Neurosurgical correction in acute period TBI is subject to wounds of the soft tissues of the head, depressed fractures of the bones of the cranial vault, intracranial hematomas and hydromas, some forms of brain contusion, gunshot wounds of the skull and brain.

Soft tissue wounds of the head

Wounds of the soft tissues of the head are divided into:

1. Depending on the type of wounding agent: bruised, cut, stabbed, chopped, torn, crushed, bitten and gunshot.

2. By type: linear, stellate, scalped.

3. By depth of distribution: cutaneous, cutaneous-aponeurotic, penetrating to the bone and deeper.

Wounds of the soft tissues of the head, except for superficial skin ones (their edges do not gape, they quickly stick together, and the bleeding stops on their own), are subject to surgical treatment. Depending on the timing of surgical treatment of wounds after injury, there are:

– primary surgical treatment (PST) of the wound, performed within the first 6 hours;

– early surgical treatment of the wound, performed in the first 3 days;

– delayed surgical treatment, performed on days 4-6;

– late surgical treatment, performed after 6–7 days.

It is most optimal to perform PSO in the acute period, which promotes wound healing primary intention and transfer of open to closed TBI. However, severe vital disturbances and shock may prevent wound treatment in the first 6 hours.

The basic rules for surgical treatment of head wounds are described in the section on general principles of craniotomy. In addition to the general rules, attention should be paid to the essential details of treating head wounds, such as complete removal of foreign bodies from the wound. In lacerated and crushed wounds, only clearly non-viable areas of the edges should be removed. Careful hemostasis and a complete inspection of the wound are important. Particularly relevant is a thorough instrumental or digital inspection of the bottom of wounds when known condition inability to perform a survey craniography in the near future. If the surgeon is convinced that the bottom of the wound is intact bone, there are no deep “pockets” or significant detachment of soft tissue, he has the right to apply a primary blind suture. If there is a suspicion of a high probability of developing suppuration, then the wound is drained for 1–2 days and, in the absence of infectious complications, secondary early sutures are applied. In cases where the wounds still suppurate, after the disappearance of purulent discharge and the formation of good granulation tissue, late secondary sutures can be applied. In this case, it is advisable to economically “refresh” the edges of the granulating wound.

What to do if the ambulance personnel delivered to the hospital along with the victim a completely torn off large flap of soft tissue of the herep? In this case, after complete treatment of the wound on the head, the flap is freed from the aponeurosis and subcutaneous fatty tissue. Then perforating wounds about 1 cm in size are made on it in a checkerboard pattern and placed on the intact periosteum. If the bottom of the wound is a completely exposed bone, then its cortical layer is removed and a skin flap is placed on the “platform” prepared in this way.

Surgical treatment of depressed fractures of the calvaria

In cases where digital examination of the wound base or craniography reveals an open depressed fracture, the soft tissue wound should be dissected taking into account the course of blood vessels, nerves and cosmetic considerations. The dimensions of the wound must meet the requirements for possible craniotomy (Fig. 49). Planning of access for closed depressed fractures should comply with the requirements set out in Chapter VI. Surgical treatment of depressed fractures of the calvarial bones is indicated when bone fragments are impressed or depressed to a depth greater than the thickness of the bone. In this case, the surgeon aims to ensure decompression of the brain, exclude and, if necessary, remove the underlying hematoma, and prevent long-term consequences of TBI caused by irritation of the underlying brain by an unremoved bone fragment. Removal or lifting of bone fragments pressed into the cavity of the skull, as a rule, is carried out from a burr hole placed next to the depressed fracture (Fig. 50). You cannot immediately begin removing bone fragments from the center of the depression, since this will result in a high probability of additional injury to the underlying brain.

Rice. 49. Excision of non-viable edges of a soft tissue wound of the head (according to A. P. Romodanov et al., 1986)

The milling hole is expanded until an intact dura mater appears (Fig. 51). Small bone fragments (up to 2–3 cm) must be removed. Removable free-lying uninfected bone fragments of a larger size are not thrown away, but are kept sterile until the wound is closed, when they can be placed in the area of ​​the skull defect between the dura mater and soft tissues. Large fragments connected by the periosteum should be elevated. Reduced fragments, if they are not sufficiently immobilized, must be fastened with sutures. The edges of the formed bone defect are leveled to prepare them for subsequent plastic surgery. Particular attention should be paid to the need for a thorough inspection of the epidural space around the circumference of the formed bone defect. Very often, fragments of lamina vitrea are embedded under the edge of the bone and may remain unnoticed and unremoved, which increases the risk of developing osteomyelitis in the bone. postoperative period. To avoid this, a Volkmann spoon or a narrow spatula is used to carefully inspect the epidural space along the edge of the bone defect and remove all loose, often small, bone fragments and blood clots.

Rice. 50.

Rice. 51.

Is it possible to perform initial reposition of bones from

– be used in children in cases where the impression of bone fragments is relatively small and all bone fragments are connected through the periosteum. In adults, such manipulation is fraught with danger, since it is possible to “miss” intracranial hematomas and bleeding located under the fracture.

It is prohibited to perform such manipulation in the area of ​​the projection course of large venous sinuses.

If an intracranial hematoma, a crushed brain, or a massive contusion lesion is detected, a decompressive (flap or, more often, resection) craniotomy is performed. For small depressed, perforated, gunshot fractures, it is advisable to cut out a bone flap with the damage zone in the center (according to the De Martel principle). After adequate revision of the wound and treatment of the bone flap, the latter is placed in its original place.

Particularly difficult are cases where the depression zone is located above large venous sinuses. In such cases, surgical treatment is carried out according to the principle from the periphery to the center.

Initially, you should prepare a free flap cut from soft tissue (aponeurosis, muscle). It is flattened with the jaws of scissors and stitched in at least 4 places with ligatures. Such a flap may be needed to plastically close the area of ​​sinus damage. Therefore, it must be prepared in advance.

Several burr holes are placed on both sides of the sinus and bone resection is performed from them. When fringing the bone, undamaged adjacent areas of the sinus are exposed. Then they begin to carefully remove bone fragments. It is more advisable to remove them in one block, carefully peeling off the dura mater. If bleeding occurs from the sinus, it is immediately stopped with finger pressure.

How can you stop bleeding from a damaged sinus? There are several ways.

Rice. 52. Suturing a sinus wound with interrupted sutures (according to A. P. Romodanov et al., 1986)

1. Compression of the sinus on the sides of the wound by introducing tampons into the epidural space. However, this results in compression of the underlying brain and disruption of blood flow through the sinus. Stopping bleeding in this way is not only ineffective and traumatic, but also does not guarantee the elimination of re-bleeding after removing the tampons.

2. Direct suturing of the sinus wound by applying nodal or continuous seams(Fig. 52). To the disadvantages this method This may include the difficulty of suturing in conditions of massive bleeding and poor visibility of the edges of the sinus wound, and the possibility of cutting sutures. In addition, suturing in this way can only be done for linear wounds of the sinuses, which is rare, and when the damage is localized on the upper wall of the sinus.

3. Plastic surgery of the sinus wound with the outer layer of the dura mater according to Bruning-Burdenko. In conditions heavy bleeding such an operation is difficult to perform. In addition, the outer (conditionally infected) layer of the dura mater, facing the lumen of the sinus, can contribute to the development of septic complications (Fig. 53).

4. The simplest, most effective and reliable method can be considered plastic surgery of a sinus wound with a free flap, previously prepared, as indicated above (Fig. 54). The surgeon, after lifting the finger that was blocking the bleeding from the sinus wound, quickly applies a piece of the flap to the damaged area and presses it again with the finger. Then the edges of the flap are gradually sutured along the periphery to the dura mater with moderate tension. In most cases, this method allows you to reliably stop bleeding from a damaged sinus.

5. In cases where there are gaping injuries to two or three walls of the sinus and the bleeding cannot be stopped by any other means, the surgeon is forced to decide to bandage the sinus. Using a large round needle with a strong ligature, the sinus is stitched on both sides of the wound site (Fig. 55). If the bleeding continues, then it is necessary to coagulate or ligate the ascending veins of the brain that flow into the sinus in this area.

Rice. 53. Stages of plastic closure of a sinus wound according to Bruning - Burdenko (a, b) (according to A. P. Romodanov et al., 1986)

Rice. 54.

Rice. 55.

The anatomical features of the structure of the venous system of the brain make it possible to ligate the sagittal sinus in the anterior third relatively harmlessly for the victim. Ligation of the sinus in the middle and especially in its posterior third leads to disruption of venous outflow, rapid development of cerebral edema and, ultimately, death.

You should especially remember the need to create a trepanation window of sufficient size if a sinus injury is suspected. It must be at least 5 x 6 x 6 cm.

When injured by bone fragments of the dura mater of the brain the latter is often cut with radial incisions. Before this, careful hemostasis must be performed. The meningeal vessels coagulate and pierce the arterial trunks of the dura mater. In the parasagittal region, incisions should be made in such a way that it is possible to discard one of the flaps with the base towards the sinus.

Rice. 56. Horseshoe-shaped dissection of the dura mater with the base towards the sinus and removal of bone fragments embedded in the brain (according to A.P. Romodanov et al., 1986)

Bone fragments embedded in the brain foreign bodies, crushed areas of brain tissue are removed with tweezers, washing and suction (Fig. 56).

Bleeding from brain tissue is stopped by coagulation, application of pads soaked in hydrogen peroxide, hemostatic sponge, and application of clips.

Subsequently, the dura mater is sutured. If this is not possible due to significant protrusion of the brain into the defect, plastic closure of the dura mater defects is performed with the creation of a certain reserve in the form of a “sail”.

