Emergency Neurosurgery for the Brain
Traumatic brain injury (TBI) affects up to two percent of the population per year. These incidents take a higher toll among the young, who are more likely to be involved in high-impact sports, dangerous lines of work, car accidents and assaults. Close behind are the elderly, who are prone to serious falls, and whose injuries are often complicated by being on blood-thinning medications.
The degree of permanent damage due to a TBI may depend less on the primary injury than it does on the cascade of secondary complications that can set in hours or even days after the primary injury. The ability to identify problems before they worsen and to respond aggressively is critical to the ultimate outcome.
For these reasons, TBIs require a range of highly specialized neurosurgical services and post-surgical monitoring that is only available at certain specialized hospitals. Our dedicated team is on call 24/7 to evaluate patients in the emergency room, identify those who may require surgical intervention and carefully monitor the others as appropriate.
The first critical task in the ER is to evaluate the degree of injury. This determination is usually made based on a physical examination combined with information from the attending paramedics or witnesses to the injury. Most patients also are given a CT scan of the head.
Generally, 80 percent of TBIs are classified as mild with a Glasgow Coma Score (GCS) of 13 to 15. These patients are awake and are able to speak and follow commands. They may be confused and lethargic, but should be easily arousable. The other 20 percent are evenly divided between moderate (GCS of 9-12) and severe (GCS of 3-8). The moderate TBI patients have an altered sensorium, but are still able to follow commands. The severe TBI patients are comatose and are unable to follow even simple commands. For these patients the outcome is less certain.
Closed head injuries are typically the result of blunt trauma or a fall in which the head takes a significant hit. The impact results in stresses as the brain sloshes repeatedly from side to side within the skull before coming to rest. This motion can stretch and tear neural cells, causing diffuse disruptions in the brain’s communication network. Closed TBI may also result in a brain contusion or bruising. This is usually managed without surgery, unless the associated brain swelling becomes severe.
Mild TBI: Most patients with a mild TBI do not require surgical intervention, and ultimately make a good recovery after a period of observation, medications and time. However, a small proportion of these patients can suffer from post-concussion syndrome, with symptoms that can include memory loss, headaches, dizziness and loss of smell.
Moderate and severe TBI: The likelihood of needing surgical intervention rises in patients with moderate or severe TBI, and is usually determined by an initial CT scan followed by a CT scan a few hours after admission to check for a growing hematoma. This is especially true if the initial CT scan shows any bleeding or if the patient is on blood-thinning medications. Intracranial pressure (ICP) monitors are often surgically placed on comatose patients.
Hematomas: There may be a large hematoma outside the dura (epidural hematoma), or within the dura (subdural hematoma). If these hematomas are causing significant pressure on the brain, they need to be surgically removed with a craniotomy, which involves cutting a hole in the skull to temporarily remove a bone flap in order to access the brain. Sometimes, in a procedure known as decompressive craniectomy, the skull bone is not replaced or may be removed a few days after the injury, in order to allow the brain to swell without the ICP going to dangerously high levels.
Penetrating or open head injuries: Most penetrating injuries are caused by firearms, and vary in the damage caused by the velocity and rotational impact of the type of bullet. The management of these injuries is very specific to the type of injury, its location and the patient’s overall condition.
Post-operative care: After surgery, the patient is transferred to the ICU and continuous monitoring begins. During this time, staff watches for the subtle signs of secondary injuries. These include excessive ICP, low blood pressure, fever, high glucose levels, low serum sodium levels and seizures. All of these factors can interfere with normal recovery. Unfortunately, they are very common and occur in almost all patients. Using an array of state-of-the-art tools, our specialized teams are prepared to counter with aggressive, rapid action when indicated. Delayed intracranial hematomas or brain swelling can also require urgent surgery.
Monitoring devices: Intracranial pressure monitoring and routine CT scans form the mainstay of monitoring TBI patients. Electroencephalography (EEG) is being increasingly used as we recognize the frequency of silent seizure activity in the injured brain. Brain oxygen monitoring is also valuable in some cases. Advanced transcranial Doppler (TCD) ultrasonography is sometimes used to assess dynamic change in the brain’s blood flow velocity and perfusion. When the patient is more stable, MRI diffusion tensor imaging (DTI) is performed to give us higher resolution imaging of white matter, not only in the acute phase but also during the recovery phase.Back to Top