Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
There are a variety of types of head injuries, and the outcomes vary greatly. One type of brain injury is an epidural hematoma. The acclaimed actress Natasha Richardson suffered this type of hematoma after falling while skiing in Canada in 2009. Unfortunately, despite all of the emergency care Ms. Richardson's received, she did not survive.
An epidural hematoma occurs when there is bleeding between the dura mater (a tough fibrous layer of tissue between the brain and skull) and the skull bone. These occur when arteries are torn as a result of a blow to the head, and injury in the temple area is a common cause. Although the pattern of a lucid interval followed by later neurological symptoms is characteristic, only a minority of patients display this pattern of symptoms. Reported death rates from epidural hematoma vary widely, ranging from 5% to over 40%, depending upon the patient population under study.
To begin understand how something like this can happen, let's review the serious topic of minor head trauma and the potential that it has to become major head trauma.
Minor head injuries are defined as those where trauma
causes a temporary loss of mental function, however, there is still a potential
risk that something bad might happen. In fact, there are numerous guidelines to
help physicians decide who might need a CT scan to look for brain bleeding or
injury. The February 2009 edition of the Annals of Emergency Medicine contained
an article that compared six different sets of guidelines. The conclusion was
that each worked equally well in predicting who may or may not have bleeding in
the brain. If the symptoms were not present, then it was safe to reassure the
patient and family and let them go home. If symptoms were there, a CT scan was needed to look for
brain damage.
Head injuries are one of the most common causes of death
and disability in the United States. Every year, almost a quarter million people
are hospitalized because of traumatic injuries to the brain, and 50,000 people die. As well,
80-90,000 people sustain long-term or lifelong disabilities because of a brain
injury each year. Children are not excluded, with more than 2,500 deaths and
almost a half million emergency department visits per year for head injuries.
Blows to the head most often cause brain injury, it is
important to remember that the face and jaw are located in the front of the head. Brain injury may
also be associated with injuries to these structures. It is also important to
note that a head injury does not always mean that there is also a brain injury.
The brain is a rather soft, pliable material almost jelly-like in feel, and
is surrounded by a thin layer of cerebrospinal fluid
(CSF). The brain is
surrounded by thin layers of tissue called the meninges;
1) the pia mater, 2) the
arachnoid mater, and 3) the dura mater. The CSF is present in the space beneath the
arachnoid layer called the subarachnoid space.
The dura mater is very thick and has septae, or
partitions, that help support the brain in the skull. The septae attach to the
inner lining of the bones of the skull. The dura mater also helps support the
large veins that return blood from the brain to the heart.
The spaces between the meninges are usually very small but they can fill with
blood when trauma occurs, and this build-up of blood can potentially press into
the brain tissue and cause damage.
The skull protects the brain from trauma but it does not
absorb any of the
impact from a blow. Direct blows may cause fractures of the skull; there can be
a contusion or bruising and bleeding to the brain tissue directly beneath the
injury site. However, the brain can bounce around inside the skull if it is
subject to significant force and because of this, the brain injury may not
necessarily be located directly below the trauma site. A contre-coup injury
describes the situation in which the initial blow causes the brain to bounce and
is damaged by hitting the skull directly opposite the trauma site.
Acceleration/deceleration and rotation are the common types of forces that can
cause injuries away from the area of the skull that received the trauma.
Picture of the brain and potentially brain injury areas
Head injuries due to bleeding are often classified by the location of the
blood within the skull.
Epidural hematoma: With an epidural hematoma, the bleeding is located between the dura mater and
the skull. This is often present along the side of the head where the middle
meningeal artery runs in a groove along the
temporal bone. This
bone is relatively thin and offers less protection than other parts of the
skull. As the bleeding continues, the hematoma or clot expands. There is little
space in the skull for the hematoma to grow and as it expands, the adjacent
brain tissue is
compressed. As the pressure increases, the whole brain begins to shift and
becomes compressed against the bones of the skull. The pressure tends to build
quickly because the septae that attach the dura to the skull bones create small
spaces that trap blood. Symptoms of head injury and decreased level of
consciousness occur as the pressure increases.
Subdural hematoma: A subdural hematoma is located beneath the dura mater
(sub=below), between it and the arachnoid mater. Blood in this space is able to
dissipate into a larger space because there are no septae limiting the blood
flow. However, after a period of time, the amount of bleeding may cause
increased pressure and cause symptoms similar to those seen with an epidural
hematoma.
