Craniocerebral trauma

Traumatic brain injury is physical damage to tissue that temporarily or permanently impairs brain function. The diagnosis of traumatic brain injury is made clinically and confirmed by imaging studies (primarily CT, although MRI is of additional value in some cases). Initial treatment of traumatic brain injury involves supporting breathing, oxygenation, and blood pressure to prevent further damage. Surgery and rehabilitation may then be considered.

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

Traumatic brain injury can cause structural damage of various types. Structural changes can be macro- or microscopic, depending on the mechanism of injury and the force of impact.

A patient with a less severe traumatic brain injury may not have major structural damage. Traumatic brain injury symptoms vary widely in severity and consequences. Injuries are usually classified as open or closed.

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Epidemiology

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

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

In the United States, approximately 1.4 million people suffer a traumatic brain injury (TBI) each year; nearly 50,000 die and about 80,000 survivors are permanently disabled. Causes of TBI include motor vehicle and other transportation accidents (e.g., bicycle accidents, pedestrian accidents), falls (especially in older adults and young children), violence, and sports injuries.

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Symptoms brain injury

Recognizing the nature of the injury in TBI is often difficult. Typically, the symptoms of traumatic brain injury consist of the following syndromes, which are expressed to varying degrees 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 pulse and blood pressure, hyperhidrosis, pallor, acrocyanosis, etc.).
4. Meningeal syndrome or symptoms of meningism.
5. Dislocation syndrome.

Loss or disturbances of consciousness are one of the main general cerebral symptoms in TBI. The nature of these disturbances is traditionally assessed in points on the Glasgow Coma Scale.

Symptoms of Traumatic Brain Injury

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Forms

Based on the experience of leading neurosurgical clinics, a unified classification of TBI was compiled. It is based on the nature and degree of brain damage, since in most cases these criteria determine the clinical course, treatment tactics and prognosis. All modern classifications are based on the classification proposed in the 18th century by the French scientist Jacques Petit, who distinguished concussion of the brain (comotio cerebri), contusion of the brain (contusio cerebri) and compression of the brain (compressio cerebri). Changes and additions were made to the classification, which expanded the original classification, based on the main provisions of modern medicine.

Depending on the nature of the damage to the outer coverings of the skull and the possibility of infection of the contents of its cavity, two main types of injury are distinguished:

1. Closed craniocerebral injury (there are no violations of the integrity of the cranial vault or there are superficial wounds of soft tissues, without damage to the aponeurosis, including in the presence of fractures of the bones of the cranial vault).
2. Open craniocerebral trauma (damage to the soft tissues of the skull, accompanied by damage to the aponeurosis, fractures of the bones of the skull base that pass through the air sinuses, and fractures accompanied by liquorrhea). With this type of injury, there is a real threat of infectious complications from the contents 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 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 bones of the base of the skull, which are accompanied by cerebrospinal fluid leakage).
2. Non-penetrating (the integrity of the dura mater is preserved).

Based on the presence of concomitant lesions, the following forms of TBI are distinguished:

1. Isolated (no extracranial damage).
2. Combined (a combination of craniocerebral trauma with mechanical damage to other parts of the body. Depending on the area of damage, cranio-abdominal, craniothoracic, craniofacial, craniovertebral, cranioskeletal trauma, etc. can be distinguished).
3. Combined (combination of TBI with non-mechanical injuries: chemical, radiation, toxic, thermal injuries).

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

1. Concussion.
2. Brain contusion:
   • mild;
   • moderate severity;
   • severe degree (sometimes, depending on the predominant symptoms, extrapyramidal, diencephalic, mesencephalobulbar, cerebrospinal forms are distinguished).
3. Brain compression:
   • compression without brain contusion;
   • compression of the brain by contusion.
4. Diffuse axonal injury of the brain.
5. Head compression.

Some scientists also propose to distinguish diffuse (concussion, diffuse axonal injury) and focal (contusion, compression) brain damage. However, this classification has not found wide acceptance.

