52 Other Penetrating Intracranial Trauma

Case 52 Other Penetrating Intracranial Trauma

Domenic P. Esposito

Clinical Presentation

A 27-year-old man presents to the emergency room (ER) with a history of being struck in the head with a blunt object.

The initial Glasgow Coma Scale (GCS) in the ER is 15.

There are no focal neurologic deficits.

A computed tomography (CT) scan is obtained and shown in Fig. 52.1.

Questions

What would be your initial work-up and management plan?

Other than radiologic studies, what other studies would be indicated?

Outline your plan of care at this point.

Interpret the magnetic resonance imaging (MRI) scan shown in Fig. 52.2.
Following imaging and laboratory studies, the patient develops a right hemiparesis and a speech disturbance. What is likely the cause of these findings?
What would be your management plan at this time?
What position would you use for the operative approach?
What special arrangements would you make preoperatively?
Assuming the blunt force trauma produced a very large, somewhat stellate laceration, how would you plan your skin flap?
What nontypical neurosurgical devices might be of value in this case?
Would you give your anesthesiologist any particular instructions?

You look at the anesthesiology monitor before beginning (which is usually a good idea) and see that the patient has a pulse of 120, a systolic blood pressure of 90, and the central venous pressure (CVP) line is not connected to a monitor.
What is your next step in the management of this patient?
The patient is now stable and you open the skin flap revealing the underlying depressed skull fracture, there is no excessive bleeding at this point. Would you begin removing depressed fragments, or would you plan a bone flap (if so, describe the flap)?
Before beginning the bone work would you consider harvesting any tissue? If so, what would be some of your choices?
While performing your bony removal, copious bleeding begins from a disrupted sagittal sinus. What is your next step in management?

Fig. 52.1 Computed tomography scan of the head with (A) scout image, (B) axial, and (C) sagittal views, showing depressed skull fracture in the occipital area.

Fig. 52.2 Magnetic resonance imaging (MRI) of the brain with coronal T2-weighted (A) and sagittal T1-weighted (B) images showing the depressed skull fracture with underlying brain contusions. Magnetic resonance venography (C) showing disruption of the posterior portion of the superior sagittal sinus.

Answers

What would be your initial work-up and management plan?

Because the patient is currently stable, laboratory studies should be obtained including a complete blood count, electrolytes, type and screen, and coagulation profile.
The patient should be kept in a monitored bed while further treatment is planned.
Prophylactic anticonvulsants may be given.

Other than radiologic studies, what other studies would be indicated?

An urgent (STAT) MRI with MR venography (MRV) should be obtained; if MRV is not available a CT venogram (CTV) or angiography with late venous phases would be acceptable.

Outline your plan of care at this point.

Because it is highly unlikely that this lesion can be managed conservatively, preparations for surgical treatment should be initiated.

Interpret the MRI scan shown in Fig. 52.2.
- The MRI reveals a large subgaleal hematoma with compromise of the superior sagittal sinus and cortical contusions.
Following imaging and laboratory studies, the patient develops a right hemiparesis and a speech disturbance. What is likely the cause of these findings?
- The patients’ neurologic deterioration is most likely due to compromise of the sagittal sinus.
What would be your management plan at this time?
- This patient needs to be taken to the operating room for elevation of the depressed fracture and possible repair of the sagittal sinus.¹
What position would you use for the operative approach?
- The patient should be positioned prone with the head slightly elevated.
- Mayfield three-point rigid fixation may be used.
What special arrangements would you make preoperatively?
- Preoperative preparation should include
  - Type and cross-match at least 2 units of packed red blood cells
  - Precordial Doppler probe
  - Central line and arterial line
  - Preoperative antibiotics and anticonvulsants
- This case can very easily turn into a surgical disaster. You should arrange to have competent experienced surgical hands other than your own to assist you.
Assuming the blunt force trauma produced a very large somewhat stellate laceration, how would you plan your skin flap?
- The scalp flap was partially made by the assailant, but extension of the stellate laceration in both anteroposterior and lateral directions for good exposure is mandatory.
What nontypical neurosurgical devices might be of value in this case?
- Some nontypical neurosurgical devices that might be of help are Fogarty catheters, cell savers, and vascular grafts.
Would you give your anesthesiologist any particular instructions?
- The anesthesiologist needs to be aware of the possibility of extensive rapid blood loss and the blood needs to be ready in the room prior to bone removal.
What is your next step in the management of this patient?
- After gently reminding anesthesia of the tenuous state of the patient, insist that the patient be adequately transfused, monitored, and stabilized prior to proceeding with the procedure.
- Ensure CVP is monitored.
- Ensure the patient is being treated for shock: fluids, blood transfusion, and pressors if necessary.
The patient is now stable and you open the skin flap revealing the underlying depressed skull fracture, there is no excessive bleeding at this point. Would you begin removing depressed fragments, or would you plan a bone flap (if so, describe the flap)?
- A circular bone flap around the depressant area with multiple burr holes on either side of the sinus as well as lateral to the fragments is mandatory.2,3
Before beginning the bone work would you consider harvesting any tissue? If so, what would be some of your choices?
- Harvesting a piece of temporalis fascia to assist with possible reconstruction may be helpful.
While performing your bony removal, copious bleed ing begins from a disrupted sagittal sinus. What is your next step in management?
- Quickly remove all bone over the sinus. If proper preparations have been made, this can be hastily performed.^3,4
- Establish control of the sinus with digital pressure and assess the damage.
- In this case, a large thrombus was encountered in the distal sinus (which was probably the cause of the patient’s neurologic decline) and a 5 cm lateral laceration of the sinus was able to be repaired primarily. The sinus remained intact. This patient eventually made a complete recovery.⁵