Closed Head Trauma Lecture Slides PDF

Closed Head Trauma Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025  Objectives 1. Summarize the epidemiology of closed head injury and traumatic brain injury. 2. Determine the factors that contribute to intracranial pressure (ICP) and...

Closed Head Trauma Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025  Objectives 1. Summarize the epidemiology of closed head injury and traumatic brain injury. 2. Determine the factors that contribute to intracranial pressure (ICP) and the use of ICP monitoring as a diagnostic tool. 3. Summarize the etiology, pathophysiology, clinical features, how diagnosis is established, potential complications, prognosis and treatment of the following injuries: Diffuse lesions ○ Concussion - including post-concussive syndrome ○ Diffuse axonal injury Focal lesions ○ Skull injury ○ Cerebral contusion ○ Intracerebral hemorrhage ○ Subarachnoid hemorrhage ○ Epidural hematoma ○ Subdural hematoma 4. Identify emergent situations requiring admission and referral to neurology and/or neurosurgery.  Close Head Trauma - Epidemiology Trauma = most common cause of death in young people Head injury accounts for almost ½ of these trauma-related deaths > 1.5 million ED visits/year for head trauma - most of these are mild TBI Falls - youngest and oldest Assaults, falls, MVCs - 15-55yo Significant morbidity and mortality especially in elderly  Anatomy of the Brain Skull: Rigid and Inflexible → Brain is susceptible to rises in intracranial pressure (ICP) Dura-mater partitions: -Falx Cerebri (separates hemispheres) -Tentorium Cerebelli (separates occipital lobe from cerebellum) -Falx Cerebelli (separates cerebellar hemispheres) Brain: Takes up ~80% of intracranial cavity  Central Nervous System Three major regions: Cerebrum Cerebellum Brain stem  Cerebrospinal Fluid (CSF) Cushions brain and spinal cord against trauma Made by choroid plexus in ventricles Flows through ventricular system, then down around spinal cord ~150cc in adult  Cerebral Blood Flow (CBF) CBF profoundly impacted by CO2 & oxygen ○ Hypercapnia: cerebral _________________ ○ Hypocapnia: cerebral _________________ ○ Hypoxia: cerebral _________________ Intracranial pressure (ICP) 3 components ○ Brain ○ Blood ○ CSF Normal ICP < 15 mmHg If intracranial mass, hematoma, or cerebral edema develops, ICP ________ ○ CSF displaced from ventricles ○ Blood is displaced from brain ○ Finally, brain itself is compressed Monro-Kellie Doctrine  Herniation Transtentorial (uncal) herniation Developing hematoma causes rise in ICP forcing medial aspect of temporal lobe (uncus) through tentorium opening Deteriorating LOC Compresses corticospinal tract → Weakness on _______________ arm/leg Compresses 3rd cranial nerve ○ “Down and out” pupil ○ _________ pupil on __________ side Ominous sign → need immediate intervention or will lead to death  Head Trauma History Was there LOC? HOW LONG? If a fall…..How far did you fall? Any drugs or alcohol on board? Meds: What should you always ask about here? Any distracting injuries? Head Trauma Assessment Vital signs ○ Hypoxia and hypercarbia increase ICP ○ Hypotension → unlikely d/t head injury Neurologic exam ○ Level of consciousness - Glasgow Coma Scale ○ Pupil size/reactivity ○ Motor exam ○ Brainstem function (corneal/gag reflexes) ○ REPEATED EXAMS! Full physical exam for other signs of trauma  Head Trauma Evaluation CT head: Standard closed head imaging study (with or without contrast?) CT c-spine ○ Neck pain ○ Decreased LOC ○ Neuro deficits ○ Significant or distracting injury ○ Age/underlying disease Skull Xrays ○ Helpful for penetrating injury ○ Uncommonly used now Trauma labs  Management of Major Head Injury Key Management Steps 5 Distinct Major Head Injuries Frequency Described ABCs, C-spine immobilization 1. Epidural hematoma Reverse anticoagulation 2. Subdural hematoma (SDH) Consider seizure prophylaxis 3. Traumatic SAH Reduce ICP 