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Submitted to: Maria Aileen Chanco-Bondoc RN, MN
Submitted by: Gamboa, Christine G. BSN IV-9 Group 36
Head injuries are caused by a sudden impact or force to the head or inertial forces within the skull. It is the trauma that leads to the potential injury to the scalp, skull, or brain in which it can range from a simple bump to the skull to serious brain injury. Head injuries can cause traumatic brain injury which is an insult to the brain that is capable of producing intellectual, emotional, social, and vocational changes. Motor-vehicle accidents are the leading cause of head injuries. Clients admitted to the emergency department, most are males younger than 30 years and 50% have evidence of ingestion of alcohol or other substances of abuse. Alcohol slows down the reflexes and alters cognitive processes and perception. These physiologic changes increase the chances of being involved in an accident or altercation. A second risk factor is driving without seatbelts. Peak occurrence is during evenings, nights, and weekends. Other causes are assaults, falls, and sports related injury. In the United States, a head injury is experienced approximately every 15 seconds. Head injuries occur in about 7 million Americans every year. Among these head-injured people, more than 500,000 are hospitalized, 100,000 experience chronic disability, and about 2000 are left persistent vegetative state (Black, 2008). Adding to that, Traumatic brain injury is a major cause of death and disability worldwide, especially in children and young adults. Causes include falls, vehicle accidents, and violence. Prevention measures include use of technology to protect those who are in accidents, such as seat belts and sports or motorcycle helmets, as well as efforts to reduce the number of accidents, such as safety education programs and enforcement of traffic laws. Brain trauma can be caused by a direct impact or by acceleration alone. In addition to the damage caused at the moment of injury, brain trauma causes secondary injury, a variety of events that take place in the minutes and days following the injury. These processes, which include alterations in cerebral blood flow and the pressure within the skull, contribute substantially to the damage from the initial injury. Traumatic Brain Injury can cause a host of physical, cognitive, social, emotional, and behavioral effects, and outcome can range from complete recovery to permanent disability or death.
Epidural hematoma, a type of focal injury caused by traumatic head trauma, also called as extradural hematoma, which forms between the skull and the dura mater. It occurs in about 10% of severe head injuries and is usually associated with a skull fracture. An epidural hematoma occurs from injury to the cerebral blood vessels, most often the middle meningeal artery. Bleeding is usually continuous, and a large clot forms, which separates the dura from the skull. Epidural hematoma (ie, accumulation of blood in the potential space between dura and bone) may be intracranial or spinal. Intracranial epidural hematoma occurs in approximately 2% of patients with head injuries and 5-15% of patients with fatal head injuries. Intracranial epidural hematoma is considered to be the most serious complication of head injury, requiring immediate diagnosis and surgical intervention. Intracranial epidural hematoma may be acute (58%), subacute (31%), or chronic (11%). Spinal epidural hematoma may also be traumatic, though it may occur spontaneously. In the United States, epidural hematoma complicates 2% of cases of head trauma (approximately 40,000 cases per year). Spinal epidural hematoma affects 1 per 1,000,000 people annually. Alcohol and other forms of intoxication have been associated with a higher incidence of epidural hematoma. International frequency is unknown, though it is likely to parallel the frequency in the United States. Mortality rate associated with epidural hematoma has been estimated to be 5-50%. No racial predilection has been reported. Intracranial and spinal epidural hematomas are more frequent in men, with a male-to-female ratio of 4:1. Intracranial epidural hematoma is rare in individuals younger than 2 years it is also rare in individuals older than 60 years because the dura is tightly adherent to the calvaria and Spinal epidural hematoma has a bimodal distribution with peaks during childhood and during the fifth and sixth decades of life. Increasing age has been noted as a risk factor for postoperative spinal epidural hematoma. Manifestations are usually acute in onset because the bleeding is often arterial. With an epidural hematoma, the following sequence of events may occur: (1) the client is unconscious immediately after head trauma, (2) the client awakens and is quite lucid, (3) loss of consciousness occurs and pupil dilation response rapidly deteriorates, with onset of eye movement paralysis, on the same side as that of the hematoma, (4) the client lapses into a coma, (5) blood behind the tympanic membrane, (6) periorbital
ecchymoses (bruises around the eyes), and (7) later, a bruise over the mastoid process or battle’s sign. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient's preoperative neurologic condition. Objectives • • • • Broaden the knowledge about the disease process. To know the precipitating and predisposing factors that contributed to the development of the disease. To know each nursing responsibility that the group of student-nurse researchers would perform with each abnormality the client may manifest. To be familiar with the treatment of the disease such as its medications to be given, laboratory test/s to be performed and the health teachings to be given to the significant others of the client. • • • • • Be able to make three nursing care plan Completion of case report Determine the nursing responsibilities (prior, during and after) of all the medical management given to the patient. Search the current trends and statistics regarding the disease condition. Analyze and interpret the different diagnostic and laboratory procedures, its purpose and its essential relationship to patient’s disease condition. Current Trends
This is an anecdotal finding with implications for further studies to evaluate the role of thermoregulation in ameliorating neurological changes in patients with traumatic brain injuries. along with hyperthermia (defined in our institution as a temperature of >38. resolved within several days of thermoregulation. Neurological changes such as right-sided weakness. Epidural hematoma can result in long-term neurological deficits. Despite two temperature spikes associated with coagulase-negative staphylococcus infection and one fever episode associated with temporary suspension of cooling therapy for a catheter change.According to Medscape’s article: Intravascular Temperature Modulation as an Adjunct to Secondary Brain Injury Prevention in a Patient with an Epidural Hematoma. a temperature of 36. prompt surgical intervention and prevention of secondary brain injury can enable a full recovery. Maintaining normothermia has been shown to be associated with improved neurological outcomes (Lasater.5 °C was maintained for 13 days during the acute phase of the case study patient's hospitalization.5 °C). . 2005).
called the cranial vault. Eight plate-like bones form the human cranium by fitting together at joints called sutures. The most important of these cranial bones for the appearance of the face is the frontal bone. Thus. The cranium is that part of the skull that holds and protects the brain in a large cavity.II. which underlies the top of the face above the eyeballs. The human skull also includes 14 facial bones that form the lower front of the skull and provide the framework for most . ANATOMY AND PHYSIOLOGY The human cranium and the facial bones are the foundation for the soft tissues of the face and head. much of the visible appearance of the human face depends upon the shapes and qualities of these bones.
and clinically relevant surgical landmarks. This anatomic region is complex and poses surgical challenges for otolaryngologists and neurosurgeons alike. The frontal bone houses the supraorbital foramina. smaller cavities besides the cranial vault.) The petro-occipital fissure subdivides the middle cranial fossa into 1 central component and 2 lateral components. and posterior cranial fossae. During . continues laterally from the cribriform plate. Anterior Skull Base The anterior limit of the anterior skull base is the posterior wall of the frontal sinus. along with the frontal sinuses. and the mouth. the zygomatic or cheek bone. which is the deepest area of the anterior cranial fossa. These 22 skull bones form other. (See the image below. The skull base forms the floor of the cranial cavity and separates the brain from other facial structures. the nose. mark the posterior limit. The cribriform plate may be more than 1 cm lower than the roof of the ethmoid cavity (fovea ethmoidalis). with attention to the surrounding structures. The anterior clinoid processes and the planum sphenoidale. The frontal bone forms the lateral boundaries. and it is made of extremely thin bone compared with the relatively thick bone of the lateral fovea ethmoidalis. The fovea ethmoidalis. which. This article discusses each region. occipital. or the roof of the ethmoid cavity. This portion of the skull base consists of the orbital portion of the frontal bone. form 2 important surgical landmarks during approaches involving the anterior skull base. The skull base can be subdivided into 3 regions: the anterior. and paired parietal bones. The 5 bones that make up the skull base are the ethmoid.of the face that is important to psychological research. and the nasal bone. The greater portion of the anterior floor is convex and grooved by the frontal lobe gyri. The ethmoid bone forms the central part of the floor. middle. including those for the eyes. nerves. The important facial bones include the jaw bone or mandible. paired frontal. In the center of this region is the cribriform plate. the maxilla or upper jaw. vascular supply. the internal ear. which forms the roof of the sphenoid sinus. through which the olfactory tracts pass. sphenoid. Working knowledge of the normal and variant anatomy of the skull base is essential for effective surgical treatment of disease in this area.
