Cranio-Cerebral TraumaRe-written by: Daniel HabashiSeminar by: Dr. Jezewski (Asshole)

History

•5000 years ago•Edwin Smith Papyrus (1700 B.C.)•Description of 48 patient neurosurgically

treated in Ancient Egypt. The first time the word “brain” was used.

Neurosurgery Made By Monks

•Some more history and pictures. Nothing important for a test obviously.

Main Causes Of Cranio-Cerebral Trauma•Car accidents 50%•Falls 30%•Criminal 7%•Sport 7%

GCS – Glasgow Coma ScalePoints Eye response Verbal

responseMotor response

6 - - Obeys

5 - Oriented Localizes pain

4 Spontaneously Disoriented Flexion withdrawal

3 To verbal command

Inappropriate words

Flexion abnormal

2 To pain Incomprehensible sounds

Extension

1 No response No response No response

GCS

•GCS describes patients clinical status after head trauma and influences the speed of diagnostic and therapeutic procedures

•GCS < 8 = serious status

Neurological Examination

•Reflex•Flexion / Extension•Anisocoria (ipsilateral not contralateral)

•The most important are the dynamics of symptoms

What To Do With A Head Trauma Patient?• 1. head and trunk lifting 30 degrees• 2. Analgosedation (Dormicum + MF / Fentanyl)• 3. Osmotherapy (Mannitol) > 320mOsm/L• 4. Anticonvulsant protection• 5. Optimal ventilation parameters

▫ pO2 100mm Hg, pCO2 30-35mmHg• 6. Fighting against hypovolemic shock

▫ MAP > 90 mmHg▫ MAP < 90mmHg give Fluids: crystaloids, coloids, vasopressors

• 7. Neurological Examination• 8. ICP control

▫ ICP < 20-25mmHg▫ CPP> 60-70 mmHg

Diagnostic Procedures

•1. Head CT•2. Vertebral CT•3. Polytrauma CT•4. Chest X-Ray•5. Abdominal USG

Brain Contusion

•Structural in brain tissue mainly on the surface after trauma (this makes no sense grammatically but that’s what’s written)

•Pathomechanism:▫Acceleration / deceleration phenomenon in

head trauma▫Mechanism contr coup(?)

Brain Contusion / Traumatic intracerebral haematoma

Contusion

CT 6-8 hours

Enlargement of contusion with clinic

al impairme

nt

Craniectomy and evacuation

Implantatio

n ICP SENSOR

Subdural Hematoma

•Venous Origin (Bridge Veins)

•Acute▫(1st 24 hours after trauma)▫More typical for younger people

•Sub-acute▫(2-14 days after trauma)

•Chronic▫(few weeks even months or years after

trauma)

Subdural Hematoma – continued•The veins go from the surface of the brain

to the dura, and when they break there’s bleeding and collection of blood creating a hematoma in this space.

•Venous bleeding is different from arterial▫Slower – and that’s why we have acute,

sub-acute and chronic

Epidural Hematoma

•Always arterial in origin•In 90% of cases coexists with a skull

fracture•Acute is the most frequent type

•It’s a dynamic hematoma with fast developing symptoms (ACUTE).

•Arterial in origin because of the meningeal arteries

•Surgical treatment due to CT confirmation

•Subdural and epidural haematoma Urgent Surgery!!!

•Subdural or epidural hematoma evacuation

Anterior fossa fracture and nasal liquorrhea •Typical fractures in non-airbag deployed

car accidents•Very vey dangerous because the ethmoid,

glenoid(?) and frontal sinus fractures leads to CSF leakage from the nose and ear (temporal bone fracture)

•Can lead to bacterial infections and meningitis

Traumatic brain edemaImplantation of ICP

SENSOR

Decompressive

craniectomyUni or Bilater

al

Implantation of ICP

SENSOR

Intensive

Anti-edematous Treatment

Decompressiv

e CraniectomyUni or

Bilateral

Osmotherapy• Mannitol 20% 4 x 200 – 250ml• Glicerol 100% 4 x 200ml• Furosemide 60mg/d• Steroids?????• Decadron 0.5 – 1mg/kg 1 Bolus• Golden hour – then 4 x 8 mg• Anticonvulsants – diazepam, phenytoin

• Normothermia• Barbitural coma• ICP monitoring