1 HEAD INJURIES

2 Incidence Major cause of morbidity and mortality.Most common reasons for attending accident and emergency department. leading cause of death in the population below 45 years (working age ) the third leading cause of death, succeeded only by cardiocerebral vascular disease and cancer. Head injury is the most common cause of death in young adults (age years) and is more common in males than females.

3 Head Injuries according to Mechanisms of Injurya. BLUNT (CLOSED) Head Injuries: Road traffic accidents. Fall from height Assaults. Workplace injuries. Sport injuries. Home injuries. b. Penetrating Head injuries: Low Velocity Injuries like Stab injuries. High Velocity Injuries such as bullet and shrapnel

4 Pathophysiology of head injuriesContact Injuries Head Motion (Inertial) Injuries

5 Contact Injuries Linear skull fractures. Depressed skull fractures.Basilar skull fractures. Vascular damage (Extradural haematoma). Coup contusions Countercoup contusions

7 Coup and Countercoup

8 Head Motion (Inertial) InjuriesTranslational acceleration. Rotational acceleration. Angular acceleration.

9 Classification of Head Injuries according to the Severity of Head Injury: by using The Glasgow Coma Score (GCS)

10 The Glasgow Coma Score Points Best Eye Opening Best Verbal ResponseBest Motor Response 6 - Obeys 5 Oriented Localizes pain 4 Spontaneous Confused conversation Withdraws to pain 3 To speech Inappropriate words Abnormal flexion (decorticate) 2 To pain Incomprehensible sounds Extension response (decerebrate) 1 Nil T Intubated

11 Confused conversation Withdraws to pain 3 To speech Points Best Eye Opening Best Verbal Response Best Motor Response 6 - Obeys 5 Oriented Localizes pain 4 Spontaneous Confused conversation Withdraws to pain 3 To speech Inappropriate words Abnormal flexion (decorticate) 2 To pain Incomprehensible sounds Extension response (decerebrate) 1 Nil T Intubated

13 The Glasgow Coma Score The total points are added. The higher the score, the better is the prognosis. According to this scale, cases of head injury are classified into: Minor Head injury: GCS 15 with no loss of consciousness. Mild Head Injury: GCS 14 or 15 with loss of consciousness. Moderate Head Injury: 9-13. Severe Head Injury: 5-8 Critical : 3-4

14 Primary vs. Secondary Brain Injuries:Primary Brain Injury: occurs at the time of impact. Secondary Brain injuries: occurs at some time after the moment of impact and is often preventable.

15 Classification of Head Injuries according to the SITE of injuryScalp Injuries Skull Injuries Focal intracranial lesions Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Intracerebral hemorrhage Brain stem injury Cranial nerve injury Vascular injury Pituitary and hypothalamic injury Diffuse axonal injury

16 Scalp Injuries Scalp laceration (wounds of the scalp)Scalp Haematoma (Subgaleal Haematoma) Scalp abrasion Scalp avulsion

17 1. Scalp laceration (wounds of the scalp)Common and may give rise to severe haemorrhage if not controlled. In infants this can cause severe shock. Depressed skull fractures may underlie a scalp injury. Healing is rapid. Carry risk of infection and cellulitis

20 Management of Scalp laceration (wounds of the scalp)Plain X-ray is performed. Shaving widely around the wound. Closure in 2 layers

22 Scalp Haematoma (Subgaleal Haematoma)May be subgaleal or subpericranial. The soft fluctuant centers of scalp haematoma may be disguising as depressed skull fracture on palpation. They are always associated with skull fracture in infants.

23 Subgaleal Haematoma

24 Subgaleal Haematoma

25 Subgaleal Haematoma

26 Management of Subgaleal HaematomaIts management is symptomatic Analgesia reassurance. It should not be tapped. Correction of anaemia in children less than 1 year of age.

