Theme 7

Cranio-cerebral
and it is vertebral-cerebrospinal
the injury

Cranio-cerebral the injury

Распространенность черепно-мозговой травмы составляеч более 200 случаевна 100 тыс。 population per
year. Is separated the closed craniocerebral injury and opened, with [kotoroG] the cavity of skull communicates
with the environment and grows the probability of infectious complications. The closed craniocerebral injury
more frequently is encountered in peacetime. Conducting patients with the open craniocerebral injury relates to
the scope of neurosurgeons and traumatologists. In the present division are discussed predominantly the
questions, connected with the closed craniocerebral injury.
Classification and pathogenesis. The damage of brain can be caused by directly traumatic action in the
region of the impact and on the opposite side in the place of shock, by diffuse axonal damage, and also by
intracranial complications (hematoma, infection, edema of the brain) or by the appearing with the injury
somatical disturbances (arterial hypotonia, the disturbance of respiration and others), which lead to hypoxia of
the brain.
Depending on the morphology of the damage of brain are separated the shake-up of brain, the injury, diffuse
axonal damage and intracranial hematoma. Contusion (contusion) of the brain - necrotic [razmozzhenis] of the
sections of crust and white substance, usually combining ] by small hemorrhages and by edema of brain.
('[otryasenie] of brain presents its sharp shaking with the injury of head without the macroscopic changes with
the reversible disturbance of functions, which they connect with the [tsegkoy] degree of diffuse axonal damage.
('redi of intracranial traumatic hemorrhages on the basis of the localization are separated epidural, subdural and
intra-cerebral hematomas. ~
For understanding of the mechanism of injury it is important to know the fact THAT the cerebral hemispheres ,
surrounded by cerebrospinal liquid, are capable of move in the cavity of skull ([p]'[delyyu] from the bone structures.
If appears the sharp impact, which sets of heads} 'to the motion, cerebral hemispheres lag behind the motion of bone
structures, on the contrary, if i'tin it strikes against fixed object, the motion of cerebral hemispheres anticipates the
motion of bone structures. In both cases as a result of the rotary motion of hemispheres appears their deformation
(twisting) of the relatively rigidly fixed stem of brain, which is maximally expressed at the level of the upper
divisions of the reticular formation of the brain stem, which causes the loss of consciousness. The forces of rotation
divide or tear up the axons of nerve cells in the white substance and the stem of brain (diffuse axonal damage).
Furthermore, with the rotary motion of hemispheres their surface formations are damaged from the contact with the
bones of skull and the folds of dura mater, which leads to the development of softening (injury of brain) and
hemorrhages both in the point of impact and on the opposite side in the place of shock. Diffuse axonal damage
explains the loss of consciousness after the injury in the absence of the anatomical damages of the brain according to
the data of kt or [MRT] of head.
Light, average and severe craniocerebral injury is separated according to the degree of the disturbance of
consciousness after injury. The light craniocerebral injury, at basis of which usually lies the shake-up or light
contusion of the brain, composes majority (80%) of all cases of craniocerebral injury. It

usually it does not represent threat for the life of victim, but frequently are caused the consequences, which decrease
the quality of its life.
The fracture of the bones of skull more frequently occurs with the severe craniocerebral injury, but it is possible
with its light degree. The presence of the fracture of the bones of skull significantly increases the probability of
intracranial hemorrhage. The fracture of the bones of the base of skull is connected with the risk of damage to
carotid artery, optical nerve and other cranial nerves, entry into the cavity of the skull of air (pneumo-purpose) and
infection (meningitis, encephalitis), and also with the risk of a constant escape of cerebrospinal liquid into the
paranasal sinuses (rhino-Rhea) or the ear (otorrhea).
Epidural hematoma appears as a result of the hemorrhage from the damaged shell artery (a. meningia media) or
it is thinner frequent than the vein, with the break of temporal or parietal bone. Subdural hemorrhage appears as a
result of the defeat of the veins, which connect the venous system of brain and the sines of dura mater. An increase
in the intracranial pressure with the venous hemorrhage can lead to its stoppage and formation of chronic subdural
hematoma. More frequent subdural hematoma is formed above the surface of hemisphere, frequently from both
sides. In the majority of the cases of contusion of the brain appears sub-arachnoidal, and frequently also subdural
hemorrhage.
Clinical picture. Craniocerebral injury causes the disturbance of the consciousness, degree and duration of
which they determine its forecast. The rapid restoration of consciousness after injury testifies in favor its light
degree. The more prolonged the loss of consciousness, the more probable the contusion of the brain or the
intracranial hemorrhage. During the disturbance of consciousness gravity injury it is convenient to determine
according to the scale of coma glasgow (table. 7.1). If the sum total of marks composes 13-15, then craniocerebral
injury they estimate as light, if 8-12 - as average gravity, if 3-7 - as heavy. The average and heavy degree of
craniocerebral injury indicates the high probability of the injury of the brain and/or intracranial hematoma; for
example, subdural hematoma of [vyyav]-it [lyaetsya] in 20% of patients with the severe craniocerebral injury. On
the contrary, light craniocerebral injury in the majority of the cases is caused by the shake-up of brain, the
probability of epidural and subdural hematoma composes respectively 0,5 and 1 %. With the severe craniocerebral
injury rapid death can begin as a result of the disturbance of the function of the respiratory center of the medulla
oblongata.
£ Table 7.1
Scale of the coma of the glasgow
Index Marks
Opening of the 43
eyes: spontaneous 21
to the speech to the
pain is absent

