Skull fractures and their manifestations
There are three main types of skull bone fractures: linear fractures, comminuted fractures, and depressed fractures. The injury may be located in the cranial vault or the cranial base.
Skull base fractures have a specific clinical presentation based on two main symptoms:
- Cerebrospinal fluid leakage (CSF otorrhea or rhinorrhea). Nasal CSF leakage indicates a defect in the ethmoid or sphenoid bone, while ear leakage indicates a fracture of the petrous part of the temporal bone.
- Soft tissue hemorrhages. The localization of hematomas strictly depends on the fracture site. Damage to the anterior cranial fossa results in the "raccoon eyes sign" (periorbital ecchymosis); with a middle fossa fracture, blood accumulates in the mastoid process region; and with a posterior fossa injury, blood accumulates in the occipital region or the back of the neck.
Intracranial hematomas
Hematomas are the most frequent cause of brain compression. The primary source of bleeding is the a. meningea media (middle meningeal artery) and its branches, less commonly venous sinuses, meningeal veins, and diploic veins.
Based on the localization of the escaped blood, hematomas are classified into:
- Epidural: accumulation of blood above the dura mater (between the dura and the skull bone).
- Subdural: blood accumulates beneath the dura mater.
- Intracerebral: hemorrhage directly into the brain parenchyma.
- Intraventricular: blood breaks into the cerebral ventricles.
Main forms of brain injury
Each type of injury is characterized by its own symptom complex:
- Concussion (commotio cerebri): Gross anatomical changes are absent. Characterized by brief loss of consciousness, retrograde amnesia (memory loss for events preceding the injury), and a single episode of vomiting. Vital signs are stable; focal and meningeal signs are absent. Requires hospital observation for up to 12 days and bed rest.
- Contusion (contusio cerebri): Disruption of brain tissue integrity in a localized area. Depending on severity, it may manifest as loss of consciousness (from an hour to several days), persistent focal symptoms (aphasia, paresis), and respiratory and circulatory dysfunction.
- Compression (compressio cerebri): Occurs due to a decrease in intracranial volume caused by an expanding hematoma, depressed fracture, or traumatic brain edema. This is a life-threatening condition requiring emergency surgical decompression.
Instrumental diagnostics
To assess injury severity and detect hematomas, special diagnostic methods are used:
- Skull radiography: performed in two projections to screen for fractures.
- Lumbar puncture: puncture of the subarachnoid space (at the LIII–LIV or LIV–LV level). Allows assessment of CSF pressure, color, and transparency, and detection of blood admixtures.
- Echoencephalography (Echo-EG) and CT: determine hematoma localization and displacement of midline brain structures (M-echo).
- Angiography: used for vascular contrast imaging if other methods are unavailable.
- Exploratory trepanation: diagnostic burr holes at typical sites of blood accumulation if non-invasive methods yield inconclusive results.
Briefly: answers to topical questions
What are the grades of severity of a cerebral contusion?
Cerebral contusions are classified into three degrees of severity.
- Mild degree — loss of consciousness for up to 1 hour, mild innervation impairments.
- Moderate degree — loss or depression of consciousness for several hours, clear signs of focal damage, aphasia, paresis.
- Severe degree — loss/depression of consciousness for 24 hours or more, pronounced signs of focal damage, vital organ dysfunction, meningeal signs.
Which scale is used to assess the severity of impaired consciousness in TBI patients?
The severity of impaired consciousness in TBI patients is assessed using the Glasgow Coma Scale (Glasgow Coma Scale).
- Scoring is based on the sum of three parameters — eye opening, verbal response, and motor response.
- Range — from 15 points (clear consciousness) to 3 points (deep coma).
- Grading — 14–10 points correspond to obtundation, 9–8 points to stupor, and 7 points or lower to coma.
What are the indications for emergency surgical decompression in brain compression?
Surgical treatment for brain compression is indicated for the following causes:
- Depressed skull fractures — removal of bone fragments.
- Intracranial hematomas — evacuation of the hematoma and arrest of ongoing bleeding.
- Large volume intracerebral hematomas — surgical removal or aspiration.
What are the main meningeal signs checked in traumatic brain injury?
Meningeal signs reflect irritation of the meninges and include the basic triad of features.
- Nuchal rigidity — tonic tension of the neck muscles.
- Kernig's sign — a meningeal sign checked during examination.
- Brudzinski's signs — part of the basic triad of meningeal syndrome.
In mild cerebral contusion, these are weakly expressed (Kernig's sign, slight nuchal rigidity, pain on eye movement, photophobia).
The localization of hematomas in skull base fractures is easy to remember in an anteroposterior direction: Anterior fossa — eyes ("raccoon eyes"), Middle fossa — ears (mastoid process), Posterior fossa — neck/occiput.
Class and exam questions
How does a concussion fundamentally differ from a contusion?
In concussion, gross anatomical changes and focal neurological symptoms are absent. Contusion, however, is always accompanied by the destruction of a portion of brain tissue and clear signs of focal damage (e.g., paresis).
What is retrograde amnesia?
This is a classic symptom of cerebral concussion, where the patient cannot remember events immediately preceding the moment of injury.
Which medications are used to combat traumatic brain edema?
Intensive care incorporates powerful dehydrating agents: furosemide, urea, and mannitol.
What else to study on this topic
- Pathological anatomy of microcirculatory disturbances in concussion.
- Indications and contraindications for lumbar puncture in head injuries.
- Features of intensive care and mechanical ventilation parameters in severe brain contusions.
- Technique of diagnostic and decompressive craniotomy.
- Mechanisms of secondary injury development in traumatic brain edema.
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