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Head Injury
Head Injury
Pathophysiology and management

2nd edition

Peter L Reilly MD BmedSc FRACS

Department of Neurosurgery, Royal Adelaide Hospital,
Adelaide, Australia

Ross Bullock MD PhD

Division of Neurological Surgery, Medical College of Virginia,
Richmond, Virginia, USA

Hodder Arnold
A MEMBER OF THE HODDER HEADLINE GROUP
First published in Great Britain in 2005 by
Hodder Education, a member of the Hodder Headline Group,
338 Euston Road, London NW1 3BH
http://www.hoddereducation.com
Distributed in the United States of America by
Oxford University Press Inc.,
198 Madison Avenue, New York, NY10016
Oxford is a registered trademark of Oxford University Press

© 2005 Arnold
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronically or mechanically,
including photocopying, recording or any information storage or retrieval
system, without either prior permission in writing from the publisher, or a
licence permitting restricted copying. In the United Kingdom such licences
are issued by the Copyright Licensing Agency: 90 Tottenham Court Road,
London W1T 4LP.
Whilst the advice and information in this book are believed to be true and
accurate at the date of going to press, neither the author[s] nor the publisher
can accept any legal responsibility or liability for any errors or omissions
that may be made. In particular, (but without limiting the generality of the
preceding disclaimer) every effort has been made to check drug dosages;
however it is still possible that errors have been missed. Furthermore,
dosage schedules are constantly being revised and new side-effects
recognized. For these reasons the reader is strongly urged to consult the
drug companies’ printed instructions before administering any of the drugs
recommended in this book.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN-10 0 340 80724 5
ISBN-13 978 0 340 80724 8
1 2 3 4 5 6 7 8 9 10
Commissioning Editor: Joanna Koster
Project Editor: Naomi Wilkinson
Production Controller: Joanna Walker
Cover Design: Georgina Hewitt
Index: Indexing Specialists (UK) Ltd
Typeset in 10/12 Minion by Charon Tec Pvt. Ltd, Chennai, India
Printed and bound in the UK by CPI Bath

What do you think about this book? Or any other Hodder Arnold title?
Please visit our website at www.hoddereducation.com
Dedication

We wish to dedicate this edition to our late friend Douglas

Miller. During his incredibly productive early years of clinical
and laboratory-based TBI research in Glasgow and Richmond,
he laid down the principles upon which modern TBI care is
based. Douglas inspired a generation of neurotrauma research
and his insights remain fresh today.
This page intentionally left blank
Contents

Color plates appear between pages 112 and 113

Contributors ix

Foreword xi

Preface to the second edition xiii

Acknowledgements xv

Section 1: The Injury 1

1 Epidemiology 3
Michael R Fearnside and Donald A Simpson
2 Biomechanics of closed head injury 26
Robert Anderson and Jack McLean
3 Pathology 41
Peter C Blumbergs
4 Primary and secondary brain injury 73
A David Mendelow and Peter J Crawford
5 Intracranial pressure and elastance 93
Ian Piper
6 Injury and cell function 113
Ross Bullock and Narendra Nathoo

Section 2: Measuring and monitoring injury 141

7 Clinical examination and grading 143
Donald A Simpson
8 Alcohol, other drugs and head injury 164
Matt Gaughwin, Donald A Simpson
9 Imaging the injury 169
Evelyn Teasdale and Donald M Hadley
10 Monitoring cerebral blood flow and metabolism 215
PJ Hutchinson, DK Menon, M Czosnyka and PJ Kirkpatrick
11 Electrical function monitoring 246
R Moulton
12 Magnetic resonance spectroscopy 258
Robert Vink

Section 3: Treatment 269

13 From accident site to trauma center 271
John E Gilligan
14 The intensive care management of head injury 294
John A Myburgh
15 Sedation and anesthesia in head injury 313
GL Ludbrook and I Banks
viii Contents

