Head Injury Assesment

Present by:PUNIT DUBEY

Introduction

• The neurological evaluation of the patient with head injury remains an important comprehensive process in the diagnostic evaluation and as a baseline in assessing progress. Thorough and careful examination provides an index of generalized and focal dysfunction of the nervous system which is not provided by CT scanning, ICP monitoring or any other modern technology

• Repeated good, reliable thorough examination indicates the ongoing neurological state and the progress or failure of treatment rendered.

Purpose of an assessment• The purposes of undertaking an assessment can be summarised• as follows:• • To establish a baseline of neurological function.• • To note any trend.• • To monitor for any changes in status or complications.• • To determine any associated risk.• • To treat alterations in status.• • To determine health needs.• • To decide on intervention.• • To prevent complications.• • To predict patient outcome.

• The major goals in the evaluation of patients with head injury are:

• 1. To define the presence of intracranial mass lesion requiring operative removal.

• 2. To determine abnormal intracranial mass lesion in order to guide and direct appropriate operative or non-operative therapy.

• 3. To diagnose associated serious injuries.

• In patients who are conscious, the initial examination is as thorough as possible.

• In patient with altered consciousness, emphasis is given to certain critical aspects that will guide immediate treatment.

Epidemiology• Traumatic brain injuries (TBI) cause morbidity, mortality, disability and

socioeconomic losses in India and other developing countries. It is estimated that nearly 1.5 to 2 million persons are injured and 1 million succumb to death every year in India. Road traffic injuries are the leading cause (60%) of TBIs followed by falls (20—25%) and violence (10%). Alcohol involve ment is known to be present among 15—20% of TBIs at the time of injury. The rehabilitation needs of brain injured persons are significantly high and increasing from year to year. India and other developing countries face the major challenges of prevention, pre-hospital care and rehabilitation in their rapidly changing environments to reduce the burden of TBIs

• Gururaj G .Epidemiology of traumatic brain injuries : Indian scenario. Neurological Research 2002 Jan 24(1)24-8

History • Information regarding precise time of injury and mechanism

of injury should be obtained. Acceleration injuries as a result of vehicular accidents and falls is associated with serious diffuse brain injury and polar contusion. Impact injuries such as blow to cranial vault result in underlying focal brain damage.

A history of the patient's neurological function at the scene of the accident and during transport to the hospital should be sought from police, relatives or witnesses. Any history of loss of consciousness and seizures should be obtained. A report from a referring hospital of the patients condition should also be sought and recorded.

Information regarding drug or alcohol intake and the past medical history is also valuable.

Initial Examination • The American College of Surgeons Committee on Trauma

(1997)1 has given in its manual ATLS program for physicians, a sequence ABCDE. The airway (A), breathing (B), and circulation (C) are assessed before neurological assessment (D) and general examination (E) assessment of the consciousness is most important.

• The secondary survey of the patient is done after resuscitation. Resuscitation may improve some clinical signs. Simultaneously need for intubation and elective ventilation should be assessed. Before paralyzing patients baseline clinical record is mandatory. Pulse rate, blood pressure and respiration should be assessed and given top priority in the management of traumatic brain injury.

vitalsThe systolic pressure, diastolic pressure and pulse pressuremust be noted.If the neurosurgical patient’s blood pressure is droppingconsider:• Hypovolaemic shock from extracranial haemorrhage ordiabetes insipidus.• The patient is approaching the terminal stage.

• Hypertension associated with bradycardia suggests severely increased intracranial pressure from increasing intracranial clot.

• Unexplained hypotension with bradycardia points towards a possibility of cervical injury.

• Hypotension associated with tachycardia usually indicates presence of visceral injury elsewhere such as abdominal or thoracic injury.

• According to Stening BP below 90 mm Hg persisting for more than 60 minutes in acute subdural hematoma was strong predictor of bad outcome.

