Head TraumaHead Trauma

Dr.Ahmed M.AliDr.Ahmed M.Ali

Lecturer of NeurosurgeryLecturer of Neurosurgery

Kasr El Aini Medical SchoolKasr El Aini Medical School

Head Injury-AnatomyHead Injury-Anatomy

ScalpScalp Blood supplyBlood supply CalvariaCalvaria BrainBrain

– Occupies 80% of Occupies 80% of calvariumcalvarium

Head Injury-PathophysiologyHead Injury-Pathophysiology

Primary injuryPrimary injury– Irreversible cellular injury as a direct result of Irreversible cellular injury as a direct result of

the injurythe injury– Prevent the event Prevent the event

Secondary injurySecondary injury– Damage to cells that are not initially injuredDamage to cells that are not initially injured– Occurs hours to weeks after injuryOccurs hours to weeks after injury– Prevent hypoxia and ischemiaPrevent hypoxia and ischemia

Head Injury-Initial Evaluation Head Injury-Initial Evaluation and Managementand Management

Prevent Secondary Brain InjuryPrevent Secondary Brain Injury– HypoxemiaHypoxemia– HypotensionHypotension– AnemiaAnemia

Airway control with cervical spine immobilizationAirway control with cervical spine immobilization

– HyperglycemiaHyperglycemia– Evacuation of massEvacuation of mass

•Indications: Head CT for Concussion 1.Inclusion Criteria

1.Presenting within 24 hours for non-penetrating trauma and GCS of 14 or 152.Patients with loss of consciousness or amnesia (and at least one of the following criteria)

1.Diffuse Headache2.Vomiting3.Age over 60 years4.Alcohol Intoxication or other drug intoxication5.Short Term Memory deficit6.Signs of trauma above the clavicles7.Seizures8.GCS Score less than 159.Focal neurologic deficits10.Coagulopathy

3.Patients without loss of consciousness or amnesia (and at least one of the following criteria)1.Severe Headache2.Vomiting3.Age over 65 years4.Basilar Skull Fracture signs5.GCS Score less than 156.Focal neurologic deficit7.Coagulopathy8.Significant mechanism of injury

1.Vehicle ejection2.Pedestrian struck by vehicle3.Fall from height >3 feet or 5 stairs

Spectrum of Traumatic Brain InjurySpectrum of Traumatic Brain Injury

Mild TBIMild TBI– GCS 14-15GCS 14-15– 80% of all TBI80% of all TBI– Low RiskLow Risk

GCS 15 and no LOC, amnesia, vomiting or diffuse HAGCS 15 and no LOC, amnesia, vomiting or diffuse HA Less than 0.1% risk of hematoma requiring evacuationLess than 0.1% risk of hematoma requiring evacuation

– Medium RiskMedium Risk GCS 15 and LOC, amnesia, vomiting or Diffuse HAGCS 15 and LOC, amnesia, vomiting or Diffuse HA 1-3% risk of hematoma requiring evacuation1-3% risk of hematoma requiring evacuation CT should be done in medium risk mild TBICT should be done in medium risk mild TBI

Spectrum of Traumatic Brain InjurySpectrum of Traumatic Brain Injury

Mild TBIMild TBI– High RiskHigh Risk

GCS 14-15GCS 14-15 Neurologic deficitsNeurologic deficits Up to 10% risk of hematoma requiring evacuationUp to 10% risk of hematoma requiring evacuation Anyone with coagulopathy, drug/alcohol consumption, Anyone with coagulopathy, drug/alcohol consumption,

epilepsy, age >60 and previous neurosurgeryepilepsy, age >60 and previous neurosurgery

– DispositionDisposition No CT indicated or negative CT with GCS 15-HomeNo CT indicated or negative CT with GCS 15-Home GCS 14 and negative CT-Observation admitGCS 14 and negative CT-Observation admit

Spectrum of Traumatic Brain InjurySpectrum of Traumatic Brain Injury

Moderate TBIModerate TBI – GCS 9-13GCS 9-13– 10% of all TBI10% of all TBI– <20% mortality<20% mortality

Severe TBISevere TBI– GCS <9GCS <9– 10% of all TBI10% of all TBI– 40% mortality40% mortality

