HEAD TRAUMAHEAD TRAUMA

By Tracy Morgan, MSIVBy Tracy Morgan, MSIV

Radiology ElectiveRadiology Elective

2/25/052/25/05

Traumatic Brain Injury-Traumatic Brain Injury-EpidemiologyEpidemiology

US incidence 200/100,000 per yearUS incidence 200/100,000 per year 1/7 dead on arrival1/7 dead on arrival 80% mild, 10% moderate, 10% 80% mild, 10% moderate, 10%

severesevere Annual US mortality: 100,000 peopleAnnual US mortality: 100,000 people Annual US cost: $75-$100 billionAnnual US cost: $75-$100 billion

How and Who?How and Who?

MVA #1 causeMVA #1 cause FallsFalls ViolenceViolence SportsSports VICTIMS: VICTIMS: young men (15-24 yrs)young men (15-24 yrs)

old men & women old men & women (>75 yrs)(>75 yrs)

kids (<5 yrs)kids (<5 yrs)

The PatientThe Patient

JP is a 35 yo man presented to JP is a 35 yo man presented to OHSU EDOHSU ED

Fell off a 15-ft scaffolding onto Fell off a 15-ft scaffolding onto concreteconcrete

Coworkers witnessed the fall and Coworkers witnessed the fall and brought him to hospital immediatelybrought him to hospital immediately

Unconscious and unresponsiveUnconscious and unresponsive Glasgow Coma Scale score of 4 Glasgow Coma Scale score of 4

Differential Diagnosis—Differential Diagnosis—main 3main 3

Subdural hematomaSubdural hematoma

Epidural hematomaEpidural hematoma

Subarachnoid hemorrhageSubarachnoid hemorrhage

Mass-Effect Lesions vs Non-Mass-Effect Lesions vs Non-Mass Effect LesionsMass Effect Lesions

Mass effect lesions—require immediate Mass effect lesions—require immediate surgerysurgery

Midline shiftMidline shift of ≥5mm defined as significantof ≥5mm defined as significant Vascular occlusion, edema, increased ICP Vascular occlusion, edema, increased ICP

can worsen the initial injury--a self-can worsen the initial injury--a self-perpetuating cycleperpetuating cycle

Examples: Subdural hematoma, epidural Examples: Subdural hematoma, epidural hematomahematoma

Non-mass effect lesions—med management Non-mass effect lesions—med management in ICUin ICU

Example: Subarachnoid hemorrhageExample: Subarachnoid hemorrhage Blood spreads diffuselyBlood spreads diffusely, , no mass effect no mass effect

Subdural HematomaSubdural Hematoma

Subdural HematomaSubdural Hematoma Most common traumatic mass-effect lesionMost common traumatic mass-effect lesion

20-40% of severe head injuries20-40% of severe head injuries

Potential space btwn dural & arachnoidal meningeal Potential space btwn dural & arachnoidal meningeal layerslayers

Typically is rupture of bridging veinsTypically is rupture of bridging veins Venous bleeding=less pressure=possible delayed sx Venous bleeding=less pressure=possible delayed sx

onsetonset Usually from blow to head that jerks brain in skullUsually from blow to head that jerks brain in skull

Blunt trauma victims, elderly, alcoholicsBlunt trauma victims, elderly, alcoholics

LOC, mental status changes, focal neuro signsLOC, mental status changes, focal neuro signs Initial diagnosis usually made by noncontrast cranial Initial diagnosis usually made by noncontrast cranial

CTCT MRI is best for later determining size of hematoma MRI is best for later determining size of hematoma

and its effects on the brainand its effects on the brain

Acute Subdural Acute Subdural Hematoma CTHematoma CT

Hyperdense (white) Hyperdense (white) crescentic mass along crescentic mass along the inner skull table, the inner skull table, over the cerebral over the cerebral convexity in the convexity in the parietal region (most parietal region (most common location)common location)

Midline shift present Midline shift present with moderate or with moderate or large SDHs (note the large SDHs (note the shift in this image)shift in this image)

Acute Subdural Acute Subdural HematomaHematoma

Another example of acute subdural hematoma with a midline shift (noncontrast CT)

