What is the management of a brain contusion?

Management of Brain Contusion

Brain contusions require immediate systematic assessment with ABCDE approach, aggressive prevention of secondary brain injury through maintenance of systolic blood pressure >110 mmHg, early CT imaging, and consideration for surgical evacuation when contusions exceed specific size thresholds or cause mass effect, with particularly close monitoring for delayed deterioration in bifrontal contusions. 1, 2

Immediate Pre-Hospital and Emergency Stabilization

Airway and Ventilation Control

• Establish airway control as the absolute priority with tracheal intubation and mechanical ventilation for severe TBI patients, beginning in the pre-hospital period. 3
• Monitor end-tidal CO2 continuously to maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia. 3
• Confirm correct tracheal tube placement through EtCO2 monitoring. 3

Blood Pressure Management

• Maintain systolic blood pressure >110 mmHg from first contact—even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome. 1
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects. 1
• Avoid hypotensive sedative agents and use continuous infusions rather than boluses to prevent hemodynamic instability. 1

Initial Assessment

• Assess severity using Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity—these are the most robust predictors of 6-month neurological outcome. 2
• Age, initial GCS, and pupillary findings are validated prognostic factors from studies including over 15,000 patients. 2

Imaging Strategy

• Obtain non-contrast brain and cervical spine CT immediately without delay to guide neurosurgical procedures and monitoring techniques. 1, 2
• Use inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows). 1
• CT is the primary modality for detecting surgically treatable lesions. 2

Risk Stratification for Contusion Progression

High-Risk Features Requiring Intensive Monitoring

• Initial contusion size >14 mL—no patients with contusions <14 mL required delayed evacuation in validation studies. 4
• Presence of subdural hematoma alongside contusion (statistically significant predictor of CT progression). 4
• Bifrontal contusions >30 cm³ in awake patients (GCS ≥10)—these patients have 54% risk of acute clinical deterioration at mean 4.5 days post-injury. 5
• Low initial GCS scores combined with large contusions predict delayed deterioration. 4

Contusion Progression Patterns

• 45% of conservatively managed contusions show significant radiological progression (defined as 30% increase in size). 4
• 19% of initially conservatively managed contusions ultimately require surgical intervention. 4
• Microthrombosis forms in contused areas, extending from center to peripheral areas within 6 hours after injury. 6

Neurosurgical Intervention Criteria

Perform surgical evacuation for: 3, 1, 2

• Symptomatic extradural hematoma (any location)
• Acute subdural hematoma with thickness >5mm and midline shift >5mm
• Brain contusions with mass effect (thickness >5mm, midline shift >5mm)
• Acute hydrocephalus requiring drainage
• Open displaced skull fracture
• Closed displaced skull fracture with brain compression

Special Considerations for Bifrontal Contusions

• Manage awake patients with severe bifrontal contusions (>30 cm³) with ICU admission and early intracranial pressure monitoring. 5
• If deterioration occurs despite medical management, perform rapid bifrontal decompression—all patients managed with immediate surgical decompression had good outcomes and returned to work. 5
• Do not rely on prophylactic hypertonic saline infusions based on current evidence. 5

Intracranial Pressure Management

First-Line Medical Management

• Implement ICP monitoring in severe TBI to detect intracranial hypertension and guide ICP-directed therapy. 3, 1, 2
• Provide adequate sedation and opioids to control ICP in patients with low intracranial compliance, but avoid bolus administration that causes hypotension. 3
• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 1, 2

Second-Line Interventions for Refractory ICP

• Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults. 3
• Removal of brain contusions with mass effect is an option after failure of first-line treatment. 3

Decompressive Craniectomy

• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion. 3
• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most commonly used technique. 3
• Unilateral craniectomy shows good outcomes (GOS 4-5) in 40-57% versus 28-32% in controls, with reduced mortality (26.9% versus 48.9%). 3
• Bifrontal craniectomy showed worse outcomes in DECRA study and should be used selectively. 3

Cerebral Perfusion Targets

Standard Approach

• Maintain cerebral perfusion pressure through increasing mean arterial pressure, decreasing ICP, or both. 2

Contusion-Specific Considerations

• In patients with significant contusions (>10 mL), maintain CPP within 60-70 mmHg—lower percentage of good monitoring time with CPP in this range was independently associated with unfavorable outcome. 7
• Elevated CPP may be particularly dangerous in large contusions due to risk of brain edema worsening. 7
• Pressure reactivity index (PRx) and optimal CPP (CPPopt) may be less valid in patients with predominant focal lesions compared to diffuse injuries. 7

Observation and Monitoring Protocol

ICU Admission Criteria

• All patients with contusions >14 mL require ICU admission. 4
• All awake patients with bifrontal contusions >30 cm³ require ICU admission regardless of GCS. 5
• Patients with initial GCS <15 or contusions with subdural hematoma require intensive monitoring. 4

Serial Imaging

• Repeat CT scanning is essential as contusion progression is common (45% of cases). 4
• Four patients in validation studies required delayed contusion evacuation, with 3 showing radiological progression on follow-up scans. 4

Duration of Monitoring

• Bifrontal contusions deteriorate at mean 4.5 days post-injury, requiring extended observation period. 5
• Blood-brain barrier permeability endures at least 7 days post-TBI with biphasic opening pattern. 6

Supportive Care Measures

• Implement detection and prevention strategies for post-traumatic seizures. 2
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 2
• Consider brain tissue pO2 monitoring as an important tool in treatment regime. 6

Critical Pitfalls to Avoid

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors. 1
• Never use bolus sedation rather than continuous infusions, which causes hemodynamic instability. 1
• Never delay transfer to specialized neurosurgical center for "stabilization" at non-neurosurgical facility. 1
• Do not assume patients with GCS 15 are safe—no patients with initial GCS 15 required delayed evacuation in one series, but bifrontal contusions can deteriorate despite preserved consciousness. 4, 5
• Avoid aggressive early hyperventilation after TBI, which augments neuronal death in hippocampus. 6

Prognostic Factors

• Good GCS scores on presentation and younger age predict eventual hospital discharge (OR 1.471 and OR 0.949 respectively). 4
• Presence of focal contusion and primary or secondary ischemic events correlate strongly with high dialysate glutamate levels, which associate with raised ICP and worse outcomes. 6