27 Skull Injuries (Skull Fractures)Fractures of the Vault Fractures of the base (Basilar skull fractures)

28 Fractures of the Vault linear fractures StellateDepressed skull fractures Diastatic fractures Pond (ping pong fractures)

29 linear fractures: May be closed or opened.Require no specific neurosurgical management. Usually require computed tomography (CT) Patient should be admitted for 48 hours of observation. Fractures crossing the squamous temporal bone may lacerate middle meningeal vessels and cause extradural haematoma.

30 Linear Skull Fracture

31 Linear Skull Fracture

32 Linear Skull Fracture Bone Window

33 Linear Skull Fracture

34 Linear Skull Fracture

35 Depressed skull fracturesUsually result from sharper trauma. Depressed skull fractures may be: Closed Compound (opened)

37 Depressed Skull Fractures

38 Depressed Skull Fractures

39 Depressed Skull Fractures

40 Depressed Skull Fractures Bone Window

41 Depressed Skull Fractures

42 Depressed Skull Fractures

43 Depressed Skull Fractures

44 Depressed Skull Fractures frontal Depressed Fracture

45 Depressed Skull Fractures frontal Depressed Fracture

46 Depressed Skull Fractures frontal Depressed Fracture

47 Depressed Skull Fractures frontal Depressed Fracture

48 Closed depressed fracturesRare in adults The depressed segment rarely causes cerebral compression Plain X-ray will visualize the depressed segment. Treatment : usually conservative measures

49 Indications for surgery to raise the closed depressed fractureCosmetic .. Frontal … female Fracture involving air sinus Fracture involving venous sinus with raised ICP Underlying hematoma FND related to underlying area Usually any compound one

50 Compound depressed fractureCause profuse bleeding, leakage of CSF and prolapse of a portion of the brain. Concussion is slight and there is usually no compression. The main hazard here is the liability to infection.

51 Treatment of compound depressed fractureMedical treatment by antibiotics Surgical treatment Under GA and ETT Proper position Proper incision Foreign bodies are meticulously removed. depressed segment is gently elevated to avoid tearing of dura necrotic tissue is sucked and haemostasis is performed. any dural tear is repaired. removed bone segments are cleaned and replaced if posiible. The pericranium and the scalp are sutured.

52 Complications of depressed fracturesDural tear leading to prolapse of the brain. Infection; may lead to osteomyelitis or meningitis. Epilepsy: either early or late. Cosmetic deformity. Severe bleeding from one of the venous sinuses.

53 Diastatic fractures It is separation of a cranial suture line.It involves the coronal or lambdoid suture. Diastatic fractures are common in infants under 3 years old and rare in older age groups except as part of a more extensive skull fracture.

54 Diastatic Fractures

55 Diastatic Fractures

56 Diastatic Fractures

57 Diastatic Fractures

58 Pond (ping pong fractures)This is green stick type of fracture a smooth concave depression due to blunt trauma Usually seen in newborn and also known as ‘ping-pong fracture’, as it looks similar to a dent in a ping-pong ball. Fracture will elevate spontaneously if less than 3cm in diameter. If the fracture is more than 5cm in diameter, it may need surgical elevation.

59 Ping Pong Fractures

60 Fractures of the base (Basilar skull fractures)These are relatively frequent fractures. Occult radiologically. Diagnosed on clinical examination. They can result in CSF fistula that may persist, but which usually seals off after a few days.

61 The essential features of base of skull fracturesLeakage of cranial contents, e.g. blood, CSF, or brain matter. Injury of cranial nerves. Signs of brain injury.

62 Types of skull base fracturesAnterior fossa Middle fossa Posterior fossa

63 Anterior fossa basal fracturesMay open into the frontal or ethmoidal air sinuses, or run across the cribriform plate. Clinical presentations: Periorbital haematoma or ‘raccoon eyes’. CSF Rhinorrhoea. Rhinorrhagia. Subconjuctival haematoma. Anosmia: due to olfactory nerve injury. Nasal tip paraesthesia.

