Head Injury

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Head Injury
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Prehistorycal types of trepanation

• 1-???????????
• 2-?????????????? ???????
• 3-????????????? ? ?????????
• 4-?????? ??????????? ????????

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• Treatment of depressed skull fracture , XVI
  century

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Classification of Brain Injury, Petit, 1774

• Cerebral concussion (commotio cerebri)
• Cerebral contusion (contusio cerebri)
• Cerebral compression (compresio cerebri)

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Causes of death in different age groups

• other
• cardiovascular diseases
• trauma
• neoplasms
• head injury

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Occurrence of head injury in male and female

• Male
• Female

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Causes of head injury in Russia
Cities Percentage Percentage Percentage Percentage Percentage
Cities all causes causes causes causes
Cities all Home accident car accident Industrial injury others
?????????? 100 78,2 9,7 9,1 3
???????????? 100 70,9 18,6 5,7 4,8
??????? 100 69,2 16,1 12,3 2,4
?.????????? 100 67,6 12,5 15,3 -
?.????????? 100 57,5 15,7 10,3 16,5
??????? 100 52,3 15,2 5,4 27,5
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Causes of head injury in the USA

• Fall from e height
• Trafic accidents

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Structure of types of head injury in different
age groups and sex
Males Compression Contusion Concussion Fem
ales Compression
Contusion Concussion
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Classification of Head Injury
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On pathology basis

• focal
• diffuse

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depending on infection risk

• Closed
• Open
• penetrating
• not penetrating

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Clinical forms of head injury

• Cerebral concussion
• Brain contusion
• Mild
• moderate
• severe
• Diffuse axonal injury
• Cerebral compression
• Head compression

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Pathogenesis of head injury

• Secondary lesions
• Intracranial
• cerebral compression with hematomas
• Vioaltion of CSF and blood circulation
• Brain edema
• Extracranial
• Anemia
• hypoxemia
• hypertermia

• Initial lesions
• contusion
• diffuse axon injury
• hemorrhages
• injury of cranial nerves

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Pathology of head injury
concussion Lesions on level of cellular organelle, axons, synapses
mild contusion spot hemorrhages in cortex, local subarachnoidal hemorage
moderate contusion Primary necrosis in cortex and white substance, diffuse hemorages in 1-2 gyruses
Severe contusion Large necrosis and hemorages
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Clinical presentations of head injury

• Signs of injury on the scalp (wounds, contusion)
• Impaired consciousness
• Amnesia
• Focal neurological deficit
• Pupil asymmetry
• Cranial nerve deficit
• Paresis
• Reflex asymmetry and depression
• Aphasia
• Seizures

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Level of consciousness

1. Clear consciousness - full and adequate
   orientation and reactions. Possible amnesia.
2. Mild slight sleepiness, some time and place
   disorientantion, some slowness in command obey,
3. hypersomnia, disorientation, only elementary
   verbal contact is possible, obeys only simplest
   verbal instructions.
4. Stupor verbal contact is impossible, reactions
   and eye opening on pain are preserved.
5. Mild coma no eye opening, noncoordinated
   reactions on pain. Pupil and corneal reflexes are
   preserved.
6. Severe coma no response on pain, best motor
   response is extension or flexion. Pupil and
   corneal reflexes are decreased. Spontaneous
   respiration and blood circulation are preserved
   with probable violations.
7. Terminal coma no reflexes, muscle atonia,
   midriasis

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Glasgow Coma Scale
Eye opening Spontaneously 4 points
Eye opening Opens eyes to voice 3 points
Eye opening Opens eyes to pain 2 points
Eye opening No eye opening 1 points
Best verbal response Spontaneous, appropriate and oriented 5 points
Best verbal response Confused conversation, phrases only 4 points
Best verbal response One word speech, inappropriate words 3 points
Best verbal response Incomprehensible sounds only 2 points
Best verbal response No sounds 1 points
Best motor response Obeys commands 6 points
Best motor response Localizes pain 5 points
Best motor response Withdraws to pain 4 points
Best motor response Abnormal flexor response (decoricated rigidity) 3 points
Best motor response Abnormal extensor response (decerebrated rigidity) 2 points
Best motor response No movements 1 points
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Evaluation of consciousness after Glasgow coma
scale
Level of consciousness Points in GCS
Clear 15
Mild 13-14
Severe 11-12
Stupor 8-10
Mild coma 6-7
Severe coma 4-5
Terminal coma 3
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Severity of head injury

