V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V....
Transcript of V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V....
![Page 1: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/1.jpg)
V. CENTRAL NERVOUS SYSTEM TRAUMA
![Page 2: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/2.jpg)
I. Concussion
- Is a clinical syndrome of altered
consiousness secondary to head injury
- Brought by a change in the momentum of the
head when a moving head suddenly arrested
by impact on a rigid surface)
![Page 3: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/3.jpg)
- The characteristic neurologic picture includes
Instantaneous onset of transient neurologic
dysfunction including
1. Loss of consciousness,
2. Temporary respiratory arrest
3. Loss of reflexes.
![Page 4: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/4.jpg)
- Although neurologic recovery is complete ,
amnesia for the event persists
- Pathogenesis is unknown but may result
fromtemporary deregulation of the reticular
activating system in the brainstem
![Page 5: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/5.jpg)
Complications
1. Post concussive neuropsychiatric syndromes
typically associate with repetitive trauma are
well recognized
2. Significant cognitive impairment with distinct
pathologic findings called chronic traumatic
encephalopathy
![Page 6: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/6.jpg)
II. Direct parenchymal injuries
1. Contusions
- Caused by blunt trauma to the brain
- The pia- arachnoid is not breached
Mechanism
- A blow to the surface of the brain transmitted through the skull leads to rapid tissue displacement , disruption of vessels , hemorrhage, tissue injury
![Page 7: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/7.jpg)
- Blood can extend into the subarachnoid space
- The crest of gyri are most susceptible than the
depth of sulci
- Are common in regions of the brain overlying
rough and irregular inner skull surfaces, such
as:
![Page 8: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/8.jpg)
a. The frontal poles
b. The orbital surfaces of the frontal lobes
c. And the temporal lobe tips
Note
- Contusions are less frequent over the occipital
lobes, brainstem and cerebellum until these
sites are adjacent to a skull fracture
![Page 9: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/9.jpg)
- A person who suffers a blow to the head may
develop a contusion at the point of the contact
called coup contusions
- Or may suffer a contusion on the brain surface
opposite to the site of the contact called
contrecoup contusion
![Page 10: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/10.jpg)
- Both types of contusions have similar gross and
microscopic appearances
- The distinction is made on identification of the
point impact
a. If the head is immobile at the time of trauma,
only a coup injury is found
- Is caused by contact between the surface of the
brain and skull at the site of impact
![Page 11: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/11.jpg)
b. If the head is mobile at the time of the trauma,
both coup and contrecoup contusions may be
found
- Is thought to arise when the brain strikes the
opposite inner surface of the skull after
sudden deceleration
![Page 12: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/12.jpg)
.MORPHOLOGY :
- Are wedge-shaped with the broad base lying along
the surface at the point of the impact
- Microscopic examination
a. In the earliest stage: Edema and hemorrhage
![Page 13: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/13.jpg)
b. During next few hours:
- Extravasation of blood extend throughout the
cortex to white matter then to the
subarachnoid space
c. Old traumatic lesions
- Are depressed retracted yellow brown patches
( called plaque jaune)
![Page 14: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/14.jpg)
Early contusions at orbital gyri of frontal lobes
![Page 15: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/15.jpg)
Old contusions
![Page 16: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/16.jpg)
Contusions: Recent and old
![Page 17: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/17.jpg)
III. Diffuse axonal injury
- Trauma can also cause more subtle but
widespread injury to axons within the brain with
devastating consequences
- Axons are injured by
a. The direct action of mechanical forces with
subsequent alteration of axoplasmic flow
![Page 18: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/18.jpg)
b. Or by angular acceleration alone, which can
cause axonal injury even in the absence of
impact
Note:
- As many as 50% of patients who develop coma
shortly after trauma are believed to have white
matter damage and diffuse axonal injury.
