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 Head trauma refers to injury to the head.

may or may not include injury to the brain.
However, the terms traumatic brain injury and
head injury are often used interchangeably in
the medical literature.
 The incidence (number of new cases) of head
injury is 300 per 100,000 per year (0.3% of the
population), with a mortality of 25 per 100,000
in North America and 9 per 100,000 in Britain.
Head trauma is a common cause of childhood
Common causes of head injury are :
 traffic accidents,
 home and occupational accidents,
 falls
 assaults.

-Bicycle accidents are also a common cause

of head injury-related death and disability,
especially among children.
►A closed (non-missile) head injury is
one in which the skull is not broken.
►A penetrating head injury occurs when
an object pierces the skull and
breaches the dura mater.
► Brain injuries may be diffuse,
occurring over a wide area, or focal,
located in a small, specific area.
Brain injury can be at the site of
impact, but can also be at the opposite
side of the skull due to a contrecoup
effect (the impact to the head can cause
the brain to move within the skull,
causing the brain to impact the interior of
the skull opposite the head-impact).
 Isolated scalp trauma is generally
classified as a minor injury. Because its
many blood vessels constrict poorly,
the blood bleeds porfusely when
 Trauma may result in abrasion (brush
wound), contusion, lacerartion, or
hematoma beneath the layers of the
tissue of the scalp( sublageal
 A large avulsion ( tearing away) of the scalp
may be potentially life-threatening and is a
true emergency
 Diagnosis of a scalp injury is based on
physical examination, inspection, and
 Scalp wounds are potential portals of entry
of organisms that cause intracranial
 Therefore, the area is irrigated before the
laceration is sutured, to remove foreign
material and to reduce the risk of infection.
A skull fracture is a break in one or
more of the bones in the skull caused
by a head injury. It may occur with or
without damage of the brain.
 Skull Fractures are classified as:
 Simple
 Comminuted
 Depressed
 Basilar
 A simple ( linear) fracture
is a break in the continuity
of the bone.
 It is the most common type of skull fracture, occur in 69% of
patients with severe head injury.
 Growing fracture a linear fracture can develop and lengthen as
the brain swells. This can cause growth of cysts in the meninges
 Diastatic fractures are linear fractures that cause the bones of
the skull to separate at the skull sutures in young children whose
skull bones have not yet fused
The bottom row are images from the previous slide, showing the
comminuted but undisplaced and undepressed left squamous temporal
 Comminuted skull fractures, refers to a
splintered or multiple fracture line.
 Depressed skull fractures, when bone
fragments is embeded into brain tissue

- Depressed skull fractures carries a high risk of

increasing pressure on the brain, crushing the delicate
- Depressed skull fractures may require
surgery to lift the bones off the brain if they
are causing pressure on it.
 Basilar skull fractures, breaks in bones at the base of the
skull, require more force to cause than cranial vault
 Basilar fractures have characteristic signs: blood in the
sinuses; a clear fluid called cerebrospinal fluid (CSF)
leaking from the nose or ears; raccoon eyes (bruising of
the orbits of the eyes that result from blood collecting
there as it leaks from the fracture site); and Battle's sign
(caused when blood collects behind the ears and causes
 Radiologic Examination
 Physical Examination and Evaluation of
Neurologic Status
 CT scan
 MRI ( Magnetic Resonance Imaging)
 Cerebral Angiography
 Depends on the severity and
distribution of the underlying brain
 Localized pain ( usually suggests that a
fracture is present)
 Swelling in the region of the fracture
 Nondepressed skull fractures generally
do not require surgical treatment;
however, close observation of the
patient is essential.
 Depressed skull fractures usually
requires surgery, particularly if
contaminated or deformed fractures
are present.
Cerebral Contusion
Epidural hematoma
Subdural hematoma
Diffuse axonal injury
 Concussion, from the Latin
concutera ("to shake violently")
or the Latin concussus ("action
of striking together"), is the
most common type of traumatic
brain injury (TBI). It is a
temporary loss of neurologic
function with no apparent
structural damage to the brain.
A concussion may temporarily or
permanently damage nerve
tissue, producing amnesia,
irritability, and fatigue; memory is
often impaired. Recovery from a
concussion is generally complete
and prompt after less severe

