Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma

Patients with a head injury who "talk and die" in the 1990s

BACKGROUND

Patients who "talk and die" after head injury may represent a group who suffer delayed and therefore potentially preventable complications after injury. We have compared the clinical and pathologic features of patients who talk and die with those who "talk and live" after head injury.

METHODS

Data collected prospectively by the Scottish Trauma Audit Group were used to identify patients with a head injury and classify them according to verbal response at admission to hospital. All "talking" patients in the catchment area of a regional neurosurgical center were selected and those who died were compared with those who survived.

RESULTS

Seven hundred eighty-nine talking patients were identified. Seven hundred twenty-seven patients survived and 62 died. Patients who talked and died were older, had more severe extracranial injuries, had lower consciousness levels, and reached theater more quickly than those who talked and lived. Thirty-one of the patients that died had extra-axial hematomas.

CONCLUSION

Even with increased availability of computed tomographic scanning, some patients still talk and die after head injury.

Quantitative pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury. Technical note

The authors prospectively used a new hand-held point-and-shoot pupillometer to assess pupillary function quantitatively. Repetitive measurements were initially made in more than 300 healthy volunteers ranging in age from 1 to 87 years, providing a total of 2,432 paired (alternative right eye, left eye) measurements under varying light conditions. The authors studied 17 patients undergoing a variety of nonintracranial, nonophthalmological, endoscopic, or surgical procedures and 20 seniors in a cardiology clinic to learn more about the effects of a variety of drugs. Additionally, the authors carried out detailed studies in 26 adults with acute severe head injury in whom intracranial pressure (ICP) was continuously monitored. Finally, five patients suffering from subarachnoid hemorrhage were also studied. Quantitative pupillary measurements could be reliably replicated in the study participants. In healthy volunteers the resting pupillary aperture averaged 4.1 mm and the minimal aperture after stimulation was 2.7 mm, resulting in a 34% change in pupil size. Constriction velocity averaged 1.48 +/- 0.33 mm/second. Pupillary symmetry was striking in both healthy volunteers and patients without intracranial or uncorrected visual acuity disorders. In the 2,432 paired measurements in healthy volunteers, constriction velocity was noted to fall below 0.85 mm/second on only 33 occasions and below 0.6 mm/second on eight occasions (< one in 310 observations). In outpatients, the reduction in constriction velocity was observed when either oral or intravenous narcotic agents and diazepam analogs were administered. These effects were transient and always symmetrical. Among the 26 patients with head injuries, eight were found to have elevations of ICP above 20 mm Hg and pupillary dynamics in each of these patients remained normal. In 13 patients with a midline shift greater than 3 mm, elevations of ICP above 20 mm Hg, when present for 15 minutes, were frequently associated with a reduction in constriction velocity on the side of the mass effect to below 0.6 mm/second (51% of 156 paired observations). In five patients with diffuse brain swelling but no midline shift, a reduction in constriction velocities did not generally occur until the ICP exceeded 30 mm Hg. Changes in the percentage of reduction from the resting state following stimulation were always greater than 10%, even in patients receiving large doses of morphine and propofol in whom the ICP was lower than 20 mm Hg. Asymmetry of pupillary size greater than 0.5 mm was observed infrequently (< 1%) in healthy volunteers and was rarely seen in head-injured patients unless the ICP exceeded 20 mm Hg. Pupillometry is a reliable technology capable of providing repetitive data on quantitative pupillary function in states of health and disease.

A new reproducible model of an epidural mass lesion in rodents. Part I: Characterization by neurophysiological monitoring, magnetic resonance imaging, and histopathological analysis

OBJECT

The goal of this study was to characterize a new model of an epidural mass lesion in rodents by means of neurophysiological monitoring, magnetic resonance imaging, and histopathological analysis.

METHODS

Changes in intracranial pressure (ICP), cerebral perfusion pressure (CPP), and laser Doppler flowmetry (LDF) values, intraparenchymal tissue partial oxygen pressure (PtiO2), and electroencephalography (EEG) activity were evaluated in the rat during controlled, epidural expansion of a latex balloon up to a maximum ICP of 60 mm Hg. The initial balloon inflation was followed by periods of sustained inflation (30 +/- 1 minute) and reperfusion (180 +/- 5 minutes). Histopathological analysis and magnetic resonance (MR) imaging were performed to characterize the lesion. The time to maximum balloon expansion and the average balloon volume were highly reproducible. Alterations in EEG activity during inflation first appeared when the CPP decreased to 57 mm Hg, the LDF value to 66% of baseline values. and the PtiO2 to 12 mm Hg. During maximum compression, the CPP was reduced to 34 mm Hg, the LDF value to 40% of baseline, and the PtiO2 to 4 to 5 mm Hg. The EEG tracing was isoelectric during prolonged inflation and the values of LDF and PtiO2 decreased due to accompanying hypotonia. After reperfusion, the CPP was significantly decreased (p < 0.05) due to the elevation of ICP. Both the LDF value and EEG activity displayed incomplete restoration, whereas the value of PtiO2 returned to normal. Histological analysis and MR imaging revealed brain swelling with a midline shift and a combined cortical-subcortical ischemic lesion beyond the site of balloon compression.

