Head Injuries: Theme From April 2012 Exam

eMRCS 19/07/2015
Question 1 of 35
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
Next question
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.
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 from acceleration-deceleration trauma or a blow to
haematoma 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 the frontal and parietal lobes. May be either acute
haematoma 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 but may be seen in association with other
haemorrhage injuries when a patient has sustained a traumatic brain injury
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Question 2-4 of 35
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 Acute sub dural bleed
The correct answer is Sub arachnoid haemorrhage

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 Extra dural 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.
Next question
Intra cranial haemorrhage
Extradural Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow
haematoma to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a
Features
eMRCS 19/07/2015
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either
haematoma acute or chronic.
Intracerebral Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas
haematoma 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.
Intraventricular Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it
haemorrhage does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood
may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it
is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.
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Question 5-7 of 35
Theme: Cranial nerve lesions
A. Optic nerve
B. Oculomotor nerve
C. Trigeminal nerve
D. Facial nerve
E. Abducens nerve
F. Glossopharyngeal nerve
G. Vestibulocochlear nerve
H. Accessory nerve
I. Hypoglossal nerve
For each of the scenarios given please give the most likely cranial nerve responsible for the symptom or lesion described. Each nerve may be used
once, more than once or not at all.
5. A 63 year old man is admitted with severe headache, nausea and recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to
have diplopia.
You answered Facial nerve
The correct answer is Abducens nerve
The long intracranial course of this nerve makes it susceptible to damage early in the course of raised ICP.
6. A 32 year old lady is admitted with weakness, visual disturbance and peri orbital pain. On examination she is noted to have mydriasis and
diminished direct response to light shone into the affected eye. The consensual response is preserved.
You answered Accessory nerve
The correct answer is Optic nerve
This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve
or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil
during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response).
The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe
glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).
7. An 18 year old boy undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia.
You answered Vestibulocochlear nerve
The correct answer is Glossopharyngeal nerve
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
Next question
Cranial nerves
Cranial nerve lesions

