Craniocerebral and spinal trauma

Craniocerebral trauma
Craniocerebral trauma (CT) is the most serious group of all injuries (e.g. in the USA 2 million people suffer brain injuries every year, 20 % of injuries are fatal and the cost of treatment reaches 25 billion dollars per year)

Classification of craniocerebral trauma
CT can be divided into groups according to the mechanism of injury into direct (closed or penetrating) and indirect, according to the time of onset into acute and chronic, and according to the severity of the clinical condition into mild, moderate and severe' disability (Tab. 1., Fig. 1.). The direct acute injuries' include skull fractures, brain envelope injuries, cranial nerve injuries, vascular injuries, and especially coma, concussion, laceration, and diffuse axonal injury. In association with these, but also independently, indirect acute injuries may occur, including acute epidural haematoma, acute subdural haematoma, traumatic [[subarachnoid haemorrhage, intracerebral haematoma, swelling, brain oedema, pneumocephalus and acute cerebral hygroma, as appropriate.] In acute lesions, both direct and indirect, symptoms appear immediately or within a few hours'. An important group is also indirect chronic damage, manifesting days, weeks or years after the trauma. These include delayed intraparenchymatous hemorrhage, late posttraumatic hygroma, chronic subdural hematoma, hydrocephalus, epilepsy, and several other clinical entities.

Diffuse Axonal Palsy (DAP)
A very severe multiple axon disability that is severed by rotational and translational forces acting on the head, most commonly in the corpus callosum and brainstem. The severity of the subsequent condition is compounded by the fact that axon disruption leads to the washout of potassium, which has a toxic effect on the surrounding brain tissue. In DAP, the diagnosis is based on history of head injury, clinical status (severe impairment of consciousness) and MRI imaging (CT is unhelpful, changes are usually below its resolution). It is the most common cause of subsequent vegetative state in trauma patients.

Pneumocephalus
The presence of air in the intracranial space. It is always the result of penetrating head injuries, and may coexist with or without a complicating infection. Diagnosis is based on CT scan.

Acute cerebral hygroma
It is caused by rupture of the arachnoidea and permeation of cerebrospinal fluid into the subdural space. The acute course is caused by expansive behaviour of the hygroma, which is explained by the valve mechanism of the arachnoid tear. The clinical course and diagnosis are identical to those of subdural hematoma.

Other forms of chronic brain injury

 * Delayed intraparenchymatous hemorrhage - see ICH.
 * Hydrocephalus
 * Post-traumatic' epilepsy
 * Organic psychosyndrome

Diagnostic and therapeutic management of craniocerebral trauma
Caution: the procedure starting with the history is given for didactic reasons only, the priority is always to examine and ensure the patient's vital functions!!!

When examining the patient, it is necessary to anamnesticly determine the mechanism and intensity of injury, time since injury, duration and duration of unconsciousness, and possible risk factors - medication, comorbidities and abusive (Table 2., Fig. 7.)'.



Při hodnocení a zajištění vitálních funkcí je nutno dodržovat zásady ABC. Změříme krevní tlak, tepovou frekvenci, saturaci O2. Zhodnotíme úroveň vědomí pomocí GCS, které v pravidelných intervalech kontrolujeme. Nasadíme krční límec, kdykoli předpokládáme postižení krční páteře. Zhodnotíme i vegetativní doprovod (nevolnost, zvracení) případně výskyt křečí. Pátráme po dalších známkách úrazu (hematomy a deformace na hlavě, obličeji a po těle) a provedeme odběry tělních tekutin na základní biochemická vyšetření. Neurologickým vyšetřením je nutno zhodnotit stav vědomí po stránce kvantitativní (GCS) i kvalitativní a pátrat po ložiskových neurologických příznacích (poruchy řeči nebo chování, na hlavových nervech zvláště anisokorie a abnormality kmenových reflexů, na končetinách parézy, poruchy čití, poruchy koordinace). According to the findings, CTs are divided into severe, moderate and mild (Table 1)'. The examination of meningeal phenomena (intracranial haemorrhage, possibly secondary infection) and the status of mnestic functions (retrograde, anterograde amnesia) are essential (Tab 3.)'.

Imaging methods
The main method in acute CT diagnosis is currently CT scan. The role of native X-ray (bone structure injuries) continues to be important. MRI is more important at a later stage of diagnosis (method of choice in suspected DAP).

Diagnostic Conclusion
It is necessary to exclude other causes of impaired consciousness or coincidence with other pathologies (cardiac failure, syncope, pulmonary embolism, myocardial infarction, hypoglycaemia, epilepsy, etc.).

Therapy
For CT, the surgical solution should always be considered. Subsequent therapeutic measures must always be taken after interdisciplinary collaboration between, neurologists, neurosurgeons and intensivists. The general condition of the patient, the time elapsed since the trauma, the other diseases and the prognosis of the patient should always be taken into account. In some cases, a conservative management consisting of intensive care with simultaneous monitoring of vital signs, intracranial pressure, and repeated imaging (CT) may be chosen in cases of minor findings. Urgent surgical management is always necessary in acute epidural hematoma, when it is necessary to perform a craniotomy and treat the source of bleeding. Removal of the hematoma from the trepanation ports or from the craniotomy is also the basic surgical procedure for subdural hematoma. In traumatic SAC, in contrast to non-traumatic SAC, a conservative procedure is usually chosen. In other entities, especially ICH, DAP, cerebral edema, etc. the operative management is directed towards the normalization and reduction of intracranial pressure (ICP) and thus avoiding further involvement of vital brain areas for the time being, with constant monitoring of the clinical status (Intracranial sensor, transcranial Doppler, ventricular pressure, etc.). If necessary, a sufficiently wide craniectomy (unilateral, bilateral) can be performed. A therapeutic option also leading to a reduction of ICP is the introduction of ventricular drainage in case of the development of post-traumatic hydrocephalus.