• mild (13-15 point in Glasgow coma scale)
  cerebral concussion, slight cerebral contusion
• moderate (8-12 point) mild cerebral contusion,
  subacute and chronic cerebral compression
• severe (3-7 point) severe cerebral contusion,
  diffuse axon injury, acute cerebral compression

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• mild cerebral contusion punctated hemorages

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• mild cerebral contusion

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• mild cerebral contusion

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• contusion

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• Mild cerebral contusion

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• Mild cerebral contusion (on MRI)

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• Two contusion focuses
• 1- direct blow on the right
• 2-countercoup on the left

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• Depressed skull fracture

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• Linear fracture of occipital bones with going to
  the skull base

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• fracture of parietal and frontal bones

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• Depressed fracture of parietal bone

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• Severe cerebral contusion

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• Severe cerebral contusion

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• Severe cerebral contusion

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• Severe cerebral contusion

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• Depressed fracture of parietal and temporal bones

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• Diffuse axon injury there are no macroscopic
  lesions

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• Axonal spheres at diffuse axon injury.

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• Typical location of diffuse axon injury
  (????????) ? ?????? ????????? (???????????
  ???????)

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• Diffuse axon injury on CT (no lesions)

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• Head compression

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Cerebral compression

• Acute manifestation during 24 hours after head
  injury
• Subacute manifestation during 1 week after head
  injury
• Chronic - manifestation after 1-2 weeks after
  head injury

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Causes of cerebral compression

• Hematomas
• Epidural
• Subdural
• Intracerebral
• Bone fragment at depressed fructures
• Pneumocephalus

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Main triad at cerebral compression

• Deterioration of consciousness level
• Ipsilateral anisocoria
• contrlateral hemiparesis

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• Epidural hematoma on the left
• Subdural hematoma on the right

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• Intracerebral hematoma

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• Epidural hematoma on CT

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• Epidural hematoma in posterior fossa

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• Subdural hematoma

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• Chronic bilateral subdural hematomas

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• Subacute hematoma

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• Localization of intracerebral hematomas

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• Intracerebral hematoma on MRI

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• Intracerebral hematoma

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• Intracerebral hematoma in the frontal lobe

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• Intracerebral hematoma

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• Combination of subdural and Intracerebral
  hematomas

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• Acute traumatic pneumocephalus

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Treatment of moderate and severe head injury

• Acute resuscitation
• Diagnostic procedures
• Definitive treatment

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TreatmentAcute resuscitation

• ABC
• Air pathway cleaning of throat, airway tube,
  tracheal tube
• Breathing
• Oxygen mask for stuporose and soporose patients
• Intubation for comatose
• Circulation
• Intravenous fluids for maintaining normal blood
  pressure
• Maintaining adequate perfusion pressure of the
  brain

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TreatmentDiagnostic procedures

• Neurological examination
• State of consciousness, GCS
• Major neurological deficit
• Pupillary reflexes and symmetry
• Ocular movement
• Lower brain stem reflexes
• Motor examination (hemiparesis, reflexes)
• Pulse rate, blood pressure
• Neurovisualization
• Plain X-ray examination
• CT
• Cerebral angiography
• Diagnostic bur holes and ventriculography
• MRI

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Definitive treatment

• Typical indications for surgery
• Epidural and subdural hematomas that cause
  depressed consciousness
• Intracerebral hematoma and contusion in comatose
  and soporose patients with significant
  mass-effect on CT
• Depressed skull fractures
• Gunshot wounds
• Insertion of Intacranial pressure monitor

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Periods of head injury

• Acute 2-4 weeks
• Intermediate 2-6 weeks
• Remote

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• bur hole

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• Approach to fronto-temporal and parieto-temporal
  lobes

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• Approach to frontal lobe

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• Approach to temporal lobe

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• Approach to parietal lobe

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• Approach to occipital lobe

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• Removal of epidural hematoma

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• Dendys point for puncture of posterior horn of
  lateral ventricle

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• Kochers point for punction of anterior horn of
  lateral ventricle