1. Head Trauma Neurosurgical Department Yoon Seung-Hwan, M.D.

2. Classification • closed or penetration • focal or diffuse • primary or secondary

3. Primary injury

4. Scalp injury • contusion • laceration • hematoma

5. Skull fracture • simple or compound • depressed or linear or basal • closed or open • growing

6. Focal brain injury intracranial hemorrhage or hematoma 1. outside on dura mater: EDH 2. inner side on DM: Intracranial hemorrahge, SDH 3. SAH: most common cause(c.f. aneurysmal SAH)

7. Diffuse brain injury 1. concussion - 두부외상을 받고 반고체인 뇌가 단단한 두개강안에 서 흔들려 일시적으로 뇌의 기능이 중되었다가 완전히 회복되며 뇌실질에 기질적 변화를 일으키 지않은 가역적인 경한 뇌손상. - post-traumatic amnesia

8. 2.diffuse axonal injury - 장기간의 의식소실을 보이나 두개강내 종괴의 소견은 보이지 않음 - 1956년 Strich: duffuse degeneration of white matter - no lucid interval or IICP sign - histologic findings 1st 6 hour: axonal enfolding 12 – 24 hour: axonal swelling, retraction ball laters: clusters of microglia, gliosis yrs later: wallerian degeneration on distal site on injury

9. 3. contusion - coup and countercoup contusion - frontal or temporal lobe : common site

10. Secondary injury

11. Systemic causes - hypotension: perfusion pressure  hypoxia: PO2 60mmHg  - others hypercapnea, hyperthermia, electrolye imbalance glucose intolerance, sepsis, anemia

12. Intracranial cause 1. brain swelling - edema: vasogenic: BBB permiability  cytotoxic: Na/K pump damage CT: hypodensity - hyperemia: vasomotor paralyis, vasodilatation, cerebral blood flow , IICP CT: compression of ventricle

13. 2.herniation definition? 뇌조직이 압력차이에 의하여 병변이 발생된 구획을 벗어 나는 것. clinical menifestation related wth : expansion rapidity, ICP, mass size classification: - cingulate H. - tentorial H. tectal, central , uncal

14. 3. increasment of ICP - Monro and Kellie thesis : CSF, brain, blood - norma ICP at supine adult: 7 -15 mmHg, child: 3 - 7 mmHg - etiology 1) edema 2) hematoma 3) CSF obstruction 4) venous congestion

15. Pathophysiology on head trauma

17. Early Management emergency care - airway - breathing for preventions of secondary injury - circulation

18. Neurological examination severe head injury: GCS score check a. vital sign - Cushing response: hypertension and bradycardia - hypertension: pressure center compression on 4th ventricle floor - abnormal respiration Cheyne-Stroke resp.: diencephalon central neurogenic hyperventilation: prox. tegmentum ataxic resp. - pons and medulla - abnormal temperature

19. consciousness - center : ascending reticular activating system, ARAS - midbrain – hypothalamus -- thalamus - ARS -- cerebral cortex -- projection fiber : arousal response - alert, drowsy, stupor, semicoma, coma - GCS score 3 - 8: severe 9 -12: moderate 13-15: mild

21. pupil change - normal size: 3- 5mm - 1 mm 이상 양안에서 차이나면 비정상 - mydriasis unilateral M. and sluggish L/R: early sign of tentorial hernation mydriasis and loss of L/R: IICP c.f.) unilateral mydriasis: direct contusion, carotid-cavernous fistula - oculocephalic and oculovestibular reflex

22. motor response - Unilateral mydriais and contralateral hemiparesis: mydriasis side에 혈종이 있다. - Kernohan’s notch: cerebral peduncle 이 tentorial notch 에 손상되어혈종이 있는곳이 반신마비를 일으킨다. - decorticate posture: damage of cerebral cortex decerebrate posture: midbrain damage

23. mild head injury - posttraumatic amnesia retrograde or antegrade - headache, nausea, vomiting, dizziness - anosmia - Bell’s palsy - focal neurological deficit

24. External examination 1. head battles’s sign raccon eye sign bank sign 2. chest and abdomen 3. spine and extremity combined with 5 – 10%

25. Skull x-rays Vs vessel groove , suture line - no sclerotic border - more radiolucent - rare blanching - unilateral

26. Computed tomography(CT) indications - GCS 14 <= assoc. with loss of consciousness(LOC) focal neurological deficit memory loss skull fracture - others 1) GCS < 8 2) depressed skull Fx >1cm 3) anisocoria >1mm 4) neurological deficit 5) GCS 가 3 이상 감소 6) penetrating injury 7) hemorrhagical disorders

27. Others study MRI, Angiography, Neurophysiological study ICP monitoring - indication 1) GCS < 8 2) CT 상 basal cistern compression or 5mm midline shirting - 5 – 7 days monitoring CBF study: Nitrous oxide or xenon, Xenon CT, SPECT PET, Laser doppler,TCD, AVDO2, Spectroscopy

