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Head injury

From Wikipedia, the free encyclopedia
(Redirected fromHead trauma)
See also:Traumatic brain injury
"Head trauma" redirects here. Not to be confused withPsychological trauma.
Head injury
Other namesHead trauma
Soldier wounded at theBattle of Antietamon September 17, 1862.
SpecialtyNeuropathology,Psychiatry,Neurology
SymptomsInjury to the brain or skull
ComplicationsHydrocephalus,cerebral edema,cerebral hemorrhage,stroke,coma,nervous system damage,paralysis,death
TypesConcussion,cerebral contusion,penetrating head injury,basilar skull fracture,traumatic brain injury

Ahead injuryis any injury that results in trauma to theskullorbrain.The termstraumatic brain injuryandhead injuryare often used interchangeably in the medical literature.[1]Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

The number of new cases is 1.7 million in the United States each year, with about 3% of these incidents leading to death. Adults have head injuries more frequently than any age group resulting from falls, motor vehicle crashes, colliding or being struck by an object, or assaults. Children, however, may experience head injuries from accidental falls or intentional causes (such as being struck or shaken) leading to hospitalization.[1]Acquired brain injury(ABI) is a term used to differentiate brain injuries occurring after birth from injury, from agenetic disorder,or from acongenital disorder.[2]

Unlike a broken bone where trauma to the body is obvious, head trauma can sometimes be conspicuous or inconspicuous. In the case of an open head injury, the skull is cracked and broken by an object that makes contact with the brain. This leads to bleeding. Other obvious symptoms can be neurological in nature. The person may become sleepy, behave abnormally, lose consciousness, vomit, develop a severe headache, have mismatched pupil sizes, and/or be unable to move certain parts of the body. While these symptoms happen immediately after a head injury occurs, many problems can develop later in life.Alzheimer's disease,for example, is much more likely to develop in a person who has experienced a head injury.[3]

Brain damage, which is the destruction or degeneration of brain cells, is a common occurrence in those who experience a head injury.Neurotoxicityis another cause of brain damage that typically refers to selective, chemically inducedneuron/brain damage.

Classification

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Head injuries include both injuries to the brain and those to other parts of the head, such as thescalpandskull.Head injuries can be closed or open. A closed (non-missile) head injury is where thedura materremains intact. The skull can be fractured, but not necessarily. Apenetrating head injuryoccurs when an object pierces the skull and breaches the dura mater. Brain injuries may bediffuse,occurring over a wide area, or focal, located in a small, specific area. A head injury may causeskull fracture,which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures. Ifintracranial hemorrhageoccurs, ahematomawithin the skull can put pressure on the brain. Types of intracranial hemorrhage includesubdural,subarachnoid,extradural,andintraparenchymal hematoma.Craniotomysurgeries are used in these cases to lessen the pressure by draining off the blood.

Brain injurycan occur at the site of impact, but can also be at the opposite side of the skull due to acontrecoupeffect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact). While impact on the brain at the same site of injury to the skull is the coup effect. If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries).

Specific problems after head injury can include[4][5][6]

Concussion

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Main articles:ConcussionandPediatric concussion
Coup injury

A concussion is a form of a mild traumatic brain injury (TBI). This injury is a result due to a blow to the head that could make the person's physical, cognitive, and emotional behaviors irregular. Symptoms may include clumsiness,fatigue,confusion,nausea,blurry vision,headaches,and others.[7]Mild concussions are associated withsequelae.[8]Severity is measured using variousconcussion grading systems.

A slightly greater injury is associated with both anterograde and retrogradeamnesia(inability to remember events before or after the injury). The amount of time that the amnesia is present correlates with the severity of the injury. In all cases, the patients developpost concussion syndrome,which includes memory problems, dizziness, tiredness, sickness anddepression.Cerebralconcussionis the most common head injury seen in children.[9]

Intracranial bleeding

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Main article:Intracranial hemorrhage

Types of intracranial hemorrhage are roughly grouped into intra-axial and extra-axial. The hemorrhage is considered afocal brain injury;that is, it occurs in a localized spot rather than causing diffuse damage over a wider area.