The IOF transmits the maxillary nerve (CN V2) and infraorbital vessels. Inferior relationships — extracranial aspects The most important anatomic structures below the anterior cranial fossa are the orbits and the paranasal sinuses. The foramen cecum sits between the frontal crest and the prominent crista galli and is a site of communication between the draining veins of the nasal cavity and the superior sagittal sinus. The posterior wall is thin and adjacent to the superior sagittal sinus and frontal lobe dura.transethmoidal approaches to the anterior skull base. sits slightly posteriorly in the midline. and the inferior orbital fissure (IOF). respectively). The crista galli. The bony orbit is often a route for intracranial and extracranial spread of infection and tumors because of its direct proximity to the anterior fossa. IV. and ophthalmic nerves (cranial nerves [CN] III. as well as the ophthalmic veins. These foramina help in identifying the frontoethmoid suture line. which projects up centrally between the cerebral hemispheres. VI. In the medial aspect. The anterior clinoid processes form the posterolateral segment and help form the roof of the optic canal. this relationship is extremely important to remember. or chiasmatic sulcus. lacrimal. The posterior aspect includes the optic canal. and V1. A thorough description is beyond the scope of this article. which marks the inferior extent of the anterior . The medial wall transmits the anterior and posterior ethmoid arteries through their respective foramina. The optic chiasm. an important landmark for the optic nerve and supracavernous internal carotid artery (ICA). The image below demonstrates the relationship of the openings described above. serves as the site of attachment for the falx cerebri. and sphenoid bones. the lesser wing of the sphenoid forms the anterior clinoid process. The medial wall is closest to the apex and is formed by the orbital process of the frontal. but important anatomy and relationships are discussed. ethmoid. The lateral portion of the IOF is an important surgical landmark for positioning lateral orbital osteotomies during anterior skull base resections. trochlear. abducens. the superior orbital fissure (SOF). The optic canal transmits the optic nerve (CN II) and the ophthalmic artery. and it communicates with the infratemporal and pterygomaxillary fossae. The SOF conveys the oculomotor.
Its patency may lead to the formation of developmental anomalies. empyema. which lies about 0. which is formed from the sphenoid and occipital . and meningoencephaloceles. The posteriormost segment of the lateral orbital wall forms the anterior wall of the middle cranial fossa and is discussed in greater detail in the next section. The olfactory bulb lies along the medial edge of the frontal orbital plate and connects with the olfactory tract. The foramen cecum. causing complications such as sagittal sinus thrombosis.cranial fossa. The major structures in this area are the olfactory bulb and tract. Contents The dura mater attaches anteriorly at the frontal crest and crista galli to form the falx cerebri. The lesser wings of the sphenoid and the frontal process of the maxilla form the lateral walls. such as nasal dermoid cysts. nasal gliomas. These veins form a potential pathway for infection to spread intracranially. encephaloceles. The posterior wall is adjacent to the superior sagittal sinus and the frontal lobe dura. to gain intracranial access. The ethmoid sinuses can be found inferior to the anterior cranial fossa and medial to the orbits. Infectious processes and tumors can exploit this relationship as well. found anterior to the crista galli. which courses above the cribriform plate and planum sphenoidale. The posterior ethmoid artery foramen is also an important surgical marker for the location of the optic canal and nerve. which transmits the superior and inferior sagittal sinuses. though it may transmit a vein from the nasal mucosa to the superior sagittal sinus. The posterior limit is the clivus. The frontal sinuses arise as evaginations of ethmoid air cells into the frontal bone and have a thick anterior and thinner posterior wall.5 cm posterior to it. The frontal lobes occupy the anterior fossa and sit superior to the orbits and sinonasal tract. The superior sagittal sinus drains the superior cerebral and frontal diploic veins of Breschet. As a result. and abscess. usually ends blindly. the frontal sinus can be used as a route of surgical entry into the anterior cranial fossa. Middle Skull Base Boundaries — intracranial aspects The greater wing of the sphenoid helps form the anterior limit of the middle skull base.
The superior petrosal sinus creates a longitudinal groove in the petrous ridge. The former ascends across to the pterion. If fractured. The petrous portion of the temporal bone forms the posteromedial limit of the middle cranial fossa. The pterion is an H -shaped suture. where the frontal bone. It can be appreciated on the superior aspect of the midpetrous ridge. where it courses posteriorly. the roof of the carotid canal is frequently dehiscent. The greater wing of the sphenoid forms the anterior floor of the fossa.5 cm behind the zygomaticofrontal suture and 4 cm above the zygomatic arch. The pterion is made up of thin bone and can be easily fractured during trauma.bones. In this region lies the sigmoid groove for the ICA as it traverses the petrous apex through the cavernous sinus. with eventual formation of an epidural hematoma. a feature that makes dural elevation risky. and the parietal bone meet. The arcuate eminence is the superior extent of the superior semicircular canal. The floor and the lateral walls are grooved for the middle meningeal artery. The tuberculum sellae is an olive-shaped swelling and sits on the anterior slope between the chiasmal sulcus and the sella turcica. The eminence is an . The anterior aspect of the petrous temporal bone forms the posterior floor of the middle cranial fossa. The dorsum sellae is the furthest posterior. the greater wing of the sphenoid bone. it can result in injury to the anterior branches of the middle meningeal artery. Along the superomedial surface of the petrous temporal bone. the squamous temporal bone. The greater wing of the sphenoid forms the lateral limit as it extends laterally and upward from the sphenoid body to meet the squamous portion of the temporal bone and the anteroinferior portion of the parietal bone. The hypophyseal or pituitary fossa lies immediately posterior to the tuberculum sellae. which courses anterolaterally from the foramen spinosum and which divides into frontal and parietal branches. This area is superior to the point at which the ICA enters the cavernous sinus just above the foramen lacerum. The anteromedial petrous tip houses the trigeminal or gasserian ganglion in a region known as Meckel cave. This suture is approximately 3. The sella turcica can be found between the anterior and posterior clinoid processes and is composed of 3 sections. The body of the sphenoid makes up the central portion of the middle fossa and houses the sella turcica.
