Chmt treatment. Consequences of traumatic brain injuries - treatment. Prognosis of traumatic brain injury

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the duration and severity of which depends on the degree of mechanical impact on brain tissue.

Long-term consequences

Long-term consequences of TBI can manifest as neurological disorders:

• sensitivity disorders (numbness of the hands, feet, burning sensations, tingling sensations in various parts of the body, etc.),
• movement disorders (tremors, coordination disorders, convulsions, slurred speech, stiffness of movements, etc.),
• changes in vision (double vision, blurry focusing)
• mental disorders.

Mental disorders and behavioral disorders due to brain injuries can be expressed in different conditions: from fatigue to a pronounced decrease in memory and intelligence, from sleep disturbances to incontinence of emotions (attacks of crying, aggression, inadequate euphoria), from headaches to psychoses with delusions and hallucinations.

The most common disorder in the picture of the consequences of brain injuries is asthenic syndrome.

The main symptoms of asthenia after traumatic brain injury are complaints of fatigue and rapid exhaustion, the inability to bear additional stress, and unstable mood.

Characterized by headaches that get worse with exercise.

An important symptom of an asthenic condition that occurs after a traumatic brain injury is increased sensitivity to external stimuli (bright light, loud sound, strong odor).
It is very important to know that much depends on whether the concussion or brain injury occurred for the first time, or whether the patient has repeatedly suffered such injuries at home. The outcome and duration of treatment directly depends on this.

If a patient has a history of more than 3 concussions, the period of treatment and rehabilitation is significantly longer and the likelihood of complications also increases.

Diagnosis of traumatic brain injury

In case of traumatic brain injury, diagnostic procedures must be performed urgently.

It is also important to be examined and observed by specialists monthly after injury.
As a rule, methods of magnetic resonance imaging, computed tomography, and radiography are used in the diagnosis of TBI.

Treatment of TBI and consequences of brain injuries

In the acute period, decongestant, neurometabolic, neuroprotective, symptomatic therapy is carried out, which consists of selecting several medicines offered both in the form of tablet preparations and in the form of injections (drip and intramuscular).

This treatment is carried out for about a month. After which the patient remains under the supervision of his attending physician, depending on the severity of the TBI, from six months to several years.

For at least three months after TBI, it is strictly prohibited to take alcoholic drinks and heavy physical activity.

In addition to traditional methods of treating TBI, there are no less effective methods:

In combination with drug therapy and physical therapy, these techniques can have a more pronounced and faster effect. However, in some cases they are contraindicated for use.

Everyone knows the fact that treatment must be comprehensive, and the more techniques are used during treatment, the better.

After completing the course of treatment, the patient must be under the supervision of a doctor, and subsequently he may need repeated courses, usually once every six months.

Possible complications

If left untreated, brain injury often causes complications. The most dangerous consequences are considered to be long-term ones, which initially form latently. When, against the background of general well-being, a complex pathology develops without visible symptoms. And only after several months, or even years, an old brain injury can make itself felt.

The most common among them are:

• headaches, often with nausea and vomiting,
• dizziness,
• memory impairment,
• formation of mental pathology, etc.

Traumatic brain injuries represent a danger that the patient may not be aware of.

After hitting your head, various types of problems can arise, even when there is no visible symptoms concussions ( headache, dizziness, vomiting, pressure on the eyes, feeling of fatigue, drowsiness, blurred vision).

In many cases, the consequences of brain injury can be accompanied by displacement of the cervical vertebrae, which can also lead to:

• headaches,
• neck pain,
• memory impairment,
• increased fatigue subsequently.

Brain injury is often the trigger for diseases such as:

• facial neuritis,
• pathologies of the trigeminal and other facial nerves.

this may be accompanied by pain on one side of the face or muscle weakness on one side of the face.

The Brain Clinic conducts all types of research and comprehensive treatment of the consequences of brain injuries.

Among the causes of death in young and middle age, trauma ranks first. Traumatic brain injury (TBI) is one of the most common types of injuries and accounts for up to 50% of all types of injuries. In injury statistics, brain injuries account for 25-30% of all injuries, accounting for more than half of deaths. Mortality from traumatic brain injury accounts for 1% of total mortality.

Traumatic brain injury is damage to the bones of the skull or soft tissues, such as brain tissue, blood vessels, nerves, and meninges. There are two groups of traumatic brain injuries - open and closed.

Classification of TBI

Open damage

With an open craniocerebral injury, the skin and aponeurosis are damaged and the bottom of the wound is bone or deeper tissue. A penetrating injury is one in which the dura mater is damaged. Special case penetrating trauma - otoliquorrhea as a result of a fracture of the bones of the base of the skull.

Closed damage

In a closed head injury, the aponeurosis is not damaged, although the skin may be damaged.

All traumatic brain injuries are divided into:

• A concussion is an injury in which there are no permanent disturbances in the functioning of the brain. All symptoms that occur after a concussion usually disappear over time (within a few days). Persistent symptoms are a sign of more serious brain damage. The main criteria for the severity of a concussion are the duration (from several seconds to hours) and the subsequent depth of loss of consciousness and the state of amnesia. Non-specific symptoms - nausea, vomiting, pallor skin, cardiac dysfunction.
• Compression of the brain (hematoma, foreign body, air, focus of injury).
• Brain contusion: mild, moderate and severe.
• Diffuse axonal damage.
• Subarachnoid hemorrhage.

At the same time, various combinations of types of traumatic brain injury can be observed: bruise and compression by a hematoma, bruise and subarachnoid hemorrhage, diffuse axonal damage and bruise, brain contusion with compression by a hematoma and subarachnoid hemorrhage.

Symptoms of TBI

symptoms of impaired consciousness - stupor, stupor, coma. Indicate the presence of a traumatic brain injury and its severity.
symptoms of damage to the cranial nerves indicate compression and contusion of the brain.
symptoms of focal brain lesions indicate damage to a certain area of ​​the brain; they occur with a bruise or compression of the brain.
stem symptoms are a sign of compression and contusion of the brain.
meningeal symptoms - their presence indicates the presence of a brain contusion or subarachnoid hemorrhage, and a few days after the injury it can be a symptom of meningitis.

Treatment for concussion

All victims with a concussion, even if the injury seems mild from the very beginning, must be transported to an emergency hospital, where, to clarify the diagnosis, radiography of the skull bones is indicated; for a more accurate diagnosis, if equipment is available, a CT scan of the brain can be performed.

Victims in the acute period of injury should be treated in the neurosurgical department. Patients with a concussion are prescribed bed rest for 5 days, which is then, taking into account the characteristics clinical course, are gradually expanding. In the absence of complications, discharge from the hospital is possible on the 7-10th day. ambulatory treatment lasting up to 2 weeks.

Drug treatment for concussion is aimed at normalizing the functional state of the brain, relieving headaches, dizziness, anxiety, and insomnia.

Typically, the range of drugs prescribed upon admission includes analgesics, sedatives and hypnotics:

Painkillers (analgin, pentalgin, baralgin, sedalgin, maxigan, etc.) select the most effective drug for a given patient.

For dizziness, choose one of the available medications (cerucal)
Sedatives. They use infusions of herbs (valerian, motherwort), drugs containing phenobarbital (Corvalol, Valocordin), as well as tranquilizers (Elenium, Sibazon, phenazepam, nozepam, rudotel, etc.).

Along with symptomatic treatment in case of a concussion, it is advisable to carry out a course of vascular and metabolic therapy for faster and full recovery disorders of brain function and prevention of various post-concussion symptoms. Prescription of vasotropic and cerebrotropic therapy is possible only 5-7 days after injury. A combination of vasotropic (Cavinton, Stugeron, Teonicol, etc.) and nootropic (nootropil, aminolon, picamilon, etc.) drugs is preferable. Take Cavinton three times a day, 1 tablet. (5 mg) and nootropil 1 cap. (0.4) for 1 month.

To overcome frequent asthenic phenomena after a concussion, multivitamins such as “Complivit”, “Centrum”, “Vitrum”, etc. are prescribed, 1 tablet each. in a day.

Tonic preparations include ginseng root, eleutherococcus extract, and lemongrass fruit.

A concussion is never accompanied by any organic lesions. If any post-traumatic changes are detected on CT or MRI, it is necessary to talk about a more serious injury - brain contusion.

Brain contusion due to TBI

A brain contusion is a violation of the integrity of the brain matter in a limited area. It usually occurs at the point of application of the traumatic force, but can also be observed on the side opposite to the injury (contusion from a counter-impact). This causes destruction of part of the brain tissue. blood vessels, histological cell connections with the subsequent development of traumatic edema. The area of ​​such violations varies and is determined by the severity of the injury.
There are mild, moderate and severe brain contusions.

Mild brain contusion

A mild brain contusion is characterized by loss of consciousness after injury lasting from several to tens of minutes.

• After regaining consciousness, typical complaints are headache, dizziness, nausea, etc.
• As a rule, retro-, con-, and anterograde amnesia is noted. Amnesia (Greek: amnesia forgetfulness, memory loss) is a memory impairment in the form of loss of the ability to retain and reproduce previously acquired knowledge.
• Vomiting, sometimes repeated. Moderate bradycardia may be observed. Bradycardia is a decrease in heart rate to 60 or less per minute in an adult.
• tachycardia - an increase in heart rate over 90 beats per minute for adults.
• sometimes - systemic arterial hypertension hypertension - increased hydrostatic pressure in blood vessels, hollow organs or body cavities.
• Breathing and body temperature without significant deviations.
• Neurological symptoms are usually mild (clonic nystagmus - involuntary rhythmic biphasic movements of the eyeballs, drowsiness, weakness)
• slight anisocoria, signs of pyramidal insufficiency, meningeal symptoms, etc., often regressing within 2-3 weeks. after injury.

It is almost impossible to differentiate between a concussion and a mild cerebral contusion (concussion) by the duration of coma and post-traumatic amnesia, as well as by clinical manifestation.

The classification adopted in Russia allows for the presence of linear fractures of the cranial vault with mild brain contusion.
An analogue of a mild brain contusion in the domestic classification is a minor head injury by American authors, which implies a condition that meets the following criteria:

1) more than 12 points on the Glasgow Coma Scale (during observation in the clinic);
2) loss of consciousness and/or post-traumatic amnesia not exceeding 20 minutes;
3) hospitalization for less than 48 hours;
4) absence clinical signs contusions of the brain stem or cortex.

Unlike a concussion, with a brain contusion, the structure of the brain tissue is disrupted. So, with a mild bruise, a mild damage to the brain substance is microscopically determined in the form of areas of local edema, pinpoint cortical hemorrhages, possibly in combination with limited subarachnoid hemorrhage as a result of rupture of the pial vessels.

