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REFERAT

DIAGNOSIS AND TREATMENT OF HEAD INJURY

Disusun oleh :
Ayu Lestari
1102011057
Kepaniteraan Klinik Neurologi RSUD Pasar Rebo

Pembimbing :
Dr. Donny H. Hamid SpS

RSUD PASAR REBO JAKARTA


FAKULTAS KEDOKTERAN
UNIVERSITAS YARSI

DIAGNOSIS AND TREATMENT OF HEAD INJURY

INTRODUCTION
Among the vast array of neurologic disease, head injury ranks high in order of
frequency and gravity. In the United States, trauma is the leading cause of death in persons
younger that 45 years of age and more than half of these deaths are as a result of head
injuries. According to the American Trauma Society, an estimated 500.000 Americans are
admitted to hospitals yearly following cerebral trauma; of these 75.000 to 90.000 die and
even larger numbers, most of them young and otherwise healthy, are left permanently
disabled.
Head injury incidence is higher in young people showing a peak incidence in young
adults aged 15-24 with secondary peaks in infants and the elderly between the ages of 70-80.
Males outnumber females 2 to 1 in most studies except the very young where the incidence is
the same in males and females. The external causes of brain injury may vary relative to the
geographic area (city vs. state wide). About half are related to transport (motor vehicle,
bicycles, motorcycles, etc., pedestrian injuries). Falls are second and sports, assaults, gunshot
wounds account for most of the remainder. In some cities gunshot wounds may account for
50%.
The basic problem in head trauma is at once both simple and complex; simple because
there is usually no difficulty in determining causation, and complex because of a number of
delayed effect that complicate the injury.
In head injury, one fact is preeminent; there must be the sudden application of a
physical force of considerable magnitude to the head. The mechanical factors of importance
in brain injury are the differential mobility of the head on the neck, and of the brain within
the cranium, the tethering of the upper brainstem that allows movement of the cerebral
hemisphere around that vertex, and the striking of the brain on dural septa and bony
prominences. These mechanism resulting in damage to the structure of the cranium (skull)
and/or cerebrum (brain) differ from superficial wound on the scalp, laceration on the
meninges, damage to the intracranial or extra cranial vascularization or the tissue of the brain
itself.

Definition
Head injury is an acute injury resulting from mechanical energy to the head from
external physical forces. Operational criteria for clinical identification include one or more of
the following:
confusion or disorientation
loss of consciousness
post-traumatic amnesia
other neurological abnormalities, such as focal neurological signs, seizure and/or
intracranial lesion.
These manifestations of head injury must not be due to drugs, alcohol or medications,
caused by other injuries or treatment for other injuries (e.g., systemic injuries, facial injuries
or intubation), or caused by other problems (e.g., psychological trauma, language barrier or
co-existing medical conditions). Head injury can occur in the context of penetrating
craniocerebral injuries but in this situation, focal neurological deficits are generally more
important than any diffuse element
Classificationofinjuries:
Primaryheadinjuriesincludeskullfractures,focalinjuriesanddiffusebraininjures.
Skullfracturemayoccurwithoutbraindamage,butfocalordiffusebraininjuryisoften
present.Theseoccurasprimarydamageatthemomentofinjuryintheformofcontusions,
lacerations,diffuseaxonalinjuryorsecondarydamageinitiatedby,butnotpresentat,timeof
injury.Theseincludeintracranialhemorrhage,brainswelling,raisedintracranialpressure,
hypoxicbraindamageandinfection.

FocalInjuries
Cerebral contusions are areas of infarctions,hemorrhage, oredema within brain
tissue.Thegyralcrestismaximallyinvolvedwithvariableeffectstothesubjacentwhite

