Νευροχειρουργός Νίκος Μαραθεύτης


  Επικοινωνία : 210 5021743

All Posts in Category: Traumatic brain injury (TBI)

Frequently asked questions

 

What is a traumatic brain injury?

A traumatic brain injury is an injury to the skull and brain. It can be closed, which means that the brain is not exposed or in danger of being exposed to the external environment, or open, when the brain is exposed to the external environment. In closed injury a skull fracture may also be present, while in open one there is always a fracture. Hematoma may also be present in traumatic brain injury. A hematoma is called epidural hematoma when it is outside the dura mater of the brain. A hematoma between the dura mater and the brain is called subdural, while when the hematoma is inside the brain it is called intracerebral.
The human brain is very sensitive and well protected from injury. It is closely surrounded by membranes (the meninges), inside the hard skull which is also covered by a muscular casing

The cells that make up the brain are fragile and can be easily injured if they are stretched or torn. This happens when a blow to the head causes the brain to collide with the hard and uneven inner surface of the bones, inside the skull.

The swelling that occurs after each injury exerts even more pressure on the cells and reduces blood flow. Adequate flow and oxygenation are vital for the brain cells. Any deprivation of blood or oxygen can cause an even greater harm.

What symptoms may be caused?

Usually, closed head injuries occur when the head comes into violent contact with another object in a way that causes the brain to move abruptly inside the skull. When the fragile brain tissue receives this violent push, it is subject to focal (i.e. localised at some point) and diffuse brain injury

There are various degrees of head injuries, from mild to severe. A mild head injury usually results in reversible brain damage and thus temporarily affects the patient’s neurological functions, whereas a severe injury almost always causes neurological damage. The location and severity of the injury determines the nature and degree of permanence of the neurological problems.

How is traumatic brain injury diagnosed?

The presence of a head injury is established by the history of a blow to the head and/or the presence of physical signs of head trauma, such as fractures, abrasions, or bruises of the skull or face. Blood or cerebrospinal fluid (CSF) flowing from the nose or ear may indicate a trauma to the skull. Both the Battle sign (bruise behind the ear) and the bruises of the eyelids are indicative of fractures of the base of the skull and definitely signs of a brain injury.

In addition, there may be neurological problems, these may be general, such as coma, lethargy or drowsiness, or seizures, and/or focal, (localised), such as paralysis of an arm and/or leg, or speech disorders. Diagnostic tests such as CT scans are used in an attempt to identify possible organic damage caused by the trauma. This can be blood clots (haematoma), skull fracture etc.

If detected, these abnormalities may mean that special surgical treatment is required. However, surgery can only reduce the pressure on the brain, but it cannot improve cerebral edema or brain cell damage.

How can a traumatic brain injury be treated?

The treatment of a head injury depends on its severity. In more severe cases, surgery may be required to reduce the increased intracranial pressure by removing the hematomas.

Medical measures to reduce intracranial pressure include: hyperventilation (increasing breathing), various medications, reducing body temperature and inducing a comatose state using sedative drugs (sedation). The doctor may also place an intracranial recording device in or on the brain to measure intracranial pressure and/or cerebral blood flow so that the effects of various treatments can be recorded and the desired corrections can be made.

Intracranial pressure can be successfully controlled with medication alone, and may not ultimately be so severe as to require surgery. In combination with the other means of controlling the increased intracranial pressure, the patient should be properly oxygenated and have his/her blood pressure controlled. They may need to be put on a ventilator to get oxygen, to control the rate of breathing and the pressure inside the lungs.

Seizures can occur in any case of brain injury. If they occur, then appropriate medication is applied.

What is Primary Injury?

When the head receives a strong blow, the meninges and skull act as a protective barrier to the swelling that follows. Cerebral oedema can cause an increase in pressure in the skull, resulting in an increase in intracranial pressure, so nerve cells are damaged even more. Another cause of increased intracranial pressure and cell damage associated with brain damage is hematomas.

There is space inside the skull, just enough for the brain, cerebrospinal fluid and blood. Any increase in mass or volume damages the neurons and reduces the blood supply to the brain.

What is Secondary Injury?

If the edema is severe, it may not be possible to reduce the pressure inside the skull. This puts even more strain on the already injured brain cells, and can put pressure on the brain stem, controlling all vital functions. This is called “herniation” and is a life-threatening complication.

Not only does the increased intracranial pressure associated with edema and hematoma cause herniation, but they can also cause a reduction in the blood flow to the brain and, consequently, ischemia. This means that traumatic brain injury could also be complicated by reduced blood flow (ischemia). In this case, the neurons do not receive sufficient amounts of nutrients, such as oxygen and glucose. Ischemia then may cause an even greater damage to the neurons and leads to even greater cerebral edema and further reduction of the cerebral blood flow.

What are Level of Consciousness Changes?

