Head Injury

Tsegazeab Laeke,MD ,FCS(ECSA)

August 1,2018
 Objectives
• Review Anatomy and Physiology of Brain
as it applies to head trauma
• Discuss classification of Head Injuries
• Discuss Management of Head Injuries
– Medical
– Surgical
• Discuss issues in Management of head
injury at BLH
 Your Head is Like a Walnut….
• Hard Shell, good stuff is inside
 Brain: Anatomy and Physiology
• Unique
– Rigid Skull – filled with blood, brain, CSF
– Autoregulatory mechanism to control cerebral blood
flow
• Vasodilation/ vasoconstriction
– In response to changes in systolic BP
• Chemoautoregulation
– Vasoconstriction in response to hypocapnia
– Vasodilation in response to hypoxia
– Brain injury can disrupt this mechanism
 Brain: Anatomy and Physiology
• Acute increase in mass in brain
– Initial compensation = venous constriction and
displacement of CSF
– Eventually compensation fails, blood flow to
brain is reduced
 Monroe-Kellie Doctrine

Venous Arterial Brain CSF

Volume Volume

Compensated State (Normal ICP)

Venous Arterial Brain Mass CSF
Volume Volume

Uncompensated State (Elevated

Arterial ICP)
Brain Mass CSF
Volume
 Volume Pressure Curve
50 60

Herniation
ICP (mm Hg)
20 30 40

Point of Decompensation
10

Compensation
0

Volume of Mass
 Intracranial Pressure

10 mm Hg > 20 mm Hg >40 mm Hg
Normal Abnormal Severe
 Cushing Response
• Compensation for increased ICP

MAP – ICP = CPP

Normal 90 10 80
Cushing’s Response 100 20 80
Hypotension 50 20 30

Increased ICP may reduce CBF

may cause secondary brain injury
 Autoregulation
• If autoregulation intact, CBF is maintained
when mean arterial pressure (MAP) =50 –
160 mmHg
• In moderate or severe head injury,
autoregulation is often impaired
– Brain more vulnerable
– Episodes of hypotension can lead to secondary
brain injury
Classification of Brain Injury

GCS 14-15 GCS 9-13 GCS ≤8

Mild Moderate Severe
 Classification of Brain Injury
• Blunt Head Injury
– High vs Low velocity –
• Road traffic accidents, fall from height, assault
– Penetrating Head injuries
• Gun Shot wound, missile
 Classification of Brain Injury
• Skull Fractures
– Depressed vs non-Depressed
– Open vs Closed
• With or without CSF leak
– Location
• Vault
• Across midline
• Basilar skull fractures
– NG tube Contraindicated
 Classification of Brain Injury
• Focal
– Epidural
– Subdural
– Intracerebral
• Diffuse
– Concussion
– Multiple intracerebral contusions
– Diffuse Axonal Injury (DAI)
– Hypoxic/ Ischemic Injury
 Diffuse Brain Injury
Mild Severe
• Concussion injury
– Often normal CT head
– H/A, nausea, vomiting, +/- loss of consciousness,
• DAI
– Shear force to brain (acceleration/ deceleration/rotation)
• CT: loss of grey-white interface, slit ventricles
• High (50%) mortality rate
 Diffuse Brain Injury
Mild Severe

