HEAD INJURY

Anatomy of Head
S C A L P:
S = Skin
C = (Sub)Cutaneous Tissue
A = Aponeurosis
(Galea Aponeurotica)
L = Loose areolar tissue
P = Pericranium (Periosteum)
Skull : outer diploe
inner diploe
Meninges : Dura mater (subdural space)
Arachnoid layer(subarachnoid space)
Pia mater
 Cerebral Blood Flow
• Essential to have
continuous
cerebral blood flow
for oxygen &
glucose delivery
• Normal cerebral
blood flow (CBF) :
about 55 L/minute
for every 100 g
of brain tissue
(Adult brain : 1.2 to 1.35 kg)
 Cerebral Blood Flow
• Cerebral perfusion is kept constant across a range
of perfusion pressures by process of
autoregulation : ‘Cerebral Autoregulation’
• Flow rate is related to cerebral perfusion pressure
(CPP of 75–105 mmHg) =
mean arterial pressure (MAP of 90–110 mmHg)
minus intracranial pressure (ICP of 5–15 mmHg)
• With head injury : elevated intracranial pressure
(ICP), reduced cerebral perfusion pressure (CPP)
& reduced cerebral blood flow (CBF)
 Monro Kellie Doctrine
• Alexander Monro observed in 1783 that the
cranium is a ‘rigid box’ containing a ‘nearly
incompressible brain
• Any expansion in the contents
(haematoma & brain swelling)
may be initially accommodated by exclusion of
fluid components, venous blood &
cerebrospinal fluid (CSF)
• Further expansion is associated with exponential
rise in intracranial pressure (ICP)
• Result : hypoperfusion & herniation
Cerebral Autoregulation
 Brain Herniation
• Uncus of temporal lobe may herniate over the
tentorium : pupillary dilatation usually on same
side of any expanding haematoma
• Cerebellar tonsillar herniation through foramen
magnum compresses medullary vasomotor
& respiratory centres
• Cushing’s triad :
hypertension
bradycardia &
irregular respiration
 Head Injury
Causes of Head Injury :
• Motor-vehicle accidents : 50% of all causes
• Falls, assaults, penetrating injuries eg. gunshot
Patient may have had epileptic fit, asthmatic attack,
myocardial infarction, stroke, hypoglycaemia, etc.
ABCDE of trauma care :
• A : Airway with cervical spine protection
• B : Breathing & ventilation
• C : Circulation with haemorrhage control
• D : Disability; neurological status
• E : Exposure of patient & examined completely
to assess for other injuries
 Mechanisms of Injury
• rapid deceleration
• acceleration &/ or
• shearing : rotational effects of a blow to the head
 Primary Survey in Head Injury
• Ensure adequate oxygenation & circulation
• Check pupil size (in mm) & response to light

• Glasgow Coma Score as soon as possible

• Check for focal neurological deficits before
intubation if possible
• Check blood sugar for hypoglycaemia
 Glasgow Coma Score (GCS)

Severe brain injury : GCS < 8–9 , Moderate brain injury : GCS 8 or 9–12 , Minor brian injury : GCS ≥ 13
 Glasgow Coma Score (GCS)

Severe brain injury : GCS < 8–9 , Moderate brain injury : GCS 8 or 9–12 , Minor brian injury : GCS ≥ 13
 Examination of Head
(secondary survey)
• Look & feel over whole skull & face for cuts, bruises
& fractures (orbital rim, zygoma & maxilla)
• Check for fractured base of skull :
• Look for bleeding or CSF discharge from ears,
nose or mouth
• Look for Battle’s sign :
bruising behind ear
due to fractured
posterior cranial fossa
 Examination of Head
(secondary survey)
• Check cranial nerves
• Check eyes for movement & for damage to orbits
• Look for “raccoon” or “panda” eyes :
bilateral periorbital bruising;
due to fractured anterior
cranial fossa
• Use ophthalmoscope :
look for hyphaema
(blood in the anterior chamber of eye)
papilloedema or retinal detachment
 Complete Clinical Examination
• In moderate or severe traumatic brain injury (TBI)
there is an associated cervical spine fracture in
around 10 % of cases
• Apply cervical collar if in doubt

• Any other associated injuries is possible

• Symptoms & signs may not be obvious if patient
is unconscious
 Investigations
• Plain X-ray skull :
antero-posterior
& lateral views

• Computed Tomography (CT scan)

