What is the management for a contusion hematoma in the cranium due to a fall?

Management of Cranial Contusion Hematoma Following Fall

Immediate neurological evaluation with Glasgow Coma Scale assessment, pupillary examination, and urgent brain CT scan is mandatory to determine severity and guide treatment decisions. 1

Initial Assessment and Stabilization

Airway and hemodynamic management take absolute priority:

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion 1
• Secure airway with tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring if Glasgow Coma Scale motor score indicates severe injury 1
• Target PaCO2 between 35-40 mmHg; avoid hypocapnia as it causes cerebral vasoconstriction and ischemia 1
• Maintain PaO2 between 60-100 mmHg 1

Immediate neuroimaging is non-negotiable:

• Non-contrast CT scan of the brain characterizes hematoma size, location, mass effect, and identifies life-threatening lesions 2, 3
• Include both brain and bone windows to visualize fractures and underlying brain injury 3
• Consider CT-angiography if risk factors for vascular injury exist (cervical spine fracture, focal deficits unexplained by imaging, skull base fractures) 1

Surgical Indications

Urgent neurosurgical consultation and intervention are required for life-threatening brain lesions after hemorrhage control: 1

Specific surgical indications include:

• Subdural hematoma thickness >5 mm with midline shift >5 mm 1, 2
• Open displaced skull fracture requiring closure 1, 3
• Closed displaced skull fracture with brain compression (thickness >5 mm, mass effect with midline shift >5 mm) 1, 3
• Symptomatic extradural hematoma regardless of location 1
• Acute hydrocephalus requiring drainage 1
• Neurological deterioration despite medical management 1, 2

Craniotomy for hematoma evacuation should be considered as a lifesaving measure in deteriorating patients, despite uncertain functional benefit. 1 The 2022 AHA/ASA guidelines note a trend toward mortality benefit with surgery, and recent evidence suggests craniotomy may reduce mortality even when functional outcomes remain unclear 1.

Medical Management for Non-Surgical Cases

Conservative management is appropriate when:

• No signs of intracranial hypertension or neurological deterioration exist 2
• Hematoma is small with minimal mass effect 2
• No displacement or minimal displacement of fractures without significant underlying brain injury 3
• No dural tear or CSF leak present 3

Intracranial pressure management strategies:

• External ventricular drainage for persisting intracranial hypertension despite sedation and correction of secondary insults 1, 2
• ICP monitoring in comatose patients with radiological signs of intracranial hypertension 1
• Osmotic diuretics (mannitol 0.25-0.5 g/kg IV every 6 hours, maximum 2 g/kg) 4
• Hypertonic saline for clinical transtentorial herniation 4
• Elevation of head of bed 20-30 degrees to assist venous drainage 4

Avoid corticosteroids—they provide no benefit and may cause harm in traumatic brain injury. 4 Meta-analyses show no mortality benefit (RR 1.14,95% CI 0.91-1.42), and one RCT demonstrated increased mortality at 21 days (49% vs 23%, P<0.05) with dexamethasone 4.

Coagulation Management

For patients on anticoagulation:

• Verify anticoagulant/antiplatelet use immediately as these increase hematoma expansion risk 2
• Maintain platelet count >50,000/mm³ for systemic hemorrhage; higher values advisable for neurosurgery including ICP probe insertion 1
• Maintain PT/aPTT <1.5 times normal control during interventions 1
• For warfarin: consider reversal with prothrombin complex concentrates despite uncertain mortality benefit 1
• For dabigatran: idarucizumab 5g IV is the specific reversal agent 1

Monitoring and Follow-up

Serial neurological assessments are essential:

• Continuous monitoring of Glasgow Coma Scale, pupils, and focal deficits 2
• Elderly patients require particularly careful monitoring as small hematomas can expand rapidly, especially on anticoagulants 2
• Repeat CT imaging if neurological deterioration occurs 1, 2

Decompressive craniectomy may be considered for refractory intracranial hypertension in multidisciplinary discussion, particularly in younger patients (<65-70 years). 1, 2 This should be reserved for cases failing medical management 1, 4.

Critical Pitfalls to Avoid

• Never delay surgical intervention in symptomatic patients—this leads to neurological deterioration and worse outcomes 2
• Never attribute decreased consciousness solely to seizures in patients with seizure-related falls—these patients have 90.9% incidence of intracranial hematomas requiring high suspicion and early CT 5
• Never induce hypocapnia aggressively—it causes cerebral vasoconstriction and ischemia 1, 2
• Never use corticosteroids for brain swelling management in traumatic brain injury 4