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Head Trauma

Victor Liberto
Perspective…
SCALP
Monro-Kellie Doctrine Skull/Cervical

Intracranial Pressure Meninges/Spaces

Cerebral Blood Flow Brain


Head
Trauma

Classification of Injury Blood Vessel

Acute Neurologic Assessment Cerebrospinal Fluid

Cranial Nerve Tentorium


SCALP
Skin

Pericranium Sub Cutaneous

Loose areolar tissue Aponeurosis


SCALP
Skin
Outermost, thick
SubCutaneous
Rich blood supply
Vessels do not fully constrict if lacerated
Galea Aponeurotica
Occipito & temporo-parietalis muscles
Loose areolar
Loose attachments, Avulsion, Subgaleal
hematomas
Pericranium
Deepest, is firmly adhered to the skull itself
Skull
8 neurocranium

2 to 6 mm

Thinnest
Temporal
14 Facial Muscle

Cranial Vault & Base


Skull
• Base is irregular
• Floor of cranial cavity:
– Anterior: Frontal
– Middle: Temporal
– Posterior: Brainstem &
Cerebellum
• Foramen

Diploe
Skull
• Cranial vault is rigid and non expandable
• Average volume in adults 1.9 liter
• Cranial contents exit or enter the skull
through many foramina
• The largest, the foramen magnum, is the
site of exit of the brainstem and spinal
cord from the cranium
Basilar Skull Fracture
• Blood in ear canal
• Hemotympanum
• Rhinorrhea
• Otorrhea
• Retroauricular hematoma (Battle’s Sign)
• Periorbital ecchymosis (Racoon Eye)
• Cranial nerve deficit: Facial paralysis,
Tinnitus, Nystagmus
A case in a construction project
Meninges
• Epidural
• Subdural (vein from brain
surface to superior sagital sinus)

• Venous sinuses (drainage


from the brain, laceration of sinuses =
massive hemorrhage ) Duramater

• Meningeal artery Arachnoid


Piamater
(epidural, epidural hematoma, middle
meningeal artery over temporal fossa)

• CSF (subarachnoid, brain injury


leads to SAH
Meninges
• Dura folds: protect and compartmentalize
different parts of brain
• Midline Falx-cerebri separates 2
hemispheres
• Tentorium cerebelli partitions cerebellum
and brainstem from hemispheres
• The U-shaped free margin of this dural
fold: transtentorial herniation syndromes
that can complicate severe head injury
Brain
The only organ that can study itself and everything else

Cells that make up the


brain:
• Neuron
• Astrocytes
• Oligodendrocytes
• Schwan’s Cell
• Satellite Cell
Whose brain is this?
• Removed after
several hours of his
death…
Whose brain is this?
• 98.9 % DNA
sequence
Brain
• Roughly 100 billion neurons
• 1 neuron 15 million synapses
• Localized and whole area
Brain
• Major divisions:
– Cerebrum
– Diencephalon (thalamus & hypothalamus)
– Limbic System
– Brainstem
• Midbrain, Pons, Medulla Oblongata
– Cerebellum
Cerebrum

Parietal

Limbic System
Thalamus
Frontal Occipital
Hypothalamus

Midbrain

RAS
Temporal
Pons
Cerebellum
Reticular Formation or RAS
• Sensory reaches RF
• RF stimulate cortex:
wakefulness
• Decreased activity in RF result
in sleep
• Injured RF: unconscious even
to strong stimuli
• RF filter incoming sensory
signal
• Cerebral cortex may activate
RF
• RF regulates motor activity
• Enhance or inhibit certain
spinal nerves
• Basal ganglia or
nuclei:
– Dopamine
– Inhibit motor function
– Controlling certain
muscular activity
Brain Injury
• Primary injury:
– Contusion; coup, countercoup
– Diffuse axonal injury (white matter), confusion to
coma
– Foreign object
– Skull fracture
• Secondary injury:
– Hypoxia, hypocapnia, hypercapnia, increased ICP,
decreased CBF, hyperthermia, electrolyte, pH
disturbance
Hypocapnia…
Cerebrospinal Fluid
• Choroid plexus (20 ml/h), primarily in lateral
ventricles > Monroe > Third ventricle > Sylvius >
Fourth ventricle > exit through
– Luscka (to SAS/great cerebral vein cistern) and
– Magendie (to SAS/cistern magna)
• CSF from the ventricular system into
subarachnoid space surrounds the brain &
spinal cord
• Arachnoid granulation
65 to 195 mm H2O
or
5 to 15 mm Hg

Blood can occlude?

Brain injury can


alter pH

pH: pulmonary
drive & cerebral
blood flow
Perspective…
SCALP
Monro-Kellie Doctrine Skull/Cervical

Intracranial Pressure Meninges/Spaces

Cerebral Blood Flow Brain


Head
Trauma

Classification of Injury Blood Vessel

Acute Neurologic Assessment Cerebrospinal Fluid

Cranial Nerve Tentorium


Tentorium
• Supra-tentorial compartment
• Infra-tentorial compartment
• Midbrain passes through large aperture:
tentorial incisura
• N III may become compressed during
temporal lobe (uncus) herniation
• Parasympathetic fiber (pupillary constrictor
lie on the surface of N III; Dilatation due to
unopposed sympathetic
• Uncal Herniation:
– N III
– Parasympathetic fiber
– Corticospinal tract
• Uncal Herniation:
– Ipsilateral Pupil
Dilatation
– Contralateral
hemiplegia
Kernohan’s Notch Syndrome
• Result of the compression of the cerebral
peduncle, part of midbrain against the
tentorium due to transtentorial herniation
• Hemiplegia or hemiparesis and pupil
dilatation on the same side as the
hematoma (or mass)
Intra Cranial Pressure
• Elevated ICP reduces cerebral perfusion and
cause ischemia
• Normal resting state: 10 mmHg, more than 20
mmHg; poor outcome
• Intracranial pressure results from contributions
from intracranial fluid compartments:
– Brain tissue (more than 80% fluid)
– Arterial blood
– Venous blood
– Cerebrospinal fluid
Monro-Kellie Doctrine
• The total volume of intracranial contents
must remain constant

Venous Arterial Brain CSF

Venous Arterial Brain MASS CSF

Venous Arterial Brain MASS CSF


Brain Herniation
• Cingulate
• Brainstem
• Uncal
• Cerebellar tonsil
Cerebral Blood Flow
• 50 to 55 ml/100 grams brain tissue/minute
(human brain is 1400 grams)
• …raised ICP
• …ischemia > ischemic cascade > cellular
damage > edema, etc
• Every effort to enhance/control CBF:
– Reducing elevated ICP
– Maintain intravascular volume
– Maintain MAP
– Restoring normal oxygenation and normocapnia
• Compensatory mechanism…
Hypocapnia…