NEUROSURGERY

Day 4: Traumatic Brain Injury ALWAYS KNOW WHEN TO USE IMAGING

Jaime Lois F. Opinion III Table 51.4 findings with low risk of ICI
• Asymptomatic
Table 38-2. Glasgow Coma Scale • H/A
Behavior Response Score • Dizziness
Eye Opening Spontaneously 4 • Scalp hematoma, laceration, contusion, or abrasion
To speech 3 • No moderate nor high risk criteria (see Table 51.7 and 51.8, no loss
To pain 2 of consciousness, etc..)
No response 1
Best Verbal Oriented to time, place, and person 5 Table 51.8 Findings with high risk of ICI
Response Confused 4 • Depressed level of consciousness not clearly due to EtOH, drugs,
Inappropriate words 3 metabolic abnormalities, postictal, etc.
Incomprehensible sounds 2 • Focal neurologic findings
No response 1 • Decreasing level of consciousness
Best motor Obeys commands 6 • Penetrating skull injury or depressed fracture
response Moves to localized pain 5
Flexion withdrawal from pain 4 Table 51.7 Findings with moderate risk of ICI
Abnormal flexion (decorticate) 3 1. History of change or loss of consciousness on or after injury
Abnormal extension (decerebrate) 2 2. Progressive H/A
No response 1 3. EtOH or drug intoxication
Total Score Best response 15 4. Posttraumatic seizure
Comatose client 8 or less 5. Unreliable or inadequate history
Totally unresponsive 3 6. Age < 2 yr (unless trivial injury)
7. Vomiting
TRAUMATIC BRAIN INJURY 8. Posttraumatic amnesia
• 50-60% of head trauma patients with a GCS of <8, usually have 9. Signs of basilar skull fracture
accompanying injuries 10. Multiple trauma
• ALWAYS MAINTAIN A HIGH INDEX OF SUSPICION. 11. Serious facial injury
12. Possible skull penetration or depressed fracture
BRAIN INJURY PATHOPHYSIOLOGY 13. Suspected child abuse
Primary Brain Injury Secondary Brain Injury
(occurs at time of impact) CHILDHOOD HEAD INJURIES: STATISTICS
• Intracranial • Occurs over hours to days (hypoxia, • 85% are “mild”, but…
hemorrhage hypercarbia, hypotension/ischemia, • 80% of children with multiple traumas die because of severe head
• Diffuse axonal injury intracranial hypertension, acidosis, injury (50% in adults)
• Hyperemia/edema seizures, hyperthermia, hypothermia, o > Head/body ratio
• Ischemia, release of infections o Softer skull
toxic mediators • Goal of management for TBI is always o Open fontanelles
reduce further secondary brain injury.
DEFINING SEVERITY
INCREASED ICP AND HERNIATION • Mild- GCS (13-15)
• “Monro-Kelly- doctrine” • Moderate- GCS (8-13)
• Intracranial Volume = Volume (CNS) + Volume (CSF) + Volume (Blood) + • Severe- less than 8
Volume (Lesion) Table 53.1 Normal ICP
o Brain parenchyma (1400mL) MYTH
o Cerebral blood volume Age group Normal • Myth… Younger children recover better than older children.
(!50mL) range • Fact… The developing brain may be at more risk. It will take longer to
o CSF (150mL) (mmHg) see the effects of the brain injury.
• Clinical Signs of Increased ICP Adult and <10-15
o Pupillary dilatation older EPIDURAL HEMATOMA
(unilateral or bilateral) children • Accumulation of blood between the inner
o Asymmetric pupillary Young 3-7 membrane of skull and above the dura
reaction to light children mater.
o Decerebrate or decorticate Term infants 1.5-6 • Usually caused by damage to the middle
positioning meningeal artery.
o progressive deterioration of neurologic examination • “lucid intervals” is common but in
Epidural Hematoma but can also be
CEREBRAL PERFUSION PRESSURE Table 53.2 Cushing’s triad with found in Subdural Hematoma
AND CEREBRAL AUTOREGULATION elevated ICP • Does not cross the suture lines
• The critical parameter for 1. Hypertension • Biconvex lenticular shape
brain function and survival is 2. Bradycardia
not actually ICP, rather CBF 3. Respiratory irregularity
(cerebral blood flow) to meet
CMRO2 demand (cerebral metabolic rate of oxygen)
• CPP= MAP – ICP
• Normal CPP for adults is 50mm Hg.
• For head injury always maintain a CPP of >70mmHg

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Practice guideline: Surgical management of EDH Timing of surgery
Indications for surgery Level III: ASDH meeting surgical criteria should be evacuated ASAP (for
Level III: issues regarding timing of surgery, see text)
1. EDH volume* >30cm3 should be evacuated regardless of GCS
2. EDH with all of the following characteristics can be managed non- Surgical methods
surgically with serial CT scans and close neurological observation in Level III: ASDH meeting the above criteria for surgery should be
a neurosurgical center: evacuated via craniotomy with or without bone flap removal and
a. Volume* <30cm3 duraplasty (a large craniotomy flap is often required to evacuate the thick
b. And thickness <15mm coagulum and to gain access to possible bleeding sites).
c. And midline shift (MLS) <5mm
d. And GCS >8 PEDIATRIC FALLS FROM HEIGHTS
e. And no focal neurologic deficit • Falls From 1 - 3 Stories Often Not Fatal
*note: to estimate, the volume of a lens=1.6 to 2 x r2t = 0.4 to 0.5 x d2t = • Falls Less Than 4 Feet Often Reported in Fatal Injuries
(A x B x T)/2 as in an ellipsoid, ½ the products of the height times the AP o Unwitnessed
diameter and the thickness T. for a 1.5cm thick EDH to be <30 cc, it would o Subdurals
have to have a diameter <7.7-8.6 cm o Retinal Hemorrhages
• Falling off a Bed or Couch Should Not Kill!
Timing of surgery
Level III: it is strongly recommended that patients with an acute EDH and COUP - CONTRA COUP INJURY
GCS < 9 and anisocoria undergo surgical evaluation ASAP.

