What is the management of a small cerebral contusion (brain contusion)?

From the Guidelines

Management of small brain contusions primarily involves close monitoring and supportive care rather than surgical intervention. Patients should be admitted to a hospital for neurological observation with frequent assessments of consciousness level, pupillary responses, and motor function. CT scans should be performed on admission and repeated within 24 hours to monitor for contusion expansion, as recommended by recent guidelines 1. Pain management typically includes acetaminophen (500-1000mg every 6 hours) while avoiding NSAIDs due to bleeding risk. Seizure prophylaxis with levetiracetam (500mg twice daily for 7 days) may be considered, especially with frontal or temporal contusions. Blood pressure should be maintained below 140/90 mmHg to prevent hemorrhagic progression. Bed rest with head elevation at 30 degrees helps reduce intracranial pressure. Most small contusions (<10cc) without significant mass effect resolve without surgery, but patients should be monitored for at least 24-48 hours as contusions can expand during this period.

Some key considerations in the management of small brain contusions include:

• Close monitoring of neurological status
• Frequent CT scans to assess for contusion expansion
• Pain management with acetaminophen
• Seizure prophylaxis with levetiracetam
• Blood pressure control to prevent hemorrhagic progression
• Bed rest with head elevation to reduce intracranial pressure
• Follow-up imaging 1-3 months after injury to confirm resolution, as the risks of surgical intervention typically outweigh benefits unless there is significant neurological deterioration or increased intracranial pressure 1.

It's worth noting that the most recent and highest quality study 1 recommends urgent neurosurgical consultation and intervention for patients with life-threatening brain lesions, but this is not typically necessary for small brain contusions without significant mass effect.

From the Research

Small Brain Contusion Management

• The management of small brain contusions is crucial to prevent further complications and promote recovery.
• According to 2, hypertonic saline and mannitol are commonly used to treat raised intracranial pressure (ICP) after traumatic brain injury (TBI), but their clinical superiority has not been demonstrated.
• The study 2 found that there were no significant differences in mortality and favorable neurological outcome between hypertonic saline and mannitol, but hypertonic saline was associated with lower ICP and higher cerebral perfusion pressure at 90 to 120 minutes after treatment.

Concussion Evaluation and Management

• Concussion is a common problem that can be managed by non-neurologists, and it is often accompanied by headaches, dizziness, sleep disturbance, psychiatric symptoms, and cognitive issues 3.
• The evaluation and management of concussion involve eliminating concern for cervical spine injury and more serious TBI, and using tools such as symptom checklists, neuropsychological tests, and postural stability tests to aid diagnosis and monitor recovery 4.
• Initial management of concussion involves brief cognitive and physical rest, patient education and reassurance, and symptom management, with a gradual return to activity as tolerated 4.

Pathophysiology and Clinical Translation

• Concussions are associated with rapid brain movement and characteristic clinical symptoms, but no objective biomarkers or overt pathologic brain changes, making diagnosis difficult 5.
• The pathophysiology of concussion involves a rapid release of neurotransmitters, ionic disequilibrium, and dynamic changes in cerebral glucose uptake, with the magnitude and duration of these changes related to injury severity 5.
• Understanding the pathophysiology and clinical translation of concussion can inform management paradigms that minimize the risk of prolonged recovery and repeat injury 5.

Current Concepts and Guidelines

• Mild traumatic brain injury, or concussion, is a major health concern, and current concepts in concussion management emphasize individualized approaches and gradual return to activity as tolerated 4, 6.
• The management of concussion and mild TBI involves synthesizing recent expert consensus statements and evidence-based clinical practice guidelines, with priority interventions initiated in primary care to prevent chronicity 6.