matter.Thesearefoundin2040%ofheadinjuredpatientsstudiedbyCT.Contusionsand
lacerations occur more frequently in the frontal and temporal poles where the brain is
restrictedbythefrontalandtemporalskullbasenearthesphenoidridge.Theyoccurbeneath
thefracturesitesorbeneaththesiteoftrauma(coupinjuries)and/oroppositethepointof
injury(contracoupinjuries).Hemorrhagiccontusionsmayberelativelyminorinappearance
on initial CT scan. Over time (hours to days), the patient may develop progressive
neurologicaldeterioration.Insuchinstances,subsequentCTscanmayrevealevolutionofthe
contusion into a frank intracerebral hematoma, so called delayed traumatic intracerebral
hematoma(DTIC).
Epiduralhematomasoccurin515%offatalinjuries.Theyareusuallycausedfrom
bleedingfromameningealarterymostoftenthemiddlemeningealartery.Occasionallythey
resultfromtearsinthecapitalortransversesinuseswithsloweronsetofsymptoms.85%of
epidural hematoma patients have a skull fracture. The patient may have a lucid interval
betweeninjuryandcoma,butthisintervalmayoccurwithallconditionslistedbelowseventy
toeightypercentareinthetemporalfossa,buttheycanoccuratanylocation.Ifthepatientis
comatosefromtheonset,othertypesofbraindamagearepresent.
Subdural hematoma results from tearing and stretching of parasagittal bridging
veinsresultingfromrapidaccelerationofthebrain.Theyaremorecommonfromfallsand
assaultsthanvehicularaccidents.Arterialbleedingmayaccountfor30%ofthesehematomas.
Subduralhematomascanoccurin"pure"form,butmanyareassociatedwithcontusionsand
diffusebraininjury.
Intracerebralhematoma: Inclosedheadtrauma,thecausesandmechanismsare
muchthesameasforcontusions.Theyaremostcommoninthefrontalandtemporalpoles
andtheyareoftenassociatedwithextracerebralhematoma.Linearfracturesoccurin1050%
ofcases.

DiffuseBrainInjury
Theseareassociatedwithwidespreaddisruptionofneurologicalfunction,without
obviouslyvisiblebrainlesionsonimagingstudies.Theyarecausedbyinertialoracceleration
effectsoftheforcesappliedtothehead.Rotationalaccelerationisthoughttobetheprimary
mechanismcausingdiffusebraininjuriescanbefurtherclassifiedas:
Mildconcussion: Thereistemporarydisturbanceofneurologicalfunctionwithout
lossofconsciousness,usuallywithmildcontusionanddisorientation.Thepatientmaynot
cometomedicalattentionandmayhaveamnesiaoffivetotenminutes.
Classicalcerebralconcussion:Thereistemporary:reversiblelossofconsciousness
lasting less than six hours. The patient always has some retrograde amnesia and post
traumaticamnesia.Patientsshouldbeobservedforsubsequentdevelopmentofintracranial
hematoma.

Diffuseaxonalinjury(DAI):Thisispathologicallycharacterizedbyaxonaldamage
oractualtissuetearsandsmallbloodvesseltears.Axonsform"retractionballs'whichlater
appear as diffuse astrocytosis and demyelination. Diffuse axonal injury can be further
classifiedintomild,moderateandseverewithcorrespondingdifference,ofdurationofcorna,
neurologicalfindings,anddegreeofrecovery:

Evaluationofclosedheadtrauma
Thehistoryofanaccident,natureofandcircumstancesofinjuryandconditionafter
anaccidentwillaidinfurtherevaluationofpatientandsubsequentmanagement.

Theinitialneurologicalevaluationisbrieftoassessthelevelofconsciousnessandthe
presenceoffocalneurologicaldeficits.Ausefulandnowwidelyusedscaleofmeasurement
istheGlasgowComascale.(See:NeurologicalExam).Thisisusedtotriagepatientsandto
gradetheclinicalcourseduringtreatment. Forinstance,withpatientsunabletospeakor
followcommands,theincidenceofintracranialmasslesionsrequiringsurgeryrangesfrom
40%60%.
Afterinitialexamination,athoroughexaminationisrequired.Ofteninmajorhead
trauma,otherorgansystemscanbeseverelyinjured.Inthesecasesthereisaneedtotreat
multiplesystemssimultaneously.Immobilizationofthespinemaybeindicatedsince5%
10% of head injury patients have an associated spine or spinal cord injury. Thoracic,
abdominalandskeletalinjuriesmustbeidentifiedandmanaged.
Airwaymaintenanceisofprimaryimportance. Theoropharynxmustbeclearedof
debrisorsecretions.Intubationmayberequitedwithcurenottoextendtheneckifcervical
spinalassessmenthasnotbeendone.
Hypotensionishardlyeveraresultofintracranialbleedingunless,themedullais
already compromised. In open head injuries, blood loss from scalp laceration can be
significant,particularlyininfantsandchildren.But,intheusualsetting,othercausesofshock
mast be sought. Hypotension, however, can result from spinal injury by disrupting
sympathetictonetotheperipheralvasculature.

