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Head Trauma. Artun KIRKER. MVA FALLING OF HEIGHTS VIOLENCE SPORTS PENETRATING WOUNDS INDUSTRIAL AND DOMESTIC ACCIDENTS One of the most frequent cause of death and disability in young adults. LOC:Loss of consciousness PTA:Post traumatic amnesia. Clinical manifestations.
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HeadTrauma Artun KIRKER
MVA • FALLING OF HEIGHTS • VIOLENCE • SPORTS • PENETRATING WOUNDS • INDUSTRIAL AND DOMESTIC ACCIDENTS • One of themostfrequentcause of deathanddisability in youngadults
Clinicalmanifestations • Bilateralpreorbitalecchymosis(Racooneyes) • Ecchymosis of themastoidprocess(Battle sign) • CSF rhinorrheaorotorrhea (Ear) • Cranialnervepalsy • Bleeding • Amnesia • Loss of consciousness • Cushingreflex—HT,Bradycardia,irregularrespirations
EpiduralHematoma • Between dura andskull • %1 of headtraumaaddmissions • %80 temporalarea • Middlemeningealartery is themostcommonsource • Dural sinusesandbridgingveinsmay be thesource • Moslyaffectsyoungadults
Clinical Mani. • Brief LOC • Lucidinterval(TALK AND DIE) • İpsilateraldilatepupil • Contralateralhemiparesis
Treatment • Conservative: if GCS>8,no midlineshiftand <30 ml blood • Surgery: Anisocoriaand GCS <8 • Best prognosticfactor is consciousness
SubduralHematoma • Collection of bloodbetween dura andaracnoid • Mva,falls (Severe trauma) mostlyforyoungs • Anticoagulants can be thecause in elderly • Acute <72h--hyperdense on CT Subacute 3-7 daysaftertrauma Chronic >3 weeks--hypodense on CT • Mostly in temporalandfrontalareas • High mortality&morbility
Clinicalpresent • Comaaftertrauma • Hemiparesis • increased ICP • Alteredlevel of consciousness • Acute form maypresentwith <9 GCS
Subarachnoidhemorrhage is extravasation of bloodintothesubarachnoidspacebetweenthepialandarachnoidmembranes
Symptoms • Headache (48%) • Dizziness (10%) • Orbitalpain (7%) • Diplopia (4%) • Visual loss (4%)
Signs • Mildtomoderate BP elevation • Temperatureelevation • Tachycardia • Papilledema • Retinalhemorrhage • Global orfocalneurologicabnormalities
Clinicalpresentation • Suddenonset of severe headache (worstheadache) • Accompanyingnauseaorvomiting • Symptoms of meningealirritation (%80 maytakeseveralhours) • Photophobiaandvisualchanges • Focalneurologicdeficits (CN III, CN VI--ICP) • Seizuresduringtheacutephase (Sudden ICP increase)
Stronglyassociatedwith SAH • Aged 40 yearsorolder • Witnessedloss of consciousness • Complaint of neckpainorstiffness • Onset of manifestationswithexertion • Arrivalbyambulance • Vomiting • Diastolicbloodpressure ≥100 mm Hg orsystolicbloodpressure ≥160 mm Hg
ClinicalGradingScales • Glasgow ComaScore--Clinical • TheFisherscale—CT Based • TheHuntandHessgradingsystem
TheFisherscale (CT scanappearance) is as follows: • Group 1 - No blooddetected • Group 2 - Diffusedeposition of subarachnoidblood, noclots, andnolayers of bloodgreaterthan 1 mm • Group 3 - Localizedclotsand/orverticallayers of blood 1 mm orgreater in thickness • Group 4 - Diffuseornosubarachnoidblood, but intracerebralorintraventricularclotsarepresent
Complications • Hydrocephalus (%20) • Rebleeding (HT,Anxiety) • Vasospasm (Delayedischemiafromarterialsmoothmusclecontraction of thelargecapacitancevessels at thebase of thebrain is theleadingcause of deathanddisabilityfollowinganeurysmal SAH) • Seizures • Cardiacdysfunction & pulmonaryedema
D.D • Aseptic Meningitis • Cluster Headache • Encephalitis • First Adult Seizure • HypertensiveEmergencies • Intracranial Hemorrhage • IschemicStroke • Meningitis • Migraine Headache • TransientIschemic Attack
