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Severe closed head injury is almost universally accompanied by cortical contusions and surrounding edema The mass effect of contusional swelling, if suf ciently large, is a major factor in the genesis of tissue shifts and raised intracranial pressure The CT appearance of contusion has already been described (page 751; see also Figs 35-4 and 35-5) In the rst few hours after injury, the bleeding points in the contused area may appear small and innocuous The main concern, however, is the tendency for a contused area to swell or to develop into a hematoma This may give rise to clinical deterioration hours to days after the injury, sometimes abrupt in onset and concurrent with the appearance of swelling of the damaged region on the CT scan It has been claimed, on uncertain grounds, that the swelling in the region of an acute contusion is precipitated by excessive administration of intravenous uids ( uid management is considered further on in this chapter) Craniotomy and decompression of the swollen brain is usually of little bene t
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Traumatic Intracerebral Hemorrhage
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One or several intracerebral hemorrhages may be apparent immediately after head injury, or hemorrhage may be infrequently delayed in its development by several days (Spatapoplexie) The bleeding is in the subcortical white matter of one lobe of the brain
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or in deeper structures, such as the basal ganglia or thalamus The injury is nearly always severe; blood vessels as well as cortical tissue are torn The clinical picture of traumatic intracerebral hemorrhage is similar to that of hypertensive brain hemorrhage (deepening coma with hemiplegia, a dilating pupil, bilateral Babinski signs, stertorous and irregular respirations) It may be manifest by an abrupt rise in blood pressure and in intracranial pressure In elderly patients, it is sometimes dif cult to determine whether a fall had been the cause or the result of an intracerebral hemorrhage Craniotomy with evacuation of the clot has given a successful result in a few cases, but the advisability of surgery is governed by several factors, including the level of consciousness, the time from the initial injury, and the associated damage (contusions, subdural and epidural bleeding) shown by imaging studies The wider application of intracranial pressure monitoring and of CT scans at intervals after the injury should facilitate diagnosis and perhaps help to elucidate the pathogenesis of delayed hemorrhages Boto and colleagues determined that basal ganglia hemorrhages were prone to enlarge in the day or two after closed head injury and that those over 25 mL in volume were fatal in 9 of 10 cases It should be mentioned again that subarachnoid blood of some degree is very common after serious head injury A problem that sometimes arises in cases that display both contusions and substantial subarachnoid blood is the possibility that a ruptured aneurysm was the initial event and that a resultant fall caused the contusions In cases where the subarachnoid blood is concentrated around one of the major vessels of the circle of Willis, an angiogram may be justi ed to exclude the latter possibility This subject is addressed in Chap 34
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weighted MRI, particularly in the white matter of the corpus callosum and the temporo-occipito-parietal region This syndrome confers a high risk for slowing of development; there may be acquired microcephaly re ecting brain atrophy consequent to both contusions and infarctions A low initial Glasgow Coma Scale score, severe retinal hemorrhages, and skull fractures are associated with poor outcomes Old and recent fractures in other parts of the body should arouse suspicion of this syndrome
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Penetrating Wounds of the Head
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Missiles and Fragments The descriptions in the preceding pages apply to blunt, nonpenetrating injuries of the skull and their effects on the brain The disorders included in this section are more the concern of the neurosurgeon than the neurologist In the past, the care of penetrating craniocerebral injuries was mainly the preoccupation of the military surgeon, but with the increasing amount of violent crime in society such cases have become commonplace on the emergency wards of general hospitals In civilian life, missile injuries are essentially caused by bullets red from ri es or handguns at high velocities Air is compressed in front of the bullet so that it has an explosive effect on entering tissue and causes damage for a considerable distance around the missile track Missile fragments, or shrapnel, are pieces of exploding shells, grenades, or bombs and are the usual causes of penetrating cranial injuries in wartime The cranial wounds that result from missiles and shrapnel have been classi ed by Purvis as tangential, with scalp lacerations, depressed skull fractures, and meningeal and cerebral lacerations; penetrating, with in-driven metal particles, hair, skin, and bone fragments; and through-andthrough wounds In most penetrating injuries from high-velocity missiles, the object (such as a bullet) causes a high-temperature coagulative lesion that is sterile and fortunately does not require surgery In these instances, the main considerations are the development of infection or CSF leaks or, in the long term, epilepsy or aneurysms in distal blood vessels The latter are considered to be the result of disruption of the vessel wall by the high-energy shock wave If the brain is penetrated at the lower levels of the brainstem, death is instantaneous because of respiratory and cardiac arrest Even through-and-through wounds at higher levels, as a result of energy dissipated in the brain tissue, may damage vital centers suf ciently to cause death immediately or within a few minutes in 80 percent of cases If vital centers are untouched, the immediate problem is intracranial bleeding and rising intracranial pressure from swelling of the traumatized brain tissue Once the initial complications are dealt with, the surgical problems, as outlined by Meirowsky, are reduced to three: prevention of infection by rapid and radical (de nitive) debridement, accompanied by the administration of broad-spectrum antibiotics; control of increased intracranial pressure and shift of midline structures by removal of clots of blood and the vigorous administration of mannitol or other dehydrating agents as well as dexamethasone; and the prevention of life-threatening systemic complications When rst seen, the majority of patients with penetrating cerebral lesions are comatose A small metal fragment may have penetrated the skull without causing concussion, but this is not true of high-velocity missiles In a series of 132 patients of the latter type analyzed by Frazier and Ingham, consciousness was lost in 120 The depth and duration of coma seemed to depend on the degree of cerebral necrosis, edema, and hemorrhage In the series of the
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