Guidelines for the Surgical Management of TBI
View the complete Guidelines, including methods and detailed evidence review here
The index of Guideline recommendations can be found below
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Indications for Surgery
An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient’s Glasgow Coma Scale (GCS) score.
An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center.
Timing
It is strongly recommended that patients with an acute EDH in coma (GCS score < 9) with anisocoria undergo surgical evacuation as soon as possible.
Methods
There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.
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Indications for Surgery
An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient’s Glasgow Coma Scale (GCS) score.
All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.
A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5mmshould undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.
Timing
In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.
Methods
If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
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Indications
Patients with parenchymal mass lesions and signs of progressive neurological deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on computed tomographic (CT) scan should be treated operatively.
Patients with Glasgow Coma Scale (GCS) scores of 6 to 8 with frontal or temporal contusions greater than 20 cm3 in volume with midline shift of at least 5 mm and/or cisternal compression on CT scan, and patients with any lesion greater than 50 cm3 in volume should be treated operatively.
Patients with parenchymal mass lesions who do not show evidence for neurological compromise, have controlled intracranial pressure (ICP), and no significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging.
Timing and Methods
Craniotomy with evacuation of mass lesion is recommended for those patients with focal lesions and the surgical indications listed above, under Indications.
Bifrontal decompressive craniectomy within 48 hours of injury is a treatment option for patients with diffuse, medically refractory posttraumatic cerebral edema and resultant intracranial hypertension.
Decompressive procedures, including subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy, are treatment options for patients with refractory intracranial hypertension and diffuse parenchymal injury with clinical and radiographic evidence for impending transtentorial herniation.
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Indications
Patients with mass effect on computed tomographic (CT) scan or with neurological dysfunction or deterioration referable to the lesion should undergo operative intervention. Mass effect on CT scan is defined as distortion, dislocation, or obliteration of the fourth ventricle; compression or loss of visualization of the basal cisterns, or the presence of obstructive hydrocephalus.
Patients with lesions and no significant mass effect on CT scan and without signs of neurological dysfunction may be managed by close observation and serial imaging.
Timing
In patients with indications for surgical intervention, evacuation should be performed as soon as possible because these patients can deteriorate rapidly, thus, worsening their prognosis.
Methods
Suboccipital craniectomy is the predominant method reported for evacuation of posterior fossa mass lesions, and is therefore recommended.
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Indications
Patients with open (compound) cranial fractures depressed greater than the thickness of the cranium should undergo operative intervention to prevent infection.
Patients with open (compound) depressed cranial fractures may be treated nonoperatively if there is no clinical or radiographic evidence of dural penetration, significant intracranial hematoma, depression greater than 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus, or gross wound contamination.
Nonoperative management of closed (simple) depressed cranial fractures is a treatment option.
Timing
Early operation is recommended to reduce the incidence of infection.
Methods
Elevation and debridement is recommended as the surgical method of choice.
Primary bone fragment replacement is a surgical option in the absence of wound infection at the time of surgery.
All management strategies for open (compound) depressed fractures should include antibiotics.