HEAD INJURY

Jackson C.L BSc PT

KCMC Hospital, Moshi.
Review of the Nervous System
Organization of the Nervous System
1.The Central Nervous System
(CNS)
2.The peripheral nervous system
3.Autonomic nervous system
Nervous system -- groups of nerves
Basic Nervous system
1. Central nervous system
 CNS Levels: Neuro-anatomically levels
• The Cerebral hemisphere
• The basal ganglia

• Cerebellum

• Brain stem

• Spinal cord
1.1 The Cerebral hemisphere
 Contain apparatus higher functions
 Dominant hemisphere (Lt in Rt handed)
controls speech
 Non dominant- spatial awareness
1.1 The Cerebral hemisphere
Lobes: -undertake different functions
• Frontal hemisphere: motor control opp. side of
the body, insight, and control of emotions
(dominant hemisphere- output of speech)
• Temporal hemisphere: memory, and
emotions and dominant hemisph. of speech
• Parietal – sensation of opp. Side, appreciation
of space most in none domin
• Occipitaal – appreciation of vision
Brain -- Side View
1.2 The basal ganglia
 Located deep within the cerebral hemispheres
(telencephalon).
Consists of the corpus stratium, subthalamic
nucleus and the substantia nigra.
 Interconnected deep nuclei
• Putamen
• Caudate
• globus pallidum
• Substantia nigra
1.2 The basal ganglia
With complicated interrelations
Are involved in the integration of motor and
sensory inputs
• Controls Cognition
• Movement Coordination
• Voluntary Movement
Eg. Dzs like Pakinson’s
1.3 Cerebellum
 Coordinates movements in the same
side
 Central cerebellar structures are
important in gait and sitting balance
1.4 Brain stem
 nuclei for localisation of lesion are; CN 3, 4, 6
Contain nuclei, including reticular formation,
function in maintaining of consciousness
 Cranial nerves (3 -12)
 Large white matter tracts (from spinal cord to
the central structures and vice versa)
• Descending cortical spinal tract; decussate in the
pyramids in the medulla
Most useful, 7, 12th
1.4 Brain stem
Eg. A brain stem lesion can produce CN
lesion on the one side and limb lesion
on the other side. (Lt-side facial
sensory loss and Rt-sided sensory loss
in the arm and leg in the lateral
medullary syndrome).
1.5 Spinal cord
 Contains:
• sensory
• motor tracts
• Anterior horn cells (cell bodies of the motor neurones
that run through the ventral root.
 The motor fibres in the ventral (anterior) root
join the dorsal (posterior) root fibres and leave
the spinal canal.
 Sensory cell bodies lie outside the spinal cord,
though in the spinal within the dorsal root
ganglia
Spinal cord Anatomy
 There are 31 spinal cord segments, each
with a pair of ventral (anterior) and dorsal
(posterior) spinal nerve roots, which
mediate motor and sensory function,
respectively.
 The ventral and dorsal nerve roots
combine on each side to form the spinal
nerves as they exit from the vertebral
column through the neuroforamina
Spinal cord Anatomy
 Longitudinal organization — The spinal cord is
divided longitudinally into four regions: the
cervical, thoracic, lumbar, and sacral cord.
 The spinal cord extends from the base of the
skull and terminates near the lower margin of
the first lumbar vertebral body (L1)
 . Below that level, the spinal canal contains the
lumbar, sacral, and coccygeal spinal nerve
roots that comprise the cauda equina.
Spinal cord organization
 Segmentally;
• Nerve arise in one segment innervates
particular muscle groups (myotomes), provide
sensation for particular areas (dermatomes).
• Spinal cord segments are referred to by the
level at which the nerve root leaves the spinal
canal
Spinal cord organization
• In the cervical spine, these are numbered so
that the root leaves the spinal canal above the
vertebral body, except C8-goes below the 7 th
cervical vertebra and above the 1st thoracic
vertebra.
• In the thoracic-(T1-T12), Lumbar(L1-L5) and
sacral(S1-S5) the segment goes below the
respective vertebra
• Adult spinal cord ends (segmental level S5)at
the level of the L1 vertebra.
2. Peripheral nervous system
 Nerve root leave the spinal cord through
their exit foramina
• In the Lumbar spine-NR from the lower
end of the spinal cord form cauda equina
before leaving the lumbo-sacral spinal
canal
2. Peripheral nervous system
• Combined roots;
1.Brachial plexus (cervical)
2.Lumbosacral plexus
They then divide into named nerves
(characteristic distribution of motor and
sensory)
Motor nerve stimulation leads to release of
acetylcholine which eventually cause
muscle contraction.
Motor levels
 Major divisions of motor system clinical presentation
of muscle weakness
• Upper motor neuron, corticospinal system from
the cortex to the synapse with the anterior horn
cell
• Lower motor neurone, includes anterior horn cell
within the spinal cord, its axon extending to the
neural muscular junction
• Neural muscular junction
• Muscle weakness
3. Autonomic nervous system
Controls the autonomic aspect of nervous
system.
Divides into 2:
1.Sympathetic “alarm” system – arises from
the spinal segments (T1 to L2)
2.Parasympathetic “holyday” system – arise
from the brain stem (associated with CN 3,
7 & 9 and from the spinal segments S2 – 4)
 HEAD INJURY
 A head injury is any trauma that leads to injury of the
scalp, skull, or brain
 survivors up to 400 per 100,000 Outcome
• Disability
• Death
 Trauma is the most common cause of death in
pts under 45yrs of age in Western countries
• ½ due to head injuries
• Mortality 20 – 30 per 100,000 per year
• Disability among
Causes of head injury
 Falls
 Assaults
 Road traffic accidents (RTA)
 Tumours
 Diving accidents
Causes of head injury
About - ½ head injuries are due to RTA
In under 15yrs and above 65 yrs of age is
due to falls.
In between 15 – 65 yrs of age – assault
most common cause.
Pathology and pathogenesis of
head injury
 Skull fracture
 Diffuse brain injuries

