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Traumatic brain injury

Statistics
• 40% of all types of injuries
• 4:1000 in RUSSIA Every year , 1.5 million people
die worldide
• Age group from 20 to 50 years old
•Men have more severe injuries than women, hence
the mortality rate is 3 times higher
•Mortality rate is 5-10% for mild and moderate
injuries, up to 70% for severe traumatic brain injuries
•60% of patients with traumatic brain injuries
experience a decrease in work capacity

3.

Traumatic brain injury is damage caused by
mechanical energy to the bones of the skull,
brain, blood vessels, cranial nerves, and
meninges.

4.

Biomechanics
combined
Type of damage
Pathogenesis
Isolated
combined
Mild
Moderate
severe
primary damage\secondary damage
Type of injury
The nature of the
injury
Closed
Оpen
Severity
Clinical form
Compensationsfor
subcompensationof moderate
decompensationof gross decompensation
Shockproof
Acceleration-deceleration
combined
concussion of the brain
brain injury
diffuse axonal injurycompression of the brain
compression of the head
The clinical
phase
The injury period
Acute
Intermediate
long-term

5.

MECHANISMS OF
DYNAMICIMPACTS
"ACCELERATION - DECELERATION"diffuse damage
"BLOW - COUNTERATTACK"- focal
(local)"COMBINED"

6.

severity of primary
brain damage

7.

CLASSIFICATION OF TRAUMATIC BRAIN INJURY BY
PERIODIZATION((by L. B. Lichterman, 1990)
100
90
80
70
60
50
40
30
20
10
0
96
>96
96
>96
acute period
48
32
24
16
2
4
СГМ
3
8
УГМ лс
5
УГМсрс
8
УГМ тс
• Concussion
Cerebral contusion
10
Сдавление
intermediate period
long-term

8.

Diagnostics
1. Anamnestic triad
2. 2. External examination and palpation
3. 3.Neurological examination:General cerebral
symptomsFocal symptoms...Meningial symptom
complex
4. 4. ECHO ES
5. 5. R-graphy of the skull
6. 6. Lumbar puncture
7. 7. CTscan of the brain
8. 8. Cerebral angiography
9. 9. Application of diagnostic trefinationholes

9.

Anamnestic triad
Nausea and vomiting
Loss of consciousness after injury
Retro or anterograde amnesia

10.

ДИФФЕРЕНЦИАЛЬНАЯ
ДИАГНОСТИКА
Concussion
loss of
consciousness
General cerebral
symptoms
Short-term, moderate
Mild INJURY
Moderate INJURY
Severe INJURY
Seconds - minutes
Minutes hours
Hours - weeks
Short-term, moderate Persistent, pronounced
Persistent,
Focal symptoms
Short-term
Short-term - long-term
Long-term
Meningeal
symptoms
Possibly short-term
Long-term
Long-term
Rarely (secondary)
Often (primary)
Possible
Possible (often)
Short-term
Long-term
Stem symptoms
Fractures of the
skull bones
Vital disorders
Possible

11.

DIFFUSE AXONAL INJURY
1. Prolonged coma
2. Stem symptoms
3. Decerebration rigidity
4. Vital and vegetative disorders
5. - hypertension6. - hyperthermia
7. - hypersalivation
8. - hyperhidrosis

12.

Classification
T.Gennerelli
death
3 grade
vegetative state
2 grade
disability
1 grade
6 – 24 hours
>24 hours
>24 hours +gross stem
symptoms

13.

COMPRESSION OF THE BRAIN
BONE FRAGMENTS
AIR PRESSURE
HEMATOMA
HYGROMA
CONTUSION FOCUS

14.

Types of brain dislocations

15.

ECHOENCEPHALOGRAPHY
It is based on the location of brain structures
with varying degrees of acoustic resistance
(epiphysis, transparent septum, ventricular
walls)

16.

The principle of ECHO-COPYING in the
modes: a. "ECHO"; b. "Transmission"

17.

Typical location zones Ultrasonic sensors
1-front track
2-middle track
3-back track
A-transparent partition
B-lateral ventricle
C-III ventricle
D-pineal gland
E-occipital horn of the lateral ventricle
F- IV ventricle
G-external auditory canal

18.

The main elements of the ECHOGRAM are
normal (a) and with displacement of the
median structures (b)

19.

Analyzed parameters in
ECHOENCEPHALOGRAPHY
The amplitude and dominance of the MECHO ranges from half to full height of the
initial and final complex

20.

