eMedicine Specialties > Neurosurgery > Trauma

Closed Head Trauma: Differential Diagnoses & Workup

Author: Leonardo Rangel-Castilla, MD, Staff Physician, Division of Neurosurgery, University of Texas Medical Branch School of Medicine
Coauthor(s): Jaime Gasco, MD, Staff Physician, Department of Neurosurgery, University of Texas Medical Branch School of Medicine; Fadi Hanbali, MD, FACS, Associate Professor, Division of Neurosurgery, Department of Surgery, Texas Tech University Health Sciences Center; Associate Professor, Department of Orthopedic Surgery, Texas Tech University Health Sciences Center; Adjunct Professor, Departments of Neurosurgery and Orthopedic Surgery, Division of Neurosurgery, University of Texas Medical Branch; Paul Salinas, MD, Resident Physician, Department of Neurosurgery, University of Texas Medical Branch at Galveston
Contributor Information and Disclosures

Updated: Sep 22, 2009

Differential Diagnoses

Other Problems to Be Considered

Patients who arrive with a decreased GCS and normal findings on head CT scans may have another condition that needs to be considered. These include the following:

  • Acute ischemic stroke (within 24 h) that is not seen on head CT scan
  • Postictal state
  • Spinal cord injury
  • Intoxication or effects of illicit drug use
  • Prior medical conditions (Speaking with family members may help in differentiating acute from chronic conditions.)

Workup

Laboratory Studies

  • CBC count including platelet count
  • Blood chemistries
  • Prothrombin time (PT) or international normalized ratio (INR)
  • Activated partial thromboplastin time (aPTT)
  • Anticonvulsant (eg, phenytoin) level - For patients who have been previously loaded or who were previously on anticonvulsant medications to ensure therapeutic levels

Imaging Studies

CT scanning of the head is the criterion standard for patients with acute closed head injuries.15 A head CT scan is warranted, except for patients with only minor head trauma who are neurologically intact and not intoxicated with drugs or alcohol. Advantages and disadvantages of head CT scan are summarized in the following table. Table 3. Advantages and Disadvantages of CT scanning in the Head Trauma Evaluation

Open table in new window

[ CLOSE WINDOW ]
Table
AdvantagesDisadvantages
Noninvasive and rapidTraumatic vascular lesions may be missed.
Very sensitive for acute hemorrhageDAI is likely to be missed.
Defines nature of ICH (ie, SDH†, SAH‡)Motion artifact may limit study.
Defines anatomical location of lesionPosterior fossa lesions are poorly depicted.
Identifies fractures of the craniumDepressed skull fractures at the vertex (or along the plane of an axial scan) are poorly depicted.
Sensitive to detecting intracranial airThe scanner has a weight limit, and a patient may be too heavy.
Sensitive in identifying foreign objectsA patient may decompensate while in the scanner.
AdvantagesDisadvantages
Noninvasive and rapidTraumatic vascular lesions may be missed.
Very sensitive for acute hemorrhageDAI is likely to be missed.
Defines nature of ICH (ie, SDH†, SAH‡)Motion artifact may limit study.
Defines anatomical location of lesionPosterior fossa lesions are poorly depicted.
Identifies fractures of the craniumDepressed skull fractures at the vertex (or along the plane of an axial scan) are poorly depicted.
Sensitive to detecting intracranial airThe scanner has a weight limit, and a patient may be too heavy.
Sensitive in identifying foreign objectsA patient may decompensate while in the scanner.

