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город Харьков, ул. Академика Павлова, 46

Class 2

Class 2

 the craniocerebral trauma (CCT). Classification. An epidemiology. Closed CCT. A syndrome of the compression of the brain. Clinical course of intracranial haematomas. Methods of examination. Treatment. Early and late complications of CCCT. Treatment. Combined CCT. Open craniocerebral trauma (OCCT). Classification. The first urgent aid to the patient with OCCT. Initial surgical treatment of the penetrating and non penetrating wounds of the skull and brain. Plastics of defects of bones of the skull. Peculiarities of changes of CCT depending on the age of the patient.

I. Importance of the theme

Neurotraumatism is one of the important sections of modern medicine. Trauma of CNS constitutes 30-40 % in the general structure of traumatism, and death rate in the young and middle age considerably exceeds vascular and oncological diseases in peace, time, and also is a principal cause of death in wartime. This problem has not only medical, but also a big social significance as the level of traumatism tends to grow staidly.


2. The aims of the class:

2.1 The educational aims of the class

1. The student should know about an epidemiology of cranial brain trauma, the social importance of the problem, a history of studying this section of neurosurgery, biomechanism of the CCCT. I level

2. The student should know etiopathogenesis of the CCCT, classification, principles of diagnostics and modern methods of examination of patients, the main kinds of conservative and operative treatment, and early both late complications and methods of their treatment, principles of rehabilitation and social adaptation. II level

3. The student should be able to render the urgent aid at a place of accident, to determine a kind of the CCCT, to examine, estimate the received results of examination, to diagnose and define tactics of treatment. To master skills of surgical treatment of the wound, of controling bleeding, technique of carrying out a lumbar puncture, assistance in cranial trepanation, as well to fill in the medical documentation correctly. III-IV a level

2.2 The educational aims

To give a notion of importance of neurotraumatology being one of the key problems of modern medicine.

To form preventive orientations of clinical thinking.

To form a notion of the responsibility for timely and correct professional actions, system of the legal notions connected with treatment of patients with CCCT.

To be able to carry out the deontologycal approach to casualties, to master a skill of establishing psychological contact with the patient and his relatives.


3. Interdisciplinary integration

Table 1


To know

To be able

Normal anatomy

Anatomy of the brain

To differentiate pasts of the brain

Normal physiology


Functions of the brain


To differentiate functions of the brain

Pathological anatomy, topographical and operative surgery

Morphology of the brain substrata

To be able to impose to a mill aperture

General surgery,

faculty surgery


Asepsis, antiseptics, set of instruments, types of



To take the anamnesis, to carry out clinical study, methods of stop of bleeding control, ways of applying and removing sutures, application of bandages



Diuretics, hemostatics, nootropics, hormones

To administer conservative therapy in hemorrhage



To know section devoted to CCT


To carry out psychoneurologic examination and list clinical signs (general cerebral and focal)

Methods of diagnostics of neurosurgical diseases

To name methods of diagnostics


To estimate parameters of treatment results


4. Contents of the class

Discussion of main principles of diagnostics of traumatic injuries of the skull and brain. Significance of the anamnesis, the data of objective examination and auxiliary methods of diagnostics at definition of a kind of a craniocerebral trauma. Rendering assistance by the patient with the closed craniocerebral trauma at a pre-hospital stage of treatment. The description by students of X-ray films with single and multiple linear and splintered fractures of the skull. Demonstration of slides, preparations of bruises, compressions of the brain, macroscopic signs of dislocations of the brain. Selection by students of the instruments necessary for rendering urgent aid to the patient with the closed craniocerebral trauma.

Analysis of the patients with concussion, compression and contusion of the brain.

Discussion of pathomorphologic changes in a brain, determination of the kind of injury. The analysis of the general cerebral and focal manifestations, characteristic of various kinds of the CCCT. Significance of auxiliary methods of diagnostics of the CCCT. While discussing patients supervised by students differential diagnostics is made, medical tactics, volume of conservative treatment is defined(determined) on clinical examples.

The compression of the brain can be caused by intracranial haematomas (epidural, subdural, intracerebral, intra-ventricular), hydromas, the pressed-in fractures, and also by growing edema of the brain, pneumocephalus. TREATMENT of intracranial haematomas is SURGICAL, osteoplastic and resectional cranial trepanations.


