Traumatic brain injuries

Traumatic brain injuries

Traumatic brain injuries (TBI) 2 million people are affected in the USA / year 100.000 cases with fatal consequences financial costs for treatment are more than 25 billion USD per year (National Institute of Health, 1998).

Traumatic brain injuries clasiffication direct and indirect X acute and chronic X closed and penetrating

Classification of TBI direct indirect Concussion caused by contusion direct damage to neural tissue, axonal injury, neuronal death laceration diffuse axonal injury Subdural, epidural hematoma caused by consequences of lesions of vascular structures, veins, sinuses and arteries subarachnoid hemorrhage intraparenchymal hemorrhage acute chronic subdural hematoma delayed intraparenchymal hemorrhage other complications

Direct acute brain injuries Brain concussion reversible injury with temporarily altered functions -loss of consciousness of variable duration -retrogade and eventually anterograde amnesia -normal clinical findings -post-concusision symptoms (headache, photophobia, vegetative symptoms, altered behaviour etc.)

Direct acute brain injuries Contusion - bruise of the brain tissue by acting physical forces ( par coup ) x ( par contrecoup ) Inconstant disorder of consciousness focal symptoms brain edema Laceration the brain tissue is torn More extensive damage to brain and vessels, often followed by subarachnoidal hemorrhage (SAH) and intracerebral hematoma (ICH).

Direct acute brain injuries Diffuse axonal injury (DAI) Caused by rotation and translation traumatic forces to corpus callosum and brainstem, Diagnosis: medical history, -severe disorder of consciousness -MRI imaging -vegetative state

Indirect acute brain injuries Acute epidural hematoma (AEDH) Praha & EU: Investujeme do vaší budoucnosti Fracture of skull and rupture of medial meningeal artery Fast progredient bleeding Increase in ICP (uncal, tentorial or occipital herniation) Lucid interval Diagnosis: medical hist. -herniation symptoms -brain CT

Case report I: acute epidural hematoma 60 year old man Reffered to a hospital for a car accident (high speed, broken frontal window) No risk medication

Case report I: acute epidural hematoma GCS 7, patient intubated, at ht ebeginning speaking with paramedics, then progredient unconsiousness, anisocoria, mydriasis on the right side CT scan Acute epidural hematoma in frontal region Frontal bone fracture, signs of central herniation

Case report I: acute epidural hematoma

Epidural hematoma

Indirect acute brain injuries Acute subdural hematoma (ASDH) - the most common type among hematomas - even after negligible trauma - consequence of rupture of bridging veins - most frequently frontal and parietal location (15-20% bilaterally). - focal symptoms (from direct pressure of hematoma or from herniation), altered consciousness - common in elderly and risk patients (bleeding diathesis, bleeding tendency )

Case report II: acute subdural hematoma 82 year old woman History of chronic alcohol abuse Reffered to a hospital for a fall from stairs Worked as teacher, last year changes in behaviour and cognition CT scan performed 1 month ago, only marked atrophy of the brain. Warfarin therapy due to Atrial fibrillation

Case report II: acute subdural hematoma INR 3.2 GCS 9, left sided hemiparesis, anisocoria, mydriasis on the right side CT scan Acute subdural hematoma on the convexity of right hemisphere in Temporal-Parietal region.

Acute subdural hematoma (ASDH)

Indirect acute brain injuries ( SAH ) Traumatic subarachnoid hemorrhage -bleeding to CSF pathways and to subarachnoid space -meningeal syndrome (headache, meningeal symptoms), even altered consciousness -spasms of cerebral arteries

Indirect acute brain injuries Intracerebral hematoma (ICH) with subacute onset -as a damage to brain tissue and b. vessels -with contusion and laceration frontal and temporal localization (then direct injury) -CT: normal findings in acute stage -even progressive loss of consciousness -follow-up CT of brain (after 12-24 hours)

Indirect acute brain injuries Pneumocephalus -presence of air in the intracranial space -may accompany penetrating head injuries Acute subdural hygroma torn arachnoid mater and leakage of CSF into subdural space

Indirect chronic brain injuries ( CSDH ) Chronic subdural hematoma -may be accidental finding in CT examination -headache, altered mental functions, event. focal symptoms

Case report III: chronic subdural hematoma 58 year old man History of chronic alcohol abuse Reffered to a hospital for epileptic seizure Works as railway-worker, recently no changes in behaviour or cognition Previous day alcohol consumption higher than usually (birthday) No risk medication in a history, chronic headache

Case report III: chronic subdural hematoma INR 2.05 GCS 13, confusion, headache, no other neurological deficit CT scan

Late complications of TBI Hydrocephalus Delayed intracerebral hemorrhage Organic psychosyndrome Posttraumatic epilepsy

Diagnosis of TBI Assessment of vital signs breathing, pulse, blood pressure, oxymetric saturation ABC principle Viewing Signs of trauma (hematomas) otorrhea, rhinorrhea

