.Radiological evaluation of head trauma .doc

Neurosurgery

Head injury
Dr.saad Farhan Al- Masoudi :5th Class
Radiological evaluation of head trauma :-

CT scan : almost without exception , an unenhanced (i.e.- non contrast ) CT scan of brain suffices for patients seen in emergency department presenting after trauma or with new neurological deficit .
The main emergent conditions to rule out :
1. blood ( hemorrhages or hematomas )
a. EDH ( extradural hematoma )
b. SDH ( subdural hematoma )
c. subarachnoid hemorrhage
d. intracerebral hemorrhage
e. intraventricular hemorrhage

2. hydrocephalus .

3. cerebral swelling
4. evidence of cerebral anoxia , loss of gray white interface .
5. skull fracture ( linear , depressed , diastatic .)
6. ischemic infarction
7. pneumocephalus → air inside skull ( in skull fracture )
8. shift of midline structures


Indication for initial CT san :-
A. moderate to severe heal injury which criteria:
GCS ≤ 14
unresponsiveness
focal deficit
amnesia for injury
altered mental status
deterioration in neurological status
sign of basal or vault fractures

B. assessment prior to general anaesthesia for other procdures .

II . skull x .ray : skull x . ray affect management of only 0.4-2% patients in most reports .
Skull x. ray may be helpful in following :-
in patients with moderate risk for intracranial injuries by detecting unsuspected depressed skull fracture .
if CT scan can not obtain to identify pineal gland shifting , pneumocephalus , air fluid levels in the air sinuses , skull fractures .
in patients with penetrating missile injuries .

III . MRI :- usually not appropriate for acute head injuries while MRT is more sensative than CT, there were no surgical lesions demonstrated on MRI that were not evident on CT .

IV . arteriogram in trauma :- cerebral arteriogram useful with non missile penetrating trauma , also useful in experienced hands if CT is unavailable for diagnosing EDH .


Resuscitation of multiply injured patient :

Classified to primary survey and secondary survey with Resuscitation .

* Primary survery :- anoxia and cardiac arrest result in cessation of oxidative phosphorylation within 15 20 seconds making the brain and other tissues depend upon anaerobic metabolism and depletion of ATP stores thus , the best response is to provide an airway if an adequate one does not sexist , so I survey include :-
air way establishment
oro pharyngeal tube
naso pharyngeal tube
crico thyroidotomy .
ventilation .
after an airway is established , breathing or ventilation must be assured by auscultation of both lung fields .
circulation :
assessment and management . crystalloid solutions , blood , plasma , colloid fluid , and hyper tonic saline .

* secondary survey :-

which involve a many detailed examination of individual body regions and which include :

Head and neck

Head : wounds , fracture in face and skull , CSF leak
Neck : Neck wound , Hematoma
Chest : tension or open pneumothorax , hemothorax , cardiac tamponade and cardiac contusion .
Abdomen : abdominal injury either by penetrating or blunt trauma .
extremities : bleeding should be stopped and replaced , decrease in limbs perfusion should also be identify and treated.


* Intestine management of traumatic brain injuries :

It classified to 3 parts

A. management at accident site or during transport to hospital .
aim : To prevent hypoxia and hypotension
RX:
hypoxia corrected by :
clear air way .
air way tube and ambo bag
endotracheal tube or crico thyroidotomy
assisted ventilation with positive pressure ventilation ( PPV )

2. circulation corrected by :

- fluid replacement exp. ( NaCl , Ringer )
- military antishock trousers ( MAST) for rising BP
B. management at emergency room .
Aim : To prevent secondary brain injury and diagnose the pathology .
The management of head injury emergency unit include :
1. evaluation of patient with head inj. .I. general
2.Neurological
CT scan for unconscious patient to exclude intra cranial pathology as soon as 4 hrs .
lab test include blood gas , complete bl. Pictures coagulation profile ect
if available investigate and diagnose for cerebral blood flow ( CBF ) by Trans cranial Doppler (TCD ) ultra sonography .
treatment of patient with H.I. in emerging unit divided to .
medical treatment including assessment and resuscitation of traumatize patient by primary and secondary survey.
Surgical treatment for intracranial surgical pathology like depressed fracture hemaoma whether extrdural , subdural , intraventricular ..


C. management at intensive care unit :- which include

ventilation assessment and assistant by controlled ventilation (PEEP 15 mmHg ) or hyperventilation .
monitoring of Blood pressure .
Monitoring and treatment of fluid , volume , and electrolytes status .
seizures monitoring and treatment .
pulmonary therapy to decrease infection and oedema in ARDS or fat embolism .
Monitoring and treatment of ↑ ICP .
↑ CCP ( cerebral perfusion pressure ) to level of 60 – 70 mmHg .
nutrition and metabolic support ( NG feeling ) .

