Surgical management of traumatic brain

injuryYoumans Chapter 335

Outline• Conservative management• Indication for evacuation of intracranial hematomas• Evaluation of Relevant Findings on Computed Tomography• Preoperative preparation• Ventriculostomy• Exploratory bur holes• General consideration for supratentorial hematoma• EDH• Acute SDH

Outline• Intraparenchymal hemorrhage and contusion• Posterior fossa hematoma• Decompressive craniectomy• Depress skull fracture over a venous sinus• Chronic SDH• Cranioplasty• Complication• Depress skull fracture• Compound Frontal air sinus injury

Conservative management

Conservative management

Indication for evacuation of intracranial hematomas

• aEDH• aSDH• Intraparenchymal Hemorrhage and contusion• Posterior Fossa Mass Lesions/Hemorrhages• Depressed Skull Fractures

Guideline for the surgical management of Traumatic brain injury 2006

aEDH

• Indications for Surgery• EDH larger than 30 cc : operatively • EDH smaller than 30 cc, less than 15 mm thick, and with less than a 5-mm

midline shift in patients with a GCS score lower than 8 without focal deficit can be managed : : nonoperatively

• Timing• Patients in coma with aEDH (GCS score <9) and anisocoria

undergo surgical evacuation as soon as possible.• Important caveat• EDH in the middle fossa/inferotemporal lobe should have a lower threshold

for surgery

aSDH• Indications for Surgery• aSDH with thickness greater than 10 mm or a midline shift of greater than 5

mm on CT : operatively• All patients in coma with aSDH (GCS score <9) : ICP monitoring• A comatose patient (GCS score <9) with an aSDH smaller than 10 mm and a

midline shift of less than 5 mm should undergo surgical evacuation of the lesion if• GCS score drop > 2• asymmetric or fixed and dilated pupils• ICP exceeds 20 mm Hg.

Intraparenchymal Hemorrhage and contusion• Indication for surgery• progressive neurological deterioration referable to the lesion,medically

refractory intracranial hypertension, signs of a mass effect on CT : operatively• GCS 6-8 + frontal or temporal contusions larger than 20 cc with a midline shift

of at least 5 mm or cisternal compression on CT : operatively• Volume larger than 50 cc : operatively• not show evidence of neurological compromise, have controlled ICP, and do

not exhibit significant signs of a mass effect on CT : non-operatively + serial imaging

• Craniotomy

Posterior Fossa Mass Lesions/Hemorrhages

• Mass effect on CT brain or neurological dysfunction : Operatively• distortion, dislocation, or obliteration of the fourth ventricle• compression or loss of visualization of the basal cisterns• the presence of obstructive hydrocephalus

• Suboccipital craniectomy

Depressed Skull Fractures• Open (compound) cranial fractures depressed greater than the thickness

of the cranium : operatively• Nonoperative management

• No clinical or radiographic evidence of dural penetration• No significant ICH• No depression greater than 1 cm• No frontal sinus involvement• No gross cosmetic deformity• No wound infection• No pneumocephalus• No gross wound contamination

Evaluation of Relevant Findings on CT

• Posttraumatic Mass Volume Measurement in Patients with Traumatic Brain Injury• Radiographic Correlates of Outcome

Posttraumatic Mass Volume Measurement in Patients with Traumatic Brain Injury• ABC method• A largest diameter in slice 1• B orthogonal to A• C• Compare each 10-mm slice with slice 1.• > 75% of slice 1, count that slice as 1.• 25% to 75%, count the slice as 0.5.• < 25%, count the slice as zero (do not count the slice).• Add these totals to get “C.”

• ABC/2

Radiographic Correlates of Outcome

• Standard• 5-mm slices from the foramen magnum to the sella• 10-mm slices above the sella, parallel to the orbitomeatal line

• Compressed or absent basal cisterns • Midline shift (MLS) at the foramen of Monro• MLS = (A/2) − B.

