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Traumatic Brain Injury - Latest Updates in the Management

Jan 14 | 1:30 PM

Traumatic Brain Injury (TBI) is the modern silent epidemic as it is the primary cause of mortality in children and young adults across the developed and developing world. TBI leads to fatalities and long-term disabilities among the most productive members of society, the youth. Yearly, roughly 1.5 to 2 million people suffer a brain injury in India, with over 1 million succumbing to those injuries. However, TBI treatment has experienced a paradigm shift in recent years. Don't miss our exclusive session with Dr. Raja S Vignesh as he unpacks the latest updates in the management of TBIs!

[Music] so good evening everyone and i'm dr samadhya i welcome you all on behalf of team netflix uh today we have with us dr rajas vignesh a senior consultant neurosurgeon nilay institute of medical sciences so did one of the first aneurysm surgery in tirunelveli he has many articles papers to his name and repeated forums sir devise an intraoperative prognostic scoring system in traumatic sdh apart from this is also interested in cricket and is a fitness enthusiast a very warm welcome sir what do you mean over to you sir yeah thank you so it's a nice evening actually uh today is celebrated all over india and different names so anyway uh it is good to share some light about dramatic brain injury as i always say that uh neurosurgery uh is not that much found off by either patients nor their attenders but still it is one of the fascinating things and it has uh many positive effects on life of people so coming to traumatic brain injury so this presentation will be a a little bit of a typical presentation wherein i'd like to impart certain knowledge regarding traumatic brain injury and its management in particular where the timing of management and decision making is more important in deciding the outcome because as i always say when i was in ug period any neurosurgery mostly we come across traumatic brain surgeries so the prognosis if everyone is asked they would say yes it's not so good so so the over the years over 20 years things have changed uh in the management of tba though the concept is same we have good gadgets and better drugs and more so we have adequate facilities to treat traumatic brain injury in time so as we say time is brain so it does good for management of traumatic brain injuries as well so so we shall start now so yes trauma so the most commonly in india it is trauma it is usually a motor vehicle accident that causes major traumatic injury and we find that drunken driving not wearing seat belts and rash driving are most common causes of fat injury in india so it still so happens that people get drunk they drive and get injured and not wearing helmet seat belts so this is one of the commonest things and in old age where above 60 or 70 people have fall they have a fall at their home or workplace and get injured so commonest is trauma then yes what what to look for in a case of a traumatic brain injury when a patient comes to you so main things that are uh usually seen or reported is one thing is elvos elbow is loss of consciousness more than 10 minutes then you have retrograde and anti-grade amnesia so what is retrograde and anti-grade amnesia this is on subtle points which differentiates or will give you a guide a rough guide of the nature of traumatic brain injury retrograde amnesia is so the person will remember things that are just uh uh before the event he'll be having a good memory and uh the event alone he'll forget and once he he regains consciousness yes his memory working memory everything will be good so only that part of the incident where he lost his consciousness he will lose memory whereas things before that and after the incident he'll be having good memory so retrograde memory memory loss is one of a better science whereas anti-grade amnesia is the person gets injured he'll remember things all the things before the incident okay he'll remember all things before the incident but he'll be finding it very difficult to register and recollect things after the incident so he'll be when you examine him he'll be he'll appear good yes but he'll find it difficult to remember and register new things so this causes a lot of confusion and and this denotes a severe injury at the molecular level rather than a retrograde amnesia so when your person complains of retrograde amnesia we not worry much so clinically it indicates that uh everything is all right it could be a minor concussion or something and recovery is is really good whereas anti-grade amnesia it uh usually denotes structural brain drama structural brain damage lots of functional structural brain damage but still anti-grade people having anti-grade amnesia usually tend to recover because brain has lots and lots of plasticity previously it was thought that once you remove part of the brain our brain gets damaged it's all it's all over it's just like like end artist no it's not so proper training and cognitive training etc etc then adjacent part of the brain which are near to the functional areas will make up and they will take over the function i have seen patients in my nine years experience where i have removed a left temporal lobe okay left temporal lobe is mostly concerned with speech so when you have a left here mg in fact you will get aphasia so similarly when you remove left temporal lobe and part of frontal lobe patients usually become speechless and they will be facing but with proper training and counseling uh actually training i have seen patients recovering and able to speak a few words and sentences meaningful understand things and able to lead a near normal life they they can also able to write okay so adjacent areas of brain take over so we need not bother that traumatic uh amnesia is a very bad prognostic sign it's a it's a it's a it's a it's got a prognosis but still after good training you can recover then everybody knows she's just then vomiting vomiting uh here i am say vomiting is it denotes indirectly rise to intracranial pressure so vomiting is rise to interacting pressure and she shares if you go into the details there are you can have as two types of sheets one is an impact she seriously impacts she's a risk when the patient has an injury he'll have she just at the moment of impact of the injury are within a few minutes and later on he won't have any seizure attack so that's it that is uh so that is impact seizures so that doesn't usually require any anti-epileptics and early post-traumatic seizures are any features that occur within the first two weeks so that also carries a good prognostic sign the structural damage in the brain is probably less whereas we have another condition called late post traumatic seizures late post traumatic seizures where the seizures occur after two or three weeks so that indicates severe structural brain damage and these patients are more likely to be dependent on anti-epileptic drugs so these are the reason guidelines wherein uh previously even during my ug days and during mch also uh we used to prescribe all these antibiotic drugs once he has a head injury the patient may be taking lifelong years together like that it's not so if you could clinically classify it earlier so impact seizure we need not give you can wait and early post traumatic shifts are maybe during that period to around two to three weeks i usually use for three weeks temper it and stop and watch for it so early post traumatic seizures and impact she just won't require anti-epileptic drugs lifelong whereas late cross traumatic seizures usually wreck drugs for more than two or three years because on the brain damage is very severe and the gliosis it causes pull in the adjacent water cortex and the fusion potential is very high and these people need a proper follow-up with these eegs and other modalities so that we can taper the drug so remember this impact seizure you don't need any drugs at all and early post traumatic seizure during that period maybe within two to three weeks and late post traumatic seizure you may have to continue a longer period of anti-epileptic drugs so see this is the reason advance in management of post traumatic speeches then vomiting this you would be all knowing yes icp raised icp will get vomiting and ent bleed and csf leak this we have to look for because uh a nose bleed initially profusely bleeding nose for fracture in the nasal bones and androgen fossa you might have csf leaking through it through the front plate which is a very thin papery bone so csf leak and even in csf leak previously we this is one reason advanced which i am adding the thing is previously whenever we have csf leak we'll start on triple antibiotic we cover gram positive gram of gram negative we cover anaerobic all such antibiotics we'll be covering for 21 days or maybe 14 to 21 days for all csf so nowadays the there is shift the thing is yes let there be csf leak you manage it conservatively if it holds good you can manage conservativity and antibiotic we can start it once we see the first sign of inflammation we have either fever or rising crp or something like that any neutrophil neutrophil count rise or alpha sensorium in a normal patient so you can you can start or if at all you can have prophylactically one drug one regular broad spectrum cephalosporins will do so in my experience nowadays for the past two to three years i don't routinely start any kind of antibiotic unless there is indication and not pertaining to csf and if the patient develops infection usually that happens after 20 to 48 hours i'll start antibiotic