Operative management of traumatic intracranial hemorrhage

Abstract

1. 1. In the majority of cases of middle meningeal hemorrhage there are neurologic signs implicating the cortex on the effected side. Widely dilated pupil on the same side is seen frequently, although one case in this series had dilated pupil on the opposite side. Pupils equal in size do occur; this was true in two cases in this series.2. 2. Bloody spinal fluid of varying concentration does not rule out middle meningeal hemorrhage. In this series all punctured cases had bloody spinal fluid. To assume that the condition is one of subarachnoid hemorrhage because of the bloody spinal fluid is a grave mistake in these cases.3. 3. Lucid interval may be absent in middle meningeal hemorrhage. This was true in more than half of the cases in this series. Lucid interval may be wiped out because of (1) very rapid hemorrhage and (2) associated severe damage of the brain.4. 4. Lucid interval was seen not only in cases of middle meningeal hemorrhage but also in those with acute subdural hemorrhage, subdural collection of spinal fluid and edema of the brain.5. 5. Chronic subdural hematoma usually follows slight injury to the head, but in this series its association with severe brain injury and fracture of the skull is brought out. Seven cases had associated fracture of the skull.6. 6. The association of chronic subdural hematoma and relatively severe brain injury should be suspected in patients who remain unconscious, drowsy or disorientated for several weeks. Particularly if the spinal fluid pressure is high, an exploratory operation is justifiable.7. 7. When the question of cranial exploration arises, cases of head injury should be treated individually and if certain signs obtain operative intervention should be effected. In the presence of the proper signs exploration is justifiable even though results may not be favorable. In this clinic we are particularly impressed by a combination of all or some of the following signs as indication for exploration: 7.1. A. Dulling of the conscious state leading to unconsciousness or progressive deepening of an unconscious state already present.7.2. B. Presence and progression of localizing signs rather than neurologic signs implicating the entire nervous system.7.3. C. Increase in spinal fluid pressure.7.4. D. Low pulse rate (in some cases).