Preliminaries - National Neurotrauma Society

HEAD INJURY
Frontispiece
Copy to follow.
Frontispiece
Copy to follow.
— The illustrations on this page are black and white
visuals of illustrations from Chapter 9 which will be
colour on this page – Top left is Figure 9.8, top right is
Figure 9.43(a), bottom left is Figure 9.43(b) and bottom
right is Figure 9.58 —
HEAD INJURY
Pathophysiology and management of
severe closed injury
EDITED BY
Peter Reilly
MD, BMedSc, FRACS
Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Austalia
and
Ross Bullock
MD, PhD
Division of Neurological Surgery, Medical College of Virginia, Richmond,
Virginia, USA
Published by Chapman & Hall, 2–6 Boundary Row, London SE1 8HN,
UK
Chapman & Hall, 2–6 Boundary Row, London SE1 8HN, UK
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© 1997 Chapman & Hall
Typeset in 10 on 12 pt Palatino by Genesis Typesetting, Rochester, Kent
Printed in Great Britain by Cambridge University Press, Cambridge
ISBN 0 412 58540 5
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CONTENTS
List of contributors
Preface
PART ONE: THE INJURY
1
3
1
Pathology
Peter C. Blumbergs
39
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
39
40
40
41
46
47
48
Epidemiology
Michael R. Fearnside and Donald A. Simpson
3
1.1
1.2
1.3
1.4
3
3
3
3.9
4
6
7
8
10
10
12
14
15
16
21
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
2
ix
xi
Introduction
Definitions in epidemiology
Source data
Definitions and classification of head
injury
Deaths from trauma
Severity of trauma
Population-based national studies
Population-based regional studies
Causation
Children
Minor head injury
Counting the cost
Reducing the burden
References
Biomechanics of closed head injury
A. J. McLean and Robert W. G. Anderson
25
2.1
2.2
2.3
2.4
25
27
28
2.5
2.6
2.7
Impact to the head
Response of the head to impact
Methods of investigation
Toward an understanding of brain
injury mechanisms
Tolerance of the head to impact
The state of the art of head injury
biomechanics
References
29
34
36
36
3.21
3.22
3.23
3.24
3.25
3.26
4
Introduction
Assessment of severity of brain injury
The mechanism of brain injury
Axonal injury
Concussive syndromes
Hypoxic–ischemic damage in humans
Brain swelling
Neurotransmitter agonist–receptor
abnormalities
Hippocampal pathology in traumatic
brain injury
Traumatic vascular injury
Lacerations
Traumatic intracerebral hemorrhage
Extradural (epidural) hemorrhage
Acute subdural hematoma
Chronic subdural hematoma
Other subdural fluid collections
Subarachnoid hemorrhage
Diffuse vascular injury
Brain-stem lesions
Brain damage secondary to raised
intracranial pressure
Long-term effects
Post-traumatic vegetative state
Post-traumatic epilepsy
Head injury and Alzheimer’s disease
Brain injuries due to boxing
References
50
50
50
55
55
58
59
60
60
60
61
61
63
64
64
65
65
65
66
Primary and secondary brain injury
A. David Mendelow and Peter J. Crawford
71
4.1
4.2
4.3
71
72
73
Introduction
Primary brain damage
Secondary brain damage
vi
CONTENTS
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
5
Brain metabolism and cerebral blood flow
Alois Zauner and J. Paul Muizelaar
5.1
5.2
5.3
5.4
6
The basic principles of brain metabolism
and blood flow
Normal values for CBF and metabolism
CBF and metabolism following head
injury
References
Intracranial pressure and elastance
Ian Piper
6.1
6.2
6.3
7
Extradural hematoma
Intradural hemorrhage
Intracerebral hemorrhage
Herniation
Brain swelling
Infection
Post traumatic vascular damage
Pyrexia following head injury
Conclusion
References
The problem: raised intracranial
pressure after head injury
The principles: physiology and
pathophysiology of intracranial
pressure
References
77
78
79
79
80
83
85
85
86
86
89
94
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
168
168
169
171
172
173
173
185
197
95
97
9.11
9.12
101
9.13
9.14
89
10
101
105
117
7.1
7.2
121
7.5
7.6
7.7
7.8
7.9
7.10
121
123
209
209
210
210
213
214
215
216
11.5
11.6
11.7
Clinical examination and grading
Donald A. Simpson
145
8.1
8.2
145
146
12
Introduction
Historical aspects
Transducers
Methods of measuring ICP
Which system?
