POST-TRAUMATIC INTRACRANIAL SPACE-OCCUPYING LESIONS* · POST-TRAUMATIC INTRACRANIAL SPACE-OCCUPYING LESIONS* By LESLIE C. OLIVER, M.B., B.S. (Lond.,) F.R.C.S., F.A.C.S. Neurosurgeon,

524

POST-TRAUMATIC INTRACRANIALSPACE-OCCUPYING LESIONS*By LESLIE C. OLIVER, M.B., B.S. (Lond.,) F.R.C.S., F.A.C.S.

Neurosurgeon, West London Hospital, Royal Northern Hospital, West End Hospital for Neurology and Neurosurgery,London; Senior Neurosurgeon, Neurosurgical Centre, Oldchurch Hospital, Romford

Extradural Haematoma (syn. middlemeningeal haemorrhage)The haemorrhage may originate from the

middle meningeal vessels, the venous sinuses, orfrom diploic veins. It is usually, but not always,associated with a fracture of the skull or diastasis(separation of sutures). There is nearly always avisible scalp lesion overlying an extradural haema-toma. The classical syndrome is as follows:After an initial improvement, and usually within24 hours, the level of consciousness declines; thepulse rate increases; then it may fall belownormal; and finally it becomes fast and weak.The classical slow pulse, although of considerablediagnostic importance, is found less often than afast one. Occasionally in the early stages ofbleeding the homolateral pupil is constricted. Inthe late stages of compression, whether initiallyconstricted or not, the pupil dilates and the directand consensual light reflexes are lost. The termHutchinson's pupil is applied to these phenomena.By the time dilatation of the pupil has occurredthere is an advanced degree of compression.Therefore, the diagnosis should be made before thissign appears. Sometimes when the patient regainsconsciousness after operation dilatation of thepupil is found to be accompanied by ptosis andparalysis of the external ocular muscles suppliedby the oculomotor nerve. The complete oculo-motor palsy is caused by pressure on the nerveby herniation of the medial border of the tem-poral lobe between the tentorium cerebelli andthe brain stem. Bilateral dilatation of the pupilsis a sign of imminent death. Unilateral or bilateralabducens palsy may result from raised intracranialpressure.

Pyramidal signs may be found on the oppositeside to the haematoma or sometimes on the sameside. Homolateral pyramidal signs are caused bydisplacement of the brain stem away from the

* Based on a postgraduate lecture given at the WestEnd Hospital for Neurology and Neurosurgery onDecember Io, I957.

side of the haematoma and consequent indentationof the contralateral cerebral peduncle by the edgeof the tentorium. (The pyramidal fibres of theindented peduncle cross below in the decussationof the pyramids to the same side as the lesion.)Thus pyramidal signs are unreliable for lateralizinga haematoma. If signs of an extradural haematomaare delayed for a few days some papilloedema maybe found.

Only about half the patients with extraduralhaemorrhage develop the classical syndrome de-scribed above. Thus in many cases there is norecovery of consciousness before the onset ofcerebral compression; on the other hand, inchildhood, an initial period of coma seldom occurs;more often children are momentarily dazed andlater become drowsy and finally comatose. Theysometimes have convulsions. Also, wide separa-tion of the edges of the fracture or sutures,together with the thin elastic scalp, sometimesallows much of the blood to escape under thepericranium or galea to form a large externalhaematoma. Thus partial spontaneous decom-pression may occur. In infants, blood lost in theformation of an extradural haematoma may causesevere anaemia and profound shock.About a third of all extradural haematomas

occur other than at the classical temporal site.The location of extradural haematomas is oftenrevealed by bruising of the scalp, the position oJthe fracture and neurological signs.Posterior Fossa Extradural HaematomasThese are likely to be missed because of their

rarity. They are caused by lacerations of thetransverse or sigmoid sinuses. In the acute form,occurring within 24 hours of the injury, signs ofcompression of the medulla oblongata (repeatedvomiting, slow pulse, rising blood pressure andslowing of respiration) tend to occur without anyprevious recovery of consciousness and thereforewithout cerebellar signs. A fracture across thegroove of the transverse or sigmoid sinus may be

