Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours

Blood constituents trigger brain swelling, tissue death, and reduction of glucose metabolism early after acute subdural hematoma in rats

Outcome from acute subdural hematoma is often worse than would be expected from the pure increase of intracranial volume by bleeding. The aim was to test whether volume-independent pathomechanisms aggravate damage by comparing the effects of blood infusion with those of an inert fluid, paraffin oil, on intracranial pressure (ICP), cerebral perfusion pressure (CPP), local cerebral blood flow (CBF), edema formation, glucose metabolism ([18F]-deoxyglucose, MicroPET ), and histological outcome. Rats were injured by subdural infusion of 300 muL venous blood or paraffin. ICP, CPP, and CBF changes, assessed during the first 30 mins after injury, were not different between the injury groups at most time points (n=8 per group). Already at 2 h after injury, blood caused a significantly more pronounced decrease in glucose metabolism in the injured cortex when compared with paraffin (P<0.001, n=5 per group). Ipsilateral brain edema did not differ between groups at 2 h, but was significantly more pronounced in the blood-treated groups at 24 and 48 h after injury (n=8 per group). These changes caused a 56.2% larger lesion after blood when compared with paraffin (48.1+/-23.0 versus 21.1+/-11.8 mm(3); P<0.02). Blood constituent-triggered pathomechanisms aggravate the immediate effects due to ICP, CPP, and CBF during hemorrhage and lead to early reduction of glucose metabolism followed by more severe edema and histological damage.

Spontaneous bilateral supratentorial subdural and retroclival extradural hematomas in association with cervical epidural venous engorgement

We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patient's symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.

Hyperemia beneath evacuated acute subdural hematoma is frequent and prolonged in patients with an unfavorable outcome: a xe-computed tomographic study

OBJECTIVE

To verify the values and the time course of regional cerebral blood flow (rCBF) in the cortex located beneath an evacuated acute subdural hematoma (SDH) and their relationship with neurological outcome.

METHODS

rCBF levels were measured in multiple regions of interest, by means of a Xe-computed tomographic technique, in the cortex underlying an evacuated SDH and contralaterally in 20 patients with moderate or severe traumatic brain injury and an evacuated acute SDH. Twenty-three patients with moderate or severe traumatic brain injury and an evacuated extradural hematoma or diffuse injury served as the control group. Outcome was evaluated by means of the Glasgow Outcome Scale at 12 months.

RESULTS

Values for the maximum (rCBFmax) and the mean of all rCBF levels in the cortex beneath the evacuated SDH were more frequently consistent with hyperemia. The side-to-side differences in the mean of all rCBF and rCBFmax levels between lesioned and nonlesioned hemispheres were greater in patients with evacuated SDH than in controls (P = 0.0013 and P = 0.0018, respectively). The side-to-side difference in the maximum rCBF value was higher in SDH patients with unfavorable outcomes than in controls at 24 to 96 hours and at 4 to 7 days and higher than in patients with favorable outcomes at 4 to 7 days. The widest side-to-side difference in rCBFmax value was more elevated in patients with an evacuated SDH with unfavorable outcome than in patients with a favorable outcome (P = 0.047), whereas no differences were found in controls. The SDH thickness and the associated midline shift were greater in patients with unfavorable outcomes than in those with favorable outcomes.

CONCLUSION

On average, hyperemic long-lasting rCBF values frequently occur in the cortex located beneath an evacuated SDH and seem to be associated with unfavorable outcome.

Comparative study of decompressive craniectomy after mass lesion evacuation in severe head injury

OBJECTIVE

This study was conducted to evaluate outcome after decompressive craniectomy (DC) in the setting of mass evacuation with or without intracranial pressure (ICP) monitoring.

METHODS

Over a 48-month period (March 2000 to March 2004), 54 of 967 consecutive head injury patients underwent DC for evacuation of a mass lesion. DC was performed without ICP monitoring in 27 patients who required urgent decompression (group A) and in 27 patients who did not require urgent surgery and who had their ICP monitored for 1 to 14 days before surgery (group B).

RESULTS

In group A, the mean Glasgow Coma Scale score was 6.0; 80% had computed tomographic evidence of a shift greater than 5 mm; and 25 patients underwent DC immediately after resuscitation. In group B, the mean Glasgow Coma Scale score was 7.3; 40% had computed tomographic evidence of shift; and 75% underwent DC 24 hours or longer after presentation. Overall, 22 patients died (12 in group A and 10 in group B), 11 remained vegetative or severely disabled (3 in group A and 8 in group B), and 19 had good recovery (11 in group A and 8 in group B). Two patients were lost to follow-up. In 18 group B patients with ICP greater than 20 mm Hg before mass evacuation, ICP dropped an average of 13 mm Hg (P < 0.001). A mass lesion greater than 50 mL (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.04-7.89) and evidence of low attenuation on computed tomography before (OR, 3.3; 95% CI, 1.1-10.3) or after (OR, 2.92; 95% CI, 1.02-8.34) DC were predictors of death. A good outcome occurred in 42% of patients with and in 63% of patients without delayed traumatic injury (OR, 0.3; 95% CI, 0.1-1.1). Outcome was favorable in 78.6% of patients who had no ICP monitoring before DC versus 47.1% of patients with ICP monitoring (OR, 0.2; 95% CI, 0.1-1.2).