 Classification of Head Injuries
• Scalp : open & closed (beware of air under dura)
• Skull site : vault & base of skull
• Skull type : linear, comminuted & depressed
• Intracranial bleeding : extradural, subdural,
subarachnoid & intraparenchymal
• Brain tissue causes : diffuse, blunt
(direct, coup–contrecoup) & penetrating
 Cerebral Concussion
• Synonymous with : mild brain injury,
mild traumatic brain injury (MTBI),
mild head injury (MHI) or minor head trauma
• Most common traumatic head injury
• Temporary impairment of neurological function
that heals by itself within time; neuroimaging
normally shows no gross structural changes
to the brain as the result of the condition
• Loss of consciousness less than 30 minutes
• Post-traumatic amnesia less than 24 hours
• Glasgow Coma Score 13 to 15
Management of Mild Head Injury
• Observation period of few hours
Discharge only :
• If Glasgow Coma Score 15/15 with no focal deficits
• Normal CT brain (if indicated)
• Patient is not under influence of alcohol or drugs
• Patient is accompanied by a responsible adult
Verbal & written head injury advice given to patient
to seek medical attention if :
• Persistent or worsening headache despite analgesia
• Persistent vomiting
• Drowsiness
• Visual disturbance
• Limb weakness or numbness
 Fracture Anterior Cranial Fossa
• Nose bleeding; epistaxis
• CSF rhinorrhoea
• Leakage of Brain matter through nose
• Partial anosmia due to Olfactory nerve injury
• Haemorrhage in orbital cavity :
a) ecchymosis in lower eyelid first;
then upper eyelid (raccoon eyes)
b) subconjunctival haemorrhage; posterior limit
cannot be seen
c) Eyeball pushed forward due to retrohaematoma
• Injury to 3rd ,4th, 5th & 6th Cranial nerves
• Oculomotor nerve injury : dilated pupil
 Fracture Middle Cranial Fossa
• Ear bleeding or back of mouth
• CSF otorrhoea
• Cranial nerves affected :
a) 7th (Facial) : paralysis of facial muscles
b) 8th (Auditory) : cause deafness
c) 6th (Abducent) : cause internal strabismus
Fracture Posterior Cranial Fossa
• Extravasation of blood at sub-occipital region.
producing swelling at upper part of neck &
ecchymoses posterior to mastoid process
(Battle’s Sign)
• 9th(Glossopharyngeal),
10th(Vagus) &
11th(Accessory) cranial nerves
are occasionally injured at jugular foramen
Base of Skull (Autopsy Specimen)
Extensive fractures
involving :
both sides of
anterior cranial fossae
& left side of
middle cranial fossa
 Skull Fractures
• Closed linear fractures : conservative management
with primary closure of associated wounds
• Skull base fractures : may be complicated by CSF
leak, pituitary dysfunction or cranial nerve deficits
with anosmia, facial palsy or hearing loss :
conservative treatment, no need for prophylactic
antibiotics (CSF leak will resolve spontaneously)
• Fractures involving air sinuses : treat as open
fractures; give broad spectrum antibiotics &
reduce fractures if displaced
• Open fractures : will need exploration, debridement
& elevation
 Depressed Skull Fractures
• Inward displacement of bone fragment by at least
one thickness of skull
• Occur when small objects hit skull at high velocity
• Usually open fractures
• May lose consciousness or present with focal fits
• High risk of infection, neurological deficit &
late-onset epilepsy
Extradural space :
Space between dura mater & skull bone
• Dura mater is thick fibrous sheet, adherent to inner
surface of skull, consists of both periosteal layer
& meningeal layer
Subdural space :
Space between
dura mater &
arachnoid mater
 Extradural Haematoma
• A neurosurgical emergency : skull fracture with
rupture of an artery, vein or venous sinus
• Classically, middle meningeal artery damaged by
hairline fracture of the thin temporal bone
• A low energy injury mechanism, patient may or may
not have an initial brief loss of consciousness
• Lucid interval : with headache, but no neurological
deficit (blood slowly pushes dura away from bone)
• When decompensation passed critical period
then rapid neurological deterioration
• Reduced consciousness, headache, vomiting,
ipsilateral pupillary dilatation (Hutchinson pupil) &
contralateral hemiparesis
 Extradural Haematoma
• Plain skull X-ray : may show a faint hairline linear
crack fracture of
temporal bone

