Head Surgery – FAQs

Head injury is a general term used to describe any trauma to the head, and most specifically to the brain itself.

• Skull fracture: A break in the bone surrounding the brain and other structures within the skull.
  • Linear skull fracture: Common in children. It is a simple break in the skull that follows a relatively straight line which can occur after minor head injuries (falls, blows such as being struck by a rock, stick, or other object; or from motor vehicle accidents).
  • Depressed skull fractures: These are common after forceful impact by blunt objects which cause “dents” in the skull—most commonly, ammers, rocks, or other heavy but fairly small objects. If the depth of a depressed fracture is at least equal to the thickness of the surrounding skull bone (about 1/4-1/2 inch), surgery is often required to elevate the bony pieces, to remove dirt and other debris and to inspect the brain and its coverings for evidence of injury.
  • Basilar skull fracture: A fracture of the bones that form the base (floor) of the skull and results from severe blunt head trauma of significant force. It commonly connects to the sinus air cavities. This connection may allow CSF fluid to leak through the nose or ears and allow for air and bacteria to enter into the inside of the skull and may cause infection. Surgery is usually not necessary unless other injuries are also involved or for persistent CSF leak.
• Intracranial (inside the skull) hemorrhage (bleeding)
  • Subdural hematoma: It is the bleeding between the brain tissue and the dura mater (a tough fibrous layer of tissue between the brain and skull). The stretching and tearing of “bridging veins” between the brain and dura mater causes this type of bleeding. It may be acute, developing suddenly after the injury, or chronic, slowly accumulating after injury. They are potentially serious and often require surgery.
  • Epidural hematoma: It is the bleeding between the dura mater and the skull bone. These occur when arteries are injured after skull fractures PFE (Neuro) # 86 particularly after injury in the temple area. It is potentially serious and often requires surgery.
  • Intraparenchymal hemorrhage/cerebral contusion: It is the bleeding into the brain tissue itself. A contusion is like a bruise to the brain tissue and usually requires close observation in hospital for increase in size over time. An intraparenchymal hemorrhage is a pool of blood within the brain tissue. Minor bleeding may stop without any surgical treatment. More serious or large bleeds usually require intracranial pressure monitoring and surgery.
• Closed head injuries:It is an injury to the brain or structures within the skull that are not caused by a penetrating injury (such as a gunshot wound or stab wound). They range from very minor to potentially fatal injuries.

• Penetrating trauma: Missiles such as bullets or sharp instruments (also knives,screwdrivers, ice picks) may penetrate the skull. This often require surgery toremove debris from the brain tissue. The initial injury itself may cause immediatedeath, especially if from a high-energy missile such as a bullet.
• Blunt head trauma: These injuries may be from direct blow (a club or large missile) or from a rapid deceleration force (a fall or striking the windshield in a car accident).

• Minor blunt head injuries may involve only symptoms of brief loss of consciousness. They may result in headaches or blurring of vision or nausea and vomiting.
• Severe blunt head trauma involves a loss of consciousness lasting from several minutes to many days or longer. Seizures may result. The person may suffer from severe and sometimes permanent neurological deficits like paralysis, seizures, PFE (Neuro) # 86 difficulty in speaking, seeing, hearing, walking, or understanding or may even die.
• Penetrating trauma may cause immediate, severe symptoms or only minor symptoms despite a potentially life-threatening injury. Death may follow from the initial injury.

• Severe head trauma or a fall from more than the height of the person or a hard fall onto a hard surface or object
• Loss of consciousness for more than 1 minute, vomiting more than once, confusion, drowsiness, weakness or inability to walk, or severe headache
• Prevent movement of the neck in severe head injury or if the injured person has any neck pain. If the person needs to vomit, carefully roll them onto their side without turning the head.
• Should an injured person be allowed to fall asleep? Many people mistakenly believe that it is important to keep a person awake after they have been struck on the head.
• You do not need to keep a head injury victim awake. In many cases it is even helpful to the emergency doctor to be able to awaken a person who is now calm and rested and able to behave normally. This gives the doctor a much better assessment of the severity of the head injury.
• If a person who was initially normal after a head injury cannot be awakened or is extremely difficult to awaken, he or she may have a more serious head injury and should be evaluated by a doctor.