THE REASON FOR THE ERRORS
• asymmetry of the skull
• a combination of hematoma with multiple foci
of injury, which is manifested by multiple
complexesof large subcutaneous hematomas,
soft tissue edema in the parietal-temporal
regionbilateral hematomas, hydromas
(without displacement of median structures)

21.

Roentgenography

22.

Signs of traumatic suture divergence
• Fractures of the teeth
• Seam gaping and tooth disappearance
• The incongruence of the edges forming the
seam
• Step-like deformation

23.

X-ray of the skull, direct projection( linear fracture of the frontal bone )

24.

X-ray of the skull, lateral projection( linear fracture of the frontal, temporal bones of
the skull )

25.

X-ray of the skull in the posterior semi-axial projection(linear fracture of the occipital
bone )

26.

Signs of linear fractures
• Contrasting illuminations
• Straightness and angularity of bends
• The sharpness of the edges
• The presence of sections of separate display
fracture of the outer and inner plate (a
symptom of bifurcation or rope)

27.

X-ray of the skull, tangential projection ( depression fracture of the parietal bone )
Образец текста
Второй уровень
Третий уровень
Четвертый уровень
Пятый уровень

28.

LUMBAR PUNCTURE

29.

NEUROIMAGING CHARACTERISTICS
TRAUMATIC BRAIN INJURY

30.

CT scan of the fracture of the bones of
the cranial vault

31.

CT classification of brain injury
Type
• I is a low density zone within the range of
18-25 HUType
• II – from 26 to 50 HUType
• III – from 51 to 64 HU with areas with a
density of 18 – 25 HUType IV – from 65
to 75 HU (intracerebral hematoma)

32.

CT picture of a type I contusion lesion

33.

CT picture of a type II contusion lesion

34.

КТ картина контузионного очага III типа

35.

CT picture of a type IV contusion lesion

36.

DIFFUSE AXONAL INJURY

37.

Classification of hematomas by volume
• Up to 40 cm3 – small
• From 40 to 60 cm3 – medium *
• From 60 to 90 cm3 – large
• More than 90 cm3 - massive
* Subdural hematomas of more than 50 cm3 lead to edema, dislocation of
the brain substance. Hemorrhages with a smaller volume usually occur
without edema.

38.

CT scan of the epidural hematoma
А
Б
В
Fig. 5
Epidural hematoma 64 HU in the form of a biconvex lens adjacent to the
bones of the cranial vault:
A- frontotemporal; B- occipital; C- temporal regions

39.

40.

CT scan of subdural hematoma
in the acute period
Fig. 6
Subdural hematoma 68 HU of convex shape with an uneven inner surface
occupying the frontal-parietal-occipital region

41.

Chronic hematomas
А
Б
Fig. 7
Chronic hematomas:
A- 21 HU with a pronounced capsule; B- 18 HU.

42.

MR scan of compression of the brain by
subdural hydroma

43.

CT scan of posttraumatic
pneumocephaly

44.

MRI of the brain, chronic subdural hematoma before
and after surgery

45.

Treatment
• Conservative
• Operational

46.

The main directions of conservative treatment for
concussion
1.
2.
3.
4.
5.
6.
7.
observance of bed rest for a period of 1 week*.
sedative (elenium, sanosan, sibazone)
hyposensitizing drugs (diphedrol, pipolfen)
vegetotropic drugs (platyphylline, belloid, betacerc, euphyllin) in normal doses
orally.
dehydrating drugs (furosemide, diacarb, ethacric acid) 1 tab. in the morning for
4-6 days with correction of possible potassium deficiency (diet, panangin).
With persistent asthenia, it is advisable to use caffeine (2 ml of 10% solution 2
times a day) and other psychostimulants (acephen, sydnocarb, centedrine, 1
table each morning and afternoon).
from 3 days neuroprotectors - nootropil, gliatilin, picamilon and others
The duration of hospital stay is limited to 7-10 days. During this period, in
addition to the implementation of a course of therapeutic measures, dynamic
monitoring of the patient is carried out, excluding the compensated phase of
traumatic compression of the brain (“light gap”). It is this circumstance that
largely determines the need for hospitalization

47.

