Management of head injuries

1. Head Injuries
Prepared by Lee Meng Faang

2. Definitions
Head injury – any trauma to the head
• with/without injury to the brain due to external force with
• temporary/permanent impairment in brain function
• may/may not result in underlying structural changes in the brain.

3. Classification of Head Injury
• Primary/ Secondary
• Type of injury (Open/ Closed or Blunt/ Penetrating)
• Site of injury
• Severity of injury

4. Primary Head Injury
• Irreversible cellular injury as a direct result of the injury
• Examples:
• Skull fracture
• Contusion
• Hematoma
• Subarachnoid or focal hemorrhage
• laceration

5. Secondary Head Injury
• Damage to cells that are not initially injured
• Occurs hours to weeks after injury
Systemic effects
• Hypotension or hypertension
• Hypoxia
• Electrolyte/glucose/acid-base
abnormalities
Intracranial effects
• Ischemia
• Edema
• Infection
• Seizure
• Hemorrhage
• Hydrocephalus

6. Types of Injury
Open Head Injury/Penetrating Injury
• Results from bullet, knives etc.
• Largely focal damage
• Penetration of the skull
Closed Head Injury/ Blunt Injury
• Resulting from falls/ motor vehicle crashes etc
• Focal damage and diffuse damage
• No penetration to the skull

7. Site of Injury
Scalp Injury (Scalp lacerations)
• scalp is highly vascular, caused profuse bleeding
• major complication is infection
Skull Fractures
Minor Head Trauma
Major Head Trauma

8. Layers of Head

9. Skull Fractures
Linear Fractures
• Break in the continuity of bone without alteration of
relationship of parts
• Cause : Low velocity injuries
Depressed Fractures
• Inward indentation of skull
• Cause : Powerful blow
Comminuted fractures
• Multiple linear fractures with fragmentation of bones into
pieces
Compound fractures
• Depressed skull fractures and scalp laceration communicating
intracranial cavity

10. Basilar Fracture
Involve the floor of the skull's brain cavity
• Otorrhoea, rhinorrhoea
(due to leakage of spinal fluid into the nose and ears)
• Bulging of tympanic membrane
• Battle’s sign (unilateral bruising behind the ear, extending down the neck)
• Facial paralysis (may involve 7th or 8th cranial nerve injury)
• Tinnittus , vertigo

11. Minor Head Trauma
Concussion
• A sudden transient mechanical head injury with disruption of
neuronal activity and a change in the LOC.
• It occurs when the brain suddenly shifts inside the skull and knocks
against the skulls bony surface
• Variable period of unconsciousness or confusion
• Retrograde Short term Amnesia
• Headache, dizziness, nausea , ringing inears

12. Cerebral Contusion
• Most Common Focal injury to brain
• "salt-and-pepper" appearance on CAT scan.
• Often occurs at anteroinferior frontal, anterior
temporal and occipital regions
• Result of an impact of the brain against the skull
during an acceleration/deceleration injury.
• Petechial hemorrhages --> coalesce--> intracerebral
hematoma within hours and few days.

13. Intracranial Hematoma
• Extra-axial
• EDH (extradural/ epidural)
• SDH (subdural)
• SAH (subarachnoid)
• Intra-axial
• Intraparenchymal/ Intracerebral

14. Extradural Hemorrhage - EDH

15. Extradural Hemorrhage
• Blunt trauma to temporoparietal region
• temporoparietal locus – middle meningeal artery ( most common)
Clinical features:
• LOC → Lucid Interval → Unconsciousness
• Signs and symptoms of raised ICP;
• Focal neurological deficit
• Signs and symptoms of cerebral herniation
• may associate with skull fractures

16. Subdural Hemorrhage (SDH)
Acute SDH Subacute SDH Chronic SDH
Isodense or hyperdense: recent bleeding
Hypodense: chronic SDH
Mixed denstity: acute-on-chronic SDH

17. Mixed SDH

18. Subdural Hemorrhage
• sudden acceleration-deceleration injury with tearing of bridging veins
or direct trauma
• Risk factors: elderly, dementia, alcoholics; shaken baby syndrome;
patients on anticoagulants
• Associated with DAI
• Classified as acute, subacute or chronic
• Acute< 72 hours
• Chronic > 3 weeks

19. Subdural Hemorrhage
Acute Subdural Haematoma (<72 Hours)
• Associated with major head injury involving contusion/laceration
• Typically appears on CT scans as hyperdense crescents
• Clinical features: headache; fluctuating LOC; confusion; dilated fixed pupils; deviated gaze
Subacute Subdural Haematoma (4-21 days)
• Less severe contusion and head trauma (failure to regain consciousness may be an indicator)
• CT scan: Iso-dense/Hypodense
Chronic Subdural Haematoma (>3 weeks)
• Can present days to weeks after the initial head injury, especially in the elderly and alcoholic
populations
• May cause focal neurologic deficits, mental status changes, metabolic abnormalities, and/or
seizures
• CT scans typically shows a hypodense crescentic collection tracking between the dura and
the brain.

20. Subarachnoid Hemorrhage (SAH)
*

21. Subarachnoid Hemorrhage
Caused by extravasation of blood into the subarachnoid space between
the pia and arachnoid membranes
Causes:
• Traumatic (fracture of base of skull leading to internal carotid artery
aneurysm)
• Non- traumatic (80%):
• Ruptured cerebral aneurysm (most common: Berry Aneurysm)
• Arteriovenous malformation (AVM)
• Amyloid angiopathy; blood dyscrasias; vasculitis
Clinical Features: explosive/thunderclap headache (“worst headache”);
nausea/vomiting; decreased consciousness/coma; signs of meningeal
irritation

22. Intracerebral Hemorrhage

23. Intracerebral Hemorrhage
Haemorrhage that occurs within the brain tissues or ventricles, causing a blood clot deep in the middle of the brain
(hard to remove); pressure from this clot may cause damage to the brain (requiring surgery to relieve pressure)
Two main types:
• Intra-parenchymal haemorrhage: ICH extending into brain parenchyma (Hypertensive vasculopathy)
• Intra-ventricular haemorrhage: ICH extending into ventricles (Trauma)
• Causes: Hypertensive vasculopathy (70-80%); Ruptured AVM; Trauma; Blood Dyscrasias
Clinical presentation: rapidly progressive severe headache, building over several minutes, often accompanied by focal
neurological deficits, nausea/vomiting, decreased level of consciousness
Signs/symptoms depends of sites of haemorrhage:
• Basal ganglia/internal capsule – hemiparesis, dysphasia
• Cerebellum – ataxia, vertigo
• Pons – cranial nerve deficits, coma
• Cerebral cortex – hemiparesis, hemisensory loss, hemianopsia, dysphasia

24. Diffuse Axonal Injury (DAI)
• One of the most common and devastating types of traumatic brain injury
• Differential Movement of Adjacent regions of Brain during acceleration and Deceleration
• Damage occurs over a more widespread area than in focal brain injury (extensive lesions in white
matter tracts); process takes approximately 12-24 hours
• Major cause of prolonged COMA after traumatic brain injury
• disruption of ascending reticular connections to Cortex
• Clinical signs: decreased consciousness level; increased ICP; decerebration/decortication posture; global
cerebral oedema

25. Severity of Traumatic Brain Injury
GCS PTA (Post
traumatic
amnesia)
LOC
Mild 13-15 <1day 0-30mins
Moderate 9–12 >1 to <7 days >30 min to
<24 hours
Severe 3–8 >7 days >24hours