Neurotrauma. Béla Faludi Dept.. of Neurology University of PécsP
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1 Neurotrauma Béla Faludi Dept.. of Neurology University of PécsP
2 Emergency!!! Why here? Opened cranial injury visible: neurosurgery Closed injuries sometimes diagnosed by neurologist Masking situation: alcoholism, epilepsy, etc..
3 Cranial Spinal Peripheral nerv level
4 Craniocerebral level: USA: peoples permanently disabled Age 1-40: Death from neurotrauma: more frequent, then any other diseases together Inc.: / Closed space Intracranial volume: ml CSF volume: 130 ml Ventricular volume: 25 ml Total intracranial blood volume: 150 ml, 75 ml in the brain
5 Intracranial volume = liquor volume + blood volume + tissu volume But: To mantain the intracranial pressure constant: results predominantly from the displacement of CSF from the cranial to the spinal space. Fig 57A.2
6 Brai edema: 57A.8
7 Efect of edema depends on: Size of extra volume speed of volume change Initial intracranial compliance Elderly atrophy Child tight ventricules
8 Herniations: -Falcin (Cingular) Falx midline shft mental chnges -Tentorial (uncal): Uncus, hyppocampus 57A.3 Midbrain, cranial nerve III, ACP More dagerous -Foraminal: Posterior fosa, big supratentorial laesions oedema Circulation, breathing!!!
9 Sympthoms: see: neurological physical examination Focal neurological signs Alteration in the level of consciousness Amnestic period (retrograd, anterograd) PTA (posttraumatic amnestic period): depends on the severity of trauma minutes mild demage longer periods (weeks) sever injury
10 Tipes of neurotrauma: Commotio: Contusion: Temporary loss of consciousness, absance of focal neurological signs, no or mild structural demage (negative CT scan), amnestic period. more sever injury cortical, subcortical demage bleeding coup- contrecoup mechanism
11 CT scan of contusion:
12 Subdural hematoma: Blood in the subdural space Acut, Subacut and chronic form Arterial and venous origin Symptoms: depends on the former compliance (atrophy) Acut form 0-15% of the cranial injuries 1-2 days from the trauma mainly high pressure arterial origin similar symptoms in case of large venous rupture focal nurological signes CT Bed prognostic factor: delayed operation signs of increased ICP systemic complication (shock, coma)
13 Subacut form: Chronic form: Mortality: 50% after 3 days mainly venous origin late onset neurological signs CT Operation 1 week-months from the trauma small, asymptomatic bleeding, no sympthoms (at the begining) organization - capillarisation Big size witout symptoms CT Operation
14 CT scan of the subdural hematoma:
15
16 Traumatic intracerebral bleeding Epidural hematoma: Hematoma in the extradural space Rupture of the meningeal arterias high pressure arterial bleeding Acut, subacut, chronic form time course identical with the SDH Lucidum intervallum CT Operation
17 CT scan of epidural hematoma:
18 Complications: Hydrocephalus obstructiv, adsorptiv SAH mainly venous origin conservative therapy Subdural hygroma CSF leak Meningitis Functional vazospazm Carotidocavernosus fistul Epilepsy
19 Spinal level: Incidence:30-40/ new cases per year in the US patients now in the US 65% younger then 35, greatest incidnce between Direct (shoot, knife) and indirect (flexion, extension, rotation) injury Pathology: Contusion Compression Penetrating injuries Due to spinal stenosis, severe spondylosis: more sensitive to injury
20 Signs and symptoms: related to the level, type and severity of laesion Clinical patterns: Cauda equina laesion Conus medullaris laesion Mixed (conus and cauda) laesion Spinl cord injuries: concussion spinal shock complet cord transection incomplete cord transection Brown-Séquard sy. central cervical cord sy. Anterior cord sy. posterior cord sy. Complication: Bladder disfunction Syringomyelia Pressure sores (ulcers) Infections Muscle spasms CSF leaks Pain Vascular Sexual disfunction
21 Peripheral nerve trauma: Anatomical background 57C.1 Mechanism of laesion: From the mild compression to complet tranzsection
22 Types: Neurapraxia: mild demage Conduction block large fiber involvement Recovery: hours, days Axonometmesis: Intact endoneurium Axonal disconection Distal (Waller) degeneration Axonal regrowing down its proper course regeneration Exellent reconnection Neurometmesis: Greater degree of injury Endo and perineurial disruption Axonal demage Inadequat regrowing Bad functional outcome
23 Importance of ENG and EMG examination in case of peripheral nerve injury: Axonal demage: Early signs (immediate): sensory and motor symptoms Conduction (distal to the laesion): intact (Waller degeneration after 4-7 days) After 4-7 days: decrased amplitude 1-6 weeks: abnormal spontaneus activity fibrillation, positive sharp waves
24 Subacut-chronic phase: Reinnervation: change in the MUAP morphology no denervation signs Demielinisation Decresed conduction velocity
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