Traumatic Brain Injury

Normal structure of the Brain
1. Brain Stem
  1. Parts
    1. Medulla oblongata
      1. External
      2. Internal
        Level of decussation of pyramids
        Level of decussation of lemnisci
        Level of olive
    2. Pons
      1. External
        Anterior surface
        Posterior surface
      2. Internal
        Caudal part
        Cranial part
    3. Midbrain
      1. External
      2. Internal
        Level of inferior colliculus
        Level of Superior Colliculus
2. Middle Cerebral Artery
Types
1. Open vs. Closed
2. Focal vs. Diffuse
3. Skull fractures
  1. Linear
  2. Depressed
  3. Basilar
  4. Diastatic
4. Diffuse Axonal injury
5. Hematomas
  1. Intracranial hemorrhage
    1. Epidural
      1. Temporoparietal skull fracture
      2. Rupture of the middle meningeal artery
      3. Lucid interval
      4. Herniation - Death
        Caused by
        Cushing Reflex
        Occurs in response to increase in the intracranial pressure
        A triad of hypertension, bradycardia, and irregular breathing
        Types of herniation
      5. Lens-shaped / Shift of midline / Compression of ventricles
    2. Subdural
      1. Rupture of the bridging veins
      2. No lucid interval
      3. Clotted blood present
      4. Caused by trauma
      5. infants
        Thin wall veins
      6. Elderly
        Stretch of the bridging veins that is caused by brain atrophy
      7. Crescent-shaped
    3. Subarachnoid hemorrhage
    4. Intracerebral hemorrhage
6. Contusion
  2. Localized injury / Macroscopic
  3. Complications: Seizures / Increased ICP / Cerebral herniation / Loss of memory / Infections
7. Concussion
  1. Similarities
    1. Due to head trauma / Common / Serious
  2. Widespread injury / Microscopic
  3. Complications: Epilepsy / Post-concussion Syndrome / Second-impact Syndrome / Post-traumatic headaches and vertigo
Clinical presentation
1. Mild
  1. Loss of consciousness for a few seconds to a few minutes / No loss of consciousness, but a state of being dazed, confused or disoriented / Headache / Nausea or vomiting / Fatigue or drowsiness / Problems with speech / Difficulty sleeping / Sleeping more than usual / Dizziness or loss of balance
2. Moderate to severe
  1. Loss of consciousness from several minutes to hours / Persistent headache or headache that worsens / Repeated vomiting or nausea / Convulsions or seizures / Dilation of one or both pupils of the eyes / Clear fluids draining from the nose or ears / Inability to awaken from sleep / Weakness or numbness in fingers and toes / Loss of coordination / Profound confusion / Agitation, combativeness or other unusual behavior / Slurred speech / Coma
    1. Glasgow Coma Scale
      1. Practical method to assess the impairment in the level of conscious in response to specific stimuli
      2. It classifies traumatic brain injury (TBI) into
        Mild (14-15)
        Moderate (9-13)
        Severe (3-8)
3. Hutchinson’s pupil
  1. In case of cerebral compression
  2. Pupil on side of injury
    1. Stage 1: Constricted
    2. Stage 2: Dilated
    3. Stage 3: Dilated, fixed
  3. Pupil on opposite side
    1. Stage 1: Normal size
    2. Stage 2: Constricted
    3. Stage 3: Dilated, fixed
Management
1. Initial Resuscitation
2. Postresuscitative Care
3. Treatment of intracranial hypertension
  1. Analgesics and sedatives / Hyperventilation / Hypothermia / Osmotic agents / Corticosteroids / Decompressive craniotomy
  2. Burr hole Surgery
    1. Indications
      1. Acute subdural hematoma / Chronic subdural hematoma / Certain kinds of brain cancer / Buildup of pus around the meninges / Hydrocephalus
    2. Procedure
      1. Anesthesia / Cut hair / Drill / Dura / Drain
    3. Complications
      1. Bleeding / Infection / Blood clots / Brain injury / Another surgery required
4. Treatment and prophylaxis of complications
  1. Antiseizure / Deep venous thrombosis prophylaxis

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Traumatic Brain Injury

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	Created by Moza Almualla about 6 years ago