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Elkholy H, Elnoamany H, Hussein MA. Predictive Factors for Regression versus Progression of Nonevacuated Posttraumatic Acute Extradural Hematoma. Asian J Neurosurg 2024; 19:452-461. [PMID: 39205887 PMCID: PMC11349389 DOI: 10.1055/s-0043-1775731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Study Design This study was a retrospective study conducted from October 2020 to October 2022 on 106 posttraumatic patients with acute extradural hematomas (EDHs) who were initially planned for conservative treatment. 74 patients had spontaneous EDH regression (EDHR), while 32 patients developed EDH progression (EDHP) and were shifted for surgery. The two groups were statistically compared regarding the different demographic, clinical, and radiographic factors to identify the significant predictors for regression versus progression of acute posttraumatic EDH. Objectives Conventionally, urgent evacuation is the accepted management for EDH. However, several recent reports have described successful conservative management in selected patients. There are no adequate clues to verify patients who will have spontaneous EDHR from those at risk for EDHP and delayed surgery. The main objective of this study was to identify the significant predictors for possible regression versus progression of acute posttraumatic EDH initially planned for nonsurgical treatment. Materials and Methods A retrospective study conducted over 2 years, included 106 head trauma patients with acute EDH, who were admitted to our department and were initially planned for conservative treatment. Various demographic, clinical, and radiographic factors were analyzed to verify the significant predictors for spontaneous EDHR (EDHR group) versus EDHP and subsequent surgical evacuation (EDHP group). Results The mean age was 20.37 ± 12.712 years and the mean Glasgow Coma Scale score (GCS) was 12.83 ± 2.113. Total 69.8% of patients showed spontaneous EDHR, while 30.2% developed EDHP and were shifted for surgical evacuation. Statistical comparison showed that higher GCS ( p = 0.002), frontal location ( p = 0.022), and concomitant fissure fracture ( p = 0.014) were the significant predictors for EDHR, while younger age ( p = 0.006), persistent nausea/vomiting ( p = 0.046), early computed tomography (CT) after trauma ( p = 0.021), temporal location ( p < 0.001), and coagulopathy ( p = 0.001) were significantly associated with EDHP. Conclusion Patients with traumatic EDH fitting the criteria of initial nonsurgical treatment necessitates 48 hours of close observation and serial CT scans at 6, 12, 24, and 48 hours to confirm the regression or early detect the EDHP. Patients with high GCS, frontal hematomas, and associated fissure fracture are at low risk for EDHP. Increased alertness is mandatory for young age and patients with persistent nausea/vomiting, early CT scan, temporal hematomas, or coagulopathy.
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Affiliation(s)
- Hany Elkholy
- Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Hossam Elnoamany
- Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Mohamed Adel Hussein
- Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
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2
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Foster MA, Collins MR, Wertin TM, Azurdia AR, Lettieri SC, Feiz-Erfan I. Management of epidural hematomas of the posterior Cranial Fossa. World Neurosurg X 2024; 21:100263. [PMID: 38187504 PMCID: PMC10770538 DOI: 10.1016/j.wnsx.2023.100263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 10/29/2023] [Accepted: 11/28/2023] [Indexed: 01/09/2024] Open
Affiliation(s)
- Michael A. Foster
- Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- University of Arizona, College of Science, Tucson, AZ, USA
| | - Michael R. Collins
- Department of Radiology, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Thomas M. Wertin
- Division of Trauma, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Adrienne R. Azurdia
- Department of Emergency Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA
- Department of Emergency Medicine, Honor Health Osborn, Scottsdale, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Salvatore C. Lettieri
- Division of Plastic Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Division of Plastic Surgery, Mayo Clinic, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Iman Feiz-Erfan
- Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
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3
