A presentation on: Traumatic Head Injury.pptx

A basic holistic presentation on head trauma including injuries to the scalp, skull bones, dura mater, leptomeninges and brain tissue.

1. Traumatic Head Injury Dr. Syed Mohammad Nabeel Aamir PGY-2 Surgical Resident Abbasi Shaheed Hospital

2. Epidemiology As per data from the CDC: There were over 70,000 TBI-related deaths in the U.S. in 2021. That’s about 190 TBI-related deaths everyday. Among fatal head injury patients, half of them die within the first 24 hours. Many more are left with permanent neurological deficits.

3. Definition Head injury is a general term used to define any trauma to the head, especially the brain itself. Head injury refers to trauma to the head. This may or may not include injury to the brain. Head injury includes any trauma to the scalp, skull or brain tissues either singly or collectively.

4. Etiologies Motor vehicle accidents (44%) Falls, either by accident or during recreational activities such as biking, skating or skateboarding (26%) Violence and abuse, Sports injuries, Blunt head trauma – direct blow, Penetrating trauma (13%) Assault (9%) Firearms (8%)

5. Mechanisms of Head Trauma

6. Deformation Results from the transmission of energy to the skull through direct contact which is insufficient for the skull leading to deformation or fracture

7. Acceleration/Deceleration Injuries typically occur when the acceleration of the skull, moving in a motor vehicle, suddenly decelerates when it hits an immobile object such as the steering wheel or windshield.

8. Rotational Forces Distort the brain and can cause tension, stretching and diffuse shearing of brain tissues. Often the forces of acceleration, deceleration and rotation occur together, affecting both the brain and spinal cord.

9. Coup and Countrecoup Injury

10. Types of Head Injury

11. Anytime the skull is fractured, the patient is said to have an open head injury. If the skull is intact, the term closed head injury is used. Types of head injuries include injuries to the scalp, skull and brain.

12. Classification Scalp injuries: The scalp has many blood vessels, hence it may bleed profusely. Control bleeding with direct pressure. Skull injury: Includes fractures to the cranium and the face. If severe enough, there can be injury to the brain. Brain injury: Can be classified as direct or indirect. Direct injuries can occur in open head injury. Can be diffuse; occurring over a wide area or local; I a small, specific area.

13. Scalp Injuries Lacerations: The most minor type of head trauma Easily recognized. Bleed profusely as the scalp is highly vascularized. Major complication is infection.

14. Skull Injuries Injuries involving the bony calvarium; may or may not be associated with injury to the brain. Skull fracture: A break in the bone surrounding the brain and other structures within the skull. Types of skull fractures: Linear, Depressed, Basilar, Simple, Comminuted, Compound, Diastatic

15. Linear: A break in the continuity without alteration of the relationship of the bony parts; cause – low velocity injuries. Depressed: Inward indentation of the skull; cause – powerful blow. Comminuted: Multiple linear fractures with fragmentation of bone into pieces. Compound: Bone exits and is visible through the skin, or a deep wound exposes the bone through the skin. Closed/Simple: The bone is broken, but the skin is intact. Diastatic: Fractures occurring along the suture lines, widening them. More common in newborns and older infants Basilar: Usually caused by substantial blunt force trauma, involves at least one of the bones that compose the base of the skull. Basilar skull fractures most commonly involve the temporal bones but may also involve the occipital, sphenoid, ethmoid, and orbital plate of the frontal bone.

16. According to location Frontal Temporal Parietal Posterior fossa Orbital Basilar skull fracture

17. Temporal bone fracture Boggy temporal muscle due to extravasation of blood Oval shaped bruise behind the ear in the mastoid region (Battle sign) Otorrhea

18. Parietal bone fracture Deafness CSF otorrhea Bulging of tympanic membrane by blood or CSF Facial Paralysis

19. Orbital fracture Periorbital ecchymoses (Raccoon eyes) Optic nerve injury

20. Basilar skull fracture Otorrhea, rhinorrhea Bulging of tympanic membrane Battle sign, raccoon eyes Facial paralysis Tinnitus Vertigo

21. Traumatic Brain Injury Concussion: A sudden, transient, head injury with disruption of neuronal activity and a change in the level of consciousness. Results from direct bows to the head. It occurs when the brain suddenly shifts inside the skull and knocks against the skull’s bony surface. Brief disruption of LOC; for 5 minutes or less. Characterized by headache, dizziness, nausea or vomiting. The patient may complain of amnesia of events before or after the trauma. On clinical examination, there is no skull or dura injury. No abnormalities are detected on CT or MRI.

