Download Classification of Head Injury

Head Injury
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Prehistorycal
types of
trepanation
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Treatment of
depressed skull
fracture , XVI
century
Classification of Brain Injury,
Petit, 1774
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Cerebral concussion (commotio cerebri)
Cerebral contusion (contusio cerebri)
Cerebral compression (compresio cerebri)
Causes of head injury in the USA
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Fall from e
height
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Trafic
accidents
Classification of
Head Injury
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On pathology basis
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focal
diffuse
depending on infection risk
 Closed
 Open
 penetrating
 not
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penetrating
Clinical forms of head injury
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Cerebral concussion
Brain contusion
Mild
 moderate
 severe
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Diffuse axonal injury
Cerebral compression
Head compression
Pathogenesis of head injury
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Initial lesions
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contusion
diffuse axon injury
hemorrhages
injury of cranial
nerves
Secondary lesions
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Intracranial
cerebral compression
with hematomas
 Vioaltion of CSF and
blood circulation
 Brain edema
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Extracranial
Anemia
 hypoxemia
 hypertermia
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Pathology of head injury
concussion Lesions on level of cellular organelle,
axons, synapses
mild
contusion
spot hemorrhages in cortex, local
subarachnoidal hemorage
moderate
contusion
Primary necrosis in cortex and white
substance, diffuse hemorages in 1-2
gyruses
Large necrosis and hemorages
Severe
contusion
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Clinical presentations of head
injury
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Signs of injury on the scalp (wounds, contusion)
Impaired consciousness
Amnesia
Focal neurological deficit
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Pupil asymmetry
Cranial nerve deficit
Paresis
Reflex asymmetry and depression
Aphasia
Seizures
Level of consciousness
1.
2.
3.
4.
5.
6.
7.
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Clear consciousness - full and adequate orientation and
reactions. Possible amnesia.
Mild– slight sleepiness, some time and place disorientantion,
some slowness in command obey,
– hypersomnia, disorientation, only elementary verbal contact is
possible, obeys only simplest verbal instructions.
Stupor – verbal contact is impossible, reactions and eye opening
on pain are preserved.
Mild coma – no eye opening, noncoordinated reactions on pain.
Pupil and corneal reflexes are preserved.
Severe coma – no response on pain, best motor response is
extension or flexion. Pupil and corneal reflexes are decreased.
Spontaneous respiration and blood circulation are preserved with
probable violations.
Terminal coma – no reflexes, muscle atonia, midriasis
Glasgow Coma Scale
Eye
opening
Best
verbal
respons
e
Best
motor
respons
e
Spontaneously
4 points
Opens eyes to voice
3 points
Opens eyes to pain
2 points
No eye opening
1 points
Spontaneous, appropriate and oriented
5 points
Confused conversation, phrases only
4 points
One word speech, inappropriate words
3 points
Incomprehensible sounds only
2 points
No sounds
1 points
Obeys commands
6 points
Localizes pain
5 points
Withdraws to pain
4 points
Abnormal flexor response (decoricated rigidity)
3 points
Abnormal extensor response (decerebrated rigidity) 2 points
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No movements
1 points
Evaluation of consciousness after
Glasgow coma scale
Level of consciousness
Clear
Mild
Severe
Stupor
Mild coma
Severe coma
Terminal coma
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Points in GCS
15
13-14
11-12
8-10
6-7
4-5
3
Severity of head injury
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mild (13-15 point in Glasgow coma scale) –
cerebral concussion, slight cerebral
contusion
moderate (8-12 point) – mild cerebral
contusion, subacute and chronic cerebral
compression
severe (3-7 point) – severe cerebral
contusion, diffuse axon injury, acute cerebral
compression
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mild
cerebral
contusion –
punctated
hemorages
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mild
cerebral
contusion
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mild cerebral contusion
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contusion
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Mild
cerebral
contusion
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Mild
cerebral
contusion
(on MRI)
Two
contusion
focuses
1- direct blow
on the right
2-countercoup
on the left
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Depressed skull fracture
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Linear fracture of occipital bones with going to
the skull base
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fracture of parietal and frontal bones
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Depressed fracture of parietal bone
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Severe
cerebral
contusion
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Severe
cerebral
contusion
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Severe
cerebral
contusion
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Severe
cerebral
contusion
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Depressed
fracture of
parietal and
temporal
bones
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Diffuse axon
injury – there
are no
macroscopic
lesions
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Axonal spheres at diffuse axon injury.
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Поперечний зріз
аксона, норма
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Після травми.
відсутні
мікротрубочки
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Diffuse axon injury on CT (no lesions)
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Head
compression
Cerebral compression
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Acute – manifestation during 24 hours
after head injury
Subacute – manifestation during 1 week
after head injury
Chronic - manifestation after 1-2 weeks
after head injury
Causes of cerebral compression
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Hematomas
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Epidural
Subdural
Intracerebral
Bone fragment at depressed fructures
Pneumocephalus
Main triad at cerebral
compression
Deterioration of consciousness
level
 Ipsilateral anisocoria
 contrlateral hemiparesis
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Epidural
hematoma
on the left
Subdural
hematoma
on the
right
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Intracerebral
hematoma
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Epidural
hematoma
on CT
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Epidural
hematoma in
posterior fossa
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Subdural
hematoma
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Chronic bilateral subdural hematomas
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Subacute hematoma
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Localization of intracerebral hematomas
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Intracerebral hematoma on MRI
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Intracerebral
hematoma
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Intracerebral
hematoma in
the frontal
lobe
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Intracerebral hematoma
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Combination of subdural and Intracerebral
hematomas
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Acute traumatic
pneumocephalus
Treatment of moderate and
severe head injury
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Acute resuscitation
Diagnostic procedures
Definitive treatment
Treatment
Acute resuscitation
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ABC
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Air pathway – cleaning of throat, airway tube, tracheal
tube
Breathing –
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Circulation
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Oxygen mask for stuporose and soporose patients
Intubation for comatose
Intravenous fluids for maintaining normal blood pressure
Maintaining adequate perfusion pressure of the brain
Treatment
Diagnostic procedures
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Neurological examination
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State of consciousness, GCS
Major neurological deficit
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Pulse rate, blood pressure
Neurovisualization
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Pupillary reflexes and symmetry
Ocular movement
Lower brain stem reflexes
Motor examination (hemiparesis, reflexes)
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Plain X-ray examination
CT
Cerebral angiography
Diagnostic bur holes and ventriculography
MRI
Definitive treatment
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Typical indications for surgery
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Epidural and subdural hematomas that cause
depressed consciousness
Intracerebral hematoma and contusion in
comatose and soporose patients with
significant mass-effect on CT
Depressed skull fractures
Gunshot wounds
Insertion of Intacranial pressure monitor
Periods of head injury
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Acute – 2-4 weeks
Intermediate – 2-6 weeks
Remote
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bur hole
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Approach to fronto-temporal and parietotemporal lobes
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Approach
to frontal
lobe
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Approach
to
temporal
lobe
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Approach
to parietal
lobe
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Approach to
occipital
lobe
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Posterior
fossa
approach
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Removal of epidural hematoma
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Dendy’s
point for
puncture of
posterior
horn of
lateral
ventricle
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Kocher’s
point for
punction of
anterior horn
of lateral
ventricle