Neurol Med Chir (Tokyo) 49, 22¿25 2009

Timing of Craniotomy in a Patient With

Multiple Trauma Including Head Injury
—Case Report—

Junya FUKAI*,***, Toshihide TSUJIMOTO**, Ryo YOSHIMURA*,

Masaki RAIMURA*, Toshikazu KUWATA*, Genhachi HYOTANI*,
Michio YABUMOTO*, Toru ITAKURA***, and Ichiro KAMEI*

Departments of *Neurosurgery and **Critical Care Medicine,

Japanese Red Cross Society Wakayama Medical Center, Wakayama;
***Department of Neurological Surgery,
Wakayama Medical University School of Medicine, Wakayama

Abstract
A 7-year-old boy suffered blunt multiple injuries to the head, face, chest, and abdomen in a motor vehi-
cle accident. On admission he had impaired consciousness and dyspnea. Radiographic studies revealed
facial fracture and pulmonary contusion. Shortly after admission, he fell into shock due to intraab-
dominal bleeding. Laparotomy revealed spleen rupture. His vital signs remained unstable and bloody
drainage from the abdominal cavity continued after surgery. Computed tomography showed traumatic
intracerebral hematoma in the right temporal lobe, enlarging and compressing the brainstem. Abdomi-
nal reoperation was performed first to control the bleeding and stabilize the hemodynamics, disclosing
renal laceration. Then evacuation of the intracerebral hematoma and decompressive craniectomy was
performed. Postoperatively, his hemodynamics were stabilized. Clinical course was uneventful and
neurological deficits gradually improved. Three months after the trauma, the patient was discharged on
foot. This case emphasizes the importance of hemodynamic stability in decisions of neurosurgical indi-
cation and timing in patients with multiple trauma including head injury.
Key words: multiple trauma, head injury, abdominal injury, craniotomy, laparotomy

Introduction Recently, we treated a patient with head, chest,

Severe head injury is commonly associated with
multiple blunt systemic injuries, and the head is the
most frequent site of injury in such patients.16)
Patients with head injury have much higher mortali-
ty than patients without head injury, so head injury
is the most important cause of traumatic death.6) Im-
mediate computed tomography (CT) of the brain fol-
lowed by surgical removal of any intracranial mass
is generally recommended, but the risk of ongoing
hemorrhagic shock resulting from extracranial inju-
ries should be carefully considered.9) Occasionally
emergency operations including both neurosurgical
and general surgical interventions are required.8)
However, the priority of procedures may be difficult
to decide.
Received February 4, 2008; Accepted August 14,
2008
and abdomen injuries suffered in a motor vehicle
accident. Emergency laparotomies were performed,
followed by urgent craniotomy, resulting in good
recovery.
Case Report
A 7-year-old boy, 20 kg in weight, suffered craniofa-
cial, thoracic, and abdominal injuries in a motor ve-
hicle accident. He was immediately transferred to
our medical center. On admission, he was comatose
(Glasgow Coma Scale 4) with dyspnea. CT revealed
left zygoma fracture and left pulmonary contusion
(Fig. 1).
The patient was intubated and a chest tube was in-
serted. Shortly afterwards his vital signs became un-
stable, with distended abdomen. Ultrasonography
indicated intraabdominal bleeding. Immediate fluid
resuscitation with blood transfusion was begun.

22
 Timing of Craniotomy in Multiple Trauma 23

Emergency laparotomy revealed splenic laceration,
so splenectomy was performed. Follow-up head CT
showed intracerebral hematoma in the right tem-
poral lobe, which was enlarging and compressing
the brainstem (Fig. 2). Rapid decrease of platelet
count, remarkable prolongation of prothrombin
time, and elevation of fibrin degradation product D-
dimer suggested the disseminated intravascular
coagulation, which was supposed to be associated
with enlargement of intracerebral hematoma.
Craniotomy was considered to be necessary, but
bloody drainage from the intraabdominal cavity
continued and his hemodynamics remained unsta-
ble (Fig. 3). Therefore, repeat laparotomy was under-

Fig. 1 Computed tomography scans of the head (A,

B), chest (C, D), and abdomen (E, F) on ad-
mission revealing left zygoma fracture (B)
and left pulmonary contusion (C, D). The
spleen and left kidney were shown in E and
F, respectively.
Fig. 2 Serial computed tomography scans at 1, 2.5,
6, and 13 hours postinjury (A, B, C, and D,
respectively) demonstrating intracerebral
hematoma in the right temporal lobe, en-
larging and compressing the brainstem.

Fig. 3 (A) Time course of hemodynamics after admission. Blood transfusion (arrowheads),
hemoglobin administration (Hb), and platelet count (Plat) are indicated. FFP 2E, MAP 2E, Plt
10E, and WB 400 means 2 units of fresh frozen plasma, 2 units of concentrated red blood
cells, 10 units of platelet, and 400 ml of whole blood, respectively. (B) Computed
tomography scan just before craniotomy.