 Focal injuries

 Combined
Skull fracture
 Divided into:
1.Simple
2.Depressed
3.Basal skull
Types of brain injuries
Head injury is classified as:
• closed or
• open (penetrating).
 A closed head injury means you received a
hard blow to the head from striking an object.
 An open, or penetrating, head injury means
you were hit with an object that broke the skull
and entered the brain.
Diffuse brain injuries
 Concussion,
 the most common type of traumatic brain
injury
• Brain shaking
 Diffuse axonal injuries
Focal injuries
 Contusion,
• which is a bruise on the brain or the skull
 Intracranial hemorrhages
• Meningeal hemorrhages
• Brain hemorrhages
Meningeal haemorrhage
 Extradural haematoma- when middle
meningeal artery bleeds into the
extradural space:
• present with mental deterioration following
apparent good recovery
 Subdural haematoma
• Acute if intracerebral bleed
• Chronically – when cortical vein damage with
oozing into the subdural space
Meningeal haemorrhage
 Subarachnoid haemorrhage
• Which is just a bleeding between the
arachnoids and the pia membrane
Brain hemorrhages
 Intracerebral haematoma
• mostly occur at the site of direct trauma or
counter-coup site
Cerebral injury
 Loss of consciousness without
associated pathological changes in the
brain
 Brain damage: direct injury to the brain
• Disruption of the brain
• Shearing of axons
• Intracranial haemorrhage
Cerebral injury
 Counter coup injury”- from injury of the
opposite side of the injury
• Due to acceleration/deceleration forces
moving brain inside the brain
• There may be 20 brain injury due to brain
oedema
• ↑ ICP leads to ↓BP cause brain hypoperfusion
→cerebral ischaemia
• Infratentorial lesion →hydrocephalus
Serious head injury
 Serious head injury (concussion or contusion):
 Loss of consciousness, confusion, or drowsiness
 Low breathing rate or drop in blood pressure
 Convulsions
 Fracture in the skull or face, facial bruising, swelling at the
site of the injury, or scalp wound
 Fluid drainage from nose, mouth, or ears (may be clear or
bloody)
 Severe headache
 Initial improvement followed by worsening symptoms
Serious head injury
 Irritability (especially in children), personality
changes, or unusual behaviours
 Restlessness, clumsiness, lack of coordination
 Slurred speech or blurred vision
 Inability to move one or more limbs
 Stiff neck or vomiting
 Pupil changes
 Inability to hear, see, taste, or smell
Signs and symptoms
Head injuries may cause:
• Changes in personality, emotions, or mental
abilities
• Speech and language problems
• Loss of sensation, hearing, vision, taste, or
smell
• Seizures
• Paralysis
• Coma
Clinical features of head injury
 Varies and depend on the severity of the
injury
 Can be complicated by the delayed
events:
• Intracranial haemorrhage
• Co - existing condition
• multiple injuries (abdominal, chest injuries)
• Co-morbidity
Clinical features of head injury
 Skull #: -Periorbital bruising (Battle’s sign)
-Cranial nerve damage
-Middle ear bleeding
-Rhinorrhoea (leak of CSF form nose)
 Pupil reaction an important sign of
herniation
 Focal neurological sign
 Assessment of head injury
The level of consciousness clinically measured
Glasgow coma scale:
Eye open Score
Spontaneous……………………………………………..4
To verbal………………………………………………….3
To pain…………………………………………………….2
Never………………………………………………………1
Best verbal response
Oriented and conscious………………………………….5
Disoriented and converses………………………………4
Inappropriate words………………………………………3
Incomprehensible words…………………………………2
No response……………………………………………….1
Best motor response
Obeys command…………………………………………..6
Localise pain……………………………………………….5
Flexion withdrawal to pain………………………………..4
Abnormal flexion (decorticate rigidity)…………………..3
Abnormal extension (decerebrate rigidity)………………2
No response………………………………………………..1
Diagnosis
Depend on the clinical presentation
 LOC/COMA

