Skull fracture as a factor of increased risk in minor head injuries. Indication for a broader use of cerebral computed tomography scanning

Skull Fractures Induce Neuroinflammation and Worsen Outcomes after Closed Head Injury in Mice

The weight-drop model is used widely to replicate closed-head injuries in mice; however, the histopathological and functional outcomes may vary significantly between laboratories. Because skull fractures are reported to occur in this model, we aimed to evaluate whether these breaks may influence the variability of the weight-drop (WD) model. Male Swiss Webster mice underwent WD injury with either a 2 or 5 mm cone tip, and behavior was assessed at 2 h and 24 h thereafter using the neurological severity score. The expression of interleukin (IL)-6, IL-1β, tumor necrosis factor-α, matrix metalloproteinase-9, and tissue inhibitor of metalloproteinase-1 genes was measured at 12 h and 1, 3, and 14 days after injury. Before the injury, micro-computed tomography (micro-CT) was performed to quantify skull thickness at the impact site. With a conventional tip diameter of 2 mm, 33% of mice showed fractures of the parietal bone; the 5 mm tip produced only 10% fractures. Compared with mice without fractures, mice with fractures had a severity-dependent worse functional outcome and a more pronounced upregulation of inflammatory genes in the brain. Older mice were associated with thicker parietal bones and were less prone to skull fractures. In addition, mice that underwent traumatic brain injury (TBI) with skull fracture had macroscopic brain damage because of skull depression. Skull fractures explain a considerable proportion of the variability observed in the WD model in mice—i.e., mice with skull fractures have a much stronger inflammatory response than do mice without fractures. Using older mice with thicker skull bones and an impact cone with a larger diameter reduces the rate of skull fractures and the variability in this very useful closed-head TBI model.

Factors predicting early deterioration in mild brain trauma: a prospective study

PRIMARY OBJECTIVE

To evaluate risk factors for clinical deterioration in mild traumatic brain injury.

RESEARCH DESIGN

Prospective cross-sectional.

METHODS AND PROCEDURES

This study evaluated 203 patients with mild traumatic brain injury. A brain computed tomography scan was performed in all patients and they were observed for 6-48 hours.

MAIN OUTCOMES AND RESULTS

Among these patients, 2.5% had cerebral contusions and the most common sites for contusions were frontal lobes; 94% of patients had no hematoma in the initial scan, while 3% had subgaleal haematoma, 1.5% had subdural haematoma, 1% showed subarachnoid haemorrhage, 0.5% intracerebral haemorrhage and 0.5% epidural haemorrhage. GCS was 15 in 96.6% and 13-14 in 3.4%. GCS deteriorated in three (1.5%). Presence of coagulopathy, anticoagulant drug use, GCS of 13-14 and increased age predicted further deterioration. Among CT findings, those with midline shift, cerebral contusion and diffuse cerebral oedema deteriorated more. Among different haematoma types, only SDH predicted a worse outcome.

CONCLUSIONS

Although deterioration rarely occurs in patients with mild brain injury, those with coagulopathy, anticoagulant drug use, GCS of 13-14, increased age, midline shift, cerebral contusions, diffuse cerebral oedema and SDH were more prone to deterioration.

Indications for brain CT scan in patients with minor head injury

OBJECTIVES

Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury.

METHODS

A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals.

RESULTS

Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan.

CONCLUSION

Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury.

Survey of the management of children with minor head injuries in Sweden

BACKGROUND

This study investigates current management practice of children with MHI in Swedish hospitals to define present need for management guidelines for children.

METHODS

A cross-sectional mail survey including 51 hospitals treating children with MHI outlines management routines concerning clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up.

RESULTS

Twenty-seven per cent of the hospitals have established written criteria for referral and management of children with MHI. Eighty-eight per cent use the Swedish Reaction Level Scale for assessing the level of consciousness. Eight per cent use the paediatric Glasgow Coma Scale. Routine computerised tomography is performed in 18% of the hospitals, 12% perform skull radiography and/or radiography of the cervical spine as routine. Eighty-four per cent have established criteria for early discharge without hospitalisation.

CONCLUSION

The management of children with MHI varies in Swedish hospitals. There is a need for standardised protocols for detection of intracranial complications and guidelines for the management of MHI in children.

The significance of skull fracture in mild head trauma differs between children and adults

OBJECTIVE

The objective was to determine whether the age of patients with mild head injury and skull fracture influences the level of risk for acute intracranial injuries.