CONCLUSION

In this study, mortality after DC for mass lesion was greater than expected, and outcome did not differ between patients with or without ICP monitoring.

Is the recommended target of 4 hours from head injury to emergency craniotomy achievable?

Guidelines recommend that head-injured patients who require life-saving decompressive surgery should undergo surgery within 4 h. To assess the compliance with this recommendation 100 consecutive head-injured patients admitted to a regional neurosurgical unit (RNU) were studied. Time points from head injury to craniotomy were documented and analysed. Twenty-four patients underwent emergency craniotomy, only one being operated on within 4 h. In this cohort of patients there was no relationship between timing of surgery and outcome. In order to investigate whether it is possible to reduce delays in transportation time, theoretical models were created to determine whether direct transfer to the RNU would be faster by land or air ambulance.

Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester

Delay in transfer of patients with acute extradural (EDH) or subdural (SDH) haematoma to definitive neurosurgical evacuation has a detrimental effect on outcome. From July 2003 to December 2005 we undertook a prospective analysis of patients admitted to our unit for neurosurgical evacuation of their haematoma, who were transferred from non-neurosurgical hospitals. Data was collected for: 1) overall transfer time, 2) time taken from injury or deterioration to CT scan, 3) time from CT scan to arrival at our unit, and 4) time from arrival at our unit to surgery. Overall 81 patients were eligible, of which 39 had an EDH and 42 a SDH. The median transfer times for EDH and SDH were 5.25 hours and 6.0 hours respectively. This paper discusses the factors that may prolong delays in the transfer of patients between hospitals and the way in which our unit is trying to improve the local service for the population of Greater Manchester.

The characteristics of patients who do not seek medical treatment for traumatic brain injury

PRIMARY OBJECTIVE

To identify factors associated with not seeking medical care for traumatic brain injury (TBI).

RESEARCH DESIGN

Internet survey.

METHODS AND PROCEDURES

The survey consisted of 17 questions related to demographics, TBI case ascertainment, location and mechanism of injury, type of treatment sought, and post-concussive (PC) symptoms. Logistic regression was used to identify factors associated with not seeking medical care.

MAIN OUTCOME AND RESULTS

Of the 1381 survey respondents with TBI, 584 (42%) did not seek medical care. TBI respondents were less likely to seek care if they were older (OR 0.98, 95% CI 0.97-0.99), suffered a mild TBI grade 2/3 (OR 0.42, 95% CI 0.31-0.58), or were injured in the home (OR 0.53, 95% CI 0.36-0.78).

CONCLUSIONS

Several factors associated with not seeking medical care after TBI were identified. Raising public awareness of the signs and symptoms of TBI, and the benefits of medical care, could help increase the number of TBI patients who seek medical care.

Patients with head injuries refusing emergency medical services transport

PRIMARY OBJECTIVE

To characterize patients with head injury who refuse emergency medical services (EMS) transport to an emergency department (ED). To identify predictors of patients with head injury who refuse EMS transport.

RESEARCH DESIGN

Retrospective chart review.

METHODS

Patients with a head injury cared for by EMS during 2001 were identified. Medical records were abstracted for demographic and clinical information and reasons for refusing transport. Patients accepting transport were compared to those refusing. Reasons for refusing transport were described.

RESULTS

Three hundred and thirty-three patients with head injuries were identified. Sixteen per cent refused EMS transport. Patients refusing transport were more likely to be male, younger and victims of assault and less likely to have lost consciousness. Patients refusing transport often felt they did not need care or could obtain care later.

CONCLUSIONS

Patients with head injuries frequently refuse EMS transportation. Individuals accepting care differ significantly from those refusing care. Sufficient awareness of the risk of head injury seems to be lacking among patients.

Management and outcome of patients with acute traumatic subdural hematomas and pre-injury oral anticoagulation therapy

BACKGROUND

Acute subdural hematomas (aSDHs) are found in up to one-third of patients with severe traumatic brain injury and are associated with an unfavorable outcome in the majority of cases. Mortality ranges between 40 and 60%, but was reported to be even higher in patients undergoing oral anticoagulation therapy (OAT) at the time of injury. The objective of this study is to specifically report on the peri-operative management and outcome of patients with aSDH and pre-injury OAT.

MATERIAL AND METHODS

From June 2002 to June 2006, all patients with OAT who underwent surgical treatment of aSDH were retrospectively analysed. Results of pre-operative blood tests, the peri-operative and surgical management and the clinical courses were assessed. Patient outcome is reported according to the Glasgow Outcome Scale (GOS) at 6 months.

RESULTS

Eleven (10.3%) out of 107 patients with aSDH were on OAT. Patients with OAT were significantly older than patients without OAT (72.4 +/- 9.3 versus 59.9 +/- 17.5 years; p<0.05, Mann-Whitney U-test). Intensity of head trauma was moderate in four and severe in seven patients with a median pre-operative Glasgow Coma Scale (GCS) of 8. Median pre-treatment prothrombin time and international normalized ratio were 23% (range: 10-65%) and 3.3 (range: 1.5-10.6), respectively. Replacement therapy consisted of administration of prothrombin complex concentrates, vitamin K and FFP (fresh frozen plasma). In four patients, antithrombin was additionally given to prevent disseminated intravascular coagulation. Surgical treatment consisted of craniotomy (n=10) or craniectomy (n=1) and hematoma evacuation with intracranial pressure probe placement. Low molecular weight heparin was administered as pharmacological prophylaxis of thrombembolic events in an increasing dose post-operatively. At 6 months, six out of 11 patients survived with a median GOS of 4. All-cause mortality was 45.5%. A pre-operative GCS of < or = 8 was not associated with an increased risk of mortality (p>0.5, Fisher's exact test). No relevant rebleedings or thrombembolic complications were observed. The mortality rate of patients who did not undergo OAT was 50%.

