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Craniocerebral and Spinal Trauma 193
Craniotomy for trauma Intracranial infections
1. The patient is positioned supine, head turned laterally, and elevated Intracranial infections are associated with very high mortality and mor-
15 degrees, with shoulder support. bidity if not treated energetically. Meningitis can occur within a few
days after head injury. The predisposing factors are open skull fractures,
2. A large trauma flap (“question mark”) incision is made, starting penetrating injuries, fractures into air sinuses, and skull base fractures
anterior to the ear, above the tragus, extended rostrally above the with CSF otorrhoea or rhinorrhoea. The patient usually has a headache,
pinna, turned posteriorly circling around the occipitoparietal area, and restlessness, vomiting, photophobia, and seizures. There is high-grade
turning anteriorly to end frontally behind the hairline.
fever, rigors, neck stiffness, and a positive Kernig’s sign.
3. Haemostasis is secured by using Riney clips or artery forceps. A CSF sample is taken through lumbar puncture for cultures
4. When necessary, the temporalis muscle is dissected by using and biochemical analysis. An empirical intravenous antibiotic is
monopolar diathermy after raising the scalp flap. commenced. Intravenous (IV) benzyl penicillin (50-75 mg/kg every
6 hours) and IV chloramphenicol (1 gm every 6 hours) are effective.
5. A series of burr holes are placed encircling the area of the
haematoma, connected by using a foot plate on a power drill or a Gigli Cerebral abscess may develop following meningitis or when there is
saw. gross contamination from compound fractures. If the abscess is large,
there may be features of raised intracranial pressure. Evacuation of the
6. An epidural haematoma should now be exposed and is evacuated
abscess with appropriate antibiotic cover is essential.
with gentle suction and irrigation; bleeding vessels are controlled with
diathermy. CSF leakage and fistula
The most common cause of CSF fistula is trauma. Skull fractures and
7. The dura is “tented” to prevent re-collection, and the bone flap is
associated arachnoid tears can lead to the development of CSF leakage
replaced.
and fistula. The incidence of posttraumatic rhinorrhea in closed head
8. The scalp flap is closed in layers over a closed drain.
injury is 2–3%. CSF fistula occurs in 8.9% of penetrating head trauma.
9. In the case of acute subdural haematoma, the dura is incised, the Posttraumatic CSF leaks are seen commonly in penetrating injuries and
haematoma evacuated, and haemostasis is controlled. compound fractures of skull bones, paranasal sinuses, middle ear, and
10. The bone flap is replaced immediately and postoperative measures mastoid air cells. Basilar fractures are notorious for development of
instituted to control the brain swelling. CSF fistula. Diagnosis is usually obvious with copious CSF leakage.
Postoperative Complications A blotting paper test can be done by the bedside to show the double
2
Postoperative complications include re-collection, wound infection, and ring sign. A glucose test is positive in CSF as against mucus. β trans-
ferin is specific to CSF. An x-ray usually shows a fracture at the base
dehiscence. Re-collection of haematoma is managed by re-evacuation.
of the skull or opacity in the paranasal sinus. A CT scan is diagnostic.
Prognosis and Outcome It may show associated pneumocephalus. In difficult cases, a dye test
Children have better outcomes compared to adults for the same type (metrizamide or Iohexol injected intrathecally) can be used to locate
and severity of injury. Mortality is age dependent—it is highest in the site of the CSF leakage. Treatment is usually conservative. The use
15
infants and declines until about age 12 years, and then increases in of an antibiotic is controversial unless when leakage. Treatment is usu-
the teens. In terms of morbidity, the youngest children have the worst ally conservative. The use of an antibiotic is controversial unless there
16
outcome. Factors that influence the prognosis include low GCS at 72 are signs of meningitis. Most cases can be managed nonoperatively.
hours posttrauma, extracranial trauma, acute hypoxia, elevated raised Persistent fistulae are repaired via craniotomy.
intracranial pressure, and duration of coma. The Glasgow Outcome Pneumocephalus
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Scale (GOS; Table 30.2) gives a reproducible outcome, which means A fracture involving the paranasal sinuses could lead to intracranial gas
different patients with similar GOS scores from different centres will collection, known as pneumocephalus. When the gas is under pressure,
have similar outcomes.
it is called tension pneumocephalus, which is a surgical emergency. The
Table 30.2: The Glasgow Outcome Scale. gas may collect in the epidural, subdural, or subarrhacnoid spaces. It
may also be, within the brain parenchyma, or in the ventricular system.
Score Meaning
Intracranial infection with gas-forming organisms also cause pneu-
5 Good recovery
mocephalus. The patient presents with headache, vomiting, dizziness,
4 Moderate disability alteration in level of consciousness, and CSF leakage. An x-ray may
3 Severe disability show intracranial gas. A CT scan shows hypodense (very dark) areas.
2 Persisten vegetative state Treatment is conservative if the gas collection is small and there is no
mass effect, as the gas will resolve with time. Tension pneumocephalus
1 Death
must be urgently evacuated. Craniotomy and repair are done for per-
sistent CSF leakage.
Complications of Head Injury Cranial nerve palsy
Intracranial haematoma Any of the cranial nerves may be injured, depending on the magnitude
A majority of patients who die from head injury have an intracranial and location of trauma. The most commonly affected nerves are olfac-
haematoma that has caused brain shift and compression. This com- tory, optic, oculomotor, trochlear, abducent, facial, and vestibuloco-
plication may be present at the time of presentation or it may develop chlear nerves. Healing is usually spontaneous after a variable period
later. The haematoma may be in the epidural, subdural, or subarachnoid of time.
space. It may also be intraventricular or within the brain parenchyma. Posttraumatic hydrocephalus
The patient presents with a deteriorating level of consciousness and Hydrocephalus occurs following trauma with associated subarachnoid
localising signs or features of rising intracranial pressure. A brain CT haemorrhage. It is a communicating hydrocephalus; the patient may
scan or MRI will accurately localise the haematoma; it will also show present with the triad of dementia, gait disturbance, and urinary incon-
the size of the clot and whether there is a midline shift. Evacuation of tinence. Lumbar puncture yields CSF under normal pressure. Diagnosis
the clot through an appropriately sited burr hole or a craniotomy is life is made by CT or MRI. Symptoms can be remediated by CSF shunting.
saving. A small haematoma can be managed nonoperatively.