Craniocerebral injury is a common trauma, and its incidence is second only to extremity injuries among injuries to various parts of the body. The injury is complex and serious, and the mortality rate is high. After rescue treatment, most patients survive but are often left with different degrees of neurological dysfunction. Such as consciousness, motor, sensory, speech, cognitive function, defecation and urination and other aspects of the impairment. All these impairments can affect the life and work of patients, causing pain and difficulties to patients and their families, as well as imposing a great burden on the country. Therefore, it is important to provide early and active rehabilitation treatment for patients with craniocerebral injury so that the patient’s damaged functions can be recovered and compensated to the maximum extent.
First, the pathological changes of craniocerebral injury.
1, primary injury: is a localized intracranial injury caused by direct violence, or a hedge injury on the opposite side of the blow. Some are diffuse axonal injuries due to shear stress.
2, secondary injury: secondary injury refers to brain injury due to cerebral hypoxia, metabolic disorders, intracranial hematoma, increased intracranial pressure, etc.
3, according to whether the extracranial connection, cranial injury can be divided into.
(1) closed craniocerebral injury is characterized by post-injury cranial cavity and the outside world is not connected, if the skull base fracture and fracture line through the air sinus or rock bone, accompanied by dural tears, then cerebrospinal nasal leakage or ear leakage can occur. This type of craniocerebral injury is open, but the treatment and closed craniocerebral injury of the same, so still listed as closed craniocerebral injury.
(2) open craniocerebral injury is caused by blunt or sharp objects caused by craniocerebral injury, when the scalp has lacerations, skull fractures, dural rupture, brain and the outside world.
(3) firearm craniosynostosis war time, open craniosynostosis caused by gunfire or shrapnel. Firearm injuries can be divided into the following types.
① scalp soft tissue injuries only scalp injury, skull intact, sometimes localized brain contusion.
② non-penetrating injuries with scalp injuries and skull fractures, dura intact, but there can be local brain contusions.
③ Penetrating injuries have rupture of the scalp, skull and dura mater, and the brain tissue is severely damaged. Penetrating injury is further divided into blind canal injury, penetrating injury and tangential injury according to the form of trauma.
Second, the depth of coma and the evaluation of the severity of injury
When evaluating patients in coma after craniocerebral injury, it is necessary to ensure that the patient’s airway is open, so that the patient gets sufficient oxygen supply, and at the same time to maintain blood pressure and good peripheral circulation. Otherwise, not only are the assessment results unreliable, but also delay the patient’s resuscitation. The neurological examination should be carried out promptly and should be evaluated objectively. The depth of post-injury coma and the severity of the injury are commonly measured by the Glass Coma Scale.
1, according to the degree of coma classification.
Light type: 13-15 points, post-injury coma within 30min;
Moderate: 9-12 points, post-injury coma 30min-6h;
Heavy type: 3-8 points, 6h post-injury coma.
2, according to the severity of the disease classification: according to the coma time, positive signs and vital signs will be divided into light, medium, heavy and extra heavy.
Mild: post-injury coma time 0-30 minutes, there is a slight headache, dizziness and other conscious symptoms, no significant changes in the nervous system and CSF examination;
Moderate: 12 hours or less of post-injury coma, with slight positive neurological signs, and slight changes in body temperature, respiration, blood pressure and pulse rate;
Severe: 12 hours or more of post-injury coma, gradually worsening consciousness or re-emerging coma, with obvious positive neurological signs and significant changes in body temperature, respiration, blood pressure and pulse;
Extra heavy: the brain primary injury is heavy, post-injury coma is deep, there is de-brain tonic or with other parts of the organ injuries, shock, etc.
Third, clinical manifestations.
(a) Acute phase.
Including brain contusion, diffuse axonal injury, primary brainstem injury, cerebral edema, intracranial hematoma and other intracranial lesions, as well as injuries to other organs.
1, central nervous system: central nervous system symptoms such as impaired consciousness, high cranial pressure, motor-sensory impairment, aphasia, cognitive impairment, cranial nerve injury; it can also cause post-traumatic cerebral infarction, post-traumatic epilepsy, hydrocephalus and other complications;
2, neurological and musculoskeletal system: fractures, dislocation ossification, muscle contracture, peripheral nerve injury in the skull, face and extremities;
3, endocrine metabolic system: urolysis, abnormal ADH secretion, abnormal calcium/phosphorus metabolism;
4.Hematological system: anemia;
5, urinary system: urinary tract infection, catheter retention, neurogenic bladder;
6, digestive system: swallowing disorders, weight gain/loss, upper gastrointestinal bleeding, diarrhea, constipation;
7, respiratory system: tracheotomy, artificial respiration, pneumonia, traumatic lung injury;
8.Circulatory system: hypertension, deep vein thrombosis, carotid artery fistula;
9, skin: pressure sores;
10, the vegetative nervous system: sweating, central hyperthermia, etc.
