Brain Injury

Dr. Krisna Murti SpBS

Departemen Bedah dan Anestesi
RST Soepraoen

Curriculum Vitae

Nama : Krisna Murti , dr, Sp BS

Pangkat : Mayor CKM
Jabatan : - Ka Instal Kamar Bedah RST Soepraoen
- Konsultan Bedah saraf RS Panti
Nirmala dan RKZ
Tempat/ Tgl Lahir : Surakarta , 25 Juli 1970
Agama : Islam
Status : K 2
Alamat : Perum Dokter RST Supraun Jl. S.
Supriyadi no. 22

DIKUM : FK UNDIP 1996 ( Dokter umum)

FK UNPAD 2006 ( Spes Bedah Saraf)
National Neuroscience Institute Singapore 2003
Nagoya University Japan, advance training 2006
Berbagai kursus dan seminar DN dan LN
DIKMIL : Sepamilsuk 1993
Sussarcab Kes 1998
Sussar selam militer 1998
Selapa TNI AD 2008
Penugasan : Ops Timtim 1998 ,
Maluku 2000
Contact : HP 081219040088
EM : junor70@yahoo.com

Welcome to Trauma!
First and ForemostABCs!
airway
breathing
circulation
disability
exposure

Head Injuries:
Account for about one half of all trauma
deaths
Survivors range from baseline function to
severe morbidity
As with most trauma, broken down into
blunt and penetrating

Anatomy for Head Injuries

Scalp
may result in significant bleeding

Skull
well placed fractures place vessels and nerves at risk for injury
protective, but a rigid, fixed space

Dura
Falx separates hemispheres
Tentorium separates cerebrum

Brain
Direct (Primary)
Indirect (secondary)

Direct (Primary) Brain Injuries

Direct damage done to brain parenchyma

Damage is already done
Irreversible
Damage control (debridement)

Linear fracture

Depressed fracture

Indirect (Secondary) Brain Injury

Damage that occurs after the initial insult
Expanding mass lesions, swelling or
bleeding quickly overwhelm buffers
End result is increased intracranial pressure
(ICP) and/or herniation
Diagnosis and treatments target minimizing
the effects of these indirect insults

Intracranial Pressure (ICP)

Intracranial space essentially full of
brain, blood vessels, and a little CSF
In response to an insult, small amount
of CSF can be displaced, can decrease
blood volume, then increase ICP
At higher ICP, loss of autoregulation
occurs
Cerebral perfusion pressure = (MAPICP)
Ischemia and neuronal death

Mechanism 1: Brain Contusion

A brain contusion is defined by cell
death accompanied by hemorrhage
(leakage of blood)

The soft brain tissue is vulnerable

to contusion in head trauma
The contusion often occurs at a site
distant from the point of impact

Gross brain image from

http://neuropathology.neoucom.edu/chapter4/chapter4bContusions_dai_sbs.html#contusion

Mechanism 2: ICP
- Understanding the Determinants of
Intracranial Pressure The volume of the intracranial vault =
Intracranial Contents:
80% brain tissue
10% blood
10% cerebrospinal fluid
An increase in the volume of any of these intracranial
contents causes increased intracranial pressure
1.

The brain can swell (edema)

2.

Excess blood can accumulate due to hemorrhage

3.

Cerebrospinal fluid can accumulate due to blockage of

outflow

Mechanism 2: ICP
Key Concept #1: The intracranial vault is a
fixed volume --> Bone does not expand!

Skull image from www.mnsu.edu

Mechanism 2: ICP
- Understanding the Physics of Intracranial
Pressure -

Pressure
ICP > 20 mmHg

(mmHg)

Volume (mL)
Intracranial Pressure Rises as Brain+Bood+CSF volume Increases

Mechanism 2: ICP
- Understanding the Physics of Intracranial
Pressure ICP

CPP

This patient has dangerously high intracranial pressures, which

increase the likelihood of morbidity and mortality

Mechanism 2: ICP
Key Concept #3:
When the brain is
squeezed through the
foramen magnum
(herniation), the
brainstem is compressed,
the patient stops
breathing, and the
patient dies

Herniation schematic from Robbins and Cotran. Pathologic Basis of Disease. 7th ed. Philadelphia: Elselvier; 2005.

Normal CT

EDEMA

Categories of Brain Injuries

Diffuse
Concussion (movement to TBI!)
Diffuse Axonal Injury

Focal
Laceration (blunt) and penetrating
Contusions
Intracerebral hematomas
Epidural and subdural

Subarachnoid hemorrhage

Diffuse Brain Injuries

Concussion
Mild traumatic brain injury
No significant imaging findings
Does not mean no injury

Diffuse Axonal Injury

Severe injury globally caused by sheering of
axons
Often neurologically devastated

Mechanism : Diffuse Axonal Injury

A microscopic view of axonal degeneration

Focal Brain Injuries

Penetrating injuries often intuitively
obvious
Contusions (including contrecoup)
Hematomas
Epidural
Subdural

Subarachnoid hemorrhage

Contusions
Focal areas of
hemorrhage within the
parenchyma
Contrecoup injuries
occur from a
whiplash effect of
the brain against the
skull on the opposite
side of the initial point
of impact or injury

Subarachnoid hemorrhage
Subarachnoid blood vessels ruptured
May be the most common finding on
moderate to severe brain injuries

Penetrating Brain Injury (GSW)

Epidural Hematoma

Blood between inner

table of the skull and the
dura
Usually a tear of the
MMA
Lens shaped hematomas
that do not cross suture
lines on CT
Rare in elderly

Epidural hematoma (EDH)

Subdural Hematoma
Blood beneath the dura,
overlying the brain and
arachnoid, resulting from
tears to bridging vessels
Crescent shaped density that
may run length of skull
Very common in the elderly

Subdural hematoma(SDH)

Prehospital Care of Head Injured

Patient
Historically, most patients were
hyperventilated (bad!)
ABCs
Spinal immobilization
Initial resuscitation
Rapid transport

Head Injury Management

Management overall goal is to prevent or
minimize secondary injuries to the brain

Prevent hypoxia
Prevent hypotension
Prevent hemorrhage (anemia)
Prevent or limit increasing pressure

ED Assessment of Head Injured

Patient
ABCs (again)
History (think alternate sources)
Clues to brain injury (examples: Cushings
reflex, raccoon eyes, etc)
Physical exam treat prioritized life threats
first
The D of the ABCs (neuro exam)

Glasgow Coma Scale (GCS)

MOTOR

VERBAL

EYES

6 follow commands

5 conversant +
oriented
4 conversant +
disoriented
3 inappropriate
words
2 incomprehensible
sounds
1 no sounds

4 open
spontaneously
3 open to
command
2 open to pain

5 localizes
4 flexion/withdrawal
3 decorticate post
2 decerebrate post

1 no movement

1 doesnt open

GCS Scores
GCS 13-15

Mild head injury

GCS 9-12

Moderate head
injury

GCS < 8

Severe head injury

Management Principles
ABCs (Get used to it)
Protect spine as well (C spine injury
assumed until proved otherwise)
Stop blood loss elsewhere
Maintain perfusion (why hyperventilation is
detrimental!)

Thank You !