Contrastive cerebral contusion laceration (CCL) is a brain injury foci occurring at 180° contralateral to the violent blow, mostly in the temporal pole and temporal floor. The clinical symptoms vary in severity, and there are no uniform guidelines in the literature as to which patients require surgery and which patients can be treated conservatively, as well as the issue of bone flap removal and retention in surgical patients. In this paper, CT imaging performance was classified into four levels according to the different characteristics of intracranial pathological changes in episodic CCL, and from 2001 to 2005, 148 cases were treated according to the four-level classification, which are reported below.
1 .Clinical data
1.1 General data There were 148 cases in this group, 88 males and 60 females, aged 19~65 years old, with an average of 33.5 years old. There were 98 cases of car accident; 47 cases of fall injury; 3 cases of fall injury. There were 83 cases (56.1%) with GCS ≤ 8 points, 45 cases (30.4%) with GCS 9-12 points, and 20 cases (13.5%) with GCS 13-15 points at the time of admission.
1.2 The four-level classification was as follows
Table 1 Suggestions of four-level classification method for impulsive cerebral contusions
Pathology Class I Class II Class III Class I V
Number of foci 1 2 3 4 or more
Number of foci size <1cm 1~2cm 2~3cm >3cm
Edema range <2cm 2~3.5cm 3.5~5cm >5cm
Intracerebral hematoma None None or <2cm 2~4cm >4cm
Subdural hematoma None None or <20ml None or 20~30ml >30ml
Epidural hematoma None None or <20ml None or 20~30ml >30ml
Midline displacement None <0.5cm 0.5~1cm >1cm
Cerebral pool Clearly visible Clearly visible or blurred, with pressure Basically disappeared
Slight pressure change Pressure change
When a patient meets more than one of the above condition elements, the condition element with the highest grade shall prevail. Edema extent refers to: the layer with the largest edema area at the CT scan level was selected, and the largest transverse diameter of the edema area in that layer (including the hematoma).
In this group of cases, there were 18 cases (12%) of grade I, 32 patients (22%) of grade II, 35 patients (24%) of grade III, and 63 patients (42%) of grade IV. The higher the grade, the heavier the clinical manifestations and the lower the GCS score.
1.3 Graded treatment method Grade I and II patients were treated with conventional drugs such as dehydration, hemostasis, anti-inflammation, and improvement of cerebral circulation, and the changes of mental and pupil were closely observed. grade III and IV patients were treated with active surgery to remove intracranial hematoma and necrotic inactive brain tissue, of which grade III patients could be considered to preserve the bone flap, and grade IV patients were treated with standard large bone flap decompression.
2. Results
2.1 Treatment results: 50 patients were treated non-operatively, none of them died; 98 patients were treated surgically, 18 died and 5 survived vegetatively, the rescue rate was 82%; the total rescue rate of 148 patients was 88%. 27 out of 35 grade III patients were given bone flap preservation intraoperatively, all of them recovered well, none of them had to remove bone flap again due to cerebral edema and brain swelling.
2.2 Follow-up results After 6 months of follow-up, the mental, intellectual and memory of grade I and II patients returned to normal; 28 out of 35 grade III patients had normal mental, intellectual and memory recovery, 2 had intermittent mild headache and dizziness, 3 had memory loss, 1 had intellectual decline, and 1 had intermittent seizures; 45 grade IV patients survived, including 5 cases of vegetative survival, 40 cases The GCS score reached 12 or more, and mental, intellectual and memory were recovered to varying degrees, and 5 cases had hemiplegia.
3 , Discussion
In the process of head impact, the brain tissues in the skull undergo violent axial movement, and the frontal orbital surface and temporal pole are repeatedly rubbed and impacted with the uneven skull base, causing lacerations to occur in the soft brain tissues. In addition, skull fracture with epidural hematoma can be seen on one side of the point of impact, and subdural hematoma can be seen on the opposite side. Early CT foci of cerebral hedge injury appear as localized low-density ischemic foci, and later they appear as foci of hemorrhage or even hematoma formation with varying degrees of cerebral edema. Since the cranial CT scan can clearly show the site, size, brain pool changes and the presence of secondary damage of cerebral contusions, and can indirectly estimate the level of intracranial pressure based on the specific number of midline shifts.
In this paper, precisely according to the different degrees of intracranial pathological changes in curtain CCL, based on the performance of CT imaging, CCL is divided into four grades, grade I and II intracranial pathological changes are minor, intracranial pressure is mildly elevated, generally less than 4.0kpa,GCS generally 12 points or more; grade II intracranial pathological changes are significant, midline shift is greater than 0.5cm, less than 1cm, intracranial pressure has reached a certain degree of elevation, GCS generally 9~12 points; grade IV intracranial pathological changes are serious, midline shift is greater than 1cm, intracranial pressure is significantly elevated, GCS generally less than 8 points. We believe that grades I and II have no indication for surgery, while grades III and IV have an indication for surgery, and grade III has a better prognosis than grade IV.
Clinical characteristics of episodic CCL: diverse forms of pathological changes, sudden changes, and rapid progressiveness. Cytotoxic edema appears around the contusion foci early after brain injury, and with the prolongation of time, the vascular barrier around them is destroyed and vascular permeability increases, then vasogenic edema appears, which is most obvious 2~3 days after injury, when the intracranial pressure will rise abruptly. If the cerebral cortex and white matter contusion rupture is serious, as well as cortical vascular embolism or vascular spasm causing local ischemia and brain tissue necrosis, the vascular rupture will bleed again and then form a hematoma, which will greatly increase the intracranial pressure and lead to instant deterioration of the patient’s condition, i.e., coma and brain herniation may occur, and the prognosis is poor even if the patient is operated in time to save his life.
Therefore, the indications for surgery must be relaxed, and there should be constrained to the alteration of the pupil of the mind, so as to strive for early surgery before coma or dilatation of the pupil on one side to improve the salvage rate and prognosis. In other words, surgery should be performed when CCL evolves to III without delay. If the condition deteriorates slightly, it will be elevated to grade IV, at which time surgery will greatly reduce the salvage rate and quality of survival. Thus, grade III is the best time to operate. When a patient is admitted to the hospital with grade IV, the condition is often accompanied by brain herniation, and the patient should be treated with urgent surgery. A standard large bone flap decompression is performed to remove intracranial hematoma and inactive brain tissue. If the decompression is not obvious, frontal or temporal pole resection internal decompression can be performed to achieve the best cerebral decompression.
However, grade II patients should be monitored for 72h, closely observe the change of mental status and pupils, and dynamically review the cranial CT to prevent the development of grade III or above, so as to save life by timely surgery.
Because of a series of problems in the past, such as fluid accumulation under the flap, herniation of brain tissue through the bone window, causing local cerebral infarction, or even large cerebral edema, further aggravating brain injury, and the need to repair the skull again after surgery, we found that intraoperative preservation of the bone flap can be considered for grade III patients. After adequate removal of hematoma and necrotic brain tissue, the bone flap can be preserved if the brain pressure is relieved satisfactorily and the brain is moving well. If the cerebral pressure relief is unsatisfactory and the surface veins of the brain, especially the lateral fissure vein, are darkened, venous thrombosis and poor recovery of cerebral motion are considered, decompression of the bone flap should be considered [4].
In our group of 148 CCL patients treated by classification, the overall salvage rate was 88% and the salvage rate of critically ill patients was 82%, which is higher than the 76%-78% generally reported in China. We believe that the four-level classification method can improve the salvage rate of CCL patients and provide a basis for intraoperative bone flap debridement.