nurosurgery

HEAD INJURIES

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 15-24 years) and is more common in males than females.

Head Injuries according to Mechanisms of Injury

a. 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

Pathophysiology of head injuries

Contact Injuries Head Motion (Inertial) Injuries

Contact Injuries

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

Coup and Countercoup

Coup and Countercoup

Head Motion (Inertial) Injuries
Translational acceleration. Rotational acceleration. Angular acceleration.


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

The Glasgow Coma Score

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
Nil
Nil
T
Intubated

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
Nil
Nil
T
Intubated

The Glasgow Coma Score

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

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.

Classification of Head Injuries according to the SITE of injury

Scalp 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

Scalp Injuries

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

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

Scalp LacerationGun Shot

Scalp Laceration + Cellulitis

Management of Scalp laceration (wounds of the scalp)

Plain X-ray is performed. Shaving widely around the wound. Closure in 2 layers

Scalp Lacerations

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.

Subgaleal Haematoma

Subgaleal Haematoma

Subgaleal Haematoma

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

Skull Injuries (Skull Fractures)

Fractures of the Vault Fractures of the base (Basilar skull fractures)

Fractures of the Vault

linear fractures Stellate Depressed skull fractures Diastatic fractures Pond (ping pong fractures)

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.

Linear Skull Fracture

Linear Skull Fracture

Linear Skull FractureBone Window

Linear Skull Fracture

Linear Skull Fracture

Depressed skull fractures

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

Depressed Skull Fractures

Depressed Skull Fractures

Depressed Skull Fractures

Depressed Skull FracturesBone Window

Depressed Skull Fractures

Depressed Skull Fractures

Depressed Skull Fractures

Depressed Skull Fracturesfrontal Depressed Fracture

Depressed Skull Fracturesfrontal Depressed Fracture

Depressed Skull Fracturesfrontal Depressed Fracture

Depressed Skull Fracturesfrontal Depressed Fracture

Closed depressed fractures

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

Indications for surgery to raise the closed depressed fracture

Cosmetic .. Frontal … femaleFracture involving air sinusFracture involving venous sinus with raised ICPUnderlying hematomaFND related to underlying areaUsually any compound one

Compound depressed fracture

Cause 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.

Treatment of compound depressed fracture

Medical 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.

Complications of depressed fractures

Dural 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.

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.

Diastatic Fractures

Diastatic Fractures

Diastatic Fractures

Diastatic Fractures

Pond (ping pong fractures)

This is green stick type of fracture a smooth concave depression due to blunt traumaUsually 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.

Ping Pong Fractures

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.

The essential features of base of skull fractures

Leakage of cranial contents, e.g. blood, CSF, or brain matter. Injury of cranial nerves. Signs of brain injury.

Types of skull base fractures

Anterior fossa Middle fossa Posterior fossa

Anterior fossa basal fractures

May 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.

The Raccoon

The Raccoon



The Raccoon

Raccoon Eyes

Raccoon Eyes

Raccoon Eyes

Anterior fossa basal fractures

Anterior fossa basal fractures

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

Battle sign

Facial Nerve Palsy (LMNL)

Middle fossa basal fractures

Middle fossa basal fractures

Posterior fossa basal fractures

1. 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.

Posterior fossa basal fractures

Skull Base Fractures

Management of skull base fractures

1. Prevention of infection: prophylactic antibiotics. 2. Control of CSF leakage: conservative or surgical intervention. 3. Treatment of associated brain injury.

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.

Epidural hematoma

Incidence 1 % of head injury patient Male 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.


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%

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.

Acute Subdural hematoma

Usually 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.

Chronic subdural hematoma

Most 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.


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

Among post traumatic complications

CNS Infection Seizure Hydrocephalus CSF fistula Ischemic stroke Cerebral herniation