If the bleeding cannot otherwise be arrested it may be necessary to ligate the external carotid artery. It has been suggested by J. B. Murphy that, when the patient is seen while the symptoms of compression are coming on, instead of trephining, the hæmorrhage from the meningeal vessels should be arrested by applying a ligature to the external carotid, under local anæsthesia.
Injury to the internal carotid artery within the skull may result from penetrating wounds, or may be associated with a fracture of the base. It is almost invariably fatal. In some cases a communication is established between the artery and the cavernous sinus, and an arterio-venous aneurysm is thus produced. Ligation of the internal carotid in the neck or of the common carotid is the only feasible treatment.
Injuries of the venous sinuses may occur apart from gross lesions of the skull, but as a rule they accompany fractures and penetrating wounds. The transverse (lateral), superior sagittal (longitudinal), and cavernous sinuses are those most frequently damaged. On account of the low pressure in the sinuses, spontaneous arrest of extra-dural hæmorrhage usually takes place, and recovery ensues. In some cases, however, the amount of blood extravasated is sufficient to cause compression. If the dura mater is torn, and the blood passes into the sub-arachnoid space, it may spread over the whole surface of the brain. Sometimes the bleeding only commences after a depressed fracture has been elevated.
In the presence of an open wound, the venous source of the bleeding is recognised by the dark colour of the blood and the continuous character of the stream. It may be arrested by pressure with gauze pads or by packing a strand of catgut into the sinus (Lister), or, if this fails, by grasping the sinus with forceps and leaving these in position for twenty-four or forty-eight hours. A small puncture in the outer wall of the sinus may be closed with sutures. Signs of increasing compression call for trephining and opening of the dura if this is necessary to admit of the clot being removed.
Intra-cranial Hæmorrhage in the Newly-Born.—An extravasation of blood into the arachno-pial space frequently occurs during birth. The observations of Cushing seem to show that this is usually due to tearing of the delicate cerebral veins which pass from the cortex to the superior sagittal sinus, from the strain put upon them by the overlapping of the parietal bones, in the moulding of the head. It may sometimes be due to an excessive degree of asphyxia during birth. The extravasation is usually most marked over the central area of the cortex near the middle line, and it is often bilateral.
This condition is most frequently met with in a first-born child—and more often in boys than in girls—the labour having been prolonged and difficult, and the presentation abnormal. There is usually a history that the infant was deeply cyanosed when born, and that there was difficulty in getting it to breathe. As a rule, there is no external evidence of trauma. The anterior fontanelle is tense and does not pulsate, the pulse is slow, and for several days the child appears to have difficulty in sucking and swallowing, and is abnormally still. In the course of a few days definite symptoms of localised pressure appear. It is noticed that one leg or arm, or one side of the body is not moved, or both sides may be affected; when the paralysis is bilateral, the absence of movement is more liable to be overlooked. The infant may suffer from convulsions; there may be paralysis of certain of the ocular muscles, and inequality of the pupils; sometimes there is blindness. Persistent rigidity of the limbs, with turning of the thumbs towards the palm, is present in some cases. Lumbar puncture may reveal the presence of blood corpuscles in the cerebro-spinal fluid, and increase in the tension of the fluid.
If untreated, the condition is usually followed by the development of spastic paralysis of one or more limbs, on one or on both sides of the body (Little's disease), by blindness, deafness, and varying degrees of mental deficiency, or by Jacksonian epilepsy.
Treatment.—To obviate these after-effects the clot may be removed by raising an osteo-plastic flap, including nearly the whole of the parietal bone. The operation should be undertaken within the first week or two, and great care must be taken to keep up the body-warmth, and to prevent undue loss of blood. It may be necessary to operate on both sides, an interval being allowed to elapse between the two operations.
For the immediate relief of increased intra-cranial tension, the daily withdrawal of 10–12 c.c. of cerebro-spinal fluid by lumbar punctures may be employed, or a sub-temporal decompression operation may be performed.