CONCLUSION

A large number of patients with aSDH are on pre-injury OAT. Specific replacement therapy facilitates successful clot evacuation without bleeding complications. The overall outcome of these patients does not seem to differ from historical cohorts with aSDH without OAT, but a large prospective multicenter study is warranted to answer that question.

Prehospital management of traumatic brain injury

The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.

Acute subdural hematoma because of boxing

BACKGROUND

To identify factors determining the clinical characteristics and prognosis of acute subdural hematoma (ASDH) arising from boxing injuries by comparing with ASDH due to any nonboxing cause.

METHODS

Two groups were selected for this study: 10 patients with ASDH because of boxing injuries and 26 patients with nonboxer ASDH. All of the patients underwent neurologic examination by neurosurgeons. Primary resuscitation and stabilization as well as operative therapy were performed to all patients according to the European Brain Injury Consortium Guidelines. Two groups were compared in terms of age, the Glasgow Coma Scale at admission, neurologic findings, craniogram and brain computed tomography scan findings, operative findings, and prognosis. As potential prognostic indicators for boxers, the time interval until surgery, the Glasgow Outcome Scale, hematoma thickness, midline shift, and the site of bleeding were analyzed.

RESULTS

The characteristics of patients because of boxing injuries are that patients were younger, had lucid interval, and had no cerebral contusion or contralateral brain injury. There was no significant difference in initial Glasgow Coma Scale, hematoma thickness, midline shift, and their prognosis. The most peculiar clinical presentation of boxers' ASDH was that all bleedings were limited from "bridging veins" or "cortical veins." The prognosis of boxers was most closely correlated with the site of bleeding (r2 = 0.81; p = 0.0001) and the midline shift (r2 = 0.67; p = 0.007).

CONCLUSIONS

Our study shows that ASDH because of boxing is characterized by bleeding from bridging or cortical veins, and that the site of bleeding is a significant determinant of their prognosis.

Outcome after severe head injury: focal surgical lesions do not imply a better Glasgow Outcome Score than diffuse injuries at 3 months

BACKGROUND

Historically neurosurgeons have accepted head injured patients only in the presence of a mass lesion requiring surgical decompression. Underpinning this is an assumption that these patients have a better outcome than patients without a surgical lesion. This has meant that many patients without a surgical lesion have been managed locally in the referring hospital. However, there is now evidence that treatment of all head injured patients in a specialist centre leads to improved outcomes. Therefore, we have asked the question: does the presence of a surgical lesion imply better outcome from severe head injury?

RESULTS

We prospectively recorded the Glasgow Outcome score (GOS), at 3 months, of all the severely head injured patients treated at our institution over a two and a half year period. Of 116 patients admitted with an initial Glasgow Coma Score (GCS) of 8 or less, 58 had surgical lesions and 58 non-surgical head injuries. The two groups were well matched for presenting GCS and age. Overall our favourable outcome rate (GOS 4 and 5) at 3-months for the patients with a surgical lesion and for the non-surgical group were 47.3% and 46.6% respectively, with no significant difference between the two (P = 0.54).

CONCLUSION

The assumption in the past has always been that patients presenting in coma from traumatic diffuse brain injury will do worse than those that have a mass lesion amenable to surgical decompression. Our series would suggest that this is not the case and all severely head injured patients should expect similar outcome when cared for in a neuroscience centre.

A prospective study of the time to evacuate acute subdural and extradural haematomas

We performed a prospective, single-centre study of times to treatment of patients with life-threatening, traumatic, extra- and subdural haematomas requiring surgical evacuation between May 2006 and May 2007. The mean time to surgical decompression was 5.0 h and 32% were performed within 4 h. Patients who initially presented to a district hospital and required transfer for neurosurgery were decompressed in 5.4 h vs 3.7 h for those admitted directly. The current standard of surgical evacuation of all haematomas within 4 h is not being met. Delays were identified in every stage in the management of these patients and no single step was identified as the major cause. Initial treatment in district hospitals led to delays greater than the added driving time. There may be time savings from carrying out treatment steps in parallel instead of in series.

Predictors for functional recovery and mortality of surgically treated traumatic acute subdural hematomas in 256 patients

OBJECTIVE

The purpose of this study was to investigate the reliable factors influencing the surgical outcome of the patients with traumatic acute subdural hematoma (ASDH) and to improve the functional outcome of these patients.

METHODS

A total of 256 consecutive patients who underwent surgical intervention for traumatic ASDH between March 1998 and March 2008 were reviewed. We evaluated the influence of perioperative variables on functional recovery and mortality using multivariate logistic regression analysis.

