Blunt Cervical Vascular Injury

Cervical cerebrovascular injury occurs in approximately 1% of patients presenting with blunt trauma, but it carries a high morbidity (80%) and mortality (40%) when left undiagnosed. Cervical spine fractures, especially between C1 and C6, are at higher risk for injury to the cervical cerebrovasculature. These injuries are graded I–V in order of ascending severity. The diagnosis is established using a vascular imaging study, predominantly CT angiography. Once diagnosed, the treatment is predominantly medical with antiplatelet or anticoagulation therapy, and its presence should not preclude reduction of a fractured or subluxed vertebrae. The medical therapy should be continued for 3–6 months with regular follow-up vascular imaging to assess for progression of the injury. Overall, blunt cervical vascular injury should be suspected in patients with cervical spine fractures or trauma to the head and neck region, and it should be treated medically.

Management of Temporal Bone Fractures

Temporal bone fractures can present with a variety of symptoms and physical exam findings. Facial paralysis, hearing loss, spinal fluid leak, vestibular dysfunction, and vascular injuries are all potential issues that may occur in the setting of skull base trauma. The indications and interpretation of facial nerve electrophysiology studies with respect to the need for surgical decompression or repair are reviewed. Injuries to the middle and inner ear may result in conductive, mixed, or pure sensorineural hearing loss depending on the location of the fracture. Surgical repair of conductive or mixed hearing loss should be delayed because spontaneous improvement often occurs. CSF leakage presents with clear or serosanguineous aural discharge and typically resolves with conservative measures. Occasionally spinal fluids leaks require lumbar subarachnoid drainage or surgical exploration and repair. Evaluation and management of other issues arising as a result of temporal bone trauma will also be reviewed.

Traumatic Intracerebral Contusions

Cerebral contusions are a subtype of traumatic brain injury that classically result from coup or contrecoup injuries. Common locations for these injuries are the inferior frontal, temporal, and occipital lobes. Mass effect from edema and hemorrhagic progression are frequent with contusions. Depending on the clinical examination results and radiographic findings, treatment may be nonsurgical or surgical. A Glasgow Coma Scale (GCS) score of 8 or less warrants placement of an intracranial pressure (ICP) monitoring device. Surgery is indicated in patients with deterioration of neurological examination findings, ICP that is refractory to exhaustive medical management, or imaging findings of severe mass effect. Patients with moderate or severe traumatic brain injury (GCS <13) are typically admitted to intensive care units for close monitoring of neurological examination changes, hyponatremia, hemorrhagic progression, and postsurgical complications. Recovery varies widely, and outcomes depend on age, initial GCS score, size, and location of the contusion.

Epidural Hematoma

Although epidural hematomas (EDH) are not frequently seen with intracranial injury in trauma, they present an emergency situation that can result in significant mortality if not diagnosed and treated in a timely manner. EDH stems from bleeding from the bone rupturing an interosseous artery, the bone itself, or from a venous sinus laceration. Most EDH present with a classic biconvex shape on CT images. Venous EDH can cross the midline and are often found under the transverse or sagittal sinus. The current school of thought is that patients who present with a small (<10 mm maximal thickness) EDH with no neurological symptoms can be treated conservatively. Patients neurologically intact with a normal Glasgow Coma Scale score but an EDH of greater than 30 cc should undergo surgery.

Acute Subdural Hematoma

Acute subdural hematomas are collections of acute blood in the subdural space. They usually present as a result of significant head trauma. They can occur spontaneously in relationship to an underlying hemorrhagic lesion such as tumor, arteriovenous malformation, or aneurysm. They are more likely to be associated with cortical injury than the epidural hematoma. Neurological symptoms on presentation are related to the underlying brain injury and/or mass effect. Acute subdural blood on CT scan is hyperdense, in a crescent shape, along the inner dural surface. Emergent surgical intervention via craniotomy is indicated in patients with at least 10 mm in thickness or at least 5 mm shift, or elevated ICP, or pupillary dilatations suggesting herniation, or progression of deficit based on the Glasgow Coma Score. Conservative management of small acute subdural hematomas may be done in select situations that include proper ICU monitoring for ICP elevations and neurological deteriorations.

