Traumatic Brain and Head Injury

Question 1

What is a head injury defined as?

Answer 1

Non-degenerative, non-congenital insult to the brain from an externa mechanical force

Question 2

How common are traumatic head injuries?

Answer 2

Very = commonest cause of death and disability in people age 1-40

Question 3

What are the high risk groups for traumatic head injuries?

Answer 3

Young men and elderly, previous head injuries, residents of inner cities, alcohol and drug abuse, low income

Question 4

What are the common mechanisms of injury for traumatic head injuries?

Answer 4

Assault, falls, RTCs, sports, over half involve alcohol

Question 5

What occurs in the initial management of a traumatic head injury?

Answer 5

ATLS management = GCS, pupils, ABCs
Secondary survey = other injuries (C spine)
History = what happened and when, age, pre-existing PMH, drugs

Question 6

What are the categories of the Glasgow Coma Scale?

Answer 6

Eye opening = open spontaneously, to speech/pain, no eye opening
Motor = obeying, localising, abnormal flexing, extending, no motor response
verbal = orientated, confused, inappropriate, incomprehensible, no verbal

Question 7

What is the grading of the head injury severity scale?

Answer 7

Mild = 14 or 15, brief loss of consciousness
Moderate = 9-13
Severe = 3-8

Question 8

What patients should receive a CT within an hour of admission?

Answer 8

GCS <13 on initial assessment or <15 at 2hrs post injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post traumatic seizure or focal neurological deficit
More than one episode of vomiting
Suspicion of NAI

Question 9

What patients should receive an immediate CT is they are experiencing loss of consciousness or amnesia?

Answer 9

Age >=65, coagulopathy, dangerous mechanism of injury

Question 10

What are the categories of head injury?

Answer 10

Focal = traumatic haematoma, contusion
Diffuse = DAI

Question 11

What are the types of haematoma?

Answer 11

Extradural, subdural or intracerebral

Question 12

What is the classic presentation of a traumatic head injury?

Answer 12

Injury with loss of consciousness and recovery lucid period = rapid progression of neurological symptoms

Question 13

What are some of the symptoms of traumatic head injuries?

Answer 13

Deteriorating GCS, possible hemiparesis, unilateral fixed and dilated pupil, apnoea and death

Question 14

What is the neurosurgical role in traumatic head injuries?

Answer 14

To prevent secondary insults = hypoxia, hypotension, mass lesions, controlling ICP and CPP

Question 15

What factors are considered in the surgical decision process?

Answer 15

Age, GCS, haemodynamically stable, PMH and drug history, blood results, CT results, guidelines

Question 16

What is the management of raised ICP?

Answer 16

Sedation = propofol, benzodiazepines, barbiturates
maximise venous drainage of brain = head pf bed tilt, cervical collars, CO2 control
Osmotic diuretics = mannitol, hypertonic saline
CSF release = decompressive craniectomy

Question 17

What are some features of seizures?

Answer 17

Can cause secondary insults

Anti-epileptic medication reduces early seizures, but not late seizures

Question 18

How is diffuse axonal injury classified?

Answer 18

Adams classification (1-4) for DAI sheering interface

Question 19

Where do diffuse axonal injuries occur?

Answer 19

Where density difference is greatest = grey/white interface

Question 20

What occurs after a diffuse axonal injury?

Answer 20

Excitotoxicity and apoptosis with inflammatory mediator release

Question 21

What occurs in excitotoxicity?

Answer 21

Excitatory amino acids (glutamate) activates NMDA receptors = calcium mediated activation of proteases and lipases, further secondary cell death

Question 22

What inflammatory mediators are released following a diffuse axonal injury?

Answer 22

Cytokine and interleukins

High IL-6 levels associated with greater likelihood of death

Question 23

Can brainstem death be treated?

Answer 23

No = recovery is impossible

Question 24

What are the features of brainstem death?

Answer 24

No pupil response, corneal reflex, motor response, vestibulo-ocular reflex, gag reflex, cough reflex or respiration

Question 25

What is needed to confirm brainstem death?

Answer 25

Confirmation by two doctors = one must be consultant

Question 26

What are some issues that may occur after leaving hospital following a traumatic head injury?

Answer 26

Seizures, depression and mood swings
Alcohol and drug dependence and suicide 
Personality change and aggression
Recurrent behaviour = further head injuries 
Failure of relationships and loss of job