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

Incidence, risk factors, and clinical outcomes of acute brain swelling associated with traumatic acute subdural hematoma: a retrospective study utilizing novel diagnostic criteria

Background

Post-traumatic acute brain swelling (ABS) is a major cause of elevated intracranial pressure and thus mortality. The current definition of post-traumatic ABS has certain limitations, and there is limited information available regarding ABS associated with traumatic acute subdural hematoma (ASDH).

Objectives

To investigate the incidence, risk factors, and clinical outcomes of ABS associated with traumatic ASDH.

Design

Retrospective study.

Methods

Data for 161 patients diagnosed with traumatic ASDH were retrospectively collected. Novel computed tomography-based criteria were proposed for diagnosing ABS in patients with ASDH and determining its incidence. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of post-traumatic ABS. The Glasgow Outcome Scale (GOS) score, mortality, and functional prognosis of all patients at discharge and the proportion of intraoperative malignant brain bulge in surgical patients were taken as clinical outcome measures.

Results

A total of 45 (28%) patients experienced post-traumatic ABS, exhibiting significantly lower Glasgow Coma Scale scores on admission (p < 0.001). The incidence of hemispheric and whole-brain swelling was 8.1% and 19.9%, respectively. Risk factors independently associated with post-traumatic ABS were: (1) age [odds ratio (OR) = 0.917, p < 0.001]; (2) platelet to white blood cell ratio (PWR) (OR = 0.887, p = 0.012); and (3) traumatic subarachnoid hemorrhage (SAH) (OR = 4.346, p = 0.005). The ABS cohort had a lower GOS score [2 (1-3) versus 4 (3-5); p < 0.001], higher mortality (46.7% versus 6.9%; p < 0.001), and higher proportion of unfavorable functional prognosis (75.6% versus 34.5%; p < 0.001) upon discharge compared to the no ABS cohort, along with higher proportion of intraoperative malignant brain bulge (43.8% versus 0%; p < 0.001).

Conclusion

The incidence of ABS associated with ASDH is significantly high overall. Patients with ASDH who have young age, low PWR, and traumatic SAH are at an increased risk of developing post-traumatic ABS, and therefore of poor clinical outcomes.

Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy

OBJECTIVE

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy.

MATERIALS AND METHODS

We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes.

RESULTS

We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04).

CONCLUSION

Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

A dynamic nomogram for predicting intraoperative brain bulge during decompressive craniectomy in patients with traumatic brain injury: a retrospective study

OBJECTIVE

The aim of this paper is to investigate the risk factors associated with intraoperative brain bulge (IOBB), especially the computed tomography (CT) value of the diseased lateral transverse sinus, and to develop a reliable predictive model to alert neurosurgeons to the possibility of IOBB.

METHODS

A retrospective analysis was performed on 937 patients undergoing traumatic decompressive craniectomy. A total of 644 patients from Fuzong Clinical Medical College of Fujian Medical University were included in the development cohort, and 293 patients from the First Affiliated Hospital of Shantou University Medical College were included in the external validation cohort. Univariate and multifactorial logistic regression analyses identified independent risk factors associated with IOBB. The logistic regression models consisted of independent risk factors, and receiver operating characteristic curves, calibration, and decision curve analyses were used to assess the performance of the models. Various machine learning models were used to compare with the logistic regression model and analyze the importance of the factors, which were eventually jointly developed into a dynamic nomogram for predicting IOBB and published online in the form of a simple calculator.

RESULTS

IOBB occurred in 93/644 (14.4%) patients in the developmental cohort and 47/293 (16.0%) in the validation cohort. Univariate and multifactorial regression analyses showed that age, subdural hematoma, contralateral fracture, brain contusion, and CT value of the diseased lateral transverse sinus were associated with IOBB. A logistic regression model (full model) consisting of the above risk factors had excellent predictive power in both the development cohort [area under the curve (AUC)=0.930] and the validation cohort (AUC=0.913). Among the four machine learning models, the AdaBoost model showed the best predictive value (AUC=0.998). Factors in the AdaBoost model were ranked by importance and combined with the full model to create a dynamic nomogram for clinical application, which was published online as a practical and easy-to-use calculator.

