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
1995 1
st
edition
2000 2
nd
edition
2007 3
rd
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)
Normal CPP > 50 mm Hg
Autoregulatory mechanisms maintain CBF
at CPPs down to 40 mm Hg
CPP = MAP ICP
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
History
LOC +/-
Intoxicants
Seizure
Posttraumatic amnesia

Physical Exam
GCS
Level of consciousness
Cranial nerves
Fundoscopic exam
Motor exam
Start with ABCs
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
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
Positioning
Ventricular drainage
Osmotic diuresis
Hyperventilation (Level III temporizing measure)
Second tier
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
Pre-op
Post-op
Hemicraniectomy
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.