Craniocerebral injury

Craniocerebral trauma - physical damage to tissue, temporarily or permanently disrupting the function of the brain. The diagnosis of craniocerebral trauma is established clinically and is confirmed by visualizing research methods (primarily CT, although in some cases, MRI has an additional significance). Primary treatment of craniocereberal trauma includes support for breathing, oxygenation and blood pressure to prevent further damage. Then, surgical intervention and rehabilitation are possible.

Craniocerebral injury (TBI) is a type of head trauma, in which, along with the damage to the soft tissues of the head and skull, the brain is also injured. Craniocerebral trauma can be a consequence of direct effects on the head of a mechanical factor or indirect effects of it during sudden stopping during rapid body movement (for example, during a fall) or in case of sudden sudden acceleration.

Craniocerebral trauma can cause structural disturbances of various types. Structural changes can be macro- or microscopic, depending on the mechanism of injury and the strength of the effect.

A patient with a less severe craniocerebral trauma may not have large structural lesions. Symptoms of craniocerebral injury vary widely in severity and consequences. Damage is usually divided into open and closed.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Epidemiology

Craniocerebral trauma is one of the most common types of trauma (30-50% of all traumatic injuries), is the leading cause of death and disability of people under the age of 45 and ranks first in the structure of neurosurgical pathology.

In wartime, the main cause of craniocerebral trauma are various gunshot and explosive lesions, and in peacetime - transport, domestic and industrial injuries. According to epidemiological studies, the rate of craniocerebral trauma in economically developed countries reaches on average 4-6 cases per 1000 population. According to WHO, the number of cases of craniocerebral trauma increases by 2% per year, which, with an increase in the number of vehicles, rapid urbanization, is not always a sufficient level of behavior culture for all road users.

In the United States, craniocerebral trauma (TBI) annually receives about 1.4 million people; of which almost 50,000 people die and about 80,000 survivors become disabled. Causes of craniocerebral trauma include car accidents and other traffic accidents (for example, falls from a bicycle, accidents with pedestrians), falls (especially of the elderly and young children), violence and sports injuries.

[12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]

Symptoms of the craniocerebral trauma

It is often difficult to recognize the nature of the lesion with CCT. Typically, the symptoms of craniocerebral trauma are composed of the following syndromes, which are more or less expressed in certain forms of brain damage;

1. General cerebral symptoms (loss or disturbance of consciousness, headache, nausea, vomiting, amnesia).
2. Focal symptoms (persistent or transient).
3. Asthenovegetative syndrome (fluctuations in heart rate and blood pressure, hyperhidrosis, pallor, acrocyanosis, etc.).
4. Meningeal syndrome or symptoms of meningism.
5. Dislocation syndrome.

Loss or impairment of consciousness is one of the main cerebrovascular symptoms at CCT. The nature of these violations is traditionally estimated in points on the scale of coma Glasgow.

Symptoms of traumatic brain injury

[23], [24], [25], [26], [27], [28], [29]

Forms

Based on the experience of the leading neurosurgical clinics, a single classification of TBI was compiled. It is based on the nature and extent of damage to the brain, since in most cases these criteria determine the clinical course, therapeutic tactics and prognosis. All modern classifications are based on the classification proposed in the XVIII century. French scientist Jacques Petit, who isolated a brain concussion (comotio cerebri), a contusion of the brain (contusio cerebri) and compression of the brain (compressio cerebri). The classification was amended and supplemented, which expanded the initial classification, based on the main provisions of modern medicine.

Depending on the nature of the damage to the outer covers of the skull and the possibility of infecting the contents of its cavity, there are two main types of injury:

1. Closed craniocerebral trauma (there are no disturbances in the integrity of the veins of the cranial vault or there are superficial wounds of the soft tissues, without damaging the aponeurosis, including in the presence of fractures of the bones of the cranial vault).
2. An open craniocerebral trauma (damage to the soft woven skull of the skull, accompanied by damage to the aponeurosis, fractures of the skull base bones that pass through the airways and a fracture accompanied by liquorrhea). With this type of injury, there is a real threat of infectious complications from the content of the cranial cavity. Closed craniocerebral trauma accounts for an average of 70-75% of all TBI.

Open craniocerebral injuries, depending on the damage to the last barrier on the way to the brain - the dura mater - are divided as follows:

1. Penetrating (there is a violation of the integrity of the dura mater, including fractures of the skull base bones, which are accompanied by liquorrhea).
2. Non-penetrating (integrity of the dura mater is retained).

According to the presence of concomitant lesions, the following forms of CCT are distinguished:

1. Isolated (no extracranial lesions).
2. Combined (a combination of craniocerebral injury with mechanical injuries of other parts of the body, depending on the area of the lesion, cranio-abdominal, craniotoracic, craniophatic, craniovertebral, cranioskeletal injuries, etc.).
3. Combined (a combination of CCT with non-mechanical damage: chemical, radiation, toxic, thermal damage).

