HEAD INJURY By Dr. Keiza .N.

DEFINITION
Trauma to the head. Neurological disruption. Variable presentation.

INCIDENCE
In the USA, 500,000 new cases 10% die before hospital. 10% are severe. 10% are moderate. 80% are mild. Many deaths and comorbidities can be reduced through prompt referral .

ANATOMY
Scalp- five layers: skin, connective tissue, aponeurosis ,loose areolar tissue and pericranium skull: cranial vault- smooth, some areas thin. pterion cranial base is irregular- anterio and middle cranial fossa Meninges: three layers. Dura mater,arachnoid and pia. Brain specific functions

ANATOMY(cont)
Cerebrospinal fluid-30ml per hour, from choroid plexus Tentorium- supra and infratentorial compartments .Tentorial incisura edge closely related to third cranial nerve and uncus

PHYSIOLOGY
Intracranial pressure normal 10mmHg or 136 mm water. Above 20mmhg is abnormal Monroe Kellie doctrine -brain+blood +csf is a constant. Initial compensation, eventually exponential rise. Cerebral perfusion CPP=MAP-ICP. Perfusion pressure of <70mmhg is critical Cerebral perfusion normal is 50ml/100g of brain

CLASSIFICATION
Mechanism of injury- blunt or penetrating Severity of injury-GCS Morphology of injury- skull or intraparenchymal Primary or secondary

SKULL FRACTURE
Linear Depressed These could be open or closed

PATHOLOGY
Primary brain injury- at impact Secondary-complications-: -haematoma -brain swelling -hypoxia -infection

INTRACRANIAL BLEED
Epidural Subdural Subarachnoid intracerebral

MANAGEMENT
History Physical examination Radiological investigations skull radiograph, cat scan, MRI

PRIMARY SURVEY
A.-ABCDE B-Immobilize and stabilize the cervical spine C-Perform a brief neurological exam 1.pupillary response. 2.GCScore determination.

SECONDARY SURVEY
A-.Inspect the entire head. Remove dressings ,look for lacerations or csf B-Palpate for fractures including the wounds C-Inspect all scalp lacerations-look out for brain,depressed fractures,debris or csf D-Minineurological examination--GCS -BEST - -Eye -Motor - - Verbal Pupillary response E-Examine cervical spine F-Determine the extend of the injury G-Regular reassessment

INVESTIGATIONS
A-Radiographs B-CT SCAN -scalp -bone -subdural/epidural space -surface sulci -brain parenchyma -ventricles -midline structures and basal cisterns -posterior fossa

SPECIFIC MANAGEMENT
MILD HEAD INJURY-GCS 14 or 15 -Approx 80% of pts in A &E have mild HI -majority recover fully -3% deteriorate suddenly -ideally, all with long period of loc should have a CT scan -ideally admit for observation for 24 hours -advise to come back in case of any warning signs

MODERATE HEAD INJURY

GCS 9-13 Approx 10 % of patients in A&E departm May have focal signs. 10-20% may deteriorate Up to 40% have abnormal scans Admit even if CTscan is normal

SEVERE HEAD INJURY

GCS 3-8 Cannot follow commands Up to 30% are hypoxaemic13% hypotensive 12% anaemic Combination of hypoxia and hypotension leads up to 75% mortality. Admit all and protect airway from early

HAEMATOMA-SUBDURAL
CTscan confirmation Indications for surgery: -focal neurological signs -altered loc -features of raised ICP Burr holes or craniotomy

EPIDURAL HAEMATOMA
CT confirmation Usually ruptured middle meningeal artery occasionally dural venous sinus rupture Indication for surgery focal signs or raised ICP craniotomy

INTRACEREBRAL HAEMATOMA
Indication for surgery -raised ICP Safe access of the haematoma is very important Craniotomy Deficits may persist

LINEAR FRACTURE
Simple -no indication for surgery Compound- theatre for surgical debridement and stitching

DEPRESSED SKULL FRACTURE

Closed elevation in case it is significant Compond- Theatre for surgical debridement and elevetion Antibiotic cover

RAISED ICP
Ventillatory support Mannitol lasix

Extradural haematoma

Subdural haematoma

Bilateral subdural haematoma acute on chronic

Bilateral subdural haematoma MRI findings

Brain oedema

Post-craniotomy extradural haematoma

Post-craniotomy extradural haematoma

Intracerebral haematoma with marked brain swelling

Intracerebral haematoma