CONCLUSIONS

This novel model of an epidural mass lesion in rodents closely resembles the process observed in humans. Evaluation of pathophysiological and morphological changes was feasible by using neurophysiological monitoring and MR imaging.

A reproducible model of an epidural mass lesion in rodents. Part II: Characterization by in vivo magnetic resonance imaging

OBJECT

The goal of this study was to characterize a novel epidural space-occupying lesion caused by balloon expansion in rodents by using sequential in vivo magnetic resonance (MR) imaging.

METHODS

Ten Sprague-Dawley rats were intraperitoneally sedated. A trephination was performed over the left parietal cortex to attach a balloon-expansion device, which was secured with dental cement. Measurements were performed using a 1.5-tesla MR imaging device to obtain sequential T2-weighted and diffusion-weighted (DW) sequences in the coronal plane. A three-dimensional, constructed interference in steady state sequence was used for calculation of the balloon volume. The animal's temperature, heartbeat, and the arterial percentage of oxygen saturation were monitored continuously. After a baseline examination had been performed, the balloon was inflated for a 30-minute period until it reached a maximum volume of 0.3 ml; this procedure was followed by a period of sustained inflation lasting 30 minutes, balloon deflation, and a period of reperfusion lasting 3 hours. After perfusion fixation of the animals, morphometric analysis of the lesion size and examination of the percentage of viable neurons in the hippocampus were performed. Magnetic resonance imaging allowed for the precise visualization of the extension and location of the epidural mass lesion, narrowing of the basal cisterns, and development of a midline shift. A white-matter focus of hyperintensity, consistent with brain edema, developed, predominantly in the contralateral temporal lobe. During sustained inflation the volume of the balloon did not change and comprised 5 to 7% of total intracranial volume. During the same period the white-matter edema progressed further but no increased signal was revealed on DW images. After balloon deflation the brain reexpanded to the calvaria and imaging signs of raised intracranial pressure subsided. A cortical area of hyperintensity on T2-weighted images developed in the parietal lobe in the region of the former balloon compression. This area appeared bright on DW images, a finding that corresponded to an early cytotoxic edema. After deflation white-matter vasogenic edema in the temporal lobes regressed within 3 hours after reperfusion. The cortical edema in the parietal lobe and the ipsilateral basal ganglia became sharply demarcated. The histopathological results (that is, the extent of tissue damage) corresponded with findings of the authors' companion investigation, which appears in this issue.

CONCLUSIONS

Magnetic resonance imaging allows for a precise and sequential in vivo monitoring of a space-occupying epidural mass lesion and visualizes the time course of vasogenic and cytotoxic brain edema. This rodent model of an epidural mass lesion proved to be reproducible.

Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery

OBJECTIVE

To determine the prognostic factors of the functional outcome of patients surgically treated for acute epidural hematomas.

METHODS

Two hundred patients who consecutively underwent neurosurgery for acute epidural hematomas over the past 9-year period were studied. Clinical characteristics, radiologic findings, and the time intervals with regard to treatment course were investigated to determine the interactions between all these factors and functional outcome.

RESULTS

Functional outcome showed a significant correlation with preoperative consciousness state, Glasgow Coma Scale score, pupillary sizes, and motor posturing (chi2 test, p < 0.05). Functional outcome correlated with the period of brain herniation, the length of time of the operation, as well as the period of hospitalization (chi2 test, p < 0.05), but not with the length of time of craniotomy decompression relative to the length of time from the injury until admission. The radiologic findings of the associated brain injury, the size and the density of the clot, the degree of the brain shift, and the obliteration of the basal cisterns significantly correlated with functional outcome (chi2 test, p < 0.05), whereas no significance was attributable to skull fracture. Multivariate analysis indicated that the following four factors independently correlated with functional outcome: (1) associated brain injury, (2) best motor response, (3) hematoma volume, and (4) period of hospitalization (chi2 test, p < 0.05). A combination of the four factors led to the prediction of the functional outcome with 91% accuracy (1.5 % falsely pessimistic predictions and 7.5 % falsely optimistic prediction) and 82.1% at over 90% confidence level. These four parameters correlated significantly with preoperative neurologic deterioration (chi2 test, p < 0.05).