Depending on the severity, TBI is divided into:

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

A special group of TBIs are gunshot wounds, many of which are penetrating, and are varied depending on the type of projectile, type of firearm, trajectory of the wound channel, etc. Gunshot wounds have their own separate classification:

• blind (38.5%):
  • simple;
  • segmental;
  • radial;
  • diametrical;
• through (4.5%):
  • segmental;
  • diametrical;
• tangents (45.9%);
• ricocheting (11.1%).

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Complications and consequences

After mechanical trauma to the brain, a complex chain of pathological reactions occurs from all components of the brain and conduction pathways, which are included in the concept of "traumatic brain disease". First of all, a brain injury is characterized by a disturbance of consciousness as a manifestation of a disturbance in the connection between neurons. Any craniocerebral injury leads to disorders of the hemodynamics of the brain, which is one of the main reasons for the development of the so-called remote consequences of TBI. Sometimes many months and even years are needed for its normalization.

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

Traumatic brain injury is characterized by primary (associated with direct damage to the corresponding centers of the central nervous system) and secondary (caused by the peculiarities of the clinical course of traumatic brain injury) dysfunction of the internal organs. The most important of these are respiratory dysfunctions. The flow of pathological impulses to the lungs during severe brain injury causes a disturbance in their blood circulation, which often leads to the development of pneumonia in victims with an early onset and persistent progressive course. Victims with severe forms of TBI experience pronounced disorders of the endocrine function, severe metabolic disorders occur, sometimes gastrointestinal bleeding, perforated ulcers of the stomach and intestines and other serious complications are observed.

Prognosis and consequences of traumatic brain injury

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Diagnostics brain injury

The main objectives of examination of a patient with TBI are: determining the type of injury (closed, open, penetrating) and the nature of the brain damage (concussion, contusion, compression, diffuse axonal injury); clarifying the cause of compression (hematoma, depressed fracture, etc.); determining the severity of the patient's condition; assessing the nature of bone damage, the severity of the general somatic and neurological condition of the patient.

One of the most important components in the diagnosis of TBI is the principle of dynamic observation of the patient. The patient's condition, especially in severe TBI, can change quickly, primarily with the development of symptoms of brain compression, so its constant neurological assessment can be of decisive importance. At the same time, today it is impossible to imagine the diagnosis of TBI without modern additional research methods, among which computer (CT) and magnetic resonance imaging (MRI) have unconditional advantages.

To establish and clarify the diagnosis, patients with TBI undergo a whole range of examinations.

Mandatory examination methods:

1. General examination of the patient.
2. Collection of anamnesis of the disease (information about the time and mechanism of injury).
3. Neurological examination.
4. X-ray of the skull (craniography) in at least two projections.
5. Echocephalography.
6. Neuroimaging studies (CT, MRI).
7. Lumbar puncture (in the absence of symptoms of brain dislocation),
8. If it is not possible to perform neuroimaging studies, diagnostic search burr holes are placed.

Additional examination methods:

1. Laboratory tests:
   • general blood and urine analysis;
   • biochemical blood test;
   • cerebrospinal fluid analysis.
2. Examination by related specialists:
   • ophthalmologist;
   • otolaryngologist;
   • traumatologist.

Conducting such a complex of examinations allows obtaining complete objective information about the state of the brain (the presence of contusion foci, intracranial hemorrhages, signs of brain dislocation, the state of the ventricular system, etc.). At the same time, despite the visible advantages of neuroimaging methods, craniography has not lost its diagnostic value, which allows identifying skull fractures, metallic foreign bodies and other (secondary) craniographic signs that are a consequence of this pathology.

Types of skull fractures:

1. Depending on the condition of the soft tissues:
   • closed;
   • open.
2. By localization:
   • convexital;
   • basal.
3. By mechanism of injury:
   • straight;
   • indirect.
4. By form:
   • full;
   • incomplete.
5. By appearance:
   • linear;
   • fragmentation;
   • sunken;
   • perforated;
   • fragmented;
   • special shapes (gunshot, growing, seam breaks, concave).

