Cerebrovascular Cerebrovascular diseasedisease

&&StrokesStrokes

Dr. Osman Sadig BukhariDr. Osman Sadig Bukhari

Stroke isStroke is:: - - is za 3is za 3rdrd commonest cause of death commonest cause of death

- - 2/10002/1000//yearyear

- - male > femalesmale > females

- - uncommon uncommon before 40yearsbefore 40years except except withwith : :

- -traumatrauma

- - cardiac diseases e.g RHDcardiac diseases e.g RHD

- - congenital vascular abncongenital vascular abn

- - inflammatory arteritisinflammatory arteritis

- - vascular diseasevascular disease

- - SS anaemiaSS anaemia

Cerebral circulationCerebral circulation

Cerebral vascular diseases Cerebral vascular diseases comprisecomprise::

11 - -Thromboembolic infarction ( thrombosis Thromboembolic infarction ( thrombosis andand

embolismembolism((

22 - -Intracerebral haemorrhage (ICH)Intracerebral haemorrhage (ICH)

33 - -Subarachnoid haemorrhage (SAH)Subarachnoid haemorrhage (SAH)

44 - -Extradural hage & subdural haematomaExtradural hage & subdural haematoma

55 - -Cortical venous & dural venous sinus Cortical venous & dural venous sinus thrombthromb

Stroke Stroke is either due tois either due to::

11 - -Infarction (ischemic)Infarction (ischemic) (80-85%) (80-85%)

- - thrombosisthrombosis

- - embolismembolism

22 - -HaemorrhageHaemorrhage (15-20%) (15-20%)::

- - intracerebralintracerebral

- - subarachnoidsubarachnoid

Site of strokeSite of stroke - -internal capsule - brainsteminternal capsule - brainstem

- - cerebral cortex - basal gangliacerebral cortex - basal ganglia

- - cerebellumcerebellum

Mechanism of strokeMechanism of stroke::

11 - -Cerebral infarctionCerebral infarction (Ischemic) (Ischemic) - - thrombosis at za site of atheromathrombosis at za site of atheroma

- - embolism to a cerebral artery fromembolism to a cerebral artery from

- - extracranial vesselsextracranial vessels

- - heartheart

* * cerebral oedema may complicate cerebral oedema may complicate infarctioninfarction

and impair blood supply & cause and impair blood supply & cause furtherfurther

damagedamage

22 - -Cerebral haemorrhageCerebral haemorrhage

- -subarachnoid haemorrhagesubarachnoid haemorrhage

- - ruptured beri aneurysmruptured beri aneurysm

- - ruptured AVMruptured AVM

- - intracerebral haemorrhageintracerebral haemorrhage

- - rupture of perforating vessels rupture of perforating vessels weakenedweakened

by HT or atheromatous degenerationby HT or atheromatous degeneration

) ) micro aneurysm= 0.8-1.0 mmmicro aneurysm= 0.8-1.0 mm((

- - rupture of aneurysms or AVMrupture of aneurysms or AVM

* * SAH arterial spasm & cerebral infarctionSAH arterial spasm & cerebral infarction

* * ICH may extend to subarachnoid spaceICH may extend to subarachnoid space..

* * Disability from stroke depends on theDisability from stroke depends on the

site & extent of damagesite & extent of damage

* * Cerebellar hage can be fatal if there isCerebellar hage can be fatal if there is

compression of brain stemcompression of brain stem..

Clinical classification of strokeClinical classification of stroke 11 - -Completed strokeCompleted stroke

focal neurological episodes with symptofocal neurological episodes with sympto

lasting > 24hrslasting > 24hrs.. - - Major strokeMajor stroke

- - Minor stroke ( recovery in 1-2Ws)Minor stroke ( recovery in 1-2Ws)

22 - -Evolving strokeEvolving stroke symptoms worsening gradually or insymptoms worsening gradually or in

stepwise fashion over hrs or daysstepwise fashion over hrs or days ( ( DD= tumour, SDHDD= tumour, SDH))

33 - -Transient ischemic attackTransient ischemic attack (TIA) (TIA) symptoms lasting < 24hrssymptoms lasting < 24hrs..

