BRAIN INJURIESBRAIN INJURIES

Vinayak NarayanVinayak Narayan 2424th th OSLERSOSLERS Batch Batch

, ,Medical Medical

college ,Thrisurcollege ,ThrisurIndia India

NEUROSURGICAL CASENEUROSURGICAL CASE

A 19 yr OLD BOY HAVING THE HISTORY OF FALL A 19 yr OLD BOY HAVING THE HISTORY OF FALL FROM A BIKE ,HITTING THE RIGHT SIDE OF FROM A BIKE ,HITTING THE RIGHT SIDE OF HIS HEAD FORCEFULLY ON THE ROAD IS HIS HEAD FORCEFULLY ON THE ROAD IS BROUGHT TO THE CASUALTY .ON BROUGHT TO THE CASUALTY .ON EXAMINATION HIS PULSE:40/MIN,EXAMINATION HIS PULSE:40/MIN,

B.P :170/110mmHgB.P :170/110mmHg ON FUNDOSCOPIC EXAMINATION HE HAS ON FUNDOSCOPIC EXAMINATION HE HAS

VENOUS DISTENSION AND ABSENT VENOUS DISTENSION AND ABSENT PULSATIONS OF THE RETINAL PULSATIONS OF THE RETINAL VASCULATURE.ALSO ON SYSTEMIC VASCULATURE.ALSO ON SYSTEMIC EXAMINATION HIS LIMBS ON THE LEFT SIDE EXAMINATION HIS LIMBS ON THE LEFT SIDE ARE MORE FLACCID THAN THE RIGHT SIDE.ARE MORE FLACCID THAN THE RIGHT SIDE.

-WHAT MAY BE THE LIKELY DIAGNOSIS?-WHAT MAY BE THE LIKELY DIAGNOSIS?

DEFINITIONDEFINITION

• ANY INJURY TO THE BRAIN,REGARDLESS OF ANY INJURY TO THE BRAIN,REGARDLESS OF THE AGE OF ONSET,WHETHER MECHANICAL THE AGE OF ONSET,WHETHER MECHANICAL OR INFECTIOUS IN ORIGIN,THE RESULT OF OR INFECTIOUS IN ORIGIN,THE RESULT OF WHICH MAY BE EXPECTED TO CONTINUE WHICH MAY BE EXPECTED TO CONTINUE INDEFINITELY CONSTITUTING A INDEFINITELY CONSTITUTING A SUBSTANTIAL HANDICAP TO THE SUBSTANTIAL HANDICAP TO THE INDIVIDUAL EITHER OR WHICH MAY INDIVIDUAL EITHER OR WHICH MAY DIRECTLY RESULTING IN SOME SORT OF DIRECTLY RESULTING IN SOME SORT OF NEUROLOGICAL IMPAIRMENT.NEUROLOGICAL IMPAIRMENT.

CLASSIFICATIONCLASSIFICATION

• PRIMARY BRAIN INJURYPRIMARY BRAIN INJURY• SECONDARY BRAIN INJURY SECONDARY BRAIN INJURY

PRIMARY BRAIN PRIMARY BRAIN INJURYINJURY

• INJURY CAUSED AT THE TIME OF INJURY CAUSED AT THE TIME OF IMPACT.IMPACT.

• IRREVERSIBLE IRREVERSIBLE

• CLASSIFIED INTOCLASSIFIED INTO1.DIFFUSE AXONAL1.DIFFUSE AXONAL

2.CEREBRAL CONCUSSION2.CEREBRAL CONCUSSION3.CEREBRAL CONTUSION AND3.CEREBRAL CONTUSION AND

LACERATION LACERATION

DIFFUSE AXONAL DIFFUSE AXONAL INJURYINJURY

• DUE TO SHEAR STRESS AT GREY DUE TO SHEAR STRESS AT GREY MATTER-WHITE MATTER JUNCTION.MATTER-WHITE MATTER JUNCTION.