54
Speech: 32
is completely preserved that 1
jumbled of incomprehensible
words inarticulate sounds it is
absent
Engine reaction: the fulfillment of the instructions 6
the goal-directed reaction to painful [razdraltenie] the 54
drawing back of extremity to the painful irritation flexible 32
reaction to the painful irritation extensor reaction to the 1
painful irritation is absent

With the inspection of patient it is important to exclude the presence of the fracture of the bones of skull, and
also break of spine and extremities, damages of internal organs. The fracture of the bones of the arch of skull can be
revealed during the visual inspection and the palpation. Hemorrhage from the nose and the external auditory
passage, hematoma into the region of temple or mammiform branch after the ear (symptom of Battelle), the double-
sided bruise in the orbital region (“the symptom of glasses”) they indicate the possibility of the fracture of the bones
of the base of skull, although they can be the consequence of local injury. Expiration of [tserebrospi]-

of [nalnoy] liquid from the nose (rhino-Rhea) and the ear (otorrhea) it testifies about the fracture of the bones of the
base of skull. The fracture of the bones of skull with the light craniocerebral injury increases the probability of
intracranial pathology (hematoma, infection) 4 .
With the neurologic inspection they explain the presence of the symptoms of the focus defeat of the brain:
weakness in the extremities, the disorder of sensitivity, the disturbance of coordination and others They testify about
the structural defeat of the brain: injury and/or to hematoma. The detection of meningeal symptoms indicates the
probability of traumatic sub-arachnoidal hemorrhage, and their appearance several days after injury makes it
possible to assume the infectious process (meningitis, encephalitis). The defeat of olfactory nerve indicates the
fracture of the ethmoid bone, the defeat of facial - to the break of the pyramid of temporal bone.
With the inspection in the hospital it is necessary to exclude the damage of other organs, in the special feature
of abdominal cavity, chest, spine and tubular bones, which is most probable in the case of steadfast arterial
hypotonia (decrease in systolic arterial pressure in below 90 mm RT. st.).
Diagnosis. In the cases of the light craniocerebral injury, when there are no signs of the fracture of the bones of
skull and changes with the neurologic inspection, and also there are no factors of the risk of hematoma with the
injury of head (method of anticoagulants or the pathology of the coagulability of the blood), it is possible to limit
primary inspection by the roentgenography of skull and, if it does not reveal changes, then not carry out kt of head.
These patients must be observed in the course of several weeks and with worsening in the state produced kt or
[MRT] of head.
In the remaining cases special kt of head is necessary. If there is no possibility to conduct kt or [MRT] of head,
then are carried out the roentgenography of skull, [ekhoentsefaloskopiyu], inspection of eyeground , also, with the
suspicion for hematoma (increasing worsening in the state, the fracture of the bones of skull with roentgenography,
displacement of the middle structures of the brain with [zkhoentsefaloskopii], stagnant disks and hemorrhage into
the retina on the eyeground) can be superimposed diagnostic [frezevye] openings. Lumbar puncture is not
recommended because of the danger of the wedging of the brain and it can be produced with the suspicion to
meningitis after that how according to the data of kt or [MRT] is excluded the volumetric damage of the brain. The
roentgenography of the neck division of spine is necessary with the signs of the damage of neck. Into the plan of the
inspection of patient with the craniocerebral injury enter the clinical and biochemical analysis of the blood
(electrolytes, glucose, coagulogram, the exponential functions of the liver and kidneys), the total analysis of urine.
Diagnosis of the shake-up of the brain is based on the short-term (second or minute) loss of consciousness
[mosle] of injury, the absence of neurologic disturbances and changes with the roentgenography of skull and/or kt of
head. The I [[ri] the shake-up of brain are possible headache, vertigo, nausea, vomiting and amnesia to the events of
injury. Usually in the course of several hours or days state is normalized; however, in the part of those, who
withstood the shake-up of brain, is developed the [postkommotsionyy] syndrome, which can be the reason for more
prolonged disablement. Patients with the light craniocerebral injury must be observed in the hospital during 5-7
days.
Diagnosis of the injury (contusion) of the brain is based pA the prolonged (minute, hours or thinner frequent
days) disturbance of consciousness after injury, the presence of focus neurologic disturbances (aphasia, central
hemiparesis and others) and is confirmed by results kt or [MRT] of head. Contusion of the brain frequently is
combined with intracranial hematoma, which can develop gradually; therefore with worsening in the state of patient
with the contusion of the brain is required repeated kt or [MRT] of head for the development of possible hematoma.
Diagnosis of epidural and acute subdural hematoma is based on the progressive worsening in the state of victim
immediately after injury or through the small (minute or hours) “bright space”, which appears following the initial
loss of consciousness, and [podtverzhda]-