Subarachnoid bleed: Subarachnoid bleeding occurs in the space beneath the
arachnoid layer where the CSF is located. Often there is intense
headache and
vomiting with
subarachnoid bleeding. Because this space connects with the spinal canal,
pressure build-up tends not to occur. However, this injury often occurs in
combination with the other types of bleeding in the brain, and the symptoms can
be compounded.
Intracerebral bleed: Intracerebral bleeding occurs within the brain tissue
itself. Sometimes the amount of bleeding is small, but like bruising in any
other part of the body, swelling or
edema may occur over a period of time,
causing a progressive
decrease in the level of consciousness and other symptoms of head injury.
Sheer injury: Sometimes, the damage is due to sheer injury, where
there is no obvious bleeding in the brain, but instead the nerve fibers within the brain are
stretched or torn. Another term for this type of injury is diffuse axonal
injury.
Edema: All injuries to the brain may also cause swelling or
edema, no different than the swelling that surrounds a
bruise on an arm or leg. However, because the
bones of the skull cannot stretch to accommodate the extra volume caused by
swelling, the pressure increases inside the skull and causes the brain to
compress against the skull.
Scull fracture: The bones of the skull are classified as flat bones,
meaning that they do not have an inside marrow. It takes a significant amount of force to break the
skull, and the skull does not absorb any of that impact. It is often transmitted
directly to the brain.
Skull fractures are described by which bone is broken, whether there is an
associated laceration of the scalp, and whether the bone is depressed and
potentially pushed into the brain tissue.
Brain injuries often occur in combination with one another. The effects of
brain injury depend upon the amount of brain tissue damaged and the level of
pressure within the skull and its effects on the brain.
Headaches can be divided into two categories: primary headaches and secondary headaches. Migraine headaches, tension headaches, and cluster headaches are considered primary headaches. Secondary headaches are caused by disease. Headache symptoms vary with the headache type. Over-the-counter pain relievers provide short-term relief for most headaches.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
Nausea is an uneasiness of the stomach that often precedes vomiting. Nausea and vomiting are not diseases, but they are symptoms of many conditions. The causes of vomiting differ according to age, and treatment depends upon the cause of nausea and vomiting.
Fainting, also referred to as blacking out, syncope, or temporary loss of consciousness has many causes. Often a person will have signs or symptoms prior to the fainting episode. Diagnosis and treatment depends upon the cause of the fainting or syncope episode.
A hematoma is a collection of blood that is outside a blood vessel. There are different areas where hematomas occur including the inside the skull, scalp, ear, septum, bones, finger and toenails, and intra-abdominal. Treatment for hematomas depend on the type and location of the hematoma.
Internal bleeding occurs when an artery or vein is damaged and blood to escapes the circulatory system and collects inside the body. Internal bleeding can be caused by a variety of situations such as blunt trauma, deceleration trauma, medications, fractures, and spontaneous bleeding. Treatment of internal bleeding depends on the cause of the bleeding.
Epilepsy is a brain disorder in which the person has seizures. There are two kinds of seizures, focal and generalized. There are many causes of epilepsy. Treatment of epilepsy (seizures) depends upon the cause and type of seizures experienced.
Fractures occur when bone cannot withstand the outside forces applied to the bone. Fractures can be open or closed. Types of fractures include: greenstick, spiral, comminuted, transverse, compound, or vertebral compression. Common fractures include: stress fracture, compression fracture, rib fracture, and skull fracture. Treatment depends upon the type of fracture.
Pulmonary edema (swelling or fluid in the lungs) can either be caused by cardiogenic causes (congestive heart failure, heart attacks, abnormal heart valves) or noncardiogenic causes such as ARDS, kidney failure, high altitude, pneumothorax, pleural effusion, aspirin overdose, pulmonary embolism, and infections. The treatment of pulmonary edema depends on the cause of the condition.
Concussion is a short-lived loss of brain function that is due to head trauma. There are two types of concussion, simple and complex. Symptoms of concussion include headache, nausea, dizziness, dazed feeling, irritability, visual symptoms. Physical signs include poor concentration, emotional changes, slurred speech, and personality changes. Concussion is diagnosed with physical examination and testing. Treatment for concussion in general are treatment for control of the symptoms, and time.