Lateral to the arcuate eminence. the SOF extends inferomedially and toward the orbital apex and transmits the oculomotor nerve (CN III).important landmark during the middle fossa approach for localization of the internal auditory canal (IAC). foramen rotundum. The carotid canal forms where the petrous apex articulates with the sphenoid and occipital bone. a gap between the medial border of the petrous temporal bone and the lateral border of the clivus. respectively. The jagged foramen lacerum lies posteromedial to the foramen ovale. It transmits the maxillary division (CN V2) of the trigeminal nerve into the pterygopalatine fossa.) Beginning lateral to the clinoid process anteriorly. which may be found medial to the foramen spinosum. found medial to foramen ovale. the trochlear nerve (CN IV). It continues into the foramen lacerum on the undersurface of the skull base. It also transmits the superior ophthalmic vein. The foramen sits near the lateral wall of the sphenoid sinus. The foramen of Vesalius is found in 40% of individuals and transmits an emissary vein from the cavernous sinus. is an important radiographic . the accessory meningeal artery. The foramen rotundum lies posteroinferior to the base of the SOF. foramen ovale. the lacrimal. the lesser superficial petrosal nerve (LSPN). and nasociliary branches of CN V1. The foramen spinosum lies further posterolaterally and transmits the middle meningeal artery. The bone of the floor of the middle fossa may be dehiscent over the geniculate ganglion of the facial nerve. The foramen ovale is posterior and lateral and transmits the mandibular division (CN V3) of the trigeminal nerve. Of note. and foramen spinosum lie in an anteroposterior and mediolateral plane. The tegmen is a thin plate of bone that separates the dura of the middle lobe from the middle ear and the mastoid cavity. the thin tegmen tympani and tegmen mastoideum cover the middle ear and mastoid. and the abducens nerve (CN VI). as well as the meningeal branch of the facial nerve (CN VII). (See the image below. frontal. and emissary veins to the pterygoid plexus into the infratemporal fossa. the petro-occipital fissure. at the level of the sella turcica. Two inconsistent foramina are the innominate foramen. Foramina — intracranial aspects The SOF. and the foramen of Vesalius.
are not limited to. In the middle fossa. the petrous and sphenoid ridges. the trigeminal or gasserian ganglion. The GSPN and rostral LSPN run along the floor beneath the dura and parallel the anterior edge of the petrous bone into foramen lacerum. Here. which lies deep and parallel to the temporal bone and medial to the styloid process. which is composed of parasympathetic fibers from the facial nerve to the lacrimal gland. is an important surgical landmark. and the cavernous sinus and its contents. It is easily identified and can be followed back medially to the foramen lacerum and the petrous ICA. the GSPN joins with the deep petrosal nerve to form the vidian nerve or the nerve of the pterygoid canal. The GSPN. The pituitary stalk or infundibulum and the hypophyseal veins perforate this structure. the temporal lobe. because it lies in close proximity to various middle cranial fossa foramina. the pituitary gland. Details of cavernous sinus anatomy are discussed further in following sections of this article. The facial nerve (CN VII) and vestibulocochlear nerve (CN VIII) originate from the caudal pons. it forms the diaphragma sellae—a circular dural plate—which covers the pituitary gland. the dura strongly adheres to the clinoid processes. the intracranial portion of the ICA. Contents Important structures in the middle fossa include but. The cavernous sinus resides on both sides of the sella turcica and the body of the sphenoid bone. and the basal foramina. This area is also a landmark for the ICA. They course through the subarachnoid space and enter the porus . The GSPN branches from the geniculate ganglion and passes through a small hiatus into the middle fossa before coursing parallel to the petrous ridge of the temporal bone and entering the foramen lacerum. It also serves to anatomically divide the middle skull base into a central compartment and 2 lateral compartments. the greater superficial petrosal nerve (GSPN). In the midline. The temporal lobe takes up most of the space of the middle fossa and extends to the inferior portion of the anterior fossa.and preoperative surgical landmark.
and the mastoid bone to exit at the stylomastoid foramen and innervate the facial nerve musculature. the middle ear. The superior and inferior petrosal sinuses emerge from the posterior aspect of the cavernous sinus and eventually drain into the sigmoid sinus and the internal jugular vein. The anterior and posterior petroclinoid folds serve as the lateral borders. within the subarachnoid space.acusticus and IAC. the roof lies in close proximity to the trigeminal ganglion and within 3 mm of the sphenoid sinus. Infection of the petrous apex classically manifests as abducens palsy due to inflammation in the Dorello canal. The cavernous sinus has complex venous drainage. It extends from the SOF to the apex of the petrous temporal bone. the abducens nerve (CN VI) enters the dura superior to the clivus and enters the Dorello canal. which gives off 2-6 caroticocavernous branches that supply the hypophysis and that join branches from the middle meningeal artery. the trochlear nerve (CN IV). Along the lateral wall runs the ICA. The 3 divisions of the trigeminal traverse inferior to the tentorium cerebelli into the Meckel cave. The oculomotor nerve divides into superior and inferior divisions at the most anterior portion of the cavernous sinus. It connects anteriorly to the superior ophthalmic vein and the sphenoparietal sinus and drains posteriorly into the superior and inferior petrosal sinuses en route to the basilar plexus. and the maxillary nerve (CN V2). and the ICA may be seen. This feature is clinically relevant during surgical exploration of the middle fossa. The trochlear nerve enters at the angle between the anterior and posterior petroclinoid folds and courses the lateral wall. Running superoinferiorly in the lateral wall are the oculomotor nerve (CN III). because the eustachian tube must be traversed before the ICA is reached in this area. Running lateral to the ICA. The petroclinoid and petrosphenoidal ligaments of Gruber form the roof of the canal. From here. V2. The superficial. The eustachian tube originates at the protympanum and runs anteromedially and inferiorly. Cavernous sinus The cavernous sinus is a complex plexus of veins in the dura that can be found lateral to the sphenoid sinus. . The bone directly medial to the eustachian tube may be dehiscent. CN VII continues through the temporal bone. and V3 pass into the lateral wall of the cavernous sinus. V1. the ophthalmic nerve (CN V1).
In severe cases. At this point. infections may enter the skull base from the facial venous system and travel retrograde through the valveless ophthalmic veins into the anterior portion of the cavernous sinus. and inferior cerebral veins drain into the cavernous sinus from above. This feature is clinically important. which occur in the medial canthal. At this point. intratemporal. cavernous. and the emissary veins drain into the pterygoid plexus below the sinus. The result is cavernous sinus thrombosis. The cervical ICA can be distinguished from the external carotid because it has no branches. traumatic tears of the intracavernous carotid result in high-pressure arterial blood flooding the cavernous sinus. The ICA enters the petrous bone through the carotid foramen and runs cranially into the foramen lacerum. and supracavernous. and labial areas (danger zone of the face). They may eventually seed the cavernous sinus. and chemosis. may pass through the valveless angular and facial veins and drain superiorly into the ophthalmic veins. This vertical portion ascends 5 mm and turns anteromedially into the horizontal portion. nasal. proptosis. it is medial to the eustachian tube and anterolateral and inferior to . Interruption of the anastomotic branch of the superficial middle cerebral vein as it connects to the transverse sinus is likely to cause an infarction. Pimples and pustules. which are reported to occur with basilar skull fractures. The course can be divided into 4 parts: cervical. Knowledge of these complex relationships is necessary for recognizing the manifestations of carotid-cavernous fistulas. In the case of such fistulas.middle. and landmarks must be recognized during skull base surgery. In rare cases. The cervical portion passes near the third and fourth cervical vertebrae. pulsating exophthalmos can be observed. The intratemporal segment is difficult to mobilize because of an adherent fibrous ring. Dental infections may spread into the cavernous sinus by means of the pterygoid plexus. Clinically significant backflow in the low-pressure superior ophthalmic veins draining into the cavernous sinus then leads to venous engorgement. because the relationship with the external carotid may be aberrant. it is deep to the posterior digastric muscle and styloid process and superior and posteromedial to the external carotid artery. Internal carotid artery The course of the ICA is complex.