and that will be good because you you you can prevent antibiotic resistance and more of antibiotic abuse is being happening so so that that is with the antibiotics and csf uh many people miss uh csf lead through the year so any year bleed usually second day we may have csf so for all major csf leaks uh not major any css like through the nose that is rhinorrhea strict bedrest is the dictum strict bedrest and more so these patients will be having some pneumococcus so you treat with oxygen stick better and antibiotics as warranted so these are the main things which you will initially look for in a case of a traumatic brain injury so this yes everybody knows so i just wanted to brush up glasgow coma scale those pg aspirants and those who are doing uh where ug or mchs so the minimum scale is three i opening will be one verbal will be one and motor will go on and maximum it is fifteen so this is one point which i would remember the minimal scoring is 3 and the maximum is 15 and one thing that many people forget is it is the best response in each of the category so eye opening response means best response in i so sometimes one of the i may be opening spontaneously so otherwise you still shut maybe there is stones or something you take it first content is eye opening verbal response which is the best one motor responds to when there is some problem with uh a patient may be having hemiplegia following this trauma so he won't be moving his hands uh her hands or legs legs at all whereas the other limb it will be functioning he'll be localizing so when you consider the when you consider the one limb which is paralyzed the score will be one there will be no water response whereas when the when you look at the other limb he'll be localizing so the best motor response best eye response and best verbal response is the key in gcs so another one thing which i have to add is in role of intubation management of traumatic brain injury has changed drastically following two things one is this intubation prevention of aspiration and prevention of bed source so those these three things though they seem to be minor unrelated to the injury these are the most common cause of morbidity and mortality uh in in case of brain injury so yes any glasgow coma scale score of less than nine any glass cochlea less than nine that is eight and below you have to incubate you have to intubate why do we do this intubation yes uh previously people used to say the person is having spontaneous breathing his saturation is good his respiratory rate is good so why should i intubate because his respiratory apparatus is working good so the indication for intubation is not for these three parameters so the prime indication for intubation in a head injury patient is is level of consciousness and that indirectly or directly influences his swallowing and fractal reflexes okay because when the tracheal reflexes and swallowing reflexes are good aspiration is prevented so that is the level of conscious level wherein the scale may switch between life and death for any patient so the level of consciousness is very important wherein you the reflexes if they are preserved they are preserved he's on a safer side if he has good cough while you are doing suctioning if he has good swallowing reflux yes because ah you have 1.5 liters of salivary secretions daily entering your stomach when the reflexes are not good you are going to aspirate this 1.5 liters into the lung and when the reflexes are not good the esophageal sphincter is lacks and all things which are stored inside will regurgitate and they can enter the lung so gastric acid which is a worst chemically returned can cause severe lung damage and chemical minimalitis is a nightmare for treatment of traumatic brain injury or any injury so any injury or any physical or medic medical or surgical condition if aspiration then the prognosis is bad so so to prevent this aspiration there is indication for intubation when the reflexes are not good so always remember any gc is less than nine that is eight and below you have to incubate put in the rise tube two rail sub also that's the same thing so three things to remember in glasgow coma scale minimum is three by fifteen and the best response to be chosen maximum is 15. intubate when the indigo gcs is less than 9 yes survey what to look for yes this everybody knows conscious level whether it is alert other is obeying look at the breathing pattern then look at the movement of limbs and last three i want to emphasize because these are easily missed a person with head injury in my previous class of spinal injury i have told any patient with head injury look for other major injury injuries unless proved otherwise 83 you have you take it for granted that it should be a spine injury which you have to rule out you look for chest injury which has to be reload you look for abdominal injury which has to be ruled out you look for long bone pelvic injuries which has to be lulu so any injuries all major in the injuries you look for and roll them out so this neck pain and restriction of moments is very important i have seen patients who walk into the trauma what who walk into the trauma what talk to you and say complain they have pain in the neck unable to move the neck they not being attended or not being surveyed properly get a ct done or x-rays for other things and while doing ctr getting x-rays they die on the table okay a walking patient i have seen two or three patients because in case of spine injuries traumatic subluxations luckily the patient may be having good uh he is so fortunate that with subluxation his card is still intact and he'll be walking into your what and when you manipulate the neck everything gets injured so prevention of such injuries is mandatory so neck pain and restriction of moment is important and these things pupils lateral rectality these things you will be all knowing so watching for pupillary reaction is a must in monitoring clinically and also bps a brady guardian and hypertension go hand in hand yes remember this because in many of the ug and post graduate students i find that yes they'll call me yes sir the patient is unconscious he's having severe brain injury we are suspecting brain injury yes tell me what is the pulse and yes sir the patient is in shock the pulse is stable i cannot record the bp then how do you suspected injury so they are confused the thing is remember this even a very severe head injury patient will not usually have hypotension and tachycardia and this is a very rare possibility where a massive laceration of scalp can the patient can bleed and he can be in hypovolemic shock so remember always remember tachycardia hypotension in a setting of polytrauma yes hypovolemic shock hypovolemic shock hypovolemic shock hypovolemic thousand times it is hypovolemic shock okay so hypovolemic shock in turn can save the patient you put a broad line you rush a trial of fluid yes he will survive that that fellow is unconscious because he is not having good perfusion to the brain so the brain is in a stunned state and he is not responding and if we think that there is some blue gematoma inside the brain and he is unconscious now you can't save the patient because to evacuate that hematoma if it were there it needs a neurosurgeon to come and operate but treating a hypovolemic shock is very simple in the initial stages unless it goes for decompensated state so initial 1 hour or 25 minutes is very very crucial so clinically look for blood pressure and pulse then second one is cervical spine injury yes you can have a severe uh bradycardia and you can have hypotension in cervical spine injury when the sympathetic outflow is lost you will have bradycardia and you will have hypotension and remember the third point beware the person will be disoriented and irritable you will be thinking of head injury but it is usually due to ensuing hypoxia and he is going in for shock so and i always told previously rule out silent interrupt down would be hemonymoth here again we will think it is lucid interval yes patient has walked into the ward he's having abdominal pain which he may he may not complain might have not complained ongoing bleeding once he loses 1.5 liters he becomes unconscious and we think that yes it might be adhd expanding and he has become unconscious no so always rural hypo olympic shock and tree type of shock in case of poly trauma more so in head injury and bigger pelvic fractures too yes now when to take a city so any gc is less than 14 if the person is under the influence of drugs or alcohol or something the person is disoriented drowsy and isn't obeying any unconscious patient and obviously when there is pupillary asymmetry yes this we all know and the last one is more important because we as doctors there are many students who are just getting into medical school and probably recent pass outs and people who are into fresh practice the last one is more to save our skin nowadays i used to say to people first save your skin save your skin save your life simultaneously save your skin save your life simultaneously and save the patient okay both are equally important if this is 50 that is 50 percent you cannot say yes i am i tried 100 to save the patient i miss certain things and i am being sued in court oh no blood or nothing nothing nobody is going to help you documentation is very important similarly when to take a cd better take a ct if the patient is stable better take a ct if the patient is stable are in mri if needed so so the compelling evidence now is consumer driven compulsion and somebody is asking can you elaborate on survey to spend injury in relation to hypotension