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Head trauma is a broad designation that describes a vast array of injuries to the scalp, skull, brain, underlying tissue, and blood vessels in the head. Treatment depends on the severity of the trauma and ranges from a non-invasive approach−such as rest or medication−to open surgery.
Although most instances of head trauma are mild and individuals who sustain such injuries have full recoveries, other injuries to the head are common causes of disability and death in both adults and children. There are several different types of head injuries:
- Scalp laceration: A scalp laceration is a breaking or tearing open of the skin on the head. Despite being fairly minor, a scalp laceration can yield a surprising amount of blood because the scalp is heavily populated with blood vessels.
- Skull fracture: A skull fracture is a break in the skull bone, and there are four major types:
- Linear skull fracture: This is the most common type of skull fracture. In a linear fracture, there is a break in the bone, but the fracture does not move the bone. These patients may be observed in the hospital for a brief time and they can usually resume normal activities in a few days. Often, no interventions are necessary.
- Depressed skull fracture: This type of fracture may occur with or without a cut in the scalp. In this fracture, part of the skull is sunken in from the trauma. Depending on the severity, this type of skull fracture may require surgical intervention to help correct the deformity.
- Diastatic skull fracture: This type of fracture occurs along the suture lines in the skull. In this type of fracture, the normal suture lines are widened. These fractures are most often seen in newborns and older infants.
- Basilar skull fracture: This is the most serious type of skull fracture; it involves a break in the bone at the base of the skull. Patients with this type of fracture frequently have bruises around their eyes and behind their ears. They may also have clear fluid draining from their noses or ears due to a torn covering of the brain. These patients usually require close observation in the hospital.
- Concussion: A concussion is an injury to the brain that may cause instant loss of awareness or alertness. This change may last anywhere from a few minutes to a few hours.
- Cerebral contusion: A cerebral contusion is a bruising of the brain.
- Diffuse axonal injury: Diffuse axonal injury is the shearing of neurons and blood vessels as a result of rapid acceleration-deceleration of the body. This is a severe injury that is found when the head or body is violently shaken−often in a motor vehicle accident or as part of shaken baby syndrome. The patient is usually in a coma for a prolonged period of time, with injury to many different parts of the brain.
- Intracerebral hemorrhage: An intracerebral hemorrhage is bleeding within the brain as a result of injury; it can lead to masses of clotted blood called intracranial hematomas.
- Intracranial hematoma: There are several types of intracranial hematomas, or blood clots, in or around the brain. Physicians classify hematomas by location. These can range from mild head injuries to quite serious and potentially life-threatening injuries:
- Epidural hematoma: Epidural hematomas occur when blood clots form underneath the skull, but on top of the dura mater. They usually come from tears in the artery that runs just under the skull, called the middle meningeal artery. Epidural hematomas are usually associated with skull fracture.
- Subdural hematoma: Subdural hematomas occur when blood clots form underneath the skull and underneath the dura mater, but outside of the brain. These can form from tears in the veins that go from the brain to the dura mater, or from cuts on the brain itself. They are sometimes, but not always, associated with skull fracture.
- Intracerebral hematoma: lntracerebral hematomas occur when blood clots form in brain tissue.
Individuals who suffer head trauma experience a range of symptoms that vary according to the severity of the injuries.
Symptoms of mild head injury:
- Raised, swollen area from a bump or a bruise
- Small, superficial cut in the scalp
Symptoms of moderate to severe head injury, which require immediate medical attention:
- Loss of consciousness
- Blurred vision
- Severe headache
- Amnesia, such as difficulty remembering the events that led right up to and through the traumatic event
- Slurred speech
- Difficult walking
- Weakness in one side or area of the body
- Pale skin
- Behavior changes, including irritability
- Blood or clear fluid draining from the ears or nose
- One pupil looks larger than the other
- Deep cut or laceration in the scalp
- Open wound in the head
The full extent of a head injury may not be completely understood immediately after the traumatic event, but may be revealed with a comprehensive medical evaluation and diagnostic testing. The diagnosis of a head injury is made with a physical examination and diagnostic tests. During the examination, the physician obtains a complete medical history of the patient and asks the patient or supportive family member how the injury occurred. Trauma to the head can cause neurological problems that require further medical follow-up.
