Traumatic brain

injury and cerebral

resuscitation
Ahmad Syahir Abu Sahmah

OUTLINE
Anatomy
Scalp injury
Craniocerebral injury
Skull fracture
Primary TBI
Secondary TBI

Management
Cerebral resuscitation

Definition
Head injury is defined as blunt and/or penetrating
injury to the head (above the neck) and/or brain due
to external force* with temporary or permanent
impairment in brain function which may or may not
result in underlying structural changes in the brain.

To define traumatic head injury, three criteria must be

present:
i. mechanism - presence of external force*
ii. anatomical - scalp and/or face and/or skull with or
without brain injury (internal and external)
iii. physiological - alteration in physiology of the brain
such as LOC or amnesia

Anatomy

SCALP
S SKIN
C CONNECTIVE TISSUE
A APONEUROSIS
L LOOSE AREOLAR TISSUE

P - PERICRANIUM /
PERIOSTEUM

Ethiology

Road-traffic accidents
Falls
Domestic Accident
Recreational accidents
Industrial accidents
Assaults
Gun shot

Scalp injury
Scalp injury are common and may give rise to
exsanguinate hemorrhage if not controlled due to the
blood vessels in the dense fibrous layer, superficial to
the galea aponeurotica,
The abundance of blood vessel also help in speeding up
the recovery at the wound here.
The loose areolar tissue under the aponeuritica is a
dangerous zone for infection since pus can spread freely
in this layer and reach the intracranial sinuses through
the emissary veins.
In infant, this can cause severe shock.

Skull fracture
There are many types of skull fractures, usually cause
by an impact or a blow to the head thats strong enough
to break the bone. An injury to the brain can also
accompany the fracture, but thats not always the case.
A fracture isnt always easy to see.
However, symptoms that can indicate a fracture include:
swelling and tenderness around the area of impact
facial bruising
bleeding from the nostrils or ears

Type :

Simple linear fracture

Depressed fracture
Base of skull fracture
Orbital blow-out fracture

Simple linear fracture

Require no neurosurgical management but usually
are indicators of the force to which the head was
subjected.
Fracture crossing squamous temporal bone may
lacerate medial meningeal vessel and can cause
extradural hematoma

Should be admitted for

observation to exclude secondary
intracranial hematoma or
developing cerebral swelling.

Depressed skull fracture

Usually result from sharper trauma or
high velocity assault.
If the cortex below is damaged, there is
15% of risk developing epilepsy and
significant risk of developing infections.
Need suturing before referral for
debridement and elevation.
Contaminated wound
require debridement,
irrigation and duraplasty
before clossure.

Base of skull fracture

Relatively frequent fractures, often occults
radiologically but diagnosed on clinical ground.
Present with subconjuctival hematoma, anosmia,
epistaxis, nasal paraesthesia, CSF rhinorrhoea,
and occasionally caroticocavernous fistula.

 Periorbital hematoma or Raccoon eyes indicate

subgaleal hemorrhage and not necessarily base of
skull fracturing.
Middle fossa fracture involving petreous temporal
bone presented with Battle sign , CSF otorrhea or
rhinorrhea , ossicular disruption or cranial nerve
VII (facial) and VIII (vastibulocochlear) palsies.

Orbital blow out fracture

Blunt trauma to the eye
2 mechanisms
-Globe-to wall- direct force to eye
globe
-Bucking force to lower rim of orbit

Brain injury
Definition
Traumatic brain injury (TBI) is a nondegenerative, noncongenital
insult to the brain from an external mechanical force, possibly
leading to permanent or temporary impairment of cognitive,
physical, and psychosocial functions, with or without an
associated diminished or altered state of consciousness.
Can be classify on severity : mild(13-15), moderate(9-13) and
severe(3-8)(base on GCS ).
By cause : primary and secondary
By mechanism : closed and penetrated
Primary TBI caused at the time of impact.
Secondary TBI is subsequent or progressive brain damage
arising from event developing as a result of the primary brain
injury

