BRAIN INJURY

SUDIHARTO
NEUROSURGERY DIVISION
SURGERY DEPARTMENT

INTRUCTIONAL OBJECTIVE

I.

Departement of Neurosurgery
Lecturer : DR. dr. P. Sudiharto
Topic of Lecture :
Head injury
1. Mechanism of head injury
2. Pathophysiology of head injury
a. Primary brain injury
b. Secondary brain injury
3. Diagnosis
a. History, physical and neurological examination
b. Laboratory tests
c. Imaging studies
4. Principles of head injury management
a. Initial management
b. Early management of increased intracranial
pressure
c. Surgical management

INTRUCTIONAL OBJECTIVE

I.

Departement of Neurosurgery
Lecturer : DR. dr. P. Sudiharto
Topic of Lecture :
Head injury
1. Mechanism of head injury
2. Pathophysiology of head injury
a. Primary brain injury
b. Secondary brain injury
3. Diagnosis
a. History, physical and neurological examination
b. Laboratory tests
c. Imaging studies
4. Principles of head injury management
a. Initial management
b. Early management of increased intracranial
pressure
c. Surgical management

DEFINITION
Head injury is defined an injury to any
part of the head (e,g, face, skull)
Brain injury denotes damage to the
brain. That head and brain injuries can
occur in combination (Ruff, R, 2005)
Craniocerebral injury can involve
scalp. Skull or brain in any
combination (Pitts & Nockels, 1994)

Mechanism of Head Injury

Skull molding occurs at site of impact

A : pre injury contour

B : subdural veins (bridging vein) torn as brain rotates forward

C : contour after impact with inbending at point A and outbending at vertex

D : direct trauma to inferior temporal and frontal lobes

S : shearing strains throughout brain

MECHANISTIC CAUSES OF
HEAD INJURIES
Head injuries are due to one of two basic
mechanisms, contact or acceleration
injuries

PROCESSES AND FACTORS LEADING TO SECONDARY BRAIN

INJURY

Mass lesion, brain shift and herniation

- Intracranial hematoma (EDH, SDH,ICH)
Focal brain Swelling, edema
Cerebral ischemia
- Reduced cerebral perfusion pressure
- Hypotension
- Intracranial hypertension
- Cerebral vasospasm
- Hypoxaemia
- Seizures
- Hyperthermia
- Infection

PRIMARY HEAD INJURY

(Gennarelli, TA, 1990)
Skull Fracture

Focal Injuries

Diffus Injuries

- Linear
- Depressed
- Basilar

- Contusions
* Coup
* Centre coup
* Intermediate
- Hematomas
* Extradural/epidural
* Subdural
* Intracerebral

- Concussion
* mild
* classic
- Diffus axonal injury
* Mild
* Moderate
* severe

DIAGNOSIS OF BRAIN INJURY IS

BASED UPON :
A.
B.
C.
D.
E.

HISTORY
PHYSICAL EXAMINATION
NEUROLOGIC EXAMINATION
LABORATORY TESTS
IMAGING STUDIES

A. HISTORY

The clinical history is a most important factor in

head injury and should include :
The cause of the injury
Severity of the blow
The time, place and details of the accident
The presence of early neurologic abnormalities
(weakness, speech deorder, seizures, loss of
consciousness)
The past medical history (diabetes, hypertension)
A history of alcohol or any drugs consume

B. PHYSICAL EXAMINATION
Initial examination should be rapid and systematic
Attention must be directed to assesment of other mayor
injuries (spinal, chest, abdominalm extremities)
Inspect and feel the entire scalp
Note any injuries to the aye
Inspect the face for evidence of maxillary and mandibular
fractures
Basal skull fractures maybe recognized by the presence of :
- fresh bleeding from an ear
- cerebrospinal fluid otorrhea or rinorrhea
- bilateral ecchymoses confined to the orbits

C. INITIAL NEUROLOGIC
EXAMINATION
Glasgow Coma Score
- eye opening
- motor response
- verbal response
Pupillary size and response to light, and symmetry
Eye movement
Motor power, symmetry of limb movement
Gross sensory examination
Reflex activity
Cranial nerve deficit

D. LABORATORY TESTS

Complete blood count

Blood urea nitrogen, creatinin
Blood sugar
Blood gas analysis
urinalysis

E. IMAGING STUDIES

Skull X-rays
Computerized tomography scan
(CT Scan)
Magnetic Resonance Imaging
(MRI)

TATALAKSANA
P
R
I
M
A
R
Y
S
U
R
V
E
Y

AIRWAY & C-SPINE CONTROL

BREATHING

CIRCULATION

KONSEPNYA
RESPONSIBILITAS TERPENTING
MANAJEMEN ABC : CEGAH

HIPOVENTILASI DAN HIPOVOLEMIA

POTENSIAL TERJADINYA
SECONDARY BRAIN DAMAGE

SCALP
SKULL
MENINGES
BRAIN
LCS
TENTORIUM
GCS
ICP

MENINGES
Tiga lapis : duramater, arachnoid, piamater
Arteri Meningea Media, potensial terlibat pada kasus EDH

CAIRAN SEREBROSPINAL
Diproduksi oleh pleksus koroideus
Rata-rata 30 ml per jam
Bersirkulasi

TENTORIUM
Membagi 2 ruangan intrakranial
Supratentorial dan Infratentorial

CEREBRAL PERFUSION PRESSURE ( CPP )

Merupakan PRIORITAS UTAMA
Rumus : CPP = Mean Arterial Pressure - ICP

CEREBRAL BLOOD FLOW ( CBF )

Normal : 50 ml/100 gram otak/ menit
Bila mencapai 5 ml/ menit :
cell death & irreversible damage

TEKANAN INTRAKRANIAL
Normal : 10 mmHg ( 136 mm air )
Makin tinggi TIK makin jelek prognosis

HUKUM MONRO-KELLIE
Prinsip : total volume intrakranial bersifat TETAP,
Oleh karena kranium merupakan NON EXPANSILE BOX

Monro Kellie
Vk = V darah + V likwor + V parenkim
mmHg

Fatal
100

Tekanan
Intrakranial

60
50

Disfungsi
Otak
50

40
30

Obati
20
Volume Intrakranial

Normal

10
0

KOMPONEN MATA

KOMPONEN MOTORIK

KOMPONEN VERBAL

Fraktur Impresi

CT scan
Impresi Fraktur

TINDAKAN OPERATIF FRAKTUR DEPPRESI

BASILAR SKULL
FRACTURES

EPIDURAL
HEMATOM
Epidural

PERJALANAN KLINIK EDH

ACUTE
EPIDURAL
HEMATOMA

Subdural hematom

Pre operasi

Pasca Operasi

Intraserebral
hematom

Korpus
Alienum

FUNGSI OTAK
Sisi dominan untuk yang tidak kidal adl yg
sebelah kiri
Orang kidal, 75 % sisi dominan adalah kiri
Fungsi sisi dominan adalah untuk bahasa
dan memori yang berdasarkan bahasa
Sisi kanan untuk memori visual

LOBUS FRONTALIS
1. PRE-SENTRAL GIRUS
Pusat motorik untuk muka, tangan, kaki,
badan, dsb.
2. AREA BROCA
Pada sisi dominan adalah pusat bicara
ekspresif motorik
3. AREA MOTOR TAMBAHAN
Untuk gerakan mata dan kepala sisi yang
berlawanan
4. AREA PRE-FRONTAL
Untuk inisiatif dan personalitas
5. PARASENTRAL LOBUS
Pusat penahan BAK dan BAB