Closed Head Injury

Dr.Tanzila saba
SAW-R2
 Introduction
 Most common neurosurgical emergency

 Number One Killer in Trauma

 25% of all trauma deaths

 Major Cause of disability

 Anatomy
 Scalp
 Skull
 Meninges
– Dura Mater
– Arachnoid
– Pia Mater
 Brain parenchyma
 CSF and Blood
 Basic Anatomy - Scalp
 Very Vascular
 Bleeds Freely
 Vessels suspended in
inelastic tissue
 As a result,
vasospasms are
limited
 Basic Anatomy - Skull
 Like a closed box

 Only opening is the

foramen magnum

 Rigid structure protects

and contributes to several
injury mechanisms
 Intracranial Volume
 80%
Brain Matter
 10%
Blood
 10%
CSF
 Intracranial Volume
 Volume is Fixed at 100%

 The sum of the volume of the brain plus the CSF

volume plus the intracranial blood volume is
constant. An increase in one component should
cause a reduction in one or both of the other two.

 This is called Monroe-Kellie Doctrine

 Pathophysiology
(Response to Injury )
 Swelling occurs due to increased blood volume (not
edema)

 Natural response to injury anywhere in the body

 Increase in blood volume exerts pressure on the brain

tissue

 This eventually decreases blood flow to the uninjured

part of the brain
 Response to Injury (contd)
 CO2 levels in the blood have a critical
effect on cerebral blood vessels
 CO2 is produced by hypoxic cells
 CO2 is a very potent vasodilator
 Normal CO2 is in the range of 35-45 mm
Hg
 Mean CO2 level is 40 mm Hg
 Contd…
 Two main factors that increase intracranial
volume are:

 Vasodilation (immediately)
 Cerebral edema (24-48 hrs)
 Intracranial Pressure
 The pressure of the brain contents within the skull
is intracranial pressure (ICP)

 The pressure of the blood flowing through the

brain is referred to as the cerebral perfusion
pressure (CPP) normally 70-90 mmHg

 The pressure of the blood in the body is the mean

arterial pressure (MAP)
 Normal ICP

 Adults and older children:

Supine Standing
7-15mmHg -10mmHg

 Younger Children:
3-7mmHg

 Infants:
1.5-6mmHg
 Cerebral perfusion Pressure (CPP):
 The critical parameter for brain
functioning and survival is CPP, not
actually the ICP

 Rather it is:
Adequate Cerebral blood flow (CBF) to
meet CMRO2 demands.
Cerebral perfusion Pressure (CPP):

The pressure of blood flowing to the brain,

CPP = MAP − ICP
Where MAP= (1/3 pulse pressure) + (diastolic P).

Ideally MAP > 90 mm Hg

so, that CPP ≥ 60 mm Hg
Auto regulation of Blood Flow
 The brain had the ability to
control its environment
 As long as there is adequate
perfusion
 Mechanism whereby over a
wide range, large changes in
systemic BP produce only
small changes in CBF.
 CVR is directly proportional to
CPP in ranges 50-150 mm Hg.
 Classification
1. On Basis of Mechanism
1: Closed (Falls, RTAs)
2: Penetrating (FAI, BBI, )
2. On basis of Severity
1:Mild (GCS = 14-15)
2:Moderate (GCS = 9-13)
3:Severe (GCS = 3-8)
 Classification (contd)
3. On basis of
morphology
 Skull fractures
 Intra cranial lesions

 Skull fractures
1: Depressed / non depressed
2:Linear / stellate
3:Skull base / vault
 Classification (Intra cranial lesions)
 Focal
1: Epidural haematoma
2: Subdural hematoma
3: Contusions and intra cerebral hematoma.

 Diffuse injuries;
1: Mild concussion,
2: Classic cerebral concussion
3: Diffuse axonal injuries
 Intra cranial lesions (contd)
 Epidural / Extradural
– middle meningeal
artery/vein, dural sinus

 Subdural
– tear of bridging veins
 Intra cranial lesions (contd)
 Subarachnoid
Hemorrhage:
– blood in the CSF
spaces
 Concussion
Definition: A concussion is an alteration of
mental status due to biomechanical forces
affecting the brain. A concussion may or
may not cause loss of consciousness.

