Neurologic Injuries

• Traumatic Brain Injury
• Spine and Spinal Cord Injury
• Blunt Cerebrovascular Injury

Traumatic Brain Injury

The fellow should be able to:

• Demonstrate competency in the initial management of patients with traumatic brain injury including level of care and need for transfer
• Understanding the role of hyperosmolar therapy and difference in hypertonic saline vs mannitol on patient outcomes
• Understand the indications for intracranial pressure monitoring
• Demonstrate the ability to manage a patient with elevated intra-cranial pressure using a stepwise approach
• Utilize advanced ICP monitoring devices in the management of a patient with a TBI
• Describe the role of external ventricular drains in TBI, the management of EVDs, and the complications associated with EVDs
• Understand the role of seizure prophylaxis in TBI, indications, and controversies
• Recognize the long-term effect of TBI, understand strategies to mitigate TBI, and assist patients suffering from the effects of TBI
• Understand the diagnosis of death by neurologic criteria

Resources

• Topic Summary
• Advances in ICP Monitoring and Alternatives
  • Overview Article:
    • Gregory W. J. Hawryluk, Giuseppe Citerio, et al. Intracranial presure: current perspectives on physiology and monitoring Intensive Care Med 2022.
  • Additional Resources
    • Teodor Svedung Wettervik, Erta Beqiri, et al. Brain tissue oxygen monitoring in traumatic brain injury: part 1 - To what extent does PbtO2 refect global cerebral physiology. Critical Care 2023
    • David O. Okonokwo, MD, PhD; Lori A. Shutter, MD; et al. Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: A Phase II Randomized Trial. Neurologic Critical Care 2023.
    • Fritz-Patrick Jahns, John Paul Miroz, et al. Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury  Critical Care 2019.
• Prophylaxis for Post-Traumatic Seizures
  • Overview Articles:
    • Brandon P. Luck-Wold, Linda Nguyen, et al. Traumatic brain injury and epilepsy: Underlying mechanisms leading to seizure. Elsevier 2015.
    • David Turnbull, BM, FRCA, PhD, Nataliya Singatullina, MBBCh, FRCA, EDIC, and Charles Reilly, MBchB, FRCA, MD. A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management. Neurosurg Anesthesiol, 2016.
  • Additional Resources:
    • Early Seizure Prophylaxis Observational Study: Demetriades et al. 2017
    • Anwar Zaman, MD; Randi Dubiel, DO; et al. Seizure Prophylaxis Guidelines Following Traumanic Brain Injury: An Evaluation of Compliance. J Head Trauma Rehabil 2017.
    • Nickalus R. Khan, MD; Matthew A. VanLandingham, MD; et al. Should Levetiracetam or Phenytoin Be Used for Posttraumatic Seizure Prophylaxis? A Systematic Review of the Literature and Meta-analysis. Neurosurgery 2016.
    • Nancy R. Temkin, PhD; Sureyya S. Dikmen, PhD; et al.  Historical Article: A Randomized, Double-Blind Study of Phenytoin for the Prevention of Post-Traumatic Seizures. The New England Journal of Medicine 1990

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Spine and Spinal Cord Injury

The fellow should be able to:

• Demonstrate an understanding of the management of cervical, thoracic, and lumbar spine trauma including the role of operative vs non-operative treatment strategies
• Describe the role of CT and MRI in cervical spine trauma
• Recognize the controversies of cervical spine clearance in the unexaminable patient
• Describe the acute and long-term complications of spinal cord injury and management of these injuries
• Describe the role of blood pressure management in spinal cord injury and recognize the controversies associated with this strategy
• Discuss the role of diaphragm pacing in high spinal cord injury

Resources

• Topic Summary
• Overview Article:
  • Wang TY, Park C, Zhang H, et al. Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature. Front Surg. 2021; 8: 98736.
• Additional Resources:
  • Schroeder GD, Vaccaro AR, Welch WC, et al. Best Practices Guidelines: Spine Injury. American College of Surgeons Committee on Trauma. March 2022.
  • Blood pressure augmentation
    • Hawryluk G, Whetstone W, Saigal R, et al. Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J Neurotrauma. 2015;32::1958-67.
    • Saadeh YS, Smith BW, Joseph JR, et al. The impact of blood pressure management after spinal cord injury: a systematic review of the literature. Neurosurg Focus. 2017;43(5):E20.
  • Corticosteroids
    • Fehlings MG, Wilson JR, Tetreault LA, et al. A Clinical Practice Guideline for the Management of Patients with Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate. Global Spine Journal. 2017; 7(3):203S-211S.
  • Venous thromboembolism prophylaxis
    • Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guidelines for Health Care Providers, 3^rd: Consortium for Spinal Cord Medicine. Top Spinal Cord Inj Rehabil. 2016;22:209-40.

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Blunt Cerebrovascular Injury

The fellow should be able to:

• Demonstrate an understanding of the risk factors and incidence of BCVI in trauma
• Describe the role of screening criteria and differences between screening systems
• Understand the screening options for BCVI and limitations of each modality
• Discuss the BCVI grading system and outcomes associated with BCVI
• Describe treatment options for BCVI and controversies associated with treatment

Resources

• Topic Summary
• AAST Education Module - Blunt Cerebrovascular Injuries
• Meet the Mentors - Blunt Cerebrovascular Injury
• Overview Article:
  • Schroeder GD, Vaccaro AR, Welch WC, et al. Best Practices Guidelines: Spine Injury. American College of Surgeons Committee on Trauma. March 2022.
• Additional Resources
  • Inaba K, Byerly S, Bush LD, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial. J Trauma Acute Care Surg. 2016.
  • Awake, examinable, asymptomatic patients
    • Anderson PA, Muchow RD, Munoz A, et al. Clearance of the asymptomatic cervical spine: A meta-analysis. J Orthop Trauma. 2010; 24(2): 100–106.
  • Awake, examinable, symptomatic patients
    • Malhotra A, Wu X, Kalra VB, et al. Utility of MRI for cervical spine clearance after blunt traumatic injury: A meta-analysis. Eur Radiol. 2017; 27(3): 1148–1160.
  • Unexaminable patients
    • Badhiwala JH, Lai CK, Alhazzani W, et al. Cervical spine clearance in obtunded patients after blunt traumatic injury: A systematic review. Ann Intern Med. 2015; 162(6): 429–437.
  • Older Adults
    • Healey CD, Spilman SK, King BD, et al. Asymptomatic cervical spine fractures: Current guidelines can fail older patients. J Trauma Acute Care Surg. 2017. 

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