Transcript Case Presentation and Discussion on CNS Trauma

Case Presentation and
Discussion on Craniofacial Injury
Jeffy G. Guerra, MD
Level III Surgery Resident
Department of Surgery
Ospital ng Maynila Medical Center
24 January 2006
General Data:
B.A
6-year-old female
Sta. Ana, Manila
Chief Complaint:
“Loss of consciousness”
History of the Present Illness:
Eight hours PTA
Patient while riding on her
bicycle was allegedly hit
by a moving vehicle
sustaining head injury
(+) Loss of consciousness,
(+) Vomiting 2x
apparently recovered
no consult, no meds taken
History of the Present Illness:
One hour PTA
Patient became lethargic
and
had an episode of
vomiting
Consult
Primary Survey for Trauma
• Airway – intact no obstruction
• Breathing – spontaneous, clear breath
sounds
• Circulation – BP = 90/50, HR = 90, RR 18
Primary Survey for Trauma
• Deficits/Deformity – GCS= 13, no limb
deformities
• Exposure – none, cleared from site of
injury
5/5 5/5
100 100
++
++
5/5 5/5
100 100
++
++
motor
sensory
DTR
Initial Neurological Evaluation
•
•
•
•
•
GCS 13 (E3V4M6)
PERL 2-3mm
Full extraocular eye movement
No motor deficits on all extremities
(+) hematoma, Parietal area, right
Physical Examination
GEN
Drowsy, stretcher-borne, not in cardio-respiratory distress
VITAL SIGNS
BP= 90/50 CR= 90 RR= 18 36.9 C
HEENT
Pink palpebral conjunctiva, anicteric sclera, pupils equally
reactive to light, no nasal discharge, no pharyngeal
congestion, (+) parietal hematoma, R
CHEST
Symmetrical chest expansion, no retractions, clear breath
sounds
HEART
Adynamic precordium, normal rate, regular rhythm, no
murmurs
ABDOMEN
Flat, active bowel sounds, soft, non-tender
SKIN
Warm, dry
EXTREMITIES
(-) edema, full equal pulses on all extremities
Neurological Exam
• Cerebrum:
– drowsy
• Cerebellum:
– n/a
• E3M6V4
•
GCS= 13
Cranial Nerves:
I
n/a
II-III PERTL
III,IV,VI Full EOMs
V
(+) bicorneal reflex
VII
no facial assymetry
VIII (+) auditory stimulus
IX, X (+) gag reflex
XI
Shrug shoulders
XII
no tongue deviation
Neurological Exam
• Pathologic Reflex: (-) Babinski
5/5 5/5
100 100
++ ++
5/5 5/5
100 100
++ ++
sensory
DTR
motor
Past Medical History:
No previous hospitalization
No other pertinent medical
condition
Family History
Unremarkable
Growth and Development
Patient’s development at par with
age
Immunization History
Complete Immunization
Salient Features
6-year-old female
(+) Loss of consciousness*
(+) Lucid interval*
(+) Vomiting
GCS= 13
(+) hematoma, parietal area, right
Head Injury
↓
Traumatic Hematoma
↓
↓
Epidural *
Intradural
↓
↓
Subdural* Intracerebral
*Jamieson, KG (epidural: 50%, intradural: 45%)
Clinical Diagnosis
Diagnosis
Primary
Epidural
hematoma
secondary to
VA
Secondary
Intradural
hematoma
secondary to
VA
Certainty
Treatment
60%
Surgical/Medi
cal
40%
Surgical/Medi
cal
Surgeon directed trauma team
initial evaluation of
Head Injury
Ensure Airway:
Intubate for GCS<9
Ensure breathing: Keep
O2 Saturation >94%
Ensure Circulation:
Keep Systolic
BP >100mmHg
Signs of Elevated ICP?
(increasing obtundation,
dilated pupils)
No
Yes
GCS<15, Prolonged
LOC, or Focal Neuro
Signs?
