Tokushukai Medical Group

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Cranial Nerve Surgery Disease:Head-Neck Trauma

Chronic subdural hematoma – Hematoma is gradually compress brain.

The most common surgical operation at cranial nerve surgery region is chronic subdural hematoma. In case if there is any aged person around who suddenly become forgetful or fall easily in recently, they may onset chronic subdural hematoma. This disease is common among high-aged male or alcoholic drinker, and it may relate with the gap space between skull and brain becomes larger by brain shrunk. Impact received from bumped head causes a small amount of bleeding in this gap, bleeding is increased so that it compresses brain gradually, and in few month, compression becomes stronger then symptom appears. Head CT can diagnose this.

Surgery is to make 1cm diameter hole on skull and to wash blood tumor down. When compression to brain has released, symptom has improved. In fact, aged person, who had head bruise at Kumamoto Earthquake in April 2016, is diagnosed as chronic subdural hematoma in May/June. The report says that this disease has increased in Kumamoto more-than-normal.

Symptoms are; headache, forgetfulness, unable to speak words well, numbness on limb on one side, unable to do exercise with satisfaction and decline in morale.When advances, consciousness disturbance may occur. Unless timing has not been overlooked and receiving adequate treatment, patient will be recovered same as before. So that this disease now attracts attention as get cured dementia so that there is a case where disease is found by Head CT at Dementia Outpatient.

In case if you think symptom may be the case, it is recommended to consult with doctor and take head CT scan.On the observers’ right in the fig.1 CT photography, slot in the brain becomes vague. Observation is that grey blood tumor, between skull and brain, compresses the brain.

Cerebral contusion – Brain rapidly intumesce by cerebral bleeding.

Head is bumped heavily, and that makes a bruise on brain, that is called as cerebral contusion. It is seen at contacting part with skull, producing cerebral apoplexy, becomes larger in first few hours, and in 24 hours passed, brain is swelled gradually. In below CT observation, white blood tumor is seen at cerebellum region, and this compresses the brain stem so that consciousness disturbance has occurred. Craniotomy for removal of hematoma is performed in emergency to remove blood tumor and to release brain stem compression. Consciousness has recovered.

Fractured skull shows variety of symptoms from mild to severe injury.

They often hear from TV program or Newspaper that head is bumped in traffic accident, and person on board is severely injured by skull fracture. In fact, there are mild one to severe one in the same skull fracture. Brain surface is injured so that blood tumor is produced, then ended in lost conscious as brain contusion mentioned above. But there is a case where brain has almost no damage even skull itself has broken. In below photos, it is recognized that the skull is collapsed as depressed fracture. In bone image CT at the center, skull is collapsed but on the right CT image, there is no bleeding on brain surface so that no brain contusion is recognized. In this case patient is conscious so that course is in good condition and no surgery is required.

Acute subdural hematoma – Immediate craniotomy for removal of hematoma is necessary.

Opened head, remove skull and cut dura mater out to expose blood tumor on brain surface As explained early part, chronic subdural hematoma is common among aged person. In case blood tumor produced immediately after head injury and grows rapidly in the gap between skull and brain, compression to the brain is getting strong so that lost consciousness has occurred. In this case, it is necessary to perform immediate craniotomy for removal of hematoma.

Brain concussion – Avoid for being alone for 24 hours

In case of the blow to the back of the head where no protector is attached, concussion may occur. (by All Japan Kendo Federation HP) In case athlete blows the head in exercise or in competition, then becomes unable to continue play as they want, and there is no abnormality found by cerebral CT or MRI but damage to brain exist, there is a possibility for brain concussion. Brain concussion susceptive athlete should cease play immediately and not being alone in coming 24 hours. In case when symptoms like headache is getting severer or unable to wake-up with pixilated head, unable to identify person or place, or vomiting continues occur, go to the hospital immediately.Because of short period disorder which no abnormality has found in the image may be cured naturally, increase the exercise volume in a step-by-step manner in few days or a bit longer period. For the play with contacts is anticipated, details of brain concussion is exhibited in home page so that it may be of your reference.

Diffuse brain injury – Coma state continues but hard to be appeared in CT.