With subarachnoid hemorrhage, blood enters under the arachnoid membrane and spreads through the basal cisterns, grooves and fissures of the brain. Hemorrhage can be local or fill the entire subarachnoid space with the formation of clots. It develops acutely: the patient suddenly experiences a “blow to the head”, severe headache, vomiting, and photophobia appear. There may be one-time generalized seizures. Paralysis, as a rule, is not observed, but meningeal symptoms are pronounced - rigidity of the neck muscles (when the head is tilted, the patient’s chin cannot touch the sternum) and Kernig’s sign (the leg bent at the hip and knee joints cannot be straightened at the knee joint). Meningeal symptoms indicate irritation of the membranes of the brain due to bleeding.

Moderate brain contusion

Moderate brain contusion is characterized by loss of consciousness after injury lasting from several tens of minutes to several hours. Amnesia is pronounced (retro-, con-, anterograde). The headache is often severe. Repeated vomiting may occur. Mental disorders are sometimes observed. Possible temporary disturbances in life important functions: bradycardia or tachycardia, increased blood pressure, tachypnea - rapid shallow (not deep) breathing without disturbing the rhythm of breathing and airway patency, low-grade fever - increased body temperature within 37-37.9 ° C.

Often, meningeal and brainstem symptoms, dissociation of muscle tone and tendon reflexes along the body axis, bilateral pathological signs, etc. are detected. Focal symptoms are clearly manifested, the nature of which is determined by the localization of the brain contusion; pupillary and oculomotor disorders, paresis of the limbs, disorders of sensitivity, speech, etc. These symptoms gradually (within 3-5 weeks) smooth out, but can persist for a long time. With moderate brain contusion, fractures of the bones of the vault and base of the skull, as well as significant subarachnoid hemorrhage, are often observed.

Computed tomography in most cases reveals focal changes in the form of high-density small inclusions, non-compactly located in a zone of reduced density, or a moderate homogeneous increase in density (which corresponds to small hemorrhages in the bruise area or moderate hemorrhagic impregnation of brain tissue without gross destruction). Regarding observations at clinical picture If a moderate injury occurs, a computed tomogram reveals only areas of low density (local edema) or signs of brain injury are not visualized at all.

Severe brain contusion

Severe brain contusion, intracerebral hematomas (limited accumulation of blood when closed and open damage organs and tissues with rupture (injury) of blood vessels; in this case, a cavity is formed containing liquid or coagulated blood) of both frontal lobes.

Severe brain contusion is characterized by loss of consciousness after injury lasting from several hours to several weeks. Motor agitation is often pronounced. Severe disturbances in vital functions are observed: arterial hypertension (sometimes hypotension), bradycardia or tachycardia, disorders of the frequency and rhythm of breathing, which may be accompanied by disturbances in the patency of the upper respiratory tract. Hyperthermia is pronounced. Primary brainstem neurological symptoms often dominate (floating movements of the eyeballs, gaze paresis, tonic nystagmus, swallowing disorders, bilateral mydriasis or ptosis). upper eyelid, divergence of the eyes along the vertical or horizontal axis, changing muscle tone, decerebrate rigidity, depression or increase in tendon reflexes, reflexes from the mucous membranes and skin, bilateral pathological foot signs, etc.), which obscures focal hemispheric symptoms in the first hours and days after injury . Paresis of the limbs (up to paralysis), subcortical disorders of muscle tone, reflexes of oral automatism, etc. can be detected. Sometimes there are generalized or focal epileptic seizures. Focal symptoms regress slowly; gross residual effects are frequent, primarily in the motor and mental spheres. Severe brain contusion is often accompanied by fractures of the vault and base of the skull, as well as massive subarachnoid hemorrhage.

Computed tomography reveals focal brain lesions in the form of a heterogeneous increase in density in 1/3 of cases. An alternation of areas with increased (density of fresh blood clots) and decreased density (density of edematous and/or crushed brain tissue) is determined. In the most severe cases destruction of the brain substance spreads in depth, reaching the subcortical nuclei and the ventricular system. Observation over time shows a gradual decrease in the volume of compaction areas, their merging and transformation into a more homogeneous mass already in 8-10 days. The volumetric effect of the pathological substrate regresses more slowly, indicating the existence of unresolved crushed tissue and blood clots in the focus of the contusion, which by this time become equally dense in relation to the surrounding edematous substance of the brain. The volume effect disappears by 30-40 days. after injury indicates the resorption of the pathological substrate and the formation in its place of zones of atrophy (a decrease in the mass and volume of an organ or tissue, accompanied by a weakening or cessation of their function) or cystic cavities.

In approximately half of the cases of severe brain contusion, computed tomography reveals significant areas of intense homogeneous increase in density with unclear boundaries, indicating a significant content of liquid blood and its clots in the area of ​​traumatic brain injury. The dynamics show a gradual and simultaneous decrease over 4-5 weeks. the size of the destruction area, its density and the resulting volumetric effect.

Damage to the structures of the posterior cranial fossa (PCF) is one of the severe types of traumatic brain injury (TBI). Their peculiarity lies in their extremely difficult clinical diagnosis and high mortality. Before the advent of computed tomography, the mortality rate for PCF injury was close to 100%.

The clinical picture of damage to the PCF structures is characterized by a severe condition that occurs immediately after the injury: depression of consciousness, a combination of cerebral, meningeal, cerebellar, and brainstem symptoms due to rapid compression of the brainstem and impaired cerebrospinal fluid circulation. If there is significant damage to the substance big brain hemispheric symptoms are added.
The proximity of the location of damage to the PCF structures to the liquor-conducting pathways causes their compression and disruption of liquor circulation by a small-volume hematoma. Acute occlusive hydrocephalus is one of the most severe complications damage to PCF structures is detected in 40%.

Treatment of brain contusion

Mandatory hospitalization!!! Bed rest.

The duration of bed rest for a mild bruise is 7-10 days, for a moderate bruise up to 2 weeks. depending on the clinical course and results instrumental studies.
In case of severe traumatic brain injury (foci of crush injury, diffuse axonal damage), it is necessary resuscitation measures, which begin at the prehospital stage and continue in a hospital setting. In order to normalize breathing, ensure free patency of the upper respiratory tract (freeing them from blood, mucus, vomit, introducing an air duct, tracheal intubation, tracheostomy tracheostomy (an operation of dissecting the anterior wall of the trachea with subsequent insertion of a cannula into its lumen or the creation of a permanent opening - stoma)) , use inhalation of an oxygen-air mixture, and, if necessary, perform artificial ventilation.

Surgical treatment is indicated for brain contusion with crushing of its tissue (most often occurs in the region of the poles of the frontal and temporal lobes). The essence of the operation: osteoplastic trephination ( surgery, which consists in creating a hole in the bone in order to penetrate into the underlying cavity) and washing out brain detritus with a stream of 0.9% NaCl solution, stopping bleeding.

The prognosis for mild TBI (concussion, mild brain contusion) is usually favorable (subject to the recommended regimen and treatment for the victim).

In case of moderate injury (moderate brain contusion), it is often possible to achieve complete restoration of work and social activity of the victims. A number of patients develop leptomeningitis and hydrocephalus, causing asthenia, headaches, vegetative-vascular dysfunction, disturbances in statics, coordination and other neurological symptoms.

With severe trauma (severe brain contusion, diffuse axonal damage, brain compression), mortality reaches 30-50%. Among survivors, disability is significant, the leading causes of which are mental disorders, epileptic seizures, gross motor and speech disorders. With an open head injury, inflammatory complications can occur (meningitis, encephalitis, ventriculitis, brain abscesses), as well as liquorrhea - the leakage of cerebrospinal fluid (CSF) from natural holes or holes formed due to various reasons in the bones of the skull or spine, which occurs when integrity is violated.

Half of all deaths from traumatic brain injury are caused by road traffic accidents. Traumatic brain injury is one of the leading causes of disability in the population.

What is traumatic brain injury (TBI)?

Traumatic brain injury includes all types of head injury, including minor bruises and cuts to the skull. More serious injuries from traumatic brain injury include:

skull fracture;

concussion, concussion. A concussion is manifested by a short, reversible loss of consciousness;

accumulation of blood above or below the dural membrane of the brain (the dural membrane is one of the protective films that envelop the brain), respectively, epidural and subdural hematoma;

intracerebral and intraventricular hemorrhage (bleeding into the brain or into the space around the brain).

Almost every person has experienced at least once in their life a minor traumatic brain injury - a bruise or cut to the head that required minimal or no treatment.

What are the causes of traumatic brain injury?

Causes of traumatic brain injury may include:

skull fracture with tissue displacement and rupture of the protective membranes around the spinal cord and brain;

bruises and ruptures of brain tissue due to concussions and blows in a confined space inside the hard skull;

bleeding from damaged vessels into the brain or into the space around it (including bleeding due to a ruptured aneurysm).

Brain damage can also occur due to:

direct injury to the brain by objects penetrating the cranial cavity (for example, bone fragments, bullets);

increased pressure inside the skull as a result of cerebral edema;

bacterial or viral infection, penetrating the skull in the area of ​​its fractures.

The most common causes of traumatic brain injury are motor vehicle accidents, sports injuries, assaults, and physical abuse.

Traumatic brain injury can develop in anyone at any age because it is the result of trauma. Brain damage can occur during childbirth.

Classification of traumatic brain injuries (TBI).

The following main clinical forms of traumatic brain injury: concussion, mild, moderate and severe brain contusion, compression of the brain.

According to the risk of infection of the brain and its membranes traumatic brain injury is divided into closed and open.

With a closed craniocerebral injury, the integrity of the soft tissues of the head is not impaired or there are superficial wounds scalp without damage to the aponeurosis.

With an open traumatic brain injury, fractures of the bones of the vault or base of the skull are observed with injury to adjacent tissues, bleeding, leakage of cerebrospinal fluid from the nose or ear, as well as damage to the aponeurosis in wounds of the soft integument of the head.

When the dura mater is intact, open craniocerebral injuries are classified as non-penetrating, and when it is ruptured, they are classified as penetrating. If there are no extracranial injuries, the traumatic brain injury is isolated. When extracranial injuries occur simultaneously (for example, fractures of limbs, ribs, etc.), they speak of a combined traumatic brain injury, and when exposed to different types of energy (mechanical or chemical, radiation or thermal) - a combined one.

Based on severity, traumatic brain injury is divided into mild, moderate severity and heavy. Mild traumatic brain injury includes concussion and brain contusion mild degree, to moderate traumatic brain injury - moderate brain contusion, to severe - severe brain contusion and compression of the brain in the acute period.

There are several main types of interrelated pathological processes that occur at the time of injury and some time after it:

1) direct damage to the brain substance at the time of injury;

2) violation cerebral circulation;

3) violation of liquor dynamics;

4) disturbances of neurodynamic processes;

5) formation of scar-adhesive processes;

6) processes of autoneurosensitization.

