Craniocerebral trauma (CCT)
Craniocerebral trauma (CCT) is an injury to cranial bones and/or soft tissues (meninges, brain, nerves, vessels).
What is the cause of the disease?
The cause of the disease is hidden in its name – this is a mechanical injury, and according to the type of traumatic effect there are the following kinds of injuries: isolated, complex (trauma also affects other organs and systems) and combined (effect of mechanical energy together with thermal, chemical, etc.) CCT.
What types of CCT are known?
CCT can be classified the following way:
- closed trauma – this kind of injury does not affect the integrity of skin, sometimes there is damage to the head soft tissues without affecting aponeuroses, calvarial bones fractures without affecting adjacent soft tissues or basal skull fracture resulting in liquorrhea (cerebrospinal fluid leakage) and bleeding (ear or nose));
- open trauma – without affecting dura mater or affecting dura mater (in this case CCT is considered penetrating).
There are the following clinical forms of CCT: concussion, cerebral contusion (mild, moderate, severe), diffuse axonal injury and intracranial hemorrhage.
There are three periods in CCT, their duration changes depending on the clinical form: acute (from 2 to 10 weeks) , intermediate (from 2 to 6 months) and long-term in clinical recovery (to 2 years).
How is CCT manifested?
In concussion the integrity of cerebral tissue is not affected, but the connection between brain subdivisions can be lost for some time. Usually it is manifested in loss of consciousness of various levels and duration. After awakening a patient can suffer from vomiting, headache, nausea, dizziness, fatigue. There is a possibility of amnesia (memory loss),which goes away after a short period of time. Sweating, general fatigue and sleep disturbance are also possible. Usually all symptoms disappear after 1–2 weeks
Cerebral contusion can be mild, moderate and severe. Cerebral contusion is usually presented by long-term (from a few hours to a few weeks) loss of consciousness, memory loss and neurological symptoms. In mild contusions after wakening patients complain about headache, dizziness and nausea. Vomiting is also possible, sometimes repeated. Vital functions are usually intact. Moderate tachycardia (rapid heartbeat) or bradycardia (heart rate fall) and sometimes increased arterial pressure are observed. Body temperature and breathing do not change significantly. Usually neurological symptoms do away in 2–3 weeks. In severe injuries together with aggravation of the symptoms mentioned above neurological symptom are more advanced causing durable consequences: seizures, paralyses, speech disturbances, sensitive disorders. In critical conditions coma is possible.
Cerebral compression is caused by swelling, intracranial hemorrhage, bone impression after skull fracture. Rapidly intensifying neurological symptoms are a danger to patient’s life. Depending on severity of patient’s condition life-threatening consciousness, cardiac and respiratory disorders can develop. Diffuse axonal injury is associated with long-term coma – 2–3 weeks, respiration rate and rhythm disturbances, etc. Transition to persistent vegetative state that implies no self-consciousness, no consciousness of other people, no lucid repeated responses to external stimuli is common for this clinical form.
What is the treatment?
Treatment of patients with CCT is primarily symptomatic and focused on recovery and maintenance of normal conditions for the brain and prevention of secondary complications, for example seizures. In patients with CCT it is necessary to maintain normal arterial pressure and to exclude even short periods of hypotension (decreased arterial pressure). In adults average arterial pressure should be over 90 mm Hg.
In concussions, contusions, brain compressions the first medical aid should include immediate bed rest, respiratory control, the victim should be turned on the side to prevent from inhaling vomit. When transporting the patient should be positioned correctly – lying on his back with his cervical spine fixed.
Decision on further treatment is taken after identification of the type of injury. Excessive drug treatment is not used in brain concussions. The main purpose is to normalize brain function, relieve headache, provide for normal sleep. Various painkillers and sedatives are used for this purpose. Peptide products triggering internal pathological processes compensation mechanisms are also used. 5–7 days after CCT it is possible to start vascular therapy and to continue neurometabolic therapy for faster and more complete recovery and for prevention of different trauma consequences.
Bed rest is essential in cerebral contusions, its duration depends on severity of patient’s condition. Patients with severe CCT receive intensive care focused on decreasing intracranial pressure, maintenance of various parameters of the internal environment, fighting against complications related to internal organs. In case of seizures that can be observed in such patients anticonvulsant agents are prescribed. In some cases surgical intervention may be needed.
K. R. Badalyan
Department of Neurology, Faculty of Additional Professional Education
of Pirogov Russian National Research Medical
After treatment course is over the patient should stay under supervision of a physician, later repeated courses of neurometabolic and vascular therapy may be necessary from 2 to 4 times a year.
During at least 3 months after CCT the patients are not allowed to drink alcohol and to perform strenuous physical labor.
Apart from traditional treatment methods it is useful to receive a few courses of reflexotherapy (needle therapy), massage, physiotherapy (therapeutic exercises, hydrotherapy, etc.) that along with drug therapy can have a pronounced effect and contribute to more rapid recovery.
In general, all practical recommendations depend on CCT consequences. An injury to cervical spine soft tissues (cervical trauma) is very common in patients with CCT which is caused by excessive and sudden movements of the neck after hitting the skull. Cervical trauma can be associated with sprain of muscles, ligaments and joints of the spine, minor haemorrhage and swelling of muscles. These symptoms can occur immediately after the trauma or within a few days, a patient suffer from pain, restricted movements in cervical spine, headache, dizziness, tinnitus, lurching walk. A doctor can find a cause of these symptoms and after some examination (after cervical spine x-ray with functional tests in particular) he can advise a patient to consult a chiropractic and to wear a cervical collar within some time, prescribe non-steroid anti-inflammatory drugs, medicinal products relieving muscle spasms.
In long-term period psycho-emotional disorders are observed in patients with CCT. Marked asthenic syndrome (reduced productivity, rapid fatigue, general weakness, mood swings, tearfulness), mood disorders (anxiety, fear, depression) are common, autonomic dysfunction syndrome is also possible. In such cases it is recommended to administer anti-asthenic drugs focused on correction of these symptoms, sedatives can treat anxiety and fears. Different methods of relaxation, self-control that can be taught by a psychotherapist are also helpful. It is useful to be in the open air, to arrange your place of work properly, to take breaks every 1–1.5 hours. Restful sleep (at least 8–9 hours) is essential, a place of rest should be comfortable, a room should be aired frequently and cleaned regularly. Regular physical exercises and massage courses can also have a good effect in such cases.
In case of post-traumatic epilepsy a patient should be observed by an epileptologist; chronic administration of antiepileptic agents can be necessary in such cases.
Post-traumatic encephalopathy is also a common long-term complication of CCT. In such cases recommendations are similar to those in “Chronic brain ischemia” and “Encephalopathy”. Neurometabolic and vasoactive agents should be taken at least 2–4 times a year. Patients should eat food rich in vitamins and microelements, diverse, containing lots of proteins, polyunsaturated fats and complex carbohydrates.
In case of memory and focus disorders it is recommended to learn poems and text fragments by heart, to do crossword puzzles and to solve logic problems. It is convenient to make notes about important tasks and events.
In case of severe complications of CCT such as paralyses, marked dizziness, falls, etc., patient’s everyday life should be properly organized: furniture should be placed along the perimeter of the room so that nothing can prevent the patient from moving and be a threat if he falls down; floor coverings should be fixed. The patient should walk with support, if necessary, and wear comfortable shoes.
K. R. Badalyan
Department of Neurology, Faculty of Additional Professional Education
of Pirogov Russian National Research Medical