Olfactory nerve May be injured in basal skull fractures or involved in frontal lobe tumour extension. Loss of olfactory nerve function in
eMRCS 19/07/2015
relation to major CNS pathology is seldom an isolated event and thus it is poor localiser of CNS pathology.
Optic nerve Problems with visual acuity may result from intra ocular disorders. Problems with the blood supply such as amaurosis
fugax may produce temporary visual distortion. More important surgically is the pupillary response to light. The pupillary
size may be altered in a number of disorders. Nerves involved in the resizing of the pupil connect to the pretectal nucleus
of the high midbrain, bypassing the lateral geniculate nucleus and the primary visual cortex. From the pretectal nucleus
neurones pass to the Edinger - Westphal nucleus, motor axons from here pass along with the oculomotor nerve. They
synapse with ciliary ganglion neurones; the parasympathetic axons from this then innervate the iris and produce miosis.
The miotic pupil is seen in disorders such as Horner's syndrome or opiate overdose.
Mydriasis is the dilatation of the pupil in response to disease, trauma, drugs (or the dark!). It is pathological when light fails
to induce miosis. The radial muscle is innervated by the sympathetic nervous system. Because the parasympathetic fibres
travel with the oculomotor nerve they will be damaged by lesions affecting this nerve (e.g. cranial trauma).
The response to light shone in one eye is usually a constriction of both pupils. This indicates intact direct and consensual
light reflexes. When the optic nerve has an afferent defect the light shining on the affected eye will produce a diminished
pupillary response in both eyes. Whereas light shone on the unaffected eye will produce a normal pupillary response in
both eyes. This is referred to as the Marcus Gunn pupil and is seen in conditions such as optic neuritis. In a total CN II lesion
shining the light in the affected eye will produce no response.
Oculomotor The pupillary effects are described above. In addition it supplies all ocular muscles apart from lateral rectus and superior
nerve oblique. Thus the affected eye will be deviated inferolaterally. Levator palpebrae superioris may also be impaired resulting in
impaired ability to open the eye.
Trochlear nerve The eye will not be able to look down.
Trigeminal nerve Largest cranial nerve. Exits the brainstem at the pons. Branches are ophthalmic, maxillary and mandibular. Only the
mandibular branch has both sensory and motor fibres. Branches converge to form the trigeminal ganglion (located in
Meckels cave). It supplies the muscles of mastication and also tensor veli palatine, mylohyoid, anterior belly of digastric and
tensor tympani. The detailed descriptions of the various sensory functions are described in other areas of the website. The
corneal reflex is important and is elicited by applying a small tip of cotton wool to the cornea, a reflex blink should occur if it
is intact. It is mediated by: the naso ciliary branch of the ophthalmic branch of the trigeminal (sensory component) and
the facial nerve producing the motor response. Lesions of the afferent arc will produce bilateral absent blink and lesions of
the efferent arc will result in a unilateral absent blink.
Abducens nerve The affected eye will have a deficit of abduction. This cranial nerve exits the brainstem between the pons and medulla. It
thus has a relatively long intra cranial course which renders it susceptible to damage in raised intra cranial pressure.
Facial nerve Emerges from brainstem between pons and medulla. It controls muscles of facial expression and taste from the anterior
2/3 of the tongue. The nerve passes into the petrous temporal bone and into the internal auditory meatus. It then passes
through the facial canal and exits at the stylomastoid foramen. It passes through the parotid gland and divides at this
point. It does not innervate the parotid gland. Its divisions are considered in other parts of the website. Its motor fibres
innervate orbicularis oculi to produce the efferent arm of the corneal reflex. In surgical practice it may be injured during
parotid gland surgery or invaded by malignancies of the gland and a lower motor neurone on the ipsilateral side will result.
Vestibulo- Exits from the pons and then passes through the internal auditory meatus. It is implicated in sensorineural hearing loss.
cochlear nerve Individuals with sensorineural hearing loss will localise the sound in webers test to the normal ear. Rinnes test will be reduced
on the affected side but should still work. These two tests will distinguish sensorineural hearing loss from conductive
deafness. In the latter condition webers test will localise to the affected ear and Rinnes test will be impaired on the affected
side. Surgical lesions affecting this nerve include CNS tumours and basal skull fractures. It may also be damaged by the
administration of ototoxic drugs (of which gentamicin is the most commonly used in surgical practice).
Glossopharyngeal Exits the pons just above the vagus. Receives sensory fibres from posterior 1/3 tongue, tonsils, pharynx and middle ear
nerve (otalgia may occur following tonsillectomy). It receives visceral afferents from the carotid bodies. It supplies
parasympathetic fibres to the parotid gland via the otic ganglion and motor function to stylopharyngeaus muscle. The
sensory function of the nerve is tested using the gag reflex.
Vagus nerve Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes through the jugular foramen
and into the carotid sheath. Details of the functions of the vagus nerve are covered in the website under relevant organ
sub headings.
Accessory nerve Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and sternocleidomastoid muscles. The
distal portion of this nerve is most prone to injury during surgical procedures.
Hypoglossal Emerges from the medulla at the preolivary sulcus, passes through the hypoglossal canal. It lies on the carotid sheath and
nerve passes deep to the posterior belly of digastric to supply muscles of the tongue (except palatoglossus). Its location near the
carotid sheath makes it vulnerable during carotid endarterectomy surgery and damage will produce ipsilateral defect in
muscle function.
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Question 8-10 of 35
Theme: Head injury- assessment
A. 3
B. 4
C. 6
D. 8
E. 10
F. 15
G. 12
H. 13
I. 5
J. 7
For each of the scenarios given please determine the most likely Glasgow Coma Score. Each option may be used once, more than once or not at all.
8. A 20 year old man is hit over the head with a mallet. On arrival in the accident and emergency department he opens his eyes to pain and
groans or grunts. On application of a painful stimulus to his hands, he extends his arm at the elbow.
You answered 8
The correct answer is 6
Theme from 2011 Exam

Theme from September 2012 Exam
E=2, V= 2, M=2.
9. A 20 year old man falls over and bangs his head whilst intoxicated. On arrival in the emergency department he opens his eyes in response
to speech, and is able to speak, although he is disorientated. He obeys motor commands.
You answered 10
E=3, V=4, M=6.
10. A 20 year old man is hit over the head with an iron bar. On arrival in the emergency department he opens his eyes in response to pain, his
only verbal responses are in the form of groans and grunts. On application of a painful stimulus to his hands, he flexes his forearms away
from the painful stimuli.
You answered 12
E=2, V=2, M=4.

