Hello, everyone. My name is Ryan Kitagawa. I am the Director of Neurotrauma and Associate Professor at the University of Texas Health Sciences Center in Houston and Memorial Hermann Hospital. And today I'll be talking about complication avoidance in traumatic brain injury. I have no specific disclosures for this. So the outline of my talk will divide up the complications into three forms, the first of which is sort of the immediate complications and those that happen interoperatively. The second is the complications that happen after the surgery is done. And then of course, a unique disease in our field of expertise is penetrating traumatic brain injury with its own unique set of complications. And therefore, I'll be talking about that separately as well. So to start off with the interoperative or immediate complications after the patient arrives. And the first one is lacerations. You see here a patient with a severe traumatic brain injury with a displaced fracture that's going to require surgical treatment. But an open laceration has made it a little more complicated to how to deal with that. And we can also have very complicated situations such as penetrating injury with gunshot wounds, as well as the most complicated, and that is a shotgun blast to the face. I'm not going to go through the techniques we use for that final case simply because that requires plastic surgery assistance and otherwise, but to really focus on sort of the things that we see on a relatively frequent basis. So in order to judge how we figure out our incisions, we need a lot of tools in our toolkit in order to be able to modify these more traditional incisions for the more complicated of scenarios. You know, the reverse question mark incision, ipsilateral to the side of the lesion is sort of the workhorse incision in my practice. It allows for easy anatomical identification, but also, of course, when it comes time for the cranioplasty, if necessary, can make that procedure much, much easier. But you have to have multiple tools to utilize. You know, the reverse question mark incision extending to the contralateral side to allow for more exposure. This additionally, if you have lacerations sort of in the middle of the incision, this allows for a more broad blood supply to your flap. The traditional T-shaped incision that's been popular in the military is another option. A coronal incision incorporating a teeing off incision is an option as well, as well as your traditional tereonal incision where you have to tee it off posteriorly. You know, this is one that we occasionally use in situations such as an epidural hematoma that would have been a craniotomy but has to be converted to a craniotomy as a result of intracerebral edema. And, you know, we have to modify these based on appropriateness. And so this is a patient that I had who had a gunshot wound through the eye, required a decompressive hemicraniectomy on the left side, but also had a widely exposed and open frontal sinus fracture that would require cranialization at a later time after stabilization. This is a patient where I chose to do a three-quarters coronal incision and teeing it off posteriorly so that on the initial index surgery with a decompressive hemicraniectomy, we have a good exposure there. But also when it comes time for the cranialization of the frontal sinus when the patient is more stable, this allows us to have a good incision for that. So the key concepts of this, first and foremost, preserve the vascular supply to the scalp. I generally try to incorporate the laceration if I can, and that way the blood supply that has already been disrupted is not worsened. If this is not possible, then a larger incision is usually favored to allow for a better blood supply, as we discussed. All of my surgeries, I preserve the superficial temporal artery if it is possible, and that allows for a better blood supply to the flap as well. Always do a larger prep, even if you have a situation like we described before where it's planning to be a craniotomy for a simple epidural hematoma. You never know when things could turn more dangerous and require a larger incision and a decompression. So always be prepared for that. And of course, leave enough room for the drain and the ventriculosomy catheter if necessary in your overall prep. The other tools that you want to use, extensive undermining is sometimes necessary in order to get the flap closed. Scoring of the galea with a sharp incision can sometimes be good to allow for a larger flap for closing. Relaxing incisions is sometimes necessary, but when you're getting into that, usually involving a plastic surgery or another facial surgery service is important. And with all these tools, you can take a very complex incision or complex laceration and turn it into a relatively simple and straightforward opening and closure. So cerebral edema is another complication that we encounter quite frequently in traumatic brain injury. And it is important not only for your practice, but also for those of you taking the oral board exam. This is a very common complication to