Intra-axial bleeding

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Main article:cerebral hemorrhage

Intra-axial hemorrhage is bleeding within the brain itself, orcerebral hemorrhage.This category includesintraparenchymal hemorrhage,or bleeding within the brain tissue, andintraventricular hemorrhage,bleeding within the brain'sventricles(particularly ofpremature infants). Intra-axial hemorrhages are more dangerous and harder to treat than extra-axial bleeds.[10]

Extra-axial bleeding

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Comparison of epidural and subdural hematomas
Compared quality Epidural Subdural
Location Between theskulland the innermeningeallayer of thedura materor between outerendostealand inner meningeal layer of dura mater Between the meningeal layers ofdura materand theArachnoid mater
Involved vessel Temperoparietal locus (most likely) –Middle meningeal artery
Frontal locus –anterior ethmoidal artery
Occipital locus –transverseorsigmoid sinuses
Vertex locus –superior sagittal sinus		 Bridging veins
Symptoms (depending on the severity)[11] Lucid intervalfollowed byunconsciousness Gradually increasingheadacheandconfusion
CT scanappearance Biconvex lens Crescent-shaped

Extra-axial hemorrhage, bleeding that occurs within the skull but outside of the brain tissue, falls into three subtypes:

  • Epidural hemorrhage(extradural hemorrhage) which occur between thedura mater(the outermostmeninx) and the skull, is caused by trauma. It may result from laceration of an artery, most commonly themiddle meningeal artery.This is a very dangerous type of injury because the bleed is from a high-pressure system and deadly increases inintracranial pressurecan result rapidly. However, it is the least common type of meningeal bleeding and is seen in 1% to 3% cases of head injury.
    • Patients have a loss of consciousness (LOC), then alucid interval,then sudden deterioration (vomiting, restlessness, LOC)
    • Head CT shows lenticular (convex) deformity.
  • Subdural hemorrhageresults from tearing of the bridging veins in thesubdural spacebetween theduraandarachnoid mater.
    • Head CT shows crescent-shaped deformity
  • Subarachnoid hemorrhage,which occur between the arachnoid andpiameningeal layers, like intraparenchymal hemorrhage, can result either from trauma or from ruptures ofaneurysmsorarteriovenous malformations.Blood is seen layering into the brain alongsulciandfissures,or fillingcisterns(most often thesuprasellar cisternbecause of the presence of thevesselsof thecircle of Willisand their branch points within that space). The classic presentation of subarachnoid hemorrhage is the sudden onset of a severe headache (athunderclap headache). This can be a very dangerous entity and requires emergent neurosurgical evaluation and sometimes urgent intervention.

Cerebral contusion

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Main article:Cerebral contusion

Cerebral contusion is bruising of the brain tissue. The piamater is not breached in contusion in contrary to lacerations. The majority of contusions occur in thefrontalandtemporal lobes.Complications may include cerebraledemaand transtentorial herniation. The goal of treatment should be to treat the increasedintracranial pressure.The prognosis is guarded.

Diffuse axonal injury

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Main article:Diffuse axonal injury

Diffuse axonal injury,or DAI, usually occurs as the result of anaccelerationor deceleration motion, not necessarily an impact.Axonsare stretched and damaged when parts of the brain of differing density slide over one another. Prognoses vary widely depending on the extent of the damage.

Compound head injury

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Overlying scalp laceration and soft tissue disruption in continuity with a skull fracture constitutes "compound head injury", and has higher rates of infection, unfavorable neurologic outcome, delayed seizures, mortality, and duration of hospital stay.[12]

Signs and symptoms

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Three categories used for classifying the severity of brain injuries are mild, moderate or severe.

