• Controlling pressure inside the skull
• Alleviating brain swelling
• Repairing blood vessels and removing blood clots or foreign matter

Controlling Pressure Inside the Skull

If a head injury causes fluid to build up inside the skull or causes the brain to swell, the pressure inside the skull increases. Excessive intracranial pressure (”ICP”) can cause damage to delicate brain tissues leading to additional brain injury and lasting disability. Even higher pressure can cause death.

Physicians will suspect problems with intracranial pressure buildup based on the patient’s age, description of the injury and the onset of symptoms, examining the pupils of the eyes and CT scans, and evaluating the patient’s Glasgow Coma Score. When these indicate potential pressure on the brain, a hole is drilled in the skull (a “burr hole”) for placing one of four types of devices:

• Subdural or epidural monitor
• Subarachnoid bolt
• Intraparenchymal monitor
• Intraventricular catheter

A subdural or epidural monitor is inserted in the burr hole made in the skull. The subdural monitor penetrates the dura – the leathery outer membrane surrounding the brain – while the epidural monitor does not. Neither of these monitors can drain cerebrospinal fluid (”CSF”) to relieve ICP. And neither is as accurate and reliable as the intraventricular catheter or intraparenchymal monitor. These simpler pressure monitors may be the best choice, however, when an experienced surgeon is not immediately available to place the more invasive devices

A subarachnoid bolt extends deeper into the skull, penetrating both the dura and the arachnoid membranes. To maintain its position in the small subarachnoid space, the sensor is physically attached to the skull when its inner and outer halves are screwed together. It does not provide for drainage of CSF.

The intraparenchymal monitor is inserted into actual brain tissue (the “parenchyma”). It provides a fast, accurate and reliable way to monitor ICP, but does not provide a way to relieve pressure by draining cerebrospinal fluid. This method is used when draining CSF is not expected to be necessary or when placing an intraventricular catheter is not possible.

The intraventricular catheter is by far the most preferred device for managing intracranial pressure. In a procedure called a ventriculostomy, the catheter is inserted through brain tissue into one of the vacant areas (”ventricles”) deep within the brain. The ventricles are filled with cerebrospinal fluid making this device the most accurate and reliable, as well as allowing it to drain excess cerebrospinal fluid to actually reduce ICP.

Alleviating Brain Swelling

Physicians will first try non-surgical methods for controlling brain swelling (or “edema”) and the resulting problems from excessive intracranial pressure. Draining CSF, using specific drugs, medically inducing a coma, or hypothermia treatments are all non-surgical options.

To alleviate brain swelling surgically, the neurosurgeon may perform a craniectomy. In this procedure, the surgeon removes a section of the skull (a “bone flap”) giving the swelling brain room to expand. If the amount of bone removed is large, the procedure is called a hemicraniectomy.

If the surgeon attempts to save the bone to be surgically reimplanted later, the first operation is called a craniotomy, and the procedure to replace the bone is cranioplasty. To save the bone for later use, it may be frozen, or implanted under the skin of the abdomen until needed.

If parts of the brain tissue are obviously injured and recovery in the injured area is unlikely, the surgeon may remove the damaged brain tissue to create additional space in the skull to relieve the pressure caused by swelling. This is a partial lobectomy.

Repairing Blood Vessels and Removing Blood Clots or Foreign Matter

Bleeding inside the skull also causes an increase in intracranial pressure and can be identified using CT scans.

If the injury is an open head wound, bits of bone or foreign matter may need to be removed from the brain tissue, and the membrane covering the brain repaired.

To correct these problems, the neurosurgeon performs a craniotomy to gain access to the injured brain area. He can then remove foreign materials or clots, evacuate blood, repair blood vessels, and suture the dura as needed.

When the bone is replaced after the surgery, temporary metal plates may be installed to hold the bone flap in place while the bone knits. The metal plates are removed after the bone heals.

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Each year in the U.S., millions of children and adults experience a concussion from involvement in organized sports. In football, baseball, basketball, and soccer alone, nearly 100,000 will visit a hospital emergency room as a result of a head injury. Serious concussions and multiple mild concussions can lead to lasting disability and can sometimes be fatal. (See Brain Injuries in Sports.)

Given the potential for serious brain injury in sports activities, the American Academy of Neurology (”AAN”) has issued guidelines specifically for concussion management in sports. These guidelines for coaches apply to sports at any level, from pee-wee to pro.

Concussion Symptoms

Managing a concussion first requires recognizing its symptoms. Any player exhibiting any of the following conditions should be evaluated on the sideline before being allowed to return to the game.

• Confusion, disorientation
• Headache, dizziness, nausea, vomiting
• Uncoordinated or slow movement
• Impaired thinking or memory
• Slow or slurred speech
• Blurred vision, double vision, or sensitivity to light
• Ringing in the ears
• Loss of memory of events immediately before or after the injury
• Unconscious for any period of time

Evaluating the Concussion

Concussions can be mild or severe. Players can recover quickly from a mild concussion and the AAN guidelines allow the athlete to resume play after all concussion symptoms have cleared up. Any head injury other than the mildest concussion, however, requires a neurological examination and at least a 1-week or longer break from playing.