• White et al found that in pediatric trauma odds of survival increased 19-fold when maximum systolic blood pressure was greater or equal to 135 mm Hg

Stening WA, Berry Q, Dan N G, et al. Experience with acute subdural hematomas in New South Wales. Austral NZ] Surg 1986;56:549—56.

White JR, Farukhi Z, Bull C, Christensen J, Gordon T, Paidas C, Nichols DG. Predictors of outcome in severely head-injured children. Crit Care Med 2001 ;29(3):534—40

General Examination • Scalp wounds include small lacerations, perforating

lacerations, contused lacerations and massive avulsions. Scalp wounds may be associated with underlying skull fracture (compound injury).

• Wound and swelling should be recorded on diagram and also photographed for medico legal reasons.

• Bleeding from the nose and ear should be recorded. Associated CSF leak from nose (CSF rhinorrhea) and from ear (CSF otorrhea) are usually secondary to basal skull fractures.

If a CSF leak is present or suspected, the patient should be advised not to blow their nose for 3 weeks. Sudden increases in intranasal pressure can sometimes force air intracranially through the dural tear, which then

cannot escape. Think of this as the neurosurgical equivalent of a tension pneumothorax. There is also the risk of introducing infection.

Clear CSF mixes with blood and presents as a blood-stained, watery discharge. As

it trickles down the face the blood clots peripherally, whilethe nonclotted blood in the centre is washed away with theCSF. This forms two parallel lines referred to as“tramlining.”One test for CSF is the “ring test”: allow a few drops tofall on tissue paper; the blood clots centrally, while clearCSF diffuses outwards. Other tests include examining fluidfor eosinophils and sugar. This is helpful in distinguishingbetween CSF and mucous. More sensitive indicators includebeta-2 transferrin , although practically it iseasier to simply assume that a leak is present.

• Fractures of the orbital roofs result in bilateral periorbital hematomas (raccoon eyes).

• Orbital swelling points towards anterior cranial fossa. Its auscultation may detect carotid-cavernous fistula.

• Associated bleeding beneath the pericranium over the mastoid (Battle’s sign) is clinically apparent after 2 or 3 days.

• Facial paralysis can occur in patients with fracture of the petrous bone.

• Check the Intercanthal Distanceand Symmetry

• The ICD can be assessed in many ways ( “rule of• fifths”, ). Always remember to compare to preinjury pictures

if possible

• The forehead should be palpated for signs of depressed fracture or frontal sinus injury.

• Asymmetry or irregularity of orbital margins and nose should be checked.

• Dental occlusion should be checked to rule out mandibular fracture.

• Cervical injury should be suspected in all severe head injuries and should be ruled out radiologically.

During assessment, the cervical spine should be immobilised,either manually by an assistant, or by using a hard collar,blocks, and straps. However, combative patients mayonly tolerate a hard collar

. Forceful restraint of the head in athrashing patient simply creates a fulcrum with leverage on the neck as the rest of the body moves. In such cases, if thepatient does not quickly settle with oxygenation, correction of hypovolaemia and pain relief, then formal anaesthesia with intubation and ventilation must be considered. This is considered safer than sedating the patient without providingdefinitive airway control.

Neurological Assessment

• Rapid Trauma Neurological Examination1. Level Of Consciousness2. Pupils3. Fundus4. Extremity Movement5. involuntary movement6. Response To Pain7. Deep Tendon Reflexes8. Plantar Responses9. Brainstem Reflexes

Other useful clues include:•Abnormal skin colour (cyanosis, jaundice)•Needle-stick marks (drug overdose)•Smell of breath (alcohol, ketosis, uraemia, cyanide)

The frequency of neurological assessment

• Frequency of Observations should be performed and recorded on a half hourly basis until GCS equal to 15 has been achieved. If GCS=15 observe: half-hourly for 2 hours, then 1 hourly for 4 hours, then 2 hourly thereafter; Should the patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period, observations should revert to half-hourly. Urgent reappraisal by the supervising doctor

•

• A sustained (that is, for at least 30 minutes) drop of one point in GCS level (greater weight should be given to a drop of one point in the motor score of the GCS);

• • Any drop of 3 or more points in the eye-opening or verbal

response scores of the GCS or 2 or more points in the motor response.