Acceleration (g-forces) can exert rotational

forces in the brain, especially the
midbrain and diencephalon.
 A concussion generally involves a period
of unconsciousness lasting from a few
seconds to a few minutes. The jarring of
the brain may be so light as to cause only
dizziness and spots before the eyes
( “seeing the stars”), or it may be severe
enough to cause complete loss of
consciousness for a time. Sometimes, post
traumatic amnesia may occur lasting up to 24
 Increased pressure on the brain stem probably
accounts for the slowing or temporary suspension
of respiration and the reduced pulse rate that
accompany a concussion; additional symptoms
include pallor, sweating, and a drop in blood
pressure. Dizziness, nausea, and a dull, restless
feeling often follow a return to consciousness.
Aftereffects such as headaches, dizziness, and
nervousness may continue for several days,
weeks, or even years after the initial injury.
 Common causes include:
 sports injuries,
 bicycle accidents,
 car accidents,
 and falls;
 the latter two are the most
frequent causes among adults.
Concussion may be caused by a blow
to the head, or by acceleration forces
without a direct impact. The forces
involved disrupt cellular processes in
the brain for days or weeks. On the
battlefield, MTBI is a potential
consequence of nearby explosions.
 The patient may be hospitalized
overnight for rest and observation or
discharged from the hospital in a
relatively short time after a concussion.
 Treatment involves observing the patient
for headache, irritability, and anxiety.
( the occurrence of these symptoms after
injury is referred to a post concussion
Cerebral contusion, Latin contusio
cerebri, a form of traumatic brain
injury, is a bruise of the brain tissue.
Like bruises in other tissues, cerebral
contusion can be associated with
multiple microhemorrhages, small
blood vessel leaks into brain tissue.
Contusion occurs in 20–30% of severe
head injuries.
 Contusion can present with weakness,
lack of motor coordination, numbness,
aphasia, and memory and cognitive
problems. Signs depend on the
contusion's location in the brain.
 Contusions typically form in a wedge-
shape with the widest part in the
outermost part of the brain.
Multiple petechial
hemorrhages has sharp
ridges by which a moving
brain can be injured.

 Often caused by a blow to the head,

 contusions commonly occur in coup or contre-
coup injuries.
 In coup injuries, the brain is injured directly
under the area of impact, while in
contrecoup injuries it is injured on the side
opposite the impact.
 Contusions occur primarily in the cortical
tissue, especially under the site of impact or
in areas of the brain located near sharp ridges
on the inside of the skull.
 Numerous small contusions from
broken capillaries that occur in grey
matter under the cortex.
 Caused by shearing injuries at the time
of impact, these contusions occur
especially at the junction between grey
and white matter and in the upper
brain stem, basal ganglia, thalamus
and areas near the third ventricle.
MRI showing damage due to
herniation in a patient who had
had contusions in the frontal

 The hemorrhages can occur as the

result of brain herniation, which can
cause arteries to tear and bleed. A
type of diffuse brain injury, multiple
petechial hemorrhages are not
always visible using current imaging
techniques like CT and MRI scans.
 Since cerebral swelling presents a danger to the
patient, treatment of cerebral contusion aims to
prevent swelling. Measures to avoid swelling
include prevention of:
 hypotension (low blood pressure),
 hyponatremia (insufficient sodium),
 hypercapnia (excess carbon dioxide in the blood).
 Due to the danger of increased intracranial
pressure, surgery may be necessary to reduce it.
People with cerebral contusion may require
intensive care and close monitoring
 Epidural or extradural
(haematoma) is a type
of traumatic brain injury
(TBI) in which a buildup of
blood occurs between the
dura mater (the tough
outer membrane of the
central nervous system) Nontraumatic epidural hematoma
and the skull. The dura in a young woman. The grey area
mater also covers the in the top left is organizing hem-
spine, so epidural bleeds atoma, causing midline shift and
may also occur in the compression of the ventricle.
spinal column.
 Often due to trauma, the condition is
potentially deadly because the buildup
of blood may increase pressure in the
intracranial space and compress
delicate brain tissue. The condition is
present in one to three percent of head
injuries. Between 15 and 20% of
patients with epidural hematomas die
of the injury.
Acute Extradural Haematoma:
Intracranial haematoma - non-evacuated

