HEAD INJURY

(National Brain Centre Hospital & Siaga Hospital)

OVERVIEW

Head injury was first estimated occur in about 1 million years ago Evidenced skull damage on human predecessors now called Australopithecus africanus

Java > 300.000 years ago Peking > 100.000 years ago

Neanderthal > 40.000 years ago

Damage is found that there are two adjacent fracture lines in the posterior region of the skull

QS. Al-Maidah : 27-30 Tells the story of the first murder Adams children (Habil and Qabil) Qabil hit Habil with a rock to the head until Habil killed

BRAIN INJURY
As

defined by the National Head Injury Foundation a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.

HEAD INJURY-EPIDEMIOLOGY
1.5

million Non-fatal TBIs 370,000 Hospitalizations 80,000 cases of neurological sequela 52,000 Die from TBIs 4 billion annually for cost of treatment Peak incidence:

Males age 15-24 years

INTRODUCTION TO HEAD INJURIES

TIME IS CRITICAL Intracranial Hemorrhage Progressing Edema
Increased ICP Cerebral Hypoxia Permanent Damage

Severity is difficult to recognize Subtle signs Improve differential diagnosis

Improves survivability

1ST MANAGEMENT
Primary

survey survey therapy

Secondary Definitive

HEAD TRAUMA
Open

Skull compromised and brain exposed

Closed

Skull not compromised and brain not exposed

Head Trauma - 10

CRANIAL INJURY
Trauma must Linear Depressed Open Impaled Object

be extreme to fracture

DIRECT BRAIN INJURY TYPES

Coup

Injury at site of impact Injury on opposite side from impact

Contrecoup

Pathology of the Brain Injury:

* Not all the brain damage occurs at the time of injury * Basically two main stages of brain damage after injury - PRIMARY DAMAGE - SECONDARY DAMAGE * Last decade : Head CT Scan and MRI played very important role in diagnostic evaluation of head injury patients * Even with improved CT Scan and MRI, the precise type of damage may not be identifiable during life * The principal mechanism are : - CONTACT - ACCELERATION / DECELERATION

PRIMARY DAMAGE
* occurs at the moment of injury

* including : - laceration of the scalp

- fracture of the skull

- contusions and lacerations

- diffuse axonal injury

- intracranial hemorrhage
- other type of brain damage

SECONDARY DAMAGE * results from complicating processes that are

initiated at the moment of injury

* may not present clinically for a period of time afterward * including : - hypoxia / ischemia - swelling - infection - brain damage due to elevated intracranial pressure

BRAIN INJURY
Response to injury

Swelling of brain Vasodilatation with increased blood volume Increased ICP Decreased blood flow to brain Perfusion decreases Cerebral ischemia (hypoxia)

Head Trauma - 16

SIGNS & SYMPTOMS OF BRAIN INJURY

Altered Mental Status Altered orientation Alteration in personality Amnesia Retrograde Antegrade Cushings Reflex Increased BP Bradycardia Erratic respirations

- Vomiting Without nausea Projectile - Body temperature changes - Changes in pupil reactivity - Decorticate posturing

Assessment of Impaired Consciousness

Use practical scale Glasgow Coma Scale Three features are in dependently observed : Points * EYE OPENING Spontaneous 4 To speech 3 To pain 2 None 1 * BEST MOTOR RESPONSE Obeys commands 6 Localized to pain stimuli 5 Withdraws from pain stimuli 4 Decorticate flexion 3 Decerebrate extension 2 None 1 * VERBAL RESPONSE Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1

CLINICAL FEATURES Clinical Features Radiological Exam Pathologic name

Mild Head Injury

unconsc < 10 GCS 13 15 no neuro deficit

brain CT normal

Concussion

Moderate Head Injury unconsc 10-<6hrs brain CT abnormal Contusion GCS 9 12 pos neuro deficit Severe Head Injury unconcs > 6 hrs GCS 3 9 pos neuro deficit brain CT abnormal Contusion

SIMPLE HEAD INJURY GCS 15 no neuro deficit no unconsc

DIRECT BRAIN INJURY CATEGORIES

Focal Occur at a specific location in brain Differentials Cerebral Contusion Intracranial Hemorrhage Epidural hematoma Subdural hematoma Intracerebral Hemorrhage Diffuse Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

FOCAL BRAIN INJURY

Cerebral Contusion Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma Confusion Neurologic deficit Personality changes Vision changes Speech changes Results from Coup-contrecoup injury

BRAIN INJURIES
Cerebral contusion

Bruising of brain tissue Swelling may be rapid and severe Level of consciousness Prolonged unconsciousness, profound confusion or amnesia Associated symptoms Focal neurological signs May have personality changes

Head Trauma - 22

FOCAL BRAIN INJURY

INTRACRANIAL HEMORRHAGE

Epidural Hematoma Bleeding between dura mater and skull Involves arteries

Middle meningeal artery most common

Rapid bleeding & reduction of oxygen to tissues Herniates brain toward foramen magnum

INTRACRANIAL HEMORRHAGE
Acute epidural hematoma Arterial bleed Temporal fracture common Onset: minutes to hours

Level of consciousness Initial loss of consciousness Lucid interval follows Associated symptoms Ipsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death
Head Trauma - 24

FOCAL BRAIN INJURY

INTRACRANIAL HEMORRHAGE

Subdural Hematoma Bleeding within meninges Beneath dura mater & within subarachnoid space Above pia mater Slow bleeding Superior sagital sinus Signs progress over several days Slow deterioration of mentation

INTRACRANIAL HEMORRHAGE
Acute subdural hematoma Venous bleed Onset: hours to days

Level of consciousness Fluctuations

Associated symptoms Headache Focal neurologic signs High-risk Alcoholics, elderly, taking anticoagulants

Head Trauma - 26

INTRACRANIAL HEMORRHAGE
Intracerebral hemorrhage

Arterial or venous Surgery is often not helpful Level of consciousness Alterations common Associated symptoms Varies with region and degree Pattern similar to stroke Headache and vomiting

Head Trauma - 27

FOCAL BRAIN INJURY

INTRACRANIAL HEMORRHAGE

Intracerebral Hemorrhage Rupture blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time

 Basal

Skull

Unprotected Spaces weaken structure Relatively easier to fracture

CRANIAL INJURY

Basal Skull Fracture Signs Battles Signs

Retroauricular Ecchymosis

Associated with fracture of auditory canal and lower areas of skull Raccoon Eyes

Bilateral Periorbital Ecchymosis

Associated with orbital fractures

BASILAR SKULL FRACTURE Battles sign Raccoon eyes

Head Trauma - 31

CRANIAL INJURY
Basilar Skull Fracture

May tear dura Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate for Target or Halo sign

CRAINIAL INJURIES
Penetrating trauma

Bullet fragments
Head Trauma - 33

EDH

SDH

SAH

ICH

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