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Nervous System > Pathology of Head Injury > Flashcards

Pathology of Head Injury Flashcards

1
Q

What are the commonest cause of head injury?

A
  • Road traffic accidents
  • Alcohol-related incidents including assaults
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2
Q

What are the different kinds of head injury?

A
  • Primary insult
    • Focal and/or diffuse brain trauma
  • Secondary insult
    • Hypotension (low arterial BP)
    • Hypoxia (low blood oxygen)
    • Infection
    • Haematoma (bleeding in/around the brain)
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3
Q

What are examples of primary head injury?

A
  • Focal and/or diffuse brain trauma
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4
Q

What are examples of secondary head injuries?

A
  • Hypotension (low arterial BP)
  • Hypoxia (low blood oxygen)
  • Infection
  • Haematoma (bleeding in/around the brain)
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5
Q

How can skull fractures lead to infection?

A

Allows bacteria in

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6
Q

What is done for the initial assessment for someone with a head injury?

A
  • Conscious level assessed using Glasgow Coma Scale
  • Scored out of 15 (15 is fully conscious)
    • 13-15 is mild injury
    • 9-12 is moderate injury
    • 3-8 in severe injury
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7
Q

What does GCS stand for?

A

Glasgow coma scale

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8
Q

What are the 3 kinds of injury on the GCS?

A

Mild

Moderate

Severe

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9
Q

What score on the GCS in mild?

A

13-15

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10
Q

What score on the GCS in moderate?

A

9-12

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11
Q

What score on the GCS in severe?

A

3-8

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12
Q

What are significant consequences of head injury?

A
  • Permanent physical disability
  • Post traumatic epilepsy
  • Intracranial infection
  • Psychiatric illness
  • Chronic subdural haemorrhage
  • ‘Punch drunk’ dementia
  • Fatal outcome (uncommon)
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13
Q

What is the relationship between forensics and head injury?

A
  • Head injuries can result from
    • Accidental, homicidal and sometimes suicidal incidents
    • Accidents very common, such as falls and road traffic collisions
    • Homicidal may be consequence of being struck by a weapon or from a fall sustained as part of an insult
    • Natural disease can also occur causing collapse with a resulting head injury
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14
Q

What is the head composed of?

A
  • Scalp
    • Hair-bearing skin
    • Connective tissue
    • Aponeurotic fascia
    • Loose connective tissue
    • Pericranium
  • Skull
    • Outer and inner “tables” of compact bone separated by spongy bone
  • Meninges
    • Dura mater (dense, tough, fibrous, adherent to inner surface of the skull)
    • Arachnoid mater (delicate, transparent, envelopes in brain)
    • Pia mater (delicate, applied to the brain surface)
  • Brain
    • Cerebrum
    • Cerebellum
    • Brainstem
      • Contains vital centres providing neurological control of
    • Spinal cord
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15
Q

What are the different layers of the scalp?

A
  • Hair-bearing skin
  • Connective tissue
  • Aponeurotic fascia
  • Loose connective tissue
  • Pericranium
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16
Q

What are the 3 layers of the meninges?

A
  • Dura mater (dense, tough, fibrous, adherent to inner surface of the skull)
  • Arachnoid mater (delicate, transparent, envelopes in brain)
  • Pia mater (delicate, applied to the brain surface)
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17
Q

What are the different parts of the brain?

A
  • Cerebrum
  • Cerebellum
  • Brainstem
    • Contains vital centres providing neurological control of
  • Spinal cord
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18
Q

What are different kinds of scalp injuries?

A

Similar to those that can affect the skin, such as:

  • Abrasions
  • Bruises
  • Lactations
  • Incisions
  • Burns and scalds
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19
Q

Why is the scalp a common site for laceration?

A

Common site for laceration because it is closely applied to the skull and tearing is more likely to occur in these circumstances

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20
Q

What does the skull do?

A

Encases the brain and its membranous coverings (meninges) apart from the foramen magnum

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21
Q

What do skull fractures cause?

A

Skull fractures cause deformation of the skull, adult skulls are less able to cope with distortion that those of infants

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22
Q

What are the 2 elements of the skull?

