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Traumatic Brain Injury: Patterns of Failure of Nonoperative Management

Patel, Nirav Y. MD; Hoyt, David B. MD; Nakaji, Peter MD; Marshall, Lawrence MD; Holbrook, Troy PhD; Coimbra, Raul MD; Winchell, Robert J. MD; Mikulaschek, Andrew W. MD

The Journal of Trauma: Injury, Infection, and Critical Care: March 2000 - Volume 48 - Issue 3 - p 367-375
Annual Meeting Articles
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Objective: The circumstances of failure for nonoperative management of blunt traumatic brain injury have been poorly defined. In this study, all trauma patients identified over a 12-year period with progression of neurologic injury requiring craniotomy were retrospectively reviewed.

Methods: Data collected included demographic information, mechanism of injury, field and admission vital signs, and Glasgow Coma Scale score, medications, associated injuries, and coagulopathy. Head computed tomographic scans were reviewed, and anatomic findings were correlated with clinical changes (change in mental status or elevation of intracranial pressure) that led to subsequent CT scan and craniotomy.

Results: Of 20,100 patients, there were 852 who had computed tomographic scans with acute intracranial injuries on admission; 462 patients were managed nonoperatively. Fifty-seven patients had progression of neurologic injury (34 < 24 hours = early; 23 > 24 hours = late) that required surgery.

Conclusion: Of the variables investigated, only anatomic location of injury was found to be predictive of early failure of nonoperative management. Frontal intraparenchymal hematomas are particularly prone to early failure. Clinical examination and intracranial pressure monitoring are equally important in detecting failure and should be an integral part of nonoperative management.

From the Department of Surgery, Division of Trauma (N.Y.P., D.B.H., R.C., R.J.W., A.W.M.), Division of Neurosurgery (P.N., L.M.), Department of Family Medicine (T.H.), University of California, San Diego, Medical Center, San Diego, California.

Address for reprints: David B. Hoyt, MD, Department of Surgery, Division of Trauma, UCSD Medical Center, 8896, 200 West Arbor Drive, San Diego, CA 92103-8896.

Submitted for publication September 25, 1999.

Accepted for publication December 17, 1999.

Presented at the 59th Annual Meeting of the American Association for the Surgery of Trauma, September 16–18, 1999, Boston, Massachusetts.

© 2000 Lippincott Williams & Wilkins, Inc.