A neurological examination is performed to identify any alterations in brain function and mental status. This exam consists of evaluating hearing, motor function, swallowing, eye movements, sense of smell, sensation, balance and coordination.
Also, an individual's level of consciousness is measured according to the Glasgow coma scale, which is a 15-item scoring system, and the score is used to determine whether a traumatic brain injury (TBI) was mild, moderate or severe. A lower score indicates a more severe injury.
Imaging tests remain the most important diagnostic method. For newborns and infants, ultrasonography can be used to image the brain and detect injury or bleeding. For adults and children, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan can also be used. Although MRI is the more sensitive method, CT is superior for emergency situations and allows constant monitoring of a patient's vitals during the test.
Blood may be drawn or urine collected and sent to a laboratory so that additional tests can be performed.
Head trauma is caused by a direct blow to or or violent shaking of the head. Most often, the injuries are from motor vehicle accidents, firearm assaults, sports, falls or acts of violence, including child abuse.
When head trauma occurs, the bruising of the brain and the damage to the internal tissue and blood vessels is due to a mechanism called coup-contrecoup. A bruise directly related to trauma, at the site of impact, is called a coup lesion. As the brain jolts backward, it can hit the skull on the opposite side and
sustain a bruise called a contre coup lesion. The jarring of the brain against the sides of the skull can cause shearing of the skull's internal lining, as well as its tissues and blood vessels. In tum, this damage may lead to bleeding, further bruising or swelling of the brain.
At Columbia, our neurosurgeons use the latest surgical advances and techniques to treat head trauma,
providing the best possible outcomes.
Depending on the severity of the injury, treatment may include:
- Topical antibiotic ointment and adhesive bandage
- Hospitalization for observation
- Immediate surgical attention
For most patients, surgical treatment is not needed because the injury is mild. Patients are asked to rest both physical1y and mentally until fully recovered.
However, for moderate and severe injuries, trauma surgery is usually needed to control brain swelling and repair injuries. Trauma surgery involves stitching up head wounds, debriding and repairing skull fractures and repairing brain injuries. To repair brain injuries, the neurosurgeon can use one of two surgical approaches:
- Craniotomy is a procedure in which a section of skull is temporarily removed, al1owing the neurosurgeon to take out clotted blood, clip a blood vessel or repair another injury.
- Craniectomy, performed if brain swelling is life-threatening, involves removing a section of skull to alleviate pressure. This approach also gives the neurosurgeon access to the brain to repair brain injuries.
The potential for swelling related to intracranial pressure (ICP) is continuously monitored. To monitor intracranial pressure, a device such as an intraventricular catheter, subdural screw or epidermal sensor must first be surgically implanted in the skull.
After implantation, the ICP device is attached to a monitor that gives a constant reading of the pressure inside the skull. If the pressure rises, it can be treated right away. While the ICP device is in place, the patient will be given medication to stay comfortable. When the swelling has gone down, and there is little chance of more swelling, the device will be removed.
Elevated ICP can be treated either with medication to reduce brain swelling or by means of shunt placement, which involves implanting a catheter in the skull to drain the excess fluid.
After any head trauma, avoiding a second head injury, no matter how minor, is essential to attaining the best recovery possible. The brain is vulnerable, so even a minor impact to the head can result in an injury worse than the first.
Actions you can take to prevent head injury include:
- Always wear a seatbelt while in a vehicle.
- Don't drive when you are under the influence of alcohol or drugs.
- Wear a helmet while on a bicycle, motorcycle or horseback. Also wear a helmet during contact sports, riding skates or a skateboard, or when batting while playing baseball or softball.
- Take precautions to avoid falls around your home.
- Keep firearms unloaded and locked away.