In children under the age of 1 year, depressed fractures without bone fragments can be lifted using an elevator from a burr hole placed next to the fracture. For “old” depressed fractures in children, the bone flap inversion technique is used. In this case, several milling holes are placed along the perimeter of the indentation, which are connected by cuts. If the surgeon has the appropriate equipment at his disposal, the free flap should be preferred. The formed flap is turned over by pressing outward and fixed to the main bone.

In older children, when closed, non-penetrating, Depressed fractures are accompanied by the formation of bone fragments and there is a need to remove them; it is advisable not to throw away bone fragments. After complete treatment of the wound, the fragments are crushed with pliers and the resulting bone “crumbs” are laid in an even layer on the dura mater. Subsequently, layer-by-layer suturing of the wound is performed.

Surgical treatment of depressed fractures of fronto-basal localization

Fractures of the outer wall frontal sinus with depression, but without damage to the posterior wall, surgical intervention is not required in most cases. Often frontobasal trauma is accompanied by the formation of comminuted depressed fractures in the area of ​​the frontal sinuses and orbits. In this case, damage to the ethmoidal labyrinth, vomer, and orbital contents often occurs. Taking into account cosmetic considerations, we suggest surgical treatment of such injuries to be performed from the Zutter approach, the soft tissue incision is made approximately 1 cm posterior to the hairline. The skin-aponeurotic flap is separated from the base to the superciliary arches, exposing the area of ​​​​indentation. Existing wounds are subject to economical marginal excision only if they are clearly crushed and non-viable. This access provides a broad approach and good review. There is no need for additional soft tissue incisions. Often, novice neurosurgeons, motivating their actions by the fact that there is already a wound, expand it and thereby increase the cosmetic defect.

Following the general rules for treating depressed fractures, you should still remove bone tissue as economically as possible. Loose small fragments must be removed; large fragments are carefully lifted to the level of the mainland bone and fixed to each other with sutures. Particular care should be taken to inspect the fatty tissue of the orbit and the base of the skull. Here, small fragments that damage the dura mater, optic nerve, and eye muscles may go unnoticed. After removing all the fragments to be removed, the “clean” stage of the operation begins.

The gloves of the operating team are processed, the towels delimiting the surgical field are changed, and the intervention zone is demarcated with quilted pads. If there is a dura mater wound, it is expanded and the pole(s) of the frontal lobe(s) are inspected. Existing brain debris is washed and aspirated. Hemostasis according to generally accepted rules. The dura mater must be carefully sutured to avoid the formation of nasal liquorrhea in the postoperative period. After suturing the dura mater wound, you need to make sure that there is no damage to the membrane in other places. If any are found, be sure to suture them. The mucous membrane of the frontal sinus is carefully scraped out with a Volkmann spoon. It is not advisable to tamponade the frontal sinuses with muscles, protacryl and other means. Preference may be given to tamponade with a hemostatic sponge containing gentamicin. After this, a layer of MK series glue is applied along the inner perimeter and a semi-permeable membrane OB-20 is glued. It is possible that the mouth of the frontonasal meatus may be blocked by a small piece of crushed muscle.

Rice. 57.

1 – frontal sinus; 2 – pole of the frontal lobe; 3 – periosteal apron is fixed to the dura mater (according to Yu. V. Kushel, V. E. Semin, 1998)

We agree with the opinion of many authors about the need to distinguish the opened frontal sinuses from the dura mater. To do this, a horseshoe-shaped “apron” is cut out from the skin-aponeurotic flap in the area of ​​the opened sinus with the base towards the superciliary arches. It is stretched over the area of ​​the damaged sinus and sutured to the dura mater as close to the base as possible (Fig. 57).

Rice. 58. Plastic surgery of the frontal sinus with periosteum (according to Yu. V. Kushel, V. E. Semin, 1998). The arrow indicates duplication of the periosteum

There is an opinion that cerebrospinal fluid may leak from the holes formed at the puncture sites of the dura mater when suturing the aponeurotic “apron”, which leads to cerebrospinal fluid leakage. To avoid such a complication, another method of isolating the frontal sinuses can be used. IN back wall In the sinuses, paired holes should be drilled for passing threads at a distance of approximately 7–8 mm from each other. The aponeurotic flap or periosteum, cut in a manner similar to the above, is sutured to the posterior wall of the sinus, as shown in Fig. 58. Formation of duplication is mandatory.

Surgery of intracranial hematomas

At the qualified stage medical care the issue of surgical treatment of intracranial hematomas should be resolved unambiguously. It should be done immediately after diagnosis. In hospitals with CT or MRI monitoring capabilities, the treatment tactics for intracranial hematomas, especially “small” ones, can be decided on a case-by-case basis and does not exclude conservative management.

The intervention is planned and carried out taking into account the severity of the condition and age of the victim, the volume of the hematoma, the presence and severity of concomitant brain contusion, dislocation syndrome, extracranial chronic and traumatic pathology. Access must be adequate (at least 7 x 7 x x 8 cm), from which it is possible to remove a hematoma, contusion lesion, and achieve complete hemostasis without additional brain trauma. As already noted, preference should be given to patch craniotomy, however, the resection method of trephination also has a right to exist and is fully justified in the conditions of a central district hospital.

Rice. 59. Scheme of the most common variants of epidural hematomas with branches of the middle meningeal artery. The lines indicate Kroenlein's diagram. The circles indicate the locations of the trephination holes.

Rice. 60.

Rice. 61. Examination of the brain using a spatula after slightly widening the burr hole with bone nippers (according to V. M. Ugryumov, 1969)

Trefination technique of the skull

The overlay of the diagnostic milling hole is simultaneously the last stage diagnostic complex and the first stage of surgical treatment. Dissection of soft tissues is carried out in the projection of the point of greatest frequency of localization of intracranial hematomas about 5 cm long (Fig. 59).

The bone is skeletonized with a raspatory. The milling hole is placed with a rotary tool (Fig. 60).

The dura mater is dissected with a small cross-shaped incision, its edges are either sutured or picked up with special tweezers with small teeth (commonly called dural). A narrow brain spatula is carefully inserted into the subdural space (Fig. 61).

If a hematoma is detected, either the trefination hole is widened using a resection method, or a patch craniotomy is performed.

Features of removal of epidural hematomas

After performing the bone stage of the operation, black blood clots are present in the wound. They are removed gradually by aspiration and washing out with isotonic sodium chloride solution (Fig. 62). Detected sources of bleeding, which in most cases are branches of the meningeal artery, are subject to coagulation, clipping or suturing and ligation. However, it is not always possible for a surgeon to detect a bleeding vessel after washing off the clots. Some of the clots intimately fused to it remain on the dura mater. There is an opinion that these clots should not be removed, since they already perform a hemostatic role. We consider this tactic to be wrong.

Rice. 62. Removal of epidural hematoma with an electric aspirator (according to A. P. Romodanov et al., 1986)

In the immediate postoperative period, lysis of the clot covering the damaged branch of a is possible. meningea media, resumption of bleeding, formation of a new epidural hematoma, which necessitates repeated intervention.

In our opinion, the surgeon is obliged to detect the source of bleeding during the first intervention and ensure complete and reliable hemostasis. To do this, blood clots that “stick” to the dura mater should be carefully removed by scraping with a spatula or spoon. The visualized source of bleeding is then treated according to generally accepted rules.

Particular attention should be paid to those cases when the blood comes from the area of ​​the base of the skull and the source of bleeding is difficult to localize, then the scales of the temporal bone are bitten off as close to the base of the skull as possible, the dura mater is moved away with spatulas and the meningeal artery is coagulated at its base. If coagulation does not give the desired effect, stitching is technically impossible, since the artery is damaged in the area of ​​its exit from the foramen spinosum, then it is possible to stop the bleeding as follows: from an ordinary match treated with 96° alcohol, a pin is formed, which is embedded in f. spinosum until bleeding stops completely. A similar stop of bleeding is possible using a bone pin.

Additional hemostasis can be carried out with a 3% solution of hydrogen peroxide, small crushed pieces of muscle, or a hemostatic sponge. We consider it necessary to suture the dura mater around the perimeter of the bone defect to the aponeurosis and periosteum. This reduces the epidural space in the area of ​​the removed hematoma, improves hemostasis and reduces the risk of re-accumulation of blood in this area.

Indications for dissection of the dura mater after removal of an epidural hematoma are described in the section on general principles of craniotomy.

Features of removal of subdural hematomas

The technique for removing subdural hematomas depends on the timing of their formation, the age and severity of the condition of the victims. It is different for acute and chronic variants of the course. Preference should be given to osteoplastic access. After trephination in the area of ​​hematoma localization, a sharply tense and bluish dura mater is always visualized, which does not transmit the pulsation of the underlying brain. Some authors believe that before dissecting the dura mater, it is advisable to perform a lumbar puncture to remove 20–25 ml of cerebrospinal fluid. At the same time, a rationale is given for the decrease in intracranial pressure and the appearance of brain pulsation.

We remember that performing a lumbar puncture is not only impractical, but even dangerous, since when such a large amount of cerebrospinal fluid is removed, rapid development of brain dislocation may occur. It will be better for the patient to quickly eliminate the compression factor, which is also located in an accessible place in most cases.

After mandatory coagulation of the dura mater vessels, the latter is dissected using one of the methods indicated in Chapter VI (Fig. 63). With pronounced tension in the dura mater, it is possible to first make a dotted incision for “slow” evacuation of blood and gradual decompression of the brain. Rapid emptying of the hematoma leads to sudden changes in systemic hemodynamics. After isolating the liquid part of the hematoma, an incision is made into the dura mater, connecting the dotted incisions. Clots are evacuated by aspiration and washing out with a stream of isotonic solutions (0.9% sodium chloride, furatsilin) ​​(Fig. 64).