RESULTS

Functional recovery was achieved in 42.2% of patients and the overall mortality was 39.8%. Age (OR=4.91, p=0.002), mechanism of injury (OR=3.66, p=0.003), pupillary abnormality (OR=3.73, p=0.003), GCS score on admission (OR=5.64, p=0.000), and intraoperative acute brain swelling (ABS) (OR=3.71, p=0.009) were independent predictors for functional recovery. And preoperative pupillary abnormality (OR=2.60, p=0.023), GCS score (OR=4.66, p=0.000), and intraoperative ABS (OR=4.16, p=0.001) were independent predictors for mortality. Midline shift, thickness and volume of hematoma, type of surgery, and time to surgery showed no independent association with functional recovery, although these variables were correlated with functional recovery in univariate analyses.

CONCLUSION

Functional recovery was more likely to be achieved in patients who were under 40 years of age, victims of motor vehicle collision and having preoperative reactive pupils, higher GCS score and the absence of ABS during surgery. These results would be helpful for neurosurgeon to improve outcomes from traumatic acute subdural hematomas.

Acute Traumatic Brain Injury: A Review of Recent Advances in Imaging and Management

Acute traumatic brain injury (TBI) is a major cause of death and disability in young persons worldwide, producing a substantial economic burden on health services. New technology in computed tomography and magnetic resonance imaging is allowing the acquisition of more accurate and detailed information on cerebral pathology post-TBI. This has greatly improved prognostic ability in TBI and enables earlier identification of pathology, making it potentially amenable to therapeutic intervention. Recent advances in the management of TBI have been hampered by a lack of class I evidence arising from difficulties in applying strict study protocols to a patient subset as heterogeneous as post-TBI patients. The most definite benefits in terms of survival after TBI come from admission to a specialist neurosurgical centre, with goal-targeted therapy and intensive care services. Some traditional therapies for the treatment of acute TBI have been proven to be harmful and should be avoided. A number of management strategies have proved potentially beneficial post-TBI, but there is insufficient evidence to make definitive recommendations at present. Future therapies that are currently under investigation include decompressive craniectomy, progesterone therapy, and possibly therapeutic hypothermia.

Bilateral cortical atrophy after severe brain trauma and extradural homatoma

We report the case of a severe head injured 43-year old male patient with a large extradural hematoma, Glasgow Coma Scale 3 and dilated fixed pupils. Patient was promptly submitted to surgical evacuation of the lesion, but remained in persistent vegetative state in the post-operative time. Head computed tomography scans performed before surgery, and at early and late post-operative periods comparatively revealed extreme bilateral cortical atrophy. Late consequences of severe head trauma drastically affect the prognosis of patients, being its prevention, and neuroprotection against secondary injury still a therapeutical challenge for neurosurgeons.

Coagulopathy and inhospital deaths in patients with acute subdural hematoma

Object

Acute subdural hematoma (SDH) is one of the most lethal forms of intracranial injury; several risk factors predictive of a worse outcome have been identified. Emerging research suggests that patients with coagulopathy and intracerebral hemorrhage have a worse outcome than patients without coagulopathy but with intracerebral hemorrhage. The authors sought to determine if such a relationship exists for patients with acute SDH.

Methods

The authors conducted a retrospective analysis of consecutive patients admitted to a neurosciences intensive care unit with acute SDH over a 4-year period (January 1997–December 2001). Demographic data, laboratory values, admission source, prior functional status, medical comorbidities, treatments received, and discharge disposition were recorded, as were scores on the Acute Physiology, Age, and Chronic Health Evaluation III (APACHE III). Coagulopathy was defined as an internal normalized ratio > 1.2 or a prothrombin time ≥12.7 seconds. Univariate and multivariate analyses were performed on 244 patients to determine factors associated with worse short-term outcomes.

Results

The authors identified 248 patients with acute SDH admitted to the neurointensive care unit during the study period, of which 244 had complete data. Most were male (61%), and the mean age of the study population was 71.3 ± 15 years (range 20–95 years). Fifty-three patients (22%) had coagulopathy. The median APACHE III score was 43 (range 11–119). Twenty-nine patients (12%) died in the hospital. Independent predictors of inhospital death included APACHE III score (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.4–13.4, p = 0.011) and coagulopathy (OR 2.7, 95% CI 1.1–7.1, p = 0.037). Surgical evacuation of acute SDH was associated with reduced inhospital deaths (OR 0.2, 95% CI 0.1–0.6, p = 0.003).

Conclusions

Coagulopathy is independently associated with inhospital death in patients with acute SDH. Time to treatment to correct coagulopathy using fresh frozen plasma and/or vitamin K was prolonged.

