REVIEW

SEVERE HEAD INJURY, Spinal

injury and Subarachnoid
Haemorrhage
Carl Bruce MBBS FRCSEd,
DM, FCCS, FACS

Division of Neurosurgery
Section of Surgery
University Hospital of the
West Indies
Mona Jamaica
Practical Knowledge of Initial Care
 Cervical Spine

5-10% of Severe Head Injuries

 Evaluation in Head Injury
Resuscitation along ATLS and ACLS Guidelines
Primary Survey
Airway
Breathing
Circulation
Disability
Exposure
Adjuncts
Foley
Gastric tube
Monitoring
 History
• LOC
• Vomiting
• ENT
• Seizures
 EXAMINATION
• Conscious Level
• The Pupils
• The Motor System
• The Vital Signs
 Glasgow Coma Scale Score for Adults and Children

Function Adults Infants and Children Scor

e
Eye Opening Spontaneous Spontaneous 4
To command To sound 3
To pain To pain 2
None None 1
Verbalization Oriented Appropriate for age, 5
fixes and follows,
social smile
Disoriented Cries but consolable 4
Inappropriate Persistently irritable 3
Incomprehensible Restless, lethargic 2
None None 1
Motor Obeys commands Spontaneous 6
Localizes pain Same 5
Withdraws Same 4
Reflex flexion Same 3
Reflex extension Same 2
None Same 1
 Classification of Head Injury
• Mild GCS 14 – 15

• Moderate GCS 9 – 13

• Severe GCS 3 – 8

• Teasdale G & Jennett B Assessment of coma and impaired

conciousness. Lancet 2:81, 1974.
• Simpson DA, Cockington RA, Hanieh a., et al Head injuries in infants
and children: The value of the Paediatric coma scale. Childs Nerv Syst
7:183,1991.
 Head Injury: A & E
• Airway: clear. O2
• Breathing: Spont/Ambu/Ventilate
• Circulation: p;BP
• Head up 30°
• Immobilize neck
• IV line
• Urethral catheter
• OG/NG tube
• NPO
• Drugs: Anticonvulsants, Antibiotics,
Mannitol
Severe Head Injury Treatment
Flow Chart
Clinical Evidence of Herniation
-Decreasing level of consciousness
-Deteriorating exam
-Lateralizing Findings

YES NO
Guidelines - Clinical Herniation Guidelines - Absence of Clinical Herniation
First Tier Therapy
Second Tier Therapy

Atkinson JD
 SHI Guidelines
Clinical Herniation
Resuscitate along ATLS guidelines
Hyperventilation
Mannitol - address volume
0.25 grams/Kg - 1.0 grams/Kg
Urinary Catheter
Expeditious diagnostic study
Surgery
 ICP Monitoring rationale (I)
Increased ICP in 53-63% of pts with
GCS< 8 with abnormal CT scan
Increased ICP in 13% of pts with GCS< 8
and normal CT scan
Incidence increases when age > 40,
posturing, SBP < 90
Narayan RK, Kishore PR, Becker DP, et al: Intracranial pressure: to
monitor or not to monitor? A review of our experience with severe head
injury. J Neurosurgery 56:650-659, 1982
Guidelines for ICP monitoring
ICP treatment threshold
Standard - insufficient data
Guideline - Treat at upper threshold of
20-25mmHg
>20X5min, >30x2min, >40x1min

(Interpret ICP data with exam, CT, and

CPP data).
 SHI ICU Guidelines
(summary)

• Head elevation
• Avoid jugular obstruction
• Control temperature
• Avoid hypoxia / hypotension
• Sedation / paralysis
• Neuromuscular blockade
• Seizure prophylaxis. Nutrition. GI prophylaxis
• ICP & CPP management / CSF drainage
• Mannitol
• Hyperventilation
• Decompressive craniectomy
• Barbiturate coma
• Brain tissue monitoring
 Spinal Injuries
Mr. Carl Bruce
Consultant Neurosurgeon
Cerebrovascular and skull base surgeon
Division of Neurosurgery
 EPIDEMIOLOGY

