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SEF LUCRARI DR.

CORNELIU TOADER

TRAUMATISMELE
CRANIOCEREBRALE

DEFINITIE SI EXAMENUL CLINIC IN PRESPITAL

Alterare a starii de constienta ca


urmare a unei injurii craniene.
Ex. clinic: -imediat posttraumatic in
prespital.
-la nivelul spitalului
In prespital probleme apar in cazul TCC
grave ce necesita comportamente
speciale si decizii rapide personalul
nu are instruire neurologica.

EXAMINAREA ABCDE
A. (Airway)-circulatia libera a aerului
- prezenta de zgomote patologice.
- obstructia cailor aeriene superioare.
B. (Breathing) Respiratia eficienta acesteia: frecventa
respiratiei, amplitudine, miscarile toracelui, prezenta cianozei.
C. ( Circulation) circulatia homeostazia circulatiei: frecventa si
amplitudine puls, culoarea tegumentelor, tensiunea arteriala,
prezenta de hemoragii.
D. ( Disability) prezenta deficitelor neurologice, ex. neurologic:
nivelul starii de constienta apreciat pe scala Glasgow, ex. RFM.
E. ( Exposure ) ex. dezbracata a pacietului surprinderea si
evaluarea altor leziuni miscarile membrelor la stimulii verbali
sau durerosi.

SCALA AVPU

A: pacient vigil (alert).


V: raspunde la stimuli verbali
(responsive to vocal stimuli)
P: raspunde la stimuli durerosi
(responsive to pain).
U: nu se obtin raspunsuri
(unresponsive).

SCALA GLASGOW ( M, V, O )
Raspunsul motor:
- executa comenzi verbale = 6
- localizeaza durerea = 5
- face flexie tintita ( localizeaza
stimulul) = 4
- face flexie anormala ( nu localizeaza
st. )=3
- face extensie = 2
- lipsa raspunsului motor = 1

Deschiderea ochilor:
- spontana = 4
- la comenzi verbale = 3
- la durere = 2
- nu se produce = 1
Raspunsul verbal:
- converseaza, orientat temporo-spatial = 5
- confuz = 4
- cuvinte inadecvate = 3
- sunete neinteligibile = 2
- lipsa raspunsului verbal = 1

Totalul: 3 15 puncte.
Consemnarea corecta: scorul general si
cei 3 parametri in mod explicit (ex. GCS
8=M4, V2, O2).
Starea de coma definita dupa GCS
(GCS:3-8): - absenta deschiderii ochilor.
- absenta activitatii verbale.
- absenta raspunsului la ordine.

EX. CLINIC LA NIVELUL SPITALULUI

Neurolog/neurochirurg
Aprecierea in dinamica a semnelor
neurologice, comparativ cu cele initiale.
Ex. functiilor vitale: TA, puls, nr. respiratii.
HTA, bradicardia si modificarile
respiratorii=hipertensiune intracraniana.
Modificarile respiratorii de cauza
neurologica depind de nivelul la care este
implicat trunchiul cerebral:

Mezencefal respiratie = Cheyne-Stokes.


Mezencefal si punte = tahipnee.
Trunchi cerebral = respiratie ataxica.
Starea de constienta a pacientului.
Scorul GCS
Reactivitatea la lumina a pupilelor (RFM).
Dimensiunile pupilelor:
- anizocoria: diferenta >1 mm intre pupile.
- midriaza pupila mai mare de 4 mm.

Midriaza unilaterala+lipsa RFM la


acelasi ochi = hernie cerebrala
( mortalitate 54%).
Midriaza bilateral+lipsa bilaterala a
RFM=leziune ireversibila de tr.
Cerebral.
Pupile nornale+RFM absent = leziune
mezencefalica.
Pupile miotice bilateral+RFM absent
leziune la nivel pontin.

MISCARILE SPONTANE ALE GLOBILOR OCULARI

Miscari spontane cu axe vizuale paralele=


integritatea centrilor si cailor musculaturii
extrinsece a globilor oculari: mezencefal,
punte; nv. III, IV si VI.
Devierea in jos a globilor oculari=leziune
pontina.
Devierea laterala a gl.oculari: lez. Iritativa de
trunchi sau supratentoriala.
Paralizia miscarilor in plan vertical=lez.
Pontina.

