Neurological Disorders: Head Injuries

There is a major rise in the incidence of head injuries all over the world and this is attributed to the usage of automobiles in the modern era; and now they are one of the commonest causes for major disabilities & death. A Neurologist is commonly involved in the care of these patients along with other specialists like surgeons.

The following are the commonly encountered types:

• Closed type
• Open type
• Cerebral or brain or head concussion
• DAI (Diffuse axonal injury)
• Brain contusion
• Epidural bleed
• Subdural bleed
• Subarachnoid hemorrhage
• Bleeding in to the brain tissue
• Skull fractures
• Cranial nerve injuries
• Associated with spine or other body injuries

Closed type:

In this type the skull bone and the outer most layer of brain-covering called dura matter (outer brain coverings) are intact.

Open (penetrating) type:

There is actually a skull bone fracture and/or tear in the dura matter.

Cerebral or Brain or Head concussion:

This is the mildest form of brain injury where patient loses consciousness for brief periods, or becomes temporarily disoriented after the incident.

DAI (Diffuse axonal injury):

It is a type of brain tissue injury which results secondary to acceleration-deceleration movements of the head rather than any blunt traumas. During such movements sudden stretching of the nerve fibers called as axons takes place disrupting the brain activities. A diffuse brain swelling and minor streaks of bleeding may be seen in the brain.

Brain contusion:

This happens when there is a gross injury to the brain tissue which can be easily detected on imaging studies of the brain like CT (CAT scan) and seen as a local area of damage to brain tissue with some bleeding, swelling etc.

Epidural bleed:

This is the collection of blood in the space between the skull bone and the dura matter. This can be rapidly fatal if not surgically intervened.

Subdural bleed:

This is the collection of blood between the dura matter and arachnoid membrane (another brain-covering). An acute & rapidly evolving subdural hematoma can be nearly as dangerous as epidural bleed.

Subarachnoid bleed:

This is the entering of blood into the space between arachnoid membrane and pia matter (the inner most covering or brain) and this space contains CSF.

Bleeding in to the brain tissue:

This is usually seen with contusion of the brain.

Skull fracture:

This can occur anywhere, and if occurs in the basal region it may result in cerebrospinal fluid (CSF) leakage from the nose or ear (CSF otorrhea or rhinorrhea).

Cranial nerve injuries:

Totally there are twelve pairs of cranial nerves and injury to them will produce varieties of motor, sensory or special sense manifestations e.g. double vision, loss of smell sensation etc.

External head & body manifestations include;

• Bruises
• Scalp contusion
• Skull fractures
• Bleeding
• Ear, Eye, nose injuries
• Battle sign (ecchymosis over the mastoid bone)
• Leakage of CSF from ear and/or nose
• Concomitant spine & other body injuries
• Severe hypotension (low blood pressure) due to blood loss
• Shock etc.

Neurological manifestation includes;

• LOC (Loss of consciousness)
• Disorientation
• Seizures (fits)
• Limb paralysis
• Numbness, tingling, loss of sensation
• Cranial nerve manifestations like double vision, loss of vision, smell etc
• Bowel and/or bladder disturbances
• Paralysis of breathing muscles etc.

The following investigations are generally performed ith head injury patients;

• Heat CT scan (at the earliest)
• Brain MRI scan (if necessary)
• Spine films (x-ray, CT or MRI) if necessary
• Blood tests like CBC (complete blood count) & electrolytes
• Additional tests if necessary

Head Injuries are emergencies so quick transfer of these patients to the nearest medical facility is of paramount significance in saving their life. The neck of all these patients must be splinted until a fracture of spine is ruled out.

If subdural or epidural hematoma is noted then emergency neurosurgery consultation and evacuation of the hematoma may be necessary and can be lifesaving for many patients.

The supportive & symptomatic management will commence from the beginning and will continue as long as necessary. This may include intravenous fluids, blood transfusion, pain killers etc.

Steroids and opioids (morphine like drugs) are to be avoided for head injury patients as much as possible.

Wearing helmets, cautious driving etc are some of the doable measures that can reduce accidents & traumatic injuries considerably.