CONCLUSION

This study identifies the risk factors involved in the functional outcome of patients who underwent surgical treatment for acute epidural hematomas. Our results indicate that associated brain injury plus best motor response are the optimal set of two prognostic indicants, with 87% correct predictions and 70.1% at over a 90% confidence level. Prevention of in-hospital neurologic deterioration would improve the patients' functional outcome with a resultant unfavorable recovery rate ranging from 11.5% to 17%.

Emergency craniotomy in a rural Level III trauma center

Patients with closed head injury and expanding epidural (EDH) or subdural (SDH) hematoma require urgent craniotomy for decompression and control of hemorrhage. In remote areas where neurosurgeons are not available, trauma surgeons may occasionally need to intervene to avert progressive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompression of a combined EDH/SDH at our hospital, with complete recovery. In anticipation of future need, five surgeons at our rural, American College of Surgeons-verified Level III trauma center participated in a neurosurgeon-directed course in emergency craniotomy. Since January 1, 1991, 792 patients have been entered into the trauma registry, including 60 with closed head injury and Glasgow Coma Scale (GCS) score of 13 or less. All but seven were transferred to a regional Level II trauma center, which is a minimum flight time of 1 hour each way. All patients with EDH (5) and 2 of 14 with SDH were deemed too unstable for transport and underwent burr hole decompression followed by immediate transfer. All craniotomies were approved by the consulting neurosurgeon and were done for computed tomography-confirmed lesions combined with neurologic deterioration as demonstrated by (1) GCS score of 8 or less, (2) lateralizing signs (dilated pupil, hemiparesis), or (3) development of combined bradycardia and hypertension. One patient with a GCS score of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; range, 1-6.5 years), including the index case, function independently, although one survivor has moderate cognitive and motor impairment. We conclude that early craniotomy for expanding epidural and subdural hematomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is not possible.

Early dynamics of acute extradural and subdural hematomas

In a retrospective study volumes of 42 extradural and 102 subdural traumatic hematomas were evaluated. Results were related with the time interval between injury and initial CT scan, outcome, coma grade and subject age. Mean volumes were found to increase with time after the injury. In the first hour volumes of 8 intracranial hematomas were hardly space consuming, while they became clearly space consuming in the second and in later hours after the injury. It was therefore concluded that it should not take longer than one hour until a CT scan be performed when an intracranial post-traumatic hematoma is suspected in the comatose patient.

Prognostic factors in severely head injured adult patients with epidural haematoma's

A medline search back to 1975 was undertaken to identify relevant papers published on epidural haematomas. The search was restricted, whenever possible, to adult age and to comatose patients. Forty four relevant reports were identified. Only 4 papers reported results on multivariate analysis. In terms of prognosis, the following parameters were found to be significant: age, time from injury to treatment, immediate coma or lucid interval, presence of pupillary abnormalities, GCS/motor score on admission. CT findings (haematoma volume, degree of midline shift, presence of signs of active haematoma bleeding, associated intradural lesion) and post-operative ICP. To compare different casistics we need more informations about patients's outcome in the referral area of the neurosurgical centers, about the number of direct admissions and about the number of patients showing clinical deterioration.

Sequential computerized tomography changes and related final outcome in severe head injury patients

The authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan. 92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%). Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes. Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.

Conservative management of extradural haematomas: effects of skull fractures on resorption rate

In conservative management of extradural haematomas (EDH), several mechanisms were described to explain the resorption of the haematoma. One of these was the transfer of the clot into the epicranial space through the skull fracture. In this study, the effects of skull fracture and associated intracranial lesions in the conservative management of EDH were investigated. Skull fracture and associated intracranial lesions were found in 71.11% and 51.1% of the patients, respectively. Resorption rate was calculated using an original formula and it was 0.548 +/- 0.227 in patients with skull fracture and 0.507 +/- 0.170 in patients with both skull fractures and additional intracranial lesions. These rates were found to be significantly higher than in the patients without fracture. In conclusion, in the patients with EDH planned to be managed conservatively, skull fracture and additional intracranial lesions must not be thought as risk factors, on the contrary, resorption of the clot might be earlier than in the others.