 Based on the Monroe-Kellie Doctrine, the intracranial volume

[brain (80%), cerebral spinal fluid (CSF) (10%), and cerebral
blood volume (10%)] is fixed by the confines of the cranial
vault.
Cerebral edema, tumor, hematoma, or abscess may impinge
upon normal compartment volumes, raising intracranial
pressure (ICP).
Since brain tissue is capable of minimal compensation in
response to abnormal intracranial lesions, the CSF and cerebral
blood volume compartments must decrease accordingly to
minimize ICP elevations.
CSF compensates by draining through the lumbar plexus and
decreasing its intracranial volume. Cerebral blood volume and
cerebral blood flow (CBF) are directly related to ICP and are
normally closely controlled by autoregulation through a wide
range of systolic blood pressures, PaCO2 and PaO2
CPP = MAP ICP

Primary brain injury

Diffused axonal head injury

Cerebral concussion
Cerebral contusion and laceration

Diffused axonal brain

injury

Result from mechanical shearing at the grey-white

matter interface following severe accelerationdeceleration type forces due to differental brain
movement
This causes disruption and tearing of axons, myelin
sheaths and capillaries.

Severity can range

from mild damage
with confusion to
coma or even death.

Cerebral concussion
clinical diagnosis manifested with temporary
cerebral dysfunction, which is more severe
immediately after injury and gradually resolves after
a period of time.
Maybe accompanied with autonomic
abnormalities, bradycardia, hypotension,
swaeating and loss of consciousness
Post concussion syndrome is a complex of
symptoms persisting months after head injury
consist of variable combinations of headache,
irritabilities , depression, lassitude and vertigo.

Cerebral contusion and

lacerations
Cerebral contusion and lacerations

when a sudden physical assault on the head

causes bruising of the brain tissue.
Demonstrated withcoup-contrecoup
Demonstrated as small area of hemorrhage in
the cerebral parenchyma.
Blood brain barrier defect and cerebral edema
are invariably associated with cerebral
contusion
The pia meter and arachnoid may be torn and
intracerebral hemorrhage may accompany
this lesion.

Cerebral
contusion

Secondary brain injury

Intracranial hematomas
Cerebral edema
Hypoxemia
Ischemia
Infection
Epilapsy
Metabolic or endocrine electrolytes disturbances

Intracranial hematoma
Epidural hematoma
Occurs more common in younger age < 45y/o. Dura able to strip of
more readily in younger age.
Build up of blood occurs between the dura mater and the skull via the
meningeal artery
blood accumulation developed by the expending hematoma allowing it to
take convex configuration due to adherence of dura to the skull bone.
Clasically a lucid interval following the trauma. patient tends to present with a
fall with a brief loss of consciousness. The person wakes up, perfectly fine,
seems to be great, and not have any difficulties. After 2-3 hours, the pt
started to get drowsy and vomiting and symptoms starts to develop. The
collection of blood in that space has gotten so big that it's now pushing the
brain across in the skull, and pushing the brain down into the skull and
compressing the brain stem so that thr heart becomes irregular, breathing
becomes irregular, and patient is slipping into a coma.

 Frequently patient presented in coma and require urgent

craniectomy.
Epidural is considered surgical emergencies that will
result in death if the bleeding does not stop and the
hematoma is not removed promptly.
Prognosis is better if delay in surgical intervention is
minimized.

Subdural hemorrhage
Acccumulation of blood in the space between the
dura and arachnoid.
Disruption of a cortical vessel or brain laceration,
a/w a significant primary brain injury
Presentation: an impaired conscious level from
the time of injury, but further deterioration can
occur as the hematoma expands
Classified into : Acute SDH less then
3 days
Subacute SDH - 4-21
days
Chronic SDH more
than 21 days

Acute on chronic
subdural
hematoma,. Fresh
clotted blood
appears white,
whereas the older
altered liquid blood
appears black

Subarachnoid
hemorrhage
a subarachnoid hemorrhage is caused by the
arteries within the brain, and they run in the
arachnoid space which was the middle layer
covering the brain.
The small vessels can rip and tear during
trauma, which gives blood in the
subarachnoid space.