The basis of the pathological picture of isolated brain injuries is primary traumatic dystrophies and necrosis; circulatory disorders and organization of tissue defect.

Concussions are characterized by a complex of interconnected destructive, reactive and compensatory-adaptive processes occurring at the ultrastructural level in the synaptic apparatus, neurons, and cells.

Brain contusion- damage characterized by the presence in the substance of the brain and in its membranes of macroscopically visible foci of destruction and hemorrhages, in some cases accompanied by damage to the bones of the vault and base of the skull.

Direct damage to the hypothalamic-pituitary, brainstem structures and their neurotransmitter systems during TBI determines the uniqueness of the stress response. Impaired metabolism of neurotransmitters is the most important feature of the pathogenesis of TBI. Cerebral circulation is highly sensitive to mechanical influences. The main changes developing in this vascular system, are expressed by spasm or dilation of blood vessels, as well as increased permeability of the vascular wall. Another pathogenetic mechanism for the formation of the consequences of TBI is directly related to the vascular factor - a violation of liquor dynamics. Changes in the production of cerebrospinal fluid and its resorption as a result of TBI are associated with damage to the endothelium of the choroid plexuses of the ventricles, secondary disorders of the microvasculature of the brain, fibrosis of the meninges, and in some cases liquorrhea. These disorders lead to the development of liquor hypertension, and less commonly, hypotension.

In TBI, hypoxic and dysmetabolic disorders play a significant role in the pathogenesis of morphological disorders, along with direct damage to nerve elements. TBI, especially severe, causes respiratory and circulatory disorders, which aggravates existing dyscirculatory problems cerebral disorders and collectively leads to more pronounced brain hypoxia.

Currently there are three base periods during traumatic illness brain: acute, intermediate, remote.

The acute period is determined by the interaction of the traumatic substrate, damage reactions and defense reactions and is the period of time from the moment of the damaging effects of mechanical energy until the stabilization at one level or another of impaired cerebral and general body functions or the death of the victim. Its duration ranges from 2 to 10 weeks depending on clinical form TBI.

The intermediate period is characterized by the resorption and organization of areas of damage and the deployment of compensatory and adaptive processes until complete or partial restoration or stable compensation of impaired functions. The length of the intermediate period for non-severe TBI is up to 6 months, for severe TBI - up to a year.

The long-term period is the completion or coexistence of degenerative and reparative processes. The length of the period of clinical recovery - up to 2-3 years with a progressive course - is not limited.

All types of TBI are usually divided into closed brain injuries (CBI), open and penetrating. Closed TBI is a mechanical damage to the skull and brain, resulting in a number of pathological processes that determine the severity of the clinical manifestations of the injury. K open TBI injuries to the skull and brain should be included, in which there are wounds to the integument of the skull (damage to all layers of the skin); penetrating injuries involve disruption of the integrity of the dura mater.

Classification of traumatic brain injury according to Gaidar:

brain concussion;

brain contusion: mild, moderate, severe;

compression of the brain against the background of a bruise and without a bruise: hematoma - acute, subacute, chronic (epidural, subdural, intracerebral, intraventricular); hydro wash; bone fragments; edema-swelling; pneumocephalus.

It is very important to determine:

condition of the intrathecal spaces: subarachnoid hemorrhage; cerebrospinal fluid pressure - normotension, hypotension, hypertension; inflammatory changes;

condition of the skull: no bone damage; type and location of the fracture;

condition of the skull: abrasions; bruises;

associated injuries and diseases: intoxication (alcohol, drugs, etc., degree).

It is also necessary to classify TBI according to the severity of the victim’s condition, the assessment of which includes the study of at least three components:

state of consciousness;

state of vital functions;

state of focal neurological functions.

There are five gradations of the condition of patients with TBI.

Satisfactory condition. Criteria:

1) clear consciousness;

2) absence of violations of vital functions;

3) absence of secondary (dislocation) neurological symptoms; absence or mild severity of primary focal symptoms.

Threat to life (if adequate treatment) absent; the prognosis for recovery is usually good.

Moderate condition. Criteria:

1) state of consciousness - clear or moderate stun;

2) vital functions are not impaired (only bradycardia is possible);

3) focal symptoms - certain hemispheric and craniobasal symptoms may be expressed, often appearing selectively.

The threat to life (with adequate treatment) is insignificant. The prognosis for restoration of working capacity is often favorable.

Serious condition. Criteria:

1) state of consciousness - deep stupor or stupor;

2) vital functions are impaired, mostly moderately according to 1-2 indicators;

3) focal symptoms:

a) brainstem - moderately expressed (anisocoria, decreased pupillary reactions, limited upward gaze, homolateral pyramidal insufficiency, dissociation of meningeal symptoms along the body axis, etc.);

b) hemispheric and craniobasal - clearly expressed both in the form of symptoms of irritation (epileptic seizures) and loss (motor disorders can reach the degree of plegia).

The threat to life is significant and largely depends on the duration of the serious condition. The prognosis for restoration of working capacity is sometimes unfavorable.

Extremely serious condition. Criteria:

1) state of consciousness - coma;

2) vital functions - gross violations in several parameters;

3) focal symptoms:

a) stem - expressed roughly (plegia of upward gaze, gross anisocoria, divergence of the eyes along the vertical or horizontal axis, a sharp weakening of the pupils’ reactions to light, bilateral pathological signs, hormetonia, etc.);

b) hemispheric and craniobasal - pronounced.

The threat to life is maximum; largely depends on the duration of the extremely serious condition. The prognosis for restoration of working capacity is often unfavorable.

Terminal state. Criteria:

1) state of consciousness - terminal coma;

2) vital functions - critical impairment;

3) focal symptoms:

a) stem - bilateral fixed mydriasis, absence of pupillary and corneal reflexes;

b) hemispheric and craniobasal - blocked by general cerebral and brainstem disorders.

Survival is usually impossible.

Clinic of various forms of traumatic brain injury

Clinical picture (symptoms) of acute traumatic brain injury

Brain concussion.

A concussion is characterized by a short-term loss of consciousness at the time of injury, vomiting (usually one-time), headache, dizziness, weakness, painful eye movements, etc. There are no focal symptoms in the neurological status. Macrostructural changes in the brain substance during a concussion are not detected.

Clinically, it is a single functionally reversible form (without division into degrees). With a concussion, a number of general cerebral disorders occur: loss of consciousness or, in mild cases, a short-term blackout from several seconds to several minutes. Subsequently, a stunned state persists with insufficient orientation in time, place and circumstances, unclear perception of the environment and narrowed consciousness. Retrograde amnesia is often detected - loss of memory for events preceding the injury, less often anterograde amnesia - loss of memory for events subsequent to the injury. Speech and motor agitation are less common. Patients complain of headache, dizziness, nausea. An objective sign is vomiting.

Neurological examination usually reveals minor, diffuse symptoms:

symptoms of oral automatism (proboscis, nasolabial, palmomental);

unevenness of tendon and skin reflexes (as a rule, there is a decrease in abdominal reflexes and their rapid exhaustion);

moderately expressed or unstable pyramidal pathological signs (Rossolimo, Zhukovsky, less often Babinsky symptoms).

Cerebellar symptoms are often clearly manifested: nystagmus, muscle hypotonia, intention tremor, instability in the Romberg position. A characteristic feature of concussions is the rapid regression of symptoms; in most cases, all organic signs disappear within 3 days.

More resistant to concussions and mild bruises degrees there are various vegetative and, above all, vascular disorders. These include fluctuations in blood pressure, tachycardia, acrocyanosis of the extremities, diffuse persistent dermographism, hyperhidrosis of the hands, feet, and armpits.

Brain contusion (CBM)

Brain contusion is characterized by focal macrostructural damage to the brain matter of varying degrees (hemorrhage, destruction), as well as subarachnoid hemorrhages, fractures of the bones of the vault and base of the skull.

Mild brain contusion characterized by loss of consciousness up to 1 hour after injury, complaints of headache, nausea, vomiting. In the neurological status, rhythmic twitching of the eyes when looking to the sides (nystagmus), meningeal signs, and asymmetry of reflexes are noted. X-rays may reveal fractures of the cranial vault. There is an admixture of blood in the cerebrospinal fluid (subarachnoid hemorrhage). .Mild brain contusion is clinically characterized by a short-term loss of consciousness after the injury, up to several tens of minutes. Upon its recovery, typical complaints are headache, dizziness, nausea, etc. As a rule, retro-, con-, anterograde amnesia, vomiting, and sometimes repeated are noted. Vital functions are usually without significant impairment. Moderate tachycardia and sometimes arterial hypertension may occur. Neurological symptoms are usually mild (nystagmus, mild anisocoria, signs of pyramidal insufficiency, meningeal symptoms, etc.), mostly regressing 2-3 weeks after TBI. With mild UHM, in contrast to concussion, fractures of the calvarial bones and subarachnoid hemorrhage are possible.

Moderate brain contusion clinically characterized by a loss of consciousness after injury lasting up to several tens of minutes or even hours. Moderate brain contusion. Consciousness turns off for several hours. There is a marked loss of memory (amnesia) for the events preceding the injury, the injury itself, and the events after it. Complaints of headache, repeated vomiting. Short-term disorders of breathing, heart rate, and blood pressure are detected. There may be mental disorders. Meningeal signs are noted. Focal symptoms manifest themselves in the form of uneven pupil size, speech impairment, weakness in the limbs, etc. Craniography often reveals fractures of the vault and base of the skull. Lumbar puncture revealed significant subarachnoid hemorrhage. Con-, retro-, anterograde amnesia is expressed. Headache, often severe. Repeated vomiting may occur. Mental disorders occur. Transient disorders of vital functions are possible: bradycardia or tachycardia, increased blood pressure; tachypnea without disturbances in the rhythm of breathing and patency of the tracheobronchial tree; low-grade fever. Meningeal symptoms are often prominent. Brainstem symptoms are also detected: nystagmus, dissociation of meningeal symptoms, muscle tone and tendon reflexes along the body axis, bilateral pathological signs, etc. Focal symptoms are clearly manifested, determined by the localization of the brain contusion: pupillary and oculomotor disorders, paresis of the limbs, sensitivity disorders, etc. . Organic symptoms gradually smooth out over 2-5 weeks, but individual symptoms may be observed long time. Fractures of the bones of the vault and base of the skull, as well as significant subarachnoid hemorrhage, are often observed.