Surgery of cerebral trauma and associated critical care

The last 30 years have been both exciting and frustrating for those in the field of traumatic brain injury (TBI). Much has been learned, but no new treatment has been shown to improve patient outcomes despite the execution of many clinical trials. The overall incidence of TBI has decreased, probably because of intensive efforts toward prevention and education. Rigorous assessment of available research has produced several evidence-based guidelines for the management of neurotrauma patients. The creation of organized emergency medical services systems in many regions has improved prehospital care. Computed tomographic scans have become the gold standard for obtaining immediate images of patients with TBI, and ongoing advances in visualizing cerebral metabolism continue to be remarkable. The major current question regarding surgical treatment for TBI involves the role of decompressive craniectomy, an operation that first fell out of favor and has since (in the last three decades) enjoyed a resurgence of interest. Growing interest in the intensive care management of TBI patients helped to establish the new field of neurocritical care. Prophylactic hyperventilation is no longer recommended, and earlier recommendations for aggressive elevation of blood pressure have been softened to endorsement of a cerebral perfusion pressure of 60 mmHg. Recombinant factor VIIa is increasingly used for minimizing complications related to coagulopathy. Intracranial pressure monitoring is now recommended for the majority of TBI patients. At present, available technologies allow measurement of other aspects of cerebral metabolism including cerebral blood flow, brain oxygen tension, biochemistry, and electrical activity. Therapeutic interventions that are growing in popularity or are presently under investigation include administration of hypertonic saline, hyperoxygenation, decompressive craniectomy, and hypothermia. Rehabilitation has become accepted as an important part of the TBI recovery process, and additional work is needed to identify optimal interventions in this area. Socioeconomic factors will play a growing role in our treatment of TBI patients. Although much progress has been made in the last 30 years, the challenge now is to find ways to translate that progress into improved care and outcomes for TBI patients.

Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study

OBJECTIVE

The absence of surgical subspecialty emergency care in the United States is a growing public health concern. Neurosurgery is a field lacking coverage in many areas of the country; however, this is generally thought to be of greater concern in rural areas. Because of decreasing numbers of neurosurgeons, medical malpractice, and liability concerns, neurosurgery coverage is becoming a public health crisis in urban areas. Our objective was to quantify neurosurgical emergency transfers to academic medical centers in Cook County, IL, including patient demographics, reasons for transfer, time lapse in transfer, and effects on patient condition.

METHODS

Data on neurosurgery emergency transfers was gathered prospectively by all five of the academic neurosurgery departments in Cook County, IL, over a 2-month period. Patient demographics devoid of identifiers, diagnosis, transfer origin, time lapse of transfer, and patient condition at the time of transfer and at the receiving hospital were recorded.

RESULTS

Two-hundred thirty emergent neurosurgical transfers occurred during the study period. The most common diagnoses were parenchymal intracerebral hemorrhage (33%) and subarachnoid hemorrhage (28%). Sixty-six percent of neurosurgical transfers to academic medical facilities originated at hospitals without full-time neurosurgery coverage. The mean time to transfer for all patients was 5 hours 10 minutes (standard deviation, 3 h 42 min; range, 1-20 h 12 min). A decline in Glasgow Coma Scale score was seen in 29 patients. A shortage of neurosurgical intensive care unit beds occurred on 55% of the days in the study. Only 19% of the emergency cases were related to cranial trauma, and only 3% of transfers came from Level 1 trauma centers.

CONCLUSION

A combination of factors has led to decreases in availability of neurosurgical coverage in Cook County community hospital emergency departments. This has placed an increased burden on neurosurgical departments at academic centers, and, in some cases, delays led to a decline in patient condition. Eighty-one percent of the cases were not related to cranial trauma; thus, acute care trauma surgeons would be of little use. Coordinated efforts among local governments, medical centers, and emergency medical services to regionalize subspecialty services will be necessary to manage this problem.

The effect of haematoma, brain injury, and secondary insult on brain swelling in traumatic acute subdural haemorrhage

OBJECTIVE

The high mortality of acute subdural haematoma (ASDH) is largely explained by its frequent association with primary brain damage consisting of contusion and brain swelling. However, the nature and causes of brain swelling after traumatic brain injury are multifactorial and poorly understood. The purpose of this study was to investigate the pathophysiology of brain swelling associated with ASDH in traumatic brain injury.

METHODS

We examined whether the thickness of the haematoma, parenchymal injury, or presence of a secondary insult had an effect on traumatic brain swelling. The variables that might affect the pathophysiology of ASDH were examined, including: (1) age and mechanism of injury, (2) neurological findings, (3) secondary insult and extracranial injuries, (4) pre-operative computed tomography (CT) scan results, and (5) outcome.

RESULTS

A total of 212 patients were included in this study. On CT scan, 159 patients (75.0%) did not have brain swelling, 29 (13.7%) had hemispheric brain swelling, and 24 (11.3%) had diffuse brain swelling. Brain swelling associated with ASDH is caused by secondary insult in addition to parenchymal injury. In the present study, the outcome of ASDH associated with brain swelling was poor, even when treated with early surgical evacuation; the mortality rate of such patients was over 75%.

CONCLUSIONS

Given our findings, it is possible that the poor outcome of ASDH patients depends not only on the characteristics of the haematoma itself, but also on the presence of additional cerebral parenchymal injury and secondary insult.

Decompressive craniotomy: prognostic factors and complications in 89 patients

Decompressive craniotomy (DC) is applied to treat post-traumatic intracranial hypertension (ICH). The purpose of this study is to identify prognostic factors and complications of unilateral DC. Eighty-nine patients submited to unilateral DC were retrospectively analyzed over a period of 30 months. Qui square independent test and Fisher test were used to identify prognostic factors. The majority of patients were male (87%). Traffic accidents had occurred in 47% of the cases. 64% of the patients had suffered severe head injury, while pupillary abnormalities were already present in 34%. Brain swelling plus acute subdural hematoma were the most common tomographic findings (64%). Complications occurred in 34.8% of the patients: subdural effusions in 10 (11.2%), hydrocephalus in 7 (7.9%) and infection in 14 (15.7%). The admittance Glasgow coma scale was a statistically significant predictor of outcome ( p=0.0309).