'Efficient' timely evacuation of intracranial haematoma--the effect of transport direct to a specialist centre

Patients with intracranial haematoma following head injury may have little primary brain injury, but sustain a secondary brain injury that can often be minimized by early evacuation of the haematoma. Rapid intervention by a neurosurgeon with early evacuation of the haematoma gives a better outcome. The timing of treatment in 403 patients with severe head injuries, admitted to the Royal London Hospital between January 1991 and December 1994 was examined. All cases had been transported directly from the accident scene by the Helicopter Emergency Medical Service because the local hospital did not have neurosurgical facilities. The median time to medical intervention was 15 min (95 per cent, confidence interval (CI) 14-16) and the median time to neurosurgery was 177 min (95 per cent, CI 171-195). As secondary interhospital transfer of patients with head injuries is known to increase the time to neurosurgical intervention and is a time of great risk of secondary insult to the brain, transfer direct from the scene of the accident to an appropriate centre allows a process of care that has been shown to be associated with a better outcome.

Outcome after acute extradural haematoma, influence of additional injuries and neurological complications in the ICU

The purpose of this study was to evaluate the influence of additional, extracranial injuries and subsequent neurological complications in the intensive care unit on the functional outcome after head injury with extradural haematoma. The retrospective analysis included 139 adult patients with acute extradural haematomas admitted to the intensive care unit. Fifty-seven patients (41 per cent) were multiply injured (Injury Severity Score (ISS) = 36.5), and 82 (59 per cent) had a single head injury (ISS = 24.9). Fifty-four patients (39 per cent) developed neurological complications such as intracranial pressure (ICP) increase alone (N = 16), intracranial bleeding, ischaemic brain lesions or epileptic seizures with an associated ICP increase (N = 24) or without (N = 14). Overall, 77 per cent of the patients had a functional outcome (Glasgow outcome score 4 or 5); 46 per cent had a good recovery, 31 per cent were moderately disabled, 10 per cent were severely disabled, 4 per cent were persistently vegetative, and 9 per cent died. Differences were found between (1) patients with and without complications, (2) patients with extradural haematomas and patients with additional intracranial lesions, and (3) patients with a 'severe' Glasgow Coma Score (GCS) of 3-8 and patients with a GCS of 9-15. The presence of additional intracerebral injuries, and not extracerebral injuries, as well as the management of elevated ICP determines the final outcome in patients with extradural haematomas.

Imaging of acute head injury

This article reviews the neuroradiological evaluation of acute head injury with an emphasis on CT and MR imaging. Subacute and chronic head injury are not discussed. CT remains the modality of choice in the emergency setting, permitting rapid, comprehensive assessment of the great majority of head injuries. MR is most useful in patients in whom there is a discrepancy between clinical symptoms and CT findings. In addition, MR is the imaging modality of choice in the subacute and chronic setting. The superior contrast resolution of MR permits optimal evaluation of nonhemorrhagic (and hemorrhagic) white matter shearing injuries, and the lack of beam-hardening artifact permits a more thorough evaluation of the brain stem, posterior fossa, and cortical surface.

Early detection of delayed traumatic intracranial hematomas using near-infrared spectroscopy

Delayed intracranial hematomas are an important treatable cause of secondary brain injury in patients with head trauma. Early identification and treatment of these lesions, which appear or enlarge after the initial computerized tomography (CT) scan, may improve neurological outcome. Serial examinations using near-infrared spectroscopy (NIRS) to detect the development of delayed hematomas were performed in 167 patients. The difference in absorbance of light (delta OD) at 760 nm between the normal and the hematoma side was measured serially during the first 3 days after injury. Twenty-seven (16%) of the patients developed a type of late hematoma: intracerebral hematoma in eight, extracerebral hematoma in six, and postoperative hematoma in 13 patients. Eighteen of the delayed hematomas caused significant mass effect and required surgical evacuation. The hematomas appeared between 2 and 72 hours after admission. In 24 of the 27 patients, a significant increase (> 0.3) in the delta OD occurred prior to an increase in intracranial pressure, a change in the neurological examination, or a change on CT scan. A favorable outcome occurred in 67% of the patients with delayed hematomas, which suggests that early diagnosis using NIRS may allow early treatment and reduce secondary injury caused by delayed hematomas.

