When it comes to head trauma, in English Traumatic Brain Injury (or TBI), we mean all those conditions in which the skull is hit or hits an object or surface (the classic "Blow to the head") causing some type of damage to the skull, brain or structures surrounding it. Head trauma is a frequent indicator, particularly in the age group between 15 and 25 years, with a prevalence steadily increasing in recent years, reaching 200 - 300 cases per 100,000 people.
Causes of head injury
The causes main of head trauma they are very heterogeneous from each other, but all have in common the presence of a strong impact of the skull against a surface. We can therefore include:
- Road accidents, especially among the youngest. Represents the primary cause of head trauma, especially in cases of accidents involving mopeds and motorcycles, in which you hit the head, whether or not protected by a helmet, against the ground or against another vehicle;
- Accidental falls, to which older people are particularly prone;
- Sports, particularly those of wrestling, such as boxing or martial arts;
- Acts of violence and aggression, through blunt instruments, gunshots, edged weapons, etc.….
This event is defined "Primary lesion" and can produce different damage based on the type of object against which the skull collides: skull fracture, brain injuries, contusions, lacerations, cerebral hemorrhages, epidural or subdural hematomas, etc ... These injuries can be divided into two groups:
- Trauma closed, that is, those that do not report any interruption of the skin;
- Trauma open, that is, those in which there is an interruption of skin integrity.
Consequences of a head injury
Inside the organism, starting with the primary lesion, a series of biochemical events following the initial trauma is triggered and for this reason defined "secondary injuries":cerebral edema, due to the accumulation of liquids following the post-traumatic laceration of the vessels, thebrain hematoma, or thehydrocephalus, a condition in which there is an increase in pressure inside brain cavities called "ventricles".
All this helps to increase the pressure inside the box cranial, up to a defined condition "Intracranial hypertension", where you have severe neurological symptoms and which needs to be treated promptly. Another important secondary injury is the finding of tissue infections inside the skull, such as meningitis and abscesses, to be sought especially if the trauma occurred is of the open type.
Another type of head trauma injury is the axonal damage, which is a widespread damage to the brain parenchyma linked to the sudden deceleration or angular acceleration of the head and its contents, with "tearing" of the nerve fibers. In severe cases it can lead to an immediate and irreversible loss of consciousness even in the absence of visible head or brain injury after the trauma.
The classification of head injuries takes into consideration the severity of the event on the basis of the symptoms that the patient reports and takes the name of Glasgow Coma Scale (or GCS). It is based on three parameters that allow you to easily and quickly frame the patient:
- Opening of the eyes. With this parameter, the doctor evaluates the patient's responsiveness through the opening of the eyes. They can be given from 1 to 4 points, based on the promptness of the response and the possible use of stimuli, verbal or painful;
- Verbal response. The doctor tries to initiate a conversation with the patient, asking simple questions and evaluating the quality of the response and the articulation of the individual words. For this parameter, they are given from 1 point, equivalent to a lack of response by the patient, to 5 points, which indicate a good ability to interact;
- Motor response. This criterion, on the other hand, evaluates the ability to move the limbs following a precise command from the doctor or, if this is not possible, through painful stimulation (a pinch is often used for this purpose). They are given from 1 point, corresponding to a lack of response to both stimulations, up to 6 points, equivalent to an obedience to the verbal order.
The score can vary from a minimum of 3 points, to which a condition of marked and profound unconsciousness is associated, up to a maximum of 15 points, coinciding with a perfectly normal exam. Along this scale, we can have three classifications of trauma through the score obtained by the individual patient:
- Between 13 and 15, it indicates minor trauma;
- Between 9 and 12, it indicates moderate trauma;
- Between 3 and 8, it indicates severe trauma.
The head injury in the newborn is in the child has well-defined and different guidelines with respect to trauma in adults, due to the different consistency of the cranial bones and the different diagnostic and therapeutic pathways.
Symptoms and head trauma
Symptoms depend on the entity and type of head trauma, as well as on the affected brain area and the type of damage that affects the main organ of our body, the brain. THE symptoms they may be present in the immediate post-trauma phases, but may also appear several hours or days after the event.
There is the possibility of losing consciousness immediately after the trauma and this condition is called "concussion" or "concussion". The emotional head injury it is therefore characterized by loss of consciousness and it is easily recognized that the patient has amnesia, that is, he does not remember anything of what happened during the episode, and the duration of this symptom correlates with the severity of the traumatic event: the longer the duration of the amnesia, the greater will be the degree of injury. In non-commotional head trauma lack of consciousness prediction after the acute event.
