Basal Skull Fracture

c
‡ a linear fracture involving the base of the
skull
‡ usually associated with a dural tear and
Im a g in g S t u d ie s is found at specific points on the skull
‡ S k u l l X -r a y base
- fr a c tu r e a t th e v e r te x ‡ commonly involve the roof of the orbits,
‡ C T sc an the sphenoid bone, or portions of the
- s ta n d a rd m o d a lit y f o r a id in g in t h e
d ia g n o s is o f s k u ll fr a c tu r e s
temporal bone
‡ MRI
- fo r s u s p e c t e d lig a m e n to u s a n d
v a s c u la r in ju ri e s
c
c
c

c Basal Skull Fracture

Closed Skull Fracture
‡ Do not penetrate the bones of the skull. c !


‡ Occur from a hard blow or impact that jars the ‡ encountered in 75% of all skull base
brain within the skull. The rapid movement of
the brain within the skull can: c fractures
o Cause bruising, swelling, or tearing of ‡ 3 subtypes:
the brain tissue. c 1. Longitudinal fracture
o Stretch, pull apart, or tear nerves or
blood vessels,causing bleeding within 2. Transverse fracture
or around the brain. c 
3. Mi ed
‡ Can be more difficult to identify because there
may not be visible signs of injury, such as
bleeding or deformity.

Both open and closed head injuries may cause:
‡ A concussion
‡ A brain bruise (contusion)
‡ Bleeding within or around the brain, a life-
threatening injury. Symptoms of this type of injury
may be the same as those of a concussion. More
serious symptoms usually develop within 24
hours after the injury. In rare cases, if the
bleeding is slow, symptoms take longer to
develop.
Treatment
Open fracture
G careful irrigation and debridement
G broad-spectrum antibiotics + tetanus to oid
G wound e ploration in the operating room under
direct vision to prevent loose pieces of bone
from damaging the underlying brain
G repair of dural sinus tear
G bony segments reassembled
G if depressed: prophyla is for posttraumatic
seizures

Basal Skull Fracture c



 
 c
‡ results from a high-energy blunt trauma

with a ial compression, lateral bending,
or rotational injury to the alar ligament
c Treatment
c Closed fracture
Gelevation depressed skull fractures if the
depressed segment is more than 5 mm
below the inner table of adjacent bone
Grepair of venous sinus tear


Gif depressed: prophyla is for
posttraumatic seizures
 Basal Skull Fracture c

Clinical Manifestations: c
‡ r 

   - ecchymosis of the mastoid process of

the temporal bone (petrous temporal bone fractures)
c
‡      - periorbital ecchymosis i.e. "black
eyes" (anterior cranial fossa fractures)
‡ Cerebrospinal fluid rhinorrhea and/or rhinorrhea c
‡ Cranial nerve palsy
‡ Bleeding from the nose and ears c

c
 c
Concussion
c
‡ Symptoms of concussion include:
± headache c
± disorientation as to time, date, or place
± confusion
± dizziness

± vacant stare or confused e pression
± incoherent or incomprehensible speech
± incoordination or weakness
Diffuse A onal Injury
± amnesia for the events immediately preceding the blow
± nausea or vomiting ‡  esults from high speed injury with
± double vision stretching or shearing of brain tissues
± ringing in the ears ‡  adiographically shows petechial
hemorrhages in white matter tracts
‡ Characterized by a onal separation
‡ Secondary biochemical cascades are
Contusion largely responsible for the damage to
a ons
‡ Condition in which direct parenchymal
injury of the brain has occurred through
c
transmission of kinetic energy of the
brain and bruising analogous to what is
seen in soft tissues c
‡ Caused by the brain hitting the interior
of the skull c

c
Contusion
c
‡ Coup contusion
± minimal injury underlying the point of
contact c
‡ Countercoup contusion
± occur at the area of the brain opposite to c
the blow

± may show e tensive damage c
‡ Histologically indistinguishable
c

c c
Contusion
c
‡ Signs and symptoms include
± Severe headache c
± Dizziness
± Vomiting c
± Increased size of one pupil or sudden
weakness in an arm or leg
c
± estlessness, agitation or irritability
± Memory loss or forgetfulness
 ·rimary Brain Injury
‡ from blow, acceleration, deceleration, or c
rotation of the brain when it is slammed
back and forth on bony prominences inside
the skull
c

c
c

econdary Brain Injury

·rimary Brain Injury
‡ Clinical effects

± delayed
‡ Clinical effects
± progressive
± immediate ± preventable

± ma imal ± eg dec cerebral perfusion,
± irreversible inc IC·, cerebral edema,

hypo emia, circulatory
± e g concussion, shock
contusion, acute 
± hypo ia, ischemia, brain
subdural swelling, infection,
hematoma, diffuse hematoma