Physicalexamination:Itisimpossibletooutlineanexamappropriateforallpatients
becauseoftheenormousvariationsinindividualinjuries.Somewithminorheadtraumaare
awakeandcooperative;otherswithmultisystem,majortraumaarecomatoseandrequire
examinationbymanyphysicianssimultaneously.Theorderandpriorityofexaminationis
uniquetoeachsituation.

Inspectionofcranium:Areasofscalpconfusionandswellingmayoverliesitesof
linearordepressedfractures.

Evidenceofbasilarfracture.
a.

Raccooneyes:bloodstainingofperiorbitaltissue.

b.

Battle'ssign:ecchymosisaroundmastoid,airsinuses

c.

DrainageofCSFfromnoseorear(rhinorrheaorotorrhea,respectively).

d.

Hemotympanrrmorlacerationofexternalauditorycanal.

e.

Facialfracture.LeFortfracture:palpatestabilityoffacialbonesandorbitalrims.

f.

Palpationofmandible.

g.

Orbital injury. Inspection of globe. Note presence of proptosis or edema of


conjunctiva.

h.

Auscultationofneckandeyeorheadforbruitsmayrevealcarotidcavernousfistula
orcarotidarteryinjurysuchasatraumaticdissectionorpseudoaneurysm.

Neurological examination: The initial exam serves as a baseline for future


assessmentofimprovementordeteriorationandmustbewelldocumented.
Levelofconsciousness. TheGlasgowComaScale(GCS)isusedforstandardized
numericalassessmentsusefulforfollowingtheindividualpatientandmakingcomparisons
withinformationfrominstitutionstreatingheadtrauma.Itprovidesaqualitativemeasureof
neurological injuryseverity based on eye opening, verbal responsiveness, and motor
response.AmildinjuryisGCSof13to15,moderate812,

EYEOPENING

GLASGOW
SCALE

Spontaneous

Toverbalcommand

COMA

Topain

None

BESTMOTORRESPONSE
Obeysverbalcommands

Localizespain

Withdrawal

Flexion/abnormal

(decorticate)
Extension(decerebrate)

None

BESTVERBALRESPONSE
Oriented,conversing

Disoriented,conversing

Inappropriatewords

Incomprehensiblesounds

None

Total

315

Inpatientswhoarecommunicating,amoredetailedexamoforientationisappropriate

CranialNerveExam.Pupilreactiontolightismostimportant.Pupillaryinequality
maysignalpartialorcompleteIIINpalsyasaresultofanipsilateralcompressionbythe
uncusintothetentorialnotch.Rarely,itmayresultfromcontralateralherniation.Ineither

case,thefindingisofextremeimportancerequiringurgentdiagnosisandtreatmenttoprevent
furthereffectsofherniation.Rarelyopticnervecompressionortransactionmayproducethis
finding.Pupillarysizereflectslevelsofdamagetothebrainstem.Damagetodiencephalons
orponscausessmall,butreactivepupils.Damagetothetegmentumofmidbrainorthird
cranialnervesresultindilatedfixedpupils.Midposition,nonreactivepupilsmayoccurwith
morediffusemidbraininjury.Drugsordropswhichmayafterpupillarysizeshouldbe
avoidedinthesettingofacutetraumaasthiswilleffecttheabilitytoappropriatelymonitor
thepatientsneurologicalexam.

Funduscopicexam. Examineforretinalorpreretinalhemorrhage.Papilledemais
rarelyseensoonaftertrauma.

Corneal reflexes tests fifth cranial nerve sensation and integrity of brain stem
connectionstotheseventhcranialnerve.

Facialnerve.Completeparalysisusuallyindicatesperipheralinjury.Partialparalysis
mayindicateavarietyofcentralcausesi.e.corticalthroughbrainstern.

Olfactorynervefunctionmaybelostafterbluntinjury.Thisisoftenduetodamage
tothenervesatthecribriformplate.Itisrarefortheremaininglowercranialnervestobe
impairedinawakepatients;buttheyshouldbetestedwhenpossible.
Withdeeplycomatosepatientsoculocephalicreflexesmaybeappropriatetotest.In
theabsenceofcervicalspineinjury,dollseyemaneuver"canbedone.Theeyesdeviate
fromthedirectionofheadmotionandrapidlyreturntoneutral.Withaunilateralmidbrain
lesion,theipsilateraleyewillnotadduct,buttheeyescontralateraltothelesiondeviates
awayfromthedirectionsofheadmotion.Withlesionsofthemidponsthereisnoreflex.Ice
watercalorictestingmaybeusedtoassessthesamereflexes,butthistestconsumesmore

time.