4. Diffuse axonal injury ○ Intubate 5. Intraparenchymal hemorrhage ○ Hyperventilate to decreased CO2** ○ Elevated head of bed to 30 deg ○ IV mannitol: osmotic diuretic NEUROSURGERY! ○ Rapid evacuation often necessary **in herniatating pt  Post-Traumatic Seizures Increased risk of seizure following brain trauma Keppra or phenytoin is a common posttraumatic prophylaxis medication for ~1 week Can developed post-traumatic epilepsy (anti-epileptic does not prevent this)  Glasgow Coma Scale Both initial score and serial examinations are important GCS - Practice 75 year-old-female presenting after a fall on ice yesterday. She opens her eyes spontaneously, is confused but coherent in her speech, and does not follow commands but localizes pain. Eye: 4 points Total = 13 Verbal: 4 points Motor: 5 points GCS Practice 19yo male presenting after ejection from car in MVC. Does not open eyes, has incomprehensible sounds, withdrawals from painful stimuli Eye: 1 point Verbal: 2 points Total = 7 Motor: 4 points GCS practice 32yo male presenting after snowmobile accident without a helmet. He does not open eyes, is non-verbal, and no motor response. Total = 3  Traumatic Brain Injury (TBI) Mild: GCS 13-15 Although increased morbidity at 13 vs. 14 so Moderate: GCS 9-12 some clinicians feel 13 = moderate Severe: GCS < 8 “Less than 8, intubate”  TBI - General Management Moderate - severe brain injury ○ CT head w/o contrast ASAP ○ Reverse anticoagulation ○ Consult NSG (neurosurgery) Mild brain injury ○ Use validated decision rules to judiciously obtain imaging Canadian CT Head Rule New Orleans Criteria NEXUS II Criteria ○ Often can be discharged after workup to f/u with PCP or concussion specialist ○ Low threshold for imaging in elderly and anticoagulated patients  Diffuse Lesions Concussion Diffuse Axonal Injury Concussion - Overview Definition: alteration in mental status (confusion or disorientation) caused by trauma with or without loss of consciousness Minor head injury = minor head trauma = MTBI = concussion Pathology: Unknown; likely mild diffuse axonal injury and excitotoxic neuronal injury Functional disturbance rather than structural injury Concussion - Symptoms Early/Acute symptoms ○ Headache ○ Dizziness, imbalance ○ N/V ○ Confusion/Disorientation Following hours-days ○ Photo-/phonophobia ○ Mood/cognitive changes ○ Difficulty concentrating ○ Sleep disturbances  Concussion - Examination Usually normal Orientation and attention, short-term memory, reaction time may be affected Make sure you note: ○ Signs of scalp laceration ○ Facial and/or skull fracture (Basilar skull Fx) ○ Neck injury Persistent or progressive decline in LOC → imaging  Concussion - Imaging? CMDT Clinical Decision Making Tools GCS 65yo New Orleans/Charity Head Skull Fx Trauma/Injury Rule - MDCalc Retrograde amnesia > 30 Intoxication NEXUS Head CT Instrument - Soft tissue injury head or neck MDCalc Persistent headache or vomiting Head Imaging Decision Tools Concussion - Imaging for kiddos PECARN Pediatric Head Injury/Trauma Algorithm - MDCalc  Concussion - Disposition and Management Treatment is aimed at Most can be discharged with observation 1. Promoting resolution of current symptoms and follow up with pcp or concussion specialist 1. Avoid Second Impact Syndrome: recurrent Uncomplicated concussions can return to concussion while still symptomatic from first work after 24h of physical and cognitive concussion rest Athletes - remove from play; graduated supervised return International consensus statement, British Journal of Sports Medicine, 2009  Concussion - Prognosis Post-concussion syndrome ○ Symptoms and disability from the concussion ○ Greatest in first 7-10 days ○ Symptoms resolve in most patient by 1 month; vast majority by 3 months ○ 10-15% of people have symptoms at a year Persistent headaches ○ Migrainous features - what could be prescribed for prophylaxis? ○ Avoid opioids - why? Chronic traumatic encephalopathy: