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Difficulty: HardNeurosurgery

A 2828-year-old man is brought to the emergency department by ambulance after a high-speed motorcycle collision. He was not wearing a helmet. On arrival, he is unresponsive. His blood pressure is 175/95 mmHg175/95 \text{ mmHg}, heart rate is 52 /min52 \text{ /min}, and respiratory rate is 10 /min10 \text{ /min} and irregular. Neurologic examination reveals a Glasgow Coma Scale score of 55 (Eye opening: 11, Verbal response: 11, Motor response: 33). His right pupil is 7 mm7 \text{ mm} and unreactive to light, while the left pupil is 3 mm3 \text{ mm} and briskly reactive. He exhibits decerebrate posturing on the left side. Arrange the following steps in the most appropriate chronological order for the management of this patient.

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

Answer

The correct sequence of management is: 1) Perform endotracheal intubation, 2) Administer intravenous mannitol, 3) Obtain a non-contrast CT scan of the head, and 4) Perform an emergent craniotomy.
The correct sequence follows the ATLS protocol and neurosurgical guidelines for severe traumatic brain injury. The patient presents with a Glasgow Coma Scale score of 5, requiring immediate intubation for airway protection. The presence of Cushing triad (hypertension, bradycardia, irregular respirations) and a unilateral dilated pupil indicates elevated intracranial pressure and impending uncal herniation. Once the airway is secured, temporizing medical measures such as osmotic therapy (mannitol) must be initiated to reduce intracranial pressure. Following stabilization, a non-contrast head CT is essential to identify the underlying structural lesion. Finally, once the lesion is localized, definitive treatment is achieved through emergent surgical decompression.

Step-by-Step Solution

1
Evaluate the patient's airway, breathing, and circulation in the context of their neurologic status.
The patient has a Glasgow Coma Scale score of 5, which indicates an unprotected airway.
ATLS protocols prioritize securing the airway first. Endotracheal intubation is required immediately to prevent hypoxia and aspiration, which are potent drivers of secondary brain injury.
2
Identify clinical signs of elevated intracranial pressure and active brain herniation.
The patient demonstrates Cushing triad (hypertension, bradycardia, irregular respirations) and a right uncal herniation syndrome (right blown pupil, left decerebrate posturing).
Active herniation is a rapidly fatal neurosurgical emergency that requires immediate medical temporization (osmotic therapy such as mannitol or hypertonic saline) to reduce intracranial pressure while preparing for definitive care.
3
Determine the necessary diagnostic imaging required to guide definitive treatment.
A non-contrast computed tomography (CT) scan of the head is the imaging modality of choice.
Imaging is necessary to identify the specific etiology of the herniation (e.g., an intracranial hematoma) and its anatomical location, but it must only be performed after initial stabilization and medical temporization.
4
Select the definitive management strategy based on the presumed presence of a traumatic mass lesion.
An emergent craniotomy is required.
While medical therapies temporarily decrease intracranial pressure, the definitive, life-saving treatment for a large traumatic space-occupying lesion is surgical evacuation.

Key Concept

In patients with severe traumatic brain injury and active herniation, management follows a strict sequence: immediate airway protection (intubation), followed by temporizing medical reduction of intracranial pressure (osmotic therapy), diagnostic neuroimaging, and definitive surgical decompression.
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Topics

Neurosurgery

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