Traumatic Brain Injury

oskar
 Introduction
 TBI is a nondegenerative, noncongenital insult to the brain from an
external mechanical force, possibly leading to permanent or temporary
impairment of cognitive, physical, and psychosocial functions, with an
associated diminished or altered state of consciousness
 CDC (2013)  2.8 million emergency department
visits, hospitalization, or deaths related to
traumatic brain injury (TBI).
 Every hour, there are an average of 204 TBI-related ER visits, 33 TBI-
related hospitalizations;
and 6 TBI-related deaths.
 Initial management and prevention of secondary brain injury

Neurological Disorders Public Health Challenges. WHO. 2013

Intracranial Pressure
 10 mmHg = Normal
 >20 mmHg = Abnormal
 >40 mmHg = Life
threatening

Cerebral Blood Flow

 50 mL/100 g/min = Normal.
 < 25 mL/100 g/min = EEG abN
 < 5 mL/100 g/min = cell death

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
Autoregulation
 Autoregulation maintains CPP between 50 – 150 mmHg
 TBI causes disruption of autoregulation

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
 Epidemiology
 Insidensi 2% of population
 80% Mild HI
 Intracranial hemorrhage:
1. 25 – 45 % : Severe HI
2. 3-12 % : Moderate HI
3. 1 % : Mild
 Mortality : 10 – 35 %. Up to 80%
 Clinical Findings
 Conscious patient
 Anxious, restless, headache, vomiting, blurred vision, delirium,
paresis
 Baby : bulging fontanelle

 Unconscious patient
a.Unilateral pupil dilatation unreactive + hemiparesis contralateral 
uncal herniation(EDH, SDH, ICH)
b.Abnormal posture : decerebration + decortication
c.Papiledema and retinal bleeding with CN VI paresis
d.Hipertension and bradicardia
e.Abnormal respiration
 Neurologic Examination

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
Agarwal N, Neurosurgery Fundamentals. Thieme. 2018.
  The common phrase “less than 8, then
intubate” speaks more to the inability for
the patient to protect his/her airway.
 In fact, 56—60% of patients with GCS
score less than or equal to 8 have one or
more other organ systems injured.
 Furthermore, 4–5% have associated spine
fractures.

Agarwal N, Neurosurgery Fundamentals. Thieme. 2018.

IMAGING

 CT Scan first choice

 Skull X-ray seldom
needed
 Cervical X-ray

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
 New Orleans Criteria
CT is recommended for patients with
minor head injury (GCS 15) with any one
of the following findings:
1. Headache.
2. Vomiting.
3. Age more than 60 years.
4. Drug or alcohol intoxication.
5. Persistent anterograde amnesia.
6. Visible trauma above the clavicle.
7. Seizure
C-spine control
 Allignment
 Bony Fractures
 PVST (>5 mm abN)

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
  Chest X-ray
 Abdominal X-ray
 Pelvic X-ray

TBI guideline.www.braintrauma.org.2007
Classification
 Penetrating brain injury is a high-mortality emergency
for theneurological surgeon.
 In the presence of penetrating brain injury, thefirst
step is to initiate advanced trauma life support
resuscitation with early transportation to definitive
care.

Ellenbogen RG, Abdulrauf SI, Sekhar LN.

Principles of Neurological Surgery 3rd ed.
Philadelphia. Elsevier. 2012
 Skull Base Fracture
 19 – 21% of skull fractures
 Clinical findings :
 Rhinorrhea : anterior
 Otorrhea : medial
 Hemotympanum
 Periorbital echymosis
 Retroauricular echymosis
 CN VII paresis
 Loss of hearing
 Pneumocephalus

Qureshi NH, Kopell BH. Skull fracture. Available at http://emedicine.medscape.com/article/248108-overview#a8. Date of citation 1 Aug 2015
Qureshi NH, Kopell BH. Skull fracture. Available at http://emedicine.medscape.com/article/248108-overview#a8. Date of citation 1 Aug 2015
Vault – depressed vs linear
  Depressed skull fractures are often open,and
are associated with infection rates of up to 11%
and epilepsy in up to 15%

