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Brain injuries
1. Brain Injuries
Done By: Mohammed Amjad Hayajneh
hayajneh.mohammed1@gmail.com
5th Year Medical student
Yarmouk University
2. Brain Injury
• Brain injuries refer to the direct injury of the brain
tissue as not all head injuries associated with brain
tissue injury
• Brain injuries causes may be classified into :
1. Direct brain injury (open or close)
2. Accelerating/ Decelerating injury (Coup-
Contrecoup)
3. Shearing forces
3. Primary vs. Secondary brain injury
• Primary brain injury occurs directly at the time of
impact such as:
1. Hemispheric Contusions
2. Diffuse axonal injury
3. Cortical Lacerations
4. Concussion
• Primary brain injury cause mechanical damage
which is irreversible
• Secondary brain injury occurs at some time after
the moment of impact and is often preventable.
6. • The major focus in the management of acute
closed head injury is the prevention of secondary
injuries and the preservation of neurological
functions that are not damaged by the primary
injury.
7. Traumatic brain injury (TBI)
• A non-degenerative, non- congenital insult to the
brain from an external mechanical force, possibly
leading to permanent or temporary impairment of
cognitive, physical, and psychosocial functions, with
an associated diminished or altered state of
consciousness.
8. Types of TBI
• A traumatic brain injury can be described as being a
closed or open brain injury:
1. Closed Brain Injury
• without the skull being broken or penetrated and
the brain has not been exposed. for example
Diffuse Axonal Injury and Coup-Contracoup Injury
1. Open Brain Injury
• Open or penetrating head injury.
9.
10. Laceration
• Occur If there is penetration of the brain, either by
a projectile such as a bullet or a skull fragment from
a fracture.
• Associated with tissue tearing, vascular disruption,
hemorrhage & injury along linear path (focal
lesion).
11. Diffuse axonal injury
“shearing forces”
• Caused by traumatic shearing forces during rapid acceleration
and/or deceleration of the brain (eg, motor vehicle accident).
• An injury that occurs when the grey matter slides over the white
matter, leading to diffuse axonal injury.
• Diffuse axonal injury commonly affects white matter tracts involved
in the corpus callosum and brainstem (WHY?)
• The presence of diffuse axonal injury is usually associated with
poor prognosis.
• Usually results in devastating neurologic injury, often causing coma
or persistent vegetative state.
• Rule out other secondary causes that can cause coma
• MRI shows multiple lesions (punctate hemorrhages) involving the
white matter tracts.
• CT usually normal and normal ICP
• Microscopy: axonal swelling and degeneration.
12.
13.
14. Coup-contrecoup Contusions
• A specific type of closed-head injury
• Is an injury when the brain is thrust
against the skull opposite to the blow
side due to sudden movement of the
brain inside the skull (It is bruises of the
brain tissue).
• Coup injury occurs under the site of
impact with an object, and a
• Contrecoup injury occurs on the side
opposite the area that was hit.
• Coup-contrecoup injuries can be
caused by automobile accidents, or
abusive or violent events (such as
violently shaking a baby)
15.
16. • It causes subdural hematoma as well, but the main
problem is the brain injury not the hemorrhage
• It is more sever in elderly due to brain atrophy and
more empty space in the skull
• Most common site of injury :Frontal (behind the
forehead) and temporal lobe (underneath the
temples)
• The damage caused by coup-contrecoup injuries is
usually irreversible, so treatment is designed to
prevent further damage .
17.
18. Coup lesions Contrecoup lesions
Contusions at point of
contact
Contusions opposite to
the point of trauma
Immobile or mobile head Mobile head
19. Contusions
• MORPHOLOGY: Are wedge-shaped with the broad
base lying along the surface at the point of the
impact
• Microscopic examination: In the earliest stage:
Edema and hemorrhage (appears as a high-density
area on CT scan).
20. Management
• Aim of treatment is to prevent swelling (brain
edema CT) arise from increase ICP by:
1. Prevent hypotension
2. Prevent hyponatremia
3. Prevent hypercapnia
• Surgery may require to reduce it.
21. Concussion
• The most common type of primary head injuries.
• Reversible altered consciousness from head injury in
the absence of contusion.
• Usually resulting from blunt trauma.
• Concussions are frequent in sporting events,
particularly in children.
• The pathogenesis of the sudden disruption of nervous
activity is unknown but most likely due to
physiological cause.
• No parenchymal abnormalities on CT
22. Concussion Symptoms
• Concussions symptoms vary between people and
include physical, cognitive, and emotional
symptoms
1. Physical: Headaches (most common), dizziness,
vomiting, nausea, lack of motor coordination,
difficulty balancing, light sensitivity, seeing bright
lights, blurred vision, double vision and Tinnitus.
2. Cognitive: Confusion, disorientation, LOC,
difficulty focusing attention and Post-traumatic
amnesia
3. Emotional: emotional lability and irritability
24. Epidural hematoma
• it is collection of
blood between skull
and dura caused by
trauma .
• Source of blood :
Meningeal arteries
(esp. middle
meningeal artery)
Venous sinuses or
bone (esp. in
children)
25. • Rupture of middle meningeal artery (branch of
maxillary artery), often 2° to skull fracture (circle in
A) involving the pterion (thinnest area of the lateral
skull).
