An Overview of Head Injury Management

1. An Overview of Head Injury Management Eldad J. Hadar, M.D. Department of Neurosurgery

2. Checklist • Definitions • Glasgow Coma Scale • Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury • Operative • Nonoperative

3. 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

4. Checklist Definitions • Glasgow Coma Scale • Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury • Operative • Nonoperative

5. 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

6. Glasgow Coma Scale (GCS)

7. Intracranial Pressure (ICP) CPP = MAP – ICP • Normal CPP > 50 mm Hg • Autoregulatory mechanisms maintain CBF at CPP’s down to 40 mm Hg

8. 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)

9. Checklist • Definitions • Glasgow Coma Scale • Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury • Operative • Nonoperative

10. Mechanisms of Traumatic Brain Injury • Impact injury • Cerebral or brainstem contusions • Cerebral lacerations • Diffuse axonal injury (DAI) • Secondary injury • Intracranial hematoma • Edema • Ischemia

11. Checklist • Statistics • Definitions • Glasgow Coma Scale • Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury • Operative • Nonoperative

12. History LOC +/- Intoxicants Seizure Posttraumatic amnesia Physical Exam GCS Level of consciousness Cranial nerves Fundoscopic exam Motor exam Initial Assessment Start with ABC’s

13. Radiographic Evaluation • CT • Imaging study of choice for initial work-up • MRI • More helpful later in hospital course • Skull x-rays • Arteriography

14. 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

15. Checklist • Definitions • Glasgow Coma Scale • Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury • Operative • Nonoperative

16. 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.

17. 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.

18. Nonoperative Management • Frequent neuro checks • Frequent neuro checks • Frequent neuro checks • ICP monitoring

19. 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

20. Indications for ICP Monitoring • Loss of neurological examination • Sedation • General anesthesia

21. Clinical Scenario • 20 y.o. male in MVA • Intubated • Score 1T • Eyes open to pain • Score 2 • Briskly localizes • Score 5 • Total GCS 8T

22. ICP Monitor

23. Preferred method in Guidelines

24. 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)

25. 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.

26. Operative Management • Types of mass lesions • Epidural hematoma • Subdural hematoma • Cerebral contusion • Decompressive craniectomy/brain resection

28. 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

31. 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

32. Cerebral Contusion • Often little mass effect • Not often operative

34. Hemicraniectomy Pre-op Post-op

35. 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.