Case Presentation and Discussion on Craniofacial Injury

Jeffy G. Guerra, MDLevel III Surgery Resident

Department of SurgeryOspital ng Maynila Medical Center

24 January 2006

General Data:

B.A

6-year-old female

Sta. Ana, Manila

Chief Complaint:

“Loss of consciousness”

History of the Present Illness:

Eight hours PTA Patient while riding on her bicycle was allegedly hit by a

moving vehicle

sustaining head injury

(+) Loss of consciousness,

(+) Vomiting 2x

apparently recovered

no consult, no meds taken

History of the Present Illness:

One hour PTA Patient became lethargic and had an episode of

vomiting

Consult

Primary Survey for Trauma

• Airway – intact no obstruction

• Breathing – spontaneous, clear breath sounds

• Circulation – BP = 90/50, HR = 90, RR 18

Primary Survey for Trauma

• Deficits/Deformity – GCS= 13, no limb deformities

• Exposure – none, cleared from site of injury

5/5 5/5

5/5 5/5

100 100

100 100

++ ++

++ ++

motor sensory DTR

Initial Neurological Evaluation

• GCS 13 (E3V4M6)

• PERL 2-3mm

• Full extraocular eye movement

• No motor deficits on all extremities

• (+) hematoma, Parietal area, right

Physical Examination

GEN Drowsy, stretcher-borne, not in cardio-respiratory distress

VITAL SIGNS BP= 90/50 CR= 90 RR= 18 36.9 C

HEENT Pink palpebral conjunctiva, anicteric sclera, pupils equally reactive to light, no nasal discharge, no pharyngeal congestion, (+) parietal hematoma, R

CHEST Symmetrical chest expansion, no retractions, clear breath sounds

HEART Adynamic precordium, normal rate, regular rhythm, no murmurs

ABDOMEN Flat, active bowel sounds, soft, non-tender

SKIN Warm, dry

EXTREMITIES (-) edema, full equal pulses on all extremities

Neurological Exam

• Cerebrum: – drowsy

• Cerebellum: – n/a

• E3M6V4 • GCS= 13

Cranial Nerves:

I n/a

II-III PERTL

III,IV,VI Full EOMs

V (+) bicorneal reflex

VII no facial assymetry

VIII (+) auditory stimulus

IX, X (+) gag reflex

XI Shrug shoulders

XII no tongue deviation

Neurological Exam

• Pathologic Reflex: (-) Babinski

5/5 5/5

5/5 5/5

100 100

100 100

++ ++

++ ++

motor sensory DTR

Past Medical History:

No previous hospitalization

No other pertinent medical condition

Family History

Unremarkable

Growth and Development

Patient’s development at par with age

Immunization History

Complete Immunization

Salient Features

6-year-old female

(+) Loss of consciousness*

(+) Lucid interval*

(+) Vomiting

GCS= 13

(+) hematoma, parietal area, right

Head Injury

↓

Traumatic Hematoma

↓ ↓

Epidural * Intradural

↓ ↓

Subdural* Intracerebral

*Jamieson, KG (epidural: 50%, intradural: 45%)

Clinical Diagnosis

Diagnosis Certainty Treatment

Primary

Epidural hematoma secondary to VA

60% Surgical/Medical

Secondary

Intradural hematoma secondary to VA

40% Surgical/Medical

Surgeon directed trauma team initial evaluation of

Head InjuryEnsure Airway:

Intubate for GCS<9

Ensure Circulation: Keep Systolic BP >100mmHg

Ensure breathing: KeepO2 Saturation >94%

Signs of Elevated ICP?(increasing obtundation,

dilated pupils)

Hyperventilation to PaCO230-35mmHg<2 hours)

Mannitol 1g/kgConsider IVC placement

Consider hypertonic NaClConsider barbiturate therapy

Surgical Lesion?

Observation, other studies as necessary

Admit to ICU

Head CT Scan

Consult Neuro Surgery

Operating Room

GCS<15, ProlongedLOC, or Focal Neuro

Signs?

Yes

No

Yes

No

Abnormal

No Yes

Normal

Paraclinical Diagnostic Procedure

Do I need a paraclinical diagnostic procedure?

yes

Goal

• Determine location and size of hematoma, and accompanying brain injury

• Determine treatment plan

PARACLINICAL DIAGNOSTIC PROCEDURE

OPTIONS BENEFIT RISK COST AVAILABILITY

Skull x-ray Able to identify the fractureUnable to identify Intracranial bleeding

RADIATIONEXPOSURE

Php 150 +

CT SCAN 98% sensitivity

.

RADIATION EXPOSURE

Php 3000 -

MRI 98% sensitivity ???? Php 15000 -

ANGIOGRAPHY

98% sensitivity INVASIVE PROCEDURE

Php 5000 -

CT Scan

CT Scan Result

• There is a lentiform hyperdense focus in the right occipital convexity, measuring about 2.26 x 4.27 cm

• No shift in the midline

• No fracture

EPIDURAL HEMATOMA, RIGHT OCCIPITAL CONVEXITY

Pre-Treatment Diagnosis

Epidural Hematoma, right occipital area

secondary to Vehicular accident

Surgeon directed trauma team initial evaluation of

Head InjuryEnsure Airway:

Intubate for GCS<9

Ensure Circulation: Keep Systolic BP >100mmHg

Ensure breathing: KeepO2 Saturation >94%

Signs of Elevated ICP?(increasing obtundation,

dilated pupils)

Hyperventilation to PaCO230-35mmHg<2 hours)

Mannitol 1g/kgConsider IVC placement

Consider hypertonic NaClConsider barbiturate therapy

Surgical Lesion?

