BRAIN INJURIES

Sri maliawan
19-5-2011 ,
Faculty of MedicineUdayana University
Etiology

mekanism
ANATOMy
 scalp
Skin, subcutis, galea
aponeurotica, loose
connective tisue,
pericranium/perioste
um

Cephal haematome ?
Fracture atap tengkorak = calvaria
= cranial vault
 Fraktur dasar
tengkorak=basis
cranii=skull base
Otorhea
Rhinorhea
Periorbital echymosis (brill
haematoma = racoon eyes)
Batle sign= retroauricular
haematoma
haemotympanum
 Periorbital echymosis

atle sign= retroauricular haematoma

(brill haematoma = racoon eyes
Aerocele
infeksi
lesi nervus I, II, VII, VIII
CCF
NEUROSURGICAL CASE
A 19 yr OLD BOY HAVING THE HISTORY OF FALL
FROM A BIKE ,HITTING THE RIGHT SIDE OF HIS
HEAD FORCEFULLY ON THE ROAD IS BROUGHT
TO THE CASUALTY .ON EXAMINATION HIS
PULSE:40/MIN,
B.P :170/110mmHg
ON FUNDOSCOPIC EXAMINATION HE HAS
VENOUS DISTENSION AND ABSENT
PULSATIONS OF THE RETINAL
VASCULATURE.ALSO ON SYSTEMIC
EXAMINATION HIS LIMBS ON THE LEFT SIDE
ARE MORE FLACCID THAN THE RIGHT SIDE.
-WHAT MAY BE THE LIKELY DIAGNOSIS?
 DEFINITION
ANY INJURY TO THE BRAIN,
REGARDLESS OF THE AGE OF ONSET,WHETHER
MECHANICAL OR INFECTIOUS IN ORIGIN,THE
RESULT OF WHICH MAY BE EXPECTED TO
CONTINUE INDEFINITELY CONSTITUTING A
SUBSTANTIAL HANDICAP TO THE INDIVIDUAL
EITHER OR WHICH MAY DIRECTLY RESULTING
IN SOME SORT OF NEUROLOGICAL
IMPAIRMENT.
 GCS for adult

Eye Opening Best motor

response
Spontaneous 4 Obeys verbal command 6
To verbal command 3 Localized pain 5
To pain 2 Flexion, withdrawal 4
None 1 Abnormal flexion, decorticate
3
Extension decerebrate 2
Best Verbal response None 1

Oriented, conversing 5
Disoriented, conversing 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
 Clasifikasi klinis

Cedera kepala ringan (CKR)

= mild head injury GCS
14 -15
Cedera kepala sedang
(CKS) = moderate head
injury GCS 9-13
Cedera Kepala Berat (CKB)
 COMA

Coma = tidak sadar

GCS 3-8
Coma dalam = deep coma
GCS 3
Mata bengkak sulit di
evaluasi, E =X
Afasia motorik, V = X
 CLASSIFICATION

PRIMARY BRAIN INJURY

SECONDARY BRAIN
INJURY
 PRIMARY BRAIN
INJURY
INJURY CAUSED AT THE
TIME OF IMPACT.
IRREVERSIBLE

CLASSIFIED INTO
1.DIFFUSE AXONAL
DIFFUSE AXONAL
INJURY
DUE TO SHEAR STRESS
AT GREY MATTER-WHITE
MATTER JUNCTION.
ACCELERATION-
DECELERATION TYPE
FORCES DUE TO
DIFFERENTIAL BRAIN
 CEREBRAL
CONCUSSION
BRIEF LOSS OF
CONSCIOUSNESS
FOLLOWED BY PROMPT
RECOVERY AND WITHOUT
ANY LOCALISING
NEUROLOGIC SIGNS.
PERIOD OF AMNESIA IS
 C.CONTUSION-
LACERATION
CONTUSION SEEN AS
SMALL AREAS OF
HAEMORRHAGES OR
MINOR BRUISE IN THE
CEREBRAL PARENCHYMA
BBB DEFICITS AND
CEREBRAL EDEMA MAY
 SECONDARY BRAIN
INJURY
PROGRESSIVE BRAIN
DAMAGE EVOLVING AS A
RESULT OF PRIMARY
ONE.
CLASSIFIED INTO
1.INTRACRANIAL
HAEMATOMA
2.CEREBRAL SWELLING
 COMA

