‫د محمود شكري‬
Neurosurgery
Head Injury
External trauma applied to the head including, scalp, skull and its containing
brain tissues, which result of:
1-closed trauma as in road traffic accident falls or assaults.
2-open trauma as in gunshots, stab wounds.
Clinical classification of head injury
Primary head injury can be classified into four main categories include:
A-scalp injuries like.
Brusies, wounds, laceration, avulsion and hematoma
B-skull fractures:.
Linear, diastatic, depressed, basilar.
Skull fractures result from large energy force applied to the head during
injury; the extent and type of skull fracture depend on the severity, direction
and geometry of impact force.
1-linear fracture:
Is a single fracture line in the skull, which passes through the entire
thickness of skull.
Linear fracture indicates that patient received an impact of considerable
energy, but the patient eventual neurological disability depends on brain
injury not the linear fracture.
it increase the risk of intracranial hemorrhage, for this reason detection of
skull fracture in plain x-ray indicates the need for ct-scan of head.
Linear skull fracture require no stabilization if scalp intact. an open linear
fracture should be inspected, removal of foreign body and debridement of
damaged soft tissues.
1
2-diastatic fracture:
Is a separation of suture line, its common in infants under three years old and
rare in older age group except as apart of more extension of skull fracture.
3-depressed fracture
Result when outer table of fractured edge lies below the inner table of
surrounding intact skull at the site of impact.
Depressed fracture occur due to more localized force of impact applied to
the skull as by hammer, sport injuries like hockey stick, golf ball or vehicle
accidents .its either closed (intact scalp) or opened (compound) when
connect to the exterior through scalp injury.
Depressed fracture may associate with scalp laceration, dural laceration,
brain contusion and intracranial hemorrhage.
Diagnosis is made on the basis of skull x-ray and ct-scan of head with bone
windows.
Treatment of individual depressed fracture depends on the presence or
absence of:
-----cosmetic deformity.
-----scalp laceration.
-----dural laceration.
-----contusion or laceration of underlying brain.
-----extension of fracture to the air sinuses.
-----coexistence of associated intracranial lesion like
EDH, SDH, ICH,
cerebral contusion, midline shift and ventricular compression.
Treatment usually in form of elevation of depressed segment in case of
closed fracture or removal of depressed segment in case of compound
comminuted fracture followed by subsequent cranioplasty or bone graft 6-9
month later.
4-basilar
fracture:
Which involve anterior, middle, or posterior cranial fossa , result due to
either direct impact or propagation of stress wave through the skull from
remote impact.
Clinical sign of basilar fracture include cerebrospinal (CSF) leakage from
ear (otorrhea ),or nose (rhinorrhea ),blood behind the ear drum
2
(hemotympanum ) ,bruising behind ear (postauriculr ecchymosis or Battles
sign )bruising around eye (periorbital)ecchymosis or Raccoon eye .cranial
nerves injury specially facial (7th ) or vestibulocochlear (8th ) may occur.
The presence of these clinical sign should increase the index of suspesion
and help in the identification of basal skull fracture.
Most of basilar fracture require no treatment, persistence CSF leak may
require operative repair.
C-focal brain injuries:
Defined as macroscopically visible damage to the brain parenchyma that is
generally limited to a well defined area.
Focal brain injury includes:
1-contusion:
Bruises of neural parenchyma, its either coup contusion which occur at site
of impact or countercoup when occur remote from site of impact force.
Commonly occur at frontal and temporal area of brain but can occur
anywhere.
2-intracranial hematoma:
--EDH
--ICH
--IVH
--SDH . --SAH
--Extradural hematoma (EDH) :
Collection of blood between the inner table of the skull and dura.its result
from injury to middle meningeal artery or vein include venous sinuses , but
commonly from middle meningeal artery (MMA).
EDH associated with skull fracture in 90% of cases.
Clinical manifestation:
Disturb conscious level, Lucida interval (transient loss of consciousness
followed by return of conscious level until the growing EDH result in
unconsciousness again) ,hemi paresis , papillary dilatation .
Can be diagnosed by brain ct-scan through which hematoma will appear as a
hyperdense, biconvex (lens shape) area between the skull and dura.
Treatment should be directed first towards reducing sign and symptoms of
raised intracranial pressure (ICP) by medical treatment like head elevation,
hyperventilation, hypothermia, hypertonic saline infusion (mannitol)
,furosomide , steroid , and barbiturate .
Surgery in form of craniotomy and evacuation of hematoma.
3
--subdural hematoma :
SDH is a collection of blood in the subdural space between the dura and
brain tissue, result from tearing of the cortical vessels into subdural space .
subdural hematoma whether acute , sub acute or chronic hematoma depend
on the age of trauma ,first week , second week or more than n two
Week respectively.
SDH appear as crescentic shape in brain ct-scan may or may not associate
with skull fracture.
Treatment should be by evacuation of hematoma by craniotomy and
coagulation of cortical bleeder vessels (mainly done in acute SDH ) or
through burr hole evacuation , through which one or more burr hole opening
of skull ,then opening the dura and evacuation of hematoma (mainly done in
chronic SDH ) .
--intracerebral hematoma (ICH ):
ICH is a collection of blood inside brain parenchyma ,the mechanism is
usually acceleration –deceleration with shearing of perforating vessels,
cortical or sub cortical . its usually round shape ,most commonly in the
frontal and temporal region .
--subarachnoid hemorrhage (SAH ) :
SAH mean hemorrhage in the subarachnoid space due to rupture vessels in
that space.
--intraventricular hemorrhage (IVH ) :
IVH hemorrhage within the ventricular system.
D-diffuse brain injury :
- Concussion.
- Brain edema.
- Diffuse brain injury.
--concussion : a transient reversible neurological dysfunction due to trauma
.these injuries commonly occur after head injury and presented in many
form :
. transient loss of consciousness
. Retrograde amnesia.
. Headache.
.Vomiting.
4
--brain edema (brain swelling):
Brain edema refer to an increase in brain volume caused by increased
intracranial blood volume ,most fluid in edema accumulate in white matter
in which can expand compressing further brain tissues .
--diffuse axonal injury (DAI):
DAI refer to a prolonged post traumatic loss of consciousness rendered
patient deeply comatose with a feature of decortications or decerebration.
Usually associated with brain stem injury.
So clinical classification of head injury:
Focal brain
Scalp injury skull fracture
injury
Bruises
linear
contusion
Wounds
diastatic
E DH
Laceration
depressed
S DH
Avulsion
basilar
ICH
Hematoma
SAH
IVH
5
diffuse brain
injury
concussion
brain edema
DAI