Cranial trauma is one of the main causes of death and disability when considering the damage suffered as a traumatic injury to the skull. 
The skull fracture can be closed or exposed (with penetration). 
Closed cranial trauma means that an object hits hard but does not break the skull. 
An open trauma to the skull means that an object struck the skull and penetrated the brain.

Generally, this occurs with a high-speed knocking, such as the collision against the windshield during a car accident. It can also occur with a head shot. 
You do not have to bump your head to have a concussion. 
An impact anywhere on the body can create enough force to damage the brain. 
It does not always occur to lose consciousness with a concussion. 
The concussion can be moderate or severe. 
The effects may be visible immediately or may develop up to hours or even days later. 
Trauma is one of the leading causes of death in 1-year-old children in the United States, head trauma accounts for 80% of injuries.
In about 5% of cases, patients die at the accident site. Trauma has a strong emotional impact, psycho-social and economic development because these patients often have a relatively long stay. 
The 5-10% need care for a long time.


What are the different types of trauma to the skull?

Concussion is a trauma that can cause immediate loss of consciousness or of the senses for a time, for a few minutes to an hour after the traumatic event. 
It’s the kind of trauma that deals less damage.


Skull fractures

The bones of the skull can break with a head trauma. 
If this occurs, an x-ray should usually be done to determine the extent of the damage. 
There are different types of skull fractures:

  • Simple (or closed) fracture where the skin is not cut and the surrounding tissue is not damaged.
  • Exposed fracture where the skin tears and the surrounding tissue can be damaged.
  • Linear fracture if the bone rupture looks like a straight line
  • Fracture of the skull cap, if part of the skull is crushed inside

Exposed fractures can be more serious because there is a high risk of infection if the skin is cut. 
This is because the bacteria can get into the wound through the cut skin. 
Sinking fractures can be very serious because some small pieces of bone can press inward against the brain.


Hematoma intracraniano

There are several types of intracranial hematoma or accumulations of blood inside or outside the brain. 
The different types are classified according to their location in the brain. 
Intracranial hematomas can range from small lesions to a very serious head injury and potentially fatal.

The different types of intracranial hematomas are as follows:

The epidural hematoma is an accumulation of blood formed between the skull and the dura, the outer brain membrane. 
This is usually caused by the injury of an artery running below the skull called the middle meningeal artery, rarely caused by rupture or tearing of the dura mater’s venous sinuses. 
Epidural hematomas are usually associated with a fractured skull caused by trauma. 
The hematoma may extend to the parietal and frontal region or descend below the temporal lobes. 
The symptoms depend on the extent of the injury and the amount of blood spilled, it may appear immediately, or even after a few days.
The treatment is emergency surgery where the surgeon enters through the skull, removes the bruise from the head and stops the hemorrhage of the artery (hemostasis).

The subdural hematoma is an accumulation of blood forming below the skull between two brain membranes: the dura and the arachnoid. 
The cause may be the injury of veins ranging from the brain to the dura or a cut in the brain. The subdural hematoma sometimes occurs due to a fractured skull.

Intracerebral Contusion or Hematoma
Brain contusion is a brain injury that causes bleeding and swelling around the area where the trauma occurred. 
Contusion may occur with a fractured skull and other problems such as a subdural or epidural hematoma. 
Bleeding into the brain (also called “diffuse hemorrhage”) may occur spontaneously. When the trauma did not cause intracerebral hematoma, the common causes are high blood pressure for long periods in older adult patients, bleeding disorders in children or adults, the use of drugs that cause blood thinning or the abuse of certain drugs .

Diffuse Axonal Injury
These injuries are very common and are usually caused by a rapid movement of the brain back and forth, which can occur in the whipping stroke , with a fall or in shaken baby syndrome. 
Diffuse lesions may be mild, such as a concussion or may be very severe, such as a diffuse axonal lesion. In diffuse axonal injury, the patient is usually in coma for a long period of time, with lesions in different parts of the brain.


Causes of Head Injury

Cranial trauma affects more than 1.7 million people in the United States each year, including nearly half a million children; the dead are 52,000. 
Adults suffer cranial injuries more frequently because of falls, motor vehicle crashes, crashes, strokes and fights. 
Falls are the most frequent cause of injury in children.


Symptoms of Head Injury

A person may have different symptoms depending on the severity of the head injuries. 
The following are the most common symptoms of a concussion, however, each individual may experience symptoms differently.

