1. 1 Head Injury

2. 2 Prehistorycal types of trepanation 1-вишкрібання 2-проскрібування канавки 3-пробуравлення і вирізання 4-шляхом прямокутних розрізів

3. 3 Treatment of depressed skull fracture, XVI century

4. 4 Classification of Brain Injury, Petit, 1774 Cerebral concussion (commotio cerebri) Cerebral contusion (contusio cerebri) Cerebral compression (compresio cerebri)

5. 5 Causes of death in different age groups other cardiovascular diseases trauma neoplasms head injury

6. 6 Occurrence of head injury in male and female Male Female

7. 7 Causes of head injury in Russia CitiesPercentage allcauses Home accident car accident Industrial injury others Череповець10078,29,79,13 Новосибірськ10070,918,65,74,8 Саратов10069,216,112,32,4 С.Петербург10067,612,515,3- Н.Новогород10057,515,710,316,5 Іжевськ10052,315,25,427,5

8. 8 Causes of head injury in the USA Fall from e height Trafic accidents

9. 9 Structure of types of head injury in different age groups and sex Males Compression Contusion Concussion Females Compression Contusion Concussion

10. 10 Classification of Head Injury

11. 11 On pathology basis focal diffuse

12. 12 depending on infection risk Closed Open penetrating not penetrating

13. 13 Clinical forms of head injury Cerebral concussion Brain contusion Mild moderate severe Diffuse axonal injury Cerebral compression Head compression

14. 14 Pathogenesis of head injury Initial lesions contusion diffuse axon injury hemorrhages injury of cranial nerves Secondary lesions Intracranial cerebral compression with hematomas Vioaltion of CSF and blood circulation Brain edema Extracranial Anemia hypoxemia hypertermia

15. 15 Pathology of head injury concussionLesions on level of cellular organelle, axons, synapses mild contusion spot hemorrhages in cortex, local subarachnoidal hemorage moderate contusion Primary necrosis in cortex and white substance, diffuse hemorages in 1-2 gyruses Severe contusion Large necrosis and hemorages

16. 16 Clinical presentations of head injury Signs of injury on the scalp (wounds, contusion) Impaired consciousness Amnesia Focal neurological deficit Pupil asymmetry Cranial nerve deficit Paresis Reflex asymmetry and depression Aphasia Seizures

17. 17 Level of consciousness 1. Clear consciousness - full and adequate orientation and reactions. Possible amnesia. 2. Mild– slight sleepiness, some time and place disorientantion, some slowness in command obey, 3. – hypersomnia, disorientation, only elementary verbal contact is possible, obeys only simplest verbal instructions. 4. Stupor – verbal contact is impossible, reactions and eye opening on pain are preserved. 5. Mild coma – no eye opening, noncoordinated reactions on pain. Pupil and corneal reflexes are preserved. 6. Severe coma – no response on pain, best motor response is extension or flexion. Pupil and corneal reflexes are decreased. Spontaneous respiration and blood circulation are preserved with probable violations. 7. Terminal coma – no reflexes, muscle atonia, midriasis

18. 18 Glasgow Coma Scale Eye opening Spontaneously4 points Opens eyes to voice3 points Opens eyes to pain2 points No eye opening1 points Best verbal respons e Spontaneous, appropriate and oriented5 points Confused conversation, phrases only4 points One word speech, inappropriate words3 points Incomprehensible sounds only2 points No sounds1 points Best motor respons e Obeys commands6 points Localizes pain5 points Withdraws to pain4 points Abnormal flexor response (decoricated rigidity)3 points Abnormal extensor response (decerebrated rigidity)2 points No movements1 points

19. 19 Evaluation of consciousness after Glasgow coma scale Level of consciousnessPoints in GCS Clear15 Mild13-14 Severe11-12 Stupor8-10 Mild coma6-7 Severe coma4-5 Terminal coma3

20. 20 Severity of head injury mild (13-15 point in Glasgow coma scale) – cerebral concussion, slight cerebral contusion moderate (8-12 point) – mild cerebral contusion, subacute and chronic cerebral compression severe (3-7 point) – severe cerebral contusion, diffuse axon injury, acute cerebral compression

