HEAD INJURY

Andi Asadul Islam

Department of Surgery
Faculty of Medicine
Hasanuddin University

Head Injury
Common problem
High morbidity and mortality
Secondary insults
Worsen outcome
Often preventable

Early neurosurgical consult and transfer

Neurosurgeon Needs to Know

Age and history

Vital signs
GCS score and pupils
Alcohol/drugs (s) intake
Associated injuries
Brain CT

Intracranial Pressure (ICP)

10 mmHg = Normal
>10 mmHg = Abnormal
>40 mmHg = Severe
Many pathologic processes affect outcome
ICP brain function, outcome

Cerebral Perfusion
Pressure

MBP ICP = CPP

Normal:
90 10 = 80
Cushings Response : 100 20 = 80
Shock and Head Injury 50 20 = 30
CPP does not equal cerebral blood flow, cerebral blood
flow is the key

Autoregulation
CBF maintained with MBP of 50-160 mmHg
Moderate or severe brain injury autoregulation
often impaired
Brain more vulnerable to episode of hypotension

Cerebral Blood Flow

50 mL/100 g/min = normal
< 25 mL/100 g/min = EEG activity
5 mL/ 100 g/min = Cell death

Classifications of Head Injury

By mechanism:

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Classification Cont.
By Severity
Mild Head Injury
Moderate Head Injury
Severe Head Injury

Classification of head injury

Basal skull fracture

CSF rhinorrhea : anterior skull base

CSF otorrhea : Mid-skull base
Hemotympanum
Periorbital ecchymosis
Retroauricular ecchymosis
Facial nerve injury
Loss of hearing
Pneumocephalus

Epidural Hematoma

Associated with skull fracture (about 80 %)

Classic: middle meningeal artery tear
Lenticular / biconvex due to dural adherence to skull
Lucid interval

Epidural Hematoma
Can be rapidly fatal
Early evacuation, better prognosis
Venous epidurals : possible non surgical management
in conscious patient or without neurologic
abnormality.

Subdural Hematoma

Venous tear / brain laceration

Covers entire cerebral surface
Morbidity / mortality due to underlying brain injury
Rapid surgical evacuation recommended, especially
if >5mm shift of midline

Contusion / Hematoma

Coup / contrecoup injuries

Most common : frontal / temporal lobes
Salt and pepper appearance on CT
CT changes usually progressive
Most conscious patients : No operation

Concussion

Transient loss of consciousness

Normal head CT
Nausea, vomiting
Headache : if severe, repeat CT
Symptoms may worsen before improvement
Sequelae common

Diffuse Axonal Injury

Prolonged deep coma (not due to mass lesion)

Diffuse brain injury
Motor posturing
Frequent autonomic dysfunction

Mild Brain Injury

GCS Score = 14 15
History
Exclude systemic injuries
Neurologic exam
X-rays as indicated
Alcohol / drug screens as indicated
Liberal use of head CT
Observe or discharge based on findings

Moderate Brain Injury

GCS Score = 9 13
Initial evaluation same as for mild injury
CT-scan for all
Admit and observe
Frequent neurologic exams
Repeat CT-scan

Deterioration : manage as severe head injury

Severe Brain Injury

GCS Score = 3 8
Evaluation / resuscitate
Intubate for airway protection
Focused neurologic exam
Frequent reevaluation
Identify associated injuries

Severe Brain Injury Airway / Breathing

Airway protection
Supplemental oxygen
Assisted ventilation
Modest hyperventilation, if necessary (Paco 2 25-35
mmHg)
Frequent reevaluation / ABGs

Severe Brain Injury Circulation

Hypotension not due to brain injury
Hypotension causes secondary brain injury :
Correct hypotension quickly
Do not treat hypertension, maintain CPP

Severe Brain Injury Disability

GCS :
Eye opening
Best motor response
Verbal response

Pupillary size, equality, reaction to light

Symmetry of motor strength

Severe Brain Injury Disability

Minineurologic exam :
On patient arrival
After resuscitation
Frequently

Document changes
Consult neurosurgeon early

Severe Brain Injury Pupillary Findings

and Cause
Bilaterally constricted : drugs and pontine lesion
Unilaterally constricted : injured sympathetic pathway

Severe Brain Injury Pupillary Finding

and Cause
Bilaterally dilated : 3rd nerve compression and inadequate
CNS perfusion
Unilaterally dilated : 3rd nerve compression, tentorial
herniation and optic nerve injury

Severe Brain Injury Herniation

Deteriorating LOC (GCS score)

Pupillary asymmetry
Motor asymmetry
Cardiopulmonary arrest
Cushings triad

Indications for CT-Scan

All patients with suspicion of brain injury

Medical Management
Intravenous fluids :
Euvolemia
Isotonic

Hyperventilation, if necessary
Goal : PaCO2 at 35 mmHg

Medical Management
Mannitol
Use with signs of tentorial herniation
Dose : 0.5 1.0 g/kg IV bolus

Other
Anticonvulsants
Sedation
Paralytics

Surgical Management
Scalp Injuries
Possible site of major blood loss
Direct pressure to control bleeding
Occasional temporary closure

Surgical Management
Intracranial Mass Lesion
May be life-threatening if expanding rapidly
Immediate neurosurgical consult
Hyperventilation / mannitol
? Emergency burr holes?

Summary
Prescription (Do)
Maintain mean BP >90 mmHg
Maintain Paco2 35 mmHg
Use isotonic solution for euvolemia
Frequent neurologic exams
Liberal use of CT-scans
Early neurosurgical consult

Summary

Proscription (Dont)
Allow patient to become hypotensive
Over-aggressively hyperventilate
Use hypotonic IV fluids
Use long-acting paralytics
Paralyze before performing complete exam
Depend on clinical exam alone

The Glasgow Coma Scale

Eye opening

Spontaneous
Speech
To pain
None

Verbal response

Motor response

Obeys commands
Localizes pain
Withdraws from pain
Abnormal flexion response to pain
Extension to pain
None

Orientated
Confused conversation
Inappropriate words
Incomprehensible sounds
None