Head Trauma

An HMU EC USMLE session

 01 02 03
ANATOMY AND PATHOLOGY CLASSIFICATION
PHYSIOLOGY

04 05 06
TREATMENT POST-OPERATIVE CLINICAL CASES
GUIDELINES
We don’t do that here
INTRODUCTION

In this session we are going to

exclude penetrating brain injuries
and depressed skull fractures and
focus on intracranial lesions
ANATOMY AND PHYSIOLOGY

THE LAYERS

● The scalp and the skull

● The meninges
● Dura matter
● Arachnoid
● Pia matter
ANATOMY AND PHYSIOLOGY

INTRACRANIAL CSF
FLOWS

● Choroid plexus and ventricles

● Subarachnoid space
● Sinus

● The Monro-Kellie Doctrine: “the total

volume of intracranial contents must remain
constant”
PATHOLOGY: TYPES OF INJURIES

SKULL PARENCHYMAL VASUCULAR SEQUELAE OF

FRACTURES INJURIES INJURIES BRAIN TRAUMA

Beware of the basal Brain contusions and Leads to epidural, Cerebral edema,
skull fractures diffuse axonal subdural and hydrocephalus, other
injuries subarachnoid stuffs
hematoma
PATHOLOGY: PARENCHYMAL INJURIES

CONTUSIONS
Damage on the
surface with
PARENCHYMAL hemorrhage in the
INJURIES subarachnoid space

DIFFUSE AXONAL INJURIES

Tearing of deep
white matter regions
due to rapid
displacement of the
head and brain
PATHOLOGY: VASCULAR INJURIES

EPIDURAL HEMATOMA

● Usually due to the rupture of the middle

meningeal artery or skull fractures

● Limited by sutures

● When blood accumulates slowly patients

may be lucid for several hours before the
onset of neurologic signs
PATHOLOGY: VASCULAR INJURIES

SUBDURAL HEMATOMA

● Due to the rupture/tearing of the bridging

veins

● In people with brain atrophy, the bridging

veins are stretched and more susceptible to
tearing

● Venous bleeding makes the hematoma self-

limited, breaking down overtime

● Chronic hematomas happened when there

are recurrent bleeding.
PATHOLOGY: VASCULAR INJURIES

SUBARACHNOID HEMATOMA

● Usually nobody cares about this :<

● Because of the subarachnoid CSF flows

helps with the mass effect

● Can cause post-traumatic hydrocephalus

because of obstruction
PATHOLOGY: THE SEQUELAE

THE CIRCLE OF SEQUELAE

● Mass and lesions contributed to a raised

ICP

● Intracranial hematoma causes inflammation

and induced edema

● Cerebral edema can be vasogenic (increase

vascular permeability) and cytotoxic (due to
necrosis)
PATHOLOGY: INCREASED ICP - COMPENSATION

COMPENSATION

● Venous and CSF can be compressed out

● Reduction in perfusion caused cardiologic

compensation: reduction of heart rate to
increase systolic volume and increasing BP

● One the volume of the mass reach a critical

threshold, the patient is then fucked
PATHOLOGY: INCREASED ICP - HERNIATION

3 TYPES HERNIATION

● Subfalcine herniation:
● Through the cingulate gyrus under
the falx
● Compression of anterior cerebral
artery
● Transtentorial herniation:
● Through the tentorium (lều tiểu não)
● III nerve compromised
● Tonsillar hernitation:
● Through the foramen magnum
● Compromises vital respiratory and
cardiac centers in the medulla
“So far, so good, so what?”

