This study retrospectively reviewed the clinical records of the severe head injury patients who were admitted to our university hospitals from January 2014 to August 2017. Nine hundred thirty-one severe head patients were admitted in this time period.
The inclusion criteria were the severe head injury patients who had no motor response or an extension to pain motor response after resuscitation and a radiologically surgical ASDH in the initial head CT scan. Criteria for defining a radiologically surgical ASDH were a hematoma thickness of > 10 mm and a midline shift of > 5 mm.
Two hundred six consecutive head injury patients met the inclusion criteria of this study. Their mean age was 42.3 years, ranging from 17 to 73 years. One hundred forty-two patients (68.9%) were males.
The clinical data were collected from the medical charts and included patients’ demographics, mode of trauma, the motor response and the pupillary reaction after resuscitation, laboratory findings, radiological findings, the time between trauma and admission, preoperative, operative, and postoperative details of the surgically managed patients, hospital stay, and in-hospital mortality.
All patients were admitted to the intensive care unit (ICU) and initially managed according to the Advanced Trauma Life Support guidelines. They were intubated and ventilated to avoid hypoxia and to achieve normocapnia. Central venous line and Foley catheter were inserted for fluid balance.
After vital stabilization, all patients underwent head and cervical spine CT scan. CT thoracic spine and lumbar spine were ordered for polytrauma patients.
All the patients received a prophylactic antiepileptic (phenytoin) and a proton pump inhibitor upon admission. Intramuscular tetanus toxoid 0.5 ml and intravenous antibiotics were administered to patients with open wounds.
General care to minimize intracranial hypertension was applied and included elevation of the head of the bed 30°, keeping the head in a neutral position, controlling fever with antipyretics and cooling blankets, avoiding hypoxia and hypercapnia, controlling blood glucose to a range between 80 and 180 mg/dL, optimizing the blood pressure, and correcting serum electrolytes. Packed RBCs were administered to maintain hemoglobin concentration at a minimum of 10 g/dL.
The neurological status was classified according to the GCS score. Intracranial pressure monitoring was not performed in any patient due to unavailability. ASDH was managed either conservatively or surgically, based on the decision of the treating consultant of neurosurgery and after a written informed consent from the patients’ relatives or the manager of our hospital for the anonymous patients. Consultants who chose the conservative treatment were expecting unfavorable outcomes.
Platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degradation products, and D-dimer were obtained daily to detect any coagulopathy.
Patients were kept euvolemic with isotonic fluid resuscitation as required. Intravenous (IV) mannitol 20% was administered in an initial bolus of 1 g/kg then 0.5 g/kg q 4 h, provided that there was no hypotension. IV furosemide 1 mg/kg/day was administered 15 min after each dose of mannitol. Serum electrolytes and renal function were ordered every 12 h. Serial serum osmolarity levels were checked every 12 h to maintain an osmolarity of no more than 320 mOsm/L.
For the surgically managed patients, a wide trauma scalp flap and a wide fronto-temporo-parietal craniotomy were employed. The dura was linearly incised to decrease the intracranial pressure then a dural flap was produced to evacuate the subdural blood clot. Meticulous hemostasis was achieved followed by wide duroplasty using a large pericranial patch. The bone flap was reinserted except in cases with severe intraoperative brain swelling which did not respond to mannitol and hyperventilation; in these cases, the bone flap was placed in a subcutaneous pocket in the scalp or in the abdomen. A follow-up head CT scan was done on the first postoperative day. Drains were removed on the second or third postoperative day when the draining fluid decreased to less than 50 ml in 12 h. Sutures were removed 2 weeks after surgery.
The outcome was assessed and recorded using the Extended Glasgow Outcome Scale (GOSE) 1 month after trauma. The functional outcome was classified as “good” if the GOSE scores were ≥ 5 and as “poor” if GOSE scores were ≤ 4 .
The collected data were expressed as mean and range using SOFA statistics version 1.3.3 software.