1: Mild concussion (consiousness preserved)

2: Classic cerebral concussion (LOC < 6
Hours)
3: Diffuse axonal injuries (LOC > 6 Hours)
 High Risk Criteria
1. Altered LOC: unconsciousness, GCS<13
2. Local bony abnormalities
Skull fracture
FB with/without laceration
Puncture wound
3. Evidence of Basal Skull Fracture
Hemotympanum
Battle sign
Racoon’s eyes
 High Risk Criteria (cont)
4. Unexplained neurological signs
5. Hx previous craniotomy with shunt
6. Post-traumatic amnesia
7. Severe/worsening headache
8. Post-traumatic seizure
9. Blood dyscrasia/anticoagualants
 Management
 Airway with Cervical Spine Protection
 Breathing
 Circulation
 Disability, Neurological status ( Mx ↑ ICP)
 Exposure
 Mild Head Injury
 Approx. 80%

 GCS 14-15

 Brief LOC may be present

 Four categories
 Category 0
 GCS15
 No LOC
 No PTA
 No Risk factors

DISCHARGE HOME
 Category 1
 GCS 15
 LOC < 30 min
 PTA < 60 min
 No risk factor
CT Scan Recommended
Normal---------Discharge
Abnormal—EDH,SDH,SAH, etc
Admit Neurotrauma for Surgery/Obs..
 Category 2 & 3
 Category 2
GCS 15 with Risk factors
 Category 3

GCS 14 with or without risk factors

CT SCAN IS MANDATORY
If CT Scan Abnormal—Admit—Surgery or
obeservation for 24 hrs.
 Moderate HI
 Approx.10%
 GCS 9-13
 Follow simple commands
 Usually confused
 May have neurological deficit
 MANAGEMENT
CT Scan is advisable in all cases
Admission for observation is safest option even if
CT Scan is normal
 Moderate HI (contd)
 After Admission:

 Frequent neurological assessment

 Follow up CT Scan if cond. Deteriorates
 If pt. improves (90%) — Discharge
 If deteriorates (10%) — Repeat CT and manage
per severe head injury protocol
 Severe HI
 Cardiopulmonary stabalization
To prevent secondary insults (hypoxiema, hypotention and
anemia)
 AIRWAY
Severe HI pt. should be intubated early
 Blood Pressure
Hypotention (syst<90) in severe HI pt increases mortality
rate from 27%-50%
 Severe HI (contd)
 CATHETERS
Pt. should be catheterized and NG should be
passed

 Diagnostic Radiographs
X-ray cervical spine
X-ray chest
CT Brain
X-ray KUB
X ray pelvis
 Severe HI (contd)
 General examination
Must exclude non neurological injuries

 Neurological examination
GCS level
Pupillary response
Motor response
 Pupillary Response
1. Shape ?
2. Equality ?
3. Constricted ?
4. Dilated ?
 Interpretation
Pupillary Size Light Response Interpretation
Unilaterally Dilated Sluggish or Fixed IIIrd CN compression
secondary to tentorial
herniation
Bilaterally Dilated Sluggish or Fixed Inadequate brain
perfusion / Bilateral III
CN compression
Unilaterally Dilated Cross-Reactive (Marcus Optic nerve injury
Gunn)
Bilaterally Constricted May be difficult to Drugs (opiates)
determine Metabolic
encephalopathy
Unilaterally Constricted Preserved Injured sympathetic
pathway (Carotid sheath)
 Motor Function
 Basic exam. is completed by gross test of
motor strength by Internationaly used
Motor Function Scale:

 Normal power — 5
 Moderate Weakness — 4
 Sever weakness (anti gravity) — 3
 Severe weaknees(not anti gravity) — 2
 Trace movement — 1
 No movement— 0
 ICP TREATMENT MEASURES

OBJECTIVES:

 TREATMENT… IF ICP >20-25 mmHg

 CPP maintained ≥70 mmHg.
 Frequent clinical examinations helpful.
 CT- Brain… Rule out surgical cause.
 Non-traumatic… Ultimately treatment of
cause.
 GENERAL MEASURES
Must be routine
1) Elevate head of bed (HOB) to 30-45°.
2) Neck straight.. release collars, tapes etc.
3) Hypotension avoided.. SBP <90 mmHg.
4) Hypertension.. Controlled.
5) Hypoxia… pO2 <60 mmHg… corrected.
6) Normocarbia (pCO2= 35-40mmHg) …ventilate
if required.
7) Light sedation… codeine. 30-60mg i/m 4Hrly.
 SPECIFIC MEASURES
If general measures fails
1) Heavy sedation and/or paralysis.
2) Drain 3-5 ml CSF.
3) Mannitol 0.25-1 gm/Kg body wt. Stat, QID.
± Lasix 10-20mg QID.
4) Hypertonic Saline… continuous- 3%.
5) Hyperventilate to pCO2= 30-35mmHg
 OTHER NECESSITIES

