Head Trauma

Head Trauma
Dr Rushab Ranawat
Dept of General Surgery
Mechanism of Injury
• Dynamic force
a) Deficit occur early
b) Common
c) Force applied to the cranium for short duration (<50 ms)
• Static force
a) Severe deficit occur only late
b) Rare
c) Duration >200 ms
Dynamic forces
CONTACT forces LOCAL effects
• IMPACT Loading REMOTE effects
(more common) INERTIAL forces
• IMPULSE Loading
(less common)
IMPACT Loading - Contact forces
a) Occurs from forces during direct impact.

b) Typically cause focal injuries.
>>Local effects
• Linear and depressed fractures
• Basilar skull fractures
• Extradural hematomas
• Coup contusions
>>Remote effects
• Due to skull distortion and stress waves
IMPACT Loading – Inertial forces
• Acceleration and Deceleration injuries.
• Acceleration injuries
a) Translational – brain moves in a straight line at the centre of gravity
(pineal gland).
b) Rotational – brain moves around centre of gravity
c) Angular – combination of translational and rotational injury.
Impulsive loading
• When head is put into motion or the motion is suddenly arrested
without the head itself being struck or impacted.
Clinical classification of head injuries
• Vault
Skull fractures • Linear

• Displaced
• Basilar
Focal brain • Contusion
injuries
• Hemorrhagic (EDH, SDH, SAH, Intracerebral)
• Concussion
Diffuse brain • Mild
• Classic
injury • Diffuse axonal

• Others
Basilar skull fracture
• Involves at least one of the skull base bones viz. temporal, occipital,
sphenoid, ethmoid, orbital plate of frontal bone.
• Caused by high velocity blunt trauma.
• Findings – hemotympanum, CSF Otorrhea/rhinorrhea, mastoid
ecchymosis, racoon eyes.
Contusions
• Bruise of the brain parenchyma.
• Pia – Arachnoid is intact over a contusion, but is torn in a laceration.
• Types
a) Coup
b) Contrecoup
c) Fracture
d) Herniation
e) Gliding
• Coup – at site of impact in the absence of skull fracture.
• Contrecoup – occurs in the brain away from the site of impact.
Features of raised Intracranial Tension
• Following TBI, 3 types of brain swelling are observed
a) Swelling adjacent to contusion and intracerebral hemorrhage.
b) Diffuse swelling of unilateral cerebral hemisphere.
c) Bilateral diffuse brain swelling.
• Trauma breakdown of BBB vasogenic edema
downward herniating of brain supratentorial expanding
lesion
Extradural Hematoma
 Collection of blood in the extradural space.
 History of transient loss of consciousness following a history of blow or
fall.
 Patient soon regains consciousness and again after 6-12 hour starts
deteriorating (Lucid interval).
 Initially pupillary constriction and later pupillary dilatation occurs on the
same side >> Hutchinsonian pupils.
 Contralateral grooving of cerebral peduncle – Kernohan Notch
phenomenon
 CT shows biconvex lesion.
Subdural hematoma – acute and chronic
Acute Subdural Hematoma
• It is due to injury to the cortical veins.
• Hematoma is extensive and diffuse.
• There is no lucid interval.
• Loss of consciousness occurs immediately after trauma and is
progressive.
• CT scan shows concavo-convex lesion.
Chronic Subdural Haematoma
 It is due to the rupture of veins between dura and brain causing
gradual collection of blood in subdural space.
 It is commonly seen in elderly people following any minor
trauma like fall.
 Blood collects gradually over 2-6 weeks. Plasma and cellular
components get separated. Eventually cellular part gets
absorbed leaving only fluid component. It is called as chronic
subdural hygroma.
SUBARACHNOID HEMORRHAGE
• Haemorrhage into the subarachnoid space usually from basal
cisterns.
• Sudden onset of severe headache with vomiting.
• Features of raised intracranial pressure.
• Sudden loss of consciousness.
• In 40% of recovered patients, rebleeding occurs in 6-8 weeks
HUNT and HESS Grading of Subarachnoid
Hemorrhage.
• Grade 1: Asymptomatic
• Grade 2: Severe headache and neck stiffness
• Grade 3: Drowsy, confused or mild focal deficit
• Grade 4: Stupor, hemiparesis
• Grade 5: Decerebrate rigidity, coma
FISCHER Grading of SAH – CT scan
• I-minimal <8 mm size
• Il-moderate 8-15 mm size
• Ill- severe >15 mm size
Concussion
• Angular or rotational head motion causes transient electrophysiologic

dysfunction of reticular activating system in the upper mid brain
caused by rotation of cerebral hemisphere on a relatively fixed
brainstem.
• Biochemical changes occur – mitochondrial ATP depletion.
• No structural damage.
• Possible findings – vacant stare, disoriented, slurred speech, etc.
Post concussion syndrome
• Patient having more than 3 symptoms viz. headache, memory deificit,
dizziness, etc. within 4 weeks of injury and remain for >1 month after
onset of symptoms.
Diffuse Axonal Injury/Shearing
• A primary lesion of rotational acceleration/deceleration head injury.
• Clinically can be diagnosed when coma last >6 hours in absence of
intracranial mass or ischemia.
• Clinical grading
a) Mild -- coma for 6-24 hours
b) Moderate -- coma for >24 hours
c) Severe -- coma lasting for months
Other areas
• Brainstem
• Hypothalamus
• Pituitary
• Cranial nerves
Brain Death
• Criteria, assessment, ancillary tests
Criteria by American Academy of Neurology
a) Normothermic – temperature more than 36 degree.
b) Normotensive – SBP more than 100 mm Hg with an irreversible and
proximate known cause of trauma.
• Presence of CNS depressants, neuromuscular blocking agents,
electrolyte and endocrine disturbances should be excluded.
Assessment
a) Should lack all evidence of responsiveness to noxious stimuli.
b) Absent brainstem reflexes.
c) Should be apneic.
• Apnea test is performed by disconnecting the patient from the
ventilator but preserving oxygenation. Test is positive If respiratory
movements are absent and PaCO2 greater than 60 mm Hg.
Ancillary test
EEG, CT angio, nuclear scan to confirm Brain Death.
Board of Medical Experts to certify BD
• The RMP in charge of the hospital in which brain-stem death has
occurred.
• An independent RMP being a specialist.
• a neurologist or a neurosurgeon to be nominated by the RMP specified
in clause
• the RMP treating the person whose brain-stem death has occurred.
Thank you.

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Head Trauma

a) Occurs from forces during direct impact.

Skull fractures • Linear

Focal brain • Contusion

injury • Diffuse axonal

downward herniating of brain supratentorial expanding

• Angular or rotational head motion causes transient electrophysiologic

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