Management of acute traumatic intracranial haematoma : a study of computed tomography (CT) scan, clinical features and intracranial pressure monitoring

This thesis is based on a study of a consecutive series of acute head injured patients admitted to the Institute of Neurological Sciences in Glasgow over a three year period. Each patient had a CT scan performed which showed an acute traumatic intracranial haematoma. Literature is reviewed to highlight the earlier problems of diagnosis and controversies about different management policies now that diagnosis has been made easier by CT scan. The objectives of this study were: to analyse the features and management of a consecutive series of head injured patients found by CT scan to have an acute traumatic intracranial haematoma and whoeventually required an operation; to analyse the clinical, CT scan and intracranial pressure features in these patients and to determine the influence of each of these on the treatment of a patient; to evaluate the efficacy of intracranial pressure monitoring in the management of clinically `silent' acute traumatic intradural haematoma; and to determine the results of different initial decisions about operative and non-operative management. The overall results confirm the prognostic significance of clinical features. Patients who had abnormal CT scan features at the time of their initial assessment had a more unfavourable outcome than those with normal CT scan features. It was also found that in patients with coma score 3-10, the presence of abnormal CT scan features had the same predictive value as the coma score but that in those in the coma score group 11-15 the presence of abnormal CT scan features had an adverse effect worse than could have been determined basing on the coma score alone. The results of the patients managed by ICP monitoring in this series did not differ significantly from the previous Galbraith and Teasdale series. From the findings it is suggested that the present level of ICP at which to base the decision to operate is too high and a level of > 20mmHg is recommended. Furthermore when taking the initial decision about management it is suggested that the status of the CT scan features should be considered. Patients with abnormal CT scan features should all be operated upon immediately, regardless of how well they may appear to be. This is because the presence of abnormal CT scan features precedes neurological deterioration. In patients who are found to have low ICP, < 20mmHg, monitoring should be continued for 72 hours and thereafter a repeat CT scan should be done. The findings are finally considered in relation to patients with spontaneous intracerebral haematoma. The problems of the future are mentioned