Traumatic Brain Injury: An Overview

Traumatic brain injury (TBI) is a serious health issue that can lead to various complications and even death. Understanding the mechanisms, symptoms, and treatment of TBI is crucial.

Mechanisms of Traumatic Brain Injury

– Lucid Interval: This refers to the period of consciousness between two periods of unconsciousness following a traumatic injury. A short lucid interval usually indicates a better prognosis than a long one.

– Head Movement: When the head moves forcefully in TBI, the injury often affects both sides of the brain.

– Fixed Head: If the head is fixed during TBI, the injury tends to be concentrated on one side of the brain.

Decreased GCS Score

– Decrease of 2 points in GCS in TBI: This suggests a potential intracranial compression and a poor prognosis.

Lucid Interval

– Significance of Lucid Interval: It signifies the possibility of an extradural hematoma (EDH) rather than an intracerebral hemorrhage.

– Mechanism of Lucid Interval Formation: After an accident, the patient loses consciousness, then regains it and then loses consciousness again. The lucid interval is the period of consciousness between the two periods of unconsciousness.

Extradural Hematoma (EDH)

– Source of Bleeding: EDH typically results from a rupture of the meningeal vessels, the vessels of the spongy bone, or the venous sinuses.

– Common Locations: Temporal region and temporoparietal region.

– Reasons for Common Locations:

– Temporal Bone: Thin and fragile.

– Middle meningeal artery: Prone to dissection.

– Temporal Fossa: The lowest point of the skull base.

– Other Locations:

– Frontal region: Bleeding from the anterior ethmoid artery.

– Occipital region: Bleeding from the transverse sinus, sigmoid sinus.

– Parietal region: Bleeding from the superior sagittal sinus.

GCS Score

– GCS Score is not applicable to:

– Individuals under the influence of alcohol.

– Individuals under the influence of sedative drugs.

– Children under 5 years old.

– GCS Score:

– Motor 3 Points: Decerebrate rigidity (upper limb extension).

– Eyes 2 Points: Eyes open in response to stimulation.

– Verbal 4 Points: Slow, confused speech.

Dilated Pupil

– Progressive Pupillary Dilation: Indicates injury to the third cranial nerve.

Subdural Hematoma

– Chronic Subdural Hematoma: Can cause seizures without a lucid interval.

– Kernohan’s Sign: Contralateral hemiparesis, ipsilateral pupillary dilation.

– Cause of Kernohan’s Sign: The free edge of the tentorium cerebelli compresses the brainstem.

Cushing’s Triad

– Cushing’s Triad: Slow pulse, elevated blood pressure, irregular breathing (slow).

Skull X-ray

– Number of Unprepared Skull X-ray Positions: 4 positions: straight, right lateral, left lateral, Worms Bretton.

– Worms Bretton Position: To detect fractures extending to the occipital fossa and posterior fossa hematomas.

Diagnosis and Treatment of EDH

– Diagnosis: Based on CT scans, clinical presentation is only for reference.

– Conservative Treatment: Closely monitor consciousness, vital signs, and focal neurological signs. Perform CT scans when headaches intensify, GCS score decreases, new or worsening focal neurological signs appear.

– Indications for Emergency Surgery:

– Hematoma size > 30g.

– Thickest slice > 15mm.

– Displacement > 5mm.

– Presence of a lucid interval.

– GCS score decrease by 2 points.

Indications for Surgery for Subdural Hematoma

– Thickness >= 10mm.

– Displacement > 5mm.

– GCS score <= 8 points and:

– Consciousness impairment >= 2 points.

– Unequal or fixed dilated pupils.

– Intracranial pressure >= 20mmHg.

Indications for Surgery for Intracerebral Hematoma

– Volume > 50 cm3.

– Temporal lobe contusion > 30 cm3.

– Frontal + temporal lobe > 20 cm3 and:

– Coma (GCS score from 6 to 8).

– Displacement > 5mm.

– Compression or obliteration of the base of the skull.

– Elevated intracranial pressure unresponsive to medical treatment.

Principles of EDH Surgery

– Removal of hematoma.

– Identification and control of the bleeding source.

– Suture the dura mater.

– Subcutaneous drainage.

Cerebral Angiography

– Cerebral Angiography: Can diagnose intracerebral hematomas.

Post-Operative Treatment

– EDH:

– Antibiotics.

– Fluid replacement, pain relief.

– Anti-edema treatment.

– Monitor consciousness, vital signs, and focal neurological signs.

– Monitor drainage and wound healing.

– Subdural Hematoma:

– Post-operative antibiotics.

– Fluid replacement, pain relief.

– Monitor consciousness, vital signs, and focal neurological signs.

– Monitor drainage and wound healing.

Indications for Intracranial Pressure Monitoring

– GCS score <= 8 points and CT reveals mass effect.

– GCS score <= 8 points and 2 out of 3 criteria:

– Age > 40.

– Motor dysfunction.

– Systolic blood pressure < 90mmHg.

Nutrition After Surgery

– Nutrition: Early nutritional support through oral feeding or nasogastric tube, instead of intravenous fluids alone for the first 24-48 hours.

Conclusion

TBI is a serious condition requiring timely diagnosis and treatment. Understanding the mechanisms, symptoms, and treatment methods of TBI will help minimize complications and improve patient recovery outcomes.