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Duvvi A, Ganji M, Habal Y, Bekele H, Kim C, Yates E, Seligson S, McWhir G, Kalantari H, Singh J, Hassen GW. Emergency department burr hole simulation using 3D-printed model. Am J Emerg Med 2023; 71:104-108. [PMID: 37356338 DOI: 10.1016/j.ajem.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/09/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Traumatic epidural hematoma (EDH) with the potential to displace the brain tissue and increase intracranial pressure (ICP), is a life-threatening condition that requires emergent intervention. In rare circumstances, Emergency Physician (EP) may have to do skull trephination to reduce the ICP as a temporary measure. SPECIFIC AIMS To evaluate emergency medicine (EM) residents' comfort in performing emergency department (ED) burr holes and to assess their difficulties and evaluate comfort level before and after simulated EDH cases. MATERIALS AND METHODS A 3D-printed skull and electrical and manual drills were used for the simulation. Subjective comfort level pre and post-procedure, as well as objective procedural skills and time to complete the drill, were recorded. RESULTS Twenty EM residents participated in the simulation study. The median time to perforate through the skull was 4 s for the electric drill and 10 s for the manual drill. A comfort level of 5 and above was reported by 12 participants for the manual drill and by 17 participants for the electric drill. Six participants had mild and 2 participants had moderate observed difficulty in handling the manual and electric drill. Most participants performed both procedures successfully with one attempt only. Three participants have an overall comfort level above 5 before the simulation and 13 participants had a post-simulation. CONCLUSION The 3D-printed model assisted the ED burr hole simulation and the residents could perform the procedure with minimum difficulties.
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Affiliation(s)
- Anisha Duvvi
- Albert Einstein School of Medicine, USA; Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Mohammad Ganji
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Yasmine Habal
- Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Hebron Bekele
- Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Ceilim Kim
- Metropolitan Hospital Center, Department of Emergency Medicine, USA; Columbia University, Postbac Premed Program, USA
| | - Evan Yates
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Shterna Seligson
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Greg McWhir
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Hossein Kalantari
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Jaspreet Singh
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA
| | - Getaw Worku Hassen
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, USA.
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Muacevic A, Adler JR, Dighe O, Iratwar S, Bisen G. Decompressive Craniectomy in the Management of Low Glasgow Coma Score Patients With Extradural Hematoma: A Review of Literature and Guidelines. Cureus 2023; 15:e33790. [PMID: 36819419 PMCID: PMC9927871 DOI: 10.7759/cureus.33790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/15/2023] [Indexed: 01/16/2023] Open
Abstract
An extradural hematoma (EDH), also known as an epidural hematoma, is a collection of blood between the inner skull table and the dura mater. It is restricted by the coronal, lambdoid, and sagittal sutures, as these are dural insertions. EDH most frequently occurs in 10- to 40-year-old patients. EDH is uncommon after age 60, as dura matter adheres firmly to the inner skull table. EDH is more common among men as compared to women. EDH most commonly occurs in the temporo-frontal regions and can also be seen in the parieto-occipital, parasagittal regions, and middle and posterior fossae. An EDH contributes approximately 2% of total head injuries and 15% of total fatal head injuries. In EDH, patients typically have a persistent, severe headache, and also, following a few hours of injury, they gradually lose consciousness. The primary bleeding vessels for EDH are the middle meningeal artery, middle meningeal vein, and torn dural venous sinuses. EDH is one of the many consequences of severe traumatic brain injuries that might lead to death. EDH is potentially a lethal condition that requires immediate intervention as, if left untreated, it can lead to growing transtentorial herniation, diminished consciousness, dilated pupils, and other neurological problems. Non-contrast computed tomography (NCCT) imaging is the gold standard of investigation for diagnosing EDH. For patients with surgical indications, early craniotomy and evacuation of acute extradural hematoma (AEDH) is the gold standard procedure and is predicted to have significant clinical results. Nevertheless, there is an ongoing debate regarding the best surgical operations for AEDH. Neurosurgeons must choose between a decompressive craniectomy (DC) or a craniotomy to manage EDH, especially in patients with low Glasgow coma scores, to have a better prognosis and clinical results. This is a consultant-based review article in which we have tried to contemplate various pieces of available literature. Here, the objective is to hypothesize DC as the primary surgical management for massive hematoma, which usually presents as a low Glasgow coma score. This is because DC was found to be beneficial in clinical practice.
