Head Trauma

:Prepared by
Dr : Batool Rasheed
SAUDI BOARD PROGRAMME POST GRADUATE)
CME SUPERVISIOR-DR FIAZ MAQBOOL FAZILI
Deptt of surgery
King Fahad Hospital Madinah Al Munawarah ,Kingdom of Saudi
Arabia

Contents

1-Introduction
2-Classification
3-Radiographic evaluation
4-Initial management & resuscitation in
E/R
5-Skull Fractures
6-Acute epidural hematoma
7-Acute subdural hematoma
8-References

Introduction

?How and Who

MVA
Falls
Violence
Sports
VICTIMS:

young men (15-24 yrs)

old men & women (>75

yrs)
kids (<5 yrs)

Definitions
Concussion:
Alteration of level of consciousness as
result of closed head injury.
Contusion:
Either high density(hge contusion) or low
density(associated edema).most
common in areas where sudden
deceleration cause brain impaction on
bony prominence.
Countercoup:
The force imparted to the head may
cause brain to be thrust against the skull
directly opposite the blow.

Grading head injuries

Minimal
GCS=15
No LOC
No amnesia

Mild
moderate

Severe
Critical

GC
S14

O
R

GCS=15 PLUS
EITHER
Brief
LOC(<5min)OR
GCS=9Impaired
LOC>
13
5MIN
Focal
alertness
GCS=5neurolo
8
gical
GCS= 3deficit
4

CT classification of HI
Category

definition

mortali
ty

Diffuse injury 1

No visible intracranial
abnormality

10%

Diffuse injury 2

Cisterns present ,0-5 mm

mild shift & or lesion densities
present

14%

Diffuse injury 3

Cisterns compressed or
absent ,0-5mm midline shift,
no high or mixed density
lesion >25 cc

34%

Diffuse injury 4

Midline shift >5mm , no high

or mixed density lesion >25
cc

56%

Management in ER
Neurosurgical exam in trauma
General physical condition:
1-visual inspection of cranium :
A- evidence of basal skull fracture:
1-Racoons eyes
2-Battles sign
3-CSF rhino rhea or otorrhea
4-hemotympanum or laceration of EAC.

..Continue
B-check for facial fractures:
1-LeFort fractures: palpate for instability
of facial bones.
2-orbital rim fracture..

Cranio-cervical auscultation:

over carotid arteries, eyes globe

Physical signs of spine trauma

Seizure.

Neurological exam
1-cranial nerve exam
A-optic nerve function
1- if conscious..
2-unconscious..

B-pupil
C-facial nerve
D- abducens nerve
E- funduscopic exam

 2-level of consciousness/mental
status
A-Glasgow coma scale
B-orientation in communicating pt

3- motor exam
A-cooperative pt
B-uncooperative

C-check anal resting tone &

bulbocavernous reflex if any doubt
about spinal integrity

 4-sensory exam
A-cooperative pt:
Check pinprick , touch..
Check posterior column..

B-uncooperative pt : check central

response to noxious stimulus.

5-Reflexes

Clinical Categorization of
risk for
Intracranial Injury

1- Low risk for intracranial injury:

Asymptomatic
H/A
DIZZINESS
Scalpe hematoma, laceration, contusion,
or abrasion

Recommendations
Observation at home with
instructions:

Moderate risk for-2

intracranial injury

Findings:
H/o change or LOC
Progressive H/A
EtOH /Drugs
Age<2yr
Vomiting
Posttraumatic seizure
Posttraumatic amnesia
Signs of basilar skull fracture
Multiple trauma
Serious facial injury
Skull penetration or depressed fracture
Significant subgaleal swelling
Suspected child abuse

Recommendations
1-brain CT scan: 8-46% of minor
head injury have an intracranial
lesion
2-Skull XR:not recommended unless
CT scan not available

 3-observation
At home :criteria
1-Normal CT scan
2-Initial GCS >14
3-No moderate risk criteria
except LOC
4-PT is now neurologically intact
5-There is responsible adult can
observe the pt
6-Pt has an access to return to
hospital E/R if needed

If patient doesnt meet the

criteria we will observe
him in hospital to role out
neurological deterioration

High risk for-3

intracranial injury
Findings:
1-depressed level of consciousness not
clearly due to (alcohol)EtOH,drugs,
metabolic
2-focal neurological findings
3-pentrating skull injury .