This scan shows another intracranial haematoma, namely

an extradural. You will note that this haematoma has a concave shape, a bit like the human lens
and this is because it is occurring between the bone and the dura and is not actually lying on the
surface of the brain itself. The points of attachment of the dura limit the extension of this
haematoma anteriorly and posteriorly. You can see that there is shift of the midline. Look at the
frontal horns in their relation to the falx cerebri (falx cerebri is outlined on the normal scan). This
scan would be classified "Intracranial haematoma - non evacuated."
 Symptoms are caused by the expanding
hematoma. Usually a momentary loss of
consciousness occurs at the time of
injury, followed by an interval of apparent
recovery ( lucid interval)
 Epidural bleeds, like subdural and
subarachnoid hemorrhages, are extra-
axial bleeds, occurring outside of the
brain tissue, while intra-axial
hemorrhages, including intraparenchymal
and intraventricular hemorrhages, occur
within it.
 Epidural bleeding is rapid because it is
usually from arteries, which are high
pressure. Epidural bleeds from arteries
can grow until they reach their peak
size at six to eight hours post injury,
spilling from 25 to 75 cubic
centimeters of blood into the
intracranial space. As the hematoma
expands, it strips the dura from the
inside of the skull, causing an intense
Epidural bleeds can become large and
raise intracranial pressure, causing the
brain to shift, lose blood supply, or be
crushed against the skull. Larger
hematomas cause more damage.
Epidural bleeds can quickly expand and
compress the brain stem, causing
unconsciousness, abnormal posturing,
and abnormal pupil responses to light.
The interior of the skull
has sharp
ridges by which a
moving brain can be

The main cause of epidural hematoma is usually

traumatic, although spontaneous hemorrhage is
known to occur.
 Hemorrhages commonly result from
acceleration-deceleration trauma and transverse
forces. 10% of epidural bleeds may be venous.
Epidural hematoma commonly results
from a blow to the side of the head.
The brain may be injured by prominences on
the inside of the skull as it scrapes past them.

Epidural hematoma is usually found on the

same side of the brain that was impacted by
the blow, but on very rare occasions it can be
due to a contrecoup injury.
 As with other types of intracranial
hematomas, the blood may be aspirated
surgically to remove the mass and reduce
the pressure it puts on the brain.
 The hematoma is neurosurgically evacuated
through a burr hole or craniotomy.
 The diagnosis of epidural hematoma requires
a patient to be cared for in a facility with a
neurosurgeon on call to decompress the
hematoma if necessary and stop the bleed
by ligating the injured vessel branches.
 If they can receive surgery quickly. In TBI
patients with epidural hematomas, prognosis is
better if there was a lucid interval (a period of
consciousness before coma returns) than if the
patient was comatose from the time of injury.
Unlike most forms of TBI, people with epidural
hematoma and a Glasgow Coma Score of 3 (the
lowest score) are expected to make a worst

