Craniocereberal trauma — injury of bones of a skull and/or soft fabrics (brain covers, brain tissues, nerves, vessels). On the nature of a trauma distinguish the closed and opened, getting and not getting ChMT, and also concussion or a bruise of a brain. The clinical picture of a craniocereberal trauma depends on its character and weight. The main symptoms are the headache, dizziness, nausea and vomiting, consciousness loss, memory violation. The bruise of a brain and an intracerebral hematoma are followed by focal symptoms. Diagnosis of a craniocereberal trauma includes anamnestichesky data, neurologic survey, a X-ray analysis of a skull, brain KT or MPT.
Craniocereberal trauma — injury of bones of a skull and/or soft fabrics (brain covers, brain tissues, nerves, vessels). Classification of ChMT is based on her biomechanic, a look, type, character, a form, weight of damages, a clinical phase, the treatment period, and also a trauma outcome.
On biomechanics distinguish the following types of ChMT:
- shock and shock-proof (the shock wave extends from the place of the received blow and passes through a brain to the opposite side with bystry pressure differences);
- accelerations delays (movement and rotation of big hemispheres in relation to more fixed brain trunk);
- combined (simultaneous influence of both mechanisms).
By the form damages:
- focal (are characterized by local macrostructural damages of brain substance except for sites of destructions, small - and krupnoochagovy hemorrhages in the field of blow, antiblow and a shock wave);
- diffusion (a tension and distribution by primary and secondary ruptures of axons in the seven-oval center, a calloused body, subcrustal educations, a brain trunk);
- combined (combination of focal and diffusion injuries of a brain).
On defeat genesis:
- primary defeats: focal bruises and razmozzheniye of a brain, diffusion aksonalny damages, primary intra cranial hematomas, ruptures of a trunk, multiple intracerebral gemorragiya;
- secondary defeats:
- owing to secondary intra cranial factors (the delayed hematomas, violations likvoro-and haemo circulation owing to intra ventricular or subarakhnoidalny hemorrhage, hypostasis of a brain, hyperaemia, etc.);
- owing to secondary extra cranial factors (arterial hypertension, giperkapniya, gipoksemiya, anemia, etc.)
Are classified by the ChMT type on: closed — the damages which did not break integrity of integuments of the head; fractures of bones of the arch of a skull without damage of adjacent soft fabrics or a skull basis change with developed likvorey and bleeding (from an ear or a nose); the open not getting ChMT — without damage of a firm brain cover and the open getting ChMT — with damage of a firm brain cover. Besides allocate isolated (lack of any extra cranial damages), combined (extra cranial damages to result of mechanical energy) and combined (simultaneous influence of various energiya: mechanical and thermal/beam/chemical) craniocereberal trauma.
On weight of ChMT divide into 3 degrees: easy, average weight and heavy. At correlation of this rubrication with a scale of a coma of Glasgow easy craniocereberal injuries estimate at 13-15, medium-weight – at 9-12, heavy – at 8 points and less. The slight craniocereberal injury corresponds to concussion and a bruise of a brain of easy degree, medium-weight — to a bruise of a brain of average degree, heavy — to a bruise of a brain of heavy degree, diffusion aksonalny injury and a sharp sdavleniye of a brain.
On the mechanism of emergence of ChMT happens primary (to impact on a brain of the injuring mechanical energy does not precede any cerebral or extra cerebral accident) and secondary (to impact of the injuring mechanical energy on a brain cerebral or extra cerebral accident precedes). ChMT at the same patient can occur for the first time or repeatedly (twice, three times).
Allocate the ChMT following clinical forms: concussion, bruise of a brain of easy degree, bruise of a brain of average degree, bruise of a brain of heavy degree, diffusion aksonalny damage, brain sdavleniye. The current of each of them is divided into 3 basic periods: sharp, intermediate and remote. Temporary extent of the periods of a course of a craniocereberal trauma varies depending on the ChMT clinical form: sharp – 2-10 weeks, intermediate – 2-6 months, remote at clinical recovery – up to 2 years.
