There are three types of injuries generally falling under the category of craniocerebral traumas (or traumatic head and brain injuries). These are:

• Soft tissue injury involving the scalp

• Skull injury - fractures

• Brain injury

Soft tissue injuries are represented by a variety of wounds (lacerations, contusions, or incisions) usually treated by a surgeon in the emergency room. Patients are usually not hospitalized and are discharged after their wounds have been sutured (and are revaccinated against tetanus if needed).

Skull fractures include the so-called linear fractures which are detectable on CT scans. These pose no threat to patients but require a short hospitalization and the administration of antibiotics to prevent potential infections (meningitis or encephalitis). Another type of skull fracture is significantly more serious depressed or comminuted fracture. Such fracture is caused by objects of small mass and high velocity striking or impacting the head. These fractures may also result in brain injury. The treatment is surgical and patients are hospitalized in all cases. A surgeon performs elevation of the skull fracture (elevation of the depressed fragments into original position) and removes skull fragments in case of multi-fragmentary fractures. The dura mater must be checked because it may have been lacerated by the fracture. If so, it is sutured back together and antibiotics are administered. The third and most serious type of skull fractures are skull base fractures. Skull base fractures often lead to damage of blood vessels that enter the brain through holes in the skull base (e.g. the most important cerebral artery – the carotid artery) and can also impair cranial nerves passing through the area (e.g. optical nerve, facial nerve, oculomotor nerves). They can also cause cerebrospinal fluid leakage either from the nose or ears. All these fractures can have serious consequences including death (especially when the carotid artery is damaged). The treatment of these fractures is either surgical or conservative and it is always necessary to administer antibiotics to prevent possible infections.

Brain injury is classified from several points of view. The most important aspect is the state of consciousness of a patient after an injury and tests performed in the emergency room. Conscious patients verbally communicate and respond to a series of commands (e.g. they lift their arms or open their eyes on the physician’s command). Injured patients are often disoriented or have a partial memory loss (they cannot recall the injury, what followed, which day it is or where they are at). This type of injury is usually known as concussion. Patients are examined by a neurologist and shortly hospitalized to rule out other injuries which may become evident later (such as brain hemorrhage). Unconscious patients do not respond when they are verbally addressed and do not breathe on their own. They require breathing support and must be hospitalized in specialized departments (intensive care unit). CT (computed tomography) scan is performed immediately in all these patients to determine the cause of their unconsciousness. A direct injury of the brain tissue, the so-called diffuse axonal injury, is usually caused by traumatic shearing forces when the head is rapidly accelerated or decelarated as occurs in car accidents. The major cause of damage is the disruption of axons responsible for neural processes. Thus, the damage of these cells leads to a very serious condition which often results in death or a long-term coma. The prognosis of patients and the severity of an injury depend on the mass of damaged axons; the more axons damaged, the worse the prognosis. Surgical treatment is not a solution for this type of injury because CT scan does not indicate any pathological finding that requires a surgery. A second type of diffuse injury is a post-traumatic cerebral edema (swelling) which has similar CT results. When neural cells are damaged, they start to swell due to the suffered trauma and cannot perform neural activity. This type of injury is also very serious, cannot be treated surgically and the prognosis of patients depends on whether it is possible to quickly reduce the amount of swelling. The treatment of both these types of brain injury (diffuse axonal injury and cerebral edema) consists of drug-induced sleep, ventilation support and administration of medication which reduces the swelling of the brain (e.g. manitol).

Another type of injury in patients with loss of consciousness is post-traumatic hematoma usually caused by a rapid direct hit on the head. There are two main types of post-traumatic hematomas. The first type is a bleeding between the dura mater (a hard membrane enveloping the brain) and the skull. This bleeding is caused by a damaged artery supplying the dura which is usually the result of a skull fracture. This type of bleeding is called an acute epidural hematoma and the treatment consists of neurosurgical evacuation of the hematoma. The hematoma presses on the brain but brain tissue usually remains undamaged and that is why patients are expected to make a good outcome if a surgery quickly follows. The second type of post-traumatic bleeding is the so-called acute subdural hematoma. This bleeding usually results from tears in brain arteries between the dura mater and the brain. This injury is often accompanied with the so-called cerebral contusion. As opposed to an epidural hematoma, a subdural bleeding is much more severe (given the degree of direct brain damage) and patients’ prognosis is significantly worse even when the hematoma is evacuated. About one third of patients who remain unconscious despite all methods of treatment including surgery, die and another third remains permanently institutionalized. Only about one third of patients completely recover but, still, some have permanent deficits – changes in behavior, memory disorders or partial paralysis. The last type of brain injury is the so-called chronic subdural hematoma. In contrast to acute hematoma, chronic subdural hematoma is caused by a damaged vein connecting the brain surface with the dura and can be caused by even a minor head injury. The bleeding is slow and thus the symptoms of intracranial pressure often manifest as much as several weeks after the injury. Patients are conscious but usually have an impaired movement in extremities on one side of the body. The treatment is surgical and includes evacuation of the hematoma with a catheter and draining of the subdural space through a hole drilled in the skull. Once the hematoma is evacuated, the prognosis is good.