Surgical management

Surgery

Many patients with moderate or severe head injuries head directly from the emergency
room to the operating room. In many cases, surgery is performed to remove a large
hematoma or contusion that is significantly compressing the brain or raising the
pressure within the skull. After surgery, these patients are under observation in the
intensive care unit (ICU).

Other head-injured patients may not head to the operating room immediately, instead
are taken from the emergency room to the ICU. Since contusions or hematomas may
enlarge over the first hours or days after head injury, immediate surgery is not
recommended on these patients until several days after their injury. Delayed
hematomas may be discovered when a patient's neurological exam worsens or when
their ICP increases. On other occasions, a routine follow-up CT scanto determine
whether a small lesion has changed in size indicates that the hematoma or contusion
has enlarged significantly. In these cases, the safest approach is to remove the lesion
before it enlarges and causes neurological damage.

During surgery, the hair over the affected part of the head is usually shaved. After the
scalp incision, the removed bone is extracted in a single piece or flap, then replaced
after surgery unless contaminated. The dura mater is carefully cut to reveal the
underlying brain. After any hematoma or contusion is removed, the neurosurgeon
ensures the area is not bleeding. He or she then closes the dura, replaces the bone and
closes the scalp. If the brain is very swollen, some neurosurgeons may decide not to
replace the bone until the swelling decreases, which may take up to several weeks. The
neurosurgeon may elect to place an ICP monitor or other types of monitors if these
were not already in place. The patient is returned to the ICU for observation and
additional care.

Intubation
Patients with TBI have up to a 5% to 6% incidence of an unstable cervical spine injury.
Risk factors include a motor vehicle accident and a GCS less than 8. Therefore, all
attempts at intubation should include in-line neck stabilization to reduce the chance of
worsening a neurological injury until radiological clearance is obtained. Pre-existing
hypoxia, intracranial hypertension, full stomach, and coexisting injuries, such as cervical
spine trauma and maxillofacial injuries, may be present that predisposes a patient to
difficult airway management. Thus, careful preparation and preoxygenation is
mandatory.
Decompressive crainectomy

craniotomy decreases intracranial pressure (ICP), intracranial hypertension (ICHT), or

heavy bleeding (also called hemorrhaging) inside your skull. If left untreated, pressure
or bleeding can compress your brain and push it down onto the brain stem. This can be
fatal or cause permanent brain damage.

A craniectomy is a surgery done to remove a part of your skull in order to relieve

pressure in that area when your brain swells. A craniectomy is usually performed after a
traumatic brain injury. It’s also done to treat conditions that cause your brain to swell or
bleed.This surgery often serves as an emergency life-saving measure. When it’s done
to relieve swelling, it’s called a decompressive craniectomy (DC).

A craniectomy decreases intracranial pressure (ICP), intracranial hypertension (ICHT),

or heavy bleeding (also called hemorrhaging) inside your skull. If left untreated,
pressure or bleeding can compress your brain and push it down onto the brain stem.
This can be fatal or cause permanent brain damage.

A craniectomy is often done as an emergency procedure when the skull needs to be

opened quickly to prevent any complications from swelling, especially after a traumatic
head injury or stroke. Before performing a craniectomy, your doctor will do a series of
tests to determine if there’s pressure or bleeding in your head. These tests will also tell
your surgeon the right location for the craniectomy.

The amount of time you spend in the hospital after a craniectomy depends on the
severity of the injury or condition that required treatment. If you’ve had a traumatic brain
injury or a stroke, you may need to remain in the hospital for weeks or more so that your
healthcare team can monitor your condition. You may also go through rehabilitation if
you have trouble eating, speaking, or walking. In some cases, you may need to stay in
the hospital for two months or more before you’ve improved enough to return to
everyday functions.
You may not fully recover from a severe brain injury or stroke for years even with
extensive rehabilitation and long-term treatment for speech, movement, and cognitive
functions. Your recovery often depends on how much damage was done due to swelling
or bleeding before your skull was opened or how severe the brain injury was. As part of
your recovery, you’ll need to wear a special helmet that protects the opening in your
head from any further injury. Finally, the surgeon will cover the hole with the removed
piece of skull that was stored or a synthetic skull implant. This procedure is called a
cranioplasty.

Medical management

Anesthetic drugs
Anesthetic drugs that allow for rapid control of the airway while avoiding an increase in
intracranial pressure (ICP) and providing hemodynamic stability are preferred. Propofol
and thiopental are the most commonly used drugs, but they may cause hypotension.
Etomidate has advantages in terms of cardiovascular stability, but the possibility of
adrenal suppression exists. Ketamine is popular in trauma patients and recent evidence
suggests that its effect on ICP may be limited

Vasopressors
Vasopressors are commonly used to augment CPP in the setting of TBI, although data
comparing these drugs is limited. Previous studies have found that norepinephrine had
a more predictable and consistent effect on CPP, whereas dopamine use led to higher
ICP levels [18]. Although there is minimal evidence to support the use of one
vasopressor agent over another, a recent study suggested that phenylephrine may be
associated with improved parameters
Anticonvulsant
Subsequent to TBI, convulsive activity results in increased ICP and altered oxygen
supply to the injured brain. To prevent secondary brain injury, many studies have
attempted to study the benefit of seizure prophylaxis showed that treatment with
phenytoin was effective in decreasing the rate of posttraumatic seizures in the first 7
days of injury, but had no significant role in prevention of posttraumatic seizures after
the first week of injury.
Clinical comparisons of levetiracetam and phenytoin in prevention of early posttraumatic
seizure prophylaxis have found no significant difference in rates of early posttraumatic
seizures among patients treated with phenytoin compared with patients treated with
levetiracetam. The current BTF Guidelines recommend treatment with anticonvulsants
within 7 days of injury. No randomized controlled studies have been performed till date
to prove that one antiepileptic drug is better than another in this setting.

Anti-biotics
Since TBI patients are more likely to receive invasive monitoring and therapeutic
treatments, including mechanical ventilation, they are also more likely to be at increased
risk for the development of infections. Sources of potential infections need to be
identified and appropriate therapy should be instituted.
A common source of infection is invasive monitoring of ICP. The incidence of ICP
device infection has been reported to range from 1% to 27%. Most studies cited by the
BTF guidelines that evaluated prophylactic antibiotic coverage in patients with TBI have
shown little significant differences in infection rates. Another study that evaluated
patients who received bacitracin flushes showed a higher rate of infection among the
intervention group. The current guidelines suggest the use of antibiotic-impregnated
catheters to reduce infection rates, although this is only a Level III recommendation.
There is limited available data to support the use of antibiotic prophylaxis in TBI,
especially as data suggests that such therapy may predispose these patients to more
severe infections. However, evidence for antibiotic therapy following penetrating TBI is
robust, and therapy should be maintained for at least 7–14 days.

Sedatives
Reducing stress and the adrenocortical response is an important component of TBI
management. Even unconscious TBI patients may have increased blood pressure and
ICP resulting from this stress response. Sedative agents can reduce metabolic stress
on acutely injured brain tissue by decreasing cerebral metabolism and consumption of
oxygen in a dose-dependent manner that, in turn, decreases CBF and leads to a
reduction in ICP. Care should be taken to maintain an adequate mean arterial pressure
throughout the duration of sedation.

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metabolomic biomarkers accurately classify acute mild traumatic brain injury from
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Kumar RG, Diamond ML, Boles JA, Berger RP, Tisherman SA, Kochanek PM, et al. Acute CSF
interleukin-6 trajectories after TBI: associations with neuroinflammation, polytrauma, and
outcome. Brain Behav Immun. 2015 Mar. 45:253-62