a onal injury
c

c
r r i I r c
‡r f r t t t t l r c
ri f tim Glasgow
(fr m r Coma
t ) ftcale r
t rim r r i i r
c
‡ åq
 t
 
i r t t i ftr


r 

  ! " ri #$t #%
t i iti l i ¢ lt  t ! &"$ f '(#% c
t i ¢
‡ r lt fr m t
 t i
mi t ) !i i $*++
, r "+ ri* t #
xi , l t IP, r t , ! i $&" m + r#-#$(i . l# c
i mi lrltf ri f / ! $" ("'$%
i
i l i i iti t t c
ri i l tr m

c
e co n d a ry B ra in In ju ry
c
‡ in c lu d e s a n e n tir e c a s c a d e o f c e llu la r ,
c h e m ic a l, t is s u e , o r b lo o d v e s s e l
c ha n ge s
‡ c o n tr ib u t e t o fu rth e r d e s tr u c tio n o f b ra in
ti s s u e
‡ C o m p lic a t io n o f p r im a ry in ju r y
 M ild h e a d in ju r y - 0 C S 1 3 - 1 5
M o d e r a t e h e a d in j u r y ± 0 C S 9 ± 1 2
S e v e r e h e a d in ju r y ± 0 C S 3 ± 8
C o n t u s io n
1
‡ E n la r g e o r d e e lo p in t o tr u e
h e m a to m a
3
‡ C o n tr e c o u p i n u r y
Classification of head injury c ± C o n t u s io n s in b ra in tis s u e o p p o s ite
s ite o f i m p a c t
·

  

 ± the dura is pierced ± 4 e c e le ra tio n s o f b r a in a g a in s t s k u ll
c
    

 
± the skull is compressed between two
forces
- massive injury that usually results in 5
instantaneous death · e n e t r a t in g in u r y
6 e8
7
‡
r e m o
6 e
O p e r a t i e p lo r a t i o n
o b e c t s
n e c e s s a r y
s t i c k in g o u t o f t h e
t o

c r a n iu m
‡ 9 e b r id e m e n t , ir r ig a t io n ,
h e m o s t a s is , a n d c lo s u r e
C l a s s i f ic a t io n o f h e a d i n j u r y ‡ S m a ll o
8
b e c t w / in b r a in p a r e n c h y m a
o f t e n le f t a lo n e
      
    

   
- M a j o r p r o b l e m i n c iv ili a n li f e
- H e a d is s u d d e n ly a c c e le r a te d o r d e c e l e r a t e d
a s a r e s u lt o f a n o n- p e n e tr a tin g b l o w
- D u ra rem ains intact 2
· e n e t r a tin g in u r y
S u b ty p e s
‡ M is s i le ( b u l le t s a n d f r a g m e n t a t i o n
<
d e ic e s )
C o n c u s s io n <
‡ N o n m i s s i le ( k n i e s a n d i c e p ic k s )
‡ T e m p o r a r y n e u ro n a l d y s fu n c ti o n a ft e r n o n - ‡ X -ra y a n d C T s c a n
p e n e tr a t in g t ra u m a ‡ C e= r e b r a l a n g io g r a p h y c o =n s id e r e d if
‡ C T s c a n n o rm a l o b e c t p a s s e s n e a r a m a o r a rte ry o r
<
d u ra l e n o u s s in u s
‡ M e m o ry d i ffic u ltie s c o m m o n
‡ B r a in in h y p e rm e t a b o lic s ta te
‡ S e c o n d im p a c t s y n d r o m e
± B r a in m o r e s u s c e p ti b le to t ra u m a in 1 s t 1 - 2
weeks
3
· e n e t r a t in g in u r y
‡
:
H ig h - e lo c it y w e a p o n s c re a t e
s h o c k w a
: e t h a t d e s tr o y s s u r r o u n d i n g
t is s u e
‡ · a ti e n t t r e a t e d w / a n ti b i o ti c s
C o n t u s io n
‡ B r u is e o f t h e b r a in
1
‡ B r e a k d o w n o f s m a ll e s s e ls
‡ B r ig h t o n C T s c a n
2
‡ S m a ll a m o u n ts o f b lo o d in in u r e d
p a re n c h ym a
· rim ary B ra in In u ry
1
‡ E d e m a m a y d e e lo p c a u s in g m a s s ‡ als o þ
        
e ff e c t ;
‡ the initia l in ury to the b rain as
a d irect res ult o f th e tra um a
;
‡ sud den and pr ofou nd in u ry to
the brain th at is co nside red to
be m ore or less co m ple te at
the tim e of im p act
‡ occ urs at th e tim e of th e c ar
acc iden t, g unsh ot w oun d, or
fall
‡ ins tanta neo us onse t