Quantification of Primary and Secondary Lesions in Severe Head Injury
The current trend is to classify brain damage due to non-missile head injury as focal or diffuse. Quantitative findings will be discussed and reference will be made to both human and experimental non-human primate.
Contusions: Based on the concept of an index which takes into account the depth and extent of contusions in various parts of the brain, it has been determined that contusions are most severe in the frontal and temporal lobes; they may be entirely absent in a patient dying as a result of a head injury; there is no correlation between their severity and the nature of the injury; the concept of contrecoup must continue to be questioned; they are more severe in patients who have a fracture of the skull in comparison to those who do not; they are more severe in patients who do not experience a lucid interval than in those who do; and they are less severe in patients with diffuse axonal injury than in those who do not have diffuse axonal injury.
Raised intracranial pressure: It has been established that the pathognomonic feature of a high ICP due to a supratentorial expanding lesion is the presence of a wedge of pressure necrosis in one or both parahippocampal gyri. Pressure necrosis of this type was seen in every patient known to have had an ICP of more than 5.3 kPa (40 mm Hg) during life, and most of the patients with an ICP between 2.7 and 5.3 kPa (20–40 mm Hg), and in no patient with an ICP of less than 2.7 kPa (20 mm Hg).
Axonal injury (DAI): Increasing experience in man has allowed of the identification and grading of 122 cases of DAI in a series of 434 fatal non-missile head injuries — 10 Grade 1, 29 Grade 2 and 83 Grade 3. In our earlier studies of severe DAI, not one of the patients was able to talk after their injury: it is of interest therefore that 17 (14%) of the 122 cases — all with less severe DAI — were known to have talked soon after their injury. Evidence of lesser degrees of DAI were also found in the Penn 2 model of axonal injury.
Ischemic damage: This was found in the brains of 92% of 151 cases of fatal non-missile head injury dying between 1968–72 and in 88% of 112 cases dying between 1981–82. There was no statistical difference in amount of moderately severe and severe ischemic damage in the two groups, 55% and 54% respectively. There was evidence that an increased number of patients with severe ischemic brain damage was admitted in 1981–82 as a result of a change in the admission policy of the Department of Neurosurgery that resulted in an increased detection of intracranial haematomas.
KeywordsHead injury contusion index intracranial hypertension axonal injury secondary ischemia
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