Textbook of Traumatic Brain Injury AK Mahapatra, Raj Kumar, Raj Kamal
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1Textbook of Traumatic Brain Injury2
3Textbook of Traumatic Brain Injury
Editors AK Mahapatra MS MCh DNB MAMS FNASc Professor and Head Department of Neurosurgery All India Institute of Medical Sciences New Delhi, India Ex-Director Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India Raj Kumar MS MCh FASET FRCS MRCS MAMS MNASc Professor and Head Department of Neurosurgery Chief Trauma Center Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India Raj Kamal MS MCh Former Assistant Professor Department of Neurosurgery All India Institute of Medical Sciences New Delhi, India Foreword DK Gupta
4
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This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the editors.
Textbook of Traumatic Brain Injury
First Edition: 2012
9789380704760
Printed at
5Dedicated to
Our Respected Parents
and
Teachers
Head injury does not mean clot in brain, nor clot in brain means an operation, nor operation means cure.
– AK Mahapatra
– Raj Kumar
– Raj Kamal
6
7Contributors 9Foreword
Textbook of Traumatic Brain Injury published by Professors AK Mahapatra, Raj Kumar and Raj Kamal is not just another book in the field of Neurosurgery. The book deals with various chapters, dealing with the practical management of the patients presenting with various types of head injuries. The book is a ready-reference not only for the specialists but also to the general surgeons, the postgraduate students and all others engaged in treating children and adults with head trauma.
Trauma is a major problem not only in the developed world but also in developing countries and head injury tops it all; contributing for about 10% of the five million deaths occurring each year globally due to various kinds of injuries. In India, over 270 individuals are killed in various road-traffic accidents each day and over, 5,000 individuals suffer from long-term disabilities.
Presently, there are very few specialized trauma centers in the country; however, due to a recent awakening; many trauma centers even with postgraduate teaching and training programs are being established throughout the length and breadth of this country. Once established, there would be large need for the intensivists, researchers, general surgeons, neurosurgeons and paramedical staff tuned to handle the emergency services with promptness, compassion and care.
The contributors are very eminent and highly competent neurosurgeons of national and international fame. They have many decades of experience to back them. This is reflected very well in the book. The chapters have been written in a simple language with a clear flow of thought. The book clearly emphasizes the importance of preventive strategies at the regional and national levels including the three-tier-system of trauma management promoted by the Government of India. The book also carries the much-needed recent information in improving the outcome of the roadside accident victims.
This textbook will certainly contribute to the better understanding and management of patients with head injuries. I am sure that the book would prove very handy to the undergraduate and postgraduate students as well as to the specialists equally. The book is a welcome addition to all departmental and institutional libraries as well as being a personal asset to all the neuroscientists.
DK Gupta ms mch fams frcs (Edins Glas) dsc (hc)
Vice Chancellor
Chhatrapati Sahuji Maharaj Medical University
(Formerly KG Medical University)
Lucknow, Uttar Pradesh, India10
11Preface
Injuries claim approximately 5 million lives every year worldwide. India with its 1.25 billion population has a large share of this. Two hundred and seventy people are killed every day in India following road-traffic accidents and about 1000 people sustain permanent injuries every day. Surprisingly, there is a limited exposure to medical students during undergraduate teaching. This is by and large due to lack of neurosurgery departments and teachers. Similarly, the situation is not much different in the postgraduate courses in general surgery. Even today, many neurosurgical centers do not treat head and spinal injury patients, as a policy and send their MCh and DNB students to another neurosurgical centers for a few months training. This has raised a big question about the quality of head injury care.
Currently, there are more than 1,200 neurosurgeons in India and with over 75% working in the large cities; hence there is very little scope of having neurosurgery department in many peripheral medical colleges. In years to come, we expect head injuries to be managed by general surgeons. Realizing India's vast population and area, it is impossible to think of a neurosurgeon in each district hospital. Hence, our aim should be to provide MBBS and MS (General Surgery) students adequate exposure and skills to manage neurological injuries, though we do not expect them to operate. At this stage, it is important to realize that 90% head injuries are minor and where patient may not require either neurosurgical intervention or ICU care. What they really need is primary care, skilled observation and assurance for confidence building. Doctors and paramedics should also be trained to prehospital care including transport of severely injured patients.
With these considerations in mind, 56 chapters in the book include all important academic and clinical aspects involved in management of head injury. Some important aspects like fluid and electrolytes management which are usually overlooked. This is especially important as a large number of severely head injury patients develop metabolic and electrolyte disturbances requiring meticulous management. Endocrine problems not only occur in severely injured patients, minor head-injured patients with short-and long-term effects, adversely affect the outcome. Infective complications, like meningitis and brain abscess, are not uncommon and require special mention. Coagulopathies also in head injury patients play an important role in the management of head injuries. Rare aspects, like post-traumatic basal ganglia hematoma, traumatic cerebellar hematoma, dural sinus thrombosis, CSF otorrhea and skull base fractures, facial injuries and atlantoaxial injuries, are also included to complete the list of complications of neurosurgical trauma.
The book has been written in such a manner that it will benefit young trainee neurosurgeons, trauma experts, medical students, teachers and also academicians practicing in the area of head injury and its management. It will give some important insight to researchers in the area of genetic and molecular aspects of head injury.