After washing out the visible part of the hematoma, a false impression may be formed that it has been completely removed. This is far from true. As a rule, in such situations, approximately half of the volume of the subdural hematoma remains unremoved. This part is located under the dura mater along the periphery of the trepanation window, and the surgeon does not see it. The brain is covered with quilted pads and the remaining part of the hematoma is methodically removed using spatulas, an aspirator and washing out.

Rice. 63.

Rice. 64. Washing and aspiration of the visible part of the subdural hematoma (according to V. M. Ugryumov, 1969)

It should be remembered that the spatulas must be carefully inserted into the subdural space. The brain matter should be squeezed gently, the pressure of the jet of washing liquid should be moderate. The spatula can be removed only after the washing fluid has almost completely flowed out of the subdural space.

You should not inspect the subdural space with your finger, since this can damage the ascending parasinus veins and cause additional bleeding.

The complete removal of the hematoma is indicated by the absence of clots during washing of the subdural space, the retraction of the brain, the appearance of its pulsation, and respiratory vibrations.

The surgeon must ensure that hemostasis is complete. To do this, observe the wound for several minutes. After eliminating the compression factor, the brain straightens. In this case, slightly bleeding veins are pressed against the inner layer of the dura mater. This process promotes hemostasis. If bleeding continues, it should be localized, the trepanation window should be expanded, the source of bleeding should be visualized, and final hemostasis should be performed by coagulation.

In most cases, subdural hematomas extend over a significant part of the convexital surface of the hemisphere, and only a small part of them can be viewed. What to do if, after removing the central part of the hematoma, the brain protrudes into the bone defect and does not allow adequate washing of the subdural space without additional trauma? In this case, it is necessary to ensure that there is no intracerebral hematoma. Using fingers moistened with furatsilin, carefully palpate the brain to identify fluctuating areas. When such zones are identified, a brain puncture is performed, an intracerebral hematoma is verified, and it is removed. And only after this, when brain tension decreases, the subdural hematoma is finally removed.

If an intracerebral hematoma is not detected and the protrusion of the brain into the defect is significant and there is no pulsation, then we can think about the presence of an intracranial hematoma on the opposite side. Therefore, it is necessary to place a search burr hole on the opposite side.

For subdural hematomas extending to the base of the skull, the trepanation window must be expanded as close to the base as possible, additionally dissect the dura mater and completely remove blood clots located basally.

What to do in those cases when, after complete removal of the subdural hematoma, the brain does not straighten out and a significant residual cavity remains? Such situations are possible in subacute hematomas and in elderly patients (age-related increases in reserve spaces). Relapse (retraction) of the brain is accompanied by liquor hypotension and a decrease in central venous pressure. Clinically, victims may continue to experience deep depression of consciousness, hyperthermia, worsening focal symptoms, respiratory failure, arterial hypotension, and bradycardia. After final hemostasis, the residual cavity should be filled with isotonic solution. A drainage is placed at the base of the skull in the projection of the middle cranial fossa and the dura mater is sutured until drainage occurs. In the postoperative period, intravenous infusions of a 1% solution of calcium chloride, polyglucin, and rheopolyglucin are administered.

Issues of drainage, closing the wound with a bone flap and features of suturing soft tissues are presented in Chapter VI.

Removal of intracerebral hematomas

Intracerebral hematomas formed as a result of injury are removed by patch craniotomy or resection. Having localized by palpation the area of ​​the greatest fluctuation or elastic compaction, a place for brain puncture is selected. Such a point should, if possible, be located in a functionally insignificant area and at the apex of the gyrus. In this case, it is desirable to select a relatively avascular zone.

Rice. 65.

Rice. 66. Encephalotomy with spatulas and aspiration of intracerebral hematoma (according to V. M. Ugryumov, 1969)

It is unacceptable to choose a puncture site in the depth of the furrow, since this may damage the vessels passing there. This can lead to the development of ischemia and regional cerebral infarction. After pinpoint coagulation of the cortex, a puncture of the brain is performed using a special cannula with divisions. Often there is a feeling of a hole in the hematoma cavity. The liquid part of the hematoma is aspirated and then the cortex is dissected (encephalotomy) without removing the cannula. Before this, coagulation of the vessels is carried out along the line of the intended dissection of the cortex (Fig. 65).

Along the cannula, carefully move the brain matter apart with spatulas until the hematoma cavity is detected (Fig. 66). Often intracerebral hematomas are “born”. The remaining liquid and clots are washed out of its cavity and aspirated. If necessary, economical removal of the brain matter crushed in the perifocal zone is performed. The source of bleeding, as a rule, is rarely visualized at the time of hematoma removal. If there is one, then the bleeding is stopped by coagulation, tamponade with padded pads moistened with a 3% solution of hydrogen peroxide, and a hemostatic sponge. Hemostasis is monitored by assessing the purity of the washing fluid and the absence of “smoking” vessels in the cavity of the removed hematoma. It is recommended to monitor the brain wound for 3–5 minutes when the systolic blood pressure is at least 100 mm Hg. Art. Close surgical wound, as with other types of operations for TBI.

Removal of chronic subdural hematomas

Chronic subdural hematomas are removed in most cases by performing osteoplastic craniotomy. After access and opening of the dura mater, a capsule of gray-green or Brown. The capsule is opened and its contents are aspirated. Then, gradually grasping the capsule with fenestrated tweezers (Fig. 67), the capsule is disconnected from the dura mater and the underlying brain. At the present stage, it is believed that the capsule need not be removed. In this regard, there should be no fear that minor, tightly fixed parts of the capsule remain. The cavity formed after removal of the hematoma is filled with saline solution. In the subdural space for 1 day. Silicone tube drainage is placed. The dura mater is sutured tightly.

Rice. 67.

Rice. 68. Removal of chronic subdural hematoma by washing out through the trefination holes (according to A.P. Romodanov et al., 1986)

In patients in extreme in serious condition, in elderly victims, it is possible to empty and wash out the hematoma from 2 - 3 trefination holes without removing the capsule (Fig. 68).

Removal of intraventricular hematomas

In case of massive intraventricular hemorrhage, flushing of the ventricular system through external ventricular drains is indicated. To do this, external drainage is performed. lateral ventricle on the side of greater intensity of hemorrhage and rinse with saline solution heated to body temperature. Puncture drainage is performed by placing burr holes at typical points and introducing silicone tubes into the lumen of the lateral ventricles. More often, drainage of the posterior horns of the lateral ventricles is performed.

Technique for puncture of the posterior horns of the lateral ventricles. Position the patient lying on his stomach face down. It is important to ensure that your head is positioned correctly. It is necessary to position the head so that the line of the zygomatic process is strictly vertical, and the line of the sagittal suture is strictly in the median plane. The head is treated with antiseptics according to the accepted rules for preparing the surgical field. Then marking is done with a stick moistened with a 1% solution of brilliant green. The projection course of the sagittal sinus, the greater occipital protuberance, and the puncture point are noted posterior horn and the line of the intended cut. In this case, special pedantry and care are required to ensure that the burr hole strictly corresponds to the puncture point of the posterior horn. There are two options for puncture. In the first option, the puncture point of the posterior horn (Dandy's point) is 4 cm above the greater occipital protuberance and 3 cm outward from the midline (Fig. 69).

Rice. 69.

Rice. 70.

After applying a burr hole and pinpoint coagulation of the dura mater and the underlying cortex, the ventricle is punctured. A metal mandrel is inserted into a silicone tube with a diameter of about 2 mm, which acts as a conductor. In this case, it is very important that the tip of the drainage tube is completely smooth, without burrs. At a distance of 4–5 mm from the tip of the tube, 2–3 holes must be formed with scissors. The direction of ventricular drainage should be along the line connecting this point with the outer superior angle of the orbit of the same side. To do this, the surgeon palpates the specified angle of the orbit with the index finger of the left hand and inserts the drainage in the given direction. In this case, the drainage enters the widest part of the ventricle at its junction with the lower horn. The puncture depth is usually 5–6 cm. When the mandrin is removed, cerebrospinal fluid enters the tube. In case of severe intraventricular hypertension, it is important to prevent a sharp discharge of cerebrospinal fluid and remove it in an amount of up to 20–30 ml gradually, squeezing the distal end of the drainage with a clamp. The drainage is removed through a counter-aperture and fixed to the skin. The wound is sutured tightly. After washing the ventricle, the distal end of the drainage is extended with a sterile adapter tube, which is immersed in a closed vessel or connected to a special pressure gauge.

In the second option, the burr hole is placed at a point located 6 cm above the external occipital protuberance and 2.5 cm outward from the midline. The direction of advancement of the cannula should be along the line connecting this point with the center of the frontal tubercle of the same side. In this case, the end of the drainage tube enters the ventricular triangle.

Technique for puncture of the anterior horns of the lateral ventricles. The patient lies on his back face up. The puncture point of the anterior horn (Kocher's point) is located 2 cm anteriorly and 2 cm outward from the intersection of the sagittal and coronal sutures. The marking of the point is carried out at the intersection of the lines of the sagittal suture and the perpendicular from the middle of the zygomatic arch. The technique for placing a milling hole is typical. The direction of advancement of the cannula is parallel to the median plane to a mentally drawn line connecting both external auditory canals. The cavity of the anterior horn of the lateral ventricle is located at approximately a depth of 4.5 - 5.5 cm (Fig. 70). Intraventricular hematomas are removed both from independent access to the lateral ventricles and through the zone of breakthrough of the intracerebral hematoma. After evacuation of the intracerebral hematoma, the ventricle is penetrated and all clots are removed. Ventricular drainage is removed through the main wound.