Appropriate flexion to pain carries a higher score than decorticate posturing or inappropriate flexion.
Next question
Glasgow coma scale
Modality Options
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Eye opening Spontaneous

To speech
To pain
None
Verbal response Orientated

Confused
Words
Sounds
None
Motor response Obeys commands

Localises to pain
Withdraws from pain
Abnormal flexion to pain (decorticate posture)
Extending to pain
None
Responses are taken from each category (marks in descending order) to produce an overall score. Severe brain injuries are generally associated with
GCS <8.
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Question 11 of 35
A 33 year old lady develops a thunderclap headache and collapses. A CT scan shows that she has developed a subarachnoid haemorrhage. She
currently has no evidence of raised intracranial pressure. Which of the following drugs should be administered?
None
Atenotol
Labetolol
Nimodipine
Mannitol
Next question

Nimodipine is a calcium channel blocker. It reduces cerebral vasospasm and improves outcomes. It is administered to most cases of sub arachnoid
haemorrhage.
Spontaneous intracranial haemorrhage

Most commonly sub arachnoid haemorrhage. It is due to intra cranial aneurysm in 85% cases. Approximately 10% of cases will have normal
angiography and the cause will remain unclear. Patients with inherited connective tissue disorders are at higher risk although most cases are
sporadic.
>95% cases will have headache (often thunderclap)
>15% will have coma
Investigation
CT scan for all (although as CSF blood clears the sensitivity declines)
Lumbar puncture if CT normal (very unlikely if normal)
CT angiogram to look for aneurysms.
Management
Supportive treatment, optimising BP (not too high if untreated aneurysm) and ventilation if needed.
Nimodipine reduces cerebral vasospasm and reduces poor outcomes.
Untreated patients most likely to rebleed in first 2 weeks.
Patients developing hydrocephalus will need a V-P shunt (external ventricular drain acutely).
Electrolytes require careful monitoring and hyponatraemia is common.
Treatment of aneurysm
>80% aneuryms arise from the anterior circulation
Craniotomy and clipping of aneurysm is standard treatment, alternatively suitable lesions may be coiled using an endovascular approach. Where
both options are suitable data suggests that outcomes are better with coiling than surgery.
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Question 12 of 35
A 65 year old male with known nasopharyngeal carcinoma presents with double vision over a few weeks. On examination he is found to have left
eye proptosis and it is down and out. He reports pain on attempting to move the eye. There is an absent corneal reflex. What is the most likely
diagnosis?
Posterior communicating artery aneurysm
Cavernous sinus syndrome
Optic nerve tumour
Migraine
Cerebral metastases
Next question
Cavernous sinus syndrome is most commonly caused by cavernous sinus tumours. In this case, the nasopharyngeal malignancy has locally invaded
the left cavernous sinus. Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner's
syndrome.
Cavernous sinus
The cavernous sinuses are paired and are situated on the body of the sphenoid bone. It runs from the superior orbital fissure to the petrous
temporal bone.
Relations
Medial Lateral
Pituitary fossa
Temporal lobe
Sphenoid sinus
Contents
Lateral wall components (from top to bottom:)
Oculomotor nerve
Trochlear nerve
Ophthalmic nerve
Maxillary nerve
Contents of the sinus (from medial to lateral:)

