CEREBRAL CONTUSION

1. CEREBRAL CONTUSION

2. TRAUMATICBRAININJURY
Aninsulttothebrain,notofdegenerativeorcongenitalnature
causedbyanexternalphysicalforcethatmayproducea
diminished oralteredstateofconsciousness,which resultsin
impairmentofcognitiveabilitiesorphysicalfunctioning.Itcan
alsoresultindisturbanceinbehaviororemotionalfunctioning.

3. Highestamongtheadolescents,youngadultsand
Thoseolderthan75.
50%ofmajortraumadeathsareduetoTBI
Vehiclecrashesaretheleadingcauseof braininjury.

4. MECHANISMOFINJURY:
BLUNTINJURY
Motor vehicle injuries
falls
Assaults
PENETRATINGINJURY
Gunshot wounds
Stabbing
Explosions

5. TYPESOFBRAININJURY
CLOSEDINJURY
OPENINJURY

6. CLOSEDINJURY
Of thetwo, closed injuryisfarmore common.
Resulting from fallandmotor vehicle accidents.
Effects aremorebroad(diffuse)
Nopenetration to skull

7. OPENINJURY
Resultsfrombulletswounds.
Largelyfocaldamage
Penetrationofskull
Effectscanbeserious

8. TYPESOFHEADINJURIES
Scalplaceration
Skull fractures
Focalbraininjuries
Diffuse braininjuries

9. Focal
Cerebral contusion
Intracranial hemorrhages
Intracerebral hemorrhages
Diffuse
Concussion
Moderate diffuse axonal injury
Severediffuse axonal injury

10. Pathophysiology
Primayinjury
Atthetimeof trauma.
Irreversible cellularinjuryasadirectresultto injury.

11. Secondaryinjury
Occursafterhoursto weeks afterthe injury.
Includesinjuriesfromedema,ischemia,hypoxemia, vasospasm.

12. CEREBRALCONTUSION
Cereberalcontusionsare
basically”brainbruises”.
Mostofteninvolving thecrown
ofgyrus,theytendtobewedge
shapedwithapexextendinginto
neuralparenchyma.
Cerebralcontusionsarealso
calledgyral“crest”injuries.

13. CLASSIFICATION
COUP
COUNTERCOUP
INTERMEDIATE COUP
GLIDINGCONTUSION
HERNIATIONCONTUSION
FRACTURE CONTUSION

14. COUP
Coup contusion arethose thatoccurbeneath theimmediatearea of
impact.

15. COUNTERCOUP
Countercoupcontusionsarethosethatarethoughttobe
confinedtoareasremotefromandmostoftendirectlyopposite
theimpactsiteontheothersideofbrain.

17. INTERMEDIATECOUP
Intermediate coupoccurswithintheneuralparenchymabetween the
impactsiteandtheopposite sideofbrain.
Trueintermediatecoupcontusions occurinsylvian fissure ,where
frontalandtemporal corties maybeforcibly“slapped” againsteach
other duringthe transmissionofforce fromonesideto other.

18. GLIDINGCONTUSION
Glidingcontusionshasbeendescribed asthose thatoccuratthevertex
ofbrainandareproducedbyrostral tocaudalmovement ofbrainduring
deccelerative injuries.

19. HERNIATIONCONTUSION
They areproducedsuddenforcingofaportionofabrainagainstarigid
opening ,mostoften the incisuraoftentorium .

20. FRACTURECONTUSION
Thefracturecontusiontermis restricted tocontusionlocated
immediately underthefractureline.

21. ETIOLOGY
 Mostcerebralcontusionsresultfromnonmissileorbluntheadinjury.
 Closedheadinjuryinducesabruptchangesinangularmomentumanddeceleration.
 Thebrainissuddenlyandforciblyimpactedagainstanosseousridgeorthe
hard,knife-likeedgeofthefalxcerebriandtentoriumcerebelli.

22. PATHOLOGY
LOCATIONS
 Theyoccurinverycharacteristic,highlypredictablelocations.Nearlyhalf involve
thetemporallobes.Thetemporaltips,aswellasthelateraland inferiorsurfaces
andtheperisylviangyri,aremostcommonlyaffected.
 Theinferior(orbital)surfacesofthefrontallobesarealsofrequently affected

23.  Convexitygyri,thedorsalcorpuscallosumbody,dorsolateralmidbrain,and
cerebellumarelesscommonsitesofcerebralcontusions.
 Theoccipitalpolesarerarelyinvolved,evenwithrelativelysevereclosed
headinjury.