EVALUAREA DEFICITELOR
NEUROLOGICE

Deficite motorii.
Deficite de sensibilitate.
Paralizii de nervi cranieni.
Tulburari de vorbire.
Cand se asociaza un TVM, Scala Frankel
la traumatizatii vertebro-medulari (in
special cei cervicali).

CLASIFICAREA TCC IN FUNCTIE DE SEVERITATE

TCC grav = 3-8 pct GCS; 10%.


TCC moderat (mediu) = 9-12 pct
GCS;10%.
TCC minor = 13-15 pct GCS; 80%.

CLASIFICAREA TCC IN FUNCTIE DE TIMPUL SCURS DE


LA EVENIMENTUL TRAUMATIC

TCC
TCC
TCC
TCC

acute = evolutie 0-3 zile.


subacute = evolutie 4-21 zile.
recente = evolutie 22 zile 3 luni.
vechi = evolutie peste 3 luni.

DEFINIREA TRAUMATISMULII CRANIO-CEREBRAL

TCC este o conditie patologica ce se instaleaza


datorita actiunii unei forte mecanice asupra
extremitatii cefalice si care prin intermediul unor
mecanisme diverse (statice, dinamice cu contact
/acceleratie-deceleratie etc.) produc una din
urmatoarele situatii:
1. Modificarea starii de constienta (obnubilare,
stupor, coma).
2. Amnezie (tulburari de memorie retrograde,
anterograde, pentru evenimentul traumatic in sine)
3. Fracturi ale calvariei.

4. Tulburari neurologice (modificari ale


functiilor motorii, senzitive sau ale reflexelor,
tulburari de vorbire sau crize epileptice).
5. Modificari psihologice (dezorientare,
agitatie, confuzie, tulburari cognitive, tb. De
comportament si personalitate.
6. Leziuni intracraniene (contuzii, dilacerari,
hemoragie subarahnoidiana, hematoame
subdurale, hematoame epidurale,
intracerebrale etc.).

TCC NU este definit de una din


urmatoarele situatii:
- plagi diverse sau contuzii faciale,ale
scalpului, ale gl.oculari, urechilor, nasului
ce nu sunt insotite de unul dintre
criteriile anterior mentionate.
- fracturi ale oaselor faciale
neacompaniate de unul din criteriile
anterior mentionate.

ANATOMIA PATOLOGICE A CONTUZIEI CEREBRALE

Efect traumatic focal primar caracterizat prin prezenta


unor leziuni limitate la un teritoriu bine delimtat cu
volum diferit ce poat evaria de la cativa mm pana la
cativa cm cubi.
Leziunea contuziva = focar hemoragic, parenchim
cerebral dilacerat, necroze tisulare si edem
perilezional.
Focarele de contuzie au o distributie caracteristica
vizind polii frontali, girii orbitali, cortexul supra si
subiacent fisurii sylviene, polii temporali, zonele
laterale si inferioare ale l. temporali, zonele inferioare
ale emisferelor cerebeloase (mai rar).

RADIOGRAFIA SIMPLA A CRANIULUI?

CT CRANIAN

LEZIUNI AXONALE DIFUZE

CT CRANIAN

CONTUZIILE CEREBRALE

CT CRANIAN

CONTUZIILE CEREBRALE

Hemorrhagic contusion (coup type) in a 25-year-old man who


was hit on the head with a tire iron. Focal hemorrhagic area
(arrows) at site of blow involves the cortex maximally.

CT CRANIAN

CONTUZIILE CEREBRALE

Hemorrhagic contusions of temporal lobes (contrecoup type) in


a 37-year-old man who fell on occiput. Inferior temporal lobes
are hemorrhagic at their anterior poles

CT CRANIAN

CONTUZIILE CEREBRALE

Inferior bifrontal hemorrhagic contusions (contrecoup type),


with both inferior frontal lobes, just above cribriform plate and
roof of orbits, showing multiple superficial hemorrhagic areas.

Contrast-enhancing contusions in a patient examined 2 weeks


after injury. Inferior frontal contusions had been demonstrated
by earlier CT. Enhancement is present at contusion sites
(arrows).

CT CRANIAN

CONTUZIILE CEREBRALE

An 8-year-old male with depressed fracture of left occipital


bone and cerebellar contusion secondary to penetrating injury.
The scan shows depressed fracture occipital bone
(arrowhead), pathway of penetration (arrow), and focal
cerebellar contusion at end of pathway (open arrow).