In the normal case.the cochlea. Boundaries — extracranial aspects The anterior boundary of the middle cranial fossa is the posterolateral wall of the maxillary sinuses. the temporal carotid artery runs forward along the petrous bone at a 45° angle to the midsagittal plane. where it joins the circle of Willis through its terminal anterior and middle cerebral arteries. The lateral pterygoid plate forms the medial boundary. The anterior boundary of the infratemporal fossa is the posterior wall of the maxillary sinus. the artery is superior and lateral to the sphenoid bone in an area referred to as the carotid siphon. The last segment turns backward under the optic nerve to the anterior perforated substance. At this point. In these cases. The lateral margin consists of primarily the squamous and petrous portions of the temporal bone. giving off the caroticotympanic and pterygoid branches. The artery then enters the cavernous sinus medial to the abducens nerve (CN VI). A pulsatile tympanic membrane is sometimes observed. the carotid artery can be dehiscent in this area and extend into the middle ear cleft. A dehiscent or aberrant ICA can appear as a pinkish or white-blue mass filling the inferior portion of the middle ear. the petro-occipital sutures form its posterior boundary. At times. Finally. Lateral relationships — extracranial aspects As previously discussed. Many surgical approaches in the lateral skull base involve the infratemporal fossa. whereas the mandibular ramus and condyle create the lateral boundary. The posteroinferior boundary is the parapharyngeal space. the petro-occipital fissure divides the middle cranial fossae into central and lateral components. Contents — extracranial aspects . the greater wing of the sphenoid bone forms the superior border of the infratemporal fossa. the artery is at great risk during surgery involving the middle ear. Working knowledge of this area is imperative for the surgeon. the ICA enters the supracavernous portion. On traversing the roof of the cavernous sinus medial to the anterior clinoid process.
The IOF is at the most anterior limit of the pterygomaxillary fossa and is continuous with the infratemporal fossa. and medial and lateral pterygoid muscles. Once the foramen ovale is identified. which helps in identifying the highest portion of the cervical ICA and the carotid canal. the temporalis. Drainage of the external lateral skull base involves the internal and external jugular venous system and the retromandibular vein. The mastoid and occipital emissary veins can link the intracranial dural sinus system with the external circulation. the infratemporal fossa lies below the temporal bone.When viewed from the extracranial lateral aspect. which lies immediately posterior. provides blood to these muscles and should be preserved in case a temporalis flap is necessary to reconstruct skull base defects. Dissecting further in a medial direction reveals the cartilaginous eustachian tube and the tensor and levator veli palatini muscles. and posterior to the maxilla. Two important bony surgical landmarks may be identified in the infratemporal fossa. The maxillary nerve enters through the foramen rotundum and branches thereafter to supply sensory information from regions of the face. masseter. The first is the root of the lateral pterygoid plate. one of the terminal branches of the external carotid artery. (See the image below. which lies immediately anterior to it. Moving anteriorly past the pterygoid process. the foramen spinosum is easily identifiable immediately posterior to the foramen. Structures first identified in the infratemporal fossa include the muscles of mastication. namely. The second landmark is the sphenoid spine. one finds the pterygomaxillary fissure. which enters the fossa through the vidian or pterygoid canal en route to the pterygopalatine ganglion. as well as for the foramen ovale.) The greater petrosal nerve joins the deep petrosal nerve to form the vidian nerve. inferomedial to the zygomatic arch. . namely. The internal maxillary artery. The medial and lateral pterygoid muscles take up most of the space of the infratemporal fossa. The sphenoid spine is just medial to the condylar or glenoid fossa and posterolateral to the foramen spinosum. which transmits the maxillary artery to the pterygomaxillary fossa. Both nerves send branches to the parasympathetic sphenopalatine ganglion. This plate serves as a marker for the foramen rotundum.
or vidian nerve. the postauricular branch of the facial nerve branches off and gives rise to the occipital. The jugular foramen can be divided into the pars nervosa anteriorly and the pars venosa posteriorly. and XI. It lies posterolaterally in the lateral skull base and anteromedially to the mastoid tip. Dehiscence may be present in the lateral wall of the sphenoid. and stylohyoid branches. its lateral border is the styloid process sheath. Before exiting. X. In the extracranial aspect. bony gap between the jugular process of the occipital bone and the jugular process of the petrous bone. The deep lobe of the parotid gland and the accompanying facial nerve (CN VII) and its branches may be encountered in the lateral aspect of the extracranial skull base. The facial nerve exits the mastoid through the stylomastoid foramen and enters the substance of the parotid gland. Intracranial details of the jugular foramen are discussed in the Posterior Skull Base section. The jugular foramen. and occipital and postauricular branches of the external carotid artery provide arterial supply to the lateral skull base. The chorda tympani nerve arises from the temporal segment of the facial nerve and eventually joins the lingual nerve to supply taste to the anterior two thirds of the tongue. The facial. resulting in exposure of the carotid artery. . optic nerve. because the ICA and optic nerve are just lateral to a thin margin of bone. Sellar pneumatization of the sinus facilitates entry during transsphenoidal approaches. its anterior border is the carotid canal. and its medial borders are the hypoglossal foramen and canal. The pterygoid venous system can be highly variable in this region. is a large. can be identified in the infratemporal fossa as well. Medial relationships The sphenoid sinus can serve as an access route to the pituitary and the clivus. The internal maxillary artery. It is important to avoid disrupting the lateral wall during instrumentation. The cervical portion of the ICA ascends vertically to enter the middle fossa medial to the sphenoid spine. superficial temporal. postauricular.with branches of the occipital. or retrofacial veins. as well as to a communicating branch that joins the glossopharyngeal nerve. digastric. which transports CNs IX. with its deep temporal and middle meningeal branches. auricular.
It is created by the passage of the levator veli palatini and the cartilaginous eustachian tube through the superior constrictor muscle. it helps to form the lateral portion of the choana and part of the lateral portion of the nasopharynx. The vertebrobasilar artery and the brainstem lie posterior to the clivus. The petrous portion of the temporal bone and the greater wings of the sphenoid bone are particularly important for identifying structures. Along with the investing pharyngobasilar fascia and the superior pharyngeal constrictor muscle. The horizontal grooves for the paired transverse sinuses can be found lateral to the . The crest serves as an attachment for the falx cerebelli. The overlying tentorium cerebelli separates the cerebellum from the cerebral hemispheres above. is suspended from the skull base and clivus. The sinus of Morgagni is a weak point in the superolateral nasopharyngeal wall. located superiorly.The nasopharynx lies posterior and inferior to the sphenoid sinus along the midline. whereas the occipital bone forms the lateral walls and floor. Grooves for the superior sagittal sinus are superior to the internal occipital protuberance. The basal portion of the occipital bone (the basiocciput) and the basisphenoid form the anterior portion of the posterior skull base. This is a region for infections or tumor to potentially invade the skull base. just before its entry point into the cavernous sinus. These 2 regions combine to form the midline clivus. The occipital bone also fuses with the mastoid portion of the temporal bone to form the occipitomastoid suture. which contains the occipital sinus. and the midline internal occipital crest runs from the foramen magnum to the internal occipital protuberance. Directly superior to the nasopharynx is the foramen lacerum and the ICA. The investing fascia of the nasopharynx. The floor is grooved for the cerebellar hemispheres. Posterior Skull Base Boundaries The posterior skull base consists of primarily the occipital bone. The posterior surface of the petrous temporal bone and the lateral aspect of the occipital bone form the lateral wall. also known as the pharyngobasilar fascia. Mucosa covers the medial surface of the medial pterygoid plate. with contributions from the sphenoid and temporal bones.
