CONTUSION OF THE BRAIN (contusio cerebri; lat. contusio hurt; synonym bruise of a brain) — the brain injury which is followed by development of the centers of destruction of brain fabric with the corresponding clinical picture.
Distinguish three groups of the contusional centers in a brain: 1) in hemicerebrums or a cerebellum; 2) in a brainstem; 3) a combination of the contusional centers in hemicerebrums or in a cerebellum and in a brainstem. The center of a bruise or crush of a brain in the field of application of force or from antiblow is a constant component of a severe craniocereberal injury. But also at slighter injury quite often there are bruises of a brain which sometimes clinically clearly are not shown.
In a pathogeny of the craniocereberal injury which is followed by a contusion of a brain, special significance is attached to the following factors of mechanical character: a) — at blow in the fixed (motionless) head the skull generally remains to position of the head at injuries at rest, at impact of force on freely mobile head a body of the person, and together with it and the head receive acceleration, and then there is an injury of acceleration (or delays); b) to temporary changes of a configuration of a skull as the general or its local deformation with emergence in some cases a fracture of a skull; c) to shift of a brain in a head cavity (in relation to internal walls of a cavity and intracranial fibrous partitions): linear and rotational, to change of speed in the linear direction, linear acceleration and delay; d) dependences between physical parameters both character and the localization of the contusional centers and weight influencing a skull and a brain of force, the place of its appendix and the direction, on the one hand, a wedge, pictures — with another.
It is experimentally established that at the time of blow in a head cavity on a shock pole there is positive pressure and at the same time on an opposite pole — negative.
Among various theories developments of shock-proof damages the greatest recognition were gained by the theory of a pressure gradient developed by Gross (A. G. Gross, 1958). According to this theory, at the time of a bruise at emergence of forces of acceleration (or delays) in a head cavity there is a pressure operating during fractions of a second, at the same time pressure between the place of blow and an opposite pole is distributed by the principle of a pressure gradient with emergence of supertension in the field of application of force and negative — on an opposite pole (area of vacuum). In the field of negative pressure in substance of a brain the cavities which are falling down after cancellation of the accelerating force (shock-proof cavitation) with hemorrhages and ruptures of brain fabric and formation of a bruise on the mechanism of antiblow are formed.
A. P. Gromov's researches et al. (1972) emphasize importance of features of deformation of bones of a base of skull during the developing of bruises in perednebazalny departments of a brain. It was established that at an injury of frontal and occipital areas of the head deformation curvatures concentrate in front departments of bones of a base of skull (a roof of an orbit and big wings of the main bone) and, naturally, that at the same time injuries of a brain will be to be localized generally in basal departments of frontal lobes, polar and basal departments of the temporal shares adjacent to these areas of a skull. Preferential localization of bruises in these departments at various movements of a brain is promoted by roughnesses of a bone in a front cranial pole, a keen edge of a small wing of the main bone and bench-formed descent of a front cranial pole in average. Thus, only the combined accounting of the processes arising as in brain tissue, and bones of a skull at an experimental cherepnomozgovy injury gives the chance to a nek-swarm of degree to understand the existing patterns of an arrangement of bruises of a brain at an injury of a skull.
Bruises and crushes of a brain at an open craniocereberal injury in the field of application of force are a consequence of immediate effect of the traumatic agent, implementation of bone or metal splinters in brain fabric.
the Contusional centers at the closed craniocereberal injury most often come to light on the surface of a brain. They have an appearance of the maculas lutea or limited sites of a hemorrhagic softening of brain fabric covered with the unimpaired soft meninx, under a cut subpialny hemorrhages most often do not extend far beyond the contusional center. Quite often contusional centers have the wedge-shaped form: their top goes to depth of a brain on 1 — 2 cm. Microscopically they consist of the damaged nervous cells and hemorrhages with a perifocal zone of hypostasis. The centers of hemorrhages can be a consequence of both a rupture of vascular walls, and hemorrhages by emigration. Crush of brain fabric is the strongest extent of its damage and is characterized by rough destruction of fabric with a rupture of a soft meninx, an exit of a brain detritis to a surface, a rupture of vessels and outpouring of blood in subarachnoid space. Usually crush of a brain is localized in the field of a bruise of the head, is especially frequent in the presence of depressed fractures and ruptures of a firm meninx.
The most characteristic localization of a bruise as antiblow (contre coup) are basal and polar departments of frontal and temporal lobes of a brain. Bruises of a cerebral cortex arise in the field of antiblow considerably more often than in the place of the blow. Shock-proof damages are especially expressed at blow behind, seldom happen at blow in front, and at blows on the right and at the left shock-proof damages are more extensive, than in a place of application of force.
The contusional centers in a brainstem which are located both on its outer surface and at a ventricle, often are the main reason for death of injuries. They are observed at application of the injuring force to different departments of a calvaria. In relation to a point of application of this force the contusional centers in a trunk are shock-proof and result from blow of a trunk about an inner surface of a base of skull, bone edge of a big occipital opening and edge of cerebellar is mashed at the time of shift and deformation of a brain. Outside damages of a brainstem, as a rule, have the small sizes and in some cases come to light only at a research of a series of cuts.