We consider it advisable to use a supply-outflow system for draining wounds when removing intracerebral and intraventricular hematomas. Such a system creates conditions for washing out tissue decay products and biologically active substances from the wound, and prevents the accumulation of blood.

Removal of subdural hydromas

Subdural hydromas develop against the background of primary traumatic brain injuries of varying severity and are often combined with a compressed intracranial hematoma. The choice of surgical intervention for brain compression syndrome with subdural hydroma depends on the presence of concomitant pathology in the form of foci of brain contusion, intracranial hematomas, and traumatic cerebral edema. Removal of an isolated subdural hydroma can be performed from one or two burr holes. However, the presence of concomitant above-mentioned components of brain injury requires expanding the scope of intervention and the use of various methods of decompressive trepanation (resection or flap).

The choice of surgical method and indications for it are determined by the form and severity of brain damage. Method of choice when combining hydromas with bruises mild degree is the operation of evacuating hydraulic fluid from milling holes.

When hydroma is combined with a bruise of moderate severity and there are clear focal symptoms indicating the presence of contusion lesions, a different tactic is required. Evacuation of the hydroma must be combined with a thorough examination of the brain. In such cases, the operation begins with the application of diagnostic milling holes. After the hydroma is emptied, a wide osteoplastic trepanation is performed. In the absence of significant cerebral edema, the operation can be completed as a classic osteoplastic one. If there are significant changes in the brain, swelling, or prolapse into the wound, extensive decompression is necessary. The bone flap is removed and preserved in weak formalin solutions.

If the hydroma is combined with a severe brain contusion, then in most cases decompressive trepanation is required. If appropriate conditions are present, flap craniotomy is preferred. This allows for a full revision of large areas of the hemisphere, removal of the contusion focus and then using a preserved autograft for plastic surgery of the calvarial defect. If there is no necessary conditions, resection craniotomy can be performed.

Often subdural hydromas are combined with intracranial hematomas. In such cases, removal of the hematoma through decompressive trepanation and, in rare cases without gross morphological damage to the cerebral hemispheres and dislocation, osteoplastic trepanation is indicated.

It should be remembered that the hydroma can be localized on the opposite side of the hematoma. At the slightest suspicion of a bilateral volumetric process, it is necessary to apply milling holes on both sides.

Technique for emptying isolated subdural hydroma from burr holes. It is most advisable to place a burr hole at the junction of the frontal, parietal, and temporal lobes, since in this zone the subdural hydroma is usually the thickest. In our opinion, the milling hole should be slightly expanded, to a diameter of 3–4 cm. Emptying can be done after a cruciform dissection of the dura mater. The dura mater is usually tense, but does not have such a bluish tint as with subdural hematomas. After dissection of the dura mater, cerebrospinal fluid usually flows out like a fountain, often stained with blood. Subsequently, the subdural space is inspected, since a combination of hydroma with small blood clots is possible, and the latter are removed. A portion of the arachnoid membrane, approximately 5x5 mm in area, must then be carefully excised. This will create conditions that prevent the valve from functioning. The dura mater is sutured tightly, leaving drainage in the subdural space for 1 day. The wound is sutured according to generally accepted rules.

Practitioners often ask: how to measure the volume of a hydroma? It should be measured before dissection of the dura mater using the following method. The dura mater is punctured with a brain cannula with a 20 ml syringe, and the cannula is inserted into the subdural space. The liquor is removed with a syringe and its volume is determined.

Surgery of crush lesions of the cerebral hemispheres

IN complex treatment For patients with lesions of crush injuries in the brain, the leading link is timely and adequate surgical intervention. To substantiate the tactics of surgical treatment of this form of TBI, it is necessary to specify the often identified concepts of “concussion focus” and “crush focus.”

The crush site is a macroscopically visible area of ​​destruction-necrosis of the brain matter, imbibed with blood. Due to injury and disorders of regional cerebral blood flow at the site of injury, hypoxia and dysgemic disorders increase, which leads to deepening of necrotic processes in the area of ​​the crush site and an increase in the area of ​​necrosis. The crush site contributes to the further development of local and general violations cerebral circulation and metabolism. This leads to an increase in intracranial hypertension and the development of brain dislocation. In connection with this development of the clinical picture, the presence of a crush site serves as the basis for its removal.

With contusion lesions, in contrast to crush lesions, areas of hemorrhagic softening or imbibition with blood can be macroscopically detected. Violations of the integrity of the arachnoid and soft meninges not detected, the configuration of the sulci and gyri is preserved. Surgery should be performed only in patients with lesions of crush injuries to the brain.

To determine differentiated surgical tactics, knowledge is necessary the main anatomical variants of surgical forms of brain crush injuries.

1. Gross destruction of tissue with rupture of the pia mater: brain detritus soaked in blood and sometimes containing small blood clots. Such foci are in most cases combined with large-volume meningeal hematomas.

2. The same focus of crushing of the brain matter, but combined with minor blood clots (20 - 30 ml), which form from the cortical vessels and cover the damaged surface with a thin layer.

Table 6

Indications for surgery and timing depending on the morphology of crush lesions and types of clinigenic tegenia (according to Yu. V. Zotov et al., 1996)

3. The focus of crushing of the cortical and subcortical substance without combination with intracerebral hematoma and blood clots.

4. A focus of hemorrhagic softening in the white matter of the cerebral hemispheres, which may surround an accumulation of blood clots and liquid blood(area of ​​damage around the intracerebral hematoma) or represent a massive focus of cerebral detritus soaked in blood.

5. A limited, shallow focus of rupture of the medulla, located under a depressed or linear fracture of the calvarium.

Indications for surgical intervention and timing are determined by the anatomical variant of the surgical forms of crush lesions and the type of their clinical course (Table 6).

Contraindications for cerebral crushing are:

1) progressive type of clinical course of the process with hypertensive-dislocation syndrome of the IV degree (exorbitant coma with impaired vital functions);

2) severe somatic diseases over the age of 70 years.

Patients in this age category with intraherepeal hematoma are subject to surgical intervention aimed at its removal.

The operation of choice for the treatment of crush lesions of the brain is osteoplastic decompressive craniotomy. The advantages of this type of intervention are:

– wide access;

– the possibility of an adequate audit of the brain;

– favorable conditions for complete removal of intracranial hematomas and crush lesions;

– possibility of thorough hemostasis;

– subsequent closure of the postoperative defect with preserved autograft.

In case of severe brain contusion, decompressive craniotomy should be performed, regardless of whether there is prolapse of the brain into a bone defect or not.

In the presence of multiple crush lesions in the frontotemporal localization of one hemisphere a unilateral extended lateral approach should be used (Fig. 71).

The main requirement when performing this type of access is that the lower side of the trepanation window should be as close as possible to the base of the skull. Only if this condition is met is it possible to adequately visualize crush lesions, usually localized in the anterobasal regions of the frontal and temporal lobes.

Rice. 71.

Rice. 72. Scheme of anterolateral unilateral expanded access to the temporal and frontal lobes of the brain (according to Yu. V. Zotov et al., 1996)

When there are crush lesions in one of the viscosal and both frontal lobes of the brain developed at the Russian Neurosurgical Institute named after. prof. A. L. Polenova anterolateral approach (Fig. 72) (R. D. Kasumov).

The patient lies on his back, with his head turned in the direction opposite to the suspected areas of crush injury. The soft tissue incision begins 2 cm anterior to the auricle, perpendicular to the zygomatic arch, towards the intersection of the coronal suture and the temporal line of the frontal bone. Then it continues along the border of the scalp of the frontal region, extending beyond the midline by 5–6 cm. On the opposite side, the incision should be extended until it begins to descend downwards. The osteoplastic flap is cut out from 7 or 8 burr holes. The periosteum is dissected at the sites where the burr holes are placed using a 2-3 cm long incision and is peeled off from the bone only to the width of the intended hole. After making the hole using a Volkmann spoon, the remnants of the lamina vitrea are removed and the dura mater is carefully peeled off from the inner surface of the bone in the direction of future cuts. The wire saw guide is inserted. Advancement of the guide should be gentle, without significant effort. Sometimes, in places of dense adherence of the dura mater to the bone, it is damaged and the conductor is inserted into the subdural space. What to do in such situations?

Firstly, you should not make repeated attempts to re-pass the conductor from a given milling hole. You can try to pass the conductor from the opposite hole. If this option is unsuccessful, then you can put an additional milling hole in the middle of the distance between the previous two holes and draw a conductor from it. It is also possible to bite through the “path” connecting the two holes with Dahlgren nippers.

Before sawing the bone, the periosteum is dissected between the milling holes along the line of the intended cut. This allows you to avoid “breaking” it with a saw and makes it easier to stitch later.

Should I file down the bone at the base of the flap? We find this undesirable. The conductor in this area may damage a. meningea media or its branches, which leads to additional blood loss. It is better to bite the bone on both sides at the base from both burr holes with Dahlgren nippers. In this case, the base of the bone flap breaks quite easily. Lifting the bone flap with a rasp, carefully separate the adhesions between the dura mater and inner surface bones. If there are none, then the flap is easily turned to the base on the pedicle of the temporal muscle. The dura mater should be cut parallel to the base of the skull, then in an arcuate manner, retreating 1 - 1.5 cm from the edge of the bone towards the sagittal sinus.

Having established the presence of a crush site and significant prolapse of brain tissue into the bone defect, we consider it advisable to perform a puncture of the anterior or lower horn of the lateral ventricle. This manipulation allows you to reduce brain tension, its bulging and creates more favorable conditions for subsequent surgery at the site of crush injury. However, you should not try to obtain cerebrospinal fluid from the ventricle at any cost. There are often situations when the horn of the lateral ventricle is compressed and displaced to the opposite side. Repeated attempts to puncture him only worsen the situation.

