Current Management of Traumatic Head Injury

Asan Medical Center Neurosurgery

YoungYoung-Shin Ra

Abstract (None)

Mekong Sante Jan 2011

Contents
Birth Trauma Scalp Injury Skull Fracture Traumatic Brain Injury
Minor head injury Cerebral concussion Intracranial hemorrhage Severe head injury
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Scalp Structure
S-skin C-connective tissue (dense) A-aponeurotic layer L-loose connective tissue P-pericranium

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Skull Anatomy

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Scalp Injury at Birth

Caput succedaneum
- soft, puffy swelling of the scalp +/- associated with head molding +/- bruise 24- resolve in 24-48 hrs

Subgaleal hematoma
ill- ill-defined, firm or fluctuant mass - progresses after birth,

2but resolves in 2-3 wks - can have a large volume of blood upto 250ml
-

consider anemia or shock

Cephalhematoma - 0.2~ 2.5% of live births - rarely spontaneous in utero (0.04%) at PROM - parietal, distinct margin dont - don t cross sutures, firm to fluctuant, - small bleeding 2- resolve in 2-3 wks
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Subgaleal Hematoma
0.2~3/1000 live births, male predominance monthsRiskA 2 monthsmacrosomia, prematurity, primigravida factors; -old baby presented with scalp swelling delivery, dystocia, precipitous labor. delivery(60It occurs more commonly after vacuum delivery(6089%) results from rupture of the emissary veins Estimates of blood loss of SGH
38 mL/cm increased head circumference 260 mL/cm increase in scalp thickness

Difficult to control bleeding if coagulopathy develops

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CephalhematomaCephalhematoma-Ossified
Cephalhematoma resolve in 2-3 wks generally Rarely calcify or ossify Prietal bone location Hard mass at hemorrhagic site -> surgery if severe deformed skull for aesthetic purpose Surgery;
-> Removal of ossification +/_ cranioplasty
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Brain Injury at Birth

Incidence; not known Higher mortality and morbidity Neonatal head is subject to compression as it passes through birth canal Compliant neonatal skull against maternal spine and pelvis Usually complicated with traumatic delivery forceps, vacuum, precipitous C-section does not eliminate it (cranio-pelvic disproportion)
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Brain Injury at Birth

Skull fracture
Linear or depressed fracture

Epidural hemorrhage
Extremely rare. Associated with skull fracture

Subdural hemorrhage
Delayed delivery in post-term baby, breech presentation, forcep delivery Symptoms;; seizure, increased head circumference, tense fontanelle Treatment; anticonvulsants, correction of anemia or acidosis

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Depressed Fracture at Birth

Preop. CT

Postoperation

3 months after operation

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Depressed Skull Fracture treated by Vacuum

Before Vacuum

After Vacuum T

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Traumatic Head Injury in Children

Trauma is the main cause of death in children Brain injury is 40% of fatal childhood injuries, 100,000 ped. hospitalization/yr in USA Incidence; 200/100,000 population Mortality;10% Male > female by 2X Hyperactive, aggressive personalities Causes of injury; Motor vehicle, pedestrian, bicycle accidents, falls Child abuse <2 yrs old , Fall < 4 yrs old
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Traumatic Head Injury in Children

Thin and pliable skull -> vulnerable to injury Damage to developing brain with immature myelination -> serious sequales in function Vulnerable to hypotension and hypoxia Less brain edema and rapid recovery Neuroplasticity; language function

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Classification of Head Injury

Classification based on the severity of head injury Classification based on the anatomic findings

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Clinical Assessment for TBI

Glasgow coma scale
-widely accepted throughout the widely world since1974 -total score of 15 points 15/15; alert and fully oriented, 3/15; deep coma -not applicable to infants

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Head Injury Severity Scale

Minimal ; GCS 15, no LOC or amnesia Mild ; GCS 14, GCS 15 + LOC or amnesia Moderate ; GCS 9-13 Severe ; GCS 5-8 Critical ; GCS 3-4

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Anatomic Criteria
Focal and diffuse injury ; Focal injury ; Contusions, Hematomas Diffuse injury ; Concussion, Diffuse Axonal Injury

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Scalp Injury
Principles:
Hemostasis by compression Examination of skull Antibiotics for contaminated wound Debridement and skin closure Tetanus prophylaxis booster if age > 10 yrs

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Skull Fractures
Linear skull fracture
Most common by fall events May associated with epidural hematoma DDx with suture line and diastatic fracture

Depressed skull fracture Basal skull fracture

Raccoons' eye, battles sign CSF rhinorrhea, otorrhea
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raccoon eyes: blood is constrained by the periorbita