CONCLUSIONS

The CT value of the diseased lateral transverse is an independent risk factor and a reliable predictor of IOBB. The online dynamic nomogram formed by combining logistic regression analysis models and machine learning models can more accurately predict the possibility of IOBBs in patients undergoing traumatic decompressive craniectomy.

Mortality of Surgically Treated Neurotrauma in Elderly Patients and the Development of a Prediction Score: Geriatric Neurotrauma Mortality Score

BACKGROUND

As the population worldwide is aging, the need for surgery in elderly patients with neurotrauma is increasing. The aim of this study was to compare the outcome of elderly patients undergoing surgery for neurotrauma with younger patients and to identify the risk factors for mortality.

METHODS

We retrospectively analyzed consecutive patients undergoing craniotomy or craniectomy for neurotrauma at our institution from 2012 to 2019. Patients were divided into two groups (≥70 years or <70 years) and compared. The primary outcome was the 30-day mortality rate. Potential risk factors for 30-day mortality were assessed in a uni- and multivariate regression model for both age groups, forming the basis of a 30-day mortality prediction score.

RESULTS

We included 163 consecutive patients (average age 57.98 ± 19.87 years); 54 patients were ≥70 years. Patients ≥70 years showed a significantly better median preoperative Glasgow Coma Scale (GCS) score compared with young patients (P < 0.001), and fewer pupil asymmetry (P = 0.001), despite having a higher Marshall score (P = 0.07) at admission. Multivariate regression analysis identified low pre- and postoperative GCS scores and the lack of prompt postoperative prophylactic low-molecular-weight heparin treatment as risk factors for 30-day mortality. Our score showed moderate accuracy in predicting 30-day mortality with an area under the curve of 0.76.

CONCLUSIONS

Elderly patients after neurotrauma present with a better GCS at admission despite having more severe radiographic injuries. Mortality and favorable outcome rates are comparable between the age groups.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis

BACKGROUND

Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial.

METHODS

We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models.

RESULTS

The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC).

CONCLUSIONS

According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

Evaluation of the prognosis of acute subdural hematoma according to the density differences between gray and white matter

Objective

Acute subdural hematoma (ASDH) is a common neurological emergency, and its appearance on head-computed tomographic (CT) imaging helps guide clinical treatment. To provide a basis for clinical decision-making, we analyzed that the density difference between the gray and white matter of the CT image is associated with the prognosis of patients with ASDH.

Methods

We analyzed the data of 194 patients who had ASDH as a result of closed traumatic brain injury (TBI) between 2018 and 2021. The patients were subdivided into surgical and non-surgical groups, and the non-surgical group was further subdivided into "diffused [hematoma]" and "non-diffused" groups. The control group's CT scans were normal. The 3D Slicer software was used to quantitatively analyze the density of gray and white matter depicted in the CT images.

Results

Imaging evaluation showed that the median difference in density between the gray and white matter on the injured side was 4.12 HU (IQR, 3.91-4.22 HU; p < 0.001) and on the non-injured side was 4.07 HU (IQR, 3.90-4.19 HU; p < 0.001), and the hematoma needs to be surgically removed. The median density difference value of the gray and white matter on the injured side was 3.74 HU (IQR, 3.53-4.01 HU; p < 0.001) and on the non-injured side was 3.71 HU (IQR, 3.69-3.73 HU; p < 0.001), and the hematoma could diffuse in a short time.

Conclusion

Quantitative analysis of the density differences in the gray and white matter of the CT images can be used to evaluate the clinical prognosis of patients with ASDH.

Craniotomy or Craniectomy for Acute Subdural Hematoma? Difference in Patient Characteristics and Outcomes at a Tertiary Care Hospital

Objective  This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC). Methods  In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient. Results  Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) ( p  = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) ( p  = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group ( p  = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group ( p  < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups ( p  = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group ( p  = 0.14). Conclusion  The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma.

