Delayed epidural hematoma

Traumatic Dural Venous Sinuses Injury

The traumatic dural venous sinus injury is one of the most dangerous complications of TBI, either due to fatal intracranial compressing venous bleeding, or disturbing the intracranial pressure which could be caused by injury to the SSS On the other hand, post traumatic dural sinus thrombosis is considered a rare complication which may lead to hemorrhagic infarction with its serious consequences including epilepsy, neurological deficits, or death. Therefore, knowledge of the appropriate treatment of this kind of head injury is essential.

Development of a delayed acute epidural hematoma following contralateral epidural hematoma evacuation: case report and review of literature

The formation of a post-traumatic delayed epidural hematoma (DEDH) is a rare but well-described complication in the literature. It is defined as an extradural bleeding not evident at the first computed tomography (CT) scan performed after trauma, but evidenced by further radiological evaluations. The most supported hypothesis about the mechanism responsible for the formation of a DEDH concerns above all the loss of a tamponade effect given by the reduction of intracranial pressure with medical or surgical treatment. A 30-year-old man was admitted to the emergency department with an epidural hematoma (EDH) associated with a linear calvarial bitemporal coronal fracture. A few hours after the surgical procedure for hematoma evacuation, the patient developed a DEDH contralateral to the site of surgical procedure. The literature review identified other 27 analogue cases. The presence of a calvarial fracture contralateral to the site of a craniotomy and the intraoperative brain swelling during EDH removal are suspicious for the development of DEDH. A CT scan has to be urgently performed in this situation. The timing of postoperative radiological examinations after EDH removal has to consider possible complications and has to be balanced on the basis of patient's clinical condition and neuroradiological data, such as skull fractures or intraoperative anomalies. The development of a DEDH after the surgical removal of an EDH is a rare event, characterized by a high mortality rate. DEDH develops preferentially on the contralateral side and with a concomitant skull fracture.

Progressive epidural hematoma in patients with head trauma: incidence, outcome, and risk factors

Progressive epidural hematoma (PEDH) after head injury is often observed on serial computerized tomography (CT) scans. Recent advances in imaging modalities and treatment might affect its incidence and outcome. In this study, PEDH was observed in 9.2% of 412 head trauma patients in whom two CT scans were obtained within 24 hours of injury, and in a majority of cases, it developed within 3 days after injury. In multivariate logistic regression, patient gender, age, Glasgow Coma Scale (GCS) score at admission, and skull fracture were not associated with PEDH, whereas hypotension (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17-0.84), time interval of the first CT scanning (OR 0.42, 95% CI 0.19-0.83), coagulopathy (OR 0.36, 95% CI 0.15-0.85), or decompressive craniectomy (DC) (OR 0.46, 95% CI 0.21-0.97) was independently associated with an increased risk of PEDH. The 3-month postinjury outcome was similar in patients with PEDH and patients without PEDH (χ(2) = 0.07, P = 0.86). In conclusion, epidural hematoma has a greater tendency to progress early after injury, often in dramatic and rapid fashion. Recognition of this important treatable cause of secondary brain injury and the associated risk factors may help identify the group at risk and tailor management of patients with TBI.

Indications du scanner cérébral chez les patients présentant un traumatisme crânien bénin

OBJECTIVE

Validate the clinical criteria, which, when absent, would make it safe to bypass CT scan examination in mild cranial injuries.

MATERIAL

and methods. Prospective study including 285 patients with mild cranial injury with a Glasgow score of 15, a normal clinical examination but transitory loss of consciousness or suspected transitory loss of consciousness. The following clinical parameters were systematically reviewed: history of stroke; post-injury headache; post-injury vomiting; alcohol, medication, or drug intoxication; clinical signs of cervico-cranio-facial injury; post-injury convulsions; or coagulation impairment. Systematic CT exploration looked for cranial, encephalic, and facial lesions and individualized the lesions requiring neurosurgical or maxillofacial treatment.

RESULTS

Of the patients studied, 7% presented a cranioencephalic lesion and 7% a facial bone lesion. Neurosurgical intervention was necessary in 0.4% of the patients and maxillofacial surgery in 2.5%. Patients with a positive CT all had at least one clinical risk factor and patients with cranioencephalic lesions had at least two risk factors present. Had patients with no risk factors not been scanned, 15% of the patients would not have had the CT procedure.