METHOD

A study was conducted of 156 patients with skull fracture, 60 children (aged <14 years) and 96 adults, detected among 5,097 consecutive patients with mild head injury (Glasgow Coma Scale [GCS] score of 15-14 points) arriving at the Emergency Department of a Level I University Hospital Trauma Center during 1998. Acute intracranial injuries were defined as traumatic brain injuries identified by cranial computed tomography scan, excluding pneumocephalus.

RESULTS

Compared with the children, this risk of intracranial injury was 13 times greater in the adults aged 14-54 years and 16 times greater in the over-54-year-olds. Besides age over 14 years (p<0.0001), compound skull fracture (p<0.001), and a GCS score of 14 (p<0.001) were factors significantly associated with intracranial injury in the logistic regression analysis.

CONCLUSIONS

Skull fracture in mild head injury implies a greater risk of intracranial injury in adults than in children.

The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation)

Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]

Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management

The lack of a common, widely acceptable criterion for the definition of trivial, minor, or mild head injury has led to confusion and difficulty in comparing findings in published series. This review proposes that acute head-injured patients previously described as minor, mild, or trivial are defined as "mild head injury," and that further groups are recognized and classified as "low-risk mild head injury," "medium risk mild head injury," or "high-risk mild head injury." Low-risk mild injury patients are those with a Glasgow Coma Score (GCS) of 15 and without a history of loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is definitively less than 0.1:100. These patients can be sent home with written recommendations. Medium risk mild injury patients have a GCS of 15 and one or more of the following symptoms: loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is in the range of 1-3:100. Where there is one computed tomography (CT) scanner available in an area for 100,000 people or less, a CT scan should be obtained for such patients. If CT scanning is not so readily available, adults should have a skull x-ray and, if this shows a fracture, should be moved to the "high-risk" category and undergo CT scanning. High-risk mild head injury patients are those with an admission GCS of 14 or 15, with a skull fracture and/or neurological deficits. The risk of intracranial hematoma requiring surgical evacuation is in the range 6-10:100. If a CT scan is available for 500,000 people or less, this examination must be obtained. Patients with one of the following risk factors--coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, pretrauma epilepsy, or age over 60 years--are included in the high-risk group independent of the clinical presentation.

The Canadian CT Head Rule for patients with minor head injury

BACKGROUND

There is much controversy about the use of computed tomography (CT) for patients with minor head injury. We aimed to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries.

METHODS

We carried out this prospective cohort study in the emergency departments of ten large Canadian hospitals and included consecutive adults who presented with a Glasgow Coma Scale (GCS) score of 13-15 after head injury. We did standardised clinical assessments before the CT scan. The main outcome measures were need for neurological intervention and clinically important brain injury on CT.

FINDINGS

The 3121 patients had the following characteristics: mean age 38.7 years); GCS scores of 13 (3.5%), 14 (16.7%), 15 (79.8%); 8% had clinically important brain injury; and 1% required neurological intervention. We derived a CT head rule which consists of five high-risk factors (failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI 96-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT.

INTERPRETATION

We have developed the Canadian CT Head Rule, a highly sensitive decision rule for use of CT. This rule has the potential to significantly standardise and improve the emergency management of patients with minor head injury.

Value of radiological diagnosis of skull fracture in the management of mild head injury: meta-analysis

OBJECTIVES

Head injury is a common event. Most patients sustain a mild head injury (MHI), and management depends on the risk of an intracranial haemorrhage (ICH). The value of a plain skull radiograph as a screening tool for ICH is controversial. The aim of this meta-analysis was to estimate and explain differences in reported sensitivity and specificity of the finding of a skull fracture for the diagnosis of ICH, in order to assess the value of the plain skull radiograph in the investigation of patients with MHI, and to estimate the prevalence of ICH in these patients.

METHOD

After a systematic literature search 20 studies were selected that reported data on the prevalence of ICH after MHI and/or data on the diagnostic value of skull fracture for the diagnosis of ICH. The mean prevalence of ICH weighted for the sample size was determined. The sensitivity and specificity of different studies were combined using a summary receiver operator characteristic curve. Correlation analysis was used to determine factors that could explain the reported differences between studies.

RESULTS

The weighted mean prevalence of ICH after MHI is 0.083. The potential for verification bias and the percentage of patients who had suffered loss of consciousness or post-traumatic amnesia were the most significant factors explaining interstudy differences in sensitivity and specificity. Based on studies wherein at least 50% of patients had a CT study of the brain, the estimated sensitivity of a radiographic finding of skull fracture for the diagnosis of ICH is 0.38 with a corresponding specificity of 0.95.