Subacute Subdural Subacute Subdural Hematoma Hematoma

48-72 hours after the trauma, the 48-72 hours after the trauma, the lesion becomes isodense to brain—lesion becomes isodense to brain—harder to see on noncontrast head harder to see on noncontrast head CT scan CT scan Best to use CT with contrast or MRI for Best to use CT with contrast or MRI for

imaging done 48-72 hrs post-injuryimaging done 48-72 hrs post-injury Subacute SDHs may become lens-Subacute SDHs may become lens-

shaped and can be confused with an shaped and can be confused with an epidural hematomaepidural hematoma

Subacute Subdural Subacute Subdural HematomaHematoma

Noncontrast CT—note the clot appears less dense in this subacute subdural hematoma.

Epidural HematomaEpidural Hematoma

Epidural HematomaEpidural Hematoma Classically arterial bleed in 85% of casesClassically arterial bleed in 85% of cases Can be venous (middle meningeal vein or dural sinus)Can be venous (middle meningeal vein or dural sinus) 70-80% occur with temporoparietal fracture & 70-80% occur with temporoparietal fracture &

middle meningeal artery rupturemiddle meningeal artery rupture Blood pools btwn external periosteal layer of dura Blood pools btwn external periosteal layer of dura

and calvariaand calvaria ““Classic” presentation (10-33% of cases) = brief LOC Classic” presentation (10-33% of cases) = brief LOC

followed by followed by lucid intervallucid interval of several hours of several hours Due to hematoma expansion until brain’s compensatory Due to hematoma expansion until brain’s compensatory

mechanisms failmechanisms fail Obtundation, severe headache, vomiting, focal neuro Obtundation, severe headache, vomiting, focal neuro

signssigns May progress to drowsiness, coma, deathMay progress to drowsiness, coma, death

Epidural HematomaEpidural Hematoma

Extraaxial, smoothly Extraaxial, smoothly marginated, lens-marginated, lens-shaped homogenous shaped homogenous densitydensity

Rarely crosses the Rarely crosses the suture linesuture line

(because dura attached (because dura attached more firmly to skull at more firmly to skull at sutures)sutures)

Epidural HematomaEpidural Hematoma

Focal isodense or hypodense zones Focal isodense or hypodense zones indicate active bleedingindicate active bleeding

Air in acute EDH indicates fracture of Air in acute EDH indicates fracture of sinuses or mastoid air cells.sinuses or mastoid air cells.

If chronic--may appear heterogeneous If chronic--may appear heterogeneous from neovascularization and from neovascularization and granulation, with peripheral granulation, with peripheral enhancement on contrast enhancement on contrast administration administration

Epidural HematomaEpidural Hematoma

Hematoma is Hematoma is biconvex lens-biconvex lens-shaped.shaped.

Note the midline Note the midline shiftshift

Subarachnoid Subarachnoid HemorrhageHemorrhage

Subarachnoid Subarachnoid HemorrhageHemorrhage

30% traumatic and 70% nontraumatic SAH (e.g, 30% traumatic and 70% nontraumatic SAH (e.g, berry aneurysm rupture, “Worst headache of my berry aneurysm rupture, “Worst headache of my life”)life”)

Symptoms of meningeal irritation in over 75%; Symptoms of meningeal irritation in over 75%; may take several hours to developmay take several hours to develop

Neck stiffness, low back pain, bilat leg painNeck stiffness, low back pain, bilat leg pain

LOC and mental status changes from beginningLOC and mental status changes from beginning Typically no lucid intervalTypically no lucid interval

LOC, obtundation, N/V, visual changes LOC, obtundation, N/V, visual changes Blood spreads diffusely--no mass effect, unless Blood spreads diffusely--no mass effect, unless

significant edemasignificant edema May predispose to cerebral vasospasm, which May predispose to cerebral vasospasm, which

can lead to infarction (usually in nontraumatic can lead to infarction (usually in nontraumatic SAH)SAH)