Complications of CCT.

Abscess - a cavity filled with pus and delimited by a capsule from the brain substance.

Layers of the abscess:

zone of disintegration;
granulation a layer (vessels are located radially in it);
fibrous (several circularly located vessels);
perifocal zone.


The capsule is formed from vessels, hence, the deeper the abscess is located in the white substance, the thinner is it capsule. The capsule is the thickest in the cortex.

Microbes: more often it is staphylococci (the thickest capsule), diplococci, coli facillus.

Pathogenesis: an embolus - ischemia - microbes with walls of the vessel - vasculitis - perivasculitis - distribution of the abscess.

Kinds of abscess perforation:

microperforation - abscesses as "cluster of grapes";
macroperforation - abscesses can perforate in the brain substance, in ventricles of the brain, in to the subarachnoidal space.

By terms of occurrence there are early (till 3 months) and late (after 3 months) abscesses. The capsule of the abscess is formed not earlier than 3-6 weeks. Till this time it is possible to wash it out with solutions of antiseptics and antibiotics (Canamycin, Levomycetin, Gentamycin) through a fistula and drainage. As a result of it the cavity is formed which is then removed, or the cavity is closed gradually by itself and pushes out a drainage. This tactics is acceptable in deeply located abscesses.

Kinds of a surgery:

total removal.


The clinical picture of the early abscess develops from general brain and focal symptoms.

Late abscesses have a course as:

apoplexies: sudden development of general brain symptoms. More often death occurs the first 24 hours. Blood and the eye fundus can not react in any way.

By the course there are acute the period, latent, marked clinical manifestation (or - early manifestation, latent manifestation of the abscess, terminal. The latent period is a silent course of the abscess).

pseudotumorous variant of the course. Blood does not react. On the eye fundus stagnation is determined. The general brain and focal manifestations gradually grow.

More than 50 % of all abscesses are accompanied by epileptic attacks. In 30 % of cases they are first signs of the abscess. They have s course as the general and focal generalized attacks. There is marked polymorphism of attacks (multifoci in a trauma and growth of the abscess).


examination of the head;
R-graphy of the skull;
investigation of the eye fundus;
EEG - in development of seizures (only for lateralization of the process);
angiography, CT-SCAN, MRI, scintigraphy.



Epilepsy is a pathological excitation of the brain accompanying by convulsive or convulsive-free attack.


convulsive readiness of the brain;
presence of the epileptogenic center - cicatrices (cerebral, meningeal - cerebral, it is cutaneous - meningeal-cerebral);
consequences of the inflammatory process;
development of subarachnoidal cysts (inflammation, subarachnoidal haemorrhages);
presence of foreign bodies (a bone, a bullet, splinters, soft tissues);
hydrocephalus of the brain.


Structure of epileptic attacks:

the general the patient - suddenly loses consciousness, falls, the face reddens, the tonic spasms passing in to clonicoues, cyanosis of integuments, involuntary urination.
the focal - always there is an aura (motor, sensor, psychosensor, vegetative)
Jackson attacks without loss of consciousness and without generalization of spasms (motor and sensor) - convulsive discharge in some group of muscles, paresthesias in some extremity. It upper parietal lobule is affected the attack proceeds by hemitype.
psychosensor equivalents - petit mall - short-term, loss of consciousness for 20-30 seconds without any convulsive component and without falling down.


Phases of formation of the cicatrix of the brain: glial, argirophil, collagenic.

Examination of the patient with seizures:

R-graphy of the skull in two projections;
EEG - acute wave are determined in the focus. In irritation (by light, sound, hyperventilation, bemegrid 1 ml, thyopental sodium - slower waves are determined in the focus)


Indications to the operation:

foreign bodies;
the pressed-in fractures;
adhesive or cystic arachnoiditis
absence of effect of medicamentous treatment at often attacks;
progredient course of the disease;
increasing degradation of the personality.


Contra-indications to the operative intervention:

massive adhesive processes;
multiple wounds (fraction);
processes in the vital sections of the brain.


The combined trauma - simultaneous injury by one kind of mechanical energy of two or more anatomical-topographical systems (craniovertebral, cranio-transabdominal).