yes cervical spine as you all know it is a we have a sympathetic outflow which passes from cervical spine and enters the thoracic spine and from there all those things come out uh so this will be far fresh but i'll i'll just brief you that the sympathetic track gets affected in spine injury high circles manager and thoracic injuries okay so rasic and spine injuries uh you will have a affection of sympathetic outflow sympathetic system is the reason for adrenaline noradrenaline these fibers are responsible for maintaining a positive effect on the heart rate and peripheral vascular resistance okay so when the peripheral resistance is good you will have good blood pressure and the heart rate is dependent upon sympathetic and parasympathetic sympathetic drives the heart whereas parasympathetic slows the heart and peripheral resistance increased by sympathetic so now when there is cervical spine injury there is interruption of sympathetic outflow so what happens the heart slows okay so that is bradycardia okay the heart slows similarly peripheral vascular resistance is lost so there will be hypotension so brady guardian hypotension occur in high cervical spine injury and thoracic spine injury so i hope you you got it yes this i told you already so intubation drives you these two simple things change the life of a patient so always individual when the gcs is nine oro tracheal larvae is preferred rice tubes saves many immediate deaths due to silent aspirations silent aspiration kills silent aspiration kills somebody is asking about physiotherapy management that is far flesh nowadays we are managing about uh uh we are just into traumatic brain injury so we'll discuss it later so rise tube saves many immediate deaths due to silent aspiration you keep the head and elevated position 30 degrees put in a rice tube yes that saves more than 60 percent of life at least according to me they were when there is severe nasal or a pharyngeal bleed because there will be nasal bone fractures crippling from plate fracture everything will be dislodged you put in a rise tube and there is a resistance you stop or sometimes even with the resistance right shift goes inside in case of severe nasal bleed and it will be inside the anterior cranial fossa we have seen right shifts inside underground fossa uh in a ct scan so when there is severe war on sf pharyngeal blade you can uh put in the rise tip all the more cap be careful while inserting the right strip you can have your what is that uh help of your seniors intensivist anesthesiologist and uh you can very well have the intubation of things with you so that may help whether the tube is going inside or not so remember an expert will do the best job both in debate and for a rise to okay so if you are notice just try it there is uh if it is going without any problem yes it is easy yes continue otherwise the withhold ask for help okay in medicine never hesitate to ask for help however experienced you are or however nobody's you are so in medicine if a patient go with cd scan and mri but he didn't find injury but still yes it has happened even i have a recent patient yeah a 20 year old girl who had a severe injury ct serial cities are normal and serial mris are normal but she is having clinically all features of diffuse axonal injury mri couldn't pick up so yes still you can have and concussions don't show in ctr mri and i have seen two or three cases maybe this is the third case mri serial mris which i have taken over a period of three or four days are normal and still the patient is disoriented and something like that so there is something beyond imaging also so probably a metabolic scan or something may help yes first it yes always secure neck and iv line always secure neckline don't kill the patient due to other injuries in managing a traumatic brain injury traumatic brain injury management is 30 but managing the rest to 70 is very important so that you can save the brain after saving the life so saving the life is important then come comes the brain okay so then secure airway rises to bs oxygen i told and elevate the head to 30 degree elevation of head to 30 degrees improves the venous return from the brain prevents venous congestion so that is why we have elevation of it to 30 degrees then the last two things uh this is mainly i have put it for uh peripheral people where people may be practicing alone etc etc so in my years when i was a student 24 years back in peripheries they used to give phenotype and they'll rush in monetary okay they'll rush in manitoba also so among these two giving phenotype will not usually harm okay a loading dose of energy usually will not harm and i say say it may be unwarranted in many cases okay so if at all if you're in periphery and you are giving uh phenotyping it's okay because that is a commonly used anti-appropriate drug in peripheries or even in uh cities to eighty percent of uh us use tenant time so that is cheap and it is a very broad spectrum too and it does wonders so though it may be unwarranted in most cases another thing in management of traumatic brain injury yes diuretics previously we used to pump in diuretics so the first point you have to have it in your mind without a ct by your side never ever start on diuretics without because previously they thought when a patient becomes unconscious it is always due to rise to ecp something like that is uh his conscious level is coming down you give a dose of phenytoin sorry manitol or whatever the diuretic is there so he may improve it's not like so it's not so many patients have been killed by our own drug so remember this edh vs sdh an extraordinary hematoma or a subdural hematoma so after getting a ct sdhr conclusion when there is an isochorio you can do give a bolus dose of 150 to 200 ml of manual or you can have oral glycerol and three percent nacl nowadays you have you have glycerol with you can have glycerol with ah what is that monitor it is available glycerol with manitol is available and the last one dexamethasone yes steroids though controversial they may be helpful in certain situation so no harm in giving steroids but steroids to be cautiously used so i don't routinely use t rights i use for contusions and subarachnoid hemorrhage so remember this when ct is not taken when you have not ruled out an extra dural hematoma never give manitol manitol mental if it is an external hematoma and you didn't diagnose it you give manitol you are going to kill the patient this has happened in our medical college wherein a medical student who got injured there was a tiny external hematoma yes he was there in observing he was there for observation suddenly by evening five o'clock the interns are calling me sir that fellow has become unconscious all of a sudden yes we didn't know what happened yes then i had to rush up we repeated a city the amurama was so huge that he was nearly unconscious yes his glass scale was four luckily we have i operated on him and he's alive now without any deficit but on retrospection why it happened because the injury happened the day before he was an observation for 24 hours it was an observation for 24 hours and suddenly he is deteriorating that does not happen in neurosurgery later we found that by mistake by mistake they had infused manitoba okay and that man it all stripped off the dura and the edge size increased so yes somebody says majit and various brain trauma foundation guidelines yes they say so according to brain trauma foundation guidelines yes steroids are controversial and need not be used but there are occasions wherein we have seen more than evidence-based medicine sometimes things help the same thing holds good for spine injury too using steroids so there is nothing harm but i i even i say i use it only for support hemorrhage very rarely for conclusion sometimes so yes is right so steroids are all controversial and can be given in conclusion so on this one this is another thing simple thing which will avoid lot of uh morph reality and morbidity stress helps us gastric erosions are common after uh brain trauma so stress cells and gastric erosions are common you can give a commonly used ppa you can give you can give h2 blockers like land rounded so remember this why i have put it as a separate slide because uh these things uh though they look simple play a major role which we may not uh be aware of so so yes you can give ranitidin you can give ppis so the neurologistics yes in case of traumatic brain injuries for people used to give analgesics when there is scalp laceration patient is complaining of pain to avoid nsaids because in the acute setting we may not know the kidney function the hypotension can cause some loss of kidney function too and uh avoid analgesic so if you use manitol uh it may shut the kidney down so uh along with analgesics so invulnerable people are more so interstitial kidney diseases and patients with compromised marginal function yes avoid these analgesics nsaids if at all use parasitomole and you can give tramadol with uh and then saturn also tramadol with anderson vegas for few people and citron will have a very severe vomiting so yes you can give tramadol with underneath so the concept is avoid nsaid is to protect your other system okay so if at all you can do parastemal which is one of the safe one yes and this is one important slide so this holds good for years together always remember because i find i i want to communicate certain four or five points regarding traumatic brain rightly by this session so one among them is most important one is this people with that injury [Music] yes they did rate they become unconscious they may die it can happen but