Written by epgonline.org - Last updated 29 May 2018
Intracranial (head) injuries are a common reason for presentation to emergency services. Globally, the scale is hard to quantify, with some estimations suggesting 42 million present to services annually; in the United Kingdom it accounts for approximately 1.2 million annual visits to emergency care. The majority of these are minor, and do not require any intervention or further assessment. However, head injury does account for significant levels of morbidity and mortality, and is the most common cause of death and disability in people aged under 40 years in the UK.
The elderly are a particularly susceptible group – more friable bones, cerebral atrophy, and medications that inhibit coagulation all mean that they are particularly at risk of serious intracranial injury. The other large affected cohort are children and adolescents; 33–55% of head injuries in Britain are accounted for by people under 15 years old.
This section covers all injuries to the cranium, and includes brain, vascular and cranial nerve injuries.
Several types of brain injury exist, and can be divided into focal and diffuse injuries. Concussion (or mild traumatic brain injury) is the most common of the diffuse injuries, yet relatively little is known about the mechanism – aside from evidence that axonal stretching is one component. Concussion in contact sport has gained greater recognition in recent years; increasing emphasis is being paced on identifying those at risk, alongside awareness of long-term sequelae.
Cerebral contusions are focal, and often cause symptoms that relate directly to the damaged area of brain tissue. Traumatic subarachnoid, subdural and extradural haemorrhages have different mechanisms of disease, and may present in entirely different ways following a head injury. The area of the brain that is affected by bleeding also dictates the likely damaged vessels, and the speed of progression of symptoms.
The management of intracranial injuries is variable, reflecting the spectrum of injuries. Monitoring Glasgow Coma Score (GCS) is a core component, and deteriorating GCS is a red flag sign. CT is the imaging modality of choice in the acute setting; guidelines vary with age group, but are dependent on GCS, clinical suspicion of a skull fracture, any evidence of focal neurology, or global signs consistent with raised intracranial pressure or brain injury, such as persistent vomiting or seizure. In the elderly, any history of altered coagulation, including medication related, warrants careful consideration.