SUBDURAL HEMATOMA
• Accumulation occurring between
inner aspect of dura and arachnoid
mater. Some call it the “dural border
cell layer”
• Associated with damage to the
bridging veins.

MANAGEMENT OF TBI INITIAL MANAGEMENT

• Level II and III (adult and pediatric):
o AVOID HYPOTENSION AND HYPOXIA
o Know Age Based Normals (For children keep BP > 5th %tile)
o In adults, MBP > 90.
o PaO2<60 mmHg or O2 saturation <90%
o Intubate if GCS < 9 (peds) and Airway or Oxygenation is Unstable
(adults)
o Avoid Sedation if possible, not only does it alter neuro exam but it
may cause longer ICU stays, pneumonia, possibly sepsis.

EMERGENCY MANAGEMENT

AIRWAY
• Handle Neck with Caution: Assume C-spine Injury
• Use Jaw Thrust with caution make sure to protect the neck at all cost.
• Avoid Obstruction of Venous Drainage
• Intubate If GCS < 8
o If suspecting basal skull avoid nasotracheal intubation
o Prevent the ability to assess the patient verbally
o Risk of pneumonia

BREATHING
• Even a Small Rise in PaCO2 Causes a Significant Rise in ICP
• “Adequate” Breathing May Not Be Enough- Aim for PaCO2 of 35-40 Torr
• Hyperventilation Is the Quickest Way to Lower ICP If There Are Signs of
Herniation

Practice guideline: Surgical management of ASDH CIRCULATION

Indications for surgery • Blood Pressure Must Be Optimized to Help Maintain Adequate CPP
Level III: • Only Use Isotonic Fluids for Volume Expansion
1. ASDH with thickness >10mm or midline shift (MLS) >5mm (on CT) • May Need Inotropic or Pressor Support
should be evacuated regardless of GCS • Control Bleeding
2. ASDH with thickness <10mm and MLS <5mm (see text regarding the
evacuation of ASDH <10mm thick) should undergo surgical DISABILITY
evaluation if:
• Glasgow Coma Score
a. GCS drops by ≥2 points from injury to admission
o Modified for Children
b. And/or the pupils are asymmetric or fixed and dilated
• Cranial Nerve Exam
c. And/or ICP is >20 mmHg
o Including Pupillary Response to Light, Eye Position and
3. Monitor ICP in all patients with ASDH and GCS <9
Movement, Corneal Sensation, Gag

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• Motor, Sensory, Reflex Exam III- diffuse injury • MLS 0-5mm 29%
• Cranial Exam (swelling) • Basal cisterns compressed or
o Evaluate for Fractures, CSF Leak, Battle’s Sign Etc. completely effaced
• No high or mixed density lesions
>25cm3
IV – diffuse injury • MLS >5mm 44%
(shift) • No high or mixed density lesions
>25cm3
V – evacuated mass • Any lesion evacuated surgically 30%
lesion
VI – non-evacuated • High or mixed density lesions 34%
mass lesion >25cm3
MEASURES HOW TO LOWER ICP
• not surgically evacuated
1. Positioning
a. Elevate HOB 30-45
b. Head midline
2. Light sedation
a. Codeine 30-60mg
3. Avoid hypotension
4. Control Hypertension
5. Prevent hyperglycemia
6. Intubation
7. Avoid hyperventilation
8. Prophylactic hypothermia

BRAIN PARENCHYMAL INJURY

Concussion
• Transient alteration of consciousness following a non-penetrating blow
to the head.
• Substantial concern that repetitive minor head trauma may initiate a
chronic neurodegenerative process called (CTE) Chronic Traumatic
Encephalopathy.
• Second Impact Syndrome- rare condition primarily in athletes who
sustain secondary injury while symptomatic from an earlier one.

CEREBRAL CONTUSION
• High attenuation areas (AKA
hemorrhagic contusions). Usually
produce less mass effect than their
apparent size. Most common in areas
where sudden deceleration of the head
causes the brain to impact on bony
prominences.

Practice guideline: Surgical management of TICH

• Level III: Indications for surgical evaluation for TICH:
o Progressive neurological deterioration referable to the TICH,
medically refractory IC-HTN, or signs of mass effect on CT
o Or TICH volume >50cm3 cc or ml
o Or GCS = 6-8 with frontal or temporal TICH volume >20cm3 with
midline shift (MLS) ≥5mm and/or compressed basal cisterns on CT
• Non-operative management with intensive monitoring and serial imaging:
may be used for TICH without neurologic compromise and no significant
mass effect on CT and controlled ICP

TRAUMATIC AXONAL INJURY

• Believed to result from shearing forces that damage axons during
acceleration deceleration

Table 51.9 Marshall CT Classification of TBI

Category Description Mortality
I – diffuses injury • No visible pathology 6.4%
II – diffuse injury • MLS of 0-5mm 11%
• Basal cisterns remain visible
• No high or mixed density lesions
>25cm3 estimated volume, may
include bone fragments & foreign
bodies

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