16 Management of intracranial pressure and cerebral perfusion pressure 331

Peter L Reilly
17 Pediatric head injury 356
Ming L Cheng, Saad Khairi and Ann M Ritter
18 The role of surgery for intracranial mass lesions after head injury 368
Nigel Jones, Ross Bullock and Peter L Reilly
19 Missile wounds of the head 384
Bizhan Aarabi and Judson Cook
20 Neuroprotection in traumatic brain injury 406
Andrew IR Maas, Joost W Schouten and Graham M Teasdale
21 Outcome after severe head injury 441
Bryan Jennett
22 Outcome prediction after severe head injury 462
Kathryn N Hults, Lawrence F Marshall and Sharon B Marshall
23 Brain death – clinical and confirmatory tests 472
Robert Owen and Byron Young

Appendices 487

Appendix A: Antibiotic therapy for CNS infections 489

Appendix B: Seizure management in acute head injury 490

Appendix C: Possible causes of status epilepticus after head injury 490

Appendix D: Cardiovascular drugs used to augment CPP 491

Index 493
Contributors

Bizhan Aarabi Michael R Fearnside

Associate Professor Department of Neurosurgery
Director of Neurotrauma Westmead General Hospital
Department of Neurosurgery Westmead, NSW, Australia
University of Maryland School of Medicine
Matt Gaughwin
R Adams Cowley Shock Trauma Center
Director, Drug and Alcohol Resource Unit
Maryland, USA
Royal Adelaide Hospital, Adelaide, Australia
Robert Anderson
John E Gilligan
Senior Research Fellow and Deputy Director
Emeritus Director, Retrieval and Resuscitation
Centre for Automotive Safety Research
Intensive Care Unit
University of Adelaide, Adelaide, Australia
Royal Adelaide Hospital, Adelaide, Australia
I Banks
Donald M Hadley
Consultant Anaesthetist
Department of Neuroradiology
Department of Anaesthesia and Intensive Care
Institute of Neurological Science
Royal Adelaide Hospital, Adelaide, Australia
Southern General Hospital, Glasgow, Scotland
Peter C Blumbergs Kathryn N Hults
Head of Neuropathology Clinical Research Nurse, CN III
Institute of Medical and Veterinary Science University of California at San Diego, California, USA
Hanson Institute for Neurological Diseases
Clinical Professor of Pathology PJ Hutchinson
University of Adelaide, Adelaide, Australia Senior Academy Fellow and
Honorary Consultant Neurosurgeon
Ross Bullock Academic Neurosurgery Unit
Division of Neurological Surgery Department of Clinical Neurosciences and
Medical College of Virginia, Richmond Wolfson Brain Imaging Centre
Virginia, USA University of Cambridge, Cambridge, UK
Ming L Cheng Bryan Jennett
Division of Neurological Surgery Department of Neurosurgery
University of North Carolina, North Carolina, USA Institute of Neurological Sciences
The Southern General Hospital, Glasgow, Scotland
Judson Cook
Department of Neurosurgery Nigel Jones
University of Maryland School of Medicine NRF Professor of Neurosurgery
R Adams Cowley Shock Trauma Center, Maryland, USA University of Adelaide, Adelaide, Australia

Peter J Crawford Saad Khairi

Department of Neurosurgery University of North Carolina
Newcastle General Hospital, Newcastle upon Tyne, UK Department of Surgery, Division of Neurosurgery, USA

M Czosnyka PJ Kirkpatrick
Reader in Brain Physics Consultant Neurosurgeon
Academic Neurosurgery Unit Academic Neurosurgery Unit
Department of Clinical Neurosciences Wolfson Brain Imaging Centre
University of Cambridge, Cambridge, UK University of Cambridge, Cambridge, UK
x Contributors