Interpretation of ICP monitoring
Conclusion
References
Measuring cerebral blood flow and
metabolism
Alois Zauner and J. Paul Muizelaar
11.4
143
206
206
206
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
138
139
140
140
Introduction
197
200
209
11.1
11.2
11.3
143
Introduction
The initial examination
11
Introduction
The role of plain film radiography
CT in head injury
MRI in head injury
SPECT in head injury
Classification
Intracerebral lesions
Extracerebral collections
Pneumocephalus
Raised intracranial pressure and
herniation
Patterns of ischemia
Radiology in the diagnosis of brain
death
Conclusion
References
Intracranial pressure monitoring
Brian North
126
128
133
PART TWO: MEASURING AND
MONITORING INJURY
8
156
158
164
168
121
7.3
7.4
9
The definitive examination
Evaluation of injury severity
References
Imaging the injury
Evelyn Teasdale and Donald M. Hadley
Injury and cell function
Ross Bullock
Introduction
Biomechanical characteristics of
neurotrauma
Biomechanical effects and age
Major vascular damage secondary to
shear injury
Metabolic consequences of TBI
Intracellular mechanisms
Brain swelling and cellular events
after neurotrauma
Conclusion
Acknowledgments
References
8.3
8.4
8.5
Overview of CBF measurements
Xenon CBF measurements
Further direct clinical methods for
obtaining CBF
Indirect methods for obtaining CBF
and metabolism
Direct measurement of cerebral
metabolism
Comprehensive neuromonitoring
References
217
217
218
221
222
223
226
226
Electrical function monitoring
R. J. Moulton
229
12.1
12.2
12.3
12.4
12.5
229
229
230
240
240
Goals
Problems and limitations
Methods and modalities
Conclusions
References
CONTENTS
13
Transcranial Doppler
Peter J. Kirkpatrick and Kwan-Hon Chan
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
14
Introduction
The theory of TCD sonography
TCD measurements
Signal processing and data collection
Results of analysis using TCD in
head-injured patients
Role of TCD in monitoring therapy
TCD in the diagnosis of brain death
Summary
References
Magnetic resonance spectroscopy
Robert Vink
14.1
14.2
14.3
14.4
14.5
14.6
Introduction
Principles of magnetic resonance
spectroscopy
MRS studies of neurotrauma
MRI studies of brain function
Conclusion
References
249
254
255
255
258
261
262
265
267
267
269
15
From accident site to trauma center
J. E. Gilligan
271
15.1
15.2
15.3
271
271
16
Fluid, electrolyte and metabolic
management
Peter D. Thomas
16.1
16.2
16.3
16.4
16.5
Introduction
Rationale of metabolic support
Basic principles
Fluid resuscitation
Effects of intravenous fluids on the
brain
16.6 Metabolic response to injury
16.10
16.11
17
272
273
276
280
281
293
293
294
302
305
307
20
338
340
343
357
358
Sedation and anesthesia
Guy L. Ludbrook
363
18.1
18.2
18.3
18.4
18.5
18.6
18.7
363
363
363
367
369
371
Management of intracranial pressure and
cerebral perfusion
Peter Reilly
Introduction
Intracranial pressure
Cerebral perfusion pressure
Intracranial volumes
Volume–pressure relations
Principles of management
Treatment
Surgical treatment
Plan of management of raised ICP
and reduced CPP
19.10 References
293
326
327
327
333
334
Introduction
Physiology
Effects of head injury upon oxygen
delivery
Management: resuscitation
Management: maintenance of cardiopulmonary–cerebral homeostasis
Conclusion
References
19.1
19.2
19.3
19.4
19.5
19.6
19.7
19.8
19.9
281
283
289
290
315
17.1
17.2
17.3
Introduction
Cerebral pharmacology
Intravenous anesthetic agents
Muscle relaxants
Inhaled anesthetic agents
Other agents used in neuroanesthesia
Conduct of anesthesia in severe
head injury
18.8 Emergence and recovery
18.9 References
19
312
333
17.6
17.7
18