• ACCELERATION-DECELERATION ACCELERATION-DECELERATION TYPE FORCES DUE TO DIFFERENTIAL TYPE FORCES DUE TO DIFFERENTIAL BRAIN MOVEMENT.BRAIN MOVEMENT.

• WALLERIAN DEGENARATION OF WALLERIAN DEGENARATION OF NEURONS MAY OCCUR AFTER A FEW NEURONS MAY OCCUR AFTER A FEW WEEKS.WEEKS.

CEREBRAL CEREBRAL CONCUSSIONCONCUSSION

• BRIEF LOSS OF CONSCIOUSNESS BRIEF LOSS OF CONSCIOUSNESS FOLLOWED BY PROMPT FOLLOWED BY PROMPT RECOVERY AND WITHOUT ANY RECOVERY AND WITHOUT ANY LOCALISING NEUROLOGIC SIGNS.LOCALISING NEUROLOGIC SIGNS.

• PERIOD OF AMNESIA IS THE PERIOD OF AMNESIA IS THE STRIKING FEATURE.STRIKING FEATURE.

• POST-CONCUSSION SYNDROME?POST-CONCUSSION SYNDROME?

C.CONTUSION-C.CONTUSION-LACERATIONLACERATION

• CONTUSION SEEN AS SMALL AREAS CONTUSION SEEN AS SMALL AREAS OF HAEMORRHAGES OR MINOR OF HAEMORRHAGES OR MINOR BRUISE IN THE CEREBRAL BRUISE IN THE CEREBRAL PARENCHYMAPARENCHYMA

• BBB DEFICITS AND CEREBRAL BBB DEFICITS AND CEREBRAL EDEMA MAY ACCOMPANY THIS.EDEMA MAY ACCOMPANY THIS.

• LACERATION DUE TO RAPID MOVT. LACERATION DUE TO RAPID MOVT. AND SHEARING OF BRAIN TISSUE.AND SHEARING OF BRAIN TISSUE.

• PIA AND ARACHNOID MAY BE TORN PIA AND ARACHNOID MAY BE TORN

SECONDARY BRAIN SECONDARY BRAIN INJURYINJURY

• PROGRESSIVE BRAIN DAMAGE PROGRESSIVE BRAIN DAMAGE EVOLVING AS A RESULT OF EVOLVING AS A RESULT OF PRIMARY ONE.PRIMARY ONE.

• CLASSIFIED INTOCLASSIFIED INTO1.INTRACRANIAL 1.INTRACRANIAL

HAEMATOMAHAEMATOMA 2.CEREBRAL 2.CEREBRAL SWELLINGSWELLING3.CEREBRAL HERNIATION3.CEREBRAL HERNIATION

4.CEREBRAL ISCHAEMIA4.CEREBRAL ISCHAEMIA5.INFECTIONS AND OTHERS5.INFECTIONS AND OTHERS

INTRACRANIAL INTRACRANIAL HAEMATOMASHAEMATOMAS

• CLASSIFIED INTOCLASSIFIED INTO1.EXTRADURAL1.EXTRADURAL2.SUBDURAL2.SUBDURAL

3.SUBARACHNOID3.SUBARACHNOID

4.INTRACEREBRAL4.INTRACEREBRAL

EXTRADURAL EXTRADURAL HAEMATOMAHAEMATOMA

• DUE TO LACERATION OR DUE TO LACERATION OR RUPTURE OF MIDDLE RUPTURE OF MIDDLE MENINGEAL ARTERY.MENINGEAL ARTERY.

• LUCID INTERVAL IS THE NOTABLE LUCID INTERVAL IS THE NOTABLE FEATUREFEATURE

SUBDURAL SUBDURAL HAEMATOMAHAEMATOMA

• MOST COMMON INTRACRANIAL MOST COMMON INTRACRANIAL MASS LESIONS ARISING FROM MASS LESIONS ARISING FROM HEAD TRAUMA.HEAD TRAUMA.