Severe brain contusion. Severe brain contusion is clinically characterized by loss of consciousness after injury lasting from several hours to several weeks. Characterized by prolonged loss of consciousness (lasting up to 1-2 weeks). Gross violations of vital functions are detected (changes in pulse rate, pressure level, frequency and rhythm of breathing, temperature). The neurological status shows signs of damage to the brain stem - floating movements of the eyeballs, swallowing disorders, changes in muscle tone, etc. Weakness in the arms and legs, up to paralysis, as well as convulsive seizures may be detected. A severe bruise is usually accompanied by fractures of the vault and base of the skull and intracranial hemorrhages. .Motor agitation is often expressed, and severe, threatening disturbances in vital functions are observed. The clinical picture of severe UHM is dominated by brainstem neurological symptoms, which in the first hours or days after TBI overlap focal hemispheric symptoms. Paresis of the limbs (up to paralysis), subcortical disorders of muscle tone, reflexes of oral automatism, etc. can be detected. Generalized or focal epileptic seizures are noted. Focal symptoms regress slowly; gross residual effects are frequent, primarily in the motor and mental spheres. Severe UHM is often accompanied by fractures of the vault and base of the skull, as well as massive subarachnoid hemorrhage.

An undoubted sign of fractures of the base of the skull is nasal or auricular liquorrhea. In this case, a “spot symptom” on a gauze napkin is positive: a drop of bloody cerebrospinal fluid forms a red spot in the center with a yellowish halo along the periphery.

Suspicion of a fracture of the anterior cranial fossa arises with the delayed appearance of periorbital hematomas (a symptom of glasses). When the pyramid is fractured temporal bone Battle's symptom (hematoma in the mastoid region) is often observed.

Brain compression

Compression of the brain is a progressive pathological process in the cranial cavity that occurs as a result of trauma and causes dislocation and infringement of the brainstem with the development of a life-threatening condition. With TBI, compression of the brain occurs in 3-5% of cases, both with and without UGM. Among the causes of compression, intracranial hematomas come first - epidural, subdural, intracerebral and intraventricular; This is followed by depressed fractures of the skull bones, areas of brain crushing, subdural hygromas, and pneumocephalus. .Compression of the brain. The main cause of brain compression during traumatic brain injury is the accumulation of blood in a closed intracranial space. Depending on the relationship to the membranes and substance of the brain, epidural (located above the dura mater), subdural (between the dura mater and arachnoid), intracerebral (in the white matter of the brain and intraventricular (in the cavity of the ventricles of the brain) hematomas. Compression of the brain can also be caused by depressed fractures of the bones of the cranial vault, especially the penetration of bone fragments to a depth of more than 1 cm.

The clinical picture of compression of the brain is expressed by a life-threatening increase after a certain period of time (the so-called light interval) after the injury or immediately after it of general cerebral symptoms, the progression of impaired consciousness; focal manifestations, stem symptoms.

In most cases, there is loss of consciousness at the time of injury. Subsequently, consciousness can be restored. The period of restoration of consciousness is called the lucid interval. After a few hours or days, the patient may again fall into an unconscious state, which, as a rule, is accompanied by an increase in neurological disorders in the form of the appearance or deepening of paresis of the limbs, epileptic seizures, dilation of the pupil on one side, slowing of the pulse (rate less than 60 per minute), etc. .d. According to the rate of development, acute intracranial hematomas are distinguished, which appear in the first 3 days after the injury, subacute - clinically manifested in the first 2 weeks after the injury, and chronic, which are diagnosed after 2 weeks from the injury.

How does traumatic brain injury manifest?
Symptoms of traumatic brain injury:

loss of consciousness;

Strong headache;

increasing drowsiness and lethargy
vomit;

nasal discharge clear liquid(cerebrospinal fluid or cerebrospinal fluid), especially when tilting your head face down.

Call emergency medical services immediately for a person with a traumatic brain injury, no matter how minor the injury.

If you think you have suffered a traumatic brain injury, get medical help or ask someone to help you.

With extensive head wounds penetrating into the cranial cavity, there is a high probability of brain damage. However, in 20% of cases, death after a traumatic brain injury occurs without the presence of skull fractures. Therefore, a person with a traumatic brain injury in the presence of the above symptoms must be hospitalized

Diagnosis of traumatic brain injury.

If the patient is conscious, careful identification of the circumstances and mechanism of injury is necessary, since the cause of a fall and head injury may be a stroke or an epileptic seizure. Often the patient cannot remember the events preceding the injury (retrograde amnesia), those immediately following the injury (anterograde amnesia), as well as the moment of injury itself (cograde amnesia). It is necessary to carefully examine the head to look for signs of injury. Hemorrhages over the mastoid process often indicate a fracture of the temporal bone. Bilateral hemorrhages in the orbital tissue (the so-called “spectacles symptom”) may indicate a fracture of the base of the skull. This is also indicated by bleeding and liquorrhea from the external ear canal and nose. With fractures of the calvarium, a characteristic rattling sound is heard during percussion - the “symptom of a cracked pot.”

To objectify disturbances of consciousness during traumatic brain injury, a special scale has been developed for nursing staff - the Glasgow Coma Scale. It is based on the total score of 3 indicators: eye opening to sound and pain, verbal and motor responses to external stimuli. The total score ranges from 3 to 15.

Severe traumatic brain injury corresponds to 3-7 traumatic brain injury points, moderate - 8-12 points, mild - 13-15.

Glasgow Coma Scale

Index	Score (in points)
Eye opening:
arbitrary
absent
Best verbal answer:
adequate
confused
individual words
individual sounds
absent
Best motor response:
follows instructions
localizes pain
withdraws a limb
pathological flexion
pathological extension
absent

Should be made qualitative assessment consciousness in traumatic brain injury. Clear consciousness means wakefulness, complete orientation in place, time and environment. Moderate confusion is characterized by drowsiness, mild errors in time orientation, and slow comprehension and execution of instructions. Deep Stun characterized by deep drowsiness, disorientation in place and time, following only basic instructions (raise your hand, open your eyes). Sopor- the patient is motionless, does not follow commands, but opens his eyes, defensive movements are expressed in response to local painful stimuli. At moderate coma it is not possible to wake up the patient, he does not open his eyes in response to pain, defensive reactions without localization of painful stimuli are uncoordinated. Deep coma characterized by a lack of response to pain, pronounced changes muscle tone, respiratory and cardiovascular disorders. At terminal coma There is bilateral dilation of the pupils, immobility of the eyes, a sharp decrease in muscle tone, absence of reflexes, severe disturbances of vital functions - breathing rhythm, heart rate, drop in blood pressure below 60 mm Hg. Art.

A neurological examination allows you to assess the level of wakefulness, the nature and degree of speech disorders, the size of the pupils and their reaction to light, corneal reflexes (normally, touching the cornea with a cotton swab causes a blinking reaction), strength in the limbs (a decrease in strength in the limbs is called paresis, and a complete absence in their active movements - paralysis), the nature of twitching in the limbs (convulsive seizures).

Play an important role in the diagnosis of traumatic brain injury instrumental methods tests such as echoencephalography, cranial radiography and computed tomography of the head, including contrast-enhanced computed tomography (angiography).

What examinations are needed after a traumatic brain injury?

Diagnosis of traumatic brain injury:

patency assessment airways, respiratory and circulatory functions;

assessment of the visible area of ​​skull damage;

if necessary, X-rays of the neck and skull, CT (computed tomography), MRI (magnetic resonance imaging);

monitoring the level of consciousness and vital functions of the body (pulse, breathing, blood pressure).

In cases of severe traumatic brain injury, it may be necessary to:

observation by a neurosurgeon or neurologist;

MRI and CT as necessary;

monitor and treat increased pressure inside the skull due to swelling or bleeding;

surgical intervention with accumulation of blood (hematoma);

prevention and treatment of seizures.

Scheme of examination of victims with traumatic brain injury

1. Identifying the history of injury: time, circumstances, mechanism, clinical manifestations injuries and the amount of medical care before admission.

2. Clinical assessment of the severity of the victim’s condition, which has great importance for diagnosis, triage and provision of stage-by-stage assistance to victims. State of consciousness: clear, stunned, stupor, coma; the duration of loss of consciousness and the sequence of exit are noted; memory impairment, antero- and retrograde amnesia.

3. State of vital functions: cardiovascular activity- pulse, blood pressure (a common feature in TBI is the difference in blood pressure on the left and right extremities), breathing - normal, impaired, asphyxia.

4. Condition of the skin - color, moisture, bruises, presence of soft tissue damage: location, type, size, bleeding, liquorrhea, foreign bodies.

5. Examination of internal organs, skeletal system, accompanying illnesses.

6. Neurological examination: state of cranial innervation, reflex-motor sphere, presence of sensory and coordination disorders, state of autonomic nervous system.

7. Meningeal symptoms: stiff neck, Kernig’s and Brudzinski’s symptoms.

8. Echoencephaloscopy.

9. X-ray of the skull in two projections; if damage to the posterior cranial fossa is suspected, a posterior semi-axial image is taken.

10. Computer or magnetic resonance imaging of the skull and brain.

11. Ophthalmological examination of the condition of the fundus: edema, disc congestion optic nerve, hemorrhages, condition of the fundus vessels.

12. Lumbar puncture - in the acute period, it is indicated for almost all victims with TBI (with the exception of patients with signs of compression of the brain) with measurement of cerebrospinal fluid pressure and removal of no more than 2-3 ml of cerebrospinal fluid, followed by laboratory testing.

13. CT scan with contrast in the case of hemorrhagic stroke (in the presence of blood in the cerebrospinal fluid, item 12) and suspected aneurysm rupture, or other additional diagnostic methods at the discretion of the doctor.

14. Making a diagnosis. The diagnosis reflects: the nature and type of brain damage, the presence of subarachnoid hemorrhage, brain compression (cause), liquor hypo- or hypertension; condition of the soft covers of the skull; fractures of the skull bones; the presence of concomitant injuries, complications, intoxications.

First aid for victims with severe traumatic brain injury

The results of treatment of traumatic brain injury largely depend on the quality of prehospital care and the speed of hospitalization of the victim. It is unlikely to find another type of injury where a delay in transporting the patient to the hospital for an hour or two made a significant difference. Therefore, it is generally accepted that an ambulance service that is unable to transport a victim with a severe traumatic brain injury to a neurosurgical hospital within a few minutes is not doing its job. In many countries, patients with severe traumatic brain injury are transported to hospitals by helicopter.

When providing first aid at the scene of an accident, it is first necessary to restore the airway. Along with oxygen starvation(hypoxia) a common complication traumatic brain injury is an increased accumulation of carbon dioxide in the body (hypercapnia). During transport, patients must breathe 100% oxygen. In case of multiple injuries accompanied by shock, intravenous administration of Ringer's solution, rheopolyglucin, etc. is simultaneously started. Ischemia, hypoxia or hypotension for a short period, even with a moderate traumatic brain injury, can lead to irreversible consequences in the future. If high spinal cord injury is suspected cervical region the spine must be immobilized.

Bleeding must be stopped by applying a tight bandage or quickly suturing the wound. Damage to the scalp, especially in the elderly, can lead to a sharp worsening of the condition.

