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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 123-130

Surgical management of closed-head injury


1 Department of Neurosurgery, Ministry of Health, Sharqya
2 Department of Neurosurgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt

Date of Submission24-Jan-2020
Date of Decision26-Jan-2020
Date of Acceptance06-Feb-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
MBBch, Ass. Prof. Lecturer Ahmed Swailam Mohamed
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_8_20

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  Abstract 


Purpose To evaluate cases of closed-head injury regarding clinical picture, investigations, surgical management, outcome, and prognosis.
Patients and methods A prospective study was conducted on 22 surgical cases of the 62 patients with closed-head injury. Many preoperative factors were studied to evaluate the prognosis of such cases.
Results Among 62 cases, 22 cases were subjected to surgery. Overall, 17 cases of extradural hematoma were subjected to surgery, whereas rest were associated with subarachnoid hemorrhage and acute subdural hematoma.
Conclusion Early diagnosis and management of primary lesion of closed-head injury is very important to prevent secondary brain injury.

Keywords: computed tomography, Glasgow coma scale, post-concussion syndrome, traumatic brain injury


How to cite this article:
Mohamed AS, El Hendawy MM, Adel Ismail S. Surgical management of closed-head injury. Sci J Al-Azhar Med Fac Girls 2020;4:123-30

How to cite this URL:
Mohamed AS, El Hendawy MM, Adel Ismail S. Surgical management of closed-head injury. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Jul 12];4:123-30. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/123/288290




  Introduction Top


Closed-head injury is a type of traumatic brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people [1]. Head injury is classified according to severity, outcome, and prognosis, where there are other forms of classifications such as primary and secondary, as well as focal and diffuse classifications [2].


  Patients and methods Top


A prospective study was conducted on 62 patients who came to Luxor International Hospital and Al-Zahraa University Hospital from November 2018 to November 2019. Only 22 (35%) cases had surgery, whereas the rest 65% had conservative management. Written consents were taken from all patients.

The patients included in the study had closed-head injury, and some of them were subjected to surgical interference. They comprised patients with extradural hematomas (EDH), patients with subdural hematomas (SDH), patients with cerebral contusion, patients with cerebral hemorrhage, patients with interventricular hemorrhage, and patients with subarachnoid hemorrhage (SAH).

The patients excluded from the study were the patients with open-head injury, and closed-head injury but treated conservatively.

All patients were subjected to first-aid measures, full general and neurological examination, primary survey [abdominal ultrasound, pelvis radiograph, chest radiograph, and computed tomography (CT) brain], carful follow-up of the patient and his/her neurological status, scheduled CT brain for the patients for follow-up according to his/her neurological condition, and finally surgical intervention for the indicated cases, which can be done by one of two procedures: craniotomy mainly for EDH and acute SDH and burr-hole for subacute SDH. Patients were asked to come back to the hospital if they experienced any of the following symptoms: headache, vomiting manifestation of ↑ICT (Intra Cranial Tension), newly developed weakness, and convulsion. Otherwise, scheduled follow-up of the patients was done in the outpatient clinic (OPC) at 1 week after discharge, which was done radiologically and clinically.


  Results Top


Of 62 cases of closed-head injury, 22 surgical cases were admitted during the period of November 2018–June 2019.

Preoperative and postoperative Glasgow coma scale and pupil reaction distribution of the studied cases

In this part of study, the patients were divided into two main groups: preoperative and postoperative groups. Each group is divided into six subgroups, as shown in [Table 1]. The postoperative group had only two subgroups.
Table 1 Preoperative and postoperative Glasgow coma scale outcome

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On the contrary, according to pupil reaction, patients were divided into two groups: preoperative and postoperative groups. Each group was divided into two subgroups: reactive pupil and dilated fixed pupil, as shown in [Table 2]. The postoperative groups were as follows: 21 (95.5%) patients with reactive pupil, and only one (4.5%) patient with dilated fixed pupil. This case was represented by massive EDH and brain edema, leading to brain herniation and death.
Table 2 Preoperative and postoperative pupil reaction outcome

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Post-concussion syndrome

Post-concussion syndrome is positive in 19 (86.36%) cases of the studied 22 surgical cases in the form of headache [18 (81.81%) cases], vertigo [15 (68%) cases], loss of consciousness (LOC) at the time of trauma [19 (86.36%), including 15 with LOC ≤10 min, and four with LOC ≥10 min, as shown in [Table 3], and dizziness [20 (90.90%) cases].
Table 3 Period of loss of consciousness at time of trauma for cases of post-concussion syndrome

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Follow-up of post-concussion syndrome for each parameter of the previous groups was as follows: in the headache group, the symptoms in 12 (66.66%) patients lasted for 2 months and then improved and in six (33.33%) patients lasted for 6 months and then improved. In the vertigo group, 14 (93.33%) patients improved after 3 months, whereas only one (6.6%) patient took more than 6 months to improve. In the dizziness group, 15 (75%) patients improved after about 3 months, whereas five (25%) patients improved after 6 months.

