A 60-year-old male with prior deep vein thrombosis (DVT) and pulmonary embolism (PE) on therapeutic anticoagulation, hypertension, and alcohol abuse is brought to the ED after being found down at the bottom of a flight of stairs. His GCS was 6 (eyes did not open 1, no verbal output 1, withdrawal of all extremities to painful stimulation 4). Given his poor neurologic examination, he was intubated. A head CT was completed and is shown in the image below. His initial trauma evaluation did not demonstrate any major injury, and his vital signs are normal.
Axial noncontrast head CT. Bilateral acute subdural hemorrhage with parafalcine subdural hemorrhage. There is cortical subarachnoid hemorrhage. Bilateral right more than left frontal contusions with intraparenchymal hemorrhage.
What is the next best step in management of the patient?
Correct Answer: C
ICP monitoring should be offered to patients with severe TBI (GCS 3-8) and an abnormal head CT (hematoma, contusion, swelling, herniation, or compressed basal cisterns) or severe TBI with normal head CT and two of the following: over 40 years of age, unilateral or bilateral motor posturing, or systolic BP <90 mm Hg. Although there is initial brain injury at the time of impact, there is significant risk for secondary injury including cerebral hypoperfusion and hypoxia. The goal of ICP monitoring is to limit hypoperfusion. The mainstay of management is appropriate cerebral perfusion pressure (calculated vale: mean arterial pressure − intracranial pressure), with values <50 associated with poor outcomes. ICP monitoring can be the first sign of worsening intracranial pathology. Although MRI can assist with prognosis, it is not necessary in the acute setting for ongoing initial management. MRI can be useful during the course of management to guide our outcome prognostication. Although the CT scan demonstrates SAH, it is caused by the trauma, and a CT angiogram is not needed at this time unless vascular injury (eg, carotid dissection) is suspected. Lastly, administration of dextrose prior to thiamine could precipitate Wernicke encephalopathy. Although extremely rare, and if the patient had hypoglycemia it should be treated prior to thiamine administration, there are reports of worsening neurologic symptoms in the setting of dextrose administration.
A 29-year-old male was riding a motorcycle and was involved in a collision with a truck. He was placed in a cervical collar, and his GCS at the site was 7 for which he was intubated. After 3 days in the ICU, he started to move all extremities to command. An MRI of the brain is obtained, and it showed scattered foci of bleeding, as follows:
Axial susceptibility weighted imaging (SWI) on MRI. The arrows point to areas of microhemorrhages within the brain stem and temporal lobes. There is also tentorial subdural hematoma present.
Based on what is seen on the MRI, which of the following is true?
Correct Answer: E
This patient’s MRI brain demonstrates scattered foci of microbleeds following head trauma, which caused alterations in his mental status. This pattern is suggestive of diffuse axonal injury (DAI), which is a form of shear injury caused in the setting of abrupt rotational or torsional trauma to the head. DAI has been graded into three grades of severity, based on the distribution of the microbleeds on imaging. Grade I, if microbleeds are limited to the cortex; grade II, if they involve the corpus callosum as well; and grade III, if involving the brain stem. Overall, the higher grades are associated with more severe injury. However, recent studies suggest that we need to pay more attention to the location and proximity of microbleeds to the arousal nuclei as not all microbleeds in the brain stem carry the same prognostication value. There is no indication for hemicraniectomy in the management of isolated DAI, unless there is other evidence of increased ICP or underlying mass effect. Patients with DAI often have a prolonged ICU, hospital, and rehabilitation course. DAI outcome prognostication is challenging; it is unlikely that our patient will not have any clinical deficits in 30 days from admission. Seizures may happen after traumatic brain injuries, especially in the acute phase, but there is no evidence that DAI patients are more likely to have seizures several months after the injury. Cervical spinal cord injury can be seen in patients with traumatic brain injury, but in this case presentation, there is no clinical red flag to suggest spinal cord injury. Patient was able to move his extremities to commands.