Internal carotid artery (and sympathetic plexus)
Abducens nerve
Blood supply
Ophthalmic vein, superficial cortical veins, basilar plexus of veins posteriorly.
Drains into the internal jugular vein via: the superior and inferior petrosal sinuses
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Question 13-15 of 35
Theme: Head injury
A. Subdural haematoma
B. Extradural haematoma
C. Subarachnoid haemorrhage
D. Basal skull fracture
E. Intracerebral haematoma
F. Le fort 1 fracture of maxilla
G. Le fort fracture 3 of maxilla
H. Mandibular fracture
What is the most likely diagnosis for the scenario given? Each option may be used once, more than once or not at all.
13. A 32 year old female hits her head on the steering wheel during a collision with another car. She has periorbital swelling and a flattened
appearance of the face.
You answered Basal skull fracture
The correct answer is Le fort fracture 3 of maxilla
The flattened appearance of the face is a classical description of the dish/pan face associated with Le fort fracture 2 or 3 of the maxilla.
14. A 29 year bouncer is hit on the side of the head with a bat. He now presents to A&E with odd behaviour and complaining of a headache.
Whilst waiting for a CT scan he becomes drowsy and unresponsive.
You answered Le fort 1 fracture of maxilla
The correct answer is Extradural haematoma
The middle meningeal artery is prone to damage when the temporal side of the head is hit.
Note that there may NOT be any initial LOC or lucid interval.
15. A 40 year old alcoholic presents with worsening confusion over 2 weeks. He has weakness of the left side of the body.
You answered Le fort fracture 3 of maxilla
The correct answer is Subdural haematoma
Subdural haematomas can have a history over weeks/months. It is common in alcoholics due to cerebral atrophy causing increased
stretching of veins.
Next question
Head injury
Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial
trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury.
Types of traumatic brain injury

Bleeding into the space betw een the dura mater and the skull. Often results from acceleration-deceleration trauma or a
blow to the side of the head. The majority of extradural haematomas occur in the temporal region w here skull fractures
cause a rupture of the middle meningeal artery.
Extradural
haematoma
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haematoma Features
Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either
acute or chronic.
Subdural
haematoma Risk factors include old age and alcoholism.
Slow er onset of symptoms than a extradural haematoma.
Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral aneurysm, but may be seen in association w ith other
haemorrhage injuries w hen a patient has sustained a traumatic brain injury.
Pathophysiology
Primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury)
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons
Intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral
(contre-coup) to the side of impact
Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The
normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and
hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Management
Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV
mannitol/ frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of
formal craniotomy flap
Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if
there is minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan.
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.
Interpretation of pupillary findings in head injuries

Pupil size Light response Interpretation
Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to tentorial herniation
Bilaterally dilated Sluggish or fixed Poor CNS perfusion

Bilateral 3rd nerve palsy
Unilaterally dilated or equal Cross reactive (Marcus - Gunn) Optic nerve injury
Bilaterally constricted May be difficult to assess Opiates

Pontine lesions
Metabolic encephalopathy
Unilaterally constricted Preserved Sympathetic pathway disruption
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Question 16 of 35
A 28 year old women collapses and is found to be deeply comatose with a GCS of 3. She is admitted to hospital, intubated and ventilated. A CT scan
shows an extensive sub arachnoid haemorrhage. A urinary catheter is inserted. What type of urine output would be expected?
85ml concentrated urine per hour
30ml diluted urine per hour
300ml concentrated urine per hour
Next question

An extensive CNS insult is likely to result in cerebral salt wasting (low Na, low plasma osmolality and high urine output) or centrally mediated diabetes
insipidus (high Na, high plasma osmolality and high urine output). This may either be the result of hypothalamic injury directly or the result of
disruption of the hypothalamic-pituitary connections. The result is a large volume diuresis with diluted urine.
Spontaneous intracranial haemorrhage