• • NICE : National Institute of Clinical Excellence Clinical Guideline 176 Head

Injury :Triage, Assessment, investigation and early management of head injury in children, young people and adults. 2014

LEVEL OF CONSCIOUSNESS • Teasdale and Jennett proposed that the degree of coma after

severe head injury is the most reliable clinical indicator of the severity of brain damage and present a scale to assess the depth and duration of impaired consciousness and coma. Coma was defined as the inability to obey commands, to peak, or to open the eyes, and these three behavioral aspects were incorporated into the GCS first introduced in 1974 and then revised by the addition of another motor response level in 1977.

Level Of Consciousness

• Glasgow Coma Scale

Eye Opening Best Verbal Best Motor

Spontaneous 4 Oriented 5 Obeys Command 6

To Voice 3 Confused 4 Localizes 5

To Pain 2 Inappropriate 3 Withdraws 4

None 1 Incomprehensible 2 Flexion 3

None 1 Extension 2

None 1

PEDIATRIC Glassgow Coma Scale(simpson & Reilly)

Ocular response Verbal response Motor responseOpens eyes spontaneously 4

Smiles, orientated to sounds, follows objects, interacts. 5

Infant moves spontaneously or purposefully 6

EOMI, reactive pupils( opens eyes to speech) 3

Cries but consolable, inappropriate interaction 4

Infant withdraws from touch 5

EOM impaired, fixed pupils(opens eyes to painful stimuli) 2

Inconsistently inconsolable, moaning 3

Infant withdraws from pain 4

EOM paralyzed, fixed pupils( doesn’t open eyes) 1

Inconsolable, agitated 2

Abnormal flexion to pain for an infant (decorticate response) 3

No verbal response 1

Extension to pain (decerebrate response) 2

No motor response 1

Despite its wide acceptance GCS has numerous valid drawbacks. •GCS has been criticized on following points: •1. GCS does not take account of pupillary size and reactivity, pulse rate, respiration, BP.

•2. Eye movements and other brainstem reflexes are not included in the scale.

•3. Inaccurate recording in patients with bilateral ecchymosis of the eyelids (cannot open his eyes even though fully conscious), aphasia or dysphasia.

• It is not easy to assess the conscious level in infants and young children, and mistakes are often made. Sometimes the severity of a head impact is overestimated, but the converse error is much commoner; because an injured infant cries or whimpers, it is thought to be fully conscious and serious brain damage is overlooked

Implications for practiceCaution:• Remember that the patient must not be assaultedduring testing.• Test for painful response using fingernail bed pressureor distribution of cranial nerves.• Do not use a sternal rub.A sternal rub does not stimulate pain along a cranialnerve distribution and should not be used to assessGCS. It is a technique that is unable to distinguishbetween localisation and flexion, and may give aberrantresults in the presence of a spinal injury.

Pupillary ExamPupillary size is balance between Sympathic and parasympathetic influences.Size, shape and reactivity to light are tested parameters.

Relative afferent pupillary defect (RAPD). This is regarded as a sensitive indicator of visual impairment. It should be looked for routinely inall unconscious patients with head or facial injuries ( a ). Note left pupil has constricted on opening the opposite eye ( b )

Eye Movements

• SO4,LR6, All3Injury location Abnormality

Cavernous sinus/Sup Orbital fissure All 3 Cr.N’s ( 3,4,6) are affected + V1 division

Transtentorial ( Uncal ) herniation 3 Cr.N

Raised ICP Isolated Abducens(6) palsy

Frontal eyes field ( brodman’s area 8) Ipsilateral tonic conjugate deviation

Seizure involving frontal eyes field Conjugate deviation to contralateral side

Occipital lobe injury ( unilateral) Hemianopsia + ipsilateral conjugate gaze preference

Motor assessment

Limb function should be assessed in order to identify thepresence of cerebral space occupying lesions or spinalinjuries. Document any pre existing weakness from previousillness as this will affect the interpretation of theassessment.