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Beniwal HK, Reddy MS, Rao GP, Srikrishnaditya M, Beniwal A. Prognostic Value of Swirl Sign in Acute Epidural Hemorrhage. Asian J Neurosurg 2022; 17:584-587. [PMID: 36644411 PMCID: PMC9832927 DOI: 10.4103/ajns.ajns_68_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objective The purpose of this study is to analyze and evaluate the incidence, prognostic value, and impact of swirl sign on the outcome of patients who underwent surgical treatment for epidural hematoma. Materials and Methods A retrospective analytical study on 307 acute epidural hematoma (AEDH) patients with and without swirl sign was conducted at our hospital between 2015 and 2019. All the patients in this study were treated initially as per the protocols of advanced trauma life support and surgically treated by craniotomy and evacuation of epidural hematoma. Patients with other concomitant intracerebral injuries such as subdural hematoma and contusion and those who were managed conservatively were excluded from the study. Various factors such as age, sex, mechanism of injury, Glasgow Coma Scale (GCS) score at admission, time from injury to surgery, preoperative mydriasis, location of bleed, midline shift, location of fracture, volume of hematoma, duration of stay in the hospital, and GCS score at discharge were taken into consideration and compared in between patients with and without swirl sign. Outcomes were assessed at the end of 6 months using the Glasgow Outcome Scale. Results Of the 307 patients who were operated for epidural hemorrhage, 92 had swirl sign (29.96%) and the rest had no swirl sign. Univariate analysis revealed a significant correlation between the presence of swirl sign and age, preoperative mydriasis, and time from injury to surgery. The patients with the swirl sign had an unfavorable outcome at the end of 6 months which was statistically significant. Conclusion It can be concluded that those patients with swirl sign in AEDH had an unfavorable outcome compared to those without swirl sign. Therefore, aggressive treatment and early surgery play an important role in the outcomes of the patients.
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Affiliation(s)
- Hemant Kumar Beniwal
- Department of Neurosurgery, Gandhi Medical College and Hospital, Mahbubnagar, Telangana,Address for correspondence Hemant Kumar Beniwal Department of Neurosurgery, 4th Floor, Gandhi Medical College and HospitalPadma Rao Nagar, Secunderabad, 500003, TelanganaIndia
| | | | - Golapudi Prakash Rao
- Department of Neurosurgery, Gandhi Medical College and Hospital, Mahbubnagar, Telangana
| | - Manne Srikrishnaditya
- Department of Neurosurgery, Gandhi Medical College and Hospital, Mahbubnagar, Telangana
| | - Anisha Beniwal
- Department of Critical Care Medicine, Max Hospital, Saket, New Delhi India
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Charcos IB, Wong TW, Larsen BR, Azurdia AR, Gridley DG, Vail SJ, Hollingworth AK, Lettieri SC, Feiz-Erfan I. Location of Traumatic Cranial Epidural Hematoma Correlates with the Source of Hemorrhage: A 12-Year Surgical Review. World Neurosurg 2021; 152:e138-e143. [PMID: 34033954 DOI: 10.1016/j.wneu.2021.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage. METHODS We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon. RESULTS Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002). CONCLUSIONS The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.