Some centers of an encephalomalacia form like hemorrhagic heart attacks (see) in the area where after disturbance of blood circulation the ischemic necrosis with the subsequent treatment by blood through walls of vessels in connection with their hyperpermeability developed.
An outcome To. of m at the closed craniocereberal injury is formation of a glial brain hem or shell and brain union.
The clinical picture
In difficult a wedge, is obviously possible to allocate to a picture where the symptoms and syndromes depending on concussion, a bruise and a prelum of a brain closely intertwine local symptoms of a bruise or prelums of a brain (see) that has great practical value. Symptoms concussions of the brain (see) usually tend to bystry disappearance whereas symptoms To. of m remain stationary or tend to progressing with 2 — the 3rd day after an injury, and their regress is planned not earlier than from the 2nd week after an injury. Symptomatology To. of m and its loudspeaker is defined by character of the main center of defeat and the perifocal phenomena depending on disturbance krovo-and a likvoroobrashcheniya. At an arrangement of the central site of the contusional center in functionally significant departments of a brain usually there are resistant phenomena of loss. Later development and increase of symptoms, short and perfect regress in a stage of recovery is characteristic of perifocal changes.
At injury of frontal lobes into the forefront acts psikhopatol. symptomatology at scarcity it is pure nevrol, symptoms. Sometimes slackness and an aspontannost against the background of other psikhopatol, manifestations dominate in all a wedge, a picture of the first periods of a disease. Unmotivated transitions from complacency and euphoria to attacks of rage, rage and discontent are observed. In hard cases it is shown resistant akinetically - an anamnestic syndrome. At defeat of premotorny area disturbances of motility with loss of ability to the thin differentiated movements come to light. Roughly expressed pyramidal hemiparesis or a hemiplegia are shown only at massive damages of parietofrontal area. Focal epileptic seizures, especially jacksonian type, in the acute period at a bruise of a brain as a result of the closed injury of a skull meet rather seldom and almost always demonstrate existence of the local hematoma which is subject to removal. In the late period after an injury these attacks meet often. At massive damages of a temporal share the diencephalic symptomatology is almost always observed. These damages are quite often shown by rough motive excitement against the background of the general serious condition, after escaping to-rogo more outlined temporal symptoms come to light. At severe defeats of parietotemporal area of the left hemisphere afazichesky, agnostic and apraksichesky frustration come to light (see Agnosia, Apraxia, Aphasia). At defeat of bark by a temporal and lower parietal lobe disturbances of recognition, understanding of the speech and the letter, orientation in space and in own body, psychosensorial optical, vestibular, acoustical, olfactory and flavoring and visceral frustration can be observed with derealization (see) and depersonalization (see). Bruises of basal departments of a brain (gipotalamo-pituitary area and a trunk) are clinically shown by a long loss of consciousness and a heavy neurovegetative syndrome, the main components to-rogo are disorders of breath, cardiovascular activity, thermal control, and also exchange, humoral and endocrine disturbances.
In an acute stage of a disease special attention is paid to treatment of disturbances of breath, a hemodynamics and metabolism which can be a consequence of bruises of trunk departments of a brain. At depressed fractures of a skull an operative measure with removal of fragments of a bone is shown. The center of a bruise or crush of a brain is the factor strengthening wet brain (see. Swelled also swelling of a brain ), concerning what sometimes made decompressive trepanation; for the purpose of prevention of progressing of wet brain and dislocation of a trunk (especially hernial protrusion and a vklineniye of a gippokampovy crinkle) establish indications to early operation of removal (during the first 2 days after an injury) necrotic sites of a brain (especially in the field of a lower surface a temporal and frontal lobe). Operation consists the contusional center by suction of impractical fabrics, washing by their fluid jet at a distance. If necessary carry out also a decompression and at indications a tentoriotomiya for the purpose of elimination of tentorial infringement (see. Tentorial syndrome ).
In later stages of a disease at paresis or paralyzes of extremities are shown physical therapy and to lay down. gymnastics, at afazichesky frustration — recovery treatment under observation of the logopedist. Conservative treatment at a focal epileptic syndrome as a consequence of a bruise of a brain and about l of ochechno-brain unions develops of anticonvulsant therapy, purpose of dehydrating agents for reduction of hypostasis and brain swelling and fortifying treatment. Administration of air in a subarachnoid space for the purpose of separation of friable shell and brain unions is sometimes effective. In the absence of effect of conservative methods of treatment of an epileptic syndrome excision of the epileptogenic center with separation of unions between a brain and a firm meninx is shown. At the expressed resistant symptoms of loss of function of a nervous system use of the remained working capacity for training in new professions is shown.
Forecast usually serious also depends on weight and localization of injury of a brain.
See also Craniocereberal injury .
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M. M. Irger.