Traumatic Brain Injuries: Pathophysiology, Treatment and Prevention

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Traumatic Brain Injuries: Pathophysiology, Treatment and Prevention

  1. 1. Case Presentation: Neurology/Neurosurgery Grand Rounds February 28, 2006 Gabriel Zada, MD Christopher Aho, MD Neurosurgery Blue LAC-USC Medical Center
  2. 2. Patient G.P. <ul><li>History of Present Illness: </li></ul><ul><li>44-year-old Latino man </li></ul><ul><li>Complains of progressive headache x 2-3 months </li></ul><ul><li>Headache worse throughout course of day </li></ul><ul><li>Developed nausea/vomiting 1-2 weeks prior to admission </li></ul><ul><li>Intermittent double vision, dizziness </li></ul><ul><li>Hit head while working 6 months ago, but symptoms developed much later </li></ul><ul><li>No sensory or motor complaints </li></ul><ul><li>Denies fevers, chills </li></ul><ul><li>Denies seizures </li></ul>
  3. 3. History (continued) <ul><li>Past Medical History: None </li></ul><ul><li>Past Surgical History: None </li></ul><ul><li>Medications: Tylenol, Ibuprofen for Has </li></ul><ul><li>Allergies : None known </li></ul><ul><li>Social History: </li></ul><ul><ul><li>Works for pool chemical company </li></ul></ul><ul><ul><li>Smokes ~ 5 cigarettes/day </li></ul></ul><ul><ul><li>Denies alcohol or other drugs </li></ul></ul>
  4. 4. Physical Examination <ul><li>Mental Status: </li></ul><ul><ul><li>Awake, alert, oriented to person, place, time, and situation. Speech fluent. </li></ul></ul><ul><li>Cranial Nerves: </li></ul><ul><ul><li>Right partial 3rd nerve palsy (x 1 day) </li></ul></ul><ul><ul><ul><li>Pupil 7  5mm, sluggish. </li></ul></ul></ul><ul><ul><ul><li>Partial ptosis. </li></ul></ul></ul><ul><ul><ul><li>No oculomotor deficit. </li></ul></ul></ul><ul><ul><li>Left pupil 5  3mm, brisk. </li></ul></ul><ul><ul><li>Face symmetric </li></ul></ul><ul><ul><li>Cranial nerves otherwise intact. </li></ul></ul>
  5. 5. Physical Examination <ul><li>Motor: </li></ul><ul><ul><li>Tone Normal </li></ul></ul><ul><ul><li>No pronator drift </li></ul></ul><ul><ul><li>Power 5/5 in all extremities </li></ul></ul><ul><li>Reflexes: </li></ul><ul><ul><li>2+, symmetric throughout </li></ul></ul><ul><ul><li>No Hoffman’s sign </li></ul></ul><ul><ul><li>Toes downgoing bilaterally </li></ul></ul><ul><li>Sensory: </li></ul><ul><ul><li>Sensation intact in all extremities. </li></ul></ul><ul><li>Cerebellar/Gait: </li></ul><ul><ul><li>Finger-nose-finger normal. Gait exam deferred. </li></ul></ul>
  6. 6. Head CT
  7. 16. Initial Hospital Course <ul><li>Developing concern that patient had increased intracranial pressures and brainstem herniation </li></ul><ul><li>Mannitol trial  Right 3 rd nerve palsy improved </li></ul><ul><li>Emergent neurosurgery consult requested </li></ul><ul><li>Initial concern per neurosurgery for subarachnoid hemorrhage and ruptured P-Comm aneurysm </li></ul><ul><li>Nimodipine + increased intravenous fluids started empirically </li></ul><ul><li>Emergent cerebral angiogram  no aneurysm, AVM </li></ul><ul><li>Hospital day 3: Right 3 rd palsy recurred, now with altered mental status and lethargy </li></ul>
  8. 22. CT Scan: Final Report <ul><li>High density material within confines of Circle of Willis, concerning for possible SAH. </li></ul><ul><li>Left frontal subdural collection (subacute or chronic SDH) </li></ul><ul><li>Rule out empyema, meningitis, SAH. </li></ul>