Neurol Med Chir (Tokyo) 49, January, 2009

24 J. Fukai et al.
Fig. 4 Computed tomography scans after hemato-
ma removal and external decompression (A)
and cranioplasty (B).
taken first to control the blood loss and stabilize the
hemodynamics. Renal bleeding from the left paren-
chyma was revealed and the laceration repaired.
Subsequently, the intracerebral hematoma was re-
moved and external decompression conducted
(Figs. 3 and 4). As a result, the Abbreviated Injury
Scale (AIS) scores were AIShead 4, AISface 2, AISchest 3,
and AISabdomen 4.
His vital signs stabilized after these surgical inter-
ventions. Mild hypothermia and high dose bar-
biturate therapies were instituted. The clinical
course was uneventful. His neurological deficits
gradually improved. Cranioplasty was performed 8
weeks later (Fig. 4). Three months posttrauma, the
patient was discharged on foot, when only left
oculomotor nerve palsy and mild left hemiparesis
was found.
Discussion
The aim of neurosurgical care for severe head inju-
ries is to minimize the secondary brain damage that
occurs after injury.8,11) Procedures include evacua-
tion of the intracranial space-occupying hematomas,
decompressive craniectomy, reduction of in-
tracranial volume, and external ventricular drainage
for hydrocephalus, and conservative therapy to
reduce intracranial pressure and to maintain
cerebral perfusion pressure and brain tissue oxygen
Pbto2.11) Neurosurgical intervention should be per-
formed before irreversible brainstem damage or
generalized brain damage has occurred.11) Any life-
threatening lesion in the cranial vault must be treat-
ed immediately.3,14,15) However, the prognosis for a
patient with severe head injuries depends not only
on the clinical status on admission and the in-
tracranial lesions, but also on the presence of other
systemic injuries.11)
Major extracranial injuries have important effects
on the outcome, and multiple trauma is associated
with increased mortality.11) A survey of preventable
traumatic deaths found that most central nervous
system deaths were caused by delays in cranioto-
mies,13) whereas most non-central nervous system
deaths resulted from inadequate resuscitation for ex-
tracranial bleeding.4) Timely treatment of trunk inju-
ries is very important if hemorrhagic shock is
present.15) Therefore, patients with multiple blunt
trauma including head injury sometimes require
both neurosurgical and general surgical interven-
tions,8) but the priority of diagnostic studies and in-
terventions may be difficult to decide.
The indications for cranial or general diagnostic
and therapeutic procedures may be difficult to estab-
lish in hypotensive patients with disturbed con-
sciousness. Few studies have investigated the priori-
ties for the management of patients with suspected
injuries to both the head and the chest or the abdo-
men.7,15,17,18) Resuscitation procedures can be sum-
marized as diagnosis and emergent treatment of
severe torso injury should take precedence over de-
tection and treatment of possible intracranial mass
lesion.1,7,15,17,18) Therefore, general surgery should be
performed first in a patient with ongoing hemor-
rhagic shock, and head CT can be delayed. After
stabilization of the vital signs, head CT should be
performed as soon as possible, followed by craniot-
omy to remove any intracranial mass if necessary.
This protocol depends on the likelihood of different
injuries. Although serious head injury is common,
patients with surgically correctable injuries of both
the head and the trunk are rare.16) Therapeutic
laparotomy has been delayed in more cases because
of head CT with negative findings than craniotomy
has been delayed for nontherapeutic laparotomy.16)
The frequency of urgent laparotomy is much greater
than that of emergency craniotomy.15) However, the
optimal timing of head CT and surgery for in-
tracranial versus abdominal or thoracic bleeding has
not been fully discussed because of the rare occur-
rence in hemodynamically unstable patients with
clinical signs of impending herniation.
In our case, craniotomy was successfully per-
formed after repeat laparotomies to identify and
stop the ongoing hemorrhage. This case illustrates
the dilemma for the physician who must balance the
risk of impending herniation from an intracranial
hematoma against the hemorrhagic shock from in-
traabdominal bleeding. Ongoing hemorrhage must
be controlled immediately or is likely to be fatal to
the patient. Additionally, hemorrhagic hypotension
worsens neurological outcome,5,9,10,12) so the
hemodynamics should be stabilized first. Then the
Neurol Med Chir (Tokyo) 49, January, 2009