![Page 19: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/19.jpg)
-These injuries are widespread, and asymmetric
and are most commonly found in
a. Corpus callosum
b. Paraventricular area
c. Cerebral peduncles
d. Reticular activating formation
![Page 20: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/20.jpg)
Morphology
- They take the form of axonal swellings that
appear within hours of the injury and may
persist for much longer
- The swelling can be demonstrated
immunostains for axonally transported proteins such as amyloid precursor protein
![Page 21: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/21.jpg)
IV. Traumatic vascular injuries
- It results from direct trauma and disruption of
the vessel wall and leads to hemorrhage in
different anatomic sites
![Page 22: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/22.jpg)
1. Epidural hematoma
- Normally the dura is fused with the periosteum
on the internal surface of the brain
- Dural arteries , most importantly, the middle
meningeal artery are vulnerable to injury
especially with skill fracture in which the
fracture cross the course of the vessel
![Page 23: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/23.jpg)
Note
- In children in whom the skull is deformable, a
temporary displacement of skull bones leading
to lacerations of a vessel can occur in the
absence of skull fracture
![Page 24: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/24.jpg)
- Once a vessel is torn, blood accumulating under
arterial pressure can dissect the tightly applied
dura away from the inner skull surface producing
a epidural hematoma that compresses the brain
surface.
![Page 25: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/25.jpg)
- When blood accumulates slowly, patients can be lucid for several hours between the moment of trauma and the development of neurologic signs..
- An epidural hematoma may expand rapidly and constitutes a neurosurgical emergency necessitating prompt drainage and repair to prevent death
![Page 26: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/26.jpg)
Epidural hematoma
![Page 27: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/27.jpg)
B. Subdural Hematoma
- The dura is composed of two layer,
a. The external collagenous layer
b. and inner border cell layer with scant
fibroblasts and abundant extracellular space
devoid of collagen
![Page 28: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/28.jpg)
Notes:
- When bleeding occurs, these two layers separate and create the subdural space in which the blood accumulates
- Bridging veins travel from convexities of the cerebral hemispheres through the subarachnoid space and the subdural space to empty into superior sagittal sinus
![Page 29: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/29.jpg)
![Page 30: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/30.jpg)
- These vessels are prone to tearing along their
course through the dural layers
- The venous sinuses are fixed relative to the
dura, so the displacement of the brain that
occurs in trauma can tear the veins at the point
where they penetrate the dura
![Page 31: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/31.jpg)
Susceptible people:
1. Old people with brain atrophy
- Patients with brain atrophy, the bridging veins are stretched out, and the brain has additional space within which to move, accounting for the higher rate of subdural hematomas in elderly persons.
2. Infants also are susceptible to subdural hematomas because their bridging veins are thin-walled.
![Page 32: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/32.jpg)
Morphology
Grossly,
- Acute subdural hematomas appear as a
collection of freshly clotted blood along the
brain surface, without extension into the
depths of sulci
- Flattened underlying brain and subarachnoid
space is often clear.
![Page 33: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/33.jpg)
- Typically, venous bleeding is self-limited;
breakdown and organization of the hematoma
take place over time
1. Lysis of the blood within one week
2. Growth of granulation tissue from the dural
surface into the hematoma (2 weeks)
![Page 34: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/34.jpg)
- Typically, the organized hematoma is firmly
attached to the inner surface of the dura and is
free of the underlying arachnoid, which does
not contribute to healing.
- The lesion can eventually retract as the
granulation tissue matures until only a thin layer
of reactive connective tissue remains
(“subdural membranes”).
![Page 35: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/35.jpg)
- In other cases, however, multiple recurrent
episodes of bleeding occur (chronic subdural
hematomas), presumably from the thin-walled
vessels of the granulation tissue.
- The risk of repeat bleeding is greatest in the
first few months after the initial hemorrhage
![Page 36: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/36.jpg)
Clinically
- Neurologic signs are attributable to the
pressure exerted on the adjacent brain.
- Symptoms may be localizing but more often
are nonlocalizing, taking the form of headache
confusion, and slowly progressive neurologic
deterioration.
![Page 37: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/37.jpg)
- Subdural hematomas typically become manifest
within the first 48 hours after injury.
- They are most common over the lateral aspects of
the cerebral hemispheres and may be bilateral.
![Page 38: V. CENTRAL NERVOUS SYSTEM TRAUMAmsg2018.weebly.com/uploads/1/6/1/0/16101502/cns_trauma.pdf · V. CENTRAL NERVOUS SYSTEM TRAUMA. I. Concussion - Is a clinical syndrome of altered consiousness](https://reader035.fdocuments.net/reader035/viewer/2022070912/5fb438398f42ad5c591c4a4a/html5/thumbnails/38.jpg)
• - Symptomatic subdural hematomas are treated by
surgical removal of the blood and associated
reactive tissue