Head Traumas
Anthony Safi MedIII
Neurosurgery Rotation
Glasgow Coma Scale
• GCS is the objective assessment of the level of consciousness
after trauma.
• It is divided into three categories: Eyes, Verbal and Motor; with
a maximal score of 4,5 and 6 respectively for a total of 15
points.
• A patient will be considered in a coma if they score less than 8
on the GCS.
GCS cont’d
Eyes 4- Opens 3-Opens to 2- Opens to 1- Does not
spontaneously voice painful open eyes
stimulus
Verbal 5- 4- Confused 3- 2- 1- No
Incomprehensible
Appropriate Inappropriate sounds sounds
and oriented words
Motor 6- Obeys 5- Localizes 4- 3- 2- 1- No
command painful Withdraws Decorticate Decerebrate movement
stimulus from pain posture posture
(Flexion) (Extension)
Trauma Pathology
• When a patient presents with a
unilateral, dilated non reactive
pupil is it suggestive of
ipsilateral herniation and
compressing the Oculomotor
nerve CN III.
• When a patient presents with
bilateral fixed and dilated pupils
it is a sign of diffusely increased
ICP.
Basilar Skull Fracture
• Basilar skull fractures occur on the temporal lobe most
commonly and sometimes the occipital lobe is involved.
• There are four signs that indicate a basilar skull fracture:
1. Racoon eyes (Periorbital ecchymoses)
2. Battle’s sign (Postauricular ecchymoses)
3. Hemotympanum
4. CSF rhinorrhea/otorrhea
Neuroimaging
• In a trauma patient, the following are the initial radiographic
images that are requested:
A. If patient shows altered LOC or has a GCS of less than 15, then
a Head CT scan should be performed
B. The head CT scan should be performed without IV contrast
C. C-spine CT scan
D. T/L spine x-ray in both AP and Lateral views
CT scan of C-spine
Intracranial Pressure
• Its normal values range between 5 to 15 mm H2O and it is
determined by the volume of the brain, the volume of blood and
the volume of the CSF. Physiologically, it is usually auto-
regulated and stays within the normal range.
• However, during pathological states, the ICP fails to auto-
regulate and may increase. Levels that begin to rise above 20
mm H2O require management and treatment.
• Increased ICP is commonly due to trauma which causes
swelling or bleeding within the brain. Sometimes a tight c-
collar might cause an increased ICP because it blocks venous
drainage from the brain.
• CPP which measures the net flow of blood to the brain is a
ICP cont’d
• An increased ICP causes a physiologic response known as
Cushing’s reflex.
• Cushing’s reflex is a triad of clinical signs:
1. Hypertension (CPP = MAP - ICP)
2. Bradycardia (Nucleus Tractus solitarius)
3. Decreased RR (Nucleus ambiguus)
• There are three major indications that suggest we need to
monitor ICP in a trauma patient and these are a GCS of less
than 9, an altered LOC or unconsciousness with multiple
system trauma and a decreased consciousness with a focal
ICP cont’d
• The ICP monitor bolt is placed
on what’s known as Kocher’s
point.
• Hyperventilation is a major
factor in the treatment of ICP, it
causes a decrease in Pco2 which
increases the pH and ultimately
results in cerebral
vasoconstriction which decreases
intracranial volume.
• However, a prolonged
hyperventilation might cause a
severe vasoconstriction and lead
to an ischemic brain necrosis and
should therefore be done only for
brief periods of time.
ICP treatment
• In order to treat ICP, one must follow these steps:
1. Intubate (Pco2 control)
2. Sedate (decreased cerebral blood flow and ICP; increased tolerance to ET tube) ( etomidate,
ketamine or propofol)
3. Place drain (CSF drainage by ventriculostomy)
4. Paralyze (trachea intubation, relaxation of skeletal muscles)
( succinylcholine or rocuronium)
5. Hyperventilate to Pco2 = 35
6. Elevate head of bed to 30 degrees (if spine is cleared)
Associated conditions and
management
• Trauma patients are prone to seizing, and thus in case of
seizures, administer benzodiazepines (Ativan)
• As a prophylaxis for severe trauma patients, give a 7day course
of phenytoin.
• Hyponatremia may result after head injury due to the cerebral
salt-wasting syndrome (excessive sodium excretion), however
SIADH (excessive water retention) must be ruled out first.
• Cranial nerve examination may help localize the injury in a
comatose patient. Presence of the corneal reflex indicates an
intact pons (CN V + VII). Presence of the gag reflex shows a
functioning upper medulla (CN IX + X). Beware of false
localizing sign with CN VI palsy.
Epidural hematoma
• It’s a collection of blood between the dura and the skull due to
the laceration of the meningeal arteries (MMA) by bone
fragments that result from a skull fracture.
• Common findings in patients with an epidural hematoma are an
ipsilateral blown pupil in more than 50% of the cases and a
lens-shaped hematoma on CT scan.
• Patient usually presents with loss of consciousness post injury,
followed by a “lucid interval” where the patient may be awake
and alert, however rapid neurologic deterioration ensues that
can lead to stupor, coma and death over minutes to hours.
• Patient usually requires craniotomy, to reduce pressure and
evacuate clots.
Subdural Hematoma
• It’s a collection of blood under the dura and above the
arachnoid membrane, caused by tearing of the bridging veins
that cross the subdural space or due to injury to the brain
surface with bleeding from cortical vessels.
• The are three types of subdurals:
1. Acute: with symptoms showing within 48h of injury
2. Subacute: with symptoms showing within 3 to 14 days
3. Chronic: with symptoms showing after 2 weeks or more
• The classical finding in a head CT is a curved, crescent shaped
hematoma.
Ep
Subdural Hematoma
Subarachnoid
Hemorrhage and Cerebral
Contusions
Collection of blood between the arachnoid and Pia matter.
•
Patient is given anticonvulsants and monitored.
• A cerebral contusion is a micro-hemorrhagic bruising of the
brain parenchyma. Typically two types of injuries, Coup
injuries which occur at the site of impact and Contrecoup
injuries which occur at the opposite site of the point of impact.
• One type of injury is a Diffuse Axonal Injury (DAI) which is a
shearing of the axons over a widespread area of both gray and
white matter that occur as a result of a rapid deceleration injury
which causes the brain to shift and rotate inside the skull.
Diagnosis of DAI is best made through MRI.
• Sometimes a patient might present with a neurologic deficits
Skull fracture
• A depressed skull fracture is a fracture in which a fragment(s)
of the skull is forced below the inner table of the skull.
• There are several indications for surgery in a skull fracture:
1. Contaminated wound requiring cleaning and debridement.
2. Severe deformity
3. Impingement on cortex
4. Open fracture
5. CSF leak