The most widespread trauma among possible craniocereberal (to 80% of all ChMT).
Consciousness oppression (to sopor level) at concussion can continue from several seconds to several minutes, but can be absent at all. For the short period of time retrograde, kongradny and antegradny amnesia develops. Directly after a craniocereberal trauma there is single vomiting, breath becomes frequent, but soon returns to normal. Returns to normal also arterial pressure unless the anamnesis is burdened by hypertensia. Body temperature at concussion remains normal. When the victim recovers consciousness, there are complaints to dizziness, headache, the general weakness, emergence of cold sweat, rushes of blood to the person, noise in ears. The neurologic status at this stage is characterized by soft asymmetry of skin and tendinous reflexes, a small horizontal nistagm in extreme assignments of eyes, easy meningialny symptoms which disappear within the first week. At brain concussion as a result of a craniocereberal trauma in 1,5 – 2 weeks improvement of the general condition of the patient is noted. Preservation of some asthenic phenomena is possible.
Recognition of concussion of a brain — a difficult task for the neurologist or the traumatologist as the main criteria of his diagnosing are components of subjective symptomatology in the absence of any objective data. It is necessary to get acquainted with circumstances of a trauma, using for this purpose information which is available for witnesses of an event. Inspection at an otonevrolog by whom define existence of symptoms of irritation of the vestibular analyzer for lack of loss signs is of great importance. Because of soft semiotics of concussion of a brain and possibility of a similar picture as a result of one of many dotravmatichesky pathologies, special significance in diagnostics is attached to dynamics of clinical symptoms. "Concussion" is justification of the diagnosis disappearance of such symptoms in 3-6 days after receiving a craniocereberal trauma. At concussion there are no fractures of bones of a skull. The structure of a likvor and its pressure remain normal. Intra cranial spaces are not defined on KT of a brain.
If the victim with a craniocereberal trauma recovered, first of all he needs to give comfortable horizontal position, the head has to be slightly raised. The victim with a craniocereberal trauma who is in unconsciousness needs to give so-called "saving" situation — to lay it on the right side, the person has to be turned to the earth, to bend the left hand and a leg at right angle in elbow and knee joints (if spinal fractures and extremities are excluded). Such situation promotes free passing of air to lungs, preventing a language zapadeniye, hit of emetic masses, saliva and blood in airways. On the bleeding head wounds if those are available to apply an aseptic bandage.
All victims with a craniocereberal trauma without fail are transported in a hospital where after confirmation of the diagnosis set them bed the mode for the term which depends on clinical features of a course of a disease. Lack of signs of focal damages of a brain on brain KT and MPT, and also the condition of the patient allowing to refrain from active drug treatment allow to resolve an issue in favor of the patient's extract on out-patient treatment.
At concussion of a brain do not apply chrezmernoaktivny drug treatment. Its main objectives — normalization functional a condition of a brain, knocking over of a headache, normalization of a dream. For this purpose use analgetics, sedatives (as a rule, the tableted forms).
The bruise of a brain of easy degree is revealed at 10-15% of victims with a craniocereberal trauma. The bruise of moderate severity is diagnosed for 8-10% of victims, a heavy bruise - for 5-7% of victims.
Loss of consciousness after a trauma to several tens minutes is characteristic of a bruise of a brain of easy degree. After restoration of consciousness complaints to a headache, dizziness, nausea appear. Note retrograde, kongradny, anterograd amnesia. Vomiting, sometimes with repetitions is possible. The vital functions, as a rule, remain. Moderate tachycardia or bradycardia, sometimes increase in arterial pressure is observed. Body temperature and breath without essential deviations. Softly expressed neurologic symptoms regress in 2-3 weeks.
Loss of consciousness at a bruise of a brain of average degree can last of 10-30 minutes till 5-7 o'clock. Retrograde, kongradny and anterograd amnesia is strongly expressed. Repeated vomiting and a severe headache is possible. Some vital functions are broken. Bradycardia or tachycardia, increase HELL, without breath violation, temperature increase of a body to subfebrilny is defined. Manifestation of obolochechny signs, and also stem symptoms is possible: bilateral pyramidal signs, , dissociation of meningealny symptoms on a body axis. The expressed focal signs: glazodvigatelny and pupillary violations, paresis of extremities, speech disturbance and sensitivity. They regress in 4-5 weeks.
