World Journal of Emergency Medicine ›› 2013, Vol. 4 ›› Issue (4): 252-259.doi: 10.5847/wjem.j.issn.1920-8642.2013.04.002
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Liza Victoria S Escobedo1, Joseph Habboushe1, Haytham Kaafarani2, George Velmahos2, Kaushal Shah3, Jarone Lee2(
)
Received:2013-04-15
Accepted:2013-10-11
Online:2013-12-15
Published:2013-12-15
Contact:
Jarone Lee
E-mail:lee.jarone@mgh.harvard.edu
Liza Victoria S Escobedo, Joseph Habboushe, Haytham Kaafarani, George Velmahos, Kaushal Shah, Jarone Lee. Traumatic brain injury: A case-based review[J]. World Journal of Emergency Medicine, 2013, 4(4): 252-259.
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URL: http://wjem.com.cn//EN/10.5847/wjem.j.issn.1920-8642.2013.04.002
Table 1
Indications for placement of an ICP monitoring device[3]
| 1. Patients with severe TBI with a GCS of 3-8 and an abnormal head CT 2. Patients with severe TBI and a normal head CT with two or more of the following: Age >40 Unilateral or bilateral motor posturing Systolic blood pressure <90 mmHg |
Table 2
Indications for surgical decompression of traumatic intracranial lesions[3]
| Traumatic lesions | Indications for surgical decompression |
|---|---|
| Epidural hematoma (EDH) | 30.12±8.18 |
| GCS score <9, and anisocoria | |
| Midline shift >5 mm | |
| Hematoma thickness >15 mm | |
| Hematoma volume >30 cm3 regardless of GCS | |
| Subdural hematoma (SDH) | SDH larger than 5 mm on CT |
| Hematoma thickness >10 mm | |
| Midline shift > 5 mm | |
| GCS <9 with decreas since presentation of ≥2 | |
| ICP >20 mmHg | |
| Asymmetric or fixed and dilated pupils | |
| Intraparenchymal lesions | Progressive neurologic deterioration |
| Failed medical management with CT evidence of mass effect | |
| GCS 6-8 with frontal or temporal contusions >20 cm3 and midline shift of >5 mm or cisternal compression on CT | |
| Hematoma volume >50 cm3 | |
| Posterior fossa lesions | Mass effect on CT |
| Neurologic deterioration | |
| Depressed skull fractures | Skull depression >1 cm |
| Frontal sinus involvement | |
| Dural penetration | |
| Associated intracranial hematoma | |
| Gross cosmetic deformity | |
| Infection or obvious contamination | |
| Pneumocephalus |
Table 3
Authors recommendations
| Emergency neurosurgical evaluation for surgical decompression of certain hematomas Maintain ICP <20 mmHg and CPP between 60-80 mmHg Aggressively maintain systolic blood pressure >90 mmHg Avoid hypotonic fluids and albumin for resuscitation Oxygen saturation above 93% or PaO2 >60 mmHg Euthermia Maintain normal PaCO2 (35-40 mmHg) Seizure prophylaxis for first week post-injury |
Figure 1.
Epidural Hematoma (EDH): Lenticular-shaped hemorrhage that does not cross suture lines. The hemorrhage caused most commonly by injury to the middle meningeal artery. Collection of blood between the dura mater and cranium is classically associated with a lucid interval followed by unconsciousness. Subdural hematoma (SDH): Cresent-shaped hemorrhage that crosses suture lines secondary to shearing of bridging veins between the dura and arachnoid space. Classic presentation includes gradually increasing headache and confusion after head injury. Diffuse axonal injury (DAI): MRI preferred diagnostic modality given that over half of CT scans of patients with DAI are normal on presentation. When present on CT, it appears as multiple ovoid-shaped petechial hemorrhages at gray-white junction, typically bilateral, resulting from the breaking of axons from the neuronal body. Frequently, DAI involves the frontal and temporal lobes, corpus callosum, caudate nuclei, thalamus, tegmentum, and internal capsule. Intraparenchymal hemorrhage (IPH): Collection of blood in the cerebral parenchyma. Acute hemorrhage in traumatic brain injury appears hyperdense, whereas subacute and chronic appear isodense and hypodense respectively.
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