• Traumatic subarachnoid hemorrhage (tSAH)

Preoperative Preparation• mean arterial pressure greater than 70 mm Hg (>90 mm Hg until

cerebral perfusion pressure [CPP] can be measured)• CPP higher than 60 mm Hg• euthermia, eucapnia• oxygen saturation greater than 93%• Pao2 of 95 to 100 mm Hg• ICP higher than 20 mm Hg• serum sodium concentration of 135 to 145 mEq• Intubate protect airway

Preoperative Preparation• Prophylactic hyperventilation or the use of mannitol is no longer

recommended• Unless the patient exhibits focal neurological signs (contralateral

weakness, ipsilateral anisocoria or “blown pupils,” decerebrate or decorticate posturing)• hyperventilated to a Paco2 of 30 to 32 mm Hg• given 1 g/kg of mannitol immediately

Preoperative Preparation• Anticoagulant and antiplatelet drugs• chronic alcoholism and chronic aspirin ingestion

• Recombinant factor VIIa (rFVIIa)• induce hemostasis within 10 minutes• decrease hematoma expansion in patients with hypertensive

hemorrhage and trauma• Expensive• 20 – 40 mg of rFVIIa

• 5 to 10 mg of vitamin K intravenously, platelets FFP

Ventriculostomy• Gold standard method for measuring ICP• Drainage of cerebrospinal fluid (CSF) to lower ICP• Bedside

4 cm from midline2 cm in front of coronal suture10 cm fron superior orbital rim

7-10 cm from surface of skull

Exploratory bur hole• CT unavaible• Bur hole on• ipsilateral to a dilated pupil• contralateral to the most abnormal motor response• ipsilateral to a skull fracture

General consideration for supratentorial hematoma

• Rationale for Use of a Large Craniotomy• Craniotomy Technique

Rationale for Use of a Large Craniotomy

• Require debridement • Frontal pole• Temporal pole• Inferior part of frontal lobe• Craniotomy should no closure more than 1.5-2 cm from midline :

avoid saggital sinus and parasaggital granulation

Craniotomy Technique

Craniotomy Technique

EDH• Associated linear skull fracture• Bleeding from• anterior or posterior divisions of the middle meningeal artery• middle meningeal vein, the diploic veins, or the venous sinuses

• Usually clot• Temporal location should have lower threshold for surgery

Operative technique• Frontotemporoparietal or a large pterional craniotomy• Slash incision and can extend to trauma flap • Epicenter of the EDH to provide complete exposure of the hematoma

such that the margins are approximately 5 mm less than the diameter of the EDH : allow optimal dural “hitching”• Initial bur hole is placed over the thickest part of the clot to reduce

ICP• Intramural reperfusion hematoma : develop rapidly under a removed

extradural hematoma

Operative technique• Incision• Raney clip• Strip periosteum• Craniotomy : two to four bur hole• Dural tack-up suture : no more than 2.5 cm• Central dural tack-up suture• Remove blood clot and stop bleeding source• Replace bone flap• Vacuum drain under galeal layer

aSDH• Associated intracranial lesion : contusions, hematomas, or cortical

lacerations• Important and potentially lethal complication of anticoagulant

therapy.

Operative technique• Large frontotemporoparietal craniotomy• Dura opening• Remove clot : SDH, intracerebral• Bleeding point• Cortical surface : bipolar• Bridging vein : bipolar• Sinus wall : Gelfoam,Surgicel or Aveitene and gentle temponade with

cottonoid pad

Operative technique• If diffuse oozing is persistent• PT, PTT, platelet count, and INR• Five to 10 units of FFP, rFVIIa, or up to 5 to 10 packs of platelet

concentrate• Dural peripheral tack-up sutures• Duraplasty

Intraparenchymal hemorrhage and contusion

• Repeat CT brain daily over the first 3 day• Delayed traumatic intracerebral hemorrhage : develop of radiographic

injury in 24-72 hr• Early identification and treatment, improve outcome• Bifrontal craniotomy or bifrontal decompressive craniectomy

Operative techniqueIncision : behind hairline,starting at zygoma

Burr hole temporal and frontal regionmidline low frontal burr hole :