Motorexam: Assessesfunctionsofmotortractsfromthebrainthroughthespinal
cord. In the awake patient, a complete exam is possible. In comatose or uncooperative
patientsresponsestonoxiousstimuliarerequiredtoidentifyposturingresponsesasdistinct
fromvoluntary.Decorticateposturing(flexionofelbows,wrists,andfingersandextensionof
lower extremities may be seen with lesions above the mid brain. Decerebrate posturing
(extension,adductionandpronationofupperextremitiesandextensionoflowerextremities
with foot plantar flexed) is seen with lesions below the upper mid brain and above the
vestibularnuclei.

Sensoryloss canbepartiallyassessedincomatosepatientswhentestingformotor
responses.Ifspinalcordinjuryissuspected,rectalexamshouldbedonetoassessrectaltone
andthebulbocavernosusreflex.Sensoryexamintheawakepatientshouldassesspinand
touch in the major dermatomes of the spinal cord as well as posterior column function
(vibration,andjointposition).

Reflexes: Testdeeptendonreflexesoffourextremitiesandplantarreflexes.Inthe
absenceofreflexes,spinalcordinjurymaybesuspected.Analwinkandbulhocavernosus
reflexshouldbetested.

BrainHerniationmayoccurunderthefalx,throughthetentorialnotcheitheronone
orbothsides,orthroughtheforamenmagnum.Atthetimeofinitialevaluation,oneorall
mayhaveoccurredbutinthelessseverelyinjuredpatient,carefulandfrequentassessmentis
demandedforearlydetection.

Central herniation results from diffuse bilateral supratentorial swelling or mass


effectwithdownwarddisplacementofallsupratentorialstructureswithprogressivelossof
brainfunctioninarostrocaudaldirection.Changesinmentalstatusprogresswithincreasing
(drowsinesstoconfusiontoagitationtocoma.Breathingirregularities"withpauses,small
but reactive pupils, increased muscle tone, Babinski signs and posturing then occur. If
therapy is unsuccessful, continued midbrain function is lost with eventual loss of all
brainstemfunctionanddeath.

Uncal, orlateralherniation,occursfromlesions(suchashematomas)orswelling
causing the medial edge of the temporal lobe (uncus) to herniate over and through the
tentorialnotch.Dilationoftheipsilateralpupilisanearlysignandmayoccurwithorwithout
alterationinmentalstatusinitially.Progressionofherniationmayproduce completethird
cranialnervepalsyassociatedwithcontralateralmotorparesisandlossofconsciousnessfrom
midbraincompression.Occasionally,ipsilateralhemiparesiswilloccurfromcompressionof
the opposite cerebral peduncle against the contralateral tentorial edge (Kernohans notch
phenomenon).Ifnottreatedsuccessfully,progressivelossofmidbrainfunctioncontinuesas
incentralherniation.

Cerebellar tonsil herniation through the foramen magnum usually occurs from
lesions within the posterior fossa. Depression of consciousness, alteration of respiratory
rhythm,dysconjugategazeandverticalnystagmusmaysignalitsbeginningandrespiratory
arresttheend.

Clinical assessment including radiographic studies: After one has obtained the
history and accomplished the necessary physical and neurological exanimation and
resuscitation measures adecisionregardinglikelihood ofsignificantintracranialinjuryis
made. Patients can be placed in low, moderate, and high risk groups based on physical
findingsandneurologicalexamination.

Low risk: Asymptomatic, and/or headache, dizziness, scalp hematoma,


scalplaceration,contusionorabrasionandabsenceofthemoderateorhighriskcriteria.
Moderate risk: Change of consciousness, at or subsequent to injury, increasing
headache,alcoholordrugingestion,inadequatehistory,age<2,vomiting,amnesia,signsof
basilarfracture,possibleskullpenetrationordepressedfracture.
High risk: Depressed level of consciousness not clue to alcohol, drugs; or other
causes(metabolic,seizures).Focalneurologicalsigns,decreasinglevelofconsciousness,and
obviouspenetratingskullinjuryordepressedfracture.