Indications for hospitalization for TBI

The generally accepted criteria for hospitalization for traumatic brain injury are:

1) a clear decrease in the level of consciousness,

2) focal neurological disorders (paresis of the limbs, uneven pupil width, etc.),

3) open fractures skull bones, bleeding or liquorrhea from the nose or ear canal,

4) epileptic seizures,

5) loss of consciousness as a result of injury,

6) significant post-traumatic amnesia.

Patients with severe headaches, restless, and disoriented are hospitalized until these symptoms disappear.

Treatment is carried out in neurosurgical hospitals.

Caring for patients with severe traumatic brain injury involves preventing bedsores and hypostatic pneumonia (turning the patient in bed, massage, skin toilet, cupping, mustard plasters, suction of saliva and mucus from the oral cavity, sanitation of the trachea).

Complications of traumatic brain injury

Disturbances of vital functions - disorder of basic life support functions ( external respiration and gas exchange, systemic and regional circulation). In the acute period of TBI, the causes of acute respiratory failure (ARF) are dominated by pulmonary ventilation disorders associated with impaired airway patency caused by the accumulation of secretions and vomit in the nasopharynx with their subsequent aspiration into the trachea and bronchi, and retraction of the tongue in comatose patients.

Dislocation process: temporotentorial inclusion, representing a displacement of the mediobasal sections of the temporal lobe (hippocampus) into the fissure of the tentorium of the cerebellum and herniation of the cerebellar tonsils into the foramen magnum, characterized by compression of the bulbar sections of the trunk.

Purulent-inflammatory complications are divided into intracranial (meningitis, encephalitis and brain abscess) and extracranial (pneumonia). Hemorrhagic - intracranial hematomas, cerebral infarctions.

What is the prognosis for traumatic brain injury?
Chances of recovery

The outcome of a traumatic brain injury can vary, just as the response to a traumatic brain injury varies from person to person. Some extensive penetrating wounds to the skull eventually end full recovery patient, and fairly minor injuries can have the most serious consequences. Usually the damage is more severe in cases of severe cerebral edema, increased intracranial pressure and prolonged loss of consciousness.

A fairly small number of people may remain in a permanent vegetative state after a traumatic brain injury. Qualified neurological and neurosurgical treatment in the early stages after traumatic brain injury can significantly improve the prognosis.

Recovery from traumatic brain injury can be very slow in severe cases, although improvement may last up to 5 years.

Consequences of traumatic brain injury.

The outcomes of traumatic brain injury are largely determined by the age of the victim. For example, with severe traumatic brain injury, 25% of patients under 20 years of age and up to 70-80% of victims over the age of 60 die. Even with mild traumatic brain injury and moderate traumatic brain injury, the consequences become apparent over a period of months or years. The so-called "post-traumatic syndrome" is characterized by headache, dizziness, increased fatigue, decreased mood, memory impairment. These disorders, especially in old age, can lead to disability and family conflicts. To determine the outcomes of traumatic brain injury, the Glasgow Outcome Scale (GOS) has been proposed, which provides five outcome options.

Glasgow Outcome Scale

Outcome of traumatic brain injury	Definitions
Recovery	Return to previous employment levels
Moderate disability	Neurological or mental disorders that prevent return to previous job serve yourself whenever possible
Gross disability	Inability to self-care
Vegetative state	Spontaneous opening of the eyes and maintenance of the sleep-wake cycle in the absence of response to external stimuli, inability to follow commands and make sounds
	Stopping breathing, heartbeat and electrical activity in the brain

We can talk about outcomes 1 year after the traumatic brain injury, since in the future there are no significant changes in the patient’s condition. Rehabilitation activities include physical therapy, physiotherapy, taking nootropic, vascular and anticonvulsant drugs, vitamin therapy. The results of treatment largely depend on the timeliness of assistance at the scene of the incident and upon admission to the hospital.

What are the consequences of traumatic brain injury?

The consequences of traumatic brain injury may be associated with damage to a specific area of ​​the brain or be the result general defeat brain with swelling and high blood pressure.

Possible consequences of traumatic brain injury:

epilepsy,
decrease in a certain degree of mental or physical abilities,
depression,
memory loss,
personal changes,

How is traumatic brain injury treated?

First of all, an accurate diagnosis of the nature of the injury is important; the method of treatment depends on this. A neurological examination is performed to assess the level of damage and the need for further rehabilitation and treatment.

Surgery is necessary to remove the blood clot and reduce intracranial pressure, restore the integrity of the skull and its membranes, and prevent infection.

Medicines are needed to control the degree of increased pressure inside the skull, swelling of the brain, and improve blood flow to the brain.

After discharge from the hospital, it may be necessary to observe various specialists: a neurologist, a therapist, etc.

Organization and tactics of conservative treatment of victims with acute TBI

In general, victims with acute TBI should go to the nearest trauma center or medical facility where initial medical examination and emergency medical care are provided. The fact of injury, its severity and the condition of the victim must be confirmed by appropriate medical documentation.

Treatment of patients, regardless of the severity of TBI, should be carried out in an inpatient setting in a neurosurgical, neurological or trauma department.

Primary medical assistance turns out for urgent indications. Their volume and intensity are determined by the severity and type of TBI, the severity of the cerebral syndrome and the possibility of providing qualified and specialized assistance. First of all, measures are taken to eliminate airway and cardiac problems. At seizures, psychomotor agitation 2-4 ml of diazepam solution is administered intramuscularly or intravenously. If there are signs of compression of the brain, diuretics are used; if there is a threat of cerebral edema, a combination of “loop” and osmodiuretics is used; emergency evacuation to the nearest neurosurgical department.

To normalize cerebral and systemic circulation during all periods of traumatic illness, vasoactive drugs are used; in the presence of subarachnoid hemorrhage, hemostatic and antienzyme agents are used. The leading role in the treatment of patients with TBI is given to neurometabolic stimulants: piracetam, which stimulates the metabolism of nerve cells, improves cortico-subcortical connections and has a direct activating effect on the integrative functions of the brain. In addition, neuroprotective drugs are widely used. To increase the energy potential of the brain, the use of glutamic acid, ethylmethylhydroxypyridine succinate, and vitamins B and C is indicated. Dehydration agents are widely used to correct liquorodynamic disorders in patients with TBI. To prevent and inhibit the development of adhesive processes in the membranes of the brain and to treat post-traumatic leptomeningitis and choreoependymatitis, so-called absorbable agents are used.

The duration of treatment is determined by the dynamics of regression of pathological symptoms, but requires strict bed rest in the first 7-10 days from the moment of injury. The duration of hospital stay for concussions should be at least 10-14 days, for mild bruises - 2-4 weeks.

Traumatic brain injury (TBI) is damage to the brain, skull bones and soft tissues. Every year, about two hundred people per thousand of the population face such trauma, with varying degrees of severity. The most common cause of TBI is car accidents, and WHO statistics are inexorable. Every year the number of injuries received in this way increases by 2%. The reason for this is the increase in the number of vehicles on the roads or the excessive recklessness of drivers... a mystery.

Types of injuries

There are two types of TBI:

• open craniocerebral injury - accompanied by a skull fracture and damage to the integrity of the soft tissues of the brain structures. This form of injury is considered the most dangerous, as the risk of brain infection is high. Diagnosed in 30% of cases;
• closed craniocerebral injury may be accompanied by a skull fracture, brain contusions, but without affecting the integrity of the soft tissues.

Interesting fact! According to statistics, 2/3 of all traumatic brain injuries are fatal!

CCI has its own gradation, according to the disorders caused:

• brain contusion without compression;
• brain contusion with compression;

According to severity they are distinguished:

• mild degree. This may be a concussion or contusion of the brain, accompanied by slight stunning, while consciousness remains clear. To determine the severity of TBI, the Glazko coma scale is used. On this scale, with a mild degree, the patient scores 13-15 points. Treatment in this case lasts no more than two weeks, neurological disorders do not occur. Most often, treatment is outpatient, rarely in a hospital setting;
• Moderate severity with a closed injury is accompanied by brain contusion and deep stupor. On the Glazko scale, the patient scores 8-12 points. Treatment lasts on average up to a month in a hospital setting. The condition is not accompanied by a prolonged loss of consciousness, but by the presence of neurological signs that may persist during the first month after the injury;
• severe degrees are accompanied by prolonged loss of consciousness and even coma. Occurs with acute compression of the brain; the patient scores no more than seven points on the scale. Persistent neurological disorders occur, surgical treatment is often required, and the pathological outcome is often unfavorable. Even after recovery, they remain persistent neurological changes, death is often diagnosed.

There is also a gradation of the state of consciousness:

• clear. There is a quick reaction and complete orientation in the surrounding space;
• moderate stupor is accompanied by slight retardation and slow execution of certain instructions;
• deep stupor - there is disorientation, the ability to carry out only simple commands, mental difficulties;
• stupor is a depressed consciousness during which there is no speech, but the patient is able to open his eyes, feels pain, and can indicate the location of the pain syndrome;
• moderate coma is characterized by loss of consciousness, tendon reflexes are preserved, eyes are closed, but pain receptors are not turned off, pain is felt;
• deep coma. Breathing and heartbeat knocked down, but they are preserved, tendon reflexes are absent, there is no reaction to external stimuli;
• extreme coma is incompatible with life, complete muscle atony, breathing is supported by ventilation.

Interesting fact! About 75% of the victims are men under 45 years of age.

Causes

traumatic brain injury as well as open form occurs as a result:

• traffic accident, this category includes lovers of skateboards, rollerblades and bicycles. This reason is the most common diagnosis of traumatic brain injury;
• injuries at work;
• falling from a height;
• domestic injuries, including fights.

Pathological conditions such as:

• sudden dizziness and loss of coordination, falling and resulting injury;
• alcohol intoxication;
• epileptic seizure;
• sudden fainting.

Possible signs

• Symptoms of TBI can vary depending on whether the injury is open or closed, such as a concussion, bruise, or compression of the brain. But despite this, there are a number of common symptoms that are characteristic of any brain injury. These signs include:
  fainting occurs with moderate or severe head injury. In mild cases, loss of consciousness is possible, but usually does not occur for just a few seconds or minutes;
• loss of orientation in space, unsteadiness of gait and coordination of movements. The severity of this symptom also depends on the complexity of the injury;
• headache and dizziness, these signs are characteristic of any severity of the pathology;
• nausea, vomiting, the latter is a consequence of painful shock and is not associated with the gastrointestinal tract;
• slowness of reaction, slowness of answers to questions posed, paucity of speech;
• increased sweating, pale skin;
• sleep disturbances and loss of appetite occur later;
• Bleeding from the nose or ears may occur with moderately severe injury.