Recommendation
CT scan , admit, if there are focal
findings ,notify OR to be on standby .

For rapid deterioration

consider emergency burr
holes

Radiographic Evaluation
CT scans in Trauma
The main emergent conditions to R/O:
1-Blood (hemorrhages or hematomas)

A-extra-axial blood
1-epidural hematoma

subdural hematoma-2

SAH

C-Intracranial hemorrhage

D-hemorrhagic contusion

E- intraventricular
hemorrhage

Hydrocephalus-2

cerebral swelling-3

skull fractures-5

pneumocephalus-6

Indications for initial CT

1-Presence of moderate or high risk
criteria.
2-Assessment prior to general
anesthesia for other
procedures(during which neurologic
exam cannot be followed in order to
detect delayed deterioration)

F/U CT scan
Routine F/U CT
1-pt with severe head injuries:
A-for stable pt , usually between day 3 to 5,
and again between day 10 to 14.
B-some recommend routine F/U CT several
hours after the time zero

2-for pt with mild to moderate head

injuries:
A-with an abnormal initial CT ,repeated prior to
discharge.
B-stable pt ,normal CT dont require F/U CT.

 Urgent F/U CT for

Neurological detrioration (loss of
2 or more points on GCS,
development of hemiparesis or new
pupillary asymmetry), persistent
vomiting , worsening H/A ,seizures or
unexplained rise in ICP.

Spine films
1-cerical spine:

 2-thoracic & lumbosacral spine film

based on physical findings & on
mechanism of injury.

Skull X-ray
May be helpful in :
1-depressed skull fracture.
2-pineal shift, pneumocephalus , air-fluid
levels in air sinuses.
3-pentrating missile injuries.

ER management Specifics
Admitting Order for minor head
injury:
1-bed rest with elevation of head end bed
to 30-45 degrees
2-neuro check q2hr
3-NPO until alert; then clear liquids
4-isotonic IVF(e.g.NS+20mEqKCL/L)run at
100cc/hr
5-mild analgesics.

 Admitting orders for moderate

head injury:
1-orders as for minor injury except
keep NPO for surgical intervention.
2-For GCS9-12 admit to ICU

Intubation
Secure airway by endotracheal
intubation in pt with GCS<8.
Indications for intubation:
1-depressed level of consciousness
2-sever maxillofacial trauma
3-need for pharmacologic paralysis
for evaluation or management.

Mannitol in E/R
Indications:
1-evidence of intracranial HTN.
2-evidence of mass effect(hemiparesis)
3-sudden deterioration prior to
CT(pupillary dilatation).

Rx:bolus with 0.25-1gm/kg

over<20min(for average adult :
350ml of 20%solution)

Prophylactic anticonvulsants
AED anti epileptic drugs may be used as
a treatment option to prevent early post
traumatic seizure in pt at high risk of
seizures
Conditions with increased risk:
1-acute SDH, EDH, ICH.
2-Open-depressed skull fracture with
parenchyml injury .
3-GCS<10.
4- cortical (hge)contusion.

Skull Fracture
Feature

Linear skull
fracture

Vessel
groove

Suture Line

density

Dark black

grey

grey

course

straight

curving

Follows course
of known suture
lines

branching

none

branching

Join other
suture line

width

thin

Thicker than #

Jagged, wide

Depressed Skull
Fractures
Classified as either
closed(simple#)or open
(compound#)

:Depressed Fracture in Adult

In Pediatric
Indications For surgery (simple
depressed#):
1-definite dural penetration
2-persistent cosmetic defect in older
child
3-focal neurological deficit related to
the fracture.

Ping Pong Ball Fractures

Green-stick type of fracture ,caving
in of a focal area of the skull as in
crushed area of a ping-pong ball .
usually seen in the newborn due to
plasticity of the skull.

Indication for surgery

1-radiographic evidence of
intraparenchymal bone fragment.
2-associated neurologic deficit(rare)
3-signs of increased ICP
4-signs of CSF leak deep to galea
5-difficulty with long term F/U

Basal skull Fracture

Most Basal skull fractures are

extensions of fractures through the
cranial vault.

Diagnosis
Radiographic diagnosis
CT scan alone is often poor for directly
demonstrating BSF. Plain skull x-rays &
clinical criteria are usually more sensitive.
Sensitivity of CT diagnosis can be
increased by use of bone windows with
thin cuts(,5mm)and coronal images, (BSF
appear as linear lucencies through the
skull base)

 Indirect radiographic findings (on

CT or x-ray)
that suggest BSF include:
1-pneumocephalus
2-air/fluid level or opacification of air
sinus with fluid.
Fractures of the cribriform plate or
orbital roof.