be given to you during that oral board exam. And what I always tell those that I lecture to and my trainees is that when the brain starts swelling out, it's a very anxiety provoking moment during the surgery. And first and foremost, pretend that you're at the bedside with a closed head and the ICP is extremely high. For example, if the ICP is 50, we've all seen it on many occasions. It's something that we're very comfortable with and we can calmly take care of those things. So do the same thing even when the skull is open. Elevate the head of bed. Okay. Improve the venous return. If you're at the bedside, you usually loosen up the cervical collar. If you're in the operating room and the patient is turned with their head turned, make sure that the neck is not kinked. Hyperventilation of course. Hyperosmolar therapy, whether it be with mannitol or hypertonic saline is a reasonable thing. If you're at the bedside and the patient has an interparenchymal monitor, converting that to a ventriculostomy catheter is reasonable. And the same thing is true interoperatively. Place that ventriculostomy catheter. I usually do it with the guidance of an ultrasound to make it a little bit easier. But you already have that ultrasound there. So of course you want to make sure there's not bleeding under the surface that you could potentially evacuate to create more room. Same with the complex lacerations, undermining and galeoscoring to allow for more flap in order to close. The temporalis muscle can be resected in order to create more room to have to avoid doing a frontal temporal lobectomy. Many times as the brain is swelling, closing as fast as possible is sort of the best thing to get the patient out of the operating room. But if you have no other options, the frontal temporal lobectomy is sort of the end stage of what you need to do in order to get the skin closed. So we've dealt with the lacerations. We've dealt with the intercerebral edema, and now we're dealing with the hemorrhage. What do you do in a circumstance where the hemorrhage is out of control or the patient is coagulopathic? Well, first of all, for coagulopathies, we have many tools to identify why the coagulopathy is present. So I use thromboelastography in my practice very frequently. And if it's not something you've used before, I think it is worth getting to know these things. PTRNR-PTT is sort of one of our tried and true methods, particularly in patients who are on anticoagulations such as warfarin, and antiplatelet effect assays, particularly in patients where you don't know their history. So you see this patient here, who's a 67-year-old male, fall and has a very recent stent on aspen and clopidogrel. This is a patient where very frequently hemorrhages are quite common. And so the first step is to, of course, medically correct the coagulopathy. Have a lot of different hemostatic products available for you in the operating room. Sometimes if the patient's own hemostatic pathways are inhibited, we have to encourage that with other methods. In penetrating or skull base fracture, sometimes you need to drape the neck or be in an endovascular hybrid suite in case you have a significant amount of arterial hemorrhage from the skull base. Taking a piece of the temporalis muscle and using it as a muscle plug can be an effective way to obtain hemostasis. And one of the other methods that I've learned over the course of the years of my practice is that the dura quite frequently can be very hypervascular and can bleed a lot. If it's getting to the point where it's bleeding a significant amount, you can always just resect the central portion of the dura and suture in a dural patch, which usually not only cures the hemorrhages but also acts as a hemostatic agent for epidural hematomas later on. So the medical reversal of these, it has to be directed specifically to what agent the patient is on. In terms of things like antiplatelet agents like aspen or clopidogrel, we really don't have a good reversal agent. Platelets, transfusions is sort of the hallmark of how we treat this. DDAVP is frequently used in patients with platelet dysfunction from uremia and kidney issues. It can also be used in the operating room for these antiplatelet agents. Warfarin has a lot more methods that we can reverse it, whether it be vitamin K, FFP, PCC, or factor VII. In an operative patient, PCC is sort of my treatment of choice, but you have to judge it based on why the patient is on the anticoagulation. IV heparin can be reversed with protamine. Anoxaparin with FFP and protamine, although this is an imperfect way, unlike heparin where it reverses very quickly, anoxaparin can be quite a challenge. Thrombolytics, extremely challenging thing, particularly in a patient, for example, who has a large territory stroke that has a hemorrhagic transformation as a result of that. Cryoprecipitate, FFP, and TXA are the mainstays of this. The newer agents, direct thrombin inhibitors and factor Xa inhibitors can be a very big challenge. Both of these have direct antidotes for each of these. These can be quite expensive and not