 A subdural hematoma or subdural

haematoma (British English) also known as a
subdural hemorrhage (SDH) is a type of
hematoma, a form of traumatic brain injury in
which blood gathers within the inner
meningeal layer of the dura mater (the outer
protective covering of the brain).
 Epidural hematomas are usually caused by
tears in arteries, resulting in a buildup of blood
between the dura and the skull.
Acute Subdural Haematoma Demonstrating Midline Shift:
Midline shift >5mm
Intracranial haematoma - non evacuated
Cortical contusion >1cm in diameter
Obliteration of 3rd Ventricle (not seen - refer to normal CT scan)
This CT scan shows a right sided acute haematoma, as well as an associated cerebral contusion (bruising). The
true midline has been outlined by yellow dots and you can see that the frontal horns of the lateral ventricles have
been pushed over to the left. In addition, the third ventricle is now not visible and it is also extremely difficult to
make out the basal cisterns. This scan demonstrates four of the features which are included on the Early Outcome
Form, namely midline shift greater than 5mm, intracranial haematoma - non evacuated, cortical contusion greater
than 1cm in diameter and obliteration of the third ventricle. This haematoma requires surgical evacuation, otherwise
deterioration of the patient's condition is inevitable.
Acute Subdural Haematoma
Intracranial haematoma - non-evacuated
This scan demonstrates a left sided acute subdural haematoma. The scan is taken through a slightly higher part of
the brain and shows the bodies of the lateral ventricles. The left lateral ventricle has been compressed and the
midline is deviating to the right. The right lateral ventricle is actually slightly larger than normal and this is because
the increased pressure is preventing escape of the cerebrospinal fluid from that ventricle. Dilatation of the
contralateral ventricle like this indicates that there is very significant pressure on the brain. This scan would be
classified as "Intracranial haematoma - non evacuated" on the Early Outcome Form.
 Symptoms of subdural hemorrhage have a
slower onset than those of
epidural hemorrhages because the lower
pressure veins bleed more slowly than
arteries. Thus, signs and symptoms may
show up within 24 hours but can be delayed
as much as 2 weeks. If the bleeds are large
enough to put pressure on the brain, signs
of increased ICP or damage to part of the
brain will be present.
 A history of recent head  Weakness or lethargy
injury  Nausea or vomiting
 Loss of consciousness or  Loss of appetite
fluctuating levels of
consciousness  Personality changes
 Irritability  Inability to speak or
slurred speech
 Seizures
 Ataxia, or difficulty
 Pain walking
 Numbness  Altered breathing
 Headache (either patterns
constant or fluctuating)  Blurred Vision
 Dizziness  Deviated gaze, or
 Disorientation abnormal movement of
 Amnesia the eyes.
 Subdural hematomas are most often
caused by head injury, when fast
changing velocities within the skull may
stretch and tear small bridging veins.
 Subdural hematomas due to head injury
are described as traumatic. Much more
common than epidural hemorrhages,
subdural hemorrhages generally result
from shearing injuries due to various
rotational or linear forces.
 Subdural hemorrhage is a classic finding in
shaken baby syndrome, in which similar shearing
forces classically cause intra- and pre-retinal
 Subdural hematoma is also commonly seen in the
elderly and in alcoholics, who have evidence of
cerebral atrophy. Cerebral atrophy increases the
length the bridging veins have to traverse between
the two meningeal layers, hence increasing the
likelihood of shearing forces causing a tear.
 It is also more common in patients on
anticoagulants, especially aspirin and warfarin.
Patients on these medications can have a subdural
hematoma with a minor injury.
 Diffuse axonal injury involves
widespread damage to axons in the
cerebral hemispheres, corpus
callosum, and brain stem.
 It can be seen with mild, moderate, or
severe head trauma.
 The patient experiences no lucid
intervals, immediate coma, decorticate
and decerebrate posturing and global
cerebral edema.
Diffuse Axonal Injury:
One or more petechial haemorrhages within the brain
The presence of petechial haemorrhages is usually an indication of a very severe primary brain injury. Petechial
haemorrhages tend to occur at the interface of grey and white matter. It can also occur in the dorsolateral quadrant
of the midbrain at the middle orange arrow, as well as elsewhere within the brain substance. Note on this scan,
that the lateral ventricles and the third ventricle are visible and there is no midline shift. It is often a characteristic of
diffuse axonal injury, in which there are numerous petechial haemorrhages that there is no evidence of brain
swelling, or midline shift. This scan would be classified as showing one, or more, petechial haemorrhages within
the brain.
 DAI is classified into grades based on
severity of the injury:
 Grade I, widespread axonal damage is
present but no focal abnormalities are
 Grade II, damage found in Grade I is
present in addition to focal abnormalities,
especially in the corpus callosum.
 Grade III damage encompasses both
Grades I and II plus rostral brain stem
injury and often tears in the tissue.
 DAI is the result of traumatic shearing
forces that occur when the head is
rapidly accelerated or decelerated, as
may occur in auto accidents, falls,
and assaults. It usually results from
rotational forces or severe deceleration
 Vehicle accidents are the most
frequent cause of DAI; it can also occur
as the result of child abuse such as in
shaken baby syndrome
The major cause of damage in
DAI is the disruption of axons
, the neural processes that
allow one neuron to
communicate with another.
 Diagnosisis made by clinical signs in
conjunction with a CT or MRI scan.

 DAIis difficult to detect because it does

not show up well on CT scans or with
other macroscopic imaging techniques,
though it shows up microscopically.