One simple blow can damage your brain

Skull and brain injuries (also cranial brain trauma (SHT), Traumatic Brain Injuries (TBI))

The following text is intended to inform relatives and patients about the consequences of a traumatic brain injury. It is not primarily aimed at doctors, but rather at interested laypeople.

Table of Contents:

  1. Definition of the SHT
  2. frequency
  3. Consequences of trauma
  4. Clinical course (what happens when?)
  5. Therapy (at the scene of the accident, in the emergency room, in the intensive care unit, in the operating room)
  6. rehabilitation

1. Definition
The skull and brain injury is the result of external violence on the skull and / or the brain. A distinction must be made between primary and secondary consequences of injury. Primarily means the destruction of tissue in the skull, especially in the brain, at the moment of violence. This destruction of brain tissue cannot be reversed. However, this primary damage is the starting point for the secondary consequences of the injury. The primary injury sets in motion a cascade that intensifies the primary injury sequence. This secondary consequence of injuries can, however, be curbed by the fast and effective therapy. The secondary consequence of injuries is thus the actual goal of medical therapy for skull-brain injuries.

2. Frequency
It is estimated that there are up to 400 traumatic brain injuries per 100,000 inhabitants per year. Approx. 300 injured persons per 100,000 inhabitants per year have to undergo hospital inpatient treatment. The significance of this disease becomes clear when one realizes that around 180 out of 100,000 traumatic brain injuries are so severe that long-term damage is to be expected and that more than 4,000 patients each year are permanently injured and require long-term care. This is also evident from the forty deaths per 100,000 people per year. In particular, it should be noted that head trauma is by far the most common cause of death in children up to fifteen years of age (Statistisches Jahrbuch 2000), and severe head injury is the most common cause of death for those under 45 years of age. This injury particularly affects young, active people, whose perspective on life is abruptly changed as a result of the injury. This accident changed not only the life of the patient, but also the life of relatives and friends. It should also not be underestimated that these young patients no longer pay into the social system after the accident, but become a major cost factor.

Consequences of trauma
Primary trauma consequences

The primary consequences of trauma must be distinguished between soft tissue injuries, bony injuries, injuries to vessels (arteries, veins), injuries to the meninges and actual damage to the brain substance.

Soft tissue injuries and injuries to the scalp bleed profusely. As a rule, however, this bleeding can be stopped with a pressure bandage. This bleeding is only threatening in small children. There is also a risk of infection with soiled wounds i. d. Usually not.

Bony injuries: The bony skull serves to protect the brain. If the energy has discharged in the bone and has led to a fracture, the violence that has reached the brain is less. A general distinction is made between fractures of the skullcap and injuries to the base of the skull. All fractures can heal without any problems, but there can be bleeding from the fracture line and this bleeding can put pressure on the brain. The edges of the fracture can tear small vessels (® epidural hematoma). The sharp edges of the fracture can also tear the hard meninges, especially in the area of ​​the base of the skull, or parts of the bones impale the brain. Bony injuries can also lead to cranial nerve injuries (e.g., hearing loss because the auditory nerve is impaired). Frontobasal injuries then represent a connection between the outside world and the brain. The flow of cerebral water (® Liquorrhea) is considered as evidence. If this leakage of cerebrospinal fluid does not stop quickly, surgical treatment is necessary so that no bacteria can enter the brain. Instead of the cerebral fluid, air can enter, so air (pneumatoencephalus) is then found in the x-rays or computed tomography. The injury to the meninges can in turn be closed by the brain. It is a brain prolapse. The neurosurgeon should decide whether rapid surgical treatment is necessary here or whether one can wait.

Vascular injuries: Large vessels can also be injured by a cranial brain injury. The carotid artery can tear on its way from the neck to the base of the skull (carotid dissection). This can lead to bleeding, but also to embolism and subsequent cerebral infarction. Another common injury in large vessels is a fistula in the area of ​​the so-called cavernous sinus. This is a large plexus of veins in the area of ​​the base of the skull. Here the carotid artery runs through this plexus of veins. A tear in the carotid artery in this area leads to bleeding into this venous plexus, which swells and, due to its location, affects the optic nerve and eye movement. The vascular injuries of smaller arteries are, on the one hand, bleeding on the hard meninges (epidural hematoma). Here a broken bone has torn a small artery on the hard meninges. From this it bleeds, and this bleeding leads to a bulging of the meninges towards the brain. The neurological abnormalities, especially the impaired consciousness, take some time. It may well be that the patient is awake again shortly after the accident, but then passes out because the bleeding increases and begins to crush the brain (free interval). The death rate (mortality) from epidural hematoma in unconscious patients is up to 70%. Therefore, immediate neurosurgical operation with bleeding is necessary here.

If there is bleeding between the meninges and the brain, it is called a subdural hematoma. Here the death rate is still around 50%. The violence has ruptured superficial arteries and brain tissue. From this it bleeds, and here too the bleeding increases and has a tendency to crush the brain. This bleeding also urgently requires neurosurgical treatment. If there is minor bleeding on the brain surface in the cerebral water space, one speaks of a traumatic subarachnoid hemorrhage. If there is no space-occupying bleeding, there is no need to be operative. The violence can also tear tissue, including the vessels in the brain. Then there is bleeding into the brain. This is called intracerebral hematoma. Depending on the size and location, the neurosurgeon must decide whether an operation is necessary and sensible.