there is some time frame which we must remember so any stable head injury stability in the sense if the gcs is say 12 and he stays in genesis 12 for 24 hours to 48 hours yes so that is that we call a stable if he is in 15 it is stable but if there is a drop in gcs in every hour or 4 hours or 5 hours when you monitor that is a warning sign okay so that is sedimentary version so remember a person who is deteriorating in the same day within minutes to hours is more likely due to head injury because ongoing bleed and herniation due to severe reading if there is a sdh or a contusion there is severe brain damage within 68 hours a talking patient may succumb to he may slip into coma an adh within minutes he can slip into coma but what i am mentioning is a person is stable for 48 hours then suddenly from jesus 13 his thesis goes to 6 4 no it can't happen that way within an hour it can happen that way so that is what i am reiterating remember a stable injury person worsening is a cause of concern in the sense it might not be need to head injury remember that might not be need to that constitutional thing which is inside that is least likely after he stabilizes so always rule out aspiration decision sudden aspiration seizure and kill somebody is asking is it necessary to say cp or mr in a fully oriented yes i i wrote in uh uh we saw in the previous slide uh the thing is as far as our recent guidelines no indication if the gcc is 15 or if these not have taken drugs or something like that but still we have missed major injury even in otherwise fully oriented gc 15 patients so it's no harm in taking because the risk benefit ratio is better if you can rule out by imaging so when you have the situation where you have a ct scan or mri with you and you feel that it could be a severe head injury though the person is fully conscious oriented better take it and the last point which i mentioned yes that holds good compulsion legal compulsion better taking okay so yes coming again always rule out certain aspiration in seizure then more than two years i don't see a new situation in head injury that is causing a sudden death okay yes i mean sudden death always sudden death sudden death in the sense i'll tell you within one hour or two a good pair your passion with the good gcs deteriorating dying it can never happen it's very very unusual remember this patient can die of pulmonary embolism mi and there is one condition called non-convulsive status epileptic yes that requests a high degree of suspicion and that too in a ventilated patient so yes that is rare but these things preventable cause of death you can put in uh dvt what is that you can put in dvd stockings you can put in dvd pressure pumps you you can prevent pe you can you can start you can start on low molecular damper and even after eight hours of heat injury so i start on low molecular weight apparent okay within after 8 to 6 8 to 10 hours even if i operate i used to start on low dose molecular weight apparent even if i operate a patient i used to start on low dose low molecular weight apparent so remember a dvt will kill suddenly by way of pulmonary embolism and mi can kill a non-convulsive status and aspiration chemical so remember aspiration fishes dvt pulmonary embolism myocardial infarction cause sudden death or sudden deterioration in a case of a stability injury remember this any stability injury please don't think directly that it is a head injury that is killing him no head injury is to be considered but rule out these things and remember after four or five days his chest infection and electrolyte imbalance are the major things that kill him so after four or five days hyponatremia kills many patients than the injury itself we may think uh it is as simple no it is not so hyponatremia can kill hypokalemia can kill it can cause arrhythmias we may we may not notice the patient will die then after two to three weeks remember the sepsis from an unattended bedsore will kill and more so if he has got spinal injury and last line is very very important metabolic parameter diabetes many tests yes two to three weeks it kills rule out diabetic ketoacidosis patient can present with fluctuating conscious level you may think it is due to head injury no rule of tk rule of dka diabetes can kill in a multi number of ways so always think about these things in any case of stability injury yes how can spinal injury kill oh oh boy what is this it's fine how can spinal injury it can kill if it is a high uh circle span injury a card edema can worsen and it can kill i don't know in what meaning you are asking but if i could understand this way yes a patient may be breathing normally and you can have edema in the card and can result in respiratory failure and it can cause a silent aspiration best source like that no no elaboration of spinal injury we have done in a separate class so we will we did it last time two hours spinal injury okay now cushing's response yes so what is it this everybody will be aware but still i wanted to brush up so hypertension bradycardia as i have always told yes and undergraduates maybe you may be asked these questions what are false localizing signs so it is some sixth now palsy third now palsy which are unrelated hemiparesis fundus papadima steroid mandatory in spinal injury we have covered spinal injury separately in first class first class itself so it's not mandatory uh there are two schools of thought so the dose is uh different okay so i think we are we have to stick on to head injury yes remember this is an easy thing herniation syndromes this may be asking your questions if you are still studying so one is subcalcine herniation first one second one is central transcendental urination ankylonation and upward transductive variation which is very rare and we will be frequently in encountering supplements inheritation and ankylonation so ancho herniation has the typical ankylonation as the typical things that is your hutchinson's pupil which we are taught in our ug days itself so that is ankle herniation a lot of subdued large external automa is there and the ankus of the temporal lobe is herniating inside so and sub pulse and herniation it happens um near lesions on the frontal lobe where the both anti-residual arteries go for uh compression and you may have anticipatory syndrome where the patient will be in a mute state or vegetative state so yes again you can refer uncle herniation you have ipsilateral terna policy controller lymphedema this is the kernel and notch or phenomenon okay then central trans tentorial herniation yes bilateral small pupils and decartical rostral urination so it is very bad and subfalse and urination is severe coma with the contralateral weakness and cerebellar herniation is the end stage it's the end stage everything is finished once the cerebellum marinates it'll compress the spinal centers medulla yes so it's imminent death when there is cerebral or radiation either it is upward or downward so these things for probably undergraduates are post graduates you can have it on coloring nation central transitorial sub subfalcene and cerebellar herniation yes aeration syndrome again so we used to say these four things uncle diancephalic mesencephalic and hindbrain herniation so these are grassley what are the critical features so when there is chain stock speeding we say it is thalamic or uh reinstable herniation uh hyperventilation still occurs in myth and supporting and irregular gasps are shallow breathing will indicate impending medullary herniation so yes you can note it down so these hybrid posturing decal ticket posturing hypertonia so these things uh so why do we why do we need to understand this because clinically when we are monitoring clinically when you are monitoring if you find the subtle science we can save the patient so clinical when you are monitoring these subtle signs are very very important so these we can do something either by drugs or by surgery so we may save the patient yes so this is hutchinson's people a refreshment for undergraduates post graduates whatever so three things initially there is herniation due to the pull the now gets irritated it goes for meiosis ipsilateral people goes for meiosis then the now goes for infection of blood supply is lost the same side people dilates at the same time due to traction the opposite nerve is also irritated so the opposite side people constricts and finally when there is downward total herniation that opposite now also goes for infection and the people die it so hutchinson's pupil is unequal pupils for your sick unequal peoples for your sake unequal pupils so at this stage you can find a patient if it is an sdh or contribution if you do manitobal 200 ml maybe you can save the patient take him up for surgery taking up surgery and you may save the patient okay so yes now a few points i have reserved all recent advances to the last three slips because i don't think there is much uh recent advance that is going to help in management of traumatic brain injury so i wanted to emphasis on these things so extraordinary always associated with fracture common sense of frontal temporal region source of arteries middle meningeal artery it's a coup injury it's on the same side you will have a sub gallerial hematoma on the right side you will have a fracture of the right right bone you will have a hematoma on the same side so right side injury scalp injuries on the right side you will have a fracture of the bone on the same side you will have injury to the middle meningeal artery you will have the hematoma on the same side so remember it's a coup injury middle meningeal artery is a source of bleed common