Mild brain injuries

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Symptoms of a mild brain injury include headaches, confusion, ringing ears, fatigue, changes in sleep patterns, mood or behavior. Other symptoms include trouble with memory, concentration, attention or thinking. Mental fatigue is a common debilitating experience and may not be linked by the patient to the original (minor) incident. Narcolepsy and sleep disorders are common misdiagnoses.[citation needed]

Moderate/severe brain injuries

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Cognitive symptoms include confusion, aggressive, abnormal behavior, slurred speech, and coma or other disorders of consciousness. Physical symptoms include headaches that do not go away or worsen, vomiting or nausea, convulsions or seizures, abnormal dilation of the eyes, inability to awaken from sleep, weakness in the extremities and loss of coordination. In cases of severe brain injuries, the likelihood of areas with permanentdisabilityis great, includingneurocognitive deficits,delusions(often, to be specific,monothematic delusions), speech or movement problems, andintellectual disability.There may also be personality changes. The most severe cases result incomaor evenpersistent vegetative state.[13]

Symptoms in children

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Symptoms observed in children include changes in eating habits, persistent irritability or sadness, changes in attention, disrupted sleeping habits, or loss of interest in toys.[13]

Presentation varies according to the injury. Some patients with head trauma stabilize and other patients deteriorate. A patient may present with or withoutneurological deficit.Patients with concussion may have a history of seconds to minutes unconsciousness, then normal arousal. Disturbance of vision and equilibrium may also occur. Common symptoms of head injury includecoma,confusion, drowsiness, personality change,seizures,nauseaandvomiting,headacheand alucid interval,during which a patient appears conscious only to deteriorate later.[14]

Symptoms of skull fracture can include:

Because brain injuries can be life-threatening, even people with apparently slight injuries, with no noticeable signs or complaints, require close observation; They have a chance for severe symptoms later on. The caretakers of those patients with mild trauma who are released from the hospital are frequently advised to rouse the patient several times during the next 12 to 24 hours to assess for worsening symptoms.

TheGlasgow Coma Scale(GCS) is a tool for measuring the degree of unconsciousness and is thus a useful tool for determining the severity of the injury. ThePediatric Glasgow Coma Scaleis used in young children. The widely used PECARN Pediatric Head Injury/Trauma Algorithm helps physicians weigh risk-benefit of imaging in a clinical setting given multiple factors about the patient—including mechanism/location of the injury, age of the patient, and GCS score.[15]

Location of brain damage predicts symptoms

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Symptoms of brain injuries can also be influenced by the location of the injury and as a result, impairments are specific to the part of the brain affected. Lesion size is correlated with severity, recovery, and comprehension.[16]Brain injuries often create impairment ordisabilitythat can vary greatly in severity.

Studies show there is a correlation between brain lesion and language, speech, and category-specific disorders. Wernicke's aphasia is associated withanomia,unknowingly making up words (neologisms), and problems with comprehension. The symptoms of Wernicke's aphasia are caused by damage to the posterior section of thesuperior temporal gyrus.[17][18]

Damage to theBroca's areatypically produces symptoms like omitting functional words (agrammatism), sound production changes,dyslexia,dysgraphia,and problems with comprehension and production. Broca's aphasia is indicative of damage to the posterior inferior frontal gyrus of the brain.[19]

An impairment following damage to a region of the brain does not necessarily imply that the damaged area is wholly responsible for the cognitive process which is impaired, however. For example, inpure alexia,the ability to read is destroyed by a lesion damaging both the left visual field and the connection between the right visual field and the language areas (Broca's area and Wernicke's area). However, this does not mean someone with pure alexia is incapable of comprehending speech—merely that there is no connection between their working visual cortex and language areas—as is demonstrated by the fact that pure alexics can still write, speak, and even transcribe letters without understanding their meaning.[20]Lesions to thefusiform gyrusoften result inprosopagnosia,the inability to distinguish faces and other complex objects from each other.[21][medical citation needed][22]Lesions in theamygdalawould eliminate the enhanced activation seen in occipital and fusiform visual areas in response to fear with the area intact. Amygdala lesions change the functional pattern of activation to emotional stimuli in regions that are distant from the amygdala.[23]

Other lesions to thevisual cortexhave different effects depending on the location of the damage. Lesions toV1,for example, can causeblindsightin different areas of the brain depending on the size of the lesion and location relative to thecalcarine fissure.[24]Lesions toV4can causecolor-blindness,[25]and bilateral lesions toMT/V5can cause the loss of the ability to perceive motion.[26]Lesions to theparietal lobesmay result inagnosia,an inability to recognize complex objects, smells, or shapes, oramorphosynthesis,a loss of perception on the opposite side of the body.