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Affiliation(s)
- Iris B Charcos
- Department of Surgery, Division of Neurosurgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA
| | - Tina W Wong
- Department of Surgery, Division of Neurosurgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA
| | - Brett R Larsen
- Department of Radiology, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Adrienne R Azurdia
- Emergency Medicine, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Department of Emergency Medicine, HonorHealth Scottsdale, Scottsdale, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Daniel G Gridley
- Department of Radiology, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Sydney J Vail
- Division of Trauma, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Alexzandra K Hollingworth
- Division of Trauma, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Department of Surgery and Anesthesia, Midwestern University, Glendale, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Salvatore C Lettieri
- Division of Plastic Surgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Division of Plastic Surgery, Mayo Clinic, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Iman Feiz-Erfan
- Department of Surgery, Division of Neurosurgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA.
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7
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Aromatario M, Torsello A, D’Errico S, Bertozzi G, Sessa F, Cipolloni L, Baldari B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020125. [PMID: 33535407 PMCID: PMC7912597 DOI: 10.3390/medicina57020125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 04/09/2023]
Abstract
Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.
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Affiliation(s)
| | - Alessandra Torsello
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Giuseppe Bertozzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
- Correspondence:
| | - Francesco Sessa
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Luigi Cipolloni
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00186 Rome, Italy;
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Sakamoto D, Fukuya S, Harada A, Utsunomiya H. Two pediatric cases of epidural hematoma in the posterior fossa with extension along the sigmoid sinus groove: MR evaluation. Acta Radiol Open 2020; 9:2058460120902894. [PMID: 32071767 PMCID: PMC6997969 DOI: 10.1177/2058460120902894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/04/2020] [Indexed: 11/16/2022] Open
Abstract
To discuss the computed tomography (CT) and magnetic resonance (MR) findings of
posterior fossa epidural hematoma (PFEDH) mimicking sinus thrombosis, we present
two pediatric cases with the PFEDH extending along the sigmoid sinus groove
evaluated by MR imaging (MRI) and MR venography (MRV). T2-weighted coronal MRI
can diagnose both patency of the sigmoid sinus and epidural hematoma extending
along the sinus groove. Phase-contrast MRV (PC-MRV) is also useful to evaluate
the flow state in the dural sinuses but it should be diagnosed carefully whether
low visualization of the dural sinus means only functional flow impairment or
organized occlusion due to thrombus. To avoid an unnecessary anticoagulant
therapy that may worsen epidural hematoma, it is important to recognize the
pitfall that PFEDH extending along the sinus groove is easy to misdiagnose for a
dural sinus thrombosis.
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Affiliation(s)
- Daisuke Sakamoto
- Department of Neurosurgery, Hyogo College of Medicine, Hyogo, Japan
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
| | - Shogo Fukuya
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, Japan
| | - Atsuko Harada
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
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9
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Successful conservative management of large vertex epidural hematoma. Neurochirurgie 2019; 65:438-439. [DOI: 10.1016/j.neuchi.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/16/2019] [Accepted: 05/26/2019] [Indexed: 11/17/2022]
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Elkatatny AAAM, Elreheem YAA, Hamdy T. Traumatic Dural Venous Sinuses Injury. Open Access Maced J Med Sci 2019; 7:3225-3234. [PMID: 31949521 PMCID: PMC6953929 DOI: 10.3889/oamjms.2019.535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Tarek Hamdy
- Department of Neurosurgery, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
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Teixeira SR, Gonçalves FG, Servin CA, Mankad K, Zuccoli G. Ocular and Intracranial MR Imaging Findings in Abusive Head Trauma. Top Magn Reson Imaging 2018; 27:503-514. [PMID: 30516697 DOI: 10.1097/rmr.0000000000000169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.
