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An Overview of Head Injury Management
Eldad J. Hadar, M.D.Department of Neurosurgery
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Checklist
• Definitions– Glasgow Coma Scale– Intracranial Pressure
• Mechanisms of brain injury• Evaluation of head injury• Management of head injury
– Operative– Nonoperative
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Head Injury Guidelines• 1995 – 1st edition• 2000 – 2nd edition• 2007 – 3rd edition• Level I – Accepted
principles reflecting high degree of clinical certainty
• Level II – Strategies reflecting moderate degree of clinical certainty
• Level III – Degree of clinical certainty not established
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Checklist
Definitions– Glasgow Coma Scale– Intracranial Pressure
• Mechanisms of brain injury• Evaluation of head injury• Management of head injury
– Operative– Nonoperative
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Glasgow Coma Scale (GCS)
• Introduced by Teasdale and Jennett in 1974
• Consists of 3 clinical signs that have – Prognostic significance– Good reproducibility between observers
• Scale range 3-15
• GCS < 8 has generally become accepted as representing coma / severe head injury
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Glasgow Coma Scale (GCS)
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Intracranial Pressure (ICP)
• Normal CPP > 50 mm Hg
• Autoregulatory mechanisms maintain CBF at CPP’s down to 40 mm Hg
CPP = MAP – ICP
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Intracranial Pressure (ICP)
• In head injury, ICP > 20-25 mm Hg may be more detrimental than low CPP (increasing CPP may not afford protection from intracranial hypertension).
• Aggressive attempts to maintain CPP > 70 should be avoided due to ARDS (Level II)
• CPP<50 should be avoided (Level III)
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Checklist
• Definitions– Glasgow Coma Scale– Intracranial Pressure
• Mechanisms of brain injury• Evaluation of head injury• Management of head injury
– Operative– Nonoperative
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Mechanisms of Traumatic Brain Injury
• Impact injury• Cerebral or brainstem contusions• Cerebral lacerations• Diffuse axonal injury (DAI)
• Secondary injury• Intracranial hematoma• Edema• Ischemia
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Checklist
• Statistics• Definitions
– Glasgow Coma Scale– Intracranial Pressure
• Mechanisms of brain injury• Evaluation of head injury• Management of head injury
– Operative– Nonoperative
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Initial Assessment
History– LOC +/-
– Intoxicants
– Seizure
– Posttraumatic amnesia
• Physical Exam– GCS
– Level of consciousness
– Cranial nerves
– Fundoscopic exam
– Motor exam
Start with ABC’s
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Radiographic Evaluation
• CT• Imaging study of choice for initial work-up
• MRI• More helpful later in hospital course
• Skull x-rays
• Arteriography
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Indications for CT
• Presence of any criteria placing patient at moderate or high risk for intracranial injury
• Assessment prior to general anesthesia for other procedures
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Checklist
• Definitions– Glasgow Coma Scale– Intracranial Pressure
• Mechanisms of brain injury• Evaluation of head injury• Management of head injury
– Operative– Nonoperative
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Head Injury Management
• Nonoperative• Seen in absence of significant intracranial mass
lesion.• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative• Typically required when a significant intracranial
mass lesion is present.• Decompressive craniectomy or brain resection less
common.
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Head Injury Management
• Nonoperative• Seen in absence of significant intracranial mass
lesion.• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative• Typically required when a significant intracranial
mass lesion is present.• Decompressive craniectomy or brain resection less
common.
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Nonoperative Management
• Frequent neuro checks
• Frequent neuro checks
• Frequent neuro checks
• ICP monitoring
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Indications for ICP Monitoring
• No data to support Level I recommendation
• Severe head injury (GCS 3-8) with abnormal CT (Level II)
• Severe head injury (GCS 3-8) with normal CT and 2 of the following (Level III):
• Age > 40 years
• Unilateral or bilateral motor posturing
• SBP < 90 mm Hg
• Mild-moderate head injury at discretion of treating physician
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Indications for ICP Monitoring
• Loss of neurological examination• Sedation
• General anesthesia
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Clinical Scenario
• 20 y.o. male in MVA– Intubated
• Score 1T
– Eyes open to pain• Score
2
– Briskly localizes• Score
5
• Total GCS8T
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ICP Monitor
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Preferred method in Guidelines
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Therapy for Intracranial Hypertension
• First tier• Positioning• Ventricular drainage• Osmotic diuresis• Hyperventilation (Level III – temporizing measure)
• Second tier• Sedation• Neuromuscular blockade• Hypothermia• Barbiturate coma
• Glucocorticoids not recommended (Level I)
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Head Injury Management
• Nonoperative• Seen in absence of significant intracranial mass
lesion.• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative• Typically required when a significant intracranial
mass lesion is present.• Decompressive craniectomy or brain resection less
common.
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Operative Management
• Types of mass lesions• Epidural hematoma
• Subdural hematoma
• Cerebral contusion
• Decompressive craniectomy/brain resection
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Epidural Hematoma (EDH)
• 1% of head trauma admissions• Male: Female = 4:1• Source of bleeding is arterial in 85% of
cases (middle meningeal artery)• Mortality ranges from 5-10% with optimal
management• Neurological injury caused by secondary
mechanisms
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Subdural Hematoma (SDH)
• About twice as common as EDH
• Mortality 50-90%• Impact injury much higher than with EDH
• Often associated brain injury
• Two common sources of bleeding• Tearing of bridging veins
• Cortical laceration
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Cerebral Contusion
• Often little mass effect
• Not often operative
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Pre-op Post-op
Hemicraniectomy
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Key Points
• 2 mechanisms of brain injury• Impact injury
• Secondary injury
• GCS < 8 has generally become accepted as representing coma / severe head injury
• CT is generally the imaging study of choice in the acute assessment of head injury
• Operative and nonoperative strategies are generally aimed at reducing mass effect and, therefore, reducing ICP
• Nothing beats a neuro exam.