Cerebral Blood Flow Disorder in Acute Subdural Hematoma and Acute Intraoperative Brain Bulge

Context

Acute subdural hematoma (ASDH) has a high incidence and high mortality. During surgery for ASDH, brain tissue sometimes rapidly swells and protrudes into the bone window during or after removal of the hematoma. This phenomenon, known as acute intraoperative brain bulge, progresses rapidly and can cause ischemic necrosis of brain tissue or even mortality. The mechanism of this phenomenon remains unclear.

Objective

To investigate the changes in cerebral surface blood flow during ASDH and acute intraoperative brain bulge in rats.

Methods

Adult male Sprague–Dawley rats were selected to establish an ASDH model, and acute intraoperative brain bulge was induced by late-onset intracranial hematoma. The changes in cerebral surface blood flow during ASDH and acute intraoperative brain bulge were observed with a laser speckle imaging system, and intracranial pressure (ICP) was monitored.

Results

ICP in rats increased significantly after ASDH (P < 0.05). The blood perfusion rate (BPR) values of the superior sagittal sinus, collateral vein and artery decreased significantly in rats with subdural hematomas (P < 0.05). There was no significant difference between the preoperative and 90-min postoperative BPR values of rats. ICP was significantly increased in rats with acute intraoperative brain bulge (P < 0.05) and decreased significantly after the removal of delayed hematomas (P < 0.05). The BPR of the superior sagittal sinus, collateral vein and artery decreased significantly during brain bulge (P < 0.05). After the removal of delayed hematomas, BPR increased significantly, but it remained significantly different from the values measured before brain bulge (P < 0.05).

Conclusion

ASDH may cause not only high intracranial pressure but also cerebral blood circulation disorders. Brain bulge resulting from late-onset intracranial hematoma may aggravate these circulation disorders. If the cause of brain bulge in a given patient is late-onset intracranial hematoma, clinicians should promptly perform surgery to remove the hematoma and relieve circulation disorders, thus preventing more serious complications.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

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.

Neurocritical Management of Traumatic Acute Subdural Hematomas

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement

BACKGROUND

Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

METHODS

The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

RESULTS

The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

CONCLUSIONS

In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Neurotrauma

Traumatic brain injury remains a major cause of morbidity and mortality throughout the world, affecting young and old alike. Pathologic data have been developed through observations of human autopsies and developing animal models to investigate mechanisms, although animal models do not represent the polypathology of human brain injury and there are likely to be significant differences in the anatomic basis of injury and cellular responses between species. Traumatic brain injury can be defined pathologically as either focal or diffuse, and can be considered to be either primary, directly related to the force associated with the neurotrauma, or secondary, developing as a downstream consequence of the neurotrauma. While neuropathology has traditionally focused on severe head injury, there is increasing recognition of the long-term consequences of traumatic brain injury, particularly repetitive mild traumatic brain injury, and a possible long-term association with chronic traumatic encephalopathy.

Seizures and Epileptiform Discharges in Patients With Acute Subdural Hematoma

PURPOSE

Subdural hematomas (SDH) are associated with seizures and epileptiform discharges, but little is known about the prevalence and impact of seizures, status epilepticus (SE), and epileptiform discharges on outcomes in patients with isolated acute SDH (aSDH).

METHODS

Continuous EEG reports from 76 adult patients admitted to Rush University Medical Center with aSDH between January 2009 and March 2012 were reviewed. Clinical and radiographic findings, comorbidities, treatment, and outcome parameters, such as mortality, discharge destination, need for tracheostomy/percutaneous endoscopic gastrostomy placement, and length of stay (LOS), were assessed. Univariate and multivariate analyses were performed to assess the impact of clinical seizures, SE, and epileptiform EEG on outcomes.

RESULTS

Of 76 patients with aSDH who underwent EEG monitoring, 74 (97.4%) received antiseizure prophylaxis. Thirty-two (41.1%) patients had seizures, most of which were clinical seizures. Twenty-four (32%) patients had epileptiform EEG findings. Clinical or nonconvulsive SE was diagnosed in 12 (16%) patients. Clinical seizures were not associated with outcome parameters. Epileptiform EEG findings were independently associated with longer hospital LOS (13 vs. 8 days, P = 0.04) and intensive care unit LOS (10 vs. 4 days, P = 0.002). The SE also predicted longer intensive care unit LOS (10 vs. 4 days, P = 0.002). Neither epileptiform EEG nor SE was significantly related to mortality, discharge destination, or need for tracheostomy/percutaneous endoscopic gastrostomy placement.