CONCLUSION

The plain skull radiograph is of little value in the initial assessment of MHI patients.

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee

BACKGROUND

The Scandinavian Neurotrauma Committee was initiated by the Scandinavian Neurosurgical Society to develop evidence-based guidelines for improved care of neurotrauma patients.

METHODS

A MEDLINE search identified 475 papers dealing with the management of minimal, mild, and moderate head injuries. Forty-two studies presenting class II evidence on the initial management of such injuries were reviewed and management guidelines were developed.

RESULTS

Implementation of the Head Injury Severity Scale is advocated. Patients with minimal injuries (no loss of consciousness, Glasgow Coma Scale score of 15) can be safely discharged. Routine early computed tomographic scan is recommended in cases with mild injuries (history of loss of consciousness, Glasgow Coma Scale score = 14-15) and patients with normal scans may be discharged. Computed tomographic scan and admission is mandatory in moderate injuries (Glasgow Coma Scale score = 13). All patients harboring additional risk factors should be scanned and admitted. A flow-chart for clinical decision making and a Head Injury Instruction card is introduced.

CONCLUSIONS

The Scandinavian Neurotrauma Committee suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild, and moderate head injuries.

Management of head-injured patients in the emergency department: a practical protocol

BACKGROUND

The management of head-injured patients admitted to emergency departments is not standardized.

METHODS

The authors performed a retrospective analysis of 10,000 head-injured patients admitted to the Emergency Department of our hospital in a 21-month period and, on the basis of a statistical correlation between each clinical parameter (symptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse or radiologic examinations and yet identify patients with possible life-threatening complications.

RESULTS

On the basis of this correlation the patients have been divided into four groups. In the first group (called group alpha) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They can be released into the care of relatives who are given a special instruction sheet (X rays unnecessary). No patient in group alpha had complications of any kind. The second group (group beta) is made up of patients with at least one of the following features: transient loss of consciousness, post-traumatic amnesia, a single episode of vomiting or significant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is needed. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be performed promptly. No patient in group beta with normal skull X rays developed intracranial lesions. The third group (group gamma) contains patients with at least one of the following symptoms: impaired consciousness, repeated episodes of vomiting, neurologic deficits, otorrhagia, otorrhea, rhinorrea, signs of basal skull fracture, seizures, penetrating or perforating wounds, lack of cooperation for varying reasons, patients who have undergone previous intracranial operations or been affected by coagulopathy or submitted to anticoagulant therapy, and finally, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group gamma with GCS = 15 upon admission were operated on for intracranial hematoma. The fourth group (group delta) is composed of comatose patients. Immediately following resuscitation maneuvers and prior to any surgical intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated.

CONCLUSIONS

The present protocol stresses the importance of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries.

Variation in ED use of computed tomography for patients with minor head injury

STUDY OBJECTIVE

To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury.

METHODS

This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator.

RESULTS

Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P < .0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%.

CONCLUSION

There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.

Skull fractures in children: a population study

OBJECTIVE

To provide information about children with a skull fracture in the Edinburgh area, since head injury is the single most important traumatic cause of death in children over 1 year of age.

METHODS

During the period January 1983 to December 1989, all children in the Edinburgh area under 13 years of age who sustained a skull fracture were identified. Details of the children who died primarily from a head injury, and the total number of children who were admitted to hospital with a head injury not associated with a skull fracture, were also documented. Data were obtained from the General Register Office for Scotland, Edinburgh Fiscal Office records, and Lothian Health Board records. Data on cause of injury and clinical condition were obtained.

RESULTS

3498 children under 13 years of age were admitted to hospital after sustaining a head injury and 27 died primarily as a result of their injuries; 409 children had a skull fracture and 76 of this group had cranial CT scans. Nineteen of the CT scans performed were on children who had been admitted to hospital in a coma, and all had abnormal scan findings. In addition all children with intracerebral haematomas/haemorrhages had been admitted in a coma. Road traffic accidents accounted for the greatest number of deaths (84%), associated injuries, and overall morbidity.

CONCLUSIONS

To reduce the incidence of head injuries, and the associated morbidity and mortality, the following are required: identify at risk groups; promote accident prevention; publicise the findings and guidelines concerning childhood head injuries; ensure that all children with head injuries have appropriate investigations and begin treatment as early as possible; establish clinical audit; and set up regional rehabilitation teams.