*Intracranial hemorrhage
†Subdural hemorrhage
‡Subarachnoid hemorrhage

    • CT scans are helpful in assessing the degree of intracranial injury, in predicting outcome, and, if findings are normal, in avoiding unnecessary hospitalization.44,45
    • CT scans are very sensitive to acute hemorrhage or skull fractures. CT scans aid in evaluating (1) intracranial hemorrhage, (2) skull fractures, (3) mass effect and midline shift, (4) obliteration of the basal cisterns, and (5) evidence of herniation (subfalcine, tonsillar, or uncal).
    • CT scans cannot diagnose a concussion (which is a clinical diagnosis) and are poor for diagnosing DAI. If DAI has occurred, CT scans may show small hemorrhages in the corpus callosum and cerebral peduncles. In this case, an MRI of the brain should be obtained on an elective basis when the patient is clinically stable because no effective treatment of DAI is currently available. MRI is more sensitive for detecting brainstem injuries, posterior fossa lesions, and brain edema. For advantages and disadvantages of CT scanning in patients with closed head injuries, see Table 3.
    • As a general rule, a repeat head CT scan is recommended within 4-8 hours of the initial scan in patients with intracranial hemorrhages and/or coagulopathies.46,47,48 A repeat head CT scan is recommended sooner in patients who are deteriorating neurologically.
    • Spinal cord injuries should be considered possible in patients with closed head injuries. Spinal cord injuries are present in up to 10% of these patients.42   
      • Accordingly, the cervical spine should be evaluated (with 3 views) during the initial evaluation. C1-C2 should be evaluated with a thin-cut CT scan in intubated patients. If any abnormalities are noted on the initial cervical plain radiographs, this area should be further evaluated with a CT scan. An MRI may be necessary to image a spinal cord injury.
      • A rigid cervical collar (Philly) should remain on at all times while the patient is being evaluated.

Other Tests

Order serum sodium, urine specific gravity, urine osmolarity, and serum osmolarity tests for individuals with urine output of 250 mL/h or more for 3 or more consecutive hours (pediatric patients, >3 mL/kg/h) and for patients who are thought to have diabetes insipidus. Large doses of mannitol can mask diabetes insipidus by producing a high urine output.

Procedures

  • Patients with a severe brain injury (GCS score <8), those who have labile blood pressure, those who require intensive care monitoring, and those who need surgical intervention are likely to require the placement of an indwelling urinary catheter (Foley), placement of a central venous access catheter, and invasive blood pressure monitoring via an arterial line.
  • ICP monitoring in patients with closed head injuries is a matter of controversy; however, most authors agree that invasive ICP monitoring is warranted in patients with a GCS score of 8 or less and an abnormal CT scan finding, in patients with suspected severe brain edema, or in any situation in which the ICP is suspected to be significantly elevated. The ICP offers data that supplement a reliable neurological examination and can be crucial in patients whose examination findings are affected by sedatives, paralytics, and other factors. 
    • Patients with an abnormal head CT scan finding, a GCS score of less than 8, or both who require emergent surgery on another organ system should also be considered for some form of ICP monitoring before going to the operating room (or perhaps in the operating room) because frequent neurological examinations are not possible in this setting.
    • ICP monitoring can take 1 of 2 forms, either as an intraventricular catheter or an intracranial fiberoptic monitor (Camino).
      • The intraventricular catheter is preferred in closed head injuries when the ventricles are large enough to accommodate a catheter. The advantage of the catheter is the ability to drain CSF if the ICP is elevated (>20 mm Hg), although ventricles compromised by mass effect make draining much CSF difficult. An accurate pressure reading can be lost if the ventricle collapses around the catheter tip during drainage.
      • The advantage of the fiberoptic catheter is that ICP can be monitored in patients who have very small ventricles, in whom ventriculostomy catheters cannot be inserted. The pressure measurements are not prone to fluctuations in ventricular size. Either procedure provides adequate ICP monitoring.

More on Closed Head Trauma

Overview: Closed Head Trauma
Differential Diagnoses & Workup: Closed Head Trauma
Treatment & Medication: Closed Head Trauma
Follow-up: Closed Head Trauma
Multimedia: Closed Head Trauma
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Klonoff H, Thompson GB. Epidemiology of head injuries in adults: a pilot study. Can Med Assoc J. Feb 1 1969;100(5):235-41. [Medline].

  2. Klauber MR, Marshall LF, Barrett-Connor E, Bowers SA. Prospective study of patients hospitalized with head injury in San Diego County, 1978. Neurosurgery. Sep 1981;9(3):236-41. [Medline].

  3. Annegers JF, Grabow JD, Kurland LT, Laws ER Jr. The incidence, causes, and secular trends of head trauma in Olmsted County, Minnesota, 1935-1974. Neurology. Sep 1980;30(9):912-9. [Medline].