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Affiliation(s)
- Sara Reis Teixeira
- Division of Radiology, Clinical Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto
| | | | - Carolina A Servin
- Centro Medico La Costa - Centro de Diagnóstico, Av General José Gervasio Artigas, Asunción, Paraguay
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Giulio Zuccoli
- Professor of Radiology, University of Pittsburgh School of Medicine, Director of Pediatric Neuroradiology, Children Hospital of Pittsburgh, Pittsburgh, PA
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12
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Kim JH, Yu SH, Kim BC, Lee JH, Lee JI, Choi HJ. Endovascular Treatment Following Gauze Packing for the Control of Massive Bleeding from Traumatic Transverse Sinus Lesion. Korean J Neurotrauma 2018; 14:150-154. [PMID: 30402436 PMCID: PMC6218356 DOI: 10.13004/kjnt.2018.14.2.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022] Open
Abstract
Posterior fossa epidural hematoma (EDH) is uncommon, but the related clinical deterioration can occur suddenly. Accompanying venous sinus injury and lacerations are associated with 40% to 80% mortality. The authors present one clinical case of a patient with posterior fossa EDH from transverse sinus bleeding. A 57-year-old male was injured after falling while working. He was taken to the hospital, where computed tomography scans of his brain revealed a right posterior temporal and cerebellar EDH with a right temporo-occipital fracture. He underwent a right parieto-occipital craniotomy, incorporating the fracture line. Longitudinal laceration of the right transverse sinus extending to the sigmoid sinus with profuse bleeding was identified. Four gauzes were inserted in the epidural space for tamponade of the injured sinus. Conventional angiography and coil embolization for the injured sinus were immediately performed. Subsequently, the patient was transferred to the operating room, wherein staff members removed the gauzes and remnant hematoma. Based on this experience, the authors recommend that for posterior fossa EDH from transverse sinus bleeding, bleeding control should be performed by gauze packing and endovascular treatment.
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Affiliation(s)
- Joon Hyuk Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Seung Han Yu
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jung Hwan Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Lee S, Park SK, Joo BE, Lee JA, Kong DS, Park K. The pathogenesis of delayed epidural hematoma after posterior fossa surgery. J Clin Neurosci 2017; 47:223-227. [PMID: 29037935 DOI: 10.1016/j.jocn.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/02/2017] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to analyze the pathogenesis of delayed epidural hematoma (EDH) after posterior fossa surgery. Non-traumatic, non-arterial origin delayed EDH after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure. Between April 1997 and June 2016, over 3300 patients underwent microvascular decompression (MVD) for neurovascular compression syndrome. The medical chart of four patients with delayed EDH were retrospectively reviewed. The median time from MVD to re-CT scan was 58 h (range, 33-100). All patients underwent hematoma evacuations. Intraoperative findings during hematoma evacuation revealed only an oozing hemorrhage from the transverse sinus with no definitive bleeding focus. The patients spent a median of 21.5 days (range, 11-39) at the hospital. At the last follow-up, all patients had fully recovered without significant neurological deficits and exhibited complete relief or minimal symptoms from hemifacial spasm (HFS). Postoperative uncontrolled bleeding from the dural venous sinus can sometimes cause an insidious-onset or delayed posterior fossa EDH.
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Affiliation(s)
- Seunghoon Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Ku Park
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Euk Joo
- Department of Neurology, Myongji Hospital, Seonam University School of Medicine, Gyeonggi-do, South Korea
| | - Jeong-A Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwan Park
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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14
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Guo C, Liu L, Wang B, Wang Z. Swirl sign in traumatic acute epidural hematoma: prognostic value and surgical management. Neurol Sci 2017; 38:2111-2116. [DOI: 10.1007/s10072-017-3121-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/07/2017] [Indexed: 11/24/2022]
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15
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Godoy DA, Rubiano A, Rabinstein AA, Bullock R, Sahuquillo J. Moderate Traumatic Brain Injury: The Grey Zone of Neurotrauma. Neurocrit Care 2016; 25:306-19. [DOI: 10.1007/s12028-016-0253-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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16
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17
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Shetty T, Raince A, Manning E, Tsiouris AJ. Imaging in Chronic Traumatic Encephalopathy and Traumatic Brain Injury. Sports Health 2015; 8:26-36. [PMID: 26733590 PMCID: PMC4702153 DOI: 10.1177/1941738115588745] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Context: The diagnosis of chronic traumatic encephalopathy (CTE) can only be made pathologically, and there is no concordance of defined clinical criteria for premorbid diagnosis. The absence of established criteria and the insufficient imaging findings to detect this disease in a living athlete are of growing concern. Evidence Acquisition: The article is a review of the current literature on CTE. Databases searched include Medline, PubMed, JAMA evidence, and evidence-based medicine guidelines Cochrane Library, Hospital for Special Surgery, and Cornell Library databases. Study Design: Clinical review. Level of Evidence: Level 4. Results: Chronic traumatic encephalopathy cannot be diagnosed on imaging. Examples of imaging findings in common types of head trauma are discussed. Conclusion: Further study is necessary to correlate the clinical and imaging findings of repetitive head injuries with the pathologic diagnosis of CTE.