Disorders causing strokeDisorders causing stroke comprisescomprises-:-:

11 - -Thromboembolic diseaseThromboembolic disease (infarction (infarction - - atherosclerosisatherosclerosis

- - arteriosclerosis (HT, degenerative)arteriosclerosis (HT, degenerative) - - embolism (20%)embolism (20%)

- - arteritis (syph, TA, PAN, SLE)arteritis (syph, TA, PAN, SLE) - - dissection (spontaneous, traumatic)dissection (spontaneous, traumatic) - - Vasospasm (migraine, SAH, angiogr)Vasospasm (migraine, SAH, angiogr)

- - hyper viscosity (PRV)hyper viscosity (PRV) - - anti phospholipid syndromeanti phospholipid syndrome

- - SS disease - hypotension - OCPsSS disease - hypotension - OCPs

22 - -HaemorrhageHaemorrhage - - intracerebral 50%intracerebral 50%

- - sub arachnoid 50%sub arachnoid 50%

- - AVMAVM

- - Beri aneurysmsBeri aneurysms

- - Degenerative aneurysmsDegenerative aneurysms

- - HT arteriolar aneurysmsHT arteriolar aneurysms

- - Mycotic aneurysmsMycotic aneurysms

- - Anticoagulants, thrombolytic therapyAnticoagulants, thrombolytic therapy

- - Bleeding disorders (ITP, DIC, haemopBleeding disorders (ITP, DIC, haemop

- - Alcohol, cocaine, amphetamineAlcohol, cocaine, amphetamine))

Risk factors for strokeRisk factors for stroke 11 - -Non modifiable factorsNon modifiable factors

- - age - genderage - gender - - race - hereditaryrace - hereditary

22 - -Modifiable factorsModifiable factors - - arterial HT - cardiac diseasesarterial HT - cardiac diseases

- - DM - cigarette smokingDM - cigarette smoking - - Hyperlipidaemia - ThrombocythemiaHyperlipidaemia - Thrombocythemia

- - polycythemia - Physical inactivitypolycythemia - Physical inactivity - - Obesity - OCPsObesity - OCPs

- - High alcohol intake - traumaHigh alcohol intake - trauma - - Peripheral vascular diseasePeripheral vascular disease

Transient ischemic attacks TIATransient ischemic attacks TIA DefinitionDefinition:: focal neurological symptoms focal neurological symptoms

( ( due to cerebral ischemiadue to cerebral ischemia ) )wz symptomswz symptoms lasting < 24hrslasting < 24hrs..

CausesCauses:: - - emboli or PL material from extracranialemboli or PL material from extracranial

arteriesarteries - - cardiac embolicardiac emboli

- - severe stenosis of a major arterysevere stenosis of a major artery+ + haemdynamic disturbance ( e.g V/basilarhaemdynamic disturbance ( e.g V/basilar - - small infarcts, hage, brainstem tumours small infarcts, hage, brainstem tumours

and SDH can cause TIA and SDH can cause TIA

Clinical featuresClinical features::

Carotid system Vertebrobasilar systCarotid system Vertebrobasilar syst - - amaurosis fugax - diplopia, vertigo, vomitingamaurosis fugax - diplopia, vertigo, vomiting

- - aphasia -dysphagia, dysarthriaaphasia -dysphagia, dysarthria

- - hemiparesis - facial numb & weaknesshemiparesis - facial numb & weakness

- - hemisensory loss - ataxia, nystagmushemisensory loss - ataxia, nystagmus

- - hemianopic visual - hemisensory losshemianopic visual - hemisensory loss

loss - hemianopic visualloss - hemianopic visual

lossloss

- - transient globaltransient global

amnesia & confusionamnesia & confusion

- - tetraparesis, coma, andtetraparesis, coma, and

cortical blindnesscortical blindness..

