Epidural Hematoma

All epidural hematomas > 30cc should be surgically evacuated regardless of the patient’s GCS.25

EDH <30cc and with less than 15mm thickness and less than 5mm midline shift with a GCS >8 without a focal deficit may be managed non-operatively with appropriate monitoring in the ICU setting. These patients should be urgently transported to an MTF with neurosurgical capability for monitoring in case they decompensate.

Subdural Hematoma

Craniotomy for evacuation of an acute SDH with a thickness >10mm or midline shift > 5mm regardless of the patient’s GCS.

Craniotomy for evacuation of acute SDH with a thickness <10mm and shift <5 mm is indicated when there is a decrease in GCS of 2 or more, worsening pupillary exam, and/or and ICP greater than 20mm Hg. 25

Traumatic Parenchymal Lesion

Craniotomy for evacuation of a hematoma is indicated in a patient with GCS of 6-8 with frontal or temporal contusions greater than 20 cc in volume with midline shift or at least 5mm and/or cisternal compression on CT. 25

Craniotomy for evacuation of a hematoma is also indicated in patients with lesions greater than 50 cc in volume in a salvageable patient.

Posterior Fossa Mass Lesion

Mass effect on non-contrast CT or with neurological dysfunction or deterioration due to the lesion should undergo operative intervention as soon as possible. 25

Traumatic Aneurysms

A high index of suspicion is required for penetrating injuries of the skull base or across known major vascular territories. All penetrating brain injuries should undergo a CT Angiogram or Digital Subtraction Angiogram to rule out or diagnose a traumatic aneurysm as soon as possible.8

Debridement

Removal of devitalized brain tissue is an option in penetrating head injuries and in select cases of open skull fractures.71

Foreign Body Removal

The routine pursuit of individual foreign bodies (e.g., bullets, metallic fragments, bone) within the brain may cause additional tissue damage and is generally not advisable but should be left to the discretion of the neurosurgeon. Removal of fragments from the sensory, motor, or language cortex may reduce the risk of posttraumatic epilepsy.72

Dural Management

Primary dural closure or limited duroplasty should be done in extremely limited instances as cerebral edema can progress in both severe and penetrating traumatic brain injury. Commonly, duragen or other dural substitute should be used as an overlay in the vast majority of cases during a decompressive hemicraniectomy. Dura can be reconstructed with temporalis fascia or fascia lata if a dural substitute is not available.71

Decompression

Surgical decompression, or craniectomy, should be strongly considered following penetrating combat brain trauma.5,73,74

The kinetics of combat trauma can be very different from that seen in the civilian setting. The muzzle velocities of military rifles are much higher than civilian handguns which may lead to cavitation and surrounding devitalized tissue. Additionally, blasts can create four to five different classes of injury to the brain and other organ systems complicating management.75

1. Primary blast injury: blast overpressure from pressure waves.
2. Secondary blast injury: penetrating fragmentation injuries.
3. Tertiary blast injury: displacement of the casualty or blast debris that falls on the casualty.
4. Quaternary blast injury: injury from the thermal effect or release of toxins from the blast.

During transport, interventions for intracranial hypertension are limited to medical management. Craniectomy and en route monitoring devices may facilitate earlier CCATT transport of patients out of theater, however long-range evacuation is not a benign intervention and may increase secondary brain injury. In cases of elevated ICP or in the early postoperative period, patients may be better served by delayed evacuation if possible.

Skull Flap Management

Options for U.S. and Coalition Patients:

1. Those who have penetrating brain trauma: Do not save or send the calvarium as alloplastic reconstruction techniques are used for these casualties.
2. Those who have blunt trauma: Consider abdominal subcutaneous implantation of the calvarial flap for later reconstruction if it can be done in a sterile fashion.

Options for Host Nation Patients:

1. Clean and replace.
2. Clean and replace with hinge craniectomy. This involves partial fixation of the superior aspect of the bone flap, allowing it to “hinge” outward to accommodate swelling.76
3. Craniectomy with potentially limited chances for cranioplasty in the future, depending on local rules of eligibility.
4. In some locations, low temperature tissue freezing may be possible to allow replacement at a later time.

Exploratory Burr Holes (if no neurosurgeon or CT scan is available)

Exploratory burr holes have limited practical utility. They should only be performed by a neurosurgeon or after consultation with a neurosurgeon if possible and at a location where CT scan is not available to better guide management. Refer to the CPG entitled Emergency Life-Saving Cranial Procedures by Non-Neurosurgeons in Deployed Setting for additional guidance.

ICP Monitoring and Surgical Intervention (for Host Nation Patients)

Decisions to place ICP monitors or operate on host nation nationals should consider the available resources in the host nation for long-term care and rehabilitation.