• The physical examination and the history of the exact details of the injury, the person’s past medical history, and the symptoms are often the most important information the doctor uses to make treatment decisions.
• Skull x-rays to look for any fracture or penetrating injuries is important. The fracture itself will seldom need treatment, but an underlying brain injury may.
• It may be easier to see where foreign bodies are located and how many there are with a regular x-ray than with a CT scan.
• One reason for doctors to order skull x-rays for a child is in anticipation of a possible leptomeningeal cyst. Also known as growing skull fractures, this is a rare complication of skull fracture seen in children younger than 3 years. It occurs when a skull fracture fails to heal properly. Six or more months after the initial injury, the fracture may begin to widen instead of healing. Usually parents will notice swelling, which gradually increases in size. This is not predictable or preventable but should be treated by a neurosurgeon if it occurs. Swelling or masses noted in the first few weeks to months after a head injury in children are referred to as a “pseudo-growing fracture.” They do not need treatment and will go away on their own but should be brought to your pediatrician‘s attention so it can be watched.
• CT scan is the test used most often to evaluate acute head injuries. Even small spots of blood may be seen as little white dots.
• MRI scans are also used for additional information about a brain and spine injury.
• In some cases of bleeding in or around the brain, angiography may be performed to visualize the blood vessels which involve injecting dye into the arteries of the head. X-rays are taken that show the blood vessels and may show exactly where bleeding is occurring. In some cases it is possible to stop the bleeding following angiography. This involves injecting special materials, which are released into the bleeding blood vessel and cause a clot to form.
• Other x-rays and lab tests may be performed to look for other illnesses or injuries. For example, neck injuries are common in people with severe head trauma. Spine x-rays are usually ordered before the head is moved if there is any neck pain or other symptoms of a neck injury. In a car accident, there may also be chest or abdominal injuries.

• Bleeding under the scalp, but outside the skull, creates “goose eggs” or large bruises at the site of a head injury. They will go away on their own wit time. Using ice immediately after the trauma may help decrease their size and ice should be applied for 20-30 minutes at a time and can be repeated about every 2-4 hours as needed. There is little benefit after 24 hours.
• When a minor head injury results from a fall onto carpet or other soft surface and the height of the fall is less than the height of the person who fell and there is no loss of consciousness, a doctor’s visit is not usually needed. Apply ice to lessen swelling.

• • Minor head injuries are often treated at home as long as someone is available to watch the person.
    • Bed rest, fluids, and a mild pain reliever such as acetaminophen may be prescribed. Ice may be applied to the scalp for pain relief and to decrease swelling.
    • Cuts will be numbed with a medication usually given by injection. They will then be cleansed. The doctor will then look for foreign matter and hidden injuries. The wound usually is closed with skin staples, stitches (sutures), or special skin glue. An immunization to prevent tetanus will be given if needed.
  • People with serious closed head injuries are always admitted to the hospital for observation and repeated studies to assure that the condition does not worsen.
    • Occasionally a head injury may cause elevated pressure within the skull. An intracranial pressure (ICP) monitor probe may be surgically inserted into the brain through the skull to measure the pressure. If the pressure rises too high, it may be necessary to do surgery to decompress the brain. Death is possible.
    • Medication to prevent seizures may be given to prevent or treat seizures that occur from the head injury.
    • Antibiotics are usually not required in closed head injuries.

• • When there is a closed head injury with bleeding inside the skull or penetrating head injuries, the doctor must consider the location of the bleeding, severity of the symptoms, any other injuries, and progression of symptoms. Surgery may be needed along with antibiotics to prevent infection and a breathing tube inserted (intubation) to help prevent further brain injury. Angiography may be performed.

• Wearing helmets when bike riding, inline skating, driving motorcycles, and other similar activities.
• Safety belts, car seats, and airbags when used properly can prevent head injuries in motor vehicle accidents.
• Drinking while driving should be avoided strictly.
• Fall-proofing includes checking your home for areas where someone may fall: stairs, bathtubs, throw rugs, and furniture.

Prognosis varies and depends on the severity of the injury. It is now commonly recognized that even minor head injuries can have long-term consequences (usually psychological or learning disabilities). Serious head injuries can result in anything from full recovery to death or a permanent coma.