A new application for near-infrared spectroscopy: detection of delayed intracranial hematomas after head injury

Clinical studies have documented the importance of secondary brain insults in determining neurologic outcome after head injury. Delayed intracranial hematomas are one of the most easily remediable causes of secondary injury if identified early, but can cause significant disability or death if not promptly recognized and treated. Early identification and treatment of these lesions that appear or enlarge after the initial CT scan may improve neurological outcome. Serial examinations using near-infrared spectroscopy (NIRS) to detect the development of delayed hematomas were obtained in 167 patients. The difference in absorbance of light (deltaOD) at 760 nm between the normal and the hematoma side was measured serially during the first 3 days after injury. Twenty-seven (16%) of the patients developed some type of late hematoma: an intracerebral hematoma in 8 patients, an extracerebral hematoma in 6 patients, and a postoperative hematoma in 13 patients. Eighteen of the delayed hematomas caused significant mass effect and required surgical evacuation. The hematomas appeared between 2 and 72 h after admission. In 24 of the 27 patients, a significant increase (>0.3) in the deltaOD occurred prior to an increase in intracranial pressure or a change in the neurological examination, or a change on CT scan. Early diagnosis using MRS may allow early treatment and reduce secondary injury caused by delayed hematomas.

One-year outcome following craniotomy for traumatic hematoma in patients with fixed dilated pupils

Forty consecutive patients who underwent craniotomy for traumatic hematoma after developing bilateral fixed dilated pupils were studied to determine the factors influencing quality of survival and to seek criteria for management. Clinical and computerized tomography (CT) data were correlated with outcome 1 year after craniotomy. The functional recovery (good outcome or moderate disability) rate was 25%, with a mortality rate of 43%. Patients with subdural hematoma had a higher mortality rate (64%) compared to patients with extradural hematoma (18%) (chi-square test, p > 0.05). Other factors associated with markedly increased morbidity and mortality were increasing age (> 20 years), a prolonged interval (> 3 hours) between loss of pupillary reactivity and craniotomy, compression of basal cisterns, and presence of subarachnoid hemorrhage on CT. There were no survivors among patients exhibiting any of the following features: surgery 6 hours or more after bilateral loss of pupillary reactivity; age greater than 65 years; or absent motor response. Apart from the latter group, the nature of motor response (before pharmacological paralysis and intubation) was not a reliable predictor of mortality. The results suggest that the presence of an acute subdural hematoma is the single most important predictor of negative outcome in patients with bilateral unresponsive pupils.

Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care

This study records the incidence and timing of postoperative hematomas in neurosurgical patients and analyzes the best use of neurosurgical intensive care. In 2305 patients undergoing freehand or stereotactic biopsy, elective or emergency craniotomy, or posterior fossa surgery, 50 (2.2%) developed a hematoma. Clinical deterioration as a result of postoperative hematoma occurred within 6 hours of surgery in 44 patients and more than 24 hours after surgery in six patients. Although patients undergoing posterior fossa surgery or emergency craniotomy warrant longer periods of intensive-care observation, patients having elective supratentorial operations can safely be transferred to a neurosurgical ward for observation, provided they have regained their preoperative neurological status by 6 hours postsurgery.

Rapid infusion system for neurosurgical treatment of massive intraoperative hemorrhage

Using an illustrative case of severe closed head injury that resulted in a posterior fossa epidural hematoma (EDH) and supratentorial epidural/subdural hematomas (SDH), the massive blood losses associated with operative repair of the torn sigmoid sinus and the significant fluid losses associated with refractory diabetes insipidus were treated by the intraoperative use of the Rapid Infusion System (RIS, Haemonetics). The RIS can rapidly infuse warm blood, crystalloid, or colloid at rates up to 1.5 L/min, thereby limiting the commonly associated hypotension, hypothermia, and coagulopathies. During the suboccipital craniectomy for evacuation of the EDH and repair of the sigmoid sinus, the patient required 18 units of blood replacement secondary to a large tear in the sigmoid sinus. During a separate craniotomy for evacuation of the SDH, the patient also developed diabetes insipidus, which increased the operative fluid replacement to 39 L. Despite these massive blood and fluid losses, the RIS limited the hypotension to less than 2 min and prevented hypothermia and the frequently associated coagulopathies. When used in a neurosurgical setting associated with massive blood and/or fluid losses, the RIS accomplishes three important objectives: (1) rapid infusion of intravenous fluids for maintaining perfusion pressure, (2) rapid warming of fluids despite high intravenous infusion rates of cold crystalloids, thereby preventing intraoperative hypothermia, and (3) continuous monitoring of infusion rates and totals.

