Head Injuries. Dr. S.R. Hulathduwa MBBS , DLM.MD . DMJ(Path) ( Lond .) DMJ( Clin )( Lond .) Dip.Crim . MFFLM(UK ) Senior Lecturer Department of Forensic Medicine University of Sri Jayewardenapura. Regional Injuries. This includes Head injuries Neck injuries Facial injuries
Dr. S.R. Hulathduwa
MBBS, DLM.MD. DMJ(Path) (Lond.) DMJ(Clin)(Lond.) Dip.Crim. MFFLM(UK)
Department of Forensic Medicine
University of Sri Jayewardenapura
(force directly applied to head)
e.g. assaults, accidents, falls
e.g. fall off height landing on feet or buttocks,
blow to chin, hitting the ground of a motor cyclist in RTA
e.g. violent shaking(shaken body syndrome)
e.g. blows, shaking, etc..
The following anatomical peculiarities modify the nature and the extent of head injuries.
- hair, scalp, skull, meninges, brain and base of skull
e.g. scalp bruises are better felt than seen.
-Bleed profusely even PM.
-Easy spread of infection.
incised wounds, stabs, burns
- acute, sub acute, chronic
intra ventricular haemorrhages.
eg. RTA, fall off height. etc..
May give the false sense of a fracture of the underlying skull on external palpation.
How to differentiate?
eg. Stellate – blunt rods /falling backwards.
-usually on an area where the skull is thin. E.g. temporal bone.
-also can penetrate the orbit.
a)Deciding the approximate range of fire arm discharge.
b) Deciding the proximity of the victim to the explosion.
c) Differentiating dry heat from scalds (moist burns) and corrosive burns
-perforating and/or blast lacerations.
-blast and/or perforating lacerations.
-also by blows with blunt weapons on an unsupported head.
-may represent the forward and downward components of the force applied, thus indicating the direction of the blow/position of the victim. (pointer #)
- Can be a focus of post traumatic epilepsy at a later time.
e.g. RTA, falls, blunt heavy weapon with a large striking surface.
e.g. long, heavy, thin, blunt weapon.
- When a cutting/stabbing weapon is withdrawn from the skull, the fractured fragments may be elevated.
- If the soft tissue/meninges are caught in between the two edged of a fracture, in an infant, the # will widen with time delaying healing. Brain tissue may even herniate through the defect with time.
- Around the foramen magnum.
Eg. Fall on the back of the head.
(blunt, sharp, cutting, stabbing, firearm, sharpnel)
(e.g temporal Vs occipital)
(eg. Age, bone diseases, etc..)
e.g. depressed # on the vertex are usually due to a direct blow while a linear # in occipital area. Extending in to base of skull is more suggestive of a fall backwards.
(acute, sub acute, chronic)
The following can be included as cerebral injuries,
Symptoms occur rapidly in temporal and parietal EDH, enabling early diagnosis.
1.) classical presentation (yet rare) immediate loss of consciousness
Spontaneous recovery with lucid interval
Gradual deterioration of level of consciousness until death
3). Unconscious from the beginning
Dies without regaining consciousness
EDH is considered to be always traumatic in origin; 85% are associated with skull #
After established cerebral oedema due to increased intracranial pressure, EDH will have a poor prognosis, though successfully evacuated.
When the skull of the dead body is subjected to intense heat, blood will seep from the diploe and collect above the dura.
Also burst lobe following a spontaneous intra cerebral haemorrhage, is also non traumatic.
Usually does not occur as an isolated injury, thus category of hurt is not clear cut.
A chronic SDH will be seen as a brownish, cystic, gelatinous mass containing fluid of various colours (red/brown/yellow), adherent to dura and covered with a neo membrane.
SDH is common in extremes of age. E.g. infants – shaken baby syndrome
-elderly – due to shrunken brain with widened sub dural space.
-chronic alcoholics punch drunk syndrome
-may be FIOCN
1. Primary traumatic
due to diffuse rotational trauma to brain, bridging vessels are ruptured. The SAH is diffuse. There may be other associated injuries such as SDH, contre-coup injuries.
2. Secondary traumatic
due to localized trauma to brain (eg. A cerebral contusion or a laceration). There will be localized SAH in that area.
3. Extension of a traumatic intra-cerebral or/and intra ventricular haemorrhage in to sub arachonoid space.
4. Basal SAH can occur due to lateral neck trauma resulting in the rupture of vertebral vessels (how to demonstrate a vertebral artery damage in the autopsy?)
5. Sudden fluctuation of the pressure in the neck arteries without actual trauma to vessels in the neck.
e.g. sudden compression of the neck in manual strangulation.
Categorization of hurt is difficult when associated with other injuries. May depend on the individual case.
Read clinical presentation.
Eg. CANTU classification
“transient loss of consciousness immediately following blunt trauma to head, with spontaneous recovery, usually associated with retrograde amnesia, with no demonstrable macroscopic brain damage.”
NB : some times these features may persist for a considerable time. eg. rupulsion for alcohol, personality changes
(read compensation neurosis)
(legal validity of statement)
NB:- brain stem concussion – category of hurt
e.g. RTA, falls and assaults
Rarely can occur due to violent shaking without an impact injury on the head.
Has a spectrum of clinical presentation. Commonly the victims are deeply unconscious and in a vegetative state (intact brain stem)
DAI is ideally a histological diagnosis, if the patient had survived for few days, retraction bulbs (axonal bulbs) may be seen in H&E, Silver/Gold stain and Beta A.P.P. may show early changes.
Contre coup injuries – discuss
- usually with occipital impact
e.g. # of base of skull – posterior cranial fossa brain stem Impinges on the free margin of tentorium.
Forward movement when the brain stem impact with bone.
- Contre coup mechanism
- small, peripheral, circular, solitary (or few in number) usually between the aqueduct and outer end of Substantia Nigra.
Immediate loss of consciousness
Rapid deterioration of unconscious state to end up in an early death.
Volitional activities are not possible
Secondary brain stem haemorrhages are also called “Duret haemorrhages”
(hypoxic ischaemic encephalopathy)
e.g. 1. closed head injury resulting In raised ICP.
2. severe crush injury to chest, resulting in inadequate chest movements.
3. focal reduction of cerebral blood flow leading to infracts. (common sites are hippocampus and basal gangila)
e.g: eyes, ear, mouth, nose, jaw, etc..
Post traumatic epilepsy ( pre disposing factors are prolonged unconscious state, depressed #, hematoma formation, surface brain injury, infection)
Prolonged unconscious/ vegetative state complications of unconsciousness leading to death
e.g. head injury, haemorrhages, global Ischaemia etc.
say an EDH for example
Brain is heavy, oedematous, and water logged, Sulci are flattened and gyri are narrowed.
Also midline shift / pushed
(initially contra lateral lateral ventricle is dilated)
- compression of anterior cerebral artery
(supra callosal branches)
- Frontal lobe infarcts
Now the mid brain is compressed against the free margin of tentorium resulting in an indentation called “Kernohons Notch”
CN III – fixed dilated pupil
CN VI – paralysis of lateral rectus
Not mere cerebral lacerations or other specific structural injury to brain.