Head Injury- Clinical
Manifestations, Diagnosis and
Management
• Dr Gumar Jaya Saleh SpBS
CROSS-SECTION
HEAD INJURY -
DEFINITION
• Any injury that results in
trauma to the SCALP,
SKULL or BRAIN.
• TRAUMATIC BRAIN
INJURY and HEAD
INJURY are often used
interchangeably.
Head Injury
• Causes
– Motor vehicle accidents
– Falls
– Assaults
– Sports-related injuries
– Firearm-related injuries
HEAD INJURY - TYPES
OPEN HEAD INJURY: CLOSED HEAD INJURY
There is penetration to the skull. There is NO penetration to the skull.
COUP-CONTRECOUP
INJURIES
• Damage may occur
directly under the site
of impact (COUP), or
it may occur on the
side opposite the
impact
(CONTRECOUP).
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 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 -
MECHANISMS
PRIMARY INTRACRANIAL SECONDARY INTRACRANIAL
INJURY INJURY
•It is the initial neuronal •Secondary injuries are the
damage that occurs result of the
IMMEDIATELY as result of neurophysiological and
trauma. anatomic changes, which occur
from MINUTES to DAYS
after the original trauma.
HEAD INJURY -
MECHANISMS
PRIMARY INTRACRANIAL SECONDARY INTRACRANIAL
INJURY INJURY
• Cerebral Laceration • Edema
• Cerebral Contusion
• Impaired Metabolism
• Epidural Hematoma
• Subdural Hematoma • Altered Cerebral Blood Flow
• Subarachnoid Hematoma
• Intracerebral Hematoma • Free Radical Formation
• Diffuse Axonal Injury
• Excitotoxicity
SCALP INJURIES
LACERATIONS SUBGALEAL HEMATOMA
Head Injury
• Scalp lacerations
– The most minor type of head trauma
– Scalp is highly vascular profuse
bleeding
– Major complication is infection
SKULL INJURIES
CLOSED FRACTURES OPEN FRACTURES
• Open fractures have
potential for serious
infection.
• A closed fracture has a
• Any foreign matter impaled
significant chance of in the skull should be left in
associated intracranial place for removal by the
haematoma. neurosurgeons.
• Cover it lightly with a
sterile dressing that has been
moistened with a sterile
saline.
SKULL INJURIES
CT SCAN OT
SKULL INJURIES
DEPRESSED FRACTURES/COMPOUND NON-DEPRESSED LINEAL
DEPRESSED FRACTURES FRACTURES
SKULL INJURIES - BASILAR
SKULL FRACTURE
BRAIN INJURIES
DIFFUSE FOCAL
• Contusion
• Brain Lacerations
• Concussion • Epidural haematoma
• Diffuse Axonal Injury • Subdural haematoma
• Subarachnoid haemorrhage
• Parenchymal haematoma
SKULL INJURIES - BASILAR
SKULL FRACTURE
RACCOON EYE
SKULL INJURIES - BASILAR
SKULL FRACTURE
BATTLE’S SIGN
SKULL INJURIES - BASILAR
SKULL FRACTURE
BLEEDING FROM THE EAR CSF LEAKAGE FROM THE EAR
CANAL OR NOSE
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
BRAIN INJURIES
DIFFUSE FOCAL
• Contusion
• Brain Lacerations
• Concussion • Epidural haematoma
• Diffuse Axonal Injury • Subdural haematoma
• Subarachnoid haemorrhage
• Parenchymal haematoma
HEAD INJURY (DIFFUSE) -
CONCUSSION
• Brain injury that does • There may be brief
not result in any confusion,
evidence of structural disorientation,
alteration. headache, dizziness,
amnesia.
• Return of
consciousness • CT scan is normal.
moments or minutes
after impact.