The bruise of a brain of heavy degree is followed by loss of consciousness from several hours to 1-2 weeks. Quite often it is combined with fractures of bones of the basis and arch of a skull, plentiful subarakhnoidalny hemorrhage. Disorders of the vital functions are noted: the violation of a respiratory rhythm which is sharply increased (sometimes lowered) pressure, takhi-or a bradiaritmiya. Blocking of passability of airways, an intensive hyperthermia is possible. Focal symptoms of defeat of hemispheres often mask behind the stem symptomatology coming to the forefront (, look paresis, a dysphagy, , , a detserebratsionny rigidnost, change of tendinous reflexes, emergence of pathological-foot reflexes). Symptoms of oral automatism, paresis, focal or generalized epipristupa can be defined. Restoration of the lost functions goes hard. In most cases gross residual motive violations and frustration of the mental sphere remain.
Choice method at diagnosis of a bruise of a brain is brain KT. On KT define a limited zone of the lowered density, fractures of bones of the arch of a skull, subarakhnoidalny hemorrhage are possible. At a bruise of a brain of moderate severity on KT or spiral KT in most cases reveal focal changes (not compactly located zones of the lowered density with small sites of the increased density).
At a bruise of heavy degree zones of non-uniform increase in density (alternation of sites of the increased and lowered density) are defined on KT. Perifokalny hypostasis of a brain is strongly expressed. The gipodensivny path to the area of the nearest department of a side ventricle is formed. Through it there is a dumping of liquid to products of disintegration of blood and brain fabric.
Diffusion aksonalny injury of a brain
For diffusion aksonalny injury of a brain typically long coma after a craniocereberal trauma, and also pronounced stem symptoms. The coma is accompanied by a symmetric or asymmetric detserebration or a decortication both the spontaneous, and easily provoked irritations (for example, painful). Changes of a muscular tone are very variable (a gormetoniya or diffusion hypotonia). Display of pyramidal and extrapyramidal paresis of extremities, including asymmetric tetraparesis is typical. Except gross violations of a rhythm and frequency of breath also vegetative frustration are shown: temperature increase of a body and arterial pressure, , etc. Characteristic of a clinical course of diffusion aksonalny injury of a brain is transformation of a condition of the patient from a long coma in a tranzitorny vegetative state. Approach of such state is demonstrated by spontaneous opening of eyes (at the same time there are no signs of tracking and fixing of a look).
The KT-picture of diffusion aksonalny damage of a brain is characterized by increase in volume of a brain as a result of which under a sdavleniye there are side and III ventricles, subarakhnoidalny konveksitalny spaces, and also brain basis tanks. Quite often reveal existence of melkoochagovy gemorragiya in white substance of hemispheres of a brain, a calloused body, subcrustal and stem structures.
Sdavleniye of a brain
Sdavleniye of a brain develops more than in 55% of cases of a craniocereberal trauma. Most often the intra cranial hematoma (intracerebral, Epi - or subduralny) becomes the reason of a sdavleniye of a brain. Hazard to life of the victim is posed by promptly accruing focal, stem and all-brain symptoms. Existence and duration of a so-called "light interval" — developed or erased — depends on severity of a condition of the victim.
On KT define biconvex, is more rare plano-convex limited a zone of the increased density which adjoins the arch of a skull and is localized within one or two shares. However, if bleeding sources a little, the zone of the increased density can be the considerable size and have crescent the form.
Treatment of a craniocereberal trauma
At receipt in intensive care unit of the patient with a craniocereberal trauma it is necessary to hold the following events:
- Survey of a body of the victim during which find or grazes, bruises, deformations of joints, changes of a shape of a stomach and a thorax, krovo-exclude and/or a likvorotecheniye from ears and a nose, bleeding from a rectum and/or an urethra, a specific smell from a mouth.