In this case, you should immediately begin Lengthening the severity of brain injury.

It is important to radically remove the brain crush zone along with the transition zone. After partial removal of the crush site, intracranial hypertension not only remains, but also continues to increase. Removal is performed first by subpial aspiration, then by economical resection of clearly non-viable areas of the cortex with careful coagulation and clipping of blood vessels. It is important during the operation to determine the boundaries of the crush site to be removed, i.e., the zone of destruction and the transition zone. The destruction zone is detritus, and there are no special difficulties here. Detritus is washed off quite easily with a stream of liquid from a rubber bulb. Transition zone- this is not rejected, but imbibed with blood, brain matter of flabby consistency, easily removed with an aspirator at a vacuum of 0.6 - 0.8 atm. Maintaining such a vacuum allows for differentiated aspiration. In this case, the intact brain matter is much more difficult to aspirate.

Currently, an ultrasonic aspirator is widely used in neurosurgery, which can be used for microsurgical operations and allows tissue fragmentation within a small radius from the tip without damage. blood vessels.

In the area of ​​brain damage - the area of ​​the crush site, treated using an ultrasonic aspirator - the formation of a delicate glial scar over the entire surface of the damaged area is subsequently noted. There is no inflammatory reaction in this area. The minimal amount of damage to the brain substance after resection with an ultrasonic aspirator is due to the ability of the instrument to differentiate normal and damaged tissue by structure and water content, which facilitates the removal of only damaged tissue on the border with “healthy” without injuring the latter.

The use of ultrasonic aspiration in the surgery of brain crush lesions is currently, of course, the preferred option. The domestic industry today produces the “Ultrasonic Surgical Aspirator UZKH-M-21 M”, which fully meets the requirements of modern neurosurgery.

After radical removal of the crush site, it is advisable to install inflow and outflow drainage into the area of ​​its bed. If there are indications, it is possible to perform a dissection of the falciform process ( falxotomy).

Absolute indications for falxotomy:

– dislocation of the hemisphere under the falciform process;

– axial transtentorial dislocation;

– severe intracranial hypertension and brain prolapse into the trepanation window, regardless of the presence and location of crush lesions.

Relative indications for falxotomy:

– crush lesions in one or both frontal lobes without brain dislocation;

– the presence of a contusion focus of the temporal lobe with a slightly pronounced temporotentorial dislocation;

– vital disorders that develop more often with diffuse brain contusion.

When performing a falxotomy, the sagittal sinus is mobilized at the base next to the cock's comb, sutured, ligated in two places approximately 1 cm apart, and divided. Then the falciform process is dissected. In this case, it is very important to spare the ascending venous vessels as much as possible. After careful hemostasis, the dura mater is not sutured, but is reconstructed with a preserved allograft. The operation ends with decompression of the skull. The bone flap is preserved using one of the accepted methods. The wound is sutured in layers and left for 1 day. active drainage under the skin.

Documentation of the surgeon's actions in the operation protocol. The surgical protocol must include:

– type of operational access;

– the condition of the bones before intervention on them (size, shape of the fracture, etc.);

– trepanation window size;

– the state of the dura mater before its dissection;

- description appearance cerebral cortex (gyri, grooves, their color);

– the source of bleeding, if one is identified;

– approximate volume of removed hematoma, hydroma;

– state of the brain after evacuation of clots, removal of the crush site;

– whether the dura mater was sutured, the method of its plastic surgery;

– reasons that necessitated external decompression;

– method of drainage of the ventricular system of the brain, if one is used;

– a method of external wound drainage.

According to the mechanism of action on the skull and brain, impact trauma is distinguished, with which mechanical damage localized at the site of application of traumatic force, anti-shock, when brain damage is localized at a distance from the force applied to the skull, and their combination.

By type of injury TBI divided into closed and open, the latter in turn divided into those that do not penetrate the cranial cavity and those that penetrate. Closed TBI includes injuries to the skull and brain that are not accompanied by soft tissue wounds and damage to the dura mater. Such lesions are most resistant to the occurrence of purulent infection. Open TBI includes injuries to the skull and brain, in which there are wounds to the soft tissues of the head. With such injuries, due to the presence of anastomoses between the venous and arterial systems, a purulent infection may develop

To penetrating TBI include injuries to the skull and brain, accompanied by damage to the dura mater. In 40.3% of patients, fractures of the base of the skull are accompanied by micro- or macrocerebrospinal fluid leakage from the nose (in case of damage to the anterior cranial fossa) or ear (in case of a fracture of the temporal bone). The fistulas that arise in this case are the entrance gates and can cause the development of intracranial purulent infection.

Skull fractures. There are fractures of the vault and fractures of the base of the skull. Fractures of the base of the skull are most often presented in the form of cracks in the bottom of the anterior (frontal, ethmoid, sphenoid bone), middle ( temporal bone, its scales and pyramid, main bone) or posterior (occipital bone) of the cranial fossa.

Cranial vault fractures can be in the form of single or multiple cracks, comminuted (depressed or non-depressed) fractures - isolated or multiple. It should be noted that the severity of the victim’s condition is determined not so much by the nature of the skull fractures as by the severity of the brain damage.

The following are distinguished: types of brain damage.

Brain concussion. In quantitative terms, this is the main type of TBI (up to 70-75%). A concussion occurs with a relatively small mechanical injury head due to the acceleration imparted to the brain at the time of injury. There are many ambiguities and controversial positions in the pathogenesis of concussion. The opinion of S. Scheidegger (1948) remains relevant: “It is easier to say what is not a concussion than to define this concept.”

For fresh concussions There are no traumatic macrostructural changes in the brain substance

Brain contusion. This term currently refers to the focus of macroscopic damage to the brain substance that occurs at the time of injury. Brain contusions clinical course are divided into mild, moderate and severe bruises.

Diffuse axonal brain injury is a special type of TBI. Most often, such injuries are formed as a result of rotational movements of the brain, which can occur both with rotational trauma (trauma with rotational acceleration) and with local exposure to trauma (blows to the head, a fall from a height, a kick to the chin). In this case, rotation of the more mobile hemispheres of the brain occurs while its trunk is fixed. With local trauma, such as a kick to the chin, individual layers of the brain can become displaced in relation to each other. Even a slight displacement of individual layers of the brain can lead to rupture of nerve fibers and blood vessels, to asynapsia (impaired conduction of nerve impulses at the synapse level).

Brain compression. There are increasing and non-increasing compression. Increasing compression of the brain occurs with intracranial hematomas, non-increasing compression is observed with pressure on the brain from bone fragments during depressed skull fractures. This division, however, is very arbitrary, since under the influence of secondary factors, when bone fragments put pressure on the brain, local and then widespread cerebral edema occurs, which leads to increasing pressure on the brain, an increase in both intracranial and intracerebral pressure.
Most dangerous to the patient's life intracranial hematomas.

Intracranial traumatic hematomas according to the course they are divided into acute, subacute and chronic. Chronic hematomas include hematomas with a formed capsule, which usually occurs in the middle to the end of the 3rd week after injury. Before capsule formation, hematomas are considered acute. Subacute hematomas include those in which the capsule is not completely formed, and its clinical manifestations characterized by mild symptoms.

By location, intracranial hematomas are divided into epidural (blood accumulates between the bones of the skull and the dura mater), subdural (blood accumulates between the brain and the dura mater) and intracerebral (blood accumulates in the brain parenchyma).

There are also multiple intracranial hematomas, which are particularly difficult.

Features of shock in combined TBI. As a rule, shock during TBI develops against the background of massive bleeding. Decrease in blood pressure below 70 mm Hg. leads to cerebral ischemia, which complicates the process of restoring its functions. Violations of central and peripheral hemodynamics lead to an increase in cerebral edema and dislocation

With combined TBI, shock may develop against the background of the victim’s unconscious state (coma) and be accompanied by bradycardia. The erectile shock phase in such patients is usually longer. Blood pressure, despite massive blood loss, may be normal or even slightly elevated. Pulse pressure decreases or (much less frequently) increases slightly. With normal systolic pressure, a pulse of weak filling is detected.

Traumatic brain injury (TBI)

Among people under 50 years of age, head injuries are more likely to cause death and disability than any other neurological disease, despite the fact that the brain is protected by the thick bones of the skull.

The brain can be damaged even if the integrity of the skull bones is preserved. Many of its injuries are associated with the sudden acceleration that the skull acquires following a shock caused by a strong blow to the head or a sudden stop when colliding with a stationary object, and brain damage can occur both at the point of impact and on the opposite side.

TBI includes all types of injuries that are accompanied by general cerebral and focal symptoms, which are signs of damage to the brain, meninges and cranial nerves, regardless of the violation of the integrity of the skull bones.

General cerebral symptoms include:

• loss of consciousness;
• headache;
• dizziness;
• amnesia;
• nausea and vomiting;
• noise in ears;
• tachycardia, bradycardia;
• meningeal symptoms (stiff neck - the patient cannot reach the chest with his chin; Kernig - bent at the hip and knee joint the leg does not straighten at the knee; Brudinsky - when you tilt your head, your legs involuntarily bend);
• convulsive syndrome.

Focal symptoms:

• asymmetry of the face (the corner of the mouth is drooping, the cheek is “swallowing”);
• anisocoria;
• paresis and paralysis;
• disorders of speech, vision, hearing, swallowing, etc.

Types of traumatic brain injury:

• closed and open (penetrating and non-penetrating);
• with and without damage to the skull bones:
  • - fractures of the cranial vault: depressed, perforated, comminuted, complete and incomplete;
  • - fracture of the base of the skull;
  • - damage to the facial skull;
• with and without damage to brain structures:
• - concussion;
• - brain contusion (of varying severity);
• - compression of the brain.