– 50% morbidity50% morbidity– 40% positive CT40% positive CT– 8% NS intervention8% NS intervention

– <10 make moderate <10 make moderate recoveryrecovery

ADMISSION CRITERIA:•Disturbed conscious level <15•Fully conscious but sleepy or drowsy•Post traumatic fits•Fracture base•Repeated vomiting•Neurological deficits•CAT scan showed any pathology (hemorrhage, depressed fracture)•Severe amnesia •Patients with severe head injury•Severe intolerable headache

Increased ICP-ManagementIncreased ICP-Management Hypertonic SalineHypertonic Saline

– Improves CPP and brain tissue OImproves CPP and brain tissue O22 levels levels

– Decreased ICP by 35% (8-10 mm HG)Decreased ICP by 35% (8-10 mm HG)– CPP increased by 14%CPP increased by 14%– MAP remained stableMAP remained stable– Greatest benefit in those with higher ICP and Greatest benefit in those with higher ICP and

lower CPPlower CPP– Repeated doses were not associated with Repeated doses were not associated with

rebound, hypovolemia or HTNrebound, hypovolemia or HTN– 30 mL of 23.4% over 15 minutes30 mL of 23.4% over 15 minutes

Increased ICP-ManagementIncreased ICP-Management

MannitolMannitol– Osmotic agentOsmotic agent– Effects ICP, CBF, CPP and brain metabolismEffects ICP, CBF, CPP and brain metabolism– Free radical scavengerFree radical scavenger– Reduces ICP within 30 minutes, last 6-8 hoursReduces ICP within 30 minutes, last 6-8 hours– Volume expansion, reduces hypotensionVolume expansion, reduces hypotension– DosageDosage

0.25-1 gm/kg bolus0.25-1 gm/kg bolus

Increased ICP-ManagementIncreased ICP-Management

HyperventilationHyperventilation– Not recommended as prophylactic interventionNot recommended as prophylactic intervention– Never lower than 25 mm HgNever lower than 25 mm Hg– Reduces ICP by vasoconstriction, may lead to Reduces ICP by vasoconstriction, may lead to

cerebral ischemiacerebral ischemia– Used as a last resort measureUsed as a last resort measure

– Maintain PaCOMaintain PaCO22 at 30-35 mm Hg at 30-35 mm Hg

Specific Head InjuriesSpecific Head Injuries

Scalp LacerationsScalp Lacerations– May lead to massive blood lossMay lead to massive blood loss– Small galeal lacerations may be left aloneSmall galeal lacerations may be left alone

Skull FractureSkull Fracture– Linear and simple comminuted skull fracturesLinear and simple comminuted skull fractures

Exploration of woundExploration of wound Prophylactic antibiotics are controversialProphylactic antibiotics are controversial Occipital fractures have a high incidence of other Occipital fractures have a high incidence of other

injuryinjury If depressed beyond outer table-requires NS repairIf depressed beyond outer table-requires NS repair

Specific Head InjuriesSpecific Head Injuries Skull FracturesSkull Fractures

– Basilar FractureBasilar Fracture Most common-petrous portion of temporal bone, Most common-petrous portion of temporal bone,

the EAC and TMthe EAC and TM Dural tearDural tear

– CSF otorrheaCSF otorrhea– CSF rhinorrheaCSF rhinorrhea– Battle SignBattle Sign– Raccoon SignRaccoon Sign

CSF testingCSF testing– Ring sign, glucose or CSF transferrinRing sign, glucose or CSF transferrin

Should be started on prophylactic antibioticsShould be started on prophylactic antibiotics– Ceftriaxone 1-2 gmCeftriaxone 1-2 gm

– HemotympanumHemotympanum– VertigoVertigo– Hearing lossHearing loss– Seventh nerve palsySeventh nerve palsy

Specific Head InjuriesSpecific Head Injuries

Brain HerniationBrain Herniation– Four TypesFour Types

Uncal TranstentorialUncal Transtentorial Central TranstentorialCentral Transtentorial CerebellotonsillarCerebellotonsillar Upward Posterior Upward Posterior

FossaFossa

Specific Head InjuriesSpecific Head Injuries

Traumatic Subarachnoid HemorrhageTraumatic Subarachnoid Hemorrhage– Most common CT finding in moderate to severe Most common CT finding in moderate to severe

