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Neuro Surgical Emergencies
Prof. M. Natarajan MS
Chief Neuro Surgeon, K.G. Hospital
Head Trauma
Head Injury forms 50% of all trauma related deaths. Increasing usage of two wheelers accounts for majority of cranial injuries among the younger ones in their - 'Productive age Group". Immediate and aggressive management of Brain Injured victims in a well equipped centre will save most of them to go back to their original profession.
Head Trauma involves
It may be closed or open injury.
Scalp Injuries
Small scalp lacerations are not significant unless it is associated with brain injury. But extensive scalp avulsions may result in shock and death. These patients require immediate arrest of the active bleeders. They may need volume replacement through blood transfusion especially in paediatric age group.
- Simple Fissured
- Skull Fractures
- Compound Depressed
- Simple Fractures
No active treatment is warranted. Fractures passing through a major vascular channel needs close observation because of the possible formation of intracranial heamatomas. Examples:- Middle meningeai'artery, vein, saggital sinus, lateral sinus.
Skull Base Fracture
- Fractures involving anterior cranial fossa extending into ethmoidal, sphenoidal sinuses.
- Fractures involving petrous temporal bone in the middle cranial fossa. Occipital bone fractures involving foramen magnum.
Anterior and middle cranial fossae present with cerebro spinal fluid rhinorrhoea and ottorrhoea. They may be associated with anosmia and facial palsy. Chances of developing meningitis is more. If CSF leak persists even after one week, and medical measures prove futile, surgery is indicated. Basal fractures associated with intracranial heamatomas, surgery is mandatory.
Simple depressed fracture in paediatric age group is called Pond Depressed Fracture. If it is over the motor corex it needs to be elevated.
Compound Depressed Fractures
Needs Surgery. All the in driven fragments are to be excised. Dural lacerations, if any, need to be sutured primarily or duraplasty to be done using either pericranial, temporalis or fascia lata grafts.
Brain Injuries
'Concussion Brain' is defined as BRIEF PERIOD OF LOSS OF CONSCIOUSNESS and total recovery within 24 hours without any residual deficit. Probable pathology is
- Due to temporary ischaemia to centrencephalon Epi
- Sudden increased release of acetyl choline with subcellular damage of ARAS.(Ascending Reticular Activating Bio System)
Contusion Brain
It indicates severe injury to the brain parenchyma. 'Coup' and 'contre coup' contusions are common. Contused area is usually bloody and oedematous. Subpial bleeding is seen. Contusion evokes severe tissue reaction and Acut vasogenic oedema.
Neurological deficits such as hemiplegia, aphasia, faciobrachial weakness, obtundation or coma are encountered. Some patients may require contusionectomy or decompression.
Diffuse Axonal Injury
In this type of brain injury, shearing or tearing of axone from neurons occur in white matter. This is often seen when brain moves violently within the skull as seen in acceleration or deceleration injuries.
Grade I
Axonal injury in the white matter of hemisphere, corpus callosum.
Grade II
Focal lesion in corpus callosum, cerebellum.
Grade III
Focal lesion in dorsolateral part of the rostral brain stem.
Brain Ischaemia, Brain Oedema, Raised Intracranial Pressure
Brain Ischaemia
Following head injury, auto regulatory vesodilation is reduced. Hyperemic response to arterial hypoxia is reduced. These vascular reactivity changes are reflected in cerebral blood flow. CBF in head injury patients tend to slow down to less than 18 ml/100 g/ min. where as in normal individual it is 66 to 70 ml/ 100 g / min.
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