The main directions of conservative treatment for mild
and moderate brain injuries
improvement of cerebral blood flow
- improvement of rheological properties of blood (rheopolyglucin, cavinton, euphyllin)
- relief of cerebral vascular spasm (nimotop *, complamin, stugeron, papaverine, etc.)
improvement of energy supply to the brain (10% glucose solution in the form of a polarizing
mixture with subcutaneous insulin injection, )
• elimination of pathological shifts of water sectors in the cranial cavity (lasix 0.5-0.75 mg/ kg,
glycerin 70-75 ml., euphyllin 10.0 ml. 2.4%, diacarb)**
• metabolic therapy (nootropics, cerebrolysin, actovegin, gliatilin)
• hemastatic, anti-enzyme therapy (dicinone, kontrical, gordox, trasilol)
• hyposensitizing therapy 1-11/2 weeks. (diphenhydramine, pipolfen, suprastin, diazoline, tavegil,
etc.)
• sedative therapy
• analgesics
• anticonvulsants according to indications (depakin, phenazepam, finlepsin, benzonal)
• anti-inflammatory treatment
____________________________________________________________________________________
* with spasms caused by subarachnoid hemorrhage (2 mg /hour for 2 weeks, then switch to Table.
form)
** dehydration therapy is performed only after diagnostic lumbar puncture

48.

Indications for the conservative treatment of severe
brain contusions
• the victim's stay in the subcompensation phase or moderate
clinical decompensation
• consciousness – stunning 1-2 (at least 10 points on the scale)
• absence of signs of dislocation of the brain stem
• the volume of the fracture site according to CT or MRI data is not
more than 30 cm3 in the temporal lobe, not more than 50 cm3
for the frontal lobe
• Absence of signs of dislocation of the median structures by CT
and MRI of no more than 10 mm, without a pattern of
deformation covering the tank

49.

50.

Indications for surgical intervention
• Brain compression syndrome
• The severity of hypertension-dislocation
syndrome

51.

THE PURPOSE OF SURGICAL
TREATMENT
REDUCING THE MASS EFFECT
REDUCTION OF ICP
REDUCING THE CONCENTRATION
OF NEUROTOXIC SUBSTANCES

52.

Indications for surgical treatment of severe brain
contusions
• Persistent stay of the victim in the phase of gross clinical
decompensation
• consciousness – (less than 10 points on the scale)
• pronounced clinical signs of brain stem dislocation
• the volume of the fracture site according to CT or MRI data is
more than 30 cm3 in the temporal lobe, more than 50 cm3 for
the frontal lobe with homogeneity of its structure
• the presence of signs of dislocation of the median structures
on CT and MRI of more than 10 mm, the pattern of
deformation of the enclosing tank

53.

Indications for surgical treatment of epi
and subdural hematomas
(A.A. Potapov)
1.
2.
3.
4.
5.
6.
7.
8.
Pronounced clinical signs
Deepening the oppression of consciousness
Large volume of hematomas
Lateral displacement of the midline structures is greater
than 5-7 mm
Pronounced deformation of the basal cisterns
Gross compression of the homolateral lateral ventricle,
dislocation hydrocephalus
The presence of a depressed fracture
Hematomas of posterior cranial fossa less than 20 ml

54.

Indications for conservative treatment
of epi and subdural hematomas
(Potapov A.A.)
1. The volume is less than 30 ml for temporal
localization and less than 50 ml for frontal
localization
2. Volume less than 20ml with subtentorial
localization
3. Asymptomatic hematomas with a volume of
less than 50 ml

55.

Indications for surgical treatment for
parenchymal hemorrhages
1. The volume is more than 30 ml for temporal localization and
more than 40 ml for frontal and parietal localization
2. The diameter is more than 4 cm, if the hematoma causes a
violation of consciousness before copulation.
3. Gross focal neurological deficit
4. Dislocation syndrome is more than 5 mm.

56.

Indications for surgical treatment of a
depressed fracture
1. The presence of a depressed fracture
2. Intracranial injuries
3. Dislocation syndrome

57.

Indications for conservative treatment
of a depressed fracture
1. Asymptomatic course
2. Absence of intracranial substrates
3. The affected area is outside the functionally
significant zones.
4. The area is less than 10 cm2 and the depth is
less than 1 cm
Dynamic EEG

58.

59.

60.

Trepanation of the skull
• Bone and plastic surgery
• Resection
• Diagnostic trefining holes

61.

General principles of trepanation
• Skin incision, taking into account the localization of blood
vessels and nerves
• The base of the cutaneous aponeurotic flap is directed to
the base of the skull
• The autopsy of TMO is X – shaped or horseshoe-shaped
in the vascular-free zone
• The main stage of the operation
• TMO suturing
• Fixation of the bone flap during osteoplastic trepanation