Category Archives: Head

Head

What Happens To Your Average Subarachnoid Hemorrhage?

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Management of traumatic brain injury (TBI) is a common issue faced by trauma professionals. And isolated subarachnoid hemorrhage (SAH) is one of the more common presentations. In many centers, this diagnosis frequently results in admission to the hospital, neurosurgical consultation, and repeat imaging.

Is this too much care? We adopted a practice guideline nearly two years ago based on our own clinical experience that eliminated the last two. Patients were still admitted for neurologic monitoring for 16 hours. But is even this too much?

What we really need is a better understanding of the natural history of uncomplicated traumatic SAH. Well, a study from Sunnybrook and the University of Toronto does just that. They performed a 17 year meta-analysis of the literature on isolated SAH with mild TBI (GCS 13-15). They pared their initial literature search of nearly 2900 studies down to the usual few, 13 in this case. All but one were retrospective, of course, and they had the usual design flaws.

Here are the factoids:

  • How many patients eventually needed neurosurgical intervention?  0 (Well, almost zero. It was 0.0017%, to be exact.)
  • How many had progression of the SAH? About 6%
  • How many had neurologic deterioration? 0.75%, which included two  patients with increased headache and one with some confusion. Two developed intraparenchymal hemorrhage (one was on anticoagulants)
  • How many died? Only 1 died from neurologic causes, and that patient was anticoagulated at the time of injury.

Bottom line: It looks like we may be overdoing it for patients with isolated SAH and mild TBI. The natural history seems to be fairly benign, unless the patient is taking anticoagulants. The type of drug was not specified, so warfarin, aspirin, clopidogrel, and the newer anticoagulants should all be included.

Perhaps it’s time to update the our practice guidelines further. It looks like most of these simple, isolated SAH can be evaluated and released. However, if the GCS is 13 or 14, they should still be admitted for monitoring for a short period. And if on anticoagulants, admission with a repeat CT is in order.

Related posts:

Reference: The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury: A meta-analysis. J Trauma , published ahead of print, July 8 2017.

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Head

Tips For Taking Care Of CSF Leaks

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The management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients.

  • Ensure that the patient actually has a CSF leak. In most patients, this is obvious because they have clear fluid leaking from ear or nose that was not present preinjury. Here are the options when the diagnosis is less obvious (i.e. serosanguinous drainage):
    • The “halo” or “double ring sign” is a form of pillow chromatography. The blood components separate from the CSF as they move through the pillow fabric, creating a clear ring or halo surrounding a bloody spot. This is the cheapest, fastest test and is actually fairly reliable.
    • High resolution images of the temporal bones and skull base. If an obvious breach is noted, especially if fluid is seen in the adjacent sinuses, then a CSF leak is extremely likely.
    • Glucose testing. CSF glucose is low compared to serum glucose.
    • Beta 2 transferrin assay. Don’t do it!! This marker is very specific to CSF. However, the test is expensive and results may take several days to a few weeks to receive. Most leaks will have closed before the results are available, making this a poor test.
  • Place the patient at bed rest with the head elevated. The basic concept is to decrease intracranial pressure, which in turn should decrease the rate of leakage. This same technique is used for management of mild ICP increases after head injury.
  • Consider prophylactic antibiotics carefully. The clinician must balance the likelihood of meningitis with the possibility of selecting resistant bacteria. If the likelihood of contamination is low and the patient is immunocompetent, antibiotics may not be needed.
  • Ear drops are probably not necessary. They may confuse the picture when gauging resolution of the CSF leak.
  • Wait. Most tramatic leaks will close spontaneously within 7-10 days. If it does not, a neurosurgeon or ENT surgeon should be consulted to consider surgical closure.

References:

  1. Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol, 1997;18:188-197.
  2. Brodie HA. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulas. Arch Otolaryngol Head, Neck Surg. 123:749-752.
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Head

Do We Really Need To Consult Neurosurgery For Mild TBI?

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We consult our neurosurgeons too often. Think back on all the head injured patients you have admitted and placed a neurosurgical consult. How many times did they recommend something new or different, or take them to surgery? Not very often, I would guess.

This is becoming a hot topic. Check out the references below to read about a few other studies that have taken a similar approach.

The trauma group at Scripps Mercy in San Diego retrospectively reviewed their admissions to determine how often patients with mild TBI (GCS > 13) and some degree  intracranial hemorrhage required neurosurgical intervention, even if they were intoxicated or taking anti-platelet or anticoagulant drugs. A total of 500 patients were studied over a 28 month period.

Here are the factoids:

  • 49 (10%) of patients required some sort of neurosurgical intervention (41 craniotomy/craniectomy, 8 ICP monitors)
  • 93% of patients had neurosurgical consultation, and made additional recommendations in only 10 (2%),none of which changed management
  • There was no clinical difference in GCS between those who received an intervention and those who did not
  • Epidural and subdural hematomas were significant predictors of neurosurgical intervention
  • Intoxication or use of anti-platelet or anticoagulant drugs was not associated with intervention. These were present in 30% of all patients!
  • Unsurprisingly, ICU and hospital length of stay were longer in patient who underwent an intervention

Bottom line: As I said, this seems to be a hot research topic. And in this study, the numbers are getting larger and the criteria more inclusive (alcohol and anticoagulants allowed).

