Published on 10/04/2015 by admin

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Last modified 10/04/2015

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CHAPTER 18 Neurosurgery

Head injuries

image It is recommended that all patients are monitored using the Glasgow Coma Scale after initial resuscitation (→ Table 4.1, in Ch. 4). In all cases, the diagnosis and initial treatment of serious extracranial injuries takes priority over investigations of head injury, or transfer to a neurosurgical unit.

Assessment of head injury

Evaluate CNS injury

Assess the level of consciousness as this is the most significant factor after head injury. Use GCS (→ Table 4.1) and check pupillary reactions. Pupillary changes may indicate brain swelling or compression. Pressure on a cerebral hemisphere causes the third nerve on that side to be stretched over the edge of the tentorium. The resultant paralysis of the nerve allows unopposed action of the dilator pupillae under the control of the sympathetic nervous system and the pupils dilate. There is also loss of light reaction of the pupil on the affected side. If compression continues, the contralateral third nerve is compressed and the opposite pupil also dilates and is fixed to light. Bilateral fixed dilated pupils in a patient with a head injury are a grave prognostic sign and recovery is rare. Pupillary changes are always late signs (‘undertaker signs’), and are always preceded by an alteration in conscious level caused by raised intracranial pressure. Direct blows to the eyes can cause dilated pupils in patients without severe brain injury.

Skull fractures

They may be further classified as follows:

Intracranial bleeding