1. Prophylaxis against stress/steroid induced Gastric ulcer.

2. Aggressive control of fever.
3. Arterial line… BP, ABG’s.
4. CVP or PA line.
5. IV Fluids. Adequate resuscitation.. urgent.
=Acquire Euvolemia.
-Choice is..
--Isotonic e.g. NS + 20 mEq KCl/L.
--Hypotonics. Ringers lactate.. best avoided.
-Restrict fluids in SAH.
6. Pressors e.g. Dopamine preferred to bolus fluids.
7. Seizures prophylaxis.
 SECOND TIER THERAPY
If still the secondary measures fails
1) Repeat CT- Head… Rule out surgical cause.
2) EEG… rule out status epilepticus
(not clinically evident.)
3) High dose barbiturate therapy.
4) Hyperventilation to pCO2= 25-30 mmHg.
(Capnography should be the standard to guide
ventilation )
5) Hypothermia
6) Decompressive craniectomy± Large contusions
evacuation.
7) Lumbar drainage.
8) Hypertensive therapy.
 TREATMENT
 Medical therapy

 Surgical therapy
 Medical Therapy
 Manitol :
– Effective for control of Raised ICP, after severe
HI, (Limited data suggests that bolus doses are
effective)

 Barbiturates :
– high dose therapy may be considered in hemodynamically
stable severe HI pts. with I/C HTN refractory to maximal
medical and surgical therapy, for lowering of ICP
 Medical Therapy (Contd)
 Steriods
– Controversial, Its use is not recommended for
improving outcome or reducing ICP in pts with
severe HI.

 Furosemide

 Anticonvulsants
 Surgical Therapy
 Indications:
– EDH
– SDH
– DSF
– Venous sinus injuries
– Posterior fossa hematoma
– Contusions/ intra cerebral hematomas (with >
5mm midline shift)
 Prognosis
 The glasgow outcome scale (GOS) has been
widely accepted as a standard mean of
describing outcome in HI pt.
Good recovery (G) Return to pre injury level of
function
Moderately disabled (MD) Has deficit, but is able to look after
self
Severely disabled (SD) Un able to look after self

Vegetative (V) No evidence of higher mental

function
Dead (D)
 The Study

OUTCOME OF HEAD INJURY PATIENTS

DUE TO ROAD TRAFFIC ACCIDENT:
EXPERIENCE IN LADY READING
HOSPITAL, PESHAWAR

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Objective

 To study the different causes and aspects of

head injury in patients of road traffic
accidents.

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Material and Methods
 Type of Study: Observational

 Place: Neurosurgery Deptt. PGMI, Lady Reading Hospital,

Peshawar

 Duration: 06 Months, January 2010 to June 2010.

 No. of cases: 668

 Inclusion criteria: Patients of all ages with either sex

 Exclusion criteria: Patients of head injury having associated

thoracic, abdominal orDR. MUHAMMAD
pelvic injuriesUSMAN, LRH-
PESHAWAR
 Data Presentation
 Data was entered in the statistical program, SPSS software
version 17

 All the data is expressed in percentages.

 Data was analyzed using pi charts, tables and bar graphs.

 Clinical details, CT scan, management and outcome of the

patients were reviewed

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Results :
Mechanism of Injury
Total Cases of Trauma

2% 5%
6% RTA
H/O Fall
9% FAI
Physical Assault
48% BBI
H/O Blunt Trauma

30%

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Male : Female
Male : Female

33%

Male = 447
67% Female = 221

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Address
 Majority of the patients are from the
Peshawar and periphery (small villages),
followed by Charsadda Mardan and Swabi.
 Age wise Distribution

(n=668)
(n=668)
24.20% 24.20%
21.20%

12.10%
9.10%
6.10%
3.00%

< 10 10-20 21-30 31-40 41-50 51-60 > 60

Years Years Years Years Years Years Years
DR. MUHAMMAD USMAN, LRH-
PESHAWAR
 Comparison
 The most common age group affected in an International study
was between 21-40 years (n=1341, 54.24%) and is consistent
with the studies available from other countries*.