• Might present with transient loss of consciousness
→ recovery (“lucid interval”) → rapid deterioration
due to hematoma expansion.
26. • CT shows biconvex (lentiform),
hyperdense blood collection not
crossing suture lines.
• Scalp hematoma (arrows in A ) and
rapid intracranial expansion
(arrows in B ) under systemic
arterial pressure → transtentorial
herniation, CN III palsy.
29. Subdural hematoma
• It is blood collection under the dura
• Can be acute (traumatic, high-energy impact →
hyperdense on CT) or chronic (associated with
mild trauma, cerebral atrophy, elderly, alcoholism
→ hypodense on CT).
• Also seen in shaken babies.
• Acute subdural hematoma is very severe (mortality
rate is more than 90%)
30. • Types:
1- Acute: bleeds develop within 48 hours of injury ,
has a high mortality rate and needs immediate
surgical decompression. (hyperdense on CT) caused
by sever trauma that lead to tearing of cortical
vessels.
2- Subacute: bleeds develop within 3 to 14 days
3- chronic: bleeds develop after two weeks or
longer, cerebral atrophy (hypodense on CT) mainly
occur in elderly due to brain atrophy that lead to
stretch of bridging veins .
31.
32. • Crescent-shaped
hemorrhage (red arrows in
C and D ) that crosses
suture lines.
• Can cause midline shift
(yellow arrow in C ),
findings of “acute on
chronic” hemorrhage (blue
arrows in D ).
33. Treatment
• Acute
Evacuation by craniotomy
due to clot
Small hematomas with
little mass effect maybe
managed conservatively.
• Chronic
Burr hole
34. Subarachnoid hemorrhage
• Bleeding due to trauma (most
common cause), or rupture of an
aneurysm or arteriovenous
malformation.
• Rapid time course.
• Patients complain of “worst headache
of my life.”
• Bloody or yellow (xanthochromic)
lumbar puncture.
• No intervention is generally performed
for subarachnoid hemorrhage alone.
35. • ↑ risk of developing
communicating and/or non-
communicating
hydrocephalus.
• Obstruction of CSF pathways
(ie, acute, obstructive,
noncommunicating type)
and blockage of arachnoid
granulations by scarring (ie,
delayed, nonobstructive,
communicating type)
36. • Vasospasm can occur due to blood breakdown or
rebleed 3–10 days after hemorrhage → ischemic
infarct; nimodipine used to prevent/reduce
vasospasm
37. Subarachnoid hemorrhage is generally feathery in
appearance on CT scan, as it’s mixed with cerebrospinal fluid
38. Intraparenchymal hemorrhage
• Most commonly caused by systemic hypertension.
• Also seen with trauma, amyloid angiopathy
(recurrent lobar hemorrhagic stroke in elderly),
vasculitis, neoplasm.
• May be Secondary to reperfusion injury in
ischemic stroke.
• Hypertensive hemorrhages (Charcot-Bouchard
microaneurysm) most often occur in putamen of
basal ganglia (lenticulostriate vessels), followed by
thalamus, pons, and cerebellum.
40. Intraventricular Hemorrhage
• It is a bleeding into the
brain's ventricular system
• It can result either from
physical trauma or hemorrhage
in stroke
• This type of hemorrhage is
particularly common in infants
(Neonatal intraventricular
hemorrhage)
• Complications involve increase
ICP and hydrocephalus.
41. Brain edema
• Brain edema is defined as an abnormal
accumulation of fluid within the brain parenchyma,
producing a volumetric enlargement of the tissue.
• Cerebral edema is a life-threatening condition
• Can lead to increase ICP , herniation and LOC .
42. Classification
• According to distribution
o Focal
o Diffuse
• According to mechanism
o Cytotoxic edema
o Vasogenic edema
o Interstitial edema (transependymal)
o Osmotic edema
o Hydrostatic edema
47. Interstitial edema
• On CT, the combination of
ventriculomegaly and
increased periventricular
hypodensity is suggestive
of the diagnosis of
interstitial edema
52. • Ipsilateral CNIII compression
Loss of parasympathetic innervation
Dilated (“blown”) pupil
Lack of pupillary constriction to light
• Collapses ipsilateral posterior cerebral artery
Visual loss – cortical blindness
Homonymous hemianopsia
• Cerebral peduncle compression
• Can be on side of lesion (contralateral paresis)
• Can also be on opposite side (ipsilateral paresis)
Kernohan's notch
• That means patients can present with Hemiparesis or quadriparesis
53. Transtentorial Henrniation
Central Herniation
• Thalamus, hypothalamus, and medial
parts of both temporal lobes forced
through tentorium cerebelli
• Somnolence, LOC
• Initially: small, reactive pupils
• Later: nonreactive
• Caudal displacement of brain stem →
rupture of paramedian basilar artery
branches → Duret hemorrhages.
• Usually fatal.
55. Tonsillar Herniation
• Cerebellar tonsils herniate downward through the
foramen magnum
• Cerebellar tonsils herniate downward through the
foramen magnum
• Most commonly caused by a posterior fossa mass
lesion
• Compression of medulla results in depression
centers for respiration and cardiac rhythm control
• Cardiorespiratory failure
Editor's Notes
alteration the brain's physiology
Rupture of middle meningeal artery
• Branch of maxillary artery