Coma is the inability to waken or react to the surrounding environment. The Glasgow Coma Scale is frequently used to measure the depth of coma. Causes of coma include trauma, bleeding, edema, lack of oxygen, poisoning, or hypoglycemia. Prognosis for a patient in a coma depends on the cause of the coma.
A brain hemorrhage is a type of stroke caused when an artery bursts in the brain, causing localized bleeding in the surrounding tissue. Causes of brain hemorrhage include aneurysm, liver disease, brain tumor, head trauma, high blood pressure, and blood vessel abnormalities. Symptoms include sudden severe headache, nausea, vomiting, loss of balance, tingling, numbness, vision changes, loss of consciousness, and loss of fine motor skills. Treatment depends upon the cause, location, and size of the brain hemorrhage.
Psychotic disorders are a group of serious illnesses that affect the mind. Different types of psychotic disorders include schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, shared psychotic disorder, delusional disorder, substance-induced psychotic disorder, paraphrenia, and psychotic disorders due to medical conditions.
Aphasia is a condition that is the result of damage to portions of the brain. It can be caused by stroke, head injury, brain tumor, or infection. There are two types of aphasia, fluent and non-fluent. Some patients may fully recover from aphasia over time, while others may not.
Medical shock is a life-threatening medical condition. There are several types of medical shock, septic shock, anaphylactic shock, cardiogenic shock, hypovolemic shock, and neurogenic shock. Causes of shock include heart attack, heart failure, heavy bleeding (internal and external), infection, anaphylaxis, spinal cord injury, severe burns, chronic vomiting or diarrhea. Low blood pressure is the key sign of sock. Treatment is dependant upon the type of shock.
Seizures are divided into two categories: generalized and partial. Generalized seizures are produced by electrical impulses from throughout the brain, while partial seizures are produced by electrical impulses in a small part of the brain. Seizure symptoms include unconsciousness, convulsions, and muscle rigidity.
Brain lesions (lesions on the brain) are caused by trauma, inflammation, autoimmune diseases, cancers, other diseases, stroke, bleeding, pituitary adenomas, and cerebral palsy. Symptoms of brain lesions include headache, nausea, fever, neck pain and stiffness, affected vision and speech, weakness or paralysis to one side of the body. Diagnosis of brain lesions is generally with imaging studies like CT or MRI scans. Treatment and prognosis of brain lesions depends on the cause of the lesion.
The most common cause of a black eye is due to an injury to the face or head. Most black eye injuries are minor and heal on their own, however, some may lead to significant injury. In addition to trauma to the face, cosmetic surgery can cause a black eye(s) as a side effect. People should be aware of the situations in which medical care should be sought immediately for a black eye.
Hemophilia is one of a group of inherited bleeding disorders. Hemophilia A and B are inherited in an X-linked recessive genetic pattern and is more common in males. Symptoms of hemophilia include bleeding into the joints, muscles, GI or urinary tract, or brain or skull. Treatments for hemophilia is generally replacement of blood clotting factors.
Idiopathic means that the cause of the condition isn't known. Thrombocytopenic means there's a lower than normal number of platelets in the blood. Purpura refers to purple bruises caused by bleeding under the skin. Idiopathic thrombocytopenic purpura (ITP) is a bleeding condition in which the blood doesn't clot as it should. This is due to a low number of blood cell fragments called platelets.
Hypersomnia is a condition where a person has excessive daytime sleepiness and trouble staying awake during the day. Treatment for hypersomnia includes medication, CPAP machines, and lifestyle changes.
Stroke is the third leading killer in the United States. Some of the warning signs of stroke include sudden confusion, trouble seeing with one or both eyes, dizziness, loss of balance, and more. Stroke prevention and reatable risk factors for stroke include lowering high blood pressure, quit smoking, heart disease, diabetes control and prevention.
A computerized axial tomography scan is an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. Computerized axial tomography is more commonly known by its abbreviated names, CT scan or CAT scan. A CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments.
A large donut-shaped x-ray machine takes x-ray images at many different angles around the body. These images are processed by a computer to produce cross-sectional pictures of the body. In each of these pictures the body is seen as an x-ray "slice" of the body, which is recorded on a film. This recorded image is called a tomogram. "Computerized Axial Tomography" refers to the recorded tomogram "sections" at different levels of the bod...
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