+ +

evidence ofevidence of

underlyingunderlying

diseasedisease

* * TIAs may herald completed stroke andTIAs may herald completed stroke and

25%25% of pts wz completed stroke recallof pts wz completed stroke recall

previous TIAprevious TIA

* * TIAs require to investigate za underlyingTIAs require to investigate za underlying

cause & prevent to reduce za completedcause & prevent to reduce za completed

strokestroke

* * 40%40% of pts wz TIAs suffer completedof pts wz TIAs suffer completed

stroke in 5 yearsstroke in 5 years..

* * 25%25% of pts wz TIAs die from stroke orof pts wz TIAs die from stroke or

coronary heart diseasecoronary heart disease..

* * management of TIAsmanagement of TIAs

- - identify risk factors & correctidentify risk factors & correct

- - antiplatelets reduce za risk of strokeantiplatelets reduce za risk of stroke

by 25%by 25%..

- - anticoagulants for definite cardiacanticoagulants for definite cardiac

source of thromboembolismsource of thromboembolism..

- - carotid endarterectomy reduce za riskcarotid endarterectomy reduce za risk

of stroke by 75%of stroke by 75%..

Clinical features of strokeClinical features of stroke Depends on za site & extentDepends on za site & extent

11 - -Acute focal neurological deficitAcute focal neurological deficit:: - - Hemiparesis +/- dysphasia is theHemiparesis +/- dysphasia is the

commonest presentation. Weakness 1commonest presentation. Weakness 1stst

and recovery takes place over days, Wsand recovery takes place over days, Ws or monthsor months..

- - Hypotonia, depressed reflexes andHypotonia, depressed reflexes and extensor reflex occur initially, followedextensor reflex occur initially, followed

later by hypertonia & hyper reflexialater by hypertonia & hyper reflexia.. - - Monoparesis or dysphasia occur wz corticalMonoparesis or dysphasia occur wz cortical

lesionslesions - - Hemianaethesia & visual fields defectsHemianaethesia & visual fields defects

- - With brain stem lesions C/f depends onWith brain stem lesions C/f depends on the structures involved and leads tothe structures involved and leads to

coma due to damage to reticularcoma due to damage to reticular activating system. The cardinal featureactivating system. The cardinal feature

is ipsilateral nuclear signs andis ipsilateral nuclear signs and contralateral signs of pyramidal & S/Tcontralateral signs of pyramidal & S/T

tract lesions signs (tract lesions signs (crossedcrossed)).. - - With severe strokes flaccid paralysis isWith severe strokes flaccid paralysis is accompanied by HA, vomiting, seizuresaccompanied by HA, vomiting, seizures

gaze paresis, impaired consciousnessgaze paresis, impaired consciousness -/+ -/+ papilloedema 2ndry to cerebralpapilloedema 2ndry to cerebral

oedemaoedema - - Ataxia & hemisensory loss occur with deeplyAtaxia & hemisensory loss occur with deeply

seated lacunar infarctsseated lacunar infarcts..

22 - -DementiaDementia:: gradual decline in intellectual fn, spgradual decline in intellectual fn, sp in ischemic strokes, with or withoutin ischemic strokes, with or without

sensorimotor limb deficit or gait disordsensorimotor limb deficit or gait disord

33 - -SAHSAH:: - -HA. Neck stiffness & vomitingHA. Neck stiffness & vomiting

- - with or without focal neurological defiwith or without focal neurological defi

44 - -Diseases of cerebral circulationDiseases of cerebral circulation ** ** General med ex wz PR & rhythm, BPGeneral med ex wz PR & rhythm, BP,,

peripheral vessels, carotid bruits, heartperipheral vessels, carotid bruits, heart ex & complete neurological ex leads toex & complete neurological ex leads to

correct diagnosiscorrect diagnosis..