* Outcome prediction in severe head injury . by

neurological status
GCS
Brain stem function
Pupillary responsiveness .

age of patients younger children , infant and elderly patient had a poor prognosis

Neurological status and age of patient one the most important prediction factors .


vital sign :- hypoxia , hypotension .
CT scan finding like brain shift or cisternal obliteration → poor prognosis .
increase ICP for those more than 30 mmHg after medical and surgical treatment → poor prognosis .
evoked potentials like somatosensory evoked potential and brain stem auditory evoked potential if they are abnormal → poor prognosis

* Indications for admission to hospital in patient with head trauma :

History : 1. history of impaired consciousness or fits
2. progressive headache .
3. vomiting
4. post traumatic amnesia 30 min .
5. Dizziness or blurring of vision .
6. unreliable or inadequate history .
7. unaccompanied patient or patient with diffuclt access to hospital

Examination :-

8. any neurological abnormality or impaired consciousness .
9. evidence of basal or depressed fracture .
10. suspected skull penetration .

Diffuclt to assess :-

11. all children under 6 years
12. patient under the effect of alcohole or drugs.

Radiological evaluation :-
13. all skull fracture .
14.abnormality on CT scan


Medial indication :-
15. diabetic , hypertensive or with history of other chronic diseases .
16. patient under treatment with anticoagulant , insulin or other potential drugs .

Skull fractures :

* linear # : DX:- skull x-ray , CT scan
RX :- conservative unless there is underlying hematoma like EDH.


Depressed # :- DX: skull x-ray , CT scan . to treat this type of fracture we have to classify it to open fracture ( compound ) and closed fracture ( simple ) ie no wound over it .
Indication for surgical correction or elevation of fracture .
compound fracture ( open )
associated with neurological deficit .
associated with epilepsy
associated with CSF leak ie dural laceration .
closed fracture but cause significant cosmetic deformity like close fracture in frontal bone .
closed fracture but extend to air sinuses .
closed fracture associated with under lying hematoma like EDH , SDH .

RX: 1.antibiotic treatment .

2. antiepileptic drugs if # associated with fits
3. surgical treatment by elevation of # ( craniectomy ) and dural suturing if teared .


* comminuted # and dislatic # treated conservatively unless there is underlying hematoma .

Acute traumatic intracranial hematomas :-

*Extramural hematomas :- incidence of epidural or extramural H. 1% of head trauma , male 4:1 , most occure in young adult .
The temperoparietal fracture disrupts the middle meningeal artery as it exist in a bony groove at the pterion causing arterial bleeding that dissect dura from inner table of skull and this kind of bleeder compromise 85% of source in EDH, some case bleeding come form middle meningeal vein or dural sinuses .

Clinical features :-

brief post traumatic loss of consciousness (L.O.C )
followed by a lucid interval for several hrs .
then obtundation , ipsilateral dilatation of pupile , contra lateral hemiparesis .
if not treated it can go to produce decerebrate rigidity , respiratory distress and death .
other presenting finding vomiting , fit , hyperreflexia , Bradycardia is a late finding .

DX : skull x-ray , CT scan . ( Dome shape ) .

RX : →
conservative treatment for small hematoma ≤ 1cm maximal thickness with minimal neurological deficit ( sign & symptoms ) .
surgical treatment by ( craniotomy ) for .
colt removal
homeostasis
prevent reaccumulation .


* Subdural hematoma :-
The magnitude of impact damage is usually much higher in acute subdural than in extradural hematoma . which generally makes this lesion much more lethal .

C.F : mostly due to compressing of under lying brain tissue with midline shift in addition to parenchymal brain damage and possibility of cerebral oedema .

DX: CT scan ( crescent shape ) .

RX : rapid surgical evacuation should be considered for symptomatic hematoma that are greater than about 1 cm at the thickness points . small hematoma usually does not require evacuation .
Evacuation of hematoma by craniotomy flap .

Complications of head injury :

infections :- meningitis , abscess
CSF fistula
chronic subdural hematoma
late epilepsy
post concussion syndrome
carotid cavernous fistula ( cc fistula )
tumor !!

penetrating injury to head ( Gun shot ) :

Gunshot injury to head account for the majority of penetrating brain injuries .

* primary injuries : result from a number of factor , include :

injury to soft tissue scalp , facial injuries .
comminuted fracture of bone leading to adjacent vascular injury .
cerebral injury ether direct inj by bullet or missile or indirectly through shock wave and coup + contrecoup from missile impact injury .

* secondary injuries :

cerebral oedema →↑ICP .
↓ in CPP CPP = MAP - ICP
↓ cardiac output .
Respiratory instability .

Management : in steps

General and neurological evaluation .
Resuscitation of patients .
Re evaluation again after resuscitation .
Management that depend on neurological status ( GCS ) .

GCS < 13 → surgical debridement of injury site

GCS G -12 →surgical debridement unless IC inj. is bihemispheric or intraventricular hemorrhage
GCS > 6 →No surgical treatment unless there is extradural hematoma


Conservative treatment in penetrating injury include .
AB
Antiepileptic
Suturing of injury site (inlet of bullet )










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