SAH--workupSAH--workup

CT without contrast—the most CT without contrast—the most sensitive studysensitive study best within 24 hrs after event; at day 3 best within 24 hrs after event; at day 3

is 80% sensitive, 50% at 1 weekis 80% sensitive, 50% at 1 week may be negative in 10-15% of patients may be negative in 10-15% of patients look for evidence of hydrocephalus, look for evidence of hydrocephalus,

intraparenchymal clot, intraventricular intraparenchymal clot, intraventricular hematoma, and interhemispheric hematoma, and interhemispheric hematomahematoma

Classification of SAHClassification of SAH

Fisher grading system—based on degree Fisher grading system—based on degree and location of SAHand location of SAH

Grade I - No subarachnoid blood seen on CTGrade I - No subarachnoid blood seen on CT

Grade II - Diffuse or vertical layers of SAH <1 Grade II - Diffuse or vertical layers of SAH <1 mm thickmm thick

Grade III - Diffuse clot and/or vertical layer >1 Grade III - Diffuse clot and/or vertical layer >1 mm thick mm thick

Grade IV - Intracerebral or intraventricular clot Grade IV - Intracerebral or intraventricular clot with diffuse or no subarachnoid bloodwith diffuse or no subarachnoid blood

Subarachnoid Hemorrhage Subarachnoid Hemorrhage on CTon CT

High density in the High density in the sulcal, cisternal, or sulcal, cisternal, or fissural fissural subarachnoid spacesubarachnoid space

Symmetry is intactSymmetry is intact

No midline shift No midline shift (usually)(usually)

SAH—more examplesSAH—more examples

• Subarachnoid hemorrhage in the right sylvian fissure

SAH—more examplesSAH—more examples

Blood in the sulci

Edema causing a midline shift

Management of Head Management of Head TraumaTrauma

THE BASICSTHE BASICS

Emergency Management—the Emergency Management—the basicsbasics

Remember your ABC’s!Remember your ABC’s! Cervical spine precautions—5% Cervical spine precautions—5%

incidence of assoc spine fractures incidence of assoc spine fractures with significant head injury (usually with significant head injury (usually C1-C3)C1-C3)

Noncontrast CT scan is gold standardNoncontrast CT scan is gold standard Neuro exam—if comatose, Glasgow Neuro exam—if comatose, Glasgow

Coma ScaleComa Scale

Glasgow Coma ScaleGlasgow Coma Scale

Eye OpeningEye Opening Best Verbal Best Verbal ResponseResponse

Best Motor Best Motor ResponseResponse

Spontaneous    4 Spontaneous    4

To verbal To verbal command    3 command    3

To pain    2 To pain    2

None    1 None    1

Oriented, Oriented, conversing    5 conversing    5

Disoriented, Disoriented, conversing   4 conversing   4

Inappropriate words    Inappropriate words    3 3

Incomprehensible Incomprehensible sounds 2 sounds 2

No verbal response    No verbal response    1 1

Obeys verbal Obeys verbal commands 6 commands 6

Localize to pain    5 Localize to pain    5

Flexion/Flexion/withdrawal    4 withdrawal    4

Abnormal flexion Abnormal flexion (decorticate)    3 (decorticate)    3

Extension Extension (decerebrate)    2 (decerebrate)    2

No response No response (flacid)    1 (flacid)    1

Glasgow Coma ScaleGlasgow Coma Scale

Score of 15 = normalScore of 15 = normal 131315 = mild head injury (awake, 15 = mild head injury (awake,

no significant focal deficits)no significant focal deficits) 9912 = moderate (altered 12 = moderate (altered

sensorium and/or focal deficits, but sensorium and/or focal deficits, but can follow simple commands)can follow simple commands)

8 or below = severe (cannot follow 8 or below = severe (cannot follow even simple commands)even simple commands)

ManagementManagement

Surgical or Surgical or Medical?Medical?