In case of mild blunt trauma, we can also experience physical symptoms such as headache, nausea, vomiting, feeling of lightness in the head, lack of motor coordination, poor balance, dizziness, sensation of buzzing and whistling hearing, bad taste in the mouth, altered vision (blurred, double or feeling of tired eyes), tiredness and lethargy, or a change in sleep patterns; among the cognitive ones, on the other hand, there may be sudden changes in mood or behavior, alterations in memory and concentration, confusion or attention deficit. These symptoms can emerge even hours after the head injury (late symptoms).
In case of brain trauma moderate or severe, in addition to all the physical symptoms of mild facial or head trauma, there may be dilation of the pupils of one or both eyes, difficulty speaking, complete loss of coordination, agitation, convulsions up to a state of profound unconsciousness; from the cognitive point of view, there are serious alterations in behavior, in the maintenance of attention for a long time, in social relationships, in the ability to judge, reason and think. If the patient is a child, they may have difficulty communicating this range of symptoms. Clinical signs that must induce the suspicion of head trauma are characterized by inconsolable and persistent crying, increased hostility and irritability as well as the obstinate refusal to take any type of food.
Head Trauma Diagnosis
There diagnosis head trauma is first posed through physical examination of the affected area. All possible signs of the fall are sought (such as bump, skin lacerations, hematoma, possible fractures with possible crushing of the skull), immediately evaluating the patient's neurological status through the GCS and the diameter of the pupils, then stabilizing any altered vital functions of the patient (ventilation, flow and blood pressure, etc.).
After having collected a careful medical history on the possible risk factors related to the fall (such as the use of antiplatelet or anticoagulant drugs for other pathologies, old age, previous epilepsy), however, it is necessary to use neurological imaging techniques, aimed at detecting the presence of any neurological damage related to the fall or its possible complications (such as bleeding). For lower costs, for the reliability of the images and for the greater speed of execution, in emergency cases the Computed Tomography (CT), which allows to evaluate the possible presence of cerebral hemorrhage, cerebral edema or lesions of the nervous tissue.
There Nuclear Magnetic Resonance (MRI), instead, it allows for more information regarding secondary damage to the trauma, such as ischemia and neurological damage, and therefore the long-term prognosis, but it is carried out later, as long periods of time are required for the correct image acquisition.
Other main neuroimaging techniques used can be:
- Radiography, now supplanted by TC;
- Angiography, to be used in case of trauma penetrating the skull as they detect a possible involvement and / or structural alterations of the cranial vessels;
- Tomography to Issue of Positron (PET), to evaluate the metabolism and neurological activity of the affected area.
This condition should not be underestimated in the long term. It is possible that the patient, during the post-traumatic course, may suffer from symptoms never experienced before and which must be carefully monitored by the doctor: among these, it is necessary to pay close attention to possible severe headaches, to manifestations of post-traumatic epilepsy or other temporary alterations of consciousness, cognitive and motor deficits and infections. Therefore, the long-term evaluation of the functionality of the brain is necessary, also through the ElectroEncephalogram (or EEG), which studies and monitors the patient's electrical activity, and intracranial pressure. Studies will have to be more in-depth and serialized in cases of severe head trauma.
Head Trauma Therapy
What is the treatment specific for the outcomes of a head injury? After having stabilized all the vital parameters and after having framed the site of the trauma and any associated damage, the therapeutic path is based primarily on the severity of the traumatic event. In cases of mild head injury, the following can be used / advised:
- Paracetamol, if the patient reports pain in the affected area. Other anti-inflammatory drugs are avoided, as they have a greater anticoagulant activity and could cause worsening of the clinical picture, such as any cerebral hemorrhages;
- High flow oxygen, to maintain high tissue oxygenation;
- Complete rest from any type of physical and mental activity, such as using phones or computers;
- Heated intravenous fluids, to avoid patient hypotension and hypothermia;
- Antipyretics and antiemetics, in case there is a fever and vomiting that cannot be stopped.
In addition to the drugs used in mild head injuries, one is needed in moderate to severe cases therapy more complex:
- Admission to an intensive care unit, where vital signs are constantly monitored, and subsequently to neurosurgery, if it is possible to drain the bleeding and correct any deformity of the skull with surgery;
- Osmotic diuretics, to reduce the extent of intracranial hemorrhage and favor its reabsorption;
- Broad spectrum antibiotic therapy, especially if the cranial bone skeleton is particularly damaged and not very stable;
- Stronger analgesics, such as weak opioids, up to using sedatives in particularly severe cases;
- Benzodiazepines, to quell possible epileptic seizures.
Rehabilitation and post-trauma recovery
After the acute state, the patient is directed to a rehabilitation process, managed by professional doctors and aimed at the physical, functional and psychological recovery of the traumatized patient. In the Italian territory there are many neurological rehabilitation centers, specialized in functional and psychological recovery after neurological events such as stroke, brain hemorrhages or head trauma.