Neurotrauma

Trauma is the 5th leading cause of death in Singapore (MOH health facts 2003). It remains the leading cause of death in young adults with traumatic brain injury (TBI) accounting for up to 75% of trauma-related deaths.

The GCS score.....what exactly is it?

The Glasgow Coma Scale (Teasdale & Jennet Lancet 2:81-84, 1974) is the most widely used scoring system for quantifying the level of consciousness in head injury. It has low interobserver variability and can predict outcome fairly reliably. Importantly, it allows one to monitor a patient with head injury with greater confidence as a change in the GCS score would indicate a significant change in conscious level. With a minimum score of 3 and a maximum score of 15, it gives a numerical value to a patients ability to open his eyes, his best verbal response and his best motor response to painful stimulus.

Please explain some terms in traumatic brain injury (TBI)

Mild head injury: GCS 13-15; Moderate head injury: GCS 9-12 and
Severe head injury: GCS 3-8.

Concussion: Refers to alteration of consciousness in TBI. In mild concussion, there is confusion and disorientation without amnesia (loss of memory). In moderate concussion, confusion is associated with retrograde or antegrade amnesia (loss of memory before or after the traumatic insult). In the classical concussion, there is loss of consciousness with some degree of amnesia.

Contusions: Refers to 'bruising' or 'bleeding' in the brain as a result of vascular (blood vessel) and tissue disruption.

Brain Herniation: An expanding mass or brain swelling can cause parts of the brain to shift, compressing on vital structures. This can result in impairment of blood flow (infarction), accumulation of brain fluid (hydrocephalus) or in severe cases, compression of the brainstem leading to death. There may be associated neurological deterioration.

How is a patient with severe traumatic brain injury managed?

Patients with severe traumatic brain injury (TBI) are often managed in specialised mordern neurointensive care units run by both neurosurgeons and neurointensivits (an anaesthetist specialised in neurosurgical intensive care). Protocol driven strategies are employed, and these have been shown to improve patient outcome. The aims of management are to prevent further brain damage (secondary damage), protect vulnerable areas(ischaemic areas) in the brain, allow the brain to autoregulate (regulate its own blood flow) and to detect any adverse effects (eg, expanding mass lesion). Multimodality monitoring is common place in many neurointensive care units. This includes the monitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP), Tissue oxygenation (PtiO2), Brain temperature, Pressure reactivity (PRx), cerebral blood flow (CBF) and Jugular venous saturation (SjvO2). Not allow does it allow the timely detection of adverse events, it allows us to optimize treatment. Surgery in iteslf, forms only part of the intensive care amarmentarium.

Brain contusions

Acute Subdural Haematoma / SDH

An acute subdural haematoma is a collection of blood between the brain and its outer membrane (dura). It is typically caused by tearing of blood vessels when the impact of injury to the skull is great, such as that which occurs in a motor vehicular accident, fall or assault. This same impact can also result in severe primary brain swelling, diffuse injury to the brain (diffuse axonal injury) as well as brain contusions. Acute SDH's are therefore associated with a mortality of 60% or more.

Acute SDH's which are thick (>5 to 10mm) often cause 'midline shift' which refers to the shifting of the brain from one side to the other within the rigid constrains of the skull. Clinically, the patient is often drowsy or comatosed. Such acute SDH's should be treated with a operation to evacuate the blood clot. Post-operatively, the brain may continue to swell with secondary brain injury setting in. Management thereafter would include strategies to reduce brain swelling, prevent futher injury and maintain adequate blood flow and oxygenation to the brain tissue.

Acute subdural haematoma

Posterior Fossa EDH

Acute Extradural Haematoma / EDH

Find out more about posterior fossa extradural haematomas!

An acute extradural haematoma is a collection of blood outside of the outer membrane of the brain (dura) and under the skull. It typically results from a skull fracture that has torn an artery on the dura. An EDH, if large, can cause compression of the brain followed by clinical deterioration and even death. On the other hand, prompt surgery to evacuate the EDH often leads to a good outcome.

Classical signs and symptoms include those of a 'lucid interval' (where a patient with an EDH sometimes regains consciousness after trauma, followed by a neurological deterioration again), headache, one-sided weakness or unequal pupil size.While small EDH's may be left alone, large EDH's would require a surgical craniotomy to evacuate the clot.

Acute Extradsural Haematoma

Please read this: Disclaimer

email: info@neuro-surg.com