What is the appropriate treatment for a patient with a left parietooccipital contusion?

Management of Left Parietooccipital Contusion

Immediately secure the airway through endotracheal intubation and mechanical ventilation, maintain systolic blood pressure >110 mmHg using vasopressors without delay, obtain urgent non-contrast CT brain imaging, and proceed to surgical evacuation if the contusion demonstrates mass effect with thickness >5mm and midline shift >5mm. 1, 2, 3

Immediate Stabilization (Pre-Hospital and Emergency Department)

Airway Management

• Perform endotracheal intubation and mechanical ventilation immediately for all severe TBI patients, beginning in the pre-hospital period 1, 2, 3
• Confirm correct tracheal tube placement through continuous end-tidal CO2 monitoring 1, 2, 3
• Maintain PaCO2 within normal range (target 35 mmHg), as hypocapnia induces cerebral vasoconstriction and risks brain ischemia 4, 3

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg from the moment of first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 1, 2, 3
• Use vasopressors (phenylephrine or norepinephrine) immediately for any hypotension rather than waiting for fluid resuscitation or sedation adjustment, which have delayed hemodynamic effects 4, 1, 2, 3
• Place central venous and arterial catheters for continuous monitoring 4

Imaging Strategy

• Obtain non-contrast CT of the brain and cervical spine immediately without any delay to guide neurosurgical procedures and monitoring techniques 1, 2, 3
• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone) 2, 3
• CT is superior to MRI in the acute setting for detecting surgical lesions and can be performed rapidly in monitored patients 5

Neurosurgical Intervention Criteria

Perform surgical evacuation (craniotomy and hematoma evacuation) for brain contusions meeting any of the following criteria: 4, 1, 2, 3

• Brain contusion with mass effect (thickness >5mm with midline shift >5mm)
• Progressive neurological deterioration despite medical management
• Refractory intracranial hypertension despite first-line treatments
• Associated symptomatic extradural or subdural hematoma
• Acute hydrocephalus requiring drainage

Surgical Technique for Parietooccipital Contusion

• Perform fronto-parieto-temporo-occipital craniectomy up to the midline with diameter of at least 12 cm 4
• Perform durotomy and enlargement duroplasty 4
• Do not remove ischemic brain tissue unless there is associated hematoma requiring evacuation 4
• Place intracranial pressure monitor 4

Intracranial Pressure Monitoring and Management

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy 1, 2, 3
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available 2
• Consider external ventricular drainage for persisting intracranial hypertension despite sedation and correction of secondary brain insults 4

Medical Management of Elevated ICP

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death 1, 2, 3
• Use propofol by continuous infusion (not bolus) in combination with normocapnia to decrease intracranial pressure 1, 2
• Consider osmotherapy with mannitol 20% or hypertonic saline, targeting serum osmolality of 300-310 mOsmol/kg 4
• Consider increasing PEEP from 0 to 5-15 cm H₂O, which is associated with decreased ICP and improved cerebral perfusion pressure 1, 2

Coagulation Management

• Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes 1, 2
• Correct coagulation disorders before craniectomy according to their etiology 4
• If the patient received antiplatelet drugs, consider preoperative platelet transfusion 4
• Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio if needed, then modify based on laboratory values 2

Supportive Care Measures

• Implement detection and prevention strategies for post-traumatic seizures 1, 2, 3
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function 1, 2, 3
• Apply general intensive care concepts including sepsis bundles, lung-protective ventilation, strict blood glucose control, treatment of hyperthermia, and early enteral nutrition 4
• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin or low molecular weight heparin from the second postoperative day after consulting neurosurgery 4

Postoperative Management

• Perform control CT after 24 hours or earlier if signs of intracranial hypertension are present 4
• Attempt waking from sedation as soon as there are no more signs of significant intracranial hypertension 4
• Begin early mobilization and rehabilitation in the ICU once the patient is stable 4

Critical Pitfalls to Avoid

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors 3
• Never use bolus sedation rather than continuous infusions, which causes hemodynamic instability 1, 2, 3
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility 1, 2, 3
• Never perform prophylactic hyperventilation (PaCO2 <35 mmHg), as this induces cerebral vasoconstriction and ischemia 4, 3

Prognosis and Follow-up

• Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes, reduces length of stay, and enhances communication with family members without reducing survival 1, 2
• MRI is more sensitive than CT for follow-up imaging of parenchymal changes and should include gradient-recalled-echo sequences to detect hemosiderin 5
• Parietooccipital lesions in the dominant hemisphere may result in topographical disorientation, visual field defects, and other neuropsychological sequelae requiring long-term rehabilitation 6