readily available in a lot of institutions, and so many times we have to resort to things like four-factor PCC, particularly in factor Xa inhibitors. We've dealt with cerebral edema. We've dealt with lacerations. We've dealt with hemorrhages. Well, there's also other things about the patient intrinsically that can be very complicated, particularly in an emergency surgery situation. We have this particular patient here that I dealt with, a 76-year-old male, hypertension, hyperlipidemia, on dual antiplatelet agents, had a syncopal fall. He's awake, alert, has no focal deficits, but does have quite a significant subdural hematoma. Now, the thing that concerned me the most was the fact that the patient passed out before their fall, and so we had time in this awake and alert patient in order to do an echocardiogram, and that showed critical aortic stenosis. This is a patient where you want to pause. You want to not rush this patient to the operating room, particularly since they're essentially neurologically intact, and you want to work this up further. The cardiologist basically told us that they were not able to treat the aortic stenosis in this acute period of time, and so we're left with a very challenging circumstance in a patient who is very high risk for surgery and yet does have a lesion that could potentially be operative, and so knowing that ahead of time allowed us to treat this lesion. We basically left the lesion alone until it lysed into a subacute subdural hematoma. We did the patient awake with burr holes to drain it out to avoid the potential complication for the aortic stenosis, and the patient did quite well along the way. So us as neurosurgeons, we need to know the things that we need to inform our anesthesiologist on, and in my discussions with many anesthesiologists, the things that they're most concerned about. Severe aortic stenosis, particularly in a patient with a depressed ejection fraction. Compressive pulmonary mass. That's a patient who, despite being intubated, can lose their ventilation quite quickly. Active cardiac ischemia is another thing that they're concerned about. Pulmonary hypertension and pulmonary fibrosis are something that are not necessarily contraindications for surgery but something that they need to know about ahead of time. And one of the things that I always perceived as a significant problem is congestive heart failure, but as long as it's not decompensated, it's something that most anesthesiologists are comfortable in dealing with interoperatively, particularly in an emergency situation. So we've gone through a lot of the immediate and interoperative complications, and now we move on to the post-operative complications specifically for traumatic brain injury. How do we deal with those as they come up? So hygromas is a very big challenge, particularly in the decompressive hemicraniectomy population. If you look at this patient that I dealt with very early in my career that I learned a lot from, you know, we can talk about the hygroma. So he's a 26-year-old male, status post a very high velocity injury with what we see here as an operative left-sided subdural hematoma. The patient underwent an uncomplicated decompressive craniectomy with clot evacuation. As you can see, there was some ischemia as a result of the patient's herniation prior to surgery. Now the patient, it recovered quite well. He was hemiplegic and aphasic, but was at least awake and localizing on one side. And on hospital day seven, we noticed that his flap was significantly more full, and therefore we obtained imaging studies that demonstrated a large hygroma on that side. This hygroma became symptomatic, and therefore we did a burr hole to drain out that lesion. On hospital day 14, the flap was full again, and here we go again with a large-sided hygroma, this time on the ipsilateral side. We did serial aspirations on this lesion, and it proved to be refractory. My thought was because the incision wasn't fully healed to instead do a ventricular peritoneal shunt on this patient. And in actuality, immediately after the ventricular peritoneal shunt, everything was doing fine. And then the flap became full again several days later, and what actually happened was that their ipsilateral hygroma grew to the point where it actually pushed the shunt out of the ventricle. And so now we're dealing with a complicated situation of bilateral hygromas, and what do we do in this particular patient? And so we converted the ventricular peritoneal shunt to a subdural peritoneal shunt, allowed that to decompress, and then did perform a cranioplasty on the patient. Now, it is important to note that this is obviously a sign of hydrocephalus and a sign of a disorder of CSF absorption. And so we had to be prepared to eventually put an infraventricular shunt back. And so what I learned from this patient and in my practice over the years is that these can be quite a challenge. If the hygroma is asymptomatic without significant mass effect, generally speaking, I just monitor these. Many times when the hygroma is underneath where the decompression