Management of Left Temporal Lobe Contusion Hematoma (Contrecoup)
Immediate transfer to a specialized neurosurgical center is mandatory, as mortality rates are significantly lower in neurosurgical centers compared to non-specialized facilities, even for patients not requiring surgical intervention. 1
Immediate Assessment and Stabilization
Airway and Hemodynamic Management
- Maintain systolic blood pressure >110 mmHg at all times, as even a single episode below this threshold markedly increases mortality 1
- Control ventilation through tracheal intubation with mechanical ventilation and end-tidal CO2 monitoring, targeting EtCO2 of 30-35 mmHg before obtaining arterial blood gas 1
- Ensure oxygen saturation >90% while avoiding hyperoxia after stabilization 2
- Target mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 2
Neurological Evaluation
- Assess Glasgow Coma Scale with particular attention to motor response and pupillary reactivity 1, 2
- Monitor for signs of increased intracranial pressure: pupillary abnormalities, hypertension, and bradycardia 3, 4
- Perform transcranial Doppler on arrival if available; concerning findings include diastolic velocity <20 cm/s and pulsatility index >1.4 1
Imaging Protocol
Initial CT Scanning
- Perform brain and cervical CT scan without delay using inframillimetric sections with double fenestration (central nervous system and bone windows) 1
- The CT scan guides neurosurgical procedures and monitoring techniques 1
CT-Angiography Indications
- Obtain CT-angiography of supra-aortic and intracranial arteries if risk factors present: cervical spine fracture, focal neurological deficits not explained by brain imaging, or basal skull fractures 1, 3
Neurosurgical Intervention Criteria
Immediate Surgical Indications
Emergency neurosurgery is required for 1, 4:
- Symptomatic extradural hematoma (any location)
- Significant acute subdural hematoma (thickness >5 mm with midline shift >5 mm)
- Acute hydrocephalus requiring drainage
- Open displaced skull fracture requiring closure
- Closed displaced skull fracture with brain compression (thickness >5 mm, mass effect with midline shift >5 mm)
Temporal Lobe-Specific Considerations
- Temporal contusions have high propensity for rapid deterioration and require close monitoring 5, 6
- Larger temporal lobe hemorrhage volumes are strongly associated with worse cognitive outcomes and brain atrophy 7
- Removal of brain contusions with mass effect is an option after failure of first-line intracranial pressure management 1
Intracranial Pressure Monitoring
ICP Monitoring Indications
Place ICP monitor in patients with 1:
- Glasgow Coma Scale <9 with abnormal CT findings (compressed basal cisterns, midline shift >5 mm, traumatic subarachnoid hemorrhage)
- Need for emergency extracranial surgery (except life-threatening procedures)
- Neurological evaluation not feasible due to sedation
Post-Evacuation ICP Monitoring
Monitor ICP after hematoma evacuation if any single criterion present 1:
- Preoperative Glasgow Coma Scale motor response ≤5
- Preoperative anisocoria or bilateral mydriasis
- Preoperative hemodynamic instability
- Preoperative severity signs on imaging (compressed basal cisterns, midline shift >5 mm, other intracranial lesions)
- Intraoperative cerebral edema
- Postoperative appearance of new intracranial lesions
Intracranial Hypertension Management
Target Parameters
- Maintain cerebral perfusion pressure between 60-70 mmHg when ICP monitoring available 1
- CPP >70 mmHg increases risk of respiratory distress syndrome without improving neurological outcome 1
- CPP <60 mmHg is associated with poor outcome 1
Stepwise Treatment Approach
Use escalating interventions, reserving aggressive treatments for non-responders 1, 8:
First-line measures 4:
- Elevate head of bed 20-30 degrees
- Restrict free water
- Avoid excess glucose
- Minimize hypoxemia and hypercarbia
- Treat hyperthermia
Osmotic therapy: Administer mannitol 20% or hypertonic saline at 250 mOsm dose over 15-20 minutes for threatened intracranial hypertension or signs of herniation 1, 4
External ventricular drainage: Consider for persistent intracranial hypertension despite sedation and correction of secondary brain insults 1, 4
Decompressive craniectomy: Reserve for refractory intracranial hypertension after multidisciplinary discussion 1, 2
Critical Pitfalls to Avoid
- Never use corticosteroids for traumatic brain injury management, as they provide no mortality or neurological benefit 4, 2
- Do not allow hypotension (systolic BP <110 mmHg) at any point, as this markedly increases mortality 1
- Avoid prophylactic hyperventilation; maintain PaCO2 between 35-40 mmHg after stabilization to prevent cerebral vasoconstriction 4
- Do not delay transfer to neurosurgical center while attempting medical stabilization at non-specialized facility 1
- Temporal lobe contusions require particularly vigilant monitoring due to high risk of rapid, fatal deterioration 5, 6
Monitoring During Hospitalization
Observation Requirements
- Minimum 24-hour hospital observation is essential for any documented contrecoup injury on CT, even if initially asymptomatic 3
- Frequent neurological examinations to detect secondary deterioration 2
- Serial CT scanning if clinical deterioration occurs 1
Coagulation Management
- Maintain prothrombin time/activated partial thromboplastin time <1.5 times normal control during interventions 1
- Utilize point-of-care tests (thromboelastography/rotational thromboelastometry) if available to optimize coagulation 1
Complications and Long-Term Considerations
- Brain abscess can develop at contusion sites (rare but important to recognize early) 9
- Significant residual blood products persist at 6 months post-injury, representing ongoing source of secondary brain injury 7
- Larger temporal lobe hemorrhage volumes correlate with worse attention and executive function scores at 6 months 7
- Temporal lobe lesions show robust correlation between volume and brain atrophy 7