Pathology of open cranial brain injury

2021-01-30 12:00 AM

The skull is broken, may have many pieces of skull embedded in the clinically recognized brain or X-ray. Often the skull is more extensive than soft tissue.


An open cerebral wound is a type of wound seen both during war and peacetime. But in the war, the proportion of war is higher (about 7-10% of all kinds of wounds caused by war).

Compared with closed cranial trauma, open cranial lesions are easier to diagnose when cerebrospinal fluid or cerebral organization protrudes through the wound. However, there are also cases that the most difficult to diagnose are the wounds that pass through the skull or open the sinuses. Management attitude is usually indicated for surgery.


According to the agent

Fire injuries are often caused by shrapnel and bombs. Bullet wounds are usually simple wounds but cause great damage and brain matter destroys and cerebrospinal fluid escapes, especially the shrapnel fragments often cause puncture wounds, injuring many organizations. The brain and blood vessels, small perforation of the skin and skull, often seal the cerebrospinal fluid and the blood cannot flow out easily causing a skull hematoma.

According to the anatomical location of the skull

The forehead, the apex, and the temporal region usually accounts for a high rate of 21-23%. The wounds in the posterior fossa and occipital region, the sinus wounds accounted for 1-5% had high mortality rates.

Classification by depth

Cerebral puncture wounds: Lesions that damage the skin, skull and sclera. A wound with only one hole and an object in the skull.

Trans-brain wounds: Are wounds that penetrate both walls of the skull, usually by bullets, the wound is often filled with cerebrospinal fluid, fragments of the skull lying out of the skin or sticking to the mucosa right away. love.

Tangential puncture wounds: Wounds where the path tangent to the skull can be caused by bullets or by slashing machetes.

The traumatic brain injury with the small sinuses: Usually the maxillary sinus, the frontal sinus, the sinus floor, the sinus cavity or the dominant sinus.

Cranial wounds connected to venous sinuses: Commonly the vertical and transverse sinuses. This type of wound is heavy, often severe patients have high mortality before, during and after surgery.

Open-brain infected cranial wounds: are late open cranial wounds, clearly visible brain organization shows necrotic wounds. The patient is in the condition of meningitis.

Pathological anatomy

Macroscopic can be seen from the outside to the inside of a typical open skull wound as follows:

The scalp is torn, sometimes there is a little brain organization attached to the hair that looks like a bean paste, has a mushroom shape in the middle of the wound, around it can be seen blood or cerebrospinal fluid.

The skull is broken, may have many pieces of skull embedded in the clinically recognized brain or X-ray. Often the skull is more extensive than soft tissue.

Perforated meninges can be rough or sharp depending on the agent.

The internal brain organization is crushed, oedema, if the wound comes late, there may be purulent niches inside or a crushed brain organization with scattered hematoma.



For open lobe cranial lesions according to the type of lesion as classified above and early or late admission to hospital, the local systemic symptoms and neurological signs differ.

If coming soon after being injured, the patient can be in anaesthesia for 10-15 minutes and then regains consciousness, the patient may or may not be paralyzed depending on the location of the wound. For this type of wounds often are bleeding cerebrospinal fluid or white brain tissue that has not yet been infected.

If arriving late, the patient usually has meningitis infection, high fever, stiff neck, pus wound on the site and pseudo membranes covering the brain organization are protruding. If the CSF is tested, leukocytes will also increase in the cerebrospinal fluid.

Examining and diagnosing a patient with open traumatic brain injury involves the following steps:

Exam of the skull

Hair should be shaved to make it easier to examine and determine the location and size of the wound. It is necessary to determine the extent of skull injury, the degree of damage with brain matter and cerebrospinal fluid protruding through the wound, absolutely not using probes to diagnose open cranial wounds because it will cause further damage to the nests. brain function and infection.

Neurological examination

Need to examine the state of consciousness, main nerve function.

Perceptual examination: Need to accurately assess the Glasgow-scale coma.

Examination of nerve functions:

Motor examination to see if the patient is paralyzed: Doing tests on Baree hands, Baree feet, Mingazigni from which to determine the degree of disturbance of the motor system or polio.

Examining the sensation for a disturbance of the delicate tactile depths.

So should examine the feeling of pain.

A quadriplegic tendon reflex exam compares both sides and determines which side has an increase or decrease in change.

Examination of cranial nerves: Examining all nerves in the acute stage is difficult, so only some major nerves such as II, III, IV, VI are examined.


X-ray is an accurate diagnostic tool that clearly shows the location and image of skull damage and the size and position of fragments of bone to help remove these bone samples thoroughly. X-rays also show the size and location of the foreign bodies in the skull.

For computed tomography, in addition to detecting damage of bone structure, sinus structure, foreign objects in the skull have contrast properties, it also shows clear images of brain pounding, hematoma, oedema of cerebral parenchyma or foci of abscess in late open cranial wounds.

Progression of cranial wounds

Through the following stages:

Stage 1: The acute phase, the first 3 days after injury, can have the following complications: respiratory and cardiovascular disorders, traumatic shock and blood loss, brain compression due to intracranial hematoma.

Stage 2: Early complications, this phase lasts from day 3 to the end of the first month after injury, the patient gradually recovers from coma and shows signs of focal nerve damage. .

Stage 3: The intermediate phase, gradually reducing early complications, this phase lasts from 2 to 6 months, the patient recovers gradually, gradually reducing the early complications, recuperate.

Stage 4: Late complications, from 6 months to 2 years, at this stage may encounter some complications such as cerebral abscess, skull inflammation, cerebrospinal fluid.

Stage 5: The sequelae phase, lasting from the second year onwards, restores the nerve functions, leaving only the physical sequelae of the brain.

The principles of treatment


Open cranial wound is indicated for surgery, surgery as soon as possible. However, if the traumatic brain injury has brain protruding much or shows brain stem damage, the victim is in a state of lethargy, respiratory and cardiovascular disorders need to resuscitate before surgery. Management of an open cranial wound: remove the broken bones and crush the brain, remove the foreign bodies if possible, and then turn the open cranial wound into a closed inside out. There are instances where a piece of gas or foreign object is deep in the base of the skull such as a marble fragment if the patient is awake and the wound stops bleeding on its own, emergency surgery may not be needed.

First aid and first aid

Some points should be noted as follows:

To monitor the patient's perception, if the patient is gradually comatose or has a certain amount of consciousness, it is necessary to have further diagnostic imaging steps to monitor for brain compression usually caused by hematoma or cerebral oedema. emergency.

It is necessary to give antibiotics to inject or drink at high doses to avoid meningitis and to use early to limit the stain on the wound and brain.

If the patient has dyspnoea with dyspnoea, the endotracheal intubation may be required, depending on the circumstances of each ventilation site.

Exercises to explore the wound with tools, using strong antiseptics such as iodine are not recommended.


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