Dr. Jorge Torales
Neurosurgeon · Skull base and spinal endoscopy
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Trauma surgery
Neurotrauma: treatment of traumatic brain injury (TBI)
Urgent surgical management and follow-up of traumatic brain injury: intracranial haematomas, cerebral contusions, skull fractures, and chronic sequelae. 24-hour immediate response.
What is it?
Neurotrauma: treatment of traumatic brain injury
Neurotrauma encompasses injuries to the nervous system caused by trauma. Traumatic brain injury (TBI) is one of the leading causes of death in people under 45. Intracranial haematomas (extradural, subdural, intraparenchymal) may require urgent surgery. The time from injury to treatment is the single most important modifiable prognostic factor.
1h
critical window in extradural haematoma for maximum recovery
40-60%
mortality of acute subdural haematoma without surgery
70-80%
functional recovery after timely surgery for chronic haematoma
Symptoms
When to consult a neurosurgeon?
After a head injury, warning signs include:
- Loss of consciousness, even briefly, following the impact
- Lucid interval followed by deterioration (classic sign of extradural haematoma)
- Progressive headache not relieved by analgesics
- Projectile vomiting, especially in children
- Altered speech, vision, or movement
- Confusion, irritability, or progressive drowsiness
- Pupil asymmetry or inability to be roused
- Post-traumatic seizures
Urgent attention: Any head injury with loss of consciousness, vomiting, progressive headache, or neurological deterioration requires an urgent CT scan. Time is the critical factor.
Treatments
Techniques we use
Acute subdural haematoma evacuation
Urgent surgery via wide craniotomy. Prognosis is directly proportional to the speed of evacuation (golden rule: within the first 4 hours).
Chronic subdural haematoma drainage
Burr hole under local or general anaesthesia. The liquefied haematoma is drained through two holes. Excellent prognosis with discharge in 2-3 days.
Extradural haematoma surgery
Urgent craniotomy. Prognosis is excellent if surgery is performed before cerebral herniation · many young patients achieve full functional recovery.
Decompressive craniectomy
Removal of a large bone flap to allow expansion of cerebral oedema. Indicated for refractory raised intracranial pressure. Reconstruction (cranioplasty) is performed 2-6 months later.
ICP monitoring
Intraventricular or intraparenchymal catheter for continuous intracranial pressure measurement. Guides treatment in severe TBI (Glasgow ≤8).
Depressed skull fracture repair
Elevation of the depressed bone fragment when there is neurological compromise or dural laceration. The dura is repaired and the skull reconstructed.
Our protocol
How we approach each case
Every patient with severe TBI (Glasgow ≤8) is admitted to the neurocritical care unit with ICP monitoring, invasive arterial blood pressure monitoring, and cerebral oximetry. The Brain Trauma Foundation protocol guides management: maintaining ICP below 22 mmHg, cerebral perfusion pressure 60-70 mmHg, normoxia, and normocapnia. When intracranial hypertension is refractory, medical treatment is escalated (deep sedation, osmotherapy, hypothermia) and decompressive craniectomy is considered as a last resort. Post-discharge follow-up includes neurorehabilitation, neuropsychology, and radiological review.
Perioperative protocol
How we organise each case
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1 · Pre-operative assessment
Stabilisation of the polytrauma patient (ABCDE), urgent CT scan, Glasgow Coma Scale assessment, and Marshall / Rotterdam CT scoring.
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2 · Surgery
Immediate surgical evacuation of haematomas with mass effect. Decompressive craniectomy when ICP exceeds thresholds refractory to medical treatment.
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3 · Immediate post-operative care
Neurocritical care unit with continuous ICP, CPP, and, where indicated, cerebral oxygenation monitoring (PtiO₂). Application of the Brain Trauma Foundation protocol.
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4 · Discharge and follow-up
Variable according to severity. Comprehensive neurological rehabilitation coordinated with neuropsychology and speech therapy. Surgical follow-up and deferred skull reconstruction if craniectomy was performed.