Diagnosis and management of minor head injury: a regional multicenter approach in Italy

Two series of patients admitted to the hospital after a minor head injury were collected in two different periods (1985 and 1989) in a regional hospital with a 24-hour computed tomography (CT) service, but without a neurosurgical unit. In 1988, a regional protocol on the management of patients with minor head injury (based on the presence of skull fractures in adults and on clinical parameters in children) was adopted. There was a 21% reduction in hospital admission in adults, and the number of skull x-ray films performed in children decreased significantly (p < 0.01). A more liberal use of CT examinations in asymptomatic patients with skull fractures produced an earlier identification of patients with extradural hematomas who were sent to neurosurgery before clinical deterioration with good results. Detection of cerebral contusions was clinically less important. Based on the availability of CT scanners in our area and on the results of our study, we have proposed new guidelines in management of minor head injury. The CT scans are obtained in patients with a Glasgow Coma Scale score of 13 or less. Skull x-ray films are obtained in patients older than 10 years with a Glasgow Coma Scale score of 14/15. If a fracture is found, the patient is sent to the nearest regional center for CT examinations. Children younger than 10 years are sent to a regional hospital with 24-hour CT availability for clinical observation or other indicated studies.

CT and clinical criteria for conservative treatment of supratentorial traumatic intracerebral haematomas

In search of guidelines for the management of traumatic intracerebral haematomas (TICHs) with slight mass effects on computed tomography (CT) scans, the author reviewed the records of 29 patients who did not undergo surgery and 11 patients who did. It is found that patients with a TICH volume of less than 15 ml, a midline shift of less than 5 mm, an open perimesencephalic cistern on CT scans, a Glasgow Coma Scale (GCS) score of 12 or more, and an absence of lateralizing signs may be treated conservatively and expected to make a good recovery. On the other hand, with zero mortality and satisfactory outcomes, the patients under-going early surgery tended to have a TICH volume of more than 15 ml, a midline shift of more than 5 mm, an obliterated perimesencephalic cistern on CT scans, a GCS score of less than 12, and the presence of lateralizing signs. However, the position of such features as the criteria of early operation for a TICH is weakened by the retrospective nature of this study because some surgical patients, free of lateralizing signs in particular, might have managed to do well without craniotomy.

Extradural haematomas: how many deaths can be avoided? Protocol for early detection of haematoma in minor head injuries

Since 1988 in the referral area of the Neurosurgical Unit of Cesena, Italy, a protocol for prevention of deterioration in minor head injury was adopted. Adult patients admitted to any hospital with a GCS score of 15 and 14 (transient) without neurological deficit are submitted to skull x-ray: if a fracture is present the patient is sent for CT to the nearest regional Center. In children skull x-ray is not routinely performed and the patients are admitted for observation to the nearest regional hospital. To assess the effects of such a protocol on morbidity and mortality of extradural haematoma (EDH), from June 1989 to September 1991 a consecutive series of 95 patients harbouring a significant acute EDH was collected. Mean age was 31 years; in 70% trauma was caused by a road traffic accident. The patients were divided into 3 categories: a) Clinical deterioration: mean GCS at surgery was 7.7; out of 27 patients, 12 had anysocoria and 3 bilaterally fixed pupils; the outcome showed only two deaths, one related to the EDH and the other to cardiac arrythmia. Most of the patients deteriorated either during transport after being recognized as at risk or already in Neurosurgery allowing rapid surgical treatment. b) Impaired consciousness (18 cases) and c) Minor head injury (50 cases) are groups of patients treated without morbidity and mortality. If we compare these results with those of a previous study of our group done in 1980-86, there is a statistically significant difference concerning both mortality and morbidity. Our protocol proved therefore to be adequate in preventing most deaths that occurred following clinical deterioration in an apparently low risk patient.

A prospective evaluation of radiologic criteria for head injury patients in a community emergency department