  4. Kalsbeek WD, McLaurin RL, Harris BS 3rd, Miller JD. The National Head and Spinal Cord Injury Survey: major findings. J Neurosurg. Nov 1980;Suppl:S19-31. [Medline].

  5. Kraus JF, Black MA, Hessol N, Ley P, Rokaw W, Sullivan C, et al. The incidence of acute brain injury and serious impairment in a defined population. Am J Epidemiol. Feb 1984;119(2):186-201. [Medline].

  6. Kraus JF. Epidemiology of head injury. In: Cooper PR, ed. Head Injury. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 1987:1.

  7. US Census Bureau, Population Division. Data as of July 2003. Available at: http://www.census.gov/cgi-bin/popclock. [Full Text].

  8. Feliciano DV, Moore EE, Mattox KL. Trauma. 3rd ed. McGraw-Hill: 1996:267-1065.

  9. Kraus JF. Epidemiology of head injury. In: Cooper PR, ed. Head Injury. 3rd ed. Baltimore: Lippincott Williams & Wilkins; 1993:1-25.

  10. Schwartz SI, Shires GT. Principles of Surgery. 7th ed. New York: McGraw-Hill; 1999:1880-1881.

  11. Frankowski RF, Annegers JF, Whitman S. Epidemiological and descriptive studies, Part 1. The descriptive epidemiology of head trauma in the United States. In: Becker DP, Povlishock JT. Central Nervous System Trauma Status Report. William Byrd Press: Richmond, Va; 1985:33.

  12. Foulkes MA, Eisenberg HM, Jane JA, Marmarou A, Marshall LF. The Traumatic Coma Data Bank: design, methods, and baseline characteristics. J Neurosurg. November 1991;75:S8-S13.

  13. Valadka AB, Robertson CS. Surgery of cerebral trauma and associated critical care. Neurosurgery. supplement 2007;61(1):203-21.

  14. National Academy Press. Injury in America: A Continuaing Public Health Problem. Washington, DC: National Academy Press; 1985:1.

  15. Valadka AB, Ward JD, Smoker WR. Brain Imaging in Neurologic Emergencies. Anaheim, Calif:. Society of Critical Care Medicine;1993:1.

  16. Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury. JAMA. Sep 8 1999;282(10):954-7. [Medline].

  17. De Beaumont L, Lassonde M, Leclerc S, Théoret H. Long-term and cumulative effects of sports concussion on motor cortex inhibition. Neurosurgery. Aug 2007;61(2):329-36; discussion 336-7. [Medline].

  18. Viano DC, Casson IR, Pellman EJ. Concussion in professional football: biomechanics of the struck player--part 14. Neurosurgery. Aug 2007;61(2):313-27; discussion 327-8. [Medline].

  19. Chang EF, Meeker M, Holland MC. Acute traumatic intraparenchymal hemorrhage: risk factors for progression in the early post-injury period. Neurosurgery. Apr 2006;58(4):647-56; discussion 647-56. [Medline].

  20. Cairns CJ, Andrews PJ. Management of hyperthermia in traumatic brain injury. Curr Opin Crit Care. Apr 2002;8(2):106-10. [Medline].

  21. Miller JD. Surgical management of acute and chronic subdural hematoma. In: Schmidek HH, Sweet WH, eds. Operative Neurosurgical Techniques: Indications, Methods, Results. 2nd ed. Philadelpia: WB Saunders Co; 1998:33.

  22. Maxeiner H, Wolff M. Pure subdural hematomas: a postmortem analysis of their form and bleeding points. Neurosurgery. Mar 2002;50(3):503-8; discussion 508-9. [Medline].

  23. Jenkins A, Teasdale G, Hadley MD, Macpherson P, Rowan JO. Brain lesions detected by magnetic resonance imaging in mild and severe head injuries. Lancet. Aug 23 1986;2(8504):445-6. [Medline].

  24. Miller JD, Sweet RC, Narayan R, Becker DP. Early insults to the injured brain. JAMA. Aug 4 1978;240(5):439-42. [Medline].

  25. Wilkins RH, Rengachary SS. Neurosurgery. 2nd ed. New York:. McGraw Hill;1996:2603-2720.

  26. [Best Evidence] Christensen J, Pedersen MG, Pedersen CB, Sidenius P, Olsen J, Vestergaard M. Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study. Lancet. Mar 28 2009;373(9669):1105-10. [Medline].