All types of TBI are divided according to severity:

• for the lungs - concussion, mild brain contusion;
• moderate severity - moderate brain contusion, subarachnoid hemorrhage, skull fractures;
• severe - fracture of the base of the skull, destruction of brain matter, compression of the brain.

However, on prehospital stage There are no special examination methods and a mild TBI can suddenly develop into a severe one, so the ambulance paramedic needs to treat any head injury as severe.

An open injury is considered to be one that is accompanied by damage to the aponeurosis and penetrating damage to the integrity of the dura mater.

Examination methods:

• radiography in two or more projections;
• spinal tap;
• ECHO-EG;
• fundus examination;
• blood pressure profile;
• encephalangiography.

Consultations with a neurologist and an ophthalmologist are required.

A blow to the head with a blunt hard object or a blow to the head against a hard object can be accompanied by crushing of the skin, subcutaneous tissue, damage to the aponeurosis, and fracture of the skull bones. The angle of injury matters. Direct mild bruises of the soft tissues of the head result in the formation of a “bump” - a subcutaneous hematoma. With tangential blows, a forcible displacement of the aponeurosis occurs with damage to the loose subaponeurotic tissue and the formation of an extensive and flat hematoma in it. Bone fractures with closed trauma without skull deformation are detected only by x-ray.

First aid for damage to the soft tissues of the head, superficial wounds: the hair around is cut wide, the wound is washed with hydrogen peroxide, furatsilin, its edges are treated with an antiseptic and a dry sterile (“cap”) or pressure (“bridle”) bandage is applied. You cannot check the depth of damage with your finger or probe.

Victims with extensive injuries, suspected fractures of the skull bones, damage to the aponeurosis, or damage to brain structures are transported to the hospital in a lateral decubitus position.

Facial wounds heal primarily. Wounds of the scalp are prone to suppuration.

Brain concussion. Trauma causes functional disorders of the brain without morphological damage. As a rule, it manifests itself only as general cerebral symptoms, the duration and severity of which depends on the severity of the injury. A short-term spasm of blood vessels is replaced by their dilation, which leads to cerebral edema and an increase in intracranial pressure.

The victim briefly loses consciousness and may vomit. After the return of consciousness, memory loss occurs (retrograde amnesia), headache, nausea, tinnitus, dizziness, asymmetry of blood pressure when measured in both arms, low-grade fever, sleep disturbance, etc. persist for a long time.

Brain contusion. This type of injury is classified as severe and is always accompanied by anatomical (morphological) damage to the brain substance. Bruises can be mild (petechial hemorrhages), moderate (soaked in blood) and severe (destruction of brain matter). In this regard, in addition to general cerebral symptoms, there are focal symptoms, and focal symptoms appear from the moment of injury. The number and brightness of the manifestation of focal symptoms depend not so much on the degree of destruction of brain tissue, but on the localization of the affected area (for example, destruction of the visual nuclei causes loss of vision, damage to the nuclei facial nerve- facial asymmetry, etc.). Bruises of the “silent” parts of the brain ( frontal lobes) do not produce focal symptoms, but subsequently manifest as a decrease in intelligence. The bruise is often combined with hemorrhages of various locations, hematomas and is accompanied by focal or general traumatic cerebral edema. Bruised areas liquefy and dissolve, forming cysts or scars.

Compression of the brain. Traumatic compression of the brain occurs with depressed fractures, damage to cerebral vessels and vessels of the meninges, even without bone damage. The middle one is most often damaged cerebral artery or venous sinuses formed by the dura mater in places where it is incompletely adjacent to the bones of the skull. In this regard, a distinction is made between epidural and subdural hematomas. Damage to the meninges may be accompanied by damage to adjacent areas of the brain. Intracerebral hematomas occur.

The classic picture of compression of the brain by a hematoma at the first moment resembles the clinic of a concussion, but after some time after the improvement of the condition, called the light interval, the victim’s condition begins to quickly deteriorate. General cerebral and focal symptoms appear and increase (anisokaria, mydriasis on the side of compression, facial asymstria, grinning, deviation of the tongue, paresis, paralysis, etc.), and the patient falls into a coma. The severity and duration of improvement, the so-called light interval, depend on the location and rate of growth of the hematoma. With depressed fractures, there is no light gap. Focal symptoms are more pronounced with epidural localization of the hematoma. Blood during lumbar puncture is detected in subdural localization and intracerebral hematomas communicating with the ventricles of the brain.

Without timely assistance, death occurs from herniation of the brain into the foramen magnum.

Fracture of the base of the skull. A fracture of the base of the skull occurs as a result of indirect trauma. The fracture line may begin at the cranial vault and extend to the base.

The victim is usually unconscious with impaired breathing and hemodynamics, the severity of which depends on the severity of the injury. There are symptoms of contusion or compression of the brain. The injury is often accompanied by bleeding from the nose (damage to the ethmoid bone), ears, and leakage of cerebrospinal fluid (damage to the dura mater). In the first hours, the cerebrospinal fluid mixes with the blood. To determine the presence of cerebrospinal fluid in the blood, it is necessary to moisten gauze with bloody liquid. If there is cerebrospinal fluid on the gauze, a light ring (rim) forms around the bloody spot. Leakage of brain matter is extremely rare. There are signs of paresis and paralysis of the cranial nerves exiting the base of the skull. Usually, the next day, bruises appear around the eyes - a “symptom of glasses”, in the area of ​​the mastoid processes (injury of the posterior cranial fossa), under the mucous membrane of the pharynx.

The prognosis is poor, especially for fractures of the middle cranial fossa, since here surgical intervention is almost impossible, and the chances of infection entering the cranial cavity are very high.

In its pure form, bruise and compression of the brain, damage to the meninges are rare.

In differential diagnosis, it is important to consider the following:

• a concussion is manifested only by general cerebral symptoms;
• with brain contusion (destruction of brain matter), focal symptoms appear immediately after the injury;
• intracranial hematoma is characterized by the presence of a light gap - the period between the restoration of consciousness immediately after the injury and its repeated loss;
• with an epidural hematoma, the light gap is short and there will be no blood in the cerebrospinal fluid. There will be no blood even with a hematoma inside the brain tissue if it does not communicate with the ventricles of the brain;
• a subdural hematoma has a longer clear gap and there will be blood in the cerebrospinal fluid, since the subdural space communicates with the intrathecal space of the spinal cord.

It must also be remembered that brain damage and hematoma can be localized on the opposite side of the injury.

Urgent Care for various types of TBI. At concussion:

• treat and bandage the wound;
• for excessive arousal: intravenously 2-L ml of 0.5% diazepam solution per 20 ml of 0.9% sodium chloride solution or 20 ml of 40% glucose;
• mandatory hospitalization in a hospital (surgical or neurological department).

At bruises and compression of the brain:

• stabilization of the cervical spine - Shants collar until the nature of the injury is clarified;
• restoration of patency of the upper respiratory tract (triple dose of Safar, removal of mucus, sputum, foreign objects from the oral cavity, installation of an air duct);
• oxygen inhalation - start with 100%, then gradually reduce the concentration to 40%;
• in the presence of apnea, hypopnea, or increasing cyanosis, transfer the patient to mechanical ventilation in the mode of moderate hyperventilation (RR - 16-20 per minute, tidal volume - 600-800 ml);
• hospitalization in a hospital with a neurosurgical service; in case of respiratory and cardiac dysfunction - hospitalization in the intensive care unit;
• During transportation, take all measures to prevent tongue retraction and blood leakage into the respiratory tract. It should be remembered that loss of consciousness, cardiac and respiratory arrest can occur at any time during transportation.

Bruises and compression of the brain can be accompanied by convulsions, hypertension and pain syndromes.

At excitement and convulsions:

Intravenous administration of 2-4 ml of 0.5% diazepam solution (10-20 mg - 0.2 mg/kg) at a rate of 2-5 mg/min per 10 ml of 0.9% sodium chloride solution or 20 ml 5% glucose (if the seizures do not stop, intravenous administration of diazepam in the same dose is repeated after 15 minutes).

At presence of signs hypertension syndrome :

• intravenous administration 2-A ml of 1% solution of furosemide (in case of decompensated blood loss or associated trauma, do not administer furosemide);
• intravenous administration of 30-90 mg of prednisolone or 4-12 mg of dexamethasone;
• Ventilation in hyperventilation mode (RR 16-20 per minute, tidal volume - 600-800 ml).

At pain syndrome:

Intravenous administration of 2 ml of a 50% solution of metamizole or 50-100 mg of tramadol (1-2 ml of a 5% solution), or jet or intramuscular administration of 10-30 mg of ketorolac per 10 ml of 0.9% sodium chloride solution .

Principles of treatment of victims with TBI. In the hospital, victims with severe TBI are hospitalized in intensive care if they require mechanical ventilation, or in the neurosurgical department. The necessary diagnostic procedures are performed, patients are examined by a neurologist, neuro-oculist. In the absence of indications for surgery (hematomas, depressed fractures), drug therapy is prescribed aimed at decompressing the brain (diuretics, magnesium sulfate, 40% glucose), improving its blood supply and protecting against hypoxia; when excited - sedatives.

Complications of open TBI: encephalitis, meningitis, brain abscesses, traumatic hydrocephalus (impaired outflow of cerebrospinal fluid), traumatic epilepsy.

Under head injury understand damage to the skull and intracranial contents (brain, meninges, blood vessels, cranial nerves) mechanical energy.

