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1. Traumatic Brain Injuries and CNS
Infection
Dr Husam Al-Anbari
MBChB, FIBMS, FAANS, MsC (Clin.Ed. Melbourne -Australia)
Consultant Neurosurgeon , Lecturer , Fellow –RMH -Neurosurgery, St Vincent’s Hospital, Pain Fellow- Precision Centre- Melbourne- Australia, Master
degree Clinical Education –University of Melbourne - Australia
University of Al-Ameed
College of Medicine

2. objectives
• To know how to assess patients with traumatic brain injuries ,
different types of ICH and skull fractures and how to maange each
one.
• To outline surgical aspects of CNS infection

3. Samples of Final exam MCQ – Ministry of
Heigher education exam
• Q61- A Young age male presented to the emergency department with initial loss of consciousness after head
trauma. After 30 minutes, he became conscious again. However, after 2 hours the patient became
unconscious again.
The most likely diagnosis is:
• (A) Subdural hematoma
(B) Epidural hematoma
(C) Intracerebral hematoma
(D) Subarachnoid hemorrhage (E) Intraventricular hemorrhage
• Answer is B

4. Samples of Final exam MCQ – Ministry of
Heigher education exam
• 100. A 78-year-old woman is found unresponsive to pain or speech on the ward by a nurse 3 days after
carotid endarterectomy. On examination there is no speech, no eye opening to pain, and there is abnormal
rigid extension of her arms and legs. Calculate the Glasgow Coma scale(GSC) of this patient:
• a. 5
• b. 3
• c. 4
• d. 6
• e. 7
• Correct answer is C

5. Samples of Final exam MCQ – Ministry of
Heigher education exam
Correct is C

6. Samples of Final exam MCQ – Ministry of
Heigher education exam
Correct is
B

7. Notes
• The most important questionsin final year 6 is about traumatic brain
injury
• So you need to focus on
üGCS
üTypes of ICH and their presentations

8. Case study
• 35 yo male patient presented to you in ED
• He sustained RTA
• What are your lines of management ?

9. Apply ATLS
1. Primary survey
• nABCDE (NEUROLOGICAL abcde)
• N = neck (Should mainatin the neck stablised with neck collar or sand bags
if collar not available)
• A airway , B breathing , C circulation
• D Disability 3 things
1. GCS
2. Pupillar size and reaction to light
3. Motor function (any weakness)
• E exposure

10. •2. Secondary Survey
Focused history
Head to toe examination
(general and neurological exam)

12. Glasgow Coma Scale (GCS)
• The Glasgow coma scale gives a numerical value to the three most important
parameters of the level of consciousness: 1. opening of the eyes, 2. best verbal
response and 3. Best motor response.
• The sum of the three parameters of the Glasgow coma scale refers to the score.
• Regarding the grading,
üa score of 8 or less indicates a severe injury;
üa score of 9-13 indicates moderate injury,
üwhile the score of 13-15 means mild head injury.
• The Glasgow Coma Scale (GCS) is a widely used scoring system with good
repeatability.

13. Note:
The scale is used to assess
level of consciousness and is
not designed for following
neurologic deficits.
General practice is to record
a ''T" (for "intubated") next
to the verbal score.

14. 2. Physical examination in E.R
• Major trauma must be assessed rapidly; the examination can be put in two
categories:
A. General physical condition (towered neurological
orientation )
• Visual inspection of cranium.
• Facial fractures
• Periorbital edema, proptosis.

15. • Signs of skull base fracture: Raccoon's eyes: periorbital ecchymoses, Battle's
sign: postauricular ecchymoses (around mastoid air sinuses), CSF
rhinorrhea/otorrhea, Hemotympanum or laceration of external auditory canal.
• Cranio-cervical auscultation: (carotid arteries and eye ball).
• Physical signs of trauma to spine: bruising, deformity.
• Evidence of seizure: single, multiple, or continuing
(status epilepticus).

16. B. Neurological examination:
• 1. Level of consciousness by measuring Glasgow coma scale.
• 2. Cranial nerve examination (including pupil size---important---).
• 3. Motor exam (focal neurological signs in the limbs---important---)
• 4. Sensory examination
• 5. Reflexes.

17. 3. Investigations. (lab and radiological)
• Lab including CBC, RBS, RFT, LFT, TSH , Blood group , virology and may be others
• The best radiological investigation in head injury is the native brain CT scan (native means:
without contrast) in addition to basic radiological studies like cervical x-ray, CXR, pelvic x-ray.
• Indications of brain CT scan in head trauma:
1. history of change or loss of consciousness on or after injury
2. progressive H/A
3. posttraumatic seizure
4. unreliable or inadequate history
5. Age> 60 yo . (unless trivial injury)
6. repeated vomiting

18. 7. posttraumatic amnesia
8. signs of basilar skull fracture
9. serious facial injury
10.possible skull penetration or depressed fracture
11.suspected child abuse
12.significant subgaleal swelling
13.Focal neurological deficit
Note in children try to avoid CT scan unless indicated

19. 3. Medical and surgical treatments.
1. Mild head injury can be treated in ED then may discharge the patient
but if moderate or severe head injury you should admit to hospital , If
GCS ≤ 8---Admit the patient to ICU.
2. I.V fluids (N/S or lactated Ringer) or transfuse blood according to the
patient's need.

20. 3. Give antibiotics in the following situations:
• Scalp wounds.
• Basal skull fractures.
• Compound depressed fractures.
• Penetrating and missile injuries.
• Pre and Post operatively.

