Craniocerebral trauma is one of the leading causes of death and disability when the damage suffered is considered a traumatic injury to the brain.
Skull injuries can be closed or open (with penetration).
A closed craniocerebral trauma means that an object hit the head hard, but the skull is not broken.
An open craniocerebral trauma means that an object has hit the head and entered the brain. This usually happens when a blow occurs at high speed, for example, an impact against the windshield in a car accident. It can also be done with a pistol shot in the head.
To suffer a concussion, it does not require a blow to the head.
An impact anywhere on the body can develop sufficient force to damage the brain. With a concussion, you don’t always lose consciousness. The vibrations can be mild to severe. The effects can be immediately visible or develop after hours and even days.
Trauma is one of the leading causes of death in children over 1 year of age in the United States. Craniocerebral trauma accounts for 80% of injuries.
In about 5% of cases, patients die at the scene of the accident. Ceriocerebral trauma has a strong emotional, psycho-social and economic impact because patients often require a long hospital stay.
5-10% need to be transferred to long-term care.
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What are the different types of craniocerebral trauma?
The concussion is a craniocerebral trauma that results in the sudden loss of consciousness or vigilance for a period of a few minutes to about an hour after the traumatic event.
It is the type of craniocerebral trauma that causes less damage.
Skull fracture
The bones of the skull can fracture in case of trauma to the head.
If this happens, an X-ray must be taken to determine the extent of the damage.
There are several types of fractures of the skull, including:
- Simple (or closed) fracture in which the skin has remained undamaged and the surrounding tissue has not been damaged.
- Open fracture, in which the skin is injured and the surrounding tissue may be damaged.
- Linear fracture, when the fracture of the bone presents itself as a straight line.
- Impression fracture, when part of the bone has been pressed inwards.
Open fractures can be much more dangerous, because there is a high risk of infection if the skin is injured.
This is possible because bacteria can enter the wound via the skin injury. Impression fractures can be very dangerous because small pieces of bone can be pressed inside and thus against the brain.
Intracranial hematoma
There are several types of intracranial hematoma or accumulation of blood inside or outside the brain.
The different types are classified according to their location in the brain.
Intracranial hematomas can vary from minor injuries to the head to very serious and potentially fatal lesions.
The different intracranial hematoma types are:
Epidural hematoma is a collection of blood that forms between the skull bone and the hard meninges, i.e. the outer lining of the brain.
It is usually caused by injury to an artery that runs just below the skull and is called the media meningeal artery. It is rarely caused by the rupture or bursting of the venous sinus of the hard meninges.
Epidural hematomas are generally associated with a skull fracture caused by closed trauma.
The hematoma can spread to the parietal and frontal areas or below the temporal lobe.
Symptoms depend on the accident event and the amount of blood leaked. They can occur immediately, but also only after a few days.
The therapy consists of immediate surgical intervention, in which the surgeon opens the skull and clears the hematoma, as well as prevents bleeding of the artery (hemostasis).
Subdural hematoma, which is an accumulation of blood that spreads under the skull between two layers of the meninges: the hard meninges and the arachnoid.
The cause may be injury to one of the veins leading from the brain to the meninges, or an incision in the brain itself. The subdural hematoma sometimes occurs with a skull fracture.
Contusion or intracerebral hematoma
Brain contusion is an injury to the brain that leads to bleeding and swelling within the area where the trauma occurred.
Contusions can occur with skull fractures and along with other blood accumulations such as subdural or epidural hematomas.
Bleeding inside the brain itself (also called “intraparenchymal hemorrhage”) can occur spontaneously. If the trauma is not the cause of an intracerebral hematoma, the most common causes are long-term high blood pressure in elderly patients, bleeding disorders in children or adults, taking medications that thin the blood, or drug abuse.
Diffuse axonal damage
These lesions are relatively common and are caused by momentary rapid forward and backward movement of the brain, as occurs in whiplash, falls or shaking trauma of a child.
The diffuse injuries can be mild, such as a concussion, or severe, such as diffuse axonal damage. With diffuse axonal damage, the patient is in a coma for a long time with damage in different parts of the brain.
Causes of craniocerebral trauma
Traumatic brain injury affects 1.7 million people a year in the United States, including about half a million children; the death toll stands at 52,000.
Adults are much more likely to suffer skull injuries due to falls, traffic accidents, beatings and combative confrontations.
Falls are the most common traumas in children.
Symptoms of craniocerebral trauma
A person may have different symptoms depending on the severity of damage to the head.
The following are the most common symptoms of craniocerebral trauma, but each sufferer may also have other symptoms.
Mild craniocerebral trauma:
- Swollen zone with bump/bruise or bruise
- Small incision on the surface of the scalp
- Headache
- Hypersensitivity to noise and light
- Irritability
- Confusion
- Swaying or spinning vertigo
- Disturbances of equilibrium
- Nausea
- Memory disorders and/or lack of concentration
- Change in sleep rhythm
- Blurred vision
- “Tired” eyes
- Hearing noises (tinnitus)
- Changes in taste
- Feeling of fatigue/lethargy
Moderate to severe craniocerebral trauma (it needs immediate medical attention)
Symptoms may include any of the above, in addition:
- Loss of consciousness
- Severe headaches that do not pass
- Recurrent nausea and vomiting
- Loss of short-term memory and difficulty remembering the circumstances that led to the trauma
- Confusion
- Gait uncertainty
- Weakness in a part of the body
- Sweats
- Pallor (pale skin)
- Epileptic seizures or convulsions
- Altered behaviors, including irritability
- Bleeding or clear fluid leakage from the nose and ears
- One pupil (dark center in the eye) appears larger than in the other eye
- Deep cut or tear in the scalp
- Open head wound
- Foreign bodies that have entered the head
- Coma is a state of unconsciousness from which a person cannot be awakened; it responds minimally or not at all to stimuli and is not capable of any voluntary activity.