CONCLUSION

Selecting CT indications in cases of mild cranial injury with loss of consciousness using a simple and validated evaluation can save 15% of CT procedures without missing any cranial, encephalic, or facial lesions.

[Delayed epidural hematoma after mild head injury]

BACKGROUND

Traumatic delayed epidural hematoma (DEH) can be defined as insignificant or not seen on the initial CT scan performed after a trauma but seen on the subsequent CT scan as a "massive" epidural bleeding.

CASE REPORT

We presented two cases of traumatic DEH after mild head injury. Both patients were conscious and without neurological deficit on the admission. Initial CT scan did not reveal intracranial hematoma. Repeated CT scan, that was performed after neurological deterioration, revealed epidural hematoma in both cases. The patients were operated with a favorable surgical outcome.

CONCLUSION

Traumatic DEH could occur in the patients with head injuries who were conscious on the admission with a normal initial CT scan finding. Early detection of DEH and an urgent surgical evacuation were essential for a good outcome.

Mild head injury: reliability of early computed tomographic findings in triage for admission

OBJECTIVE

To search the literature for case reports on adverse outcomes in patients with mild head injury where acute computed tomography (CT) findings had been normal.

METHODS

Mild head injury was defined as head trauma involving amnesia or loss of consciousness, but where neurological findings are normal on arrival at hospital (GCS 15). The scientific literature was systematically searched for case reports where an early CT was normal and the patient deteriorated within two days. In these cases, early discharge despite a normal CT head scan would have been hazardous.

RESULTS

Two prospective studies were found that investigated the safety of early CT in 3300 patients with mild head injury, as were 39 reports on adverse outcomes describing 821 patients. In addition, 52 studies containing over 62 000 patients with mild head injury were reviewed. In total, only three cases were deemed to have experienced an early adverse outcome despite a normal CT and GCS 15 on initial presentation. In another eight cases with incomplete descriptions, the interpretation was doubtful. Many reports of complications were not relevant to our question and excluded. These reports included cases with more severe head injury/not GCS 15 at presentation, complications that occurred after more than two days, or initial CT findings that were not fully normal.

CONCLUSION

Very few cases were found where an early adverse event occurred after normal acute CT in patients with mild head injury. The strongest scientific evidence available at this time shows that a CT strategy is a safe way to triage patients for admission.

The importance of serial neurologic examination and repeat cranial tomography in acute evolving epidural hematoma

Computed tomography (CT) has revolutionized the diagnosis and management of head-injured patients, and its increasing availability has led to its liberal use. CT scanning provides excellent anatomic detail of the brain as fixed static images, but the dynamic nature of human physiology means that many injury patterns will evolve in time. We describe an 8-year-old child who had fallen 8 feet from a tree. He had a brief loss of consciousness but a normal neurologic evaluation on arrival to the emergency department (ED). He underwent expedited cranial CT scanning, which revealed no acute brain injury. Two and one half hours later, the patient had a mild depression in consciousness, prompting a second CT scan in the ED, which revealed an acute epidural hematoma. He had acute surgical evacuation of the hematoma and made a full neurologic recovery. This case illustrates that a single early CT examination may at times provide a false sense of security and underscores the importance of serial neurologic examinations.

Indications for computed tomography in patients with minor head injury

BACKGROUND

Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT.

METHODS

In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients.

RESULTS

Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings.

CONCLUSIONS

For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.

Delayed post-traumatic epidural hematoma. A review

Post-traumatic acute epidural hematoma (EDH) is generally visible on the CT scan done immediately after admission: occasionally, it only comes to light at a later scan and is then termed delayed (DEDH). Since the introduction of CT, the frequency of this occurrence has gone up from 6-13% to 30%. The mechanisms responsible for the delayed appearance of the epidural hematoma a "tamponade" effect are usually increased endocranial pressure and post-traumatic arterial hypotension as well as, in a limited number of cases, coagulopathy, CSF drainage, and arterio-venous shunt. The authors report 5 of their own cases and 45 published cases and discuss the characteristics of this particular form of hematoma and its outcome.