2015, trauma, brain

Traumatic Brain InjuryRobert Lieberson, MD, FACS

Brain, Spine, and Peripheral Nerve Surgery

Your Learning ObjectivesAt the conclusion of this session, you will be able to:1. understand the demographics of TBI; 2. discuss the approach to the TBI patient; 3. describe the examination and the evaluation

of the TBI patient;4. recognize many of the common injuries;5. be familiar with some of the medical

treatment options;6. be aware of some of the surgical options; and,7. appreciate the prognosis in TBI.

My Teaching ObjectivesProvide a framework for understanding:1. in an emergency start with ABCs or ABCDEs;2. remember the GCS as top down and small

number of options to large;3. think about the rest of your examination from

the top down;4. think about brain injuries from the outside in;

and,5. think about TBI treatment in terms of re-

establishing “normal.”

“Doctors are men who prescribe

medicines of which they know little, to

cure diseases of which they know less,

in human beings of whom they know

nothing.”

– Francois Marie Arouet Voltaire

(1694-1778)

1. Demographics of TBI 2010

> 50 K Deaths

> 280,000 Hospitalization

s~ 2,500,000

Emergency Room Visits

? Alternate care or no care

789,925

Men

574,870

Women

At least 3 to 5 million TBIs

per year in the US

By cause All ages Assault

11% Struck By/

Against15%

Unknown/Other19%Motor Vehicle-

Traffic14%

Falls41%

Frequency by age

0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 +0

200

400

600

800

1000

1200

1400

Per 1

00,0

00

2. Approach to the TBI Patient

Schematic behavior ("on autopilot“) versus attentional behavior (problem-solving)

Failures of schematic behavior are “slips” (lapses in concentration, distractions, or fatigue).

Failures of attentional behavior are “mistakes” (lack of training or experience).

In health care, most errors are caused by “slips.”

Checklists reduce the risk of “slips.”

2. Approach to the TBI Patient

Advanced Trauma Life Support (ACS)

www.cdc.gov/TraumaticBrainInjury/ Guidelines for the Management of

Severe Traumatic Brain Injury, 3rd Edition, 2007

Guidelines for the Surgical Management of Traumatic Brain Injury, 2006

Guidelines for Management and Prognosis of Severe Traumatic Brain Injury, 2000

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents, 2nd Edition, 2012

Ghajar J, Hariri RJ, Narayan RK, Iacono LA, Firlik K, Patterson RH.

Survey of critical care management of comatose, head-injured patients in the United States.

Critical Care Med. 1995 Mar;23(3):560-7.

Adherence to the TBI guidelines improves outcomes, but in a survey of ICUs in 45 states:

Only 28% of neurosurgeons routinely measure ICP

83% still use hyperventilation and osmotic diuretics

29% still maintain PaCO2 < 25 mm Hg 44% still use corticosteroids

Start with Advanced Trauma Life Support Primary Survey

ABCDEs Secondary Survey

GCS from the top down (EVM) General examination from the top down Neuro examination from the top down

Tertiary Survey PMH, FH, SH, Meds, Allergies, ROS

If the patient deteriorates, return to the primary survey and start over

3. Evaluation of the TBI Patient

ATLS primary survey

ABCDE (different than the ABCs of CPR) Airway (remember the c-spine precautions) Breathing (exclude pneumothorax,

tamponade, etc) Circulation (and also control hemorrhage) Disability/neurological (AVPU [alert, verbal,

painful, unresponsive], pupils and spinal cord (GCS goes with secondary survey)

Environmental (remove clothes, correct/prevent hypothermia)

ATLS Secondary Survey

Complete history Top down examination (including GCS) X-rays and lab

Focused abdominal sonogram for trauma (FAST exam)

Evaluates pericardium, right and left upper abdomen and pelvic region for blood

CBC, BMP, coags, type and screen, tox, ABG, pregnancy

Non-contrast CTs of C-spine, chest, abdomen, and pelvis

Maintain PaO2 > 60 mm Hg and SBP ≥ 65 mm Hg

ATLS Tertiary Survey

Careful and complete examination, serial assessments, rate of delayed diagnosis can be 10%

