Injuries to the Carotid.
—Injuries to the carotid within the cranium are exceedingly rare. Still, it has been injured in basal fractures and penetrating wounds.
Arteriovenous Aneurysm.
—Development of arteriovenous aneurysms after basal injuries is occasionally noted. They will occasionally give rise to pulsating exophthalmos. Pulsating tumors within the orbit which push the eye forward not infrequently occur after serious head injury. Of 77 cases collected by Rivington, 41 had a traumatic origin.
Subdural Hemorrhages.
—Subdural hemorrhages are not infrequent in the skulls of the newborn, and constitute the so-called apoplexia neonatorum. They may occasion convulsions and paralyses of irregular type, while if the extravasations become infected multiple abscess may result.
In adults subdural hemorrhages are most commonly connected with brain lesions which have been already spoken of as contusions. They may be the starting points for pachymeningitis. Their most common results are disturbances of consciousness and mentality. Paralytic dementia follows in some of these cases. Extensive subdural hemorrhage may give a clinical picture corresponding to extradural. Disseminated minute ecchymoses constitute minute focal lesions, which are, however, usually so distributed as to confuse and prevent accurate diagnosis. Apoplexy or intraventricular hemorrhages, especially from the lenticulostriate artery (Charcot’s “artery of hemorrhage”), have until very recently never been regarded as warranting surgical interference. Of late, however, especially in the ingravescent or progressive forms, ligature of the common carotid has been of some service, though in order to render this effective ligation should be done early.
Traumatic Intraventricular Hemorrhage.
—Traumatic intraventricular hemorrhage occurs in much the same way as meningeal, by contre-coup. Individuality of symptoms is lost in the general comatose condition of the patient, but when operation is performed, as it is usually best to perform it, if no extradural clot be found and if brain tension be evidently increased, the dura should be opened; after which, if no subdural clot be seen, the ventricles should be tapped with an exploring instrument. In this case, if blood be removed by aspiration, a knife should be passed directly into the ventricle, after which blood, if present, will promptly escape. Dennis was the first to diagnosticate the presence of intraventricular clot and to deliberately incise into it, and I have myself repeatedly imitated this procedure, both with and without success.
In every case in which superficial or cortical hemorrhage can be recognized—or even suspected—or intraventricular hemorrhage as well, one should insist upon exploration. This means trephining, with perhaps aspiration of the ventricular contents. Tapping of the ventricle is described under Treatment for Hydrocephalus, while trephining is described at the end of this chapter.