Traumatic brain injury (TBI) is one of the most common types of injuries in peacetime, accounting for about 40% of all types of injuries. TBI falls into the category of severe injuries human body, accompanied by high mortality: from 5 to 70%. IN war time the frequency of injuries to the skull and brain is constantly increasing: Great Patriotic War– 11.9%; Vietnam – 15.7%; Afghanistan - 14.4%; Chechnya – 22.7%.

Mechanism of injury

direct and indirect.

Pathogenesis.

In the pathogenesis of TBI, special importance is attached to two main factors of a mechanical nature: 1) temporary changes in the configuration of the skull, such as its general or local deformation, with the occurrence in some cases of a skull fracture; 2) displacement of the brain in the cranial cavity (in relation to the internal walls of the cavity and intracranial fibrous septa) - linear and rotational displacement, speed change in the linear direction, linear acceleration and deceleration.

Types and classification of skull injuries.

Injuries to the skull and brain are divided into closed And open (wounds) . Distinguish firearms And non-firearm injuries. Closed TBI includes injuries in which there is no disruption of the integrity of the scalp. Open is a head injury with the presence of a wound in the soft tissues of the skull (aponeurosis), as well as a fracture of the base of the skull, accompanied by bleeding or liquorrhea from the ear or nose. When the dura mater is intact, open craniocerebral wounds are classified as non-penetrating , and if its integrity is violated - to penetrating .

Classification.

1. I. Closed head injuries: Brain concussion; 2. Brain contusion: - mild; - moderate severity; - severe. 3. 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. 4. Condition of the intrathecal spaces: - subarachnoid hemorrhage; — cerebrospinal fluid pressure: normotension, hypotension, hypertension. 5. Condition of the skull: - no damage to bones; - type and location of the fracture. 6. Condition of the skull: - bruises; - abrasions. 7. Associated injuries and diseases. 8. According to its severity, closed craniocerebral injury is divided into three degrees: – mild (concussion and mild brain contusion), moderate severity (moderate brain contusion) and severe (severe brain contusion with compression).
2. II . Gunshot wounds skull and brain: By type of wounding projectile: - bullet, - fragmentation. 2. According to the nature of the injury: - soft tissue, - non-penetrating with bone damage, - penetrating. 3. By type of wound channel: - blind, - tangential, - through, - ricocheting. 4. By localization: - temporal, - occipital, other areas. 5. According to the type of fracture of the skull bones: - linear, - depressed, - crushed, - perforated, - splintered. 6. By the number of wounds: - single, - multiple. 7. By the influence of combinations of various factors: - mechanical, - radiation, - thermal, - chemical. 8. According to the nature of the brain damage: - concussion, - bruise, - crushing, - compression. 9. According to the severity of the injury: - mild, - moderate severity, - heavy. 10. According to the severity of the wounded person’s condition: - satisfactory, - moderate, - severe, - terminal. 11. Blind wounds: - simple, - radial, - segmental, - diametric, - ricocheting, - tangential. 12. Penetrating wounds: - segmental, - diametrical, - tangential.

During TBI, it is customary to distinguish the following periods:

1) acute period - from the moment of injury to stabilization at different levels of functions impaired due to injury (from 2 to 10 weeks depending on clinical form and severity of TBI);

2) intermediate period - from the moment of stabilization of functions until their full or partial restoration or stable compensation (for mild TBI - up to two months, for moderate TBI - up to four months, for severe TBI - up to six months);

3) long-term period - clinical recovery or maximum possible recovery impaired functions or the emergence and (or) progression of new pathological conditions caused by TBI (up to two years or more). A detailed diagnosis, including all elements of this classification, can only be made in a specialized hospital.

Clinical picture damage to the skull and brain consists of general cerebral and local (focal) neurological symptoms. General cerebral symptoms include headache, nausea, vomiting, dizziness, etc. Local (focal) symptoms depend on the location of the brain damage and can manifest as hemiparesis, hemiplegia, speech, and visual disturbances.

Closed TBI clinic.

1. Closed injury brain, accompanied by symptoms of a concussion is a functionally reversible form of brain injury. It is characterized by short-term loss of consciousness from several seconds to several minutes, retro- and anterograde amnesia, vomiting, headache, dizziness and other autonomic disorders. As a rule, only general cerebral neurological symptoms are noted in the neurological status. There are no injuries to the skull bones, the pressure of the cerebrospinal fluid and its composition are without deviations from the norm. The condition of patients usually improves during the first or second week.
2. Closed brain injury accompanied by symptoms of brain contusion (degrees - easy, medium, severe). Brain contusion mild degree characterized by loss of consciousness from several minutes to one hour. Then headache, dizziness, nausea, vomiting, retro- and anterograde amnesia are noted. Vital functions are usually not impaired, a moderate increase in heart rate, respiration, and rise in blood pressure is possible. Focal symptoms are mild (nystagmus, pyramidal insufficiency) and disappear after 2-3 weeks. Unlike a concussion, subarachnoid hemorrhages and skull fractures are possible. Brain contusion medium degree characterized by loss of consciousness after injury lasting from several minutes to several hours. Retrograde and anterograde amnesia and other cerebral symptoms are pronounced. Complaints of severe headache, repeated vomiting, possible transient disturbances of vital functions in the form of bradycardia, tachycardia). Nesting symptoms are clearly manifested, determined by the localization of the brain contusion - hemiparesis, speech disorders, visual disturbances, etc. A lumbar puncture usually reveals blood-stained cerebrospinal fluid flowing out under increased pressure. Craniograms often reveal a fracture of the skull bones. Brain contusion severe accompanied by loss of consciousness from several hours to several weeks. Observed severe violations vital functions: bradycardia or tachycardia, often with arrhythmia, arterial hypertension, breathing disorder. In the neurological status, stem symptoms come to the fore: floating movements of the eyeballs, accommodation paresis, tonic nystagmus, swallowing disorders, decerebrate rigidity (generalized or focal seizures). As a rule, brain contusion is accompanied by fractures of the bones of the vault or base of the skull, massive subarachnoid hemorrhages.
3. Closed brain injury accompanied by symptoms of increasing compression of the brain (with or without bruises of the brain). Brain compression syndrome is characterized by a life-threatening increase at various intervals after injury (the so-called “light period”) of general cerebral, focal and brainstem symptoms. Depending on the background (concussion, brain contusion) against which traumatic compression of the brain develops, the latent period can be pronounced, erased or completely absent. Clinically, pupil dilation appears on the side of compression, and hemiplegia on the opposite side. The appearance of bradycardia is characteristic.

Brain injury clinic.

At the suggestion of E.I. Smirnov (1946) it is customary to divide the flow pathological processes with a brain injury for five periods.

They are called periods of traumatic brain disease:

– initial period – “chaotic” according to N.N. Burdenko, lasting about three days. Characterized by a predominance of general cerebral symptoms over local ones, disturbances of consciousness, breathing, cardiovascular activity, act of swallowing;

II – period of early reactions and complications – (infections and dyscirculation), lasting up to three weeks – 1 month is characterized by an increase in edema-swelling of the brain, its protrusion (benign prolapse). The wounded regain consciousness, focal symptoms are revealed, the course is complicated by the development of meningitis, meningoencephalitis, and suppuration of the wound canal. As a result of the development of infection, malignant protrusions (secondary prolapses) occur;

III – liquidation period early complications and a tendency to limit the infectious focus, begins in the 2nd month after injury and lasts approximately 3-4 months (depending on the severity of the injury). With a smooth course, the wound heals and recovery occurs.

I V – period of late complications , begins 3-4 months after injury and lasts 2-3 years, characterized by the formation of late brain abscesses, outbreaks of meningitis, meningoencephalitis;

V – period of long-term consequences associated with the presence of a meningeal scar. May last long years after injury.

Diagnosis of TBI:

1. Identifying a history of injury.

2. Clinical assessment of the severity of the condition.

3. State of vital functions.

4. Condition skin- color, moisture, bruising, presence of soft tissue damage.

5. Examination of internal organs, skeletal system, concomitant diseases.

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

10. Computer or magnetic resonance imaging of the skull.

11. Ophthalmological examination of the condition of the fundus.

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

Providing assistance during the stages of medical evacuation.

First aid

comes down to applying an aseptic bandage to the wound and carefully removing the wounded. The wounded, who are unconscious, are carried out on their sides (in order to prevent aspiration of vomit), they need to unfasten their collar and loosen their belt. If the tongue is retracted and there are signs of asphyxia, insert an air duct (S-shaped tube, breathing tube TD-1). Do not administer drugs (respiratory depression).

First aid

– bandaging the bandage, ventilation of the lungs using a breathing apparatus DP-10, DP-11, oxygen inhalation with a KI-4 apparatus, maintaining cardiovascular and respiratory activity (intramuscular administration of 2 ml of cordiamine, 1 ml of caffeine). Evacuation of the wounded, first of all, on a stretcher.

First aid

– combating asphyxia, carrying out artificial ventilation of the lungs with the DP-9, DP-10 apparatus, oxygen inhalation with the KI-4 apparatus, maintaining cardiovascular and respiratory activity (administration of 2 ml of cordiamine, 1 ml of caffeine, 1 ml of 5% ephedrine).

If necessary, correct the bandage, administer a prophylactic dose of antibiotics (500,000 units of streptomycin, 500,000 units of penicillin), carry out seroprophylaxis for tetanus subcutaneous injection 0.5 ml tetanus toxoid.

Those wounded in the skull with ongoing bleeding from soft tissue wounds are sent to the dressing room to perform hemostasis using a pressure bandage and applying a clamp to the bleeding vessel. The wounded are not detained at this stage; those with ongoing intracranial bleeding and liquorrhea are evacuated first; those wounded in the second place are evacuated. soft fabrics skulls Before transportation, cardiovascular and respiratory devices and an airway are administered according to indications.

