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to the head
and face region.
Head Injury
S1 Unit
DEFINITION & TYPES OF HEAD INJURY
PATHOPHYSIOLOGY
Clinical Features
PRIMARY BRAIN INJURIES
EXTRADURAL HAEMATOMA
and
SUBDURAL HAEMATOMA
ASSESSMENT OF SEVERITY OF HEAD INJURY
INVESTIGATION
CONSERVATIVE MANAGEMENT
OF HEAD INJURY
SURGICAL MANAGEMENT OF HEAD INJURY
C O M P LIC A T IO N S O F H E A D
IN JU R Y
DEFINITION & TYPES
OF HEAD INJURY
NITHA.J
Head injury
Traumatic insult to the head that may result in
any injury to the soft tissue bony structures
and/or brain.
TRAUMATIC BRAIN
INJURY[TBI]
Traumatic brain injury (TBI) is a
nondegenerative, noncongenital insult to the
brain from an external mechanical force,
possibly leading to permanent or temporary
impairment of cognitive, physical, and
psychosocial functions, with an associated
diminished or altered state of consciousness.
CLASSIFICATION OF
HEAD INJURY
Based on the Severity
GCS: Best predictor of neurological outcome
GLASGOW COMA SCALE
OBEYS 6
LOCALISES 5
WITHDRAWS 4
ABNORMAL FLEXION 3
EXTENSION 2
RESPONSE 1
NIL
VERBAL RESPONSE SCORE
ORIENTED 5
CONFUSED CONVERSATION 4
INAPPROPRITE WORDS 3
INCOMPREHENSIBLE SOUNDS 2
NIL 1
Severity of TBI
Severity GCS
Minor 15
Mild 14-15
Moderate 9-12
Severe 3-8
OPEN HEAD
INJURY
Implies
communication
b/w the intra dural
contents & outside
CLOSED HEAD
INJURY
Scalp is intact and
there is no
communication
between the OPEN HEAD INJURY
intradural contents
and the
atmosphere
PATHOLOGICAL
CLASSIFICATION
FOCAL DIFFUSE
Confined to specific Distributed in a more
areas general manner
Cerebral laceration Cerebral edema
Contusion Concussion
Intracranial Diffuse axonal injury
hemorrhage
Based on the time of
onset
Primary Brain Secondary Brain
Injury Injury
ØDiffuse axonal injury Ø Brain swelling
ØCerebral concussion Ø Intracranial
Haemorrhage
ØCerebral contusion
Ø Infection
ØCerebral laceration
ØTraumatic
subarachnoid
haemorrhage
CLASSIFICATION OF SKULL
FRACTURE
COMMINUTED
FRACTURE
DEPRESSED FRACTURE
SCALP LACERATION
GCS
The scale was published in 1974 by Graham
Teasdale and Bryan J. Jennett, professors of
neurosurgery at the University of Glasgow.
The pair went on to author the textbook
Management of Head Injuries (FA Davis 1981,
ISBN 0-8036-5019-1), a celebrated work in
the field.
The University of Glasgow is the fourth-
oldest university in the English-speaking
world and one of Scotland's four ancient
universities
PATHOPHYSIOLOGY
Nithin Humayoon
Neuronal Injury
Chromatolysis
Wallerian Degeneration
Retrograde Degeneration
Transneural degeneration
Regeneration
Brain metabolism
Ø CMRO2: 3.5 ml/100g/min
Cerebral Blood flow
Ø 55ml/100g/min
Cerebral Autoregulation
Cushing’s Reflex
ICP and brain herniation
The addition of mass lesion is compensated
by displacement of CSF and venous blood
out of cranial cavity.