  27. Bouma GJ, Muizelaar JP, Stringer WA, Choi SC, Fatouros P, Young HF. Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenon-enhanced computerized tomography. J Neurosurg. Sep 1992;77(3):360-8. [Medline].

  28. Bouma GJ, Muizelaar JP, Bandoh K, Marmarou A. Blood pressure and intracranial pressure-volume dynamics in severe head injury: relationship with cerebral blood flow. J Neurosurg. Jul 1992;77(1):15-9. [Medline].

  29. Aggarwal S. Time course of cerebral flow and metabolic changes following severe head injury. Presented at: The 61st Annual Meeting of the American Association of Neurological Surgeons. Boston, Mass:. April 1993.

  30. Marion D, Obrist WD, Penrod LE, et al. Treatment of cerebral ischemia improves outcome following severe traumatic brain injury. Presented at: The American Association of Neurological Surgeons. Boston, Mass:. April 26 1993.

  31. Obrist WD, Marion DW, Aggarwal S. Time course of cerebral blood flow and metabolic changes following severe head injury. Presented at: The 61st Annual Meeting of the American Association of Neurological Surgeons. Boston Mass: April 1993.

  32. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. Feb 1993;34(2):216-22. [Medline].

  33. Gopinath SP, Robertson CS, Contant CF, Hayes C, Feldman Z, Narayan RK, et al. Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry. Jun 1994;57(6):717-23. [Medline].

  34. Marmarou A, Signoretti S, Fatouros PP, Portella G, Aygok GA, Bullock MR. Predominance of cellular edema in traumatic brain swelling in patients with severe head injuries. J Neurosurg. May 2006;104(5):720-30. [Medline].

  35. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 13 1974;2(7872):81-4. [Medline].

  36. Jagger J, Fife D, Vernberg K. Effect of alcohol intoxication on the diagnosis and apparent severity of brain injury. Neurosurgery. Sep 1984;15(3):303-6. [Medline].

  37. Pal J, Brown R, Fleiszer D. The value of the Glasgow Coma Scale and Injury Severity Score: predicting outcome in multiple trauma patients with head injury. J Trauma. Jun 1989;29(6):746-8. [Medline].

  38. Waxman K, Sundine MJ, Young RF. Is early prediction of outcome in severe head injury possible?. Arch Surg. Oct 1991;126(10):1237-41; discussion 1242. [Medline].

  39. Vollmer DG. Prognosis and outcome of severe injury. In: Cooper PR, ed. Head Injury. 3rd ed. Baltimore:. Lippincott Williams & Wilkins;1993:533-581.

  40. Salcman M, Schepp RS, Ducker TB. Calculated recovery rates in severe head trauma. Neurosurgery. Mar 1981;8(3):301-8. [Medline].

  41. Born JD, Albert A, Hans P, Bonnal J. Relative prognostic value of best motor response and brain stem reflexes in patients with severe head injury. Neurosurgery. May 1985;16(5):595-601. [Medline].

  42. Townsend CM, Sabiston DC, Beauchamp RD, et al. The Biological Basis of Modern Surgical Practice. 16th ed. WB Saunders Co: Sabiston Textbook of Surgery:; 1994:317-376.

  43. Langfitt TW, Gennarelli TA. Can the out come from head injury be improved?. J Neurosurg. Jan 1982;56(1):19-25. [Medline].

  44. Livingston DH, Loder PA, Koziol J, Hunt CD. The use of CT scanning to triage patients requiring admission following minimal head injury. J Trauma. Apr 1991;31(4):483-7; discussion 487-9. [Medline].

  45. Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, et al. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma. Sep 1992;33(3):385-94. [Medline].

  46. McBride DQ, Patel AB, Caron M. Early repeat CT scan: importance in detecting surgical lesions after closed head injury. J Neurotrauma. 1993;10:S227,203.

  47. Stein SC, Ross SE. Moderate head injury: a guide to initial management. J Neurosurg. Oct 1992;77(4):562-4. [Medline].