The National Spinal Cord Injury Registry – Ducker. T., and Perot P.:
1974 -1975
 Level of injury
• Thoracic(T1-T11) 15%
• Thoracolumbar(T12-L1/2) 15%
• Lumbosacral (L2-S5) 15%
• Cervical 55%

Spine …vol 26 # 24S,p

S3
 ANATOMY
• Cervical Spine
– 7 vertebrae
– Lordosis
• Thoracic Spine
– 12 vertebrae
– Kyphosis
• Lumbar Spine
– 5 Vertebrae
– Lordosis
• Sacral Spine
– 5 Vertebrae
 Anatomy
• Spinal Cord
– Foramen Magnum to L2 in adults
– Cauda Equina from L2
 Prognostic factors
• Age
• Level of injury
• Neurologic grade
 Resuscitation
• ATLS Guidelines
• Primary survey
• Adjuncts to primary survey
• Secondary survey
• Consults/Investigations/management
 Severity of Neurologic deficit
• Complete ASIA Gd A……….45%
• Incomplete ASIA Gd B ……..15%
• Incomplete ASIA Gd C………10%
• Incomplete ASIA Gd D………30%

• ASIA: American Spinal Cord Injury

Association
 Examination
• Sensory

• Motor
 Classification of Lesion
• Complete

• Incomplete

• Level
 Management
• Pre hospital
– Extrication
– Stabilization
– Transport
• Evaluation and management in emergency
room
– Stabilization
– ABC’s
– X–ray’s, CT scan
– Neurological Examination and documentation
– MRI scan
 No investigation
• Awake
• Alert
• No neck pain
• Normal range of movement
• No neurological deficit
• No intoxication
• No distracting injury
 Investigations
• C-spine radiographs
• Chest radiographs
• Pelvic radiographs
 Investigation
• C-Spine X-rays
– AP
– Lateral
– Odontoid
– Swimmers View
– Flexion/Extension
• CT scan
• MRI scan
 Management
• ICU admission
• Adequate oxygenation
• Maintain Blood Pressure
• DVT prophylaxis
– LMWH and pneumatic compression stocking
• Skin care
• Bladder care
• Gastric protection
• Nutrition
• Rehabilitation
 Management
• Quadriplegia
– Definition
– Immobilization
– ICU admission
– NG tube
– Catheter
– Respiratory Support

• Paraplegia
– Definition
– Immobilization
– Catheter
 Shock
• Hypovolaemic Shock
– Low BP
– Tachycardia
• Neurogenic Shock
– Low BP
– Bradycardia
• Spinal Shock
 SCI : Classification
ASIA/IMSOP Impairment scale
• Grade A Complete -No motor/sensory function to
S4,5
• Grade B Incomplete-Sensory only below level
toS4,5
• Grade C “ -Motor preserved: key muscles <
gr.3
• Grade D “ -Motor preserved:key muscles >
gr. 3
• Grade E Normal
*this scale improves the ability to be precise re.
 Frankel paraplegia scale
• A :complete: motor & sensory paraplegia
• B :sensory only: motor complete, sacral
sparing
• C : motor useless  Grade II
• D : motor useful  Grade III
• E : recovery: no weakness, sensory loss,
sphincter disturbance. ± abnormal
reflexes
 Neurogenic Shock
• S.N.S disruption---vascular pooling, BP P
• worse c blood loss, vent., position
• (no compensatory tachycardia)
• Rx = Volume till BP/perfusion adequate
• alpha adrenergic agonists +Swan
• SVR=(MAP-CVP) times 80/C.O.
 Neuroprotection in acute
spinal cord injury
• Ten random./pros./controlled trials to
date
• >>men ,16-75 yrs
• NASCIS-1 : ‘84 no difference c MP
• NASCIS-2 : ’90 MP-- improved :1st 8
hrs.
(30 mg/kg for 15 mins wait 45 mins then
5.4mg/kg for 23 hrs)
• NASCIS-3 : ‘97 MP--improved(if started
 Division of Neurosurgery
Section of Surgery
University Hospital of the West Indies
Mona Jamaica

Carl Bruce MBBS FRCSEd, DM, FCCS, FACS

12/31/2018 Neurosurgery UHWI 46

Aneurysms and Subarachnoid
haemorrhage
• Subarachnoid haemorrhage
– Incidence 10 – 12/100,000 population
– Peak age 55-60 years
– 10% die at home
– 15-20% rebleed in 2 weeks
– 8% mortality from progressive deterioration
– 7% morbidity & 7% mortality from cerebral vasospasm
– A third have a good results

Broderick, J., Brott, T. and Tomsick, T. et al (1993). Intracerebral haemorrhage more than twice as common as
subarachnoid haemorrhage. J Neurosurg. 78: 188-91
12/31/2018 Neurosurgery
Sahs, A., Wibbelink, D. and Turner, J. (1981). UHWI
Aneurysmal subarachnoid haemorrhage: Report of the cooperative47study.