• CLASSIFIED INTOCLASSIFIED INTO1.ACUTE1.ACUTE

2.SUBACUTE2.SUBACUTE3.CHRONIC3.CHRONIC

ACUTE SUBDURAL ACUTE SUBDURAL HAEMATOMAHAEMATOMA

• LESS THAN THREE DAYSLESS THAN THREE DAYS• TORN-BRIDGING VEINS OR FOCAL TORN-BRIDGING VEINS OR FOCAL

TEARS OF CORTICAL ARTERIES TEARS OF CORTICAL ARTERIES ARE THE USUAL CAUSESARE THE USUAL CAUSES

• BLOOD FOLLOWS SUBDURAL BLOOD FOLLOWS SUBDURAL SPACE OVER THE BRAIN SPACE OVER THE BRAIN CONVEXITYCONVEXITY

• BURST TEMPORAL LOBE?BURST TEMPORAL LOBE?

CHRONIC SUBDURAL CHRONIC SUBDURAL HAEMATOMAHAEMATOMA

• MORE THAN 21 DAYSMORE THAN 21 DAYS• MOST COMMON IN INFANTS AND MOST COMMON IN INFANTS AND

ADULTS OVER 60 YRS OF AGEADULTS OVER 60 YRS OF AGE• MANIFESTED AS PROGRESSIVE MANIFESTED AS PROGRESSIVE

NEUROLOGICAL DEFICITS MORE NEUROLOGICAL DEFICITS MORE THAN 3WKS AFTER THE TRAUMATHAN 3WKS AFTER THE TRAUMA

SUBARACHNOID SUBARACHNOID HAEMORRHAGEHAEMORRHAGE

• TRAUMATIC ONES ARE TRAUMATIC ONES ARE DIFFUSE,USUALLY CONTINUOUS DIFFUSE,USUALLY CONTINUOUS OVER THE FRONTAL LOBES AND OVER THE FRONTAL LOBES AND THE TIPS OF TEMPORAL LOBETHE TIPS OF TEMPORAL LOBE

• TRAUMATIC LESIONS ARE TRAUMATIC LESIONS ARE USUALLY ASSOCIATED WITH USUALLY ASSOCIATED WITH SUBDURAL H’GE OR BRAIN SUBDURAL H’GE OR BRAIN LACERATIONLACERATION

INTRACEREBRAL INTRACEREBRAL HAEMATOMASHAEMATOMAS

• TRAUMATIC CONTUSIONS ARE TRAUMATIC CONTUSIONS ARE COALESCED INTO CONTUSIONAL COALESCED INTO CONTUSIONAL HAEMATOMAHAEMATOMA

• DISRUPTED CEREBRAL TISSUE DISRUPTED CEREBRAL TISSUE RELEASES THROMBOPLASTIN RELEASES THROMBOPLASTIN WHICH FURTHER POTENTIATES WHICH FURTHER POTENTIATES H’GEH’GE

• SWIRL SIGN??SWIRL SIGN??

CEREBRAL SWELLINGCEREBRAL SWELLING

• EITHER FOCALLY OR DIFFUSELY EITHER FOCALLY OR DIFFUSELY THROUGH OUT CEREBRUM OR THROUGH OUT CEREBRUM OR CEREBELLUMCEREBELLUM

• USUAL PATHOLOGY IS THE LOSS USUAL PATHOLOGY IS THE LOSS OF VASOMOTOR TONEOF VASOMOTOR TONE

• CEREBRAL CONTUSION AND CEREBRAL CONTUSION AND PETECHIAL H’GES ALSO PETECHIAL H’GES ALSO CONTRIBUTE TO BRAIN SWELLINGCONTRIBUTE TO BRAIN SWELLING

CEREBRAL ISCHAEMIACEREBRAL ISCHAEMIA

• COMMON AFTER SEVERE HEAD COMMON AFTER SEVERE HEAD TRAUMATRAUMA

• USUALLY CAUSED BY USUALLY CAUSED BY HYPOXIA ,IMPAIRED CEREBRAL HYPOXIA ,IMPAIRED CEREBRAL PERFUSION OR BOTHPERFUSION OR BOTH

