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Severe Traumatic Brain Injury: Evolution and Current Surgical Management

  • Authors: Randy S. Bell, MD; Chris J. Neal, MD; Christopher J. Lettieri, MD; Rocco A. Armonda, MD
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Target Audience and Goal Statement

This activity is intended for emergency room physicians, neurosurgeons, trauma surgeons, and others caring for patients with severe traumatic brain injury.

The goal of this activity is to review head trauma management guidelines.

Upon completion of this activity, participants will be able to:

  1. Outline the evolution of surgical approaches for severe traumatic brain injury (TBI) as they relate to current management
  2. Discuss the clinical approach to evaluate and treat persistently elevated intracranial pressure in patients with severe TBI
  3. Review head trauma management guidelines for severe TBI


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  • Randy S. Bell, LCDR, MC, USN, MD

    Resident, Teaching Fellow, Uniformed Services University of Health Sciences, Bethesda, Maryland; Senior Resident, National Naval Medical Center and Walter Reed Army Medical Center, Washington, DC


    Disclosure: Randy S. Bell, LCDR, MC, USN, MD, has disclosed no relevant financial relationships.

  • Chris J. Neal, MD

    Washington, DC

  • Christopher J. Lettieri, MD

    Associate Professor of Medicine, Uniformed Services University, Bethesda, Maryland; Staff Physician, Pulmonary, Critical Care and Sleep Medicine, Walter Reed Army Medical Center, Washington, DC


    Disclosure: Christopher J. Lettieri, MAJ, MC, USA, MD, has disclosed no relevant financial relationships.

  • Rocco A. Armonda, LTC, MC, USA, MD

    Director of Cerebrovascular Neurosurgery, National Naval Medical Center and Walter Reed Army Medical Center, Bethesda, Maryland; Associate Professor of Neurosurgery, Uniformed Services University of Health Sciences, Bethesda, Maryland


    Disclosure: Rocco A. Armonda, LTC, MC, USA, MD, has disclosed no relevant financial relationships.


  • Jo-Ann Strangis

    Director of Content, Medscape, LLC


    Disclosure: Jo-Ann Strangis has disclosed no relevant financial relationships.

  • Jacqueline A. Hart, MD

    Freelance Clinical Editor, Medscape, LLC, Boston, Massachusetts


    Disclosure: Jacqueline A. Hart, MD, has disclosed no relevant financial relationships.

  • Ariana Del Negro

    Editorial Director, Medscape Cardiology


    Disclosure: Ariana Del Negro has disclosed no relevant financial relationships.

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Severe Traumatic Brain Injury: Evolution and Current Surgical Management

Authors: Randy S. Bell, MD; Chris J. Neal, MD; Christopher J. Lettieri, MD; Rocco A. Armonda, MDFaculty and Disclosures



The approach to patients with severe penetrating or closed head traumatic brain injury (TBI) is guided by the certainty that, as time progresses, cerebral tissue can be irreversibly lost. Early intervention, either surgical or medical, is therefore the standard. The purpose of this paper is to outline the evolution of the surgical approach to the patient with severe TBI in an effort to clarify current management paradigms. Because many of the most significant advances in surgery occur during wartime, this evolutionary timeline will focus heavily on contributions made during military conflict. A general review of head trauma management guidelines will be provided in an applicable framework.

History of Surgical Techniques for Penetrating and Closed Head Injuries

Penetrating Head Injuries

Progress in most fields of human endeavor has historically been made during periods of extremis and often at the cost of human life. Nowhere is this more apparent than the paradoxical gains made in surgical techniques during military conflict. Prior to World War I (WWI), head injury was universally misunderstood, often complicated by untreatable infection, and therefore approached in an expectant manner (a term reflecting the limited resources available that were purposely focused toward those patients likely to survive vs those likely to die). Dr. Harvey Cushing pioneered battlefield neurosurgery in WWI, adopting a surgical approach for penetrating head injuries that included radical scalp and skull debridement followed by a watertight closure.[1] His efforts were unfortunately hampered by the lack of noninvasive imaging and inefficient battlefield triage and transport that resulted in delayed operative interventions. This approach continued until the Israeli-Lebanese conflict of the 1980s when a more conservative surgical strategy of limited local debridement and closure was adopted. This nihilistic approach resulted from continued poor outcomes in the setting of penetrating head injuries. Aggressive decompression (hemicraniectomy) followed by conservative debridement with good dural closure and intracranial pressure (ICP) monitoring is the current standard of care for those with severe penetrating TBI in the war in Iraq.[2] Early data indicate that good functional recovery can occur in this combat setting.[2]

The approach to civilian penetrating head trauma has largely followed approaches recommended during wartime. The most important distinction is that civilian weapons fire smaller projectiles with muzzle velocities that are approximately equal to one half that of military weaponry. In these cases (and provided no thalamic or brainstem injury has occurred), a strategy of local debridement and closure continues to be acceptable.

Closed Head Injuries

Closed head injuries are TBIs without penetration of the dura or brain parenchyma. The approach to civilian closed head injury is based in large part on lessons learned from the Traumatic Coma Data Bank (TCDB).[3,4] The TCDB was a National Institute of Neurological Disorders and Stroke project that prospectively followed 1030 patients admitted to 4 trauma centers with severe head injuries, defined as having a Glasgow Coma Score (GCS) of 8 or less after resuscitation. Of these patients, 313 patients were excluded because they were either dead on arrival, did not survive resuscitation efforts, had a penetrating injury, or lacked sufficient documentation of their prehospital course. Of the remaining 717 patients with severe closed head injury, 72% did not require a craniotomy, meaning that a majority of their care focused on the medical management of ICP and the prevention of secondary injury.[5]

An important and often overlooked aspect of treating severe TBI is the prevention and treatment of secondary injuries. These sometimes seemingly innocuous events profoundly affect outcomes. In some studies a single episode of hypotension or hypoxia was found to significantly increase morbidity and mortality.[6] Chesnut and colleagues,[5] for example, found that hypotension, defined as a systolic blood pressure < 90 mm Hg, occurred in almost 35% of patients with severe TBI and was associated with a 150% increase in mortality. Early aggressive resuscitation efforts, continued monitoring of patients, and prevention of secondary injuries were determined to be critical to outcomes.[5] Further discussion on the role of monitoring and treating elevated ICP is discussed later in this review.