Head Injury
Pathophysiology
• 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 INJURY (DIFFUSE) -
DIFFUSE AXONAL INJURY
Head Injury
Pathophysiology
• Diffuse axonal injury (DAI)
– Clinical signs:
Level of Consciousness
ICP
• Decerebration or decortication
• Global cerebral edema
• 90% regain consciousness from severe
DAI
BRAIN CONTUSION
SUBDURAL HEMATOMA
SCHEMATIC CT SCAN
SUBARACHNOID
HEMATOMA
SCHEMATIC CT SCAN
HEMATOMAS
CEREBRAL EDEMA
NORMAL CT SCAN CEREBRAL EDEMA
SYMPTOMS
• Confusion/Irritibility • Speech/Swallowing
Difficulty
• Drowsiness
• CSF Leakage
• Dizziness
• Ear Bleeding
• Nausea & Vomiting
• Numbness/Paralysis
• Amnesia
• Coma
SYMPTOMS
SYMPTOMS
GLASGOW COMA SCALE
MINIMUM=3/15 MAXIMUM=15/15 INTUBATION <8/15
GLASGOW COMA SCALE
(GCS)
SEVERITY SCORE
GLASGOW COMA SCALE
(GCS)
SEVERITY LOSS OF CONSCIOUSNESS
COMPLICATIONS
• Personality Changes
LONG-TERM EFFECTS
• Parkinson’s
• Hypopituitarism e.g. DI
• Post-Traumatic Seizures • Alzheimer’s Dementia
• Infections e.g. Meningitis
• Vasospasm, Aneurysm
• Coma, Brain Death
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
Battle’s Sign
Fig. 55-13
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
have a
cervical spine (C-spine) injury and immobilized with until
clinical
clinical and radiographic studies
studies can prove
prove otherwise
otherwise
• Minimize
Minimize CSF leak
–– Bed
Bed flat
flat
–– Never
Never suction
suction orally;
orally; never
never insert
insert NG
NG tube;
tube; never
never use
use Q-Tips
Q-Tips in
in
nose/ears;
nose/ears; caution
caution patient
patient not
not to
to blow
blow nose
nose
• Place sterile gauze/cotton ball around area
Definitive Rx:
•• Measures
Measures to
to reduce
reduce ICP
ICP
•• Supportive
Supportive management
management
•• Surgery
Surgery
Head Injury
Cerebral Contusion Cerebral Laceration
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
SCHEMATIC CT SCAN
Epidural hematoma
Source
Source of Bleed :
Temperoparietal
Temperoparietal locuslocus (most
(most likely)
likely) -- Middle
Middle meningeal
meningeal artery
artery
Frontal
Frontal locus
locus -- anterior
anterior ethmoidal
ethmoidal artery
artery
Occipital
Occipital locus
locus -- transverse
transverse or or sigmoid
sigmoid sinuses
sinuses
Vertex
Vertex locus
locus -- superior
superior sagittal
sagittal sinus
sinus
Clinical Features:
•• LOC>>>
LOC>>> LucidLucid Interval
Interval >>
>> unconsciousness
unconsciousness
•• s/s
s/s of
of raised
raised ICP
ICP
•• Focal
Focal neurological
neurological deficit
deficit
•• s/s
s/s of
of cerebral
cerebral herniation
herniation
Epidural and Subdural Hematomas
Epidural Hematoma
Subdural Hematoma
Fig. 55-15
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
probably from repeat minor bleeds
CT scan : hypodense
Epidural 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) Bridging veins
- Middle meningeal artery
Frontal - anterior ethmoidal artery
Occipital - transverse or sigmoid
sinuses
Vertex - superior sagittal sinus
Symptoms Lucid interval followed Gradually
by unconsciousness increasing headache and co
nfusion
CT appearance Biconvex lens- limited by suture Crescent shaped- crosses
lines suture lines
Fig. 55-15
Subarachnoid Hemorrhage
Causes:
Causes:
•• Rupture
Rupture ofof Berry
Berry aneurism(MCC)
aneurism(MCC)
•• Trauma
Trauma (fracture
(fracture at
at the
the base
base of
of the
the skull
skull leading
leading to
to internal
internal
carotid
carotid aneurysm)
aneurysm)
•• Amyloid
Amyloid angiopathy
angiopathy
•• Blood
Blood dyscrasias
dyscrasias
•• Vasculitis
Vasculitis
Clinical
Clinical Features:
Features:
•• Explosive
Explosive or
or thunderclap
thunderclap headache,
headache, “worst
“worst headache
headache of
of my
my life”,
life”,
•• nausea
nausea and
and vomiting,
vomiting, decreased
decreased LOC
LOC or
or coma.
coma.
•• Signs
Signs of
of meningeal
meningeal irritation
irritation
Intracerebral Hemorrhage
(ICH)
Intracranial
Intracranial hemorrhage
hemorrhage is is hemorrhage
hemorrhage that
that occurs
occurs within
within
the
the brain
brain tissue
tissue itself;
itself; an
an intra-axial
intra-axial hemorrhage.
hemorrhage.
