This document provides an overview of head injury management, including definitions of key terms like the Glasgow Coma Scale and intracranial pressure. It describes mechanisms of traumatic brain injury and the evaluation of head injuries through history, exam, and radiographic imaging. It outlines guidelines for both nonoperative management, which typically involves monitoring and treating intracranial pressure, and operative management when significant mass lesions are present like epidural or subdural hematomas. The guidelines provide recommendations for indications for intracranial pressure monitoring and therapies to reduce elevated intracranial pressure through medical, surgical, and in more severe cases, barbiturate-induced coma interventions.

1. An Overview of Head Injury
Management
Eldad J. Hadar, M.D.
Department of Neurosurgery

2. Checklist
• Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

3. Head Injury Guidelines
• 1995 – 1st
edition
• 2000 – 2nd
edition
• 2007 – 3rd
edition
• Level I – Accepted
principles reflecting high
degree of clinical certainty
• Level II – Strategies
reflecting moderate degree
of clinical certainty
• Level III – Degree of
clinical certainty not
established

4. Checklist
Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

5. Glasgow Coma Scale (GCS)
• Introduced by Teasdale and Jennett in 1974
• Consists of 3 clinical signs that have
– Prognostic significance
– Good reproducibility between observers
• Scale range 3-15
• GCS < 8 has generally become accepted as
representing coma / severe head injury

6. Glasgow Coma Scale (GCS)

7. Intracranial Pressure (ICP)
• Normal CPP > 50 mm Hg
• Autoregulatory mechanisms maintain CBF
at CPP’s down to 40 mm Hg
CPP = MAP – ICP

8. Intracranial Pressure (ICP)
• In head injury, ICP > 20-25 mm Hg may be
more detrimental than low CPP (increasing
CPP may not afford protection from
intracranial hypertension).
• Aggressive attempts to maintain CPP > 70
should be avoided due to ARDS (Level II)
• CPP<50 should be avoided (Level III)

9. Checklist
• Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

10. Mechanisms of Traumatic Brain
Injury
• Impact injury
• Cerebral or brainstem contusions
• Cerebral lacerations
• Diffuse axonal injury (DAI)
• Secondary injury
• Intracranial hematoma
• Edema
• Ischemia

11. Checklist
• Statistics
• Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

12. Initial Assessment
History
– LOC +/-
– Intoxicants
– Seizure
– Posttraumatic amnesia
• Physical Exam
– GCS
– Level of consciousness
– Cranial nerves
– Fundoscopic exam
– Motor exam
Start with ABC’s

13. Radiographic Evaluation
• CT
• Imaging study of choice for initial work-up
• MRI
• More helpful later in hospital course
• Skull x-rays
• Arteriography

14. Indications for CT
• Presence of any criteria placing patient at
moderate or high risk for intracranial injury
• Assessment prior to general anesthesia for
other procedures

15. Checklist
• Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

16. Head Injury Management
• Nonoperative
• Seen in absence of significant intracranial mass
lesion.
• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative
• Typically required when a significant intracranial
mass lesion is present.
• Decompressive craniectomy or brain resection less
common.

17. Head Injury Management
• Nonoperative
• Seen in absence of significant intracranial mass
lesion.
• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative
• Typically required when a significant intracranial
mass lesion is present.
• Decompressive craniectomy or brain resection less
common.

18. Nonoperative Management
• Frequent neuro checks
• Frequent neuro checks
• Frequent neuro checks
• ICP monitoring

19. Indications for ICP Monitoring
• No data to support Level I recommendation
• Severe head injury (GCS 3-8) with abnormal CT (Level II)
• Severe head injury (GCS 3-8) with normal CT and 2 of the
following (Level III):
• Age > 40 years
• Unilateral or bilateral motor posturing
• SBP < 90 mm Hg
• Mild-moderate head injury at discretion of treating
physician

20. Indications for ICP Monitoring
• Loss of neurological examination
• Sedation
• General anesthesia

21. Clinical Scenario
• 20 y.o. male in MVA
– Intubated
• Score 1T
– Eyes open to pain
• Score 2
– Briskly localizes
• Score 5
• TotalGCS 8T

22. ICP Monitor

23. Preferred method in Guidelines

24. Therapy for Intracranial
Hypertension
• First tier
• Positioning
• Ventricular drainage
• Osmotic diuresis
• Hyperventilation (Level III – temporizing measure)
• Second tier
• Sedation
• Neuromuscular blockade
• Hypothermia
• Barbiturate coma
• Glucocorticoids not recommended (Level I)

25. Head Injury Management
• Nonoperative
• Seen in absence of significant intracranial mass
lesion.
• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative
• Typically required when a significant intracranial
mass lesion is present.
• Decompressive craniectomy or brain resection less
common.

26. Operative Management
• Types of mass lesions
• Epidural hematoma
• Subdural hematoma
• Cerebral contusion
• Decompressive craniectomy/brain resection

28. Epidural Hematoma (EDH)
• 1% of head trauma admissions
• Male: Female = 4:1
• Source of bleeding is arterial in 85% of
cases (middle meningeal artery)
• Mortality ranges from 5-10% with optimal
management
• Neurological injury caused by secondary
mechanisms

31. Subdural Hematoma (SDH)
• About twice as common as EDH
• Mortality 50-90%
• Impact injury much higher than with EDH
• Often associated brain injury
• Two common sources of bleeding
• Tearing of bridging veins
• Cortical laceration

32. Cerebral Contusion
• Often little mass effect
• Not often operative

34. Pre-op Post-op
Hemicraniectomy

35. Key Points
• 2 mechanisms of brain injury
• Impact injury
• Secondary injury
• GCS < 8 has generally become accepted as representing
coma / severe head injury
• CT is generally the imaging study of choice in the acute
assessment of head injury
• Operative and nonoperative strategies are generally aimed
at reducing mass effect and, therefore, reducing ICP
• Nothing beats a neuro exam.

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