BRAIN INJURIES

Vinayak Narayan
24th OSLERS Batch
,
Medical college
,Thrisur
India
 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.
 CLASSIFICATION

• PRIMARY BRAIN INJURY

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

• CLASSIFIED INTO
1.DIFFUSE AXONAL
2.CEREBRAL CONCUSSION
3.CEREBRAL CONTUSION AND
DIFFUSE AXONAL INJURY
• DUE TO SHEAR STRESS AT GREY
MATTER-WHITE MATTER JUNCTION.
• ACCELERATION-DECELERATION TYPE
FORCES DUE TO DIFFERENTIAL
BRAIN MOVEMENT.
• WALLERIAN DEGENARATION OF
NEURONS MAY OCCUR AFTER A FEW
WEEKS.
 CEREBRAL
CONCUSSION
• BRIEF LOSS OF CONSCIOUSNESS
FOLLOWED BY PROMPT RECOVERY
AND WITHOUT ANY LOCALISING
NEUROLOGIC SIGNS.
• PERIOD OF AMNESIA IS THE STRIKING
FEATURE.
• POST-CONCUSSION SYNDROME?
 C.CONTUSION-
LACERATION
• CONTUSION SEEN AS SMALL AREAS
OF HAEMORRHAGES OR MINOR
BRUISE IN THE CEREBRAL
PARENCHYMA
• BBB DEFICITS AND CEREBRAL EDEMA
MAY ACCOMPANY THIS.
• LACERATION DUE TO RAPID MOVT.
AND SHEARING OF BRAIN TISSUE.
• PIA AND ARACHNOID MAY BE TORN
 SECONDARY BRAIN
INJURY
• PROGRESSIVE BRAIN DAMAGE
EVOLVING AS A RESULT OF PRIMARY
ONE.
• CLASSIFIED INTO
1.INTRACRANIAL HAEMATOMA
2.CEREBRAL SWELLING
3.CEREBRAL HERNIATION
4.CEREBRAL ISCHAEMIA
5.INFECTIONS AND
OTHERS
 INTRACRANIAL
HAEMATOMAS
• CLASSIFIED INTO
1.EXTRADURAL
2.SUBDURAL
3.SUBARACHNOID
4.INTRACEREBRAL
 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 THE BRAIN CONVEXITY
• BURST TEMPORAL LOBE?
 CHRONIC SUBDURAL
HAEMATOMA
• MORE THAN 21 DAYS
• MOST COMMON IN INFANTS AND
ADULTS OVER 60 YRS OF AGE
• MANIFESTED AS PROGRESSIVE
NEUROLOGICAL DEFICITS MORE
THAN 3WKS AFTER THE TRAUMA
 SUBARACHNOID
HAEMORRHAGE
• TRAUMATIC ONES ARE
DIFFUSE,USUALLY CONTINUOUS
OVER THE FRONTAL LOBES AND THE
TIPS OF TEMPORAL LOBE
• TRAUMATIC LESIONS ARE USUALLY
ASSOCIATED WITH SUBDURAL H’GE
OR BRAIN LACERATION
 INTRACEREBRAL
HAEMATOMAS
• TRAUMATIC CONTUSIONS ARE
COALESCED INTO CONTUSIONAL
HAEMATOMA
• DISRUPTED CEREBRAL TISSUE
RELEASES THROMBOPLASTIN WHICH
FURTHER POTENTIATES H’GE
• SWIRL SIGN??
CEREBRAL SWELLING
• EITHER FOCALLY OR DIFFUSELY
THROUGH OUT CEREBRUM OR
CEREBELLUM
• USUAL PATHOLOGY IS THE LOSS OF
VASOMOTOR TONE
• CEREBRAL CONTUSION AND
PETECHIAL H’GES ALSO CONTRIBUTE
TO BRAIN SWELLING
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
• KERNOHAN’S NOTCH
PHENOMENON??
• DURET HAEMORRHAGES??
 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
 GRADING OF BRAIN
INJURIES
• GRADE 1- ALERT &ORIENTED WITHOUT
NEUROLOGICAL DEFICIT
• GRADE 2-- IMPAIRED CONSCIOUSNESS BUT
UNABLE TO FOLLOW ATLEAST A SIMPLE
COMMAND OR ALERT WITH A FOCAL
NEUROLOGICAL DEFICIT
• GRADE 3- UNABLE TO FOLLOW EVEN A SINGLE
COMMAND B’COZ OF IMPAIRED
CONSCIOUSNESS
• GRADE 4- NO EVIDENCE OF BRAIN
FUNCTION[BRAIN DEAD]
 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 DAMAGE
• NEUROLOGICAL
&NEUROPSYCHOLOGICAL DEFICITS
• NEUROENDOCRINE &METABOLIC
DISTURBANCES
 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
 NO HEAD INJURY IS TOO
SEVERE TO DESPAIR OF,NOR
TOO TRIVIAL TO IGNORE
-HIPPOCRATES

PRESENTATION:VINAYAK NARAYAN
EFFECTS:NISHANTH
 Thank You…

Forever Yours
Vinayak
Narayan.