1 Head Injury

2 Prehistorycal types of trepanation

3 Treatment of depressed skull fracture, XVI century

4 Classification of Brain Injury, Petit, 1774 Cerebral concussion (commotio cerebri) Cerebral contusion (contusio cerebri) Cerebral compression (compresio cerebri)

5 Causes of head injury in the USA Fall from e height Trafic accidents

6 Classification of Head Injury

7 On pathology basis focal diffuse

8 depending on infection risk Closed Open penetrating not penetrating

9 Clinical forms of head injury Cerebral concussion Brain contusion Mild moderate severe Diffuse axonal injury Cerebral compression Head compression

10 Pathogenesis of head injury Initial lesions contusion diffuse axon injury hemorrhages injury of cranial nerves Secondary lesions Intracranial cerebral compression with hematomas Vioaltion of CSF and blood circulation Brain edema Extracranial Anemia hypoxemia hypertermia

11 Pathology of head injury concussionLesions on level of cellular organelle, axons, synapses mild contusion spot hemorrhages in cortex, local subarachnoidal hemorage moderate contusion Primary necrosis in cortex and white substance, diffuse hemorages in 1-2 gyruses Severe contusion Large necrosis and hemorages

12 Clinical presentations of head injury Signs of injury on the scalp (wounds, contusion) Impaired consciousness Amnesia Focal neurological deficit Pupil asymmetry Cranial nerve deficit Paresis Reflex asymmetry and depression Aphasia Seizures

13 Level of consciousness 1. Clear consciousness - full and adequate orientation and reactions. Possible amnesia. 2. Mild– slight sleepiness, some time and place disorientantion, some slowness in command obey, 3. – hypersomnia, disorientation, only elementary verbal contact is possible, obeys only simplest verbal instructions. 4. Stupor – verbal contact is impossible, reactions and eye opening on pain are preserved. 5. Mild coma – no eye opening, noncoordinated reactions on pain. Pupil and corneal reflexes are preserved. 6. Severe coma – no response on pain, best motor response is extension or flexion. Pupil and corneal reflexes are decreased. Spontaneous respiration and blood circulation are preserved with probable violations. 7. Terminal coma – no reflexes, muscle atonia, midriasis

14 Glasgow Coma Scale Eye opening Spontaneously4 points Opens eyes to voice3 points Opens eyes to pain2 points No eye opening1 points Best verbal respons e Spontaneous, appropriate and oriented5 points Confused conversation, phrases only4 points One word speech, inappropriate words3 points Incomprehensible sounds only2 points No sounds1 points Best motor respons e Obeys commands6 points Localizes pain5 points Withdraws to pain4 points Abnormal flexor response (decoricated rigidity)3 points Abnormal extensor response (decerebrated rigidity)2 points No movements1 points

15 Evaluation of consciousness after Glasgow coma scale Level of consciousnessPoints in GCS Clear15 Mild13-14 Severe11-12 Stupor8-10 Mild coma6-7 Severe coma4-5 Terminal coma3

16 Severity of head injury mild (13-15 point in Glasgow coma scale) – cerebral concussion, slight cerebral contusion moderate (8-12 point) – mild cerebral contusion, subacute and chronic cerebral compression severe (3-7 point) – severe cerebral contusion, diffuse axon injury, acute cerebral compression

17 mild cerebral contusion – punctated hemorages

18 mild cerebral contusion

19 mild cerebral contusion

20 contusion

21 Mild cerebral contusion

22 Mild cerebral contusion (on MRI)

23 Two contusion focuses 1- direct blow on the right 2-countercoup on the left

24 Depressed skull fracture

25 Linear fracture of occipital bones with going to the skull base

26 fracture of parietal and frontal bones

27 Depressed fracture of parietal bone

28 Severe cerebral contusion

29 Severe cerebral contusion

30 Severe cerebral contusion

31 Severe cerebral contusion

32 Depressed fracture of parietal and temporal bones

33 Diffuse axon injury – there are no macroscopic lesions

34 Axonal spheres at diffuse axon injury.

35 Поперечний зріз аксона, норма Після травми. відсутні мікротрубочки

36 Diffuse axon injury on CT (no lesions)

37 Head compression

38 Cerebral compression Acute – manifestation during 24 hours after head injury Subacute – manifestation during 1 week after head injury Chronic - manifestation after 1-2 weeks after head injury

39 Causes of cerebral compression Hematomas Epidural Subdural Intracerebral Bone fragment at depressed fructures Pneumocephalus

40 Main triad at cerebral compression Deterioration of consciousness level Ipsilateral anisocoria contrlateral hemiparesis

41 Epidural hematoma on the left Subdural hematoma on the right

42 Intracerebral hematoma

43 Epidural hematoma on CT

44 Epidural hematoma in posterior fossa

45 Subdural hematoma

46 Chronic bilateral subdural hematomas

47 Subacute hematoma

48 Localization of intracerebral hematomas

49 Intracerebral hematoma on MRI

50 Intracerebral hematoma

51 Intracerebral hematoma in the frontal lobe

52 Intracerebral hematoma

53 Combination of subdural and Intracerebral hematomas

54 Acute traumatic pneumocephalus

55 Treatment of moderate and severe head injury Acute resuscitation Diagnostic procedures Definitive treatment

56 Treatment Acute resuscitation ABC Air pathway – cleaning of throat, airway tube, tracheal tube Breathing – Oxygen mask for stuporose and soporose patients Intubation for comatose Circulation Intravenous fluids for maintaining normal blood pressure Maintaining adequate perfusion pressure of the brain

57 Treatment Diagnostic procedures Neurological examination State of consciousness, GCS Major neurological deficit Pupillary reflexes and symmetry Ocular movement Lower brain stem reflexes Motor examination (hemiparesis, reflexes) Pulse rate, blood pressure Neurovisualization Plain X-ray examination CT Cerebral angiography Diagnostic bur holes and ventriculography MRI

58 Definitive treatment Typical indications for surgery Epidural and subdural hematomas that cause depressed consciousness Intracerebral hematoma and contusion in comatose and soporose patients with significant mass-effect on CT Depressed skull fractures Gunshot wounds Insertion of Intacranial pressure monitor

59 Periods of head injury Acute – 2-4 weeks Intermediate – 2-6 weeks Remote

60 bur hole

61 Approach to fronto-temporal and parieto- temporal lobes

62 Approach to frontal lobe

63 Approach to temporal lobe

64 Approach to parietal lobe

65 Approach to occipital lobe

66 Posterior fossa approach

67 Removal of epidural hematoma

68 Dendy’s point for puncture of posterior horn of lateral ventricle

69 Kocher’s point for punction of anterior horn of lateral ventricle