Intraventricular
hemorrhage

blood that goes into the ventricules , where the

cerebral spinal fluid is made.
Mimic hydrocephalus symptoms
Associated with subarachnoid hemorrhage or
brain contusion.
May need extra
ventricular
drainage or
ventriculostomy

Intraparenchymal
hemorrhage
acute accumulation of blood in the parenchyma of
the brain.
Commonly seen in penetrated injury of the brain

Cerebral hernia
Occurs due to increase of intracranial pressure due to
hematoma/mass.
3 major type :
- transtentorial
- cerebellar tonsil
- subfalcine
- foramen magnum
Further increase ICP causes herniation into foramen magnum /
coning. Coning subsequently causing Duret hemorrhage when
blood supply to brainstem is cut.
Traction to pituitary stalk can result in Diabetes incipidus.
With progression of herniation, pupil become midsize and
unreactive and invvariably irreversible events leading to
brainstem death.

Management

**Anaesthesia administer
adhering to principle of
neuroanaesthesia

Patients with mild head injury without CT

scan and with all the following criteria can
be safely observed in emergency
department* for a minimum of six hours:
- Glasgow Coma Scale score 15 on arrival or two hours
later
- no neurological abnormality
- age <65 years old
- not on any anticoagulant or antiplatelet therapy
- no history of coagulopathy
- no multiple injuries
- not intoxicated and not under influence of psychotropic
drugs

 Patients with mild head injury who have been

observed for six hours in emergency
department should be admitted if they have:
- clinical significant abnormalities on head CT imaging if it is
performed
- Glasgow Coma Scale Score <15*
- worrying signs (e.g. vomit >2 times, seizure, diffuse
headache, amnesia, abnormal behavior or neurological deficit)*
- other body system injuries requiring admission
- social problems or no supervision by a responsible adult
*Patients should have a head CT before admission

 Criteria to be met by patients of

head injury prior to discharge:
- Presence of willing responsible adult for at
least 24-hour observation
- Verbal and written discharged advice given to
responsible caregivers and discussed prior to
discharge
- Easy access to an emergency response system
e.g. 999
- Living within reasonable access to medical
care.
- Availability of home transport.

 Decompressive craniectomy
Increases buffering capacity of cranium.
Allow outward herniation preventing compression of
brain. Allow outward herniation, preventing compression
of brainstem structures and reconstruct brain perfusion `
ICP reduction vary from 15-85% depending on size of
bone removed. `
Durotomy further decreases ICP
Burr hole
Usually in case of chronic Subdural Hematoma
Extraventricular drainage
Incase of presence of increase ICP, hydrocephalus a/w
intraventricular hemorrhage

Cerebral resuscitation
Methods attempt to reduce the effects of
cerebral ischemia and damage, in order to
improve neurological outcomes
Protective measures before the second insults
by :
Maintain adequate oxygen supply & CPP
Reduce/ prevent raise of ICP
Reduce cerebral metabolic rate oxygen
consumption (CMRO2)
Reduce cell damage
AIM :

 Maintain cerebral blood flow

 Reduce CMRO2
Reduce CMRO2

Sedation

- Aim for sedation score Rikers score : -3

Temperature
Control

- maintain normothermia and avoid hyperpyrexia

Glycaemic control

- Aim dxt 6-10

Electrolytes

- regular monitoring of
electrolytes,urea,creatinine,blood sugar,
osmolality are important to determine fluid and
electrolyte therapy.

Seizure
prophylaxis
Analgesics

administration of Iv Phenytoin
eg: give IV Fentanyl before suctioning or any
procedure

 Enteral feeding 25kcal/kg/day

Aim urine output < 0.5 cc/kg/h not to exceeed
3cc/kg/h
Stress ulcer prophylaxis
TED stocking mechanical compression

Reference
Williams, Bailey and Love's Short Practice of
Surgery, 26th Edition
brain injury resuscitation guideline 2009
MOH CPG Early Management of Head Injury
(2015)
Brain trauma foundation guideline
ACS management of brain trauma
SIGN 130 Brain injury rehabilitation in
adults 2013

THANK YOU
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