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Total: 7 (Severe)
Total = M+V+E = 3-15
• Severity GCS Death/Vegetative
– Mild 14-15 5%
– Moderate 9-13 27%-54%
– Severe 3-8 54%-80%
• ~ 1500 ml
– 85- 90% brain
– 10% intravascular cerebral blood volume
– <3% CSF
Compliance
• Based on the pressure volume index
within the intracranial vault
Compliance = change in volume
change in pressure
Intracranial compliance
Head injury
Cerebral edema
Herniation
Intracranial compartment
• Divided into 3 compartments by 2 major
dural structures:
1. Tentorium cerebelli
– supra (cerebral hemispheres) and infratentorial
(brainstem and cerebellum) compartments
2. Falx cerebri
– divides the supratentorial compartment into left and
right hemispheres
Herniation
• Displacement of a portion of the brain from
its normal compartment into another one
• Terminal event: ischemia infarction
• Types of herniation syndromes:
1. Uncal or transtentorial
2. Cingulated or subfalcine
3. Central transtentorial herniation
4. Tonsillar herniation
Uncal / Transtentorial
Herniation
• Most dramatic and most common herniation
syndrome
• Herniation of the inferomedial part of the
temporal lobe (uncus) into the tentorial notch
• Progressively impaired consciousness,
anisocoria (ipsilateral), hemiplegia &
hemiparesis (contralateral)
• Compress third cranial nerve
Cingulated / Subfalcine
Herniation
• Cingulate gyrus on the medial aspect of the
frontal lobe is displaced across the midline
under the free edge of the falx
• may compromise blood flow through the
anterior cerebral artery complexes
• Headache, weakness of the lower
extremities (contralateral), NO anisocoria
• Can occur in conjunction with transtentorial
herniations
Central Herniation
• Downward displacement of the
diencephalons and midbrain centrally thru
the tentorial incisura
• May cause significant upper brainstem
compression
• bilaterally small reactive pupils, Cheyne-
Stokes respirations, loss of vertical gaze,
bilateral arm dysesthesia, obtundation
Tonsillar herniation
• Results from acute expansion of posterior fossa
lesions
• cerebellar tonsils herniate thru the foramen
magnum into the upper spinal canal,
compressing the medulla and upper cervical
spinal cord
• cardiorespiratory arrest, hypertension, Cheyne-
Stokes respiration, neurogenic hyperventilation,
impaired consciousness, pposturing problems
• worst prognosis
Patient
• GCS of 7 (severe head injury)
• Linear fracture on L temporal area
• L = withdraws to pain, R = extended
(decerebrate)
• No verbal output
• Pupils R = 3mm RTL, L = nonreactive
(anisocoric)
Uncal or Transtentorial
Herniation
Anisocoria
Uncal herniation