Multiple cerebellar contusions in a patient with head injury who


died of other causes. Four discrete areas of contusion of the
cerebellar cortex are identified.

CT CRANIAN

HEMATOMUL INTRACEREBRAL

Well-defined, hyperdense intracerebral hematoma in the


anterior inferior temporal lobe.

CT CRANIAN

HEMATOMUL INTRACEREBRAL

Intracerebral posterior temporal hematoma with contiguous


subdural hematoma (arrowheads). Subdural blood extends
into the interhemispheric fissure (arrows). A moderate midline
shift of ventricles is evident.

CT CRANIAN

LEZIUNI ALE SUBSTANTEI CENUSII


SUBCORTICALE

Intracerebral hematoma at the head of the caudate nucleus in a


child involved in an automobile accident. This hematoma was a
superior extension of a larger white matter hematoma.

CT CRANIAN

LEZIUNI ALE TRUNCHIULUI CEREBRAL

Primary brain stem hematoma in an 18-year-old male involved


in motor vehicle accident with multiple lacerations and loss of
consciousness. On physical examination the patient had
pinpoint pupils with the right eye abducted and the left eye in
the midline. Diagnosis was pontine exotropia. The only
abnormality on the patient' s CT examination was a hemorrhage
(arrowheads) in the upper pons.

TRATAMENTUL CONTUZIE CEREBRALE GRAVE

IOT + ventilatie mecanica.


Antiedematoase dexametazona
Depletive manitol.
ICP monitoring.
Trepanatie controversata cand avem
deplasare a liniei mediene.
Volet decompresiv FTPO uni sau
bilateral.

CT CRANIAN

LEZIUNI ALE TRUNCHIULUI CEREBRAL

Shearing injury in a 16-year-old who was involved in a motor


vehicle accident. CT demonstrates multiple focal areas of
hemorrhage within the temporal lobe, and a hemorrhage
(arrowhead) within the mesencephalon. It is most likely that the
hemorrhage within the mesencephalon is primary and a
manifestation of the shearing injury. However, the
perimesencephalic cisterns between the temporal lobes and
upper brain stem are obliterated, and a secondary hemorrhage
within the upper mesencephalon cannot be excluded. Based on
autopsy findings it was thought that the brain stem lesion was
primary in origin.

Secondary brain stem hemorrhage in a 20-year-old male with


severe bilateral contused temporal lobes with bilateral temporal
lobe herniation. CT shows a focal hemorrhage (arrowheads)
within the tegmentum of the upper pons. The brain stem shows
focal areas of decreased density suggesting edema or
contusion due to injury. Portions of the prepontine cistern
remain

CT CRANIAN

HEMATOMUL INTRACEREBRAL

Cerebellar hematoma in a 28-year-old male with multiple trauma including head injury. A large
right inferior cerebellar hematoma (arrowheads) and multiple contralateral hemorrhagic
frontal contusions are present. The patient showed evidence of brain stem dysfunction and
died within 24 hours.

HEMATOMUL EPIDURAL

Acumulare de singe intre dura mater si cutia


craniana.
1% dintre TCC.
Raportul barbati/femei=4:1.
Apare de obicei la adultii tineri, rar sub 2 ani si
peste 60 (dura mai aderenta de tablia interna).
Sursa arteriala prin sectionarea a. meningee
medii 85%, vena meningee si sinusurile durale
15%.
Clasificare: cauza arteriala, cauza venoasa.

SEMNE CLINICE

Scurta pierdere de cunostinta survenita


posttraumatic.
Un interval liber de citeva ore.
Obnubilare, hemipareza controlaterala si
midriaza ipsilaterala.
Netratat rigiditate prin
decerebrare,hipertensiune intracraniana, tb.
respiratorii si moarte.
Evolutie: ore, zile, rar sapt (sursa arteriala,
sursa venoasa).

INVESTIGATII PARACLINCE

Rg. craniana: poate identifica fracturi


craniene: in 40% dintre pacienti
acestea nu se identifica in special la cei
sub 30 de ani.
CT scan nativ: hiperdensitate biconvexa
adiacenta tabliei interne, uniforma si de
cele mai multe ori cu efect de masa.

CT CRANIAN

HEMATOMUL EXTRADURAL

Clotted epidural hematoma in a 52-year-old man examined 12


hours after a fall. Patient was wide awake and without focal
neurologic deficit. CT shows a homogeneously dense biconvex
epidural hematoma (arrowheads). Linear fracture not shown.