Coma = tidak sadar

GCS 3-8
Coma dalam = deep coma
GCS 3
Mata bengkak sulit di
evaluasi, E =X
Afasia motorik, V = X
 Complication Acute
1 Epidural hematoma
 INTRACRANIAL
HAEMATOMAS
CLASSIFIED INTO
1.EXTRADURAL
2.SUBDURAL
3.SUBARACHNOID
4.INTRACEREBRAL
Susfected intracranial
haemorhage ?
Subjective : cephalgia, nausea,
vomitting and vertigo getting
worst or gradually proggress.
reslessness
Cushing response
Alteration df consciousness
Lateralisation.
 lateralisation
Anisocor of pupilRight
Right and left light Reflect
of pupil is not equal.
Hemiparese or hemiplegia
Refleck babinsky, positive
at the right or left leg.
 EXTRADURAL
HAEMATOMA
DUE TO LACERATION OR
RUPTURE OF MIDDLE
MENINGEAL ARTERY.
LUCID INTERVAL IS THE
NOTABLE FEATURE
 SUBDURAL
HAEMATOMA
MOST COMMON
INTRACRANIAL MASS
LESIONS ARISING FROM
HEAD TRAUMA.
CLASSIFIED INTO
1.ACUTE 2.SUBACUTE
3.CHRONIC
 ACUTE SUBDURAL
HAEMATOMA
LESS THAN THREE DAYS
TORN-BRIDGING VEINS
OR FOCAL TEARS OF
CORTICAL ARTERIES ARE
THE USUAL CAUSES
BLOOD FOLLOWS
SUBDURAL SPACE OVER
 CHRONIC SUBDURAL
HAEMATOMA
MORE THAN 21 DAYS
MOST COMMON IN
INFANTS AND ADULTS
OVER 60 YRS OF AGE
MANIFESTED AS
PROGRESSIVE
NEUROLOGICAL DEFICITS
 SUBARACHNOID
HAEMORRHAGE
TRAUMATIC ONES ARE
DIFFUSE,USUALLY
CONTINUOUS OVER THE
FRONTAL LOBES AND
THE TIPS OF TEMPORAL
LOBE
TRAUMATIC LESIONS ARE
 INTRACEREBRAL
HAEMATOMAS
TRAUMATIC CONTUSIONS
ARE COALESCED INTO
CONTUSIONAL
HAEMATOMA
DISRUPTED CEREBRAL
TISSUE RELEASES
THROMBOPLASTIN
CEREBRAL SWELLING
EITHER FOCALLY OR
DIFFUSELY THROUGH
OUT CEREBRUM OR
CEREBELLUM
USUAL PATHOLOGY IS
THE LOSS OF
VASOMOTOR TONE
CEREBRAL ISCHAEMIA
COMMON AFTER SEVERE
HEAD TRAUMA
USUALLY CAUSED BY
HYPOXIA ,IMPAIRED
CEREBRAL PERFUSION
OR BOTH
CEREBRAL HERNIATION
TYPES ARE
1.TRANSTENTORIAL
2.FORAMEN MAGNUM
3.SUBFALCINE
KERNOHANS NOTCH
PHENOMENON??
DURET
 INFECTIONS,SEIZURES
&HYDROCEPHALUS
PENETRATING SKULL
TRAUMA,DEPRESSED SKULL
FRACTURES &BASE OF SKULL
FRACTURES ALL PROVIDE PORTALS
FOR CNS INFECTION
OBSTRUCTION TO CSF OUTFLOW DUE
TO INTERVENTRICULAR BLOOD OR
POST TRAUMATIC COMMUNICATING
HYDROCEPHALUS
SEIZURES INCREASES ICT;INCREASED
CHANCE FOR BRAIN INJURY
COMPLICATIONS OF HEAD
INJURY
PRIMARY-CONCUSSION,BONE
FRAGMENTATION,BRAINSTEM
CONTUSIONS,CORTICAL LACERATIONS
&DIFFUSE AXONAL
INJURY
SECONDARY-INTRACRANIAL
HAEMATOMAS,CEREBRAL
EDEMA,HYPOXAEMIA,ISCHAEMIA,
INFECTION,EPILEPSY,METABOLIC OR
ENDOCRINE DISTURBANCES
 MANAGEMENT
THE KEY ASPECTS IN MANAGEMENT ARE
1.ABCDE RULES OF TRAUMA
MANAGEMENT[ATLS] 2.ACCURATE
CLINICAL ASSESSMENT 3.IDENTIFY
THE PATHOLOGICAL PROCESS
INVOLVED 4.RADIOLOGICAL
ASSESSMENT [X- RAY SKULL,CT
SCAN ,MRI] 5.OTHER NEWER OPTIONS
 SUMMARY OF
MANAGEMENT
Patient with CLOSED HEAD INJURY

