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A Medicolegal View of Head Trauma Complications

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A Medicolegal View of Head Trauma Complications A MEDICOLEGAL VIEW OF HEAD TRAUMA COMPLICATIONS Thesis Submitted for full fulfillment of M.D. Degree in Forensic Medicine and Clinical Toxicology By Ahmed Ibrahim Mohammed Ewis Forensic medicine Society - Beni Suef Government- Ministry of Justice M.Sc.in forensic medicine and clinical toxicology Under supervision of Prof. Mervate Hamdy Abd El Salam Professor of Forensic Medicine and Clinical Toxicology Faculty of Medicine - Cairo University Prof. Abla Abd El Rahman Ali Assistant Professor of Forensic Medicine and Clinical Toxicology Faculty of Medicine - Cairo University Prof. Amany Salah Mohammed Assistant Professor of Forensic Medicine and Clinical Toxicology Faculty of Medicine - Cairo University Dr. Mohammed Adly Mohammed Lecturer of Forensic Medicine and Clinical Toxicology Faculty of Medicine - Cairo University Faculty of Medicine Cairo University 2012 Acknowledgment First of all thanks to Allah With the deepest feeling of gratitude , I would like to express my appreciation to Prof.Dr. Usama Ibrahim El-Barrany. Prof. and Head of forensic medicine and toxicology department, Faculty of medicine, Cairo University, for his continuous support and encouragement. I am deeply indebted to Prof. Dr.Mervate Hamdy Abd El- Salam. Prof. of forensic and toxicology for her unlimited help, meticulous supervision and sincere supervision during the preparation of this work which are above all commentaries. My sincere thanks and gratitude to Prof.Dr.Abla Abd El- Rahman Ali. Prof. of forensic and toxicology for her great support, valuable suggestions and encouragement. I would like to express my deepest gratitude to Prof. Dr.Amany Salah Mohammed. Prof.of forensic and toxicology, for her grateful effort, help guidance, valuable assistance and guidance throughout this work. I would like to present my sincere thanks to Dr. Mohammed Adly Mohammed. Lecturer of forensic and toxicology, for his great support and encouragement. I am deeply indebted to Prof. Dr. Dina Shokry. Prof. of forensic and toxicology, for her kind care, close supervision and her worthy remarks are beyond my words of thanks. My abundant thanks and gratitude to Prof. Dr. Aly Gamal El-Din Abd El- Aal. Prof. of forensic and toxicology, for his kind care, for his continuous support and encouragement. I would like to present my great thanks to Faculty of Medicine- Cairo university (Kasr El Aini hospital), Faculty of Medicine of Beni Suef University, General hospital of Beni Suef, Psychiatry hospital of Beni Suef, Al Eman center of radiology at Beni Suef and hospital of Ophthalmology of Beni Suef. I am deeply indebted to all my professors and colleagues in the forensic and toxicology department, Faculty of medicine, Cairo university, for their constructive guidance, effective help and enthusiastic cooperation. Table of Contents Topic Page List of Abbreviations I List of Tables II List of Figures III-IV List of Charts V Abstract VI Introduction and Aim of the work (1-2) Review of literature: - Chapter –I: Anatomy of Head (3-15) - Chapter – II: Anatomy of Cranial Nerves. (16-22) - Chapter – III: Pathology of Head Injury (23-40) - Chapter – IV: Complications of Head Trauma (41-56) Subjects and Methods (57- 72) Results and figures of investigations (73-114) Discussion (115- 122) Summary, Conclusions and Recommendations (123- 133) References (134- 152) )0-5( انمهخص انعربي Arabic Summary List of abbreviations CSF Cerebrospinal fluid LOC Loss of consciousness duration CN I Olfactory nerve SIADH Syndrome of inappropriate antidiuretic hormone CN II Optic nerve CSW Cerebral salt wasting CN III Oculomotor nerve DI Diabetes insipidus CN IV Trochlear nerve AH Anterior hypopituitarism CN V Trigeminal nerve PAI Primary adrenal insufficiency CN VI Abducent nerve GRH Gonadotropin-releasing hormone CN VII Facial nerve LH Luteinizing hormone CN VIII Vestibulocochlear nerve FSH Follicular stimulating hormone CN X Vagus nerve ANS Autonomic nervous system CN XI Spinal accessory nerve PTM Post-traumatic meningitis CN XII Hypoglossal nerve UMNL Upper motor neurone lesion TBI Traumatic Brain Injury LMNL Lower motor neurone lesion MVCs Motor Vehicle Collisions ENG Electronystagmography SDH Subdural haematoma MRA Magnetic resonance Angiography ICP Intracranial pressure IQ Intelligence quotient ASDH Acute subdural hematoma Hge. Haemorrhages SAH Subarachnoid haemorrhage Fig. Figure ICH Intracerebral haemorrhage Isol. Isolated IVH Intraventricular haemorrhage PCS Post-concussion syndrome DAI Diffuse axonal injury ICU Intensive care unit aPTT activated partial thromboplastin Freq. Frequency time PT Prothrombin time M Motor complication CBC Complete blood count Cn Cranial nerves affection ABG Arterial blood gases E Epilepsy