Traumatic brain injury surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Joanna Ekabua, M.D. [2]
Overview
Surgery is not a first-line treatment option for patients with traumatic brain injury.
Indications
- Surgery is usually reserved for patients with either:[1][2]
- Subdural/epidural hematoma >10mm in thickness.
- Midline shift >5mm
- Cerebral edema
- Syncope
Surgery
- Surgery is not a first-line treatment option for patients with traumatic brain injury.
- Approximately half of severely head-injured patients will need surgery to remove or repair hematomas or contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.
- Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. When an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This leads to an increase in the pressure within the skull, called intracranial pressure (ICP). High ICP can cause delicate brain tissue to be crushed, or parts of the brain to herniate across structures within the skull, potentially leading to severe damage. Medical personnel measure a patient's ICP using a probe or catheter. The instrument is inserted through the skull to the subarachnoid level and is connected to a monitor that registers ICP. If a patient has high ICP, he or she may undergo a ventriculostomy, a procedure that drains cerebrospinal fluid (CSF) from the ventricles to bring the pressure down by way of an external ventricular drain.
- Decompressive craniectomy is a last-resort surgical procedure in which part of the skull is removed in an attempt to reduce severely high ICP.[3]
Contraindications
Some contraindications to decompressive craniectomy include[4]
- Traumatic brain injury patients with dilated and fixed pupils, and aGCS of 3 after resuscitation.
- Age >65 years old
- Devastating trauma in which the patient will not survive > 24hours.
- Irreversible disease in the short term.
- Uncontrollable ICH > 12hours aside from all energetic therapeutic measures.
- Oxygen arteriovenous difference <3,2vol%, measured on the side of craniectomy.
- Brain tissue oxygenation (PtiO2) <10mmHg in the obvious healthy area since patient admission.
References
- ↑ Servadei F, Compagnone C, Sahuquillo J (2007). "The role of surgery in traumatic brain injury". Curr Opin Crit Care. 13 (2): 163–8. doi:10.1097/MCC.0b013e32807f2a94. PMID 17327737.
- ↑ Galgano M, Toshkezi G, Qiu X, Russell T, Chin L, Zhao LR (2017). "Traumatic Brain Injury: Current Treatment Strategies and Future Endeavors". Cell Transplant. 26 (7): 1118–1130. doi:10.1177/0963689717714102. PMC 5657730. PMID 28933211.
- ↑ Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, and Eisenberg HM. (2006) Outcome following decompressive craniectomy for malignant swelling due to severe head injury. Journal of Neurosurgery. Volume 104, Issue 4, Pages 469-479. PMID 16619648. Retrieved on [2007-01-21]]
- ↑ Alvis-Miranda H, Castellar-Leones SM, Moscote-Salazar LR (2013). "Decompressive Craniectomy and Traumatic Brain Injury: A Review". Bull Emerg Trauma. 1 (2): 60–8. PMC 4771225. PMID 27162826.