in frontal temporal region always also for your level it is always assorted fractured very rarely we have immediate veins that get ruptured and you have a contralateral uh abdominal atom also but that is far flesh so head injury external autonomy always also fracture common sites source of bleeding is middle meningeal artery and coup injury yes clinical features as i said earlier lvoc headache vomiting nearby no split lucid interval can occur which we discuss small to large life threatening then it can be clearly asymptomatic without any signs or the patient may present in a comatose state at gc15 hutchinson's people we have discussed other signs we have already discussed so uh edh a patient with a huge amateur can be walking into you and he may die within two hours a small hematoma he'll be walking with you over six years he'll literate and die and patient present with uh in a comment or state so three things can happen in an edge okay yes what do we do we do a ct brain and your religion will be a bi-convex extra actual lesion associated with fracture so in tamil we used to say you you all know be aware of you you may be aware of our south indian dish italy idli dish is very famous it is by convex it is biconvex so in tamil we used to say idli madri idli shape is edh edh idli shape okay bi convex lenticular okay lens shape so edh is it the shape and is associated with fracture okay then management anti-epileptics i have already told you edh we don't usually give there may be impact seizures yes sometimes you can give remember the second line that is what is this presentation is all about not about most reason advanced remember no anti-administration contra indicated will kill the patient by expansion of clot conservative disease is above 15 and if it is small edh still even if it is larger nowadays by experience by experience we put most of the patients on careful observation clinical monitoring and eating usually resolves more than one centimeter we do operate and more than 30 ml these things yes these are all textbook guidelines but after operating thousands of cases we find that even i have left three centimeter size big edh with mass effect without any clinical deterioration yes patient improves it gets absorbed and or it becomes chronic idiots into uh two weeks time we just put a bar only by accurate and go so yes but uh textbook wise literature wise these are the indications and remember any posterior fossa edh be careful be careful be careful be careful because that can kill a patient within minutes it can kill the patient within minutes posterior foci edh a posterior fossa idh we have certain things uh the fourth ventricular compression even if the udh is very small you have to operate it can kill with acute hydrocophys can kill the patient with acute hydrocarbons or koni so posterior fossa edh cerebellar hematoma whatever it is these these things go in a similar way any hematoma in the posterior fossa if it is uh the fourth entity is obscured in ct scan if it is obscured in c operate so that that denotes mass effect whether the hematoma is one centimeter or it is just 5 ml don't bother you operate okay so then last slide is very important in extra durable hematoma uh when gcs is four if there is uh contusion or sdh are less than six we don't usually operate and i don't do my major surgeries going for conservative measures because surgeries don't help there because there is severe brain damage so they don't help so but remember the last line a patient with extraordinary hematoma gcs3 if he is having spontaneous respiration and if the pupils are still dilated and he is breathing regularly you can operate he will make he may survive like a wonder boy after surgery so remember any edh you're gonna operate if the even if the gcc is three if it is needed okay then yes yes subdural hematoma this is uh common in injury among young there are two things two types of several amateur my young versus old alcoholics okay young versus golden alcoholic young nowadays i find many people drinking alcohol as if it is water so yes so their their brains age will be above 50 only even at 20 years if you drink alcohol lots and lots your brain gets atrophied and it will be a 50 year old brain so head injury young non-alcoholics versus old and alcoholic youngs are the same so in young it is an acute sdh it is associated with contusion that is the brain matter brain substance is shattered it is damaged and the surface oozes and that ooze gets collected as subdural hematoma so that is brain damage the cortex gets ruptured the brain gets pulverized okay it gets ruptured and the bleeding that stagnates in the subdural space is hematoma so that is that pattern of eda sdh you encounter in young whereas the other one is old age and alcoholics there is snapping of the bridging veins in the parenchyma and the blood passively collects beneath the neural in this case there is no brain damage actually brain damage is due to mechanical compression similar to that of an edge in alcoholics and chronic patients so the iris will be very thick dense but patient will be doing well because there is no intrinsic parenchymal brain damage whereas in young there is intrinsic severe pancreal brain damage the brain gets shattered it bleeds the surface whose get collected as an acute sdh so remember these two things in a ct itself while looking at that you can prognosticate so uh i suppose uh many people are throwing some likes and hearts so they are understood good so sdh clinical features loc vomiting she's just anisochoria etc low gcs remember the last three it's a contour co injury there will be a fracture opposite to the side of sdh and this is important because as there is intrinsic severe brain damage the secondary mediators of injury inflammation and all other secondary medical injury will worsen the brain damage and the icp will rise rapidly and there is severe clinical deterioration and this raised icp will throw a busier cycle creating more brand brain damage and more what is that ill effects due to the secondary mediators and as i always say prover prognosis if the gcs is below nine okay sdh and contusion it is a it has got poor prognosis if the disease is below nine yes ct brain you will have a plano convex or concave or convex lesion it is hyper intense so ed sdh is like banana you can remember a banana or a semi-leaner shape banana okay you can have a banana that is idli so food you will remember edh and banana is sdh okay so sdh is associated with diffuse axonal injuries very severe injury so it can present as acute on chronic and atropic brain old and alcoholics too so as we are more concerned about traumatic brain injury i am discussing about the acute test dates okay chronic is in is in itself a separate topic there's a holy management uh will you manage yes circulation airway breathing conservative anti-edema drugs manitoba frozen dexamethasone this controversial and anti-able drugs have to be given antibiotics if needed and these are indications sd is more than one centimeter as there is more than one centimeter a midline shift more than one centimeter and even this brain trauma uh foundation guideline say so but i again say after operating more than thousand odd cases even we put sdh under conservative management you go to sd generate conservative management and uh yes last thing i will discuss later uh decompressive cranectomy duroplasty these are all in neurosurgeon's perspective but still you should remember so there is a paradigm shift in management surgical management neurosurgeons we have changed the mode of craniotomies craniotomies rather cranictomies in sdhs previously we used to remove the whole skull it is a hemi crane activity we used to say yeah 15 to 20 centimeter size uh thing and still patient doesn't survive nowadays i do you know it is recommended we do a mini cranectomy we do a five centimeter size screen activity and we do some other procedures which i will discuss yes prognosis it depends upon size gcs midline shift size less than five mm less than uh what is that five mm early surgery better prognosis any traumatic brain injury or fine car injury if at all if you feel you have to operate operate it early early early early operated early and a size more than one centimeter midline shift more than one centimeter associated contusion why i say associated conclusion is associated contusion denotes it is structural parenchymal damage okay delayed surgery poor prognosis yes so i wanted to show this imaging so for the first one yes now everybody will be able to say first one is it is semilunar shape semilunar shape and it is banana like so the first one must be an sdh is it not so first one is an sdh and there is an intraventricular bleed too there is an intraventricular bleed too in the right occipital hunt okay then the second one yes aerodynamic oh this is an answer also coming out second one is an edh it is an idly shape yes great that is ugly shape it is semilunar bicon convex shape lens shape and the third one anybody i'd be really happy if uh people answered that third one right because i was sah is there yes i agree sah is there there is some temporarily sage and some temporalist no no not the larger one the next one below edh the third one is below edh one sh is there what else is there maybe you can zoom and see what else is there s.a.h is there ten dollars is posterior cerebellar contusion is there yes what else what what do you find in temporal lobe mid lane shift no no no no no no there is not much of midline ship do you find anything in the right temporal lobe anything in the right temporal lobe right temporal lobe no no