Chronic light trauma:

  • Puffy area with a lump
  • Small, shallow cut of the scalp
  • Headache
  • Hypersensitivity to noise and light
  • Irritability
  • Confusion
  • Dizziness or dizziness
  • Problems with balance
  • Nausea
  • Memory and / or concentration problems
  • Change in sleep pattern
  • Blurred vision
  • Eyes “Tired “
  • Ringing in the ears
  • Taste alteration
  • Feeling of fatigue

Moderate to severe trauma to the head injury (immediate medical attention need)
Symptoms may include any of the above listed beyond:

  • Loss of consciousness
  • Severe headache that does not go away
  • Recurrent nausea and vomiting 
  • Short-term memory loss, such as difficulty recalling events that led to the traumatic event
  • Confusion
  • Difficulty walking
  • Weakness in one area of ​​the body
  • Transpiracao
  • Paleness (pale)
  • Convulsions
  • Behavioral changes, including irritability
  • Loss of blood or clear fluid from the nose or ears
  • A pupil (dark area in the center of the eye) looks larger compared to another eye
  • Deep cut or laceration of the scalp
  • Open wound on the head
  • Foreign objects that penetrate the head
  • Coma is a state of unconsciousness in which a person can not be awakened; responds only minimally or does not respond to the stimuli, does not present any voluntary activity.
  • The vegetative state is a condition of brain damage in which a person has lost his thinking skills and perception of the external environment but maintains some basic functions like breathing and blood circulation.
  • Incarceration syndrome or Locked-In syndrome is a neurological condition in which a person is conscious, can think and reason, but is unable to speak or move.

Symptoms of a head trauma may resemble other disorders or illnesses. You should always consult your doctor for the diagnosis.


Diagnosis of head injury

NMR Cranial Trauma

The first steps in caring for a traumatic brain injury patient are the physical examination and analysis of the accident details. 
The patient’s medical history and medications are important information for deciding on the next steps. 
The x-ray  skull is rarely done to evaluate head injuries. 
It is more important to evaluate the function of the brain, rather than looking at the bones that surround the brain. 
Computed tomography of the head allows you to examine and find bleeding and swelling in certain areas of the brain. 
It can also evaluate bone lesions of the skull and look for bleeding in the facial sinuses associated with skull fractures. 
Computed tomography does not evaluate the functionality of the brain.
Patients with an axonal rupture may be in a coma. 
Several guidelines exist to decide whether computed tomography should be performed on patients who are awakened after a minor trauma to the skull.

Another examination done many times in case of head trauma is magnetic resonance imaging that shows the bones and all soft tissues inside the head.


Treatment of head injury

Specific treatment for a head injury is determined by your physician based on:

  • Age, general health and medical history
  • The extent of damage to the head
  • Type of trauma
  • Tolerance to specific drugs, procedures or therapies
  • Expectations for treatment outcomes
  • The opinions or preferences of the patient.

Depending on the severity of the injury, treatment may include:

  • Ice
  • Home
  • Antibiotic ointment and adhesive bandage
  • Note
  • Points
  • Hospitalization for observation
  • Moderate sedation or assisted breathing with a breathing machine, a mechanical ventilator, or a respirator.

Treatment of skull fractures

Most cranial fractures can heal on their own, especially if they are simple linear fractures. 
The healing process can last several months, although the pain usually goes away in about 5-10 days. 
If the fracture is opened, your doctor prescribes antibiotics (medicines to fight infections caused by bacteria) to prevent infection . 
If the fracture is severe or there is depression, surgery may be needed to help prevent damage to the brain. 
Usually the operation is performed under general anesthesia . 
During the operation, all bone pieces that have been pressed inward can be removed and put back into their correct position.
If necessary, the wire or nets can be used to reconnect the skull fragments. 
Once the bone is in place, it should heal spontaneously. 
If desired, the surgeon explains the procedure that is performed in more detail.

Elevation and surgical decompression

Surgical decompression is necessary in the presence of an epidural or subdural hematoma that expands rapidly and causes increased compression and intracranial pressure. 
Surgical decompression should be considered for patients with head trauma and refractory intracranial hypertension with a potentially recovering brain.

Craniotomy, surgical drainage of an epidural hematoma, and repair of blood vessels should be done immediately if there are signs of increased intracranial pressure, mental disorders, neurological signs, pupil changes, or a midline deviation.

Conservative treatment with monitoring monitored with intensive pediatric therapy is indicated if the hematoma is less than 2 cm, there are no focal neurological signs, mental disorders or pressure effects with midline deviation.

A subdural hematoma with medial deviation or altered mental status should be aspirated urgently. 
A small subdural hematoma with no pressure effects should be managed conservatively with monitoring. 
Surgical drainage of subdural hematoma is not necessary in most cases. 
Most patients with penetrating wounds need surgical “cleaning” and evacuation of the hematoma, they should also take antibiotics as prevention and anticonvulsants.


Skull fractures with depression need surgery if the depth of the depression is greater than 1 cm and if the bone fragments are causing compression against the brain tissue.


Long-term considerations for people with head trauma

The key is to promote a safe environment for children and adults to avoid cranial trauma. 
The use of safety belts when riding a car and a helmet (used properly) for activities such as horseback riding, cycling, motorcycling, skiing, skating and skateboarding can protect the head from any serious injury.
People who have suffered a severe brain injury may lose some parts of their muscles, the ability to speak, sight, hear or taste, depending on the area of ​​brain damage. 
We can also see changes in personality or behavior in the long and short term. 
These people require management of medicine and rehabilitation ( physical therapy , occupational therapists and speech therapists) in the long run.
The amount of recovery of the person depends on the type of brain injury and other medical problems that may exist. 
It is important to focus on maximizing a person’s ability at home and in the community. 
Patient recovery is encouraged if it tends to reinforce self-esteem and promote independence.

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