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Affiliation(s)
- Teena Shetty
- Hospital for Special Surgery, New York, New York
| | | | - Erin Manning
- Hospital for Special Surgery, New York, New York
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18
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Delayed post-traumatic large subgaleal hematoma caused by diastasis of rhomboid skull suture on the transverse sinus. Childs Nerv Syst 2015; 31:621-4. [PMID: 25142690 DOI: 10.1007/s00381-014-2531-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 08/13/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This study aimed to consider an appropriate treatment for large subgaleal hematoma with skull fracture and epidural hematoma (EDH). CASE REPORT A 6-year-old boy presented at our hospital with head trauma, and computed tomography (CT) showed a thin EDH in the right temporo-occipital area and cranial diastasis in the right lambdoidal suture. However, no neurological deficits were identified in the patient. One week after trauma, he visited our hospital again with a massive fluctuant watery mass extending from the forehead to the right temporoparietal areas, and laboratory data revealed that he was anemic. CT showed a massive subgaleal hematoma with extremely high density around the cranial diastasis. Damage of the transverse sinus was suspected, and emergent sinus repair surgery was performed. The surgery disclosed that bleeding from the transverse sinus was flowing out extracranially through the cranial diastasis. The subgaleal and epidural hematomas were removed, and bleeding from the sinus was stopped by dural tacking sutures along the transverse sinus. Postoperative CT demonstrated complete disappearance of epidural and subgaleal hematomas. The patient recovered from general fatigue without blood transfusion and was discharged 9 days after surgery. CONCLUSIONS The therapeutic strategy for massive subgaleal hematoma is individualized. However, treatment for massive subgaleal hematoma with skull fracture should not be considered the same as for hematoma without skull fracture. Emergent surgery is recommended before neurological deterioration is recognized in the patient if damage to the dural sinus is suspected.
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19
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Al-Qazzaz MA, Jabor MAM. Medico-legal study of intracranial causes of death. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2014. [DOI: 10.1016/j.ejfs.2014.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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20
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Lapadula G, Caporlingua F, Paolini S, Missori P, Domenicucci M. Epidural hematoma with detachment of the dural sinuses. J Neurosci Rural Pract 2014; 5:191-4. [PMID: 24966568 PMCID: PMC4064195 DOI: 10.4103/0976-3147.131680] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Epidural hematoma (EH) is a neurosurgical emergency that requires early surgical treatment. It is rarely extended bilaterally causing a detachment of the dural sinus or sinuses. The authors present two rare cases of EH with dural sinus detachment and describe how they suspend them. In these cases it is crucial to firmly suspend the dura mater and the dural sinus to the inner skull surface to prevent postoperative rebleeding.
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Affiliation(s)
- Gennaro Lapadula
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Federico Caporlingua
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Sergio Paolini
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli (Isernia), Italy
| | - Paolo Missori
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Maurizio Domenicucci
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
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21
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Ma J, Li H, Cheng L, Lin S. Vaccum drainage system application in the management of operation-related non-regional epidural hematoma. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2013; 7:7. [PMID: 23842198 PMCID: PMC3751531 DOI: 10.1186/1750-1164-7-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 07/01/2013] [Indexed: 11/26/2022]
Abstract
Background Epidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique. Methods Seven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system. Results The vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed. Conclusions Compared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis.
