Morning Report: Traumatic Brain Injury - AANS Guidelines

Thanks to Dr. McMillan for today’s Morning Report!

Traumatic Brain Injury – American Association of Neurological Surgeons Guidelines

Case#1: A 45 year-old man helmeted motorcyclist struck by van, negative loss of consciousness, and currently GCS 15 and appropriate but complaining of headache. CT scan shows a small, lenticular hematoma along the left-parietal extradural space consistent with acute epidural hematoma. It measures 9 mm at the greatest and there is no appreciable midline shift. What is the most appropriate neurosurgical intervention?

Ultimately up to the consulting neurosurgeon’s and institution’s experience and comfort in managing the injury, but according to published AANS guidelines, an acute epidural hematoma of <15 mm clot thickness, and less than 5 mm midline shift in patient with GCS > 8 can be managed non-operatively. Of note, guidelines state EDH of greater than 30 cm3 should be surgically evacuated regardless of the patient’s GCS score.

Case#2: A 36 year-old woman presents by trauma notification for ped-struck and is comatose with GCS 8. EMS reports that initially GCS 13-14, but she has since worsened. CT scan shows a crescent-shaped, right-parietal hematoma approximately 7mm thick consistent with acute subdural hemorrhage. There is trace midline shift, less than 5mm. What is the appropriate neurosurgical intervention?

Discuss with the surgeon, but according to published AANS guidelines, acute SDH in a comatose (GCS < 9) patient with GCS decline by 2 or more points from time of injury and time of hospital admission (presentation) should undergo surgical evacuation of the lesion even if it is less than 10 mm thick and less than 5mm midline shift. Additional indications with clots not meeting criteria are asymmetric or fixed and dilated pupils, or ICP > 20 mmHg.

Case#3: A 19 year-old male is the victim of assault by baseball bat where he was struck once in the right side of the head. He denies loss of consciousness, but is complaining of headache, and has a hematoma and bleeding to the right frontoparietal region of his scalp, but no apparent exposed intracranial tissue, fluid leakage or gross cosmetic deformity. CT scan shows a skull fracture of the region underlying the wound with maximal depression of the fracture fragments less than the thickness of the cranium, and no apparent dural penetration. What is the appropriate neurosurgical intervention?

According to published AANS guidelines, an open, depressed skull fracture can be managed non-operatively if there is no: 1. Depression > thickness of cranium, or >1 cm, evidence of dural penetration, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus, or gross wound contamination. If more depressed than thickness of cranium, should be operatively repaired to reduce chances of infection, (elevation and debridement). All strategies for dealing with open fractures include antibiotics.

The following are excerpts from the referenced AANS guidelines:

American Association of Neurological Surgeons: Guidelines for the Surgical Management of Traumatic Brain Injury

Chapter 3. Surgical Management of Acute Epidural Hematomas

Indications for Surgery

An epidural hematoma (EDH) greater than 30 cm³ should be surgically evacuated regardless of the patient’s GCS score.
An EDH less than 30 cm³ and with less than a 15-mm thickness and with less than a 5 mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial CT scanning and close neurological observation in a neurosurgical center.

Timing

It is strongly recommended that patients with an acute EDH in coma (GCS score <9) with anisocoria undergo surgical evacuation as soon as possible.

Methods

There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.

Bullock, M. Ross, et al. Chapter 3. Surgical Management of Acute Epidural Hematomas. In: Guidelines for the Surgical Management of Traumatic Brain Injury. Neurosurgery. 58(3) (Supplement):S2-16-S2-24, March 2006. Retrieved from https://www.braintrauma.org/pdf/protected/Surgical_Guidelines_article_2.pdf on 6/13/2014.

Chapter 4. Surgical Management of Acute Subdural Hematomas.

Indications for surgery

An acute subdural hematoma (SDH) with a thickness greater than 10mm or a midline shift greater than 5mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient’s GCS score.
All patients with acute SDH in coma (GCS <9) should undergo intracranial pressure monitoring.
A comatose patient (GCS<9) with an SDH less than 10 mm thick and midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mmHg.

Timing

In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.

