Central Nervous System Trauma

Estrada Bernard, MD

Division of Neurosurgery

UNC Chapel

Central Nervous System Trauma

U.S fatalities >150,000/yr SCI >10,000/yr Disabled (prev) >200,000

Central Nervous System Trauma –Incidence (San Diego)

Head Inj

All

Head Inj

Mod/Sever

Spinal

1978 295 40

1981 180 44

1992 150 33 4.2

1997 144 34 4

Central Nervous System Trauma

Assume spinal injury Maintain alignment Watch for spinal shock

Head Injury

Primary Secondary

Secondary Head Injury

Elevated ICP Hypotension Hypoxemia/Hypercapnia Ischemia Seizures

Central Nervous System Trauma – Acute Evaluation

Primary survey (ABC) Initial neurological exam Post resuscitation exam

Central Nervous System Trauma – Airway Mgmt

Avoid hypoxia Avoid hypercarbia Avoid aspiration

Central Nervous System Trauma - Resuscitation

Goals BP > 90 mm Hg PaO2 > 60 mm Hg

Central Nervous System Trauma – Acute Mgmt

??? Sedation ??? Neuromuscular blockade ??? Mannitol ??? Hyperventilation

Cranial Nerve Injury

Olfactory

Optic

Abducens

Facial

Vestibulocochlear

Central Nervous System Trauma - Pathophysiology

Mediators Mechanical Neuroexcitation Free radical production

Skull Fractures

Types Risk factors

Skull Fractures

Linear 62% of severe HI

Depressed Simple Compound

Basilar csf fistula

Head Injury Mechanisms

Contact Skull deformation

Local - skull fx, EDH, coup Remote - vault, basilar fxs

Shock wave Contrecoup ICH

Head Injury Mechanisms

Acceleration Surface strain

SDH Contrecoup

Deep strain Concussion Dai

Focal Injury

Hematoma Extradural Subdural Intracerebral

Contusions Coup Contrecoup

Diffuse Injury

Concussion Diffuse axonal injury

Mild Moderate Severe

Central Nervous System Trauma – Clinical Trials

Cholinergic agents Corticosteroids Barbiturates Neuroexcitatory antagonists Free radical scavengers Calcium channel antagonists Hypothermia

Central Nervous System Trauma – Elevated ICP Rx

Progressive neurologic deterioration Transtentorial herniation

Steroids for Spinal Cord Injury

8 hour therapeutic window Methylprednisolone 30 mg/kg bolus 5.4 mg/kg/hr infusion over 23 hours

Cervical Spine Injuries

Atlanto-occipital dislocation Odontoid fractures Hangman’s fracture Jefferson’s fracture

Burst fractures Hyperflexion-anterior subluxation Facet dislocations Hyperextension injuries

Cervical Spine Injuries

Central Nervous System Trauma

Prevention is better than cure