Multiple trauma - simultaneous injury by one kind of damaging energy of one body, or several bodies of one system (multiple contusions of the brain, multiple fractures of the lower extremity).

The combined affection - injury of the organism by various damaging factors working simultaneously (mechanical, thermal, radial energy).


damages of the facial skeleton
damages of the thorax and respiratory organs
damages of the abdominal cavity
damages of the spine and spinal cord
cranial damages

Classification of combined CCT by a degree of severity:

severe CCT and severe extracranial (shock in 70 %)
severe CCT and not severe extracranial (shock in 14-15 %)
not severe CCT and severe extracranial (shock in 40-50 %)
not severe CCT and not severe extracranial (shock in 4-5 %)

The leading part in development of shock in CCT is played by an extracranial pathology. The shock in isolated CCT develops in:

multiple injures of the bones of the arch and the basis of the skull (of type)
multiple injures of soft tissues of the head (of hemorrhagic type)
in children (any haematomas can cause a hypovolemic shock)

Difference of shock from damages of the brain stem. If there is a decrease of hemodynamics, disturbances of breath and stem (floating eyeballs, anisocoria, Chaine-Stocks respiration) it should be attributed to CCT. Isolated CCT has shock in 1-1.5 % of cases.

In mild CCT there is an amplification of function of the hypophysis (secretion of СТH grows), promoting the prompt formation of an osseous callous. And in severe CCT - function of the hypophysis is suppressed.


Facial damages:

single fracture of the jaw
traumatic extraction of a tooth
injures of soft tissues, without a severe bleeding
Лефор 2, 3
multiple damages of the facial skeleton

Thoracic damages

fracture of the clavicle
fracture up to 3 ribs without damage of the organs of the chest, nerves and vessels
fracture of ribs with damage of the vessels
damage of the organs of the chest
damage of the organs of the mediastinum

Transabdominal damages

subserous rupture of the gut
any damages of hollow and parenchymatous organs

Vertebral damages

fracture of bodies, arches, but without damage of the spinal cord and roots
fracture of bodies, arches with damage of the spinal cord or roots

Damages of the locomotor system:

the closed single fracture of the forearm, shin
fracture of the pelvis, hip, open fractures, multiple fractures of bones, tearing off of the feet



Fatty embolism is characterized by sudden, quick onset (hemiparesis or a plegia, disturbances of consciousness, narrow pupils). In LP - liquor is pure or hemorrhagic. On the 2nd-3rd day there is fat in urine.

Typically haematoma has a gradual onset.

Fatty microthrombembolism occurs more often in the diencephalic areas.


Differential diagnostics of fatty embolism and intracranial haematoma

Intracranial haematoma

Fatty embolism

Severity of a craniocerebral trauma

characteristic severe CCT

the combined damages and CCT are usually a little milder

Severity of the combined damages


usually severe

Disturbance of consciousness

gradual aggravation of a degree of disturbance of consciousness

sudden sharp disturbance of consciousness

Pyramidal symptoms

gradual increase

are sharply expressed at once. If there is no pyramidal manifestation, diencephalic and mesencephalic signs develop (paresis of the look, narrowing of pupils, floating eyeballs)

Eye fundus

vessels are dilated

spasm of the arteries, haemorrhages, veins are fragmented


displacement of the M - echo

There is no displacement of the median structures

Lumbar puncture

the increased pressure, blood in liquor

transparent or xanthochromatic

Diagnostic mill apertures


Nothing is defined

R-graphy of the lungs

There is no thing

The lung with "snow"


petechial rash on a lateral surface of the stomach, fat in urine on the 2nd-3rd day


For the prevention of development of fatty embolism in patients with the combined trauma it is necessary to administer the preparations having immediate effect:

rheologic properties of blood
Lipin, Lipostabil, Essentiale
antagonists of calcium (Verapamil, Nifedipine)
to increase ОЦК (10 % NaCl 100 ml + 100 ml Rheopolyglucin)
ГОМК, Nootropics, Difenin
transfusion of liquids under the control of intracranial pressure (the control of blood osmolarity: if osmolarity is normal - intracranial pressure is normal too, if osmolarity of plasmas is reduced - intracranial pressure is always increased). It implies, that in the first 2-3 days it is better to administer osmodiuretics, and then saluretics.
Carrying out of functionally stable osteosynthesis (plates, a spoke, but not a nail):
the first 4-6 hours – in mild or moderate CCT without disturbances (shock)
on removing from a shock - in mild or moderate CCT and a shock accompanying it
after stabilization of vital functions – in severe CCT with vital disorders