NO CONCUSSION CONCUSSION

NEUROLOGIC EXAM. & X-RAY NEUROLOGIC EXAM. & X-RAY

NORMAL ABNORMAL ABNORMAL NORMAL

OBSERVE FOR 24hrs

SEND HOME

SEND HOME IF NORMAL

ADMIT TO NMCH
 POST ADMISSION

After Admission

CT or MRI BRAIN SCAN

NORMAL BLOOD CLOT

SUBDURAL OR INTRACEREBRAL CLOT

OBSERVE FOR 24 hrs EPIDURAL CLOT

CLOT LARGE OR
CONSULT NS
NEUROLOGIC SIGNS PRESENT

Sx INDICATED AT TIMES
SURGICAL EVACUATION
NON-ACCIDENTAL HEAD
INJURIES
INFANTILE CHRONIC
SUBDURAL HAEMATOMA
OR EFFUSION
BIRTH TRAUMA IS A
FREQUENT CAUSE
FUNDOSCOPY,CT,MRI
 MISSILE INJURIES
CAUSES CEREBRAL DAMAGE BY,
1.MECHANICAL LACERATION OF
BRAIN TISSUE 2.SHOCK WAVE
PROMULGATED AHEAD OF THE
MISSILE 3.CAVITATION IN THE WAKE
OF MISSILE
HIGH
VELOCITYINJURY,TRANSVENTRICULAR
WOUNDS & A LOW GLASGOW COMA
SCALE ARE ASSO. WITH FATAL OUTCOME
 DELAYED EFFECTS OF
HEAD INJURY
POST-TRAUMATIC
EPILEPSY
CEREBRO SPINAL FLUID
FISTULA
POST-CONCUSSIONAL
SYMPTOMS
CUMULATIVE BRAIN
NEUROSURGICAL CASE
A 19 yr OLD BOY HAVING THE HISTORY OF FALL
FROM A BIKE ,HITTING THE RIGHT SIDE OF HIS
HEAD FORCEFULLY ON THE ROAD IS BROUGHT
TO THE CASUALTY .ON EXAMINATION HIS
PULSE:40/MIN,
B.P :170/110mmHg
ON FUNDOSCOPIC EXAMINATION HE HAS
VENOUS DISTENSION AND ABSENT
PULSATIONS OF THE RETINAL
VASCULATURE.ALSO ON SYSTEMIC
EXAMINATION HIS LIMBS ON THE LEFT SIDE
ARE MORE FLACCID THAN THE RIGHT SIDE.
-WHAT MAY BE THE LIKELY DIAGNOSIS?
 NEUROSURGICAL CASE
+VE FINDINGS
A 19 yr OLD BOY HAVING THE HISTORY OF FALL
FROM A BIKE ,HITTING THE RIGHT SIDE OF HIS
HEAD FORCEFULLY ON THE ROAD IS BROUGHT
TO THE CASUALTY .ON EXAMINATION HIS
PULSE:40/MIN,
B.P :170/110mmHg
ON FUNDOSCOPIC EXAMINATION HE HAS
VENOUS DISTENSION AND ABSENT
PULSATIONS OF THE RETINAL
VASCULATURE.ALSO ON SYSTEMIC
EXAMINATION HIS LIMBS ON THE LEFT SIDE
ARE MORE FLACCID THAN THE RIGHT SIDE.
-WHAT MAY BE THE LIKELY DIAGNOSIS?
PATHOPHYSIOLOGY
 -HIPPOCRATES
NO HEAD INJURY IS TOO
SEVERE TO DESPAIR OF,NOR
TOO TRIVIAL TO IGNORE
Thank you
 Clasifikasi klinis

Cedera kepala ringan (CKR)

= mild head injury GCS
14 -15
Cedera kepala sedang
(CKS) = moderate head
injury GCS 9-13
Cedera Kepala Berat (CKB)