If patient deteriorates, return and repeat the primary survey

History Events surrounding the

accident Seatbelt, helmet, position in

motor vehicle, direction of impact, speed, damage to windshield or steering wheel

Assess for EtOH or illicit drugs Drugs may confound the

examination Was there a seizure at the

time of the accident

HistoryMechanism of Injury

Rotational most likely to cause shearing

Lateral and AP cause coup and contra-coupand subdurals

Local injury to the temporal bone causes epidurals

Examination—General Head

Scalp lacerations May be associated with significant blood loss

Depressed skull fracture (convexity fractures) Most skull fractures non-displaced

CSF rhinorrhea or otorrhea, raccoon eyes, Battle’s sign (basilar skull fractures)

Significant head injuries can occur without external stigmata

Spine Step-off Tenderness

Passive rewarming Hypothermia may confound the neurological

examination

Examination—Glasgow Coma Scale

GCS 13-15 is “mild”

GCS 9-12 is “moderate”

GCS 3-8 is “severe” and equates to coma

Eyes

Verbal

Motor

Top Down4

56

Examination—Glasgow Coma ScaleTop down (EVM); fewest categories to most.

Eyes

Verbal

Motor

Top Down4

56

1 None

2 Decerebrate

3 Decorticate

4 Withdraws

5 Localizes

6 Normal

Motor

1 None

2 Sounds

3 Word Salad

4 Disoriented

5 Normal

Verbal

1 None

2 To Pain

3 To Voice

4 Normal

Eyes

Neurological Examination A complete neurological examination on

every patient (organized from top down) Mental status Cranial Nerves (including pupils) Motor (rate power from 0/5 to 5/5) Sensory (light touch and pin prick) Reflexes (0, 1, 2, 3, 4) Coordination/Gait

Post Traumatic AmnesiaRetrograde versus antegrade

Fixed and Dialated Pupils No patient with

bilateral fixed and dilated pupils for more than 90 minutes had a favorable outcome.

Many surgeons will consider surgery futile if 3 to 6 hours have elapsed.

Papiledema

Normal Disc

Late Papiledema (grade

IV)

Early Papiledema (grade II)

Indications for CT

Mild TBI (GCS ≥ 13) New Orleans Criteria

No CT if GCS 15, + LOC, no neuro deficit, age > 3 years CT if headache, vomiting, seizure, intoxication, short term memory

deficit, age > 60, injury above the clavicle Canadian CT Head rule

No CT if GCS 13-15, + LOC, no neuro deficit, no seizure, no anticoagulation, age > 16 years

CT if: High risk—GCS < 15 after 2 hours, suspected convexity or basilar skull

fracture, vomiting ≥ 2 times, or age ≥ 65; or, Medium risk—retrograde amnesia > 30 minutes, severe mechanism

(pedestrian vs. car, ejected from car, or fall from > 1 m or five stairs)

Indications for CT

Moderate TBI (GCS 9-12) or Severe TBI (GCS ≤ 8) All get a head CT

CT is positive in 93% of patients with a severe TBI A negative CT does not guarantee a “favorable”

prognosis Obliteration of basal cisterns associated with

“unfavorable” outcomes in 97% of cases

4. Recognize Common Injuries

Layers from outside to inside

Scalp Contusion

Caput succedaneum

Subgaleal hematoma

Subperiosteal hematoma or cephalohematoma

Subgaleal versus subperiosteal hematoma

Epidural hematoma

Subdural hematoma

Subarachnoid Hemorrhage

Cerebral Contusion

Axonal Shearing Injuries

Intraventricular Hemorrhage

Through and Through Gunshot Wound

Marshall Classification of CT findingsDiffuse injury I—No visible pathology on CTDiffuse injury II—Cisterns present, midline

shift < 5 mm, no high-density lesion > 2.5 cm

Diffuse injury III—Cisterns compressed or absent, no high-density lesion > 2.5 cm

