CEREBRAL CONTUSION Presentation Slide share

CEREBRAL CONTUSION

1. CEREBRAL CONTUSION

2. TRAUMATIC BRAIN INJURY An insult to the brain, not of degenerative or congenital nature caused by an external physical force that may produce a diminished or altered state of consciousness , which results in impairment of cognitive abilities or physical functioning. It can also result in disturbance in behavior or emotional functioning.

3. MECHANISM OF INJURY: BLUNT INJURY Motor vehicle injuries falls Assaults PENETRATING INJURY Gunshot wounds Stabbing Explosions

4. TYPES OF BRAIN INJURY CLOSED INJURY OPEN INJURY

5. CLOSED INJURY O f the two, closed injury is far more common. Resulting from fall and motor vehicle accidents. Effects are more broad (diffuse) No penetration to skull

6. OPEN INJURY Results from bullets wounds. Largely focal damage Penetration of skull Effects can be serious

7. TYPES OF HEAD INJURIES Scalp laceration Skull fractures Focal brain injuries Diffuse brain injuries

8. Focal C erebral contusion I ntracranial hemorrhages I ntracerebral hemorrhages Diffuse C oncussion Moderate diffuse axonal injury Severe diffuse axonal injury

9. Pathophysiology Primay injury At the time of trauma. Irreversible cellular injury as a direct result to injury.

10. Secondary injury O ccurs after hours to weeks after the injury. Includes injuries from edema ,ischemia, hypoxemia, vasospasm .

11. CEREBRAL CONTUSION Cereberal contusions are basically ”brain bruises” . Most often involving the crown of gyrus ,they tend to be wedge shaped with apex extending into neural parenchyma. Cerebral contusions are also called gyral “crest” injuries.

12. CLASSIFICATION COUP COUNTERCOUP INTERMEDIATE COUP GLIDING CONTUSION HERNIATION CONTUSION FRACTURE CONTUSION

13. COUP Coup contusion are those that occur beneath the immediate area of impact.

14. COUNTERCOUP Countercoup contusions are those that are thought to be confined to areas remote from and most often directly opposite the impact site on the other side of brain.

15. INTERMEDIATE COUP Intermediate coup occurs within the neural parenchyma between the impact site and the opposite side of brain. True intermediate coup contusions occur in sylvian fissure ,where frontal and temporal corties may be forcibly “slapped” against each other during the transmission of force from one side to other.

16. GLIDING CONTUSION Gliding contusions has been described as those that occur at the vertex of brain and are produced by rostral to caudal movement of brain during deccelerative injuries.

17. HERNIATION CONTUSION They are produced sudden forcing of a portion of a brain against a rigid opening , most often the incisura of tentorium .

18. FRACTURE CONTUSION The fracture contusion term is restricted to contusion located immediately under the fracture line .

19. ETIOLOGY Most cerebral contusions result from nonmissile or blunt head injury. Closed head injury induces abrupt changes in angular momentum and deceleration. The brain is suddenly and forcibly impacted against an osseous ridge or the hard , knife-like edge of the falx cerebri and tentorium cerebelli .

20. PATHOLOGY LOCATIONS They occur in very characteristic, highly predictable locations. Nearly half involve the temporal lobes. The temporal tips, as well as the lateral and inferior surfaces and the perisylvian gyri , are most commonly affected . The inferior (orbital) surfaces of the frontal lobes are also frequently affected

21. Convexity gyri , the dorsal corpus callosum body, dorsolateral midbrain, and cerebellum are less common sites of cerebral contusions. The occipital poles are rarely involved, even with relatively severe closed head injury.

22. MICROSCOPIC FEATURES Perivascular microhemorrhages rapidly form and coalesce over time into more confluent hematomas. Edema surrounding the hemorrhages develops. Activation and proliferation of astrocytes together with macrophage infiltration ensue. Necrosis with neuronal loss and astrogliosis as well as hemosiderin-laden macrophages are present in subacute and chronic lesions .

23. SYMPTOMS Vomiting Lethargy Headache Confusion Paralysis Loss of consciousness Loss of memory

24. Alteration of mental state Speech difficulties Seizures Focal neurological deficits

25. IMAGING CT SCAN FINDINGS: ACUTE : The most frequent abnormality is the presence of petechial hemorrhages along gyral crests immediately adjacent to the calvaria . A mixture patchy hyperdense hemorrhagic foci surrounded by ill-defined hypodense areas of edema is common. (salt and pepper appearance)

26. Lesion "blooming" over time is frequent and is seen with progressive increase in hemorrhage, edema, and mass effect . Small lesions may coalesce , forming larger focal hematomas. Development of new lesions that were not present on initial imaging is also common.

27. CHRONIC: Haemorrhagic foci turns isodence and then hypodense . Eventually the areas became encephalomalacic with volume loss and there is hypodensity of the involved parenchyma.

28. Multiple CT images over time demonstrate the evolution of a hemorrhagic parenchymal contusion in a typical location over the petrous ridge of the temporal bone. The hematoma is not visible on day 1 (top row left), but appears and enlarges over the next few days (top row right and middle row left), a typical course for contusion. At day 17 (middle row right), all that remains is a hypodense hematoma that has already begun to involute. 1 year from the initial trauma, the previous hematoma has evolved into a small amount of encephalomalacia (bottom row).

29. MRI MRI is much more sensitive than CT in detecting cerebral contusions but is rarely obtained in the acute stage of traumatic brain injury.

30. T1 scans may show only mild inhomogeneous isointensities and mass effect.

31. T2 scans show patchy hyperintense areas (edema) surrounding hypointense foci of hemorrhage .

32. FLAIR scans are most sensitive for detecting cortical edema and associated tSAH , both of which appear as hyperintense

33. MANANGEMENT Prevention of secondary injury. Hypoxemia Hypotension Anemia Hyperglycemia

34. INDICATION FOR ICP MONITORING Severe head injury ( gcs <8) with abnormal ct. Severe head injury with normal ct and 2 of following : Age>40 SBP <90 Decerebrate or decorticate posturing.

35. INVASIVE SYSTEMS: Intraventicular Intraparenchymal Subarachnoid Epidural. NONINVASIVE SYSTEMS: TCD Tissue resonance analysis Ocularsonography Intraocular pressure

36. THERAPY FOR INTRACRANIAL HYPERTENSION FIRST TIER: P ositioning V entricular drainage Osmotic diuresis Hyperventilation

37. SECOND TIER: S edation Neuromuscular blockade Hypothermia Barbiturate. Decompression craniectomy Evacuaton of contused brain

38. SURGICAL INDICATION: Progressive neurological deterioration, refracatory intracranial hypertension, signs of mass effect on ct Volume >50ml Gcs 6-8 with frontal or temporal contusion volume >20ml with mid line shift >5mm.

39. COMPLICATION POST traumatic amnesia Post concussion syndrome Post traumatic epilepsy Infections Metabolic abnormalities Vascular abnormalities .