Traumatic Brain injury

87

Table 6.5 Types of craniosynostosis (Continued)

Type

Fused suture

Shape of head

Remarks

plagiocephaly

premature fusion (or incomplete

asymmetrical (e.g., flattened

fusion) of a coronal suture

on one side)

often due to

asymmetrical

muscle tone in

cerebral palsy

88 6

Diseases of the Brain and Meninges

early epileptic seizures;

extensive skull fracture, but no neurological deficit;

bleeding from the ear or nose (indicating a basilar

another patient may sustain a relatively minor blow to

skull fracture).

the head that ruptures a bridging vein and produces a

The depth of impaired consciousness or coma in a brain-

slowly growing subdural hematoma, which can com-

press the brain and ultimately cause coma and death. The

injured patient is graded numerically on the Glasgow

clinical state of the patient after traumatic brain injury

Coma Scale (Table 6.6).

can be classified as follows (in order of increasing sever-

Important aspects of the initial physical examination

ity):

are:

the patient’s level of consciousness (see above);

Skull contusion. Patients with the simple skull contu-

externally visible injuries, especially of the head;

sion syndrome have no evidence of a brain injury, i. e., no

bleeding and possibly flow of cerebrospinal fluid from

loss of consciousness or amnesia, a normal neurological

the nose or ears, or in the pharynx (a CSF leak is con-

examination, and normal intracranial findings on CT or

clusive evidence of an open brain injury, while bleed-

MRI (if performed). Some patients with this syndrome

ing is not);

have scalp lacerations, or even skull fractures, and head-

injuries of the cervical spine;

ache may be present. Adequate therapy consists of a tem-

periorbital hematoma; neurological findings (pupil-

porary restriction of activity and symptomatic medica-

lary reflexes, visual impairment, nystagmus, deaf-

tion, as required (analgesics, antiemetics).

ness, weakness, pyramidal tract signs), general state

Concussion (= mild traumatic brain injury) is character-

of health, and, in particular, circulatory status.

Ancillary tests, to be performed as indicated by the

ized by a brief, transient loss of consciousness, usually last-

ing no more than a few minutes and sometimes followed

clinical situation, include cervical spine radiographs and

by a period of confusion. The periods of retroand antero-

a CT and/or MRI scan of the head. Skull radiographs are

grade amnesia are very brief. Headache, dizziness, nausea,

hardly ever indicated.

and (sometimes) vomiting are common accompani-

ments of concussion in the early phase. A standard neu-

Traumatic brain injuries are often accompanied by

rological examination reveals no deficit. In the past, it

! cervical spine injuries.

was generally assumed that concussion produced no

structural damage to the brain, but T2-weighted MR im-

ages do, in fact, reveal diffuse axonal injury in some

Grades of Severity of Traumatic

patients. Moreover, neuropsychological testing reveals

that some patients said to have sustained no more than a

Brain Injury

concussion actually have deficits of certain characteristic

types, collectively designated minimal brain injury. Oc-

The clinical grade of severity of traumatic brain injury is

casional patients suffer from persistent posttraumatic

closely correlated with the initially evident extent of

headaches. The clinical distinction between concussion

structural damage to the skull and brain, but the correla-

and brain contusion (see below) is not always easy to

tion is not absolute. For example, a patient may have an

draw.

a

b

skull

intracerebral hematoma

acute subdural hematoma

epidural space

dura mater

subdural space

arachnoid

subarachnoid space

brain

chronic subdural hematoma

epidural hematoma

CSF fistula

rhinogenic posttraumatic meningo-

malresorptive hydrocephalus

posttraumatic focal epilepsy

encephalitis