ANSWER: (D) HypothermiaREF: Comprehensive Board Review in Neurology by Mark K. Borsody (Thieme) Page 63See APPENDIX- 81 below TRAUMATIC INTRACRANIAL HEMATOMASTriple H therapy of subarachnoid hemorrhage used to ameliorate cerebral perfusion, consists of:HypervolaemiaHypertensionHaemodilution APPENDIX- 81TRAUMATIC INTRACRANIAL HEMATOMAS: Extradural hemorrhageSubdural hemorrhageSubarachnoid hemorrhageCAUSELower-energy trauma with less resultant primary brain injury causing rupture of middle meningeal artery, usually traumatic coup injury (rapid because it is usually from arteries) 10% of epidural bleeds may be venous, 70-80% of epidural hematomas (EDHs) are located in the temporoparietal regionHigh energy impacts with rupture of bridging veins (superior cerebral vein) slower onset than those of epidural hemorrhages because the lower pressure veins bleed more slowly than arteries , most often around the tops and sides of the frontal and parietal lobes, A subdural hematoma (SDH) is the most common type of intracranial mass lesionHead trauma > Rupture of berry s aneurysmIntracerebral hematomas and subarachnoid hemorrhages can also result from strokes.PEAK AGEYounger than 20 yearsBimodal age 60 and older,50 yearsHISTORYFollowing injury, the patient may or may not lose consciousnessSubdural hematomas are divided into acute, subacute, and chronic, depending on the speed of their onset.Risk factors:1. Shaken baby syndrome2. Blood thinners(anticoagulants)3. Long-term alcohol abuse4. Dementia5. Elderly6. AlcoholicsSubarachnoid hemorrhage (SAH) range from subtle prodromal events to the classic presentation. Prodromal events often are misdiagnosed, while the classic presentation is one of the most pathognomonic pictures in all of clinical medicine.SIGNS & SYMPTOMS* Hypertension* Bradycardia* Bradypnea* Severe headache* Vomiting* SiizuresEDH has a classic three-stage clinical presentation that is probably seen in only 20% of cases. The patient is initially unconscious from the concussive aspect of the head trauma.The patient then awakens and has a lucid interval while the hematoma subclinically expands. As the volume of the hematoma grows, the decompensated region of the pressure-volume curve is reached, ICP increases, and the patient becomes lethargic and herniates. Uncal herniation from an EDH classically causes ipsilateral third nerve palsy and contralateral hemiparesis.* Loss of consciousness* Instability* Seizures* Disorientation* Ataxia* Altered breathing pattern* Blurred vision* Persistent headache,* Fluctuating drowsiness,* Confusion* Memory changes* Paralysis on the side of the body opposite the hematoma* Speech or language impairment* Severe headache with a rapid onset ("thunderclap headache")* Confusion or a lowered level of consciousness* Seizures* Photophobia* Focal neurologic deficit (hemiparesis, aphasia, hemineglect, cranial nerve palsies memory loss)* Motor neurologic deficits* Subhyaloid retinal hemorrhage & papilledema*| Temperature (secondary to chemical meningitis)*| Blood pressure* Neck stiffness usually presents six hours after initial onsetof SAH,* Isolated dilation of a pupil and loss of the pupillary light reflex may reflect brain herniation as a result of rising intracranial pressure * Oculomotornerve abnormalities (affected eye looking downward and outward and inability to lift the eyelid on the same side) or palsy,* "sympathetic surge" i.e. overactivation of the sympathetic systemGRADINGNilBender grading systemWorld Federation ofNeurosurgeons (WFNS)classification:Group 1Normal mental function, no focal signsGradeGCSFocalneurologicaldeficitGroup 2Lethargic, focal neurologic signsGroup 3Stuporous,marked focal neurologic signs115Absent213-14Absent313-14PresentGroup 4Coma, sign of hibernation (pupilary dilation, decerebrate or decorticate posturing, respiratory arrest)47-12Present or absent5<7Present or absentFischer scale (CT scan appearance)Markwalder grading systemGradeAppearance of hemorrhageGroup 0No neurologic signs1None evidentGroup 1Headache, reflex2Less than 1 mm thick asymmetry3More than 1 mm thickGroup 2Altered mental status, bemiparesis4Diffuse or none with intraventricular hemorrhage or parenchymal extensionGroup 3Stupor but responsive, hemiplegia Group 4Coma, decerebrate or decorticate posturing CT SCANOn head CT the dot is bright, biconvex (lentiform), and has a well-defined border that usually respects cranial suture lines.On head CT scan, the clot is bright or mixed-density, crescent-shaped (lunate) with a concave surface away from the skull, may have a less distinct border, and does not cross the midline due to the presence of the falxsensitivity of 98% within the first 12 hours 8t 93% within 24 hoursIn general, blood localized to the basal cisterns, the sylvian fissure, or the intra-hemispheric fissure indicates rupture of a saccular aneurysm.Anterior communicating artery aneurysms often are associated with interhemispheric and intraventricular hemorrhages. Middle communicating artery and posterior communicating artery aneurysms are associated with intraparenchymal hemorrhagesEpidural hematoma (EDH) forms an extraaxial, smoothly marginated, lenticular, or biconvex homogenous densityWhile MRI is superior for demonstrating the size of an acute subdural hematoma (SDH) and its effect on the brain, noncontrast head CT is the primary means of making a diagnosis and suffice for immediate management purposesTREATMENTPatients who meet all of the following criteria may be managed conservatively: clot volume <30 cm3, maximum thickness < 1.5 cm, and GCS score >8.Open craniotomy for evacuation of the concealed clot and hemostasis is indicated for EDH which are not managed conservativelyOpen craniotomy for evacuation of acute SDH is indicated for any of the following: thickness > 1 cm, midline shift >5 mm, or GCS drop by two or more points from the time of injury to hospitalization. Nonoperatively managed hematomas may stabilize and eventually reabsorb, or evolve into chronic SDHsPrompt neurosurgery or radiologically guided interventions with medications and other treatments to help prevent recurrence of the bleeding and complications. Many aneurysms are treated by a less invasive procedure called "coiling", which is carried out by instrumentation through large blood vessels.MORTALITY15 and20%30% overall, 60 to 80% in acute SDHUp to half of all cases of S AH are fatal and 10-15% of casualties die before reaching a hospitalPOORPROGNOSIS* Advanced age* Intradural lesions* Temporal location* Increased hematoma volume* Rapid clinical progression* Pupillary abnormalities* Increased intracranial pressure* Lower Glasgow coma scale (GCS)* No lucid interval* Acute subdural hematomas* Glasgow coma scale <7* Age >80* Acute duration* hypodensity of SDH on CT scan