- Establish teleconsultation with neurosurgeon. Video consultation is preferred. If unable to communicate with a neurosurgeon, recommend a multi-disciplinary discussion that includes the local command authority prior to proceeding.
- Make every effort to evacuate the patient to a facility where neurosurgery is available within approximately 4 hours.
- Assess indications for craniectomy.
- Assess availability of follow-on care.
- Ensure that maximal medical/critical care management and resuscitation of the patient’s intracranial condition has occurred. This should include appropriate blood component resuscitation, 3% saline, anticonvulsant, sedation, etc. in accordance with the JTS Neurosurgery and Severe Head Injury CPG.2
- Ensure that the surgeon training and the facility resources are adequate.
- If all of the above indications are met, then, in consultation with a neurosurgeon (when possible), consider intervention as follows: (Note: Review Emergency War Surgery Manual for further details.3)
Closed Head Injury
If no CT scan is available, an accurate neurological examination must be obtained for the purposes of localizing the lesion. A skull X-ray may improve localization in cases of skull fracture or penetrating brain injury.
Proper positioning of the patient is very important.
- Avoid any compression of the neck to assure unhindered jugular venous outflow.
- The head should be positioned slightly higher than the chest.
- Rotate the head 30-40° off midline such that the side being operated on is highest.
- Mark the midline of the scalp, as well as the location of anticipated burr hole and craniotomy incisions, prior to draping the head.
Once localized, exploratory burr holes will be made over the frontal, temporal and parietal convexities using electric drill for the purposes of identifying a hematoma.
- If necessary, the dura can be opened carefully through the burr hole following cauterization if hemorrhage is subdural.
- If evidence of epidural or subdural bleeding or high intracranial pressure is encountered, a craniectomy should be performed.
- Burr holes alone are unlikely to be helpful in the setting of severe TBI.
Once the decision to proceed with craniectomy is made, the dura must be carefully separated from the inner table of the skull (Penfield 1-3 instruments) and the burr holes connected with the electric drill using either a side cutting bit or a “matchstick” bit.
- An appropriately sized craniectomy is usually at least 15cm long in the sagittal plane and 12cm in height in the coronal plane, however a smaller craniectomy may be advisable in the far-forward setting.
- Take care to stay off midline in order to avoid injury to the superior sagittal sinus.
- If the hematoma is epidural, it must be evacuated and the bleeding source cauterized.
- If subdural, the dura must be opened, the hematoma evacuated, and if visible, the bleeding source cauterized.
- Do not replace the bone.
- If not visible, do not search for a bleeding source.
- If subdural hematoma, do not close the dura.
In all circumstances, the scalp must be closed.
If the brain herniates rapidly out after dural opening, close the scalp immediately.
Penetrating Head Injury
Penetrating brain injury is one of the most challenging indications for cranial procedures performed by neurosurgeons.
- Exploration without teleconsultation from a neurosurgeon is not recommended.
- There is often deep and uncontrollable bleeding that may not be evident on the cortical surface.
- Surgical exploration below the surface of the brain is NOT recommended.
- Surgical intervention should be limited to removing bone, opening the dura, controlling bleeding, and closing the skin rapidly.
If cranial contents are herniated from either the entry or exit wound, allow this to continue. Do not close the wound.
Adequately resuscitate as necessary, and transport at the soonest opportunity.
If evacuation to a higher level of care is not possible, recognize that intervention in this case may be futile.