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 Adam’s 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 TBI’s 370,000 Hospitalizations 80,000 cases of neurological sequela 52,000 Die from TBI’s 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 MANAGEMENTPrimary survey

Secondary survey

Definitive therapy

HEAD TRAUMA

Open • Skull compromised

and brain exposed

Closed• Skull not compromised

and brain not exposed

10Head Trauma -

CRANIAL INJURY

Trauma must be extreme to fracture Linear Depressed Open Impaled Object

DIRECT BRAIN INJURY TYPES Coup

Injury at site of impact

Contrecoup Injury on opposite

side from impact

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)

16Head Trauma -

SIGNS & SYMPTOMS OF BRAIN INJURY Altered Mental Status

Altered orientation Alteration in personality Amnesia

Retrograde Antegrade

Cushing’s 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’ brain CT normal Concussion GCS 13 – 15 no neuro deficit

Moderate Head Injury unconsc 10’-<6hrs brain CT abnormal Contusion GCS 9 – 12 pos neuro deficit

Severe Head Injury unconcs > 6 hrs brain CT abnormal Contusion GCS 3 – 9 pos neuro deficit

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

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FOCAL BRAIN INJURYINTRACRANIAL HEMORRHAGE

Epidural HematomaBleeding 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 HEMORRHAGEAcute epidural hematoma • Arterial bleed

Temporal fracture commonOnset: minutes to hours

• Level of consciousnessInitial loss of consciousness“Lucid interval” follows

• Associated symptomsIpsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death

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FOCAL BRAIN INJURYINTRACRANIAL 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 HEMORRHAGEAcute subdural hematoma• Venous bleed

Onset: hours to days• Level of consciousness

Fluctuations • Associated symptoms

HeadacheFocal neurologic signs

• High-riskAlcoholics, elderly, taking anticoagulants

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INTRACRANIAL HEMORRHAGEIntracerebral hemorrhage• Arterial or venous

Surgery is often not helpful• Level of consciousness

Alterations common• Associated symptoms

Varies with region and degreePattern similar to strokeHeadache and vomiting

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FOCAL BRAIN INJURYINTRACRANIAL HEMORRHAGE

Intracerebral HemorrhageRupture blood vessel within the brainPresentation similar to stroke symptomsSigns and symptoms worsen over time

Basal SkullUnprotectedSpaces weaken

structureRelatively

easier to fracture

CRANIAL INJURY

Basal Skull Fracture Signs Battle’s 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

Battle’s sign Raccoon eyes

31Head Trauma -

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

33Head Trauma -

Bullet fragments

EDH

SDH

SAH

ICH

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