Neurosurgeons play a very important role in patients with more moderate to injury to their brain, and with spine injuries. But their input may not be needed in many patients with milder injuries. These data suggest that, in patients with GCS > 13, only subdural and epidural hematomas require consultation because they are much more likely to require intervention. 

This parallels a practice guideline we have in place where patients with subarachnoid or small intraparenchymal hemorrhage, or a linear skull fracture are managed by the trauma service without neurosurgical consultation. We do involve them if there is any intracranial hemorrhage with a history of anticoagulant use, however.

We all need to use our neurosurgeons wisely, and this paper helps to clarify situations where they may and may not be needed. 

Related posts:

Reference: Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury. J Trauma 82(4):776-780, 2017

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Head

Everything You Wanted To Know About: Cranial Bone Flaps

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Patients with severe TBI frequently undergo surgical procedures to remove clot or decompress the brain. Most of the time, they undergo a craniotomy, in which a bone flap is raised temporarily and then replaced at the end of the procedure.

But in decompressive surgery, the bone flap cannot be replaced because doing so may increase intracranial pressure. What to do with it?

There are four options:

  1. The piece of bone can buried in the subcutaneous tissue of the abdominal wall. The advantage is that it can’t get lost. Cosmetically, it looks odd, but so does having a bone flap missing from the side of your head. And this technique can’t be used as easily if the patient has had prior abdominal surgery.

2. Some centers have buried the flap in the subgaleal tissues of the scalp on the opposite side of the skull. The few papers on this technique demonstrated a low infection rate. The advantage is that only one surgical field is necessary at the time the flap is replaced. However, the cosmetic disadvantage before the flap is replaced is much more pronounced.

3. Most commonly, the flap is frozen and “banked” for later replacement. There are reports of some mineral loss from the flap after replacement, and occasional infection. And occasionally the entire piece is misplaced. Another disadvantage is that if the patient moves away or presents to another hospital for flap replacement, the logistics of transferring a frozen piece of bone are very challenging.

4. Some centers just throw the bone flap away. This necessitates replacing it with some other material like metal or plastic. This tends to be more complicated and expensive, since the replacement needs to be sculpted to fit the existing gap.

So which flap management technique is best? Unfortunately, we don’t know yet, and probably never will. Your neurosurgeons will have their favorite technique, and that will ultimately be the option of choice.

Reference: Bone flap management in neurosurgery. Rev Neuroscience 17(2):133-137, 2009.

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Complications, Head

Rest vs Physical Activity After Mild Pediatric Concussion: Which Is Better?

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One of the most common recommendations after a child or young adult sustains a mild TBI is to rest. And even better, brain rest. I’ve written about that topic several times over the years.

But what about physical rest? There is a large body of literature documenting the numerous mental and physical benefits of exercise. Couldn’t they also apply after concussive injury to the brain? A study published recently tried to determine if physical activity or lack of it after mild TBI was helpful in reducing the incidence of post-concussive symptoms.

This was a planned analysis of prospectively collected data from nine research network hospital emergency departments in Canada. Children from age 5 through 17 were enrolled if they had received a concussion within 48 hours of the ED visit, as defined by the 2012 Zurich consensus. They were excluded if they had a positive head CT, GCS < 14, or pre-existing cognitive deficits.

Initial research data was collected during the ED visit, and followup phone calls were made by the research team at 7 and 28 days. They asked about self-reported level of physical activity on day 7, and post-concussive symptoms and their change over time on days 7 and 28.

Here are the factoids:

  • Of 3063 patients enrolled, 84% completed the ED assessment. 171 were excluded because they could not be contacted for the activity assessment on day 7.
  • Post-concussive symptoms were present in 30% of these children overall
  • 70% participated in physical activity during the first week: 32% light aerobic, 9% sport-specific, 6% non-contact drills, 4% full-contact practice, and 18% full competition (ignoring doctor’s orders?)
  • Overall, early activity was associated with a lower risk of post-concussive symptoms (25% vs 44%)
  • In patients who were symptomatic at day 7, symptoms were decreased at 28 days in patients who engaged in light aerobic activity, moderate activity, and even full-contact activity

Bottom line: This was a well designed study, but obviously with a number of limitations. Physical activity was self-reported, there may have been other factors that could not be controlled, and the study did not inquire about activity between days 7 and 28.

But this study appears to suggest that, like in most other areas, exercise is good. Even for the brain recovering from a concussion. Obviously, a really good randomized study would be the gold standard, but I doubt that will be done anytime soon. Trauma professionals may want to consider a cautious return to light to moderate activity as soon as the child feels well enough. But keep in mind that, in general, the onset of fatigue is a good indicator that it is time to stop activity and rest. And full contact should probably be avoided, especially because of the risk of re-injury.

Related posts:

Reference: Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 316(23):2504-2514, 2016.

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