Diagnostics of TBI KT Clinical examination Level of consciousness Brainstem symptoms Focal symptoms Meningeal sy. Behavioral changes, memory disturbances GCS cranial nerves, pupils anisocoria, mydriasis! Altered motor functions, sensory f., coordination, speech disorder amnesia

Suspected fracture of skull or neurological symptoms GCS < 12 GCS 13-14 GCS 15 Pt. dismissed CT Deteriorating consciousness, neurological symptoms Fracture Xray of skull Monitoring Risk group neurosurgical consultation SURGERY

Risk groups in TBI Age > 65 years subdural hematoma Medication Mechanism of injury Other diseases Abuse warfarine,sedative d., barbiturates, analgesics car accidents, falls form height, being attacked hepatopathy, TB, stroke, brain surgery in medical history, coagulation disorders alcohol, drugs of abusey higher risk of bleeding, resp. distortion of clinical picture fractures of skull, skull base, mostly polytrauma,cervical spine trauma tendency to bleeding subdural hematoma, tendency to bleeding hepatopathy

Therapy valid principles of ABC fixation of C spine and transport to ICU at traumatology, neurosurgical or orthopedic Neurosurgical interventions *Except from chronic hematomas in patients over 70 years without middle-line structures shift, where conservative approach can be applied

Spinal cord injuries (SCI)

Spinal cord injuries (SCI) Classification according to extent of injury Complete Transversal lesions of spinal cord Loss of all spinal cord functions distally from lesioned segment (spinal shock), Incomplete Lesions of spinal cord parts and of pathways that pass through them posterior cord sy. lateral cord sy., Brown-Séquard s hemiplegia

Mechanism of SCI lateral bending, dislocation, axial loading, rotation forces (whiplash injury, hyperflexion, hyperextension) compression and lesion by vertebral fragments or by hematoma secondary ischemic spinal cord lesion caused by vascular damage 25 % of SCI are associated with traumatic brain injury!!!

Location of the lesion SC segments don t correspond to verebral levels!!!

Dermatomes

Complete loss of motor, sensory functions, including proprioception Praha & EU: Investujeme do vaší budoucnosti Neurological examination Partial loss of motor, sensory functions Dominating symptom Loss of sensory f., contralerally thermic and nociceptive. Homolat.paresis and altered proprioception Loss of motor and sens. functions, preserved proprioception Loss of proprioception motor f., and nociceptive and thermic sensory f. normal Distal weakness more pronounced on upper limbs, dysesthesias., Syringo-myelic dissociation under lesion level Location Transversal SC lesion Brown- Séquard s hemisyndrome Anterior SC lesion sy. Posterior SC lesion sy. Central SC lesion sy. Pathology Histology Contusion or even necrosis transection of SC Localized necrosis after contusion, laceration, hemorrhage, ischemic lesion

Respiratory changes in SCI depending on the lesion level Level of lesion TLVC Coughing C1 and C2 5-10% not present C3 to C7 20% non-effective,weak Th 1-Th 4 30-50% weak under Th 5 minimal alteration normal *Level of SC lesion and respiratory failure, represented by Total Lung Vital Capacity TLVC

Vegetative dysfunction in SCI Hypotension Bradycardia Misleading especially when concomitant hypovolemic shock is present!!!!! Urinary retention Hypothermia Constipation Ileus, priapism *Horner syndrome (ie, ipsilateral ptosis, miosis, anhydrosis) present in higher lesions due to interruption of the descending sympathetic pathways from the hypothalamus.

Spinal shock quadriplegia with upper and lower extremity areflexia; anesthesia below the affected level neurogenic shock (hypothermia and hypotension without compensatory tachycardia) loss of rectal and bladder sphincter tone; In acute phase, lasts up to 12 weeks

Classification of SCI according to Frankel A. Complete neurological injury No motor and sensory f. under the lesion level B. Incomplete neurological injury C. Incomplete neurological injury D. Incomplete neurological injury E. Normal motor and sensory functions Preserved sensation only Partially preserved motor f., muscle strength under 3 Preserved motor f., muscle strength more than 3

Muscle strength grading acc. to muscle test Grade 5 Grade 4 Grade 3 Grade 2 Grade 1 Grade 0 Pacient can resist against maximal force, full extent of movements Patient can resist against strong, moderate force and gravity, full extent of movements Contraction with movement against gravity, not against force, full extent of movements Contraction, weak movements, not against gravity Weak contraction, no movements (twitch, traces) No contraction activity

Diagnosis Imaging techniques: X-ray (3 projections anteroposterior, lateral, ( fracture transoral odontoid ( imaging CT examination (axial sections, 3D MRI in soft tissue lesion lesion including spinal cord (possibility of direct sagittal sections). Other diagnostic techniques: electromyography, somatosensory evoked potentials, motor evoked potentials

Therapy ABC principles are valid administration of bolus methylprednisolone 30 mg/kg ( effect (anti-shock and antiedematous obligatory insertion of urinary catether fixation of spine and transport to spinal unit, or to traumatology, neurosurgical or orthopedic centres in stabilized position operative stabilization of spine and SC decompression