If it is not possible to perform CT or MRI, preference in the diagnosis of TBI should be given to echoencephalography (determination of the displacement of the median M-echo) and the imposition of diagnostic exploratory burr holes.

In cases of severe TBI, it is important to monitor intracranial pressure in order to conduct appropriate therapy and prevent the most dangerous complications. For this purpose, special pressure measuring sensors are used, which are installed in the epidural space by applying burr holes. For the same purpose, catheterization of the lateral ventricles of the brain is performed.

Diagnosis of traumatic brain injury

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Treatment brain injury

When providing first aid to patients with TBI, the first steps should be to normalize breathing and prevent aspiration of vomit and blood, which usually occurs in unconscious patients. To this end, it is necessary to lay the victim on his side or turn his head to the side, and make sure that the tongue does not sink back. The airways should be cleared of mucus, blood, and vomit, intubation should be performed if necessary, and adequate ventilation of the lungs should be ensured if breathing is insufficient. In parallel, measures are taken to stop external bleeding and maintain cardiovascular activity. Bleeding can be stopped at the prehospital stage by pressing the vessel, applying a pressure bandage, or ligating the vessel. Patients with severe traumatic brain injury should be urgently taken to a specialized hospital.

In the absence of indications for surgical treatment of the patient (in case of concussion, brain contusion, diffuse axonal injury), conservative measures are carried out, the nature of which is determined by the clinical form and severity of the patient's condition with TBI, the severity of neurological symptoms (intracranial hypo- or hypertension, cerebrovascular accidents, cerebrospinal fluid circulation disorders, etc.), as well as concomitant complications, the age of the victim, anamnestic and other factors.

Intensive care for severe TBI primarily includes measures to normalize respiratory function, combat edema-swelling of the brain. In cases of severe brain contusion with crushing and pronounced edema, antienzyme drugs, antihypoxants and antioxidants, vasoactive drugs, and glucocorticosteroids are used. Intensive care also includes maintaining metabolic processes using enteral (tube) and parenteral nutrition, correcting acid-base and water-electrolyte balance disorders, normalizing osmotic and colloid pressure, hemostasis system, microcirculation, thermoregulation, prevention and treatment of inflammatory and trophic complications. In order to normalize and restore the functional activity of the brain, psychotropic drugs are prescribed, including nootropics and GABAergic substances, as well as agents that normalize the exchange of neurotransmitters.

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

Surgical treatment of craniocerebral trauma includes primary surgical treatment of open injuries, stopping bleeding, eliminating brain compression and cerebrospinal fluid leakage. For all types of craniocerebral trauma with soft tissue damage, primary surgical treatment of the wound is performed and antitetanus toxoid is administered.

Surgical intervention is also used in cases of post-traumatic complications: suppuration of a brain wound, abscesses, traumatic hydrocephalus, epileptic syndrome, extensive bone defects, vascular complications (carotid-cavernous fistula) and a number of other changes.

Treatment of traumatic brain injury

Rehabilitation after traumatic brain injury

Rehabilitation is a system of measures aimed at restoring impaired functions, adapting the patient to the environment and his participation in social life. The implementation of these measures begins in the acute period of craniocerebral injury. For this purpose, the following tasks are solved:

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

The implementation of the above tasks is facilitated by a set of measures - drug therapy, exercise therapy, occupational therapy. In the presence of disabling complications of craniocerebral trauma, professional reorientation of the patient is necessary.

The prognosis of traumatic brain injury is as much a mandatory component of each medical history as the diagnosis. When a patient is discharged from the hospital, the immediate functional results are assessed and the final results of treatment are predicted, which determines the complex of medical and social measures for their optimization.

One of the important links in the comprehensive system of rehabilitation of disabled people who have suffered from a condition such as traumatic brain injury is professional rehabilitation, which consists of psychological orientation of the disabled person to work activity indicated to him by his health condition, work recommendations on rational employment, professional training and retraining.

Rehabilitation after traumatic brain injury