21. 4. Antacids like proton pump inhibitors to prevent stress ulcer.
5. Pain medication, mainly acetaminophen.
6. Management of raised ICP including Mannitol (to decrease ICP).

22. 7. Prophylactic antiepileptic drugs: usually we use carbamazepine
(Tegretol) tab. 200 mg. BID used in:
• Acute subdural, epidural, or intracerebral hematoma, or cortical
hemorrhagic contusion.
• Open-depressed skull fracture with parenchymal injury.
• Seizure within the first 24 hours after injury.
• Penetrating brain injury.
• Surgery is indicated if there is an intracranial pathology necessitating
evacuation or removal, like EDH or compound depressed fracture

23. Types of ICH
• 1. Contusion /Intracerebral hematoma
• 2. EDH (extradural hemorrhage)
• 3. SDH (subdural hemorrhage), (acute vs chronic)
• 4. IVH (Intraventricular Hemorrhage)
• 5. SAH (subarachinooid hemorrhage)

24. Types of ICH 1. Cerebral contusions

25. 2. Extradural (Epidural )hematoma (EDH)
• It is defined as a bleeding through
the space between the dura mater
and the cranium. Incidence of EDH
is 1% of head trauma admissions.
• Shape in CT will be convex like
• Ratio of male: female = 4:1. Usually
occurs in young adults, and is rare
before age 2 years or after age 60
(perhaps because the dura is more
adherent to the inner table in
these groups).

26. Presentation
• Onset: Symptoms may have a lucid interval, where the patient
briefly conscious then after a while (e.g 30 min) starts to lose
consciousness, this is called Lucid interval
• Or the patient may stay conscious or may present unconscious from
the start
• Headache: Severe, localized headache is a common symptom.
• Focal Neurological Deficits: Depending on the location and size of
the hematoma, patients may exhibit focal neurological deficits
• Neurological deficit such as ipsilateral dilated pupil and contralateral
weakness especially if the EDH is in temporal area because
hematoma will compress 3d cranial nerve at the same side with
motor strip which can cause weakness at the other side.
• Treatment: if small size can be treated conservatively, if large size
then craniotomy

27. 3. Acute subdural hematoma (ASDH)
• It is a collection of blood in the space between dura
and arachnoid mater. Shape in CT or MRI will be
crescent or banana
• The magnitude of impact damage, as opposed to
secondary damage, is usually much higher in acute
subdural hematoma (ASDH) than in epidural
hematomas, which generally makes this lesion
much more lethal.

28. Chronic subdural hematoma (CSDH)
• Case scenario
• 65 yo male patient presented
with progressive mild right side
weakness and headache , he
mentioned mild head trauma
few weeks ago, this is his CT
brain , what is the diagnosis?

29. Chronic subdural hematoma (CSDH)
• It is the form of subdural
hematomas occurring usually in
geriatric people suffering minor
traumas to the head, symptoms of
mass effect may occur after days of
this trivial trauma.
• With brain CT scan it appears as
with ASDH but with low density
(hypodense).
• If symptomatic, it can be treated in
most of the cases with burr-holes
evacuation.

30. 3. Traumatic subarachnoid hemorrhage (SAH)
• It is the bleeding accumulated in the
subarachnoid space,
• Traumatic (SAH) occurs in about 35% of
traumatic brain injuries.
• It is most commonly seen in the cerebral sulci
and to a lesser extent in the Sylvian fissure
and basal CSF cisterns .
• Brain CT scan is almost always the first scan
obtained; the classical picture is spider like
hyperdensity if it is occurred in the basal
cisterns.
• Traumatic subarachnoid hemorrhage has a
better prognosis than aneurysmal SAH
• usually treated conservatively.

31. 4. Traumatic intraventricular hemorrhage (IVH)
• It is a collection of blood within
the ventricular system of the
brain.
• It can lead to a significant
morbidity due to the
development of obstructive
hydrocephalus in many patients.
• It might extend into brain
parenchyma
• The treatment is usually external
ventricular drain (EVD).

32. CNS infection surgical aspects

34. BRAIN ABSCESS
• Mostly single may be multiple
• Majority Supratentorial (means above tentorium cerebelli which
includes cerebrum), 10% infratentorial (cerebellum and brain stem)
• Mostly the origin is Metastatic:
hematogenesis, direct spread from adjacent structures
But may be due to penetrating brain injury or post operative.

35. Clinical Presentation
• Neurologic:
– Raised ICP (nausea , vomiting)
– Focal neurologic deficits(hemiparesis)
– Epileptic seizures
• Systemic toxicity ( Fever, malaise)
• Symptoms of primary focus infection(Otitis , sinusitis etc)

36. Diagnosis
• CBC complete blood count – Leukocytosis
– Raised ESR CRP
• Method of Choice- CT scan of Brain, brain MRI – Ring enhancing
Lesion

38. Treatment -Medical
• SPECIFIC TREATMENT – Anti-microbial therapy – should be triple AB
and with high dose
• MEASURES TO REDUCE ICP
– Mannitol
– corticosteroids
• ANTI-EPILEPTIC DRUGS AED

39. Treatment – Surgical
• GOALS:
– Obtain pus for culture & sensitivity
– Decrease ICP
• TECHNIQUES:
– Burr hole & aspiration
– craniotomy and excision / drainage with removal of abscess wall , this
is a definite treatment and should be done to all brain abscesses
whenever possible