An Overview of Head Injury Management

Eldad J. Hadar, M.D.Department of Neurosurgery

Checklist

• Definitions– Glasgow Coma Scale– Intracranial Pressure

• Mechanisms of brain injury• Evaluation of head injury• Management of head injury

– Operative– Nonoperative

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

Checklist

Definitions– Glasgow Coma Scale– Intracranial Pressure

• Mechanisms of brain injury• Evaluation of head injury• Management of head injury

– Operative– Nonoperative

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

Glasgow Coma Scale (GCS)

Intracranial Pressure (ICP)

• Normal CPP > 50 mm Hg

• Autoregulatory mechanisms maintain CBF at CPP’s down to 40 mm Hg

CPP = MAP – ICP

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)

Checklist

• Definitions– Glasgow Coma Scale– Intracranial Pressure

• Mechanisms of brain injury• Evaluation of head injury• Management of head injury

– Operative– Nonoperative

Mechanisms of Traumatic Brain Injury

• Impact injury• Cerebral or brainstem contusions• Cerebral lacerations• Diffuse axonal injury (DAI)

• Secondary injury• Intracranial hematoma• Edema• Ischemia

Checklist

• Statistics• Definitions

– Glasgow Coma Scale– Intracranial Pressure

• Mechanisms of brain injury• Evaluation of head injury• Management of head injury

– Operative– Nonoperative

Initial Assessment

History– LOC +/-

– Intoxicants

– Seizure

– Posttraumatic amnesia

• Physical Exam– GCS

– Level of consciousness

– Cranial nerves

– Fundoscopic exam

– Motor exam

Start with ABC’s

Radiographic Evaluation

• CT• Imaging study of choice for initial work-up

• MRI• More helpful later in hospital course

• Skull x-rays

• Arteriography

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

Checklist

• Definitions– Glasgow Coma Scale– Intracranial Pressure

• Mechanisms of brain injury• Evaluation of head injury• Management of head injury

– Operative– Nonoperative

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.

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.

Nonoperative Management

• Frequent neuro checks

• Frequent neuro checks

• Frequent neuro checks

• ICP monitoring

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

Indications for ICP Monitoring

• Loss of neurological examination• Sedation

• General anesthesia

Clinical Scenario

• 20 y.o. male in MVA– Intubated

• Score 1T

– Eyes open to pain• Score

2

– Briskly localizes• Score

5

• Total GCS8T

ICP Monitor

Preferred method in Guidelines

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)

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.

Operative Management

• Types of mass lesions• Epidural hematoma

• Subdural hematoma

• Cerebral contusion

• Decompressive craniectomy/brain resection

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

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

Cerebral Contusion

• Often little mass effect

• Not often operative

Pre-op Post-op

Hemicraniectomy

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.