Finally. and the labyrinthine vessels (branches of the anterior inferior cerebellar artery en route to the inner ear). The hypoglossal foramen is inferomedial to the jugular foramen and near the jugular tubercle. it transmits the CNs VII and VIII. The jugular tubercle may be medial to the lower aspect of the jugular foramen. The sulcus for the inferior petrosal sinus sits posterior to the clivus and anterior to the petrous apex. It transmits the endolymphatic duct. X. It is formed by the anterior processus jugularis of the petrous bone and the occipital bone in its posterior aspect. The jugular foramen extends laterally from the posterior aspect of the occipital condyle. but its path is highly variable. The sigmoid sulcus can be found in the lateral aspect of the posterior cranial fossa in the mastoid portion of the temporal bone. and XI enter its rough anterior end (pars nervosa). and the hypoglossal venous plexus. The inferior petrosal sinus usually enters this portion of the jugular foramen between CNs IX and X. They descend to the mastoid angle of the parietal bone to become continuous with the sigmoid sulcus. CNs IX. It ends at the jugular foramen. the nervus intermedius. . Foramina The porus acusticus is the opening of the IAC. the ascending pharyngeal artery may send a posterior meningeal branch through the jugular foramen. and it serves as a landmark for the hypoglossal foramen. and it lies at the posterior end of the petro-occipital fissure. Found on the posterior surface of the petrous bone. a meningeal branch of the ascending pharyngeal artery. It may even enter the internal jugular vein below the skull base. Emissary veins in connection with the sigmoid sinus may leave the posterior fossa through mastoid foramina.internal occipital protuberance. The vestibular aqueduct is posteroinferior to the IAC. It transmits the hypoglossal nerve (CN XII). The sigmoid sinus and the jugular bulb enter the foramen at its smooth posterior end (pars venosa).
the superior cerebellar arteries. X. and XI. Suboccipital region The mastoid tip serves as the origin for the sternocleidomastoid. the spinal accessory nerve. (See the image below. and nerves IX.) Inferior relationships — extracranial aspects A surgeon must have knowledge of the outer regions of the skull base. and the apical ligament of the dens and membrane tectoria. the trapezius muscle is most superficial. the suboccipital triangle is exposed. On entering the posterior fossa through the foramen magnum. which travel to the cerebellopontine angle in close relationship to CNs VII and VIII. The structures that pass through are the medulla oblongata. numerous long and short pontine arteries. The basilar artery then branches into the labyrinthine artery. The basilar artery then branches into the anterior inferior cerebellar arteries. (See the image below. and the cerebral and cerebellar hemispheres lie in the posterior fossa. the pons. In the posterior aspect. Immediately deep lies the splenius capitis and cervicis muscles and the semispinalis capitis muscle. Dura and the tentorium cerebelli enclose the various aforementioned venous sinuses. the medulla. Contents The midbrain. CNs VII and VIII and the nervus intermedius exit through the porus acusticus. and. The posterior inferior cerebellar arteries usually branch off from the vertebral arteries before forming the midline basilar artery at the base of the pons. while the posterior digastric muscle originates deep to this area. the vertebral arteries ascend ventral to the roots of CNs IX.) . CN XII exits through the hypoglossal canal. because these regions often serve as access points during surgery. finally. and XI traverse the jugular foramen. the vertebral and posterior spinal arteries. which make up the posterior portion of the circle of Willis. X. CNs VII-XII exit through the posterior fossa. On reflection of these muscles from the superior nuchal line.The brainstem communicates with the vertebral canal through the foramen magnum.
The occipital artery courses posteriorly deep to the mastoid tip. Surgical approaches in this area allow mobilization of the vertebral artery and access to the foramen magnum.The suboccipital triangle is superficial to the ligaments connecting the atlas to the axis and contains the occipital artery. the greater occipital nerve. The atlantic portion exits the atlas at the transverse foramen medial to the lateral rectus capitis muscle and curves posteriorly behind the lateral mass of the atlas. atlantic. The atlantic portion is encountered in the suboccipital triangle of the nuchal region and is covered by the semispinalis capitis muscle. The subarachnoid portion of the artery is considered to lie in the posterior cranial fossa proper. foraminal. and the C1 nerve. the vertebral artery. and subarachnoid. It then passes medially along the groove on the posterior arch of the atlas and pierces the atlantooccipital membrane to enter the vertebral canal and subarachnoid space. . Vertebral artery The vertebral artery originates from the subclavian artery and has 4 parts: cervical. a complex of veins.
PATHOPHYSIOLOGY Schematic Diagram .III.
MODIFIABLE FACTORS: NON-MODIFIABLE FACTORS: AGE GENDER Alcohol Drinking Substance Abuse Motor-Vehicular Accident Assaults Falls Sport-related injuries Brief contact force Severe head injuries or skull fracture Injury to the cerebral blood vessels (Middle Meningeal Artery) Rupture of the outer surface of the dura mater and the skul Rapid continuous bleeding .
Leaking of blood between dura mater and the skull Collection of blood Mass or Clot Formation Pressure on the brain Rapid increase of the pressure inside the head (Increase Intracranial pressure) Additional brain injury Permanent brain damage Coma Confusion Drowsiness or Altered level of awareness Enlarged Pupil in one eye Severe headache Death Synthesis of the disease Definition of the disease Epidural hematoma is a mass of blood in the space between the inner table of the skull and the dura mater (the leathery outer covering of the brain). Typically caused by traumatic brain injury. . the bleeding into the epidural space can cause pressure on the brain which can lead to neurological symptoms including coma and death if severe enough.
• Substance Abuse – contributes to injuries among adolescents and young adults because it has negative effects on perception. Non-Modifiable factors . The fracture can tear blood vessels in this area. slipping. particularly if they are in the temporal area and cause a fracture of the bone of the skull. and reaction time • Motor-Vehicular Accident – leading cause of death from injury and sometimes associated with alcohol drinking causes slight to severe physical injuries. Modifiable/Non-Modifiable Factors Modifiable factors • Alcohol Drinking – Alcohol slows the reflexes and alters cognitive processes and perception that could lead potential accident due to decrease alertness. • Falls – most common cause of non-fatal injuries sometimes associated with alcohol drinking. • Assaults – physical assaults that are caused by an object that causes a strong impact on a certain body part that could lead to minor or to even severe injury. • Sport-related injuries – injuries that happen accidentally that is acquired during falling. etc.This can occur with more severe head injury. they can also occur with relatively mild injuries. leading to the hematoma. judgment.
• Coma. which can cause injury if they accidentally fall. due to increase activity could engage in dangerous activities such as climbing. In older persons. In children. this can sometimes lead to irreversible brain . confusion. Confusion. and Drowsiness or altered level of consciousness – due to the pressure caused in the brain. permanent brain damage. this causes depressed level of consciousness. • Permanent brain damage – due to the increase pressure in the brain. coma. • Enlarged pupil in one eye .• Age – any age group is affected and can have the potential of acquiring injuries. due to the increase age. The diagnosis of an epidural hematoma is based on the patient symptoms. can often cause changes in the pupils of the eyes • Death – due to the permanent brain damaged caused by the increased pressure. thus causing an increase pressure on the brain. there could be degeneration of certain abilities. problems in vision and ambulation is sometimes the cause of injuries to the elderly. Not all of these clinical manifestations are present in every epidural hematoma. causing shift of the brain from one side to the other. this causes additional damage on the brain and permanent brain damage could occur if it is not immediately manage. Sign and symptoms with rationale The clinical manifestations of an epidural hematoma are increase ICP.pressure on one side of the brain. enlarged pupil in one eye. leading to confusion and even coma. drowsiness or altered level of consciousness and even death. • Increase ICP – increase in ICP is brought about the accumulation of blood that causes compression. the physical signs and the CT scan and MRI findings.
