Complications include focal neurologic deficits depending on the site of hematoma and brain injury, increased intracranial pressure leading to herniation of brain and ischemia due to reduced blood supply and seizures. Subarachnoid hemorrhage
A subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Trauma can also cause SAH when the arteries and veins coursing through the subarachnoid space are ruptured. It is usually located at the cerebral sulci near the vertex of the head and spare the basal cisterns on CT scan. Severe trauma can cause SAH in all parts of the brain. When the SAH volume is large, rarely it can cause cerebral infarction a few days after trauma due to arterial vasospasm. Although CT scan is performed more often than MRI to detect SAH, MRI is more sensitive than CT in this aspect. SAH shows hyperintense signal of Fluid-attenuated inversion recovery (FLAIR) sequence and blooming artifact on susceptibility weighted imaging (SWI).Computed tomography angiography (CT angiography) or Magnetic resonance angiography (MR angiography) should be done if fracture involves the carotid canal, because in such cases, posttraumatic vasospasm can occur, thus cutting blood supply to the brain. Besides, intracranial hemorrhage that are atypical for trauma should also be investigated further with CT or MR angiography to look for other causes of intracranial bleeds apart from trauma causes. Such atypical patterns includes: isolated SAH in the basal cisterns, isolated large-volume SAH in the Sylvian fissure, and isolated SAH in the anterior interhemispheric fissure.
These are pseudoaneurysm, caused by thrombus clogging the distal arteries, which results in inflammation and small tears at the site of occlusion. These inflammation and thrombis can caused by infective endocarditis, artificial heart valve or other heart problems. Similar to vasculitis, rupture of mycotic aneurysm also causes SAH in cerebral sulci, mostly located in the vertex. If mycotic aneurysm is located more proximally, it will produce diffuse SAH pattern. CTA or MRA would produce focal outpouching or increase in diameter of the vessel. Meanwhile, GRE/SWI MRI sequence would produce focal hypointensity. Small mycotic aneurysms are difficult to be seen on CT or MRI. Thus, DSA is useful in identifying these lesions. Management
For those who is already on blood thinners such as aspirin or clopidogrel for prevention of myocardial infarction or stroke, traumatic intracranial hemorrhage should prompt the use of platelet function assays (PFA-100) to assess the effect of these antiplalelet agents. After that, plateletpheresis can be started to increase the aggregation of platelets, thus stopping the intracranial bleed. In those with impaired kidney functions, desmopressin or cryoprecipitate can be used instead.From limited observational data, it may be relatively safe to restart blood thinners after an ICH as it is asscoated with reduced thromboembolic complications with similar risk of recurrent hemorrhage when compared to those did not start blood thinners after an ICH. Comparison
References
Further reading
Shepherd S. 2004. "Head Trauma." Emedicine.com. Vinas FC and Pilitsis J. 2004. "Penetrating Head Trauma." Emedicine.com. Julian A. Mattiello, M.D., Ph.D. Michael Munz, M.D. 2001.