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Editors

TimoKoivisto
TeemuLuoto

Brain Injury and Skull Fracture

Essentials

  • The possibility of an acute injury to the brain must be recognized in a patient with head injury.
  • The possibility of an intracranial haemorrhage Traumatic Cerebral Haemorrhages must always be kept in mind. Computed tomography (CT) of the head is the primary investigation in establishing such a haemorrhage.
  • The severity of the brain injury (mild, moderate, severe) is evaluated on the basis of the history of the events, the patient's clinical state and the findings (including imaging).
  • Refer a patient in need of emergency treatment to a health care unit that has the possibility of performing a CT scan and providing intensive care. If the patient is transported to a hospital, make sure that the accompanying person has sufficient competence in emergency medical care.
  • The level of consciousness and the general condition of the patient are monitored even if the brain injury is mild, until a severe intracranial injury is excluded.
  • The patient's overall condition and findings (level of consciousness, unconsciousness, memory gap, orientation, neurological findings) are recorded carefully, because they are important for organising long-term follow-up and from the insurance-juridical perspective.

Diagnosis of brain injury

  • The diagnosis of brain injury is based on the patient's level of consciousness (GCS scale, see below), the memory gap after the injury, duration of unconsciousness, neurological findings and findings in brain imaging.
  • The level of consciousness is the principal factor concerning the choice of treatment location, the intensity of therapy, the seriousness of the injury and the prognosis.

Level of consciousness

  • If the patient has any disturbance in the level of consciousness, he/she must be directly referred to the emergency department of a hospital.
  • Patient's initial level of consciousness is recorded and changes are monitored.
  • The level of intoxication in an intoxicated patient is assessed.
  • Glasgow Coma Scale (GCS) is used in the assessment of level of consciousness, see Prehospital Emergency Care and table T1. A video demonstration of the assessment is available at http://www.glasgowcomascale.org/.

Glasgow Coma Scale (GCS)

CriteriaScore
Eye openingSpontaneously4
To sound3
To pressure2
None1
Verbal responseOrientated5
Confused4
Words3
Sounds2
None1
Best motor responseObeys commands6
Localising5
Normal flexion4
Abnormal flexion3
Extension2
None1
Total3-15 points

Acute head imaging

  • CT scan is the primary imaging examination in a brain injury. Skull x-ray should not be used.
  • The indications of a CT scan of the head after a head injury (even one of the following is enough)
    • GCS < 13 when assessing the patient at the emergency department for the first time
    • GCS < 15 at the emergency department two hours after the injury
    • Suspected open or depressed skull fracture
    • Sign of a basal skull fracture
      • Haematotympanum, periorbital haematoma, subcutaneous haematoma on the mastoid cells (Battle's sign), CSF rhinorrhoea or CSF otorrhoea
    • Post-traumatic convulsive seizure
    • Focal neurological deficit
    • More than one episode of vomiting after the injury
    • Anticoagulant medication
      • If the patient uses concomitantly more than one antiaggregatory drugs, a head CT scan should be readily performed.
    • Amnesia or unconsciousness AND one of the following:
      • age ≥ 65 years
      • known blood coagulation disorder
      • dangerous mechanism of injury (a pedestrian knocked down by a motor vehicle, a person flown out of a vehicle, falling down from the height of over 1 meter or (in a staircase) of more than 5 steps, for example)
      • retrograde amnesia of over 30 minutes
  • CT scan is also indicated if the symptoms of a patient with head injury are difficult to assess due to, e.g., intoxication with alcohol or with illegal or legal drugs, or due to psychiatric problems.
  • In association with the head CT scan, the possibility of a fracture in the cervical spine should be assessed. If needed, a CT scan of the cervical spine should be performed.

Skull fractures

  • Associated with direct head injuries
  • The possibility of a brain injury must always be remembered when suspecting a skull fracture
  • CT scan is the primary investigation in establishing a skull fracture.

Calvarial (skull cap) fracture

  • Calvarial fractures are usually linear and in good position.
  • Depressed fractures, in which a part of the skull is depressed inwards, are rarer.
  • It is important to keep the possibility of a depressed fracture in mind and palpate the patient's head.

Fracture of the base of the skull

  • The base of the skull may be fractured in the areas of the anterior, middle and posterior cranial fossa.
    • Fracture in the anterior cranial fossa is the most common type.
  • Associated with a risk of cerebrospinal fluid fistula and meningitis if extending to the paranasal sinuses or to the petrous part of the temporal bone.
  • Fracture in the anterior cranial fossa: signs may include CSF leakage from the nose (tear in the dura mater), periorbital haematoma (“raccoon eyes”) and loss of smell because of injured olfactory bulb Disturbances of the Sense of Smell. Sometimes symptoms related to the nerves innervating the eyes (blindness, double vision, ptosis).
  • Fracture in the middle cranial fossa: signs may include immediate or delayed CSF leakage from the ear (tear in the dura mater), hearing impairment or loss, and possibly vertigo. Blood behind the tympanic membrane (haemotympanum) may be suggestive of a fracture in the middle cranial fossa. A bruise over the mastoid air cells (retroauricular haematoma, Battle's sign) may also be suggestive of a fracture in the middle and/or posterior cranial fossa. Facial nerve palsy (cranial nerve VII, see Peripheral Facial Paralysis) is possible. It develops usually within a few days.
  • Fracture in the posterior cranial fossa is rare, but predisposes to an epidural haematoma following a tear in the transverse sinus.

Treatment

  • Follow-up at a hospital
  • Fractures very rarely require treatment, but they indicate the strength of the blow on the head and may mean an increased risk of cerebral bleeding or contusion Traumatic Cerebral Haemorrhages.
  • In children, the fracture may sometimes expand by itself - children's fractures (in less than 2-3-year-olds) should be controlled once within a few months after the injury.
  • A depressed fracture is often treated by surgery, if it causes a depression on the brain (depression more than the thickness of the bone) or is located in a visible area of the skin.
  • An open depressed fracture must be treated within 24 hours due to the risk of infection (meningitis and brain abscess).
  • There is no evidence on the effectiveness of prophylactic antimicrobials in fractures of the base of the skull (with or without CSF leakage) Antibiotic Prophylaxis for Preventing Meningitis in Patients with Basilar Skull Fractures.
  • CSF leakage usually stops spontaneously within 1-2 weeks.
    • If the leakage continues, the tear in the dura is to be patched at a neurosurgical unit.

Indications for neurosurgical consultation

  • Send the CT scans by electronic means to a neurosurgical unit and consult the neurosurgeon in charge in the following situations:
    • CT scan shows an abnormality, e.g. haematoma, brain contusion, depressed fracture
    • patient with a head injury and clearly decreased level of consciousness, even if the head CT is normal
    • CSF leakage from the nose or ear
    • open or depressed skull fracture.

    References

    • Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma 2000 Apr;48(4):760-6. [PubMed]
    • Jagoda AS, Bazarian JJ, Bruns JJ Jr et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008;52(6):714-48. [PubMed]
    • Head injury: assessment and earlymanagement. Clinical guideline CG176. National Institute for Health and Care Excellence (NICE) http://www.nice.org.uk/guidance/cg176/resources/head-injury-assessment-and-early-management-35109755592901.
    • Menon DK, Schwab K, Wright DW et al. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil 2010;91(11):1637-40. [PubMed]
    • Singh B, Murad MH, Prokop LJ et al. Meta-analysis of Glasgow coma scale and simplified motor score in predicting traumatic brain injury outcomes. Brain Inj 2013;27(3):293-300. [PubMed]