  9. 23. Brain MRI
  10. 49. MRI: Final Report <ul><li>Bilateral SDH </li></ul><ul><li>Evidence of SAH </li></ul><ul><li>Diffuse meningeal enhancement </li></ul><ul><li>Decreased caliber of right ICA and MCA, may be suggestive of vasospasm. </li></ul>
  11. 50. Hospital Course (continued) <ul><li>Lumbar Puncture felt to be contraindicated </li></ul><ul><li>Right ventriculostomy placed on HD#5 </li></ul><ul><li>ICPs range: -6 to 4 </li></ul><ul><li>CSF studies: </li></ul><ul><ul><li>RBCs 485, WBCs 0, Glucose 59, Protein 8 </li></ul></ul><ul><ul><li>PMNs 84, Lymphocytes 10 </li></ul></ul><ul><li>No improvement in neuro status. </li></ul><ul><li>Patient became progressively more obtunded and developed additional left 3 rd nerve palsy,. </li></ul>
  12. 59. MRI: Final Report <ul><li>Interval placement of R frontal ventriculostomy </li></ul><ul><li>Left greater than right SDH </li></ul>
  13. 60. Hospital Course (continued) <ul><li>Discussion over intracranial hypertension versus hypotension began. </li></ul><ul><li>Patient started on trial of IV caffeine, supine position. </li></ul><ul><li>ICP Monitor (Bolt) placed to recheck ICPs </li></ul><ul><li>ICP range: -7 to 5 </li></ul><ul><li>That night, patient developed rapid progression of bradycardia to the 40s + apneic episodes </li></ul><ul><li>Emergent CT myelogram ordered </li></ul>
  14. 82. Diagnosis <ul><li>Spontaneous Intracranial Hypotension (SIH) secondary to Cervical and Thoracic CSF leak </li></ul><ul><li>CSF Leak at C1-C3 Left epidural space </li></ul><ul><li>Additional leak from T6-T10 ventrally </li></ul><ul><li>Patient started on IV caffeine drip </li></ul><ul><li>Placed in Trendelenburg position with increase in ICPs to 10-18 range and improvement in mental status </li></ul>
  15. 83. Treatment <ul><li>Anesthesia contacted for emergent epidural blood patch </li></ul><ul><li>Case done in IR suite under fluoroscopic guidance </li></ul><ul><li>C2 region received 8 cc autologous blood patch </li></ul><ul><li>T6-7 region received 21 cc blood patch </li></ul><ul><li>Immediate relief of headaches and increased ICPs to 15-19 (flat) </li></ul>
  16. 85. Post-treatment Course <ul><li>Post-patch day 1: Patient awake, alert x 2. Complete resolution of 3 rd nerve palsies </li></ul><ul><li>Bolt removed </li></ul><ul><li>Sat up post-patch day 2 </li></ul><ul><li>Patient home day 7 following procedure, completely intact </li></ul>
  17. 86. Spontaneous Intracranial Hypotension (SIH) <ul><li>Patient Demographics: </li></ul><ul><ul><li>Often occurs in middle-aged patients </li></ul></ul><ul><ul><li>Mean age ~40 years </li></ul></ul><ul><ul><li>Female preponderance </li></ul></ul><ul><ul><li>Higher incidences in patients with Marfan’s disease, other connective tissue diseases, and weightlifters </li></ul></ul>
  18. 87. Spontaneous Intracranial Hypotension (SIH) <ul><li>Clinical findings: </li></ul><ul><ul><li>Orthostatic headache </li></ul></ul><ul><ul><ul><li>similar to post-lumbar puncture spinal HA </li></ul></ul></ul><ul><ul><li>Exacerbated by laughing, coughing, Valsalva, physical exertion </li></ul></ul><ul><ul><li>Often refractory to analgesic agents </li></ul></ul><ul><ul><li>Nausea/vomiting, anorexia, neck pain/rigidity, dizziness, diplopia are common </li></ul></ul><ul><ul><li>Cranial nerve palsies (often VI) </li></ul></ul><ul><ul><li>Diverse presentation: Hearing changes, galactorrhea, facial numbness, radicular symptoms, parkinsonism, seizures, coma, death have been reported </li></ul></ul>