 The age group 20-40 years is the most active phase of life,
physically and socially, and hence outnumbers the other road
users. They, therefore account for the maximum number of
accidental deaths.

 It is comparable with our study.

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 GCS at Time of Presentation
45.00%
40.00%
35.00%
30.00%
25.00%
20.00% 39.40% 39.30%
15.00%
10.00% 21.20%
5.00%
0.00%
GCS = 3-8 (Mild HI) GCS = 9-13 (Mod. HI) GCS = 14-15(Sev. HI)
(n=668)

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Injury Severity*

– Mild = 39.40%
– Moderate = 39.30%
– Severe = 21.20%

 In Qatar the incidence of the severity of injury

was mild in most of the victims*.

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Radiological Findings
Findings No of Patients % age
EDH 102 15.20
Brain edema 102 15.20
Brain contusions 81 12.10
Skull bone linear # 61 9.10
Linear # and Pneumocephalus 61 9.10
Subgaleal Hematoma 61 9.10
Acute SDH 42 6.28
DSF 40 6.00
SAH 40 6.00
ICH 20 3.00
Post-traumatic Hydrocephalus 08 1.19
Unremarkable 50 7.48

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Radiological Findings
(n=668)

EDH
Others 15%
Brain Edema
30% 15%

Subgaleal hematoma Brain Contusions

9% 12%
Linear fracture with Skull bone linear fracture
pneumocephalus 9%
9%
DR. MUHAMMAD USMAN, LRH-
PESHAWAR
Radiological Images

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
Radiological Images

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
Radiological Images

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
Radiological Images

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Management
 All patients were managed as per standard protocol

 Care of the airway and breathing

 Restoration and maintenance of hemodynamics

 Optimal environment for the brain (by taking care of

intracranial pressure)

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Treatment
100.00%
90.00% 87.90%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00% 12.10%
10.00%
0.00%
Surgery Conservative
(n=668)

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Outcome
1. Discharged = 90.9%
a) Satisfactory = 68%
b) Refer for neurohab. = 22.9%

2. Mortality = 9.1%
(these were of severe HI).

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
Hospital Stay

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Conclusion
 First priority in managing head injury pts
should be prompt physiological
resuscitation – restoration of BP,
oxygenation and ventilation.

 Hypotention / hypoxia should be avoided,

because it ↑es the morbidity & mortality.

 Routine use of steroid is not recommended

DR. MUHAMMAD USMAN, LRH-
PESHAWAR
 Conclusion (contd)
 Manitol is effective in decreasing ICP but is not to
be used prophylactically.

 Prophylactic hyperventilation therapy further

reduces cerebral blood flow and thus has been
associated with poorer outcomes.

 Cerebral ischemia should be avoided by

maintaining the CPP greater than 60 mmHg.
 References
 Bener A, Rahman YS, Mitra B. Incidence and severity of head and
neck injuries in victims of road traffic crashes: In an economically
developed country. Int Emerg Nurs. 2009;17(1):52-9.
 Teasdale GM, Jenett B. Assessment of come and impaired
consciousness
 Salgado MSL, Colombage SM . Analysis of fatalities in road
 accidents. Forensic Sci Int 1998; 36; 91-6.
 Sahdev P, Lacqua MJ, Singh B, Dogra TD. Road Traffic fatalities in
Delhi: causes, injury patterns and incidence of preventable deaths.
Accid Ann Prev 1994;26: 377-84.
 Friedman Z, Kungel C, Hiss J, Margovit K, Stein M, Shapira S . The
Abbreviated injury scale – a valuable tool for forensic documentation
of trauma. Am J Forensic Med Pathol 1996;17: 233-8.
DR. MUHAMMAD USMAN, LRH-
PESHAWAR
 Contd…
 World report on road traffic injury prevention.
Geneva (Switzerland), World health organization, 2004.
(http:/www.who.int/violence_injury_prevention)
 Bovet B. Health transition and emerging cardiovascular
disease in developing countries : situation and strategies
for prevention, Super course.
 Henchir N. Epidemiology of traffic accidents in Tunisia
[thesis]. Sousse : Medicine
Faculty of Sousse 2001.

DR. MUHAMMAD USMAN, LRH-

PESHAWAR
 Thank you very Much

Thank You very Much