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Head Injury-Clinical Manifestations, Diagnosis and Management
Head Injury-Clinical Manifestations, Diagnosis and Management
• TRAUMATIC
BRAIN INJURY and
HEAD INJURY are
often used
Head Injury
• Causes
– Motor vehicle accidents
– Falls
– Assaults
– Sports-related injuries
– Firearm-related injuries
HEAD INJURY - TYPES
OPEN HEAD INJURY: CLOSED HEAD INJURY
There is penetration to the skull. There is NO penetration to the skull.
COUP-CONTRECOUP
INJURIES
• Cerebral Contusion
• Impaired Metabolism
• Epidural Hematoma
• Subdural Hematoma • Altered Cerebral Blood Flow
• Subarachnoid Hematoma
• Intracerebral Hematoma • Free Radical Formation
• Diffuse Axonal Injury
• Excitotoxicity
SCALP INJURIES
LACERATIONS SUBGALEAL HEMATOMA
Head Injury
• Scalp lacerations
– The most minor type of head trauma
– Scalp is highly vascular profuse
bleeding
– Major complication is infection
SKULL INJURIES
CLOSED FRACTURES OPEN FRACTURES
• Open fractures have
potential for serious
infection.
• A closed fracture has a • Any foreign matter impaled
significant chance of in the skull should be left in
associated intracranial place for removal by the
haematoma. neurosurgeons.
• Cover it lightly with a sterile
dressing that has been
moistened with a sterile
saline.
SKULL INJURIES
CT SCAN OT
SKULL INJURIES
DEPRESSED FRACTURES/COMPOUND
NON-DEPRESSED LINEAL
DEPRESSED FRACTURES FRACTURES
SKULL INJURIES - BASILAR
SKULL FRACTURE
BRAIN INJURIES
DIFFUSE FOCAL
• Contusion
• Brain Lacerations
• Concussion • Epidural haematoma
• Diffuse Axonal Injury • Subdural haematoma
• Subarachnoid haemorrhage
• Parenchymal haematoma
SKULL INJURIES - BASILAR
SKULL FRACTURE
RACCOON EYE
SKULL INJURIES - BASILAR
SKULL FRACTURE
BATTLE’S SIGN
SKULL INJURIES - BASILAR
SKULL FRACTURE
BLEEDING FROM THE EAR CSF LEAKAGE FROM THE
CANAL EAR OR NOSE
Head Injury
• Contusion
• Brain Lacerations
• Concussion • Epidural haematoma
• Diffuse Axonal Injury • Subdural haematoma
• Subarachnoid haemorrhage
• Parenchymal haematoma
HEAD INJURY (DIFFUSE) -
CONCUSSION
• Brain injury that does • There may be brief
not result in any confusion,
evidence of structural disorientation,
alteration. headache, dizziness,
amnesia.
• Return of
consciousness • CT scan is normal.
moments or minutes
after impact.
Head Injury
Pathophysiology
MILD 13-15
MODERATE 9-12
SEVERE 3-8
GLASGOW COMA SCALE
(GCS)
LOSS OF
SEVERITY CONSCIOUSNESS
• Vasospasm, Aneurysm
• Skull fractures
– Linear Skull Fracture
– Depressed Skull Fracture
– Diastatic Skull Fracture
– Basal Skull Fracture
– Compound Skull Fracture
– Compound elevated Skull Fracture
– Growing Skull Fracture
Battle’s Sign
Fig. 55-13
Investigations
X-ray
CT scan: standard modality
MRI
Epidural Hematoma
Subdural Hematoma
Fig. 55-15
Subdural hematoma
– Occurs from bleeding between the dura mater and
arachnoid layer of the meningeal covering of the
brain
– Source of bleed: Bridging veins; May be caused by
an arterial hemorrhage
– Much slower to develop into a mass large enough to
produce symptoms.
Cause: Acceleration-deceleration injury, direct
trauma,
Risk factors: Elderly, dementia, alcoholics, shaken
baby syndrome, pts on anticoagulants
Subdural hematoma
Location Between the skull and the dura Between the dura and
the arachnoid
Involved vessel Temperoparietal (most likely) - Bridging veins
Middle meningeal artery
Frontal - anterior ethmoidal artery
Occipital - transverse or sigmoid
sinuses
Vertex - superior sagittal sinus
Symptoms Lucid interval followed Gradually
by unconsciousness increasing headache and co
nfusion
CT appearance Biconvex lens- limited by suture Crescent shaped- crosses
lines suture lines
Fig. 55-15
Subarachnoid Hemorrhage
Causes:
• Rupture of Berry aneurism(MCC)
• Trauma (fracture at the base of the skull leading to
internal carotid aneurysm)
• Amyloid angiopathy
• Blood dyscrasias
• Vasculitis
Clinical Features:
• Explosive or thunderclap headache, “worst headache
of my life”,
• nausea and vomiting, decreased LOC or coma.
• Signs of meningeal irritation
Intracerebral Hemorrhage
(ICH)
Intracranial hemorrhage is hemorrhage that occurs
within the brain tissue itself; an intra-axial
hemorrhage.
Two main types:
1)Intraparencymal hemorrahge- ICH extending into
brain parenchyma; MCC- HTNsive vasculopathy
2)Intra-ventricular hemorrhage- ICH extending into
ventricles; MCC –trauma
Causes:
Hypertensive vasculopathy(70-80%)
Ruptured AVM
Trauma
Blood dyscracias
Intracranial Hemorrhage
Extra- axial hemorrhage
• Epidural hematoma
• Subdural hematoma-
Acute
Chronic
• Subarachnoid hemorrhage
Intra-axial hemorrhage
• Intra-parenchymal
hemorrhage
• Intra-ventricular
hemorrhage
Intracerebral Hemorrhage
(ICH)
Clinical presentation: Rapidly progressive severe headache,
building over several minutes, often accompanied by focal
neurological deficits, nausea and vomiting, decreased level of
consciousness.
Clinical feature:
• Compression of I/L CN III- I/L fixed dilted pupil
• Compression of I/L PCA- C/L homonymous hemianopsia
• Compression of C/L crus cerebri- I/L hemiparesis
• Duret hemorrhage
Diagnostic Studies
CT scan –
• A GCS score less than 15 after blunt
head trauma warrants a patient with no
intoxicating consideration of an urgent
CT scan.
CT findings
Fig. 55-15
CT findings
Fig. 55-15
Diagnostic Studies
Exception :
In Subdural hematoma with GCS=15- hematoma >10mm ,or
>5mm midline shift ---- requires Surgical decompression
• Burr-hole
• Craniotomy- bone flap is temporarily removed from
the skull to access the brain
• Craniectomy – in which the skull flap is not immediately
replaced, allowing the brain to swell, thus reducing
intracranial pressure
• Cranioplasty - surgical repair of a defect or deformity of
a skull.
TREATMENT - ACUTE STAGE
(SURGERY)
DECOMPRESSIVE CRANIOTOMY
Management
4) Medical therapy:
Health Promotion
• Prevent car and motorcycle
accidents
• To Wear safety helmets
Rehabilitation
Ambulatory and Home Care
• Nutrition
• Bowel and bladder management
• Spasticity
• Dysphagia
• Seizure disorders
• Family participation and education