Traumatic Brain Injury

Pinnacle Surgery Residents November 8, 2011

MariaElaina Sumas, MD PNNI Pennsylvania Neurosurgery & Neurosciences Institute, Inc

Overview
The problem or epidemiology Head injury classification Physiology Initial Approach to the Patient Intracranial Pressure Management

Epidemiology
Trauma leading cause of death < 45 yrs
Up to 50% are due to fatal head injuries

500,000 head injuries per year

70,000 will die from their head injury 50,000 will have permanent disabilities

Total cost to nation ~25 billion dollars

Medical/Surgical Rehabilitation Home Care Lost Income

High Risk Groups

Age: 15 24 yrs (rises again 60 65 yrs) Sex: males > females (ratio 2.0 2.8) Race: nonwhites > whites Socioeconomic Status: low income families Other: alcohol intoxication (up to 72%)

Classification of Head Injury

Mechanism Severity Morphology

Classification of Head Injury Mechanism

Closed
Hi Velocity Low Velocity

Penetrating
Gunshot Wounds Other Open Injuries

Mechanism
Motor Vehicle Accidents most common
Automobiles Motorcycles Bicycles/Pedestrians

Falls elderly Assaults Sports and Recreation

Classification of Head Injury

Severity
Glasgow Coma Scale
Mild: Moderate: Severe: GCS 13-15 GCS 9-12 GCS < 8

COMA by definition is GCS < 8

Classification of Head Injury

Morphology
Skull Fractures
Vault Basilar

Intracranial Lesions
Focal

(Epidural, Subdural, Intracranial)

Diffuse

Cerebral Spinal Fluid

Produced by the choroid plexus
Volume 90 - 150 ml 0.35 ml/kg/hour Approx. 500 ml / day

Reabsorbed through the arachnoid villi Communicating Hydrocephalus from blocked drainage:
Inflammation of the arachnoid villi Hemorrhage breakdown proteins Intraventricular hemorrhage

Vasculature: Somatic versus Brain Endothelium

ICP: Monroe- Kellie Principle

Rogers (1996) Textbook of Pediatric Intensive Care p. 646

Approach to Head injured Patient

Airway Breathing Circulation ABC established Neurologic examination
Localizing signs Sedated, pupils, GCS score History? Imaging

Glasgow Coma Scale (GCS)

Severe CHI
GCS 3-8

Moderate CHI
GCS 9-13

Mild CHI
GCS 14

Teasdale G., Jennett B., LANCET (ii) 81-83, 1974.

CHI Trauma patient

Neurologic Exam Coagulation parameters
Will Increase

Serum sodium Dilantin 7-10 days Intubate? Image

Normal Imaging Studies

CT Scan

MRI
Axial T2

MRI
Sagittal T1

Head Trauma Categories

Skull fractures Concussions Contusions Penetrating Injuries Hematomas / Hemorrhage
Subarachnoid Epidural Subdural
Acute Chronic

Intraparenchymal

Skull Fractures
Linear
Convexity
Open Closed

Basilar
Anterior Fossa CSF leaks Middle Fossa temporal bones Occipital Condyles - stable

Depressed
Open Closed

Skull Fractures Clinical Signs

No NGT in head trauma patients

Open Depressed Skull Fracture

Open Depressed Skull Fracture Open Depressed

Penetrating Head Trauma

Non-Missile Low velocity Knife, Blades Vascular injury

Penetrating Head Trauma

High velocity
Gun Shot Account for 35% of head injury deaths <45y/o >90% Mortality Muzzle Velocity
Hand guns (<250 m/s) Rifle/military (750m/s)

Impact Velocity >100m/s = Fatal

Concussion
Definition: An alteration of an alert cognitive state in which you are aware of yourself and your situation, as a result of nonpenetrating trauma to the brain Mild traumatic brain injury Does not require a loss of consciousness Neuroimaging - normal

Diffuse Axonal Injury

Shear Mechanism: Acceleration-Deceleration

Diffuse Axonal Injury (DAI)

Shearing injury of axons Deep cerebral cortex Thalamus and basal ganglia Corpus Callosum Brainstem Punctate hemorrhage and parenchyma edema

Neuroscience for Kids www.faculty.washington.edu/chudler/cells/html

Subarachnoid Hemorrhage
Blood in the Subarachnoid space No mass effect Most common cause: Trauma Aneurysm?

Cerebral Contusion

ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

Cerebral Contusion
Acceleration - Deceleration Injuries Location Frontal lobe Temporal lobes Expand or Blossom over next 24 hrs Normalize coagulations parameters Serial clinical exams (NICU or INICU) Monitor Sodium Serial CT scan until no change

Epidural and Subdural Hematoma

ALL-NET Pediatric Critical Care Textbook - Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

Epidural Hematoma
(EDH)
1% of CHI admissions Male to Female 4:1 Ages 3-60 y/o Arterial source
Middle Meningeal Artery

Lucid interval Mortality 10-15% CT scan

Biconvex lesion (lenticular) Associated temporal fracture

Epidural Hematoma (EDH)

Middle Meningeal Artery Constrained by Sutures

Foramen Spinosum

Acute Subdural Hematoma (SDH)

2-3% of CHI admissions Male to Female 3:1 Age average 40-50 y/o Venous bleeding Associated with brain injury
Shear injury to parenchyma Operate less than 4hrs Mortality 30%

Mortality 50-90%

Larger surface area than EDH CT scan

Crescent shape Convexity may be along falx, tentorium

Chronic Subdural Hematoma (SDH)

2-3% of CHI admissions Male to Female 2:1 Age average 65-70 y/o Risk factors
Shunt Alcoholics Coagulopathies

