An external trauma that applied
the scalp, skull and its
containing brain tissues.
Open
The external environment become in continuity with
intracranial structures like in bullet injury & stab wound injury
Closed
When physiological barriers that protect the intracranial
structures remain intact
It can be
Head trauma
Linear #
EDH
Vault # (outer & inner table)
SDH
SAH
Intracranial hematoma
ICH
Clinical types of head
trauma
Skull fracture
Depressed #
Skull base # (anterior, middle &
Other type of fractures is Diastatic fractures
that occur in pediatric group . There will be
separation between suture lines .
The management is conservative
IVH
It is focal depression of skull bone
(the outer table of depressed segment become below the inner table of surrounding bone)
It can open or closed depending on scalp tissue if injured or not
Infection (meningitis, encephalitis & brain abscess)
Neurological deficit & epilepsy
due to cortical brain injury
CSF leakage
Single # line through full thickness of skull (outer & inner table)
Complications
Depressed #
Linear #
Vault skull fracture
Usually intact neurologically
Just need observation (no surgical intervention)
Pneumocephalus
Intracranial bleeding
*if closed => conservative & surgery just for cosmetic
*if open => surgical emergency due to risk of infection
-Do craniectomy + repair dural tear + evacuation of hematoma if present + close the scalp over surgical bed
-after 6-9 months do cranioplasty using synthetic or autologous graft
Treatment
ACF #
Here the # line pass through
cribriform plate so give the
following features
Raccoon’s eye
CSF rhinorrhea
Epistaxis
Anosmia if pt. is conscious
Hospital admission
Otorrhea
Measures to reduce ICP
Antibiotic prophylaxis
If CSF leakage stopped within 2 weeks
so no further intervention is required
If CSF leakage continue after 2 weeks ,
Do surgery to repair the dural tear
Follow up
Otorrhagia
Management => conservative
Skull base #
MCF #
Hemotympani if no apparent bleeding
Battle sign
Facial N. injury => facial palsy
Vestibulochoclear N. injury => hearing loss + disequilibrium
PCF # => rare bcz occipital bone is hard
HEAD TRAUMA
An external trauma that applied
the scalp, skull and its containing *
brain tissues*.
Open trauma
Can be either:
When external environment become in
continuity with intracranial structures like
bullet injury & stab wound.
Closed trauma
When the physiological barriers that protect
the intracranial structures remain intact.
Clinical types of head trauma:
Skull fracture:
Vault fracture (outer & inner table)
Intracranial hematoma:
Basal skull fracture
Extradural (epidural) hematoma (EDH)
the fracture line pass through cribriform plate so give the
following features:
Single fracture line through full thickness of skull (outer & inner table)
Linear fracture
Subarachnoid hemorrhage (SAH)
Usually intact neurologically
Just need observation (no surgical intervention)
Raccoon’s eye
Anterior cranial fossa fracture
Intraventricular hemorrhage (IVH)
Epistaxis
Anosmia
It can open or closed depending on scalp tissue if injured or not
Features are:
Infection (meningitis, encephalitis & brain abscess)
Neurological deficit & epilepsy due to cortical brain injury
Otorrhea
Pneumocephalus
Otorrhagia
Complications
Middle cranial fossa fracture
Intracranial bleeding
Hemotympani if no apparent bleeding
Battle sign
Treatment:
Facial N. injury => facial palsy
If closed => conservative & surgery just for
cosmetic
If open => surgical emergency due to risk of
infection
Do craniectomy + repair dural tear +
evacuation of hematoma if present + close
the scalp over surgical bed
Intracerebral hematoma (ICH)
CSF rhinorrhea
It is focal depression of skull bone (the outer table of depressed
segment become below the inner table of surrounding bone)
Depressed fracture
Subdural hematoma (SDH)
Vestibulochoclear N. injury => hearing
loss + disequilibrium
Posterior cranial fossa fracture
rare because occipital bone is hard
Management of basal skull fracture → conservative
-after 6-9 months do cranioplasty using
synthetic or autologous graft
Hospital admission
Head elevation
Hyper-oxygenation
Hypertonic saline & mannitol
Diuretic
Measures to reduce ICP
Steroids
Analgesics
Anti-epileptic
If all these measures failed:
Decompression craniectomy
Antibiotic prophylaxis
Follow up
If CSF leakage stopped within 2 weeks so no further intervention is
required
If CSF leakage continue after 2 weeks , Do surgery to repair the dural tear
Collected by: Muntadher Noaman
Intracranial hematoma
epidural
1. Extradural h.(EDH):
• Hematoma between
Inner table
of skull
bone and dura.
