0:00

You can tell how influential a textbook

0:03

is by the number of editions it has.

0:06

I'm going to be referring to the Youmans,

0:09

that's not Yousem,

0:10

but Youmans and Winn Neurological surgery textbook,

0:15

which is in its 7th edition,

0:17

as well as some material from the

0:20

Yousem Neuroradiology requisites,

0:22

which is in the fourth edition.

0:23

So, as you can see, Youmans wins out.

0:27

When the neurosurgeons are debating

0:29

whether or not to take a patient to the operating

0:31

room for an intraparenchymal hemorrhage,

0:34

they usually will refer to the Glasgow Coma Scale,

0:37

which I have written out here.

0:39

And this looks at the response of the eyes,

0:42

the verbal response, motor response,

0:46

and it is graded on these bases into severe head trauma,

0:50

moderate trauma and mild traumatic brain injury

0:54

by the scoring system.

0:55

So you can refer to this.

0:57

The lower numbers are much worse.

1:00

From Youmans and Winn's 7th edition.

1:04

These are the indications for surgery

1:07

for intraparenchymal hemorrhage.

1:09

I'm providing this because it will instruct you what

1:13

to put into your CT scan report when one

1:16

sees an intraparenchymal hematoma.

1:19

So, what it says is that

1:20

patients with parenchymal mass lesions

1:22

and signs of progressive neurologic deficits

1:25

that should be taken to surgery.

1:28

Any lesion greater than 50 CCs in volume

1:32

should be treated operatively.

1:33

And the neurosurgeons look at the volume pretty simply.

1:37

They look at the AP diameter,

1:39

the transverse diameter,

1:41

and the superior-inferior diameter,

1:42

and they multiply those three factors and then divide

1:46

by two to obtain the volume of the hematoma.

1:49

So, obviously,

1:50

a hematoma might be in multiple different shapes,

1:53

but this is, by convention,

1:55

the way they measure the volume of a hematoma.

1:57

And if it's over 50 CCs in volume,

2:00

then that patient will go to the OR.

2:04

Also, they say that any patient

2:06

who has a severe head injury,

2:08

Glasgow Coma Scale 6-8,

2:10

remember, the lower numbers are worse,

2:12

who has a frontal or temporal contusions that's greater

2:15

than 20 CCs in volume,

2:17

with midline shift greater than equal

2:19

to 5 mm, or cisternal compression on CT scan.

2:23

So this is the reason why we measure from the midline

2:26

the displacement of the septum pellucidum.

2:29

And this is why we look at the uncus in order to see

2:33

whether or not there's cisternal compression,

2:35

because these are the indications for surgery

2:38

for an intraparenchymal hematoma.

2:41

Nonsurgical patients are followed.

2:44

They are usually followed with serial CT scans at our

2:48

institution at 6-hour intervals for the first 24 hours.

2:52

Now, if we have a spot sign,

2:54

which shows that the hemorrhage

2:56

is actively bleeding,

2:57

they may do it at a shorter interval.

3:00

But patients who have parenchymal mass lesions who don't

3:03

show neurologic compromise and have a favorable

3:05

Glasgow Coma Scale, where they can control

3:07

the intracranial pressure,

3:09

and this is why we often see pressure monitors placed

3:13

shortly after head injury,

3:15

and no signs of the mass effect or the volumetric changes,

3:19

those patients will be followed.