64 The Raccoon

65 The Raccoon

66 The Raccoon

70 Anterior fossa basal fractures

71 Anterior fossa basal fractures

72 Middle fossa basal fracturesInvolve the pertrous temporal bone. Clinical presentations: CSF Otorrhoea. Haemotympanum. Battle sign; discoloration over the mastoid process. VII and VIII cranial nerve palsies.

75 Middle fossa basal fractures

76 Middle fossa basal fractures

77 Posterior fossa basal fractures1. Boggy swelling or discoloration at the neck due to extravasations of blood in the suboccipital region. 2. Injury to cranial nerves: usually involve 9th, 10th, and 11th cranial nerves at the jugular foramen. 3. Retraction of the head and stiffness of the cervical muscles due to upper cervical nerves irritation.

78 Posterior fossa basal fractures

80 Management of skull base fractures1. Prevention of infection: prophylactic antibiotics. 2. Control of CSF leakage: conservative or surgical intervention. 3. Treatment of associated brain injury.

81 Indications for surgery(repair of tear)Persistence of rhinorrhoea more than 10 days Presence of a fracture involving the frontal or ethmoidal sinus. Occurrence of meningitis.

82 Epidural hematoma Incidence 1 % of head injury patientMale to female 4:1 Affecting young adult , rare before 2 and above 60 years Temporoparietal depressed fracture can disrupt the middle meningeal arterythrough its bony groove within pterion causing bleeding that dissect dura from the inner table Source of bleeding from middle meningeal artery, middle meningeal vein , dura venous sinuses and diploic space in skull fracture.

83 Stage of concussion: brief period of loss of consciousness. Clinical Picture: Stage of concussion: brief period of loss of consciousness. Stage of lucid interval: patient recover from concussion, blood will accumulate gradually in the extradural space. Stage of compression: shown clinically as: Gradual progressive deterioration in the level of consciousness. Contralateral hemiparesis due to cortical compression. Tentorial herniation, with compression of oculomotor nerve, with dilatation of ipsilateral pupil. As the coma deepens the blood pressure rises and the pulse and respiration slow down (i.e. features of increased intracranial pressure). NOTE: this classic picture is found only in the minority of patients (less than one-third of cases).10-30%

84 CT scan will show biconvex or lens shaped hyperdense lesion due to adherence of the dura to the inside of the cranium at the sites of sutures. An extradural haematoma is a neurosurgical emergency that will result in death if the haematoma is not removed promptly. Surgical treatment by evacuation of haematoma via Emergency Craniotomy. Care must be taken in assessing patients with linear fractures crossing the middle meningeal territory.

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89 Acute Subdural hematomaUsually due to MORE SEVERE injury with a poorer outcome. Source of bleeding (haematoma): include: Most result from tears of a cortical artery. Cortical lacerations or contusions. Bleeding from tears in the dural venous sinuses. Clinical Picture: patient will present with a picture similar to that of an extradural haematoma, but there is persistent loss of consciousness with no lucid interval. Ct scan will show a crescent hyperdence collection because blood follows the subdural space over the convexity of the brain. Acute Subdural Haematoma are rapidly evolving lesions and early evacuation via craniotomy is mandatory.

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91 Chronic subdural hematomaMost common in infants and in adults over 60 years of age secondary to SLIGHT blow to the head which may pass unnoticed. Source of bleeding (haematoma): usually from bridging veins as they pass to the venous sinuses. The patients present with progressive neurological deficits more than 3 weeks after the trauma, or progressive headache , memory disturbances. The initial head injury is often completely forgotten. CT scan: the acute clotted blood is initially appears white (hyperdence), but as it liquefies, it slowly becomes black (hypodense). They should be drained if they continue to enlarge. They are evacuated by drilling burrholes over the collection and washing it out with warmed saline.

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94 Subarachnoid Haemorrhage (SAH):Trauma is the commonest cause of SAH although aneurysms are the most common cause of spontaneous SAH. Traumatic SAH is managed conservatively

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97 Among post traumatic complicationsCNS Infection Seizure Hydrocephalus CSF fistula Ischemic stroke Cerebral herniation