TRAUMATIC BRAIN INJURY

: General Overview

Handoyo Pramusinto
 Objectives
 Describe basic intracranial physiology.
 Evaluate the head / brain-injured patient.
 Perform necessary stabilization procedures.
 Determine appropriate disposition
 Head Injury
 Common problem
 High morbidity and mortality
 Secondary insults
• Worsen outcome
• Often preventable
 Early neurosurgical consult and transfer
 Neurosurgeon Needs to Know

 Age And History

 Vital signs
 GCS score and pupils
 Alcohol/drug(s) intake
 Associated injuries
 Brain CT
 Intracranial Pressure (ICP)

 10mm Hg = Normal
 >20 mm Hg = Abnormal
 >40 mm Hg = Severe
 Many pathologic processes affect outcome
 ↑ICP →↓Brain function,↓outcome
 Autoregulation

 CFB maintained with X BP of 50 -160 mm Hg

 Moderate or severe brain injury → autoregulation
often impaired
 Brain more vulnerable to episodes of hypotension
 Cerebral Blood Flow

 50 mL/100 g/min normal

 < 25mL/100 g/min ↓EEG activity
 ≤ 5 mL/100 g/min cell death
 Classifications
Blunt High velocity
By Low velocity
Mechanism
GSW
Penetrating Other

GCS = 14-15
Mild

By Moderate GCS = 9-13

Severity
Severe GCS = 3- 8
 Classification
By Morphology
Linear vs stellate
Vault Depressed/ non depressed
Skull Open/ closed
Fracture
Basilar With / without CSF leak
With / without cranial palsy
Fraktur Impresi
 CT scan
Fraktur Depresi
TINDAKAN OPERATIF FRAKTUR DEPPRESI
 Basal Skull Fracture
 CSF rhinorrhea  Retroaucricular
anterior skull base ecchymosis
 CSF otorhea :  Facial nerve
midskull base injury
 Hemotympanum  Loss of hearing
 Periorbital  Pneumocephalus
ecchymosis
BASILAR SKULL
FRACTURES
 Classifications
By Morphology • Epidural
• Subdural
Focal Injury • Intracerebral

• Mild concussion
Diffuse Injury • Classic
concussion
• Diffuse axonal
injury
 Epidural Hematoma
 Associate with skull fracture
 Classic : Middle meningeal artery

tear
 Lenticular/biconvex due to dural

adherence to skull
 Lucid interval
 EPIDURAL
HEMATOM

Epidural
 Epidural Hematoma

 Can be rafidly fatal

 Early evacuation pragnosis
 Venous epidurals : Possible
nonsurgical management
 Subdural Hematoma

 Venous tear /brain laceration

 Covers entire cerebral surface
 Morbidity /mortality due to underlying
brain injury
 Rapid surgical evacuation recommended,
especially if > 5 mm shift of midline
Subdural hematom
Korpus
Alienum
 Contusion/Hematoma
 Coup/contrecoup injuries
 Most common :Frontal /temporal lobes
 “Salt and pepper” Appearance on CT
 CT changes usually progressive
 Most conscious patients : No operation
 Concussion
 Transient loss of consciousness
 Normal Head CT
 Nausea vomiting
 Headache: if severe, repeat CT
 Symptoms may worsen before
improvement
 Sequalae Common
 Diffuse Axonal Injury

 Prolonged deep coma (not due to

mass lesion)
 Diffuse brain injury
 Motor posturing
 Frequent autonomic dysfunction
 Mild Brain Injury
 GCS Score = 14-15  X-ray as indicated
 History  Alcohol/drug
 Exclude systemic screen as
injuries indicated
 Neurologic exam  Liberal use of
head
 CT

Observe or discharge based on

findings
 Moderate Brain Injury

 GCS Score = 9-13  Admit and observe

 Initial evaluation • Frequent
same as for mild neurologic exams
injury • Repeat CT scan
 CT scan for all  Deterioration :
Manage as severe head
injury
 Severe Brain Injury

 GCS Score = 3 - 8
 Evaluate/resuscited
 Intubate for airway protection
 Focused neurologic exam
 Frequent reevaluation
 Identify associated injuries
 Severe Brain injury
Airway / Breathing
 Airway protection

 Supplemental oxygen

 Assisted ventilation if

necessary
( PaCO₂ at 25-35mm Hg )
 Frequent re-evaluation/ABGs
 Severe Brain Injury

Circulation
 Hypotension not due to brain injury

 Hypotension causes secondary brain injury

• Correct hypotension quikly

• Do not treat ↑BP, maintain CPP
 Severe Brain Injury
Disability
 GCS

• Eye opening
• Best motor response
• Verbal response
 Pupillary size equality, reaction to light

 Symmetry of motor strength

 Severe Brain Injury
Disability
 Minineurologic exam

• On patient arrival
• After resusciation
• Frequently
 Document changes

 Consult neusurgeon early

Severe Brain Injury

Cause
 III rd Nerve compression
bilaterally
 Inadequate CNS perfusion

 III rd nerve compression

tentorial herniation
 Optic nerve injury
Severe Brain Injury
Cause
 Drugs
 Pontine lesion

 Injured
sympathetic
 pathway
 Severe Brain Injury

 Herniation
 Deteriorating LOC (GCS score)
 Pupillary asymmetry
 Motor asymmetry
 Cardiopulmonary arrest
 Cushing’s triad
 Indications for CT Scan

All patients with suspicion

of brain injury
 Medical Management
 Intravenous fluids
• Euvolemia
• Isotonic
 Hyperventilation, if necessary
• Goal : PaCO₂ at 25-35 mm Hg
 Medical Management
 Mannitol
• Use with signs of tentorial herniation
• Dose : 0.5 –1.0 g/kg IV bolus
 Other
• Anticonvulsants
• Sedation
• Paralytics
 Surgical Management

Scalp injuries
 Possible site of major blood loss

 Direct pressure to control bleeding

 Occasional temporary closure

 Surgical Management

Intracranial Mass Lesion

 May be life threatening if expanding rapidly

 Immediate neurosurgical consult

 Hyperventilation / Mannitol

 ? Emergency burr holes ?

Question
Summary : Prescription (Do)
 Maintain mean BP > 90 mm Hg
 Maintain PaCO₂ between 25 - 35
mm Hg
 Use isotonic solution for euvolemia
 Frequent neurologic exams
 Liberal use of CT scans
 Early neurosurgical consult
Summary : Proscription (Don,t)

 Allow patient to become

hypotensive
 Over-aggressively hyperventilate
 Use hypotonic IV fluids
 Use long acting paralytics
 Paralyze before performing
complete exam
 Depend on clinical exam alone