• Infratentorial: infarct, haemorrhage, tumor,

inflammatory lesion
• Supratentorial:Subarrhcnoid haemorrhage,
extradural and subdural haematoma,
intracranial haemorrhage, tumor, infarct
Diagnosis
 Diffused: Metabolic (hper/hypglyceamia,
hypo/hypernatraemia, hypoxia, acidosis,
hypothyroidism, hepatic failure), Toxic,
Drugs, Alcohol, Epilepsy (multiple
sedative-bezodiazepam/others),
hypothermia, Infection (meningitis,
encephalitis)
Investigation
Depends on the severity of the head injury
 Mild h/injnury without LOC or if LOC <5min no
skull # OPD Mnx with alert of possible
deterioration
 At risk of complication need admissio and
monitoring:
• LOC 5-10min,seizure at onset, altered level of
consciousness, local signs on Exam, evidence of
skull#
 CT scan or MRI needed for those at risk
Management
Treatment aim to prevent secondary brain
damage:
 Avoiding hypotension
 Maintain oxygenation
 Avoid raise intracranial pressure
• Evacuate haematoma
• Shunt for hydrocephalus
• Giving mannitol
• Mechanical ventilation
• Forced hyperventilation
Rehabilitation
 Physiotherapy
 Occupational therapy
 Speech therapy may be required
 Other aspects
• There may be needed psychotherapy in case
of psychological/behavioural change with
frontal lobe disinhibition and memory loss
OTHER COMPLICATIONS
 Difficult in concentration and sleep poorly
 Phobia- i.e. driving after MTA
 Migraine like headache
 CN involvement (loss of function)
• Anosmia (loss of sense of smell) fibre damage through
the cribriform palate (this is permanent)
• Post traumatic vertigo.
OTHER COMPLICATIONS
 Post traumatic epilepsy
 Post traumatic amnesia.24hrs/intracrania
haematoma- Risk 12% in 5yrs.
 Pulmonary problems
 DVT
 Contractures
 Pressure sores
 Muscular weakness
Prognosis
Depends upon
• the severity of the head injury
• Age: the younger the age the better recovery
• PTA in < 1hr - 90% recovery to normal work within
2/12
• PTA > 24hrs – 80% pts back to work within 6/12
• Pts with more severe head injury are left with disability
(have better improvement after 2yrs than those of
stroke)