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October 1958 OLIVER: Post-Traumatic Intracranial Space-Occupying Lesions 525

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FIG. i.-Incision for an extradural haematoma at the classical site in the temporal region.The diagnosis had first been confirmed by means of a burr-hole made through thesmall incision above the ear.

the only indication of a haematoma in the posteriorfossa. The acute type of posterior fossa haema-toma tends to be associated with severe braindamage; hence the mortality is high. The sub-acute form shows itself several days after injury.Manifestations of medullary failure (vide supra)follow a period of improvement in the state ofconsciousness and, in conscious patients, cerebellarsigns may be found. The chronic form showsitself some months after injury and is usuallymistaken for a posterior fossa tumour. Persistentheadache, vomiting, papilloedema and cerebellarsigns occur. Ventriculography shows hydro-cephalus, displacement of the fourth ventricleaway from the side of the lesion and forwardkinking of the aqueduct.The mortality of extradural haemorrhage is

still 50 per cent.! This deplorable state of affairsis mostly due to lack of recognition of its rapidlylethal nature. Any decline in level of consciousnessor development of new neurological signs shouldlead to immediate action. If a patient in traumaticcoma does not rapidly improve a neurosurgeonshould be consulted without delay. Lumbar punc-ture contributes nothing to the diagnosis and maykill the patient by causing a temporal or cerebellarpressure cone, and furthermore the lumbarcerebrospinal fluid pressure is often raised in headinjuries when there is no space-occupying lesion,and conversely, as the result of cerebellar coning,

the pressure may be normal or even subnormal inthe presence of a large haematoma.

OperationExtradural haemorrhage is one of the most

rapidly lethal conditions in surgery. Mere sus-picion of it should lead to diagnostic burr-holeswithout delay. Opiates and barbiturates are for-bidden, for the former depress the alreadythreatened or affected vital centres, and the latterdepress still more the level of consciousness.Many patients are too restless for local anaes-thesia alone. Sometimes coma is so deep that noanaesthetic of any kind is required.A burr-hole is made over the suspected site of

the haematoma (the precise measurements givenin some textbooks of surgery have no value).When the diagnosis is correct blood is seen assoon as the inner table of the skull is perforated.As much of the haematoma as possible is removedby suction and the extent of the dural strippingascertained with the aid of a malleable probe.A bone flap is then planned accordingly (Fig. i).Bleeding from the middle meningeal vessels iscontrolled by electrocoagulation, silk sutures,metal clips or occasionally by plugging theforamen spinosum with the pointed end cut froma sharpened match stick. When metal clips areused, a small incision is made in the dura parallelto the vessel so that the clips can be applied.

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POSTGRADUATE MEDICAL JOURNAL

Bleeding from dural sinuses or veins is arrestedby application of muscle ' stamps' or gelatin spongetogether with elevation of the patient's head.Bleeding from bone is controlled with bonewax.When an extradural haematoma is not revealed

by the first burr-hole, the dura mater is opened.If an acute subdural haemorrhage is found asmall rubber catheter is passed beneath the duramater and the blood aspirated. Some of it mayhave to be washed out with normal saline injectedthrough the catheter. If neither an extraduralnor a subdural haematoma is found, but thebrain is bulging, a small stab is made in anavascular part of the exposed cortex with a pointedtenotome, and a fine brain cannula passed into it.An intracerebral clot may thus be discovered.After elevation of a bone flap, the surface of thebrain is incised in a relatively silent area and theclot evacuated by means of low-pressure suction.