—SOMEONE FAMOUS
CLASSIFICATION: SEVERITY

GLASGOW GLASGOW GLASGOW

13-15 9-12 <8

MILD INJURY MODERATE SEVERE INJURY

INJURY
MANAGEMENT: PRIMARY SURVEY

PRIMARY SURVEY and

RESUSCITATION

● Airway
● Breathing
● Circulation
● Disability
● Exposure
MANAGEMENT: PRIMARY SURVEY

AIRWAY AND BREATHING

● Transient respiratory arrest and hypoxia are

common with severe brain injury and can
cause secondary brain injury

● Endotracheal intubation in comatose patient

(GCS 3-8)

● SaO2 > 98% is desirable

MANAGEMENT: PRIMARY SURVEY

CIRCULATION

● Hypotension with tachycardia: hypovolemic

shock

● Hypotension with bradycardia: neurogenic

shock (disruption of autonomic pathways)

● Hypertension and bradycardia: Due to an

increase in ICP

● Hypertension and tachycardia: Due to pain

MANAGEMENT: PRIMARY SURVEY

DISABILITY AND EXSPOSURE

● GCS score

● Pupils sizes, response to light and symmetry

● Always assume a cervical spine injury is

present before being ruled out
MANAGEMENT: SECONDARY SURVEY

DON’T MISS ANY OTHER INJURIES

● Detailed neurological examination

● Oral-maxillofacial injuries
● Spine
● Chest
● Abdomen
● Pelvis
● Extremities
MANAGEMENT: INDICATION FOR CT

IN VIETNAM, HOWEVER

● Cho đi chụp hết!

WHAT TO DO, NEXT?

SURGICAL
MEDICAL TREATMENT TREATMENT
IV fluids Scalp wounds
Correction of anticoagulation Depressed skull fracture
Edema and ICP Intracranial masses
Penetration
Ở đây chúng tôi
không dạy đọc CT,
cảm ơn!
INDICATION FOR SURGERY

EPIDURAL HEMATOMA

● GCS ≤ 8 and anisocoria

● Hematoma volume ≥ 30 cm3

● Hematoma volume < 30 cm3 with:

○ Thickness ≥ 15 mm

○ Midline shift ≥ 5 mm

○ GCS ≤ 8

○ Focal neurologic deficit

INDICATION FOR SURGERY

EPIDURAL HEMATOMA

● Effaced cisterns (xóa bể đáy)

● Deteriorating neurologic status

INDICATION FOR SURGERY

SUBDURAL HEMATOMA

● Thickness ≥ 10 mm

● Midline shift ≥ 5 mm

● Thickness < 10mm and midline shift < 5

mm with:

○ GCS worsening by ≥ 2 point

○ Asymmetric or fixed and dilated

pupils

○ ICP ≥ 20 mm Hg
INDICATION FOR SURGERY

CHRONIC SUBACUTE SUBDURAL HEMATOMA

● Thickness ≥ 10 mm and/or midline shift ≥ 7

mm

● Any thickness that caused mass effect,

midline shift, neurological sign/symptoms
INDICATION FOR SURGERY

CONTUSION OF THE FRONTAL AND

TEMPORAL LOBES
● Volume ≥ 50 cm3

● Temporal lobe hematoma > 30 cm3

● Volume ≥ 20 cm3 with:

○ GCS 6-8

○ Midline shift ≥ 5mm

○ Cisternal compression
INDICATION FOR SURGERY

CONTUSION OF THE FRONTAL AND

TEMPORAL LOBES

● Mass lesion associated with:

○ Progressive neurologic decline

○ Mass effect

○ Refractory intracranial hypertension

CASE STUDY

A very typical case…?

● A 14 years old female patient enter the ED

department because of headache 3 hours
after a motorcycle accident:

● Initially, the patient is awake, GCS 14

Symmetric pupils, 2mm, light response (+)
Normal BP and heart rates

● CT
CASE STUDY

2 hours later…

● Patient GCS deteriorated to 12

● CT: Left parietal Epidural hematoma

○ 20 x 76 mm

○ Midline shift 5mm

CASE STUDY

Post-operative

● Patient GCS 14
● Surgical wounds: dry and clean
● Catheter: 100ml, pink-ish fluid removed at
day 2
● Headache, nausea since day 1
● No fever, normal BP and HR

● CT: epidural hematoma with 3mm midline

shift