[etsya] by results kt or [MRT] of head. With epidural hematoma in patients frequently appear contralateral
hemiparesis and homolateral (thinner frequent contralateral) injury of oculomotor nerve with mydriasis, and also
epileptic fits. Similar clinical symptoms can be observed , also, with acute subdural hematoma. In the cases of the
subacute (development of symptoms in the flow from 2 to 14 days) or chronic (appearance of symptoms after 14
days) course of subdural hematoma is observed prolonged “bright space” after injury, and then usually appear
headache, focus neurologic disturbances (aphasia, central hemiparesis and other), epileptic fits and disorder of
consciousness.
Chronic subdural hematoma frequently are caused complexities in diagnostics, because it can develop through
the continuance (months and even years) after the light craniocerebral injury, about presence of which the patients
frequently forget. This situation is characteristic for the elderly people, and also for the patients, who assume
anticoagulants. In all cases of suspicion to traumatic subdural hematoma is necessary special kt or [MRT] of head,
which makes it possible to place diagnosis. With the absence of timely treatment the majority of patients with the
traumatic intracranial hemorrhage die as a result of edema of brain and compression of its stem. Small subdural
hematomas can be reduced independently, but these patients require a constant observation in neurosurgeon and
repeated kt or [MRT] of head for affirming the favorable course of disease.
 All patients with the craniocerebral injury it is necessary to hospitalize into the neurosurgical hospital in order
in the case of the need for conducting the special operation, which is capable of saving the life of victim.
Forecast, flow and the complication of craniocerebral injury. The forecast of craniocerebral injury is
determined by its gravity, presence of the [sochetannykh] injuries and diseases, by age of patient, by opportuneness
of rendering to medical aid. Flow of heavy and average gravity of the cranio- cerebro THE HOWL of injury can be
complicated by the arterial hypertonia
or by hypotonia, by arrhythmia of heart, by edema of the lungs, [aspiratsi]-
by [onnoy] pneumonia, by the embolism of pulmonary artery, by the syndrome
the disseminated intravascular coagulation and other
11 [ri] to severe craniocerebral injury of about 50% of the patients
they perish, and in 20% of patients is developed chronic [vegeta]
[tivnoe] state or remains the rough neurologic
defect. g
With the injury of head. [msTzga] grow heavy degree frequently in the first hours or during the days after injury
it begins death. In some patients after the continuance of the disturbance of consciousness vitally important
functions are normalized , patients open eyes, in them is restored the cycle “sleep- it is cheerful -[STvovanie]”, but
they are deprived of cognitive functions and of normal reaction (chronic vegetative state). In the part of the patients
the restoration is better than in patients with the chronic vegetative state, but remain steadfast neurologic
disturbances (central hemiparesis, aphasia and other). In the majority of patients with the injury of head is observed
gradual restoration neurologic of functions, usually most significant during first 6 mo. from the moment of injury. In
some patients after contusion of the brain appear changes in the personality and reduction in the intellect, which
entails serious problems in their social and everyday adaptation. In these cases the observation and treatment in
psychiatrist is required.
Post-traumatic epilepsy it appears on the average [u] 5% patients, it is more frequent in patients with contusion
of the brain and/or hematoma, in the majority of the cases large convulsive fits are observed.
Postconcussion syndrome it is manifested by head BO -[I] yu, vertigo, disturbance of sleep, [razdrazhitelnos]-i
mho, by reduction in the concentration of attention, by worsening in the memory, increased by fatigue and decrease
of fitness for work after the transferred craniocerebral injury. It more frequently appears after light craniocerebral
injury (shake-up or the lung of contusion of the brain), its origin is unclear, is assumed the role of the light diffuse of
[aksonal]-