CONCLUSIONS

Seizures and epileptiform EEG findings are very common in patients with aSDH despite antiseizure prophylaxis. While clinical seizures did not affect outcomes, the presence of epileptiform EEG findings and SE was independently associated with longer intensive care unit LOS and hospital LOS.

Mnesic Profiles According to the Size of Pericerebral Hematoma in Patients with Traumatic Brain Injury

OBJECTIVE

The study aims to assess mnesic performances of patients, following a head injury with pericerebral hematoma, according to the size of the hematoma.

METHODS

Cognitive performances of a group of 25 patients with large (≥10 mm) pericerebral hematomas were compared with those of a matched group of 25 patients with small (<10 mm) ones and a matched group of patient with moderate-severe traumatic brain injury with no pericerebral hematoma.

RESULTS

Executive function and information processing speed were not significantly different. Mnesic performances of the large hematomas group were more impaired: cuing effect (63.5 vs. 80% and 83%; p = 0.002; x03B7;2 = 0.183) and total recall (37.5/48 vs. 43.2 and 44.2; p = 0.022; x03B7;2 = 0.65) of the Free and Cued Recall Test.

CONCLUSION

Memory of those in the large hematomas group was impaired with probable storage/consolidation disorders. To identify specific cognitive disorders resulting from large hematomas, it is justified to systematically screen these disorders and to adapt their management.

Magnetic resonance imaging of traumatic brain injury: a pictorial review

Traumatic brain injury (TBI) is a significant source of major morbidity and mortality in blunt trauma patients. Computed tomography (CT) is the primary imaging modality of choice for patients with potential brain injury in the acute setting, with magnetic resonance imaging (MRI) playing a role in evaluating equivocal CT findings and may help with determining long-term prognosis and recovery. MRI is being utilized more commonly in the acute and subacute setting of TBI; therefore, radiologists should be familiar with the MRI appearance of the various manifestations of TBI. Here, we review the imaging of common intracranial injuries with illustrative cases comparing CT and MRI.

Hemispheric differences in the surgical outcomes of patients with traumatic acute subdural hematoma

Background

Our assumption that prognosis of patients with traumatic acute subdural hematoma (ASDH) does not differ significantly according to the hemispheric laterality has never been verified.

Methods

A review of the charts/radiographic images of 61 adult traumatic ASDH patients (33 left/28 right) was conducted. Intergroup comparison was made on the demographics, autonomic/laboratory data, and outcomes (90-day mortality rate). Based on the presence of concomitant brain contusion, patients were further quadrichotomized as: left ASDH with contusion (n = 14), right ASDH with contusion (n = 16), left ASDH without contusion (n = 19), and right ASDH without contusion (n = 12). Comparisons were made on demographic and outcome variables between the left ASDH with contusion and right ASDH with contusion, and between the left ASDH without contusion and right ASDH without contusion. Multivariate regression analysis was conducted to identify clinical variables correlated with fatality.

Results

There were no significant differences in the demographic, autonomic, and laboratory data between the left and right ASDH patients. However, 90-day mortality rate was significantly higher in the left ASDH patients when concomitant contusion was present (79% vs. 25%, p = 0.009). However, there were no significant hemispheric differences in the mortality rate among those without contusion (32% vs. 33%, p = 0.77). Multivariate regression analysis showed that left ASDH was correlated with fatality among those with contusion (OR: 6.620; 95% CI: 1.219-46.249).

Conclusions

This study is probably the first to report that the left ASDH patients fared substantially worse than the right-sided counterparts. Future trials on traumatic ASDHs may benefit from considering hemispheric differences in the outcomes.