mood and cognitive changes ○ Correlated with lifetime exposure to repetitive head injury  Post Concussion Syndrome Common sequelae of TBI (30-80%) Sx: HA, dizziness, neuropsychiatric sx, cognitive impairment for days- weeks after injury Complication definition and diagnosis ○ Symptoms vague and subjective ○ Can be caused by varying degrees of head injury ○ Underlying pathophysiology not clearly defined ○ Tests can be normal or abnormal and not consistent  Post Concussion Syndrome - Symptoms Headaches Sleep Disturbances Psychological and cognitive symptoms - 15-20% meet criteria for psychiatric disease ○ Personality changes ○ Irritability ○ Anxiety and/or depression ○ Intolerance to noise ○ Sensitivity to alcohol ○ Impaired memory and concentration  Post Concussion Syndrome - Diagnosis & Management Diagnosis Management Neuropsychological testing Unique to patient and symptoms - most need reassurance/education Neuroimaging (CT scan and/or MRI brain) Cognitive and physical rest EEG (usually not needed unless Headache management unique features) Sleep/wake management Psychological interventions  Diffuse Axonal Injury - Overview Persistent loss of consciousness, coma, or persistent vegetative state resulting from severe rotational shearing forces or deceleration Pathology: Tearing/shearing of nerve fibers at time of impact CT scan can be normal despite profound neurological deficit ○ Could also show scattered white matter hemorrhages → torn axons Best seen on MRI Mortality 33% - usually due to cerebral edema  Focal Lesions Skull Injury Cerebral Contusion Intracerebral Hemorrhage Subarachnoid Hemorrhage Subdural Hematoma Epidural Hematoma  Skull Fractures - Linear vs Depressed Linear non-depressed Depressed skull fracture: fracture: If scalp intact, Often requires surgical generally no tx needed intervention  Skull Fractures - Open Can be associated with large scalp lacerations which can be difficulty to control Often associated with depressed skull fx IV antibiotics and often neurosurgical intervention Basilar Skull Fractures Fracture through base of skull Most common: Temporal bone Racoon eyes: tarsal plate sparing Hemotympanum: blood behind TM Battle’s sign: bruising behind ear Ring/Halo sign: CSF leakage Tx: Most often just close monitoring, but monitor closely - especially for brain bleed  Racoon Eyes Hemotympanum Halo sign/CSF leak Battle’s Sign  A Note about Pediatric Skull Fx “Egg shell” like breaks in skull Consider non-accidental trauma  Cerebral Contusion Focal hemorrhage area on brain, often with surrounding edema Pathology: Head impact on either… ○ Same side as impact (Coup Injury) ○ Opposite side of impact (Contrecoup injury) Clinical Features: ○ Often LOC longer than with concussion ○ Focal neuro deficits common Imaging: CT Treatment: Control ICP  Intracerebral Hemorrhage Parenchymal hemorrhage Pathology: Disruption of small intraparenchymal vessels Can lead to expanding mass lesion Presentation: Varies widely depending on size and location Intracerebral Hemorrhage - Symptoms & Management Symptoms: Management: Headache Decrease ICP Nausea, vomiting Evacuation of hematoma Hemiparesis LOC  Subarachnoid Hemorrhage Without setting of trauma - what causes SAH? Traumatic SAH: Accumulation of blood between the surface of brain (________) and the arachnoid membrane Pathology: Multifactorial ○ Direct extravasation from adjacent cerebral contusion ○ Arterial dissection ○ Direct damage to smaller veins or arteries  SAH - Symptoms & Management Symptoms Management Headache Often no surgical Nausea/vomiting intervention - Maybe coiling Neck stiffness Treat ICP Photophobia Subdural Hematoma - Overview Location: Subdural space Mechanism: Shearing of bridging veins ○ Acute: MVC, blunt force trauma, falls ○ Acute & Chronic: Older patients, alcohol use disorders Most Fatal  Subdural Hematoma - Symptoms Wide spectrum of manifestations Can have additional bleeds (epidural, SAH, cerebral