Objective structured clinical examination (OSCE)
Tristan Barrett, Nadeem Shaida, Ashley Shaw, Adrian K. Dixon in Radiology for Undergraduate Finals and Foundation Years, 2018
This is an unenhanced CT examination of the head. The high density (white) bones of the cranium make this easy to differentiate from MRI.There is widespread low attenuation within the left hemisphere with associated midline shift to the right. Midline shift is best assessed by drawing a vertical line centrally and assessing displacement of structures (in this case the frontal horns of the lateral ventricles), see image below. Left and right can be confusing to some, but the convention is to always display axial images as if looking up from below, thus the left side of the patient is always the right-hand side of the image. The appearances are due to a large ischaemic stroke in the region of the left middle cerebral artery. Given the size of the territory involved, the patient is likely to have presented with significant symptoms: right-sided hemiplegia (paralysis) or hemiparesis (‘weakness’) and right facial weakness. Speech is also likely to be affected as the left hemisphere is dominant in the majority (90–95% of right-handed and 65–75% of left-handed individuals); loss of consciousness is less likely than with haemorrhagic stroke.
Neurosurgery
Gozie Offiah, Arnold Hill in RCSI Handbook of Clinical Surgery for Finals, 2019
Presentation➣ Classic but rare lucid interval.➣ May be conscious or unconscious➣ Bleeding occurs between the skull and dura mater.➣ Space occupying.➣ Middle meningeal artery (MMA) affected in 80% of cases.➣ Signs include fixed, dilated pupil on the affected side (CN III damage).➣ Can lead to uncal/transtentorial herniation, which leads to respiratory arrest➣ CT Brain features:Biconvex/lentiform disc.Midline shift.Ventricular compression.Will NOT cross sutures.
Pancakes
R. Annie Gough in Injury Illustrated, 2020
Another one of Gene's cases was a motor vehicle collision with a closed head injury. Gene's client suffered a brain bleed. The radiology report read, “Frontal subdural hematoma measures up to 8 mm in thickness and extends from the left frontal region anteriorly to the high left posterior frontal region. Left to right midline shift has increased 2 mm.” The axial CT images showed a thin rim of blood against the skull. Gene was convinced the bleed was too small, and that he had nothing substantial to show. “Eight millimeters is so tiny, it won't even show up.” I immediately asked that he send the CT on DICOM disc or upload it to DropBox. The report said the subdural was only 8 mm in thickness, but I wanted to see the surface area of the bleed spreading under the dura. After all, the report noted it was large enough to cause midline shift. His client did have a residual brain injury. Yet, Gene was still convinced the bleed was too small. He reluctantly asked his staff to send the radiology disc to my address. When we discussed the radiology, I explained again with food. The radiologist was describing the thickness or the height of a pancake. I had to look at the radiology images to see how big the pancake was in diameter. Was it a teaser little dollar pancake 8 mm thick, or a wide, fall-off-the-edge-of-the-platter pancake 8 mm thick? My animation guru subcontractor had a radiology software in which he could build 3D reconstructions of various anatomy. I asked him to run the data and I was pleased to see a decent sized bleed. Remember, any amount of blood in the brain is bad. This was a decent volume of blood, and the visual aid stood alone. No case is “too small” for a visual artist to consider what an attorney might be able to show the jury.
Decompressive hemicraniectomy in the management of subcortical spontaneous intracerebral hemorrhage
Published in International Journal of Neuroscience, 2020
Ifeanyi Iwuchukwu, Cuoung Bui, Billie Hsieh, Vivek Sabharwal, Alaa Mohammed, Harold McGrade, Erin Biro, Doan Nguyen, Olawale Sulaiman
Standard practice at our institution for ICH management include serial head CT at 6 hr intervals to demonstrate hematoma stability and/or a 18–24 hr follow up head CT. Each patients initial and follow up neuroimaging studies were reviewed for ICH location, hematoma volume, midline shift, intraventricular hemorrhage (IVH), and Graeb scores. The ABC/2 formula, a validated formula, was used to calculate hematoma volume [17]. The Graeb score measures IVH severity using a 12-point scale centered on gross hemorrhage size and ventricle dilatation with higher scores indicating worse intraventricular hemorrhage [18]. A 30% increase in hematoma volume on follow-up 24-hour neuroimaging was defined as hematoma expansion. Midline shift was defined as lateral deviation of the septum pellucidum from the midline; a central line connecting the anterior and posterior attachments of the falx to the skull at the level of the foramen of munro in millimeters.