10 mm above nasion

Bilateral dura opening with the flap base to ward the saggital sinus

Most proximal SSSDouble-ligated and cut as close to the crista galli

PolectomyFrontal

Posterior fossa hematoma• Silent and slow• Obstructive hydrocephalus and brain stem compression• Most common : EDH• Seizure prophylaxis ; coexistent supratentorial injury

Operative techniqueflexed anteriorly at the occipitocervical junction

bone removal over the venous sinusesperformed lastdecompress upper : edge of transverse sinus inferior : foramen magnum

Decompressive craniectomy• always be extensive, approximately 15-cm craniectomy(AP diameter)• frontotemporoparietal craniectomy or bifrontal craniectomy• the dura must be opened widely as well• intractable ICP develops after a craniotomy has already been performed : T-off incision

Depressed skull fracture• Indication for surgery• the depth of the depressed fragments of the fracture is equal to or

greater than the width of the surrounding bone• the fracture occurs over cosmetic areas such as the forehead• the fracture is of a compound variety• there is a significant underlying ICH that requires surgery.

Linear incision or lazy S incision

Burr hole at the edge of fracture

not apply any downward pressure on the underlying dura and brain.

MiniplatesDura graftWhen the wound is heavily contaminated or more than 24 hours old : delayed cranioplasty 1 to 2 months later

Compound frontal air sinus injury• Nondepressed fractures through only the posterior wall of the frontal

sinus : do not surgical repair• When the force is significant enough to penetrate the anterior and

posterior tables : high rate infection sepsis

bicoronal craniotomyIncision 15 mm behind hairlineholes over the sagittal sinus in the midlinesinus mucosa removed : prevent mucocele

coronal flap is elevated to the supraorbital rim and the zygomatic archesvascularized galeal flap basedostia are occluded with a muscle plug

fractures of the floor of the frontal fossa

Depressed skull fracture over a venous sinus• Occlusion of major sinus raise ICP with deteriorating neurological

status : urgent fracture elevation• Transverse sinus : drainage of supratentorial and infratentorial,

significant asymmetry(right side dominant)• Preoperative angiography or MRA• Measuring ICP during occlusion,if pressure more than 20 mmHg :

mannitol, hyperventilation

Most important Head above heart

Right atrial catheter Esophageal stethtoscope

Remove Rongeurs

Gentle temponade Repair after insert shunt

Directly suture defect

Onlay patch graft

Chronic subdural hematoma• 3 wks or more after injury• Symptom and sign are variable and non-specific : headaches,decline in

motor function, motor deficit• Coagulpathy and anticoagulant therapy are accelerate these symptom• Indication : > 1 cm. of maximum thickness or mass effect• Management • Bur hole with drainage• Twist drill drainage• Craniotomy• Shunting

Cranioplasty• Indication : after decompressive craniectomy for raised ICP• 6-8 wk after procedure• Hocky helmet before cranioplasty• Autulogous bone flap• Sterile in -70 C freezer• Patient’s own abdominal subcutaneous tissue : complication bone resorption

• Methy methacrylate and titanium mesh

Mannitol with hyperventilateStop bleeding for prevent postcranioplasty hematoma

Subgaleal plane : NSS to infiltrating

Piece of wet gauzeCold salineMaterial in plastic bag

Large cranioplastyComputer-assisted design

Complication• Bleeding• Recurrent hematoma• FFP, platelet conc,rFVII• Final hemostasis should be achieved at PaCO2 35-40 mmHg and Valsalva

maneuver• Profuse bleeding from laceration of the carotid artery from base of skull :

angiography and intra-arterial balloon occlusion

• Coagulopathy associated with TBI• Risk factor for DIC• Brain rich in thromboplasmin(tissue factor)

Complication• Acute/intraoperative brain swelling• MAP at 70-80 mmHg• Reassess ET tube, ABG, Hyperventilation• Bleeding from ipsilateral or contralateral hematoma : intraoperative US• Hypothermia or pentobarbital• Etomidate or propofol

• Postcraniotomy hematoma• Skull base fracture and CSF leak