CHAPTER 25 TRAUMATIC BRAIN INJURY: IMAGING, OPERATIVE AND NONOPERATIVE CARE, AND COMPLICATIONS
The previous chapter described pathophysiology and initial management of traumatic brain injury (TBI) patients. This chapter provides an overview of selected aspects of surgical management, nonoperative care, complications, and outcome.
SURGICAL MANAGEMENT
Brain Swelling
Rapid brain swelling is a major concern after evacuation of an acute SDH. The speed with which this phenomenon occurs suggests that defective autoregulation may play an important role. A popular current practice is simply to leave the native dura open (but loosely cover the brain with a dural graft) and not replace the bone flap. Some neurosurgeons strongly advocate this practice, and it does seem to be effective in lowering intracranial pressure (ICP), but its effects on outcome remain unclear. Publications going back several decades report that a persistent vegetative state was commonly seen in survivors.1 Other concerns are that decompressive craniectomies may be performed too frequently or for poor or inadequate indications. Often, the bony opening that is left behind is too small, causing the swollen brain to strangulate and die, with the resulting edema tracking back intracranially and further aggravating intracranial hypertension.
Implicit in the previous discussion is the need to close the dura before brain swelling makes this impossible. As mentioned previously, this goal may seem antiquated in light of the current popularity of simply not replacing the bone flap. However, the authors have rarely encountered problems using this strategy, even when a retractor had to be used to gently depress swelling brain while the dural edges were forcibly pulled together with forceps so that they could be sutured together. This experience is consistent with laboratory data suggesting that decompressive craniectomy may actually promote cerebral edema.2
NONOPERATIVE MANAGEMENT
Secondary Insults
The prehospital emphasis on prevention and early treatment of secondary cerebral insults continues during the ICU management of these patients and, in fact, forms the foundation of their management. Special attention should be paid to basic metabolic and physiologic parameters, including blood pressure, oxygenation, hemoglobin concentration, and serum sodium concentration. Surgery for associated injuries that do not absolutely require immediate treatment, such as facial fractures, hand or foot injuries, and even most long-bone fractures, is best deferred while the injured brain is still vulnerable to possible intraoperative metabolic disturbances.