Traumatic Brain Injury and Cerebral Resuscitation

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Traumatic brain

injury and cerebralresuscitation

Ahmad Syahir Abu Sahmah


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OUTLINE

Anatomy

Scalp injury

Craniocerebral injury

Skull fracture

rimary T!I

Secondary T!I

"ana#ement

Cerebral resuscitation


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$e%nition

&ead injury is de%ned as blunt and'or penetratin#injury to the head (abo)e the neck* and'or brain dueto e+ternal force, -ith temporary or permanentimpairment in brain function -hich may or may notresult in underlyin# structural chan#es in the brain.

To de%ne traumatic head injury/ three criteria must bepresent0

i. mechanism 1 presence of e+ternal force, ii. anatomical 1 scalp and'or face and'or skull -ith or

-ithout brain injury (internal and e+ternal*

iii. physiolo#ical 1 alteration in physiolo#y of the brainsuch as LOC or amnesia


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Anatomy


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SCAL

S 2 S3IN

C 2 CONNECTI4E TISSUE

A 2 AONEU5OSISL 2 LOOSE A5EOLA5 TISSUE

1 E5IC5ANIU" '

E5IOSTEU"


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Ethiolo#y 5oad1tra6c accidents

7alls

$omestic Accident

5ecreational accidents

Industrial accidents

Assaults

8un shot


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Scalp injury Scalp injury are common and may #i)e rise to

e+san#uinate hemorrha#e if not controlled due to theblood )essels in the dense %brous layer/ super%cial tothe #alea aponeurotica/

The abundance of blood )essel also help in speedin# upthe reco)ery at the -ound here.

The loose areolar tissue under the aponeuritica is adan#erous 9one for infection since pus can spread freelyin this layer and reach the intracranial sinuses throu#h

the emissary )eins.

In infant/ this can cause se)ere shock.


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Skull fracture

There are many types of skull fractures/ usually causeby an impact or a blo- to the head that:s stron# enou#hto break the bone. An injury to the brain can also

accompany the fracture/ but that:s not al-ays the case.A fracture isn:t al-ays easy to see.

&o-e)er/ symptoms that can indicate a fracture include0

s-ellin# and tenderness around the area of impact facial bruisin#

bleedin# from the nostrils or ears


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Type 0

Simple linear fracture

$epressed fracture

!ase of skull fracture

Orbital blo-1out fracture


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Simple linear fracture

5e;uire no neurosur#ical mana#ement but usuallyare indicators of the force to -hich the head -assubjected.

7racture crossin# s;uamous temporal bone may

lacerate medial menin#eal )essel and can causee+tradural hematoma

Should be admitted forobser)ation to e+clude secondaryintracranial hematoma orde)elopin# cerebral s-ellin#.


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$epressed skull fracture Usually result from sharper trauma or

hi#h )elocity assault.

If the corte+ belo- is dama#ed/ there is of risk de)elopin# epilepsy andsi#ni%cant risk of de)elopin# infections.

Need suturin# before referral fordebridement and ele)ation.

Contaminated -oundre;uire debridement/irri#ation and duraplastybefore clossure.


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!ase of skull fracture

5elati)ely fre;uent fractures/ often occultsradiolo#ically but dia#nosed on clinical #round.

resent -ith subconjucti)al hematoma/ anosmia/

epista+is/ nasal paraesthesia/ CS7 rhinorrhoea/and occasionally caroticoca)ernous %stula.


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eriorbital hematoma or ?Raccoon eyes: indicatesub#aleal hemorrha#e and not necessarily base ofskull fracturin#.

"iddle fossa fracture in)ol)in# petreous temporal

bone presented -ith ?Battle sign / CS7 otorrhea orrhinorrhea / ossicular disruption or cranial ner)e4II (facial* and 4III ()astibulocochlear* palsies.


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Orbital blo- out fracture

!lunt trauma to the eye

@ mechanisms

18lobe1to -all1 direct force to eye

#lobe 1!uckin# 2 force to lo-er rim of orbit


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!rain injury

$e%nition

Traumatic brain injury (T!I* is a nonde#enerati)e/ noncon#enitalinsult to the brain from an e+ternal mechanical force/ possiblyleadin# to permanent or temporary impairment of co#niti)e/physical/ and psychosocial functions/ -ith or -ithout an

associated diminished or altered state of consciousness.

