A 21 year old man is involved in a road traffic accident. After a transient period of concussion he is
found to have a GCS of 15 by the paramedics. On arrival at hospital he is monitored in a side room
of the emergency department. When he is next observed he is noted to have a GCS of 3 and a
blown right pupil. Which of the processes below best accounts for this deterioration?
Hydrocephalus
Intraventricular bleed
Sub dural bleed
Trans tentorial herniation
Sub arachnoid haemorrhage
Theme from April 2012 Exam
The presence of a blown right pupil is a sign of a third cranial nerve compression. The most likely
cause is an extradural bleed. However, since this option is not listed the process of trans tentorial
herniation would be the most applicable answer. Intraventricular bleeds are typically more common
in premature neonates, deterioration due to hydrocephalus is more chronic.
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Head injuries
Head injury is the commonest cause of death and disability in people aged 1-40 years in the UK. In
the UK 1.4 million people will attend emergency departments each year with a recent head injury.
The typical patterns are described below:
Extradural Bleeding into the space between the dura mater and the skull. Often results
haematoma from acceleration-deceleration trauma or a blow to the side of the head. The
majority of extradural haematomas occur in the temporal region where skull
fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
, Some patients may exhibit a lucid interval
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around
haematoma the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral aneurysm
haemorrhage but may be seen in association with other injuries when a patient has
sustained a traumatic brain injury
,Theme: Intracranial bleeds
A. Intraventricular haemorrhage
B. Chronic sub dural bleed
C. Acute sub dural bleed
D. Extra dural haemorrhage
E. Sub arachnoid haemorrhage
Please select the most likely underlying diagnosis for the scenario described. Each option may be
used once, more than once or not at all.
2. A 50 year old alcoholic man attends the emergency department. His main reason for
presenting is that he has no home to go to. On examination he has no evidence of
involvement in recent trauma, a skull x-ray fails to show any evidence of skull fracture. He
is admitted and twelve hours following admission he develops sudden onset headache,
becomes comatose and then dies.
You answered Intraventricular haemorrhage
The correct answer is Sub arachnoid haemorrhage
Theme from April 2013 Exam
The absence of trauma here makes an acute sub dural and extra dural bleed unlikely.
Chronic sub dural bleeds would usually cause a more gradual deterioration than is seen
here. The absence of any skull fracture also makes an underlying intra cranial bleed less
likely. Sudden onset headaches, together with sudden deterioration in neurological function
are typical of a sub arachnoid haemorrhage.
3. A 50 year old lady is admitted having fallen down some stairs sustaining multiple rib
fractures 36 hours previously. On examination she is confused and agitated and has clinical
evidence of lateralising signs. She deteriorates further and then dies with no response to
resuscitation.
You answered Intraventricular haemorrhage
The correct answer is Acute sub dural bleed
The time frame of deterioration of an acute sub dural bleed would fit with this scenario.
They are highly lethal and not uncommon injuries. As the bleed enlarges, lateralising signs
may be seen and eventually coning and death will occur.
4. A male infant is born at 28 weeks gestation by emergency cesarean section. He is taken to
theatre for a colostomy due to an imperforate anus. He initially seems to be progressing
well. However, he begins to develop decerebrate posturing and is becoming increasingly
, obtunded.
Intraventricular haemorrhage
Acute neurological deterioration in premature neonates is usually due to intraventricular
haemorrhage. Diagnosis is made by cranial ultrasound. Development of hydrocephalus may
necessitate surgery.
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Intra cranial haemorrhage
Extradural Bleeding into the space between the dura mater and the skull. Often results
haematoma from acceleration-deceleration trauma or a blow to the side of the head. The
majority of extradural haematomas occur in the temporal region where skull
fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around
haematoma the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Intracerebral Usually hyperdense lesions on CT scanning. Arise in areas of traumatic
haematoma contusion with fuse to become a haematoma. Areas of clot and fresh blood
may co-exist on the same CT scan (Swirl sign). Large haematomas and
those associated with mass effect should be evacuated.
Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral
haemorrhage aneurysm but may be seen in association with other injuries when a patient
has sustained a traumatic brain injury
found to have a GCS of 15 by the paramedics. On arrival at hospital he is monitored in a side room
of the emergency department. When he is next observed he is noted to have a GCS of 3 and a
blown right pupil. Which of the processes below best accounts for this deterioration?
Hydrocephalus
Intraventricular bleed
Sub dural bleed
Trans tentorial herniation
Sub arachnoid haemorrhage
Theme from April 2012 Exam
The presence of a blown right pupil is a sign of a third cranial nerve compression. The most likely
cause is an extradural bleed. However, since this option is not listed the process of trans tentorial
herniation would be the most applicable answer. Intraventricular bleeds are typically more common
in premature neonates, deterioration due to hydrocephalus is more chronic.
Please rate this question:
Discuss and give feedback
Next question
Head injuries
Head injury is the commonest cause of death and disability in people aged 1-40 years in the UK. In
the UK 1.4 million people will attend emergency departments each year with a recent head injury.
The typical patterns are described below:
Extradural Bleeding into the space between the dura mater and the skull. Often results
haematoma from acceleration-deceleration trauma or a blow to the side of the head. The
majority of extradural haematomas occur in the temporal region where skull
fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
, Some patients may exhibit a lucid interval
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around
haematoma the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral aneurysm
haemorrhage but may be seen in association with other injuries when a patient has
sustained a traumatic brain injury
,Theme: Intracranial bleeds
A. Intraventricular haemorrhage
B. Chronic sub dural bleed
C. Acute sub dural bleed
D. Extra dural haemorrhage
E. Sub arachnoid haemorrhage
Please select the most likely underlying diagnosis for the scenario described. Each option may be
used once, more than once or not at all.
2. A 50 year old alcoholic man attends the emergency department. His main reason for
presenting is that he has no home to go to. On examination he has no evidence of
involvement in recent trauma, a skull x-ray fails to show any evidence of skull fracture. He
is admitted and twelve hours following admission he develops sudden onset headache,
becomes comatose and then dies.
You answered Intraventricular haemorrhage
The correct answer is Sub arachnoid haemorrhage
Theme from April 2013 Exam
The absence of trauma here makes an acute sub dural and extra dural bleed unlikely.
Chronic sub dural bleeds would usually cause a more gradual deterioration than is seen
here. The absence of any skull fracture also makes an underlying intra cranial bleed less
likely. Sudden onset headaches, together with sudden deterioration in neurological function
are typical of a sub arachnoid haemorrhage.
3. A 50 year old lady is admitted having fallen down some stairs sustaining multiple rib
fractures 36 hours previously. On examination she is confused and agitated and has clinical
evidence of lateralising signs. She deteriorates further and then dies with no response to
resuscitation.
You answered Intraventricular haemorrhage
The correct answer is Acute sub dural bleed
The time frame of deterioration of an acute sub dural bleed would fit with this scenario.
They are highly lethal and not uncommon injuries. As the bleed enlarges, lateralising signs
may be seen and eventually coning and death will occur.
4. A male infant is born at 28 weeks gestation by emergency cesarean section. He is taken to
theatre for a colostomy due to an imperforate anus. He initially seems to be progressing
well. However, he begins to develop decerebrate posturing and is becoming increasingly
, obtunded.
Intraventricular haemorrhage
Acute neurological deterioration in premature neonates is usually due to intraventricular
haemorrhage. Diagnosis is made by cranial ultrasound. Development of hydrocephalus may
necessitate surgery.
Please rate this question:
Discuss and give feedback
Next question
Intra cranial haemorrhage
Extradural Bleeding into the space between the dura mater and the skull. Often results
haematoma from acceleration-deceleration trauma or a blow to the side of the head. The
majority of extradural haematomas occur in the temporal region where skull
fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around
haematoma the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Intracerebral Usually hyperdense lesions on CT scanning. Arise in areas of traumatic
haematoma contusion with fuse to become a haematoma. Areas of clot and fresh blood
may co-exist on the same CT scan (Swirl sign). Large haematomas and
those associated with mass effect should be evacuated.
Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral
haemorrhage aneurysm but may be seen in association with other injuries when a patient
has sustained a traumatic brain injury
