head and spinal cord injury diagnosis and strongmanagementstrong.pdf

Head and Spinal Cord Injury: Diagnosis and Management Prashant Chittiboina, MD, MPHa, Hugo Cuellar-Saenz, MDb, a c Christina Notarianni, MD , Raul Cardenas, MD , Bharat Guthikonda, MDa,* KEYWORDS Traumatic brain injury Intracranial pressure Management Cerebrovascular injury Pediatric Spinal cord injury Vertebral injury INTRACRANIAL PRESSURE MANAGEMENT In modern neurotraumatology, intracranial pressure (ICP) management is a central tenet. The incidence of raised ICP or intracranial hypertension (ICHTN) is very high in modern neurotrauma units. In patients with demonstrable mass lesions, up to 63% may have ICHTN. By contrast, up to 13% of patients with a normal initial computed tomogram of head (CT Head) may have ICHTN.1 Elevated ICP, in turn, is an independent predictor of worse outcomes in patients with severe traumatic brain injury (TBI).2–4 Increased ICP is also directly related to increased mortality in such patients.2 In patients with sustained ICHTN, control of ICP within thresholds leads to improved outcomes.5 In addition, inability to control ICP is a predictor of poor outcomes.1 Since the 1970s, significant reductions in morbidity and mortality have been achieved in patients with severe TBI with intensive management protocols. ICP control is an integral part of management protocols.6 Pathophysiology In TBI, ICHTN can be caused by various factors. Cerebrospinal fluid (CSF) parameters may be responsible for up to one-third of ICP elevation; predominantly due to a decrease in CSF absorption and an increased resistance to outflow. Vascular factors a Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, 1501 King’s Highway, Shreveport, LA 71130, USA b Division of