• CT scan brain :
an extradural haematoma
appears as a lentiform or
lens-shaped or
biconvex hyperdense lesion
between skull & brain with
compression of surrounding brain & midline shift
 Extradural Haematoma
• Urgent surgery : burr-hole with evacuation of
haematoma & control bleeding
• Overall mortality : about 10 to 20%
 Acute Subdural Haematoma
• Rupture of cortical vessels from high energy force
• Significant primary brain injury
• No lucid interval
• Loss of consciousness immediately with
deterioration as the haematoma expands
• Dura is not adherent to the brain as it is to the skull,
so subdural blood is free to expand across the
brain surface giving a diffuse concave
appearance (as seen on CT scan)
 Acute Subdural Haematoma
• CT scan : diffuse concave or
crescent-shaped hyperdense
appearance of haematoma
over surface of brain
with midline shift of brain

• Emergency surgery if acute subdural bleeds of

significant size or with significant midline shift
• Overall mortality : about 50%
 Chronic Subdural Haematoma
• Usually old person
• May be on antiplatelet or anticoagulant medication
• Recent fall or falls
• Cerebral atrophy in old brain
• Veins, that are stretched in subdural space, rupture
after only minor trauma, bleed & then tamponade
• Clot lyses, then by osmotic expansion, produces
the mass effect of midline shift of brain
• Clinically present with headache, drowsiness,
neurological deficit & seizures
 Chronic Subdural Haematoma
• CT scan : diffuse hypodense crescent-shaped area
over brain surface
• May have multiple lesions,
of mixed densities indicating
lesions occurring at
different times

• Drainage of haematoma using burr holes,

often under local anaesthetic
 Traumatic
Subarachnoid Haemorrhage
• Severe trauma to head
• Loss of consciousness
• Severe headache on
regaining consciousness
• Neck stiffness
(nuchal rigidity)
• Photophobia
• CT scan : blood in ventricles
& subarachnoid space (bloody cerebrospinal fluid)
 Cerebral Contusion
• Contusions are common
• Located where brain is in contact with rough
surface inside the skull
• At inferior frontal lobes & temporal poles
• ‘Coup–contrecoup’ injury
• Injury at site of impact combined with
contusion elsewhere
sustained
as the brain
rebounds from
initial impact
 Cerebral Contusion
• Local : causing focal signs or symptoms or
• Generalized : with widespread damage to the brain
• Increased vascular permeability in contused brain
produces cerebral oedema
• CT scan : heterogenous lesion due to injured brain
matter & blood
• Surgery : rarely needed
• Delayed evacuation to reduce mass effect
 Diffuse Axonal Injury
• Primary brain injury; from high energy accidents
• Patient comatose for long time
• CT brain : often normal appearance
or haemorrhagic foci in
corpus callosum & brainstem

• Pathological diagnosis, made at post-mortem

 Non-accidental Injury
• Be on the alert
• Head injury in children & vulnerable adults may be
due to abuse
• Delayed presentation, multiple injuries of varying
durations, retinal haemorrhages, bilateral chronic
subdural haematomas, multiple skull fractures &
neurological injury without external signs of
trauma
Prevention of Secondary Brain Injury
• Brain swelling &
mass lesions
contribute to
raised intracranial
pressure,
which compromises
perfusion,
leading to
secondary
brain injury &
further swelling
 On-going Management of
Severe Head Injury
• Aim : to minimise secondary brain injury
• Method : intubate & ventilate patient with adequate
sedation & pressure monitoring
• Key parameters : oxygenation & ventilation,
blood pressure, intracranial pressure,
electrolyte balance
• Control fever
• Achieve control of intracranial pressure
Intracranial Pressure Management
Initial : Head up, loosen collar, optimise ventilation
Optimise electrolyte balance
Sedation & seizure control
Intermediate : Mannitol/ frusemide/ hyperventilation
Heavy sedation, paralysis
CSF drainage (external ventricular drainage)
Avoid fever, reduce body temperature/ cooling
Late : Induction of thiopentone coma
Decompressive craniectomy; unilateral or
bifrontal decompressive craniectomy
 Other Complications
Local (head) : General :
Wound infection Oral thrush & mouth ulcers
Meningitis Dental caries & abscess
Encephalitis Aspiration/ orthostatic pneumonia
Brain abscess Decubitus ulcer (bed sore)
CSF leak Urinary tract infection
Seizures/ fits Joint stiffness, osteoporosis
Syndrome of Malnutrition, hypovitaminosis
inappropriate Deep vein thrombosis &
anti-diuretic pulmonary embolism
hormone(SIADH) Psychological depression
Peptic ulcer (Cushing’s ulcer)