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
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•
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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)
CPP = MAP – ICP
• Normal CPP > 50 mm Hg
• Autoregulatory mechanisms maintain CBF
at CPP’s down to 40 mm Hg
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
Start with ABC’s
History
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LOC +/Intoxicants
Seizure
Posttraumatic amnesia
• Physical Exam
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GCS
Level of consciousness
Cranial nerves
Fundoscopic exam
Motor exam
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
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•
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 GCS
8T
ICP Monitor
Preferred method in Guidelines
Therapy for Intracranial
Hypertension
• First tier
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Positioning
Ventricular drainage
Osmotic diuresis
Hyperventilation (Level III – temporizing measure)
• Second tier
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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
Hemicraniectomy
Pre-op
Post-op
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.