Brain concussion

One of the types of TBI is a concussion, which is considered the mildest possible TBI, the consequences of which are reversible. Pathology occurs as a result of vibration in the brain structures. The clinical picture increases instantly, following the injury, depending on the severity of the concussion, it also recedes quickly, not counting severe forms. Among the characteristic symptoms are:

• vomiting, often repeated;
• short-term fainting, usually lasting several minutes;
• tinnitus and dizziness;
• painful reaction to bright lights and loud sounds;
• headache;
• sleep disturbance;
• tachycardia;
• increased sweating;
• irritability, etc.

The prognosis for a concussion is usually favorable for any severity of the pathology. Symptoms that occur can be relieved with medications and peace, eventually they disappear completely.

Patients with a concussion are hospitalized in a hospital, where treatment usually lasts from three to fourteen days, depending on the severity of the situation.

First aid for a concussion:

• call an ambulance;
• lay the patient on a flat surface;
• turn your head to the side;
• unbutton your shirt, jacket, remove your tie and other items that may impede breathing;
• if there is a bleeding wound on the head, apply a sterile bandage.

Upon admission to a medical facility, the patient is x-rayed to exclude the possibility of a skull fracture and then treatment is prescribed.

Patients with a concussion require bed rest with complete rest. You should not watch TV, read or write. To eliminate cerebral symptoms, ganglion-blocking drugs are prescribed, including chlorpromazine or pentamin. To improve brain activity in the treatment of concussion, nootropic drugs are prescribed:

• piracetam;
• aminalon;
• pyriditol.

It is also recommended to take B vitamins, calcium supplements, and anesthetics for headaches. If the patient has injuries to the soft tissues of the head, antibacterial therapy is carried out to avoid infection and suppuration of the wound.

In severe cases, when 3-5 days after the start of treatment the symptoms do not subside or, on the contrary, increase, a lumbar puncture is prescribed to examine the cerebrospinal fluid. If increased intracranial pressure is detected, dehydration drugs are prescribed:

• mannitol;
• diacarb;
• magnesium sulfate;
• albumen.

If the pressure, on the contrary, is reduced, intravenous administration of drugs such as:

• polyglucin;
• peptides;
• hemodesis;
• sodium chloride solution.

In the case of a favorable course of treatment of the pathology, patients are discharged from the hospital after 7-10 days of their stay there. In cases where general cerebral and focal symptoms persist, hospital stay is extended. After discharge from the hospital, patients require gentle treatment.

Brain contusion

Another type of TBI is a brain contusion, which is a more serious injury compared to a concussion. The pathology is accompanied by necrosis of neurons at the site of injury. Often a bruise is accompanied by rupture of small vessels in the brain, hemorrhage or leakage of cerebrospinal fluid.

A bruise may occur with or without tissue compression. Just like other TBIs, there are three degrees of severity from mild to severe.

The main symptoms of brain contusion:

• loss of consciousness, diagnosed in moderate and severe cases, in the second case there is a deep coma;
• vestibular disorders;
• paresis of limbs and impaired coordination of movements;
• metabolic disorders;
• Skull fractures and blood in the cerebrospinal fluid are common;
• meningeal symptoms are often added to the general clinical picture, in particular, severe headaches that persist for a long time;
• repeated vomiting;
• rapid, shallow breathing;
• arrhythmia and tachycardia;
  high blood pressure;
• increased body temperature as a response to a stressful situation.

With severe brain contusions, the prognosis is extremely unfavorable, and death is more common.

Treatment in this case directly depends on the severity of the process. For mild bruises, treatment is the same as for a concussion.

If the bruise is of moderate or severe severity, treatment is aimed at normalizing cardiac and respiratory function, as well as nervous reactions. Appointment possible surgical treatment which involves excision of necrotic brain tissue. To combat a number of symptoms, the following are prescribed:

• for high blood pressure - antipsychotic medications, for example, diprazine or aminazine;
• to eliminate tachycardia - novocainamide, strophanthin;
• antispasmodic and sympatholytic agents;
• at elevated body temperature above 38 degrees, antipyretics are prescribed;
  in case of severe cerebral edema, diuretics are administered, for example, furosemide, as well as drugs such as aminophylline, diacarb, etc.;
• nootropics to improve cerebral circulation and the activity of its structures: aminalon, Cerebrolysin, piracetam.

Brain compression

This pathological condition may occur immediately at the time of injury or later as a result of the formation of a hematoma. In the first case, a depressed fracture requires surgical intervention. Depressed fragments are usually straightened after surgery and recovery, and the person continues his normal life. Neurological symptoms disappear if surgical treatment is not performed; especially in childhood, there is a high risk of epileptic seizures in the future.

In 2-16% of all TBIs, compression of the brain occurs through the development of an intracranial hematoma. The cause of its occurrence can be either a bruise or a stroke. A hematoma after an injury develops in a matter of hours, but begins to show its symptoms of compression of the brain later. Most often, as a result of injury, a single hematoma occurs, but multiple hematomas can be diagnosed.

Hematomas can be:

• sharp;
• subacute;
• chronic.

In the case of acute hematoma, the patient's condition progressively worsens, prompt surgical intervention is necessary. With the second two types of hematomas, symptoms increase gradually, and their progress can be noticeable days, weeks and even months after the injury, as a result of a slow increase in the volume of the hematoma.

When the brain is compressed by a hematoma, signs such as:

• decreased tendon and abdominal reflexes;
• convulsions;
• the occurrence of hallucinations and delusions;
• decreased sensitivity of the limbs, up to paresis or paralysis;
• increased ICP;
• disturbances in the functioning of the optic nerves.

Traumatic brain injury is damage to the brain of varying severity. Each of the injuries: concussion, bruise or compression of the brain requires serious medical attention. The severity of the consequences of a TBI can vary greatly, depending on the complexity of the injury. Mild degree TBI, as a rule, leaves no consequences; moderate severity may result in persistent neurological impairment. The consequences of severe form can be fatal.

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Despite the achievements modern medicine, traumatic brain injury (TBI) remains one of the most severe and complex pathologies in neurology. Even seemingly minor injuries (concussion) can lead to long-term disorders of the nervous system, and often do not respond well to traditional therapy. Severe TBI (brain contusion, diffuse axonal torsion) sometimes leads to the patient’s death or severe disability.

TBI remains one of the main causes of disability in the population

Statistics show that in last years the incidence of traumatic brain injury has a steady upward trend, especially in people young. Moreover, the share of severe injuries skull and brain, the consequences of which are post-traumatic encephalopathy, intellectual impairment, liquor hypertension.

Pathogenesis of TBI

Most often, traumatic brain injury is the result of mechanical impact on the head and neck area. The most common situations are: road accidents, being hit by a hard object, falling from a height, less often the cause is compression of the head or sudden acceleration of the human body.

Thus, the following main causes of brain damage during trauma can be identified:

1. Local disruption of tissue structure due to sudden impact with a heavy object (impact, fall).
2. Diffuse damage to brain tissue, for example due to acceleration.
3. Compression of intracranial structures.

As a result of the damaging factor, a cascade of pathological reactions is triggered, leading to disruption of the interaction of intracerebral structures, and in case of severe injuries, organic changes in brain tissue with progressive swelling. Scientists have proposed several theories of the pathogenesis of brain injury: displacement of the brain inside the skull, changes at the molecular level, impact mechanism, and others. The whole complex of pathological changes is called traumatic brain disease.

Classification of TBI

All types of TBI are usually divided into closed and open

Depending on the characteristics of damage to the soft tissues of the head and bones of the skull, traumatic brain injury can be open or closed.

Closed skull injury is characterized by a lack of communication between the intracranial cavity and external environment. Moreover, even the presence of cracks or fractures of bones does not violate the closed space of the cranium. Presence of damage to the soft tissues of the head (wounds, abrasions) with preserved integrity bone tissue allows us to consider such a head injury closed.

In turn, open TBI is a head injury in which there is communication between the cranial cavity and the external environment. If at the same time there is a violation of the integrity of the dura mater, then such head injuries are penetrating; in other cases, a non-penetrating injury is diagnosed.

In modern neurology, traumatic brain injury is classified as follows:

• Brain concussion.
• Brain contusion (mild, moderate, severe).

One type of traumatic brain injury is bruise

• Compression of intracranial structures.

A concussion is considered a relatively mild type of head injury. More severe ones include bruise and compression of the brain, which can additionally be aggravated by skull fractures, subarachnoid hemorrhage, cerebral edema, and intracranial hematoma. The latter, depending on the location, can be: intracerebral, epidural, subdural, intraventricular.

Course of traumatic brain injury

Any traumatic brain injury has three periods in its development: acute, intermediate and long-term consequences.

First period characterized by the development of pathological changes in brain tissue immediately after exposure to a damaging factor. Symptoms depend on the degree of changes occurring in the brain, swelling of brain structures, the presence or absence of other injuries (combined injury), and the initial somatic status of the patient. Its duration is at least two weeks or more.

In the interim Damage to the nervous tissue and, accordingly, lost functions are restored. Compensatory and adaptive mechanisms in the body are also activated, which contributes to the patient’s adaptation in the presence of severe damage to the central nervous system. The duration of this period for a concussion and mild bruise of the brain is up to six months, for more severe injuries – about a year.

Final period head injuries – restorative. Depending on the severity of the damage, it may last a year or two or more than two years. As a rule, during the first two years after injury, most patients develop post-traumatic encephalopathy, which requires treatment in neurology. With the right therapeutic approach, restoration or adaptation of the central nervous system occurs.

Symptoms

Symptoms of traumatic brain injury largely depend on the degree of brain damage, the presence of focal changes and swelling associated with encephalopathy. An important criterion for the severity of TBI is the patient’s state of consciousness and the presence of focal and cerebral symptoms.

Brain concussion

This type of head injury is classified as minor injuries brain. Its characteristic features are:

• Loss of consciousness for a short time (seconds, several minutes).
• A state of mild stupor after injury.
• Presence of diffuse headache.
• Nausea, less often single vomiting.
• Sometimes retrograde amnesia, less often anterograde.

With a concussion, the fact of impaired consciousness occurs in almost all cases and can vary from complete loss of consciousness to a state of “cloudness” in the head, slight stunning. When examining the patient, diffuse symptoms are revealed: nystagmus, sluggish reaction of the pupils to light, asymmetry of reflexes, pathological reflexes (Marinescu, Rossolimo, Babinsky). Again, against the background of existing encephalopathy, these signs are persistent, and with a concussion they disappear within 3-5 days. Disorders of autonomic innervation - frequent consequences concussions, instability of blood pressure, sweating, a feeling of “heat” in the body, and coldness of the extremities are usually observed.

Symptoms of concussion depending on severity

Brain contusion

This type of head injury is characterized by focal damage to brain structures. Often a brain contusion is accompanied by fractures of the skull bones, hemorrhages under the membranes of the brain, and rapidly increasing swelling. Subsequently, this often leads to post-traumatic encephalopathy.