Most commonly sub arachnoid haemorrhage. It is due to intra cranial aneurysm in 85% cases. Approximately 10% of cases will have normal
angiography and the cause will remain unclear. Patients with inherited connective tissue disorders are at higher risk although most cases are
sporadic.
>95% cases will have headache (often thunderclap)
>15% will have coma
Investigation
CT scan for all (although as CSF blood clears the sensitivity declines)
Lumbar puncture if CT normal (very unlikely if normal)
CT angiogram to look for aneurysms.
Management
Supportive treatment, optimising BP (not too high if untreated aneurysm) and ventilation if needed.
Nimodipine reduces cerebral vasospasm and reduces poor outcomes.
Untreated patients most likely to rebleed in first 2 weeks.
Patients developing hydrocephalus will need a V-P shunt (external ventricular drain acutely).
Electrolytes require careful monitoring and hyponatraemia is common.
Treatment of aneurysm
>80% aneuryms arise from the anterior circulation
Craniotomy and clipping of aneurysm is standard treatment, alternatively suitable lesions may be coiled using an endovascular approach. Where
both options are suitable data suggests that outcomes are better with coiling than surgery.
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Question 17 of 35
A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present. Which one of
the following diagnoses needs to be urgently excluded?
Weber's syndrome
Internal carotid artery aneurysm
Multiple sclerosis
Posterior communicating artery aneurysm
Anterior communicating artery aneurysm
Next question
Painful third nerve palsy = posterior communicating artery aneurysm
Given the combination of a headache and third nerve palsy it is important to exclude a posterior communicating artery aneurysm
Third nerve palsy
Features
eye is deviated 'down and out'
ptosis
pupil may be dilated (sometimes called a 'surgical' third nerve palsy)
Causes
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm (pupil dilated)
cavernous sinus thrombosis
Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis
*this term is usually associated with sixth nerve palsies but it may be used for a variety of neurological presentations
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Question 1 of 18
A 23 year old man was driving a car at high speed whilst intoxicated, he was wearing a seat belt. The car collides with a brick wall at around
140km/h. When he arrives in the emergency department he is comatose. His CT scan appears to be normal. He remains in a persistent vegetative
state. What is the most likely underlying cause?
Extradural haemorrhage
Sub dural haemorrhage
Intracerebral haemorrhage
Diffuse axonal injury
Next question
Diffuse axonal injury occurs when the head is rapidly accelerated or decelerated. There are 2 components:
1. Multiple haemorrhages
2. Diffuse axonal damage in the white matter
Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal
damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.
Head injury

Extradural
haematoma Features
acute or chronic.
Subdural
Pathophysiology
hypoxia
eMRCS 19/07/2015
Management



Pontine lesions
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A 8.4%
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B 8.3%
C 8.5%
D 10%
E 64.7%
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Question 2-4 of 18
Theme: Visual defects
A. Right homonymous hemianopia

B. Left homonymous hemianopia
C. Right superior quadranopia
D. Left superior quadranopia
E. Right inferior quadranopia
F. Left inferior quadranopia
G. Upper bitemporal hemianopia
H. Lower bitemporal hemianopia
What is the most likely visual field defect for the scenario given? Each option may be used once, more than once or not at all.
2. A 42 year old woman is admitted to the vascular ward for an endarterectomy. Her CT report confirms a left temporal lobe infarct.
You answered Left homonymous hemianopia
The correct answer is Right superior quadranopia
Temporal lesions cause a contralateral superior quadranopia. Think temporal area is at the top of the head i.e. superior quadranopia.
3. A 22 year old man is referred to urology with possible urinary retention. He is passing huge amounts of urine. Post void bladder ultrasound
is normal.
You answered Right inferior quadranopia
The correct answer is Lower bitemporal hemianopia
Theme from January 2012 exam

This patient has diabetes insipidus due to a craniopharyngioma. Lesions at the optic chiasm classically produce a bitemporal hemianopia,
however note lesions that spread up from below ie pituitary tumours, the defect is worse in the upper fields and if a lesion spreads down
from above ie craniopharyngiomas, the visual defect is worse in the lower quadrants. Therefore this patient is likely to have a lower
bitemporal hemianopia.
4. A 53 year old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct.
Right inferior quadranopia
Parietal lesions cause a contralateral inferior quadranopia.
Next question
Superior quadranopia = temporal lobe lesion