Brain injuries, whether mild, moderate or severe, also cause an alteration in the person’s ability to react and respond to the external environment. This is called a “change in the patient’s level of consciousness”. The level of consciousness varies from full alertness, through the ability to respond appropriately when the patient is awakened from sleepiness and lethargy, then to diminished reactions and up to coma. Coma represents the complete loss of consciousness and the inability to respond to stimuli in the environment in any way other than reflexively. Both the degree and duration of the coma reflect the severity of the brain injury. The longer the patient stays in a coma, the less chance of a good outcome.

Only after sufficient alertness has been achieved can the characters and qualities of the patient’s reactions be seen and appreciated. The content of the patient’s reactions is the most important element to assess when determining any change in personality, behaviour and quality of life. Changes due to brain injury can range from mild or barely noticeable to very significant. Given the complexity of the brain, it is very difficult to predict the extent of these changes. There are no tests or X-rays that show these changes. This uncertainty of outcome is the most difficult part that patient families face.

Read More

Intracerebral hematoma (contusion)

thlaseis1

Post-traumatic intracerebral hematoma occurs following TBI. It may not be accompanied by a skull fracture. Its diagnosis is made by CT. Clinically, the patient presents with neurological symptoms such as disturbances of the level of consciousness, peritraumatic amnesia, disorientation, agitation, drowsiness, weakness of one side of the body, and other symptoms. If the contusion is limited and the neurological image is good, no surgery is required, only hospitalization for a few days and a repeat CT scan. However, if the symptoms are severe or worsen, surgical removal of the hematoma is required to decompress the brain. Permanent removal of part of the skull bone may be required to create enough space in the brain and to treat cerebral edema (swelling of the brain). Sometimes fractures are fatal despite surgery, or they may leave the patient with severe permanent disability.

Read More

Skull fractures

kranio1

 

Skull fractures occur following a head injury and are diagnosed by a simple skull x-ray. Following that, a cerebral CT scan should always be performed, in order to rule out the coexistence of hematoma under the skull, which can put pressure on the brain and be life-threatening for the patient. If there is no hematoma, surgery is not required unless the fracture has displaced the bone inside the skull, exerting pressing on the brain (depressed cranial fructure). Therefore, the depressed cranial fracgture is restored with surgery, unless it is very small. If the head injury in the fracture area is open, then the fracture is called complicated and it requires surgical treatment to remove any foreign bodies to prevent infection. The patient is hospitalized for a few days in order for the patient’s neurological image to be monitored. In simple fractures, 1-2 days of hospitalization are enough for simple follow-up.

Read More

Epidural hematoma

episkliridio

 

This is a hematoma that forms under the bones of the skull, including the meninges of the brain. These hematomas usually occur following a fracture of the skull bones and are usually due to bleeding of the arteries running between the meninges and the bone, in the fracture area. The diagnosis is made by cerebral CT. It is more common in young people. If not diagnosed and operated on immediately, this can be fatal. The symptoms include severe headache, vomiting, drowsiness, loss of consciousness, neurological deficit (weakness of one side of the body), and after their onset, symptoms usually progress rapidly. If diagnosed early, symptoms are relieved via a simple craniotomy, which has a very good prognosis.

Read More

Acute subdural hematoma

kakoseis1

 

Unlike the chronic subdural hematoma, acute subdural hematoma is a very severe condition with approx. 50% mortality. It is commonly seen in severe traumatic brain injuries and may coexist with other lesions, such as epidural hematoma and intracerebral hemorrhage. Clinically the patient’s neurological picture is poor, and if the hematoma is not removed, the patient rapidly progresses. In some cases, if the hematoma is small, does not cause displacement of the brain and the neurological image is good, the patient can be monitored in the hospital, having a clinical evaluation of his neurological clinical image and a repeat CT in a few days to see if the hematoma is absorbed. In such cases, it may develop into chronic hematoma.
Surgery, when required, removes the hematoma and usually one or more injured veins are identified in the area between the meninges and the brain. After surgery, the patient may be required to remain in the intensive care unit to treat and prevent possible cerebral edema and ischemia. Older people have a worse prognosis, and use of anticoagulants before the injury has a negative effect on the prognosis. Many of the surviving patients present with severe disabilities, and their recovery process is long and painstaking.

 

Read More

Chronic subdural hematoma

 

 

Chronic subdural hematoma is a collection of bloody fluid between the meninges and the brain. It may occur following a head injury and can even occur 1-2 months after the blow. It is most commonly seen in the elderly, and chronic anticoagulant therapy (incl. aspirin) appears to increase its incidence. Clinically, the patient presents with headache, gradual onset of gait instability, confusion, agitation, or weakness on one side of the body. There may also be drowsiness and lethargy. The patient’s history usually includes a blow to the head, which may not have been particularly severe. The diagnosis is made by CT. If it causes symptoms, it must be surgically removed. Usually 2 cranial trepanations are made (small holes in the skull measuring one centimeter in diameter) and the fluid is removed, decompressing the brain. The operation can be performed even with local anesthesia, in selected patients. Repeated removal of the fluid may be required, as recurrence is not uncommon. Sometimes the hematoma is small and does not require surgical removal; CT follow-up is required. Administration of medication (cortisone) may be required. This is a benign condition that usually has a good outcome.

Read More