How should a patient with a moderate-to-severe contrecoup traumatic brain injury be managed?

Management of Contrecoup Traumatic Brain Injury

Patients with moderate-to-severe contrecoup TBI should be immediately transferred to a specialized neurosurgical center by a medicalized prehospital team, with management focused on preventing secondary brain injury through aggressive correction of hypotension (maintain SBP >110 mmHg) and hypoxemia (maintain SaO2 >90%), followed by urgent brain CT imaging and ICP-guided therapy. 1

Immediate Prehospital Management

Transfer to Specialized Centers

• Severe TBI patients must be managed by a prehospital medicalized team and transferred immediately to a specialized center with neurosurgical facilities, as this significantly improves survival and neurological outcomes compared to non-specialized centers. 1
• This benefit applies even to patients who ultimately do not require neurosurgical procedures, due to accumulated expertise and neurosurgeon availability. 1

Prevention of Secondary Brain Injury

• Maintain systolic blood pressure >110 mmHg through fluids and vasopressors as needed. 1, 2
• Maintain oxygen saturation >90% to prevent hypoxemia. 1, 2
• The combination of hypotension and hypoxemia carries a devastating 75% mortality rate, making their prevention the highest priority. 1, 2
• Duration of hypoxemic episodes (SaO2 <90%) is a critical predictor of mortality. 1

Initial Hospital Assessment

Clinical Severity Assessment

• Document the Glasgow Coma Scale (GCS) with all three components (eye, verbal, motor) recorded separately, along with pupillary size and reactivity. 1, 2
• The motor component is the most robust predictor of outcome. 3
• Assess for signs of basilar skull fracture (rhinorrhea, otorrhea, hemotympanum, retroauricular hematoma, periorbital hematoma), displaced skull fracture, post-traumatic seizures, and focal neurological deficits. 1

Immediate Imaging

• Perform brain and cervical CT scan without delay in all severe (GCS ≤8) and moderate (GCS 9-13) TBI patients. 1
• CT findings provide objective severity assessment independent of consciousness level, with intraparenchymal lesions, hemorrhage, and mass effect correlating with injury severity. 3
• Use nested, inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (CNS and bone windows). 1

Transcranial Doppler Assessment

• Consider TCD on arrival to assess cerebral perfusion through Pulsatility Index (PI) calculation. 1
• For severe TBI (GCS <9): if diastolic velocity (Vd) <20 cm/s and PI >1.4, immediately implement therapeutic measures to improve brain perfusion. 1
• TCD should be incorporated into the FAST examination protocol for multiple trauma patients. 1

Intensive Care Management

ICP and CPP Optimization

• Maintain cerebral perfusion pressure (CPP) by optimizing mean arterial pressure (MAP) through fluids/vasopressors and/or decreasing intracranial pressure. 4, 5
• Direct ICP monitoring should guide therapy in conjunction with clinical examination and repeat imaging as indicated. 4
• Consider brain tissue oxygen (PbtO2) monitoring as it shows promise in optimizing cerebral blood flow. 4

Ventilation Management

• Target EtCO2 between 30-35 mmHg prior to obtaining arterial blood gas samples to adjust mechanical ventilation. 1
• Avoid both hypoxia and hyperventilation-induced cerebral vasoconstriction. 4, 5

Refractory ICP Management

• Utilize bedside maneuvers, sedation, hyperosmolar therapy, and CSF drainage as first-line measures. 4
• For refractory cases, consider barbiturate coma or decompressive craniectomy. 4

Ongoing Monitoring and Complications

Neurological Monitoring

• Perform frequent neurological checks: every 15 minutes for the first 2 hours, then hourly for 4-12 hours depending on risk level. 2
• Any decrease of ≥2 points in GCS or new neurological deficits mandates immediate repeat CT scanning. 2

Additional Management Priorities

• Provide early seizure prophylaxis for post-traumatic epilepsy prevention. 4, 5
• Recognize and treat paroxysmal sympathetic hyperactivity (PSH) if it develops. 4, 5
• Implement venous thromboembolism prophylaxis when appropriate. 4, 5
• Optimize nutrition as therapy. 4, 5
• Reverse anticoagulation appropriately if present. 4

Critical Pitfalls to Avoid

• Do not use biomarkers (S100b, NSE, UCH-L1, GFAP, MBP, tau protein) for routine clinical decision-making, as uncertainties remain despite associations with outcomes. 1, 2
• Do not delay transfer to specialized centers—outcomes are significantly worse in non-specialized facilities. 1
• Do not tolerate even brief episodes of hypotension or hypoxemia, as protocols focused on preventing these secondary insults significantly reduce mortality. 1