MANAGEMENT OF CRANIOCEREBRAL TRAUMA

JAMES SORIANO, M.D. Fellow, Academy of Filipino Neurosurgeons Fellow, Philippine College of Surgeons Chief, Section of Neurosurgery, Davao Doctors Hospital Program Director, Southern Philippines Integrated Neurosurgical Training Program Chairman, Southern Philippines Joint Committee for Neurosurgical Training

Use of Glasgow Coma Scale 1. Minimal Head Injury GCS 15, no LOC, (-) amnesia 2. Mild Head Injury - GCS 14 / GCS 15 + LOC < 5 min /

impaired alertness or memory 3. Moderate Head Injury - GCS 9-13 / LOC > = 5 min

OR focal neurologic deficit 4. Severe Head Injury - GCS 5 8 5. Critical Head Injury - GCS 3 4

I. Grading of Craniocerebral Injuries

ALTERNATE SCORING SYSTEM

1. Mild Head Injury - GCS 14 15 2. Moderate Head Injury - GCS 9 13 3. Severe Head Injury - GCS

II. Evaluation of Head Injury

1. Neurosurgical examination a. General Physical examination 1. 50 60% of GCS

b. Neuro- oriented physical exam 1. visual: raccoons eye, battles sign/ CSF rhinorrhea or otorrhea / hemotympanum 2. palpate: instability of facial bones/ orbital rim step-off 3. auscultate over carotids/ globe of eye

2. Neurologic exam a. GCS/ Orientation if communicative

b. Cranial nerve II (funduscopy and vision) / III/

eye movement/ VII c. motor exam- cooperative/ uncooperative,

spine function evaluation if doubtful d. sensory cooperative/ uncooperative

(central response of grimace/vocalization) e. reflexes f. resistance to neck flexion (defer if cervical injury)

3. Laboratory exams

a. Blood tests tailored-made to physical findings.

b. Skull xrays especially penetrating

injuries / spine xrays

c. Cranial ct scan - non contrast unless necessary

1. GCS

III. Management of Head Injuries Objective: Detect and Treat Intracranial Hypertension

Treatment/ Measures to Lower ICP: - prevent brain ischemia by maintaining normal CBF and metabolism - treat with persistent elevations above 15 25 mmHg if surgical lesion --- operate!

A. General Measures 1. Positioning- elevate head and back

30 45 degrees, head midline

2. Avoid hypotension (SBP < 90 mmHg)

3. Normovolemia

4. control hypertension

5. prevent hyperglycemia

6. intubate patients with GCS

B. Measures for Increased ICP

1. heavy sedation and/or paralysis when necessary 2. CSF drainage, when using intraventricular catheter ICP monitor)

3. OSMOTIC THERAPY

a. mannitol- 0.25 1 gm/kbw bolus < 20 min give q 4- 6 hrs

-may alternate w/ furosemide:

adults: 10 20 mg IV q 6 hrs pedia: 1mg/kg max 6 mg max IV.

- may alternate with hypertonic saline

b. euvolemia or slight hypervolemia

c. hold osmotic therapy if serum osmolarity >/= 320 mOsm/L or SBP < 100.

4. Hyperventilation (HPV) to pCO2 = 30 -35 mmHg

a. do not use prophylactically

b. avoid aggressive HPV (pCO2)

C. Second tier therapy for persistent IC-HTN no previous surgical lesion or postoperative

If IC-HTN refractory to A + B:

1. repeat head CT scan to r/o new, surgical condition

2. EEG to r/o status epilepticus

1. high dose barbiturate therapy: if ICP remains > 20 25 mmHg

2. hyperventilate to pCO2 = 25 30 mmHg 3. hypothermia: monitored for drop in

cardiac index, thrombocytopenia, elevated creatinine clearance and pancreatitis

4. decompressive craniectomy

IV. Management of Specific Injuries

1. Superficial Injuries a. Scalp contusion cold compresses then warm compresses

b. Scalp Hematomas 1. Subgaleal hematoma crosses suture lines 2. Subperiosteal hematoma (cephalhematoma)

- no evacuation - resolves 2- 4 weeks

c. Scalp lacerations- CDW (foreign bodies)

deep sutures/ single layer.

2. Skull Fractures

a. Linear skull fractures Posttraumatic Leptomeningeal Cyst/ growing skull fx

b. Depressed skull fractures tx 1. Simple/ closed cosmetic/ deficit related to underlying brain/ CSF leak

>thickness of skull

2. Open/ compound surgical

3. Cerebral/ Intracranial Injuries

a. Cerebral concussion transient alteration in consciousness as a result of non-penetrating traumatic injury to the brain - no gross or microscopic parenchymal abnormalities - symptomatic treatment

b. Cerebral contusion/ traumatic intracerebral hemorrhage 1. common in brain abutting bony prominences: frontal, temporal, occipital poles 2. medical treatment unless herniation 3. coupe vs contrecoupe injuries

c. Hematomas 1. Subarachnoid hemorrhage- most common cause is severe head injury

2. Traumatic subdural hygroma -simple vs. complex - tear in arachnoid - asymptomatic hygromas do not need treatment

3. Acute epidural hematoma

- rare below 2yrs old and after 60 yrs old

- 85% arterial bleeding (usually from middle meningeal artery)

- lucid interval - < 30%, 60 % with fracture

- Kernohans notch phenomenon

- lens-shaped(biconvex) hematoma on CT scan

Indications for surgery: 1. any symptomatic epidural hematoma 2. acute epidural hematoma> 1cm. may do medical treatment if < 1cm thick 3. pediatric epidural hematoma 4. > 30 cc hematoma volume

4. Subdural hematoma- from brain contusion/ laceration or bridging vein laceration a. Acute subdural hematoma - presents within 3 days after head injury

- crescent- shaped on ct scan

- Indications for surgery : symptomatic hematomas, > 1cm thick

> 30 cc volume

b. Subacute subdural hematoma presents 4 days to 2- 3 wks after trauma - clot starting to dissolve/ various stages of dissolution - clot may be isodense with brain - Indications for surgery: as in acute subdural hematoma

c. Chronic subdural hematoma - presents usually > 3 weeks and 1cm maximum thickness,

> 30 cc volume