  48. Stein SC, Spettell C, Young G, Ross SE. Delayed and progressive brain injury in closed-head trauma: radiological demonstration. Neurosurgery. Jan 1993;32(1):25-30; discussion 30-1. [Medline].

  49. Rangel-Castillo L, Robertson CS. Management of intracranial hypertension. Crit Care Clin. Oct 2006;22(4):713-32; abstract ix. [Medline].

  50. Rosner MJ, Daughton S. Cerebral perfusion pressure management in head injury. J Trauma. Aug 1990;30(8):933-40; discussion 940-1. [Medline].

  51. Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. Nov 1991;75(5):731-9. [Medline].

  52. von Helden A, Schneider GH, Unterberg A, Lanksch WR. Monitoring of jugular venous oxygen saturation in comatose patients with subarachnoid haemorrhage and intracerebral haematomas. Acta Neurochir Suppl (Wien). 1993;59:102-6. [Medline].

  53. Muizelaar JP, van der Poel HG, Li ZC, Kontos HA, Levasseur JE. Pial arteriolar vessel diameter and CO2 reactivity during prolonged hyperventilation in the rabbit. J Neurosurg. Dec 1988;69(6):923-7. [Medline].

  54. Muizelaar JP, Wei EP, Kontos HA, Becker DP. Mannitol causes compensatory cerebral vasoconstriction and vasodilation in response to blood viscosity changes. J Neurosurg. Nov 1983;59(5):822-8. [Medline].

  55. Muizelaar JP, Lutz HA 3rd, Becker DP. Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head-injured patients. J Neurosurg. Oct 1984;61(4):700-6. [Medline].

  56. Takagi H, Saito T, Kitahara T, et al. The mechanism of the ICP reducing effect of mannitol. Berlin: Springer-Verlag; 1993:729-33.

  57. Cruz J, Miner ME, Allen SJ, Alves WM, Gennarelli TA. Continuous monitoring of cerebral oxygenation in acute brain injury: injection of mannitol during hyperventilation. J Neurosurg. Nov 1990;73(5):725-30. [Medline].

  58. Gasco J, Sendra J, Lim J, Ng I. Linear correlation between stable intracranial pressure decrease and regional cerebral oxygenation improvement following mannitol administration in severe acute head injury patients. Acta Neurochir Suppl. 2005;95:73-7. [Medline].

  59. Chesnut RM, Gautille T, Blunt BA, Klauber MR, Marshall LF. Neurogenic hypotension in patients with severe head injuries. J Trauma. Jun 1998;44(6):958-63; discussion 963-4. [Medline].

  60. Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD. High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg. Jul 1988;69(1):15-23. [Medline].

  61. Mattox KL, Maningas PA, Moore EE, Mateer JR, Marx JA, Aprahamian C, et al. Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial. Ann Surg. May 1991;213(5):482-91. [Medline].

  62. Vassar MJ, Perry CA, Gannaway WL, Holcroft JW. 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg. Sep 1991;126(9):1065-72. [Medline].

  63. Winter JP, Plummer D, Bottini A, Rockswold GR, Ray D. Early fresh frozen plasma prophylaxis of abnormal coagulation parameters in the severely head-injured patient is not effective. Ann Emerg Med. May 1989;18(5):553-5. [Medline].

  64. Hawryluk GW, Cusimano MD. The role of recombinant activated factor VII in neurosurgery: hope or hype?. J Neurosurg. Dec 2006;105(6):859-68. [Medline].

  65. Clinchot DM, Otis S, Colachis SC 3rd. Incidence of fever in the rehabilitation phase following brain injury. Am J Phys Med Rehabil. Jul-Aug 1997;76(4):323-7. [Medline].

  66. Ginsberg MD, Busto R. Combating hyperthermia in acute stroke: a significant clinical concern. Stroke. Feb 1998;29(2):529-34. [Medline].

  67. Thompson HJ, Tkacs NC, Saatman KE, Raghupathi R, McIntosh TK. Hyperthermia following traumatic brain injury: a critical evaluation. Neurobiol Dis. Apr 2003;12(3):163-73. [Medline].

  68. Bullock R, Chesnut RM, Clifton G, et al. Guidelines for cerebral perfusion pressure. In: Guidelines for the Management of Severe Head Injury. New York Brain Trauma Foundation: 1995:8-1– 8-10.