If fatty embolism has developed, it is necessary to influence development of collateral vessel. Transfusion of liquids under the control of intracranial pressure (the control of blood osmolarity: if osmolarity is normal - intracranial pressure is normal too, if osmolarity of plasma is reduced - intracranial pressure is always increased).

Antagonists of calcium
increase of resistency of the brain tissue to hypoxia
The Signay-cocktail - is introduced once a day intravenously

500 ml of 20 % Mannitol

50 mg Dexasone (Metipred)

500 mg of vitamin Е

500 mg Difenine

preparations increasing elasticity of vessels (Trentalum, Theonicol) in the acute the period
Lipostabil, Inhibitors of proteases, Essentiale

Ether intramuscularly

Control questions:

The causes of a compression of the brain of a traumatic genesis.
The basic clinical signs of epidural haematoma.
The basic clinical signs of subdural haematoma.
The radiological characteristic of the pressed-in fracture of bones of the arch of the skull.
The clinical characteristic of intracerebral and intra-ventricular traumatic haemorrhage.
Early complications of CCT.
Late complications of CCT.
The basic clinical signs of a posttraumatic abscess of the brain.
Combined CCT. Classification, rendering the specialized medical aid.


5. The plan and organizational structure of the class.

Maintenance of the class: a class room, tables, scheme, slides, x-ray films, slide films, slide projector, macropreparations, sets of instruments for rendering the urgent aid to- the patient with a craniocerebral trauma, cabinets(studies) of the auxiliary diagnostics, working dressing and operational, thematic patients.

6. Materials of methodological maintenance of the class.

6.1 Materials of the control over a preparatory stage of the class.


1. Questions.

• anatomo-physiological peculiarities of the brain in various age groups;

• peculiarities of blood supply of the brain, membranes, bones of the skull; liquor system of the brain;

• radiological methods of examination of the patient with CCCT;

• focal and general brain symptoms of CCCT;

• meningeal symptoms;

• groups of preparations for complex therapy of CCCT: dehydration, hemostitics, hormonal, nootropics.


6.1.2 Materials of methodological maintenance of the basic stage of the class.


1. Tests of 1 level

1) In what space of the skull cavity there is liquor? Variants of the answer:

а) Epidural space.

b) Subarachnoidal space

c) Subdural space.

d) A sagittal crack.

e) A tentorium of the cerebellum.

Correct answer: b)

2) In injury of what area of the brain does sensor aphasia develop? Variants of the answer:

а) A pole of a frontal lobe.

b) Basal departments of the right frontal area.

c) Center of Broquar.

d) Center of Wernique.

e) A parietal lobe.

Correct answer: d)


6.1.3 Test of 2 level with a freely designed answer.

List general brain symptoms of the CCCT (eight). Correct answers:

а) A headache.

b) Dizziness.

c) Vomitting.

d) Developments of stagnation on the eye fundus.

e) Bradycardia.

f) Disturbances of consciousness.

j) Craniographic signs.

i) Episyndrome.


6.1.4 Tests of II level with a multiple choice.

Name the preparations related to group of nootropics. Variants of the answer:

а) Cinnarisin.

b) Cerebrolysin.

c) Furosemid.

d) Aminalon.

e) Pyracetam.

f) Nootropil.

g) Pantogam.

i) Cogitum.

j) Trentalum.

k) Sincumar.

Incorrect: а) c) f) k) j)



№1. During quarrel the victim was knocked by a hammer on a head. He did not lose consciousness. There was bleeding from a wound in the left parietal area. He was brought to a neurosurgical hospital. On examination: a lacerated-contused, moderately bleeding wound in the left parietal area, hemiparesis on the right. It is necessary to make the preliminary diagnosis, to define the plan of examination and treatment.

The answer: the preliminary diagnosis - the open penetrating pressed-in fracture in the left parietal area. The plan of examination – craniograms in two projections, echoencephalography. The plan of treatment –establishment of the pressed-in fracture, a decompression of the brain.

