4 results
Trauma: traumatic brain injury
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
-
- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 169-179
-
- Chapter
- Export citation
-
Summary
Introduction
Head injury can be defined as any alteration in mental or physical functioning related to a blow to the head. The most affected are young adults and societal cost is significant (emotional and financial), estimated at $25 billion per annum in the USA alone, excluding inpatient costs.
Classification
▪ Neurological impairment: mild (GCS 14–15), moderate (GCS 9–13) or severe (GCS 3–8). See Trauma Scoring Systems Chapter for GCS.
▪ Anatomical: focal (extradural, subdural and intra-cerebral haematoma) vs. diffuse (concussion, multiple contusions, diffuse axonal injury (DAI), hypoxic injury).
▪ Mechanism: blunt vs. penetrating.
Incidence
180–220 cases per 100 000 population (US), approximately 600 000 each year. Of these 10% are fatal, 75% are minor, the remainder equally divided between moderate and severe. Males are affected more than females (2:1) and it is commoner in the under 35s.
Aetiology
Road accidents are the commonest cause. Also falls, occupational injuries, sports and leisure accidents. Violence and penetrating trauma increases in cities with a population >100 000.
Pathophysiology concepts
Monro-Kelly doctrine: total intra-cranial volume (1500 ml) is fixed due to the inelastic nature of the skull and is composed of brain (85–90%), blood (10%), and CSF (<3%). Cerebral oedema, haemorrhage, focal haematoma and hydrocephalus increase these components. An increase in one of these compartments will require a compensatory decrease in the others in order to maintain intracranial pressure (ICP). Normal ICP=10–15 mmHg. At the point where the compensatory mechanisms are exhausted, ICP exponentially rises (see Figure 21).
Spinal cord injury
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
-
- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 551-557
-
- Chapter
- Export citation
-
Summary
Spinal cord injury (SCI) involves an insult to the spinal cord with resultant disturbance in motor, sensory or autonomic function which may be temporary or permanent.
Important definitions
Paresis: partial loss of power; weakness.
Plegia: total loss of power; paralysis.
Myelopathy: caused by damage to the spinal cord, which ends at L1.
Radiculopathy: damage/compression to nerve roots with symptoms in the distribution of the root.
Tetraplegia or quadriplegia: injury involving all four limbs.
Monoplegia: of one limb.
Paraplegia: bilateral lower-limb involvement.
Neurogenic shock: triad of hypotension, hypothermia and bradycardia due to interruption of sympathetic nervous system input (T1 – L3) with unopposed vagal input. Note: hypovolaemic shock causes tachycardia.
Spinal shock: a transient physiological reflex with depression of spinal cord function associated with loss of all motor and sensory function, including reflexes and anal tone, below the level of injury. Catecholamine release will lead to a transient hypertension, followed by hypotension and accompanied by flaccid paralysis, double incontinence and priapism. Duration may be hours to days until function returns to the reflex arcs below the injury level.
Classification
ASIA (American Spinal Injury Association) impairment scale: A (complete motor and sensory loss including S4–5); B (incomplete: sensory but no motor function preserved below injury); C (incomplete: motor function preserved below injury with power < 3); D (incomplete: motor function preserved below injury with power ≥ 3); E (normal). An incomplete lesion may progress to a complete lesion and vice versa.
Brain tumours
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
-
- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 540-543
-
- Chapter
- Export citation
-
Summary
Introduction
2% of all cancer deaths are due to brain tumours and 20% of paediatric neoplasms are in the CNS. Overall they account for 10%of all malignancies. Although it is difficult to generalize about all brain tumours, there are some common themes.
Classification
May be according to cell origin (see table) or histological grading by the World Health Organization (WHO):
▪ Grade I: benign – growth is slow, cells are similar to normal cells and rarely spread into adjacent tissue; total excision can be curative.
▪ Grade II: growth is slow but local spread possible. The tumour may ‘transform’ into higher grade.
▪ Grade III: malignant – growth is quick, cells are pleomorphic with higher nuclear-to-cell ratio. Local spread likely.
▪ Grade IV: highly malignant – aggressive growth with high mitotic rate.
Incidence
15–20 per 100 000 (primary and metastatic); 35 000 new cases per annum (USA).
20–30% of patients with systemic cancer will have brain metastases. Gliomas 7 per 100 000; meningiomas 1.2 per 100 000. Meningiomas and pituitary adenomas slightly commoner in women. 3.6 per 100 000 children per annum have a primary brain tumour, the second commonest cause of paediatric cancer after leukaemia, and the most prevalent solid tumour in children.
Aetiology
Unknown in most cases. Developmental abnormality: teratoma, dermoid, epidermoid, craniopharyngioma, chordoma, hamartoma, angioma, ganglioneuromas. Hereditary: haemangioblastoma in von Hippel-Lindau disease; meningiomas and acoustic neuromas in neurofibromatosis; astrocytomas in tuberous sclerosis. Immunosuppression: lymphoma. Radiation: meningioma, sarcoma, glioblastoma.
Symptoms
Benign slow growing tumours may reach large size without causing significant symptoms.
Hydrocephalus
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
-
- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 544-550
-
- Chapter
- Export citation
-
Summary
Definition
Hydrocephalus (HC) is a hydrodynamic disorder of CSF due to a disturbance of formation, flowor absorption of CSF that leads to an increase in volume occupied by this fluid within CNS. (Note: increased CSF volume also observed in cerebral atrophy but this is not due to a hydrodynamic disorder, but a passive filling of the increased vacant space; hence the old term ‘hydrocephalus ex vacuo’.)
Classification
Functional:
Obstructive or non-communicating: block is proximal to arachnoid granulations with an obstruction of CSF flow in the ventricular system or its outlets to the subarachnoid space.
Communicating: full communication exists between the ventricles and subarachnoid space with CSF circulation blocked at level of arachnoid granulations. Causes: decreased CSF absorption, venous drainage insufficiency, or CSF overproduction (rare).
Alternative classifications:
Acute (over days)/subacute (weeks)/chronic (months or years).
Congenital or acquired.
Arrested HC: stabilization of known ventricular enlargement after compensation. These patients are prone to decompensation, e.g. with aminor head injury.
Normal pressure hydrocephalus (NPH): a triad of dementia, abnormal gait, and urinary incontinence, in the absence of papilloedema and in the presence of normal CSF pressures on lumbar puncture.
Incidence: 3/1000 live births with congenital HC. Incidence of acquired HC unknown, but about 100 000 V-P (ventriculo-peritoneal) shunts performed in developed countries per annum.
Gender: M:F=1:1. In NPH M > F. X-linked HC in Bickers-Adams syndrome.
Age: bi-modal age curve with peaks in infancy and adulthood (40%).