OVERVIEW

Head injury was first estimated occur in about

1 million years ago

Evidenced skull damage on human

predecessors now called Australopithecus
africanus
 Java > 300.000 years ago

Peking > 100.000 years ago

Neanderthal > 40.000 years ago

Damage is found that there are two adjacent

fracture lines in the posterior region of the skull
 QS. Al-Maidah : 27-30 Tells the story of the
first murder Adams children (Habil and
Qabil)

Qabil hit Habil with a rock to the head until

Habil killed
BRAIN INJURY

As defined by the National

Head Injury Foundation
a traumatic insult to the
brain capable of producing
physical, intellectual,
emotional, social and
vocational changes.
 HEAD INJURY-EPIDEMIOLOGY
1.5million Non-fatal TBIs
370,000 Hospitalizations
80,000 cases of neurological sequela
52,000 Die from TBIs
4 billion annually for cost of treatment
Peak incidence:
Males age 15-24 years
INTRODUCTION TO HEAD
INJURIES

TIME IS CRITICAL
IntracranialHemorrhage
Progressing Edema
Increased ICP
Cerebral Hypoxia

Permanent Damage

Severity is difficult to recognize

Subtlesigns
Improve differential diagnosis
Improves survivability
1ST MANAGEMENT
Primary survey

Secondary survey

Definitive therapy
HEAD TRAUMA
Open
Skull compromised
and brain exposed

Closed
Skull not compromised
and brain not exposed

Head Trauma - 10
CRANIAL INJURY

Trauma must be extreme to fracture

Linear
Depressed
Open
Impaled Object
 DIRECT BRAIN INJURY TYPES

Coup
Injury at site of
impact
Contrecoup
Injury on opposite
side from impact
Pathology of the Brain Injury:
* Not all the brain damage occurs at the time of injury
* Basically two main stages of brain damage after injury
- PRIMARY DAMAGE
- SECONDARY DAMAGE
* Last decade : Head CT Scan and MRI played very
important role in diagnostic evaluation of
head injury patients
* Even with improved CT Scan and MRI, the precise
type of damage may not be identifiable during life
* The principal mechanism are :
- CONTACT
- ACCELERATION / DECELERATION
PRIMARY DAMAGE
* occurs at the moment of injury

* including : - laceration of the scalp

- fracture of the skull

- contusions and lacerations

- diffuse axonal injury

- intracranial hemorrhage

- other type of brain damage

SECONDARY DAMAGE

* results from complicating processes that are

initiated at the moment of injury

* may not present clinically for a period of time

afterward

* including :
- hypoxia / ischemia
- swelling
- infection
- brain damage due to elevated intracranial
pressure
BRAIN INJURY
Response to injury
Swelling of brain
Vasodilatation with increased blood volume
Increased ICP
Decreased blood flow to brain
Perfusion decreases
Cerebral ischemia (hypoxia)

Head Trauma - 16
SIGNS & SYMPTOMS
OF BRAIN INJURY

Altered Mental Status - Vomiting

Altered orientation Without nausea
Alteration in personality Projectile
Amnesia
- Body temperature changes
Retrograde
- Changes in pupil reactivity
Antegrade
- Decorticate posturing
Cushings Reflex
Increased BP
Bradycardia
Erratic respirations
 Assessment of Impaired Consciousness

Use practical scale Glasgow Coma Scale

Three features are in dependently observed :
Points
* EYE OPENING
Spontaneous 4
To speech 3
To pain 2
None 1
* BEST MOTOR RESPONSE
Obeys commands 6
Localized to pain stimuli 5
Withdraws from pain stimuli 4
Decorticate flexion 3
Decerebrate extension 2
None 1
* VERBAL RESPONSE
Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
CLINICAL FEATURES

Clinical Features Radiological Exam Pathologic

name

Mild Head Injury unconsc < 10 brain CT normal Concussion

GCS 13 15
no neuro deficit

Moderate Head Injury unconsc 10-<6hrs brain CT abnormal Contusion

GCS 9 12
pos neuro deficit

Severe Head Injury unconcs > 6 hrs brain CT abnormal Contusion

GCS 3 9
pos neuro deficit

SIMPLE HEAD INJURY GCS 15

no neuro deficit
no unconsc
DIRECT BRAIN INJURY
CATEGORIES
Focal
Occur at a specific location in brain
Differentials
Cerebral Contusion

Intracranial Hemorrhage

Epidural hematoma

Subdural hematoma

Intracerebral Hemorrhage

Diffuse
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury
FOCAL BRAIN INJURY

Cerebral Contusion
Blunt trauma to local brain tissue
Capillary bleeding into brain tissue
Common with blunt head trauma
Confusion

Neurologic deficit

Personality changes

Vision changes

Speech changes

Results from
Coup-contrecoup injury
BRAIN INJURIES
Cerebral contusion
Bruising of brain tissue
Swelling may be rapid and severe

Level of consciousness
Prolonged unconsciousness,

profound confusion or amnesia

Associated symptoms
Focal neurological signs

May have personality changes

Head Trauma - 22
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE

Epidural Hematoma
Bleeding between dura
mater and skull
Involves arteries
Middle meningeal

artery most common

Rapid bleeding &
reduction of oxygen to
tissues
Herniates brain toward
foramen magnum
INTRACRANIAL
HEMORRHAGE
Acute epidural hematoma
Arterial bleed
Temporal fracture common

Onset: minutes to hours

Level of consciousness
Initial loss of consciousness

Lucid interval follows

Associated symptoms
Ipsilateral dilated fixed pupil, signs of increasing

ICP, unconsciousness, contralateral paralysis,

death
Head Trauma - 24
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Subdural Hematoma
Bleeding within meninges
Beneath dura mater & within

subarachnoid space
Above pia mater

Slow bleeding
Superior sagital sinus

Signs progress over several days

Slow deterioration of mentation
INTRACRANIAL
HEMORRHAGE
Acute subdural hematoma
Venous bleed
Onset: hours to days

Level of consciousness
Fluctuations

Associated symptoms
Headache

Focal neurologic signs

High-risk
Alcoholics, elderly, taking anticoagulants

Head Trauma - 26
INTRACRANIAL
HEMORRHAGE
Intracerebral hemorrhage
Arterial or venous
Surgery is often not helpful

Level of consciousness
Alterations common

Associated symptoms
Varies with region and degree

Pattern similar to stroke

Headache and vomiting

Head Trauma - 27
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE

Intracerebral Hemorrhage
Rupture blood vessel within the brain
Presentation similar to stroke symptoms
Signs and symptoms worsen over time
 Basal Skull
Unprotected
Spaces weaken
structure
Relatively
easier to fracture
CRANIAL INJURY

Basal Skull Fracture Signs

Battles Signs
Retroauricular Ecchymosis

Associated with fracture of

auditory canal and lower

areas of skull
Raccoon Eyes
Bilateral Periorbital

Ecchymosis
Associated with orbital

fractures
BASILAR SKULL FRACTURE
Battles sign Raccoon eyes

Head Trauma - 31
CRANIAL INJURY

Basilar Skull Fracture

May tear dura
Permit CSF to drain

through an external
passageway
May mediate rise of ICP

Evaluate for Target or

Halo sign
CRAINIAL INJURIES
Penetrating trauma

Bullet fragments
Head Trauma - 33
EDH
SDH
SAH
ICH
THANK YOU