If the first burr-hole reveals no evidence of anextradural, subdural or intracerebral haematoma,burr-holes are made at other sites on the sameside. Thus if the first burr-hole was made in thetemporal region, others are made in the frontal andparietal regions. Failure to find a haematoma onone side should always lead to burr-holes on theother side. When there is occipital bruising anda fracture overlying the transverse or sigmoidsinuses there is the possibility of an extraduralhaematoma in the posterior fossa; burr-holesshould therefore be made in this region. Theexposure can be extended by lengthening theburr-hole incision and removal of bone withrongeurs. In this way the site of the haemorrhage-usually a lacerated transverse or sigmoid sinus-can be exposed.The Pseudohaematoma Syndrome

Diagnostic burr-holes are often made in casesin which there is a classical syndrome of extra-dural haematoma, but no haematoma is dis-covered. Some patients recover spontaneously,but many die. At autopsy one or more of thefollowing lesions may be found: (a) Severe lacera-tion and contusion of the cerebral hemispheres,(b) cerebral oedema, or (c) haemorrhage in thebrain stem. The cause of the initial improvementin these patients is obscure. Cerebral oedemarevealed by burr-holes should be treated bydehydration therapy.Subdural HaematomaThere are two types of haematoma occurring

between the dura and arachnoid, acute andchronic. An acute subdural haematoma is fre-quently found in severe head injuries. Thecollection of blood is usually small and is asso-ciated with other more serious lesions, e.g. lacera-

tion or contusion. In these circumstances itcontributes little or nothing to the clinical picture,but if discovered when exploratory burr-holes aremade, the blood should nevertheless be removed.Rarely a large subdural haematoma arises fromtorn meningeal vessels which have bled under thedura mater instead of over its outer surface, or asubdural haematoma of considerable size may becaused by spontaneous haemorrhage from anintracranial aneurysm. In both cases the blood isaspirated through a rubber catheter passed intothe subdural space through a burr-hole, and thecausal lesion appropriately treated.A chronic subdural haematoma may reveal itself

a few weeks, months or even years after a minorhead injury, although not infrequently there is nohistory of injury. The cause is thought to betearing of veins passing between the cerebralcortex and the venous sinuses. The haematomabecomes surrounded by a capsule. In adults,chronic subdural haematoma is sometimes bi-lateral, whereas in early childhood it is almostalways bilateral. The diagnosis is made when apatient develops evidence of raised intracranialpressure, and sometimes also lateralizing signs, afew weeks after a head injury. Occasionally thecourse is fulminating or there may be merely avague mental disturbance reminiscent of thedementia caused by a frontal tumour. In fact,intracranial tumour is the most likely diagnosiswhen there is no history of head injury. Whenthe lesion has been overlooked the capsule tendsto be thick, and indeed the haematoma maybecome completely organized into a fibrous masswith patches of calcification.

In early childhood, birth trauma is held to bea major factor in the aetiology. A history of othertypes of head injury is more often lacking inchildren than in adults and there is no charac-teristic clinical picture in the majority of cases.Thus infants may show nothing more than rest-lessness and bad temper, or there may be general-ized convulsions (the commonest symptom of thelesion in early life), and vomiting. There ispyrexia in more than half the cases and bulgingof the fontanelle in somewhat less than half.The circumference of the head may be two orthree inches more than average. Retinal haemor-rhages are quite common, but papilloedema is rare.The tendon reflexes may be exaggerated, butparesis of limbs is found in only a small proportionof cases. The manifestations in early life are thusvague and therefore subdural haematoma shouldbe one of the conditions considered when a childis not thriving.Investigations

Plain radiography usually gives no evidence of

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October I958 OLIVER: Post-Traumatic Intracranial Space-Occupying Lesions 527a chronic subdural haematoma, although in long-standing haematomas in children there may beenlargement of the calvarium on the affected sidein unilateral cases, and also elevation of the lesserwing of the sphenoid (as seen through the orbitin an antero-posterior view of the skull). Theremay also be separation of the cranial sutures(diastasis). Occasionally calcification of thehaematoma is shown radiologically. Electro-encephalography shows electrical 'silence' or lowpotentials over the haematoma. When the diag-nosis of subdural haematoma is made the appro-priate investigation is exploration by means ofburr-holes. In doubtful cases carotid angiographyis sometimes carried out. In the presence of ahaematoma the vascular tree is seen to be dis-placed to the opposite side. A frontal haematomacauses displacement of the corresponding anteriorcerebral artery towards the opposite side, anddownward deflection of the middle cerebral arteryand its branches. In some cases angiographyreveals no abnormality. Ventriculography is notperformed deliberately when a subdural haema-toma has been diagnosed, but it may reveal thepresence of one when the investigation is carriedout for a suspected intracranial tumour.