Urban and Schwarzonberg: Baltimore-Munich

 Epidemiology
• Increases each decade peaks in the
40”s and 50’s
• Above age 40 years
• 2.74 : 1

Sahs, A., Wibbelink, D. and Turner, J. (1981).

Aneurysmal subarachnoid haemorrhage: Report of
the cooperative study. Urban and Schwarzonberg:
12/31/2018 Baltimore-Munich
Neurosurgery UHWI 48
 Clinical features
• Headaches – 97% (Sentinel/Warning 30-60%)
• Worse headache of there life, sudden onset
• Vomiting
• Syncope
• LOC – may subsequently recover
• Neck pains – meningismus
• Kernig’s & Brudzinski signs
• Photophobia
• Focal cranial nerve deficit third nerve with diplopia
and/or ptosis

12/31/2018 Neurosurgery UHWI 49

 Hunt and Hess
Grade Description
Classification of SAH
1 Asymptomatic, mild headache

2 Cr. N. palsy (3rd,4th) moderate to severe headache, nuchal

rigidity

3 Mild focal deficit, lethargy, confusion

4 Stupor, moderate to severe hemiparesis, early decerebrate
rigidity

5 Deep coma, decerebrate rigidity moribound appearance

Hunt, W. and Hess, R, (1968); Surgical risk as related to time of intervention in the
12/31/2018 Neurosurgery aneurysms.
repair of intracranial UHWI J Neurosurg; 28:14-20. 50
 WFNS
WFNS GRADE GCS score Major focal deficit

1 15 absent
2 13-14 absent
3 13-14 present
4 7-12 Absent or present

5 3-6 Absent or present

Drake CG. Report of World Federation of Neurological Surgeons Committee on a

universal subarachnoid hemorrhage grading scale. J Neurosurg. 1988; 68: 985–
986

12/31/2018 Neurosurgery UHWI 51

 Investigation
• CT Scan
• Lumbar Puncture
• Angiogram

12/31/2018 Neurosurgery UHWI 52

 CT SCAN SAH

12/31/2018 Neurosurgery UHWI 53

12/31/2018 Neurosurgery UHWI 54
 Fisher grade – A
predictor of vasospasm
Fisher group Blood on CT scan

1 No SAH
2 Diffuse or vertical layers
< 1mm thick
3 Localized clot or vertical
layers > 1mm thick
4 Intracerebral or
intraventricular clot

Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid
hemorrhage visualized by computerized
12/31/2018 tomographic
Neurosurgery UHWIscanning. Neurosurgery. 1980; 6: 55
1–9
Distribution of Aneurysms on the Circle of Willis

Location Frequency (%)

Anterior communicating 30.3

Posterior communicating 25
Middle cerebral 20
ICA Bifurcation 4.5
Anterior choroidal 4.3
Vertebrobasilar 4
Pericallosal 2.8
Anterior cerebral 1.5
Carotid Opthalmic

12/31/2018 Neurosurgery UHWI 56

Sahs et al Cooperative study 1969
 Treatment
• Surgery
– External
ventricular
drainage for
hydrocephalus
– Repair by
clipping of neck
• Endovascular
therapy

12/31/2018 Neurosurgery UHWI 57

 MBBS REVIEW
• Rational for ICP TREATMENT
 Guidelines for Absence of Clinical
Herniation First Tier Therapy
1.Elevation of head of bed – option
-reduces ICP by enhancing venous outflow, but also reduces
mean carotid pressure- no net change in CBF. Controversial.
Rosner MJ and Daughton S: Cerebral perfusion presssure management in head injury. J
Trauma 30:933-941, 1990