Traumatic brain injury

Traumatic brain injury (TBI) is a significant source of morbidity and mortality throughout the world. This article discusses the epidemiology, pathophysiology, and clinical presentations of minor, moderate, and severe TBI. Controversial topics, such as hypertonic saline for increased intracranial pressure, prehospital intubation of patients who have experienced TBI, and the use of recombinant factor VIIa, are addressed.

Treatment of extradural haemorrhage in Queensland: interhospital transfer, preoperative delay and clinical outcome

OBJECTIVES

To measure preoperative delays and clinical outcomes of patients with extradural haemorrhage, comparing patients presenting to hospitals with no neurosurgical facilities, with those presenting directly to neurosurgical centres.

METHODS

Retrospective case study with data collected from 10 centres. Patients were identified with a search of the Queensland Trauma Registry database. A total of 315 charts were reviewed, of patients presenting or referred to Queensland's public hospitals between 2002 and 2004 inclusive.

RESULTS

A total of 261 patients were included in the study. One hundred and fifty-nine patients presented to hospitals with no neurosurgical facilities; 102 presented directly to neurosurgical centres. Forty-six patients underwent interhospital transfer (IHT) before decompressive craniotomy; their median time interval from presentation to operation was 8 h 5 min. This delay was significantly greater than that for 25 patients admitted directly to neurosurgical centres (median 4 h 19 min; P = 0.0006). After excluding patients who had sustained hypoxic or hypotensive insults or serious extracranial injuries, all deaths (five) occurred in patients undergoing IHT before craniotomy.

CONCLUSIONS

IHT of patients with extradural haemorrhage causes significant preoperative delay.

Quand faut-il décider d'un transfert en milieu neurochirurgical spécialisé?

The annual incidence of severe head injury lies between 9 and 25/100000 inhabitants, depending on the criteria used for its definition. In most countries, the shortage in neurosurgical ICU beds makes it impossible to take in charge all patients with a severe brain injury. But the beneficial effect of a specialized neurosurgical ICU on outcome after brain injury has been demonstrated in several retrospective studies. Ideally, the best strategy is to admit the patients with a severe head injury directly in a neurosurgical centre. When this is not possible, the appropriate decision of a secondary transfer relies on the quality of the relationships between physicians in the community and the neurosurgical hospitals. Teleradiology is the best method to avoid unnecessary transportation or deleterious delays before transfer. In an era of decreasing medical budgets, technical improvements to enhance medical cooperation should be encouraged.

Imaging after brain injury

Head injury remains an important cause of death and disability in young adults. This review will discuss the role of structural imaging using computed tomography (CT) and magnetic resonance imaging (MRI) and physiological imaging using CT perfusion, 131Xe CT, MRI and spectroscopy (MRS), single photon emission computed tomography, and positron emission tomography (PET) in the assessment, management, and prediction of outcome after head injury. CT allows rapid assessment of brain pathology which ensures patients who require urgent surgical intervention receive appropriate care. Although MRI provides greater spatial resolution, particularly within the posterior fossa and deep white matter, a complete assessment of the burden of injury requires imaging of cerebral physiology. Physiological imaging techniques can only provide 'snap shots' of physiology within the injured brain, but they can be repeated, and such data can be used to assess the impact of therapeutic interventions. Perfusion imaging based on CT techniques (xenon CT and CT perfusion) can be implemented easily in most hospital centres, and provide quantitative perfusion data in addition to structural images. PET imaging provides unparalleled insights into cerebral physiology and pathophysiology, but is not widely available and is primarily a research tool. MR technology continues to develop and is becoming generally available. Using a complex variety of sequences, MR can provide data concerning both structural and physiological derangements. Future developments with such imaging techniques should improve understanding of the pathophysiology of brain injury and provide data that should improve management and prediction of functional outcome.

Damage control surgery and casualty evacuation: techniques for surgeons, lessons for military medical planners

Damage Control Surgery (DCS) is a three-phase team-based approach to maximal injury penetrating abdominal trauma. In Phase I, the hypothermic, coagulopathic, acidotic, hypotensive casualty undergoes a proactively planned one-hour time limited laparotomy by an appropriately trained surgical trauma team. In phase II physiological stabilization takes place in the Intensive Care Unit. In phase III--definitive repair occurs. DCS is extremely resource intensive but will save lives on the battlefield. A military DCS patient will perioperatively require fourteen units of blood and seven units of fresh frozen plasma--half the blood stock of a light-scaled FST. Two DCS patients will in one day, exhaust this FSTs oxygen supply. We know that hypothermic patients with an iliac vascular injury (initial core temp < 34 degrees C) suffer four-fold increases in their mortality, yet we cannot heat our tents above 20 degrees C during a mild British winter. Our primary casualty retrieval is excessively slow. A simple casevac request has to go to too much 'middle-management' before a flight decision is made. In Vietnam, wounded soldiers arrived in hospital within twenty-five minutes of injury. In Iraq in 2005, that figure is over one hundred and ten minutes. We use support or anti-tank helicopters that are re-roled on an adhoc basis for the critical care and transport of our sickest patients. We still do not have a dedicated all-weather military helicopter evacuation fleet despite significant evidence that intensive care unit level military evacuation is safe and eminently achievable in both in the primary and secondary care setting. Should we not be asking why?

