Traumatic Brain Injury

(Ⅲ)
Department of Neurosurgery,The First
Affiliated Hospital of Zhengzhou University
Xu Bin
Traumatic Intracranial
Hematoma
 Overview
 Traumatic intracranial hematoma accounts
for 10% of the closed craniocerebral injury.
 The hematoma is a secondary brain injury
and gives rise to increased intracranial
pressure, herniation, and brain death.
 It is very important for neurosurgeons to
diagnoses the hematoma and deal with it
immediately
 Classification
Depending on the time of presence of
symptoms:
Acute hematoma (within three days)
Subacute hematoma(3 days~3 weeks)
Chronic hematoma (after 3 weeks)
 Classification
 According to the site of the
hematoma:
Extradural hematoma
Subdural hematoma
Intracerebral hematoma.
 Epidural hematoma
 A collection of blood that lies
outside of the dura mater (between
the dura mater and the skull)
 Biconvex high-density
 Acute Extradural Hematoma

 Site: A collection of blood between the

skull and the dura
 Bleeding source: middle meningeal
artery and veins; dural sinuses such as
the superior sagittal and transverse
sinuses; the dura is separated from the
bone, diploic veins.
An epidural hematoma occurs as a result
of skull fracture and laceration of a
meningeal vessel,usually the posterior
branch of the middle meningeal
artery.All skull fractures are
accompanied by small epidural
hematomas,usually venous in origin and
arising from the diploic space.
When the dura is stripped from the
inner table of the skull adjacent to a
fracture and arterial bleeding from a
lacerated meningeal artery begins
filling the space,the dura is further
stripped and a large extradural mass
that causes severe brain compression
may occur.
Occasionally,the space is filled with venous
blood,most commonly when fracture lines
cross the superior or transverse sinuses;the
venous collection arising either from
laceration of the sinuses or venous tributaries
to the sinuses.Epidural hematomas may
occur after minor head injury.There may be
no loss of consciousness or only a transient
concussive state with rapid return of normal
brain function.
Epidural hematomas also may accompany
more severe head injury with skull
fracture.Only one-third of patients with
epidural hematomas will have a classic
“lucid interval” with a definite period of
essentially normal brain function
following impact,before the expanding
epidural hematomas causes progressive
loss of consciousness and focal
neurological deficits.
Epidural hematomas are the most common
lateral to the temporal lobes where the skull
is thinned and the meningeal vessels are
numerous.With expansion of the
hematoma,there is medial compression of the
temporal lobe that causes a contralateral
hemiparesis and eventual transtentorial
herniation as the medial temporal lobe
compresses midbrain structures at the
tentorial incisure.
As many as one-third of patients with
epidural hematoma do not present to a
physician until the onset of coma.The death
rate from epidural hematomas approaches
30-50% in some series,chiefly because of a
delay in recognition of the expanding
intracranial hematoma.Therefore,admission
for observation is justified for head-injured
patients who loss consciousness for 2 minutes
or more or if skull x-rays shows a new
fracture.
 Clinical Findings
 Disturbance of consciousness:
Coma (caused by primary injury)
called primary coma
Lucid interval
Coma (caused by hematoma, this
coma is the symptoms of the cerebral
herniation). Called secondary coma.
 Clinical Findings
If the primary brain injury is severe,
the sufferer may have not lucid
interval. And when the primary brain
injury is slight, the sufferer may have
not first coma. So the key point is the
disturbance of consciousness may
appear some later or aggravated
progressively after head injury.
 Clinical Findings
Pupillary Alteration: ipsilateral
constricted or dilated pupil caused
by the oculomotor nerve injury.
This is the symptoms of the
cerebral herniation.
 Clinical Findings
 Motor disturbance: paralysis on
the contralateral side caused by
compression of the ipsilateral
cerebral peduncle.
 Vital signs alteration: Cushing’s
response.
 Diagnosis Measures
 A: clinical finding and signs
 B: CT examination is very
important for definition of the
diagnosis.
Extradural hematomas may be
seen in the posterior fossa and
are most reliably demonstrated
on CT scan or vertebral
angiography.
Positions of exploratory trephination
 Treatment
 When patient with mild symptoms
and CT scan shows only a small
degree of hemorrhage the
dehydration and careful
observation can be applied.
 Performing operation at once to
removing the hematoma is a main
selection for severe patients.
 Subdural Hematomas
Subdural hematomas are the most
common intracranial mass lesions that
result from head injury.Most subdural
hematomas are the result of torn bridging
veins that drain blood from cerebral
cortex to major overlying dural sinuses.
They may go unrecognized for a time
or may accompany devastating
primary cerebral injury in patients
who are unconscious from the time of
injury;these patients have a high
death rate.
Subdural hematomas may be small at
onset of symptoms if there is marked
accompanying cerebral edema.In an
elderly patient with a “brain smaller
than the skull,”a hematoma may become
quite large before neurologic symptoms
or signs appear.
Subdural hematomas are often classified
according to the length of time between
injury and onset of symptoms.
 Subdural haematoma
1.Tear of veins that bridge dura mater cause a
collection of blood under the dura mater
adjacent to the brain
2.Acute SDH is a surgical emergency
 Acute stage: high density
 2-4weeks: iso-dense (with the brain tissue)
 3-4weeks later: lower density
 Mix-density: may be a fresh bleeding into a
chronic lesion
SDH
Acute Subdural Hematoma
 Site: A collection of blood
between the dura and arachnoid.
 Bleeding source: cerebral
surface blood vessel, dural
sinuses.
These present within 24 hours after
injury.The death rate is higher in acute
subdural hematomas than in any other
category of closed head injury.There is
often associated severe brain contusion
or laceration,which leads to progressive
cerebral edema and cerebral injury even
after the acute subdural hematoma is
recognized and removed.
Although most acute subdural
hematomas are venous in
origin,laceration of cortical arteries
occasionally gives rise to a more rapidly
evolving hematoma.Early evacuation of
these mass lesions is mandatory,although
the death rate remains above 75% for
patients with the combination of
extrinsic brain compression and intrinsic
brain damage.
 Clinical Findings
 Because the hematoma is
always combined with cerebral
contusion and laceration, it may
be difficult to diagnosis in some
case depending on signs and
symptoms merely. At this time
the CT examination is very
important for diagnosis.
 Clinical Findings
 Unconsciousness from the
beginning and rapid deterioration
 The signs and symptoms of the
cerebral herniation
 Diagnosis mainly depends on CT
scan
 Treatment