Surgical Treatment of Raised Intracranial Pressure

Traumatic brain injury (TBI) is a common problem encountered in the emergency department, and neurosurgeons are typically involved early in the management. Prompt physical examination and head CT are crucial to assess TBI patients and determine their management plan. Intracranial pressure (ICP) monitoring is indicated for patients with altered mental status and abnormal imaging. ICP management is a tiered approach, with early tiers involving nonsurgical, and medical interventions. For patients with uncontrolled elevation of ICP, there are three possible surgical interventions: external ventricular drain placement, evacuation of mass lesion, and/or decompressive craniectomy (unilateral or bilateral). Finally, when patients who underwent craniectomy recover from the acute phase of TBI, cranioplasty is performed for cosmetic purposes and potential neurological benefit.

Evaluation and Management of Frontal Sinus Fractures

Frontal sinus fractures are usually associated with traumatic brain injury and nasoorbitoethmoidal fractures. Much of the available evidence is retrospective, and management algorithms vary. In general, nondisplaced fractures without nasofrontal outflow tract (NFOT) obstruction may be managed with clinical and radiographic follow-up whereas fracture displacement, NFOT obstruction, and persistent CSF leaks are indications for operative management. The bicoronal incision and bifrontal craniotomy allow for proper access to the frontal sinus. If there is NFOT obstruction, the sinus should be cranialized or possibly obliterated if only the anterior table is fractured. The NFOT and sinus are packed with bone chips, fat, or muscle and then sealed with a pericardial graft, fascial graft, or synthetic dural substitute. Inadequate cranialization or obliteration can result in mucocele or mucopyocele, intracranial extension of which can lead to brain abscess or meningitis. Complications can occur years after the initial injury so long-term follow-up is necessary.

Occipital Condyle Fractures

Occipital condyle fractures are a rare entity most commonly associated with traumatic injuries. Head CT is the most sensitive method for detecting such fractures, and follow-up MRI to identify ligamentous injury is necessary to determine if the fracture is unstable or if there is compression of neural elements. Surgical intervention with either a Halo device or internal fixation is only necessary in the setting of unstable fractures or when there is evidence of bilateral fractures or avulsed fragments causing neural compression. Most patients recover with little to no lasting symptoms, though it is important to watch for a delayed presentation of lower cranial nerve deficits.

Management of Complex Scalp Injuries

Complex scalp wounds require an understanding of basic anatomy and a broad knowledge of options for surgical repair. The scalp is comprised of five layers: skin, subcutaneous fat, galea aponeurotica, loose areolar tissue, and pericranium. The vascular supply is provided from vessels branching primarily off the external carotid artery. Sensation is provided by the trigeminal and C2–C3 nerves. A surgical team should evaluate all full-thickness and complex scalp lacerations, especially those associated with underlying skull fractures. Complications include wound dehiscence and infection. Clinicians must remain extremely vigilant in following these patients because an infection can lead to underlying osteomyelitis of the skull, meningitis, or subdural empyema. Often, multiple surgical teams may be involved, and a planned stepwise approach may provide the best outcome for the patient.

Penetrating Brain Injuries

Penetrating brain injury (PBI) may result from missiles (high velocity) or non-missiles (low velocity), with the latter having a better prognosis and more frequently resulting in favorable patient outcomes. Certain risks, complications, and management principles are common across all types of PBI. These include the potential for the development of mass lesions, cerebral edema, and neurological deterioration, as well as a high risk of concomitant cerebrovascular injury, CSF leak, infection, and posttraumatic seizures. In most cases, urgent surgical treatment is warranted to mitigate these associated risks. This chapter will focus primarily on the assessment, diagnostic workup, decision making, and management of non-missile and low-velocity PBI.