SHT secondary injuries:
What is meant here is the cascade of further damage after the actual event with bleeding, brain swelling and cerebral edema, which leads to a progressive deterioration of brain tissue, but worsens the primary damage and can even result in death.

The danger of secondary brain damage is shown most clearly in the problem of intracranial pressure. In order to understand the process, one must realize that the brain is enclosed by the solid, bony skull. Whilst every other injury leads to swelling (the bump after a blow to the arm), the brain also has a tendency to swell after an injury. This is countered by the bony sheathing. Within the skull the essential components within the skull are of course the brain, the cerebrospinal fluid and the blood, which is necessary to supply the brain with oxygen and sugar. Every change, i.e. an increase in the brain due to swelling or an increase in blood due to bleeding, must lead to an increase in pressure within the bony skull. The danger of this increase in pressure is that it is not a linear function, but an exponential one. An example should illustrate the danger: A patient has suffered an accident. He was briefly passed out, then wakes up again, but a small fracture crack begins to bleed. This only leads to a moderate increase in intracranial pressure. The intracranial pressure continues to rise slowly, and another small increase in volume now leads to a massive increase in intracranial pressure, which makes him unconscious, and another small increase in the volume in the head leads to an increase in intracranial pressure that is now so massive that the patient dies. Since the doctor, who sees the patient for the first time, of course does not know whether such a mechanism is present at all, and since he therefore also does not know whether a possible bleeding can lead to such a situation, the doctor will advocate this after a TBI to monitor the patient in the hospital for a day.

What happens when
Examination procedure at the accident site and in the emergency room:
The doctor who comes to the patient first has to ensure that the vital functions (adequate breathing and adequate blood pressure) are safely achieved. If breathing is not safe, for whatever reason, or if the patient is unconscious (coma), he will insert an airway tube into the windpipe and initiate ventilation. To ensure adequate blood pressure, one or more needles will be placed in the veins and given fluids and / or medication to improve blood flow. In the TBI, the next step is to check the state of consciousness. Under one Clouding of consciousness a reduced perception of the environment and of himself is to be understood in the patient. A unconsciousness is defined as not responding to a response or a request, not opening the eyes, neither spontaneously nor when requested, or to painful stimuli. Unconsciousness is coma. Internationally and also in Germany, it has proven useful to estimate and document the impaired consciousness and thus the severity of the damage to the brain using the so-called Glasgow Coma Scale. This is a relatively simple scale that awards points for eye opening, the best verbal response to speech and the best motor (movement) reaction. You can achieve a maximum of fifteen, a minimum of 3 points. A patient who has three points is at great risk. The Glasgow Coma Scale has proven itself in recent years. Other classifications have significant difficulties in application. The division according to the duration of the unconsciousness into first, second and third degree TBI has the disadvantage that, especially at the beginning of the treatment, one naturally does not know how long the patient will be unconscious and means the old division into the commotio contusio and compressio, that the patient has no visible damage to the brain with a pure commotio (concussion). In the case of commotio contusio, detectable damage is found during the dissection or during computed tomography or magnetic resonance imaging, and a compressio is an extensive rupture of brain tissue. This diagnosis is only possible at least through a complex x-ray diagnosis and of course does not help at the scene of the accident. On the basis of the preliminary examination by the Glasgow Coma Scale, at least the severity of the injury to the brain can be estimated. It has been defined that a patient who scores three to eight points has severe TBI. Nine to twelve points are considered moderate brain injury, and twelve to fifteen points are defined as mild TBI. Another essential examination is the look in the eyes. Normally, even in a comatose patient, a pupil will narrow immediately when light shines into the eye. If the right or left pupil is wide compared to the opposite side, this is highly suspect that there is a mass (hemorrhage), especially if there is no narrowing after exposure to light in the eye. An acute threat to life must be assumed if both pupils are wide in a comatose patient and remain wide even when exposed to light. In the case of an awake patient with a unilaterally wide pupil, one will initially think of a blow to the eye or an earlier eye operation.

The ambulance will ask the patient to move their arms and legs. If the patient is unconscious, he will set a pain stimulus and thus check whether arms and legs are being moved. This examination hardly takes any time and provides important information: If the patient only moves arm and leg on one side, acute damage to the brain on the opposite side must be assumed. But if he only moves his arms and not his legs, this is highly suspicious of a spinal cord injury. An injury to the cervical spine must be assumed for every unconscious patient after an accident, and therefore, in case of doubt, a neck tie is also put on here. All findings are documented.

After the patient has stabilized, the question arises as to which TBI injured person goes to which hospital?

Since there is only one neurosurgical department in university clinics and large hospitals and, on the other hand, the number of TBI injuries far exceeds what the neurosurgical clinics can take care of, ways of distributing patients must be found.