GL Ludbrook Robert Owen

Professor, Department of Anaesthesia and Intensive Care University of Kentucky Chandler Medical School
University of Adelaide and Royal Adelaide Hospital Division of Neurosurgery, Lexington, KY, USA
Adelaide, Australia
Ian Piper
Andrew IR Maas Department of Clinical Neurosciences
Department of Neurosurgery Western General Hospital
Erasmus MC, University Hospital Rotterdam Crewe Road South
Rotterdam, the Netherlands Edinburgh, Scotland
Lawrence F Marshall Peter L Reilly
Professor and Chair Clinical Professor and Director
Division of Neurological Surgery Department of Neurosurgery
University of California at San Diego, California, USA Royal Adelaide Hospital, Adelaide, Australia
Sharon B Marshall Ann M Ritter
Assistant Professor of Surgery University of North Carolina,
Director of Clinical Research Department of Surgery, Division of Neurosurgery
University of California at San Diego, California, USA USA
Jack McLean
Joost W Schouten
Professor and Director
Department of Neurosurgery
Centre for Automotive Safety Research
Erasmus MC
University of Adelaide, Adelaide, Australia
University Hospital Rotterdam
A David Mendelow Rotterdam, the Netherlands
University of Newcastle upon Tyne
Donald A Simpson
Newcastle upon Tyne, UK
Clinical Professor and Emeritus Neurosurgeon
DK Menon Department of Neurosurgery
Professor and Head, Division of Anaesthesia and Royal Adelaide Hospital, Adelaide, Australia
Co-Chair, Acute Brain Injury Program
Wolfson Brain Imaging Centre Evelyn Teasdale
University of Cambridge, Cambridge, UK Department of Neuroradiology
Institute of Neurological Sciences
R Moulton Southern General Hospital, Glasgow, Scotland
Associate Professor and Chairman
Division of Neurosurgery Graham M Teasdale
University of Ottawa, Ottawa, Canada Department of Neurosurgery
Institute of Neurological Sciences
John A Myburgh The Southern General Hospital
Associate Professor Glasgow, Scotland
University of New South Wales
and Director of Research Robert Vink
Department of Intensive Care Medicine Department of Pathology
St George Hospital, Sydney, Australia University of Adelaide, Adelaide, Australia

Narendra Nathoo Byron Young

Department of Neurosurgery University of Kentucky Chandler Medical School
Cleveland Clinic Foundation Division of Neurosurgery
Cleveland, OH, USA Lexington, KY, USA
Foreword

From the earliest medical writings in Ancient Egypt, physi- of combining in-depth analysis and discussion with clearly
cians have endeavoured to communicate their views on the communicated, emphatic messages for practical clinical man-
nature and treatment of head injuries. The explosion of agement. They draw extensively on the expanding array of
knowledge in the last half of the twentieth century immensely evidence-based guidelines produced in the last decade.
increased understanding, advanced management and improved The contributors come from a wide range of clinical and
outcome. It also made the task of drawing together a compre- scientific disciplines and the international perspective is
hensive picture ever more formidable. In the first edition of emphasised in the way that they are spread across the three
their book, Peter Reilly and Ross Bullock rose admirably to continents of Europe, Australasia and America. Despite this,
the challenge and have done so even more successfully in the they complement each other effectively, resulting in a picture
new edition. that is comprehensive yet also clear and coherent. In addition
There is almost no limit to the perspectives from which to the undoubted skills of the editors, this can be held to
head injuries can be viewed, reflecting the myriad of problems reflect more than a third of the contributors being linked
they can present. In perhaps no other condition are events in together, directly or indirectly, through what may be referred
the organ primarily affected of such complexity and potentially to as the “Glasgow School”, of multidisciplinary approach to
devastating, accompanied by so many disturbances through- head injuries, initiated in the late 60s by Bryan Jennett Hume-
out the whole body which in turn complicate and worsen the Adams and A Murray Harper. It was this environment that
events in the brain. The editors have drawn together contri- brought Peter, Ross, myself and many others together as col-
butions that deal admirably with the complex processes of leagues, career-long collaborators and lifelong friends. The new
injury and the increasingly sophisticated diagnostic and ther- edition of this invaluable guide to the management of severe
apeutic interventions in the acute stage, along with consider- head injuries carries the school’s tradition securely and success-
ations of the epidemiology of injury and the after effects on fully into another millennium. The first edition has survived
the mind and lifestyle that may last for months and years. The on my bookshelves for the last 8 years, protected by a large
result is a comprehensive yet balanced compilation of con- (and unique) label stating “Not to be borrowed”! Clinicians
temporary knowledge. and scientists throughout the world will value, benefit from,
It is reassuring that some of the fundamental concepts are and cherish the new edition just as highly and enthusiastically.
now so well established that the revisions required have con-
cerned matters of detail. Conversely, and appropriately, the Graham Teasdale
most extensive and substantial changes are in the section con- Professor Emeritus of Neurosurgery, University of Glasgow
cerned with treatment, where almost half of the contributions President, Royal College of Physicians
are entirely fresh. These new chapters continue the approach and Surgeons of Glasgow
This page intentionally left blank
Preface to the second edition