Neuro-Ophthalmic Literature Review
Published in Neuro-Ophthalmology, 2021
David A. Bellows, Noel C.Y. Chan, John J. Chen, Hui-Chen Cheng, Peter W. MacIntosh, Jenny A. Nij Bijvank, Michael S. Vaphiades, Konrad P. Weber, Sui H. Wong
A number of treatment approaches have been advocated for persistent visual complaints following mild traumatic brain injury. These include devices such as binasal occlusion, yoked prisms, vertical prisms, and filters, as well as vestibular training. We discuss the rationale and the evidence for each of these approaches. Binasal occlusion has been advocated for visual motion sensitivity, but it is not clear why this should help, and there is no good evidence for its symptomatic efficacy. Base-in prisms can help manage convergence insufficiency, but there are few data on their efficacy. Midline shift is an unproven concept, and while the yoked prisms advocated for its treatment may have some effect on egocentric neglect, their use in mild traumatic brain injury is more questionable. A wide variety of posttraumatic symptoms have been attributed to vertical heterophoria, but this is an unproven concept and there are no controlled data on the use of vertical prisms for mild traumatic brain injury symptoms. Filters could plausibly ameliorate light intolerance but studies are lacking. Better evidence is emerging for the effects of vestibular therapy, with a few randomised controlled trials that included blinded assessments and appropriate statistical analyses. The authors conclude that without more substantial evidence, the use of many of these techniques cannot be recommended and should be regarded as unproven and in some cases implausible.
Subdural drainage techniques for single burr-hole evacuation of chronic subdural hematoma: two drains frontal-occipital position versus one drain frontal position
Published in British Journal of Neurosurgery, 2021
Qiangjun Wu, Qin Liu, Duoning Chen, Zhufeng Chen, Xuecai Huang, Ming Luo, Shike He
The low recurrence rate in patients with TFOP may be explained by the reasons as follow: 1) In this study, we found that midline shift on first postoperative day was greater in OFP group than the TFOP group. Prior studies had shown that larger postoperative midline shift was associated with a higher risk of recurrence.6,23 Because large postoperative midline displacement reflected poor reexpansion of the brain, which may predispose to re-accumulation of the hematoma.23 2) Our results showed patients with OFP had much more residual subdural air than those with TFOP. Many studies reported that the amount of residual air was correlated positively with the recurrence rate of CSDH.15,18,24 Massive subdural air is thought to disturb adhesion between the inner and outer hematoma membrane and thus facilitate postoperative recurrence. 3) Patients with TFOP had larger percent of hematoma evacuation and smaller residual subdural fluid volume compared with OFP in the present study. In accordance with the findings of Motiei-Langroudi et al., there were fewer recurrences of CSDH in patients with larger amount of hematoma evacuation after surgery.24 Stanišić et. al also found that higher residual total hematoma cavity volume on first postoperative day was an independent predictor for hematoma recurrence.25 The possible mechanism is that persistence of hematoma space postoperatively may inhibit brain reexpansion and prevent reduction of the hematoma cavity.25 For these reasons, patients treated with TFOP may have a lower risk for recurrence compared to those with OFP.
Related Knowledge Centers
- Abnormal Posturing
- Brainstem
- Hematoma
- Intracranial Pressure
- Neuroimaging
- Traumatic Brain Injury
- Stroke
- Brain
- CT Scan
- Magnetic Resonance Imaging