Traumatic brain injury

Hématome extra-dural

1- Epidural hematoma:

– Fresh Blood Collection (organized fresh clot) between the vault of the skull and the dura is lifted and pushed. This is an extreme emergency treatment.

– The origin of the bleeding is usually a tear of the middle meningeal artery next to a fracture line, or more rarely a tear duremérien sinuses. The temporal localization is the most usual.

– The epidural hematoma is very rare in the elderly because of the strong adhesion of the dura to bone.

Traumatic brain injury


– Clinical symptoms typically evolves in 3 stages: trauma, free interval, neurological worsening. Trauma is of varying importance, often associated with a loss of initial brief acquaintance. Then a free interval of 6 to 24 hours without particular symptom except banal headache;And signs of intracranial hypertension with consciousness disorder, pyramidal irritation, anisocoria and language disorder.

– The evolution is fatal in the absence of adequate treatment

– Little or no neurological signs for HED located in less eloquent areas (prefrontal cortex, vertex, occipital region).

– Scanner without injection: extraparenchymal spontaneous hyperdense in convex lens.

– The treatment is neurosurgical (for cranial flap) in emergency with prophylactic antiepileptic treatment.

– Operated early before the signs of suffering brain stem, the prognosis is favorable in the absence of serious associated parenchymal lesions.

2- Acute subdural hematoma:

– Effusion of fresh blood between the arachnoid and the dura, following an indirect shock usually without skull fracture.

– The primary injury is a ruptured vein corticodurale (rarely wound cortical artery).

– The hematoma is growing rapidly throughout the subdural space. It is usually associated with underlying parenchymal lesions (hemorrhagic contusion, brain edema).

– The acute subdural hematoma is more common in the elderly or chronic ethyl patient (because of brain atrophy).

– The clinical presentation is usually acute with free short interval after injury, consciousness of rapidly worsening disorder, motor deficit. The disease progresses rapidly to severe coma with signs of cerebral herniation.

– The objective brain scan extraparenchymal a spontaneous hyperdense convex outside, concave inside, willingly extended throughout the cerebral hemisphere, with the center line of engagement. It shows parenchymal lesions associated (edematous contusion, hemorrhagic contusion, intracerebral hematoma.

– The treatment is neurosurgical (for cranial flap) in emergency before the onset of irreversible signs of suffering. The prognosis is poor with a mortality of 50% to 80%.

– Abstention is the rule when the very moderate volume of the hematoma does not explain the significant mass effect (due to the fact underlying contusion) to the scanner, the prognosis here is related to the bruise itself even. The scanner should be repeated to monitor

3- Contusion and hematoma interparenchymateux:

– Parenchymal injury involving petechial haemorrhages and brain edema reaction.

– In some cases, during evolution, petechial haemorrhages worsen to constitute an intracerebral hematoma.

– Clinic: after a major trauma, secondary neurological deterioration with neurological signs of localization.

– The scanner initially shows the bruise as a heterogeneous and poorly interparenchymateuse spontaneous hyperdense limited within a hypodense zone (edema).

– The treatment is medical first stage of no mass effect contusion. In case of aggravation with mass effect, surgical indication is discussed.

4- Diffuse cerebral edema (brain swelling):

– A diffuse cerebral edema may be in contact with a brain contusion home or in the absence of parenchymal lesions visible to the initial scanner. This is called diffuse axonal injury with vasogenic and cytotoxic edema.

– Is seen more often in children or adolescents

– After violent trauma, rapid deterioration of consciousness progressing to coma with signs of axial pain and autonomic disorders.

– The scanner shows an overall hypodensité of all the cerebral hemispheres, a loss of cortical sulci and the basal cisterns, erasing the ventricles.

– The intracranial pressure is high with instability of the cerebral perfusion pressure and cerebral blood flow.

– The treatment involves the neurosédation, the prognosis is grave.

5- Wound cranio-cerebral:

– This is a neurosurgical emergency. There is a scalp wound with brain matter after. X-rays of the skull and the scanner are systematic.

– Treatment involves a esquillectomie then repair the dura injured after local cleaning. Antibiotics are widely quoted because of the increased risk of infection.

6- Embarrure:

– The embarrure requires the scanner to judge the possible underlying injuries. The diagnosis is clinical (palpable depression of the vault, not to be confused with subcutaneous hematoma), confirmed by radiographs of the skull (systematic).

– If embarrure closed without neurological repercussions, its lifting is done in a cold antiepileptic and aesthetic purposes.

– Have urgent surgical indication that:

* The embarrure closed with a neurological impact (seizures, motor deficit contralateral to a embarrure Rolandic, aphasia if embarrure temporal side of the dominant hemisphere);

* Embarrure the open.