it's not in fact it's it's hypodense fracture no fracture is not seen i'm asking no no i'm asking hemotomous what is that hematoma that is in the right temporal lobe that's what i'm asking you what is it amatoma in the right temporal lobe right temporal lobe anybody else no it's not idiots ah it is subdural yes that is subdural acute hemorrhage and there is and there is intra dural or intraparent chemical there is contusion also there is subdural hematoma there is separated hemorrhage and there is contusion also okay there is constitutional a subdural and intra parenchymal contusion is there and some message is there tend to release h is there so that is uh the third one and this larger imaging yes can anybody tell what is this larger imaging larger image larger image no it's not durable is there conclusions are there but what is striking there what is striking in this large city everywhere it is white for a striking in this large city anybody i v i v h i v h s i v h i v h is not there no yes diffuse external injury no no what is that subarachnoid hemorrhage excellent subarachnoid hemorrhage so it is all the subarachnoid spaces are filled with you can see the sylvian system filled with uh blood you can see the perimeter yes it is dilated ventricles that's right the dilated ventricles are perfect and you have subarachnoid spaces all filled with blood the intra hemispheric fissure anterior posterior are filled with blood the sylvian fissure is filled with blood you have perimeter caphalic systems arachnoid systems we used to say like spider leg appearance around the midbrain you have blood and as somebody rightly pointed out yes ventricle two has that yes it's diffuse say h this patient was brought as a traumatic uh brain injury but this fellow had a fall following a massive aneurysm rupture okay so it was a massive aneurysm rupture for which he fell and he was brought in as a case of head injury so yes so now yes imaging people ask for i think i have done my best for the imaging yes anti-arima measures i have already told so these are the doses of anti-edema measure nowadays instead of manitol we use hypertronic saline when there is it can prevent hyponatremia also so these are the things which you have to deal with okay and beware of kidney okay in non oliguric renal dysfunction you can very well use monitor in non oliguric renal dysfunction we can use mannitol but oligarchy cranial dysfunction use with caution so but for undergraduate level it is okay when the kidney function is not good avoid manitoba that is a standard teaching but if at all you want you can use it when it is a non oligary stable renal failure but you have to hydrate adequately so exactly stop hypertronic saline if sodium crosses 155 now rather not 155 you can you can slow it down if it crosses above 145 to because thereafter sometimes there will be rapid spurts so not 155 i would recommend 145 to 150 keep it around 145 to 150 because more than 155 again hypernitremia seizures again you can have cerebral demand death so no never 150 fights so 145 above stop it or taper it or be cautious use diuretics okay so yes yes these are certain measures because uh we have to still they whole good elevate the head avoid serum hypoassismality because it will result in rebound edema increasing edema avoid hypotonic saline hyperventilation yes hyperventilation remember these are the reason advances previously it was thought that if you give if you have prolonged ventilation gives good results no nowadays it's not so hyperventilation short spurts short bursts of hyperventilation your hyperinflate for two minutes ventilate normally then after one hour you can hyperinflate for three minutes or four minutes or five minutes it will reduce icp so frequent hyper inflation in in phases that will be better in reducing icp not wrong hyperventilation as previously thought an external ventricular range yes in higher setups we do manage head injury in a better way because we put a cisternal what is that uh icp monitors uh very very rarely a few of the intensivists are comfortable with the lumbar drains also and sometimes you put in a barrel and place an icp monitor but though they are very good and precise in monitoring icp clinical monitoring will suffice okay what is brain death when there is no brainstorm reflexes no spontaneous breathing it is brain dead okay so yes then glucocorticoids nowadays not used and third one sorry last but one induced hyperthermia induced hypothermia and induced coma are again and again time and again the best modalities to reduce icp when the gz is very very low they shut the brain down keep the brain in induced coma and prevent all these worsening of such a secondary mediator induced injuries so induced hypothermia induced hypothermia induced coma phenobarbital coma that is one of the best drugs that reduces uh your uh cerebral metabolism slows down shuts down the brain and all would have heard about michael schumacher the legend formula one legend who underwent two craniotomies and he was put in phenomenal coma for around uh three or four weeks by which they could save him otherwise you'd have been dead so very severe injuries better if you have good facilities you can have induced hypothermia and induced coma yes surgical aspect also i wanted to tell so previously it was decompressive cranectomy uh the last one hemicranictomy was done nowadays it is not done it is now historical only and this one is sub temporal decompression we put a minicranectomy we decompress the temporal path vein transplantation possible so far not so uh sub temporal decompression wherein you remove the sphenoid ridge and temporal bone you make the androgen fossa and the middle clinic as one then cystostomies are the recent advances in surgery and by my experience they are the best one previously even over three years before we used to do cisternas uh for sub frontal system we used to open the opto charismatic systems perimeter capacitance but that was a difficult procedure actually it will take time but nowadays what i practice now is i do i am doing a study also i open the silicon system which is very very easy silicon system opening it takes around hardly two minutes and when that is difficult i remove a sheet of arachnoid i remove a sheet of arachnid in the convexity that also does the job of cystostomy well so this is one reason advanced if there are neurosurgeons or neurosurgery post graduates they may be knowing yes cystostomies do wonderful job they do wonderful job and one of my colleagues here he doesn't do that too if there is severe injury he puts a lumbar drain and he drains so but our methodical teaching and literature say yes raised icp you will kill the patient by lumbar drains but he is doing in a different way and uh so far there is good improvement too so removing the csf reducing pressure do minimalistic procedure cystostomies i do uh sylvian cystinostomy okay so hemichronectomy is not done nowadays yes it's a left temper operate occipital idiots yes now we have some interesting videos can we have the first video please this is one case of edh extraordinary hematoma this patient was taken in gcs3 okay gcs3 you could see so this indicates second to third stage of herniation this is very poor prognosis okay the next video please the very same patient the next day what an idiot i have seen a patient i have seen a patient literally walking out of the eot a tomato station operated walking out of the ego during the first leg so extraordinary you operate even the gcs is three next next next video please this is one another edh where you can see he's moving his right upper limb and he couldn't move his left upper limb this immediate post up okay this immediate post up can you play the video again so the weakness has improved his immediate post up see pre-op prehabited semiplesia is his gcs is around m5 and he's able to raise his arm so this is a this is what is that is needed time time is brain so time saves brain so if you delay it by another hour you would have been dead by now so next next video please yes this is one one girl subdue limit on my large subdued hematoma she was decelerating so according to brain trauma foundation you cannot expect a recovery but post up she is answering okay she was a 23 year old mother just delivered four days back met with an rta and we could save her you could you could see that okay so she was decelerating if we go as per brain trauma foundation guidelines i shouldn't have operated so this is three months later her weakness has improved so this is what if at all you are going to operate give the benefit of doubt explain to the patient attenders that yes so and so there is a possibility that maybe two or three percent are even five percent the patient may improve so next slide please so we have seen edh we have seen on sdh2 so this is anisoforia patient is grasping this is a small boy i think he was around six or seven years old he was gasping literally in deathbed next slide this was some sdhs [Music] yes yes remember this a neurosurgical death is a stepladder deterioration and not a sudden death like you might remember this and somebody has asked about physiotherapy uh that is one cornerstone in rehab one cornerstone both cognitive physical and mental physiotherapy will do wonders in traumatic brain injury that's what i was emphasizing in in my first session itself physiotherapy is the cornerstone all these patients who who were not able to use their upper limbs and lower limbs especially that second girl the 23 year old girl you would have noticed she was not able to move her limbs but after three months she was able to move so that