Traumatic brain injury: assessment, resuscitation and early management

This review examines the evidence base for the early management of head-injured patients. Traumatic brain injury (TBI) is common, carries a high morbidity and mortality, and has no specific treatment. The pathology of head injury is increasingly well understood. Mechanical forces result in shearing and compression of neuronal and vascular tissue at the time of impact. A series of pathological events may then ensue leading to further brain injury. This secondary injury may be amenable to intervention and is worsened by secondary physiological insults. Various risk factors for poor outcome after TBI have been identified. Most of these are fixed at the time of injury such as age, gender, mechanism of injury, and presenting signs (Glasgow Coma Scale and pupillary signs), but some such as hypotension and hypoxia are potential areas for medical intervention. There is very little evidence positively in favour of any treatments or packages of early care; however, prompt, specialist neurocritical care is associated with improved outcome. Various drugs that target specific pathways in the pathophysiology of brain injury have been the subject of animal and human research, but, to date, none has been proved to be successful in improving outcome.

Surgical treatment of intracerebral haemorrhage

PURPOSE OF REVIEW

Controversy still exists about the management of spontaneous intracerebral haemorrhage. This review summarizes our current knowledge on indications and benefits of surgery for intracerebral haemorrhage. It further describes the detailed meta-analysis of the surgical results in lobar (superficial) supratentorial intracerebral haemorrhage, summarizes the limited information on the surgical treatment of cerebellar intracerebral haemorrhage, and identifies three ongoing trials.

RECENT FINDINGS

A meta-analysis of 12 prospective randomized controlled trials of neurosurgical intervention in spontaneous intracerebral haemorrhage shows a strong trend to reduced mortality (0.85; 95% confidence interval 0.71-1.02). There is an apparent significant benefit from surgery in the three trials in which lobar intracerebral haemorrhage was identified in relation to both death and disability (0.58; 95% confidence interval 0.36 - 0.92). No surgical trial data are available for spontaneous cerebellar intracerebral haemorrhage or for any type of traumatic intracranial haemorrhage. Three trials are ongoing to resolve existing uncertainties.

SUMMARY

Clinicians are encouraged to discover if the suspected beneficial role of surgery truly exists by randomizing patients with intracerebral haemorrhage in the ongoing prospective randomized controlled trials in the following circumstances: lobar intracerebral haemorrhage (clot reaches to within 1 cm of the cortical surface), STICH II; intraventricular haemorrhage (clot maximum size of 30 ml), CLEAR IVH; deep intracerebral haemorrhage and minimal invasive surgery, MISTIE.

A Crisis in the Delivery of Care to Patients With Brain Injuries in South Texas

BACKGROUND

To determine the opinions of neurosurgeons regarding the care of the injured and to assess the impact of these attitudes on the care of the patients with brain injuries.

METHODS

A survey was sent to the 2,465 active members of the American Association of Neurologic Surgeons. A manpower assessment of neurosurgical coverage of South Texas was also performed.

RESULTS

In total, 872 surveys were returned (35%). Seventy-one percent of the respondents were over the age of 44. Eighty-seven percent of neurosurgeons stated that they currently provide trauma care: 74% at Level I or II trauma centers. The majority of neurosurgeons treated <5 trauma patients per week, 80% placed 2 or fewer intracranial pressure (ICP) monitors per month. Fifty-nine percent of the respondents preferred not to treat trauma patients because of (1) perceived increased medicolegal risk (80%), (2) conflict with elective practice (75%), (3) time required (70%), and (4) inadequate compensation (65%). Fifty-six percent received no compensation for trauma call. The majority of neurosurgeons indicated that no personnel other than neurosurgeons should be allowed to perform trauma craniotomies (90%) or insert ICP monitors (76%). However, 61% thought that non-neurosurgeons should be able to perform neuro-critical care. A maldistribution of neurosurgeons was identified in South Texas, with much of the population uncovered for trauma care. Significant delays in definitive neurosurgical care were identified as a result of this maldistribution.

CONCLUSIONS

One-half of neurosurgeons prefer not to care for trauma patients because of perceived added time commitment, conflicts with elective practice, lack of compensation, and perceived medicolegal risk. But, they thought that only neurosurgeons should provide emergency neurosurgical procedures. These attitudes appear to impinge on the care of the patients with brain injuries in South Texas.

Trauma care at rural level III trauma centers in a state trauma system

BACKGROUND

Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care.

METHODS

During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail.

RESULTS

A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5.

CONCLUSIONS

Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.

Are pre-hospital time and emergency department disposition time useful process indicators for trauma care in Italy?

BACKGROUND

It is recommended that process indicators (PI) for trauma-care be validated in the setting where they are applied for quality assurance (QA) and quality improvement (QI). In a pilot attempt at trauma QA and QI, we evaluated pre-hospital time (PT) and emergency department disposition time (EDt) as possible PIs in three Italian trauma-referral hospitals.