7- Fracture of skull base:

– It concerns mainly the anterior stage of the skull. They may be associated with breccias and ostéoméningées be a CSF leak through the nose and ears or meningitis.

– A fracture of the prior stage must be considered clinically on the finding of a bilateral periorbital ecchymosis or a runny CSF, an anosmia

– The rock fracture (petrous pyramid) are suspected by the existence of a bruise or mastoid otorragie or CSF collection in the middle ear to the original rhinorrhea via the Eustachian tube. Reaching the inner ear; peripheral facial paralysis.

– These signs are rarely present in the immediate waning of trauma because of the usual presence of cerebral edema which fills the gap. He appeared in a few days when the edema regress.

– Scanner with study “bone window” possibly with intrathecal injection of radiopaque product reconstitution and coronal. Pneumatocele intracranial.

– The neurosurgical treatment is necessary since the CSF leakage is symptomatic.

8- chronic subdural hematoma:

– This is a lysed blood effusion collected between the cortex and the dura. it occurs very often in people aged or alcoholic (brain atrophy) or is favored by anticoagulation.

– The clinical symptoms appear several weeks after a trauma Benin as a progressive intracranial hypertension syndrome with headache, psychic slowing, confusion or dementia, progressive hemiparesis.

– In the absence of treatment, the disease progresses to the temporal engagement and death.

– The objective scanner hypodense a juxtaposition bone extraparenchymal collection associated with mass effect on the brain. The hematoma is sometimes bilateral (with no mass effect). It can be as isodense and only noticed by the mass effect.

– Neurosurgical Treatment is therefore the clinical signs are present or there is a mass effect on CT. It consists of an evacuation of the hematoma with a single burr hole usually under local anesthesia.

9- The scalp lesions:

They are usually harmless when isolated. However, they must be trimmed and sutured quickly. Indeed, scalp contains many blood vessels that can cause an abundant hemorrhage especially in children.

10- concussion:

Clinically it results in a loss of immediate but transitory knowledge of variable duration, proportional to the size of the acceleration experienced, probably by a transient stunning of the reticular activating system of the brain stem.

Macro cell or axonal changes and microscopic are conventionally absent but we can observe biochemical and ultrastructural changes (localized rupture of the blood-brain barrier, depletion of mitochondrial ATP).

11- Appendix:

* Bruises and brain hemorrhages:

It may be micro-foci of intraparenchymal hemorrhages, petechial. These localized vascular ruptures are responsible for impaired blood-brain barrier to cause a focal edema also favored by the loss of self-regulation of anatomically healthy vessels.

At a higher degree of brain contusions are present, brain contusion focus is more extensive in area and depth (bilateral fronto-basal contusions, frontotemporal or bipolar symmetrical in stroke injury against sudden hemispheric poles).

This contusion can progress to tearing of nerve tissue associated with a more or less hemorrhagic suffusion realizing cerebral attrition. The traumatic intracerebral hematoma is rare and usually seen in the cranio-cerebral wounds or firearms.

* All of these glial brain damage cause reactions that can lead to the formation of epileptogenic the cause of post-traumatic epilepsy.

* CT scan: We performed a brain scan automatically in case of impaired alertness, mental confusion or focused neurological deficit. It must be performed in case of fracture of the arch or the base even in the absence of disturbances of consciousness. Epidural hematoma discovered on CT in a patient still conscious and operated heal without sequelae

* The skull standard radiographs are systematic (front, profile and impact of Worms, even in incidence of Blondeau).

* The intellectual impairment should suggest hydrocephalus posttraumatic normal pressure.

CT is essential in doubt.

* Post-traumatic epilepsy often starts late (6 months to several years). Preventive treatment is essential. It requires the scanner to not overlook a chronic subdural hematoma.

* Some fractures can damage brain nerve on its way:

– Olfactory tract (ethmoid fracture or sifted blade);

– Optic nerve (fracture of the sphenoid);

– III, IV or VI in fractures of the greater wing of sphenoid and some fractures the rock;

– Achievement of VII and VIII in the fractures of the rock;

– Achievement of IX, X or XI in the occipital fractures irradiated jugular foramen (often very violent trauma and coma).

* Carotid-cavernous fistulas: Diagnosis is on clinical exophthalmos with pulsatile and blower; conjunctival hyperemia; conjunctival vessel dilation in “Medusa head”. The diagnosis is confirmed by CT or MR angiography (superior ophthalmic veins dilated and arterialized, exophthalmos, more or less cavernous anomaly.