28. Treatment classifications - mild: GCS 13/14 12 – 24 시간동안 안정 - moderate : GCS 9-12 입원 하여 6시간내에 CT - severe: GCS 3-8 ICU admission

29. ICP managment 1. head elevation - 30도 거상 2. ABR - anxiolytics, neuromuscular blockers 3. hyperventilation- PaCO2를 20-30 mmHg으로 유지 4. CSF drainage 5. hypertonic soluion – reflex autoreguation을 유지 ECF 감소 6. diuretics 7. barbiturates – loading dose : 10mg/kg 를 30분동안 점적하고 이후 3시간동안 5mg/kg으로 유지하다가 그 이후 1-2mg/kg로 유지함

30. Prevention of secondary brain damage superoxide dismutase steroid – methyprednisolone, trilazad hyperbaric oxygen therapy hypothermia BBB stabilization, preservation of cell skeleton, inhibition of ional exchange, releasing nerotransmitters others – CDP-choline, nimodipine, GM1 monosialogangiosides

31. Scalp injury 5 layers of scalp s: skin, c: cutanuous, a: aponeurotica l: loose areolar tissue, p: pericranium 종류 1) laceration 2) avulsion 3) chemical injury

32. Skull fracture Meaning: 1) 충격이 크다 2) 두개강내 혈종이나 감염 가능성 시사 종류 1) linear fracture 2) depressed fracture 3) basal skull fracture CSF rhinorrhea or otorrhea ecchymosis, pneumocephalus hemotypanum, cranial nerve injury 4) diastatic fracture - 2mm 이상 seperation

33. Growing fracture • 두개골 골절의 0.6% • 6세이전 parietal region에 잘발생 • saucerization or eversion • 3 세미만에서 fracture line이 2mm 이상 벌어지면 주이 요망 • initial skull fracture --- progressing to seperation

34. Epidural hematoma(EDH) vessel: dural vessel, diploic vein, venous sinus middle meningeal artery – M/C site temporal or temporoparietal side 가 많다 ## lucid interval : 외상후 처음 의식소실후 의식회복이 되었다가 다시 의식을 잃는 경우 치료: 수술

36. 소아나 노인에게 적은 이유 - skull fracture 빈도가 적다 - 골절면이 예리하지 못하다 - middle menigeal artery의 goove 가 얕거나 없다. - dura mater 가 봉합선에 단단히 붙어있다

37. Acute subdural hematoma(SDH) • bridging vein, cortical vessel, sinus injury • 증상이 심하고 손상이 광범위하여 예후가 불량하다. • 진단은 CT가 가장 정확하다. • expiratory trephination • 치료: 수술과 항경련제 투여

39. Chronic SDH • head trauma 3 weeks later c.f) subacute: 3 days to 3 weeks • 50 대이상 남성에서 많다. • chronic alcoholism, seizure patients • pathophysiology: osmotic pressure or rebleeding theory • 치료: 수술

41. Subdural hygroma • etiology: - 외상으로 arachnoid 손상 - 뇌척수액이 subdural space 으로 유입 - 파열된 지부막이 one-way valve 역할 • CT상 저음영으로 관찰됨

42. Intracerebral hematoma(ICH) - elderly men에게 많다 - 측두엽과 전두엽이 80내지 90% 차지함 - delayed traumatic intracerebral hematoma (DTICH) 원인) 감압수술후 출혈과 뇌부종에 의한 뇌압박 – 국소빈혈 – 뇌조직 괴상과 이차적인 출혈 뇌좌상부위의 동맥 연축 혈종제거후 tamponade 효과 소실 뇌손상후 유리되는 효소의 부산물로인해

44. T-subarachnoid or intraventricular hemorrhage(SAH or IVH) • associated with hydrocepahlus • tentorial hemorrhge • SDH, interhemispheric • IVH

46. Complications after head trauma • pneumocephalus • CSF fistula rhinorrhea – eustachian tube – otorrhea Dx: CSF test sugar, eosinophil, radioisotope & CT cisternography

48. Tx ABR, 20도 head elevation 수술: 1) 6 내지 8일동안 CSF 양이 감소하지 않음 2) 초기에 양이 줄었으나 10일내지 12일 이상 지속 3) pneumocephalus 가 동반된 경우 4) meningitis 5) sinus or compound fracture

49. - empyema - osteomyelitis - traumatic brain abscess - vascular complications CCF: internal carotid artery 손상으로 ICA 혈액이 직접 cavernosu sinus 로 흘러들어 cavernosus sinus 압력이 증가되는 경우 aneurysm

50. Postconcussional syndrome • 외상후 발생한 비정신병적 정신증상등을 말한다. • 두통, 현기증, 피로, 자극과민, 집중곤란, 정신적 업무 수행의곤란, 기억장애, 불면증