Head Injury- Clinical
Manifestations, Diagnosis
and Management
Dr kamkar Aeinfar
Neurosurgery
department of tehran
university
Classification
Direct
Primary injury caused by forces of trauma
Indirect
Secondary injury caused by factors resulting
from the primary injury
Direct Brain Injury Types
Coup
Injury at site of
impact
Contrecoup
Injury on opposite
side from impact
Brain Injury
Indirect brain injury
• Results from hypoxia
or decreased perfusion
• Response to primary injury
• Develops over hours
Management
• Good prehospital care can help prevent
Head Trauma - 5
Direct Brain Injury
Categories
Focal
Occur at a specific location in brain
Differentials
Cerebral Contusion
Intracranial Hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral Hemorrhage
Subarachnoid hemorrhage
Diffuse
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury
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
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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
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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
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CT findings
Epidural Hematoma Subdural Hematoma
Fig. 55-15
CT findings
Subarachnoid hemorrhage Intracerebral hematoma
Fig. 55-15
Diffuse Brain Injury
Due to stretching forces placed on individual nerve cells
Pathology distributed throughout brain
Types
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury
Brain Anatomy
Intracranial volume
• Brain
• CSF
• Blood vessel volume
Dilatation with high pCO2
Constriction with low pCO2
Slight effect on volume
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Intracranial Perfusion
Cranial volume fixed
80% = Cerebrum, cerebellum & brainstem
12% = Blood vessels & blood
8% = CSF
Increase in size of one component diminishes size of
another
Inability to adjust = increased ICP
Decreased level of consciousness
is an early indicator of
brain injury or rising ICP.
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Glasgow Coma Scale
Suspect severe brain injury GCS <9
*Decorticate posturing to pain
**Decerebrate posturing to pain
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Extremity Posturing
Decorticate
• Arms flexed
and legs extended
Decerebrate
• Arms extended
and legs extended
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Early efforts
to maintain brain perfusion
can be life-saving.
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Management
1) Supportive Measures:
• Endotracheal intubation for patients with decreased level of
consciousness and poor airway protection.
• Cautiously lower blood pressure to a MAP less than 130 mm
Hg, but avoid excessive hypotension.[10]
• Rapidly stabilize vital signs, and simultaneously acquire
emergent CT scan.
• Maintain euvolemia, using normotonic rather than
hypotonic
fluids, to maintain brain perfusion without exacerbating brain
edema
• Avoid hyperthermia.
• Facilitate transfer to the operating room or ICU.
Management
2) Decrease cerebral edema:
• Modest passive hyperventilation to reduce PaCO2
• Mannitol, 0.5-1.0 gm/kg slow iv push
• Furosemide 5-20 mg iv
• Elevate head 20-30 degrees, avoid any neck vein
compression
• Sedate and paralyze if necessary with morphine and
vecuronium (struggling, coughing etc will elevate
intracranial pressure)
Management
3) Surgical Evacuation of hematoma:
• No surgical intervention if collection <10ml
Indication of surgical decompression:
• The GCS score decreases by 2 or more points between the
time of injury and hospital evaluation
• The patient presents with fixed and dilated pupils
• The intracranial pressure (ICP) exceeds 20 mm Hg
Exception :
In Subdural hematoma with GCS=15- hematoma >10mm ,or
>5mm midline shift ---- requires Surgical decompression
SAH: whn a cerebral aneurysm is identified on
angiography, clipping and coiling is done to prevent re-bleed
Management
Sugical Decompression contd..
Types:
• Burr-hole
• Craniotomy- bone flap is temporarily removed from
the skull to access the brain
• Craniectomy – in which the skull flap is not immediately
replaced, allowing the brain to swell, thus reducing
intracranial pressure
• Cranioplasty - surgical repair of a defect or deformity of
a skull.
Management
4) Medical therapy:
• Antihypertensives - reduce blood pressure to prevent exacerbation
of intracerebral hemorrhage in hypertensive encephalopathy. Eg
Nicardipine, labetolol; CCB help relieve vasospasm in SAH and
decrease further damage
• Diuretics - Mannitol, CAI
• Anticonvulsants – reduce frequency of seizures and prophylaxis of
seizures eg: Fosphenytoin
• Antipyretics- to Rx fever and pain relief eg: Acetaminophene
• Antidote-
VitK/FFP for warfarin overdose;
protamine for heparin overdose
• Antacids- prophylaxis for Cushing’s gastric ulcer eg: Famotidin
• Glucorticoids may help reduce the head and neck ache caused by
the irritative effect of the subarachnoid blood.
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Remember…
…it’s okay if you do not diagnose the
patient’s problem. It’s not okay if you fail to
take care of what you are trained to take
care of.
Thank
you
