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Magazine
Head injuries — the facts
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Looking at the issue of head injuries, Dr. R. MURALI says that nowhere is the adage `prevention is better than cure' more applicable.
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K. PICHUMANI
One solution ... wearing a helmet reduces the risk of debilitating injuries.
Driving in the U.S. is on the right side,
Driving in the U.K. is on the left side,
Driving in India is Suicide!
THIS pithy aphorism graphically tells us the sad state of affairs on the roads of India. We have one of the highest accident rates per vehicle in the world. Our mortality and morbidity rates are also correspondingly high. Head injuries account for a very high percentage of these figures and is emerging as one of the biggest killers. Needless to add that as the number of vehicles (especially two wheelers) goes up, the scenario will only worsen.
The brain is housed in a rigid bony structure (the skull), covered by a thick layer called the scalp. Under the bone is a thick watertight membrane called the dura which surrounds the brain and contains a watery fluid called cerebrospinal fluid (CSF) in which the brain "floats". The brain is made up of two halves (the right and left) or cerebral hemispheres united in the midline.
At the centre is the brainstem which continues down as the spinal cord.
When a person sustains a head injury, the doctor (neurosurgeon) uses certain terms to explain the condition of the patient. It would help if we are aware of some common ones:
1. Trauma means injury.
2. Unconscious: is a "lack of awareness of surroundings". This term is frequently misused. A feeling of giddiness or dizziness is not "unconsciousness" and needs to be differentiated from it. Coma is a deep level of unconsciousness.
3. Concussion: This is a temporary loss of consciousness (usually a few minutes) followed by full recovery. Here there is only temporary functional impairment but no structural damage.
4. Contusion: Here there is structural damage in the brain with areas of patchy bleeding.
5. Skull fracture: This is to due to a focal contact injury and can be linear (like a line) or depressed (one fragment being pushed below the other). It can further be classified as simple (closed) or compound (open) depending on whether there is a wound overlying it.
Contrary to popular belief, a fracture itself is not harmful and by itself does not require further treatment.
In fact a fracture may allow the bone to take the brunt of the injury sparing the brain. A compound (open) depressed fracture needs surgical intervention for cleaning the wound and removing small fragments or elevating the depressed segment. The broken bone can pierce the dura (the protective membrane surrounding the brain) and expose the brain to the outside which can result in infection (meningitis).
6. Haematoma: This is a collection of blood in a confined space. This is of three kinds:
(a) Extradural hematoma (EDH): This is a collection of blood between the skull and the dura, and is outside the brain.
This is due to an injury to the blood vessel on the dura. Here there is usually no brain injury. If large, it requires surgical removal and outcome is excellent.
(b) Subdural hematoma (SDH): This is a collection of blood under the dura but outside the brain and there is usually associated brain injury. If large, this may require surgery and if the brain damage is severe, outlook is guarded.
(c) Intracerebral hematoma (ICH): This is a collection of blood within the brain matter and may necessitate surgical evacuation if large. Outcome depends on associated brain injury.
7. Brainstem injury: this is a severe injury involving vital areas in the brain controlling functions like breathing, blood pressure and consciousness. This can be fatal or may take a long time for recovery.
8. Edema: Otherwise known as brain swelling, this is due to water collection in the brain tissue surrounding an injured area. Just like the hand or leg the brain too "swells" after an injury. This usually starts 24 hours after injury and reaches a peak on the third or fourth day. Unfortunately, unlike in other areas, the brain is confined in a rigid structure (the skull) which cannot expand. This increases the pressure inside the skull and can be fatal if it is severe and not controlled by various "anti-edema measures".
One must understand that unlike an injury to the hand or leg, brain injury is an ongoing dynamic process which proceeds even after the initial event. This is why a person who is well at the time of admission may deteriorate later even when getting treatment.
A CT scan is a special type of x-ray that has revolutionised the diagnosis and treatment of brain lesions both traumatic and non-traumatic (like tumours). (Its inventor, Godfrey Hounsfield, very deservingly won the Nobel prize and was also knighted). It reveals the brain structure inside the skull and gives valuable information to the neurosurgeon.
However, it can only show the structure and not the function. Hence sometimes one is faced with the paradoxical situation of a patient who has a "normal" scan but is in coma!
Frequently asked questions:
Are all head injuries serious?
No. They range from the trivial to the fatal depending on the severity, site and associated injuries.
Should all head injuries be seen by a doctor?
Yes. If necessary, the patient is advised to be under observation for 24 hours as sometimes a clot may develop slowly and patient may develop symptoms after sometime.
Is there a difference in being injured on the right side or left?
Yes. In most (98 per cent) of us, the left brain (the dominant hemisphere) has the centres for speech, understanding, memory, etc. Hence a left brain injury is always worse than a similar injury on the right. Also, one must remember that the right half of the brain controls the left side of the body (face, upper and lower limbs) and vice versa (the nerve fibres "cross over" to the opposite half in the lower part of the brain). Hence a left brain injury will cause dysfunction of the functionally more important right side of the body.
Can one get fits (seizures) after head injury?
Yes, a minority do and these can be controlled with drugs.
Is brain surgery dangerous?
With recent advances in ICU care and anaesthesia, brain surgery is safe and effective. Though frightening for most people, opening of the skull (Craniotomy) is by itself safe and harmless.
Can the outlook for the patient be predicted accurately?
Even with current "state of the art" techniques we cannot accurately predict the final outcome. Recovery in the brain and spinal cord is a slow process and only a year (roughly) after a severe injury one can tell with reasonable certainty what the final recovery will be. Hence you will find doctors saying many times that we do not know the outcome in the initial days of the injury. The poor doctor is not ignorant!!
Nowhere are the words "Prevention is better than cure" more aptly applied.
The saddest part of the situation is that a good and simple means of preventing this devastating injury is available but has not made us more responsible — by wearing a HELMET. It saves lives and reduces debilitating injuries. A little discomfort in carrying it either in the hand (while not driving) or wearing it goes a long way in avoiding a catastrophe.
Let me end by saying
WEAR A HELMET UNLESS YOU'RE THICKHEADED!!
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