Brain contusion (concussion) - symptoms and treatment

A mild form of TBI leads to the development of a concussion. The pathological condition provokes a temporary disruption of interneuronal connections. A simple disease requires timely treatment and strict adherence to doctor’s instructions in order to avoid consequences and disorders of the brain, hearing and vision.

Features of pathogenesis

The human brain is normally located in the cerebrospinal fluid. Sudden movements of the head provoke the development of hydraulic shock associated with a sharp drop in pressure. Sometimes the GM hits the inner surfaces of the skull.

Injuries and contusions lead to concussion with fainting. After some time, the severity of symptoms decreases, and a focal disorder remains in a separate area of ​​the brain. The clinical picture of the pathology is formed against the background of changes in the chemical and physical properties of individual neurons. Loss of contact between cells leads to functional dysfunction.

Patient care at home

Management of patients is limited to short-term (from 1-2 to 5-7 days) placement in a hospital, during which instrumental examinations, history taking, and symptomatic therapy are carried out. To relieve symptoms and accelerate regeneration, drugs that affect the central nervous system are prescribed.

Regression of symptoms occurs independently, without the use of medications. In some cases, recovery takes from several weeks to several months.

In older patients, recovery takes a longer period from 3 to 6-12 months.

After discharge from the hospital, the patient is sent home under the supervision of family and friends.

They are given a list of symptoms, the occurrence of which requires immediate return to the hospital:

• increasing headache;
• repeated vomiting;
• signs of fluid leakage from the nasal or ear canal, characteristic of liquorrhea.

Immediately after discharge, it is recommended to remain in bed and avoid physical and mental stress. A gentle regime is necessary for 1-2 days.

In case of a concussion, bed rest is mandatory.

To prevent the development of complications, you should avoid:

• heavy physical activity;
• playing sports;
• watching television programs;
• long periods of time at the computer;
• reading books;
• listening to music on headphones;
• drinking alcohol;
• smoking.

Relatives should monitor the condition of the injured person. In most cases, loved ones do not contact a neurologist to monitor their condition after discharge from the hospital. This kind of inattention is especially dangerous for children.

The negative consequences of injury can manifest themselves in the form of:

• periodic headaches, weakness;
• fatigue;
• deterioration in school performance;
• emotional lability: mood swings, aggressiveness, tearfulness.

To prevent complications, it is recommended to be examined regularly by a neurologist for a year after the injury.

Examination by a neurologist.

Classification of pathology

The disease occurs in three degrees of severity, which are divided into:

1. Mild form - passes without short-term loss of consciousness. The patient experiences spatial disorientation, cephalalgia, dizziness, and nausea. Symptoms are recorded within 20 minutes after the injury and can be supplemented by an increase in temperature up to 38 degrees. Subsequently, the signs of pathology spontaneously disappear and the condition stabilizes.
2. Moderate – the injury does not cause fainting and manifests itself with a standard clinical picture. Unlike a mild concussion, symptoms last more than 20 minutes, and the disease can provoke short-term memory loss. Retrograde amnesia is characterized by the absence of events that occurred a few minutes before the TBI.
3. Severe – manifested by short-term fainting. Events are erased from memory under the influence of retrograde amnesia, clinical signs of a concussion persist for several weeks. The condition is accompanied by sleep and appetite disturbances, nausea, problems with orientation in space, cephalgia, and fatigue.

First aid for concussion

1. If one or more symptoms are present, immediately call an ambulance or take the victim to a doctor.
2. Treat a wound on the head if it appears as a result of an impact.
3. For an hour or until the doctor arrives, it is important not to fall asleep, but to remain at rest.
4. If you lose consciousness, lay the person on his side, bend his knees, and put his hands under his head.
5. If symptoms of a concussion do not immediately appear, it is recommended to rest and not begin vigorous activity.

Sources of development of pathology

The root causes of the development of the disease are represented by a variety of TBIs that provoke a mechanical impact on the victim’s skull. Sources include:

• household;
• sports;
• production;
• road transport etiology.

A concussion is formed during falls, sudden deceleration or acceleration of movement, or contact with hard objects. A change in axial load becomes a source of disease.

Clinical signs

A pathological condition also occurs with minor head injuries, which requires special attention to the patient’s condition. Primary symptoms of a concussion include:

• disturbances in clarity of consciousness - the deviation disappears after a short period of time;
• attacks of dizziness - the symptom is present even at rest, intensifies when trying to tilt the head or move, the problem is associated with poor circulation in the vestibular region;
• pulsating cephalgia, extraneous noise in the ears;
• feeling of weakness, lethargy;
• vomiting or nausea - occurs once;
• incoherence of speech.

