This topic is concerned with management guidelines of traumatic cerebral contusions

Recommendations:

Initial Management:

▪️ Avoid hypoxia.

o   Strong recommendation.

▪️   Avoid hypotension.

o   Strong recommendation

▪️  Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2. (if not available refer to a tertiary center)

o   Strong recommendation.

▪️   Brain imaging (CT) must be available and repeated as much as needed. (if not available refer to a tertiary center)

o   Strong recommendation.

▪️   We recommend ICU admission and close neurological observation with CT monitoring for the development and progression of brain stem compression. ( if not available refer to a tertiary center)

o   Strong recommendation.

▪️  Follow-up head CT scan within 6 to 8 hours following brain injury must be obtained.           ( if not available refer to a tertiary center)

o   Strong recommendation.

▪️  The availability of equipped neurosurgery operating room is essential for management.    (if not available refer to a tertiary center)

o   Strong recommendation.

➡️Conservative management:

▪️ We recommend seizures prophylaxis in patients with frontal and temporal lobe cerebral contusions

o   Strong recommendation

➡️Mechanisms to reduce ICP is divided into 3 tiers:

If elevation of ICP is confirmed clinically and/or radiologically or ICP  monitoring (if available) the priority is control of ICP:

Tier 0

Head elevation and the same measures in the initial management

o   Strong recommendation

Tier 1

▪️     We recommend mannitol for control of IC-HTN (within hospitals).

▪️  Intermittent boluses may be more effective than continuous infusion

▪️  Effective doses range from 0.25–1 gm/kg body weight

▪️  Avoid hypotension (SBP < 90mm Hg) which may result from the diuretic effect of mannitol, which can lead to decrease circulating fluid volume

o   Strong recommendation.

▪️    Try to adjust partial pressure of carbon dioxide (PaCO2) at lower ranges of normal val­ues (i.e. 35-38 mmHg).

o   Conditional recommendation.

Tier 2

▪️    Consider the use of neuromus­cular blocking agents (NMBAs).

o   Conditional recommendation

▪️    We recommend targeting a cerebral perfusion pressure (CPP) of  60-70mm Hg

o   Strong recommendation.

▪️   Try to adjust the partial pressure of CO2 at 32-35 mmHg (mild hypocapnia)

o   Conditional recommendation

Tier 3

▪️   High-dose barbiturate therapy may be used for IC-HTN refractory to maximal medical and surgical ICP-lowering therapy. Patients should be hemodynamically stable before and during treatment.

o   Conditional recommendation

➡️Surgical intervention: surgery may be indicated in the following indications:

▪️    Progressive neurological deterioration referable to the TICH, medically refractory IC-HTN

▪️   Signs of mass effect on CT

▪️   TICH volume > 50cm3 cc or ml

▪️  GCS = 6–8 with frontal or temporal TICH volume > 20 cm3 with midline shift  ≥ 5mm  and/or compressed basal cisterns on CT

o   Conditional recommendation

➡️Types of surgery:

▪️   If the contusion with the surrounding edema cause mass effect according to the site you may do frontopolar lobectomy or tempropolar lobectomy

o   Conditional recommendation

▪️  If the hemorrhagic contusion coalesced to form intracerebral hematoma you may do evacuation

o   Conditional recommendation

▪️   Decompressive craniotomy with duroplasty may be indicated in cases in which the usual mechanisms to reduce the ICP are uneffective.

o    Conditional recommendation

This topic is concerned with management guidelines of depressed skull fractures.

➡️Recommendations

Initial Management: (as a part of initial TBI management)

▪️ Avoid hypoxia.

² Strong recommendation.

▪️ Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2.

² Strong recommendation.

▪️ Avoid hypotension.

² Strong recommendation.

▪️ We recommend ICU admission and close neurosurgical observation with CT monitoring if needed (if not available, refer to a tertiary center). 

² Strong recommendation. 

▪️ The availability of equipped neurosurgery operating room is essential for management (if not available, refer to a tertiary center). 

² Strong recommendation.

▪️ Anti-seizure medications (ASM):

Consider the use of ASMs (e.g., phenytoin, valproate, or carbamazepine) to decrease the incidence of early PTS (within 7 days of TBI).

² Conditional recommendation

➡️Definitive management

▪️  surgical management may be indicated in Patients with open (compound) depressed cranial fractures (evidenced by CT) with:

▪️   Depression greater than the thickness of the cranium.

▪️   Clinical (CSF leak / hernia cerebri) or radiographic (pneumocephalus) evidence of dural violation.

▪️   Underlying significant intracranial hematoma or hemorrhagic contusions.

▪️ Frontal sinus involvement.

▪️  Gross cosmetic deformity.

▪️   Wound infection.

▪️  Dural venous sinuses compromise impeding blood flow as evident in 3D CT and MRV brain.

² Conditional recommendation

▪️  Surgery may be indicated for closed depressed skull fractures if:

–  the depression is causing a focal deficit through pressure on the adjacent cortex.

–  the closed fracture is depressed and causing a cosmetic abnormality, for example fractures over the forehead.

² Conditional recommendation

▪️  Surgery (if indicated) is recommended as soon as possible after stabilization and coverage of umbrella of antibiotics.

²  Strong recommendation

▪️  patients with open (compound) depressed cranial fractures may be treated conservatively in the absence of the previously mentioned surgical indications.

² Conditional recommendation