Selecting conservative or
operative treatment
depending on patient’s
signs and symptoms and
CT scan.
 Chronic subdural hematoma
 Chronic subdural hematoma is a
common disease caused by head
injury in the elderly. The injury itself
is often trivial and it may be weeks
or months before it declares.
 Bleeding source: small vein
crossing the subdural space.
 Chronic SDH
 In the chronic form, only blood
effuses into the subdural space as a
result of rupture of the bridging
veins, usually due to closed head
injury. The effusion is a gradual
process resulting, weeks after the
injury, in headache and progressive
focal signs that reflect the location
of the mass.
 Clinical feature
 The onset of symptoms is
characteristically insidious. Headache,
mental changes, drowsiness and
vomiting usually occur. There is often
a mild hemiplegia but signs of raises
intracranial pressure are not
prominent.
These hematomas are discovered
with progressive neurological deficits
that occur later than two weeks
following head injury.In some
instances,the initial head injury is
completely forgotten and patients
may be evaluated for possible brain
tumors or dementias such as
Alzheimer’s disease.
Headache is common and focal neurological
deficits may appear,dementia and increasing
lethargy usually cause the patient to be
brought in for medical evaluation.The initial
hemorrhage may be relatively small or may
occur in elderly patients with large ventricles
or a dilated subarachnoid space.Membranes
deriving from dura mater and arachnoid
encapsulate the hematoma,which remains
clotted for 2-3 weeks and then gradually
liquefies.
The patient may have no symptoms
for prolonged periods,only to become
symptomatic when the hematoma
enlarges by additional bleeding into
the cavity from friable blood vessels
in the capsule.
Chronic subdural hematomas are
most common in infants and in
adults over sixty years of age.Because
of the slow and insidious
development of symptoms,the
patient’s behavior may be attributed
to a psychiatric rather than physical
cause.
Chronic subdural hematomas are
bilateral in 20% of patients and best
demonstrated with CT or MRI scans or
radionuclide brain scan,all of which will
accurately demonstrate the lesion.The
liquefied chronic subdural hematoma
usually can be removed adequately by
bur holes placed over the cavity.
 Diagnosis
 Early diagnosis depends upon the
possibility being borne constantly in
mind when fluctuating physical and
mental changes occur in the elderly.
 MRI examination is a non-traumatic
and best method for diagnosis.
 Treatment
 Burr hole in the ipsilateral
parietal bone should be made to
remove the hemorrhage. The
prognosis is always good for
most of patients.
 Intracerebral hematoma
 Intracerebral hematoma is always
accompanied with severe
contusion and laceration of
cerebral tissues. The symptoms
and signs depend on the location
of the lesion.
Subarachnoid hemorrhage
 A acute condition involving
sudden hemorrhage into the
space between the arachnoid
membrane and the pia mater
 Intracerebral hemorrhage
 From small arterioles within the
brain
 The frontal and temporal lobes are
classic sites
 High density
1. Traumatic ICH
2. Spontaneous ICH
 Clinical Findings

