Welcome

Traumatic Brain Injury

(Ⅰ )
Department of Neurosurgery,The First
Affiliated Hospital of Zhengzhou University
Xu Bin
HEAD ANATOMY
 Skull Anatomy
The skull is a rounded
layer of bone designed to
protect the brain from
penetrating injuries.
Interior Skull Surface
Bony ridges
The base of the skull is rough,
with many bony
protuberances.These ridges can
result in injury to the temporal
lobe of the brain during rapid
acceleration.

Injury from contact with

skull
Blood Vessels of the Skull
The brain requires a rich
blood supply, and the space
between the skull and
cerebrum contains many
blood vessels.These blood
vessels can be ruptured
during trauma, resulting in
bleeding.

Groove for middle

meningeal artery
 The Meninges
The meninges are
layers of tissue that
separate the skull and
the brain.
Skull
Dura mater
Arachnoid
Layer
Pia Mater
Brain
Among central nervous system
disorders,craniocerebral trauma is
second only to stroke as a cause of
death.Traumatic injury is the leading
cause of death in persons below age 45
and head injury constitutes a major
portion of deaths in this group.
Approximately 500,000 head
injuries,accounting for the loss of
70,000 lives,occur each year in
the USA.Craniocerebral trauma
produces severe disability and
imposes a huge financial and
psychologic burden on the
patient,the patients family and
society.
Epidemiology of Head Injury
❧2,000 people /100,000/year attend hospital
❧300 of these will be admitted
❧Prevalence of significant disability
estimated at 150/100,000
Every 21 Seconds One Person In The U.S.
Sustains A Brain Injury
Epidemiology of Head Injury
❧Age: 15-25 years
❧Sex: M:F ~ 3:1
❧Causes: Falls
Road Traffic Accidents
Assault
Sports
Work
❧Alcohol: ~ 50%
 Overview
❧Head injury is a common traumatic
disease in normal time. It has a high
mortality rate. According to the
anatomic position injured, head injury
can be divided into three types. That is
scalp injury, skull fracture and
cerebral injury, which could happened
separately or simultaneously.
 The
stereotactic
phenomena
explain the
deep cerebral
lesions.