IV Intravenous C Cognitive complications CT Computerized tomography S Sensory complications MRI Magnetic resonance image Au Autonomic disturbance CBF Cerebral blood flow HBO Hyperbaric oxygen PTE Posttraumatic epilepsy SIADH Syndrome of inappropriate antidiuretic hormone PTA Post-traumatic amnesia CSW Cerebral salt wasting GCS Glasgow Coma Scale DI Diabetes insipidus PVS Permanent Vegetative State AH Anterior hypopituitarism VS Vegetative State PAI Primary adrenal insufficiency PTSD Post-traumatic stress disorder GRH Gonadotropin-releasing hormone CRF Corticotropin-releasing factor LH Luteinizing hormone HPA Hypothalamic-pituitary-adrenal FSH Follicular stimulating hormone axis Isol. Isolated Cn Cranial nerves affection PCS Post-concussion syndrome E Epilepsy ICU Intensive care unit C Cognitive complications Freq. Frequency S Sensory complications M Motor complication Au Autonomic disturbance I List of tables No of Topic of table page table 1 Glasgow Coma Scale 37 2 Levels of TBI severity 42 3 TBI severity using PTA alone 42 4 Head trauma types within different age groups (years) 87 5 Severity of head trauma regarding to consciousness level (GCS) and death incidence within 89 different age groups (years) 6 Head trauma regarding to open or closed within different age groups (years) 91 7 Head trauma types within gender 93 8 Head trauma severity regarding to conscious level (GCS) and death incidence within gender 95 9 Head trauma types regarding to open or closed within gender 97 10 Head trauma sequelae within gender 99 11 Head trauma severity regarding to conscious level (GCS) and death incidence within different 101 types of head trauma 12 Sequelae of head trauma within different age groups (years) 103 13 Sequelae head trauma within types of head trauma 105 14 Head trauma severity regarding to conscious level (GCS) and death incidence within different 107 sequelae of head trauma 15 Head trauma regarding to open or closed with sequelae of head trauma 109 II List of figures No of Topic of figure page figure 1 Layers of head (cross section) 49 2 Anterior view of skull 49 3 Lateral view of skull 50 4 Skull base (external view) 50 5 Skull base (internal view) 51 Anatomy of meninges 51ِ 6 7 Anatomy of the brain (external view) 52 8 Brain stem (anteroinferior view) 52 9 Longitudinal section of brain 53 10 Longitudinal section of brain (ventricules) 53 11 Anatomy of cranial nerve nuclei 54 12 Plain x- ray (anteroposterior view) shows depressed fracture with radiating fractures, at onset of trauma. 13 Plain x-ray (anteroposterior view) shows comminuted depressed fractures at left temporal and parietal bone with numerous skull fracture radiating from it, at onset of trauma. 14 Plain x-ray (anteroposterior view) shows inlet of firearm shots at occipital bone with distribution of shots allover brain, at onset of trauma. 15 Plain x ray shows two firearm bullets inside skull, at onset of trauma. 16 CT scan with 3 dimensions reveals depressed fractures of skull vertex with extension of fissure fractures into parietals bilaterally, at onset of trauma. 17 CT scan with 3 dimensions reveal depressed fracture with bone loss at left parietal with brain contusion, at onset of trauma. 18 CT scan reveals depressed fracture of right frontal bone, at onset of trauma. 19 CT scan (A, B) reveal depressed comminuted fracture of right parietal bone with right parietal lobe contusion and laceration, at onset of trauma. 20 CT scan reveals huge extradural hge. at left temproparietal area with right shift of midline, at onset of trauma. 21 MRI shows huge extradural hge at left temproparietal III area compressing left lateral ventricle, at onset of trauma. 22 CT scan (A,B) show tunnel fracture (tangential single bullet) of left temporal and parietal bones, loss of bones,comminuted depressed fractures with extradural haemorrhage and left temporal and parietal lobes contusions, at onset of trauma. 23 MRI shows subgaleal calcified haematoma, after 6 months of trauma. 24 MRI reveals prominent ventricular system, after 6 months of trauma. 25 CT scan reveals bilateral parietal large extradural haemorrhage. at right,.at left side, after 6 months of trauma. 26 CT scan reveals bilateral frontoparietal subdural hygroma, after 6 months of trauma. 27 MRI shows left high parietal encephalomalacia, left parietal fracture, after 6 months of trauma. 28 MRI reveals right parietal large area of encephalomalacia with depressed fracture of right parietal bone, after 6 months of trauma . 29 CT scan reveals site of trephine operation at right parietal bone with depressed fracture with right extradural hge.with mild shift of middle line to opposite side, after 6 months of trauma. 30 CT scan reveals comminuted depressed fracture of frontal bone with right frontal encephalomalcia, after 6 months of trauma. IV List of charts No of chart
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