contusions) Can be asymptomatic Focal neurologic symptoms based on location of bleed (frontal lobe, parietal lobe, etc) Seizures Stupor, herniation symptoms Subdural - Diagnosis CT scan “Sickle-shaped”/”Crescent-shaped” Commonly in the frontoparietal and middle cranial fossa Bleed can cross the suture line  Subdural - Management Reverse anticoagulation Neurosurgical consult Surgical burr hole or craniotomy to evacuate clot based on clot thickness, midline shift, GCS, ICP levels, pupillary responses Subacute and Chronic Subdural Hematoma  Epidural Hematoma - Overview Location: Epidural space ○ Temporal bone fracture Mechanism: Usually middle meningeal artery trauma Appearance: Biconvex/Lens Can rapidly progress to herniation  Epidural Hematoma - Signs and symptoms Brief LOC, then “lucid period”, followed by deteriorating mental status Headache Nausea/Vomiting Focal neuro deficits - 3rd nerve palsy ○ Tentorial herniation  Epidural hematoma - Diagnosis CT head Lens shaped hematoma Does not cross suture line  Epidural Hematoma Neurosurgery emergency Often emergent craniotomy Manage ICP Review Pictures Imaging Review… A 67 year-old man was noted to have word finding difficulty and was dragging the right leg when walking. Imaging Review… A young adult, 18 years of age, presented to the emergency department with severe traumatic brain injury (TBI) resulting from a bicycle versus vehicle head-on collision. The patient initially presented in a promising condition but quickly deteriorated into a state of unconsciousness with no meaningful responses to stimuli or coordinated voluntary movement https://www.cureus.com/articles/11985-trauma- induced-acute-epidural-hematoma-the-rising-sun- in-a-progressively-lethargic-man#!/ Imaging Review A 25-year-old male who presented to the ED after a motor vehicle collision (MVC) with a speed of 50 m/h, frontal impaction and there was no roll over, or ejection from the car with minimal epistaxis and a small superficial wound over the nose. No initial CT scan 3.5 wks later - persistent HAs - this image… https://www.cureus.com/articles/7576 9-subacute-bilateral-subdural- hematoma-delayed-presentation-with- headache-one-month-post-mild- Imaging Review An 18-year-old intoxicated man was assaulted with a glass bottle on the left parietal region of his head and had a 5-minute loss of consciousness. The patient went home, but 2 hours after the injury, he presented to a local emergency department with severe headache, nausea, and vomiting. https://www.nejm.org/doi/full/1 0.1056/NEJMicm0706764 Imaging Review : 28 year old patient with end stage renal disease and hypertension presents with a seizure. https://radiologypics.com/2013/02/ 15/non-traumatic-intracranial- intracerebral-hemorrhage/ Brain Imaging A 47-year-old woman presented with headache and vomiting; her CT scan in the emergency department revealed _________________________. https://emedicine.medscape.com/arti cle/1164341-overview  Clinical Feature Pathology Imaging Mgt Key features Concussion Intracerebral hematoma SAH SDH Epidural hematoma Diffuse Axonal Injury  Clinical Feature Pathology Imaging Mgt Key features alteration in mental Unknown: mild mild Not usually needed Brain rest; symptom Concussion status caused by axonal injury Head CT - negative mgt - most resolved trauma w/w/o LOC by 3mo Generally develops Small Head CT - within NSG, ICP, maybe Intracerebral after injury - varying intraparenchymal brain tissue surgery hematoma presentations vessels (brain tissue) Traumatic or non- NonTraum - Head Ct NSG, ICP SAH traumatic Aneurysm, AVM Trauma - mult causes Elderly, alcoholic, Bridging Veins Head CT - NSG! SDH possible delayed Crescent shaped presentation Lucid interval Middle meningeal Head CT - NSG! Epidural ARTERY Convex hematoma Persistent LOC, coma Shearing of nerve Head CT - Can be NSG/Neurology Diffuse Axonal or persistent fibers negative! Injury vegetative state MRI for confirmation