The head trauma is largely grouped to focal brain injury (brain concussion, subdural hematoma) and diffuse brain injury (axonal injury). There is a case where brain concussion is included, and severity is classified with the duration of consciousness disturbance. Diffuse brain injury is sometime hard to be observed by CT immediately after injury although coma continues after injury, but interventricular bleeding, subarachnoid bleeding around midbrain and basal ganglion insult are the characteristic observation. With this observation, it can be predictable that higher brain dysfunction is easy to disability. Especially, primary damage on brain stem or cerebellum is the partial phenomenon of diffuse brain injury, and severe injury case is common.

Various after effects caused by head trauma

Symptoms with Head Trauma (Keisuke Takahata, Hajime Tabuchi, Masasi Mimura,(Brain and Nerve p849-857 68, 7th Edition, July 2016))

In subacute phase, within one month from reception of injury, symptoms are high brain dysfunction or traumatic epilepsy. In half year passed chronic phase, symptoms are altered personality or PTSD (posttraumatic stress disorder). Symptoms becomes obvious as shown above.

Higher brain dysfunction

Since acute phase treatment has completed so that when patient returns to school or to office, peoples around do not understand disorder so that person is commonly left behind the society, thus higher brain dysfunction after head trauma becomes a social problem. For example, school deputy principle is hospitalized with brain contusion, rehabilitation is intercepted at early stage so that school deputy principal gets full score in Hasegawa’s dementia scale. Although this person has returned to work, this person becomes unable to host the teachers’ meeting, or school office work processing capacity has decreased so that school principal is tearing a hair out. It happens to face this kind of case.

Higher brain dysfunction is the disease where motor paralysis, disorder perception, or language, recognition, behavior disorder caused by disorder of the central nervous system which is unable to explain with motor paralysis, disorder perception, or dementia.

Approximately 76% of the cases registered in Higher Brain Dysfunction Assistance Model Project is Traumatic Brain Injury, and this takes 72% of young individuals under the age 39, common among production age zone, and rehabilitation is socially important towards school attendance or occupation. For the case where started rehabilitation within 6 months from the time of injury, it has indicated the improvement tendency with 46%, but for the case which rehabilitation starts over 1 year passed, improvement is shown only at the rate of 14%.

As for the said Deputy Principal, to perform rehabilitation with the conscious of social reintegration, if the occupational therapy is performed with interviewing details of the work, prediction before discharge from hospital is possible. Even though it may be difficult to recover 100% with the condition before injury, but if the understanding was obtained from the work place, start with light work or transfer to the other section, consider gaining alternative method, working circumstance which do not produce weariness of brain is necessary. Local government who has higher Brain Dysfunction Center is increasing so that making contact with them at the time of hospitalization, having good recognition of family member’s disability, performing counselling, family guidance and support, and to make smooth start to the society,

Late-onset after effect disease

Late-onset after effect disease, which may occur after few years passed from injury, has been focused recently. Chronic traumatic encephalopathy, Psychiatric Disorder following Traumatic Brain Injury (PDFTBI), Alzheimer disease, Amyotrophic lateral Sclerosis, Traumatic Parkinson's Disease are listed but they are neurodegenerating diseases and having progressive characteristics of gradually getting worse.

Intracranial hypotension syndrome – Developed by cervical trauma

When excessed stress is applied to cervical spine caused by cervical trauma or chiropractic, membrane covering spinal cord breaks, and spinal fluid leaked out, so that brain become unable to keep intracranial pressure normal condition, resulted with headache, nausea/emesis, buzzing, dizziness like after effects. This is the disease called as Traumatic low-cerebrospinal fluid pressure syndrome. MRI is useful for this disease. If in case leaking of spinal fluid is confirmed by MRI, Epidural Blood Patch Therapy, which is injecting own blood into extradural space to patch leaked part, may relieve headache. In below figure, dura mater in head is contrasted by contrast MRI.

Blow-out fracture of orbit – Pummeling or collision play is the cause

Bone fracture occur at bone fragility part like inferior wall of orbit or endothecium by precipitous intraorbital pressure increase caused by eyeball is pressured from front side with battering, elbow hit at collision play and smashed with a ball.

Vertical movement of eyeball is accompanied by impairment in inferior rectus muscle (one of muscle which moves eyeball) breakout from bone fracture part, then it causes double vision (see things in double). Although application of surgical operation and its timing are not standardized, appropriate judgement by doctor is inevitable.