- Vegetative status is the state of brain damage in which a person has lost his ability to think and perceive his environment. Only some basic functions such as breathing and blood circulation are preserved.
- Locked-in syndrome, or the syndrome of imprisonment, is a neurological condition in which a person is conscious. He can think and rationalize, but is unable to speak and move.
The symptoms of craniocerebral trauma may be similar to other disorders or pathologies. It is always necessary to consult the doctor for a diagnosis.
Diagnosis of craniocerebral trauma
The first steps in admitting a patient with traumatic brain injury are physical examination and analysis of the exact course of events.
The patient’s medical history and the medications they take are important pieces of information to decide next steps.
X-rays of the skull are rarely used to determine cranial injuries.
Assessing brain function is more important than examining the bones surrounding the brain.
Computed tomography (CT) of the head allows the examination and detection of possible bleeding and edema formation in certain areas of the brain.
It can also be used to assess bony injuries to the skull and detect bleeding in the sinuses of the face associated with a skull fracture.
CT does not assess brain function.
Patients with axonal damage may be comatose.
There are several guidelines for deciding whether a CT scan should be performed on the awake patient after minor craniocerebral trauma.
Another exam that is often performed during traumatic brain injury is magnetic resonance imaging (MRI), which shows the bones and also all the soft tissue inside the head.
Treatment of craniocerebral trauma
The special therapy of craniocerebral trauma is determined by the attending physician on the following basis:
- Age, general health and medical history
- Extent of head damage
- Type of craniocerebral trauma
- Tolerance to certain drugs, procedures or therapies
- Expectation for the course of craniocerebral trauma
- Patient view or patient preference
Depending on the severity of the damage, therapy can consist of the following measures:
- Ice
- Be quiet
- Local antibiotic ointment and patch dressing
- Observation
- Surgical suture
- Hospitalization for observation
- Moderate sedation or machine-assisted ventilation, mechanical ventilation or breathing mask
Treatment of skull fractures
Most skull fractures recover on their own, especially if they are simple and linear fractures.
The healing process can take many months, although the pain usually passes within 5-10 days.
If it is an open fracture, the doctor prescribes antibiotics (drugs used to fight bacterial infections) to prevent infection.
If the fracture is serious or an impression fracture, surgery may be needed to prevent brain damage.
Operations are usually performed under general anesthesia.
During the operation, pieces of bone that have shifted inside are removed and returned
to their original position. If necessary, a metal wire or mesh can be used to hold the skull fragments in place.
Once the bone is in its position, it can heal spontaneously.
If desired, the surgeon will explain in detail how he will proceed.
Increase and surgical pressure relief
Surgical pressure relief is required with an epidural or subdural hematoma, which spreads rapidly and increases intracranial and local pressure.
Surgical pressure relief should be considered in patients with craniocerebral trauma and refractory intracerebral pressure with potentially recoverable brain functions.
Skull opening, surgical drainage of an epidural hematoma and restoration of blood vessels must be done immediately if: there are signs of an increase in intracerebral pressure, mental changes, neurological signs, pupil changes or displacement of the midline.
Conservative therapy with close monitoring in the pediatric intensive care unit is indicated when the hematoma is less than 2 cm and there are no focal neurological signs, mental changes or intracranial pressure signs with displacement of the midline.
A subdural hematoma with midline displacement or disturbances of consciousness must be aspirated immediately.
A small subdural hematoma without pressure effects can be treated conservatively under strict supervision.
Surgical drainage of the subdural hematoma is not required in most cases.
Most patients with penetrating lesions require surgical “clearance” and removal of the hematoma. In addition, they need antibiotics for prevention and anticonvulsants.
Impression fractures of the skull require surgery if the depth of the impression is greater than 1 cm and the bone fragments press against the brain tissue.
Long-term observations in people with traumatic brain injury
The key is to create a safe environment for children and adults to prevent cranial trauma.
The use of seat belts when driving and the use of a helmet (with a correct fit) during activities such as horseback riding, cycling, motorcycling, skiing, skating and skateboarding can protect the head from any serious damage.
People who have suffered severe brain damage may lose function in certain muscle groups. Also, the abilities of speech, vision, hearing or taste may be limited depending on the area of damage in the brain.
Changes in personality or behavior can also occur over a short or long period of time.
These people need medical care and rehabilitation (physiotherapy, occupational therapy and speech therapy) over a longer period of time.
The quality of recovery depends on the type of brain damage and other medical problems that may be present.
First of all, one must focus on restoring a person’s abilities for a life at home and in the community as much as possible.
The patient’s recovery is favored when self-esteem is strengthened and independence is promoted.
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