(ii) Recovery period.
Complex and diverse. Mental disorders, cognitive disorders, speech disorders, swallowing disorders, cranial nerve damage, pyramidal bundle damage, hydrocephalus, skeletal muscular system, others: such as endocrine system, hematological system, circulatory system, and related problems of the vegetative nervous system. In short, the symptoms caused by craniocerebral injury are complex and diverse, due to different causes of injury, different parts of the injury, the severity of the business situation is different leading to craniocerebral injury patients with more complex clinical manifestations, which also brings us more trouble in the rehabilitation.
Fourth, the diagnosis of craniocerebral injury
According to the history of trauma and physical examination, as well as the application of CT or MRI is now extremely common, the diagnosis is generally not difficult, but it should be noted that sometimes early imaging does not necessarily have a very clear lesion, clinicians must be based on clinical manifestations and objective physical examination results to determine the condition and make a diagnosis.
V. Complications
1. Post-traumatic epilepsy.
Early epilepsy refers to epilepsy occurring within 24 hours after injury, accounting for about 30%; middle epilepsy refers to epilepsy occurring between 24 hours and 4 weeks after injury, accounting for about 13%; late epilepsy refers to traumatic epilepsy occurring from 4 weeks to several years or even a decade after injury, accounting for about 84%. The pathological mechanism and clinical features are unclear and may be directly induced by the trauma. Treatment: Prophylactic use of antiepileptic drugs is not advocated, and drug therapy uses the smallest dose to completely control seizures without side effects, so the dose should start small and gradually increase to completely control seizures, and according to the time of the patient’s seizures, the medication should be taken in a planned manner; once the selected drug is effective, it is best to use a single drug and not easily replaced. If the patient is still seizure-free after complete discontinuation of medication, it can be regarded as a clinical cure; for a few advanced refractory epilepsy when systematic medication is ineffective, surgery is required.
2. Post-traumatic hydrocephalus.
Predisposing factors: subarachnoid hemorrhage, increased intracranial pressure within 24 hours after trauma, intracranial infection, etc.
Incidence: about 19%.
Diagnostic criteria.
(1) A clear history of trauma;
(2) Clinical presence of dementia, unsteady gait, and one of the symptoms of urinary incontinence;
(3) CT shows: enlarged ventricles, hypodensity around the frontal horn of the lateral ventricles, but no atrophy of the cerebral gyrus and no widening of the cerebral sulcus.
Treatment: Dynamic observation must be made, and early surgical treatment if necessary.
3.Post-traumatic cerebral infarction.
Traumatic cerebral infarction is a pathological condition caused by local cerebral blood supply disorder due to injury, resulting in ischemic damage to brain tissue and neurological dysfunction, which is one of the complications of craniocerebral injury and a special type of cerebral infarction. Age, hypotension or shock, subarachnoid hemorrhage, cerebral contusion, subdural hematoma, concurrent brain herniation, and combined diabetes mellitus are risk factors for post-traumatic cerebral infarction secondary to craniocerebral injury. Simple focal infarcts are treated reliably with comprehensive medical treatment; simple large cerebral infarcts and focal infarcts complicated by craniocerebral injury can achieve good results with active surgical decompression and timely improvement of microcirculation; large cerebral infarcts complicated by heavy craniocerebral injury and the elderly have poor prognosis; pediatric traumatic cerebral infarcts mostly have a clear history of minor head trauma, mostly occurring in the basal nucleus area on one side, and conservative treatment is the main treatment. The diagnosis is mainly based on clinical manifestations and imaging examinations, and conservative treatment is the main focus, early detection and treatment is the key to success.
4.Traumatic hypocranial pressure syndrome.