TreatmentA chronic subdural haematoma is usually

drained through burr-holes. The dura mater isopened and the outer membrane of the haematomais punctured (the surgeon is careful not to mistakea large cortical vein for a haematoma). A rubbercatheter is passed into the haematoma. If thealtered blood is in the fluid state much of it willflow out. The remainder is evacuated by salineirrigation through the catheter. Burr-holes arethen made on the opposite side, for subduralhaematomas are frequently bilateral. Furtherirrigation of the cavity may be required in a fewdays if the patient's condition does not improve,or deteriorates. If the haematoma is composedof clotted blood it is necessary to elevate a boneflap to remove it.

In children, especially during infancy, themanagement is different, for sudden evacuation oflarge subdural haematomas has a high mortality.Treatment begins with aspiration of not morethan io ml. of blood daily on alternate sides.(N.B.-Subdural haematomas are bilateral inchildren in the majority of cases.) Aspirationsare carried out through the coronal sutures at adifferent point each day and well away from themidline. After about a week when the patient'scondition is sufficiently improved, burr-holes aremade to see whether or not a membrane hasformed. It is particularly important in childrento remove all the membrane of subdural haema-

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FIG. 2.-A giant left subdural hydroma, in a child of7 years, demonstrated by partial replacement of thefluid with air. Note also enlargement of the skullon the side of the hydroma. Despite this change,symptoms had been present for only ten weeks;they were pain on the left side of the head, attacksof vomiting, drowsiness and double vision.

tomas to prevent cortical atrophy. Removal iscarried out after elevation of a large osteoplasticflap. It is of the utmost importance immediatelyto replace all blood lost during operation. Afteroperation, repeated aspiration of the subduralspace is often necessary. During the early yearsof life, when the brain is growing rapidly, it isvitally important to avoid missing a subduralhaematoma which, if untreated, causes markeddementia.

Subdural Hygroma (syn. subdural hydroma)Subdural collections of clear or yellow fluid of

high protein content may occur, with or withouta history of head injury (Fig. 2). They causeincreased intracranial pressure. Some cases followmeningitis, especially that caused by H. influenzae.The traumatic hydromas are assumed to followtears in the arachnoid. Hygromas, whether trau-matic or inflammatory, are frequently bilateral.Treatment is the same as for subdural haematomas,including removal of any capsule which mayhave formed.

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528 POSTGRADUATE MEDICAL JOURNAL October 1958

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FIG. 3.-This boy, aged I8 months, had had thepointed end of a pencil driven through the medialend of the right upper lid and the roof of theorbit. In three weeks a right frontal abscessdeveloped. It was successfully treated by theaspiration method.

Cerebral AbscessWhen fractures of the skull are open to the

exterior or into the nasal air sinuses or middleear, and when the membranes of the brain arepenetrated, there is a strong tendency to intra-cranial infection. A brain abscess is almost cer-tain to form if fragments of bone, hair, or otherforeign material remains in the brain; the presenceof a missile is much less likely to cause an abscess.Therefore only the most easily accessible missilesshould be removed. There is no justification forinflicting further damage on the brain in order toremove a missile which may never cause suppura-tion. Small penetrating wounds produced byother means are dangerous, for they are apt to beignored as a possible source of intracranial com-plications (Fig. 3).An abscess of the brain behaves like a tumour,

giving rise to increased intracranial pressure andsometimes localizing signs. Thus there are drowsi-ness, headache, vomiting and often, though notalways, a mild or moderate degree of papilloedema.

Any abnormal neurological signs are dependenton the site of the abscess.

InvestigationsLumbar puncture is avoided for the reasons

given under 'Extradural Haematoma,' but if doneinadvertently the c.s.f. obtained is usually clearalthough there is a moderate increase in thewhite cells. There should be no organisms inthe fluid either on direct examination or afterculture. When there is doubt about the presenceor location of an abscess, ventriculography and/orcarotid angiography should be done.