CEREBRAL HERNIATIONCEREBRAL HERNIATION

• TYPES ARE TYPES ARE 1.TRANSTENTORIAL1.TRANSTENTORIAL2.FORAMEN MAGNUM2.FORAMEN MAGNUM

3.SUBFALCINE3.SUBFALCINE• KERNOHAN’S NOTCH KERNOHAN’S NOTCH

PHENOMENON??PHENOMENON??• DURET HAEMORRHAGES??DURET HAEMORRHAGES??

INFECTIONS,SEIZURES INFECTIONS,SEIZURES &HYDROCEPHALUS&HYDROCEPHALUS

• PENETRATING SKULL PENETRATING SKULL TRAUMA,DEPRESSED SKULL TRAUMA,DEPRESSED SKULL FRACTURES &BASE OF SKULL FRACTURES &BASE OF SKULL FRACTURES ALL PROVIDE PORTALS FRACTURES ALL PROVIDE PORTALS FOR CNS INFECTIONFOR CNS INFECTION

• OBSTRUCTION TO CSF OUTFLOW DUE OBSTRUCTION TO CSF OUTFLOW DUE TO INTERVENTRICULAR BLOOD OR TO INTERVENTRICULAR BLOOD OR POST TRAUMATIC COMMUNICATING POST TRAUMATIC COMMUNICATING HYDROCEPHALUSHYDROCEPHALUS

• SEIZURES INCREASES ICT;INCREASED SEIZURES INCREASES ICT;INCREASED CHANCE FOR BRAIN INJURYCHANCE FOR BRAIN INJURY

GRADING OF BRAIN GRADING OF BRAIN INJURIESINJURIES

• GRADE 1- GRADE 1- ALERT &ORIENTED WITHOUT ALERT &ORIENTED WITHOUT NEUROLOGICAL DEFICITNEUROLOGICAL DEFICIT

• GRADE 2-GRADE 2--- IMPAIRED CONSCIOUSNESS BUT IMPAIRED CONSCIOUSNESS BUT UNABLE TO FOLLOW ATLEAST UNABLE TO FOLLOW ATLEAST

A SIMPLE A SIMPLE COMMAND OR ALERT WITH A COMMAND OR ALERT WITH A FOCAL FOCAL NEUROLOGICAL DEFICITNEUROLOGICAL DEFICIT

• GRADE 3-GRADE 3- UNABLE TO FOLLOW EVEN A UNABLE TO FOLLOW EVEN A SINGLE SINGLE COMMAND B’COZ OF COMMAND B’COZ OF IMPAIRED IMPAIRED CONSCIOUSNESSCONSCIOUSNESS

• GRADE 4GRADE 4- - NO EVIDENCE OF BRAIN NO EVIDENCE OF BRAIN FUNCTION[BRAIN DEAD]FUNCTION[BRAIN DEAD]

COMPLICATIONS OF HEAD COMPLICATIONS OF HEAD INJURYINJURY

PRIMARY-PRIMARY-CONCUSSION,BONE CONCUSSION,BONE FRAGMENTATION,BRAINSTEM FRAGMENTATION,BRAINSTEM CONTUSIONS,CORTICAL CONTUSIONS,CORTICAL LACERATIONS &DIFFUSELACERATIONS &DIFFUSE AXONAL AXONAL

INJURYINJURY

SECONDARY-SECONDARY-INTRACRANIAL INTRACRANIAL HAEMATOMAS,CEREBRAL HAEMATOMAS,CEREBRAL EDEMA,HYPOXAEMIA,ISCHAEMIA,EDEMA,HYPOXAEMIA,ISCHAEMIA,INFECTION,EPILEPSY,METABOLIC INFECTION,EPILEPSY,METABOLIC OR OR ENDOCRINE DISTURBANCESENDOCRINE DISTURBANCES

