Cranial Traumatism

The concept of cranial traumatism or crânio-cerebral traumatism ( TCC ) covers the traumatisms of neuro-cranium (left high cranium containing the brain) and of the brain.

The clinical demonstrations depend on the importance of the impact and the associated factors (age, preexistent pathologies others, associated traumatisms). From the anatomical situation of the head, the cranial traumatism is often associated with traumatisms of the cervical rachis (Entorse S, Luxation S, Fracture S), face (maxillo-facial contusions, wounds, fractures) and eyepieces.

The immediate and remote after-effects of the cranio-cerebral traumatisms are often the consequence of the lesions generated on the central nervous system (brain and cervical Spinal-cord). They burden the future with the victims and their families and their social costs and financier is high.

On the clinical level there exist three principal categories of cranial traumatisms: light (without loss of consciousness and cranium fracture), average (with a initial loss of consciousness exceeding a few minutes or with cranium fractures) and serious (with Coma from the start - without or with associated cranium fractures).

Important progress was made in the fast medical assumption of responsibility of the victims and in the fast and precise diagnosis of the lesions which can profit from a surgical treatment. In spite of this progress, more than 50% of the serious cases die or keep a handicap with life. The forecast is thus generally related to the importance of the signs and initial lesions (to the moment of the accident).

Epidemiology

The cranial traumatisms are the leading cause of mortality and severe handicap before 45 years. The main causes are: accidents of the public highway (approximately 50 %), sporting accidents, the industrial accidents, accidents in the home, aggressions.

Various types of traumatisms

The concussion

It is about a shock of the consecutive brain to a fall or a blow on cranium, accompanied by a temporary or initial loss of consciousness. It is about a temporary dysfunction of the ascending réticulée Substance (SRA) located in the depth of the brain and which is responsible for the maintenance of the state of awakening. It is the consequence of the concentric propagation and the concentration of the shock waves towards the center of the brain (phenomena stereotaxic).

It is the most banal table and there is no visible lesion radiologically in the brain. The cranial traumatism caused an immediate loss of consciousness. The patient “is struck”, “KB”. The alarm clock occurs spontaneously in a few seconds - minutes - hours after the traumatism according to the importance of the shock. There exist sometimes transitory disorders of the recent memory of fixing. A medical supervision or neurosurgical is essential to detect the possible secondary complications: Hématome extra-dural, hématome under-dural, cerebral edema.

A loss of consciousness or an isolated light commotion often remains without consequences. They can involve a Syndrome post-commotionnel. The repeated commotions can however support occurred of the serious neuro-degenerative diseases like the Parkinson's disease or the Maladie of Alzheimer even several decades afterwards.

The cerebral contusion

In this case, there exist anatomical lesions of the Cerveau (necroses hemorrhagic with edema), either on the level of the impact, or on the other hand (effect of consequence).

These cerebral lesions cause neurological overdrawn signs of localization: reduction in the muscular force or the sensitivity of a member, asymmetry of the Reflex S ostéotendineux, Sign of Babinski, Aphasia, etc

These disorders regress under medical care (anti-œdémateux). Sometimes, the cerebral edema is enough important to cause a beginning of cerebral Engagement (engagement of the low part of the brain under the forgery of the brain towards the cerebral hemisphere controlatéral, engagement of the lower part of the brain in the occipital foramen). A méningée Hémorragie can be associated with a cerebral contusion, and results in headaches, a stiffness of nape of the neck and disorders of the conscience.

The major Coma from the start

It is a commotion of maximum gravity. The patient presents a Coma major and persistent after the shock because the dysfunction of the ascending réticulée substance is deeper. Signs of decerebration are possible testifying to the presence to mesencephanlic lesions and axonales diffuse.

The scanner is applied urgently to the search for curable lesions surgically. If there exists a operable Hématome, the intervention is carried out immediately. In the contrary case, a medical care of reanimation is undertaken in specialized milieu (Anti-œdémateux, respiratory reanimation etc) and begins a clinical and radiological monitoring from the evolution. In the event of secondary aggravation, new radiological examinations will seek in particular lesions which have occurred secondarily and which could profit from an surgical operation (hématome extradural, hématome under-dural, hydrocéphalie)

The forecast depends on the importance of initial lesions, the age and the general state of the patient before the accident. More the coma is surface and the young patient and in good health before the accident, more the chances of cure are large.

Initial evaluation of a cranial traumatism

It makes it possible to separate the benign traumatisms manifestements and those which will require a catch of load in hospital medium.

The interrogation of the victim and/or the witnesses endeavors to inform the type of accident and impact, this last not making it possible however to prejudge gravity of the lesions.

Disorders of the conscience must be required and quantified according to the scale of Glasgow.

One will be wary systematically of a possible cervical traumatism with a possible hazard of Tétraplégie (paralysis of the four members) in the event of imprudent mobilization. In the same way, a traumatism associated with another part of the body will have to be sought on a purely systematic basis.

A cranial scanner will have to be made in urgencies in the event of a deficit of the conscience, even transitory or of which has occurred secondary, in the event of neurological deficit (lowers mobility of a member, disorders of the word, amnesia), with the slightest doubt on a cranial fracture, in the event of which has occurred of convulsive crisis or vomiting. In the child, the indication of a scanner is even broader, more especially as it is young.

Radiological signs

The osseous lesions can miss completely in spite of a cerebral attack.

Linear fracture

A bone of the cranium (frontal, occipital, parietal or temporal) is fissured.

Fracture with depression/Embarrure

The bone of the cranium (frontal, occipital, parietal or temporal) is fractured and of the osseous fragments are inserted what can cause a wound or a compression on the Cerveau.

Fracture base of cranium

The Os sphénoïde is fissured. Generally linear

Intracranial hemorrhages

One speaks about intracranial hemorrhage when there is a bleeding inside cranium, around or in the brain.

Extra-dural Hématome

The Hématome extra-dural or epidural is an accumulation of blood between the bone of cranium and the Dure-mère (fibrous envelope of the brain belonging to the Méninges). The Hématome extra-dural is a surgical urgency absolute. It develops in a few hours and can result in the death of the patient by cerebral Engagement if nothing is done.

Hématome under-dural

It is about épanchement blood located enters, outwards the Dure-mère, and in inside the Arachnoïde. It can occur in an acute way, during the hours following the traumatism ( hématome under-dural acute ). It is then frequently associated with a cerebral contusion of which can depend the forecast. It can also be constituted with low noise, and be uncovered fifteen days, even weeks after a traumatism relatively not very important ( hématome under-dural chronicle ).

Intracerebral hemorrhage

It is about one bleeding inside the cerebral parenchyma.

Méningée hemorrhage

A méningée hemorrhage is observed in 1/3 of the severe cranial traumatisms. It can be secondary with the lesion of a vessel meninx, or with a hemorrhagic suffusion starting from a hearth of contusion of the cerebral cortex.

Assumption of responsibility

Any cranial traumatism with disorders of the conscience, even transitory, must have an immediate medical assumption of responsibility comprising, at least, a monitoring of the state of consciousness during 24:00 This time can be shortened if the cranial scanner is normal.

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