Electroencephalography is likely to show slowwaves of marked amplitude and phase-reversal inthe region of a supratentorial abscess. When abrain abscess has been localized its extent can bedemonstrated by positive contrast radiography.Diodone (Pyelosil), 2-3 ml., is injected into theabscess cavity after some of the pus has beenaspirated. The skull is then X-rayed. Someneurosurgeons use Thorotrast (thorium dioxide),for it has the advantage of remaining in situ andthus the progress of the abscess can be followedby radiography. But there is experimental evi-dence to show that Thorotrast, acting as a foreignbody, stimulates gliosis. Therefore if resolutionof an abscess is desired after aspiration, therapidly absorbable contrast medium, diodone,should be employed. Furthermore, it is a violationof surgical principles to leave an unabsorbableforeign body in a septic place.Methods of Treatment

Aspiration. A burr-hole is made over the siteof the abscess. A small incision, a few milli-metres long, is made in the dura mater with around-ended tenotome. An avascular point on thesurface of the brain is punctured with a pointedtenotome, and a blunt-ended brain needle ispassed into the abscess cavity. The pus is aspiratedand replaced by 2-3 ml. penicillin solution(ioo,ooo units per ml.); only a small volume offluid is injected to avoid rupture of the capsulewhich may be extremely thin. Sometimes anabscess heals after one penicillin replacement, butthe procedure may have to be repeated severaltimes. The cannula (brain needle) is then passedthrough the original burr-hole between the sutures.Considerable judgment is needed in spacingaspirations. Needling should be repeated if thepatient's general and neurological state do notimprove; it should not be delayed until deteriora-tion occurs. At first, aspiration and penicillinreplacement may be needed at intervals of 24-48hours, but when progress is satisfactory, theintervals become longer and longer until no morepus can be aspirated. The majority of abscesses

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October 1958 OLIVER: Post-Traumatic Intracranial Space-Occupying Lesions 529

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FIG. 4.-An aerocele and spontaneous ventriculogram produced by a fracture involvingthe frontal sinuses. After repair of the torn dura mater the patient made an uneventfulrecovery.

can be completely cured by this technique. Theaspiration technique is particularly applicable toabscesses which involve the motor cortex, thespeech zones or the optic radiations when othermethods would cause severe neurological deficits.Furthermore, aspiration may be life-saving forpatients who are too ill to undergo a majoroperation.Primary Excision. This is the most recent

method of treatment, and is made possible by theuse of antibiotics. The advantage is that theanxious period of observation required by theaspiration technique is eliminated. Primary ex-cision of the abscess is particularly indicatedwhen it is situated in a relatively silent part ofthe brain, e.g. the frontal or cerebellar lobeswhere a neurological deficit is unlikely to becaused by excision. It is also the best methodof treating an abscess following an open headinjury, for any indriven fragments of bone orforeign bodies are automatically removed and theinfection is thus brought to an end.

Secondary Excision. Excision of the abscesscapsule is carried out when aspiration alone fails.

Some neurosurgeons, however, excise the abscesscapsule as a routine as soon as aspiration is unpro-ductive. Before enucleation, penicillin (2o,ooounits in 5 ml. of normal saline) is injected into theventricles, and it is also given systemically, to'cover' the operation and the post-operativeperiod. After excision of the abscess capsule, thewound is closed without drainage.

If the responsible organism can be discovered,an antibiotic to which it is sensitive is given in allmethods of surgical attack.

AeroceleAn aerocele is a collection of air in the brain

arising from a fracture which opens into the airsinuses. Sometimes air penetrates into the corre-sponding lateral ventricle producing a ventriculo-gram (Fig. 4). The condition is usually discoveredon routine radiography before a build-up of intra-cranial pressure can occur. The patient shouldbe warned not to blow his nose. Sometimesthere is an associated c.s.f. rhinorrhoea, but withor without it, aerocele calls for immediate cranio-tomy and repair of the dural defect with fascia lata.

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