No
Observation, other
studies as necessary
Yes
Hyperventilation to PaCO2
30-35mmHg<2 hours)
Mannitol 1g/kg
Consider IVC placement
Consider hypertonic NaCl
Consider barbiturate therapy
Head CT Scan
Normal
Abnormal
Consult Neuro Surgery
No
Admit to ICU
Surgical
Lesion?
Yes
Operating Room
Paraclinical Diagnostic Procedure
Do I need a paraclinical diagnostic
procedure?
yes
Goal
• Determine location and size of hematoma,
and accompanying brain injury
• Determine treatment plan
PARACLINICAL DIAGNOSTIC PROCEDURE
OPTIONS
BENEFIT
RISK
COST
AVAILA
BILITY
Skull x-ray
Able to identify the
fracture
Unable to identify
Intracranial bleeding
RADIATION
EXPOSURE
Php 150
+
CT SCAN
98% sensitivity
RADIATION
EXPOSURE
Php 3000
-
.
MRI
98% sensitivity
????
Php 15000
-
ANGIO
98% sensitivity
INVASIVE
PROCEDURE
Php 5000
-
CT Scan
CT Scan Result
• There is a lentiform hyperdense focus in
the right occipital convexity, measuring
about 2.26 x 4.27 cm
• No shift in the midline
• No fracture
EPIDURAL HEMATOMA, RIGHT
OCCIPITAL CONVEXITY
Pre-Treatment Diagnosis
Epidural Hematoma, right occipital area
secondary to Vehicular accident
Surgeon directed trauma team
initial evaluation of
Head Injury
Ensure Airway:
Intubate for GCS<9
Ensure breathing: Keep
O2 Saturation >94%
Ensure Circulation:
Keep Systolic
BP >100mmHg
Signs of Elevated ICP?
(increasing obtundation,
dilated pupils)
No
Yes
GCS<15, Prolonged
LOC, or Focal Neuro
Signs?
No
Observation, other
studies as necessary
Yes
Hyperventilation to PaCO2
30-35mmHg<2 hours)
Mannitol 1g/kg
Consider IVC placement
Consider hypertonic NaCl
Consider barbiturate therapy
Head CT Scan
Normal
Abnormal
Consult Neuro Surgery
No
Admit to ICU
Surgical
Lesion?
Yes
Operating Room
Critical Factors for Surgical
evacuation
• Patient’s neurologic status
• Imaging findings
• Extent of extracranial injury
Indications for Surgical Evacuation
• Subdural or epidural hematoma
– >5mm thick
– Midline shift
– GCS<8
Controversial groups needing
evacuation
• Subdural or epidural hematoma
– 5-10mm thick
– GCS of 9 - 13
Goals of Treatment
• Complete evacuation of hematoma
• Resolution of neurologic deficit
• Prevention of complications of herniation
Treatment Options
Options
Medical
Benefit
Risk
Cost
Availability
SR = 23%*
MR: >15%
(with salvage
surgery)
P 4000/day
Available
SR = 90100% *
MR: 0-5%
P 15,000
Available
Craniotomy
*Laboto et al
Treatment Plan
Craniotomy
Evacuation of Hematoma
Pre-operative Preparation
• Informed consent
-Plan Carefully explained to relatives
• Psychosocial support
• Optimize patient’s health
- Resuscitation
• Screen for any condition that will interfere
with treatment
• Prepare materials for OR
Operative Technique
•
•
•
•
•
Patient supine under GETA
Asepsis/Antisepsis
Sterile drapes placed
Skin Incision carried from temporo-parietal area
Initial burr hole made over the temporal bone
with a cone-shaped burr
• Bone between burr holes were cut using a Gigli
saw
• Bone flap raised
Intraop Findings
• Upon opening, noted
a 50ml reddish to
brown fluid at the
occipital epidural
layer.