Novel method for emergency craniostomy for rapid control and monitoring of the intracranial pressure in severe acute subdural hematoma

Acute subdural hematoma (ASDH) is a critical condition following the onset of traumatic brain injury, and it is essential to immediately reduce elevated intracranial pressure (ICP). Single burr hole surgery/twist drill craniostomy is commonly performed in patients with ASDH as an emergency surgical intervention, usually preceding decompressive craniotomy. A novel method using a cerebrospinal fluid (CSF) drainage catheter kit for rapid drainage of ASDH is described. Percutaneous twist drill craniostomy using a CAMINO(®) micro ventricular bolt pressure-temperature monitoring kit was performed in the emergency room in 12 patients with severe ASDH. The kit contained a closed-system CSF drainage and pressure-temperature monitoring catheter, which allowed aspiration of the hematoma and monitoring of the ICP. The tip of the catheter was inserted into the hematoma from the forehead. The mean initial ICP was 61 mmHg, with a range of 31 to 120 mmHg. The liquid hematoma was aspirated, and the ICP was temporarily controlled to the normal range. Pupil dilation recovered immediately after aspiration of the hematoma in 3 patients. No complications occurred either during or after the operation. This new method for craniostomy is easy, safe, and effective to monitor and rapidly control ICP in the emergency room. This technique also offers the possibility of evaluating the patient's prognosis and determining indications for further decompressive craniectomy by the continuation of ICP control under ICP monitoring and evaluation of the reversibility of pupillary findings in ASDH patients.

Decompressive craniectomy with multi-dural stabs - A combined (SKIMS) technique to evacuate acute subdural hematoma with underlying severe traumatic brain edema

Context:

The decompressive craniotomy alone or with dural flap opening to evacuate acute subdural hematoma with underlying brain edema in severe traumatic brain injury has proved either insufficient in the first place or has fatal complications secondly.

Aims:

To reduce the fatality of conventional procedures and to evacuate acute subdural hematoma with severe brain edema by a combination of decompressive craniotomy and multi-dural stabs (SKIMS-Technique) without brain pouting and lacerations in low Glasgow coma scale (GCS) score patients.

Settings and Design:

The prospective study was conducted in the Department of Neurosurgery, from June, 2006 to June 2011, under a uniform protocol.

Materials and Methods:

A total of 225 patients of severe brain trauma were admitted to the accident and emergency unit of Neurosurgery and after initial resuscitation a CT brain was performed. All patients had a GCS score of 8 and below. All patients were ventilated postoperatively and ICP was monitored.

Statistical Analysis Used:

The data was analyzed and evaluated by the statistical methods like student's T-test. The analysis of Variance was used where-ever applicable.

Results:

The survival of multi-dural stab group was 77.31% (92/119) with good recovery in 42.02% (50/119) and a mortality of 22.69% (27/119) as compared with 46.23% (49/106) survival in open dural flap (control) group with 15.09% (16/106) good recovery and mortality of 53.77% (57/106).

Conclusions:

This new approach, known as SKIMS-Technique or Combined Technique i.e., “decompressive craniectomy with multi-dural stabs”, proved much effective in increasing survival of low GCS and severe traumatic brain edema patients with acute subdural hematoma.

Novel use of optokinetic chart stimulation to restore muscle strength and mobility in patients with subdural haemorrhage: two case studies

BACKGROUND AND PURPOSE

The aim of these case studies is to report on the novel use of optokinetic chart stimulation to restore muscle strength and functional independence in severely disabled patients with subdural haemorrhage.

METHODOLOGY

An optokinetic chart was moved in front of the patient: from side to side, up and down and finally forwards and backwards. Once the patient could stand optokinetic chart stimulation was supplemented by sensory interaction for balance.

RESULTS

In first case study contractures in the knees improved from 90° short of full passive knee extension bilaterally to full active extension of the right knee joint and 25° short of full active extension of the left knee joint. The Barthel index improved from 0/20 to 18/20. In the second case study the Barthel Index improved from 0/20 to 18/20. From being bed bound the patients were independently mobile with a walking aid, on discharge.