Depending on the degree of damage (mild, moderate or severe), the severity of symptoms may vary. The following signs are characteristic of a mild brain contusion:

• Loss of consciousness (tens of minutes).
• Nausea, sometimes repeated vomiting.
• Amnesia, retrograde or anterograde.
• Diffuse headache, dizziness.

The neurological status determines diffuse or focal symptoms. Most patients have skull fractures and subarachnoid hemorrhage.

With moderate to severe brain contusion, the severity of symptoms is much higher. In this case, the duration of loss of consciousness can be several hours, and in severe cases, several weeks. For such damage characteristic features are focal changes: impaired oculomotor function, damage to the cranial nerves, sensory and motor disorders (paresis, paralysis).

Symptoms of traumatic brain injury

In severe TBI, brainstem disorders occur, which is caused by swelling of brain structures: fluctuations in blood pressure, pathological breathing rhythms, disturbances in thermoregulation, and muscle tone. Meningeal signs are determined (stiff neck, Kernig's, Brudzinski's symptoms). Serious head trauma may be accompanied by seizures.

Severe brain contusions are almost always combined with fractures of the cranial bones, often the base of the skull, traumatic hemorrhages, and swelling of brain tissue. Externally, the “symptom of glasses” is sometimes determined - a sign of a fracture of the front part of the skull, liquorrhea from the nose or ears.

Severe traumatic brain injury almost always leaves consequences in the form of post-traumatic encephalopathy. Symptoms regress after a few months, but residual effects can be persistent, sometimes for life.

Brain compression

This type of traumatic brain injury is particularly severe and, if left untreated, often leads to the death of the patient. Compression of the brain by an intracranial hematoma (epi-, subdural or intracerebral) leads to displacement of stem structures and, as a result, disruption of vital functions. This type of injury can be an independent pathology or combined with other types of brain damage (for example, brain contusion).

Compression of the brain may be caused by an intracranial hematoma

Characterized by a gradual increase in the severity of general cerebral, focal symptoms, signs of cerebral edema with dislocation (displacement) of brain structures. The onset of compression symptoms is often preceded by a so-called “lucid period” after the injury, when the patient feels well for some time. It is especially common in children.

Complications of TBI

Traumatic brain disease can have both early and long-term consequences. Early complications of traumatic brain injury include:

• Brain swelling.
• Displacement of the median stem structures.
• Secondary intracranial hemorrhages (hematomas, subarachnoid hemorrhage).
• Secondary inflammatory process (meningitis, encephalitis).
• Extracranial inflammatory phenomena (pneumonia, bedsores, sepsis).
• Respiratory failure.

Long-term consequences are largely determined by the severity of the traumatic brain injury. The most common include:

• Post-traumatic encephalopathy (asthenia, headaches, autonomic disorders).
• Persistent focal disorders (paresis, paralysis, visual impairment, hearing, speech).
• Epileptic syndrome.
• Mental disorders.

Diagnostics

Methods for diagnosing traumatic brain injuries

The diagnosis of traumatic brain injury is established in neurology on the basis of an initial examination by a doctor, medical history and patient complaints. Additional examination methods are required.

At a minimum, an X-ray of the skull is required for a concussion; for more severe injuries, a computed tomography or magnetic resonance imaging of the brain is required.

In the hospital, a neurologist or neurosurgeon also prescribes general clinical and biochemical blood tests and an ECG. If combined traumatic injuries are suspected, R-graphy of the chest organs, extremities, ultrasound of the abdominal organs. According to indications in neurology, a lumbar puncture is performed, which helps to identify subarachnoid hemorrhage and secondary purulent meningitis.

Treatment

Any traumatic brain injury requires observation and treatment in an inpatient setting (neurosurgery, neurology, traumatology). In exceptional cases, outpatient treatment of a mild concussion is permitted, but only after preliminary diagnosis and examination by a neurosurgeon or neurologist. Mild therapy degree of brain damage requires bed rest for at least a week, elimination autonomic dysfunction, prescription of nootropics, sedatives, normalization of blood pressure.

Treatment of patients with TBI should be carried out in a hospital setting

For more serious injuries, therapy includes the following measures:

1. Maintaining vital functions of the body: breathing at an optimal level (ventilation if necessary), correcting blood pressure numbers to ensure sufficient brain perfusion. To increase blood pressure, colloidal solutions and sympathomimetics are administered intravenously. High blood pressure numbers are corrected by prescribing antihypertensive drugs.
2. Fighting cerebral edema. For this purpose, osmotic diuretics (mannitol) are used. Elimination of cerebrospinal fluid hypertension is achieved by drainage of the cerebrospinal fluid ducts.
3. In the presence of hemorrhagic complications, hemostatic agents (aminocaproic acid) are used.
4. To improve microcirculation in affected tissues and prevent secondary ischemia, antiplatelet agents, vasoactive agents (Trental, Cavinton), and calcium channel blockers are prescribed.
5. Elimination of hyperthermia is achieved by the introduction of non-steroidal anti-inflammatory drugs, neuroleptics, artificial hypothermia, and the administration of neuroleptics.
6. Antibacterial therapy for the prevention of secondary purulent complications. Especially indicated for open injuries of the skull and brain.

Surgical treatment is mandatory in case of rapidly increasing swelling and compression of the brain by intracranial hematoma. It is indicated when the volume of the latter is more than 30 cm³, as well as signs of dislocation of the middle structures. Modern techniques elimination of hematomas involves minimally invasive intervention using endoscopic equipment.

Rehabilitation

The rehabilitation plan for patients with TBI is drawn up individually

The effects of a head injury can vary greatly depending on the severity of the damage to brain structures. This may be a mild asthenic syndrome after a concussion, or post-traumatic encephalopathy with focal neurological disorders and cerebrospinal fluid discirculation.

Therefore, a rehabilitation plan is drawn up for each patient strictly individually.

If treatment is carried out in neurology or rehabilitation center, it includes several main points:

• Drug therapy. Nootropics (Phenotropil, Encephabol, Ceraxon, Cerebrolysin), adaptogens (tincture of ginseng, Eleutherococcus, Leuzea and others), multivitamin complexes, B vitamins (neurorubin, milgamma). After severe TBI it is prescribed anticonvulsants(Depakine, carbamazepine).
• Physiotherapeutic treatment. Darsonval, magnetic therapy, IRT; restorative massage, as well as aimed at restoring movements in paretic limbs.
• Psychotherapy. Here, the help of a psychologist is needed; both individual psychotherapeutic sessions and group classes. Children who have suffered severe traumatic brain injuries especially need the help of a psychologist.

Patient consulting with a psychotherapist

• Kinesiotherapy. This includes different kinds physical activity, exercise therapy, exercises in the pool, elements of sports.

After completing the main course of rehabilitation in neurology, it is recommended Spa treatment. It is better to take it in a specialized sanatorium for people with central nervous system diseases. If necessary, cosmetic surgeries are performed to restore post-traumatic defects of the face and head.

Rehabilitation after a traumatic brain injury is especially difficult for people with intellectual and mental disorders. Such consequences are sometimes observed after severe traumatic brain injuries.

In this case, treatment of traumatic encephalopathy is carried out in specialized centers or neurology under the supervision of a psychiatrist.

Even after a mild TBI, post-traumatic encephalopathy can manifest itself through depression, dyssomnia, decreased performance and chronic fatigue. In such cases, the prescription of antidepressants is required, and for increased anxiety - daytime tranquilizers.

Post-traumatic encephalopathy may develop after a traumatic brain injury.

A full range of rehabilitation measures helps not only restore the patient’s health, but also return him to full health. social life, restore professional skills. After severe injuries with persistent dysfunction of the nervous system, a disability group is established by decision of the MSEC. To obtain it, you must submit an extract from neurosurgery or neurology to the district clinic.

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Traumatic brain injury (TBI) is one of the most common types of injuries and accounts for up to 50 % of all types of injuries, and in recent decades is characterized by both an increasing trend in the proportion of brain injuries and their severity.

Traumatic brain injury(TBI) is one of the most common types of injuries and accounts for up to 50 % of all types of injuries, and in recent decades is characterized by both an increasing trend in the proportion of brain injuries and their severity. Thus, TBI is increasingly becoming a multidisciplinary problem, the relevance of which is increasing for neurosurgeons, neurologists, psychiatrists, traumatologists, radiologists, etc. At the same time, recent observations show insufficient quality and non-compliance with the continuity of conservative therapy.

There are several main types of interrelated pathological processes:

1) direct damage to the brain substance at the time of injury;

2) cerebrovascular accident;

3) violation of liquor dynamics;

4) disturbances of neurodynamic processes;

5) formation of scar-adhesive processes;

6) processes of autoneurosensitization.

The basis of the pathological picture of isolated brain injuries is primary traumatic dystrophies and necrosis; circulatory disorders and organization of tissue defect. Concussions are characterized by a complex of interconnected destructive, reactive and compensatory-adaptive processes occurring at the ultrastructural level in the synaptic apparatus, neurons, and cells.

Brain contusion is an injury characterized by the presence in the substance of the brain and in its membranes of macroscopically visible foci of destruction and hemorrhage, in some cases accompanied by damage to the bones of the vault and base of the skull. Direct damage to the hypothalamic-pituitary, brainstem structures and their neurotransmitter systems during TBI determines the uniqueness of the stress response. Impaired metabolism of neurotransmitters is the most important feature of the pathogenesis of TBI. Cerebral circulation is highly sensitive to mechanical influences.

The main changes that develop in the vascular system are expressed by spasm or dilation of blood vessels, as well as increased permeability of the vascular wall. Directly related to the vascular factor is another pathogenetic mechanism for the formation of the consequences of TBI—a violation of liquor dynamics. Changes in the production of cerebrospinal fluid and its resorption as a result of TBI are associated with damage to the endothelium of the choroid plexuses of the ventricles, secondary disorders of the microvasculature of the brain, fibrosis of the meninges, and in some cases, liquorrhea. These disorders lead to the development of liquor hypertension, and less commonly, hypotension.

In TBI, hypoxic and dysmetabolic disorders play a significant role in the pathogenesis of morphological disorders, along with direct damage to nerve elements. TBI, especially severe, causes respiratory and circulatory disorders, which aggravates existing cerebral dyscirculatory disorders and collectively leads to more pronounced brain hypoxia.

Currently (L. B. Likhterman, 1990) there are three basic periods during traumatic brain disease: acute, intermediate, and remote.

The acute period is determined by the interaction of the traumatic substrate, damage reactions and defense reactions, and is the period of time from the moment of the damaging effects of mechanical energy until the stabilization of impaired cerebral and general body functions at one or another level or the death of the victim. Its duration ranges from 2 to 10 weeks, depending on the clinical form of TBI.

The intermediate period is characterized by the resorption and organization of areas of damage, and the development of compensatory and adaptive processes until complete or partial restoration or stable compensation of impaired functions. The length of the intermediate period for non-severe TBI is up to 6 months, for severe TBI – up to a year.

