Complications of Neurosurgical Trauma

• Carotid-Cavernous Sinus Fistula (CCF)
• Rupture of intracavernous portion of the carotid artery into the cavernous sinus
• Change in Mental Status
• Etiology is varied - delayed or expanding hemorrhage, worsening cerebral edema, blossoming contusion, infarction, seizures, infection, hypoxia, metabolic derangements
• Evaluate patient and order appropriate tests
• Urgent head CT to R/O structural lesion
• CSF Leak
• Commonly occur with basilar skull fracture
• Most resolve without intervention
• May present weeks to months after trauma with clear fluid drainage or meningitis
• If no resolution within 3-5 days, consider lumbar drainage X1 week
• Decubitis Ulcers
• Check skin on bedridden patients several times each week
• Treat early skin breakdown aggressively
• Deep Venous Thrombosis
• Must have high index of suspicion to avoid missing clots
• Suspect with unexplained episode 02 desaturation, c/o leg discomfort, low grade fevers without source
• Diagnosis is by non-invasive Dopplers or venogram
• Diabetes Insipidus (DI)
• Persistent urine output >300 cc/hr with specific gravity <1.002
• Generally an ominous sign and evidence of herniation
• Treatment is aggressive fluid replacement with close sodium monitoring
• Can give SQ aqueous pitressin or IV dDAVP if unable to keep up with fluid losses
• Failure to Wean Ventilator
• Copious secretions are common in prolonged intubations
• Trach may be necessary to get patient off ventilator
• Fecal Impaction
• Regular bowel regimen (colace, qod MOM/Dulcolax supp) is essential
• Gastronintestinal Ulceration
• Often arise in stressed patients, especially if on steroids
• Treat heme positive NG output aggressively (Maalox down NG q2-4°)
• GI consult as needed
• Hearing Loss
• Acoustic nerve (CN VIII) is the most commonly injured cranial nerve in head injury
• Etiology: Fracture through petrous ridge
• Direct injury to tympanic membrane or middle ear structures
• ENT consult as needed
• Hemotympanum
• Blood behind the tympanic membrane
• Generally resolves without intervention
• ENT consult as needed
• Hydrocephalus
• Onset may occur weeks to months following injury
• Suspect in patients who have a slow, gradual decline in neuro status
• Generally is communicating hydrocephalus
• Internal Carotid Dissection
• Consider in patients with focal neurologic deficits but normal initial head CT
• Can produce Horner’s syndrome
• Angiography confirms diagnosis
• Missed Injury
• Not uncommon in unconscious patients at presentation
• Investigate all complaints in patients as they recover normal mental status
• Neurogenic Pulmonary Edema
• Flash pulmonary edema occasionally seen after head injury
• Requires aggressive ventilatory support
• Generally resolves as quickly as it appears
• Pancreatitis
• A potential complication of blunt abd trauma, prolonged ICU course
• Suspect in patients not tolerating po intake, unexplained abdominal distention, or with low grade fevers with no explanation
• Check amylase and lipase levels for diagnosis
• Treatment is strict NPO with hyperalimentation until resolution
• Pneumonia
• Frequent complication of prolonged intubation
• Check daily CXRs on intubated patients
• Aggressive pulmonary toilet is essential
• Post-Concussion Syndrome
• Headache, anxiety, insomnia, dizziness, irritability, fatigue, poor concentration, poor memory, and/or visual complaints
• Symptomatic treatment as needed
• Post-Traumatic Headache
• Difficult problem to resolve
• May persist for months after trauma
• Try NSAIDs; narcotics generally exacerbate the problem
• Post-Traumatic Seizures
• Impact seizures have little significance and are not treated
• Delayed seizures occur in approximately 5% of trauma patients
• Predisposing factors: Early seizure (within lst week), prolonged post-traumatic amnesia, intracranial hematoma, depressed skull fracture, penetrating injury
• Pulmonary Embolism
• Must have high index of suspicion to avoid missing
• Suspect with any unexplained episode of 02 desaturation
• Diagnosis is by VQ scan or pulmonary angiogram
• SIADH (Syndrome of Inappropriate ADH Secretion)
• Frequent after trauma and surgery
• Urinary dumping of sodium despite hyponatremia
• Watch electrolytes for declining sodium levels
• Treatment is strict FLUID RESTRICTION -usually 1000-1200 cc/day or less
• Rarely salt tabs or hypertonic saline is needed
• Subgaleal Fluid Collection
• CSF escapes through dural tear and skull fracture into the subgaleal compartment under skin
• Generally resolve over time
• Require surgical correction of leak if expanding or persistent
• Urinary Tract Infection
• Frequent complication of catheterization
• Remove all Foley catheters as soon as possible