Diffuse injury IV—Midline shift > 5 mm, no high-density lesion > 2.5 cm

Evacuated mass—Any lesion surgically evacuated

Non-evacuated mass—High-density lesion > 2.5 cm but not surgically evacuated

Traumatic dissections

5. Medical Treatment Options Primary Injury

Occurs at the moment of trauma Contusion, damage to blood vessels, axonal shearing, blood brain barrier

changes, fractures, and meningeal injury Secondary Injury

Begins in the hospital (causes significant disability, preventable) Ischemia and cerebral hypoxia (due to hypotension and impaired

autoregulation) Cerebral edema (raised intracranial pressure, brain herniation) Metabolic changes such as hypercapnia and acidosis Infection (meningitis, brain abscess) Release of neurotransmitters (excitotoxicity) Viscous Cycles (edema causes more ischemia which causes more edema) Systemic complications (pneumonia, DVT)

TBI Guidelines 3rd Edition, 2007

Three classes of evidence Class I: Relevant screening test; credible reference standard;

reference standard independent of screening test; reliability of test assessed; few indeterminate results; large number of patients.

Class II: Relevant screening test; reasonable although not best standard; standard independent of screening test; moderate number of patients.

Class III: Has fatal flaws; inappropriate reference standard; screening tests improperly administered; small number of patients.

Three levels of recommendation (based on class of evidence, highest level with at least one recommendation given)

15 categories, only 14 stated “level of evidence” Level I: 1/14 (steroid use) Level II: 10/14 (BP, Mannatol, Abx, ICP monitoring, ICP

threshold, CPP, anesthetics, nutrition, Sz meds, hyperventilation)

Level III: 3/14 (hypothermia, DVT, brain O2 monitoring)

I. Blood Pressure and Oxygenation B. Level II—Hypotension (SBP < 90 mmHg) should be

avoided. C. Level III--Hypoxia (PaO2 < 60 mmHg or O2 saturation <

90%) should be avoided

Single most important intervention is maintaining SBP and CBF CBF should be between 50 and 70 Under 50, risk of ischemia Over 70, risk of ARDS

TBI Guidelines (I)

TBI Guidelines (II)

II. Hyperosmolar Therapy B. Level II--Mannitol is effective to treat ICP. Doses of 0.25 to 1

g/kg. C. Level III--Restrict mannitol use prior to ICP monitoring to

patients with signs of herniation or progressive neurological deterioration.

Albumen, SAFE trial of 7000 patients, ↑ ICP, No Benefit Hypertonic Saline

↓ cerebral edema, ↑ flow through small vessels, ↑ MAP Avoids the diuresis, ↓ BP seen, and renal issues with Mannitol

Mannitol Rapid decrease ICP in emergencies Renal damage if Osm over 320

TBI Guidelines (II)

II. Hyperosmolar Therapy

TBI Guidelines (III)

III. Prophylactic Hypothermia C. Level—Better outcomes with temperatures of 32–33°C

for > 48 hours. Difficult to do.

First studies by Temple Fay (1895-1963, Temple U) ↓ metabolic rate, ↓ apoptosis ↓ neuroexcitatory damage, ↓

inflammatory damage, ↓ free radicals ↓ Cerebral Blood Flow, ↓ ICP

But ↓ Platelet Function Rewarming Problems (↑ K+, ↓ glucose)

TBI Guidelines (III)

Prophylactic Hypothermia Tylenol, fans, ice bags, etc—not

adequate Intravenous heat exchangers may be

effective Shivering can be controlled with

warming of the hands Induced Normothermia

Preventing fever spikes may be as advantageous as hypothermia

Pending studies Eurotherm 3235 (600 patients) - UK POLAR-RCT (500 patients) – Australia

and NZ

TBI Guidelines (IV and V)

IV. Infection Prophylaxis B. Level II--Periprocedural antibiotics for intubation should be administered. Early tracheostomy

should be performed to reduce ventilator days. C. Level III--Routine ventricular catheter exchange or prophylactic antibiotic use is not

recommended. V. Deep Vein Thrombosis Prophylaxis

C. Level III--Compression stockings are recommended. Low molecular weight heparin (LMWH) or low dose unfractionated heparin should be used, however, there is an increased risk of hemorrhage. There is no clear preferred agent.

