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Difficulty: MediumNeurosurgery

A 2424-year-old man is brought to the emergency department after falling off his skateboard and striking the right side of his head. Witnesses report he had a brief loss of consciousness lasting approximately 11 minute, followed by a period where he was awake and conversing. En route to the hospital, he became progressively lethargic and unresponsive. On arrival, his blood pressure is 170/95170/95 mmHg, heart rate is 5252/min, and respirations are 1010/min and irregular. His Glasgow Coma Scale score is 66 (Eye: 11, Verbal: 22, Motor: 33 with abnormal flexion). Physical examination reveals a right pupil that is 77 mm and nonreactive to light, as well as left-sided hemiparesis. Arrange the following management steps in the most appropriate chronological sequence for this patient.

  1. 1Perform endotracheal intubation
  2. 2Administer intravenous mannitol
  3. 3Obtain a noncontrast CT scan of the head
  4. 4Perform an emergent right-sided craniotomy

Answer

The correct chronological sequence is: 1) Perform endotracheal intubation, 2) Administer intravenous mannitol, 3) Obtain a noncontrast CT scan of the head, and 4) Perform an emergent right-sided craniotomy.
The management of severe traumatic brain injury with impending herniation follows a strict protocol prioritizing the ABCs (Airway, Breathing, Circulation) followed by targeted neurological interventions. The patient's GCS of 6 dictates immediate endotracheal intubation (Step 1). Following airway securement, the presence of uncal herniation (blown right pupil, left-sided hemiparesis, Cushing triad) requires emergent medical reduction of intracranial pressure using osmotic agents like intravenous mannitol (Step 2). Once temporizing measures are in place, the patient can be safely transported for a noncontrast CT scan of the head to precisely identify the etiology, typically an epidural hematoma in this classic 'lucid interval' presentation (Step 3). Finally, definitive surgical management via craniotomy and hematoma evacuation is performed (Step 4).

Step-by-Step Solution

1
Evaluate the patient's airway and Glasgow Coma Scale (GCS) score.
Recognize a GCS of 6 and irregular respirations.
Patients with a GCS < 8 cannot protect their airway and require immediate endotracheal intubation according to Advanced Trauma Life Support (ATLS) protocols.
2
Assess for signs of increased intracranial pressure and brain herniation.
Identify Cushing triad (hypertension, bradycardia, irregular breathing) and uncal herniation (ipsilateral blown pupil, contralateral hemiparesis).
Active herniation requires immediate medical temporizing measures (osmotic therapy like intravenous mannitol or hypertonic saline) to reduce intracranial pressure before transport.
3
Determine the need for diagnostic neuroimaging.
Plan a noncontrast CT scan of the head.
Once the patient is hemodynamically and medically stabilized, neuroimaging is necessary to confirm the specific pathology (classic epidural hematoma in this vignette) and guide surgical planning.
4
Plan definitive treatment based on suspected findings.
Proceed to an emergent right-sided craniotomy.
The definitive treatment for a rapidly expanding epidural hematoma causing uncal herniation is immediate surgical evacuation.

Key Concept

The management of severe traumatic brain injury with signs of uncal herniation follows a strict chronological sequence: airway protection (intubation), medical reduction of intracranial pressure (osmotic therapy), diagnostic imaging (CT head), and definitive surgical evacuation.
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Neurosurgery

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