Head Injury- Clinical Manifestations, Diagnosis and

Management

AHMED JEMALCLINICAL-1(HO)

JAN 5,2015

Head Injury

• Any degree of traumatic brain injury ranging from scalp laceration to LOC to focal neurological deficits

Head Injury

• Causes

–Motor vehicle accidents

– Falls

–Assaults

– Sports-related injuries

– Firearm-related injuries

Head Injury

• High potential for poor outcome

• Deaths occur at three points in time after injury:

– Immediately after the injury

–Within 2 hours after injury

– 3 weeks after injury

Head Injury

TYPES:

• Scalp laceration

• Skull Fractures

• Minor Head Trauma

Concussion and post-concussion syndrome

• Major Head Trauma: Cerebral contusion

Laceration

Head Injury

• Scalp lacerations

– The most minor type of head trauma

– Scalp is highly vascular → profuse bleeding

–Major complication is infection

Head Injury

• Skull fractures

– Linear Skull Fracture

–Depressed Skull Fracture

–Diastatic Skull Fracture

– Basal Skull Fracture

–Compound Skull Fracture

–Compound elevated Skull Fracture

–Growing Skull Fracture

–Coup & Contrecoup

Head Injury

• Skull fractures

– Location of fracture alters the presentation of the manifestations

– Facial paralysis

–Conjugate deviation of gaze

– Battle’s sign, Raccoon eyes

Battle’s SignBattle’s Sign

Fig. 55-13

Head Injury

• Basal Skull fractures– CSF leak (extravasation)

into ear (Otorrhea) or nose (Rhinorrhea)

– High risk infection or meningitis

– “HALO Sign ” on clothes of linen

– Possible injury to Internal carotid artery

– Permanent CSF leaks possible

Investigations

X-ray CT scan: standard modality

MRI

Bleeding from the ear or nose in cases of suspected CSF leak -"halo" or "ring" sign , when dabbed on a tissue paper

CSF leak - analyzing the glucose level and by measuring tau-transferrin.

Management

Pre-hospital care:• Patients with severe head injuries should be assumed to

have a cervical spine (C-spine) injury and immobilized with until clinical and radiographic studies can prove otherwise

• Minimize CSF leak– Bed flat– Never suction orally; never insert NG tube; never use Q-Tips

in nose/ears; caution patient not to blow nose

• Place sterile gauze/cotton ball around areaDefinitive Rx: • Measures to reduce ICP • Supportive management• Surgery

Head Injury

• Minor head trauma– Concussion : head injury with a temporary

loss of brain function concussion can cause a variety of physical, cognitive , and emotional symptoms.

Cause: Sudden acceleration and deceleration injury eg: Car accident, sports injury, bicycle accident etc

Head InjuryTypes of Head Injuries

ConcussionPresentation:Physical-headache, LOC, Amnesia, s/s of ↑

ICP(Cushing’s triad) , convulsions Cognitive : confusion, irritability,

behavioral changes

Head Injury

• Minor head trauma

– Postconcussion syndrome

• 2 weeks to 2 months

• Persistent headache

• Lethargy

• Personality and behavior changes

Head Injury

• Major head trauma

– Includes cerebral contusions and lacerations

– Both injuries represent severe trauma to the brain

Head Injury

• Major head trauma– Contusion• The bruising of brain tissue within a focal

area that maintains the integrity of the pia mater and arachnoid layers associated with multiple micro-hemorrhages, small vessel bleed into brain tissue

– Lacerations• Involve actual tearing of the brain tissue• Intracerebral hemorrhage is generally

associated with cerebral laceration

Head Injury

Cerebral Contusion Cerebral Laceration

Head InjuryPathophysiology

• Diffuse axonal injury (DAI)

–Widespread axonal damage occurring after a mild, moderate, or severe TBI

– Seen in half the cases of head injury

– Process takes approximately 12-24 hours

Head InjuryPathophysiology

• Diffuse axonal injury (DAI)

–Clinical signs:

∀↓ Level of Consciousness

∀↑ ICP

•Decerebration or decortication

•Global cerebral edema

• 90% regain consciousness from severe DAI

Intracranial Hemorrhage

Extra- axial hemorrhage• Epidural hematoma• Subdural hematoma-

Acute

Chronic• Subarachnoid hemorrhage

Intra-axial hemorrhage• Intra-parenchymal

hemorrhage• Intra-ventricular

hemorrhage

Epidural hematoma

– Results from bleeding between the dura and the inner surface of the skull

– MC type of traumatic Intracranial bleed, rarely occurs spontaneously

– A neurologic emergency– Bleed is Venous or arterial origin

Epidural hematoma

Source of Bleed : Temperoparietal locus (most likely) - Middle

meningeal artery

Frontal locus - anterior ethmoidal artery

Occipital locus - transverse or sigmoid sinuses

Vertex locus - superior sagittal sinus

Clinical Features: • LOC>>> Lucid Interval >> unconsciousness

• s/s of raised ICP

• Focal neurological deficit

• s/s of cerebral herniation

Subdural hematoma

– Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain

– Source of bleed: Bridging veins; May be caused by an arterial hemorrhage

– Much slower to develop into a mass large enough to produce symptoms.

