Injury of brain and skull

Saranchimeg Enkhtuvshin
MD, Training PhD
Department of Orthopedic and Traumatology
Anatomy

The skull is made up of cranial bones and facial bones.

Epidemiology
● Brain injury continues to be an enormous public health problem, even in the
21st century.
● It is one of the most common causes of admissions to the emergency
department worldwide.
● Head injuries occur in all age groups, with a peak incidence between the ages
of 16 and 25 years, and are more common in males than females.
● Considering 100% of all injuries, craniocerebral injuries account for 38-42% of
all injuries according to WHO data.
● According to statistics from the Ministry of Health of Mongolia, 29-35% of all
injuries are craniocerebral injuries.
Cause
Classification Central nervous
system

skull-brain injury spinal-cord injury

Classification

Open head injury

An open head injury is one in which something
breaks your scalp and skull and enters your brain.

Skull-brain Closed head injury

injury A closed head injury is any injury that doesn’t
breaks your skull.
Classification
You may need to be hospitalized if you have a serious head injury. The
treatment you receive at the hospital will depend on your diagnosis.
• Mild – 7-10 days
• Moderate – 2-3 weeks
• Severe – 3-6 weeks
By the time of loss of consciousness:
• 0-30 min concussion if continued
• 30-2 hours mild bruises
• 2 hours to 24 hours is a moderate bruise
• 24-3 days is a severe contusion
• If you are unconscious for more than 3 days, it is
considered a nerve injury.
Сoncussion

• A concussion is an injury
to the head area that
may cause instant loss
of awareness or
alertness for a few
minutes up to a few
hours after the traumatic
event.
Сoncussion
Causes :
Motor vehicle accidents, falls, and sports
injuries are common causes of concussions. Any
sport that involves contact can result in a
concussion.
Among children, most concussions happen
on the playground, while bike riding, or when
playing sports such as football, basketball, ice
hockey, wrestling, or soccer.
Сoncussion Types of Concussions
Mild Concussions (Grade 1)
Mild concussions can occur as the result of a hard blow to the head or severe shaking—such
as from being hit in the head with a hard object or suffering mild whiplash during a hard stop in
a car. Mild concussions can cause some temporary dizziness and/or disorientation, but don’t
usually have lasting effects.
Moderate Concussions (Grade 2)
Moderate concussions are caused by more severe impacts to the brain—such as those
caused in vehicular accidents or by acts of violence. These concussions are often
accompanied by internal bleeding in or near the brain (i.e. contusions), and many more severe
and long-lasting effects than mild concussions.
The symptoms of a Grade 2 concussion may last for longer than a Grade 1 concussion.
Severe Concussions (Grade 3)
A concussion may be considered severe (or a Grade 3 concussion) if it results in a temporary
loss of consciousness. These concussions always warrant immediate medical attention from a
trained professional and may have permanent effects on coordination, speech, and cognition.
Сoncussion
Symptoms: ● Headache.
● Nausea or vomiting.
● Confusion, temporary loss of consciousness.
● Balance problems/dizziness/lightheadedness.
● Double or blurry vision.
● Ringing in the ears.
● Sensitivity to light and noise.
● Feeling tired or drowsy.
● Changes in sleep patterns (sleeping much more or less than
usual or can’t sleep).
● Trouble understanding and/or concentrating.
● Depression or sadness.
● Being irritable, nervous, and anxious.
● Feelings of being “just not right” or in a "fog."
● Difficulty paying attention, forgetfulness, memory loss.
Сoncussion
CT scan
Сoncussion
Treatment
1. Physical and mental rest
2. Pain medication: aspirin and nonsteroidal
anti-inflammatory drugs (NSAIDs)
3. No surgery is needed
Сontusions
Cerebral contusion is a more severe degree of damage
with bruising and cerebral edema leading to diffuse or localized
changes
Recovery is slower than after a concussion and may be
incomplete, leaving a neurological deficit.

Causes:
• Sudden fast movements
• Falling
• Bumping into something
• Or being hit, or kicked
 Сontusions Types of Contusions
Mild Contusions
Common head injuries resulting from blows to the head (such as from walking into an object
headfirst, being struck with a baseball, or similar events) can result in a mild contusion. Mild head
contusions often only have surface bruising at the site of the impact, and may be associated with
some pain at the injury site, but with no noticeable long-term effects.
Moderate Contusions
Moderate contusions may cause internal bleeding near or around the brain, and are often caused by
more severe head traumas. These contusions may be accompanied by concussions and can cause
more severe symptoms, such as short-term memory loss, difficulty focusing, and loss of
consciousness. Some moderate contusion symptoms may persist, even after treatment/recovery.
Severe Contusions
Severe contusions can be life-threatening conditions that require immediate medical attention. When
these contusions occur in the brain, they can result in concussion-like symptoms (and are extremely
frequently paired with concussions). Severe contusions should always be treated as soon as possible
to prevent or limit permanent harm. Even with treatment, there may be permanent damage—although
prompt care can limit the severity of these effects.
Сontusions
Symptoms:
● Changes in cognition such as alterations in
personality, or reductions in intelligence.
● Difficulty understanding speech.
● Memory challenges.
● Localized numbness or tingling.
● Difficulty coordinating movements.
● Difficulty speaking.
● Problems with attention.
Сontusions
Treatment
Contusion treatment options will vary depending on the severity of the
contusion and its location in the head. Mild contusions may go away with the
simple passage of time. Meanwhile, moderate and severe contusions may require
invasive surgery and/or the use of prescription medication.
Contusion treatment regimens should be prescribed by an expert physician
after undergoing a thorough examination. During the examination, doctors may:
• Visually inspect the injury site;
• Palpate (touch) the injury area to test for pain;
• Take x-rays of the injury; and/or
• Conduct a magnetic resonance imaging (MRI) scan to check for the extent of
the contusion (and the possible presence of non-visible bruises on the brain).
 Alcohol Use After Traumatic Brain
Injury
• Up to two-thirds of people with TBI have a history of alcohol abuse or risky
drinking.
• Between 30-50% of people with TBI were injured while they were drunk and
about one-third were under the influence of other drugs.
Intoxication:
• The amount of alcohol in the blood is 0-1% light intoxication
• 1-3% deep alcohol
• 5% lethal dose
Complications:
• Brain
• swelling
• Meningitis
• Abscess
• Embolism
Compression
Compression of the brain is a condition in which something increases
the amount of pressure pushing on the brain, which can damage brain
tissue.
Compression is usually caused by bleeding into the skull. As the
bleeding continues, the brain is compressed and the clinical condition
becomes worse. Decompression and arrest of the bleeding can be life-
saving.
Patients with concussion and contusion are at their worst immediately
after injury and then recover. The compression causes steady
deterioration instead of recovery, although there may be a lucid interval.
Compression
Symptoms:
● Recent head injury
● Headache
● Noisy, slow breathing
● Slow pulse, unequal pupil size
● High temperature
● Drowsiness
● Change in behavior
● Unconsciousness
Skull fractures
Skull fractures
A skull fracture is any break in the cranial bone with one
major cause: being an impact or a blow to the head
that’s strong enough to break the bone. An injury to the
brain can also accompany the fracture,(not always the
case.) A fracture isn’t always easy to see. However,
symptoms that can indicate a fracture include:

● swelling and tenderness around the area of

impact
● facial bruising
● bleeding from the nostrils or ears
Skull fractures
Linear fracture
Breaks in the bone that transverse the full
thickness of the skull from the outer to the inner
table
The common type of the skull fractures
Cause: blunt force trauma
Little clinical significance unless they parallel in
close proximity or transverse a suture, or they
involve a venous sinus groove or vascular
channel.
Complications: suture diastasis,
venous sinus thrombosis, and
epidural hematoma.
 Skull fractures Depressed skull fracture
Blunt force trauma: struck with a hammer,
rock, or getting kicked in the head.
11% of severe head injuries high risk of
increased pressure on the brain, or a
hemorrhage to the brain that crushes the
delicate tissue.
Compound depressed skull fractures:
laceration over the fracture, risk of
contamination, and infection.
Complex depressed fractures: dura mater is
torn and may require surgery to lift the bones
off the brain if they are pressing on it by
making burr holes on the adjacent normal
skull.
 Skull fractures Diastatic fracture
Cranial abnormalities in cleidocranial dysplasia including
diastatic sutures.(Sutural diastasis is an abnormal widening
of the skull sutures. It may be physiological in a neonate
during a growth spurt.)

fracture line transverses one or more sutures of the skull

causing a widening of the suture.
usually seen in infants and young children. Sutural diastasis
may also occur in various congenital disorders such as
cleidocranial dysplasia and osteogenesis imperfecta
in adults - lambdoidal suture, severe head injuries. Due to the
trauma, diastatic fracture occurs with the collapse of the
surrounding head bones. It crushes delicate tissue, similarly to
a depressed skull fracture.
Skull fractures Basal fracture
The floor of the cranial vault (skull
base), require more force than 4%
of severe head injury patients.
Basilar fractures have characteristic
signs:
● blood in the sinuses;
● cerebrospinal fluid rhinorrhea (
CSF leaking from the nose) or
from the ears (cerebrospinal
fluid otorrhea)
Skull fractures
Diagnosis
Extradural hematoma
● Hematoma in extradural space
● Common site-temporal region
● The classic story of an extradural hematoma is the patient
who walks into the hospital after a minor head injury and
gives a clear, sensible history.
● Extradural hemorrhage can be caused by damage to the
middle meningeal artery. As the artery bleeds, a hematoma
develops and the brain is gradually compressed.
Extradural hematoma
● CT scan: lentiform (lens-shaped or
biconvex) hyperdense lesion and most
frequently beneath the squamous part of
the temporal bone. EDHs are hyperdense,
somewhat heterogeneous, and sharply
demarcated. Depending on their size,
secondary features of mass effect (e.g.
midline shift, subfalcine herniation, uncal
herniation) may be present.
● Treatment: immediate surgical evacuation
via craniotomy
Epidural hematoma

Epidural hematomas occur when a blood clot forms underneath the skull, but on
top of the dura, the tough covering that surrounds the brain.
They usually come from a tear in an artery that runs just under the skull called
the middle meningeal artery.
Epidural hematomas are usually associated with a skull fracture.
Epidural hematoma
A large lentiform-shaped hematoma that does not
cross the cranial sutures is noted at the left parietal
lobe, causing significant midline shift and
entrapment hydrocephalus. An overlying left parietal
bone fracture can be seen on the bone window.
Other findings include:
● scalp edema overlying the left parietal area
● bilateral temporal intraparenchymal bleeds
● left parietal intraparenchymal bleed
Epidural hematoma
Craniotomy or laminectomy is
followed by evacuation of the
hematoma, coagulation of
bleeding sites, and inspection of
the dura. The dura is then
tented to the bone and,
occasionally, epidural drains are
employed for as long as 24
hours.
Subdural hematoma
● Clinical features:
○ Headache
○ Cognitive decline
○ Focal neurological deficits
○ Seizures
● Overall 85% of subdural haematomas
are unilateral in adults. However, 75-85%
are bilateral in infants.
● CT scan: concavo-convex lesion
Subdural hematoma
Subdural hematoma
Subdural hematoma
● Treatment: surgical evacuation via craniotomy
Diagnosis
Diagnosis
Treatment
Treatment
Treatment
Treatment
Treatment