Differential diag of acute strokeDifferential diag of acute stroke 11 - -cerebral tumourscerebral tumours

22 - -subdural haematomasubdural haematoma

33 - -cerebral abscess, cystscerebral abscess, cysts

44 - -Todd's paralysisTodd's paralysis

55 - -demyelinating disordersdemyelinating disorders

66 - -hypoglycemiahypoglycemia

77 - -encephalitisencephalitis

88 - -hysterical conversionhysterical conversion

Investigation of strokeInvestigation of stroke 11 - -Investigations to confirm the diagnosisInvestigations to confirm the diagnosis

? ( ? ( Ischemic, ? HagicIschemic, ? Hagic =) =)CT brain, MRICT brain, MRI,,

and L punctureand L puncture..

22--Investigations to establish za underlyingInvestigations to establish za underlying

diseasedisease= ECG, Echo, CXR, MRA, Doppler US= ECG, Echo, CXR, MRA, Doppler US,,

carotid angiographycarotid angiography..

33 - -Investigations to identify risk factorsInvestigations to identify risk factors==

CBC, blood sugar, lipid profile, serologyCBC, blood sugar, lipid profile, serology

for syphilis, clotting studies, serology forfor syphilis, clotting studies, serology for

collagen diseases, blood cultures forcollagen diseases, blood cultures for

SBE is suspected, sickling test, tests forSBE is suspected, sickling test, tests for

thrombophilia (protein C & S, anti thrombin 3thrombophilia (protein C & S, anti thrombin 3

Management of strokeManagement of stroke The aim isThe aim is-:-:

11 - -To minimize brain damageTo minimize brain damage 22 - -To reduce disability through rehabilitatiTo reduce disability through rehabilitati

33 - -Tom prevent complicationsTom prevent complications 44 - -To treat za underlying causeTo treat za underlying cause..

55--To prevent za recurrence of strokeTo prevent za recurrence of stroke 66 - -To refer pts wz SAH to neurosurgeryTo refer pts wz SAH to neurosurgery..

** ** To admit or not depends on za clinicalTo admit or not depends on za clinical state & facilities at home ( TIAs & minstate & facilities at home ( TIAs & min

stroke at homestroke at home))

** ** General measuresGeneral measures:: - - ABCABC

- - nursing carenursing care - - fluid balance & nutritionfluid balance & nutrition

- - urinary cath if not continenturinary cath if not continent - - physiotherapy, occupational, speechphysiotherapy, occupational, speech

and psychotherapyand psychotherapy ** ** Specific therapySpecific therapy::

11 - -Med treatmentMed treatment - - anti hypertensivesanti hypertensives not given at the not given at the

start unless very high (> 180/110)start unless very high (> 180/110) as some pts show reactive increase in BPas some pts show reactive increase in BP..

It is gradually lowered after za 1It is gradually lowered after za 1stst week week

- - Anti plateletsAnti platelets reduce za incidence of reduce za incidence of stroke by 25% e.g. aspirin 75-300mgstroke by 25% e.g. aspirin 75-300mg

dipyridamol 75 tds, clopidogreldipyridamol 75 tds, clopidogrel - - Anti coagulants only if there is aAnti coagulants only if there is a

source of emboli & avoided in za 1source of emboli & avoided in za 1stst

2Ws following infarction. It may be2Ws following infarction. It may be used in evolving stroke, but C/I inused in evolving stroke, but C/I in

intra cranial hage & cerebral tumoursintra cranial hage & cerebral tumours which should be rouled out by CTwhich should be rouled out by CT

- - ThrombolysisThrombolysis (tpA) in USA given (tpA) in USA given within 3hrswithin 3hrs..