Team
Neurosurgeons who treat this condition
Dr. Abel Ferrés Pijoan
Neurosurgeon · Spine, neuro-oncology, and skull base
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Dr. Pedro Roldán Ramos
Neurosurgeon · Spine, functional, and brain surgery
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Dr. Jhon A. Hoyos Castro
Neurosurgeon · Spine, peripheral nerve, and skull base
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Dra. María Elena Filadoro
Neurosurgeon · Functional, epilepsy, and spine
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Dra. M. Noelia Sosa Echeverría
Neurosurgeon · Functional and stereotaxy
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Dra. Giulia Guizzardi
Neurosurgeon · Minimally invasive and skull base
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Outcomes
Prognosis and recovery
Prognosis depends on initial severity (Glasgow), age, associated injuries, and speed of treatment. In extradural haematoma with early surgery, full recovery occurs in 70-80% of otherwise healthy young patients. In acute subdural haematoma, mortality remains high despite treatment (30-60%). In chronic subdural haematoma, 80-90% of patients regain their previous level of function. Severe TBI may leave motor, cognitive, or behavioural sequelae in a significant proportion of patients; early neurological rehabilitation improves functional outcome.
Frequently asked questions
Answers to your questions
What is an acute subdural haematoma?
It is a collection of blood between the dura mater and the arachnoid following a traumatic brain injury. It results from rupture of bridging veins and carries a high mortality (40-60%) if not treated urgently. Surgical evacuation via craniotomy is required within the first few hours.
What about a chronic subdural haematoma?
This is a slowly evolving blood collection (over weeks), common in older patients, those on anticoagulants, or following minor trauma. It is treated with a small burr hole and drainage of the liquefied haematoma. The prognosis is excellent and patients are typically discharged in 2-3 days.
When is surgery indicated for a traumatic brain injury?
Surgery is indicated for haematomas with significant mass effect (midline shift >10 mm or volume >30 cc), expanding lesions with neurological deterioration, refractory raised intracranial pressure, or depressed skull fractures with neurological compromise.
What is intracranial pressure (ICP) monitoring?
It is a fine catheter that continuously measures ICP following severe TBI. It allows early detection of raised intracranial pressure and guides treatment (cerebrospinal fluid drainage, osmotherapy, deep sedation, or decompressive craniectomy if refractory).
Can someone fully recover after a TBI?
Recovery depends on initial severity (Glasgow Coma Scale), the anatomical injury, and the speed of treatment. Mild TBI usually results in full recovery. Severe TBI (GCS 3-8) may leave motor, cognitive, or behavioural sequelae. Early neurological rehabilitation improves functional outcome.
References
What the clinical guidelines say
"The time from injury to surgical treatment is the single most important modifiable prognostic factor in acute intracranial haematomas."
"Intracranial pressure monitoring in severe TBI (Glasgow ≤8) is the standard of care for guiding treatment and improving outcomes."
Bibliography
Scientific references consulted
Studies and clinical guidelines on which our approach to this condition is based.
- Carney N. et al. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition. Neurosurgery. 2017. View publication
- Cooper DJ. et al. Decompressive craniectomy in diffuse traumatic brain injury (DECRA). N Engl J Med. 2011. View publication
- Hutchinson PJ. et al. Trial of decompressive craniectomy for traumatic intracranial hypertension (RESCUEicp). N Engl J Med. 2016. View publication
- Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale (GCS). Lancet. 1974. View publication
- Maas AIR. et al. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: Rotterdam score. Neurosurgery. 2005. View publication
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What our patients say
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"I arrived with a glioma I had been told was inoperable. Here they reviewed it at the tumour board and offered me a plan. The surgery was a success. Four years on, I am well."
Cervical disc herniation
"For years I had a cervical disc herniation, operated on by another team with no improvement. Minimally invasive surgery gave me back my mobility and took the pain away."
International patient
"I travelled from outside Spain. The team reviewed my case before I came and gave me a clear plan. Caring people and impeccable technique."
Request information
Assessment after head injury
If you have sustained a TBI and would like a review of sequelae or post-operative progress, please send us your study results and clinical report. Response within 24-48 hours.