CT CRANIAN

HEMATOMUL EXTRADURAL

Chronic venous epidural hematoma in an 11-year-old boy who


had fallen 9 days earlier and who noticed left proptosis I day
ago. Patient was wide awake and without neurologic deficit.
Post-injection CT shows an enhanced epidural membrane
(arrowheads). Contents of epidural hematoma are of mixed
(increased and decreased) density (asterisk). Fracture roof of
orbit not shown.

CT CRANIAN

HEMATOMUL EXTRADURAL

Two images demonstrate low-density material within epidural hematoma (arrowheads).


In addition to marked compression of right lateral ventricle and subfalcine shift on all
cuts, there is evidence of underlying ischemia (decreased density both cortically and
subcortically) in left cerebral hemisphere.

CT CRANIAN

HEMATOMUL EXTRADURAL

Acute epidural hematoma in a 30-year-old woman involved in a


motor vehicle accident. Occipital skull fracture was present.
Large biconvex epidural hematoma (arrowheads) extends both
infra- and supratentorially. Origin was from laceration of the
transverse sinus. Note the presence of hydrocephalus and the
obliteration of quadrigeminal plate cistern.

CT CRANIAN

HEMATOMUL EXTRADURAL

Chronic venous epidural hematoma posterior fossa in a 5-yearold child with multiple falls. Contrast-enhanced CT shows
biconvex posterior fossa mass with an enhancing membrane
(arrowheads). The central portion is hypodense. Surgery
revealed a chronic venous epidural hematoma.

TRATAMENTUL HEMATOMULUI
EPIDURAL
Medical: mici EDH cu grosime sub 1 cm
si simptomatologie, nu exista semne de
herniere, poate exista o crestere in
dimensiuni 5-16 zi necesita
craniotomie.
Indicatii chirurgicale:
- toate EDH simptomatice.
- EDH asimptomatice peste 1 cm
grosime.
- la copii.

OBIECTIVELE TRATAMENTULUI CHIRURGICAL

Evacuarea cheagurilor: scaderea ICP si


a efectului de masa.
Hemostaza riguroasa:electrocoagulare
pt.a meningee medie si vena, ceara in
singerarile intradiploice.
Suspendarea durei mater la os sau
galee (place dural tack-up sutures).

HEMATOMUL SUBDURAL

Acumulare de singe in spatiul sudural


(dura-foita externa a arahnoidei).
Magnitudinea impactului este mai mare
in ASDH decat in EDH, leziunea este mai
frecvent letala decat EDH.
Simptomele sunt date de compresiune,
deplasare de linie mediana (angajare),
leziuni asociate intraparenchimatoase si
edemul cerebral.

MECANISME DE PRODUCERE

Acumulare de singe in jurul parechimului cerebral


lacerat (contuzionat), adesea nu exista interval
liber, semnele de lateralizare apr tarziu si sunt mai
putin evidente decit in EDH.
Ruperea venelor in punte in timpul mecanismului
de acceleratie-deceleratie in timpul miscarii
violente a capului. Afectarea primara a creierul
este mai putin severa, pare interval liber si
deteriorarea rapida este mai tirzie.
La pacientii cu terapie aticoagulanta si/sau
antiagreganta dupa traumatisme minore.

EXAMENE PARACLINICE
CT scan cerebral nativ:
-masa hiperdensa cu aspect de lentila
biconcava ce se atenueaza la tablia interna.
- cel mai adesea pe convexitate dar poate fi si
interemisferic, pe tentoriu sau in fosa
posterioara.
- membranele se formeaza incepind cu ziua a
patra.
- isi modifica densitatea in timp ajungind
izidens dupa 2 sapt.

CLASIFICAREA ASDH DUPA CT

Acut: 1- 3 zile hiperdens.


Subacut: 4 zile 2,3 saptamini, izodens
cu creierul.
Cronic: peste 3 sapt pina la 3-4
luni,hipodens comparabil cu CSF.

CT CRANIAN

HEMATOMUL SUBDURAL

Acute subdural hematoma with multiple hemorrhagic


contusions. A large extracerebral collection of blood (arrows)
encompasses the entire hemisphere. Multiple irregular
hemorrhagic areas (arrowheads) involve the underlying
hemisphere. A marked midline shift of ventricles is evident.