2.Avoidance of jugular venous outflow

obstruction – option
-reduces ICP by enhancing venous outflow
3.Control of body temperature – option.
Hyperthermia contributes to elevated ICP and fosters secondary
brain injury mechanisms; maintain patient in normothermic
state.
-reduces metabolic rate
 Guidelines for Absence of Clinical
Herniation First Tier Therapy
4.Avoid hypoxia and hypotension - class II
-(SBI <90 mm Hg) normalize intravascular volume.Use pressors
if needed
Chestnut R. et al. the role of brain injury in determining outcome
from severe head injury. J Traurma. 34: 1993
5.Sedation – option
-reduces elevated sympathetic tone and HTN induced by
movement, tensing abdominal musculature
6.Neuromuscular blockade- option
-Routine or prolonged use may be associated with increased
complications. Use for specific indications i.e. transport,
refractory ICP
 Guidelines for Absence of Clinical
Herniation First Tier Therapy
7.Seizure prophylaxis - Standard/Class I
(Decrease acute seizures but no effect on late seizures)
Temkin N., et al. A randomized, double-blind study of phenytoin
for the prevention of post-traumatic epilepsy. N Engl J Med. 323:
1973.

8.ICP and CPP (Cerebral Perfusion Pressure )

CPP should be maintained at a minimum of 70 torr
Changarris D,. Et al. correlation of cerebral blood flow,
intracranial pressure and Glasgow Coma Scale to outcome. J
Trauma. 27: 1997.
(Narayan R. J Neurosurg 1998. Valadka A 1999)
 Guidelines for Absence of Clinical
Herniation First Tier Therapy
9.CSF drainage – option
Significant retrospective analysis confirms that CSF drainage
can lower elevated ICP by decreasing intracranial volume

10.Mannitol - class II/guideline

-Expands plasma volume, increases serum tonicity, may
improve rheologic properties of blood (0.25 g/kg to 1g/kg,Osm <
320)

• Schwartz M,and Tator C., et al. The University of Toronto Head Injury
Treatment Study: A prospective randomized comparison of
pentobarbital and mannitol. Can J Neurol Sci. 11; 1984.
Severe Head Injury Treatment
Flow Chart
Clinical Evidence of Herniation
-Decreasing level of consciousness
-Deteriorating exam
-Lateralizing Findings

YES NO
Guidelines - Clinical Herniation Guidelines - Absence of Clinical Herniation
First Tier Therapy
Second Tier Therapy

Atkinson JD
 Guidelines for Absence of Clinical
Herniation Second Tier Therapy
1.Hyperventilation to Pco2 < 30mmHg
Standard - Avoid in first 5 days
Guideline - Specifically avoid during first 24
hours
Option - May be used for brief periods
“Blow off” (reduce) pCO2, decrease CBF, and decrease
ICP
Muizelaar P., et al. Adverse effects of prolonged
hyperventilation in patients with severe head injury. A
randomized clinical trial. J Neurosurg. 75: 1991.
2.Hypertensive therapy (use of pressor agents)
Option - Mild to Moderate may lower ICP
 Guidelines for Absence of Clinical
Herniation Second Tier Therapy
3.Hypothermia
option - Lowers ICP and ? Decrease infarct size
(No improvement in outcome Guy C 1999)
4.Decompressive craniectomy/lobectomy
option - improved outcome in selected patients
Guerra, Gaab et al J Neuralsurg 1999

5.Barbiturate ICP control

Guidelines. not for prophylaxis
GCS 4-8 Refractory IC-HTN
 Guidelines for Absence of Clinical
Herniation Second Tier Therapy
Glucocorticoid therapy
Standard - no decrease in ICP
no improvement in outcome
(Braakman R., et al. Megadose steriods in severe head injury. J Neurosurg. 58:
1983
Cooper R., et al. Dexamenthasone and severe head injury. A prospective
double-blind study. J Neurosurg. 51: 1979.)
Nutrition
Guideline - 140% RME non-paralyzed
- 100% RME paralyzed
Begin Day # 3
15% calories as protein by Day # 7
Clifton L., et al. Enternal hyperalimentation inhead injury. J Neurosurg. 62: 1985.