Management of Head Injuries with normal CT
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1) A 7-year-old male child presented with a severe head injury after falling 4 stories, with an initial normal CT scan but gradually rising intracranial pressure. 2) The patient underwent an emergency decompressive craniectomy due to refractory elevated ICP, which improved his condition and he was successfully extubated on the third postoperative day. 3) An audit of over 2000 head injury patients at this trauma center over 18 months found that 53% had severe injuries, with an overall mortality of 22%, rising to 36% for severe injuries.
Management of Head Injuries with normal CT
- 1. Deepak Agrawal Dept of Neurosurgery, JPN Apex Trauma Centre MANAGEMENT OF SEVERE HEAD INJURY WITH ‘NORMAL’ CT HEAD
- 2. Case history 7 year male child Fall from height (4 th floor ) 2 hours back H/o LOC following fall Presented to emergency with laboured respiration Post resuscitation GCS E2Vet M5 Secondary survey - no other significant systemic injuries. FAST negative.
- 3. NCCT head at admission
- 5. ICU MANAGEMENT Patient was admitted in neurotrauma ICU Managed as per standard protocol for severe head injury Head elevation 30 0 Neutral neck position Sedation (Fentanyl & Midazolam) ventilation with normocapnea Osmotic agents (mannitol) and diuretics (furosemide)
- 6. ICU MANAGEMENT Continous 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
- 7. In view of refractory raised ICT, decompressive craniectomy was planned. Patient taken up for emergency surgery
- 8. Surgery Large fronto-temporo-parietal craniectomy performed Brain tense intra-op. Augmentation duraplasty using pericranial graft. Calvarial flap cryo-preserved for later replacement.
- 9. Postoperative Course Patient became conscious & GCS improved to E4VetM6 within a span of 2hrs following surgery Successfully extubated on POD 3, to be discharged.
- 12. Indications for Intracranial Pressure Monitoring Evidence Level Level I: None 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. 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
- 13. The gray zone No level I evidence yet for ICP monitoring CT may not detect all significant lesions Head injury is evolving and dynamic CT at best permits periodic serial monitoring Hence at JPNATC, a low threshold for ICP monitoring. Aggressive surgical management for refractory elevated ICP
- 14. 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 GROUPS Minor head injury (GCS 13-15) Moderate head injury (GCS 9-12) Severe head injury (GCS 8 or less)
- 15. Observations Total patients: 2068
- 16. OBSERVATIONS (AGE GROUP INCIDENCE) PEDIATRIC (< 12 YR)= 328 ( 15 %) ELDERLY (>60 YRS)= 181 ( 8 %)
- 17. OBSERVATIONS (INCIDENCE OF VARIOUS H.I. GROUPS) MINOR HI -29% MOD. HI -18% SEVERE HI -53%
- 18. OBSERVATIONS SEVERE HEAD INJURY
- 19. 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
- 20. 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
- 21. OUTCOME (GOS ) OVERALL DEATH - 454 / 2068 (22%) 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%
- 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 CONSERVATIVE 3-8 78 203 MODERATE HEAD INJURY SURGERY 9-12 109 18 CONSERVATIVE 9-12 226 27 MINOR HEAD INJURY SURGERY 13-15 23 2 CONSERVATIVE 13-15 561 12
- 23. COMPARISON WITH WORLD LITERATURE 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%
- 24. CONCLUSIONS Aggressive 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.
- 25. THANK YOU !