MANAGEMENTMANAGEMENT

• THE KEY ASPECTS IN MANAGEMENT THE KEY ASPECTS IN MANAGEMENT AREARE 1.1.ABCDEABCDE RULES OF TRAUMA RULES OF TRAUMA

MANAGEMENTMANAGEMENT[ATLS][ATLS]2.ACCURATE CLINICAL 2.ACCURATE CLINICAL

ASSESSMENTASSESSMENT 3.IDENTIFY THE 3.IDENTIFY THE PATHOLOGICAL PATHOLOGICAL PROCESS INVOLVEDPROCESS INVOLVED 4.RADIOLOGICAL 4.RADIOLOGICAL ASSESSMENT [X-ASSESSMENT [X- RAY RAY SKULL,CT SCAN ,MRI]SKULL,CT SCAN ,MRI]5.OTHER NEWER OPTIONS5.OTHER NEWER OPTIONS

SUMMARY OF SUMMARY OF MANAGEMENTMANAGEMENT

NO CONCUSSION CONCUSSION

NEUROLOGIC EXAM. & X-RAY NEUROLOGIC EXAM. & X-RAY

NORMAL ABNORMAL ABNORMAL NORMAL

SEND HOME

OBSERVE FOR 24hrs

SEND HOME IF NORMAL

ADMIT TO NMCH

Patient withPatient with CLOSED HEAD INJURYCLOSED HEAD INJURY

POST ADMISSIONPOST ADMISSION

After Admission

CT or MRI BRAIN SCAN

NORMAL BLOOD CLOT

OBSERVE FOR 24 hrsSUBDURAL OR

EPIDURAL CLOTINTRACEREBRAL CLOT

CLOT LARGE OR NEUROLOGIC SIGNS PRESENT

SURGICAL EVACUATION

CONSULT NS

Sx INDICATED AT TIMES

NON-ACCIDENTAL HEAD NON-ACCIDENTAL HEAD INJURIESINJURIES

• INFANTILE CHRONIC SUBDURAL INFANTILE CHRONIC SUBDURAL HAEMATOMA OR EFFUSION HAEMATOMA OR EFFUSION

• BIRTH TRAUMA IS A FREQUENT BIRTH TRAUMA IS A FREQUENT CAUSECAUSE

• FUNDOSCOPY,CT,MRIFUNDOSCOPY,CT,MRI

MISSILE INJURIES MISSILE INJURIES

• CAUSES CEREBRAL DAMAGE BY,CAUSES CEREBRAL DAMAGE BY,1.MECHANICAL LACERATION OF 1.MECHANICAL LACERATION OF

BRAIN TISSUEBRAIN TISSUE 2.SHOCK WAVE PROMULGATED 2.SHOCK WAVE PROMULGATED AHEAD OF THE MISSILE AHEAD OF THE MISSILE 3.CAVITATION IN THE WAKE OF 3.CAVITATION IN THE WAKE OF

MISSILEMISSILE• HIGH HIGH

VELOCITYINJURY,TRANSVENTRICULAR VELOCITYINJURY,TRANSVENTRICULAR WOUNDS & A LOW GLASGOW COMA SCALE WOUNDS & A LOW GLASGOW COMA SCALE ARE ASSO. WITH FATAL OUTCOME ARE ASSO. WITH FATAL OUTCOME

DELAYED EFFECTS OF DELAYED EFFECTS OF HEAD INJURYHEAD INJURY

• POST-TRAUMATIC EPILEPSYPOST-TRAUMATIC EPILEPSY• CEREBRO SPINAL FLUID FISTULACEREBRO SPINAL FLUID FISTULA• POST-CONCUSSIONAL SYMPTOMSPOST-CONCUSSIONAL SYMPTOMS• CUMULATIVE BRAIN DAMAGECUMULATIVE BRAIN DAMAGE• NEUROLOGICAL NEUROLOGICAL