Methods

If surgical evacuation of an acute SDH in a comatose patient (GCS<9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.

Bullock, M. Ross, et al. Chapter 4. Surgical Management of Acute Subdural Hematomas. In: Guidelines for the Surgical Management of Traumatic Brain Injury. Neurosurgery. 58(3) (Supplement):S2-16-S2-24, March 2006. Retrieved from https://www.braintrauma.org/pdf/protected/Surgical_Guidelines_article_2.pdf on 6/13/2014.

Chapter 5. Surgical Management of Traumatic Parenchymal Lesions.

Indications

Patients with parenchymal mass lesions and signs of progressive neurological deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on CT scan should be treated operatively.
Patients with GCS scores of 6 to 8 with frontal or temporal contusions greater than 20 cm³ in volume with midline shift of at least 5mm and/or cisternal compression on CT scan, and patients with any lesion greater than 50 cm³ in volume should be treated operatively.
Patients with parenchymal mass lesions who do not show evidence for neurological compromise, have controlled intracranial pressure (ICP), and no signs significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging.

Timing and Methods

Craniotomy with evacuation of mass lesion is recommended for those patients with focal lesions and the surgical indications listed above, under Indications.
Bifrontal decompressive craniectomy within 48 hours of injury is a treatment option for patients with diffuse, medically refractory posttraumatic cerebral edema and resultant intracranial hypertension.
Decompressive procedures, including subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy, are treatment options for patients with refractory intracranial hypertension and diffuse parenchymal injury with clinical and radiographic evidence for impending transtentorial herniation.

Bullock, M. Ross, et al. Chapter 5. Surgical Management of Traumatic Parenchymal Lesions. In: Guidelines for the Surgical Management of Traumatic Brain Injury. Neurosurgery. 58(3) (Supplement):S2-16-S2-24, March 2006.

Chapter 6. Surgical Management of Posterior Fossa Mass Lesions

Indications

Patients with mass effect on CT scan or with neurological dysfunction or deterioration referable to the lesion should undergo operative intervention. Mass effect on CT scan is defined as distortion, dislocation, or obliteration of the fourth ventricle; compression or loss of visualization of the basal cisterns, or the presence of obstructive hydrocephalus.
Patients with lesions and no significant mass effect on CT scan and without signs of neurological dysfunction may be managed by close observation and serial imaging.

Timing

In patients with indications for surgical intervention, evacuation should be performed as soon as possible because these patients can deteriorate rapidly, thus, worsening their prognosis.

Methods

Suboccipital craniectomy is the predominant method reported for evacuation of posterior fossa mass lesions, and is therefore recommended.

Bullock, M. Ross, et al. Chapter 6. Surgical Management of Posterior Fossa Mass Lesions. In: Guidelines for the Surgical Management of Traumatic Brain Injury. Neurosurgery. 58(3) (Supplement):S2-16-S2-24, March 2006. Retrieved from https://www.braintrauma.org/pdf/protected/Surgical_Guidelines_article_2.pdf on 6/13/2014.

Chapter 7. Surgical Management of Depressed Cranial Fractures

Indications

Patients with open (compound) cranial fractures depressed greater than the thickness of the cranium should undergo operative intervention to prevent infection.
Patients with open (compound) depressed cranial fractures may be treated nonoperatively if there is no clinical or radiographic evidence of dural penetration, significant intracranial hematoma, depression greater than 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus, or gross wound contamination.
Nonoperative management of closed (simple) depressed cranial fractures is a treatment option.

Timing

Early operation is recommended to reduce the incidence of infection.

Methods

Elevation and debridement is recommended as the surgical method of choice.
Primary bone fragment replacement is a surgical option in the absence of wound infection at the time of surgery.
All management strategies for open (compound) depressed fractures should include antibiotics.

Bullock, M. Ross, et al. Chapter 7. Surgical Management of Posterior Fossa Mass Lesions. In: Guidelines for the Surgical Management of Traumatic Brain Injury. Neurosurgery. 58(3) (Supplement):S2-16-S2-24, March 2006. Retrieved from https://www.braintrauma.org/pdf/protected/Surgical_Guidelines_article_2.pdf on 6/13/2014.