Subdural Hematoma--Subdural Hematoma--Surgical ManagementSurgical Management

Symptomatic SDH > 1cm at thickest Symptomatic SDH > 1cm at thickest point requires point requires rapid evacuationrapid evacuation

Smaller SDH often do not require evacuation—Smaller SDH often do not require evacuation—surgery may increase brain injury if severe swelling surgery may increase brain injury if severe swelling & herniation thru craniotomy& herniation thru craniotomy

Large craniotomy flap that allows access from Large craniotomy flap that allows access from skull base to midline—broad access required skull base to midline—broad access required because these lesions are unpredictablebecause these lesions are unpredictable

Clot removal--open dura & suction/irrigate clotClot removal--open dura & suction/irrigate clot Hemostasis--identify and cauterize bleeding Hemostasis--identify and cauterize bleeding

vesselvessel

Epidural Hematoma—Epidural Hematoma—Surgical ManagementSurgical Management

Indications: Indications: Any symptomatic EDHAny symptomatic EDHAny asymptomatic if > 1cmAny asymptomatic if > 1cm

More limited craniotomyMore limited craniotomy Remove clot—often easier than in SDH Remove clot—often easier than in SDH

because dura is less fragile than cortex because dura is less fragile than cortex (helps contain hematoma and can be (helps contain hematoma and can be manipulated)manipulated)

Hemostasis--identify & repair bleeding Hemostasis--identify & repair bleeding vesselvessel

Subarachnoid HemorrhageSubarachnoid Hemorrhage—Medical Management—Medical Management

Two different treatment strategies:Two different treatment strategies:1.1. Cerebral perfusion pressure managementCerebral perfusion pressure management2.2. Intracranial pressure therapy—focus on Intracranial pressure therapy—focus on

decreasing the ICPdecreasing the ICP

Controversy exists as to which treatment Controversy exists as to which treatment focus is best, but outcomes are generally focus is best, but outcomes are generally similar.similar.

Subarachnoid HemorrhageSubarachnoid Hemorrhage—Medical Management—Medical Management

Cerebral perfusion pressure Cerebral perfusion pressure therapytherapy

CPP = mean arterial pressure – intracranial CPP = mean arterial pressure – intracranial pressurepressure

Maintain CPP at 70mmHg or greaterMaintain CPP at 70mmHg or greater Hypotension is devastating—maintain MAP to keep Hypotension is devastating—maintain MAP to keep

cerebral perfusioncerebral perfusion Focus on MAP maintenanceFocus on MAP maintenance

Elevate MAP--mild hypervolemia & vasopressorsElevate MAP--mild hypervolemia & vasopressors Bed flat to maintain CPPBed flat to maintain CPP

Subarachnoid HemorrhageSubarachnoid Hemorrhage—Medical Management—Medical Management

ICP therapy—focus on decreasing ICPICP therapy—focus on decreasing ICP Normal ICP 10mmHg or less, treat if it reaches Normal ICP 10mmHg or less, treat if it reaches

20mmHg20mmHg drain CSF via ventriculostomy to decrease ICPdrain CSF via ventriculostomy to decrease ICP mannitol (osmotic diureses & decr blood viscosity mannitol (osmotic diureses & decr blood viscosity

vasoconstriction vasoconstriction decr cerebral blood decr cerebral blood volumevolume decr ICP) decr ICP)

HyperventilationHyperventilation cerebral vasoconstriction cerebral vasoconstriction decr ICP to PaCo2 of 30-35 (but be careful decr ICP to PaCo2 of 30-35 (but be careful because can exacerbate cerebral ischemia)because can exacerbate cerebral ischemia)

raise head of bed 30 degrees to lower ICP (helps raise head of bed 30 degrees to lower ICP (helps with venous drainage)with venous drainage)

Medical Management Medical Management cont.cont.

Treatment is complex—the following are Treatment is complex—the following are guidelinesguidelines:: ICP monitoring ASAP for all pts w/ GCS ICP monitoring ASAP for all pts w/ GCS

score <8 or abnl CT scanscore <8 or abnl CT scan #1 goal—maintain bp and airway (avoid #1 goal—maintain bp and airway (avoid

hypotension!!)hypotension!!) No mannitol or hyperventilation for No mannitol or hyperventilation for

prophylaxis (i.e., before ICP monitoring) prophylaxis (i.e., before ICP monitoring) unless signs of intracranial hypertension like unless signs of intracranial hypertension like herniation or rapid neuro declineherniation or rapid neuro decline