DISCUSSION

With optokinetic chart stimulation leading to reversal of knee flexor contractures in one case and restoration of independent mobility in both cases, more research is needed to investigate use of optokinetic chart stimulation in patients with severe subdural haemorrhages and other traumatic brain injuries.

Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy

BACKGROUND

Acute subdural haematomas (ASDH) occur commonly following traumatic brain injury and may be evacuated by either craniotomy (CR) or decompressive craniectomy (DC). We reviewed a series of consecutive patients undergoing evacuation of a traumatic ASDH at a regional centre, comparing observed clinical outcomes (assessed by Glasgow Outcome Scale at six months) with those predicted by the CRASH-CT prognostic model.

METHODS

Retrospective review of prospectively collected data.

RESULTS

Ninety-one patients were identified (51 DC and 40 CR ). Eighty-five had available admission data sets from which predicted outcome could be calculated. The DC group were younger than the CR group (p = 0.015). The DC group also had a greater proportion of patients whose pre-intubation GCS was ≤8 (p = 0.001), with significant extracranial injuries (p = 0.001) and obliterated basal cisterns (p = 0.001) on their pre-operative CT scan. Bone flaps in the DC group (n = 45) were longer (mean 11.6 cm; 95 % CI: 11.1-12.1) in comparison to bone flaps in the CR (n = 34) group [(mean 10.2 cm; 95 % CI: 9.35 - 10.9); p = 0.0024] The mean CRASH-CT predicted risk of 14-day mortality and of unfavourable outcome at six months was significantly higher in the DC group compared with the CR group. Eighty-eight patients had available 6-month Glasgow Outcome Scale scores. Favourable outcomes were observed in 42 % of DC versus 45 % of CR (p = 0.83). The overall mortality rate was 38 % in DC versus 32 % in CR (p = 0.65). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95 % CI: 0.51-1.07) for DC and 0.90 (95 % CI: 0.57-1.35) for CR.

CONCLUSIONS

CR and DC for traumatic ASDH are both commonly used for primary evacuation of ASDH. Primary DC may be more effective than CR for selected patients with ASDH. Class I evidence is required in order to refine the indications for DC following evacuation of ASDH.

Seizures after evacuation of subdural hematomas: incidence, risk factors, and functional impact

Object

The purpose of this study was to evaluate the incidence of seizures or epileptiform abnormalities on electroencephalography (EEG) studies in patients undergoing surgical treatment for acute subdural hematoma (SDH).

Methods

This was a retrospective study of 134 consecutive patients with acute or acute-on-chronic SDH who underwent surgical treatment at the authors' institution between January 2004 and July 2008. Detailed information was collected regarding baseline clinical data (including preexistent functional impairment); Glasgow Coma Scale (GCS) sum scores before and 24 hours after surgery; presence of clinical seizures; EEG findings; and functional outcome on discharge and up to the 6-month follow-up. All brain CT scans were reviewed to calculate SDH volume and midline shift. The Glasgow Outcome Scale (GOS) score was used for functional assessment, and GOS scores of 1–3 were considered indicative of poor outcome. Univariate and multivariate logistic regression analyses were performed to identify statistical associations.

Results

Clinical seizures or epileptiform changes on EEG were observed during the acute postoperative period in 33 patients (25%). Preexistent functional impairment and seizures/epileptiform EEG findings after surgery were independently associated with poor functional outcome upon hospital discharge (p < 0.001 for both). Preexistent functional impairment (p < 0.001), lower GCS score before surgery (p = 0.04), and lower GCS score 24 hours after surgery (p = 0.007), but not seizures/epileptiform EEG findings, were independently associated with poor functional recovery at 1- to 6-month follow-up evaluations. Seizures/epileptiform EEG findings had a strong association with lower GCS scores after surgery (p = 0.01), and they were more common in patients who underwent evacuation by craniotomy (p = 0.02).

Conclusions

Epileptic complications are common after acute SDH evacuation, and should be suspected in patients with an unanticipated depressed level of consciousness after surgery. Seizures worsen early functional outcome, but delayed favorable recovery is possible. Therefore, one should be cautious when discussing prognosis in the early postoperative period of patients with epileptic complications.