25. MICROSCOPICFEATURES
 Perivascularmicrohemorrhagesrapidlyformandcoalesceovertimeintomore
confluenthematomas.Edemasurrounding thehemorrhagesdevelops.Activation
andproliferationof astrocytestogetherwithmacrophageinfiltrationensue.
 Necrosiswithneuronallossandastrogliosisaswellashemosiderin-laden
macrophagesarepresentin subacuteandchroniclesions.

26. SYMPTOMS
 Vomiting
 Lethargy
 Headache
 Confusion
 Paralysis
 Lossofconsciousness
 Lossofmemory

27. Alteration ofmental state
Speech difficulties
Seizures
Focalneurologicaldeficits

28. IMAGING
CTSCANFINDINGS:
 ACUTE:
 Themostfrequentabnormalityisthepresenceof petechialhemorrhagesalonggyralcrests
immediatelyadjacenttothecalvaria.Amixturepatchyhyperdensehemorrhagicfoci surroundedby
ill-definedhypodenseareasofedemais common.(saltandpepperappearance)

29.  Lesion"blooming"overtimeisfrequentandisseenwithprogressiveincreasein
hemorrhage,edema,andmasseffect .Smalllesionsmaycoalesce,forminglarger
focalhematomas.Developmentof newlesions thatwerenotpresentoninitial
imagingisalsocommon.

32. CHRONIC:
Haemorrhagicfociturnsisodenceandthenhypodense.
Eventuallytheareasbecameencephalomalacicwithvolumelossandthereis hypodensityoftheinvolved
parenchyma.

33. MultipleCTimagesovertimedemonstrate
theevolution ofa hemorrhagicparenchymal
contusioninatypicallocationoverthe
petrous ridgeofthetemporalbone.The
hematomaisnotvisibleonday1(top row
left),butappears and enlargesoverthenext
fewdays (top rowrightandmiddlerow left),
atypical courseforcontusion.Atday 17
(middlerowright), allthatremainsis a
hypodensehematomathat hasalready
begunto involute.1yearfromtheinitial
trauma, theprevious hematomahasevolved
intoa smallamount ofencephalomalacia
(bottom row).

34. MRI
 MRIismuchmoresensitivethanCTindetectingcerebralcontusionsbutisrarely
obtainedintheacutestageof traumaticbraininjury.

35. T1scansmayshowonlymild
inhomogeneous
isointensities andmasseffect.

36. T2scansshowpatchyhyperintense
areas(edema)surroundinghypointense
fociofhemorrhage.

37. FLAIRscansaremostsensitive for
detectingcorticaledemaand
associatedtSAH,bothofwhichappear
ashyperintense

38. MANANGEMENT
Prevention ofsecondary injury.
Hypoxemia
Hypotension
Anemia
Hyperglycemia

39. INDICATIONFORICPMONITORING
 Severeheadinjury(gcs<8) withabnormalct.
 Severeheadinjurywithnormalct and2offollowing:
Age>40
SBP<90
Decerebrateordecorticateposturing.

40. INVASIVE SYSTEMS:
Intraventicular
Intraparenchymal
Subarachnoid
Epidural.
NONINVASIVE SYSTEMS:
TCD
Tissueresonanceanalysis
Ocularsonography
Intraocularpressure

41. THERAPYFORINTRACRANIALHYPERTENSION
FIRSTTIER:
Positioning
Ventriculardrainage
Osmoticdiuresis
Hyperventilation

42. SECOND TIER:
Sedation
Neuromuscularblockade
Hypothermia
Barbiturate.
 Decompressioncraniectomy
 Evacuatonof contusedbrain

43. SURGICALINDICATION:
 Progressiveneurologicaldeterioration,refracatoryintracranialhypertension,signs
ofmasseffecton ct
 Volume>50ml
 Gcs6-8withfrontalortemporalcontusionvolume>20mlwithmidlineshift>5mm.

44. COMPLICATION
 POSTtraumaticamnesia
 Postconcussionsyndrome
 Posttraumaticepilepsy
 Infections
 Metabolicabnormalities
 Vascularabnormalities.