foot damage and psychogenic factor. The more the time past after injury, the more probable the role of psycho-
social factors or rent relations in [ge] to Neza the presented to patient complaints (judicial trial, the formulation of
disablement). The year after light craniocerebral injury the manifestations of postconcussion syndrome (most
frequently headache, vertigo, the increased fatigue) remain in Yu 15% of patients. ITpi the progressive worsening
in the state sick [sledue] to remember about the possibility of chronic subdural the theme of [tomy] and other
complications, whose diagnostics [trebus] repeated kt or [MRT] of head.
Treatment. Rendering to special aid to the patient with sharp craniocerebral injury is directed toward the
guarantee of passability of the respiratory tract, the stabilization of arterial pressure and the fight with the shock
with his development. The special hospitalization of patient into the neurosurgical department is necessary. With
the transport of patient in the unconscious state is required the immobilization of neck division and caution with the
displacement of the patient in the relation with the probability of an injury of the neck division of spine, who
frequently appears, especially with the severe craniocerebral injury.
Its surgical removal is produced with the development of epidural or subdural hematoma. During the intra-
cerebral hemorrhage the operation is shown with large, accessible for the surgical intervention hematomas, which
cause the displacement of cerebral [strU]kt[UR] or heavy neurologic disturbances, and also in the cases of the
ineffectiveness of conservative therapy.
With the contusion of the brain, and also in patients with the intracranial hemorrhage (if is not accomplished
surgical treatment) is conducted the conservative therapy, directed on the guarantee of normal respiration, stable is
arterialGO of pressure and the preventive maintenance of complications. Great significance has general care of
patient. With increase in the intracranial pressure and edema of the brain use the hyperventilation, [v]/[v]
introduction 100-200 ml 20%- GO of the solution of the mannitol (with need every 4-6 ch), and when the effect is
possible of [v]/[v] is absent, the introduction of barbiturates. For an improvement in the metabolic processes in the
brain and its blood supply it is possible to employ Cavinton (15-30 mg/day inward or [v]/[v]), [nimodipin] (120
mg/day inward or [v]/[v]), Piracetam (4-12 g/day inward or [v]/[v]), [tserebrolizin] (10-50 ml/ay of [i]/[v] drop)
and other [neyroprotektivnye] means (however their effectiveness it is not proven) '.
With the development of meningitis of [naznachayut]'" antibiotics. They use also with the preventive purpose
with the open craniocerebral injury, especially with the expiration of liquor (rhino-Rhea or otorrhea).
With the shake-up of brain is recommended bed rest, whose duration (from the twenty-four hours to several
days) is determined individually, and are carried out symptomatic treatment (analgesics, sedative means and others).
The I (agio are dynamic observation of the patient, since after “bright space” is possible the development of
hematoma. Many patients, xwho after injury do not have any objective disorders, complain about the headache, the
vertigo, the disturbance of sleep and the poor health, which in the majority of the cases is connected with s. by the
increased anxiety or by depression as reaction to the injury and with the special feature of personality (premorbid
neurotic or depressive type of personality). In these cases the tranquilizers or antidepressants can help.
With the development of epileptic fits a constant method of anticonvulsive means is recommended. It is more
than in 50 % patients fits cease and the gradual cancellation of anticonvulsive means under the control is possible
EEG.
With the postconcussion syndrome are expedient rational psychotherapy, gradual increase in the load, die the
increased anxiety they are effective tranquilizers, with the depression - antidepressants at the individually selected
dose. One should say to patient about the high probability of a gradual improvement in the state, recommend as it is
possible faster to return to the work

and to the usual method of life. With expressed [emotsional] disorders is expedient the consultation psychiatrist!!
Postconcussion syndrome is encountered more frequently and [sokhrani] of [etsya] are longer in those cases, when
in the connection with the injury of goal you appears judicial trial, and/or is possible compensation for that caused to
patient damage. On this regulating the juridical problems, connected The I by injury, it relates to the important
components of the rehabilitation of patient with the postconcussion syndrome. On the contrary, last the body flow of
court trial, repeated of [mnogochis] feudatory studies only strengthen the fear of patient and decrease his motivation
to return to the work.