Maintain CPP >70mm HgMaintain CPP >70mm Hg

Medical Guidelines cont.Medical Guidelines cont. If ICP rises to 20-25mmHg, then consider tx If ICP rises to 20-25mmHg, then consider tx

to lower it (ventriculostomy, mannitol bolus)to lower it (ventriculostomy, mannitol bolus) Consider high-dose barbiturates in Consider high-dose barbiturates in

hemodynamically stable pts w/ elevated ICP hemodynamically stable pts w/ elevated ICP refractory to ventriculostomy and mannitolrefractory to ventriculostomy and mannitol

Hyperventilation only as last resort, due to Hyperventilation only as last resort, due to potential to exacerbate cerebral ischemia, potential to exacerbate cerebral ischemia, especially in first 5 days post-injuryespecially in first 5 days post-injury

Current research into hypertonic saline Current research into hypertonic saline infusions and induced hypernatremia to infusions and induced hypernatremia to reduce ICP, instead of using mannitolreduce ICP, instead of using mannitol

ReferencesReferences1. Becske T, Jallo G. Subarachnoid hemorrhage www.emedicine.com. Accessed Feb 1. Becske T, Jallo G. Subarachnoid hemorrhage www.emedicine.com. Accessed Feb

10 2005.10 2005.2. Chestnut RM. Guidelines for the management of severe head injury: What we know 2. Chestnut RM. Guidelines for the management of severe head injury: What we know

and what we think we know. and what we think we know. J of Trauma: Injury, Infection, and Critical Care. J of Trauma: Injury, Infection, and Critical Care. 1997; 42:19-22.1997; 42:19-22.

3. Gordon M. Univ of Kansas SOM. 2003. Available at 3. Gordon M. Univ of Kansas SOM. 2003. Available at http://www.pharmacology2000.com/822_1/page1.htm Accessed Feb 12 2005.http://www.pharmacology2000.com/822_1/page1.htm Accessed Feb 12 2005.

4. Greenberg MS. 4. Greenberg MS. Handbook of Neurosurgery. Handbook of Neurosurgery. 55thth ed. New York: Thieme Medical ed. New York: Thieme Medical Publishers; 2001.Publishers; 2001.

5. Gruen JP. Subarachnoid hemorrhage. USC Neurosurgery website 2000. Available 5. Gruen JP. Subarachnoid hemorrhage. USC Neurosurgery website 2000. Available at http://uscneurosurgery.com/glossary/s/subarachnoid%20hemorrhage.html. at http://uscneurosurgery.com/glossary/s/subarachnoid%20hemorrhage.html. Accessed Feb 12 2005.Accessed Feb 12 2005.

6. Lee, B. 2000. Available at http://www.pathguy.com/bryanlee/subdural.htm. 6. Lee, B. 2000. Available at http://www.pathguy.com/bryanlee/subdural.htm. Accessed Feb 12 2005.Accessed Feb 12 2005.

7. Marshall, LF. Head Injury: Recent Past, Present, and Future. 7. Marshall, LF. Head Injury: Recent Past, Present, and Future. Neurosurgery. Neurosurgery. 2000; 2000; 47(9): 546-561.47(9): 546-561.

8. Price DD, Wilson SR. Epidural hematoma. www.emedicine.com. Accessed Feb 10 8. Price DD, Wilson SR. Epidural hematoma. www.emedicine.com. Accessed Feb 10 2005.2005.

9. Scaletta, T. Subdural hematoma. www.emedicine.com. Accessed Feb 10 2005.9. Scaletta, T. Subdural hematoma. www.emedicine.com. Accessed Feb 10 2005.10. Valadka AB, Narayan RK. Injury to the cranium. In: Feliciano DV, Moore EE, 10. Valadka AB, Narayan RK. Injury to the cranium. In: Feliciano DV, Moore EE,

Mattox KL, ed. Mattox KL, ed. Trauma.Trauma. 3 3rdrd edition. Stamford, CT: Appleton & Lange; 1996:267- edition. Stamford, CT: Appleton & Lange; 1996:267-278.278.

11. Net Medicine Homepage. 1996. Available at 11. Net Medicine Homepage. 1996. Available at http://www.netmedicine.com/xray/ctscan/ct24.htm. Accessed Feb 12 2005.http://www.netmedicine.com/xray/ctscan/ct24.htm. Accessed Feb 12 2005.