Of the previous results, we found that there were some relations among the nonimproved patients as follows.

All patients with headache, dizziness, and vertigo experienced long periods of LOC at the time of trauma (≥10 min) and took longer period of time for recovery than those of the same groups with shorter time of LOC.

Neurological deficit

Regarding neurological deficit [four (18.18%) cases], one of them had grade 4 right-side weakness and the rest varied between grades 2 and 3 left-side weakness. Regarding seizures [eight (36.3%) cases], seven (87.5%) patients improved in the form of ↓antiepileptic drugs doses after about 6 months, whereas one (12.5%) patient did not improve, as the case was still on antiepileptic drugs.

The patient with non-improved weakness presented with huge EDH compress the matter area came late to our hospital 6hrs after trauma (delayed surgical manner).

Radiological finding

Most lesions were EDH [17 (77.27%) patients] and then SDH [five (22.72%) cases]. The studied 22 cases were subdivided as follows: three (60%) patients had acute SDH and two (40%) patients had subacute SDH. EDH were associated with Sub Arachnoid Hemorrhage (SAH) in (four patient i.e. 23.5 %) three of these four patients. EDH was also associated with brain edema in 10 (58.8%) patients, and midline shift in six (35.3%) patients of the studied 17 cases.

SDH was associated with SAH in two (40%) patients, brain edema in one (20%) patient, and midline shifts in one (20%) patient of the studied five cases.

SAH presented in suprasellar cistern in four (18.18%) patients (all with EDH cases), and in the sylvian fissure in three (13.63%) patients, comprising two of them with SDH and only one with EDH.

Midline shift was found in seven (31.81%) of the studied 22 cases, which were distributed as follows according to their amount: 3–4 mm in three (42.85%) patients, 6–8 mm in three (42.85%) patients, and 8–11 mm only in one (14.28) patient.

Of the previous data, we found the following relations: among the cases associated with SAH midline shift and brain edema, their Glasgow coma scale (GCS) ranged between 13 and 8.

Postoperative follow-up CT findings were as follows: all SDH CTs were free, whereas all follow-up CTs of EDH cases were free except, one case, which died 3 days after operation. Moreover, SAH follow-up CTs showed improvement after ∼3 months, except three patients with midline shift of more than 6 mm, who took more than 6 months to improve.

Surgical procedures

Of the 22 studied cases, the majority of them submitted to craniotomy [20 (90.90%) patients], where 17 (85%) patients were EDH, whereas three (15%) patients were acute SDH. On the contrary, two (9.09%) patients were subacute SDH operated by burr-hole technique: one patient was done by single burr-hole technique and one case was done by double burr-hole technique ([Table 4]).
Table 4 Craniotomy and Burr-hole techniques distribution

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Survival and mortality rate outcome

Of our 22 studied cases, 21 (95.5%) cases survived, whereas one (4.5%) case died (Chart 1). One of the causes of death of the patient was severe midline shift, which was more than 8.5 mm in this case as well as massive brain edema.



Illustrative cases

Case 1

A 32-year-old male patient with history of head trauma owing to having been kicked by an animal (Buffalo). He experienced a period of LOS of about 5 min. He came to the emergency room (ER) with GCS 14/15, repeated vomiting, and both pupils were regular rounded and reactive. First aid was done to him, and full laboratory examination and arterial blood gas revealed abnormalities (PCO2:↑ pH:↓). CT brain was done which revealed a massive right frontal EDH ([Figure 1]) with more than or equal to 5 mm midline shift and then the patient was prepared for surgery. Evacuation of hematoma was done by craniotomy procedure.
Figure 1 Preoperative CT scan right frontal massive EDH. CT, computed tomography; EDH, extradural hematoma.

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After 24-h follow-up, CT was done ([Figure 2]) showing complete evacuation and no recollection. Two days later, the patient was discharged fully conscious. One month later, the patient visited our hospital OPC with post-concussion syndrome in the form of headache and amnesia, which lasted for 3 months.
Figure 2 Follow up CT scan 24 h post right frontal massive EDH evacuation. CT, computed tomography; EDH, extradural hematoma.