Extradural haematoma. Report of 37 consecutive cases with survival

The availability of CT scanning has considerably improved the results in patients with extradural haematoma (EDH). However, only few reports referred the "zero-mortality" which today could be considered as possible. This goal was achieved by us recently even in those patients suffering from rapidly developing EDH. A series of 37 consecutive patients with EDH operated on during the last years is presented. 27 patients were comatose GCS 3-8 on admission (within 6 hours after the injury) and underwent surgery immediately; in 7 cases the operation was performed 6 to 25 hours after the injury, soon after the worsening of the level of consciousness; 3 patients were awake at time of surgery and were operated on later than 24 hours after the injury when signs of neurological deterioration appeared. All of our patients survived and 35 of them (95%) fully recovered. We believe that the duration of brain compression is the main factor strongly correlated with outcome. Therefore, in our opinion the primary prerequisite in order to obtain a good result is the prompt evacuation of EDH; furthermore, in this was it is possible to try to prevent brain ischaemia due to clot pressure, mostly the infarction on deeply situated territories.

Statistical analysis of the factors affecting the outcome of extradural haematomas: 115 cases

115 traumatic extradural haematoma cases who were treated surgically at Cerrahpasa Medical Faculty Neurosurgery Department between 1987 and 1992 are evaluated. When factors affecting the outcome were examined, a strong correlation was found between the result and Glasgow coma scale (GCS) (p < 0.00001). The existence of a fracture, the interval between onset of haematoma symptoms and intervention and the existence of an intracerebral haematoma together with contusion accompanying intradural haematoma, affect the outcome in a negative direction. There was no statistical correlation between the outcome and the age of patient, localization of the haematoma and aetiology.

Evacuation of traumatic intracerebral haematomas using a simplified stereotactic procedure

The authors present a series of 37 traumatic intracerebral haematomas (ICH) evacuated by a simplified stereotactic surgical procedure. The mortality rate was 80% in patients with Glasgow coma scale (G.C.S.) scores of 3-5 and 25% in patients with scores of 6-7. There were no deaths in patients with G.C.S. of 8 or more. With the exception of the first group of patients, the results were better than those achieved by wide craniotomy. The importance of reduced operative trauma in patients with ICH, which often are associated with multifocal or diffuse brain injuries, are discussed.

Clinical characteristics of traumatic extradural hematoma: a comparison between children and adults

In this study of 43 children who had surgery for traumatic extradural hematoma (EDH) at Frenchay Hospital, England, between 1975 and 1987, the authors attempt to outline the various clinical characteristics of EDH which are different in children (age range 1-15 years) and adults (age range 16-84 years). The results confirm that children with traumatic EDH are less likely to have injury be caused by an RTA, are less likely to remain unconscious from the time of injury to the time of the operation, and are less likely to require immediate surgery (less than 6 hours after injury). In addition, the CT scan is less likely to show in associated intradural injury, and the outcome is significantly better.

Acute subdural haematoma in adults: an analysis of outcome in comatose patients

The authors analysed a series of 200 adult patients admitted to the Department of Neurosurgery, Medical University of Lódź with a diagnosis of acute subdural haematoma (ASDH). 63% of them were surgically treated within the first 4 hours after head injury, the others were operated on 4 to 16 hours after trauma. All patients had GCS below 10 for the whole time period from trauma to surgery. Younger patients 18-30 year old had lower mortality-25%, while patients above 50 revealed 75% mortality. Analysis of operative timing and outcome, no benefit revealed when surgery was performed within first 4 hours. However, the patients operated on later than 4 hours after trauma had smaller midline shift and less pronounced brain contusion. It must be taken into account that some patients who could benefit from early surgery-those with quickly developing haematomas and intracranial hypertension-had no chance to arrive and died in peripheral hospitals. Despite our results we advocate an urgent evacuation of haematoma, as early as possible after trauma. Significant correlation was found between midline shift, cerebral contusion on CT scans and results of surgery. Patients with bigger midline shift or presence of focal cerebral contusion revealed higher mortality and worse outcome than patients with smaller shift and no cerebral contusion visible on CT pictures.

[Extradural hematoma: comparative radiological study between comatose and non-comatose patients]

A series of 129 patients harbouring extradural hematomas was analysed considering the neurological state immediately before operation as the most consistent variable. Seventy eight patients were considered to be comatose (Group I) and 51 were noncomatose. Among the comatose group, 30 were investigated with computerized tomography (23.3% mortality, 50% good results), 31 were submitted to angiography (48.3% mortality, 38.7% good results), and 17 were operated based on the neurological examination and skull radiography (47% mortality, 35.2% good results). The presence or absence of skull fracture and the density of hematoma did not change the final outcome. Associated intracranial lesions increased the mortality and lowered the good results in both groups. Frontal hematomas (10 cases) in the comatose group were associated with high mortality (52.6%) due to bad neurological state (Glasgow 3-5) and to isolated or multiple intracranial associated lesions (6 patients).