As further expansion of mass occur quite
small rise in volume result in large
increase in ICP and Brain herniation can
occur
MECHANISM of brain
injury
Distortion of the brain
Mobility of the brain in relation to the skull and
membrane
Configuration of interior of skull
Deceleration and acceleration of injury
Cerebral Concussion
Cerebral Contusion
Cerebral Laceration
Primary brain injury
Diffuse neuronal damage
Shearing lesions
Contusion
Lacerations
Traumatic SAH
Ø Extent of primary injury is reflected by state of
consciousness and presence of focal
neurological deficit
Secondary brain injury
Brain swelling: odema, venous congestion,
hypoxia
Intra cranial hemorrhage:Extradural, subdural,
intracerebral
Infection
Ø Open head injury: Generalized meningitis,
subdural empyema, brain abscess
Ø Closed head injury: Infection of sub pericranial
blood clot
Causes of secondary brain
injury
Hypoxia:PO2 < 8kPa
Hypotension: Systolic BP<90mm Hg
Raised ICP: >20mm Hg
Low cerebral perfusion pressure:<65mm Hg
Pyrexia
Seizures
Metabolic Disturbance
Raised ICT Cerebral compression
Decreased Cerebral perfusion Brain
ischaemia
Pressure on motor cortex C/l hemiparesis
Herniation of cingulate gyrus:
Subfalcine herniation
response
Normal pupil
size: 2.5-5mm
Anisocoria &
asymmetrical
sluggish light
response- 3rd
CN
compression on
side of mass
lesion
(hematoma)
Pinpoint pupil
<1mm
Pontine hemorrhage
Bilateral dilated unreactive pupil
Severe midbrain compression
Symptoms and Signs of
raised ICT
Normal upper limit: 15mm Hg
SYMPTOMS
Ø Impairment of consciousness
Ø Headache
Ø Vomiting
Ø Convulsions
SIGNS
Ø Papilloedema
Ø Bradycardia
Ø Hypertension
Ø Changes in respiration
Ø B/l Babinski’s sign
Fracture skull
Signs of base of skull fracture
Bilateral periorbital edema (racoon eyes)
Battle’s sign (bruising over mastoid)
Skull fracture
CSF
rhinorrhoea/CSF
otorrhoea
Hemotympanum
Signs of meningeal
irritation
Neck stiffness
Kernig’s sign
Straight leg raising test
Brudzinski’s sign
Focal neurological deficit
Cortical involvement
Ø Frontal lobe-
C/l paralysis(monoplegia),Gaze palsy,Changes in
BY
POOJA P S
PRIMARY BRAIN INJURIES
Diffuse axonal injury
Cerebral concussion
Cerebral contusion
Cerebral laceration
Traumatic subarachnoid haemorrhage (SAH)
DIFFUSE AXONAL INJURY
Acceleration deceleration type of forces causes
mechanical shearing at the grey white matter
interface (due to differential brain
movement).
This causes disruption and tearing of axons
myelin sheath and blood capillaries over an
extensive area.
Can present as mild confusion followed by
recovery or coma or death
Cerebral concussion
It is a clinical diagnosis
A brief temporary physiological paralysis of
function with out organic structural damage
with amnesia/transient loss of consciousness
followed by complete recovery .
Brady cardia, hypotension and sweating may
be present.
CEREBRAL CONTUSION
Circumscribed areas of brain tissue destruction
accompanied by extravasation of blood into
the affected tissues.
Produced by blunt force.
Most common in frontal and temporal lobe.
FEATURES OF
CONTUSION
Bruising
Swelling of cortical gyri
Brain edema
Shearing damage to nerve cells and
axons.
Bleeding due to tearing of small blood
vessels in the brain.
Focal neurological deficit ( > 24 hrs )
may be present
Recovery may/may not occur.
Cerebral laceration
A cerebral laceration is a similar to contusion
except that, the pia-arachnoid membranes
are torn over the site of injury in laceration
Focal deficits are the rule.
Subarachnoid
hemorrhage
Bleeding into the subarachnoid space—the
area between the arachnoid membrane
and the piamater surrounding the brain
(containing blood vessels)
WFNS(World Federation of Neurological
Surgeons) grading of SAH
SUBARACHNOID
HAEMORRHAGE
SYMPTOMS
E xp o su re
Intactness of skull and spine are assessed
Fracture stabilised
Management
Neuro observation
Monitor vitals
Catheterisation
Antibiotics
Antiedema measures
Antacids
Intravenous fluids
Triage
Triage originated and was first formalized in
World War I by French doctors treating the
battlefield wounded at the aid stations behind
the front. Much is owed to the work of
Dominique Jean Larrey during the Napoleonic
Wars.
INVESTIGATION
PRIYANKA P.G
SKULL XRAY
CT
CEREBRAL ANGIOGRAPHY
LUMBAR PUNCTURE
SKULL XRAY
INDICATION
Repeat CT scan should be considered:
Scalp injuries
Skull injuries
Cerebral injuries
SCALP INJURIES
§Scalp haematoma
Aspiration,compression bandage &
antibiotic coverage
§Scalp Laceration
Clean-excision of devitalised
tissue-irrigation-suture
SKULL FRACTURES
Linear fractures
No specific treatment required
Depressed fractures
1)Small and shallow without any focal
signs-no indication for surgery
2)Compound
Compound depressed fractures-
Small-conservative management
Large-
1.Wound enlarged
2.Saline irrigation
3.Creation of burr hole
4.Elevation of depressed bone
HAEMATOMAS
Extradural haematoma
Subarachnoid Haemorrhage
Indication for surgery- CT large
haematoma, decreased consciousness, focal
neurological deficit
Clipping & coiling done
Clipping via craniotomy to locate aneurysm
Intracerebral haemorrhage
Surgery indicated-haematoma >3cm,presence of
structural vascular lesion in a young patient
CRANIOTOMY
Definition
Preceded by an CT scan
CRANIOTOMY
urgical management of raised intracranial
ressure:-
)Early evacuation of focal haematomas
)Cerebrospinal fluid drainage by ventriculostomy
Delayed evacuation of swelling contusions
)Decompressive craniectomy
COMPLICATIONS OF
HEAD
INJURY
BY
Radhika.V
P o st C o n cu ssio n a l S y n d ro m e
Treatment
Immediate-measures to reduce intracranial
pressure
Longterm- monitoring of ICP
CSF shunt may be
required
Cranial Nerve Palsies
Craniofacial injuries
THANK YOU