is, those would just resolve on their own. If it is expanding and causing mass effect, what I do is I do a contralateral burr hole to drain out that fluid, and I plan that incision such as a shunt. If it is ipsilateral to the side and causing problems, I do serial aspirations, but ultimately the treatment for this is a cranioplasty. So for example, in the patient that we looked at before, the mistake that I made under these conditions was I should have drained out the ipsilateral hygroma, allowed the wound to heal, perform the cranioplasty, and then converted the ipsilateral drain into a ventricular peritoneal shunt. So in general, if they're refractory and have concerns, then do a cranioplasty. Many times you'll actually see patients who have these large hygromatous things, but the flap is actually quite sunken, and in those conditions, a cranioplasty is ultimately the treatment for that of choice. Post-trefunation syndrome, okay? This is a disorder that we see frequently with decompressions. So we see this 70-year-old male that was hit by a bicycle, was localizing on exam. At 70 years of age, generally speaking, I really try to put the bone back on, but this particular patient had a significantly swollen brain, and on ultrasound had multiple contusions, and so we elected to leave the bone off. You see his immediate post-op CT, and his CT at one week, where the patient actually recovered quite well and was awake and following commands. At three weeks, when the patient was getting ready to go to rehab, we see his imaging study here. His flap was full but soft, and we're at a point where we were comfortable in allowing him to go to rehabilitation. At one month, really just a week later, we got contacted because his right-sided weakness was significantly worsened, and he was no longer able to walk. And what we see here is that the flap is sunken in quite a bit, and we see compression of the underlying brain. So what is post-trefunation syndrome? Well, it's atmospheric pressure pushing against the skin, which is pushing against the brain itself that's causing symptoms. So these can be highly variable. Sometimes they become quite mild. A lot of patients with hemicraniectomies complain of headaches and dizziness, and many times it does improve with the cranioplasty. They can develop, like our patient, a moderate amount of hemiparesis, but still awake and alert and following commands. Under the most severe of circumstances, you can have patients who, if they are minimally conscious to begin with, they develop these severe stormy episodes in a delayed fashion. Under the worst of circumstances, herniation can be involved. It's usually worse when patients are older and have more cerebral atrophy. If they have very significant cerebral edema at their time of surgery, and as the cerebral edema decreases, the brain can get quite sunken as they have loss of cerebral tissue. And of course, the patient with a decompressive hemicraniectomy that requires a shunt are very high risk from over-shunting. So how do we treat this? This is an urgent situation, but you don't need to go emergently to the operating room. You need to relieve the atmospheric pressure against the flap itself. So lay the head of bed flat, or even in a Trendelenburg position to allow this to expand out. So when I get a call in the middle of the night, patient has deteriorated, their flap is very sunken. I don't need to rush that patient to the OR. Leave them flat, work up their condition, make sure it's not something else, hydrate them. If they have a shunt, increase the shunt setting to the maximum setting. But ultimately the treatment is cranioplasty in these patients. It doesn't need to be done in an immersion fashion, but certainly should be done relatively urgently along the way. Wound breakdown. This can be a big challenging circumstance. There are patients who pick at their wounds. There's patients who have very poor nutrition as a result of their severe brain injury or their baseline conditions. And so sometimes the wound doesn't heal so well. So of course the best treatment is avoidance. What we see here is a patient with a cervical collar where the cervical collar was rubbing up against their skin behind their ear and causing this ulceration. So remove their collars if they're not necessary. Mobilize the patient early. The most likely place of wound breakdown is always towards the back where the head is rubbing against the bed or the pillow. Particularly in posterior fossa decompressions, very common problem. Keep the posterior wound off the bed. If the patient has a tracheostomy and it's rubbing up against that area, make sure there's a lot of padding in the back. If you start noticing an early breakdown, early washing and rinsing with ointment, not because it necessarily protects against infection, but more it keeps the friction against the skin from causing those problems. And then daily dressing changes, of course, with things like xeroform that allows for a friction-free closure. And in the end, a lot of times we can manage these things without an operation. We see this