  19. 88. SIH: Diagnosis <ul><ul><li>Often misdiagnosed (94% in one series) </li></ul></ul><ul><ul><li>14% misdiagnosed as SAH and underwent cerebral angiography </li></ul></ul><ul><ul><li>Diagnostic delay: 4 days to 13 years (mean 20 days) </li></ul></ul><ul><ul><li>CT Scan often misleading </li></ul></ul><ul><ul><li>Lumbar Puncture: </li></ul></ul><ul><ul><ul><li>Opening pressures usually < 60 mm H20 in SIH </li></ul></ul></ul><ul><ul><ul><li>(normal 150-400 mm H20) </li></ul></ul></ul><ul><ul><li>“ Sucking noise” reported with LP on occasion, indicating subatmospheric pressure </li></ul></ul><ul><ul><li>CSF studies: </li></ul></ul><ul><ul><ul><li>increased protein, lymphocytic pleocytosis,xanthochromia </li></ul></ul></ul>
  20. 89. SIH: Radiographic Findings <ul><li>CT Scan: </li></ul><ul><ul><li>Effacement of basal cisterns </li></ul></ul><ul><ul><li>Subdural hygromas/hematomas </li></ul></ul><ul><ul><li>Pseudo-SAH: (10%) </li></ul></ul><ul><ul><ul><li>Hyperdensity in basal cisterns (? obliteration of cisterns with arterial + venous engorgement) </li></ul></ul></ul><ul><li>MR Imaging: </li></ul><ul><ul><li>Diffuse meningeal enhancement (pachymeninges, not leptomeninges) </li></ul></ul><ul><ul><li>Venous sinus engorgement </li></ul></ul><ul><ul><li>Pituitary gland enlargement/hyperemia </li></ul></ul><ul><ul><li>Downward displacement of brain/ tonsillar ectopia </li></ul></ul><ul><ul><li>Subdural fluid collections and hematomas, often without mass effect (50%) </li></ul></ul>
  21. 90. SIH: Radiographic Findings <ul><li>CT Myelography </li></ul><ul><ul><li>Study of choice for localizing leaks </li></ul></ul><ul><ul><li>Lower cervical and thoracic region most common </li></ul></ul><ul><ul><li>Often reveals CSF leaks and meningeal diverticula </li></ul></ul><ul><ul><li>Better localization than spinal MR imaging </li></ul></ul><ul><ul><li>Sensitivity: 67% in one study </li></ul></ul><ul><li>Radionuclide Cisternography </li></ul><ul><ul><li>Radioactive tracer injected into lumbar subarachnoid space </li></ul></ul><ul><ul><li>Normally, CSF travels upwards and is absorbed into sinuses </li></ul></ul><ul><ul><li>Can detect CSF leaks </li></ul></ul><ul><ul><li>Sensitivity: 60% for actual CSF leak, 90% for “abnormal study” </li></ul></ul><ul><li>Doppler Flow Imaging </li></ul><ul><ul><ul><li>Superior ophthalmic vein engorgement on TCDs </li></ul></ul></ul><ul><ul><ul><li>Sensitive/specific in 26 of 26 patients (100%) </li></ul></ul></ul><ul><ul><ul><li>Compared to healthy volunteers </li></ul></ul></ul><ul><ul><ul><li>Improved with treatment </li></ul></ul></ul>
  22. 91. SIH: Pathophysiology <ul><li>Brain weighs approximately 1500g </li></ul><ul><li>Intracranial weight is ~ 48g because of suspension in CSF </li></ul><ul><li>Brain otherwise supported by meninges, veins, cranial nerves (esp. CNs V, IX, X) </li></ul><ul><li>Depletion of CSF in SIH causes downward pressure on these structures with traction on cranial nerves </li></ul><ul><li>Monro-Kellie Hypothesis: Decreased CSF leads to venous engorgement and cerebral edema/hyperemia. </li></ul>