Can be classify on se)erity 0 mild(


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!ased on the "onroe13ellie $octrine/ the intracranial )olumeDbrain (>*/ cerebral spinal Fuid (CS7* (*/ and cerebralblood )olume (*G is %+ed by the con%nes of the cranial)ault.

Cerebral edema/ tumor/ hematoma/ or abscess may impin#e

upon normal compartment )olumes/ raisin# intracranialpressure (IC*.

Since brain tissue is capable of minimal compensation inresponse to abnormal intracranial lesions/ the CS7 and cerebralblood )olume compartments must decrease accordin#ly tominimi9e IC ele)ations.

CS7 compensates by drainin# throu#h the lumbar ple+us anddecreasin# its intracranial )olume. Cerebral blood )olume andcerebral blood Fo- (C!7* are directly related to IC and arenormally closely controlled by autore#ulation throu#h a -ideran#e of systolic blood pressures/ aCO@ and aO@

C H "A 2 IC


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rimary brain injury $iused a+onal head injury

Cerebral concussion

Cerebral contusion and laceration


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$iused a+onal braininjury 5esult from mechanical shearin# at the #rey1-hite

matter interface follo-in# se)ere acceleration1deceleration type forces due to dierental brainmo)ement

This causes disruption and tearin# of a+ons/ myelinsheaths and capillaries.

Se)erity can ran#e

from mild dama#e-ith confusion tocoma or e)en death.


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Cerebral concussion

clinical dia#nosis manifested -ith temporarycerebral dysfunction/ -hich is more se)ereimmediately after injury and #radually resol)es aftera period of time.

"aybe accompanied -ith autonomicabnormalities/ bradycardia/ hypotension/s-aeatin# and loss of consciousness

ost concussion syndrome is a comple+ ofsymptoms persistin# months after head injuryconsist of )ariable combinations of headache/

irritabilities / depression/ lassitude and )erti#o.


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Cerebral contusion andlacerations Cerebral contusion and lacerations

-hen a sudden physical assault on the headcauses bruisin# of the brain tissue.

$emonstrated -ithcoup1contrecoup

$emonstrated as small area of hemorrha#e inthe cerebral parenchyma.

!lood brain barrier defect and cerebral edemaare in)ariably associated -ith cerebralcontusion

The pia meter and arachnoid may be torn andintracerebral hemorrha#e may accompanythis lesion.


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Cerebralcontusion


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Secondary brain injury

Intracranial hematomas

Cerebral edema

&ypo+emia

Ischemia

Infection

Epilapsy

"etabolic or endocrine electrolytes disturbances


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Intracranial hematoma

Epidural hematoma Occurs more common in youn#er a#e J K=y'o. $ura able to strip of

more readily in youn#er a#e.

!uild up of blood occurs bet-een the dura mater and the skull )ia the

menin#eal artery

blood accumulation de)eloped by the e+pendin# hematoma allo-in# it totake con)e+ con%#uration due to adherence of dura to the skull bone.

Clasically a lucid inter)alfollo-in# the trauma. patient tends to present -ith a

fall -ith a brief loss of consciousness. The person -akes up/ perfectly %ne/seems to be #reat/ and not ha)e any di6culties. After @1 hours/ the ptstarted to #et dro-sy and )omitin# and symptoms starts to de)elop. Thecollection of blood in that space has #otten so bi# that its no- pushin# thebrain across in the skull/ and pushin# the brain do-n into the skull andcompressin# the brain stem so that thr heart becomes irre#ular/ breathin#

becomes irre#ular/ and patient is slippin# into a coma.


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7re;uently patient presented in coma and re;uire ur#entcraniectomy.

Epidural is considered sur#ical emer#encies that -ill

result in death if the bleedin# does not stop and thehematoma is not remo)ed promptly.

ro#nosis is better if delay in sur#ical inter)ention isminimi9ed.


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Subdural hemorrha#e

Acccumulation of blood in the space bet-een thedura and arachnoid.

$isruption of a cortical )essel or brain laceration/a'- a si#ni%cant primary brain injury

resentation0 an impaired conscious le)el fromthe time of injury/ but further deterioration canoccur as the hematoma e+pands

Classi%ed into 0 1Acute S$& 2 less then daysSubacute S$& 1 K1@

Traumatic Brain Injury and Cerebral Resuscitation

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