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Case 2

A 35-year-old male patient presented with history of 4-h duration of head trauma. There was no History (Hx) of fits nor LOS. He came to the ER with GCS 13/15, repeated vomiting, O/E both pupils are regular rounded and reactive, and right-side weakness 3/5. First aid was done to him. Full laboratory examination and arterial blood gas were normal. CT brain was done, which revealed left frontotemporoparietal acute SDH ([Figure 3]) with more than or equal to 6 mm midline shift, and then the patient was admitted to the Neurosurgery Intensive Care Unit. The patient was prepared for surgery. Evacuation of hematoma was done for the case by craniotomy.
Figure 3 Preoperative CT scan left frontotemporoparietal acute SDH. CT, computed tomography; SDH, subdural hematoma.

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After 24 h, follow-up CT was done ([Figure 4]), showing no recollection, midline shift decreased, and weakness improved. Few days later, the patient was discharged fully conscious to complete his medication at home. One month later, the patient visited our hospital OPC, where weakness was still found (2/5) and physiotherapy was recommended, with follow-up every 2 weeks. Three months later, weakness improved.
Figure 4 Follow up CT scan 24 h post left frontotemporoparietal acute SDH. CT, computed tomography; SDH, subdural hematoma.

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  Discussion Top


In the present study, which lasted around 12 month of practical research, of 62 cases, 22 (35%) of our hospital ER-transferred cases needed surgical interference, and the rest were managed conservatively.

According to GCS, the patients were divided into two main groups: preoperative and postoperative groups. Each group was divided into six subgroups. The postoperative group had only two subgroups.

On the contrary, according to pupil reaction, patients were divided into two groups: preoperative and postoperative groups (as above). Each group was divided into two subgroups: reactive pupil and dilated fixed pupil, as shown in [Table 2]. The postoperative groups were as follows: 21 (95.5%) patients with reactive pupil, and only one (4.5%) patient with dilated fixed pupil. This case was represented by massive EDH and brain edema, which led to brain herniation and death.

Yang et.al. [3] reported that patients were divided into three groups according to their GCS score at admission (GCS 3–5, GCS 6–9, GCS >9), and the frequency of complications among the three groups was compared (61.8% for GCS 3–5, 38.5% for GCS 6–9, and 35.7% for GCS >9). The majority of the cases had a GCS ≤ 8 (95.5%), while cases of GCS ≥8 (12.9%), whereas cases of GCS less than or equal to eight (95.5%).

By comparison between Yang and colleagues and the present study, the percentage of less complicated cases in the present study was 95.5% whereas in the study by Yang and colleagues was 12.9%.

According to pupillary reaction, in the present study, 4.5% had abnormal and the rest had normal reactions, whereas in the study by Özsaraç et al. [4], 14.2% of cases had abnormal pupils whereas the rest were normal.

The results suggested that patients with severe head trauma at admission had a significantly higher incidence rate of low GCS as well as complications.

Post-concussion syndrome was positive in 19 (86.36%) cases of the studied 22 cases in the form of headache [18 (81.81%) cases], vertigo [15 (68%) cases], LOC at the time of trauma [19 (86.36%) cases, comprising 15 (%) patients with LOC ≤10 min, and four (%) with LOC ≥10 min], and dizziness [20 (90.90%) cases].

According to neurological deficit [four (18.18%) cases], one of them had grade 4 right-side weakness and the rest varied between grades 2 and 3 left-side weakness. Regarding seizures [eight (36.3%) cases], seven (87.5%) patients improved in the form of ↓antiepileptic drug doses after about 6 months, whereas one (12.5%) patient did not improve as the case was still on antiepileptic drugs.

The patient with nonimproved weakness presented with huge EDH compression, and the matter area came late to our hospital 6 h after trauma (delayed surgical manner).

Jourdan et al. [5] reported that regarding headache (36%), 40% of them lasted for 2 months and then improved; regarding vertigo (58.3%), 80.5% improved after about 3 months; regarding dizziness (70%), 90% improved after about 3 months; regarding neurological deficit (30%), 60% totally improved after about 6 months; and regarding seizures (14.7%), 80% of them improved after about 6 months. Blennow et al. [6] reported that 80–90% of cases represented with post-concussion syndrome. Falk [7] study reported that 23% of post-concussion syndrome cases were fully recovered in the follow-up and 22% lasted for 1 month. The study by Cohen [8] stated that all patients with headache, dizziness, and vertigo experienced long period of LOC at the time of accident, which made them lasted longer period of time for recovery than those of the same groups but with shorter time of LOC, which the same as the present study. The study by Satz [9] showed that nonimproved weakness and seizure conditions were owing to age only, and this differs with respect to the present study, as mention previously.