• MMA injury.
How occur?
• 90% skull fracture.
Most common
• Frontal or temporal.site of EDH
• Biconvex in CT.
• Lucida interval.
• Surgical emergency.
Blood appear
hyperdense on CT
2-subdural hematoma
• Collection of blood in
SD space.
• Between brain and
dura.
Diffuse axonal injury
• Associated with serious
So patient usually in
brain injury. comma
• Mainly venous injury. Source
• Acute, sub acute or
chronic.
Acute = hyperdensity
Subacute = isodensity + mass effect
• Cresent in CT
Chronic = hypodensity
‫كونسيرتف‬
‫ وهمات نطي فلود‬، ‫كالسيوم جنل بلوكر‬
3. Subarachnoid hemorrhage:
• Hrr. With in
subarachnoid space.
• Between arachnoid and
piamater.
• Due to head trauma. Or
HTN
• Due to ruptured
cerebral aneurysm.
• Occipital headach. Severe
• Meningism.
‫عندي وجع راس مصاير مثلة گبل‬
‫سبيس اكوبانك ليشن‬
4. Intracerebral hematoma ICH
• Bleeding within a
cerebral parenchyma.
• Due to torn perforating
vesseles, cortical or sub
cortical.
• Traumatic or
spontenious(hypertensi
Hemorrhagic stroke
on).
• Commonly frontal or
temporal.
5. Intraventricular hrr.( IVH)
Either due to trauma or rupture of AV malformation
• Bleeding into
ventricular system.
Serious presentation = comma state
Bcz the trauma affect core of brain
and associated with diffuse axonal
injury
Treatment conservative
And surgery if bleeding cause
hydrocephalus by clott formation
- so Make external ventricular
drainage system
Hyperdense within the ventricular system
and may there is air fluid level ..!
Other type of injury is contusion of brain which usually occur in poles of brain
There is coup and countercoup contusion due to acceleration & deceleration injury
Presentation: same as that of SOL
On CT we will see mixed or heterogenous density
Management = conservative + surgical intervention in special circumstances
focal affect ‫كل هذا اللي حجينا هو‬
diffuse effect ‫اكو‬
1-concussion Transient, reversible loss of consciousness or neurological deficits
‫ ساعة‬٢٤ ‫مؤقت ما يتجاوز‬
It’s functional disturbance of neurons , not organic damage so
on CT and MRI it’s normal
Management = conservative, observation and reassurance
2-diffuse axonal injury
It’s severe and serious injury that occur in head trauma and lead
to comma state which need RCU admissions when GCS < 8.
After stage of comma the patient will be in vegetative state
3-diffuse cerebral edema It’s called cytotoxic or malignant edema.
We should use all conservative measures to control it &
if we cannot we will use decompressive craniectomy
Clinical presenration and squele:
1. Vital signs disturbance: BP, PR, RR, Temp.
2. Decreasing conscious level: GCS
3. Intracranial hypertension: signs and
symptomes of raised ICP.
4. Pupillary examination(size and light reflex).
False localizing sign
5. Cranial nerve palsies: abducent nerve is the
commonest n. Involved because of the
longest anatomical course.
Optic and oculommotor
‫فولز لوكاليزن ساين‬
Hemiparesis
Hemplegia
Diplegia
Quadriplegia
6. Motor weakness.
7. Sensory loss.
8. Respiratory irregularties: ataxic breathing,
chyene- stokes breathing.
9. Herniation syndrom.
10. Brain death.
Important in spinal cord injury not in head
Brain has soft consistency so hematoma will compress it & result in
herniation at following site
Herniation syndrom
•
All line of management to prevent this ..
Herniation beneath
Subfalcine. falx cerebral or
cingulate gyrus
• Uncal.
Herniation of medial part of
temporal lobe through
tentorium cerebelli & cause
compression on brain stem
• Central.
Herniation of diencephalon through
tentorium cerebelli
Tonsilar = herniation of tonsils of cerebellum through foramen magnum
Reverse or upward herniation occur in posterior cranial fossa tumor
Management-- medical to reduce ICP --- 4H
* head elevation 30 degree not more than it
*hypothermia
* hyperventilation
*hypertonic solution such as manittol
Surgeria
- craniotomy
- craniectomy
-craniostomy or burrhole