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Head Injury

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Prehistorycal types of trepanation

1-вишкрібання 2-проскрібування канавки 3-пробуравлення і вирізання 4-шляхом прямокутних розрізів

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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

all causes

Home accident

car accident

Industrial injury

others

Череповець 100 78,2 9,7 9,1 3

Новосибірськ 100 70,9 18,6 5,7 4,8

Саратов 100 69,2 16,1 12,3 2,4

С.Петербург 100 67,6 12,5 15,3 -

Н.Новогород 100 57,5 15,7 10,3 16,5

Іжевськ 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

MalesCompression

Contusion

Concussion

Females 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

ClosedOpen

penetratingnot 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

Initial lesions contusion diffuse axon injury hemorrhages injury of cranial

nerves

Secondary lesions Intracranial

cerebral compression with hematomas

Vioaltion of CSF and blood circulation

Brain edema Extracranial

Anemia hypoxemia hypertermia

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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 consciousness1. 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 ScaleEye opening

Spontaneously 4 points

Opens eyes to voice 3 points

Opens eyes to pain 2 points

No eye opening 1 points

Best verbal response

Spontaneous, appropriate and oriented 5 points

Confused conversation, phrases only 4 points

One word speech, inappropriate words 3 points

Incomprehensible sounds only 2 points

No sounds 1 points

Best motor response

Obeys commands 6 points

Localizes pain 5 points

Withdraws to pain 4 points

Abnormal flexor response (decoricated rigidity) 3 points

Abnormal extensor response (decerebrated rigidity) 2 points

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 focuses1- direct blow on the right2-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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Поперечний зріз аксона, норма

Після травми. відсутні мікротрубочки

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Typical location of diffuse axon injury (кружечки) і вогнищ геморагій (заштиховані ділянки)

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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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Розрізи для доступу до задньої черепної ямки

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Removal of epidural hematoma

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Dendy’s point for puncture of posterior horn of lateral ventricle

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Kocher’s point for punction of anterior horn of lateral ventricle