By Tedler D. Depaynos, MD
The patient is a taxi driver but because of the quarantine he was forced to stay at home. To keep himself busy, he started extending the roofing of his garage. While doing something at the floor, an iron bar which he placed temporarily at the ceiling suddenly fell down hitting his head. It was good that his daughter playing beside him was not hit.
He did not lose consciousness but the pain that followed made him give up what he was doing. There was no laceration but swelling with hematoma of the scalp was palpated. It was incidental that some town mates dropped by the following day after delivering some vegetables who advised him to do some “native rites” so that it would not be repeated. He was not so keen in following the suggestion because bottled alcoholized water was not available at that moment and the rites would then not be complete. Just to feed his visitors, however, he let them butcher with murmuring prayers two of the roosters he was raising on his backyard.
He eventually recovered from the pain and the swelling apparently subsided but he claimed that during the night when the weather was cold he experienced headaches. The headache was tolerable but it made him uncomfortable. During day time when the weather is “hot” his headache recurs and sometimes accompanied by a “little dizziness”. When he related this to a colleague driver who was also a neighbor, he was advised to undergo a CT Scan.
Due to the Covid 19 precautions at that time, the doctor’s clinics at the hospital were still closed so that he was not able to see his private MD. He was seen, however, at the emergency room and was interviewed why he needed a CT Scan and not a plain x-ray of the skull. He just related what he felt and that it was just an advice of a neighbor. Nevertheless, the resident MD examined him and felt a “skull depression” at the site of injury which appeared to be deep. This was confirmed by a plain x-ray and although no neurological deficits were obtained it is possible that the depression reached his brain tissues and caused swelling or even bleeding resulting in the “attacks” of his headaches. Hence, a CT Scan was done.
In treating head traumas, the layers of the head basically are always taken into consideration in the analysis of injuries. Outside the skull is the scalp which is very vascular but any injury in this layer is easily treated. There could be contusion, hematoma which are usually just observed or even lacerations which could be sutured. Since this is a very vascular layer, even small lacerations may cause bleeding that may appear profuse and may cause shock reactions not only from the patient but from observers. This explained the swelling and hematoma the patient incurred. He was lucky that there was no laceration.
Fractures of the skull may occur and diagnosis is usually confirmed by skull x-rays. Most of the time, nothing is done especially if the fractures are not exposed (open) or even depressed but not deep enough to compress the brain. The exposed fracture is just cleaned and the wound sutured. Depressed fractures are carefully assessed and if the brain is compromised elevation is done. Fractures may imply the severity of the injury although in many instances, there may be no fracture but the brain incurred severe injury. Hence, aside from a thorough neuro exam, a CT Scan is now routinely done to determine other injuries.
The brain is in a closed space limited by the skull. Jarring then of the brain when traumatized may cause injury on both sides. The least serious is cerebral concussion. There is no evident anatomical injury. There is just a sudden physiologic cessation of function which would make the patient unconscious. This is likened to the unplugging of a home appliance briefly and classical examples are those experienced by boxers who were knocked down but recovered within 10 seconds. Clinically, patients with cerebral concussion should not lose consciousness for more than 5 minutes. To observe for further injuries, however, those patients are advised admission in the hospital for at least 24 hours.
In cerebral contusion, there is apparent loss of consciousness for at least 5 minutes and retrograde amnesia may be evident. These patients may not remember the events before they got unconscious. There could be swelling of the brain tissues with compression of the tiny blood vessels causing destructions of some brain cells on both sides depending on the intensity of the trauma. Peak of swelling is usually on the 3rd day so that neurological deficits may become more obvious or worsened during that time. With time the swelling may subside but brain cells may be destroyed. Luckily, the human brain is packed with super plenty of brain cells so that the resulting neurological deficits may be taken care of by other healthy ones in minor cases resulting in clinical recovery even if partially. Patients are routinely advised admission for at least 72 hours for observation.
Worst scenario is bleeding inside the skull. In general, this is classified as bleeding above the covering of the brain called dura (epidural) and bleeding below the dura (subdural) or within the brain itself (intracerebral). Those above the dura are usually coming from arteries and those below are from veins. Hence, the former is more acute because of fast bleeding and the latter usually chronic and insidious because of slow bleeding. With the free accumulation of blood within the closed skull space, brain compression may occur. The manifestations depend on the amount of blood accumulated and the site of brain mainly compressed.
With fast compression due to arterial bleeding, the patient loses consciousness fast and if not immediately relieved, the patient may expire. Unlike in venous bleeding, the accumulation is a slow process and signs of brain compression may occur after weeks, months or even years. In those cases they may be mistaken as brain tumors, when actually they are just slow accumulation of blood but enlarged suddenly when they absorbed water. In both cases surgery is a must, the former on emergency basis and the later as soon as diagnosed.
Patients usually equate skull fracture to head injury. They forget to consider the brain itself. Luckily the bleeding in the brain tissue is usually from small blood vessels. Since blood is admixed with the brain, it cannot be drained except in few instances where the accumulation is localized and large. In many cases, the surgical drainage may cause more brain damage because of an inaccessible location so that mere supportive treatment is given.
X-rays of the skull will just show a picture of the bones and not the brain. To know specific injuries to the brain, a CT scan is a must and this may be repeated or done in a series to monitor the progress of the patient. Foremost, however, is close physical monitoring.
Although there was a depressed fracture in this patient, he had no history of loss of consciousness. The brain was not hurt so much but the CT Scan revealed a very minimal bleeding. Swelling just like the edema in the scalp may have already subsided when he sought consultation. Surgery was not advised then and since the accident happened several weeks earlier, the patient was prescribed medications and was advised to return for follow-up especially if his headaches would worsen.
He was much relieved while driving home because nothing serious occurred. He was silently thankful to his town mates and was thinking that his headache may be due to the incomplete “native rites”. **