- - Manitol 200ml 20% & dexamethazoneManitol 200ml 20% & dexamethazone reduce mortality in pts with brain oedemareduce mortality in pts with brain oedema

2ndry to severe stroke2ndry to severe stroke.. - - BaclofeBaclofen (GABA antagonist) for spasticityn (GABA antagonist) for spasticity

22 - -Surgical treatmentSurgical treatment

- - carotid endarterectomycarotid endarterectomy in TIAs and in TIAs and

minor stroke when stenosis is > 70%minor stroke when stenosis is > 70%

reduce incidence of stroke by 75%reduce incidence of stroke by 75%..

Avoided over 65 yearsAvoided over 65 years..

- - surgical evacuation of haematomasurgical evacuation of haematoma if if

accessible & if pat continue to accessible & if pat continue to deteriorate e.g cerebellar hage to deteriorate e.g cerebellar hage to

prevent brainstem compressionprevent brainstem compression . .

33-- RehabilitationRehabilitation

- - identify risk factors & treatidentify risk factors & treat

- - TR 2ndry depressionTR 2ndry depression

PrognosisPrognosis - - 25%25% die as a direct result of strokedie as a direct result of stroke..

More in hagic strokeMore in hagic stroke..

- - 50-75%50-75% who survive stroke achieve fnalwho survive stroke achieve fnal

independency in 3Msindependency in 3Ms

- - poor outcome in pts wz deep coma andpoor outcome in pts wz deep coma and

dense hemiplegiadense hemiplegia

- - recurrent stroke in5-10%/ yearrecurrent stroke in5-10%/ year

- - patient may die of cardiovascular dispatient may die of cardiovascular dis..

Complications of acute strokeComplications of acute stroke - -pneumonia - dehydrationpneumonia - dehydration

- - hyponatraemia - hypoxaemiahyponatraemia - hypoxaemia

- - hypoglycemia - DVThypoglycemia - DVT

- - seizures - subluxation of jointsseizures - subluxation of joints

- - frozen shoulder - pressure soresfrozen shoulder - pressure sores

- - UTI - constipationUTI - constipation

Lateral medullary syndromeLateral medullary syndrome - - due to occlusion of PICA or vertebral artdue to occlusion of PICA or vertebral art..

- - there is ipsilateral ataxia, nystagmusthere is ipsilateral ataxia, nystagmus,,

facial numbness, palatal palsy, diplopiafacial numbness, palatal palsy, diplopia

( ( 66thth CN CN & ) & )HornersHorners

- - contralateral S/T signs. Hemiparesis rarecontralateral S/T signs. Hemiparesis rare

- - often vertigooften vertigo..

Weber syndromeWeber syndrome - - ipsilateral 3ipsilateral 3rdrd cranial N palsy cranial N palsy

- - contralateral pyramidalcontralateral pyramidal

Pontine hagePontine hage - - impaired consciousnessimpaired consciousness

- - hyperpyrexiahyperpyrexia - - pinpoint pupilspinpoint pupils

- - paresisparesis

Visual cortical infarctsVisual cortical infarcts - - cortical blindnesscortical blindness

- - hemianopiahemianopia

Lacunar infarctsLacunar infarcts< - < - 1.51.5 cmcm

- - commonly HTcommonly HT - - pure motor, sensory or cerebellarpure motor, sensory or cerebellar

Multi infarct dementiaMulti infarct dementia - - stepwise gradual intellectual lossstepwise gradual intellectual loss

- - pseudobulbar palsypseudobulbar palsy - - Parkinsonian gaitParkinsonian gait..

Water shed infarctsWater shed infarcts - - multiple infarcts at border zones betweemultiple infarcts at border zones betwee

areas supplied by cerebral arteriesareas supplied by cerebral arteries following prolonged periods of cerebralfollowing prolonged periods of cerebral

ischemiaischemia - - cortical blindnesscortical blindness

- - amnesiaamnesia - - intellectual impairmentintellectual impairment..