was cornerstone physiotherapy physiotherapy is mandatory it is a cornerstone in recovery now as we discussed we have our topic as recent advances which i think in traumatic brain injury does not help much but still to do some justice to the topic i wanted to throw few slides okay reason views one is primary versus this neurosurgery post graduates may be knowing what is primary decompressive craniectomy what is secondary decompository activity so primary is yes there is sdh or conclusion this is slow you take up for surgery immediately secondary is you observe a patient for some time he did rates you open i don't i don't advise secondary at all i go in for primary if at all you want operate operate operate how to identify specifically ruptured aneurysm it is by ct angiogram only then how gate how gate improved post-op yes that's what i was telling no physiotherapy physiotherapy physiotherapy it will improve it will improve i have i can show you patients where mca influx we have successfully decompressed and dead simultaneous st amc bypass surgery is walking okay walking not alone walking talking also mca in fact so yes physiotherapy is the cornerstone okay come coming back again primarily it is done in acute stage and contusion these are large hemi craniotomies previously and secondary indication is to lower icpc you follow the icp is raising you operate but i would rather go for a primary surgery if the gcs is around 10 to 12 itself because in my experience and my teachers are others too it is good if you operate early large hemi crane activities are not absolutely beneficial nowadays i would say and post operatively and recovery too they create lots of problems sunk and flux syndromes etc etc nowadays i do sub temporal decompression and many of uh neurosurgeons do subterm decompression with cystinophostomys which are as effective as symptom of unruptured aneurysm is another topic probably the organizers are willing i can go on aneurysms tumors and so on if viewers are also interested so i can do series of classes in neurosciences i would rather appreciate if i get chances so yes but for your question symptom of unruptured aneurysm you won't have symptoms for unruptured animalism may be an incidental finding you can have very rarely if there is a leaking aneurysm some some aneurysms leak okay slight leaks uh you can have some suboccipital headache or some little headaches episodic that is what more than that you don't usually have silent aneurysms unruptured or silent until they burst and go for coma deep coma okay so again large grain item is not so useful do a subtemporal decompression if there are neuro neuro post neuro surgical post graduates i would say do a sub temporal decompression you can if you have a good microscope you can do a two to three centimeter size barrel work on the silicon system let out csf and nowadays this is for neurosurgical post graduates i used to put a external ventricular drain in the silicon system bring it out just like an evd keep it for 48 hours and remove it so if there are neurosurgical post graduates maybe some hair will grow after surgery yes definitely yes but not me not much on the scar line scar line usually it may not grow but the remaining hair will yes so neurosurgical post graduates if any are there so we we do evds we i put in a drain in the silicon system bring it out keep it for 20 to 48 hours and remove it that is as effective as any large crane ectomis what can be done for tomatoes patients yes we discussed uh ventilation and other modalities whatever that can be done one was a camouflage patient with edh whichever had operated so it depends upon what is the cause recent advances yes this is the actual topic per se i have summarized in three four points there are many number of biochemical markers this can be done only in advanced centers wherein they they probably they can just like imaging just like imaging they can guide you ct is normal mri looks normal if these things are elevated you can say yes traumatic brain injury severe drive glial fibrillary astrocytic protein gfab has more correlation with the severity of hip injury and microsomal rna in the blood it is one of the earliest things to rise in traumatic brain injury but these things are of more of theoretical and research value mcq purpose you may have it gfab and microsomal rna you can remember these four things you can remember yes so this is what happens in brain injury axon injuries astrocytes get activated gfa be released yes hundred be released okay actual injury top protein is released and from the neuronal soma the neuronal body you see h l one so these are all uh for your mcq purpose rather i would say okay not more than that so that's why i put it last okay i don't find any reason at once that is contributing much to uh management of tb except for physiotherapy cognitive therapy or something like that so yes and people a few neurologists who would treat uh brain injury they use cerebral pals what is that protein layers and they use ct colon but i don't find they are useful in traumatic brain injury so for mcu purpose students yes so this is what you can have gfa b s hundred b u c h l one and you can have microsomal rna okay so this is for m c h purpose yes ah remember this one this is also a research drug amino cyclin we'll be uh using for uh atypical uh respiratory symptoms so just like doc sagin this is a wonder drug now which they say have proven good in mice model and few human trials also i co-pour in p4 inhibitor okay so this is one thing a reason advanced which part of brain injury what is it so menocycline has these effects okay so sometimes they may ask you an mcq what is the antibiotic that is used in management of traumatic brain injury suffer toxins separate oxygen mineral cycling ciprofloxacin we won't go for amino cycling so remember minocycline reduced neuronal laptop process brain edema it reduces blood brain barrier barrier disruption repair it helps so so minocycline is one drug so with that i have come to the conclusion of management of traumatic brain injuries so thank you for patient listening so any more questions i will be happy to take up oh thank you so much sir we have a question from dr samia ranjin what major precaution should be taken by physiotherapy major precaution during physiotherapy is a major thing is um prevention of contractures okay prevention of contractures is main and prevention of pressure source pressure zones and what we're doing is should be avoided over doing physiotherapy should be avoided a qualified physiotherapist in case of severe uh what is that motor weakness or some subtle weaknesses yes even if you uh go about it in a harsh manner it won't affect but in cases of power from one to two uh or three it should be strictly professional because you you need to know what is the power in the trunk what is the power in the hip or what is the power in the knee so that you have you can give graded exercises so that is one major thing in physiotherapy prevention of contractures then you have to give proper thing then another one which yes somebody has rightly pointed which i totally missed i forgot chest physiotherapy when i was telling about rise tube and intubation chest physiology is very much important very very important spirometer is very important it saves lives spirometer is very important saves life if pyramid is not available you can use a balloon you can use a balloon you can put a hole in the balloon and ask them to ask the patient to in play so that that does a lot of uh wonders chest infection is prevented lung complaints increases so oxygenation is good so yes asking could tranuxamic acid help yes it is again just like steroids people think it works they give some people think it doesn't work they don't give but i don't find any harm in doing we we sometimes repeat two doses even during surgeries so yes which part of brain injury is more dangerous probably brainstem midbrain medulla ons more dangerous life threatening a simple injury a tiny injury can be devastating then few other questions i think we have missed that are good yes so we have a question from dr kailash uh if patient is having symptoms of acute onset of weakness of half serve body followed by spurt speech in that case ct head or mri is helpful mr mr is good mri is good previously we were taught that if you suspect hemorrhage or infect first do a ct scan but now mri is readily available all over at least in tamilnadu we have an mri center every 25 kilometers i guess so mri is good it can detect hematoma it can directly impact so mri is good best modalities for cerebral or injury if there is an indication operate operate operate operate operate i will always say operate right so so uh dr abu is asking role of occupational therapy in yes i emphasize nah previously physiotherapy and occupational therapy therefore they go hand in hand they go hand in hand in rehab long time rehabilitation a good center with good occupational therapist and rehab therapist the outcome will be far far better than without them so occupational therapy physiotherapy and cognitive therapy are cornerstones of recovery so very much important right so so we have wonderful comments from dr andrea like a very good session so thank you so much dr vishnu priyasi's wonderful session sir uh excellent session thank you so much dr hima what other record what precautions should be taken and post-operative patients if they need emergency dental treatment emergency dental treatment like maybe a fracture of mandible or something like that okay that uh it depends on the centers okay we do we do ask them to simultaneously fix such