The influence of concomitant intradural pathology on the presentation and outcome of patients with acute traumatic extradural haematoma

The pre-operative and early postoperative CT scans of 120 patients who had surgery for acute extradural haematoma were reviewed, 88 cases (73%) had an extradural haematoma alone (Group 1) while 32 cases (27%) had an additional intradural abnormality (Group 2). The abnormalities were a subdural haematoma in eight, a haemorrhagic contusion in 16 and hemisphere swelling in eight. The two groups were compared with regard to the findings that an additional intradural abnormality is likely to be associated with an older age, an injury following a road traffic accident, a GCS less than 7 at operation, additional extracranial injuries and a poorer outcome. The increase in the percentage of patients who were unconscious from the onset and the decrease in those who were always conscious with a concomitant intradural damage was without statistical significance.

Head-injured patients who talk and deteriorate into coma. Analysis of 211 cases studied with computerized tomography

Of 838 patients with severe head injuries admitted since the introduction of computerized tomography, 211 (25.1%) talked at some time between trauma and subsequent deterioration into coma. Of these 211 patients, 89 (42.2%) had brain contusion/hematoma, 46 (21.8%) an epidural hematoma, 35 (16.6%) a subdural hematoma, and 41 (19.4%) did not show focal mass lesions. Thus, four of every five patients who deteriorated into coma after suffering an apparently nonsevere head injury had a mass lesion potentially requiring surgery: the mass was intracerebral in 52.3% of the cases and extracerebral in 47.6%. Patients aged 20 years or less had a 39% chance of having a nonfocal mass lesion (diffuse brain damage), a 29% chance of having an epidural hematoma, and a 32% chance of having an intradural mass lesion; patients over 40 years had only a 3% chance of having a nonfocal mass lesion, an 18% chance of having an epidural hematoma, and a 79% chance of having a intradural mass lesion. Sixty-eight (32.2%) patients died and 143 (67.8%) survived. The following were independent outcome predictors (in order of significance): Glasgow Coma Scale score following deterioration into coma, the highest intracranial pressure during the patient's course, the degree of midline shift, the type of intracranial lesion, and the age of the patient. In contrast, the mechanism of injury, the verbal Glasgow Coma Scale score during the lucid interval, and the length of time until deterioration or until operative intervention did not influence the final result.

Delayed epidural hematoma

A case of delayed epidural hematoma is described who had an initial computerized tomography (CT) scan reported as normal. Repeat CT scan at 48 h demonstrated a right temporal epidural hematoma. A skull fracture was not observed radiographically or at surgery. The world literature is reviewed and the criteria for repeat CT scanning is discussed.

Quantification of midline shift as a predictor of poor outcome following head injury

A retrospective study of patient outcome, based on admission computed tomography, was carried out in 75 consecutive patients with head injury. Computed tomography data collected included the type and extent of intracranial hemorrhage, the extent of midline shift, and the ratio of midline shift compared with the extent of intracranial hemorrhage. Midline shift was considered to be out of proportion to intracranial hemorrhage when the midline shift of the septum pellucidum exceeded the extent of the hemorrhage as measured radially from the inner table of the skull. When computed tomography data were analyzed by logistic regression, significant predictive factors for poor outcome were intracranial hemorrhage (34%), intracranial hemorrhage with midline shift (61%), and midline shift out of proportion to the extent of intracranial hemorrhage (88%). When patient outcome and mortality rates are considered, our study indicates that midline shift out of proportion to the extent of intracranial hemorrhage is a highly useful predictor of poor patient outcome following head injury.

Extradural haematoma in the Irish Republic: an analysis of 82 cases with emphasis on 'delay'

Eighty-two cases of extradural haematoma were analysed to elucidate the factors contributing to delay in treatment and poor outcome. The majority of cases occurred in the first three decades of life with falls being the commonest aetiological factor. Five distinct modes of presentation are described. Excessive delay occurred in recognizing the condition and in subsequent transfer of patients. This resulted in many patients being operated on while in coma. Associated intracranial and extracranial injury occurred in a significant number of cases. Recommendations for the management of these patients are outlined.

