Traumatic brain injuries

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Traumatic brain injuries

Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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). Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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



Classification of TBI

direct

Concussion caused by direct contusion

damage to neural tissue, axonal injury, neuronal death laceration

diffuse axonal injury

chronic

indirect Subdural, epidural intraparenchymal hematoma hemorrhage caused by consequences of lesions of vascular structures, veins, sinuses and arteries subarachnoid hemorrhage

subdural hematoma

acute

delayed intraparenchymal hemorrhage

other complications Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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). Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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)

• 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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

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




• 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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277





Epidural hematoma




• 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 ) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

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. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Acute subdural hematoma (ASDH)




• Traumatic subarachnoid hemorrhage (SAH)‫‏‬ -bleeding to CSF pathways and to subarachnoid space

• -meningeal syndrome (headache, meningeal symptoms), even altered consciousness • -spasms of cerebral arteries




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)




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 • Chronic subdural hematoma (CSDH)‫‏‬ • -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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Diagnosis of TBI

Assessment breathing, pulse, of vital blood pressure, signs oxymetric saturation

Viewing

ABC principle

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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Suspected fracture of skull or neurological symptoms

GCS < 12

GCS 13-14

GCS 15

Pt. dismissed

Deteriorating consciousness, neurological symptoms

CT

Risk group

Xray of skull Fracture Monitoring neurosurgical consultation

SURGERY Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Risk groups in TBI

Age

> 65 years

subdural hematoma

Medication

warfarine,sedative d., barbiturates, analgesics

higher risk of bleeding, resp. distortion of clinical picture

Mechanism of injury

car accidents, falls form height, being attacked

fractures of skull, skull base, mostly polytrauma,cervical spine trauma

Other diseases

hepatopathy, TB, stroke, brain surgery in medical history, coagulation disorders

tendency to bleeding

alcohol, drugs of abusey

subdural hematoma, tendency to bleeding hepatopathy

Abuse



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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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!!! Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Location of the lesion

SC segments don´t correspond to verebral levels!!!



Dermatomes


Complete loss of motor, sensory functions, including proprioception


Loss of sensory f., contralerally – thermic and nociceptive. Homolat.paresis and altered proprioception

Dominating symptom

Location

Pathology Histology

Neurological examination

Transversal SC lesion

Contusion or even necrosis – transection of SC

BrownSéquard´s hemisyndrome

Loss of motor and sens. functions, preserved proprioception

Anterior SC lesion sy.

Partial loss of motor, sensory functions

Loss of proprioception – motor f., and nociceptive and thermic sensory f. normal

Posterior SC lesion sy.

Distal weakness more pronounced on upper limbs, dysesthesias. , Syringo-myelic dissociation under lesion level

Central SC lesion sy.

Localized necrosis after contusion, laceration, hemorrhage, ischemic lesion Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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%

Th 1-Th 4

30-50%

under Th 5

minimal alteration

non-effective,weak weak normal

*Level of SC lesion and respiratory failure, represented by Total Lung Vital Capacity TLVC Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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

Preserved sensation only

injury C. Incomplete neurological

Partially preserved motor f.,

injury

muscle strength under 3

D. Incomplete neurological

Preserved motor f., muscle

injury

strength more than 3

E. Normal motor and sensory

functions



Muscle strength grading acc. to muscle test Grade 5

Grade 2

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

Grade 1

Weak contraction, no movements (twitch, traces)

Grade 0

No contraction activity

Grade 4 Grade 3



Diagnosis

Imaging techniques: X-ray (3 projections anteroposterior, lateral, transoral – odontoid fracture)‫‏‬

CT examination (axial sections, 3D imaging)‫‏‬ MRI in soft tissue lesion lesion including spinal cord (possibility of direct sagittal sections). Other diagnostic techniques: electromyography, somatosensory evoked potentials, motor evoked potentials Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Therapy

• ABC principles are valid • administration of bolus methylprednisolone 30 mg/kg (anti-shock and antiedematous effect)‫‏‬ • 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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

Traumatic brain injuries

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