 .Progressing deterioration of state

of consciousness.
 .Severe headache, vomiting.
 .The hemiparesis may be found.
 Diagnosis
Clinical findings
CT scan
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 Treatment
 The conservative and operative
treatment should be chosen
according to the sufferer’s
clinical manifestation and CT
scan. When the symptoms of
cerebral herniation appear, the
operation of removing the
hematoma should be done.
PENETRATING HEAD INJURY
•Penetrating injury to the brain occurs from
the impact of a bullet, knife or other sharp
object that forces hair, skin, bone and
fragments from the object into the brain.
•Objects traveling at a low rate of speed
through the skull and brain can ricochet
within the skull, which widens the area of
damage.
A "through-and-through" injury
occurs if an object enters the skull,
goes through the brain, and exits the
skull. Through-and-through
traumatic brain injuries include the
effects of penetration injuries, plus
additional shearing, stretching and
rupture of brain tissue.
The devastating traumatic brain
injuries caused by bullet wounds
result in a 91% firearm-related
death rate overall. Firearms are the
single largest cause of death from
traumatic brain injury.
This would be either high velocity injury
which is uncommon in our society or
slow velocity injury as a result of
penetration of the base of the scalp with
sharp objects. The base of the skull is
thin bone and could easily be penetrated
especially in children with sharp objects
as tree branches and knitting needles.
This results in skull base fracture and
damage to the brain overlying that area.
 Outcome of brain injury
Outcome after head injury depends on
many factors.Increasing age and
preexisting illness contribute to a poor
prognosis.Penetrating
injuries,particularly gunshot wounds are
associated with poorer outcome
compared with blunt trauma.
The presence of an intracranial
hemorrhage also implies a suboptimal
result. Subdural hematoma has a poorer
prognosis than epidural hematoma.
Combined subdural and intracerebral
hemorrhage has the worst prognosis of
all severe head injury subtypes.
Other important factors that influence
outcome include delay in
treatment,multiple trauma and systemic
insults such as acidosis,hypoxia and
hypotension.Predictors of poor prognosis
include evidence of brainstem
dysfunction on the initial examination
and refractory intracranial hypertension
within the first few days of injury.
Subacute subdural hematomas become
apparent several days after injury and
are associated with progressive
lethargy,confusion,hemiparesis or other
hemispheric deficits.Removal of
hematoma usually produces striking
improvement.
 Malignant Brain Edema
Syndrome
 Head trauma causes clot; swelling
↑due to hyperemia; ↑intracranial
pressure
 Rapid neurological deterioration,
coma , death
 EMS (life-threatening)
 The summary
Head Injury
Scalp injury == hematoma, laceration.
Skull fracture == vault of the skull
(linear fracture, depressed fracture).
Base of the skull (linear fracture)
Cerebral injury == primary cerebral
injury and secondary cerebral injury
 The summary
 Primary cerebral injury
Injury -- coma -- relieve or lucid
 Secondary cerebral injury
injury -- lucid -- coma
 primary + secondary injury
injury -- coma (primary) --lucid
interval -- coma (secondary)
 The summary
 Primary cerebral injury
concussion -- conservative treatment
contusion and laceration -- conservative
treatment
 Secondary cerebral injury
brain edema dehydration,
diuretic,
hematoma cortisone.
operation
IIP