Craniocerebral trauma

Craniocerebral injury . Mechanical trauma of the skull determines the compressed (transitory or permanent) brain tissue, the tension and displacement of its layers, the transient sharp increase in intracranial pressure. Displacement of the brain substance can be accompanied by rupture of brain tissue and blood vessels, brain contusion. Usually these mechanical disturbances are supplemented by complex discirculatory and biochemical changes in the brain.

Depending on whether the injury to the integrity of the skin of the skull and its tightness or they are violated, the craniocerebral trauma is divided into closed and open injuries.

Closed craniocerebral traumas are traditionally divided into concussion, bruising and compression; Conditionally, they also include a fracture of the base of the skull and a crack in the arch with preservation of the skin.

Concussion is characterized by a triad of signs: loss of consciousness, nausea or vomiting, retrograde amnesia. Focal neurological symptoms are absent.

A brain contusion is diagnosed in cases when cerebral symptoms are supplemented with signs of focal brain lesion. Diagnostic boundaries between concussion and brain contusion and a slight bruise of the brain are very unsteady, and in this situation the term "concomitant-contusion syndrome" is most appropriate, indicating the degree of its severity. A brain injury can occur both at the site of the injury and on the opposite side by the anti-blow mechanism. The duration of loss of consciousness during a concussion is in most cases from several to tens of minutes.

Brain compression implies the development of traumatic hematoma, often epidural or subdural. Their timely diagnosis involves two unequal situations. With a simpler one, there is a "light period": the patient who has come to consciousness after a while starts to "load" again, becoming apathetic, listless, and then co-located. It is much more difficult to recognize hematoma in a patient in a coma, when the severity of the condition can be explained, for example, by a bruise of the brain tissue. The formation of traumatic intracranial hematomas with increasing volume is usually complicated by the development of the tentorial hernia - protrusion of the brain-compressed hematoma into the aperture of the cerebellar nerve, through which the brainstem passes. Its progressive depression at this level is manifested by the defeat of the oculomotor nerve (ptosis, mydriasis, divergent strabismus) and contralateral hemiplegia.

Fracture of the base of the skull is inevitably accompanied by a bruise of the brain of one degree or another, characterized by the penetration of blood from the cranial cavity into the nasopharynx, periorbital tissues and conjunctiva, into the cavity of the middle ear (with otoscopy, the cyanotic color of the tympanic membrane or its rupture is detected). Bleeding from the nose and ears may be a consequence of local trauma, so it is not a specific sign of fracture of the base of the skull. Equally, the "symptom score" is also often the result of a purely local injury to the face. Pathognomonic, although not necessarily, the outflow of cerebrospinal fluid from the nose (rhinorrhea) and the ears (otorrhoea). Confirmation of the discharge from the nose of the cerebrospinal fluid is a "teapot symptom" - an obvious increase in rhinorrhea when the head is tilted forward, as well as the detection of glucose and protein in the discharge from the nose, respectively, in their content in the cerebrospinal fluid. Fracture of the pyramid of the temporal bone can be accompanied by paralysis of the facial and cochleovestibular nerves. In some cases, paralysis of the facial nerve occurs only a few days after the injury.

Along with acute hematomas, trauma to the skull can be complicated by a chronically increasing accumulation of blood above the brain. Usually in such cases there is a subdural hematoma. Typically, such patients - often elderly people with reduced memory, suffering, in addition, alcoholism - go to the hospital already in the stage of decompensation with the compression of the brainstem. The trauma of the skull, which was many months ago, is usually not severe, the patient amnesizes.

The main clinical signs and survey data that are crucial for assessing the severity and nature of closed craniocerebral trauma, as well as some aspects of medical tactics, can be reduced to an indicative scheme. The state of consciousness-depth and duration of loss of consciousness, as a rule, correlate with the severity of the trauma. Evaluation of vital signs - pulse, blood pressure, respiration, body temperature - should be repeated, in severe cases - at intervals not exceeding 30 minutes. Detection of paralysis of the extremities. Anisocoria, in which the sharp narrowing of the pupil is replaced by its enlargement, is a sign of an intracranial hematoma, though not indicative of hemispheric localization. Local (Jacksonian) convulsive attacks are characteristic for bruises of the brain and hematomas. A study of the rigidity of the occipital muscles is necessary to detect subarachnoid hemorrhage; While palpating the cervical spine, you can detect its fracture, often associated with severe trauma to the skull.

