Commentary 5.4.1.

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Extracranial surgery timing

Jaroslav Plas

Emergency extracranial surgery is to be preferred over transport or head CT, as far as the patient remains haemodynamically unstable1. Some clinicians advocate early internal fixation of limb fractures or maxilofacial deformities. Others prefer delayed surgery1.

If early extracranial surgery is preferred, both full cardiovascular monitoring and ICP monitoring are expected. Principles of neuroanaesthesia should be kept: that means to avoid cerebral vasodilatation and episodes of hypotension. Preoperative evaluation of the coagulation systém is recommended. Also monitoring of the neurological condition (pupils) and preferably  ICP and/or neurophysiologic monitoring during surgery is advocated. There can nevertheless occur unknown development of focal mass lesions with midline shift despite such monitoring. That is why European Brain Injury Consortium (EBIC) does not recommend to perform early extracranial surgery for non life-threatening cases of injuries1.

A serious problem can e.g. come about if abdominal surgeon has stopped spleen  bleeding, while at the same time epidural haematoma has grown to the stadium of bilateral mydriasis. That is why it is necessary to accent treatment of intracranial hypertension as well. A general surgeon does not often know that after shock was managed (by abdominal surgery, etc.) he or she is already operating under condition of brain death. And so I recommend a parallel solution: no matter that these situations do not occur frequently, the surgery in both abdomen and head at the same time is possible. It should be incessantly accented that the treatment of elevated ICP is prior. The time distance from the incident of injury is not decisive. What is crutial here is the state of the pupils:

· in case of central brain herniation the critical moment is the spread of both pupils from initial miosis (change from diencephalic to  mesencephalic stage),

· in case of temporal herniation the critical moment is also the spread of bilateral mydriasis: one-side mydriasis proceeds here from the paresis  of peripheral nerve (n. III.); the spread of the second pupil is here mesecephalic sign as well! If bilateral mydriasis is started, the prospect of survival is about 5%2.

Greenberg2 divided influence of third ventricle shift on consciousness in acute temporal herniation as follows:

shift (mm) state of consciousness
0 – 3  full
3 – 4 somnolence
6-8,5 stupor
8 – 13 coma

Even if the state consciousness failure is not defined exactly and unambiguously enough in Greenberg´s table, it can be quite well utilized for neurosurgical practice.

References:

1. Maas AIR, Dearden M, Teasdale GM, et al: EBIC-Guidelines  for management of severe head injury in adults. Acta  Neurochir(Wien) 1997;139:286-294.

2. Greenberg MS: Head trauma. In Greenberg MS: Handbook of  Neurosurgery. 3rd ed, Lakeland, Florida:Greenberg Graphics  Inc,1994:521-569.

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Last updated: 2000-08-04