It is necessary to transport the wounded to the skull in a prone position and it is better to immediately go to the EMS stage, bypassing the intermediate stages of medical evacuation.

Qualified medical care .

The wounded who, as a result of medical triage, are subject to surgical treatment at this stage for health reasons (refusal to surgery may result in death).

Emergency surgical interventions are performed for the following wounds and injuries: wounds and injuries of the head and neck, accompanied by: - ​​asphyxia (tracheal intubation or tracheostomy); — external bleeding (stopping external bleeding by ligating the vessels of the integumentary tissue or tight tamponade of the wound); — craniotomy and postsurgical surgical treatment of brain wounds are not performed at the stage of providing qualified assistance (including in cases of compression of the brain).

Sorting of skull wounded patients into primary and secondary care during mass admission will often have to be carried out without removing the bandage.

Determination of transportability is made based on an assessment of the general condition, preservation of the reaction of the pupils and corneal reflexes, the state of the pulse, breathing, bandage, etc.

During evacuation, provide for: - wounded with damage to the soft tissues of the skull without focal neurological symptoms - in the emergency room; - wounded with a concussion - in the VPNG. All other wounded open damage the skulls are sent to a specialized neurosurgical hospital.

Specialized assistance .

The hospital provides comprehensive specialized surgical care wounded who did not receive qualified surgical care.

1. Questions for self-control.
2. Mechanism of traumatic brain injury.
3. Classification of gunshot injuries of the skull and brain.
4. Classification of non-gunshot injuries of the skull and brain.
5. Clinical picture of a concussion.
6. Clinical picture of brain contusion.
7. Clinical picture of brain compression.
8. Diagnosis of combat trauma to the skull and brain.
9. The volume of medical care at the stages of medical evacuation.
10. Possible complications of traumatic brain injury and their prevention.

Closed traumatic brain injury includes concussion, brain contusion and brain compression. This division of them is conditional; their combination is often observed - traumatic disease brain.
The cause of a closed craniocerebral injury is often direct trauma (a blow to the head with a heavy object, a fall on the head).

Brain concussion. The most common pathology of all skull injuries. As a rule, no damage to the skull bones is observed with a concussion. The impact of a short and strong blow sets the brain and the liquid component (cerebrospinal fluid, blood) in motion. Morphologically, very minor changes are observed: short-term spasm of blood vessels followed by their dilation, venous stagnation, swelling of the brain and membranes, pinpoint hemorrhages. The duration of these changes is 1-2 weeks.
Clinical picture. The leading symptoms of a concussion are loss of consciousness from several minutes to several hours and retrograde amnesia (the patient does not remember what happened to him). Vomiting may occur. There is pallor of the skin of the face and, less commonly, hyperemia. Breathing is shallow. With a mild concussion, the pulse quickens (tachycardia); with a severe concussion, on the contrary, it slows down (bradycardia). A uniform narrowing or dilation of the pupils and a slight smoothing of the nasolabial fold may be observed. Subsequently, headache, dizziness, tinnitus, heaviness in the head, aching in the eyes appear, aggravated by their movement and bright lighting (Mann-Gurevich symptom). During spinal puncture, there is usually no pathological changes in the cerebrospinal fluid, but its pressure may be increased. A few days after the injury, insomnia, irritability, sweating, general weakness, and divergent strabismus when reading (Sedona symptom) develop.
Depending on the severity of the injury, according to the Petit classification, three degrees of concussion are distinguished: mild ( momentary loss consciousness without retrograde amnesia), moderate severity (with retrograde amnesia, but without general or focal craniocerebral disorders) and severe (with significant brain disorders).
Treatment. The basis of treatment is strict bed rest. In case of concussion mild cases of brain damage are prescribed for 1-2 weeks, for moderate cases - for 2-3 weeks, for severe cases - for 3-4 weeks. Neuroplegic, antihistamine and vitamin preparations. When cranial pressure increases, 40-60 ml of a 40% glucose solution, 10-20 ml of a 10% sodium chloride solution, 5-10 ml of a 40% solution of hexamine are administered intravenously, 10 ml of a 20% solution of magnesium sulfate is administered intramuscularly, and diuretics are prescribed. A salt-free diet with fluid restriction is indicated.
In cases of cerebral edema, an additional 5-10 ml of 2% is administered intravenously. hexonium solution, 1-2 ml of 2% diphenhydramine solution, 50-100 mg of cortisone or hydrocortisone. When intracranial pressure decreases, it is administered subcutaneously or intravenously. saline or distilled water.
Brain contusion. A bruise has a more severe clinical picture compared to a concussion. Morphologically, foci of destruction of the medulla (rupture, softening, crushing, hemorrhage, etc.) are noted in the brain tissue. The affected area is most often located in the cortex, subcortical layer and meninges. Bruises and hemorrhages in the brain stem, cerebellum, and cerebral ventricles are especially dangerous.
The clinical picture resembles a severe concussion: loss of consciousness occurs for a longer period of time, followed by lethargy for several days or even weeks. Retrograde amnesia is more pronounced. The temperature rises, neutrophilic leukocytosis, and a constant admixture of blood in the cerebrospinal fluid are noted.
In case of brain contusion, local central symptoms predominate: paralysis and paresis of cranial nerves and limbs, hemiplegia, pathological reflexes.
Treatment is carried out according to the same scheme as for a concussion, but the condition of the internal organs, depending on brain stem disorders, is taken into account. In case of breathing problems, mucus is sucked out from the trachea and bronchi through the intubated larynx and oxygen is given at the same time. The patient is administered lobeline and cititon. When these phenomena increase, a tracheostomy is applied and controlled breathing is established. To normalize blood circulation, cardiovascular drugs (caffeine, cordiamine, etc.) are used.
Compression of the brain. A more severe course is noted. Pathoanatomical changes boil down to a gradual increase in compression of the brain due to its edema and growing hematoma (vascular rupture). Based on their location, hematomas are divided into: subdural (under the dura mater), epidural (above the dura mater), subarachnoid (under the pia mater) and intracerebral (into the substance of the brain).
Clinical picture. When the brain is compressed, especially due to a hematoma, there is a so-called light interval from several minutes to several hours, followed by loss of consciousness. Bradycardia appears up to 40-50 beats per minute. The pupils are initially constricted, then dilate. Vomiting occurs and the act of swallowing is disrupted. During the daytime, severe headache and dizziness are observed.
In differential diagnosis between different types. For hematomas, clinical presentation and spinal puncture indicators are of great importance. With an epidural hematoma, loss of consciousness occurs quite quickly, and cerebrospinal fluid pressure is increased. With a subdural hematoma, the light gap is longer and there is blood in the cerebrospinal fluid. With a subarachnoid hematoma, the lucid interval can last up to several days, and loss of consciousness may not occur at all. There is a large admixture of blood in the cerebrospinal fluid.
As general cerebral symptoms increase, the focal symptomatology of compression and dislocation of the brain becomes more pronounced: paresis and paralysis of the cranial nerves on the side of the hemorrhage (anisocoria, ptosis upper eyelid, constriction followed by dilation of the pupil, strabismus), paresis and paralysis of the muscles of the limbs (monoplegia with pathological reflexes, epileptiform convulsions) - on the opposite side.
Treatment is mainly surgical. The essence of the operation is craniotomy, emptying the hematoma and stopping bleeding (decompressive craniotomy). If there is no significant damage to the brain matter and reliable stop bleeding, a defect in the bones of the skull is closed using the preserved bone flap. If it is impossible to perform primary plastic surgery of the bone defect, it is carried out after several months.
Fractures of the cranial vault. The mechanism is direct trauma. By nature, a fracture of the skull vault can be in the form of a crack, a ring-shaped fracture and defects bone tissue. The latter type of fractures is observed mainly in gunshot wounds.
Fractures can be complete, that is, spread over the entire thickness of the bone, and incomplete, when only the outer or inner plates of the cranial vault are broken. At comminuted fractures, as well as a fracture of the internal plate, the meninges and medulla are damaged. The same picture can occur with open fractures.
Clinical picture. There are general cerebral symptoms associated with concussion and cerebral edema, and focal symptoms caused by damage to certain parts of the brain, which can increase.
Treatment. In case of closed skull fractures and the absence of intracranial bleeding, treatment is carried out according to the same scheme as for closed craniocerebral injury. For intracranial bleeding, fragmentation and open fractures, surgical intervention is indicated. The operation is based on the principle of removing depressed bone fragments and stopping bleeding.
Fractures of the base of the skull. The mechanism of injury is a fall from a height onto the head or legs. In this case, damage occurs to the bones of the base of the skull (basal and temporal bones).
Clinical picture. In diagnosis, the main role is played by anamnestic data, localization of bruises and bleeding. If the anterior cranial fossa is damaged, bruises appear in the eyelid area and around the eyes - a “symptom of glasses” (Fig. 124), as well as nosebleeds; if the middle and posterior cranial fossae are damaged, bruises in the throat area and bleeding from the ears appear. If the posterior cranial fossa is damaged, there will be bruising in the area of ​​the mastoid processes. Sometimes there is a leakage of cerebrospinal fluid from the nose and ears. When the base of the skull is fractured, the cranial nerves are often damaged: the facial, abducens and oculomotor. Due to irritation of the meninges, the phenomena of meningism (stiff neck muscles) occur.
Treatment is carried out according to the same principle as the treatment of a concussion. Spinal tap with the release of cerebrospinal fluid, it reduces intracranial pressure, which leads to a decrease in headaches and dizziness. To prevent infection, antibiotics are prescribed. If there is bleeding, it is not recommended to rinse ear canal and nose due to the possibility of infection. Nasal tamponade is performed only if there is severe bleeding.