Furthermanagementofthesegroups.

LowRisk:Observationanddischargedwithheadsheet(instructiononcarefulobservationat
home)towatchformoderateorhighrisksigns.

ModerateRisk:Extendedobservationinhospitalsetting.Manyofthesepatientswillneed
CTscanning.

HighRisk.AllshouldhaveemergencyCTscanandneurosurgicalconsultation.

Radiographic evaluation: current imaging modalities are skull xrays,


computedtomography(CT);magneticresonanceimaging(MRI),andcerebralangiography.

CTscanistheprimaryimagingmodalityforinitialdiagnosisandmanagement.Itis

quickly available, safe, fast and can be performed on patients with serious and multiple
injuries.Itcandemonstratehematomas,subarachnoidblood,contusion,cerebralswelling,
ventricularandsubarachnoidcisterncompressions.Fracturesoftheskullcanbeseenwell
withtheuseofboricwindowsonCT.Immediatedecisionsregardingsurgicaltreatmentcan
bemade.

MRI is rarely used at present for emergency evaluation of intracranial


trauma.Ittakesmuchlonger,iscumbersometousewithresuscitationequipment,andmay
be contraindicated in patients with implanted metal devices. However, its multiplanar
capacitiesdemonstratepathologymoreaccurately,particularlyinbrainstemandposterior
fossa.Itsbrainuseisinassessmentofpatientsinsubacutestageofinjury.

Skullxrays:Routineuseofskullxraysiscontroversial.Theyaffectmanagementin
only0.4%to2%ofpatients.Alinearfractureimpliesthatgreatforcetoskulloccurred.213
ofpatientshospitalizedwithskullfracturehavesignificantintracranialinjury.Therefore,the
useofskullxraysisdictatedbyriskassessmentofinjuredpatient(seeabove).Inmost
instances,CTprovidesadequateinformationregardingskullfracturesas,wellassuperior
imagingoftheintracranialcontents,andthereforeskullfilmsarenotneeded.

Spinefilms.Itthenatureofinjuryandotherriskfactorsarepresent,cervicalspine
films should be made. The craniocervical juncture to C7 must be visualized. Special
techniquessuchasaswimmersviewmayberequiredtovisualizelowercervicalspine.If
inadequatevisualizationispossiblewithplainxrays,thenspineCTmayberequired,but
plain xrays are still the imaging modality of choice to screen for fractures. Similarly,
thoracicandlumbarspinefilmsareindicateddependingonhistory,mechanismofinjuryand
mentalstatusofpatient.

Management
Prehospital:Airwaymaintenanceofutmostimportance:Thirtypercentofseverely
headinjuredpatientsarehypoxemicinER.Oralornasopharyngealairwaysorintubationis
requiredwithoutextensionofneckifpossible. Hypotensionisassociatedwithincreased
morbidityandmortality.Itisusuallyduetoextracranialcauses.Atpresentisotonicsalineor
Ringerslactatesolutionarethefluidsmostoftenusedinitially,

Scalpinjuries:Scalplacerationsmaycausesignificantbloodtossifmultipleorlarge.
Hemostasisisobtainedbypressureorclampingofobviousarterialbleeders.Repairisdone
after thorough cleaning and inspection for foreign material, underlying fractures. Scalp
avulsionmayrequirescalpflaporskingrafting.
Linear skull fractures: Require no treatment, but indicate high probability of
intracranialinjuryandtherefore,aCTscanoftheheadshouldbeobtained.

Depressed skull fracture: Best assessed by CT scan and skull xrays. Elevation
requireddependingondepth,andlocationofdepression.Ininfantsandchildrenadepression
ofafewmillimetersmaybeleftalone.Surgicalrepairofdepressionovermajorvenous
sinusesmaybebestavoidedbecauseofseverebloodlossifthesinusistamponadedby
fragment removed surgically. Though there is little evidence that elevation of closed
depressedfractureaffectsneurologicaloutcome,oralterstheincidenceofseizures,theyare
usuallyelevatedtocorrectcosmeticdefects.

Compoundskullfractures:Requireelevationanddebridementandclosureofdurait
torn.Bonefragmentscanbereplacedunlessthereisseverecontaminationofthewoundor
theinjuryisoldandinfected.