The following describes how to evaluate a concussion’s severity, with Grade 1 being the mildest.

• Grade 1. Temporary disorientation, no loss of consciousness, all symptoms clear up in less than 15 minutes.
• Grade 2. Temporary disorientation, no loss of consciousness, symptoms persist for 15 minutes or more.
• Grade 3. Any loss of consciousness, whether for seconds or minutes.

If the player remains unconscious, have emergency medical personnel transport the player to the emergency room. Because of possible neck or spine injuries, do not remove protective gear and do not move the player. In case of vomiting, roll the athlete gently to one side being careful to keep the head and spine aligned.

If on the other hand the player loses consciousness only briefly, take the player to get a neurological evaluation.

Sideline Assessment

A mild, Grade 1 concussion is the most common, but it can be the most difficult to identify since the symptoms may be brief. Nonetheless, it’s important to recognize even a mild concussion because a second mild concussion can have serious implications.

When no loss of consciousness occurs, evaluate the player for other symptoms. To determine if a player is suffering from deteriorated mental or physical function, ask the player to:

• Identify the date, day of the week, month, location, opponent (Orientation)
• Recall what happened, previous opponents, recent events (Memory)
• Count from 10 backwards; recite the months of the year in reverse order (Concentration)
• Walk or run a short distance, perform calisthenics (Intact senses and motor function)

Evaluate the athlete every 5 minutes for improvement. If the symptoms all clear up within 15 minutes, the player can return to the competition. If the symptoms do not clear up in less than 15 minutes, the player has a Grade 2 concussion.

Sidelining the Player

A concussion greater than a Grade 1, or two or more concussions of any grade, require a player to get a neurological evaluation and take a minimum of one to two weeks away from the sport. The risk of permanent or fatal injury from repeated brain trauma is too serious to be taken casually.

Detailed guidelines for evaluation, treatment, and limitations on sports activities are available in the complete paper from the American Academy of Neurology, Practice Parameter: The Management of Concussion in Sports.

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Linear Skull Fracture

Most linear skull fractures do not require specific treatment. A simple, relatively straight-line crack is detectable in X-rays or CT scans and will eventually heal on its own.

If symptoms of bleeding inside the skull or an underlying brain injury are not present, the patient is typically treated for any external head wound and sent home with instructions to watch for late-developing signs that may indicate a brain injury. The patient should be cautious against any additional head trauma that can aggravate the injury. When no brain trauma is evident, a full recovery can be expected.

Basilar Skull Fracture

Due to its unique location, a linear skull fracture at the base of the skull can create complications. The break can sometimes extend into the sinus cavities and can also cause a tear in the membrane (the “dura”) surrounding the brain.

Because the dura surrounds the cerebrospinal fluid, in which the brain floats, a tear in it allows the fluid to leak out. This appears as a clear or pink-tinged fluid escaping from the nose or ears. A concern is that the tear in the dura may provide a path for infection. Some physicians may prescribe an antibiotic although many do not.

Sometimes bloody fluid leaking from the dura may collect under the skin around the eyes or behind the ears causing a bruised appearance. This is a sign of a more serious brain injury and is treated separately from the fracture.

The tear in the dura can seal itself in as little as 48 hours, but patients are often admitted to the hospital for a brief period. If leaking fluid persists, it may be necessary to implant a drainage tube to give the dura a better opportunity to heal. Lacking any sign of serious brain injury or later infection, recovery is usually uncomplicated.

Comminuted Skull Fracture

When the skull bone is broken into fragments, it’s referred to as a comminuted fracture, or a multi-fragmentary or radial fracture. Treatment is based on severity.

A simple comminuted fracture – with the bones remaining in alignment and not depressed – is itself not exceptionally serious. Similar to a linear fracture, the bone can be expected to heal without specific treatment. Because of the potentially fragile nature of the break, the patient should take precautions against any subsequent head trauma.

If bone fragments are dislodged, surgery may be required to align or remove fragments. If the bone has not penetrated the dura and there are no signs of injury beyond a possible concussion, a full recovery can be expected. However, concussion symptoms may persist for some months. (See Understanding Post-Concussion Syndrome.)

If the bone fragments are pushed inward, the injury is called a depressed skull fracture.

Depressed Skull Fracture

A head injury resulting in a noticeable depression in the skull is a depressed skull fracture. Treatment is often determined by the depth of the depression, whether it’s accompanied by an open wound, and the degree of accompanying brain trauma.

In the best case, the depression is not greater than the skull’s thickness and the skull is not exposed. Lacking any signs of brain damage requiring treatment, the fracture may not be treated and allowed to heal on its own, or for cosmetic reasons, it may be surgically elevated.

Deeper depressions and those with open wounds are frequently accompanied by damage to the brain. Surgery to elevate the bone and remove any fragments is often required. Surgery may also be needed to treat bleeding inside the skull. In these cases, mild to severe impairment and disability due to the brain injury can be expected.

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