According to Radiological findings The majority of Lesions were Extra Dural Hematoma (EDH) (17 patients i.e. 77.27 %) then Sub Dural Hematoma (SDH) (five cases i.e. 22.72 %) of the studied 22 cases were divided as follows: (3 patients i.e. 60 %) were Acute SDH and two (40%) patients were subacute SDH. EDH were associated with SAH in four (23.5%) patients three of these four patients. EDH were also associated with brain edema in 10 (58.8%) patients, and midline shift in six (35.3%) patients of the studied 17 cases.

SDH was associated with SAH in two (40%) patients, brain edema in one (20%) patient, and midline shifts in one (20%) patient of the studied five cases.

SAH presented in suprasellar cistern in four (18.18%) patients (all with EDH cases), and in the sylvian fissure in three (13.63%) patients (two of them with SDH and only one with EDH).

Midline shifts were found in seven (31.81%) patients of the studied 22 cases, which were distributed as follows according to their amount: 3–4 mm in three (42.85%) patients, 6–8 mm in three (42.85%) patients, and 8–11 mm only in one (14.28%) patient.

Of the previous data, we found the following relations: cases associated with SAH midline shift, and brain edema, their GCS ranged between 13 and 8.The study by Özsaraç et al. [4] reported that most hemorrhages were cases of EDH (45%) and then cerebral contusion cases (10%). The study by Waganekar et al. [10] stated that follow-up of CT findings was as follows: in 80% of SDH cases, follow-up CTs were free, whereas all follow-up CTs of EDH cases was free, as well as SAH follow-up CTs took about 4 months to show improvement, except the cases with midline shift of more than 11 mm, which died.

Postoperative follow-up CT findings were as follows: all SDH CTs were free, whereas all follow-up CTs of EDH cases were free except, one case, which died 3 days after operation. Moreover, SAH follow-up CTs took about 3 months to show improvement, except three patients with midline shift of more than 6 mm, and they took more than 6 months to improve.

According to survival and mortality rates outcome of our 22 studied cases, 21 (95.5%) cases survived, whereas one (4.5%) case died. Of the previous data, one of the causes of deaths was severe midline shift, which was more than 8.5 mm in this case, as well as massive brain edema.

The study by Yang et al. [3] reported that the mortality rate was 23.1% of the studied cases. Jourdan et al. reported that about 10% of TBI cases, is responsible for the worse consequences, with 39% early mortality rates and 60% unfavorable outcomes [5]. Ann charlotte, study reported that 97% of conducted cases survived while the rest died [5]. Jennett, study reported that 97 % of conducted cases survived while the rest died [11].


  Conclusion Top


Early diagnosis and management of primary lesion of closed-head injury is very important to prevent secondary brain injury and to decrease mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ibrahim NG, Smith RJ, Margulies C. Physiological and pathological responses to head rotations in toddler piglets. J Neurotrauma 2010; 27:1021–1035.  Back to cited text no. 1
    
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Özsaraç M, Karcioglu O, Topacoglu H. Clinical indicators of traumatic brain injury and skull fracture in pediatric head trauma patients. Turk J Med 2009; 9:153–158.  Back to cited text no. 4
    
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Jourdan C, Bayen E, Pradat-Diehl P. A comprehensive picture of 4-year outcome of severe brain injuries. Results from the PariS-TBI study. Ann Phys Rehabil Med 2016; 59:100–106.  Back to cited text no. 5
    
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Falk AC. Head injuries in children, incidence, sequel, and informational needs, 2008, Karloniska Institute.  Back to cited text no. 7
    
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Cohen J. Statistical power analysis for the behavioral science. 2nd ed. Hillsdate, NJ: Lawerence Erlbaum Associates; 1988.  Back to cited text no. 8
    
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Satz P. Brain reserve capacity on symptoms onset after brain injury. Am Psychol Assoc 1993; 7:273–295.  Back to cited text no. 9
    
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Waganekar A, Sadasivan J, Prabhu AS. Computed tomography profile and its utilization in head injury patients in emergency department, 2018.  Back to cited text no. 10
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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