A quantitative study of some factors affecting the outcome of experimental epidural bleeding in swine

During an experimentally induced aggressive epidural bleed the effect on outcome of haematoma volume, cerebral perfusion pressures, intracranial pressure gradients and ventilation were examined in a swine model. Two groups of experiments were performed using either spontaneous ventilation (group 1, n = 6) or mechanical ventilation for 1 hour (group 2, n = 7). The preparations were otherwise identical. An animal was considered to have succumbed when the EEG became irreversibly isoelectric within a total follow-up time of 80 minutes. Mechanical ventilation had a marked effect on survival. All spontaneously ventilated animals succumbed, 4 of them in less than 60 minutes, the remaining 2 between 60 and 80 minutes after the start of bleeding. All mechanically ventilated animals survived for the 60 minutes while the ventilator was connected. Following disconnection 2 animals started to breathe spontaneously and survived the final 20 minutes of the 80 minutes of the follow-up time. The remaining 5 succumbed following apnoea. The size of haematoma did not differ significantly between the groups. Two additional factors, hypoventilation and a secondary rise in supratentorial pressure, contributed to a lethal outcome. Hypoventilation was an inevitable precursor of the isoelectric EEG. There was a close correlation between the development of hypoventilation and intracranial herniation. A secondary rise in supratentorial pressure, unrelated to ventilation, was seen after cessation of bleeding in 8/13 cases. It was associated with a falling supratentorial perfusion pressure and EEG attenuation, suggesting a secondary intracranial expansion, possibly due to oedema, hydrocephalus or both. It is concluded that mechanical ventilation in the acute stage of epidural bleeding may be of clinical value.(ABSTRACT TRUNCATED AT 250 WORDS)

Gas bubbles within acute intracranial epidural haematomas

In order to assess the actual incidence of gas bubbles trapped within acute intracranial epidural haematomas, as revealed by computed tomography (CT) of the skull, a series of 204 patients with surgically verified epidural haematomas was retrospectively reviewed. Gas bubbles were observed on CT scan in 22.5% of the cases, with the incidence rising to 37% when CT scanners of the last generation were employed. The available data failed to demonstrate the actual source of intracranial gas. No correlation was found between the presence of gas bubbles and outcome. No patient in the whole series showed any sign of intracranial infection.

Recurrent hematomas following craniotomy for traumatic intracranial mass

Of 850 patients who underwent craniotomy for evacuation of a traumatic intracranial mass, 59 (6.9%) developed a second hematoma at the operation site, which required a second operation. Compared to those who did not, patients who developed postcraniotomy hematoma (PCH) had a significantly higher incidence of evidence of alcohol intake and preoperative mannitol administration; a higher percentage had a bad outcome. Coagulopathy was frequent in PCH patients. Although three-quarters of the initial hematomas were intradural, 69% of the PCH's were predominantly extradural. The large potential space underlying a craniotomy bone flap may predispose to development of a PCH. Intracranial pressure (ICP) was monitored in 39 of the 59 PCH patients, which allowed earlier detection of the PCH in 22 (56%). In 17 patients, the ICP failed to rise despite clinical deterioration, and detection of the PCH was delayed, significantly worsening the outcome in this group.

Non-neurosurgical operative intervention in head-injured patients

Guidelines relating to non neurosurgical operative intervention in head-injured patients are not available for the British Isles. We present a series of seven patients with extradural haematoma operated upon in the referring hospital prior to transfer to our unit. The cases were analysed in an attempt to elucidate the efficacy of the emergency procedures and the associated problems. Recommendations are made in order to generate discussion on this aspect of head injury management.

Analysis of the dynamics of experimental epidural bleeding in swine

The effects on epidural bleeding of two major factors were studied in a swine model. These were detachment of the dura from the skull and an epidural arteriovenous shunt. Firstly the effect of differing degrees of detachment of dura was studied in the absence of a shunt. Secondly the effect of the shunt was examined with a constant degree of dural detachment. Increasing the degree of the detachment of the dural from the skull increased the rate and volume of bleeding. In addition the greater the degree of dural detachment from the skull the easier it was for further dura stripping to take place. The shunt reduced the epidural pressure and increased the bleeding pressure. Sometimes it reduced the force which, acting on the dura would strip more dura free, but never enough to preclude further dura stripping. Larger shunts were associated with a longer bleeding duration. It is concluded that the effects of dura detachment and the epidural shunt acting in concert can explain the delayed expansion of an epidural haematoma and are consistent with the known variability of clinical epidural haematomas.