- Comprehensive x-ray investigation: a skull in 2kh projections, cervical, chest and lumbar department of a backbone, a thorax, bones of a basin, the top and lower extremities.
- Ultrasonography of a thorax, ultrasonography of an abdominal cavity and zabryushinny space.
- Laboratory researches: general clinical blood test and urine, biochemical blood test (creatinine, urea, bilirubin etc.), blood sugar, electrolytes. These laboratory researches need to be conducted and further, daily.
- ECG (three standard and six chest assignments).
- Research of urine and blood on the content of alcohol. In case of need hold consultation of the toxicologist.
- Consultations of the neurosurgeon, surgeon, traumatologist.
Obligatory method of inspection of victims with a craniocereberal trauma is the computer tomography. As relative contraindications to its carrying out hemorrhagic or traumatic shock, and also unstable haemo dynamics can serve. Define the pathological center and its arrangement, quantity and volume by KT hyper - and gipodensivny zones, situation and degree of shift of median structures of a brain, a state and a damage rate of a brain and skull. At suspicion of meningitis carrying out a lyumbalny puncture and a dynamic research of a likvor which allows to control changes of inflammatory character its structure is shown.
Neurologic survey of the patient with a craniocereberal trauma it is necessary to spend each 4 hours. For definition of extent of violation of consciousness use a scale of a coma of Glasgow (a condition of the speech, reaction to pain and ability to open/close eyes). Besides, determine the level of focal, glazodvigatelny, pupillary and bulbarny frustration.
Injured with violation of consciousness of 8 points and less on a scale of Glasgow the intubation of a trachea thanks to which normal oxygenation is supported is shown. Oppression of consciousness to the level of a sopor or a coma — the indication to carrying out auxiliary or controlled IVL (not less than 50% of oxygen). With its help optimum cerebral oxygenation is supported. Patients with a severe craniocereberal injury (the hematomas revealed on KT, brain hypostasis etc.) need monitoring of intra cranial pressure which needs to be supported at the level of lower than 20 mm hg. For this purpose appoint , a hyperventilation, sometimes — barbiturates. Apply escalation or deeskalatsionny antibacterial therapy to prevention of septic complications. For treatment of post-traumatic meningitis use the modern antimicrobic medicines allowed for endolyumbalny introduction ().
Food of patients is begun not later than 3 three days after ChMT. Its volume is increased gradually and at the end of the first week which passed from the date of receiving a craniocereberal trauma, it has to provide to 100% caloric need of the patient. The way of food can be enteralny or parenteral. For knocking over of epileptic attacks appoint anticonvulsive medicines with the minimum titration of a dose (to levetiratseta, valproata).
As the indication to operation serves the epiduralny hematoma over 30 cm ³. It is proved that the method providing the fullest evacuation of a hematoma — transkranialny removal. The sharp subduralny hematoma over 10 mm thick is also subject to surgical treatment. To patients in a coma delete a sharp subduralny hematoma by means of a kraniotomiya, keeping or deleting a bone rag. The Epiduralny hematoma more than 25 cm ³ is also subject to obligatory surgical treatment.
The forecast at a craniocereberal trauma
Brain concussion — mainly reversible clinical form of a craniocereberal trauma. Therefore more than in 90% of cases of concussion of a brain recovery of the victim with a complete recovery of working capacity becomes an outcome of a disease. At a part of patients after the sharp period of concussion of a brain note these or those manifestations of a postkommotsionny syndrome: violations of cognitive functions, moods, physical wellbeing and behavior. In 5-12 months after a craniocereberal trauma these symptoms disappear or significantly smooth out.
Predictive assessment at a severe craniocereberal injury is carried out by means of a scale of outcomes of Glasgow. Reduction of a total number of points on a scale of Glasgow increases probability of a failure of a disease. Analyzing the predictive importance of an age factor, it is possible to draw a conclusion on its significant effect both on an invalidization, and on a lethality. The combination of a hypoxia and arterial hypertension is an adverse factor of the forecast.