.
The
stereotactic
phenomena
explains
the
importance
of the
contrecoup
cerebral
lesions.
❧Meninges
❧Bones
❧Scalp
Head injuries can range from a minor
bump on the head to a devastating brain
injury. Learning to recognize a serious
head injury and implementing basic first
aid can make the difference in saving
someone's life. Common causes of head
injury include traffic accidents, falls,
physical assault and accidents at home,
work, outdoors or while playing sports.
The brain is a soft organ which
floats in fluid inside the skull. In
an accident the brain can be
damaged by bruising, tearing,
shearing, shaking or twisting.
Bleeding can occur in or around
the brain.
The brain is divided into sections called
lobes. The lobes carry out different
functions around the body. Typically in a
Traumatic Brain Injury (TBI) the
frontal and temporal lobes are damaged.
These lobes control functions which
include learning, emotions, memory, and
language. Every brain injury is very
different, however, and no area of the
brain is invulnerable.
Head injury can be classified as
either closed or opening.
opening The signs
and symptoms of a head injury may
occur immediately or develop slowly
over several hours.
 Closed Head Injury
When a person receives an impact to the head
from an outside force, but the skull does not
fracture or displace this condition is termed a
"closed head injury". In closed head injury,
the head sustains a blunt force by striking
against an object. Again, separate
terminology is added to describe the brain
injury. For example, a person may have a
closed head injury with a severe traumatic
brain injury.
 Opened Head Injury
If the force that hits a person's head is great
enough, the skull can fracture or become out
of place. When this happens, the person is
described as having an "open head injury".
This terminology is referring to the condition
of the skull and not the brain. Separate terms
are used to describe the condition of the
brain. For example, a person may be
described to have an open head injury with a
severe traumatic brain injury.
In opening head injuries, a high velocity
object breaks through the skull and
enters the brain. When the head receives
an impact from an outside source, if the
brain is injured the brain may swell. If
the skull is fractured or displaced, this
can allow the brain room to swell and
can assist in reducing the squeezing of
brain tissues.
If the skull is fractured or displaced, bone
fragments from the skull can enter the brain
and cause further injury. Because the skull is
damaged or open, it cannot protect the brain
as it did before. The once protected brain is
now exposed, which leaves it vulnerable to
infections and further injury.
Persons with an open head injury may be
assigned to wear a helmet to protect the
exposed brain from impact and further
injury.If a piece of the skull is displaced
during traumatic injury, that piece of
skull may be surgically replaced at a
later date. An artificial skull piece may
be applied also.
PATHOLOGY OF BRAIN INJURIES
❧Scalp injuries
❧Skull fracture
❧Cerebral concussion
❧Cerebral contusion
❧Diffuse Axonal Injury
❧Epidural hematoma
❧Subdural hematoma
 SCALP
This consists of five layers; the first three
layers are bound together and moved as a
unit. The layers are:
A.Skin
B.Subcutaneous tissue
This is a fibro-fatty layer. The fibrous septa
unite the skin to the underlying aponeurosis
of the fronto- occipitalis muscle. The scalp
Vessels lie within this layer.
C.Epicranial aponeurosis
This is a thin fibrous sheath attached to the
bellies of the Fronto-occipitalis muscle. Deep
to it is the sub aponeurotic space.
D.Loose areolar layer
Occupying the sub aponeurotic space. This
layer contains emissary veins.
E.Pericranium
Which is periosteum of the skull bone.
The scalp is very vascular and laceration
can cause severe loss of blood. The
vessels within the scalp do not constrict
when injured because the wall is
adherent to the surrounding fibre fatty
tissue in the subcutaneous area. Bleeding
can be controlled by applying pressure
or suturing the scalp.
Scalp:
Scalp lacerations are common and are
important chiefly as sources of
significant hemorrhage or
infection.Thick scalp with its overlying
hair provides a cushion for the skull and
brain;blunt trauma commonly cause
stellate burst lacerations.
Numerous arterial and venous
anastomoses contribute to brisk
bleeding but also to effective
healing.Most of these vessels lie in the
subcutaneous fat immediately
superficial to the galea,the dense
fibrous tissue that makes the scalp
stiff and unyielding.
scalp injury
❧Hematoma of the scalp
(1) Subcutaneous hematoma
(2) Subgaleal hematoma
(3) Subperiosteal hematoma
❧Laceration of scalp
Subcutaneous hematoma
❧hematoma lie in subcutaneous
tissues layer. As there are much
longitudinal fibrous tissues between
skin and subcutaneous layer, the
hematoma is not liable spreading.
Clinical finding is a swelling limited.
Subgaleal hematoma
❧hematoma is located in subgaleal
layer. Because this layer is
rarefaction and has no separated
tissues, the hematoma always spread
to total head. Clinical finding is skull
enlarged, swelling and fluctuation.
Subperiosteal hematoma
❧hematoma is located in subperiosteal
layer. As periosteum is tight junction
to bone in bone suture, the
hematoma is limited in one cranium,
and always goes along with bone
fraction.
laceration of scalp
❧always wounded by sharp object,
such as knife. If the galea
aponeurotica break, the wound will
be dehiscence like baby’s mouth, and
have much more bleeding.
Treatment: debridment and suture
the whole layers
Treatment
❧Scalp hematoma can be absorbed by
itself. If it is tremendous and can not
be absorbed after 2 weeks, suction
hematoma through puncture is
necessary.
Fracture of the skull
Classification
❧(1) Classified by shape:
❧linear fracture
❧depressed fracture
❧Compound fracure
❧(2) Classified by site:
❧fracture of the vault of the skull
❧fracture of the base of the skull
 Skull Fracture
❧Blunt trauma
❧Severe headache,
nausea, deformity,
“raccoon eyes”,
bleeding/CSF (nose,
ear)
❧Immobilize, EMS,
monitor for
complications
(intracranial
bleeding, infection)
 fracture of anterior
fossa: raccoon eyes