Cerebellar hageCerebellar hage - - headache is severe & occipitalheadache is severe & occipital

- - brainstem symptoms may occur e.gbrainstem symptoms may occur e.g

diplopia, vertigo wz rapid deterioration ofdiplopia, vertigo wz rapid deterioration of

conswciousnessconswciousness

- - may cause acute hydrocephalusmay cause acute hydrocephalus

- - immediate surgical evacuation of haematimmediate surgical evacuation of haemat

Subarachnoid hage (SAH)Subarachnoid hage (SAH) - - 10%10% of strokesof strokes

- - CausesCauses:: - - Berry aneurysm 70%Berry aneurysm 70%

- - AVM 10%AVM 10% - - rare causesrare causes

- - extension of I/C hage - anticoagulextension of I/C hage - anticoagul - - rupture of atheromatous vesselrupture of atheromatous vessel

- - bleeding disorders - brain tumoubleeding disorders - brain tumou - - acute bact meningitis - arteritis SLEacute bact meningitis - arteritis SLE

- - spinal AVM - co arcitation of Aospinal AVM - co arcitation of Ao - - APKD - Marfan’sAPKD - Marfan’s

Berry aneurysmBerry aneurysm:: - - post & ant communicating arteriespost & ant communicating arteries

- - middle cerebral artmiddle cerebral art - - basilar, PICA, retinal & intra cavernousbasilar, PICA, retinal & intra cavernous

carotid artcarotid art - - bleedsbleeds

- - pressure on surrounding structures e.gpressure on surrounding structures e.g . . 33rdrd CN CN AVMAVM::

- -developmental anomaly within za braindevelopmental anomaly within za brain - - SAHSAH

- - focal neurological deficits & epilepsyfocal neurological deficits & epilepsy..

Clinical featuresClinical features:: - - occurs during exertion high Bpoccurs during exertion high Bp

- - sudden severe occipital headachesudden severe occipital headache - - neck stiffness & +ve Kerning signneck stiffness & +ve Kerning sign

- - fever & vomitingfever & vomiting - - photophobia & irritabilityphotophobia & irritability

- - consciousness may be lost & seizuresconsciousness may be lost & seizures may developmay develop

- - sub hyaloid hage & papilloededemasub hyaloid hage & papilloededema - - focal neurological signs (ischemia fromfocal neurological signs (ischemia from

arterial spasm & bleeding into brainarterial spasm & bleeding into brain - - CT diagnosticCT diagnostic

- - LP if CT is –ve (hagic)LP if CT is –ve (hagic) - - look for bruits over head & eyeslook for bruits over head & eyes

- - DD= meningitis, migraine, meningism, C malarDD= meningitis, migraine, meningism, C malar

ComplicationsComplications:: - - hydrocephalus due to obstruction ofhydrocephalus due to obstruction of

subarachnoid space by clotssubarachnoid space by clots.. - - intra cranial arterial spasm & neurological intra cranial arterial spasm & neurological

deficitsdeficits ManagementManagement::

- - Immediate : bed rest, control of HTImmediate : bed rest, control of HT,, dexamethazone if brain oedemadexamethazone if brain oedema

- - Specific: refer to neurosurgical unit asSpecific: refer to neurosurgical unit as soon as diag is proven.? Angiographysoon as diag is proven.? Angiography,,

clipping of za neck of aneurysmclipping of za neck of aneurysm micro embolization, focal R/T & surgery micro embolization, focal R/T & surgery

for AVMfor AVM

PrognosisPrognosis::

- - 50%50% early mortalityearly mortality

- - 10-20%10-20% die from rebleeding within 2Wsdie from rebleeding within 2Ws

- - comatosed pts & those wz severecomatosed pts & those wz severe

neurological deficit carry bad prognosisneurological deficit carry bad prognosis . .