Fluid therapy in uncomplicated postoperative and post-traumatic states
Disorders of water and electrolyte
balance
Special fluid and electrolyte
problems in the neurosurgical patient
Conclusions
References
Respiratory and cardiovascular support
John A. Myburgh
17.4
17.5
261
Introduction
15.9
15.10
15.11
16.9
261
269
15.4
15.5
15.6
15.7
15.8
16.8
243
244
245
247
PART THREE: TREATMENT
General aspects of trauma
Management at the accident site
Transportation to and between
hospitals
The Level 1 trauma center
Care of the patient in the hospital
Setting surgical priorities
Radiological examination
The effects of concurrent medical
conditions
Transport modalities
Summary
References
16.7
243
vii
373
379
380
385
385
385
388
388
388
390
393
400
401
405
The role of surgery for intracranial mass
lesions after head injury
Nigel Jones, Ross Bullock and Peter Reilly
409
20.1
20.2
409
409
Introduction
Post-traumatic lesions on CT
viii
CONTENTS
20.3
Indications for evacuation of
intracranial hematomas
20.4 Techniques for craniotomy
20.5 Specific surgical problems
20.6 References
21
Neuroprotection in head injury
Graham M. Teasdale and Paul E. Bannan
423
21.1
21.2
423
Introduction
From preclinical research to clinical
benefit
21.3 Treatments undergoing clinical
evaluation
21.4 Conclusion
21.5 References
22
409
411
416
421
424
425
435
436
Outcome after severe head injury
Bryan Jennett
439
22.1
22.2
22.3
22.4
22.5
439
439
442
443
444
Outcome after severe head injury
Glasgow Outcome Scale
When to assess outcome
Ethical issues
Brain death
22.6
22.7
22.8
22.9
22.10
22.11
22.12
22.13
22.14
The vegetative state
Neurophysical sequelae in
conscious survivors
Cerebral hemispheres
Cranial nerve deficits
Delayed complications
Mental sequelae
Deficits of intellectual (cognitive)
function
Personality change
References
Appendices
447
449
449
450
451
454
454
457
459
463
A Antibiotics recommended for infections of
the CNS
B Seizure management in acute head injury
C Possible causes of status epilepticus after
head injury
D Cardiovascular drugs used for augmentation
of cerebral perfusion pressure
465
Index
467
463
464
464
CONTRIBUTORS
Robert W. G. Anderson BE
Road Accident Research Unit,
University of Adelaide,
Adelaide,
Australia
Michael R. Fearnside MS, FRACS
Department of Neurosurgery,
Westmead Hospital,
Westmead,
Australia
Paul E. Bannan FRACS
Department of Neurosurgery,
Royal Perth Hospital,
Perth,
Australia
J. E. Gilligan FANZCA, FFICANZCA
Intensive Care Unit,
Royal Adelaide Hospital,
Adelaide,
Australia
Peter C. Blumbergs FRACP, FRCPA
Department of Neuropathology,
Institute of Medical and Veterinary Sciences,
Adelaide,
Australia
Donald M. Hadley PhD, FRCR
Department of Neuroradiology,
Institute of Neurological Sciences,
Southern General Hospital,
Glasgow,
UK
Ross Bullock MD, PhD
Division of Neurological Surgery,
Medical College of Virginia,
Richmond,
Virginia,
USA
Bryan Jennett CBE, MD, FRCS
Department of Neurosurgery,
Institute of Neurological Sciences,
Southern General Hospital,
Glasgow,
UK
Kwan-Hon Chan MS, FRCS
Division of Neurological Surgery,
University of Hong Kong,
Queen Mary Hospital,
Hong Kong
Nigel Jones DPhil, FRACS
Department of Neurosurgery,
Royal Adelaide Hospital,
Adelaide,
Australia
Peter J. Crawford BSc, FRCS
Department of Neurosurgery,
Newcastle General Hospital,
Newcastle upon Tyne,
UK
Peter J. Kirkpatrick BSc, MSc, FRCS(SN)
Academic Department of Neurosurgery,
Addenbrooke’s Hospital,
Cambridge,
UK
x
CONTRIBUTORS
Guy L. Ludbrook FANZCA
Department of Anaesthesia,
Royal Adelaide Hospital,
Adelaide,
Australia
A.J. McLean BE, ME, SMHygSD
Road Accident Research Unit,
University of Adelaide,
Adelaide,
Australia