Causes

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Head injuries can be caused by a large variety of reasons. All of these causes can be put into two categories used to classify head injuries; those that occur from impact (blows) and those that occur from shaking.[27]Common causes of head injury due to impact aremotor vehicle traffic collisions,home and occupational accidents, falls,assault,and sports related accidents. Head injuries from shaking are most common amongst infants and children.[28]

According to the United StatesCDC,32% oftraumatic brain injuries(another, more specific, term for head injuries) are caused by falls, 10% by assaults, 16.5% by being struck by or against something, 17% by motor vehicle accidents, and 21% by other/unknown ways. In addition, the highest rate of injury is among children ages 0–14 and adults age 65 and older.[29]Brain injuries that include brain damage can also be brought on by exposure to toxic chemicals, lack of oxygen, tumors, infections, and stroke.[30]Possible causes of widespread brain damage include birth hypoxia, prolongedhypoxia(shortage ofoxygen),poisoningbyteratogens(includingalcohol),infection,andneurological illness.Brain tumorscan increase intracranial pressure, causing brain damage.

Diagnosis

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See also:Head injury criterion

There are a few methods used to diagnose a head injury. A healthcare professional will ask the patient questions revolving around the injury as well as questions to help determine in what ways the injury is affecting function. In addition to this hearing, vision, balance, and reflexes may also be assessed as an indicator of the severity of the injury.[29]A non-contrast CT of the head should be performed immediately in all those who have sustained a moderate or severe head injury. A CT is an imaging technique that allows physicians to see inside the head without surgery in order to determine if there is internal bleeding or swelling in the brain.[31]Computed tomography (CT) has become the diagnostic modality of choice for head trauma due to its accuracy, reliability, safety, and wide availability. The changes in microcirculation, impaired auto-regulation, cerebral edema, and axonal injury start as soon as a head injury occurs and manifest as clinical, biochemical, and radiological changes.[32]An MRI may also be conducted to determine if someone has abnormal growths or tumors in the brain or to determine if the patient has had a stroke.[33]

Glasgow Coma Scale(GCS) is the most widely used scoring system used to assess the level of severity of a brain injury. This method is based on objective observations of specific traits to determine the severity of a brain injury. It is based on three traits eye-opening, verbal response, and motor response, gauged as described below. Based on the Glasgow Coma Scale severity is classified as follows, severe brain injuries score 3–8, moderate brain injuries score 9-12 and mild score 13–15.

There are several imaging techniques that can aid in diagnosing and assessing the extent of brain damage, such ascomputed tomography(CT) scan,magnetic resonance imaging(MRI),diffusion tensor imaging(DTI) andmagnetic resonance spectroscopy(MRS),positron emission tomography(PET), single-photon emission tomography (SPECT). CT scans and MRI are the two techniques widely used and are the most effective. CT scans can show brain bleeds, fractures of the skull, fluid build up in the brain that will lead to increased cranial pressure. MRI is able to better detect smaller injuries, detect damage within the brain, diffuse axonal injury, injuries to the brainstem, posterior fossa, and subtemporal and sub frontal regions. However, patients with pacemakers, metallic implants, or other metal within their bodies are unable to have an MRI done. Typically the other imaging techniques are not used in a clinical setting because of the cost, lack of availability.

Management

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See also:Traumatic brain injury § Treatment,andAcquired brain injury § Treatment

Most head injuries are of a benign nature and require no treatment beyondanalgesicssuch as acetaminophen. Non-steroidal painkillers such as ibuprofen are avoided since they could make any potential bleeding worse. Due to the high risk of even minor brain injuries, close monitoring for potential complications such asintracranial bleeding.If the brain has been severely damaged by trauma, a neurosurgical evaluation may be useful. Treatments may involve controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second-line alternatives include decompressive craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients), barbiturate coma, hypertonic saline, and hypothermia. Although all of these methods have potential benefits, there has been no randomized study that has shown unequivocal benefit.

