Deepak AgrawalDept of Neurosurgery, JPN Apex Trauma

Centre

MANAGEMENT OF SEVERE HEAD INJURY WITH ‘NORMAL’

CT HEAD

Case history7 year male childFall from height (4th floor ) 2 hours backH/o LOC following fallPresented to emergency with laboured

respiration Post resuscitation GCS E2Vet M5

Secondary survey - no other significant systemic injuries.

FAST negative.

NCCT head at admission

ICU MANAGEMENTPatient was admitted in neurotrauma ICUManaged as per standard protocol for severe

head injury Head elevation 300

Neutral neck positionSedation (Fentanyl & Midazolam)ventilation with normocapneaOsmotic agents (mannitol) and diuretics

(furosemide)

ICU MANAGEMENTContinous ICP Monitoring using Codman®

intraparenchymal catheter

Initial ICP was 15 mmHg

Gradual increase in ICP noticed

2 hrs after admission ICP rose to 40 mmHg

In view of refractory raised ICT, decompressive craniectomy was planned.

Patient taken up for emergency surgery

Surgery

Large fronto-temporo-parietal craniectomy performed

Brain tense intra-op.

Augmentation duraplasty using pericranial graft.

Calvarial flap cryo-preserved for later replacement.

Postoperative Course

Patient became conscious & GCS improved to E4VetM6 within a span of 2hrs following surgery

Successfully extubated on POD 3, to be discharged.

Post-operative scans

Post-operative scans

Indications for Intracranial Pressure MonitoringEvidence Level A.Level I: None B.Level II: Intracranial pressure (ICP) should be monitored in

all salvageable patients with a severe traumatic brain injury (TBI) (GCS 3 – 8 after resuscitation) and an abnormal CT scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.

C.Level III: ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure (BP) < 90 mm Hg.

American Association of Neurological Surgeons Guidelines

The gray zone No level I evidence yet for ICP monitoringCT may not detect all significant lesionsHead injury is evolving and dynamicCT at best permits periodic serial monitoringHence at JPNATC, a low threshold for ICP

monitoring.Aggressive surgical management for

refractory elevated ICP

Audit of Head injury at JPNATC

PERIOD: Nov 2007- Apr 2009 (18 months)

STUDY POPULATION : Head injured patients admitted in department of Neurosurgery, JPNATC

PATIENTS GROUPSMinor head injury (GCS 13-15)Moderate head injury (GCS 9-12)Severe head injury (GCS 8 or less)

Observations

Total patients: 2068

< 10 yr, 305, 15%

11-20 yr, 306, 15%

21-30 yr, 489, 23% 31-40 yr, 378,

18%

51-60yr, 158, 8%

61-70yr, 101, 5%

41-50 yr, 251, 12%

71-80yr, 80, 4%

OBSERVATIONS (AGE GROUP INCIDENCE)

PEDIATRIC (< 12 YR)= 328 ( 15 %)ELDERLY (>60 YRS)= 181 ( 8 %)

MINOR, 598

MOD, 380

SEVERE, 1090

0

200

400

600

800

1000

1200

OBSERVATIONS (INCIDENCE OF VARIOUS H.I. GROUPS)

MINOR HI -29%MOD. HI -18%SEVERE HI -53%

OBSERVATIONS SEVERE HEAD INJURY

809

281

0

200

400

600

800

1000

SURG(76%)

CON(24%)

OUTCOME(MORTALITY)

GROUP NO. OF IN-HOSPITAL

MORTALITY

TOTAL CASES

%

Overall 454 2068 22

Minor HI 14 598 2

Moderate HI 45 380 12

Severe HI 395 1090 36

OUTCOME

( MORTALITY AS PER AGE GROUP)

GROUP NO. OF MORTALITY

TOTAL CASES

%

Children (< 12 yrs)

118 305 38

Adult ( 20-50 yrs) 191 1118 17

Elderly ( 50-80 yrs)

126 339 37

Glasgow Outcome Score

(Following Severe Head Injury)

%age

1 Death 36%

2 Vegetative 18%

3 Severe disabled 12%

4 Mod. disabled 16%

5 Good recovery 18%

OUTCOME (GOS )

OVERALL DEATH - 454 / 2068 (22%)

OUTCOME (SURGERY vs CONSERVATIVE )

MODE OF TREATMENT ADMISSON GCS SCORE

SURVIVED DIED P VALUE

SEVERE HEAD INJURY

SURGERY 3-8 617 192 <0.05

CONSERVATIVE3-8 78 203

MODERATE HEAD INJURY

SURGERY9-12 109 18

CONSERVATIVE9-12 226 27

MINOR HEAD INJURY

SURGERY13-15 23 2

CONSERVATIVE13-15 561 12

Author MORTALITY

OVERALL

MINOR MODERATE

SEVERE

Kagan RJ 1994 26.7% - - 41.4%

Fakhry SM 2004 28.8% - - -

Udekwu P 2004 21% - - 31.5%

AIIMS 2009 22% 2% 12% 36%

COMPARISON WITH WORLD LITERATURE

CONCLUSIONSAggressive neurosurgical management may

improve outcome in head injured patients

Audit of our data shows that outcome in severe head injuries is comparable with the best centers in the world.