Intraaxial contusions and hematomas

Contusions are areas of small hemorrhages surrounded by necrotic brain, usually at the gyral peaks in the frontal and temporal lobes where the brain is surrounded by uneven skull which it strikes during trauma. A hematoma is a mass of blood, free of intervening brain, which pushes the surrounding brain aside. Contusions may evolve and become larger, leading to increasing edema, necrosis, and extension of the contusion.

Small contusions may simply be observed, but large contusions, particularly those occurring in the temporal lobes, where a small mass can cause significant neurological deterioration, should have early surgery. If necessary, temporal or frontal lobectomies, including resection of up to 4 cm of the dominant temporal lobe or 6 cm of the non-dominant temporal lobe, may be performed. Contusions in eloquent brain may be observed and treated with aggressive management of increased intracranial pressure. Multiple contusions are treated in the same way. However, if one of these evolves and becomes a dominant intracranial mass, it may require removal. The majority of contusions can initially be treated non-surgically.

Post-traumatic intracerebral hematomas are uncommon. As with contusions, temporal hematomas are much more likely to cause neurological deficit than frontal or occipital hematomas. In a study of patients with intracerebral hematoma involving a single lobe, no patient with either frontal or parieto-occipital hematomas developed signs of transtentorial herniation, whereas 17 per cent with temporal lobe hematomas developed herniation syndrome. No patient with temporal hematomas less than 30 ml showed herniation findings, whereas 17 per cent of patients with hematomas larger than 30 ml had herniation findings ( Andrews et al. 1988).

The surgical treatment of hematomas is similar to that of contusions. We recommend that all patients with a Glasgow Coma Scale (GCS) score of 8 or less receive intracranial pressure monitoring. Hematomas are evacuated in patients who are deteriorating neurologically, have midline shifts greater than 1 cm, medication-resistant intracranial pressure elevations, and temporal hematomas greater than 30 ml.

Delayed traumatic intracerebral hematomas commonly occur within the first 48 to 72 h following injury. They usually occur in areas of brain with small or unseen trauma and/or hypoxia. Significant hypotension following trauma appears to be an important contributor to the formation of these hematomas. Indications for surgical treatment of delayed hematomas are similar to those for primary traumatic hematomas.

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