№ 2. The brick has fallen to the head of the patient 32 ages. There was a short-term loss of consciousness. The wound in the frontal area was treated by iodine, the aseptic bandage was applied. In the evening the condition of the patient and headache worsened, there was, vomitting, weakness in the left extremities. On examination: anisocoria D is more than S, a moderate hemiparesis on the left, in the posterior parts of the frontal area on the right, parasacrally, a contused wound of 2,5 cm; on X-ray images – the pressed-in fracture in this area. What is preliminary diagnosis and what tactics should be applied on examination and treatment of this patient?

The answer: the preliminary diagnosis is the open penetrating pressed-in fracture in the posterior part of the frontal area on the right. Medical tactics will consist in carrying out primary surgical treatment of the wound, elimination of the pressed-in penetrating fracture of the arch of the skull with administration of the anti-inflammatory therapy directed at the prevention of early and late purulent processes.

№ 3. During hunting the victim has received a gunshot wound. The entrance aperture was moderate bleeding, located in the right temporal area. Was at the moment of examination the patient on conscious. Anisocoria D is more than S. Make the preliminary diagnosis and defines methods of diagnostics and the treatments indicated to this patient.

The answer: the preliminary diagnosis is open gunshot injury of the skull and brain of the right temporal area. It is necessary to make craniograms, CT-scan - study. Medical tactics – to make primary surgical treatment of the entrance aperture with the subsequent administration of anti-inflammatory and dehydration therapy.

№ 4. The patient was brought to the special traumatological department in the condition of alcoholic intoxication. Psychomotor excitation was marked. In the area of the left temple the ecchymosis is revealed, bloody fluid discharged from the external acoustic meatus on the left. The diagnosis is alcoholic intoxication. Treatment was administered. In 6 hours after admission the patient had an attack of tonic spasms, the anisocoria (the left pupil was more than right), a condition of deep sopor developed. Estimate the condition of the patient; specify the plan of examination and treatment. What tactical mistake has been made in establishing the diagnosis?

The answer: the condition of the patient is extremely severe with a syndrome of dislocation and wedge of the brain stem in the big aperture of stem structures of the brain. The plan of examination – a craniography, CT-scan - study. According to vital indications urgent operation is indicated decompressive cranial trepanation in the left frontal-temporal area, removal of haematoma. The tactical mistake was, that liquorrhoea from the left was underestimated ear, as a symptom of fracture of the basis and the arch of the skull (middle cranial fossa) and probability of development of intracranial traumatic haemorrhage that has not been taken into account on primary examination of the patient because of his alcoholic intoxication.


6.2 Materials of methodological maintenance of the basic stage of the class.

Professional algorithm of examination of the patient with CCCT:

1. Examination of the patient.

2. An anamnesis (duration of a trauma, heredity).

3. Complaints (a headache, vomitting, disturbances of sight, seizures).

4. Objective examination of internal organs (necessarily AP and pulse on both hands).

5. Study of disturbances of consciousness a degree (a coma by Glasgow from 3 up to 15).

6. Study of 12 pairs of the cranial nerves.

7. Study of the motor-sensitive sphere (reflexes, definition of sensitivity disorders).

8. Definition of statics and coordination.

9. Definition of the meningeal syndrome.

10. Local examination of the head.

11. Detection of liquid, outflow blood from the nose, ears.

12. Detection of external damages of the soft tissues.

13. Craniograms in two projections.

14. Additional methods of investigation if necessary.


Professional algorithm of carrying out a lumbar puncture:

1. Position of the patient on the right side.

2. Legs are bent in the knees and held against the stomach.

3. Treatment of the hands with an antiseptic, sterile gloves.

4. Treatment of the field with 5% iodine, then alcohol at the level of 3-5 lumbar vertebra.

5. Local anesthesia with 0,5% by a solution of Novocaine at the level of the intervertebral fissure between the 4th and 5th lumbar vertebra.

6. The control of a needle (presence of a mandrin, an sharpness of the needle).

7. A lumbar puncture. During the puncture there is sensation of two obstacles (a yellow ligament and the dura mater membrane) and downfall.