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Affiliation(s)
- Jun Ma
- Department of Neurosurgery, Capital Medical University-Beijing Tiantan Hospital, Beijing, China
| | - Huan Li
- Department of Neurosurgery, Capital Medical University-Beijing Tiantan Hospital, Beijing, China
| | - Linggang Cheng
- Department of Neurosurgery, Capital Medical University-Beijing Tiantan Hospital, Beijing, China
| | - Song Lin
- Department of Neurosurgery, Capital Medical University-Beijing Tiantan Hospital, Beijing, China ; Beijing Tiantan Hospital, Dongcheng District, Beijing, China
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22
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Chauvet D, Reina V, Clarencon F, Bitar A, Cornu P. Conservative management of a large occipital extradural haematoma. Br J Neurosurg 2013; 27:526-8. [PMID: 23428147 DOI: 10.3109/02688697.2013.769499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 26-year-old male presented with a mild confusion and hemianopsia after traumatic brain injury. Cerebral CT-scan revealed a 62.5 cm(3) left occipital extradural haematoma (EDH). Although conventional neurosurgical management would have been to evacuate the haematoma, a conservative strategy was preferred, and the patient made a total recovery.
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Affiliation(s)
- D Chauvet
- Department of Neurosurgery, Pitié-Salpêtrière Hospital , Paris , France
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23
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Araujo JLV, Aguiar UDP, Todeschini AB, Saade N, Veiga JCE. Epidemiological analysis of 210 cases of surgically treated traumatic extradural hematoma. Rev Col Bras Cir 2013; 39:268-71. [PMID: 22936224 DOI: 10.1590/s0100-69912012000400005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 02/05/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the epidemiology, clinical and radiological presentation of patients with traumatic extradural hematoma (EDH) undergoing neurosurgical procedures. METHODS We performed a chart review of 210 patients admitted to the emergency department with EDH diagnosed by CT scan and surgically treated between August 1998 and January 2008. Variables analyzed were: age, gender, clinical and radiological presentation, mechanism of injury and neurological status at discharge from hospital. RESULTS In 49.2% trauma mechanism was fall; 89.2% of patients were male, 49.7% of cases had a Glasgow Coma Scale (GCS) between 13 and 15; 61% of patients had age between 20 and 49 years; the location of EDH was the temporo-parietal and temporal in 26.5% and 19.6% of the cases, respectively; 32.8% had associated intracranial lesions, with skull fractures seen in around 45% of cases; 76.2% of surgically treated patients were discharged with minimal or no neurologic deficit. CONCLUSION We observed that, in the study population, EDH appears more often in males, in the fourth decade of life, and is more related to falls. On admission, GCS was observed between 13 and 15 and it is appropriate to mention the involvement of the temporo-parietal region in most cases. We believe that knowledge of the epidemiology of traumatic epidural hematoma can assist in developing public health measures aimed at prevention and early identification of this disease in the population.
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Manto M, Habas C. Traumatismes de la fosse postérieure. LE CERVELET 2013:157-160. [DOI: 10.1007/978-2-8178-0447-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Habibi Z, Meybodi AT, Haji Mirsadeghi SM, Miri SM. Burr-hole drainage for the treatment of acute epidural hematoma in coagulopathic patients: a report of eight cases. J Neurotrauma 2012; 29:2103-7. [PMID: 22216933 DOI: 10.1089/neu.2010.1742] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Craniotomy has been accepted as the treatment of choice for the management of acute epidural hematomas (AEDH). However, in practice, it seems possible to evacuate AEDH via a single burr hole instead of the traditional craniotomy in certain circumstances. Among 160 patients with AEDH meeting criteria for evacuation admitted to the emergency and accident division of our center between 2006 and 2009, we found 8 cases of hematoma appearing isodense to brain parenchyma on computed tomography (CT), who had concomitant coagulopathy. These patients were managed by burr-hole drainage for treatment of the liquefied AEDH. A closed drainage system was then kept in the epidural space for 3 days. In all 8 patients, AEDH was evacuated successfully via burr-hole placement over the site of hematoma. The level of consciousness and other symptoms improved within the first day, and no patient required an additional routine craniotomy. For patients with slowly-developing AEDH in the context of impaired coagulation, burr-hole evacuation and drainage might be a less invasive method of treatment compared to conventional craniotomy.