A
  • Skull vault (upper part)
    • Includes frontal bone, squamous temporal bones and occipital bone which are separate by sutures
  • Skull base (upon which the brain rests)
    • Divided into anterior, middle and posterior cranial fossa
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23
Q

What is the skull vault composed of?

A
  • Includes frontal bone, squamous temporal bones and occipital bone which are separate by sutures
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24
Q

What is the skull base divided into?

A
  • Divided into anterior, middle and posterior cranial fossa
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25
Q

What are the different kinds of skull fractures?

A
  • Linear
    • Commonly temporo-parietal blow or fall onto side or top of head
  • Depressed
    • Focal impact may push fragments inwards to damage meninges, blood vessels and the brain
    • Risk of meningitis and post-traumatic epilepsy
  • Comminuted (mosaic)
    • Fragmented skull
  • Ring fracture
    • Fracture line encircling the foramen magnum caused by a fall from height, usually langing on the feet
  • “Contre coup” fracture
    • Fracturing of the orbital plates (anterior fossa) caused by a fall onto the back of the head
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26
Q

What commonly causes a linear skull fracture?

A
  • Commonly temporo-parietal blow or fall onto side or top of head
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27
Q

What causes a depressed skull fracture?

A
  • Focal impact may push fragments inwards to damage meninges, blood vessels and the brain
28
Q

What are people at risk of after a depressed skull fracture?

A
  • Risk of meningitis and post-traumatic epilepsy
29
Q

What is a comminuted (mosaic) skull fracture?

A
  • Fragmented skull
30
Q

What is a ring skull fracture?

A
  • Fracture line encircling the foramen magnum caused by a fall from height, usually landing on the feet
31
Q

What is a contre-coup skull fracture?

A
  • Fracturing of the orbital plates (anterior fossa) caused by a fall onto the back of the head
32
Q

What are intracranial haemorrhages named by?

A

Named by their position within the skull in relation to the meninges, such as:

  • Extradural haemorrhage
  • Subdural haemorrhage
  • Subarachnoid haemorrhage
33
Q

What are examples of different kinds of intracranial haemorrhage?

A
  • Extradural haemorrhage
  • Subdural haemorrhage
  • Subarachnoid haemorrhage
34
Q

What is the main consequence of an intracranial haemorrhage?

A

Accumulation of blood within the rigid skull increased intracranial pressure (ICP) and results in compression of the brain, causing symptoms such as reduced conscious level

Death will occur as ICP increases without intervention, usually due to compression of the brainstem due to herniation of the cerebellar tonsils into the foramen magnum

35
Q

What does ICP stand for?

A

Intra-cranial pressure

36
Q

What does accumulation of blood in the skull due to haemorrhage and raised ICP lead to?

A

Compression of the brain causing symptoms such as reduced conscious level

Death will occur as ICP increases, usually due to compression of the brainstem due to herniation of the cerebellar tonsils into the foramen magnum

37
Q

What is an extradural haemorrhage?

A

Bleeding occurring between the dura mater and the skull

38
Q

What does the accumulation of blood due to an extradural haemorrhage do to the dura mater?

A

Accumulation of blood strips the dura of the inner surface of the skull

39
Q

What do most extradural haemorrhages arise due to?

A

Majority arise due to damage of an artery with a skull fracture (80-90%), but very occasionally can be caused by large venous channels

Classically caused by bleeding from the middle meningeal artery where it crosses the inner aspect of the squamous temporal bone

40
Q

Bleeding from what artery is what classically causes an extradural haemorrhage?

A

Middle meningeal artery where it crosses the inner aspect of the squamous temporal bone

41
Q

What can occur in patients with an extradural haemorrhage in terms of timing of symptoms?

A

“Lucid interval” can occur where the victim initially seems okay, without neurological symptoms, but then deteriorates catastrophically later

Time period for symptoms is variable but can take many hours

42
Q

What is a subdural haemorrhage?

A

Bleeding occurring beneath the dura and above the arachnoid

43
Q

What is a subdural haemorrhage usually caused by?