TBI continues to be a major problem worldwide. Fatalities This edition of the book incorporates the latest evidence-
from head injuries from motor vehicle accidents are increas- based US guidelines on severe head injury management, and
ing, particularly in developing countries, and are predicted to surgical management of TBI. However, these guidelines do not
become the third largest cause of death by 2010. In the United take account of the enormous body of knowledge from animal
States alone, over 3.5 million disabled head injury survivors models, and ‘expert opinion’.
exist in the community. Sadly, penetrating brain injury remains This book aims to provide the reader with a conceptual
an increasing problem in many communities as a result of framework, and detailed synthesis of the mechanisms of brain
urban violence and armed conflict. damage in TBI, and then integrates imaging, management
In the 1950’s, over 80% of patients with severe head injuries and the functional consequences. We have therefore divided
died as a result of their injuries. In the twenty-first century, the book into three parts – mechanisms of injury, measuring
mortality rates of around 25% are commonly reported. and monitoring the injury, and treatment for the injury.
Since the first edition in 1997 there have been substantial There are new chapters on penetrating injuries, pediatric
advances in the understanding of the pathophysiology of severe brain injury and outcome measures and brain death. Appen-
brain injury derived from laboratory models and clinical dices detail management algorithms.
studies. A clearer understanding of the events which occur in This second edition is designed mainly to assist neurosur-
the minutes to hours following brain injury lead to the devel- geons, trauma surgeons and intensivists managing patients with
opment of a number of agents with neuroprotective effects in severe traumatic brain injury, but we hope it will provide
laboratory models. The search for ways to apply this knowl- an integrated reference framework for researchers, and all the
edge continues. many other diverse groups of physicians and scientists, who
The development and wide application of guidelines for come into this field.
management of all types of head injury and the wider avail-
ability of rapid prehospital care, CT scans, and intensive care Peter L Reilly
units has set generally accepted standards of management, Ross Bullock
although there remain many areas of controversy.
This page intentionally left blank
Acknowledgements

We are grateful to the outstanding authors who have con- Our wives Helen and Amanda have sacrificed much, over
tributed their expertise and to the publishers Hodder Arnold many years, to allow us to pursue our goals. We are deeply
Health Sciences for their superb support and cooperation in grateful, for their support in accepting with forbearance this
preparing this edition. additional preoccupation in the lives of their husbands.
This page intentionally left blank
 SECTION
1
The Injury

1. Epidemiology 3
Michael R Fearnside and Donald A Simpson

2. Biomechanics of closed head injury 26

Robert Anderson and Jack McLean

3. Pathology 41
Peter C Blumbergs

4. Primary and secondary brain injury 73

David Mendelow and Peter J Crawford

5. Intracranial pressure and elastance 93

Ian Piper

6. Injury and cell function 113

Ross Bullock and Narendra Nathoo
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