Depending on the type and nature of damage to the brain, the following clinical forms of CCT are distinguished:

1. Brain concussion.
2. Contusion of the brain:
   • light degree;
   • moderate severity;
   • severe (sometimes, depending on the prevailing symptoms, extrapyramidal, diencephalic, mesencephaloplasmic, cerebrospinal forms are isolated).
3. Brain compression:
   • compression without a bruise of the brain;
   • compression by a bruise of a brain.
4. Diffuse axonal brain injury.
5. Head compression.

Some scientists also propose to distinguish diffuse (concussion, diffuse axonal damage) and focal (bruised, compressed) brain damage. However, this classification has not found wide distribution.

Depending on the degree of severity, TBI is isolated:

• light (brain concussion and brain contusion of mild severity);
• average severity (brain contusion of moderate severity, chronic and subacute compression of the brain);
• severe (severe brain contusion, acute compression of the brain, diffuse axonal injury).

A special group of CTB consists of gunshot wounds, many of which are penetrating, differ in variety depending on the nature of the wounding projectile, the type of firearm, the trajectory of the wound channel, etc. Firearm wounds have their own separate classification:

• blind (38.5%):
  • simple;
  • segmental;
  • radial;
  • diametrical;
• Through (4,5%):
  • segmental;
  • diametrical;
• tangential (45.9%);
• ricochet (11.1%).

[30], [31], [32]

Complications and consequences

After causing a mechanical trauma to the brain, a complex chain of pathological reactions occurs from all components of the brain and the pathways that enter into the concept of "traumatic brain disease." First of all, a brain injury is characterized by a violation of consciousness as a manifestation of a disruption of the connection between neurons. Any craniocerebral injury leads to cerebral hemodynamics disorders, which is one of the main causes of the development of the so-called long-term effects of the CTB. Its normalization sometimes takes many months and even years.

These disorders can aggravate the mechanical: damage to the nervous tissue: circulatory disorders cause secondary necrosis around the primary (from the brain injury) and require vigorous treatment to prevent it.

Craniocerebral trauma is characterized by primary (associated with direct affection of the corresponding centers of the central nervous system) and secondary (due to the peculiarities of the clinical course of craniocerebral trauma), a violation of the function of internal organs. The most important of these are breathing disorders. The flow of pathological pulses to the lungs in severe brain trauma causes a violation of hemocirculation in them, which often leads to the onset of pneumonia with early onset and persistent progressive course. In patients with severe forms of TBI, severe disorders of the endocrine function are observed, severe metabolic disorders occur, sometimes there are gastrointestinal bleeding, perforated ulcers of the stomach and intestines, and other formidable complications.

The prognosis and consequences of craniocerebral trauma

[33], [34], [35], [36], [37], [38], [39], [40], [41], [42]

Diagnostics of the craniocerebral trauma

The main tasks of examining a patient with CCT are: determining the type of injury (closed, open, penetrating) and the nature of brain damage (concussion, bruising, compression, diffuse axonal damage); clarification of the cause of compression (hematoma, depressed fracture, etc.); determination of the severity of the patient's condition; evaluation of the nature of bone lesions, the severity of the general-somatic and neurological condition of the patient.

One of the most important components in the diagnosis of CCT is compliance with the principle of dynamic observation of the patient. The patient's condition, especially with severe TBI, can change rapidly, primarily with the development of symptoms of brain compression, so his constant neurological evaluation can be crucial. At the same time, it is impossible to imagine the diagnosis of TBI without modern additional methods of research, among which computer (CT) and magnetic resonance imaging (MRI) are the absolute advantages.

To establish and clarify the diagnosis, patients with CCT carry out a whole complex of examinations.

Compulsory methods of examination:

1. General examination of the patient.
2. Collection of anamnesis of the disease (information about time, mechanism of injury).
3. Neurological examination.
4. Radiography of the skull (craniography) minimum in two projections.
5. Echinacephalography.
6. Neurovisualizing studies (CT, MRI).
7. Lumbar puncture (in the absence of brain dislocation symptoms),
8. If there is no possibility to perform neurovisualizing studies - the imposition of diagnostic search milling holes.

Additional survey methods:

1. Laboratory research:
   • general analysis of blood and urine;
   • blood chemistry;
   • analysis of cerebrospinal fluid.
2. Inspection by related specialists:
   • ophthalmologist;
   • an otolaryngologist;
   • traumatologist.

Carrying out such a complex of examinations allows obtaining full-fledged objective information about the state of the brain (the presence of foci of injury, intracranial hemorrhages, signs of brain dislocation, the state of the ventricular system, etc.). In spite of the visible advantages of neurovisualizing methods, craniography, which allows to detect fractures of the skull bones, metallic foreign bodies and other (secondary) craniographic signs, which are the consequence of this pathology, has not lost its diagnostic value.

