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Among the vast array of neurologic diseases, cerebral trauma ranks high in order of frequency and gravity In the United States, in persons under 45 years of age, trauma is the leading cause of death, and more than half of these deaths are due to head injuries Each year, according to the American Trauma Society, an estimated 500,000 Americans are admitted to hospitals following cerebral trauma; of these, 75,000 to 90,000 die and even larger numbers, most of them young and otherwise healthy, are left permanently disabled The basic problem in craniocerebral trauma is at once both simple and complex: simple because there is usually no dif culty in determining causation namely, a blow to the head complex because of a number of delayed effects that may complicate the injury As for the trauma itself, nothing medical can be done, for it is nished before the physician arrives on the scene At most there can be an assessment of the full extent of the immediate cerebral injury, an evaluation of factors conducive to complications and further lesions, and the institution of measures to avoid such additional problems But of the disastrous intracranial phenomena that can be initiated by head injury, several fall within the purview of the neurologist, for they are secondary effects that evolve during the period of medical observation, offering possibilities of treatment No doubt, new techniques of cellular biology will expose phenomena that are set in motion by traumatic injury of nerve cells and glia Some of these changes may be reversible, but at the moment, such knowledge is limited It is a common misconception that craniocerebral injuries are matters that concern only the neurosurgeon and not the general physician or neurologist Actually, some 80 percent of head injuries are rst seen by a general physician in an emergency department, and probably fewer than 20 percent ever require neurosurgical intervention of any kind even this number is decreasing Often the neurologist must take charge of the head-injured patient, or his opinion is sought in consultation To enact his role effectively, he must be familiar with the clinical manifestations and the natural course of primary brain injury and its complications and have a sound grasp of the underlying physiologic mechanisms Such knowledge must be up to date and immediately applicable, particularly as it relates to the interpretation of computed tomography (CT) and magnetic resonance imaging (MRI), both of which have greatly enhanced our ability to deal with head trauma and its complications The present chapter reviews the salient facts concerning craniocerebral injuries and outlines a clinical approach that the authors have found useful over the years Matters pertaining to spinal injury are considered in Chap 44.

The very language that one uses to discuss certain types of head injury divulges a number of misconceptions inherited from previous generations of physicians Certain words have crept into the medical vocabulary and have often been retained long after the ideas for which they stood have been refuted attesting to the disadvantage of premature adoption of explanatory terms rather than descriptive ones The word concussion, for example, implies 747

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a violent shaking or jarring of the brain and a resulting transient functional impairment Yet despite numerous postulates of physical changes within nerve cells, axons, or myelin sheaths (vibration effects, formation of intracellular vacuoles, etc), little convincing con rmation of their existence has been possible in humans or in experimental animals Similarly the word contusion, meaning a bruising of cerebral tissue without interruption of its architecture, is applied rather indiscriminately to a variety of clinical states, some of which could not depend on a pathologic change of this type, eg, minor contusion state or syndrome an expression introduced by Wilfred Trotter, who was himself critical of words that embalm a fallacious theory In all attempts to analyze the mechanisms of closed, or blunt (nonpenetrating), head injury, one fact stands pre-eminent that there must be the sudden application of a physical force of considerable magnitude to the head Unless the head is struck, the brain suffers no injury except in the rare instances of violent exionextension (whiplash) of the neck and somewhat controversial cases of crush injury to the chest or explosive injury with a sudden extreme increase of intrapulmonary pressure The factors of particular importance in brain injury are the differential mobility of the head and brain, the tethering of the upper brainstem while allowing movement of the cerebral hemispheres, and the relationship of injured parts of the brain to dural septa and bony prominences As to concussive injuries, it is useful to point out that all concussions involve a physical force that imparts motion to the stationary head or a hard surface that arrests the motion of a moving head, ie, concussion does not occur if the head is stationary This is the basis of most civilian head injuries, and they are notable in two respects: (1) they frequently induce at least a temporary loss of consciousness and (2) even though the skull is not penetrated, the brain may suffer gross damage, ie, contusion, laceration, hemorrhage, and swelling A theory that would bring into plausible form these physical and gross neuropathologic changes and their relation to transient loss of consciousness (concussion) or prolonged coma has been formulated only in relatively recent years By contrast, high-velocity missiles may penetrate the skull and cranial cavity or, rarely, the skull may be compressed between two converging forces that crush the brain without causing signi cant displacement of the head or the brain In these circumstances the patient may suffer severe and even fatal injury without immediate loss of consciousness Hemorrhage, destruction of brain tissue, and, if the patient survives for a time, meningitis or abscess are the principal pathologic changes created by injuries of these types They offer little dif culty to our understanding These various types of head injuries are illustrated in Fig 35-1 The relation of skull fracture to brain injury has been viewed in changing perspective throughout the history of this subject In the rst half of the century, fractures dominated the thinking of the medical profession, and cerebral lesions were regarded as secondary Later, it became known that the skull, though rigid, is still exible enough to yield to a blow that could injure the brain without causing fracture Therefore the presence of a fracture, although a rough measure of the force to which the brain has been exposed, is no longer considered an infallible index of the presence of ce-.

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