Observation, other studies as necessary

Admit to ICU

Head CT Scan

Consult Neuro Surgery

Operating Room

GCS<15, ProlongedLOC, or Focal Neuro

Signs?

Yes

No

Yes

No

Abnormal

No Yes

Normal

Critical Factors for Surgical evacuation

• Patient’s neurologic status

• Imaging findings

• Extent of extracranial injury

Indications for Surgical Evacuation

• Subdural or epidural hematoma – >5mm thick– Midline shift– GCS<8

Controversial groups needing evacuation

• Subdural or epidural hematoma – 5-10mm thick– GCS of 9 - 13

Goals of Treatment

• Complete evacuation of hematoma

• Resolution of neurologic deficit

• Prevention of complications of herniation

Treatment Options

Options Benefit Risk Cost Availability

MedicalSR = 23%*

MR: >15% (with salvage

surgery)P 4000/day Available

CraniotomySR = 90-100% *

MR: 0-5% P 15,000 Available

*Laboto et al

Treatment Plan

Craniotomy

Evacuation of Hematoma

Pre-operative Preparation

• Informed consent -Plan Carefully explained to relatives

• Psychosocial support• Optimize patient’s health

- Resuscitation

• Screen for any condition that will interfere with treatment

• Prepare materials for OR

Operative Technique

• Patient supine under GETA• Asepsis/Antisepsis• Sterile drapes placed• Skin Incision carried from temporo-parietal area• Initial burr hole made over the temporal bone

with a cone-shaped burr• Bone between burr holes were cut using a Gigli

saw• Bone flap raised

Intraop Findings

• Upon opening, noted a 50ml reddish to brown fluid at the occipital epidural layer.

Operative Technique• Hematoma evacuated• NSS wash• Hemostasis assured• Correct instrument and sponge count• Temporo-pareital bone fixed• JP drain placed• Closure of the scalp using Silk 3-0• Dry sterile dressing• Patient tolerated the procedure

Operation Done

Craniotomy

Evacuation of Epidural Hematoma

Final Diagnosis

Epidural Hematoma, occipital area, R secondary to Vehicular Accident

Operation done

Craniotomy

Evacuation of Hematoma

Post-operative Management

• Basic needs supplied– Antibiotics

– Analgesia

– Comfort

• VS and NVS monitoring

• Patient maintained on NPO

Post-operative Management

• 1st HD NPO, mannitol

135 ml of PRBC was Transfused

• 3rd HD GCS= 15

NGT, drain and Foley Cath removed, mannitol taperd

• 5th HD DAT, D/C

Follow Up care

• 1 week after discharge for ROS

• 4 weeks after discharge to asses for any neurological changes

Sharing of Knowledge

BRAIN -- invested by various membranes

floated in a clear fluid and encased in a bony vault

-- 1,200 – 1,400G

-- 2% - 3% TBW

3 MembranesDura matter -- pachymaninx

-- outermost layerArachnoid -- middle layer

-- delicate non vascular membarne

Pia matter -- innermost layer -- follows contour of the brain

* Leptomeninges- arachnoid and pia matter

Cerebro Spinal Fluid-- Clear colorless fluid

-- containing small amount of CHON, glucose and potassium

-- serves as support and cushion of the CNS against Trauma

Head Injuries- most common cause of traumatic death in children

Main Causes:- Falls- Motor vehicular crashes- Pedestrian accidents- Bicycle injuries- Other injuries

Pathophysiology

• Brain swelling

• Increase mass effect

• Increase Intracranial Pressure

• Compromised brain perfussion

• Herniation of brain tissue across the tentorium, falx or through the foramen magnum causing significant morbidity and often death

Moderate to Severe Head Injuries-- usually present in obtunded or combative state-- Late clinical Findings:

unequal and non reactive pupilsfocal neurologic findingsabnormal posturing

In-hospital resuscitation and evaluation of moderate head injuries

• Rapid, systematic manner with diagnostic and therapeutic maneuvers proceeding simultaneously

• ABC’s of Trauma (airway, ventilation, preventing hypoxia and hypotension)

Initial neurologic evaluation and management

• In moderately injured, examination is abbreviated and should focus on– Level of consciousness– Pupillary light reflex– Extraocular eye movement– Motor examination

• Head should be palpated

• Signs of basal skull fracture(otorrhea)

• Triad suggestive of transtentorial herniation– Deteriorating level of consciousness– Pupillary dilatation– Hemiparesis

• Neurological exam: unreliable in accurately predicting intracranial pathology, tomography is usually indicated

Criteria for CT scanning following craniocerebral trauma

• GCS 14 or less

• GCS 15 with the following– Documented loss of consciousness– Focal neurologic deficit– Signs of basal skull fracture

Skull radiography and angiography

• In the absence of CT scan, skull radiographs are helpful

• Fractures are seen on– Epidural hematoma 66-100%– Subdural 18-60%– Intracerebral 40-80%

• Presence of skull fracture, although suggestive of hematoma is not a reliable indicator of the type of intracranial injury

• In rapidly deteriorating or comatose patient, cerebral angiography or exploratory burr holes is indicated

Early repeat CT: when indicated?