Basilarskullfractures: SuspectedonclinicalgroundsCSFrhinorrheaorotorrhea
occurin511%.Fractureoftheethmoidplate,orbitalplateorsphenoidsinususuallycause
rhinorrheaandfractureofpetrousportionoftemporalboneusuallycausesotorrhea.Most
CSFleaks(80%)willceasewithinoneweek.

ImagingofanteriorcranialfossaortemporalbonebytomographyorCTwiththeuse
of intrathecal contrast media are sometimes required to demonstrate site of CSF leak.
Controversyexistsovertinningandnecessityofsurgicalrepair.Someadvocaterepairinall
patientssincedevelopmentofmeningitislaterisnotuncommon.Othersrecommendrepair
only

if

leaks

persist

more

than

week.

Repairisaccomplishedbyeitherintracranialorextracranialapproaches.Endoscopic
transnasal/transsinusroutesofrepairperformedinconjunctionwithotolaryngologistmaybe
indicatedincertaincasesIntheabsenceofmeningitistheuseofantibioticsisnotindicated.

Epidural hematoma: Incidence 1 %to 2%of patients admitted forhead injury.


Clinicalpresentationcanvaryfromneverunconscioustounconsciousatalltimes,initially
consciousandsubsequentunconscious,initiallyunconsciousandsubsequentconsciousor
initiallyunconscious,lucid,thenunconscious. Dependsonseverityofinitialtrauma.Only
onethirdhaveclassic"lucid"interval.Symptomsprogressrapidlyusuallywithin6hours.
Maybedelayed,however.Signsandsymptomsareasdescribedintheherniationsyndrome
section,usuallylateralherniation.CTscanisthebestdiagnosticstudy,butifnotpossibleand
the patient's condition dictates immediate surgery, a burr note should be made over the
temporalareaipsilateraltothedilatedpupil,orareaofcontusionorfracture.Iffound,partial
evacuationimmediatelydecreasesintracranialpressure(ICP)andisfollowedbycraniotomy
orcraniectomytoremoveallclotandcontrolbleedingsite.Ifnothingisfound,frontaland
parietalburrholescanbeplacedononeorbothsides.Inmostcases,CTscancanbedone
andthesurgicalflaptailoredappropriately.Delayindiagnosisisthemaincauseofmortality
and morbidity. Mortality varies from 5%43%. Mortality is less in younger patients.

Additionalbraininjury(subduralhematoma,intracerebralhematomaorcontusion)triplesthe
mortality.

Acutesubduralhematoma:Aboutonethirdare"simple"subduralhematomasand
therestareassociatedwithcerebralcontusion,intracerebralhematomaand/ordiffuseaxonal
injury.Patientsonanticoagulationhaveincreasedriskfollowingtrauma.Thespectrumof
clinicalpresentationissimilartoextraduralhematoma(seeabove).Onethirdtoonehalfof
patientshavepupillaryinequality,halfhavehemiparesisandotherfindingsofherniation.CT
scanningisthediagnostic.procedureofchoicedisclosingthepresenceofclot,degreeofshift
andintraaxiallesions.

Ifthesubduralislessthan1cmthick,itmaybeobserved,butitmustbefollowedby
repeatscans.Comatosepatientswiththinhematomasprobablyhaveparenchymaldamage
andneedtobeaggressivelymonitoredwithimagingorICPmonitoring.

Subdural hematoma > 1 cm or with significant mass effect requires operative


treatmentusuallywithalargecraniotomyflapovertheappropriateareaandremovalofas
much clot as possible. Associated "burst" injuries of frontal or temporal poles, may be
resectedatsametime.BurrholesmaybeusedtosearchforclotifaCTscanwasnotdone,
butadequateremovalisrarelypossible.Comatosepatientstreatedwithinfourhoursfare
betterthanthosetreatedlaterwith30%,vs.90%mortality.Also,patientsover65,those
injuredinmotorcycleaccidents,andthosewithICP>45postoperativelyfareworse.