21. 21 mild cerebral contusion – punctated hemorages

22. 22 mild cerebral contusion

23. 23 mild cerebral contusion

24. 24 contusion

25. 25 Mild cerebral contusion

26. 26 Mild cerebral contusion (on MRI)

27. 27 Two contusion focuses 1- direct blow on the right 2-countercoup on the left

28. 28 Depressed skull fracture

29. 29 Linear fracture of occipital bones with going to the skull base

30. 30 fracture of parietal and frontal bones

31. 31 Depressed fracture of parietal bone

32. 32 Severe cerebral contusion

33. 33 Severe cerebral contusion

34. 34 Severe cerebral contusion

35. 35 Severe cerebral contusion

36. 36 Depressed fracture of parietal and temporal bones

37. 37 Diffuse axon injury – there are no macroscopic lesions

38. 38 Axonal spheres at diffuse axon injury.

39. 39 Поперечний зріз аксона, норма Після травми. відсутні мікротрубочки

40. 40 Typical location of diffuse axon injury (кружечки) і вогнищ геморагій (заштиховані ділянки)

41. 41 Diffuse axon injury on CT (no lesions)

42. 42 Head compression

43. 43 Cerebral compression Acute – manifestation during 24 hours after head injury Subacute – manifestation during 1 week after head injury Chronic - manifestation after 1-2 weeks after head injury

44. 44 Causes of cerebral compression Hematomas Epidural Subdural Intracerebral Bone fragment at depressed fructures Pneumocephalus

45. 45 Main triad at cerebral compression Deterioration of consciousness level Ipsilateral anisocoria contrlateral hemiparesis

46. 46 Epidural hematoma on the left Subdural hematoma on the right

47. 47 Intracerebral hematoma

48. 48 Epidural hematoma on CT

49. 49 Epidural hematoma in posterior fossa

50. 50 Subdural hematoma

51. 51 Chronic bilateral subdural hematomas

52. 52 Subacute hematoma

53. 53 Localization of intracerebral hematomas

54. 54 Intracerebral hematoma on MRI

55. 55 Intracerebral hematoma

56. 56 Intracerebral hematoma in the frontal lobe

57. 57 Intracerebral hematoma

58. 58 Combination of subdural and Intracerebral hematomas

59. 59 Acute traumatic pneumocephalus

60. 60 Treatment of moderate and severe head injury Acute resuscitation Diagnostic procedures Definitive treatment

61. 61 Treatment Acute resuscitation ABC Air pathway – cleaning of throat, airway tube, tracheal tube Breathing – Oxygen mask for stuporose and soporose patients Intubation for comatose Circulation Intravenous fluids for maintaining normal blood pressure Maintaining adequate perfusion pressure of the brain

62. 62 Treatment Diagnostic procedures Neurological examination State of consciousness, GCS Major neurological deficit Pupillary reflexes and symmetry Ocular movement Lower brain stem reflexes Motor examination (hemiparesis, reflexes) Pulse rate, blood pressure Neurovisualization Plain X-ray examination CT Cerebral angiography Diagnostic bur holes and ventriculography MRI

63. 63 Definitive treatment Typical indications for surgery Epidural and subdural hematomas that cause depressed consciousness Intracerebral hematoma and contusion in comatose and soporose patients with significant mass-effect on CT Depressed skull fractures Gunshot wounds Insertion of Intacranial pressure monitor

64. 64 Periods of head injury Acute – 2-4 weeks Intermediate – 2-6 weeks Remote

65. 65 bur hole

66. 66 Approach to fronto-temporal and parieto- temporal lobes

67. 67 Approach to frontal lobe

68. 68 Approach to temporal lobe

69. 69 Approach to parietal lobe

70. 70 Approach to occipital lobe

71. 71 Розрізи для доступу до задньої черепної ямки

72. 72 Removal of epidural hematoma

73. 73 Dendy’s point for puncture of posterior horn of lateral ventricle

74. 74 Kocher’s point for punction of anterior horn of lateral ventricle