Back to top. Get to Know Us. English Choose a language for shopping. Audible Download Audio Books. Alexa Actionable Analytics for the Web. Shopbop Designer Fashion Brands. The UC Neurotrauma Center will coordinate care with specialists in many fields, including vestibular therapists, optometrists, speech pathologists, neurologists and others. After a patient is discharged home they will need constant supervision for the next hours from a loved one to watch for changes. Recovery will happen over a few weeks but can take up to a few months. Patients are encouraged to go easy on themselves as they recover.
Patients with a severe TBI often have multiple areas of primary brain injury and are at increased risk of secondary injury. The inflammatory response of a brain injury causes extra fluid to collect in the brain in an attempt to heal the injury. In other areas of the body, swelling edema is a good response, but it can be dangerous in the brain where space is limited by the skull.
This swelling happens gradually and can occur up to a week after the primary injury. Nurses and doctors in the neuroscience intensive care unit NSICU will monitor patients closely for signs of cerebral edema, or swelling of the brain tissue, by analyzing their responsiveness and exam results. Neuromonitoring includes monitoring brain activity and often involves placing a monitor inside the brain.
Neuromonitoring allows us to detect and treat brain pressure increases and brain oxygen level decreases. Surgery is sometimes necessary to repair skull fractures, repair bleeding vessels or remove large blood clots. These procedures help transition their care from the Neuroscience Intensive Care Unit to an area that will focus on weaning patients from a breathing machine and starting more therapy sessions. These procedures are not necessary for every brain injured patient, however if required they can safely be removed once a patient no longer needs their help for recovery.
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The recovery process varies by patient and can be prolonged. Often after a severe TBI a patient may be different from the way they were before the injury. There are local patient support groups that might make this transition easier. The latest physiologic monitoring is available, including cerebral oxygenation, continuous EEG and minimally invasive cardiac output. The NSICU also houses its own portable CT scanner which allows on-demand imaging inside the unit while eliminating the risk of moving critically ill patients to another floor.
Our neurointensivists are experts in the relatively new specialty known as neurocritical care. Patients in the NSICU typically have experienced a significant neurological event, such as a stroke or traumatic brain injury, and most have undergone neurosurgery. Because families are seldom prepared for the crisis that brings a loved one to the NSICU, they too require support and information.
Thus, placement of ventriculostomy should be considered early in the setting of anticipated brain swelling that does not require more major forms of decompression, such as those discussed below. They also can be used to supplement ventriculostomy readings when continuous CSF drainage is chosen for management, to take advantage of their capacity for reliable, continuous ICP measurement; the authors typically use a fiberoptic parenchymal monitor in children requiring continuous ventriculostomy drainage as an extra means of following pressures. While these are general principles, the exact efficacy of these approaches in children awaits further prospective study [ 61 ].
While some contused tissue is best removed by surgical evacuation, other contusions can be handled by decompressive surgery, leaving the tissue largely intact. If an entire hemisphere or bifrontal region can be expected to swell, either because of prior evacuation of a subdural hematoma—a lesion often associated with hemispheric brain swelling—or because of large contusions, decompressive craniectomy can be performed.
This has been employed with increasing frequency in the past decade and sometimes enables preservation of parenchyma during the period of maximal swelling while minimizing the risk of progressive compromise of adjacent tissue. Multiple studies have demonstrated that decompressive craniectomy, either bifrontal or, more often, unilateral, is associated with best outcomes if performed early in the course of predicted swelling [ 62 , 63 , 64 , 65 ]. Similar decompression can be accomplished in the setting of cerebellar contusions as well as large penetrating lesions such as some gunshot wounds in which significant tissue sparing may be anticipated.
However, when physiologic damage results from hypoxic-ischemic injury or other diffuse metabolic insult, or when herniation infarcts have already occurred, decompression may be life-saving but with poor neurologic outcome [ 65 ]. Additionally, late complications, including shunt-dependent hydrocephalus and bone resorption, occur with high frequency after decompressive craniectomy.
Thus, families need to be informed that multiple surgeries may be needed during what can be a long and intervention-laden recovery [ 62 , 66 ]. Despite these cautions, decompressive craniectomy has come to be used more frequently in both adults and children and is considered a justified option in circumstances of swelling-prone lesions that can be anticipated to cause progressive compromise of potentially salvageable tissue that might be avoided by this surgical maneuver [ 67 ]. For initial imaging, reduced radiation head and extracranial CT protocols exist, and these typically are sufficient for initial assessment and triage.
For further assessment of significant brain or spine injuries, MRI has more sensitivity and specificity for parenchymal assessment and can often give additional information about acute injury as well as evolving pathophysiology of injury that might be used to direct further management. New, rapid MRI sequences can often be performed safely, limiting the amount of time that the patient is in the imaging suite.
MRI is used increasingly both in the acute setting emergency department and as the follow-up imaging modality of choice in pediatrics [ 72 ]. The National Institutes of Health, along with other government agencies, sponsored the creation of common data elements for traumatic brain injury, with CT and MRI parameters for children, which can be used to guide imaging decisions, protocols, and interpretation [ 73 , 74 ]. There remain few high-level, evidence-based recommendations for the acute care of children with severe TBI.
The increased use of advanced MRI imaging modalities may allow for more tailored, pathoanatomic management of head injury in children. Duhaime and Murphy declare no conflicts of interest relevant to this manuscript. This article does not contain any studies with human or animal subjects performed by any of the authors.
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Skip to main content Skip to sections. Advertisement Hide. Download PDF. Update in Pediatric Neurotrauma. Part of the following topical collections: Topical Collection on Pediatric Trauma. Purpose of Review Globally, the incidence of traumatic brain injury TBI is increasing with significant costs and consequences to society. Summary The increased use of MRI and other advanced imaging modalities may help direct pathoanatomic classification and individualized treatment of head injury in children. General Principles The main goal of surgery is to relieve dangerous tissue shifts and, less commonly, to decrease globally increased intracranial pressure.
Patients presenting with extraaxial hemorrhages—epidural and subdural hematomas—are evaluated via the initial assessment algorithm Fig. It should be kept in mind that epidural hematomas in infants and young children most often occur from low-height falls, and that they may progress rapidly or, in the case of venous hemorrhages, more slowly [ 59 ]. Mass lesions causing immediate or potential compromise are best evacuated before irreversible injury occurs to adjacent tissue [ 59 ]. Mass lesions close to sites in which tissue shifts are more likely to cause compromise of vessels or of critical tissue—such as those in the temporal region near the tentorial incisura and brainstem, those near the falx which can cause subfalcine herniation and compromise of the anterior circulation, and those in the posterior fossa which can cause brainstem compression or compromise of the posterior arterial circulation via herniation through the foramen magnum—are all managed with a high index of suspicion for potential deterioration.
These lesion scenarios may prompt prophylactic surgical intervention to decrease the chance of sudden irreversible decline even before herniation is imminent. Open image in new window Open image in new window. Intracranial Pressure Monitoring and Ventriculostomy The goal of intracranial pressure monitoring is to supplement the continuous evaluation of the head-injured patient beyond what serial neurologic exams and serial imaging can provide.
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Brain Swelling and Decompressive Craniectomy While some contused tissue is best removed by surgical evacuation, other contusions can be handled by decompressive surgery, leaving the tissue largely intact. Conclusions There remain few high-level, evidence-based recommendations for the acute care of children with severe TBI. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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Neurotrauma: Managing Patients with Head Injury
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