Traumatic low cranial pressure syndrome is a syndrome produced by the patient lying on his side with lumbar puncture pressure below 7.84kPa. It may originate from post-injury cerebral vasospasm that inhibits the function of the choroid plexus to secrete cerebrospinal fluid, or it may be secondary to cerebrospinal fluid leakage, severe dehydration from shock, hyponatremia, hyperventilation and excessive cerebrospinal fluid release from surgery or lumbar puncture. The main symptom is headache which occurs 1-2 hours or 2-3 days after the injury, located in the forehead and back of the occipital area, which is aggravated with the elevation of the head position and can radiate to the whole body, but the headache is reduced or disappears when the head is in the lying position or low position. The second is vertigo and vomiting every time when the head position changes or after severe headache; the diagnosis of traumatic hypocranial pressure syndrome mainly relies on clinical features and lumbar puncture manometry to confirm the diagnosis.
5.Post-cranial injury syndrome.
Post-craniocerebral injury syndrome is a group of autonomic dysfunction or psychiatric symptoms that exist for a long time after the recovery period in patients with craniocerebral injury. Including headache, hypersensitivity, irritability, concentration disorder, memory impairment, dizziness, insomnia, fatigue and other symptoms. There is no abnormality in neurological examination and no positive finding in neuroradiological examination.
VI. Some factors related to prognosis
After craniocerebral trauma, the most important factor to determine the prognosis is the degree of brain injury, which is marked by the depth and duration of coma. The literature reports that coma lasting more than a week often results in permanent disability, either intellectual or physical, or both. Death as a direct result of craniocerebral injury often occurs within 2-3 days after the injury. There are many factors that affect recovery from craniocerebral injury, with most recovery occurring within 6 months of trauma, after which recovery becomes slower. Therefore, the timing of patient assessment also affects the prediction of prognosis. In addition, the prognosis is also related to the timing of the start of the post-traumatic rehabilitation program, with early start having better results and preventing somatic complications. The Glasgow Prognostic Scale, as modified by Jennett et al, provides a statistical indication of the correlation between early clinical presentation and prognosis.
Glasgow prognostic scale
1. Vegetative state: a persistent state characterized by reduced responsiveness and arousal, with eye opening, sucking, yawning and local motor responses
2. Severe disability: a prognosis characterized by consciousness, due to cognitive-behavioral or physical disability, including dysarthria and dysphasia, with patients requiring 24-hour care
3. Moderate disability: a prognosis in which the patient is independent in daily life, family and social activities, but still has a disability. Patients may have memory or personality changes, mild hemiparesis, dysphagia, ataxia, secondary epilepsy, or significant cranial nerve palsy.
4. Good recovery: the patient can re-enter normal social life and return to work, there may be mild persistent legacy
Seven, the rehabilitation evaluation of craniocerebral injury
1, the evaluation of the general condition
Pay attention to the evaluation of the patient’s general condition, including cardiopulmonary function, skin condition, eating condition, diarrhea; to understand the past medical history, whether there is hypertension, coronary heart disease, diabetes, etc. and the current medication; to understand whether the patient has other traumas such as fractures, and fracture healing, etc.
2.Evaluation on impairment
The evaluation of cognitive disorder, language disorder, swallowing disorder, motor disorder, balance disorder, etc. can be referred to the relevant chapters, and the degree of coma can be evaluated by Glasgow Coma Scale.
3.ADL evaluation
Generally, the internationally recognized Barthel index is used.
5.Disability evaluation
The general application of disability rating scale (DRS) to assess the degree of disability of craniocerebral injury, DRS is a widely used simple and effective prognostic assessment method. It includes 8 items in 4 major categories: arousal, awareness and responsiveness: cognitive ability for self-care activities; dependence on others; and psychosocial adaptability.
The DRS is more sensitive than the GOS in detecting and assessing clinical changes in patients after severe traumatic brain injury and can also be used to screen those most likely to benefit from rehabilitation. the DRS is measured once/d for the first 3 d after injury; once a week for the next 3 weeks; and then once every 2 weeks until 16 weeks after injury. those with a DRS score of 20 or less are expected to improve and improve.