Types of fractures of the skull bones:

1. Depending on the condition of soft tissues:
   • closed;
   • open.
2. By localization:
   • convective;
   • basal.
3. By the mechanism of injury:
   • Direct;
   • indirect.
4. According to the form:
   • complete;
   • incomplete.
5. By type:
   • linear;
   • fragmented;
   • depressed;
   • perforated;
   • fragmented;
   • Special forms (gunshot, growing, tearing, concave).

If CT or MRI can not be performed, preference in diagnosing CCT should be given to a zhoeencephalography (determination of the displacement of the median M-axis) and the imposition of diagnostic search milling holes.

In cases of severe head injury, monitoring of intracranial pressure is important for the purpose of appropriate therapy and prevention of the most dangerous complications. For this purpose, special pressure sensors are used, which are installed in the epidural space by the application of milling holes. Catheterization of the lateral ventricles of the brain is carried out with the same purpose.

Diagnosis of craniocerebral trauma

[43], [44], [45], [46], [47], [48], [49], [50]

Treatment of the craniocerebral trauma

When providing first aid to patients with CCT, the first measures should be actions aimed at normalizing breathing and preventing aspiration of vomit and blood, which usually occurs in patients who are in an unconscious state. To this end, it is necessary to lay the victim on his side or turn his head to the side, to control, so that there is no tongue twisting. It is necessary to release the respiratory tract from mucus, blood and vomit, if necessary - to intubate, and in case of insufficient breathing - to provide adequate ventilation of the lungs. At the same time, measures are taken to stop external bleeding and maintain cardiovascular activity. Stop bleeding at the prehospital stage can be carried out by pressing the vessel, applying a pressure bandage, dressing the vessel. Patients with severe craniocerebral trauma should be rushed to a specialized hospital.

In the absence of indications for surgical treatment of the patient (with concussion, brain contusion, diffuse axonal damage) conservative measures are carried out, the nature of which is determined by the clinical form and severity of the patient's condition with CCI, the severity of neurologic symptoms (intracranial hypo- or hypertension, cerebral circulatory disturbances, impaired circulation of cerebrospinal fluid, etc.), as well as concomitant complications, the age of the victim, anamnestic and other factors.

Intensive therapy for severe head injury includes, first of all, measures to normalize the function of breathing, fighting swelling-swelling of the brain. In cases of severe brain contusion with crushing and pronounced edema, use antiferment preparations, antihypoxants and antioxidants, vasoactive drugs, glucocorticosteroids. Intensive therapy also includes the maintenance of metabolic processes using enteral (parenteral) and parenteral nutrition, correction of acid-base and water-electrolyte balance disturbances, normalization of osmotic and coloid pressure, hemostasis system, microcirculation, thermoregulation, prevention and treatment of inflammatory and trophic complications. To normalize and restore the functional activity of the brain, prescribe psychotropic drugs, including nootropics and GABA-ergic substances, as well as the means that normalize the exchange of neurotransmitters.

Measures for caring for patients with TBI include prophylaxis of bedsores and hypostatic pneumonia, passive gymnastics to prevent the formation of contractures in the joints of the limbs.

Surgical treatment of craniocerebral trauma includes primary surgical treatment with open injuries, stopping bleeding, eliminating compression of the brain and liquorrhea. In all types of craniocerebral trauma with soft tissue injuries, primary surgical treatment of the wound is performed and tetanus toxoid is injected.

Surgical intervention is also used in cases of posttraumatic complications: with suppurative wounds, abscesses, traumatic hydrocephalus, epileptic syndrome, extensive bone defects, vascular complications (carotid-cavernous anastomosis) and in a number of other changes.

Treatment of craniocerebral trauma

Rehabilitation after traumatic brain injury

Rehabilitation is a system of measures aimed at restoring disturbed functions, adjusting the patient to the environment and his participation in social life. The implementation of these measures begins in the acute period of craniocerebral trauma. To this end, the following tasks are solved:

1. organization of the most favorable conditions for restoring the activities of reversibly damaged structures and structural and functional restoration of the integrity of damaged tissues and organs as a result of growth and reproduction of specific elements of the nervous tissue;
2. prevention and treatment of complications from the respiratory and cardiovascular systems;
3. prevention of secondary contractures in the paretic limbs.

Fulfillment of these tasks is facilitated by a complex of measures - drug therapy, exercise therapy, occupational therapy. In the presence of disabling complications of craniocerebral trauma, a professional reorientation of the patient is necessary.

The prognosis of craniocerebral trauma is as much an obligatory part of every medical history as the diagnosis. When the patient is discharged from the hospital, the nearest functional results are evaluated and the final results of treatment are predicted, which determines the complex of medical and social measures for their optimization.

One of the most important links in the complex rehabilitation system for people with disabilities who have suffered such a condition as a brain injury is professional rehabilitation, which consists of the psychological orientation of the disabled person to work, shown to him for health reasons, labor recommendations for rational work placement, vocational training and retraining.

Rehabilitation after traumatic brain injury