Planoconvex or crescent-shaped epidural hematoma must be differentiated hemorrhage. On rare occasion. Plain radiographs of the vertebral column may identify a cavernous angioma. CT myelography may be used when MRI is unavailable or if the patient cannot tolerate MRI. CLINICAL INTERVENTION AND MANAGEMENT Diagnostic Procedures CT scan Plain radiography of the head (skull radiography) may reveal skull fractures. o CT scanning may also depict air collections and displacement of brain parenchyma. Subdural hematomas may rarely appear convex and mimic epidural hematomas. lateral. with peripheral enhancement on contrast administration. though regions of hypodensity may be seen with serum or fresh blood.damage that in long run could cause dysfunction of the brain leading to death. Noncontrast CT scanning of the head not only visualizes skull fractures but also directly images an epidural hematoma. Myelography outlines the epidural space and may illustrate a spaceoccupying mass. IV. o Chronic epidural hematoma may have a heterogeneous appearance due to neovascularization and granulation. and odontoid views are useful to identify associated traumatic fractures. Subacute lesions are homogenously hyperdense. though CT scanning has largely replaced the use of skull radiography because the diagnostic information is so much greater with CT. . o Acute epidural hematoma may appear as a hyperdense lenticular-shaped mass situated between the brain and the skull. an acute epidural may appear completely from isointense subdural with respect to brain. Cervical spine radiographs with anteroposterior.
If the bone flap is not replaced.o Clinical deterioration should prompt repeat imaging with CT scanning. Minimally invasive surgical procedures. for trauma. A craniotomy is used for many different procedures within the head. Procedure . the procedure is called a craniectomy. tumor. Craniotomy Craniotomy is the surgical removal of a section of bone (bone flap) from the skull for the purpose of operating on the underlying tissues. may be used in selected cases. coagulation of bleeding sites. MRI Demonstrates the evolution of an epidural hematoma. • Surgical Procedure Although several recent reports have described successful conservative management of epidural hematoma. occasionally. including the use of burr holes and negative pressure drainage. Spinal cord enhancement may be apparent and should be distinguished from inflammation or neoplasia. surgical evacuation constitutes definitive treatment of this condition. usually the brain. epidural drains are employed for as long as 24 hours. infection. aneurysm. • • • Spinal MRI may delineate the location of an epidural hematoma and identify an associated vascular malformation. though this imaging modality may not be appropriate for patients in unstable condition. etc. Gadolinium-enhanced magnetic resonance arteriography (MRA) may further define the extent of an arteriovenous malformation. Craniotomy or laminectomy is followed by evacuation of the hematoma. Diffusion-weighted imaging with the use of periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) MRI may be used for improved detection of acute spinal epidural hematoma. The bone flap is replaced at the end of the procedure. and inspection of the dura. The dura is then tented to the bone and.
then both bones are mentioned. This is called a suboccipital craniectomy. If part of two adjacent bones is opened. The small circles indicate craniectomy.• The craniotomy is labeled by which part of the skull is opened. The dark blue line indicates where the bone is cut. When the bone removal is more to the side and just behind the mastoid bone it may be called a retromastoid craniectomy. Occasionally an abnormality is situated in the low brainstem or cerebellum and may extend to the upper spinal cord. The Outline of a midline suboccipital used to start the bone removal. In the temporal areas. In these instances a cervical laminectomy may also accompany the suboccipital craniectomy Outline of a fronto-temporal bur holes. Surgery on the back part of the brain beneath the tentorium is usually carried out by removal of the lower part of the occipital bone. . The craniectomy may be in the midline or to one side or the other. the neurosurgeon may carry out a craniectomy in which the bone is not replaced 2. The blue craniotomy. fronto-temporal craniotomy (Figure 10) 1. Note the bur holes that are indicates where bone is removed and area indicates the bone removed. for example. which are covered by muscle. The darker blue area not replaced. A frontal craniotomy indicates the opening is in the frontal bone while a parietal craniotomy involves opening the parietal bone.
The drill bit is made so that as soon as the center of the drill bit penetrates the bone. The skull is cut between each two adjacent burr holes in a progressive manner until the bone flap is separated from the surrounding skull. The craniotome resembles an air drill with a protective footplate. widen the hole without cutting the underlying dura. The holes are positioned around the periphery of the proposed bone flap. Cuts are then made with the craniotome from hole to hole until the bone flap is free . A small hook on saw guide allows a wire saw (Gigli saw) to be drawn under the skull in the same path as the guide. This is accomplished in one of two ways The oldest method involves the passage of a thin metal strip (saw guide) between two adjacent holes. and the holes can also be tailored in shape.light blue area is replaced after the surgery. the drill stops The last method uses an air driven burr to gradually remove bone until the dura is seen. Making the holes may be accomplished in one of three ways at the discretion of the surgeon The oldest method. which lines the inner surface of the skull Another method is by using a special air powered drill. 2. This method allows the smallest holes. The saw driven by hand then cuts the bone from inside out The air driven craniotome has for the most part replaced the manual method. The first bit has a point and is used to just penetrate the bone. which have more of a curvature. The strip is placed between the skull and the dura. A series of small holes (bur holes) are made in the skull. The second and third bits. • The incision in the scalp is designed to expose the skull over the lesion to be removed • Removal of the bone flap is done in the following manner: 1. which is still used by many surgeons. involves a set of three drill bits and a hand drill.
the dura is cut around the tumor leaving a margin of normal dura. The dura is then cut within the margins of the skull opening. used. After the bone flap is removed. banked human dura. Gortex plastic or an absorbable collagen matrix . 3. the underlying dura is cut to expose the lesion. Wire Gigli saw for cutting bone. If the lesion is a meningioma that is attached to the dura. Operative photograph showing the Gigli saw being Air craniotome being used in surgery. When there is a loss of dura.Photograph of an air drill making a bur hole. various substitutes can be used such as bovine pericardium (covering of the heart).
The scalp is then sutured closed . If the bone cannot be replaced (infected or invaded by tumor) a prosthesis can be used. 5. Courtesy A. The cut bone is elevated. Sloan. Following removal of the lesion. M. This has been shown to extend life by two to four months.4. the surgeon may wish to line the cavity left by removal of the tumor with an absorbable wafer impregnated with an anticancer drug.D. MRI obtained after partial removal of a malignant brain tumor (glioblastoma multiforme) in which the tumor was treated with absorbable wafers (arrows) impregnated with an anticancer drug. all bleeding is secured. These are usually made of titanium mesh or plastic. When the surgery is for a malignant brain tumor. the dura is sutured closed and the bone flap restored to the skull with wire sutures or titanium miniplates and screws. What occurs next depends on the specific lesion that is found. Burr holes in cosmetically exposed areas are covered with small titanium plates.
The magnification varies between 4 and 16x. Operating Microscope. Ultrasonic Aspirator. The small tip of the instrument vibrates back and forth at thousands of times per second. The ultrasonic aspirator is used to remove tumors from the brain with a minimum of brain movement. The microscope has markedly improved the surgery of aneurysms of the brain arteries and tumors at the brain base 2. The human hand can make very small and accurate movements as long as the eye can see it. A picture is thus produced which can guide the surgeon to the lesion . This allows magnification of small brain structures particularly the blood vessels and nerves at the base of the brain. There are several instruments that have improved the ease and accuracy of a craniotomy: 1. It is similar to the ultrasound used by an obstetrician to image a fetus in the womb. Intraoperative Doppler Ultrasound. The magnification provided by the operating microscope has added another dimension to operating. Sound waves are sent out from the instrument (transducer) that strike the target lesion and bounce back to the recording portion of the transducer. thus liquefying the tumor tissue and allowing it to be easily sucked away with a minimum of injury to the surrounding brain 3. The intraoperative ultrasound is used for localizing a lesion below the surface of the brain.Titanium mesh cranioplasty used for • replacement of an infected bone flap.