• Multiple Diffuse
Contusions
• Hypoxic Ischemic Injury
– Often secondary injury due to
raised ICP
 Epidural Hematoma
• Classic:
– Usually associated with skull
fracture – tear in middle
meningeal artery
– Often younger patients
– “lens shaped”
– Lucid interval
– Management: Evacuation
 Subdural Hematoma
• Clasically
– Older patient
– Venous tear
– CT: covers brain surface
– Management: Surgery if
decreased LOC, local
deficit
Intracerebral Hematoma (Contusion)
• Common
– in up to 30% Head traumas
– Frontal/ temporal region
• Coup/ contracoup injury
• CT: may evolve over time
• Management: variable
– Patient’s LOC
– Mass effect, location
 Management of Brain Injuries
• Priorities
– Minimize secondary brain injury
• ABCs
• A C = C-spine
• = Airway – is he protecting his airway?
– GCS< 9 = unable to protect airway ---- intubate
– Hypercapnia causes vasodilation, increasing ICP
• B = Breathing – is it compromised
– E.g. any secondary lung injuries?
– Administer O2
– Hypoxemia causes vasodilation, increasing ICP
• C = Circulation – is it adequate?
– Maintain sBP > 90 mm Hg
 Focused Neurological
Examination
• GCS Score:
– Motor – 6
– Speech – 5
– Eyes – 4
• Pupils
• Lateralizing signs
 Medical Management
• ABC’s
– Ensure Adequate Oxygenation/ Ventilation
• PaCO2 – normal (35 mm Hg)
– IV Fluids
• Isotonic – NS or Ringer’s
• Goal : Euvolemia
 Indications for Imaging
• Standard of Care?
– Skull X-ray
– Pre-contrast CT of the head
– C-spine x-ray
 Medical Management: Mannitol
• To be used with signs of tentorial herniation
• Dose: 1.0 gm/kg IV bolus
• Only use in the acute setting
• Functions:
– Plasma expander ---- increases CBF
– Osmotic effect – draws in edema from brain
• Alternative: Lasix – 40mg IV
 Medical Management:
Hyperventilation
• To be used with signs of tentorial herniation
• Should only be used in the acute setting
– Can significantly reduce ICP
– Not effective > 24 hours
 Medical Management: Head
Elevation
• Increases venous return/ decreases cerebral
venous congestion
• Use only if no contraindications
Medical Management: Anti Seizure
Medications
• If severe head injury (GCS ≤ 8),penetrating
head injury,history of seizure disorder
• Reduces risk of acute seizures in first week
only
– 30% incidence in severe head injury, 1% mild to
moderate
• Load phenytoin IV 1gm over 1 hour then 300mg od X 7
days (73% reduction – Temken, NEJM 1990)
– No effect on late seizures
 Medical Management: Sedation
and Paralytics
• Generally NO
• May help reduce ICP in agitated patient
however
• Loose neurological examination
• May induce hypotension
 Medical Management: Antibiotics
• Yes: open skull fractures (controversial)
• Yes: prophylactic prior to OR
• Within 30 minutes of scalp incision
 Medical Management: ICP
Monitoring and Management
• ICP Monitoring Device
– External Ventricular Drain
– Richmond Bolt/ Camino Catheter
• ICP Management
– Drain CSF
– Sedation/ paralytics
– Mannitol, 3% NS
 Medical Management:
Controversial
• Barbituate Coma
– Usually with ICP device
– Loose neurological examination
• Hypothermia Treatment
 Surgical Management
• Scalp laceration alone
– Can be site of major blood loss
– Focus on controlling bleeding
• Direct pressure
• Suture in layers
– 3.0 vicryl galea = strength layer
– 3.0 non-absorbable for skin
 Surgical Management
• Skull Fractures
– Linear, closed – conservative management
– Linear open – close overlying skin
– Basal Skull fracture
• Assess for CSF leak (nose, ear)
• Assess CN involvement
– Temporal bone fracture – LMN CN VII palsy
 Surgical Management
• Depressed Skull Fractures
– If not depressed > depth of bone – conservative
management
– If depressed > depth of bone
• Elevate bone
• Examine for dural tear ------ close (4.0 vicryl, non-cutting)
• Examine for epidural of subdural collection
 Surgical Management
• If CT head
– Epidural/ subdural collection
• >5mm midline shift with focal deficit ----- OR
– Contusions
• Generally non-surgical
– Non-dominant frontal/ temporal with decreased LOC
– DAI
• Completely non surgical
 Surgical Management
• If NO CT head and patient has decreased
LOC and lateralizing signs
– Exploratory burr holes
• Which ones?
– In order of likelihood of location
 Surgical Management:
Craniectomy
• EXTREMELY controversial
• Removal of Bone Flap
• Allows Brain to swell while preventing
rises in ICP
• Limitations
– “stretch of brain structures”
– ? Allows poor grade patients to survive
 Summary
• Your Head is Like a Walnut……….
• Initial Management: ABCs
• Evidence of Tentorial Herniation
– Think temporizing measures
• Airway, hyperventilate, mannitol, elevate head
• Surgical Management
– Consult your neurosurgeon