1. A busy night in casualty

2. Case 1  An 18yr old rugby player received a blow to the head during a tackle with brief loss of consciousness. He recovered but was substituted for a rest. Whilst sitting on the bench 5 minutes later he collapsed with sustained loss on consciousness. He is brought in by blue light ambulance.

3.  What are the possible causes?  What is the investigation of choice?  Why did he initially recover and then what happened?

4. Patient Normal scan

5. Middle meningeal artery is a branch of maxillary artery It enters the foraman spinosum to supply the bones of vault of skull Its branches cause grooves which can be seen on inside of skull It is vunerable to injury in fracture of temporal bone producing an extradural haematoma

7. Case 2  An elderly man fell at home. He was brought to A/E, assessed as minor head injury and allowed home. A few weeks later he was brought back with increasing confusion and some mild left sided weakness.

8.  What could cause a left sided weakness (hemiparesis) and why? What investigations would you request?

9. Patient Normal CT scan

10. Subdural haematoma  Blood accumulates in subdural space following rupture of vein  More common in elderly where cerebral atrophy can increase vunerability of bridging veins to tearing as cross subdural space  Symptoms often indolent and fluctuate  Does not have to show focal signs

12. Case 3  A 35 yr old business man was driving along the road when his female passenger says he developed a sudden pain in the back of his head and briefly lost consciousness. She fortunately guided the car to the side of the road without incident. He is brought to A/E drowsy having vomited in the ambulance.

13.  What are the possible diagnoses?  What investigations could you perform and do any of these carry any risks?

15. “circle of Willis”

16. Berry aneurysm

17. Subarachnoid haemorrhage  Account for 10% of cerebrovascular disease  Commonest cause is saccular “berry” aneurysm  Most common on “circle of Willis”  Blood clot in subarachnoid space can lead to obstruction of CSF flow and hydrocephalus  50% dead or moribund before reach hospital, further 10- 20% die in early weeks from further bleeding  Refer to neurosurgeons for surgery etc.

18. Case 4  An 25 yr old medical student is brought into A/E after celebrating the end of his exams with history from ambulance staff that he had been found vomiting, suffered a cut to his head when he fell over but was becoming more drowsy. Neurological examination revealed no focal abnormality and an emergency CT scan of his head is normal.

19.  How do assess drowsiness?  What are the possible causes of his illness?  What additional investigations might be needed?

20. Glasgow Coma scale

21. Causes of coma  Altered consciousness is produced by three types of process affecting the brain stem, reticular formation and the cerebral cortex Diffuse brain dysfunction Diffuse brain dysfunction Generalized metabolic or toxic (e.g. septicaemia) disordersGeneralized metabolic or toxic (e.g. septicaemia) disorders Direct effect on brain stem Direct effect on brain stem Indirect effect on brain stem Indirect effect on brain stem lesions above the tentorium cerebellilesions above the tentorium cerebelli

22. Diffuse brain dysfunction  Drug overdose, alcohol  CO poisoning  Anaesthetic gases  Hypo / Hyperglycaemia  Hypoxia  Renal failure  Hepatic failure  Hypo / hypernatraemia  Hypothermia  Cerebral malaria  Encephalopathy and so on and so on