OVERVIEW

Head injury was first estimated occur in about

1 million years ago
Evidenced skull damage on human
predecessors now called Australopithecus
africanus

Java > 300.000 years ago

Peking > 100.000 years ago

Neanderthal > 40.000 years ago

Damage is found that there are two adjacent

fracture lines in the posterior region of the skull

QS. Al-Maidah : 27-30 Tells the story of the

first murder Adams children (Habil and
Qabil)
Qabil hit Habil with a rock to the head until
Habil killed

BRAIN INJURY
As

defined by the National

Head Injury Foundation
a traumatic insult to the
brain capable of producing
physical, intellectual,
emotional, social and
vocational changes.

HEAD INJURY-EPIDEMIOLOGY
1.5

million Non-fatal TBIs

370,000 Hospitalizations
80,000 cases of neurological sequela
52,000 Die from TBIs
4 billion annually for cost of treatment
Peak incidence:
Males

age 15-24 years

INTRODUCTION TO HEAD
INJURIES
TIME

IS CRITICAL

Intracranial

Hemorrhage
Progressing Edema
Increased ICP
Cerebral Hypoxia
Permanent Damage

Severity
Subtle

is difficult to recognize

signs
Improve differential diagnosis

Improves survivability

1ST MANAGEMENT
Primary

survey

Secondary

survey

Definitive

therapy

HEAD TRAUMA
Open

Skull compromised
and brain exposed

Closed

Skull not compromised

and brain not exposed

Head Trauma - 10

CRANIAL INJURY
Trauma

must be extreme to fracture

Linear
Depressed
Open
Impaled Object

DIRECT BRAIN INJURY TYPES

Coup
Injury

impact

at site of

Contrecoup
Injury

on opposite
side from impact

Pathology of the Brain Injury:

* Not all the brain damage occurs at the time of injury
* Basically two main stages of brain damage after injury
- PRIMARY DAMAGE
- SECONDARY DAMAGE
* Last decade : Head CT Scan and MRI played very
important role in diagnostic evaluation of
head injury patients
* Even with improved CT Scan and MRI, the precise
type of damage may not be identifiable during life
* The principal mechanism are :
- CONTACT
- ACCELERATION / DECELERATION

PRIMARY DAMAGE
* occurs at the moment of injury
* including : - laceration of the scalp
- fracture of the skull
- contusions and lacerations
- diffuse axonal injury
- intracranial hemorrhage
- other type of brain damage

SECONDARY DAMAGE
* results from complicating processes that are

initiated at the moment of injury

* may not present clinically for a period of time

afterward
* including :
- hypoxia / ischemia
- swelling
- infection
- brain damage due to elevated intracranial
pressure

BRAIN INJURY
Response to injury

Swelling of brain

Vasodilatation with increased blood volume

Increased ICP

Decreased blood flow to brain

Perfusion decreases

Cerebral ischemia (hypoxia)

Head Trauma - 16

SIGNS & SYMPTOMS

OF BRAIN INJURY

Altered Mental Status

Altered orientation
Alteration in personality
Amnesia
Retrograde
Antegrade
Cushings Reflex
Increased BP
Bradycardia
Erratic respirations

- Vomiting
Without nausea
Projectile
- Body temperature changes
- Changes in pupil reactivity
- Decorticate posturing

Assessment of Impaired Consciousness

Use practical scale Glasgow Coma Scale
Three features are in dependently observed :
Points
* EYE OPENING
Spontaneous
4
To speech
3
To pain
2
None
1
* BEST MOTOR RESPONSE
Obeys commands
6
Localized to pain stimuli
5
Withdraws from pain stimuli
4
Decorticate flexion
3
Decerebrate extension
2
None
1
* VERBAL RESPONSE
Oriented
5
Confused conversation
4
Inappropriate words
3
Incomprehensible sounds
2
None
1