A

Usually caused by bleeding from bridging veins which pass from the surface of the brain into the large venous channels within the dura

Any motion which causes rotational or “shearing” forces can cause these veins to stretch and be torn

44
Q

Who is at greater risk of a subdural haemorrhage?

A

People with atrophic (small) brains at greater risk because smaller brain has greater capacity for movement and the veins may already be stretched to some degree

45
Q

Is a lucid interval seen in subdural haemorrhage?

A

It can be

46
Q

What can subdural haemorrhage progress to?

A

Can get a chronic subdural haemorrhage which may cause chronic confusion

47
Q

What is a subarachnoid haemorrage?

A

Bleeding beneath the arachnoid membrane and above the brain

48
Q

What is the most common cause of subarachnoid haemorrhage?

A

Most common cause is natural disease, such as rupture of a cerebral artery aneurysm

Frequently seen in association with cerebral contusions (bruising of the brain)

49
Q

What is traumatic basal SAH?

A

“Traumatic basal SAH” is a specific entity in forensic medicine:

  • Typically result of forceful impact to the upper part of the side of the neck causing abrupt rotational movement in the head leading to rupture of the vertebra-basilar circulation
50
Q

What does SAH stand for?

A

Subarachnoid haemorrhage

51
Q

What does traumatic basal SAH typically result from?

A
  • Typically result of forceful impact to the upper part of the side of the neck causing abrupt rotational movement in the head leading to rupture of the vertebra-basilar circulation
52
Q

What are the consequences of subarachnoid haemorrhage?

A

Collapse is usually rapid and death can occur very quickly due to irritant effects of blood in the subarachnoid space

53
Q

What are examples of intrinsic brain injuries?

A
  • Cerebral oedema
    • Common and rapid result of brain injury, especially in children
    • Can develop in minutes and lead to massive brain swelling with raised ICP and “coning”
  • Cerebral contusion and laceration
    • Direct mechanical damage to the brain substance
    • May occur anywhere in the brain
    • Different kinds of contusions
      • Coup contusions
        • When the head is struck by a heavy blow
        • Found directly under the site of impact
      • Contre-coup contusions
        • Caused by a moving head striking a fixed object
        • Contusions found diametrically opposite the site of the head impact
54
Q

What can cerebral oedema lead to?

A
  • Can develop in minutes and lead to massive brain swelling with raised ICP and “coning”
55
Q

What is cerebral contusion and laceration?

A
  • Direct mechanical damage to the brain substance
56
Q

What are different kinds of brain contusions?

A
  • Coup contusions
    • When the head is struck by a heavy blow
    • Found directly under the site of impact
  • Contre-coup contusions
    • Caused by a moving head striking a fixed object
    • Contusions found diametrically opposite the site of the head impact
57
Q

What is a coup brain contusion caused by?

A
  • When the head is struck by a heavy blow
  • Found directly under the site of impact
58
Q

What is a contre-coup brain contusion caused by?

A
  • Caused by a moving head striking a fixed object
  • Contusions found diametrically opposite the site of the head impact
59
Q

Where is a coup brain contusion found in relation to the site of injury?

A
  • Found directly under the site of impact
60
Q

Where is a contra-coup brain contusion found in relation to the site of injury?

A
61
Q

What is an axon?

A

Elongated processes of nerve cells which permit transmission of signals between different parts of the brain and between the brain and body

62
Q

What does DIA stand for?

A

Diffuse traumatic axonal injury

63
Q

What can diffuse traumatic axonal injury only be diagnosed by?

A

tDAI diagnosis can only be made by microscopy of the brain tissue

64
Q

What is DAI usually caused by?

A

Usually tDAI occurs due to vehicular collisions and falls from heights, serious rotational forces applied to brain tissue can shear axons

65
Q

What are some areas of the brain particularly susceptible to DAI?

A
  • Corpus collosum
  • Para-sagittal white matter
  • Posterior internal capsule
  • Dorsolateral aspect of the rostral brainstem
  • Cerebellar peduncles
66
Q

What happens to patients, clinically, when DAI is fully developed?

A

Clinically, victims are comatose when tDAI is fully developed

Concussion may be the clinical manifestation of lesser degrees of axonal injury, may have retrograde amnesia

Nervous System (48 decks)

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