The patient notes pain in the eye, doubling of objects in the field of vision. The pathology provokes a fear of sunlight, even at the usual level, increased sensitivity to sounds, and disturbances in coordination of movements.

Diagnostics

To make a diagnosis, a number of examinations are carried out:

• medical history, neurological examination – obtaining initial information about the patient’s condition;
• MRI - allows you to detect swelling, hemorrhages, traumatic injuries;
• X-ray of the cervical spine - helps to detect or exclude fractures;
• checking the functioning of brain impulses.

If a concussion is suspected, a full medical examination is required to detect and prevent the development of complications caused by the injury.

A concussion can lead to the death of parts of the brain, damage to the inner ear, hemorrhages and fractures.

Determining the presence of a concussion

After suffering a trauma, it is necessary to determine whether consequences have arisen. Several methods are used at home:

1. A standard test is for the victim to close his eyes, move his arms to the sides and touch his nose with his index finger. Difficulties in completing the task appear even with minor injuries.
2. Additional – carried out with eyes closed and hands raised. The patient needs to walk in a straight line in this position. Disorientation is manifested by falling or deviating from the route.

The severity of symptoms depends on the severity of the injury. Major clinical signs may persist for up to 72 hours after TBI. The above symptoms are not always present in pathology. Traumatologists advise visiting a doctor and undergoing a full laboratory diagnostic examination to confirm the diagnosis.

Recommendations for the treatment of concussions

If hospitalization is not required, with the permission of a doctor, a mild concussion can be treated at home:

1. Bed rest and rest are required, no work. Long sleep is very important.
2. You cannot read, watch TV, play computer games or use gadgets.
3. Under no circumstances should you play sports.
4. You are allowed to listen to music, but not through headphones.
5. You can use herbal sedative drops or herbal infusions.
6. In your diet, you should give preference to dairy and plant products, limit salt intake - to prevent increased pressure, including intracranial pressure.

If the patient seeks medical help in a timely manner and all recommendations are followed, recovery will occur quickly and without complications.

Therapeutic methods

Regardless of the severity of the TBI, the patient needs professional help. The level of injury is determined in the hospital, with CT scans or fluoroscopy taken.

The acute phase of the disease requires sending the victim to the neurosurgical department. For a mild concussion, the patient is prescribed bed rest for 5 days, and the total time spent in the hospital is one week. The specified time is relevant only in the absence of associated complications.

At home, the patient continues therapy according to the doctor’s recommendations. He needs to avoid mental and physical stress and sleep more. The correct approach to treatment will allow you to avoid the consequences of a concussion and make a full recovery.

Attempts to ignore TBI and refusal of medical care are fraught with the development of various complications, deterioration of the general condition, problems with hearing, vision, and normal functioning of the brain. At the slightest sign of a concussion, the patient needs hospitalization and full rehabilitation therapy.

Brain contusion (concussion) - symptoms and treatment

A patient with suspected traumatic brain injury should receive medical attention as soon as possible. Since it is impossible to reverse brain damage resulting from trauma, treatment measures should be aimed at stabilizing the patient's condition and preventing secondary damage.

Conservative treatment of brain contusions

In the setting of traumatic illness, decreased or increased intracranial pressure, decreased blood oxygen saturation, high temperature, and increased blood glucose levels can have a detrimental effect on the brain. In this regard, the main directions of therapy for people with severe bruises are identified [4]:

• breathing support (ventilators, oxygen mask);
• correction of blood circulation and infusion therapy (medication);
• treatment of intracranial hypertension;
• neuroprotection - protection of neurons from damage, carried out with medications.

Basic therapy. For victims with severe TBI, an open airway is created by removing saliva, blood and vomit. Sedatives and muscle relaxants are used as needed (designed to relax muscles, block nerve impulses and reduce pain.). Correction of elevated body temperature is necessary (using antipyretic drugs and/or physical conditioning methods) [4].

The development of convulsive syndrome in persons with a brain contusion is considered dangerous and requires immediate response. Seizures are always accompanied by rapid intracranial hypertension, an increase in the volume of intracranial hematomas, increased oxygen consumption in the brain, its blood supply and increased cerebral edema [13]. Prophylactic use of anticonvulsants (according to multicenter studies) in people with TBI reduces the likelihood of seizures in the acute period, but does not reduce the risk of their occurrence in the long-term period.