• When hemorrhagic but nonsurgical lesion in initial CT, a repeat within 4 – 8hrs should be done

• 60% with initial nonoperative lesion on initial CT required surgical intervention after the repeat

Interpreting Neurological findings

• Ipsilateral pupil dilatation - expanding hematoma causing transtentorial temporal herniation and oculomotor nerve impingement

• Moderate anisocoria and sluggish pupil – impending uncal herniation

Surgical management of acute traumatic intracranial hematomas

• Subdural or epidural hematoma – 5mm thick– Midline shift– GCS<8

Exploratory Burr holes

• First burr hole-temporal region, above the zygomatic arch according to neurological findings– Ipsilateral to the dilated pupil– Contralateral to the abnormal motor response– Ipsilateral to the skull fracture

Medical management of Intracranial hypertension

• Preemptive measures– Head elevation to 30 degrees– Mild hyperventilation (PaCO2 30-35mmHg)– Maintenance of euvolemia– Maintenance of CPP 70mmhg or higher– Maintenance of normothermia (<37.5) – Seizure prophylaxis

• Primary therapy– Ventricular cerebrospinal fluid drainage– Sedation– Neuromuscular blockage

• Secondary therapy– Bolus mannitol

• Tertiary therapy– Metabolic suppressive therapy with

barbiturates or profopol

Discussion

Complications of head Injuries

- dural tears

- Cerebral damage

- subdural and extradural hematoma

- Growing skull fracture

Discussion

Traumatic Intracerebral Hematomas & Contusion

--can occur in any region of the brain

--most commoly in subfrontal & anterior temporal regions at the base of the brain

--due to the impact of the brain on the rough surface of the skull base

--these may start as small lesions but may progressively enlarge

Discussion

Epidural Hematoma

--blood collects between the dura and inner table of the skull

--associated with arterial bleeding from the middle meningeal artery

--associated with lucid intervals, or period of unconsciousness

-- CT: Lenticular shape( football shape) hyperdense( white) he along the skull table

DiscussionSubdural Hematoma

--most common traumatic mass lesion

--20-40% of severely head injured px

--potential space between dura & arachnoidal meningeal layers

--ascribed to tearing of small veins that bridges the spaces between

cerebral cortex and overlying dura

-- CT: crescent shaped hyperdense hge

References1. Bricolo, AP, Pasut A. extradural hematoma: towards zero mortality:

A Prospective study.Neurosurgery.1984. pp14:8-122. Cooper, PR. Post traumatic mass lesions. Head Injury. 3rd ed.

Baltimore, william and wilkins.1993.pp275-3293. Haselberger, K, Putcher, A et al. prognosis after acute subdural and

epidural hemmrrhage. Acta Neurochir. 90:111-1164. Laboto, RD. head injured patients who talke and deteriorate into

coma. Analysis of 211 cases studied with CT. J Neurosurg. 75:256-261.

5. Ota F, Head Trauma and Hemorrhage. Department of pediatrics, university of Hawaii John A. Burns School of Medicine. May 2002

6. Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II.7. Youmans, JR. neurological surgery. A comprehensive guide to the

diagnosis and management of neurosurgical problems. 4th ed. Vol 3.

MCQ

1. Which of the following condition has a lens or football shaped findings on cranial CT scan?

a. Subdural hematoma

b. Epidural hematoma

c. Subarachnoid hge.

d. Cerebellar hge.

MCQ

2. What is the most common site of bone fracture in head trauma?

a. Temporal bone

b. Occipital bone

c. Parietal bone

d. Frontal bone

MCR

3. A 4-year-old child fell and hit his head on the carpet about 5 hours ago. There is no reported history of loss of consciousness or vomiting. His PE is normal, and he is acting appropriately at the time of visit. What would be your next management?1. Order for a CT scan2. Close Observation3. Refer to specialist4. Parental education

MCR 4

4. Which of the following statements are true regarding brain injury?

1. The extent is a function of the mechanism of injury

2. Contusions may occur on the side of the brain that is opposite the side of initial impact

3. Contusions tend to involve the anterior portions of the frontal and temporal lobes

4. The effects of secondary edema and hematoma enlargement may be delayed for several days

MCR

5. The following are included in the presumptive therapy in treating intracranial hypertension.

1. Head elevation to 30 degrees

2. Mild hyperventilation (PaCO2 30- 35mmHg)

3. Maintenance of euvolemia

4. Maintenance of CPP 70mmhg or higher

Case Presentation and Discussion on CNS Trauma

By:

JGGuerra, MD

Department of Surgery

Ospital ng Maynila Medical Center

Thank You For Your Kind Attention