MRC grading system.

Muscle strength ScoreNormal strength 5Reduced strength but can still move againstresistance 4Movement against gravity but not againstResistance 3Movement with gravity eliminated 2Palpable contraction but no visible movement 1No movement 0

Involuntary movements

Types of involuntary movement.

Name MovementAthetosis - Snakelike movements of the limbs.Chorea - Thrashing arm movements, known as St

Vitus dance.Tremor- Tremor may occur at rest or on activity

and may involve a hand, limb or more than one limb or the entire body.

Position of limbs.

Score Category Explanation3 Normal When one examines the patient

the limbs are in a normalposition.

2 Decorticate The arms are flexed, the legsare extended.

1 Decerebrate The arms and legs are extended.

Brainstem Reflexes

Facial palsy unilateral 7 N injury- Basilar skull #

Corneal reflex ( V1+V2) Rostral Pontine function

Dolls eye maneuver Vestibuloocular function

Gag and cough reflex 9,10th N + brainstem swallowing centers

Deep tendon and superficial reflexes

• DTR’s exaggerated after traumatic brain injury due to cortical disinhibition

• Decreased / absent after Spinal cord injury• Asymmetric DTR’s unilateral brain/spine injury• Superficial lost/decreased in corticospinal

dysfunction and helpful in localizing lesions

seizures These are important and must be recorded. A seizure maybe motor or sensory depending on the area involved. Thefollowing must be noted:• Any predisposing factors.• Type of seizure.• Generalised seizure.• Focal seizure.• Duration.

Neurodiagnostic Evaluation Skull Radiograph Controversial usage, costs> benefits

CT Contiguous slices from vertex to foramen Magnum.Extend to C3 if upper spine # suspectedBrain, Blood and Bone windows

Indications controversial, a must in1.Penetrating head trauma2.basilar/ depressed skull #3.Posttraumatic seizure4.Severe head injuryIn addition anyone with,1.Altered level of consiousness2.Focal deficits3.Persistent headaches

MRI Better than CT in subacute and chronic phases of injury to detect contusions

Indications for CT scan in head injured/unconsciouspatient1. GCS <13 on initial assessment in the emergency department2. Neurological deterioration in resuscitated patient3. GCS <15 at 2 h after the injury4. Suspected open or depressed skull fracture5. Any sign of basal skull fracture (haemotympanum, “panda” eyes,6. CSF leaking from the ear or nose, Battle’s sign)7. Post-traumatic seizure8. Focal neurological deficit9. More than one episode of vomiting10. Amnesia for events more than 30 min before impact11. Diagnosis uncertain

Clinical Features In Head Trauma

• Scalp Injuries • Skull Fractures• Depressed Skull Fractures• Basilar Skull Fractures• Vascular Injuries• Penetrating Head Injury• Intracranial Hemorrhage

– Epidural Hematoma– Subdural Hematoma– Subarachnoid Hemorrhage– Intracerebral Hemorrhage

Scalp Injuries

• Most are laceration– Simple Linear/ Stellate treatment in emergency

department– Extensive, Degloving/Avulsion Repair GA– Overlying Depressed Skull farcture Infections

Repair and Elevation Of fracture– Hematomas

Skull Fractures• Thin skull is fracture common place.• Risk of factors associated intracranial injuries

1. Open 2. Closed3. Linear (3/4) 4. Comminuted ( multiple branches)5. Diastatic ( edges split apart)<3yr6. Depressed7. Basilar

Depressed Skull #

• From focal blow• Closed 10-15% seizures Treatment for

cosmetic reasons• < skull thickness- no elevation

Basilar Skull #

Epidural Hematomas (EDH)

• Peak incidence in 2nd decade • Source meningeal vessel, Dural venous sinus,

diploic vein from skull fracture• History of minor head injury with fall • Clinical presentaion wrt size, location, rate of

accumulation– Lucid interval (33%), non specific– Confusion, lethargy, agitation, focal neurological

deficits.