A. David Mendelow PhD, FRCS(SN)
Department of Neurosurgery,
Newcastle General Hospital,
Newcastle upon Tyne,
UK
R. J. Moulton MD, FRCS(C)
Division of Neurosurgery,
University of Toronto,
Toronto,
Canada
J. Paul Muizelaar MD
Division of Neurological Surgery,
Medical College of Virginia,
Richmond,
Virginia,
USA
John A. Myburgh DA(SA), FANZCA, FFICANZCA
Intensive Care Unit,
Royal Adelaide Hospital,
Adelaide,
Australia
Brian North RFD, FRCS, FRACS
Department of Neurosurgery,
Royal Adelaide Hospital,
Adelaide,
Australia
Ian Piper PhD
Department of Clinical Physics,
Institute of Neurological Sciences,
Southern General Hospital,
Glasgow,
UK
Peter L. Reilly MD, BMedSc, FRACS
Department of Neurosurgery,
Royal Adelaide Hospital,
Adelaide,
Australia
Donald A. Simpson AM, MS, FRCS, FRACS
Road Accident Research Unit,
University of Adelaide,
Adelaide,
Australia
Evelyn Teasdale MRCP, FRCR
Department of Neuroradiology,
Institute of Neurological Sciences,
Southern General Hospital,
Glasgow,
UK
Graham M. Teasdale FRCP, FRCS (Edinb. and Glasg.)
Department of Neurosurgery,
Institute of Neurological Sciences,
Southern General Hospital,
Glasgow,
UK
Peter D. Thomas FRACP, FANZCA, FFICANZCA
Intensive Care Unit,
Royal Adelaide Hospital,
Adelaide,
Australia
Robert Vink PhD
Department of Physiology and Pharmacology,
James Cook University of North Queensland,
Townsville,
Australia
Alois Zauner MD
Division of Neurological Surgery,
Medical College of Virginia,
Richmond,
Virginia,
USA
PREFACE
Brain injury remains one of the most difficult and
challenging problems facing many clinicians, particularly neurosurgeons and intensivists. In major trauma
centers there has been a steady decline in the mortality
rate due to severe head injury of about 10% per decade
since the mid 1970s, but this does not seem to be
reflected in an overall population-based decline, even
in ‘developed’ countries (Jennett et al., 1977; Klauber et
al., 1989; Marshall et al., 1991; Waxweiler et al., 1996).
This suggests that a more widespread application of
modern principles of neurotrauma care could save
many lives throughout the world. It is the goal of this
book to provide a theoretical and practical foundation
upon which such care can be based.
We wish to thank our colleagues who have contributed their tremendous expertise to these chapters. We
owe a strong debt of gratitude to the Glasgow school,
and in particular to Bryan Jennett and Graham
Teasdale, both of whom have contributed fundamentally to our own views on head injury and indeed to
all neurosurgeons. We also wish to acknowledge the
outstanding contribution to neurotrauma made by our
friend the late Douglas Miller. The originality and
clarity of his thoughts and words have challenged and
enlightened all those seeking to understand more
clearly the complexity of brain injury.
Peter Reilly and Ross Bullock
Adelaide, South Australia and Richmond, Virginia,
December 1996
References
Jennett, B., Teasdale, G., Gailbraith, S. et al. (1977) Severe head injuries in 3
countries. Journal of Neurology, Neurosurgery and Psychiatry, 40, 291–298.
Klauber, M. R., Marshall, L. F., Leursen, T. G. et al. (1989) Determinants of head
injury mortality: importance of the low risk patient. Neurosurgery, 24,
31–36.
Marshall, L. F., Gautile, T., Klauber, M. R. et al. (1991) The outcome of closed
head injury. Journal of Neurosurgery, 85, 528–536.
Waxweiler, R., Thurman, D., Spiezek, J. et al. (1996) Monitoring the impact of
traumatic brain injury: a review and update, in Traumatic Brain Injury:
Bioscience and Mechanics, (eds F. A. Bandak, R. H. Eppinger and A. K.
Ommaya), M. A. Liebert, New York, pp. 1–8.