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
 CONCUSSION
 Transient loss of consciousness.
 Normal head CT.
 Nausea, vomiting.
 Headache : If severe, repeat CT.
 Symptoms may worsen before improvement.
 Sequelae common.
EPIDURAL HEMATOMA

 2,7 – 4% of TBI
 Mortality 0% if patient not
in coma.
 If patient in coma 10 – 20%
 Early evacuation good
prognosis.
 Classic : Middle meningeal
artery tear.
 Lenticular/biconvex due to
dural adherence to skull.
 Lucid interval.
 Can be rapidly fatal.
SUBDURAL HEMATOMA

 12 – 29% severe TBI

 Mortality 40 – 60%
unless surgery 3-4 hours
 Venous tear/brain
laceration.
 Covers entire cerebral
surface.
 Morbidity/mortality due to
underlying brain injury.
CONTUSION/HEMATOMA

 8% of all TBI
 Coup/contrecoup injuries
 Most common :
frontal/temporal lobes
 “Salt & pepper” appearance
on CT
 CT changes usually
progressive
 Most conscious patients : no
operation.
 SUBARACHNOID HEMORRHAGE

 Most common in
fatal head injury
 Causes vasospam
and ischemia
 Hydrocephalus as
sequele
 DIFFUSE AXONAL INJURY

 Prolonged deep
coma ( not due to
mass lesion )
 Diffuse Brain injury
 Motor posturing
 MANAGEMENT

 Goal :
 Maintain adequate CPP
 Prevent secondary brain injury
Medical Management
1. Head up 15-30 degree
2. Airway assured : prevent hypercarbia and hypoxia.
3. Assisted ventilation : PaCO2 30 mmHg
4. Prevent Hypotension. MAP 90 – 100 mmHg
5. Euvolemia
6. Mild hypotermia ???
7. Manitol 0,25- 1 g/kgBB
8. Pentobarbital 2-2,5 mg/kgBB/hour
Surgical
1. ICP insertion
2. Craniotomy evacuation: EDH, SDH, ICH
3. CSF diversion for hydrocephalus
4. Decompressive craniectomy –
Medical fail  hemicraniectomy
5. Emergency burr hole ???

TBI guideline.www.braintrauma.org.2007
severity
 Mild Head Injury
 GCS Score = 14 - 15.
 3% deteriorate unexpectedly
 History
 Exclude systemic injuries
 Neurologic exam
 X-rays as indicated
 Alcohol/drug screen as indicated
 Liberal use of head CT
Observe or discharge based on findings

TBI guideline.www.braintrauma.org.2007
Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier.
2012
 Moderate Head Injury
 GCS Score = 9 - 13.
 10% will deteriorate into coma
 40% abnormal CT  8% surgery
 Initial evaluation same as for mild injury.
 CT scan for all.
 Admit & observe :
• Frequent neurologic exams.
• Repeat CT scan.
 Deterioration : Manage as severe head injury.
Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
 Severe Brain Injury
 GCS Score = 3 - 8.
 Evaluate/resuscitate.
 Intubate for airway protection.
 Focused neurologic exam.
 Frequent reevaluation.
 Identify associated injuries.
Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier.
2012
SUMMARY
Prescription ( Do )
 Maintain mean BP > 90 mmHg.
 Maintain PaCO2 between 25 & 35 mmHg.
 Use isotonic solution for euvolemia.
 Frequent neurologic exams.
 Liberal use of CT Scans.
 Early neurosurgical consult.
SUMMARY
Prescription ( 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.
 Pengendara motor kecelakaan 4 jam SMRS
GCS=E3M5V4=12, pupil anisokor, ф 3/5, RC +/↓, Parese -/-
Pasien ditemukan dalam keadaan tidak sadar 5 jam SMRS
GCS=E1M3Vt=5, pupil bulat isokor, RC -/-, Parese -/-
Thank You