CT CRANIAN

HEMATOMUL SUBDURAL

Acute subdural hematoma (uncomplicated by associated


parenchymal damage) in an 8-year-old child with headache and
confusion following a fall. Subdural hematoma (arrowheads)
with proportional mass effect is demonstrated.

CT CRANIAN

HEMATOMUL SUBDURAL

Acute interhemispheric subdural hematoma in an elderly man


who fell off a bar stool and became comatose. Hematoma lies
on one side of the falx cerebri, and the sulci are obliterated on
the side of the hematoma.

Whiplash shaking injury (child abuse), with acute


interhemispheric parafalcene subdural hematoma
(arrowheads), in a 9-month-old infant who had
received"artificial resuscitation from a baby-sitter" by rapid toand-fro shaking motions.

CT CRANIAN

HEMATOMUL SUBDURAL

Chronic subdural hematoma. Enhanced CT demonstrates


medially displaced vessels (arrowheads) on the cerebral
surface and inward displacement of the hemispheric white
matter. The extracerebral collection is almost isodense. An
enhancing membrane (open arrows) divides the collection
into two pockets.

CT CRANIAN

HEMATOMUL SUBDURAL

SEMIOLOGIE:

LEZIUNE HETEROGENA:

ZONE FOCALE IZODENSE /


ZONE MARGINALE,
NEREGULATE, LAMINARE
HIPERDENSE IN FAZA ACUTA
ZONA HIPERDENSA /
COLECTIE SEMILUNARA
HIPODENSA FAZA CRONICA
NIVEL DE SEDIMENTARE
COMPARTIMENTALIZARE

Chronic subdural hematoma in a 78-year-old woman with obtundation


of 2 days' duration. There had been a progressive downhill course with
decreasing alertness over last month. Bilateral extracerebral
collections displace brain medially, compress cortical sulci, and cause
ventricles to be narrowed from side to side. Note higher-density blood
(arrows) dependent in both collections.

CT CRANIAN

HEMATOMUL SUBDURAL

Bilateral isodense chronic subdural hematomas (asterisks) in


an 80-year-old patient. Note the medially displaced white matter.
Ventricles are unusually small for age 80, and sulci are not seen
(very unusual for age).

CT CRANIAN

HEMATOMUL SUBDURAL

Acute subdural hematoma (arrowheads) in the posterior fossa


of a young child who received a blow to the occipital region.

Chronic subdural hematoma in the posterior fossa of an


anticoagulated 65-year-old woman with headaches, ataxia, and
papilledema. There is a hyperdense mass (arrowheads) in the
left-side posterior fossa. Surgery disclosed new bleeding into
chronic subdural hematoma.

CT CRANIAN

EDEMUL CEREBRAL DIFUZ

Bilateral cerebral swelling shown in an 8-year-old child involved


in an auto accident. Ventricles are small and bilaterally
compressed. No focal traumatic lesions are seen.

CT CRANIAN

PNEUMOENCEFALIA

Subarachnoid pneumocephalus and hemorrhage in a child with


a basilar skull fracture. Increased density in frontal
interhemispheric fissure, chiasmatic cistern, and ambiens
cistern (arrowheads) is due to acute subarachnoidal bleeding.
Lucency in interpeduncular cistern is air (arrows). Temporal
horns are dilated (open arrows) because of acute
hydrocephalus.

Pneumatocele in 21-year-old man 5 weeks postfracture of roof


of orbit and hemorrhagic contusion of inferior frontal lobe, with
accompanying change in affect and behavior. Coronal CT
shows comminuted fracture of orbital roof, roof of ethmoid
sinus, and cribriform plate region. Air is seen tracking from
fracture site into an intraparenchymal collection.

TRATAMENTUL CHIRURGICAL AL
ASDH

Evacuarea chirurgicala rapida la cele


simptomatice peste 1 cm grosime in
punctul maxim.
Volet mare pentru a putea identifica
sursa singerarii si a o coagula.
Dren epidural aspirativ.

OPTIUNI CHIRURGICALE IN HEMATOMUL SUBDURAL


CRONIC

Doua gauri de trepan cu irigare cu sol


salina.
O singura gaura cu irigare si aspirare.
O singura gaura cu pasare de
drensubdural ce se mentine 24-48 de
ore.
Twist drill craniostomy cu dren subdural
rata mare de recurenta.
Craniotomie cu excizia membranelor
subdurale.