  23. 92. SIH: Treatment Options <ul><li>Symptomatic relief (Conservative Management) </li></ul><ul><ul><li>Often successful as first-line therapy </li></ul></ul><ul><ul><li>Supine position </li></ul></ul><ul><ul><li>Caffeine or theophylline (IV or PO) effective in ~75% of cases (vasoconstriction resulting in decreased CBF) </li></ul></ul><ul><ul><li>Fluid restoration: Increased IV/oral hydration, salt intake, CO2 inhalation </li></ul></ul><ul><ul><ul><li>No proven efficacy for these therapies </li></ul></ul></ul>
  24. 93. SIH: Treatment Options <ul><li>Epidural Blood Patch </li></ul><ul><ul><li>Technique developed by Gromley </li></ul></ul><ul><ul><li>85-90% efficacy for first trial </li></ul></ul><ul><ul><li>Up to 98% efficacy with repeat patches </li></ul></ul><ul><ul><li>Most effective if placed within 1 level of the leak </li></ul></ul><ul><ul><li>If leak site undetectable, may place patch in lumbar spine and place in trendelenburg position (up to 9 level efficacy in models) </li></ul></ul><ul><ul><li>Immediate relief often observed (90%) </li></ul></ul><ul><ul><ul><li>Initial relief: gelatinous seal over hole </li></ul></ul></ul><ul><ul><ul><li>Long-term: Collagen deposition, fibroblast activity, scar formation </li></ul></ul></ul>
  25. 94. SIH: Treatment Options <ul><li>Surgical repair of CSF leak: </li></ul><ul><ul><li>For refractory cases </li></ul></ul><ul><ul><li>Especially for meningeal divertcula </li></ul></ul><ul><ul><li>Treatment with ligation of diverticula </li></ul></ul><ul><ul><li>Meningeal tears show less success with surgical repair </li></ul></ul><ul><ul><li>Fibrin Glue reported with success </li></ul></ul>
  26. 95. SIH: Long term Outcomes <ul><li>Berroir S, Neurology, 2004: </li></ul><ul><ul><li>30 patients receiving early epidural blood patch </li></ul></ul><ul><ul><li>Follow-up time 1-4 years </li></ul></ul><ul><ul><li>77% of patients cured with epidural blood patch </li></ul></ul><ul><ul><ul><li>57% after 1 patch </li></ul></ul></ul><ul><ul><ul><li>20% after 2 nd patch </li></ul></ul></ul><ul><li>Kong DS et al, Neurosurgery, 2005: </li></ul><ul><ul><li>13 patients treated with nonsurgical measures </li></ul></ul><ul><ul><li>Mean follow-up 51 months </li></ul></ul><ul><ul><li>One recurrence (8%) </li></ul></ul><ul><ul><li>Six patients with persistent HAs (4 mild, 2 moderate) </li></ul></ul>
  27. 96. References <ul><li>1. Paldino M et al. Intracranial hypotension Syndrome: a comprehensive review. Neurosurgical Focus 15 (6). 2003, 1-8. 1. </li></ul><ul><li>2. Schievink WI et al. Pseudo-subarachnoid hemorrhage: A CT finding in SIH. Neurology 2005;65: 135-137 </li></ul><ul><li>3. Schievink WI et al. Misdiagnosis of spontaneous intracranial hypotension. Arch Neurol. 60 (12). 2003. 1713-18. </li></ul><ul><li>4. Inenaga C. Diagnostic and surgical strategies for intractable SIH. J Neurosurg. 94(4). 2001. 914-916. </li></ul><ul><li>5. Schievink WI et al. SIH mimicking aneurysmal SAH. Neurosurgery. 48(3). 2001. 516-517. </li></ul><ul><li>6. Rai A et al. Epidural Blood Patch at C2: Diagnosis and Treatment of SIH. AJNR. 26. 2005. 2663-2666. </li></ul><ul><li>7. Berroir S et al. Early epidural blood patch in SIH. Neurology 63; 1950-1951, 2004. </li></ul><ul><li>8. Kong, DS et al. Clinical features and long-term results of SIH. Neurosurgery. 57(1). 2005. 91-96. </li></ul>
  28. 97. Thank You

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