  69. Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, et al. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst. Feb 2001;17(3):154-62. [Medline].

  70. Guerra WK, Gaab MR, Dietz H, Mueller JU, Piek J, Fritsch MJ. Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg. Feb 1999;90(2):187-96. [Medline].

  71. Schneider GH, Bardt T, Lanksch WR, Unterberg A. Decompressive craniectomy following traumatic brain injury: ICP, CPP and neurological outcome. Acta Neurochir Suppl. 2002;81:77-9. [Medline].

  72. Guidelines for the management of severe traumatic brain injury. XII. Nutrition. J. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Neurotrauma. 2007;24 Suppl 1:S77-82.

  73. Greenberg MS. Handbook of Neurosurgery. 5th ed. Thieme Medical Publishers; 2001:258-259.

  74. Szaflarski JP, Meckler JM, Szaflarski M, Shutter LA, Privitera MD, Yates SL. Levetiracetam use in critically ill patients. Neurocrit Care. 2007;7(2):140-7. [Medline].

  75. Alexandre A, Colombo F, Nertempi P, Benedetti A. Cognitive outcome and early indices of severity of head injury. J Neurosurg. Nov 1983;59(5):751-61. [Medline].

  76. Levin HS, Gary HE Jr, Eisenberg HM, Ruff RM, Barth JT, Kreutzer J, et al. Neurobehavioral outcome 1 year after severe head injury. Experience of the Traumatic Coma Data Bank. J Neurosurg. Nov 1990;73(5):699-709. [Medline].

  77. Vollmer DG, Torner JC, Jane JA, et al. Age and outcome following traumatic coma: Why do older patients fare worse?. J Neurosurg. 1991;75 (suppl):S37-S49.

  78. [Guideline] Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep. Jan 23 2009;58:1-35. [Medline].

  79. Bingham H. Electrical burns. Clin Plast Surg. Jan 1986;13(1):75-85. [Medline].

  80. Bouma GJ, Muizelaar JP. Cerebral blood flow, cerebral blood volume, and cerebrovascular reactivity after severe head injury. J Neurotrauma. Mar 1992;9 Suppl 1:S333-48. [Medline].

  81. Chan KH, Dearden NM, Miller JD, Andrews PJ, Midgley S. Multimodality monitoring as a guide to treatment of intracranial hypertension after severe brain injury. Neurosurgery. Apr 1993;32(4):547-52; discussion 552-3. [Medline].

  82. Chan KH, Miller JD, Dearden NM, Andrews PJ, Midgley S. The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg. Jul 1992;77(1):55-61. [Medline].

  83. Colohan A, Dacey RG, Alves WM, et al. Neurologic and neurosurgical implication of mild head injury. J Head Trauma Rehab. 1986;10(9):13-21.

  84. Contant CF, Robertson CS, Gopinath SP, et al. Determination of clinically important thresholds in continuously monitored patients with head injury. J Neurotrauma. 1993;10:S57.

  85. Dendooven AM, Lissens M, Bruyninckx F, Vanhecke J. Electrical injuries to peripheral nerves. Acta Belg Med Phys. Oct-Dec 1990;13(4):161-5. [Medline].

  86. Dendooven AM, Lissens M, Bruyninckx F, Vanhecke J. Electrical injuries to peripheral nerves. Acta Belg Med Phys. Oct-Dec 1990;13(4):161-5. [Medline].

  87. Engrav LH, Gottlieb JR, Walkinshaw MD, Heimbach DM, Trumble TE, Grube BJ. Outcome and treatment of electrical injury with immediate median and ulnar nerve palsy at the wrist: a retrospective review and a survey of members of the American Burn Association. Ann Plast Surg. Sep 1990;25(3):166-8. [Medline].

  88. Gallagher JP, Sanders M. Trauma and amyotrophic lateral sclerosis: a report of 78 patients. Acta Neurol Scand. Feb 1987;75(2):145-50. [Medline].

  89. Iob I, Salar G, Ori C, Mattana M, Casadei A, Peserico L. Accidental high voltage electrocution: a rare neurosurgical problem. Acta Neurochir (Wien). 1986;83(3-4):151-3. [Medline].