fracture of posterior
fossa:Bell’s sign
Skull:
A variety of skull injuries may follow blunt
trauma:
1.Simple skull fracture-Linear non-displaced
vault fractures are common and require no
specific treatment but are important as
markers of the significant force that was
delivered to the head.The patient must be
carefully observed for 12-24hours for possible
neurologic deterioration secondary to
intracranial hematoma.
Diagnosis:plain film of skull(axial or
tangent)
2.Depressed skull fractures-These usually
occur as a result of low-velocity injuries
such as blows by small objects.The inner
table of the skull invariably suffers greater
damage than the outer table.These injuries
may result in dual or brain lacteration,and if
the depression is greater than the thickness
of the skull or if it involves the posterior wall
of the frontal sinus,surgical elevation may
required.
3.Compound fractures-These are
fractures in which the overlying
scalp has been lacerated.Proper
treatment is essentially the same as
with simple fractures and includes
adequate wound debridement and
closure of the laceration.
4.Basal skull fractures-These exceedingly
common fractures are diagnosed largely on
clinical grounds.As with liner fractures
involving the vault of the skull,basal fractures
are important as markers of the severity of
injury.In addition,they may cause
cerebrospinal fluid leakage,with the
attendant risk of meningitis or brain abscess
formation.
Cerebrospinal fluid leaks usually result
from fractures into the paranasal
sinuses or mastoid air cells with
laceration of the overlying dura and
loss of cerebrospinal fluid into the nose
or ears.Basilar skull fractures also may
injure cranial nerves that course
through the skull base.
Treatment
❧(1) Using antibiotics.
❧(2) Avoiding cough, constipation.
❧(3) If the CSF leakage can not be
stopped in four weeks, the operation
should be done.
 Ping Pong Skull Fracture
This is a green stick fracture of the skull , it
occurs in the first few months of life when the
skull bones are still soft. It is caused after
falls when the skull hit the edge of a blunt
structure as the edge of a table .It shows as a
deformity of the skull , it looks as a shallow
trench on the surface of the skull. If large and
showing as a significant deformity it can be
easily treated by elevating the depressed bone
fragment.
Injury to the brain is either localized or
diffuse. Localized injury is the result of
deformation of the brain at the point of
impact, by a small object as a hammer, or a
rock or a golf ball. The result is injury to the
scalp, skull fracture and this could be
associated with dural laceration and
underlying brain contusion or laceration.
Usually there is a localized surrounding
edema around the site of the impact.
Localized
injury
 DIFFUSE BRAIN INJURY

This carries a greater risk of damage

to the brain and the mechanisms
involved in this injury are
acceleration/deceleration injury.
injury
In acceleration injury the head is put into
motion from a stand still position, as a result
of which the different layers of the brain
travels at different velocities with shearing
effects and rotation of the brain within the
skull. The shearing stresses between different
layers of the brain result in petechial
haemorrhages as well as diffuse axonal injury
involving the white matter and brain stem.
This is seen in motor vehicles accidents where
the car is hit from the back.
Acceleration injury
In deceleration injury the head is
brought to a stand still from a moving
position as in falls. The same mechanism
applies.
Deceleration injury
COMPRESSION INJURY
The head is compressed between two
solid objects as in motor vehicle
accidents. The result is multiple linear
fractures particularly in the weak
areas of the skull base resulting in
multiple cranial nerve injuries.
COMPRESSION INJURY
The extent of the diffuse injury and the
axonal damage determines the outcome.
The more severe the injury is, more
brain damage occurs with more axonal
injury . This would be associated with
higher morbidity and mortality.
The brain may be injuried directly under the
site of impact(coup injuries) or in some
instances,diagonally opposite to the point of
impact(contrecoup injuries).Because of the
rough surface of the floor of the frontal and
temporal fossae,the anterior and inferior
portions of the frontal and temporal lobes are
in particular jeopardy.Abrupt movement of
the brain within the skull causes contusion of
these areas.
TBI: A biological event within the
brain
❧Tissue damage
❧Bleeding
❧Swelling
Mechanisms of Injury
❧Focal
❧Polar
❧Diffuse axonal
❧Secondary insults
 Focal Polar

Diffuse axonal Secondary

Injury to the brain is caused by rapid
deceleration,acceleration,rotation or a
combination of these associated with a blow
to the head.The initial impact can produce
neuronal and axonal disruption,which
constitutes the primary jnjury.Any
jnjury subsequent
complication such as an intracranial
hematoma,cerebral
edema,hypoxia,hypotension,hydrocephalus or
endocrine disturbance characterizes
secondary injury,which
injury compounds the initial
insult.