There are NO guidelines for Lovenox or similar in patients with TBI. Giving Lovenox BEFORE a craniotomy is NOT safe. In patients with a “bleed,” starting Lovenox 24 to 48 hours AFTER the CT has stabilized and there is

no more bleeding is probably safe. In post-op craniotomy patients, starting Lovenox 24 or 48 hours after surgery, or when the drains

stop producing fresh blood, is probably safe.

TBI Guidelines (VI through VIII)

VI. Indications for Intracranial Pressure Monitoring B. Level II--Monitor Intracranial pressure (ICP) in all salvageable patients

with a severe TBI (GCS 3–8) and an abnormal CT scan. C. Level III--ICP monitoring is indicated in patients with severe TBI with a

normal CT scan if two or more of the following: age over 40 years, unilateral or bilateral motor posturing, or SBP < 90 mm Hg.

VII. Intracranial Pressure Monitoring Technology A ventricular catheter and an external strain gauge is the most accurate,

low-cost, and reliable method. It can be recalibrated. Strain gauge devices provide similar benefits, but cost more and cannot be recalibrated.

VIII. Intracranial Pressure Thresholds B. Level II—Treat ICPs above 20 mm Hg. C. Level III—Use a combination of ICP values, clinical findings, and CT

findings to guide treatment (common sense).

TBI Guidelines (VI through VIII)(Monro-Kellie doctrine)

Alexander Monro (1733-1817), Scottish a famous-anatomist, surgeon, and lecturer

George Kellie (1720-1779), Scottish anatomist and surgeon who studied under Monro


Brain

Arterial Blood

Venous Blood

CSF

ECF

140 to 270 cc of CSF (25 in the ventricles)

1050 to 1150 cc of

brain

200 cc of ECF

100 cc of venous blood

50 cc of arterial blood

Mannitol

Ventricular

DrainageHyper-

ventilation


Brain

Arterial BloodVenous Blood

CSF

ECF

Brain


CSF

ECFSubdural

Hematoma


Brain


CSF

ECF

Subdural Hematoma


Brain


CSF

ECFSubdural

Hematoma


TBI Guidelines (IX and X)

CPP = MAP - ICPCerebral Perfusion Pressure is MAP minus

ICP. If MAP is 90 and ICP is 20, CPP is 70.CPP should be 50 to 70 mmHg.CPP over 70—ARDS more likely.CPP less than 50—No brain perfusion!


↓ CBF

Failure of Oxydative

Metabolism

Na2+/K+ Pump Failure

↑ Cellular Edema

↑ ICP

Secondary InjuryVicious Cycle

TBI Guidelines (VI through VIII)ICP Monitoring Technology

A ventricular catheter and external strain gauge are the most accurate, reliable, and method of monitoring.

Ventriculostomies allow CSF Drainage.

Convenient, fast, accurate.

Cannot be recalibrated after insertion, and are expensive ($6,000 to $10,000).


Objectives of ICP Monitoring

Maintain cerebral perfusion (and therefore oxygenation)

Remove CSF (if possible)Avoid secondary injury

TBI Guidelines (VI through VIII)Herniation

1.Subfalcine2.Transtentorial3.Uncal4.Transforaminal5.Upward (Posterior

Fossa)6.Through a cranial

defect

TBI Guidelines (VI through VIII)Basal Cisterns

TBI Guidelines (VI through VIII)Herniation

TBI Guidelines (IX and X)

IX. Cerebral Perfusion Thresholds B. Level II—Ovrly aggressive attempts to keep CPP > 70 mm Hg with fluids

and pressors should be avoided because of the risk of adult respiratory distress syndrome (ARDS).

C. Level III--CPP of < 50 mm Hg should be avoided. The CPP value to target lies within the range of 50–70 mm Hg.

X. Brain Oxygen Monitoring and Thresholds C. Level III—Maintain jugular venous saturation > 50% or brain tissue

oxygen tension >15 mm Hg. The technology exists but is limited.

TBI Guidelines (XI to XV)

XI. Anesthetics, Analgesics, and Sedatives B. Level II--Prophylactic barbiturates not recommended. Barbiturates for ICP

refractory to all other treatment helpful but cause significant morbidity. XII. Nutrition

B. Level II--Full caloric replacement by day 7. XIII. Anti-seizure Prophylaxis

B. Level II—Prophylactic, long-term anti-epileptics not recommended. Anticonvulsants decrease early seizures but early seizures not associated with worse outcomes.