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Battles sign (>24 hours)

L CSF otorrhea: CSF otorrhea target sign (pillow case chromatogram)

look in the ear: hemotympanum indicates a fracture

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Growing Skull Fracture in Children

1% of all skull fractures Below 1 year of age Synonym:Post-traumatic leptomeningeal cyst Parietal bone mostly 2-3 mm separated skull fracture with dura tear at injury -> erosion of skull in several weeks or years Symptons:hemiparesis, seizure Treatment; dura repair and cranioplasty,
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Traumatic Brain Injury

Diagnostic Radiology Skull x-rays; skull fracture is well visible Brain CT scans: Indicated in GCS<14, skull fractures in x-ray, or severe headche and vomiting most helpful for acute hemorrhage Brain MRI scan: diffuse axonal injury, helpful to chracterize chronic hemorrhage

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Minor head injury

First used in a paper by Rimel et al. (1981) MHI was used to describe the following group of patients 1. GCS of 13-15 on admission 2. a loss of consciousness of less than 20 min 3. admitted to hospital for less than 48 hours

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Minor Traumatic Brain Injury

Physiologic disruption of brain function as menifested by one of the followings
any period of loss of consciousness any loss of memory for events immediately before or after the accident any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused) focal neurological deficit(s) that may or may not be transient;
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Cerebral Concussion
Clinical syndrome by traumatic alteration of consciousness Clinical hall marks; confusion and amnesia 3 grades:
consciousness(LOC)(Mild ; loss of consciousness(LOC)(-), confusion or disorientation(+) Moderate ; LOC(+) < 5 minutes, amnesia(+) Severe ; LOC(+) > 5 minutes,

Shearing stress within brain substance Admission criteria

GCS 15 and CT normal; diacharge home with cautions 13GCS 13-14 or abnormal CT; addmission and observe Mekong Sante Jan 2011 deterioration

PostPost-Concussional Syndrome
Physical
Headache (especially exertional) Dizziness Nausea Fatigue Poor balance

Psychiatric
anxiety/depression

Cognitive
Impaired Memory Poor Concentration, Slow processing
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Outcomes of Minor Head Injury

Complete recovery is rule Mortality is extremely uncommon Morbidity is rare but more common is neurobehavioral morbidity Parental anxiety -> overprotection of children -> school absence! Reassurance, Reassurance, Reassurance

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Traumatic Intracranial Hemorrhage

Epidural hematoma
Linear skull fracture at temporal or parietal bone Middle meningeal arterial bleeding Lucid interval; deterioration of consciousness after recovery from loss of consciousness Treatment; emergency craniotomyh and removal of hematoma

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7-yearCase; 7-year-old boy

C.C. ; Drowsy mentality after minor head injury 2007.12.10. 3 hours before arrival to ER, he fell down from a account desk at the market by accident. Height of desk was 1 meter; its floor was made by cement. Without LOC, he continueously compaints of continuous headache after HI -> sleep tendency 1 hour visit to ER and vomiting(+).
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xSkull x-rays on Admission

Brain CT scan 4 hrs after Trauma

Post operative Brain CT scan

Traumatic Intracerebral Hemorrhage

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Traumatic Intracranial Hemorrhage

Acute subdural hemorrhage
Rupture of bridging vein or cortical vein Brain contusion assciated Poor mental state is common

Chronic subdural hemorrhage

Light or minor trauma without loss of consciousness Arachnoid membrane ruptured -> subdural hygroma -> sudbdural hemorrhage gradually
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Severe TBI in Children

Less mortality than adults (24% VS 45%) Less mass lesion than adults (24%vs 46%) Predictors of poor outcomes
Poor GCS motor score Loss of pupillary reaction to light Mechanism: Motor Vehicle Accident > fall accident Hypotension Multiple Injuries Mass Lesions
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Clinical Severity of Head Injury

Glasgow Coma Scale (15)
Eye opening (E, 4) Best motor response (M, 6) Best verbal response (V, 5)

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Mortality according to GCS

80 70 60 50 40 30 20 10 0 3 4 5 6 7 8 9 10 11 12 13 14 15

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Complications of Childhood Traumatic Brain Injury

PostPost-traumatic seizure
Prophylactic anticonvulsants is contrversy

Pneumocephalus
Severe headache Spontaneously resolve but possibility of meningitis

CSF rhinorrhea, otorrea

Prophlylactic antibiotics; controversy

Infection or meningitis
Basal skull fracture associated usually Bacterial meningitis Fever or seizure

Vasculopathy
Dissecting aneurysm
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