VIII. Rehabilitation treatment after craniocerebral injury
The functional impairment caused by cranio-cerebral fingerprint injury is diverse and varies greatly from patient to patient, therefore, it is not possible to use a uniform model for rehabilitation for all patients, and the treatment plan should be different from individual to individual. Rehabilitation of craniofacial injuries is often long term. Therefore, it is important to have a long-term plan along with a short-term plan. The former lies in saving lives and stabilizing the condition. The latter is to plan for the patient’s problems and rehabilitation so that he or she can live independently and return to family and society. Most of the physical disorders after injury have been stabilized within 1 year, but the cognitive, behavioral and psychosocial problems often last for a long time. Therefore, after the acute phase and when the condition is stable, it is advisable to make a comprehensive neuropsychological examination in order to set the goal of long-term rehabilitation. If there are also behavioral, emotional, and cognitive disorders, they must be addressed first, otherwise the patient may resist, resist, or treat rehabilitation negatively, or many retraining methods may not be effective due to poor attention and memory. Cognitive rehabilitation is often long-term, so it is important to teach the patient’s family some practical methods that can be used for long-term training at home.
(a) Early rehabilitation: stabilize the condition, improve wakefulness, promote recovery from amnesia, prevent complications, and promote functional recovery.
1.Prevent pressure sores, prevent joint contractures, prevent infection, and rationalize body position.
2.maintaining nutrition, maintaining water and electrolyte balance.
3.Rousing treatment.
4.Management of the bladder.
5.Treatment of comorbidities.
6. If the condition allows, hyperbaric oxygen therapy can be started early.
(B) rehabilitation treatment during the recovery period: emphasize the comprehensive and holistic, craniocerebral injury patient disorders are characterized by.
1, there are behavioral, emotional, cognitive disorders, must first be dealt with, otherwise the patient may resist, resist, negative treatment of rehabilitation, or because of attention, memory and many retraining methods can not be effective. Music stimulation – Choose music that the patient is familiar with and likes, adjust the appropriate volume, and let the patient listen to the music and observe the patient’s reaction to the music through the patient’s facial expressions or changes in pulse, breathing, and eye opening. Verbal stimulation – the patient’s close people call, speak and care with verbal commands. Photoelectric stimulation – stimulation of the retina and cerebral cortex by changing colored light, 2 times/d, 1 h/time. Skin stimulation – The patient’s skin is stimulated with different sensory stimuli and passive activities to provide various sensory and kinesthetic afferents.
2, the condition is often complex, often multi-systemic lesions exist at the same time, such as both cone bundle damage and extrapyramidal damage, and may also be combined with ataxia, in the training should be accurately identified problem points.
3. Patients often develop disuse syndrome, such as joint contracture deformity, abnormal posture, abnormal gait, etc., due to the lack of early rehabilitation, which must be corrected in time, and if necessary, surgery is needed to facilitate the rehabilitation process. Once the vital signs are stable and the patient is conscious, the patient should be helped to perform deep breathing, active limb movement, bed activities and sitting and standing exercises as soon as possible, gradually. The patient can be trained with a tilt table, and the angle of the bed can be gradually increased, so that the patient can gradually adapt to prevent postural hypotension, osteoporosis and urinary tract infection.
4.Extraction of tracheal tube: gradually block the tube and test the blood oxygen level until the tube is blocked for 48 hours and the blood oxygen level is still within the normal range, then the tube can be considered to be removed.
5.Gastric tube problem: If the swallowing function has improved, swallowing function training should be actively carried out and the gastric tube should be removed as early as possible; if the gastric tube is not removed within a short period of time, gastrostomy should be done as early as possible.
6, the problem of urinary catheter: should do a good job of bladder management, must be regular and quantitative water intake, clamped urinary catheter regularly open, to maintain bladder function.
7, management of post-traumatic epilepsy: prophylactic application of antiepileptic drugs is not advocated. For patients with confirmed post-traumatic epilepsy, antiepileptic drugs can be used reasonably according to the type of seizure.
8. Treatment of hydrocephalus: For patients at high risk of hydrocephalus, CT or MRI and clinical symptom changes should be monitored regularly, and ventriculo-abdominal shunt surgery should be performed when appropriate.
9.Cranial repair: For cranial defects caused by trauma or surgery, the patient’s general condition, as well as the defect site, size, intracranial pressure, infection and other conditions, and the duration of the disease, should be considered whether to perform repair surgery. The skull defect should be repaired as soon as the condition allows.
10, the application of hyperbaric oxygen therapy, hyperbaric oxygen therapy is through the blood circulation to carry more oxygen to the damaged tissues and organs, to correct the tissue hypoxia, to promote tissue repair and functional recovery. In the hyperbaric oxygen chamber, pure oxygen of more than 1 atmosphere pressure is given to carry more oxygen to the damaged tissues and organs through human blood circulation to promote the repair and functional recovery of the damaged tissues.