The guidelines of the German Society for Neurosurgery for the treatment of craniocerebral trauma recommend:

  1. A patient with minimal TBI, i.e. H. Possibly a brief memory return of the actual event, but otherwise awake and without significant disability or a patient with a Glasgow Coma Scale of twelve to fifteen points should be brought to a clinic that is able to take an X-ray at any time (Reason: If there is a fracture in the skull admission, the probability of bleeding on the brain is significantly increased). If the x-ray shows no abnormalities and the patient is otherwise neurologically normal, inpatient monitoring is advisable.
  2. Patients with moderate craniocerebral trauma (Glasgow Coma Scale nine to twelve points) should be taken to a hospital where an X-ray examination and additional computed tomography can be performed at any time and who are still able to closely monitor such a patient. H. preferably intensive care, to be monitored. You should also be able to perform a control computer tomography at any time in the event of deterioration and, if necessary, organize the implementation of an operative measure.
  3. Severe craniocerebral injuries, d. H. Comatose and especially patients with concomitant injuries as well as all open craniocerebral trauma should be brought to a center that is able to carry out x-ray diagnostics, intensive care monitoring and necessary operations at all times.

In the hospital:
In the emergency reception At the hospital, the neurosurgeon on duty will examine the patient with colleagues from the other specialist discipline (anesthesia, trauma surgery and maxillofacial surgery, ophthalmologists ...). The process is similar to that at the scene of the accident. However, if the patient is ventilated and anesthetized, the examination is of course more difficult. Depending on the assessment of the threat to life, a plan for further diagnosis and therapy is drawn up with colleagues from the other discipline. If the patient is unconscious, it is important to urge a rapid computed tomography of the skull, as this is the only way to safely assess the situation in the head.

Shows up in the Computed Tomography a bleeding in the brain or a bone fracture that enters the brain, or an accumulation of air in the brain, will have to be decided on the basis of the overall situation whether an operation should be carried out immediately or whether one can wait. Depending on the situation, it may also have to be decided when a control of this computed tomography is to be carried out.

The seriously injured patient is taken to the intensive care unit. This is where breathing and circulation are ensured.

The secondary brain damage harbors the risk of brain swelling in the next few days. This swelling of the brain can become so threatening that even healthy parts of the brain are crushed, the blood supply to the brain decreases and this leads to the death of the patient. The principles of treatment are a good supply of oxygen to the brain through safe ventilation and good blood pressure. In order to ensure ventilation, it is usually necessary to give the patient sleeping pills and painkillers. Various solutions can be used to draw water from the brain and thus reduce the tendency to swell. You can also reduce the brain's need by taking a sleep pill (barbiturate coma). Despite all intensive care efforts, the severe traumatic brain injuries are life-threatening diseases and it is not always possible to save the patient's life. It is important to note that the so-calledNeuroprotective drugs (drugs that pretend to protect the brain), and especially drugs from the group of steroids, have not been able to show in scientific studies that they really help.

In order to improve intensive medical therapy, neurosurgery has introduced various additional monitoring methods in special clinics in recent years. So that the treatment of the increasing intracranial pressure can be carried out in a targeted manner, it is advisable to place a small probe on or in the brain and thus measure the intracranial pressure directly. Furthermore, one can estimate the oxygen consumption by inserting a small probe at the base of the skull (saturation measurement in the so-called jugular bulb). In some specialized clinics it is also possible to measure the oxygen and carbon dioxide levels in the brain as well as temperature and pH directly. The depth of an artificial coma (barbiturate coma) can be checked with a permanent EEG.

If, despite all intensive care efforts, the patient's condition deteriorates further, the surgical option of removing the skull bone can be considered. Whether such a so-called decompressive craniotomy should be carried out must be discussed in each individual case. This is a major procedure and the decision as to whether this is a sensible and appropriate therapy for the patient is a decision of the neurosurgeon.

If it turns out over several days that there is no longer any increase in intracranial pressure, the intensive care measures will be reduced. Only now will it be possible to determine what neurological damage the patient has actually suffered from the injury and, in particular, what level of alertness he can achieve at this point in time. You will now consider whether the ventilation therapy can be ended and the ventilation tube removed. If intensive medical therapy is no longer necessary, the patient will be transferred to a normal ward.

The patient who does not require intensive care is admitted to the normal ward after the diagnosis and the decision as to whether an acute operation is necessary. Here, too, there is close monitoring.

For all patients, depending on the neurological damage and their level of alertness, it will have to be decided whether a rehabilitation medical measure is indicated. For patients with severe neurological damage, there are special centers that have dedicated themselves to this task and that have a great deal of experience in this area.
It is important for loved ones to know that the final result, i.e. H. With what permanent damage does my relative come out of this TBI that can be answered at the earliest after the end of the rehabilitation.

Many patients who have suffered such minor injuries that they have not been transferred to a rehabilitation clinic also complain of headaches or difficulty concentrating after a long period of time.

A long-term consequence of a traumatic brain injury can be convulsions. This so-called. Epileptic seizures can occur for the first time after a long time. If such seizures become known, seizure therapy must be carried out. Driving vehicles is not recommended for patients with known seizure disorders. These patients, as well as those with dizzy spells after an injury, should not work on scaffolding either.