It is vertebral-cerebrospinal (spinal)the injury

Pathogenesis. In peacetime the injury of spinal cord usually appears as a result of the drop, the unsuccessful diving
into the water, the car wreck and occurs due to the compression of vertebrae in the vertical plane in the combination
with the rapid excessive flexure or straightening of head ([antero]- or [retrogiperrefleksii]). As a result the break of
the bonds of spine occurs the displacement of upper on bell toward the front according to the relation to underlying,
that usually causes the break of body or arcs of vertebrae, also, as a result of this crushing of spinal cord. Gravity of
injury is strengthened when the associated degenerate- dystrophic changes in the spine or innate narrow vertebral
channel are present.
Clinical picture. As a whole, the injury of spinal cord is manifested by paraplegia or tetraplegia with paralysis
of sphincters and loss of sensitivity of lower than defeat level. Symptoms depend on defeat level.
Damage of spinal cord at the level of upper neck segments ([s], [s] 3) are caused cessation of respiration and
immediate death, if mechanical ventilation of lungs is not conducted. With the lower level of defeat is observed
tetraplegia or lower paraplegia, the loss Sensitivities according to the conductor type are lower than defeat level and
pelvic disorders. In the first hours after [Rrnvmy] the symptomatology can increase, for example, from appropriate
[tetrapareza] to tetraplegia in connection with the growth the cheek of spinal cord.
In the stage of the spinal shock, which appears immediately after 1 ' [ravmy], disappear all forms of reflexes
of lower than damage level, appears the nonretention of urine because of the atony of the bladder, paralytic
intestinal impassability as a result of the atony of bowels is possible. Subsequently (through The I 2 weeks.,
sometimes later) the stage of spinal shock begins be changed to gradually by the stage of increased reflector
[iozbuzhdeniya] in the parts of the bodies, which are innervated by the neurons of lower than damage level. In
patient pathologic flexible reflexes (Babinski symptom , shielding reflexes ), appear and then they rise tendinous
reflexes, the tone of the bladder and bowels rises. The hyper-reflection of the bladder is expressed by frequent and
imperative urges to the urination, its automatic emptying with the small filling. During the complete damage of
spinal cord the paralyzed lower extremities are bent. With the defeat of the cervical enlargement of muscle of the
paralyzed hand or brush the reflexes atrophy and disappear.
 The degree of restoration is determined by the prevalence of defeat over the diameter of spinal cord. During
its partial damage usually is observed gradual, the most significant into first 6 mo., restoration of engine, sensitive
and pelvic functions.
Diagnosis it is based on clinico- anamnestic data. Great significance they have the roentgenography of spine,
kt and [MRT], which make it possible to determine break and displacement of vertebrae, the volume of the defeat
of spinal cord.
Treatment. Patients must be located in the traumatological or neurosurgical departments, which are
specialized in the spinal injury.
The treatment of breaks and displacement of spine relates to the scope of traumatologists and consists into
[ortopedi]-the [cheskom] elimination of subluxation and fixation of spine. The effectiveness of laminectomies,
and also high doses of corticosteroids for the purpose of the decompression of spinal cord with ladder- me it is not
completely proven. In sick, transferred [spinal] injury, great significance has therapeutic gymnastics and gradual
social and everyday adaptation.

Table 7.2
Brief information about the closed craniocerebral injury
Brief Shake-up the Injury the brain Intracranial
informatio brain hematoma
n
Pathogenesis Diffuse Necrotic softening the Hemorrhage from
[aksonalygoe] substance of the damaged artery or
on[vrezhdenie] headsfoot brain vein from [obrazova]
[niem] of hematoma

Clinical [Kratkovremen]noy Prolonged disturbance [Meningeal]-

picture the disturbance the knowledge, the focus symptoms, focus
consciousness neurologic the not[vrologicheskie]
disturbance disturbances,
onexponential
worsening in the
state
X- Absence The absence is more The break is more
ray[grafiya] from[meneniy] frequent the changes frequent the bones
to [che]the of the skull
turnip
Kt of the head Absence Center (centers) of the Region ([obla]to
from[meneniy] [poniyasennoy] density [sti]) the increased
(softening) density
(hematoma)
Treatment To Treatment of edema the Surgical the
[simptomatiche]the brain, [simpto] removal of
[skaya] therapy [maticheskaya] hem[tomy]
those[rapiya]