CLINICAL FEATURES

name
Mild Head Injury

Clinical Features

unconsc < 10
GCS 13 15
no neuro deficit

Radiological Exam

brain CT normal

Pathologic

Concussion

Moderate Head Injury unconsc 10-<6hrs brain CT abnormal Contusion

GCS 9 12
pos neuro deficit
Severe Head Injury

unconcs > 6 hrs

GCS 3 9
pos neuro deficit

SIMPLE HEAD INJURY GCS 15

no neuro deficit
no unconsc

brain CT abnormal Contusion

DIRECT BRAIN INJURY

CATEGORIES

Focal
Occur at a specific location in brain
Differentials
Cerebral Contusion
Intracranial Hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral Hemorrhage
Diffuse
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury

FOCAL BRAIN INJURY

Cerebral Contusion
Blunt trauma to local brain tissue
Capillary bleeding into brain tissue
Common with blunt head trauma
Confusion
Neurologic deficit
Personality changes
Vision changes
Speech changes
Results from
Coup-contrecoup injury

BRAIN INJURIES
Cerebral contusion

Bruising of brain tissue

Swelling may be rapid and severe

Level of consciousness
Prolonged unconsciousness,
profound confusion or amnesia

Associated symptoms
Focal neurological signs

May have personality changes

Head Trauma - 22

FOCAL BRAIN INJURY

INTRACRANIAL HEMORRHAGE

Epidural Hematoma
Bleeding between dura
mater and skull
Involves arteries
Middle meningeal
artery most common
Rapid bleeding &
reduction of oxygen to
tissues
Herniates brain toward
foramen magnum

INTRACRANIAL
HEMORRHAGE
Acute epidural hematoma

Arterial bleed
Temporal fracture common
Onset: minutes to hours

Level of consciousness
Initial loss of consciousness
Lucid interval follows

Associated symptoms
Ipsilateral dilated fixed pupil, signs of increasing
ICP, unconsciousness, contralateral paralysis,
death
Head Trauma - 24

FOCAL BRAIN INJURY

INTRACRANIAL HEMORRHAGE

Subdural Hematoma
Bleeding within meninges
Beneath dura mater & within
subarachnoid space
Above pia mater
Slow bleeding
Superior sagital sinus
Signs progress over several days
Slow deterioration of mentation

INTRACRANIAL
HEMORRHAGE
Acute subdural hematoma

Venous bleed
Onset: hours to days

Level of consciousness
Fluctuations

Associated symptoms
Headache
Focal neurologic signs
High-risk
Alcoholics, elderly, taking anticoagulants

Head Trauma - 26

INTRACRANIAL
HEMORRHAGE
Intracerebral hemorrhage

Arterial or venous
Surgery is often not helpful

Level of consciousness
Alterations common

Associated symptoms
Varies with region and degree
Pattern similar to stroke
Headache and vomiting

Head Trauma - 27

FOCAL BRAIN INJURY

INTRACRANIAL HEMORRHAGE

Intracerebral Hemorrhage
Rupture blood vessel within the brain
Presentation similar to stroke symptoms
Signs and symptoms worsen over time

 Basal

Skull

Unprotected
Spaces

weaken
structure
Relatively
easier to fracture

CRANIAL INJURY

Basal Skull Fracture Signs

Battles Signs
Retroauricular Ecchymosis
Associated with fracture of
auditory canal and lower
areas of skull
Raccoon Eyes
Bilateral Periorbital
Ecchymosis
Associated with orbital
fractures

BASILAR SKULL FRACTURE

Battles sign

Raccoon eyes

Head Trauma - 31

CRANIAL INJURY

Basilar Skull Fracture

May tear dura

Permit CSF to drain
through an external
passageway
May mediate rise of ICP
Evaluate for Target or
Halo sign

CRAINIAL INJURIES
Penetrating trauma

Bullet fragments
Head Trauma - 33

EDH

SDH

SAH

ICH

THANK YOU