4. It has only slightly affected large lesions. a significant improvement in brain surgery is made possible by the marriage of modern imaging studies (CT and MRI) and computer graphics. The electronic data that are the source of the images are transferred to a computer in the operating room. error Using this technique. This information is transferred directly to the computer. The feducials are registered on the CT or MRI are matched to the corresponding feducials on the patient's head. A receiver positioned near the operating table registers the position of the diodes and thus the position of the head feducials. The pointer or any other instrument containing the diode array can then be used to direct the surgeon to the lesion with no more than a 1-2 mm. the head is pinned in a head holder to rigidly hold it in place. the surgical trauma to the brain is reduced and the size of the craniotomy is minimized. This is translated into a faster and better recovery with discharge from hospital frequently occurring in 24 hours . Stereotaxic Image Guided Craniotomy in the last few years. The patient is then placed in the CT or MRI unit and a series of images are obtained. particularly small lesions and lesions beneath the surface of the brain. diffuse brain lesions and surgery for ruptured cerebral aneurysm Prior to surgery. The latter is accomplished with a pointer containing an array of light emitting diodes. This computer reconstructs the CT or MRI images and produces a three dimensional picture of the head containing the lesion as well as a reconstruction of the head and lesion in three planes After the patient is anesthetized. small markers (feducials) that show up on CT or in the MRI are applied to the head of the patient. This frameless stereotaxic (three dimensional) image guided surgery is a major advance in the removal of lesions inside the skull.
Computer screen as seen by the neurosurgeon during image guided surgery.a. The red asterisk lies on the tumor imaged in blue c. The red 'cross hairs' is the position of the instrument being used by the surgeon. Note the images have been flipped from side to side so that the surgeon has a left sided image to his own left side. MRI of left frontal metastatic brain tumor (arrow). The arrows point to a yellow line that represents the direction of 'attack' chosen by the surgeon. Note: MRI images show the left side to the viewer's right b. The right lower image shows the skin surface of the patient with multiple donut shaped feducials on the surface. Post-operative MRI showing complete removal of the .
A catheter inserted in an artery may be used to continuously monitor the blood pressure Intracranial pressure may be monitored through a small catheter placed within the head and connected to a pressure gauge Blood may be drawn to determine to determine the level of red blood cells. and to determine the concentration of sodium and potassium In some cases.tumor Complications Complications following craniotomy are primarily related to involvement of the brain and its coverings. Some of the complications are: • • • • • • • • • • • • Complications of anesthesia (see Anesthesia) Infection Hemorrhage and/or post-operative hematoma Leak of cerebrospinal fluid Brain swelling Raised intracranial pressure (pressure inside the head) Paralysis Hydrocephalus (see Shunt for Hydrocephalus) Loss of sensation Loss of vision Loss of speech Memory loss Recovery • • • • • • • • Following surgery the patient is usually admitted to the intensive care unit Level of consciousness is carefully observed for any change Blood pressure is carefully monitored along with the pulse. a tube may be left in the windpipe to control respiration. Antibiotics are usually given to prevent infection Medication is frequently given to suppress the possibility of seizures .
• If there are no serious problems. Additional therapies include Radiation therapy is usually given following removal of both metastatic tumors and tumors that originate in the brain such as a glioblastoma multiforme. At this time sutures or staples may have to be removed. hospitalization may be delayed Transfer to a rehabilitation unit may be necessary Further care • The patient returns to the surgeon's office 7-10 days following discharge. A craniotomy for an infection is usually for a brain abscess. Malignant tumors of the brain usually have a gloomy outlook. If there is recurrence. however. loss of speech. The after care for a brain tumor differs depending on whether it is benign or malignant 1. Frequently the patient must be kept on specific antibiotics for the infectious agent causing the abscess. Survival following surgery doubles if radiation therapy is given Chemotherapy has been used for glioblastoma but often helps only slightly and frequently has unwanted side-effects Immunotherapy involves stimulating the patient's own immune system to fight the tumor. The patient's tumor (glioblastoma multiforme) taken at the time of surgery is used to make a vaccine (like the polio vaccine). Patient with benign tumors usually have to be followed for several years to be sure there is no recurrence. On occasion antibiotics may be necessary for several months. Continued care depends on the lesion. Early trials have shown that immunotherapy improves survival in some patients with minimal side-effects . Prolonged follow up is usually required for infection and tumor • Infections. • Brain tumors. which stimulates blood cells to create lymphocytes that will find and attack the tumor. the patient may be discharged the following day. The vaccine is given to the patient. the alternatives are usually repeat surgery or radiation therapy 2. hospitalization may be considerably longer depending on the lesion and the difficulty of the procedure • • If there are problems such as weakness.
In some cases. whereas vitamin K and protamine may be administered to restore normal coagulation parameters. the nurse may also need to provide seizure precautions. As hyperthermia may exacerbate neurological injury. mild analgesics or codeine to control course since that time intracranial pressure pain. especially the mechanism of injury and clinical Close monitoring of the neurological status. Note precisely the size of the the side opposite the injury. Antacids are used to prevent gastric ulcers associated with traumatic brain injury and spinal cord damage. Patients with spinal epidural hematoma may require high-dose methylprednisolone when spinal cord compression is involved. Notify the physician immediately if dilation of pupils occurs. . Anticonvulsants are used routinely to avoid seizures that may be induced by cortical damage. and steroids such as dexamethasone according to physician’s prescriptions. pupils in mm. Nursing Management • • • • • Obtaining an accurate history. Assess motor responses bilaterally. acetaminophen may be given to reduce fevers. observing for signs of increased Physical examination against a baseline neurological assessment Elevation of the head of the bed 300 to reduce the intracranial pressure Administration of diuretics such as mannitol. check for positive Babinski Assess for decreased sensory response bilaterally but with special emphases on Monitor pupillary dilation and response to light. Immobilized patients may require heparin for prevention of venous thrombosis. including the administration of prophylactic anticonvulsants • • • • Monitor LOC using the Glasgow scale or some other objective scale.Novel therapeutic approaches o o Endovascular embolization to minimize bleeding during the acute stage Thrombolytic evacuation using closed suction drain Medication Regimen Osmotic diuretics. such as mannitol or hypertonic saline. may be used to diminish intracranial pressure.
Provide nursing measures related to respiratory care. Do not put a pillow under the head as it may flex the head forward and could impede venous outflow. providing O2 therapy. suctioning.a transducer that is placed under the dura mater. possible with the patient. Elevate the HOB suctioning. leaving the dura intact. doing blood gases. . That would include Maintain fluid restriction. the fever will not respond to antipyretics so a hypothermia blanket will be necessary. • • Provide nursing care to prevent complications such as damage to the eyes. • Maintain a desired temperature range either with the use of antipyretics or a hypothermia blanket. A similar device is the subdural catheter . Turn by logrolling every 1 2 hours. It is very important to separate stimuli such as turning. Involve them in the care of the patient if they wish to participate. ICP. Provide emotional support to the family. dressing changes. bathing. (will be discussed later) Control noise and stimulation from the environment. EC is a transducer that is placed between the skull and the dura. monitoring ventilator settings. and changing the bed. to 30 degrees (except for a dural tear). skin. Always encourage them to talk to and touch the patient.• • • • Monitor vital signs. Allow a rest period between each activity as the continued stimuli will cause the ICP to rise. Notify physician if any deviation from parameters. • • Administer prescribed medications. If the patient has a hypothalamic injury. These patients need to be kept a little dry to help control Position the patient to maintain venous outflow from the brain. Allow them to spend as much time as or oral mucous membranes. injection. Answer questions for them when possible or refer them to the MD • ICP monitoring device-Monitor ICP via the Epidural catheter if present.
