Ischemic brain damage in traumatic brain injury (TBI): Extradural, subdural, and intracerebral hematomas and cerebral contusions

Mendelow, AD

doi:10.1017/CBO9780511659096.051

Ischemic brain damage in traumatic brain injury (TBI): Extradural, subdural, and intracerebral hematomas and cerebral contusions

Lookup NU author(s): Emeritus Professor David Mendelow

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Abstract

© Cambridge University Press 2014. The management of patients with severe traumatic brain injury (TBI) is very similar to that of patients with ischemic brain damage from stroke. Ever since Graham et al. showed that the incidence of ischemic brain damage in head-injured patients who died was consistently near 90% (1,2), it has been known that the prevention and treatment of ischemia should be an important component of the management of severe TBI. These patients are cared for in the same critical care environment as patients with ischemic stroke, often in intensive care units (ITUs) and in high-dependency units (HDUs) run by neuro-intensivists and neurosurgeons. Similar arguments can be made for including a description of the care of patients with subarachnoid and intracerebral hemorrhage in a book of this nature. In all these four conditions brain ischemia is one of the main underlying causes of neuronal damage (3-6). This fact has been one of the main reasons for undertaking experimental and clinical trials of neuroprotective agents in these four conditions. Epidemiology of head-injured patients Head injury affects ten times more people than stroke. Although the vast majority of these injuries are minor or mild, any one of them can later give rise to an extradural hematoma and it is impossible to predict with any certainty, in advance, which patient with a mild head injury will deteriorate. Many of the mild injuries do not even attend hospital, so data can only be based on attendees at emergency departments. Only 0.3% of all head-injured patients that present to emergency departments will have an extradural or a subdural hematoma, so that there is a real problem in recognizing those few who need immediate treatment. That is why the UK NICE Guidelines for the triage of head injury are so important. Their scientific foundation is based on the Canadian CT head rule (7) which was re-evaluated in a second set of patients (8) and found to have very high sensitivity and specificity for diagnosing clots that required neurosurgical evacuation. When compared with other diagnostic rules, the Canadian CT head rule produced the greatest reduction in the number of CT scans without missing a single surgical case (Fig. 36.1 (9)). Data that have been collected about head-injured populations depend very much on the population base from which they are gathered.