Distinctive CT findings of this condition & markers of severity

• Findings
  • Hyperdense/lentiform opacity, usually at temporoparietal region underlying the scalp region
  • Constrained by cranial suture lines
  • Does not extend into hemispheric fissure
• Markers of severity
  • Size of opacity – depth & extent along the bone
  • Midline shift & herniation
    • Calvarial herniation
    • Loss of sulci
    • Effacement of lateral ventricles
  • Swirl sign – suggests active bleeding
  • Contusion / hypodensity at site or contre-coup
  • Skull fracture underlying

Indications for surgery

• Size
  • >30mL volume
  • >15mm thickness
  • >5mm midline shift
• Site
  • Posterior fossa – limited space
• Clinical features
  • Low GCS
  • Blown pupil
  • New focal neurology
  • Worsening neurology over time

24-48h management plan

• Review imaging & op note & any other notes available prior to arrival to assess for risks / complications
• A – protect while GCS low to minimise aspiration / obstruction
• B – maintain
  • Normoxia – SpO2 >92, PaO2 >60
  • Normocarbia – PaCO2 35-40
  • (Oxygen more important than CO2)
  • Minimise high intrathoracic pressure (ie ICC if needed)
  • Early extubation if possible
• C – Maintain MAP >70-80mmHg, if ICP monitoring available target CPP 60-70 instead
• D
  • Short-acting sedation only or avoid altogether to facilitate frequent neurological assessment
  • Unilateral pupillary dilatation warrantes urgent CT, neurosurg consult, ICP control eg hypertonic saline, head up / bed tilt depending on spinal precautions, loosen any neck ties/ligatures
  • Seizure prophylaxis – Levetiracetam ONLY if seizures noted as part of presentation, and only for 7 days
  • EVD – care as usual of this if present
• E – Na 140-150, Mg >1.0, K 4-5 to avoid arrhythmias
• F
  • Avoid albumin / hypertonic solutions / dextrose-containing solutions per SAFE study
  • Monitor UO & maintain euvolaemia with 0.9% saline or CSL
• G – BSL 6-10, NBM until swallow is safe, NG feeds if required
• H
  • Monitor Hb in case of other injuries, target >100
  • Correct coagulopathy
  • Plt >100
  • DVT MECHANICAL prophylaxis only until no signs of bleeding/coagulopathy, repeat CT stable at 24-48h and neurosurg happy
• I
  • Avoid hyperthermia
  • Antibiotic prophylaxis if dirty wound or requested by surgeons
  • ADT if needed
  • Wound care (scalp wound / neurosurgical incision)
  • EVD care