22. Traumatic Brain Injury Contusion: Bruising of the brain tissue over a focal area; usually associated with a closed head injury. The majority occur in the frontal an temporal lobes. The patient loses consciousness for a considerable period of time.

23. Traumatic Brain Injury Diffuse Axonal Injury: Characterized by extensive, generalized damage to the white matter of the brain. Axons are stretched and damages when parts of the brain of differing densities slide over one another. Can be seen with mild, moderate or severe head trauma and results in axonal swelling and disconnections. May cause cerebral edema and raised ICP.

24. Intracranial Hematoma Collection of blood occurs when the brain is forced against the inside of the skull, resulting in a pool of blood outside the cerebral vessels or in between the skull and brain. There are 3 types; Epidural Subdural Intraparenchymal

25. Epidural Hematoma Collection of blood between the inner surface of the skull and dura mater. Commonly bleeding by arterial origin – disruption of the middle meningeal artery. Most common type of intracranial hemorrhage. Neurological emergency.

26. Epidural Hematoma The patient is initially unconscious after trauma. Awakens and has a lucid interval followed by a rapid decrease in LOC. Headache, nausea, vomiting. On CT Scan, a bright, biconvex shaped clot is seen with well-defined borders that usually respects the suture lines.

27. Epidural Hematoma A rapid craniotomy for evacuation of the congealed clot and hemostasis is required for EDH Prevention of cerebral herniation can drastically improve outcomes.

28. Subdural Hematoma Occurs from bleeding between the dura mater and the arachnoid layer of the meninges. Usually results from venous bleeding from tearing of a bridging vein running from the cerebral cortex to the dural sinuses. Hematoma may be slower to develop. The types are: Acute subdural hematoma Sub-acute subdural hematoma Chronic subdural hematoma

29. Acute Subdural Hematoma Develops 24-48 hours after severe head trauma. Commonly related to acceleration-deceleration injury. Clinical manifestations are the same as raised ICP. The size of the hematoma determines the clinical presentation. Decreasing LOC from drowsy and confused to unconsciousness. Headache. Ipsilateral pupil dilation. Motor signs.

30. Acute Subdural Hematoma On head CT Scan, the clot is bright or mixed-density, crescent shaped (lunate) and may have a less distinct border. Does not respect suture lines. Craniotomy for removal of the clot and decompression in indicated for any acute SDH more than 1cm in thickness or smaller hematomas that are symptomatic.

31. Subacute Subdural Hematoma Usually occurs within 2-14 days of the injury. Alteration in mental status as the hematoma develops. Progression depends on the size and location of the hematoma.

32. Chronic Subdural Hematoma Develops over weeks to months after a seemingly minor head injury. Peak incidence is in 50-60 years of age. Clinically manifests as progressive alteration in LOC.

33. Subarachnoid Hemorrhage Bleeding occurs between the arachnoid and pia mater. Causes: Rupture of berry aneurysm Trauma (basilar skull fracture) Clinical features: Thunderclap headache. “Worst headache of my life”. Nausea, vomiting, decreased LOC or coma. Signs of meningeal irritation.

34. Subarachnoid Hemorrhage Increased attenuation is seen in the CSF spaces over the cerebral hemisphere Xanthochromia on Lumbar puncture.

35. Subarachnoid Hemorrhage The main goal of treatment is to stop the bleeding ad prevent rebleeding. CCBs are started to prevent vasospasm and control high arterial pressure.

36. Intracerebral Hemorrhage Hemorrhage that occurs within the brain parenchyma itself. Two main types: Intraparenchymal Hemorrhage – ICH extending into brain parenchyma. Intraventricular Hemorrhage – ICH extending into the ventricles. Causes: Hypertensive vasculopathy (70-80%). Ruptured Aneurysm. Trauma (16%).

37. Intracerebral Hemorrhage Rapidly progressive, severe headache building over several minutes, often accompanied by focal neurological deficits, nausea and vomiting, decreased LOC. Signs and symptoms depend on the site of hemorrhage: Basal ganglia and internal capsule – Hemiparesis, dysphasia Cerebellum – ataxia, vertigo Pons – cranial nerve deficits, coma Cerebral cortex – Hemiparesis, hemisensory loss, hemianopsia, dysphasia.

38. Intracerebral Hemorrhage Treatment may include lifesaving measures, symptom relief and complication prevention. Control BP and raised ICP. Early hemostatic therapy.

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