XIV. Hyperventilation B. Level II--Prophylactic hyperventilation (PaCO2 < 25 mm Hg) is dangerous. C. Level III--Temporizing measure only. Most harmful early when CBF most reduced.

XV. Steroids A. Level I—Steroids are not recommended—cause increased mortality. This is the only level II recommendation.

TBI Guidelines Summary

Intubate if: Poor airway protection

or GCS ≤ 8 Extubate early

PaO2 > 60 mmHG or O2 Sat > 90%

PaCO2 = 35 to 40 mm HG

Keep SBP > 90 and CPP 50-70 A single episode of

hypotension doubles mortality

Avoid hypotonic solutions (LR or ½ NSS)

Avoid hyperglycemia

Mannitol Signs of herniation

or progressive deterioration not due to extracranial causes

Dose 0.25 to 1 g/Kg Avoid before ICP

monitoring Avoid if hypotensive

Hypothermia QUESTIONABLE. Steroids NOT helpful. Anticonvulsants NOT for

prophylaxis. Antibiotics NOT for prophylaxis. Hyperventilation NOT advised. Full caloric replacement early. DVT prophylaxis (SCDs, +/-

anticoagulation). Avoid high dose Propofol. Barbiturates only in desperation.

TBI Guidelines Summary

TBI Guidelines Summary Monitor ICP in all “severe” head injury patients (GCS ≤ 8) with an abnormal CT.

Monitor ICP in all “severe” head injury and a normal CT if two or more of the following:Age ≥ 40 years;Systolic blood pressure ≤ 90 mm Hg; and,Unilateral or bilateral posturing.

Not in the TBI GuidelinesDecompressive Craniectomy

Has waxed and waned in popularity over the last 30 years

Indications now not entirely clear.May be helpful for hemispheric or MCA strokes.For TBI, probably to be done in desperation only.A very large craniectomy is required.May occasionally cause worse problems (strangulation of

the brain under the new defect).May convert deaths into vegetative survivors.

Not in the TBI GuidelinesTransfusion thresholds

Historical: 30% or 10 g/dLReassessed 1980s—infection risk and cost AABB Guidelines (2012)

Hgb <6 g/dL – Transfusion recommended Hgb 6 to 7 g/dL – Transfusion generally indicated Hgb 7 to 8 g/dL – Transfusion should be considered in postoperative

surgical patients Hgb 8 to 10 g/dL – Transfusion generally not indicated, but should be

considered for: symptomatic anemia; ongoing bleeding; acute coronary syndrome (cardiac surgery literature supports 30%)

Transfusion thresholds for TBI undefined Some including Carlson, 2006, suggest that the same guidelines apply Many neurosurgeons believe that because of the brain’s higher O2

consumption, a hematocrit near 30% reduces risk and improves outcome.

6. Surgical Management of TBI 2006 Addresses Four Classes of

Lesion Epidural Hematomas Subdural Hematomas Contusions (Parenchymal

Lesions) Posterior Fossa Mass Lesions

Surgical Management of Epidurals

Indications for Surgery An epidural over 30 cm3 should be removed regardless of the GCS score. An epidural less than 30 cm3 and with less than a 15-mm thickness and

with less than a 5-mm midline shift and with a GCS score greater than 8 without focal deficit can be managed nonoperatively but need serial scans and close follow-up.

Timing Patients with an acute epidural in coma with anisocoria need surgery

immediately. Methods

Craniotomy. Exceptions

Venous epidurals.

How do you determine volume on CT

Kothari, et al, 1996. Find largest diameter (call it A) Find diameter at 90 degrees to A (call it B) Count the CT slices where the clot is seen and

multiply by slice thickness to find the depth (call that C)

Lesion volume = In a 30 cc lesion, the average value of A, B, and C

is about 4 cm or 1½ inches

How do you measure shift on CT?