AK Mahapatra
Raj Kumar
Raj Kamal
23Abbreviations
A
AAMVAs
— American Association of Motor Vehicle Administrators
AANS
— American Association of Neurological Surgeons
ABGs
— Arterial Blood Gases
ACA
— Anterior Central Artery
ADH
— Antidiuretic Hormone
AMPA
— (2-amino-3-(5-methyl-3-oxo-1, 2-oxazol-4-yl) propanoic acid)
ANP
— Atrial Natriuretic Peptide
APV
— Anterior Posterior View
APP
— Amyloid Precursor Protein
APTT
— Activated Partial Thromboplastin Time
ARDS
— Adult Respiratory Distress Syndrome
ATLS
— Acute Trauma Life Support
AVDO2
— Arteriovenous Desaturation of Oxygen
AVM
— Arteriovenous Malformation
B
BAEP
— Brainstem Auditory Evoked Potential
BBB
— Blood-brain Barrier
BISIG
— Brain Injury Interdisciplinary Special Interest Group
BNP
— Brain Natriuretic Peptide
BSH
— Brainstem Hematoma
C
CNG
— Compressed Natural Gas
CBF
— Cerebral Blood Flow
CCF
— Caroticocavernous Fistula
CCT
— Central Conduction Time
CG
— Ciliary Ganglion
CMRO2
— Cerebral Metabolism Rate of Oxygen
COAD
— Chronic Obstructive Airway Disease
CPP
— Cerebral Perfusion Pressure
CS
— Cavernous Sinus
CSF
— Cerebrospinal Fluid
CSWS
— Cerebral Salt Wasting Syndrome
CT
— Computed Tomography
CVP
— Central Venous Pressure
CVR
— Cerebral Vascular Resistance
D
DAI
— Diffuse Axonal Injury
DCS
— Dorsal Column Stimulation
DI
— Diabetes Insipidus
DIC
— Disseminated Intravascular Coagulation
DNA
— Deoxyribonucleic Acid
DSA
— Digital Subtraction Angiography
DSI
— Day Since Injury
DTPA
— Diethylene Triamine Pentaacetic Acid
E
EM
— Excitatory Amino Acid
EACA
— Epsilon Aminocaproic Acid
ECA
— External Carotid Artery Special Interest Group
ECD
— Ethylene Cytosine Dimer
ECF
— Extracellular Fluid
EDH
— Extradural Hematoma
EEG
— Electroencephalography
EO
— Evidence of
EP
— Evoked Potential
EVD
— External Ventricular Drainage
F
FDP
— Fibrin Degradation Product
FFA
— Free Fatty Acid
FFP
— Fresh Frozen Plasma
FIB
— Fibrinogen Assay
FSH
— Follicular Stimulating Hormone
FV
— Flow Velocity
G
GH
— Growth Hormone
GABA
— Gamma Aminobutyric Acid
GCS
— Glasgow Coma Scale
GOS
— Glasgow Outcome Scale24
GR
— Good Recovery
GnRH
— Gonadotropin Releasing Hormone
I
ICF
— Intracellular Fluid
ICH
— Intracerebral Hematoma
ICP
— Intracranial Pressure
ICU
— Intensive Care Unit
IIT
— Insulin Tolerance Test
IVH
— Intraventricular Hemorrhage
L
LED
— Light Emitting Diode
LGB
— Lateral Geniculate Body
LP
— Lumbar Puncture
M
MAP
— Mean Arterial Pressure
MCA
— Middle Cerebral Artery
MCTC
— Metrizamide Computed Tomograpy Cisternography
MD
— Mild Disability
MLF
— Medial Longitudinal Fasciculus
MOFS
— Multiple Organ Failure Syndrome
MP
— Methylprednisolone
MRC
— Medical Research Council
MRI
— Magnetic Resonance Imaging
N
NHDS
— National Hospital Discharged Survey
NIH
— National Institute of Health
NMDA
— N-Methyl-D-Aspartate
NOS
— Nitric Oxide Synthetase
NSI
— Neurological Society of India
P
PCA
— Posterior Cerebral Artery
PCS
— Post-concussion Syndrome
PDS
— Paroxysmal Depolarization Shift
PEEP
— Positive End-expiratory Pressure
PET
— Positron Emission Tomography
PFEH
— Posterior Fossa Extradural Hematoma
PGD
— Prostaglandin
PI
— Pulsatility Index
PT
— Prothrombin Time
PTA
— Post-traumatic Amnesia
PTE
— Post-traumatic Epilepsy
PTH
— Post-traumatic Hydrocephalus
PTN
— Pretectal Nucleus
PTT
— Partial Thromboplastin Time
PVS
— Persistent Vegetative State
R
RBC
— Red Blood Corpuscle
REM
— Resting Metabolic Expenditure
RIA
— Radioimmune Assay
RN
— Red Nucleus
S
SAH
— Subarachnoid Hemorrhage
SD
— Severe Disability
SDH
— Subdural Hematoma
SEPs
— Sensory Evoked Potentials
SIADH
— Syndrome of Inappropriate ADH Secretion
SO
— Suggestive of
SOV
— Superior Ophthalmic Vein
SPECT
— Single Photon Emission Computed Tomography
SSS
— Superior Sagittal Sinus
T
TBGH
— Traumatic Basal Ganglia Hematoma
TBI
— Traumatic Brain Injury
TCD
— Transcranial Doppler
TPN
— Total Parenteral Nutrition
TCDB
— Traumatic Coma Data Bank
TCT
— Thrombin Clotting Time
TDAI
— Traumatic Diffuse Axonal Injury
THAM
— Tris-hydroxymethyl aminomethane
TIA
— Transient Ischemic Attack
TPFL
— Traumatic Posterior Fossa Lesion
TSH
— Thyroid Stimulating Hormone
V
VOC
— Voltage Operated Channel
VOR
— Vestibulo-ocular Reflex
VP
— Ventriculoperitoneal
W
WHO
— World Health Organization