METHODS

We used registry data on all the 753 major (ISS>15) trauma cases admitted to the participating hospitals between the 1 July 2004 and the 31 June 2005. The distribution of PT and EDt in the hospitals was investigated together with the performances of the hospitals. The performances were evaluated in terms of patient outcome with multivariate regression models. Outcome measures were trauma death, Euroqol 5-D (EQ5D), and Glasgow Outcome Score (GOS). The possible PIs were then evaluated as independent predictors of outcome.

RESULTS

In the hospital with the best outcome-measures (Hospital A) PT and EDt were also the shortest. The differences in PT and EDt were significant (p<0.05) versus Hospital B and Hospital C, respectively. However, at the patient level, longer PT and EDt were not independently associated with bad outcome. Neither a threshold could be found that indicated higher risks of bad outcome. EDt>120 min was paradoxically associated with lower mortality.

CONCLUSION

Although PT and EDt were significantly shorter in the hospital with best outcome performances, we could not confirm at the patient level their expected independent association with outcome. More evidence is needed before these indicators can be validated as standard tools for system analysis in our setting.

Care of Central Nervous System Injuries

The primary method of improving outcome from traumatic brain injury is through avoiding secondary insults to the injured brain. Although surgery is important, most management is critical care. Evidence-based guidelines continue to be developed to assist in directing care. With modern monitoring systems, a physiologic-based approach is increasingly applicable, allowing focused treatment for intracranial hypertension and ischemia. It is important to balance and integrate the care of the injured brain into the overall care of the polytrauma patient.

Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage

OBJECTIVE

Intracranial hemorrhage in patients receiving oral anticoagulant (OAC) therapy is associated with poor neurological outcome. Prothrombin complex concentrate (PCC) is the gold-standard therapy to normalize hemostasis but remains underused. Ultra-rapid reversal of anticoagulation could reduce the time to biological and surgical hemostasis, and might improve outcome. We report the use of bolus infusions of PCC to immediately reverse anticoagulation and allow for urgent neurosurgical care.

DESIGN

Prospective, observational study.

SETTING

Neurosurgical intensive care unit, university hospital.

PATIENTS AND PARTICIPANTS

Eighteen patients with OAC-associated intracranial hemorrhage requiring urgent neurosurgical intervention.

INTERVENTIONS

All patients received 20 UI/kg of PCC as an intravenous bolus infusion (3 min) and 5 mg of enteral vitamin K. Surgery was started immediately, without waiting for blood sample results.

MEASUREMENTS AND RESULTS

Serial blood samples were performed to assess prothrombin time. Coagulation was considered normal when the international normalized ratio was </= 1.5. All patients, including nine who were over-anticoagulated, had complete reversal of anticoagulation immediately after the bolus of PCC. No hemorrhagic or thrombotic adverse effect was observed intra- or postoperatively.

CONCLUSIONS

A bolus infusion of PCC completely reverses anticoagulation within 3 min. Neurosurgery can be performed immediately in OAC-related intracranial hemorrhage. This study shows that OAC-treated patients can be managed as rapidly as non-anticoagulated patients.

Spontaneous resolution of acute cranial subdural hematomas

Acute cranial subdural hematoma (SDH) represents a common consequence of traumatic brain injury. The vast majority of acute SDHs larger than 10mm in thickness require immediate surgical evacuation. In rare occasions, however, spontaneous resolution may occur. In our current communication, we present four cases of spontaneous resolution of acute cranial SDH. Further more, the proposed theories explaining spontaneous resolution of acute SDH, as well as, clinical parameters and imaging characteristics that might predict such phenomenon, are also reviewed. The possibility of spontaneous resolution of an acute SDH, although remote, may impact the decision making process regarding the management of these patients under certain conditions.

Extended survival after evacuation of subdural hematoma in a 102-year-old patient: case report and review of the literature

BACKGROUND

Outcomes for elderly patients undergoing craniotomy for evacuation of subdural hematoma (SDH) have been reported to be poor with high mortality rates.

CASE DESCRIPTION

We present the case of a patient who underwent craniotomies at the age of 102 years, and again at the age of 103 years, for acute SDHs with good recovery to her premorbid neurologic condition. A 102-year-old woman presented after falling to the floor, and underwent a left-sided craniotomy for evacuation of a large, left hemispheric acute SDH. She recovered from that event and returned home. Six months later, she presented after falling again and was found to have a large, right hemispheric acute SDH. A right-sided craniotomy was performed and again she made good recovery with return to her neurologic baseline.

CONCLUSION

We report this unique case of good recovery after 2 separate craniotomies for acute SDH in a patient older than 100 years. Implications of acute SDH in the elderly are discussed, as relevant to this case, with a review of the literature. Although the morbidity and mortality of acute SDH are high, particularly in elderly patients, there is potential for good recovery and excellent outcome in appropriately selected patients.

Neurosurgery in the elderly: brain tumors and subdural hematomas

Primary malignant brain tumors present a formidable challenge to surgeons, patients, and families. Although the prognosis in elderly patients approaches only 6 months, aggressive resection and adjuvant treatment may be indicated in a select group of patients who have preserved functional status. Subdural hematomas in the geriatric population usually are chronic. Patients often benefit from evacuation but their advanced age and significant comorbidities often increase perioperative morbidity and mortality. Minimally invasive evacuation, possibly under local anesthesia, often is indicated as an initial treatment.