Clinicians will often consult clinical decision support rules such as the Canadian CT Head Rule or the New Orleans/Charity Head injury/Trauma Rule to decide if the patient needs further imaging studies or observation only. Rules like these are usually studied in depth by multiple research groups with large patient cohorts to ensure accuracy given the risk of adverse events in this area.[34]

There is a subspecialty certification available for brain injury medicine that signifies expertise in the treatment of brain injury.[35][36]

Prognosis

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Prognosis, or the likely progress of a disorder, depends on the nature, location, and cause of the brain damage (seeTraumatic brain injury,Focal and diffuse brain injury,Primary and secondary brain injury).

In children with uncomplicated minor head injuries the risk of intracranial bleeding over the next year is rare at 2 cases per 1 million.[37]In some cases transient neurological disturbances may occur, lasting minutes to hours. Malignant post traumatic cerebral swelling can develop unexpectedly in stable patients after an injury, as can post-traumaticseizures.Recovery in children with neurologic deficits will vary. Children with neurologic deficits who improve daily are more likely to recover, while those who are vegetative for months are less likely to improve. Most patients without deficits have full recovery. However, persons who sustain head trauma resulting in unconsciousness for an hour or more have twice the risk of developing Alzheimer's disease later in life.[38]

Head injury may be associated with a neck injury. Bruises on the back or neck, neck pain, or pain radiating to the arms are signs of cervical spine injury and merit spinal immobilization via application of acervical collarand possibly a longboard. If theneurological examis normal this is reassuring. Reassessment is needed if there is a worseningheadache,seizure,one-sided weakness, or has persistent vomiting.

To combat overuse of head CT scans yielding negative intracranial hemorrhage results, which unnecessarily exposes patients to radiation and increase time in the hospital and cost of the visit, multiple clinical decision support rules have been developed to help clinicians weigh the option to scan a patient with a head injury. Among these are the Canadian Head CT rule, the PECARN Head Injury/Trauma Algorithm, and the New Orleans/Charity Head Injury/Trauma Rule all help clinicians make these decisions using easily obtained information and noninvasive practices.

Brain injuries are very hard to predict in the outcome. Many tests and specialists are needed to determine the likelihood of the prognosis. People with minor brain damage can have debilitating side effects; not just severe brain damage has debilitating effects. The side-effects of a brain injury depend on location and the body's response to injury. Even a mildconcussioncan have long term effects that may not resolve.

History

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The foundation for understanding human behavior and brain injury can be attributed to the case ofPhineas Gageand the famous case studies by Paul Broca. The first case study on Phineas Gage's head injury is one of the most astonishing brain injuries in history. In 1848, Phineas Gage was paving way for a new railroad line when he encountered an accidental explosion of a tamping iron straight through his frontal lobe. Gage observed to be intellectually unaffected but exemplified post-injury behavioral deficits. These deficits include: becoming sporadic, disrespectful, extremely profane, and gave no regard for other workers. Gage started having seizures in February 1860, dying only four months later on May 21, 1860.[39]

Ten years later,Paul Brocaexamined two patients exhibiting impaired speech due to frontal lobe injuries. Broca's first patient lacked productive speech. He saw this as an opportunity to address language localization. It wasn't until Leborgne, formally known as "tan", died when Broca confirmed the frontal lobe lesion from an autopsy. The second patient had similar speech impairments, supporting his findings on language localization. The results of both cases became a vital verification of the relationship between speech and the left cerebral hemisphere. The affected areas are known today asBroca's areaand Broca's Aphasia.[40]

A few years later, a German neuroscientist,Carl Wernicke,consulted on a stroke patient. The patient experienced neither speech nor hearing impairments but had a few brain deficits. These deficits included: lacking the ability to comprehend what was spoken to him and the words written down. After his death, Wernicke examined his autopsy that found a lesion located in the left temporal region. This area became known asWernicke's area.Wernicke later hypothesized the relationship between Wernicke's area and Broca's area, which was proven fact.[41]

Epidemiology

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Head injury is the leading cause of death in many countries.[42]

See also

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References

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