Venous bleed and re-bleed Bilateral 20-25% CT scan

Crescent shape Convexity Acute, subacute and chronic components

Subdural Hematoma
Signs & Symptoms

Medical Management

Monroe- Kellie Principle

Rogers (1996) Textbook of Pediatric Intensive Care p. 646

Herniation Syndromes
1. Cingulate herniation under falx 2. Uncal herniation over tentorium 3. Central herniation 4. Cerebellar tonsillar herniation into foramen magnum

Coma and ultimately death result when 2, 3, or 4 produce brainstem compression

Uncal Herniation
3rd Nerve Tentorium

Multimodal Monitoring
ICP Monitor Pb02 Monitor CBF Monitor Microdialysis TCDs EEG Perfusion CT

ICP MANAGEMENT

Normal ICP <10-15mmHg CPP = MAP-ICP Treat > 20mmHg

Indications for ICP Monitoring GCS < 8 and either a) abnormal CT b) nl CT and 2 of the following: I. Age > 40 II. SBP< 90 mmHg III. Posturing Others: unable to follow commands to OR with potential for fluids prior to removal of intracranial mass

Cerebral Blood Flow

Regulation of Cerebral Vascular Resistance
CBF
Normal 50 - 100 ml / min

(mmHg)
Normal 60 - 150 mmHg

MAP

(mmHg) Normal 30 - 50 mmHg

PaCo2

Rogers (1996) Textbook of Pediatric Intensive Care pp. 648 - 651

Circulatory Support: Maintain Cerebral Perfusion Pressure

6
Number of Hypotensive Episodes

5 4 3 2 1

Good Moder Severe Vegeta Dead Outcome

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

0

Promote Venous Drainage

Head of bed elevated No outflow obstruction Collar Trach ties

Dicarlo in ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/\protect/icp-tx-3.htm

Feldman et al. (1992) Journal of Neurosurgery, 76

Hyperosmolar Therapy: Increase Blood Osmolarity

Brain cell Blood vessel

Fluid

Movement of fluid out of cell reduces edema Osmosis: Fluid will move from area of lower osmolarity to an area of higher osmolarity

Hypertonic Fluid Administration

Fisher et al. (1992) Journal of Neurosurgical Anesthesiology, 4 Reduction in mean ICP in children 2 hours after bolus administration of 3% saline Taylor et al. (1996) Journal of Pediatric Surgery,31(1) ICP is lowered by resuscitation with hypertonic saline vs. lactated ringers solution in an animal model Qureshi et al. (1998) Critical Care Medicine, 26(3) Reduction in mean ICP within 12 hours of continuous infusion of 3% saline acetate solution Little continued benefit after 72 hours of treatment

Hyperosmolar Therapy
Goal: Sodium 145-155

Sodium: square ICP: circle

Qureshi et al. (1998) Critical Care Medicine, 26(3)

Hyperventilation?
Management of very acute elevation of intracranial pressure Preemptive for activities known to increase intracranial pressure Keep PCO2: 32-35 cmH20

--- Moderate and transient

Reduction of Cerebral Metabolic Rate: Medications

Reduction in cerebral oxygen requirement Anticonvulsants - Prevent seizure activity Pentobarbital Adverse effects include hypotension and bone marrow dysfunction Used only after unsuccessful attempts to control ICP and maximize CPP with other therapies Improved outcome not fully supported by research
Traeger et al. (1983) Critical Care Medicine, 11 Ward et al. (1985) Journal of Neurosurgery, 62(3)

Reduction of Cerebral Metabolic Rate: Hypothermia

Metz et al. (1996) Journal of Neurosurgery, 85(4) 32.5 C reduced cerebral metabolic rate for oxygen (CMRO2) by 45% without change in CBF, and intracranial pressure decreased significantly (p < 0.01) Marion et al. (1997) New England Journal of Medicine, 336(8) At 12 months, 62% of patients (GCS of 5-7) cooled to 32-33 C have good outcomes vs. 38% of patients in control group

Side-effects: Potassium flux Coagulopathy Shivering Skin Breakdown

Slow re-warming Close monitoring

Theraputic Moderate Hypothermia is not a Replacement for Hemicraniectomy

BUT A CRITICAL ADJUNCT WHEN THERE IS MORE THAN ICP ISSUES!!!!

Complications of Decompressive Craniotomy

Remote Hemorrhages

Complications of Decompressive Craniotomy

Remote Hemorrhages Subdural Hygromas

Complications of Decompressive Craniotomy

Remote Hemorrhages Subdural Hygromas Brain Herniation

Complications of Decompressive Craniotomy

Remote Hemorrhages Subdural Hygromas Brain Herniation Syndrome of the Trephine

Complications of Decompressive Craniotomy

Remote Hemorrhages Subdural Hygromas Brain Herniation Syndrome of the Trephine Bone resorption

Complications of Decompressive Craniotomy

Remote Hemorrhages Subdural Hygromas Brain Herniation Syndrome of the Trephine Bone resorption Infection

Family Contact and ICP

Presence, touch and voice of family / significant others... Does not significantly increase ICP Has been demonstrated to decrease ICP

Bruya (1981) Journal of Neuroscience Nursing, 13 Hendrickson (1987) Journal of Neuroscience Nursing, 19(1) Mitchell (1985) Nursing Administration Quarterly, 9(4) Treolar (1991) Journal of Neuroscience Nursing, 23(5)

Thank You

In 1848, Phineas T. Gage, foreman of a railroad construction crew, was setting a charge of explosives with a 13 pound, 31/2 iron tamping rod, the charge exploded and the tamping rod went through his frontal skull, destroying his prefrontal cortex. He survived! Regaining his physical health in a few weeks. However, his personality changed dramatically."