Cerebral venous thrombosisCerebral venous thrombosis - - UncommonUncommon

- - Causes patchy hagic ischemia & ICPCauses patchy hagic ischemia & ICP

- - predisposing factorspredisposing factors

- - dehydration - hypotensiondehydration - hypotension

- - polythycemia - pregnancypolythycemia - pregnancy

- - Anti phospholipid syndrome - OCPAnti phospholipid syndrome - OCP

- - Severe intercurrent infectionSevere intercurrent infection

- - Para nasal sinusitis - Facial skin infectionPara nasal sinusitis - Facial skin infection

- - Otitis media - mastoiditisOtitis media - mastoiditis

- - meningitis -Subdural embyemameningitis -Subdural embyema

- - Fracture skull - penetrating head inuryFracture skull - penetrating head inury

11 - -Cortical venous thrombosisCortical venous thrombosis

- - feverfever

- - focal cerebral dysfunctionfocal cerebral dysfunction::

- - epilepsy - hemiparesisepilepsy - hemiparesis

- - dysarthriadysarthria

22 - -Cerebral venous sinus thrombosisCerebral venous sinus thrombosis

Depends on za sinus involvedDepends on za sinus involved

a- cavernous sinus: Often bilaterala- cavernous sinus: Often bilateral

- - pt very ill, headache, ptosispt very ill, headache, ptosis,,

proptosis, ophthalmoplegia, feverproptosis, ophthalmoplegia, fever

papilloedema, sensation ophth Vpapilloedema, sensation ophth V

b- Superior sagittal sinusb- Superior sagittal sinus::

headache, seizures, papilloedemaheadache, seizures, papilloedema,,

-/+ -/+ advancing motor & sensory defadvancing motor & sensory def

c- Transverse sinusc- Transverse sinus::

hemiparesis, seizures, & papilloedemhemiparesis, seizures, & papilloedem

spreading to jugular foramenspreading to jugular foramen

X1, X, X11 palsiesX1, X, X11 palsies..

InvestigationsInvestigations

- - CT, MRA to detect occluded v or sinusCT, MRA to detect occluded v or sinus

- - CSF under pressureCSF under pressure

TreatmentTreatment

- - broad spectrum antibioticsbroad spectrum antibiotics

- - drain infected site ( sinus, middle ear)drain infected site ( sinus, middle ear)

- - dexamethazone for brain oedemadexamethazone for brain oedema

- - anticoagulants early on may limit theanticoagulants early on may limit the

spread of thrombosisspread of thrombosis..

Chronic subdural haematoma (SDH)Chronic subdural haematoma (SDH) - - affects elderly & alcoholics even withaffects elderly & alcoholics even with

minor head traumaminor head trauma

- - fluctuating headache, drowsiness andfluctuating headache, drowsiness and

confusionconfusion

- - focal signs: hemiparesis, hemisensoryfocal signs: hemiparesis, hemisensory

lossloss

- - seizures, papilloedma, stupor & comaseizures, papilloedma, stupor & coma

- - fatal if untreatedfatal if untreated

- -conservative TR hoping that spontaneousconservative TR hoping that spontaneous

stopping of bleeding, otherwise burr holestopping of bleeding, otherwise burr hole..

Extradural hageExtradural hage - - due to tearing of middle meningeal artdue to tearing of middle meningeal art

following linear skull vault fracturefollowing linear skull vault fracture.. - - brief loss of consciousness (concussion)brief loss of consciousness (concussion)

followed by lucid interval of recoveryfollowed by lucid interval of recovery - - with progressive hemiparesis, stupor andwith progressive hemiparesis, stupor and

rapid transtentorial coning with ipsilatrapid transtentorial coning with ipsilat dilated pupil followed by dilatation ofdilated pupil followed by dilatation of of za other, quadriparesis & death ifof za other, quadriparesis & death if

untreateduntreated.. - - prompt CT & MRI if suspected & urgentprompt CT & MRI if suspected & urgent

neurosurgeryneurosurgery . .