and report changes. After 2 days of NI. the patient will achieve timely wound healing. After 7 days of NI. EXPECTED OUTCOME Short term: . NURSING CARE PLAN Impaired Skin Integrity ASSESSMENT S>ø O > The patient manifests: -immobility -destruction in skin integrity -redness on the area -trauma -pain -surgical incision/wound >The patient may manifest: -edema -swelling NURSING DIAGNOSIS Impaired skin integrity related to surgery AEB destruction of skin layers and surface and invasion of body structures 20 open reduction internal fixation. After 7 days of NI. >To promote patient’s sense of wellbeing. >Assist with general hygiene and comfort measures. >Use a foam mattress. the patient will exhibit improved skin lesions or wounds. There is destruction on the skin layers of the affected part. RATIONALE > To provide evidence of the effectiveness of the skin care regimen.V. the patient shall have achieved timely wound healing. >To minimize >Maintain proper environmental conditions. bed cradle. the patient shall have exhibited improved skin SCIENTIFIC EXPLANATION The procedure is invasive in nature since it will require an incision and the use of mechanical implants. >To promote comfort and sense of wellbeing. describe and document skin condition. Long term: After 2 days of NI. Long term: OBJECTIVES Short term: NURSING INTERVENTIONS >Inspect skin every shift.
lesions or wounds. >Position patient for comfort and minimal pressure on bony prominences and change his position at least every 2 hours. >To reduce pressure. >To >Perform prescribed treatment regimen for the skin condition involved. >Warn against tampering with the wound or dressings. monitor progress. >Instruct family members in a skin care regimen. promote circulation and minimize skin breakdown. >To maintain or modify encourage compliance. . skin breakdown.-itching or other devices. >To reduce potential for infection.
therapy. >To relieve the patient of pain. Risk for Infection ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED .current >Administer pain medication and monitor its effectiveness.
Long term: After 5 days of >Change surgical/wound dressings. INTERVENTIONS >Observe for localized signs of infection at sutures or surgical incision wound. interventions to prevent/reduce risk of infection. the patient will manifest absence of infection. EXPLANATION The surgical wound is at risk for infection since there is destruction in the first line of defense of the body which is the skin. Long term: After 5 days of NI. This entitles different pathogenic organisms to invade the surgical wound. NI. . as indicated. may manifest: -hyperthermia -chills -diaphoresis -increase WBC -pain and swelling on the surgical site -alteration in VS -seizures DIAGNOSIS Risk for infection related to tissue destruction 20 to open reduction internal fixation. using proper technique for changing/disposing of contaminated materials. the patient shall have identified >To check for the presence of infection and give necessary interventions. >To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms. fever. there can be growth and spread of infectious microorganisms and so an infection will arise. >To check for any signs of infection. Short term: After 2 days of NI. >Note signs and symptoms of sepsis.S> ø O>The patient manifests: -presence of surgical incision/wound >The patient may manifest: The pt. If it is not properly taken cared of like proper cleaning and changing of dressings. OUTCOME Short term: After 2 days of NI. the patient will identify interventions to prevent/reduce risk of infection. diaphoresis. the patient shall have manifested absence of infection. chills.
>Note and report laboratory values. >To provide a global view of the patient’s immune function and nutritional >Administer/monitor medication regimen and note patient’s response. status. >To determine effectiveness of therapy. > To educate the family about the right procedure to clean and change dressings.>Teach family how to clean incision site daily and remind them to change dressings as needed. Risk for Disuse Syndrome ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED .
immobilization of the affected part is prescribed for a few days. DIAGNOSIS Risk for disuse syndrome related immobilization due to being comatose secondary to epidural hematoma EXPLANATION After the surgery. for indications of infection or other complications. blood pressure. > To assess > Monitor temperature. pulse and respirations at least every 4 hours. GI status. respiratory status. >To prevent or OUTCOME Short term: After 3 days of NI. Prolonged immobilization may lead to muscle atrophy. >Inspect skin every shift and protect areas subject to irritation. ability to move about and decrease risk INTERVENTIONS > Avoid positions that put prolonged pressure on body parts and compress blood vessels. GI status. mitigate skin breakdown. ability to move about and .S>ø O > The patient manifests: -coma -prolonged inactivity or immobility -pain -changes in integumentary and musculoskeletal status -presence of surgical wound >The patient may manifest: -changes in cardiovascular status. nutritional status and genitourinary status AEB decrease fatigability. impeded blood circulation and ineffective tissue perfusion which arises to the occurrence of disuse syndrome. Short term: After 3 days of NI. the patient shall have demonstrated a decrease in significant changes in cardiovascular status. respiratory status. >Perform passive ROM exercises at least once per >To prevent joint contractures. nutritional status and genitourinary status AEB decrease fatigability. > To enhance circulation and help prevent tissue or skin breakdown. the patient will demonstrate a decrease in significant changes in cardiovascular status.
Long term: After 5 days of NI. the patient will maintain muscle strength and tone and joint ROM.respiratory status. the patient shall have maintained muscle strength and tone and joint ROM. Long term: After 5 days of NI. > To prevent cracking and possible infection. >Provide or help with daily hygiene. . shift. decrease risk for muscle atrophy. muscle atrophy. and other complications of prolonged inactivity. GI status. nutritional status and genitourinary status for muscle atrophy. keep skin dry and lubricated.
particularly if they are in the temporal area and cause a fracture of the bone of the skull. The surgical management most widely used is craniotomy which is indicated to evacuate the hematoma. surgical management. Typically caused by traumatic brain injury. The nurse must provide adequate knowledge to the patient and also to the SO to rule out anxiety and misconceptions. possible diagnostic procedures or test. they can also occur with relatively mild injuries. Also. She must provide her health teachings like the proper management of the surgical wound. the nurse must help the patient to achieve timely wound healing and to increase the level of wellness and prevent the occurrence of complications. leading to the hematoma. and nursing management. In this case report. its manifestations. This can occur with more severe head injury. The fracture can tear blood vessels in this area.VI. the bleeding into the epidural space can cause pressure on the brain which can lead to neurological symptoms including coma and death if severe enough. risk factors and causes. And. prevent and manage coagulation of bleeding sites. and inspection of the dura. the benefits of the surgery and the complications that may occur. . the nurse must be aware of her responsibilities to provide quality care to the patient. CONCLUSION An Epidural hematoma is a mass of blood in the space between the inner table of the skull and the dura mater (the leathery outer covering of the brain). the main focus is to broaden the knowledge about epidural hematoma.
2009 http://www.VII.nursing-lectures.blogtopsites.com/outpost/51b3b6303a2d9b8b95c8ddae04460e4a http://hematomatreatment.ncbi.yoursurgery.com/article/882627-overview#a1 http://www. Eight Edition.wikipedia.com/ProcedureDetails. 2002 Medical Surgical Nursing.nih. BIBLIOGRAPHY Modern Medical Guide.medscape.medscape.nytimes.cfm? Proc=19scape.com/2011/02/head-trauma-and-nursing-intervention.html http://www.com/article/824029-followup http://www.org/wiki/Epidural_hematoma .html http://health.com/health/guides/disease/extradural-hemorrhage/overview.gov/pubmedhealth/PMH0002385/ http://en.nlm.com/nursing-care-of-subdural-and-epidural-hematomas/ http://emedicine. Revised Edition.com/nursing-care-of-subdural-and-epidural-hematomas/ http://emedicine.com/viewarticle/580271_5 http://hematomatreatment.