Operative Technique
•
•
•
•
•
•
•
•
•
Hematoma evacuated
NSS wash
Hemostasis assured
Correct instrument and sponge count
Temporo-pareital bone fixed
JP drain placed
Closure of the scalp using Silk 3-0
Dry sterile dressing
Patient tolerated the procedure
Operation Done
Craniotomy
Evacuation of Epidural Hematoma
Final Diagnosis
Epidural Hematoma, occipital area, R
secondary to Vehicular Accident
Operation done
Craniotomy
Evacuation of Hematoma
Post-operative Management
• Basic needs supplied
– Antibiotics
– Analgesia
– Comfort
• VS and NVS monitoring
• Patient maintained on NPO
Post-operative Management
• 1st HD
NPO, mannitol
135 ml of PRBC was
Transfused
• 3rd HD
GCS= 15
NGT, drain and Foley Cath
removed, mannitol taperd
• 5th HD
DAT, D/C
Follow Up care
• 1 week after discharge for ROS
• 4 weeks after discharge to asses for any
neurological changes
Sharing of Knowledge
BRAIN -- invested by various membranes
floated in a clear fluid and
encased in a bony vault
-- 1,200 – 1,400G
-- 2% - 3% TBW
3 Membranes
Dura matter -- pachymaninx
-- outermost layer
Arachnoid -- middle layer
-- delicate non vascular
membarne
Pia matter -- innermost layer
-- follows contour of the brain
* Leptomeninges- arachnoid and pia matter
Cerebro Spinal Fluid
-- Clear colorless fluid
-- containing small amount of CHON,
glucose and potassium
-- serves as support and cushion of the
CNS against Trauma
Head Injuries- most common cause of
traumatic death in children
Main Causes:
- Falls
- Motor vehicular crashes
- Pedestrian accidents
- Bicycle injuries
- Other injuries
Pathophysiology
•
•
•
•
•
Brain swelling
Increase mass effect
Increase Intracranial Pressure
Compromised brain perfussion
Herniation of brain tissue across the
tentorium, falx or through the foramen
magnum causing significant morbidity and
often death
Moderate to Severe Head Injuries
-- usually present in obtunded or
combative state
-- Late clinical Findings:
unequal and non reactive pupils
focal neurologic findings
abnormal posturing
In-hospital resuscitation and evaluation
of moderate head injuries
• Rapid, systematic manner with diagnostic
and therapeutic maneuvers proceeding
simultaneously
• ABC’s of Trauma (airway, ventilation,
preventing hypoxia and hypotension)
Initial neurologic evaluation and
management
• In moderately injured, examination is
abbreviated and should focus on
– Level of consciousness
– Pupillary light reflex
– Extraocular eye movement
– Motor examination
• Head should be palpated
• Signs of basal skull fracture(otorrhea)
• Triad suggestive of transtentorial
herniation
– Deteriorating level of consciousness
– Pupillary dilatation
– Hemiparesis
• Neurological exam: unreliable in
accurately predicting intracranial
pathology, tomography is usually indicated
Criteria for CT scanning following
craniocerebral trauma
• GCS 14 or less
• GCS 15 with the following
– Documented loss of consciousness
– Focal neurologic deficit
– Signs of basal skull fracture
Skull radiography and angiography
• In the absence of CT scan, skull
radiographs are helpful
• Fractures are seen on
– Epidural hematoma
– Subdural
– Intracerebral
66-100%
18-60%
40-80%
• Presence of skull fracture, although
suggestive of hematoma is not a reliable
indicator of the type of intracranial injury
• In rapidly deteriorating or comatose
patient, cerebral angiography or
exploratory burr holes is indicated
Early repeat CT: when indicated?