Chronicsubduralhematoma.Subduralhematomadetectedaftertheacuteinjury.
Threefoursareover50yearsofage.Overage70,theincidenceincreasessharplyto
7.4/100,000/yr.Historyoftraumaisobtainedinonly50%to75%ofpatientsandmaybe
mild. Contributing factors are alcoholism and seizures. CT and MR scans are the best

diagnosticmodalities.Chronicsubduralhematomasmaybebilateralsonomidlineshiftis
evident. Some are isodense on CT and the scan can easily be misinterpreted. Cerebral
angiographyisveryaccurate,butrarelyrequiredtoday.Dependingontheirsize,chronic
subduralhematomasmaybemanagedoperativelyormedically.

Treatmentofchronicsubduralhematomas:

Operative
Burrhole. Bulkofhematomaisdrainedrapidlyandthedrainisattachedtoclosed
drainagesystemfornext2448hrs.
Crainotomyisoccasionallyrequiredforsolid,organizedorloculatedchronicsubdural
hematomas.
Subduralperitonealorsubduralatrialshuntoccasionallyisrequired,particularlyin
pediatricpatients.
Medical:Forasymptomaticormildlysymptomaticcollections,

use of low dose

steroids,rest,issuccessful.SerialCTscansrequiredtoassessresolution.
Cerebralcontusionsandhematoma.Managementisoftennotclearcut.CTscans
are required to assess the size and extent. Some require lop monitoring and appropriate
managementofventilationandosmoticagents.Frontalandtemporalpolecontusionsmay
requireremovalononeorbothsides.Suddenherniationmayoccur12weeksafterinjury
becauseofdelayedenlargement,necrosisandswelling

Hematomas of posterior fossa are relatively uncommon when compared to


supratentorialspace.Incidencereportedfrom3%13%ofallextraduralhematomasand1%
ofsubduralhematomas.Occipitalskullfractureisfoundintwothirdsormore. Headache
andstiffneckarethemostcommonsymptoms.Cerebellarsignsareseeninlessthanhalfand
maybeconfusedwithlesionselsewhere.Manypatientsmaydieundiagnosed.CTscanisthe
bestimagingstudy,butmayrequirespecialpositioningandmorefrequentcutstodetect
Hydrocephalusispresentinonethirdofpatientsandsupratentoriallesionsinaboutonehalf.
Surgicalremovalis,requiredandwithextraduralhematomastheclotmayextendabovethe
transversesinusrequiringexplorationaboveit.Mortalityisreportedfront15%to24%for
extraduralhematomasand42%70%forsubduralhematomas.
Gunshotinjuries:Approximately70%ofpatientsdieatthesceneofinjury.Injury
severityisdependentonsizeandtypeofmissileandvelocityofinjury.Flaccidpatientsall
die.Decerebratepatientshaveamortalityof95%97%.CTscanisthebestinitialstudyfor
detectionofbonefragments,courseofmissile,hemorrhageandswelling.Forviablepatients,
surgeryisrequiredtoremovehematoma,nonviablebrain,missilesandbonefragmentswhen
feasible,andtorepairandclosetheduraandscalp.Dependingontheseverityofinjury,
surgerymaybedonethroughasmallcraniectomyoritmayrequirealargeflaptodealwith
extensive bilateral brain damage. Retained bonefragments may cause delayed abscess
formationrequiringfurthersurgery.
MedicalManagementofSevereHeadInjuries: Thebasicgoalsaretomaintain
normalbloodpressure,adequatearterialoxygenation,controlbodytemperature(hypothermia
worsensoutcome)andfluidandelectrolytebalance.

ManagementofRaisedICP: Controlofelevatedintracranialpressureisthemost
importanttreatmentmodalityforheadinjuredpatient.Approximately40%ofpatientswith
lossofconsciousnesswilldevelopintracranialhypertensionatsomepointduringtreatment
anditslevelisastrongpredictorofoutcome.Upperlimitsofnormalinadultsandolder
childrenis1015mmHg,children37mmHgandinfants1.56mmHg.Cerebralbloodflow
inthecriticalparameterforbrainsurvivalanddependsoncerebralperfusionpressure(CPP)
whichisdefinedas:CPP=MAPBICP. MAPismeanarterialpressure;ICPisintracranial

pressure.Therefore,carefulcontrolofsystemicbloodpressureandICPisvitalinseverehead
injury.Oneepisodeofhypotension(SRP=90)afterinjuryincreasesmortality50%compared
to27%without.Hypoxiaalsoplaysasignificantrole.TreatmentofsmallrisesinICPmay
preventlateruncontrollableelevationsofICP.ThegoaloftherapyistokeepICPbelow15
20mmHgandmaintainCPPabove50mmHg.