Cause: Acceleration-deceleration injury, direct trauma,

Risk factors: Elderly, dementia, alcoholics, shaken baby syndrome, pts on anticoagulants

Subdural hematoma

– Acute subdural hematoma(<72hrs)• High mortality• Associated with major direct trauma (Shearing

Forces)

Clinical Features:

Headache, fluctuating LOC, confusion, dilated fixed pupil, deviated gaze

CT scan: hyperdense

Subdural hematoma

– Subacute subdural hematoma• Occurs within 4-21 days of the injury• Failure to regain consciousness may be an

indicator

CT scan: Isodense or hypodense– Chronic subdural hematoma(>3wks)

• Develops over weeks or months after a seemingly minor head injury, probably from repeat minor bleeds

CT scan : hypodense

Epidural and Subdural HematomasEpidural and Subdural Hematomas

Fig. 55-15

Epidural Hematoma

Subdural Hematoma

Epidural and Subdural HematomasEpidural and Subdural Hematomas

Hematoma type Epidural Subdural

Location Between the skull and the dura Between the dura and the arachnoid

Involved vessel Temperoparietal (most likely) - Middle meningeal artery Frontal - anterior ethmoidal arteryOccipital - transverse or sigmoid sinusesVertex - superior sagittal sinus

Bridging veins

Symptoms Lucid interval followed by unconsciousness

Gradually increasing headache and confusion

CT appearance Biconvex lens- limited by suture lines

Crescent shaped- crosses suture lines

Fig. 55-15

Subarachnoid HemorrhageCauses:

• Rupture of Berry aneurism(MCC)• Trauma (fracture at the base of the skull leading to

internal carotid aneurysm)• Amyloid angiopathy

• Blood dyscrasias

• Vasculitis

Clinical Features:

• Explosive or thunderclap headache, “worst headache of my life”,

• nausea and vomiting, decreased LOC or coma.• Signs of meningeal irritation

Intracerebral Hemorrhage (ICH)

Intracranial hemorrhage is hemorrhage that occurs within the brain tissue itself; an intra-axial hemorrhage.

Two main types:

1)Intraparencymal hemorrahge- ICH extending into brain parenchyma; MCC- HTNsive vasculopathy

2)Intra-ventricular hemorrhage- ICH extending into ventricles; MCC –trauma

Causes:

Hypertensive vasculopathy(70-80%)

Ruptured AVM

Trauma

Blood dyscracias

Intracerebral Hemorrhage (ICH)

Clinical presentation: Rapidly progressive severe headache, building over several minutes, often accompanied by focal neurological deficits, nausea and vomiting, decreased level of consciousness.

S/S depend site of hemorrhage:

Basal ganglia/internal capsule - hemiparesis, dysphasia

Cerebellum - ataxia, vertigo

Pons - cranial nerve deficits, coma

Cerebral cortex - hemiparesis, hemisensory loss,

hemianopsia, dysphasia

Complications

• Neurological deficits or death• Seizures• Obstructive Hydrocephalus• Spasticity• Urinary complications

• Aspiration pneumonia• Cushing’s ulcer• Neuropathic pain• Deep venous thrombosis• Pulmonary emboli

• Cerebral herniation

Cerbral Herniation

Brain herniation is a deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull.

“Brain herniation represents mechanical displacement of normal brain relative to another anatomic region secondary to mass effect from traumatic, neoplastic, ischemic, or infectious etiologies. “

Cerbral Herniation

Supratentorial herniation1. Uncal2. Central (transtentorial)3. Cingulate (subfalcine)4. TranscalvarialInfratentorial herniation5. Upward (upward

cerebellar or upward transtentorial)

6. Tonsillar (downward cerebellar)

Cingulate Herniation

The most common type, the innermost part of the frontal lobe is scraped under part of the falx cerebri, the dura mater at the top of the head between the two hemispheres of the brain.

Cingulate herniation can be caused when one hemisphere swells and pushes the cingulate gyrus by the falx cerebri.

Cingulate herniation is frequently believed to be a precursor to other types of herniation

Uncal Herniation

common subtype of cerebral herniation following raised ICP

Innermost part of the temporal lobe, the uncus, can be squeezed so much that it moves towards the tentorium and puts pressure on the brainstem, most notably the midbrain

Clinical feature:

• Compression of I/L CN III- I/L fixed dilted pupil

• Compression of I/L PCA- C/L homonymous hemianopsia

• Compression of C/L crus cerebri- I/L hemiparesis

• Duret hemorrhage

Diagnostic Studies

CT scan –• A GCS score less than 15 after blunt

head trauma warrants a patient with no intoxicating consideration of an urgent CT scan.

CT findingsCT findings

Fig. 55-15

Epidural Hematoma Subdural Hematoma

CT findingsCT findings

Fig. 55-15

Subarachnoid hemorrhage Intracerebral hematoma

Diagnostic Studies

• MRI – superior for demonstrating the size of an acute subdural hematoma.

• Cerebral angiogram if hemorrhage is confirmed (not necessary in case of classic hypertensive hemorrhage

• Cervical spine X-ray• EEG• Lumbar Pucture

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.

Management4) 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.

Preventive Measures

Health Promotion

• Prevent car and motorcycle accidents

• To Wear safety helmets

Rehabilitation

Ambulatory and Home Care

•Nutrition

• Bowel and bladder management

• Spasticity

•Dysphagia

• Seizure disorders

• Family participation and education

References:

• Harrison's Principles of Internal Medicine

• Medscape Reference http://emedicine.medscape.com• US National Library of Medicine

National Institutes of Health http://www.ncbi.nlm.nih.gov