• When hemorrhagic but nonsurgical lesion
in initial CT, a repeat within 4 – 8hrs
should be done
• 60% with initial nonoperative lesion on
initial CT required surgical intervention
after the repeat
Interpreting Neurological findings
• Ipsilateral pupil dilatation - expanding
hematoma causing transtentorial temporal
herniation and oculomotor nerve
impingement
• Moderate anisocoria and sluggish pupil –
impending uncal herniation
Surgical management of acute
traumatic intracranial hematomas
• Subdural or epidural hematoma
– 5mm thick
– Midline shift
– GCS<8
Exploratory Burr holes
• First burr hole-temporal region, above the
zygomatic arch according to neurological
findings
– Ipsilateral to the dilated pupil
– Contralateral to the abnormal motor response
– Ipsilateral to the skull fracture
Medical management of
Intracranial hypertension
• Preemptive measures
– Head elevation to 30 degrees
– Mild hyperventilation (PaCO2 30-35mmHg)
– Maintenance of euvolemia
– Maintenance of CPP 70mmhg or higher
– Maintenance of normothermia (<37.5)
– Seizure prophylaxis
• Primary therapy
– Ventricular cerebrospinal fluid drainage
– Sedation
– Neuromuscular blockage
• Secondary therapy
– Bolus mannitol
• Tertiary therapy
– Metabolic suppressive therapy with
barbiturates or profopol
Discussion
Complications of head Injuries
- dural tears
- Cerebral damage
- subdural and extradural hematoma
- Growing skull fracture
Discussion
Traumatic Intracerebral Hematomas &
Contusion
--can occur in any region of the brain
--most commoly in subfrontal & anterior
temporal regions at the base of the brain
--due to the impact of the brain on the
rough surface of the skull base
--these may start as small lesions but may
progressively enlarge
Discussion
Epidural Hematoma
--blood collects between the dura and
inner table of the skull
--associated with arterial bleeding from
the middle meningeal artery
--associated with lucid intervals, or
period of unconsciousness
-- CT: Lenticular shape( football shape)
hyperdense( white) he along the skull table
Discussion
Subdural Hematoma
--most common traumatic mass lesion
--20-40% of severely head injured px
--potential space between dura &
arachnoidal meningeal layers
--ascribed to tearing of small veins that
bridges the spaces between
cerebral cortex and overlying dura
-- CT: crescent shaped hyperdense hge
References
1. Bricolo, AP, Pasut A. extradural hematoma: towards zero mortality: A
Prospective study.Neurosurgery.1984. pp14:8-12
2. Cooper, PR. Post traumatic mass lesions. Head Injury. 3rd ed.
Baltimore, william and wilkins.1993.pp275-329
3. Haselberger, K, Putcher, A et al. prognosis after acute subdural and
epidural hemmrrhage. Acta Neurochir. 90:111-116
4. Laboto, RD. head injured patients who talke and deteriorate into
coma. Analysis of 211 cases studied with CT. J Neurosurg.
75:256-261.
5. Ota F, Head Trauma and Hemorrhage. Department of pediatrics,
university of Hawaii John A. Burns School of Medicine. May 2002
6. Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II.
7. Youmans, JR. neurological surgery. A comprehensive guide to the
diagnosis and management of neurosurgical problems. 4th ed. Vol
3.
MCQ
1. Which of the following condition has a
lens or football shaped findings on
cranial CT scan?
a. Subdural hematoma
b. Epidural hematoma
c. Subarachnoid hge.
d. Cerebellar hge.
MCQ
2. What is the most common site of bone
fracture in head trauma?
a. Temporal bone
b. Occipital bone
c. Parietal bone
d. Frontal bone
MCR
3. A 4-year-old child fell and hit his head on the
carpet about 5 hours ago. There is no reported
history of loss of consciousness or vomiting. His
PE is normal, and he is acting appropriately at
the time of visit. What would be your next
management?
1. Order for a CT scan
2. Close Observation
3. Refer to specialist
4. Parental education
MCR 4
4. Which of the following statements are true
regarding brain injury?
1. The extent is a function of the mechanism of
injury
2. Contusions may occur on the side of the brain
that is opposite the side of initial impact
3. Contusions tend to involve the anterior portions
of the frontal and temporal lobes
4. The effects of secondary edema and
hematoma enlargement may be delayed for
several days
MCR
5. The following are included in the
presumptive therapy in treating intracranial
hypertension.
1. Head elevation to 30 degrees
2. Mild hyperventilation (PaCO2 3035mmHg)
3. Maintenance of euvolemia
4. Maintenance of CPP 70mmhg or higher
Case Presentation and Discussion
on CNS Trauma
Thank You For Your Kind Attention
By:
JGGuerra, MD
Department of Surgery
Ospital ng Maynila Medical Center