Patientposition:Elevatehead3035andpreventvenousoutflowobstructioninthe
neckbymaintaininganeutralplaneoftheheadandthorax.Thereisnoneckcompressionby
externalobject;suchasacervicalcollarortape.

Anticonvulsantsareusuallygiventopreventposttraumaticseizureswhichmayraise
ICPinobtundedorcomatosepatients,evenifpharmacologicallyparalyzed.

Fluids usuallyareisotonicat75150cc/hrinadults.Inmultiinjuredpatients,more
complicatedmanagementisrequired.

AntacidorH2antagonists aregiventoanypatientonsteroids.Theyhelpprevent
stressulcersalso.

Corticosteriods:Thereisnoclearevidenceofbenefitoftheseagentsonoutcomein
headinjury,buttheyappeartoprovideasmallbenefitforpatientswithspinalcordinjury.
Corticosteroidincreasecomplicationsofinfection,hyperglycemiaasepticnecrosis.
Intubation isusuallyrequirediftheGCSis7andforanyevidenceofrespiratory
distress.
ICPmonitorisusuallyusedifGCSis<or=8.Thepatientshouldhaveundergone:

fullevaluationforsystemictrauma,haveIVaccess,acentralvenousline,arterialblood
gases;andappropriatescansorfilmsoftheheadandothersystemicinjuries.IftheCTscan
showsasurgicallesion,thepatientistakentotheoperatingroomandICPmonitorsare
installedattheendoftheprocedureifappropriate.IftheCTdoesnotindicatesurgery,an
ICPmonitorisplacedintheICU.Therearevarioustypesofmonitors.Anintraventricular
catheterismostaccurateandallowsremovalofCSFwhichmayhelpcontrolICP.Itmaybe
difficult to insert if the lateral ventricles are small. It can become occluded and dive
erroneous information.Thereis slightlyhigherriskofcausinghemorrhageatthesiteof
insertion. Other types are: subarachnoid screw (bolt), subdural, epidural, and
intraparenchyrnal (Camino fiberoptics). All monitoring devices have problems with
maintenanceofaccuracyandmaybecomeinfectedwithprolongeduse.

MeasurestoreduceICP:

HyperventilationreducesPCO2 to2530mmHg,whichcausesvasoconstrictionand
reducesintracranialbloodvolume.ItwilldecreaseICP25%to30%inmostpatients.Itwill
loseitseffectwithrepeatedprolongeduseandcanworsenischemiainareaofimpaired
perfusion Hyperventilation should only be used in the setting of acute herniation, but
otherwiseshouldbeavoidedbecauseofthepotentialtocausefurtherinjurytothebrain.
MannitolisusedifICPremainselevatedabove16mmHgfor10minuteswithpatient
atrest.Itisgivenindosesof0.25gm/Kgevery46hours.Serumhyperosmolaritycaused
bythisagentisthoughttoreducecerebraledema. However,themechanismofactionis
uncertain.Mannitolmayalsohavearheologicalbenefitthatenhancesbloodflow.Serum
osmolaritycanalsobeincreasedbyadministrationofhypertonicsaline.
Furosemideissometimesusedwithmannitol.Itislessreliablewhenusedalone.It

mayexacerbatethedehydratingeffectsofmannitolandinducehypokalemia.
BarbituatecomaissometimesusedinpatientswithuncontrollableelevationsinICP.
Improvementsintheoutcomeofpatientshasnotbeenclearlydemonstrated. Theriskof
hypertensionisgreater,particularlywiththepriorexistenceofcardiovascularcompromise.
Itsuserequiresextraordinarilycloseobservationandmonitoringcapability
Decompressivecraniectomywiththeremovalofalargeportionofthefrontotemporal
skullissometimesdoneifICPisnotcontrolledbythemeasuresoutlinedaboveinpatients
withnodemonstratedextraorintracerebrallesionthatcouldberemoved.Awidedural
openingmayberequired.Recoveryin41%ofpatientshasbeenreported.

CITITATION
Victor, M., Ropper, A. H., & Adams, R. D. (2001). Adams and Victor's
principles of neurology. New York: Medical Pub. Division, McGraw-Hill.
Coats, T. J. (2004). NICE head injury guidelines. Emergency Medicine
Journal, 21(4), 402402.

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