  90. Marshall LF, Gautille T, Klauber MR, et al. The outcome of severe closed head injury. J Neurosurg. 1991;75:S28-S26.

  91. Narayan RK. Head injury. In: Grossman RG, ed. Principles of Neurosurgery. New York: Raven Press; 1991:257.

  92. Rimel RW, Giordani B, Barth JT, Boll TJ, Jane JA. Disability caused by minor head injury. Neurosurgery. Sep 1981;9(3):221-8. [Medline].

  93. Rimel RW, Giordani B, Barth JT, Jane JA. Moderate head injury: completing the clinical spectrum of brain trauma. Neurosurgery. Sep 1982;11(3):344-51. [Medline].

  94. Rosner MJ. Pathophysiology and management of increased intracranial pressure. In: Andrews BT, ed. Neurosurgical Intensive Care. New York: McGraw-Hill; 1993:57-112.

  95. Stein SC, Young GS, Talucci RC, Greenbaum BH, Ross SE. Delayed brain injury after head trauma: significance of coagulopathy. Neurosurgery. Feb 1992;30(2):160-5. [Medline].

  96. Temkin NR, Dikmen SS, Wilensky AJ, Keihm J, Chabal S, Winn HR. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. Aug 23 1990;323(8):497-502. [Medline].

  97. Turner HB, Anderson RL, Ward JD, et al. NINDS Tramatic coma data bank: intracranial pressure monitoring methodology. J Neurosurg. 1991;75:S21.

[ CLOSE WINDOW ]

Further Reading

Clinical guidelines
Davis PC, Brunberg JA, De La Paz RL, Dormont D, Jordan JE, Mukherji SK, Seidenwrum DJ, Turski PA, Wippold FJ II, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® head trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 13 p.

Work Loss Data Institute. Head (trauma, headaches, etc., not including stress & mental disorders). Corpus Christi (TX): Work Loss Data Institute; 2008. 152 p.

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW, National Expert Panel on Field Triage, Centers for Disease Control and Prevention. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009 Jan 23;58(RR-1):1-35. 78

[ CLOSE WINDOW ]

Keywords

traumatic brain injury, TBI, closed head injury, nonpenetrating head injury, epidural hematoma, subdural hematoma, subarachnoid hemorrhage, SAH, intraventricular hemorrhage, intracranial hemorrhage, intracerebral hemorrhage, ICH, cerebral contusion, coup injury, contrecoup injury, diffuse axonal injury, DAI, generalized brain ischemia, Duret hemorrhage, brain stem injury, brain death, intracranial pressure, ICP, cerebral perfusion pressure, CPP, cerebrospinal fluid, CSF, decompressive craniotomy, motor vehicle collisions, motor vehicle accident, MVCs, contemporary neuromonitoring

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Leonardo Rangel-Castilla, MD, Staff Physician, Division of Neurosurgery, University of Texas Medical Branch School of Medicine
Leonardo Rangel-Castilla, MD is a member of the following medical societies: American Association of Neurological Surgeons and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Jaime Gasco, MD, Staff Physician, Department of Neurosurgery, University of Texas Medical Branch School of Medicine
Jaime Gasco, MD is a member of the following medical societies: American Association of Neurological Surgeons and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Fadi Hanbali, MD, FACS, Associate Professor, Division of Neurosurgery, Department of Surgery, Texas Tech University Health Sciences Center; Associate Professor, Department of Orthopedic Surgery, Texas Tech University Health Sciences Center; Adjunct Professor, Departments of Neurosurgery and Orthopedic Surgery, Division of Neurosurgery, University of Texas Medical Branch
Fadi Hanbali, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Paul Salinas, MD, Resident Physician, Department of Neurosurgery, University of Texas Medical Branch at Galveston
Disclosure: Nothing to disclose.

Medical Editor

Paul L Penar, MD, Professor, Department of Surgery, Division of Neurosurgery, University of Vermont School of Medicine
Paul L Penar, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ryszard M Pluta, MD, PhD, Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences at Warsaw, Poland; Senior Researcher, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, NIH
Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons and Polish Society of Neurosurgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.