patient here who very frequently was picking at the wounds. We superficially debrided those eschars. We allowed for improved nutrition, kept the patient away from the wound. And many times these things will heal up on their own. Now, when does a wound need to be revised? If there is an infection, if there's ulcers that are not responding to traditional treatments, or if the eschar or the wound dehiscence goes all the way down deep to the galeo layer, that's a situation where things need to be revised. So in our final minutes, we'll talk about penetrating head injury. This is a unique disease that often requires a unique treatment. Pseudoaneurysms, the intraoperative or immediately operative things that we have to worry about after penetrating trauma. At my institution, we work very hard to have a very specific protocol where every patient with a suspected penetrating head injury automatically gets, along with their non-contrast head CT, CT angiography, as well as CT venography. In general, if the patient is not acutely herniating and you do need to do a surgery, but not right away, and there is a pseudoaneurysm, I recommend you treat the pseudoaneurysm first. These can be very challenging to treat intraoperatively because the walls are very, very thin because of its pseudoaneurysm status. It also can bleed from deep down below, or the brain could be very swollen, which could make it very challenging. And so in our practice, any patient with a post-traumatic pseudoaneurysm usually goes to the hybrid suite. They're treated immediately for the aneurysm and then immediately treated afterwards for their surgical intervention. If you need to go in because of herniation syndrome or a massive hemorrhage, having aneurysm clips ready and potentially draping out the neck if it is a skull-based lesion is an important thing to know. You also have to realize is that not only is there a risk of pseudoaneurysms immediately, there's risks in a delayed fashion. We do always do a CTA at admission. We always do a CTA or a conventional angiogram at one to two weeks. We decide between the two based on how much fragmentation and how much bullets and whatnot are still contained within the brain itself. If you can't get a good look with the CTA, then an angiogram is necessary, as you see in this patient here who ended up after decompression having a delayed aneurysm rupture. CSF leakage, a big, big challenge, particularly when it's a skull-based lesion like we see here where the anterior skull base has been disrupted. Pericranial graft at the time of surgery is a very important thing. Ventriculostomy or lumbar drain is a good way to do it. Bony reconstruction is sometimes necessary if you have a large defect within the skull base. And in this particular patient and many who it passes through the anterior skull base or the frontal sinus, sometimes cranialization of the sinus is necessary. Infections are a common problem. And the big question that we always get is what do we do about antibiotics? You know, there really is no clear data. There are some recommendations out there. Hopefully in the near future, we will have some guidelines and recommendations as things are revised. But the options, you know, just perioperative like any other surgery, three to four days sort of in the perioperative period and seven days is sort of the maximum timeframe that we use it. You have an option of just your traditional Cefazolin or you can do broad spectrum antibiotics along the way. And in my practice, it really depends on the degree of contamination and the amount of retained foreign bodies. You know, if it is your very simple surface related gunshot wound in an awakened alert patient, you do a debridement, a cranioplasty at the time of surgery with titanium mesh or other reconstructive materials. That patient really just a perioperative as long as you get a good washout is fairly reasonable. In a patient who it's involving the skull base, if you have very large, wide open lacerations, if there's an active CSF leak, those are the ones where I tend to do for a prolonged period of time with broad spectrum antibiotics under those conditions. Bullet migration is something that we do see on occasion. You see this particular patient here who had a posterior fossa debridement where the bullet migrated interiorly. Really the overwhelming majority of time, the bullet does migrate a little bit. The overwhelming majority of time, you don't need to do anything about it, okay? If you're in there already and for example, for a cranioplasty and the bullet is right on the surface, it is reasonable to address that. If the bullet migrates to the point where it causes something like obstructive hydrocephalus, that's a reason to intervene. But the majority of cases, you don't need to do anything about the bullet migration. It's more of a radiographic finding than a clinical issue. So that concludes my presentation. I thank you very much for your attention.

complication avoidance

traumatic brain injury

interoperative complications

cerebral edema

hemorrhages

penetrating TBI complications