Diagnosis

• CT is diagnostic • Initial Ct Hyperdense collection beneath

skull• Actively bleeding- Mixed densities

Subdural Hematoma

• Common in infants. • Cause high velocity impact/ assault/ child

abuse/ fall from significant height.• Associated with cerebral contusions • Source cortical bridging veins/ Dural

venous sinuses.

50% are unconscious immediately.Focal deficits commonHemiparesis – 50%Pupillary abnormality- 28-78%Seizures – 6-22%

SDH’s are High density collections on CT conforming to convex surface of brainCant cross falx cerebri/ tentorium cerebelli { compartmentalized}Can cross beneath suture linesDistorstion of cortical surface/ effacement of ipsilateral ventricle/ shift of midline often noted.

• Trauma is leading cause.• Acute from disruption of

perforating vessels around circle of Willis in basal cistern

• Delayed from ruptured pseudo aneurysm.

• Treatment –to maintain intravascular volume to prevent ischemia from vasospasm.

• Mortality 39%

Subarachnoid Hemorrhage

Cerebral Contusion

Most common Focal brain InjurySites Impact site/ under skull fractureAnteroinferior frontalAnterior TemporalOccipital Regions

Petechial hemorrahges coalesce Intracerebral Hematomas later on.

Intracerebral Bleed Rare in Peditrics60% from small contusions coalesce to form larger hematoma.Rarely , violent angular acceleration bleed in deep white matter, basal ganglia, thalamusTranstentorial Herniation midbrain bleed ( Duret hemorrhages)

Common sitesAnterior Temporal and Inferior Frontal lobes { impact against lateral sphenoid bone/ floor of anterior fossa}

• CT- hyperdense/mixed • MRI- small petechial bleedTreatment- small- non operative. Resolve in 2-3

weeks• Large- Surgical drainage.• Repeat CT in small bleeds after 12-24 hr is

warranted to check large hematoma.

Penetrating Head Injury

Infants and children fall on sharp objects with thin skull and open foraminae could predispose for these injuries.

Surgical treatment. Entry wound debrided and FB removed with in driven bone fragments.Peri and post operative antibioticsProphylactic anticonvulsants

Adolescents and children Gun Shot Wounds. ( 12%) and increasing annually.

Higher mortality when 1.Low GCS on presentation (3-4)2.Bilateral hemispheric /brainstem injury3.Hemodynamic instability/ apnea/both4.Uncontrolled ICP.

• CT- localizes bullet and bone fragments• MRI- non advised till magnetic properties of bullet known.• .

Intracranial Hypertension• Pathophysiology

– ICP monitoring and control are the cornerstones of TBI management

– Normal ICP • Adults <10mmhg• Children 3-7mmhg• Infants 1.5- 6mmhg

– When to treat?• Adults > 20• Children >15• Infants >10 { Arbitrary numbers most commonly used,

pending outcome studies}

ICP measurementIntraventricular Cath coupled to ICP transducer is Gold standard.

Which patients need ICP monitoring??1.TBI + abnormal CT scan who are not following commands ( 50-63%)2.Comatose + Normal CT had lower risk ( 13%) unless associated with

1. Older age2. Systemic Hypotension ,

<90mmhg3. Motor posturing, with

these risk is upto 60%3.Most clinicians use abnormal CT scan result + low GCS scores ( < 8) as candidates for ICP monitoring

Device / method Risk / benefit

1. Intraventricular catheter Adv- drainage of CSF to reduce ICPDisAdv- infection/ ventricular compression leads to inaccuracy

2. subdural/ subarachnoid bolts( Philadelphia, Leeds, Richmond bolts)

Occlusion of port in device leads to inaccuracy

3. Fiberoptic cath ( Camino labs) Improved fidelity & longevityCan be placed Intraparenchymal/ intraventricular/ subduralUsed to drain CSFAccuracy maintained even with fully collapsed ventriclesSingle cath can be used as long as needed

Thank You