Inferior quadranopia = parietal lobe lesion
Visual field defects

Theme from April 2012 exam
left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex
eMRCS 19/07/2015
Homonymous hemianopia
Incongruous defects: lesion of optic tract
Congruous defects: lesion of optic radiation or occipital cortex
Macula sparing: lesion of occipital cortex
Homonymous quadrantanopias
Superior: lesion of temporal lobe
Inferior: lesion of parietal lobe
Mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
Lesion of optic chiasm
Upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
Lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
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2 43.3%
3 37.9%
4 46.3%
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Question 5 of 18
A middle aged lady is brought to the clinic by her husband who has noted a change in her appearance. She finds removal of rings difficult, her shoe
size has changed and photographs show a marked change in her appearance. Which of the following is most likely to be identified on neurological
examination?
Bi nasal hemianopia
Bi temporal hemianopia
Inferior quadrantanopia
Unilateral loss of vision
Next question

The patient is most likely to have developed acromegaly. Since a pituitary lesion is likely to be present; compression of the optic chiasm may occur.
Visual field defects

Theme from April 2012 exam
left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex
Incongruous defects: lesion of optic tract
Congruous defects: lesion of optic radiation or occipital cortex
Macula sparing: lesion of occipital cortex
Homonymous quadrantanopias
Superior: lesion of temporal lobe
Inferior: lesion of parietal lobe
Mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
Lesion of optic chiasm
Upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
Lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
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Question stats
A 8.5%
B 62%
C 9.1%
D 13.1%
E 7.3%
62% of users answered this question correctly
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Question 6-8 of 18
Theme: Intra cranial haemorrhage
A. Acute sub dural haematoma

B. Chronic sub dural haematoma
C. Acute extradural haematoma
D. Chronic extradural haematoma
E. Intraventricular haemorrhage
F. Sub arachnoid haemorrhage
Please select the most likely intra cranial bleeding event to account for the scenario described. Each option may be used once, more than once or
not at all.
6. A 28 year old man is playing tennis when he suddenly collapses and has a GCS of 4 when examined.
You answered Acute extradural haematoma
The correct answer is Sub arachnoid haemorrhage

A sudden collapse and loss of consciousness is most likely to be due to a sub arachnoid haemorrhage. The other potential causes in the list
usually occur as a sequel to a traumatic event, which has not occurred here.
7. A 2 day old premature neonate is born by emergency cesarean section for maternal illness. The baby is noted to become floppy and
unresponsive.
You answered Sub arachnoid haemorrhage
The correct answer is Intraventricular haemorrhage
Neonatal deterioration in premature babies is not infrequently due to intra ventricular haemorrhage. In extreme prematurity the prognosis
can be very poor.
8. A 78 year old man is brought to the emergency department by the police. He is found wandering around the town centre and is confused.
His family report that he is usually well apart from a simple mechanical fall 3 weeks previously from which he sustained no obvious injuries.
Chronic sub dural haematoma
The injuries that are responsible for chronic sub dural haematomas are usually fairly trivial and forgotten by the patient and their families.
The onset of symptoms can be insidious with vague symptomatology and confusion predominating.
Next question
Intra cranial haemorrhage
Extradural Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow
haematoma to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a
Features
eMRCS 19/07/2015
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either
haematoma acute or chronic.
Intracerebral Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas
haematoma 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.
Intraventricular Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it
haemorrhage does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood
may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it
is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.
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7 90.4%
8 76.4%
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Question 9-11 of 18
Theme: Management of head injuries
A. Intravenous mannitol
B. Parietotemporal craniotomy
C. Burr Hole decompression
D. Posterior fossa craniotomy
E. Insertion of intracranial bolt monitor
F. Discharge
G. Intravenous frusemide
What is the best immediate management plan for the injury described? Each option may be used once, more than once or not at all.
9. A 25 year old cyclist is hit by a bus traveling at 30mph. He is not wearing a helmet. He arrives with a GCS of 3/15 and is intubated. A CT
scan shows evidence of cerebral contusion but no localising clinical signs are present
You answered Parietotemporal craniotomy
The correct answer is Insertion of intracranial bolt monitor
This patient may well develop raised ICP over the next few days and Intracranial pressure monitoring will help with management.
10. A 32 year old rugby player is crushed in a scrum. He is briefly concussed but then regains consciousness. He then collapses and is brought
to A+E. His GCS on arrival is 6/15 and his left pupil is dilated.
You answered Insertion of intracranial bolt monitor
The correct answer is Parietotemporal craniotomy
This man needs urgent decompression and extradural haematoma is the most likely event, from a lacerated middle meningeal artery. The
debate as to whether Burr Holes or craniotomy is the best option continues. Most neurosurgeons would perform a craniotomy. However,
rural units and those units without neurosurgical kit facing this emergency may resort to Burr Holes.
11. A 30 year old women is injured in a skiing accident. She suffers a blow to the occiput and is concussed for 5 minutes. On arrival in A+E she
is confused with GCS 10/15. A CT scan shows no evidence of acute bleed or fracture but some evidence of oedema with the beginnings
of mass effect
You answered Intravenous frusemide
The correct answer is Intravenous mannitol
This women has raised ICP and mannitol will help reduce this in the acute phase.
Next question
Head injury management- NICE Guidelines
Summary of guidelines
All patients should be assessed within 15 minutes on arrival to A&E
Document all 3 components of the GCS
If GCS <8 or = to 8, consider stabilising the airway
Treat pain with low dose IV opiates (if safe)
Full spine immobilisation until assessment if:
eMRCS 19/07/2015
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if:
- Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
- Any focal neurology
- A CT head scan is being performed
- Initial plain films are abnormal
Immediate CT head (within 1 hour) if:

GCS < 13 on admission
GCS < 15 2 hours after admission
Suspected open or depressed skull fracture
Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear)
Focal neurology
Vomiting > 1 episode
Post traumatic seizure
Coagulopathy
Contact neurosurgeon if:

Persistent GCS < 8 or = 8
Unexplained confusion > 4h
Reduced GCS after admission
Progressive neurological signs
Incomplete recovery post seizure
Penetrating injury
Cerebrospinal fluid leak
Observations
1/2 hourly GCS until 15
Reference
1. http://guidance.nice.org.uk/CG56/QuickRefGuide/pdf/English
2. Hodgkinson S et al. Early management of head injury: summary of NICE guidance. BMJ 2014 (348):34-37.
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11 60.1%
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Question 12 of 18
A 25-year-old female with a history of bilateral vitreous haemorrhage is referred with bilateral lesions in the cerebellar region. What is the likely
diagnosis?
Neurofibromatosis type I
Neurofibromatosis type II
Tuberose sclerosis
Von Hippel-Lindau syndrome
Sarcoidosis
Next question
Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and
may lead to vitreous haemorrhage
Von Hippel-Lindau syndrome
Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene
located on short arm of chromosome 3
Features
cerebellar haemangiomas
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac tumours
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Question stats
A 9.8%
B 18.5%
C 24.4%
D 39.1%
E 8.2%
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Question 13-15 of 18
Theme: Head injury
A. Acute sub dural haematoma

B. Intra cerebral haematoma
C. Extra dural haematoma
D. Chronic sub dural haematoma
E. Basal skull fracture
F. Subarachnoid haemorrhage
G. Diffuse axonal injury
What is the most likely diagnosis for the scenario given? Each option may be used once, more than once or not at all.
13. A 18 year old boy is involved in a fall from a balcony whilst intoxicated. He has bruising over the mastoid area and is unconscious.
You answered Intra cerebral haematoma
The correct answer is Basal skull fracture
Bruising over the mastoid process of the temporal bone is battle's sign caused by a basal skull fracture.
14. A 18 year old boy falls off a balcony and hits the right side of the head. He is admitted to the emergency department and is initially lucid.
He is admitted for observation, and over the following twelve hours develops an increasing headache and confusion. A CT scan shows a
hyperdense collection of fluid with associated midline shift.
You answered Extra dural haematoma
The correct answer is Acute sub dural haematoma
Sub dural haematomas are the commonest intracranial mass lesions resulting from trauma. They are classified as acute, sub acute or
chronic according to tempo of onset. Acute sub dural haematomas will present within 72 hours of the original injury and have hyperdense
appearances on CT scanning.
15. A baby is brought to casualty unconscious and in a vegetative state. She has cigarette burns on her legs.
You answered Basal skull fracture
The correct answer is Diffuse axonal injury
The baby is likely to be a victim of shaken baby syndrome. This may result in diffuse axonal injury causing extensive lesions in the white
matter.
Next question
Head injury