Basal Skull Fracture

Clinical Diagnosis
1-CSF otorrhea or rhinorrhea
2-hemotympanum or laceration of
external auditory canal
3-battles sign
4-periorbital ecchymoses (raccoons
eyes)
5-cranial nerve injury:
A-7th & or 8th : with temporal bone fracture
B-olfactory nerve : with anterior fossa BSF
C-6TH ninjury : fracture through the clivus

Sever BSF my produce

shearing injuries to the
pituitary gland

Treatment
NG tube: Caution :cases have been
reported where an NG tube has been
passed intracranially . and is associated
with fatal outcome in 64% of cases.
Mechanism : through the week cribriform
plate.
Prophylactic Antibiotics: routine use is
controversial , but most ENT recommend
treating fracture through the nasal sinuses
as open contaminated ,with broad
spectrum antibiotics(e.g. ciprofloxacin)

Treatment
Most dont require treatment by itself,
but conditions associated with it may
require specific management include:
1-traumatic aneurysms
2-posttraumatic C-C fistula
3-CSF fistula
4-meningitis or cerebral abscess
5-cosmetic deformities
6-posttraumatic facial palsy

Epidural Hematoma

 Incidence : 1% of head trauma

admissions
Ratio of M:F = 4:1
Its usually occur in young adults & its
rare before 2yrs & after 60yrs (because
dura is more adherent to inner table)
Source of bleeding :
85% arterial bleeding , many of the
remainder due to middle meningeal
vein or Dural sinus

Presentation

10%- 27% have this classical presentation:

Brief posttraumatic LOC
Lucid interval for several hours.
Contralateral hemiparesis, ipsilateral
pupillary dilatation
Kernohans phenomenon:
Shift of the brain stem away from the mass
,produce compression of the opposite
cerebral peduncle on tentorial notch which
lead to ipsilateral hemiparesis(false
localizing sign)

Epidural Hematoma
Extraaxial, smoothly
marginated, lensshaped homogenous
density
Rarely crosses the
suture line
(because dura
attached more firmly
to skull at sutures)

Epidural Hematoma
Focal isodense or hypodense zones
indicate active bleeding
Air in acute EDH indicates fracture of
sinuses or mastoid air cells.
If chronic--may appear heterogeneous
from neovascularization and
granulation, with peripheral
enhancement on contrast administration

Epidural Hematoma

Hematoma is
biconvex lensshaped.
Note the midline
shift

Treatment

Surgical Objective
1-colt removal : lower the ICP,
eliminate mass effect.
2-hemostasis.
3-prevent reaccumulation: place
Dural tack-up suture.

Acute Subdural Hematoma

 The magnitude of impact damage is

usually higher in acute SDH than in
EDH, which generally makes this
lesion much more lethal

Causes of Traumatic
ASDH
1-accumulation around parenchymal
laceration (usually frontal or temporal)
2-surface or bridging vessels torn from
cerebral acceleration-deceleration
during violent head motion.
N.P:
RECEIVING ANTICOAGULATION
THERAPY INCREASE THE RISK OF
ASDH 7-FOLD IN MALES AND 26FOLD IN FEMALE.

Acute Subdural
Hematoma CT
Hyperdense (white)
crescentic mass
along the inner skull
table, over the
cerebral convexity in
the parietal region
(most common
location)
Midline shift present
with moderate or
large SDHs (note the
shift in this image)

Acute Subdural
Hematoma
Another
example of
acute
subdural
hematoma
with a midline
shift
(noncontrast
CT)

Subdural Hematoma--Surgical
Management
Symptomatic SDH > 1cm at thickest
point requires rapid evacuation
Smaller SDH often do not require evacuation
surgery may increase brain injury if severe swelling
& herniation thru craniotomy

Large craniotomy flap that allows access from

skull base to midlinebroad access required
because these lesions are unpredictable
Clot removal--open dura & suction/irrigate clot
Hemostasis--identify and cauterize bleeding
vessel

References
1-Principles of Neurosurgery
(Setti S.Rengachary. Richard G
Ellenbogen).
2-Handbook of Neurosurgery
(Mark S. Greenberg)
3-e-medicine website .