HEAD INJURY

Trauma to the head with or without trauma to the

brain

Classification
Based on severity- GCS
Primary or secondary brain injury

Glasgow Coma Scale

Severit GCS
y
Minor

15, no LOC

Mild

14 or 15, with
LOC

Mortali
ty
0.1%

Moderat 9-13
10%
**Motor
score: best predictor of neurological
e
outcome

Severe

3-8

40%

What is the score?

A patient who is eye opening to painful stimuli, saying
occasional words and exing to pain
GCS of 9/15 (E2, V3, M4)

What if patient is intubated?

Verbal score T
Patient who opens eyes to speech (E2), is intubated (VT) and
localises to pain (M5) has a GCS of 7T/15

Brain injury
PRIMARY

Injury sustained by brain at the time of impact

Example: Brain laceration, Brain contusion

SECONDARY

Injury sustained by brain after the impact

Often preventable

Principle causes:

Extradural haematoma
(EDH)

 Neurosurgical emergency
Nearly always associated with a skull fracture
o skull fracture is associated with tearing of a meningeal artery
and a haematoma accumulates in the space between bone
and dura meter

Most common site: temporal

As pterion is the thinnest part of the skull
Overlies the largest meningeal artery the middle meningeal
artery

Other regions: frontal and in the posterior fossa

 Clinical presentation
Initial injury
Lucid interval - headache but is fully alert and orientated with
no focal decit
Rapid deterioration (after minutes or hours)
contralateral hemiparesis
reduced conscious level
ipsilateral pupillary dilatation

 CT scan appearance
Unilateral
Biconvex (lentiforms or lens
shaped)
Hyperdense lesion
Sharply demarcated
Does not cross suture line
Associated with mass effect on
underlying brain
With or without midline shift

 Swirl sign ( Fresh/ non clotted

blood)
Less hyperdense/ isodense

Subdural haematoma
(SDH)

 Differs from EDH in terms of pathophysiology,

presentation and prognosis
Accumulates in the space between the dura and the
arachnoid
Disruption of a cortical vessel or brain laceration
Nearly always associated with a signicant primary
brain injury

 Clinical presentation
impaired conscious level from the time of injury
further deterioration as the haematoma expands

 CT scan appearance
Unilateral
Crescent (concave)
Hyperdense (acute blood)
Crosses suture line
Midline shift

**Hypodense (Black) indicates chronic SDH

 Chronic SDH

Bilateral
subacute SDH

Acute on
Chronic SDH

PRINCIPAL
MANAGEMENT OF HEAD
TRAUMA

Principal Management of Head

Trauma
Can be divided into:
1. Initial management
2. Early Neuro-assessment
3. Neuro-surgical management

INITIAL MANAGEMENT
Primary survey

Resuscitation

Secondary
survey

Patients neck should be immobilized until cervical

spine injury has excluded
ABCDE
Airway

adequate airway, secured from obstruction,

intubate if GCS is <11

Breathin
g

prevents obstructive breathing/

hypoventilation

Circulatio
n

maintains adequate blood pressure, pulse

rate, temperature

Diasabilit
y

GCS; pupillary size, equality, reaction to

light

Exposure

exposes patient from head to toe, looks for

any other bleeding sites

INITIAL MANAGEMENT
Primary survey

Resuscitation

Secondary
survey

Resuscitate patient with uid & electrolytes

Any bleeding on the scalp should be compressed
& covered by dressing
Monitor :
Airway
Verbal response
Response to pain
Consciousness

INITIAL MANAGEMENT
Obtains a rapid history of

Primary survey

Resuscitation

Secondary
survey

Also do physical examination- head, face and neck

Evidence of external head injury- subgaleal
haematoma or scalp laceration
Evidence of skull base fracture
1. Bilateral periorbital oedaema (raccoon eyes)
2. Battles sign (bruising over mastoid)
3. CSF rhinorrhoea or otorrhoea
4. Haemotympanum or bleeding from ear
Full neurological examination: tone, power,

Early Neuro-assessment
1. Assess for the conscious level by using Glasgow Coma Scale
2. Cranial nerves examinations if possible
3. Assessment of pupillary size & reaction
4. Search for CSF leaks from nose, mouth & ears
5. Examine scalp for laceration and fractures
6. Assessment of maxillofacial skeleton
7. Monitor neurological symptoms

Vomiting
Altered behaviour (confusion)
Severe & persistent headache
Seizure

Discharge criteria in mild head

injury
GSC 15/15 with no focal decits
Normal CT brain
Not under inuence of drugs or alcohol
Accompanied by a responsible adult
Verbal and written head injury advice to seek medical attention if:

Persistent/worsening headache despite analgesia

Persistent vomiting
Drowsiness
Visual disturbance
Limb weakness and numbness

**Bailey and Loves 26th Edt

Management
Observe for few hours especially when there is history
of LOC at time of injury
Evaluate if patient need admission or not
Investigations:
Imaging (CT scan of brain)
Other baseline investigations (FBC, coagulation prole, GXM)

Treatment/intervention

Radiological investigation
Skull Xray
Cervical Xray
CT scan of brain
CT scan of cervical
MRI brain/cervical

Skull and cervical Xray

Use to detect fractures or radio opaque foreign object in
the skull.

CT scan
The current standard investigation
Should be done in ALL patient with signicant head
injury
Demonstrates mass effect, ventricular size and
conguration, bone injuries, and acute hemorrhage.
Limitations: insensitivity in detecting small and
nonhemorrhagic lesion (eg contusion)

Extracerebral lesion
Extradural hematoma
Subdural hematoma
Fractures of skull base or vault

Intracerebral lesion
Odema
Contusion
Intracerebral hematoma

 Basal cistern
Midline
Sulci gyri
Ventricles
Bones

Epidural
haemorrhage

Subdural
haemorrhage

Edema with
compression on
ventricles

Intracerebral
haemorrhage

MRI
More sensitive and detail imaging study
Demonstrate: anatomic & vascular structures,
myelination process & detection small hemorrhages
Disadvantage: time consuming, sensitivity to patient
motion and incompatibility with various medical devices

Indication For Surgery

1.
2.
3.
4.

Depressed skull fracture

Epidural haematoma ~ burr holes/craniotomy
Subdural haematoma ~ craniotomy
Seizure without full recovery

Skull fracture
Exploration, debridement and elevation of fragment
Compound fracture has high incidence of infection,
neurological decit and late onset epilepsy hence
antibiotic, antiepilectics are indicated
Skull base fracture may associated with CSF leak hence
pneumococcal vaccination is indicatied

Epidural hematoma
Immediate transfer to neurosurgical unit
Immediate evacuation in deteriorating or comatose
patient or those with large bleeds with burr holes or
craniotomy
Close observation with serial imaging

Subdural hematoma
Similar to epidural hematoma
Smaller bleeds can be managed conservatively with ICP
monitoring
Evacuation using burr holes/craniotomy

Cerebral contusion
Rarely requires surgery unless to reduce mass effect