15 mm

How do you remove skull

Surgical Management of Epidurals

Surgical Management of Subdurals

Indications for Surgery An acute subdural 10 mm thick or a midline shift over 5 mm should

be removed regardless of the GCS. • All patients with an acute SDH in coma (GCS score less than 9)

should undergo intracranial pressure (ICP) monitoring. • A comatose patient with a SDH < 10-mm thick and a shift < 5 mm

needs surgery if the GCS decreased between injury and admission or if pupillary changes or if the ICP exceeds 20 mmHg.

Timing Patients with an acute subdural in coma with anisocoria need surgery


Craniotomy

Surgery—subdural hematoma

Surgical Management of Contusions

Indications Patients with parenchymal lesions

and neurological deterioration, medically refractory ↑ ICP, or mass effect on CT needs surgery.

Patients with GCS of 6 to 8, with frontal or temporal contusions greater than 20 cm3 in volume with shift > 5 mm or loss of basal cisterns, and patients with lesions over 50 cm3 need surgery.

Patients with mass lesions who do not show evidence of neurological compromise, have low ICP, and no signs of mass effect on CT may be observed with serial CTs.

Surgical Management of Contusions

Timing and Methods Bifrontal decompressive

craniectomy, within 48 hours of injury, should be considered for diffuse cerebral edema.

Decompressive procedures (subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy) are options for patients with ↑ ICP.

Surgical Management of Posterior Fossa Lesions

Indications Patients with mass effect on CT or with neurological dysfunction or

deterioration need surgery. Mass effect is distortion of the fourth ventricle, compression of the basal cisterns, or hydrocephalus.

Patients with lesions but no mass effect on CT or neurological deficit may be observed and imaged serially.

Timing Patients can deteriorate rapidly. Surgery should be done


Suboccipital craniectomy is used to evacuate posterior fossa lesions.

Surgery—posterior fossa lesions

Surgery—depressed skull fracture Indications

In driven fragments increase seizure risk Open fractures increase infection risk

Surgery—depressed skull fracture

Surgery—decompressive craniectomy

7. Prognosis (2000)

Relatively few features have been found to contain most of the prognostic information. Patient Age Severity of Injury

Difficult to quantify Intracranial pressure

Not always measured Computed tomography (CT)

Prognosis (2000)

Glasgow Coma Score (severity of injury) Works well for very low and very high

initial GCS scores. Age

Younger patients do better and those over 60 worse

Pupillary reactivity (severity of injury and ICP)

Hypotension Strongly predicts a poor outcome The only factor that can be changed

CT abnormalities predict a poor outcome (severity of injury and ICP)

Glasgow Outcome Score (GOS)

2 MD Moderate disability (disabled but independant)—travel by public transportation, can work in sheltered setting (exceeds mere ability to perform “ADLs”).

3 SD Severe disability (conscious but disabled)—dependent for daily support (may be institutionalized, but this is not a criteria).

4 PVS Persistent vegetative state—unresponsive and speechless; after 2-3 weeks may open eyes and have sleep/wake cycles.

5 D Death—most deaths from primary head injury occur within 48 hours.

1—Death (D)

2—Vegitative State (VS)

3—Lower Severe

Disability (SD-)

4—Upper Severe

Disability (SD+)

5—Lower Moderate

Disability (MD-)

6—Upper Moderate

Disability (MD+)

7—Lower Good Recovery (GR-)

8—Upper Good Recovery

(GR+)

Glasgow Outcome Score-Extended (GOS-E) Reversed the numbers Added “lower” and “upper” to the three intermediate

categories

75% “mild” Thinking memory and reasoning Sensation vision, smell, and taste Language communication, understanding Emotion anxiety, depression, personality, inappropriate behavior

25% “Moderate” or “Severe” Seizures Parkinson’s Disease Dementia Paralysis PVS

Spectrum of Effects of TBI (numerous independent variables)

More PearlsMortality from epidural

hematoma about 10%.Mortality from subdural

hematoma 40 to 60%.Hypoxia increases mortality.Hypotension doubles mortality.Recovery may continue for a year

or more.

Organize With a TBI start with ABCDEs. Remember the GCS as top down and

small number of options to large. Think about the rest of your examination

from the top down. Think about brain injuries from the

outside in. Think about TBI treatment in terms of

keeping all the numbers normal.

And now a word from our sponsor!

2015, trauma, brain

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