8. Slow pulling up of a mandrin from the needle, checking liquor presence.

9. In the extended mandrin evacuation of 1-2 ml of liquor for the analysis.

10. Removal of the needle and application of the aseptic label.


Educational task:

Define neurosurgical tactics and specify a method of treatment at each kind of fractures of the skull bones:

а) Linear fracture;

б) Pressed-in fracture:

1 - closed

2 - open

в) Multisplintered:

1 - penetrating

2 - non penetrating

Correct tactics:

а) Conservative treatment.

б) 1 - conservative tactics is possible depending on the zone;

2 - operative tactics.

в) Operative tactics in all cases.


6.3 Materials of the control of the final stage.


The test of III level.

In what form of the disease are the following symptoms observed?






Epidural haematoma

Subdural haematoma

Intracerebral haematoma

Subarachnoidal haemorrhage





Blood in the liquor


Expansion of the 3th ventricle

Displacement the M - echo

Symptom Kernig’s


Protein-cellular dissociacion
























































Situational tasks:

1) The patient is found in the yard without consciousness, a smell of alcohol from the mouth.

Locally there are edema of soft tissues in the right temporal area, anisocoria on the right, areflexia. Define the plan of examination, medical tactics.

ANSWER: hospitalization to the NEUROSURGICAL DEPARTMENT, CT-SCAN, cranial trepanation, removal of the intracranial haematoma.


2) The patient was treated for the CCCT - fracture of the temporal bone on the left. In 10 hours after of the trauma - sharp deterioration, coma 4-5 Glasgow, breath disorder, periodic tonic spasms, wide pupils have developed, photoreaction is languid, the left pupil is a little bit wider then the right one.

QUESTION: What can the change of a clinical picture are caused by? Define tactics of the doctor.

The ANSWER: Enlargement of the epidural haematoma on the left, a dislocation of the median structures of the brain. Tactics of the doctor - urgent operative intervention due to vital indications (cranial trepanation).


3) A youth of 18 years had CCCT at 12 years. The next years he periodically had headaches, had two attacks of loss of consciousness. He finished school and studies in college.

QUESTION: What is plan of examination and treatment?

ANSWER: Psychoneurologic inspection, EEG, CT-SCAN of the brain.


Control questions while analyzing patients with CCCT.

1. Classification of CCCT.

2. Name possible variants of traumatic injures of the skull.

3. What kind of trauma is fracture of the basis of the skull with liquorrhoea related to?

4. What can compression of the brain be caused by in CCCT?

5. In what cases of CCCT is the lumbar puncture made very cautiously?

6. In what cases of CCCT is the surgery applied?

7. How do you understand the term «the Light interval»? What kind of CCCT is it characteristic of?

8. What are peculiarities of clinical course of CCCT, combined with alcoholism and narcotism?

9. Describe early and late complications of CCCT.

10. Determine the scope of conservative therapy.

11. The causes of a compression of the brain of a traumatic genesis.

12. The basic clinical signs of epidural haematoma.

13. The basic clinical signs of subdural haematoma.

14. The radiological characteristic of the pressed-in fracture of bones of the arch of the skull.

15. The clinical characteristic of intracerebral and intra-ventricular traumatic haemorrhage.

16. Early complications of CCT.

17. Late complications of CCT.

18. The basic clinical signs of a posttraumatic abscess of the brain.

19. Combined CCT. Classification, rendering the specialized medical aid.


6.4 Materials of methodological maintenance of self-preparation of students.

Orientation map for students’ work with the educational literature. This form does not include student’s aid as training at the 5th year intends to develop skills of independent work with the literature.

7. The literature.

The basic:

Иргер И.М. Нейрохирургия. М.: Медицина, 1982.
Ромоданов А.П. Нейрохирургия. Киев: Здоровье, 1990.
Нейротравматология. Справочник под. ред. Коновалова А.Н. М.: Медицина, 1996.


Арутюнов И.А. Тяжелая черепно-мозговая травма. М.: Медицина, 1969.
Исаков Ю.В. Острые травматические внутричерепные гематомы. М.: Медицина, 1977.
Ромоданов А.П., Педаченко Г.А. Черепно-мозговая травма при алкогольной интоксикации. Киев: Здоровье, 1982.

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