijry enineo elon Se Toate asides opp impact secondary to rn te necrosis anders, whee the brain decelerate sn the sl (often the fone and temporal poe), Conteal contusions ‘Sremost common, but hey a will Occur within the dep white ‘Ginial presentation varies widely ai predicated on the loci and size of he lion. Many esa contusions enlarge ring the fs fe days afer injury. This can Boone very ‘Significant in pent who rota high-impact eran, Suri intervention usally nt requiel for ineacerebal ones, ‘epecally fr smal, dp subeoralconasons thew ate ges rally managed medcally. However, larger Inbar contuvons ‘ith significant signe of mas efece sometines ree cr ‘tomy and eravatin. Temporal lobe contusions are poentaly the most dangerous gven thee locaton near the beater, Repeat CT seaming i esental to follow these sions Mortl- igy tes for cerebral contsions ange from 25% 0%. Intraparenchymal Hematomas About quater of hea injury paints develop inapareney: ‘hal heaton: the are well demarested ares of ete hth ‘rte. The lnc pathophysiology ix similar to contin Mont (0%) occa thin the Foal and empl oe. est558 SECTION a» trauma injury lead 0 dsp cereal white mater hemstmss Two ‘hi of inraprenchymal emutoma ae ao sited wh Concomant slo epiral hematomas Gee Fig 5.9) ‘av nmvenvsarhemorhag, an smn by yd uy sy ao eoneonly Slay. Depntng on he ery af ules hal of hse pets present ith Tos of conscience sg nd ‘Smprome sate the sand cation othe hemorige Mel management the exent of ae for deep oe sel emorthage and fr una paens Serial vacton it dkated Sor lng sper lobar heater ined set lil sig of ms fe. Venrlar CSP die ao {ewe to monitor their ICE. These provide ean fallow neurology severely compromised pes ‘Morais vary fom 25% 105% fn pets wth an inspect honors. Te crema ute of hse \thoturve depends on thei evel of coment prea ton and loan hematoma, nd sever of concontan ines: andy. ery important decries of mest The teenager may scl have hi or her ptm patency henoctage raced what signet ed talneorca damage venir the wir con my ody ve mane age tlted ena compromise a hs ae ‘inch mini rognows for teste ret pe tele Diffuse Axonal Shear Injury ‘The combination of eoational acceleration and dscleasin, the bein doving resume impace rests in shearing | tits atonal pahways and sal ples, Highspeed ‘hice acids ate the most common eslogy in the chy Population. Very microscope, penetrating blood vse fhomaged st tmp levels including the cortcomedl junction, cpanel, intra capsle, deep ‘nd ypper brsinstem, leading to numerous sll hemor foc Early on, conventional CT scanning wll demons any abnormalsy related 9 ths pe of lesion. ‘The Temorsages say be best cen om gradient ech? wey sequences Fig. 39-10, Later there may be nonspecie i mane hypeinense lesions with atrophic changes. SI injury is very commonly asccted with ocr ints ‘ext uaumatie inl inluding feel orators. Sh Injury isa major prognostic comtabator to overall ea in most, ‘Oem the intl brn CT is unremarable, especially wh there is no concomitant hematoma, a there ae no specifi Ings asocited ith shea injury: Hower, dung the 48072 hours afer the injury cerebral edema may bes brio. Sill areas of puncte contusions can also be {nares of die sonal nary. The most common MRI adi Site ‘Figure 59-10 nensve adil Management of Severe Head nr