TBITBI– If isolated head injury, may present with If isolated head injury, may present with

headache, photophobia and meningismusheadache, photophobia and meningismus– Early tSAH development triples mortalityEarly tSAH development triples mortality– Size of bleed and outcomeSize of bleed and outcome– Timing of CTTiming of CT– Nimodipine reduces death and disability by 55%Nimodipine reduces death and disability by 55%

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Specific Head InjuriesSpecific Head Injuries

Epidural HematomaEpidural Hematoma– Occurs in 0.5% of all head injuriesOccurs in 0.5% of all head injuries– Blunt trauma to temporoparietal regionBlunt trauma to temporoparietal region– Eighty percent with associated skull fractureEighty percent with associated skull fracture– May occur with venous sinus tearsMay occur with venous sinus tears– Classic presentation only 30% of the timeClassic presentation only 30% of the time

Specific Head InjuriesSpecific Head Injuries

Subdural HematomaSubdural Hematoma– Sudden acceleration-deceleration injury with Sudden acceleration-deceleration injury with

tearing of bridging veinstearing of bridging veins– Common in elderly and alcoholicsCommon in elderly and alcoholics– Classified as acute, subacute or chronicClassified as acute, subacute or chronic

Acute <2 weeksAcute <2 weeks Chronic >2 weeksChronic >2 weeks

Specific Head InjuriesSpecific Head Injuries

Diffuse Axonal InjuryDiffuse Axonal Injury– Disruption of axons in white matter and Disruption of axons in white matter and

brainstembrainstem– Injury occurs immediately and is irreversibleInjury occurs immediately and is irreversible– Seen after MVC or shaken baby syndromeSeen after MVC or shaken baby syndrome– Usually have persistent vegetative stateUsually have persistent vegetative state– CT usually normalCT usually normal– MRI with multiple, diffuse abnormalitiesMRI with multiple, diffuse abnormalities

Specific Head InjuriesSpecific Head Injuries

Penetrating InjuryPenetrating Injury– Gunshot WoundsGunshot Wounds

Injury due to direct brain injury and cavitary effectsInjury due to direct brain injury and cavitary effects GCS predicts prognosisGCS predicts prognosis

– GCS >8 and reactive pupils = 25% mortalityGCS >8 and reactive pupils = 25% mortality– GCS <5 = nears 100% mortalityGCS <5 = nears 100% mortality

– Stab woundsStab wounds

Complications-Long Term SequelaComplications-Long Term Sequela Seizure DisorderSeizure Disorder

– 2% Early post-traumatic incidence2% Early post-traumatic incidence– Increased to 30% in children, alcoholics and Increased to 30% in children, alcoholics and

with intracranial hematomawith intracranial hematoma Prophylactic antiepileptics reduce early occurrence Prophylactic antiepileptics reduce early occurrence Use not supported by the literatureUse not supported by the literature

Concussion Concussion - - Brief LOCBrief LOC - Vertigo- Vertigo - -

NauseaNausea

- Dizziness- Dizziness - Headache- Headache - Vomiting- Vomiting

- Photophobia- Photophobia - Cognitive/Memory dysfunction- Cognitive/Memory dysfunction

Complications-Long Term SequelaComplications-Long Term Sequela

ConcussionConcussion– Up to 80% may have symptoms at 3 monthsUp to 80% may have symptoms at 3 months– 15% may have symptoms at 1 year15% may have symptoms at 1 year– Persistence of these symptoms is termed Persistence of these symptoms is termed

Postconcussive SyndromePostconcussive Syndrome– 85-90% recover after 1 year85-90% recover after 1 year– Risk factors:Risk factors:

- FemaleFemale - Litigation- Litigation - Low socioeconomic - Low socioeconomic statusstatus

Complications-Long Term SequelaComplications-Long Term Sequela

InfectionInfection– Skull fractureSkull fracture– CSF leakCSF leak– IntubationIntubation

– History of FractureHistory of Fracture FeverFever Signs of meningitisSigns of meningitis

– 33rdrd generation cephalosporin generation cephalosporin– Vancomycin Vancomycin

– ICUICU

– TreatmentTreatment Prophylactic antibioticsProphylactic antibiotics