All persons with a cerebral contusion require prevention of thromboembolic complications (deep vein rhombosis of the lower extremities and pulmonary embolism), which involves the use of compression stockings, increased physical activity and anticoagulant therapy whenever possible. Mortality in thrombosis of the veins of the lower extremities reaches 9-50% [7].

It is also necessary to control blood glucose levels and prevent complications from the gastrointestinal tract (stress ulcers, gastrointestinal bleeding). The main reason for the development of stress ulcers is the release of catecholamine hormones during injury, which are produced in response to stress, insufficient blood supply to the upper gastrointestinal tract and disruption of its self-regulation.

Respiratory support. Indications for respiratory support [3][10]:

• depression of the level of wakefulness to stupor or coma;
• lack of own breathing;
• acutely developed breathing rhythm disturbances, pathological type of breathing (Cheyne-Stokes, Kussmaul);
• tachypnea (rapid shallow breathing) more than 30 respiratory movements per minute;
• clinical signs of hypoxemia (lack of oxygen in the blood) and/or hypercapnia (excess carbon dioxide): partial pressure of oxygen in arterial blood (PaO2) less than 60 mm Hg. Art.; hemoglobin saturation with arterial blood oxygen (SaO2) is less than 90%; partial pressure of carbon dioxide in arterial blood (PaCO2) more than 55 mm Hg. Art.;
• status epilepticus (epileptic seizures do not stop for more than 30 minutes);
• maxillofacial trauma combined with trauma to the facial skeleton, cranio-orbital region (near the orbit and adjacent areas) and/or chest.

The main task of respiratory support is to maintain normal carbon dioxide tension (PaCO2 - 30-35 mm Hg) and the necessary oxygenation of blood in the arterial bed (PaO2 more than 100 mm Hg) [6][7].

If the duration of mechanical ventilation is more than 48 hours after the start of breathing support, a tracheostomy should be performed (an operation to create an external opening in the wall of the trachea to establish breathing). When a brain contusion is combined with trauma to the facial skeleton and chest, it is preferable to perform a tracheostomy immediately upon admission of the victim to the hospital [10].

Correction of blood circulation and infusion therapy. More than half of patients with a decrease in wakefulness to stupor and coma are in a state of dehydration upon admission to the hospital. Causes include bleeding, insufficient fluid intake, overheating, vomiting and/or diabetes insipidus. Performing adequate infusion therapy (intravenous administration of medicinal solutions and drugs using a dropper) makes it possible to achieve a normal total blood volume, normalize cardiac output and the delivery of blood and oxygen to the brain.

The injured brain is extremely sensitive to low blood pressure (below 90 mm Hg), which a healthy brain tolerates normally. Therefore, the management of patients with severe TBI involves maintaining blood pressure (BP should be at least 90 mm Hg), which is necessary for adequate brain perfusion (providing it with oxygen and glucose) in conditions of edema [4][5][6] [7][9]. However, aggressive attempts to maintain blood pressure using vasopressors (vasoconstrictors) should be avoided due to the risk of respiratory distress syndrome (pulmonary edema with difficulty breathing) and cerebral edema [4][7].

Treatment of intracranial hypertension. To select adequate treatment tactics, it is necessary to distinguish between intracranial and extracranial causes of high ICP. The former include intracranial hematomas, bruises, edema and/or cerebral ischemia, epileptic seizures, and meningitis. The second is a lack of oxygen supply, inadequate sedation or ventilation, impaired venous outflow from the cranial cavity, increased intrathoracic and intra-abdominal pressure [1][3]. All these reasons can accompany brain contusion.

Sedation and analgesia are first-line interventions for the treatment of intracranial hypertension [4][7]. The head of the bed must be raised by 30-40° to improve venous outflow from the cranial cavity. To treat increased intracranial pressure and protect the brain from secondary damage, craniocerebral hypothermia (lowering brain temperature) is used. It is sufficient to carry out moderate hypothermia (T = 30-31 °C) [1][4]. The use of hyperbaric oxygenation (saturation of the patient with oxygen under high pressure) is pathogenetically justified in persons with brain contusion, since this method increases the oxygen tension in arterial blood and improves oxygen saturation of the brain.

To reduce intra-abdominal pressure, drugs are used that improve intestinal motility and normalize the function of the gastrointestinal tract [4][6]. If intracranial hypertension is not responsive to drug therapy, decompressive craniotomy is indicated.