 Timing of Craniotomy in Multiple Trauma
neurosurgical indication and timing should be de-
cided. However, the importance of identification
and removal of intracranial mass lesions must not be
underestimated. A life-threatening lesion in the
cranial vault must be treated immediately.8) Suspect-
ed intracranial lesion should be evaluated by im-
mediate head CT or intracranial pressure monitor-
ing to prevent any delay in treatment.2,15) Burr hole
craniostomy or simultaneous craniotomy combined
with laparotomy or thoracotomy should be con-
sidered.
Prioritizing diagnostic and therapeutic proce-
dures in the management of multiple trauma
patients is a complex task for the trauma teams who
must balance the necessity of controlling abdominal
or thoracic hemorrhage for hemodynamic stability
against the potential risk of delaying craniotomy for
repair of treatable lesions at risk of herniation and
death. Cooperation between general surgeons and
neurosurgeons during this process is essential to en-
sure the best patient care.8)
The present case treated by emergency laparoto-
mies and urgent craniotomy shows that hemody-
namic stability should be considered in decisions of
neurosurgical indication and timing in patients with
multiple trauma including head injury.
References
1) American College of Surgeons Committee on Trau-
ma: Initial assessment and management, in: Ad-
vanced Trauma Life Support for Doctors, Instructors
Course Manual. Chicago, American College of Sur-
geons, 1997, pp 21–46
2) Andrews BT, Pitts LH, Lovely MP, Bartkowski H: Is
computed tomographic scanning necessary in
patients with tentorial herniation? Neurosurgery 19:
408–414, 1986
3) Cales RH, Trunkey DD: Preventable trauma deaths. A
review of trauma care systems development. JAMA
254: 1059–1063, 1985
4) Certo TF, Rogers FB, Pilcher DB: Review of care of
fatally injured patients in a rural state: Five year fol-
lowing. J Trauma 23: 559–565, 1983
5) Chesnut RM, Marshall LF, Klauber MR, Blunt BA,
Baldwin N, Eisenberg HM, Jane JA, Marmarou A,
Foulkes MA: The role of secondary brain injury in
determining outcome from severe head injury. J
Trauma 34: 216–222, 1993
6) Gennarelli TA, Champion HR, Sacco WJ, Copes WS,
Alive WM: Mortality of patients with head injury and
Neurol Med Chir (Tokyo) 49, January, 2009
25
extracranial injury treated in trauma centers. J Trau-
ma 29: 1193–1202, 1989
7) Huang MS, Shih HC, Wu JK, Ko TJ, Fan VK, Pan RG,
Huang CI, Lee LS, Hsu PI, Lin JM, Lin M, Hsu HK,
Yang YF, Liu M, Lee CH: Urgent laparotomy versus
emergency craniotomy for multiple trauma with
head injury patients. J Trauma 38: 154–157, 1995
8) The Japan Society of Neurotraumatology: [ JSNT
Guideline, ed 2]. Tokyo, Igaku Shoin, 2007, pp 1–21
(Jpn)
9) The Japanese Association for The Surgery of Trau-
ma: [Japan Advanced Trauma Evaluation and Care, ed
2]. Tokyo, Herusu Shuppan, 2004, pp 1–21 (Jpn)
10) Kokoska ER, Smith GS, Pittman T, Weber TR: Early
hypotension worsens neurological outcome in
pediatric patients with moderately severe head trau-
ma. J Pediatr Surg 33: 333–338, 1998
11) Meier U, Zeilinger FS, Henzka O: The use of decom-
pressive craniectomy for management of severe head
injuries. Acta Neurochir Suppl 76: 475–478, 2000
12) Pietropaoli JA, Rogers FB, Shackford SR, Wald SL,
Schmoker JD, Zhuang J: The deleterious effects of in-
traoperative hypotension on outcome in patients
with severe head injuries. J Trauma 33: 403–407, 1992
13) Rose J, Valtonen S, Jennett B: Avoidable factors con-
tributing to death after head injury. Br Med J 2:
615–618, 1977
14) Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward
JD, Choi SC: Traumatic acute subdural hematoma.
Major mortality reduction in comatose patients treat-
ed within four hours. N Engl J Med 304: 1511–1518,
1981
15) Thomason M, Messik J, Rutledge R, Meredith W,
Reeves LTR, Cunningham P, Oller D, Moylan J, Clan-
cy T, Baker C: Head CT scanning versus urgent ex-
ploration in the hypotensive blunt trauma patient. J
Trauma 34: 40–45, 1993
16) Valadka AB: Injury to the cranium, in Mattox KL,
Feliciano DV, Moore EE (eds): Trauma, ed 4. New
York, McGraw-Hill, 1996, p 377
17) Winchell RJ, Hoyt DB, Simons RK: Use of computed
tomography of the head in the hypotensive blunt-
trauma patient. Ann Emerg Med 25: 737–742, 1995
18) Wisner DH, Victor NS, Holcroft JW: Priorities in the
management of multiple trauma: intracranial versus
intra-abdominal injury. J Trauma 35: 271–276, 1993
Address reprint requests to: Junya Fukai, M.D., Depart-
ment of Neurological Surgery, Wakayama Medical
University School of Medicine, 811–1 Kimiidera,
Wakayama 641–0012, Japan.
e-mail: jun-fukai461111＠est.hi-ho.ne.jp