Neurological assessment in head trauma

Neurological assessment include several measure used to define the severity

of head injury and important lines taken in management including diagnosis
and treatment.
Neurological assessment include following:
1-vital sign monitoring.
Blood pressure, pulse rate, respiratory rate and temperature .its important to
assess vital sign in head injured patient as disturbed these sign can give clue
to the associated intracranial hypertension in head trauma .
For example Cushing reflex (increased blood pressure with associated
bradycardia & hypoventilation) can occurs with sever head injury.
Cushing reflex opposite to shock

2-state of consciousness:
Consciousness is a state of arousal or awareness level or ability to react with
external environment .it can be affected by any brain insult ,so Glasgow
comma scale GCS is indicated in head trauma to assess the degree of head
injury and so the conscious level disability.
GCS consist of three main parameters: eye opening, best verbal response
and best motor response with total 15 points.
Eye opening 4 spontiously open eye
3 open to speech
2 open to painful stimuli
1 none
Best verbal response 5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
1 none
Best motor response 6 obey commands
5 localizing to pain
4 flexing to pain (flexion withdrawal)
3 abnormal flexion
2 extension
1 none
3-pupils examination:
Including pupillary size and reaction to light (light reflex).

1
The aspect optic oculomotor system can be tested by pupillary light reflex ,
which require the afferent link of optic nerves and tracts be intact as well as
the parasympathetic oculomotor outflow for the efferent link.

4-cranial nerves examination:

The twelve cranial nerves evaluation is mandatory as it can be injured by
trauma.
Abducent nerve (6th cranial nerve )commonly affected due to long
anatomical course in the skull so it may be injured at any area been
traumatized by pathology ,olfactory nerve (1st cranial nerve ) ,facial nerve
(7th cranial nerve ) vestibulocichlear nerve (8th cranial nerve ) can injured by
skull base fracture .

5-motor response:
Motor system examination should be carried out in trauma as patient may
have focal weakness or paralysis or hemiplegia.
Motor examination includes examination of bulk, power, tone, reflexes,
coordination and gait.

6-sensory response:
Sensory system review, including superficial (pain, temperature, tactile
sensation) and deep sensation (position and vibration sense).

7-respiration:
Cortical dysfunction due to trauma may result in respiratory irregularities in
form of cheyne-stokes breathing ,which demonstrate intermixed shallow
and deep respiration in cyclical fashion ,which result in overall
hypoventilation leading to hypercarbia and hypoxia .
Hyperventilation may occur at pons injury, ataxic or irregular respiration
may occur in injury at level of medulla.

8-herniation syndrome (coning):Due to increase ICP

Two types of coning, transtentorial and central.
transtentorial coning can be in downward direction due to the temporal
lobe uncus pressing on brainstem resulting ipsilateral third nerve
palsy ,Cushing reflex and decerebrate rigidity ,it can also occur in upward
direction in posterior fosse mass or bleed pushing cerebellar tissue up
through tentorial incisura.

2
Central coning occurs when there is herniation of cerebellum and medulla
down through foramen magnum resulting in cheyne stokes breathing, apnea
and neck stiffness.

8-brain stem death:

Intracranial swelling and brain damage may lead to cessation of all brain
function.

9-polysystmatic examination:
Multi systemic review and examination are mandatory as a part of
neurological assessment as associated polysystemic injury may be expected
like cardiovascular, respiratory, abdominal, musculoskeletal and
genitourinary, that’s why team work should involve in assessment and
management of head injured patient.

Management:
Include radiological evaluation, neurological assessment and treatment of
resulting lesion.
-radiology:
Skull x-ray
Brain ct-scan
Brain MRI
EEG electroencephalogram
Angiography
-treatment:
Treatment should be carried out at site of accident, during transport, at
emergency room, at intensive care unit ICU, at theatre and on ward.
Types of treatment:
1-ABC:
Airway, breathing, ciculation.
2-neurological assessment as we discussed before.
3-ICP intracranial pressure monitoring:
There is evidence that the monitoring of ICP and the management of
elevated ICP in comatose brain injured patient may significantly improve the
outcome of sever head injuries, as raised ICP will reduce cerebral perfusion.
4-nutritional support, fluid, electrolyte, and metabolic derangement support.
5-medical and surgical treatment of raised sign and symptoms ICP ,which
include the following:

3
Medical:

a) –Head elevation: to 30 degrees can significantly reduce ICP through

gravitational drainage of blood and cerebrospinal fluid CSF so reducing
the intracranial volume which in turn reduces ICP all of which can
improve the outcome.
b) Hyperventilation: is one of the most effective means of controlling
increased ICP .its achieve it effect by reducing cerebral blood volume
and cerebral blood flow through hypocapnea (decrease PCO2) from
resulting vasoconstriction since hypercapnia produce cerebral arterial
dilatation. Hyperventilation can give through high flow oxygenation by
mask, ambubag or through endotracheal intubations and assisted
ventilation.

c) -Hypothermia: cerebral blood flow and oxygen metabolism have been

shown to decline with hypothermia, as increase body temperature can
increase ICP, increased cerebral blood volume and cerebral edema.
d) -Hypertonic solution (Mannitol): using hyperosmotic or hypertonic
drugs to drive the water from brain to the plasma in addition that it results
in CSF formation inhibition.mannitol given in a dose 0.5-1g per kg over
30 minutes.
e) Furosemide: can reduce ICP through decreasing brain edema and CSF
production.
f) Steroids: dexamethasone can have beneficial effect in reducing CSF
production and so brain edema although there is controversy about its
effect in head injury.

g) Barbiturate: it act through reducing brain metabolism and cerebral

blood flow, with care that high dose barbiturate can have a deleterious
effect through respiratory suppression.

Surgical: in form of:

a) Evacuation of hematomas like EDH, SDH, ICH by burrhole or
craniotomy.
b) Ventriculostomy to drain CSF or hemorrhage.
c) Craniectomy for associated depressed fracture or extensive brain
contusion.

6-Postoperative care, continous monitoring and physiotherapy.