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Affiliation(s)
- Zohreh Habibi
- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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26
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Thuy MNT, Ramesh R, Soh B, Drummond KJ. Cadaveric dissection identifying the left superior anastomotic vein of Trolard communicating indirectly with the superior sagittal sinus via a lateral lacuna. J Clin Neurosci 2011; 19:286-8. [PMID: 22079142 DOI: 10.1016/j.jocn.2011.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Accepted: 07/16/2011] [Indexed: 11/17/2022]
Abstract
A cadaveric dissection of the calvarium of a 90 year old woman demonstrated a left superior anastomotic vein of Trolard communicating indirectly with the superior sagittal sinus via a left lateral lacunae. This is an anatomical variant contrary to the textbook description of a direct communication between the vein of Trolard and the superior sagittal sinus. A literature search failed to identify a previous description of this variation. Possible clinical implications of this finding will be discussed.
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Affiliation(s)
- Matthew N T Thuy
- Department of Anatomy and Cell Biology, University of Melbourne, Parkville, VIC 3010, Australia.
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Inoue H, Nakagawa Y, Ikemura M, Shinone K, Okada K, Nata M. A subacute epidural haematoma extending over the occipital region and posterior cranial fossa due to a laceration in the transverse sinus. Int J Legal Med 2011; 126:467-71. [PMID: 22008787 DOI: 10.1007/s00414-011-0635-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 10/07/2011] [Indexed: 01/07/2023]
Abstract
A 6-year-old male was found dead on his stomach with massive reddish vomiting from his mouth and nose. Postmortem cranial CT revealed an epidural haematoma in the left occipital region, but the cause and origin of the haematoma were unclear. An autopsy revealed that the epidural haematoma expanded over the left temporal region and the left side of the occipital region and posterior cranial fossa, and its origin was a laceration in the left transverse sinus induced by diastases in the left lambdoidal and occipitomastoid sutures. A pathohistological examination revealed that one portion of the haematoma was an early-stage hemorrhage, while the other portion extended approximately 1 week after the hemorrhage. Moreover, approximately 1 week elapsed after the laceration of the transverse sinus. Thus, we believe that the primary haematoma was induced by the laceration in the transverse sinus approximately 1 week before death, but the haematoma ceased to enlarge due to hemostasis. However, later, the size of the haematoma rapidly increased again due to rebleeding from the laceration, which led to intracranial hypertension. Consequently, we diagnosed the direct cause of death as choking due to vomit aspiration that resulted from intracranial hypertension induced by a subacute epidural haematoma.
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Affiliation(s)
- Hiromasa Inoue
- Department of Forensic Medicine and Sciences, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
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Liu W, Ma L, Wen L, Shen F, Sheng H, Zhou B, Hu W, Zheng X, Yang X. Drilling skull plus injection of urokinase in the treatment of epidural haematoma: A preliminary study. Brain Inj 2009; 22:199-204. [DOI: 10.1080/02699050801895407] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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29
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Acute epidural hematoma of the posterior fossa—cases of acute clinical deterioration. Am J Emerg Med 2007; 25:989-95. [DOI: 10.1016/j.ajem.2007.02.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 02/16/2007] [Accepted: 02/22/2007] [Indexed: 02/07/2023] Open
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