Neuroprotection. Currently, the use of neuroprotective drugs is a promising direction in the treatment of brain contusions [9]. Based on their mechanism of action, neuroprotectors are divided into several types:

• Calcium channel blockers (Nimodipine, Breinal, Dilceren, Nimopin, Nimotop). They reduce the entry of calcium ions into the cell, reduce the level of damage and death of nerve cells under the influence of neurotransmitters and prevent apoptosis (programmed cell death).
• Antioxidants and antihypoxants (Actovegin, polyethylene glycol superoxide dismutase, Solcoseryl, Neurox, Mexidol, Armadin, Cytoflavin, Neurocard, Astrox, Meksifin, tocopherol, Methostabil, ascorbic acid, Ascovit, Nootropil, Piracetam, Noocetam, Melatonin, Cavinton, Vinpocetine, Cohen winter Q10). These drugs are nitrogen synthase antagonists, they prevent the formation of free radicals, restore the activity of antioxidant enzymes, accelerate glycolysis (the process of glucose oxidation), increase resistance to hypoxia and improve cerebral blood flow.
• NMDA receptor antagonists (Memantine, Memantal, Memorel, Noodzheron, Akatinol, Memikar, Mirvedol, Memaneurin). Reduce the damaging effects of glutamate.
• Blockers of the inflammatory and immune response (Cycloferon, COX-2 inhibitors, CD11 and CD18 antibodies). Reduce the severity of the inflammatory reaction.
• Stabilizers of cell membranes: intermediate products of phosphatidylcholine synthesis (Recognan, citicoline, Ceraxon, Proneuro, Quinelle, Neuropol, Neurocholin, Noocil, Ceresil Canon), magnesium and potassium preparations (magnesium sulfate, Aspangin, Pamaton, Asparkam, Panaspar, Panangin).
• Drugs that improve synaptic transmission (precursors for acetylcholine synthesis - Cereton, Cerepro, Gleatser, Holitylin, Delecit, Gliatilin).
• Apoptosis blockers (caspase-3 inhibitors, calpain inhibitors).
• Drugs with a neuron-specific neurotrophic effect (Cortexin, Cerebrolysate, Cerebrolysin).
• Immunosuppressants (cyclosporine A). Suppress the immune response.

Nutrition for severe brain contusion . With serious damage, patients, as a rule, cannot eat on their own, so early nutritional support (i.e., the introduction of nutrients into the body) is necessary. Such support should match the patient's protein and energy needs. Basic energy metabolism in patients with severe brain contusion corresponds to 20-25 kcal/kg per day [4][6].

Surgical treatment of brain contusions

Some patients with severe traumatic brain injury are transported to the operating room after a head CT scan. The purpose of surgery for severe brain contusion is to remove massive intracranial hematomas or correct elevated ICP.

Not all patients with TBI require emergency intervention. Since the size of a brain contusion and the volume of an intracranial hematoma may increase during the first hours/days after injury, dynamic monitoring is recommended. Treatment of such patients is carried out in an intensive care unit. If neurological disorders increase or intracranial pressure increases (if an ICP monitoring sensor was installed), a control CT scan is performed. If a significant increase in the volume of the hematoma or displacement of the brain is diagnosed, the safest option will be surgical intervention to prevent brain death.

Before surgery, the hair over the affected area of ​​the brain is shaved. After cutting the scalp and removing the skin flap, the bone is cut out. The bone is removed and the underlying dura mater is opened with the utmost care. The doctor removes the hematoma or brain contusion. In the presence of severe cerebral edema, plastic surgery of the dura mater is performed using a patch from one’s own tissue or artificial replacement material. This is necessary to prevent further displacement of the brain. In such cases, the bone is not put back in its original place.

Before “closing” the wound, it is possible to install an ICP sensor if it has not been installed previously. Upon completion of the operation, the patient is transferred to the intensive care unit for intensive treatment measures aimed at combating cerebral edema and preventing infectious and thromboembolic complications.

Decompressive craniotomy is the most aggressive treatment for intracranial hypertension [3][9]. It is used when conservative therapy is ineffective. The main goal of decompressive trephination is to increase intracranial volume. As a result, the pressure in the cranial cavity is reduced and the blood supply to the brain is normalized.

Decompressive trepanation includes infratemporal and bifrontal decompression, temporal lobectomy and hemicraniectomy. They are carried out in cases of pronounced displacement of brain structures and persistent intracranial hypertension in patients with clinical and CT signs of brain compression.

Possible postoperative complications. In the long-term postoperative period of TBI, epilepsy is registered in 13% of patients, and post-traumatic hydrocephalus in 11% [3]. Post-traumatic epilepsy occurs due to the formation of a pathological focus in the brain. Post-traumatic hydrocephalus is caused by impaired circulation (formation of adhesions) and absorption of cerebrospinal fluid.