mandibular uh fractures with wiring we put in a rice tube we feed them and if there are loose tools yes remove them and facial maxillary injuries if they can work simultaneously we can do because a single general anesthesia will do but some sometimes if the wound is not good they may wait for some time and then operate so yes we can have both simultaneously and after a period of time too any routine screening for aneurysm risk factors nobody does routine screening for aneurysm the high risk factors family state of aneurysm families of severe hypertension and episodic headaches are there indications for screening yes ich management yes if the hematoma is less icp is less go for conservative management anti-edema measures if the hematoma is of large size icp is raising a poor gcs operate uh yeah probably i think he is asking about intracerebral hematoma evacuation that is i can give a different answer too previously all intravenous glam automotives when they are larger we used to operate and remove it nowadays if it is liquefied we used to we do remove it because a solid clamatoma in removing that plot we do more structural brain damage that holds good mostly in spontaneous ich for hypertensive ich so that similar thing can be followed here also a dramatic ich if it is larger try and uh you can manage it conservatively try to do that if at all you need to operate remove little as much as possible little in the sense don't do don't increase the structural damage to the context so that is a recent guidelines so in non-traumatic hematomas we have certain trials called stitch trials s t i c h stitch trials one two three is going on so surgical treatment of intracerebral hematomas that is stitch trial so they the the findings of such trial across all nations is that operative management of traumatic subdue sorry uh interesting comma causes more damage than conservative management so that's what i mean to say to avoid aspiration when we can think that patient patient can take uh orally like is there anything special yes i'll tell uh yes as soon as he is getting his swallowing reflex and his conscious his complex is good start over start or no point in these iv fluids oral treatment is a what is that nutrition is the best nutrition it avoids unnecessary stagnation in the gut avoids unnecessary bacterial proliferation in the gut so oral as early as possible oral overall if at all if he is not able to do try arrives to feeding is there any constriction of brain during inhalation it's not constriction brother it's not constriction rather the brain pulsates okay so during arterial pulse and inspiration it pulsates it floats and it pulsates right so we have question from dr amit like in which cases to add steroids and in which cases to avoid it yeah that's what i told already according to recent guidelines no rule of the rights but personal experience out of these evidence-based medicine they are good in contusions and suburban average continuations and submarine hemorrhage yes so oh so i think people maybe indicated in any situation i i am really very clear they don't give added benefits they don't give added benefits so we don't do it but still sometimes yes they may help but i don't find uh they give added benefits how intracranial pressure no it doesn't lead to traumatic brain injury you you monitor icp by doing what is that icp monitoring devices is there any chance without major ct findings any patients have gone to what is that has gone to severe compromise in the health status i don't get that can we come again without ct and any major ct findings uh like any patient has gone to severe compromise yes yes yes they are gone they have gone sometimes the brainstem conclusions they may not be picked up by ct yes they have gone [Music] this covered vaccination recommended if you want if you don't want covet please do vaccinate for coffee do we add diuretic is it possible decent work is it but this is a very nice question is it possible to have decent work family balance in the field it all depends upon you managing the time yes it is possible it should be possible right so uh so we have question from dr kelash uh sir please explain more about window period in cva patient window period in cba patients cerebrovascular accident yes previously in our when we were undergraduates it was six of us okay then later when i suppose graduate has come down to four hours now it is one hour and as early as possible i would say because uh i think the question is about a repercussion or something or stinting or something so it is related to that any cerebrovascular accident you treat early that is what time is brain it's for hematoma it's for injury or even cba so if you have facilities for doing an angio you can stay on stenting you can do it as early as possible just like cardiac stenting if it if you have facilities for thrombolysis do it immediately if at all you don't have you you are happy so do it do it do it at the earliest do it at the earliest and chronic insufficiencies we do stmc bypass i do super shell temporal artery to middle circulatory bypass so that too helps so yes the window period is as early as possible if it is within 10 minutes it is good if it is within half an hour it is good if it is within one hour also it is good and some one to four hours is the golden period they say within one hour is the [Music] best what is sub pulse and herniation we had explained that is uh um the brain the part of the brain the frontal lobe uh herniates uh below the fox below the fox anteriorly so that causes disruption to car colossal vessels and anterior cerebral artery so its thrombosis are leads to infection the anterior territory patient will be comatosed and if one side ac or branches involve he'll have contralateral hemiplegia or sometimes uh it is related to the lower limb so he can have weakness of one lower limb alone so deep coma mute mute and in the worst stage he can be in deep coma with both lower limbs start functioning tell us the guidelines for duration of phenotype in that they have already told anthropologists we can revise impact seizures not needed early onset uh traumatic she's just that is within 14 days you may have to give it continued for two to three weeks if it is delayed she's just delayed changes are late on she says more than two weeks you may have to give it for a longer period of time see six months one year maybe serial eegs are depending upon the recurrence of seizures it may be even more than five years or life long sir tell me more about hematoma so okay i'll revise it again extraordinary hematoma same side coup injury middle meningeal artery bleed don't use manitol subdural hematoma it is contract injury fracture on the opposite side it is due to injury to the brain parakima or bleeding of bridging and the treatment you can give manitol and edh external autonomy is idly shaped or semilunar sorry what is a biconvex shape a subdural atomized banana shape or it is a semilunar shape then contusions paranormal chemical damages where you have to give manitoba and surgical indications and differ according to situations clinical feature of corona radiator in fact yes it depends upon the site corona radiator in fact the weakness will be less because it's a it's a spreading fan like spreading so which area is involved the weakness will be less rather than when it comes to the internal capsule or lower down structures if any hematoma near cavernous sinus yes temporal lobe mamma thomas you can have near camp on the sinus if the sinus gets thrombosed you will have all those uh cavernous syndromes symptoms from right from maybe second now to you can have till fifth now uh sixth now two memory loss it's uh it's a recap actually uh traumatic memory loss okay so one is a retrograde amnesia which i told the person will forget only the uh think during yeah what is that loss of consciousness before he will remember fully and after the recovering consciousness he will remember fully so you won't have any disturbance in the working memory working memory is the in the sense when i am talking you are listening so you register the words i talk you comprehend you listen you understand and you reply so this is working memory if you want to do a task you will have certain things in memory if suppose you have to uh what to say you have to remove the tire from a car you should know that first you have to uh keep up the what is that set the jack then it's a stepwise manner so for each step you have working memory so that is working memory and uh and anti-grade amnesia is severe brain damage wherein after the incident there is uh very diver there is difficulty in remembering things so that those persons will suffer a lot a kinetic mutation stroke is anterior cerebellar arteries sorry it looks like a patient is awake below the neck he'll be quadriplegic aca anterior cerebral cerebral artery syndrome so i think we've answered most of the questions so thank you so much and we are also looking forward for your next sessions and we'll take up more topics in neurosurgery we would like to call you again so thank you so much sir for coming thank you so much audience have a good night everybody thank you so much thank you thanks a lot for the opportunity


Dr. Murtuza Zozwala & 1212 others


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Medflix is a new platform by PlexusMD, India's most active and trusted doctor community. On Medflix, you can discover live surgeries, discussions, conferences and courses from some of the top doctors and institutions across the world. Join clubs in your areas of interest and access hundreds of amazing live discussions everyday.