The long-term period is the completion or coexistence of degenerative and reparative processes. The length of the period for clinical recovery is up to 2-3 years, for a progressive course it is not limited.

All types of TBI are usually divided into closed brain injuries (CBI), open and penetrating. Closed TBI is a mechanical injury to the skull and brain, resulting in a number of pathological processes that determine the severity of the clinical manifestations of the injury. TO open TBI should include injuries to the skull and brain in which there are wounds to the integument of the skull (damage to all layers of the skin); penetrating damage involves a violation of the integrity of the dura mater.

Classification of traumatic brain injury(Gaydar B.V. et al., 1996):

• brain concussion;
• brain contusion: mild, moderate, severe;
• compression of the brain against the background of a bruise and without a bruise: hematoma - acute, subacute, chronic (epidural, subdural, intracerebral, intraventricular); hydro wash; bone fragments; edema-swelling; pneumocephalus.

It is very important to determine:

• condition of the intrathecal spaces: subarachnoid hemorrhage; CSF pressure - normotension, hypotension, hypertension; inflammatory changes;
• condition of the skull: no bone damage; type and location of the fracture;
• condition of the skull: abrasions; bruises;
• associated injuries and diseases: intoxication (alcohol, drugs, etc., degree).

It is also necessary to classify TBI according to the severity of the victim’s condition, the assessment of which includes the study of at least three components:

1) state of consciousness;

2) the state of vital functions;

3) the state of focal neurological functions.

There are five gradations of the condition of patients with TBI

Satisfactory condition. Criteria:

1) clear consciousness;

2) absence of violations of vital functions;

3) absence of secondary (dislocation) neurological symptoms; absence or mild severity of primary focal symptoms.

There is no threat to life (with adequate treatment); the prognosis for recovery is usually good.

Moderate condition. Criteria:

1) state of consciousness - clear or moderate stun;

2) vital functions are not impaired (only bradycardia is possible);

3) focal symptoms - certain hemispheric and craniobasal symptoms may be expressed, often appearing selectively.

The threat to life (with adequate treatment) is insignificant. The prognosis for restoration of working capacity is often favorable.

Serious condition. Criteria:

1) state of consciousness - deep stupor or stupor;

2) vital functions are impaired, mostly moderately according to 1-2 indicators;

3) focal symptoms:

a) brainstem - moderately expressed (anisocoria, decreased pupillary reactions, limited upward gaze, homolateral pyramidal insufficiency, dissociation of meningeal symptoms along the body axis, etc.);

b) hemispheric and craniobasal - clearly expressed both in the form of symptoms of irritation (epileptic seizures) and loss (motor disorders can reach the degree of plegia).

The threat to life is significant and largely depends on the duration of the serious condition. The prognosis for restoration of working capacity is sometimes unfavorable.

Extremely serious condition. Criteria:

1) state of consciousness - coma;

2) vital functions - gross violations in several parameters;

3) focal symptoms:

a) stem - expressed roughly (plegia of upward gaze, gross anisocoria, divergence of the eyes along the vertical or horizontal axis, a sharp weakening of the pupils’ reactions to light, bilateral pathological signs, hormetonia, etc.);

b) hemispheric and craniobasal - pronounced.

The threat to life is maximum and largely depends on the duration of the extremely serious condition. The prognosis for restoration of working capacity is often unfavorable.

Terminal state. Criteria:

1) state of consciousness - terminal coma;

2) vital functions - critical impairment;

3) focal symptoms:

a) stem - bilateral fixed mydriasis, absence of pupillary and corneal reflexes;

b) hemispheric and craniobasal - blocked by general cerebral and brainstem disorders.

Survival is usually impossible.

Clinical picture of acute traumatic brain injury

Brain concussion. Clinically, it is a single functionally reversible form (without division into degrees). With a concussion, a number of general cerebral disorders occur: loss of consciousness or, in mild cases, short-term blackout from several seconds to several minutes. Subsequently, a stunned state persists with insufficient orientation in time, place and circumstances, an unclear perception of the environment and a narrowed consciousness. Retrograde amnesia is often detected - loss of memory for events preceding the injury, less often anterograde amnesia - loss of memory for events subsequent to the injury. Speech and motor agitation are less common.

Brain contusion severe severity is clinically characterized by loss of consciousness after injury lasting from several hours to several weeks. Motor agitation is often pronounced, and severe, threatening disturbances in vital functions are observed. The clinical picture of severe UHM is dominated by brainstem neurological symptoms, which overlap focal hemispheric symptoms in the first hours or days after TBI. Paresis of the limbs (up to paralysis), subcortical disturbances of muscle tone, reflexes of oral automatism, etc. may be detected. Generalized or focal epileptic seizures are noted. Focal symptoms regress slowly; gross residual effects are frequent, primarily in the motor and mental spheres. Severe UHM is often accompanied by fractures of the vault and base of the skull, as well as massive subarachnoid hemorrhage.

An undoubted sign of fractures of the base of the skull is nasal or auricular liquorrhea. In this case, the symptom of a spot on a gauze napkin is positive: a drop of bloody cerebrospinal fluid forms a red spot in the center with a yellowish halo along the periphery.

Suspicion of a fracture of the anterior cranial fossa arises with the delayed appearance of periorbital hematomas (a symptom of glasses). With a fracture of the temporal bone pyramid, Battle's symptom (hematoma in the mastoid region) is often observed.

Brain compression- a progressive pathological process in the cranial cavity that occurs as a result of trauma and causes dislocation and infringement of the trunk with the development of a life-threatening condition. In TBI, cerebral compression occurs in 3-5 % of cases, both with and without UGM. Among the causes of compression, the first place is occupied by intracranial hematomas - epidural, subdural, intracerebral and intraventricular; This is followed by depressed fractures of the skull bones, areas of crushing of the brain, subdural hygromas, and pneumocephalus.

The clinical picture of compression of the brain is expressed by a life-threatening increase in a certain period of time (the so-called light interval) after the injury or immediately after it of cerebral symptoms, the progression of impaired consciousness; focal manifestations, stem symptoms.

Complications of traumatic brain injury

Violations of vital functions - a disorder of the basic life support functions (external respiration and gas exchange, systemic and regional circulation). In the acute period of TBI, the causes of acute respiratory failure (ARF) are dominated by pulmonary ventilation disorders associated with impaired airway patency caused by the accumulation of secretions and vomit in the nasopharynx with their subsequent aspiration into the trachea and bronchi, and retraction of the tongue in comatose patients.

Dislocation process: temporotentorial inclusion, representing a displacement of the mediobasal sections of the temporal lobe (hippocampus) into the fissure of the tentorium of the cerebellum and herniation of the cerebellar tonsils into the foramen magnum, characterized by compression of the bulbar sections of the trunk.

Purulent-inflammatory complications are divided into intracranial (meningitis, encephalitis and brain abscess) and extracranial (pneumonia). Hemorrhagic - intracranial hematomas, cerebral infarctions.

Scheme of examination of victims with traumatic brain injury

• Identifying the history of the injury: time, circumstances, mechanism, clinical manifestations of the injury and the amount of medical care before admission.
• Clinical assessment of the severity of the victim’s condition, which is of great importance for diagnosis, triage and provision of stage-by-stage assistance to victims. State of consciousness: clear, stunned, stupor, coma; the duration of loss of consciousness and the sequence of exit are noted; memory impairment, antero- and retrograde amnesia.
• State of vital functions: cardiovascular activity - pulse, blood pressure (a common feature in TBI - the difference in blood pressure on the left and right extremities), breathing - normal, impaired, asphyxia.
• Condition of the skin - color, moisture, bruises, presence of soft tissue damage: location, type, size, bleeding, liquorrhea, foreign bodies.
• Examination of internal organs, skeletal system, concomitant diseases.
• Neurological examination: the state of cranial innervation, reflex-motor sphere, the presence of sensory and coordination disorders, the state of the autonomic nervous system.
• Meningeal symptoms: stiff neck, Kernig's, Brudzinski's symptoms.
• Echoencephaloscopy.
• X-ray of the skull in two projections; if damage to the posterior cranial fossa is suspected, a posterior semi-axial image is taken.
• Computer or magnetic resonance imaging of the skull and brain.
• Ophthalmological examination of the condition of the fundus of the eye: edema, congestion of the optic nerve head, hemorrhages, condition of the vessels of the fundus.
• Lumbar puncture - in the acute period is indicated for almost all victims with TBI (with the exception of patients with signs of compression of the brain) with measurement of cerebrospinal fluid pressure and removal of no more than 2-3 ml of cerebrospinal fluid, followed by laboratory testing.
• The diagnosis reflects: the nature and type of brain damage, the presence of subarachnoid hemorrhage, brain compression (cause), liquor hypo- or hypertension; condition of the soft covers of the skull; fractures of the skull bones; the presence of concomitant injuries, complications, intoxications.

Organization and tactics of conservative treatment of victims with acute TBI

In general, victims with acute TBI should go to the nearest trauma center or medical facility where initial medical examination and emergency medical care are provided. The fact of injury, its severity and the condition of the victim must be confirmed by appropriate medical documentation.

Treatment of patients, regardless of the severity of TBI, should be carried out in an inpatient setting in a neurosurgical, neurological or trauma department.

Primary medical care is provided for urgent reasons. Their volume and intensity are determined by the severity and type of TBI, the severity of the cerebral syndrome and the possibility of providing qualified and specialized care. First of all, measures are taken to eliminate airway and cardiac problems. For convulsive seizures and psychomotor agitation, 2-4 ml of diazepam solution is administered intramuscularly or intravenously. If there are signs of compression of the brain, diuretics are used; if there is a threat of cerebral edema, a combination of loop and osmodiuretics is used; emergency evacuation to the nearest neurosurgical department.

To normalize cerebral and systemic circulation during all periods of traumatic illness, vasoactive drugs are used; in the presence of subarachnoid hemorrhage, hemostatic and antienzyme agents are used. The leading role in the treatment of patients with TBI is given to neurometabolic stimulants: piracetam, which stimulates the metabolism of nerve cells, improves cortico-subcortical connections and has a direct activating effect on the integrative functions of the brain. In addition, neuroprotective drugs are widely used.

To increase the energy potential of the brain, the use of glutamic acid, ethylmethylhydroxypyridine succinate, and vitamins B and C is indicated. Dehydration agents are widely used to correct liquorodynamic disorders in patients with TBI. To prevent and inhibit the development of adhesive processes in the membranes of the brain and to treat post-traumatic leptomeningitis and choreoependymatitis, so-called “absorbable” agents are used.

The duration of treatment is determined by the dynamics of regression of pathological symptoms, but requires strict bed rest in the first 7-10 days from the moment of injury. The duration of hospital stay for concussions should be at least 10-14 days, for mild bruises - 2-4 weeks.

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