&NEUROPSYCHOLOGICAL DEFICITS&NEUROPSYCHOLOGICAL DEFICITS• NEUROENDOCRINE &METABOLIC NEUROENDOCRINE &METABOLIC

DISTURBANCESDISTURBANCES

NEUROSURGICAL CASENEUROSURGICAL CASE

A 19 yr OLD BOY HAVING THE HISTORY OF FALL A 19 yr OLD BOY HAVING THE HISTORY OF FALL FROM A BIKE ,HITTING THE RIGHT SIDE OF FROM A BIKE ,HITTING THE RIGHT SIDE OF HIS HEAD FORCEFULLY ON THE ROAD IS HIS HEAD FORCEFULLY ON THE ROAD IS BROUGHT TO THE CASUALTY .ON BROUGHT TO THE CASUALTY .ON EXAMINATION HIS PULSE:40/MIN,EXAMINATION HIS PULSE:40/MIN,

B.P :170/110mmHgB.P :170/110mmHg ON FUNDOSCOPIC EXAMINATION HE HAS ON FUNDOSCOPIC EXAMINATION HE HAS

VENOUS DISTENSION AND ABSENT VENOUS DISTENSION AND ABSENT PULSATIONS OF THE RETINAL PULSATIONS OF THE RETINAL VASCULATURE.ALSO ON SYSTEMIC VASCULATURE.ALSO ON SYSTEMIC EXAMINATION HIS LIMBS ON THE LEFT SIDE EXAMINATION HIS LIMBS ON THE LEFT SIDE ARE MORE FLACCID THAN THE RIGHT SIDE.ARE MORE FLACCID THAN THE RIGHT SIDE.

-WHAT MAY BE THE LIKELY DIAGNOSIS?-WHAT MAY BE THE LIKELY DIAGNOSIS?

NEUROSURGICAL CASENEUROSURGICAL CASE+VE FINDINGS+VE FINDINGS

A 19 yr OLD BOY HAVING THE HISTORY OF FALL A 19 yr OLD BOY HAVING THE HISTORY OF FALL FROM A BIKE ,FROM A BIKE ,HITTING THE RIGHT SIDE OF HITTING THE RIGHT SIDE OF HIS HEADHIS HEAD FORCEFULLY ON THE ROAD IS FORCEFULLY ON THE ROAD IS BROUGHT TO THE CASUALTY .ON BROUGHT TO THE CASUALTY .ON EXAMINATION HIS PULSE:40/MIN,EXAMINATION HIS PULSE:40/MIN,

B.P :170/110mmHgB.P :170/110mmHg ON ON FUNDOSCOPIC EXAMINATIONFUNDOSCOPIC EXAMINATION HE HAS HE HAS

VENOUS DISTENSION AND ABSENT VENOUS DISTENSION AND ABSENT PULSATIONSPULSATIONS OF THE RETINAL OF THE RETINAL VASCULATURE.ALSO ON SYSTEMIC VASCULATURE.ALSO ON SYSTEMIC EXAMINATION HIS EXAMINATION HIS LIMBS ON THELIMBS ON THE LEFT SIDE LEFT SIDE ARE MORE FLACCIDARE MORE FLACCID THAN THE RIGHT SIDE. THAN THE RIGHT SIDE.

-WHAT MAY BE THE LIKELY DIAGNOSIS?-WHAT MAY BE THE LIKELY DIAGNOSIS?

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

NO HEAD INJURY IS TOO NO HEAD INJURY IS TOO SEVERE TO DESPAIR OF,NOR SEVERE TO DESPAIR OF,NOR

TOO TRIVIAL TO IGNORETOO TRIVIAL TO IGNORE--

HIPPOCRATESHIPPOCRATES

PRESENTATION:VINAYAK NARAYANPRESENTATION:VINAYAK NARAYANEFFECTS:NISHANTHEFFECTS:NISHANTH

Thank You…Thank You…

Forever YoursForever Yours

Vinayak Narayan.Vinayak Narayan.