DX • Noncontrast CT • LP (CT(-) andifsuspiciouscase):Mostsensitive but can be falsepositive—Traumatic tap • CTA,MRA,Catheterangio (toidentysource)
Work-up • EKG • CXR-Forevaluation of possiblepulmonarycomplications • Serum chemistry panel - Toestablish a baselinefordetection of futurecomplications • Complete bloodcount - Forevaluation of possibleinfectionorhematologicabnormality • Prothrombin time (PT) andactivatedpartialthromboplastin time (aPTT) - Forevaluation of possiblecoagulopathy • Blood typing/screening - Toprepareforpossibleintraoperativetransfusions • Cardiacenzymes - Forevaluation of possiblemyocardialischemia • Arterialbloodgas (ABG) - Necessary in patientswithpulmonarycompromise
Keep in mind • May be traumaticorspontaneous (Truma is morecommon) • Spontaneous SAH mostlycausedbyaneurysmalrupture • %30 occurs in sleep
Treatment-Emergency • ABC!--Intubation of patientswithcoma,depressedlevel of consciousnessorhigh ICP • Monitoring--Cardiacmonitoring • Pulseoximetry • Automatedand/orarterialbloodpressuremonitoring (arterial BP monitoring is indicated in high-grade SAH orwhenbloodpressure is labile) • End-tidalcarbondioxide, ifapplicable • Urineoutputviaplacement of a Foleycatheter
Thegoals of treatment in patientswithsubarachnoidhemorrhage (SAH) are as follows: • Blood pressurecontrol • Prevention of seizures • Management of intracranialpressure • Prevention of vasospasm • Control of pain • Maintenance of cerebralperfusion
Main goal is strictbloodpressurecontrol, withfluidrestrictionandantihypertensivetherapy • >130mm Hg MAP— I.V Beta blockers (Antihypertensive of choice) • High ICP orherniaton—intubation, hyperventilation, osmoticagents (mannitol) fordecrease ICP dramatically • Patientsmust be admittedtotheintensivecareunit • To minimize stimulithatmayleadto an elevation of ICP, havethepatientplaced in a darkened, quiet, privateroomandgivenmildsedationifagitated
Prevention of rebleeding (themostdreadedearlycomplication) is clippingtherupturedberryaneurysmorendovasculartreatment (ie, coiling)
Topreventvasospasmmaintenance of normovolemia, normothermia, and normal oxygenationareparamount • Oral nimodipine is themoststudiedcalciumchannelblockerforprevention of vasospasmafter SAH • Transluminalballoonangioplasty is recommendedfortreatment of vasospasmafterfailure of conventionaltherapy
Cerebralcontusions • Bruise of theneuralparenchyma • Causedbyinjurytosmallbloodvesselsmostly in thecrown of thegyrus • 4 types: Coup: Site of impact Counter coup: Opposite site of impact Gliding: parasagittalhaemorrhagiclesion (Rostraltocaudalmovement) Intermediary: in thedeepstructure of brain
Intracerebralhemorrhage • Causedbydecelerationinjury • Frontal—temporalregion %90 • May be delayedandwith SDH and SAH • Delayedtraumaticintracerebralhemorrhage:Presence of ICH in previously normal area of brain in initial CT—MORTALITY RATE GETS HIGHER
Treatment • Considernonsurgicalmanagementforpatientswith minimal neurologicaldeficitsorwithintracerebralhemorrhagevolumeslessthan 10 mL. • Admit ICU andmonitoringandserial CT scans
DiffuseAxonalInjury • Accelerating-deceleratinginjury • Confluenthaemorrhages • Frontal-temporal %80-90 • Axonsareinjuredbyshearingandimpaired transport • Is thecause of theloss of consciousness in headtraumapatients • CT is usually not enough • MRI T2W mayshowhyperintenselesions
Concussion • Clinicalterm—Post traumaticalteration of consciousness • Minimal ornochanges on CT/MR • Mild form of diffuseaxonalinjury