A 47-year-old female with a past medical history of diabetes mellitus and asthma fell down a flight of stairs. When EMS arrives, she is unconscious (GCS 4). She is intubated in the field and brought to the ED. In the ED, she is found to have extensor posturing. CT head is obtained and shown below:
Axial noncontrast head CT. There is a large right temporal intraparenchymal hemorrhage with surrounding edema. There is mass effect with uncal herniation and compression of the midbrain and loss of the quadrageminal and ambient cisterns.
Which of the following is true about decompressive hemicraniectomy?
Correct Answer: B
Decompressive hemicraniectomy is a major life-saving surgical procedure that has been shown to reduce mortality in patients with severe TBI. It helps to relieve the pressure on brain structures by removing some portions of the skull, allowing the brain to swell outward. Based on the brain trauma foundation guidelines, large decompressive hemicraniectomies are recommended over smaller ones and are generally done on the side with the large contusions. Though they have been shown to reduce mortality, they achieve this by moving more of these patients into the “disabled” category. Posttraumatic epilepsy is occasionally seen after traumatic brain injuries, but preventing future seizures is not the primary reason for performing decompressive hemicraniectomy in TBI.
A 52-year-old female is admitted to the neuro ICU after a fall down five stairs. She did not lose consciousness but was confused for several hours after the fall. She is not intubated. A CT head was obtained and demonstrated SAH overlaying the cerebral cortex.
Axial noncontrast head CT. The arrows point out areas of subarachnoid hemorrhage present in the deep sulci of the bilateral frontal lobes.
Which of the following is true about this patient?
Trauma to the head can be associated with small foci of cortical SAH. Usually these are caused by the rupture of small superficial cortical vessels. Polycystic kidney disease can be associated with berry aneurysms causing aneurysmal subarachnoid bleeds, but not with traumatic hemorrhages. Unlike aneurysmal SAH, the risk of clinically significant vasospasm is low in these superficial traumatic SAHs. While a CT angiogram is a good way to rule out underlying vascular lesions, a catheter angiogram is not usually indicated to investigate traumatic SAH unless there is a high suspicion for vasospasm or an underlying vascular abnormality. Patients with normal coagulation profiles can still have small traumatic subarachnoid bleeds following head trauma, and this in itself is not concerning for a clotting disorder. Mild trauma of this nature is not a risk factor for large territorial strokes.
A 47-year-old male is found to have refractory elevation in ICP following a TBI in the setting of a motor vehicle accident. His neuro examination is poor, with GCS of 5. A head CT was obtained which demonstrated signs of bilateral frontal and temporal contusions.
Which of the following methods will help reduce ICP?
Elevated ICP is a common complication of acute severe TBI. There is a stepwise approach in the management of intracranial hypertension which starts with head of bed elevation, and hyperosmolar therapy (mannitol and hypertonic saline). Securing airways should always take priority and starting the patient on sedation like propofol and versed could help controlling ICP. ICP monitors should always be considered to guide treatment and provide CSF drainage if needed. If ICP remains refractory, other measures including barbiturates, to provide more sedation and reduce brain metabolism, and neuromuscular paralysis, to control shivering, should be also considered. Therapeutic hypothermia is one of the effective treatments to reduce ICP if less invasive approaches were ineffective. The effect of therapeutic hypothermia on clinical outcomes in TBI with refractory ICPs remains debated. While hyperventilation (PaCO2 of 25-30) is a good way to acutely lower ICP, it should not be used for more than 30 minutes due to the risk of rebound elevation in ICP when the PaCO2 is normalized. Elevated serum sodium is likely to benefit patients with elevated ICP, and therefore there is no reason to strictly maintain sodium below 145. Controlling seizures is helpful in keeping ICP low, but topiramate is rarely the agent used to control active seizure presentation. For intracranial hypertension refractory to initial medical management, CSF drainage, hypothermia, and barbiturate coma, decompressive craniectomy should be considered.
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