Delayed intracranial haemorrhage in patients with multiple trauma and shock-related hypotension

During an 11 year period, 10 cases of delayed traumatic intracranial haematomas, following the correction of shock, were discovered. The intracranial haematomas were not present on initial computerized tomography (CT) scans after stabilization of the vital signs. Skull fractures were found in six patients; five of them had epidural haematomas at the site of their skull fracture. Four patients developed intracranial haematomas during general anaesthesia for extracranial surgery. All the delayed intracranial haemorrhages (seven epidural haematomas and three delayed intracranial haematomas) occurred within 12 hours after initial resuscitation. Seven out of eight patients made a good recovery after surgical removal of their intracranial haematoma. The initial hypotension may have acted as a protective mechanism, obscuring the intracranial haemorrhage. Awareness of this possibility, and a high degree of suspicion in those patients who deteriorate following correction of their shock, is important. We suggest that, even with a negative initial CT scan the duration of extracranial surgery in the acute period should be as short as possible in patients with suspected head injury. If these patients fail to wake up as expected following anaesthesia or new neurologic deficits develop, an urgent follow up CT scan should be performed.