Two
Two main
main types:
types:
1)Intraparencymal
1)Intraparencymal hemorrahge-
hemorrahge- ICHICH extending
extending into
into brain
brain
parenchyma;
parenchyma; MCC-MCC- HTNsive
HTNsive vasculopathy
vasculopathy
2)Intra-ventricular
2)Intra-ventricular hemorrhage-
hemorrhage- ICHICH extending
extending into
into ventricles;
ventricles;
MCC
MCC –trauma
–trauma
Causes:
Causes:
Hypertensive
Hypertensive vasculopathy(70-80%)
vasculopathy(70-80%)
Ruptured
Ruptured AVM
AVM
Trauma
Trauma
Blood
Blood dyscracias
dyscracias
Intracranial Hemorrhage
Extra- axial hemorrhage
• Epidural hematoma
• Subdural hematoma-
Acute
Chronic
• Subarachnoid hemorrhage
Intra-axial hemorrhage
• Intra-parenchymal
hemorrhage
• Intra-ventricular hemorrhage
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
INTRACEREBRAL
HEMATOMA
SCHEMATIC CT SCAN
Complications
•• Neurological
Neurological deficits
deficits or
or death
death
•• Seizures
Seizures
•• Obstructive
Obstructive Hydrocephalus
Hydrocephalus
•• Spasticity
Spasticity
•• Urinary
Urinary complications
•• Aspiration
Aspiration pneumonia
pneumonia
•• Cushing’s
Cushing’s ulcer
ulcer
•• Neuropathic
Neuropathic pain
pain
•• Deep
Deep venous
venous thrombosis
thrombosis
•• Pulmonary
Pulmonary emboli
emboli
•• Cerebral
Cerebral herniation
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 herniation
1. Uncal
2. Central (transtentorial)
3. Cingulate (subfalcine)
4. Transcalvarial
Infratentorial herniation
5. 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 findings
Epidural Hematoma Subdural Hematoma
Fig. 55-15
CT findings
Subarachnoid hemorrhage Intracerebral hematoma
Fig. 55-15
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]
[10]
• Rapidly
Rapidly stabilize vital signs, and simultaneously acquire
emergent CT scan.
•• Maintain
Maintain euvolemia,
euvolemia, using
using normotonic
normotonic rather
rather than
than hypotonic
hypotonic fluids,
fluids,
to
to maintain
maintain brain
brain perfusion
perfusion without
without exacerbating
exacerbating brain
brain edema
edema
•• Avoid
Avoid hyperthermia.
hyperthermia.
•• Facilitate
Facilitate transfer
transfer to
to the
the operating
operating room
room or
or ICU.
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)
3) Surgical
Surgical Evacuation
Evacuation of
of hematoma:
hematoma:
•• No
No surgical
surgical intervention
intervention ifif collection
collection <10ml
<10ml
Indication
Indication of
of surgical
surgical decompression:
decompression:
•• The
The GCS
GCS score
score decreases
decreases by
by 22 or
or more
more points
points between
between the
the time
time of
of injury
injury and
and hospital
hospital
evaluation
evaluation
•• The
The patient
patient presents
presents with
with fixed
fixed and
and dilated
dilated pupils
pupils
•• The
The intracranial
intracranial pressure
pressure (ICP)
(ICP) exceeds
exceeds 20
20 mm
mm HgHg
Exception
Exception ::
In
In Subdural
Subdural hematoma
hematoma with
with GCS=15-
GCS=15- hematoma
hematoma >10mm
>10mm ,or
,or >5mm
>5mm midline
midline shift
shift ----
----
requires
requires Surgical
Surgical decompression
decompression
SAH:
SAH: whn
whn aa cerebral
cerebral aneurysm
aneurysm is
is identified
identified on
on angiography,
angiography, clipping
clipping and
and coiling
coiling is
is done
done to
to
prevent re-bleed
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.
TREATMENT - ACUTE STAGE
(SURGERY)
DECOMPRESSIVE CRANIOTOMY
Management
4) Medical therapy:
•• Antihypertensives
Antihypertensives - reduce
reduce blood
blood pressure
pressure toto prevent
prevent exacerbation
exacerbation of
of
intracerebral
intracerebral hemorrhage
hemorrhage in in hypertensive
hypertensive encephalopathy.
encephalopathy. Eg Nicardipine,
labetolol;
labetolol; CCB
CCB help
help relieve
relieve vasospasm
vasospasm in in SAH
SAH andand decrease
decrease further
further
damage
damage
•• Diuretics
Diuretics -- Mannitol,
Mannitol, CAI CAI
•• Anticonvulsants
Anticonvulsants –– reduce
reduce frequency
frequency ofof seizures
seizures and prophylaxis
prophylaxis of
seizures
seizures eg:
eg: Fosphenytoin
Fosphenytoin
•• Antipyretics-
Antipyretics- to to Rx
Rx fever
fever and
and pain
pain relief
relief eg:
eg: Acetaminophene
Acetaminophene
•• Antidote-
Antidote-
VitK/FFP
VitK/FFP forfor warfarin
warfarin overdose;
overdose;
protamine
protamine forfor heparin
heparin overdose
overdose
•• Antacids-
Antacids- prophylaxis
prophylaxis for for Cushing’s
Cushing’s gastric
gastric ulcer
ulcer eg:
eg: Famotidin
•• Glucorticoids
Glucorticoids may may help
help reduce
reduce the
the head
head and
and neck
neck ache
ache caused
caused by
by the
the
irritative
irritative effect
effect of
of the
the subarachnoid
subarachnoid blood.
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