Extradural
haematoma
eMRCS 19/07/2015
haematoma Features
acute or chronic.
Subdural
Pathophysiology
hypoxia
Management



Pontine lesions
Save my notes
eMRCS 19/07/2015
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13 86.6%
14 28.6%
15 62.2%
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Question 16 of 18
A 28 year old man falls and hits his head against a wall. There is a brief loss of consciousness. When assessed in accident and emergency he is alert
and orientated with a GCS of 15, imaging shows no fracture of the skull. What is his risk of having an intracranial haematoma requiring removal?
1 in 6000
1 in 40
1 in 4
1 in 50,000
1 in 120
Next question
Head injury and haematoma
Risk of haematoma (requiring removal) in adults attending accident and emergency units following head injury.
Injury Conscious level Risk of haematoma requiring removal
Concussion, no skull fracture Orientated 1 in 6000
Concussion, no skull fracture Not orientated 1 in 120
Skull fracture Orientated 1 in 32
Skull fracture Not orientated 1 in 4
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A 35.5%
B 18.7%
C 9.4%
D 10.8%
E 25.7%
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Question 18 of 18
Which of the following is not a form of primary brain injury?
Sub dural haemorrhage after being hit in the head with a hammer
Meningitis resulting from infected CSF rhinorrhoea after a basal skull fracture
A truck driver is involved in a road traffic accident and suffers an axonal stretch injury
A man is hit with a baseball bat and suffers a cerebral contusion
A man suffers an intraparenchymal haemorrhage after being hit in head during a car crash
Primary brain damage occurs at the point of injury. It includes contusions and diffuse axonal injury. Non reversible.
Secondary brain damage occurs after the injury. Complications include:
1. Haemorrhage
2. Meningitis
3. Herniation
4. Hypoxia
5. Oedema
6. Arterial damage: internal carotid, vertebral artery common
Head injury

Extradural
haematoma Features
acute or chronic.
Subdural
Pathophysiology
hypoxia
Management
eMRCS 19/07/2015



Pontine lesions
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D 8.2%
E 7.4%
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Head Injuries: Theme From April 2012 Exam

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eMRCS 19/07/2015

Sub dural bleed

Trans tentorial herniation

Sub arachnoid haemorrhage

Theme from April 2012 Exam

Risk factors include old age and alcoholism.

Slower onset of symptoms than a extradural haematoma.

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42.2% of users answered this question correctly

Theme: Intracranial bleeds

You answered Acute sub dural bleed

The correct answer is Sub arachnoid haemorrhage

Theme from April 2013 Exam

You answered Extra dural haemorrhage

The correct answer is Acute sub dural bleed

Intra cranial haemorrhage

Some patients may exhibit a lucid interval

Risk factors include old age and alcoholism.

Slower onset of symptoms than a extradural haematoma.

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Overall score: 25%

Theme: Cranial nerve lesions

You answered Facial nerve

The correct answer is Abducens nerve

You answered Accessory nerve

The correct answer is Optic nerve

You answered Vestibulocochlear nerve

The correct answer is Glossopharyngeal nerve

Cranial nerve lesions

Trochlear nerve The eye will not be able to look down.

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Overall score: 14.3%

Theme: Head injury- assessment

The correct answer is 6

Theme from 2011 Exam

The correct answer is 13

E=3, V=4, M=6.

The correct answer is 8

E=2, V=2, M=4.

Glasgow coma scale

Eye opening Spontaneous

Verbal response Orientated

Motor response Obeys commands

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Overall score: 10%

Theme from 2007 Exam

Sub arachnoid haemorrhage

Spontaneous intracranial haemorrhage

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41.1% of users answered this question correctly