Contusion


Background
  1. Bruises on the surface of the brain
  2. Position of injury
  3. Multiple areas can be contused by a single impact
  4. Contusions are often associated with other intracranial injuries

Pathophysiology

  1. Develop in the gray matter on brain surface; taper into white matter
  2. Parenchymal blood vessels damaged
    • Petechial hemorrhage (small, scattered areas)
    • Edema of area
  3. May see blood in subarachnoid area over involved gyrus
  4. Edema becomes more widespread
    • Local mass effect
    • Local ischemia/ infarction
    • Areas become necrotic
    • Cystic cavities form within areas

Diagnosis

*** Clinical presentation is often delayed

  1. History/ Exam
    • Head trauma with LOC
    • LOC may be brief
    • Confusion/ obtundation often
    • Variable neuro exam
    • Asymptomatic
    • Focal exam findings
      • Esp. if contusion near sensorimotor cortex
    • Ataxia
    • May see significant neuro problems
      • Seizures
      • Increased ICP
  2. Lab studies
    • Hgb/Hct, WBC count, platelets
      • Serial Hgb/Hct not useful as screening test for occult bleeding
    • Comprehensive chem panel
      • Electrolytes, glucose
      • BUN and creatinine
    • Amylase, transaminases
    • Coagulation studies
      • PT, PTT
    • Urinalysis
    • Type & cross
    • Toxicology screen
      • Serum AND urine
      • Serum ETOH level
  3. Diagnostic imaging
    • CT head (non-contrast)
      • Heterogenous/ irregular areas
        • Mixed hemorrhage, infarction, necrosis
      • Surrounding tissue often hypodense
        • Edema
      • May be at site of impact (coup) or directly opposite (contrecoup)
      • Begin to degrade after 3-4 days
    • MRI
      • More useful after 3-4 days

Treatment

  1. ABCs, IV, O2, cardiac monitor
  2. Watch for signs of increased ICP
    • Hypotension
    • Decreasing mental status
    • Nausea
    • Pupil changes, papilledema
  3. Treat increased ICP
  4. Seizures:
    • Acute seizures:
      • Lorazepam: 1 to 2 mg IV q 5 min up (max :4 mg)
      • Diazepam (0.1 mg/kg IV (up to 5 mg) q 5 minutes (max: 20 mg)
    • Long-term or prophylactic Tx:
      • Phenytoin:
        • Load: 15-20 mg/kg IV (give at < 50 mg/min)
        • May follow with 100-150 mg after 30 min
  5. Neurosurgeon consult for:
    • Positive CT
    • Negative CT with neurological deficit

 

Disposition

  1. Admit all patients
  2. Trauma/ neurosurgical consult