How to manage a 38-year-old male with a depressed fracture of the left parietal lobe, 9.3mm intracranial displacement, mild extra-axial collection, and small hemorrhagic contusions in the left parietal lobe?

Management of Depressed Skull Fracture with Intracranial Displacement

Surgical intervention with craniotomy and elevation of the depressed fragment is indicated for this 38-year-old male with a left parietal depressed skull fracture having 9.3mm intracranial displacement, mild extra-axial collection, and small hemorrhagic contusions. 1

Initial Assessment and Stabilization

1. Assess neurological status using Glasgow Coma Scale (GCS)
2. Evaluate pupil size and reactivity
3. Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion
   • Consider vasopressors (phenylephrine or norepinephrine) if needed 1
4. Ensure controlled ventilation with end-tidal CO2 monitoring
   • Avoid hypocapnia which can cause cerebral vasoconstriction and ischemia 1

Surgical Management

The American College of Emergency Physicians indicates that intracranial displacement exceeding 1cm typically necessitates surgical management. Although this patient's displacement is 9.3mm (slightly under 1cm), the presence of extra-axial collection and hemorrhagic contusions further supports surgical intervention 1.

Surgical approach should include:

• Craniotomy with elevation of the depressed fragment
• Debridement of the wound (if compound fracture)
• Repair of any dural tears
• Evacuation of associated hematomas
• Consider single-stage reconstruction with titanium mesh 1, 2

Recent evidence from a 2020 study demonstrates that immediate single-stage reconstruction with titanium mesh for compound comminuted depressed fractures is safe and offers benefits in terms of cost-effectiveness and cosmetic outcomes 2.

Management of Intracranial Pressure (ICP)

First-line measures:

• Elevate head of bed 20-30° to improve venous drainage
• Maintain euvolemia
• Treat fever and seizures if present 1

Second-line measures (if ICP remains elevated):

• Consider CSF drainage via external ventricular drain if hydrocephalus is present
• Osmotic therapy with mannitol (0.25-1 g/kg IV)
  • Mannitol works by increasing plasma osmolarity, inducing movement of intracellular water to extracellular and vascular spaces, thereby reducing intracranial pressure 1, 3

Third-line measures:

• Decompressive craniectomy for refractory intracranial hypertension after multidisciplinary discussion 1

Monitoring and Management

• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg
• Consider ICP monitoring if GCS deteriorates or CT findings worsen
• Use midazolam or propofol for sedation as needed
• Consider ketamine for analgesia 1

Prevention of Complications

• DVT prophylaxis
• Stress ulcer prophylaxis
• Seizure prophylaxis
• Maintain normothermia
• Glycemic control
• Anticoagulation with low molecular weight heparin (LMWH) should be started as soon as possible after diagnosis in patients with stable intracranial bleeding 1

Special Considerations

• A 2023 study highlighted that depressed skull fractures compressing eloquent cortex can cause focal neurologic deficits requiring emergent intervention 4
• If the fracture involves the superior sagittal sinus, monitor for delayed neurological deterioration which may occur between 4 days and 3 weeks post-injury 5

Follow-up and Rehabilitation

• Transfer to specialized centers with neurosurgical facilities if not already there
• Implement multidisciplinary rehabilitation programs to address physical, cognitive, and behavioral deficits
• Continue rehabilitation efforts even in chronic TBI cases 1