In half the cases, the craniocerebral injury is associated, ie, accompanied by damage to other organs and tissues. Examination of a patient with a trauma to the skull should include an assessment of his physical condition. Shock, found in some patients, can have either a central (damage to the hypothalamic-stem brain regions) or a somatic genesis due to concomitant damage to the thoracic and abdominal cavities with internal bleeding (rupture of the spleen!). It should be borne in mind that the trauma of the skull can be obtained by the patient in case of a fall caused by a cerebral stroke.

In all cases of craniocerebral trauma, craniography is necessary. Linear cracks of the skull in the parietal-temporal region - the indices of a possible rupture of the middle shell artery, the bleeding from which leads to the formation of an epidural hematoma. We should not strive for an acute period for radiographic verification of the fracture of the skull base bones, since the complicated packing of the patient's head can be damaged. A direct indication of damage to the bones of the skull is the detection of air in the cavity of the skull. Identification of cerebrospinal fluid in the blood indicates a subarachnoid hemorrhage that accompanies all serious brain injuries. Absence of blood testifies to the absence of a brain contusion, but does not exclude epi- or subdural hematoma; A direct correlation between the severity of the trauma of the skull and the formation of hematomas there.

Repeated punctures allow us to judge the dynamics of the composition of the cerebrospinal fluid, which to some extent helps an adequate evaluation of the course of traumatic disease. If there is a suspicion of hematoma with the phenomenon of compression of the brainstem in the tentorial or occipital orifice, the puncture should be performed only with the possibility of immediate craniotomy if the patient's condition after deterioration of the cerebrospinal fluid deteriorates.

EEG, especially repeated, significantly helps evaluate the course of the disease. Great role and echoencephalography, which allows to detect the displacement of the median structures, observed with local edema due to brain contusion and especially pronounced with hematoma. Ophthalmoscopy can detect stagnant discs and hemorrhage in the retina. In all cases of suspected intracranial hematoma, angiography is necessary; In this case, carotid artery thrombosis due to concomitant neck trauma can also be detected. Of decisive importance is computer tomokrafiya.

Differential diagnosis of traumatic coma with other coma in the absence of anamnesis is based on damage to the outer covers of the skull, the detection of blood in the cerebrospinal fluid or pathology of blood sugar (diabetes and stroke are the most common causes of coma). It is very difficult to detect brain trauma in patients with alcohol intoxication. The detection of focal neurological symptoms usually indicates that loss of consciousness is associated with a craniocerebral trauma. Equally, the detection of blood in the cerebrospinal fluid excludes the alcoholic genesis of coma.

An open craniocerebral injury is often accompanied by the introduction into the brain of foreign bodies and bone fragments. In case of damage to the dura mater (penetrating wounds of the skull), the danger of infection of the subshell space increases sharply. Open trauma to the skull sometimes occurs without a primary loss of consciousness, and the slow development of coma indicates intracranial bleeding or a progressive edema of the brain. Craniocerebral trauma can be complicated by infection (meningitis, brain abscess, osteomyelitis), vascular damage (hemorrhage, thrombosis, aneurysm formation), development of posttraumatic cerebral syndrome.

If the mechanism of the post-traumatic syndrome with obvious signs of organic damage to the brain (including traumatic epilepsy) is sufficiently clear, then the mechanism of the postcombiting symptom complex, consisting of subjective disorders (headache, dizziness, emotional lability, disability) is treated inconsistently; Admit that it is entirely due to psycho-vegetative disorders.

Treatment. At a coma caused by closed trauma of the skull, a complex of resuscitation measures, in particular, intensive dehydration for combating brain edema, is carried out. In the case of light injuries that occur with a picture of concussion, the treatment is purely individual. In the absence of objective deviations from the nervous system and with good health, there is no need to keep the patient in bed for more than a few days and to conduct drug therapy. If there is an asthenic syndrome (mild headache, dizziness), then it can be limited to the appointment of tranquilizers, and sometimes diuretics. Thus, in the basis of therapeutic tactics in this case, first of all, the data of objective examination should be based, and not the fact of the patient's concussion transferred to the patient. Hematomas are removed surgically. Surgically treated also open trauma to the skull. With fractures of the base of the skull and open trauma of the skull, a preventive prescription of antibiotics is indicated. At all stages of treatment, careful monitoring of the patient for timely recognition of intracranial hematomas is necessary.

Forecast. With a concussion of the brain, the vast majority of patients completely recover. The outcome of a brain injury and open injuries to the skull depends on the severity of brain damage. In most cases, survivors retain some or all residual cerebral symptoms. Timely removal of the hematoma saves the patient life; In many such cases there are no significant residual symptoms. In severe brain damage, mortality can reach 40-50%.

On the long-term consequences of craniocerebral trauma, see Traumatic encephalopathy.