Several management strategies for radiographic evaluation of head-injury patients have been developed, most are based on retrospective analysis. The study attempted to prospectively evaluate the previously published Masters' criteria defining low-, medium-, and high-yield patients. A community hospital emergency department with a low prevalence of serious head injury was studied, and 1,000 consecutive patients 2 years of age presenting with historical or physical evidence of blunt head trauma were asked to participate; 967 consented. The patients were categorized by staff emergency physicians as low-, moderate-, and high-yield for intracranial injury on the basis of their initial history and physical examination. These categories guided imaging decisions in accordance with the guidelines of Masters. The patients were evaluated 6 weeks later by multiple questionnaire and/or telephone calls to determine whether or not undiagnosed head injuries had been missed. The 967 patients initially evaluated were classified according to their risk of intracranial injury as follows: 886 at low risk, 78 at moderate risk and 3 at high risk. Complete follow-up data were available for 895 of these patients (93%). Of the 895, 71 patients (7.9%) did report receiving follow-up medical care for their head injury; none had evidence of missed intracranial injury requiring intervention. Therefore, it can be inferred with a 95% confidence interval that 0.4% or less of patients who were diagnosed as not having intracranial injuries requiring intervention may actually have such injuries. The application of Masters' management strategy in low-risk populations permits clinicians to safely reduce the number of radiographs ordered for patients with head injury.

Management of low-risk head injuries in an entire area: results of an 18-month survey

All patients admitted following a minor head injury (GCS is without neurological deficits) during an 18 month period in an entire area were submitted to the same diagnostic and therapeutic protocol. Adult patients were x rayed and in the cases with skull fracture (even asymptomatic), a computed tomographic (CT) scan was performed. Children (below the age of 14) did not routinely receive skull X-rays but were admitted to one of the five regional hospitals where a CT scanner was available 24 hours per day. Neuroradiologic investigations (carried out in over 600 patients) showed posttraumatic lesions in 201 cases; 113 of these patients were transferred to the neurosurgical center. There were 49 patients with extradural hematomas, 41 with brain contusions, 17 with depressed skull fractures, and six with subdural hematomas. Of these 113, 40 patients were operated on (mainly extradural hematomas); surgical indications were based on appearance of clinical deterioration, lesion volume, presence of midline shift, and/or compressed third ventricle and basal cisterns. In eight cases there was a clinical deterioration to a GCS of 13 or less; in all of these patients, the CT diagnosis (and transfer to a neurosurgical center, preceded the onset of deterioration. All patients admitted to such a center had a good outcome, but a survey of deaths related to head injury in the area revealed two fatalities following minor head injury. The only avoidable death was a patient with multiple brain contusions who developed sudden brain swelling on day 12 post-trauma. We conclude that, even if management mortality is not zero, our protocol is sufficiently safe for the treatment of minor head injury.

Epidural hematomas in children

STUDY OBJECTIVE

To describe the presentation, management, and outcome of children with traumatic epidural hematoma.

DESIGN

Retrospective chart review.

TYPE OF PARTICIPANTS

Fifty-three children diagnosed with traumatic epidural hematoma on computed tomography scan who were treated at Children's Hospital in Boston between 1980 and 1990.

MAIN RESULTS

Twenty-four of 53 children developed an epidural hematoma after a fall of less than 5 ft. At the time of diagnosis, 51 of 53 children had one or more symptoms of vomiting, headache, or lethargy. Twenty-six patients were alert, 21 were responsive to verbal or painful stimuli, and five were unresponsive or posturing. Twenty-one (40%) had acute neurologic deterioration before surgery; however, 20 (38%) were alert with normal vital signs and neurologic examinations at diagnosis. All patients survived, and at the time of discharge 45 had normal examinations and eight had neurologic abnormalities; at follow-up only four of these eight had persistent (although mild) abnormalities.

CONCLUSIONS

Although often dramatic in presentation, epidural hematoma may occur after relatively minor head trauma and in alert children with nonfocal neurologic examinations. In our study, incidence of neurologic sequelae increased if abnormal neurologic examination or depressed mental status was present at diagnosis. The outcome of children in this study is improved from that of previous studies, perhaps due to increased use of computed tomography and higher incidence of low- or moderate-impact trauma in this series.

Arachnoid cyst of middle cranial fossa and ipsilateral subdural haematoma: diagnostic and therapeutic implications in three cases

We describe three cases of arachnoid cyst of the middle cranial fossa with associated intracystic and subdural haematomas. In all of the patients the diagnosis was made before surgical treatment. No bleeding could be attributed to ruptured bridging veins. In two cases the source of bleeding was identified at the interface between the dura mater and the outer membrane at the temporal skull base. We suggest that, even if wide outer membrane membranectomy is probably not indicated, careful coagulation of the membrane at the skull base is necessary to avoid bleeding within the cyst.

Progress in the management of head injury

Three 1-year surveys of head injury management spanning a 9-year period in a single regional centre are presented. There was a reduction in total numbers of head injury admissions after guidelines for admission and referral were implemented. More liberal use of computed tomography resulted in detection of a greater number of intracranial haematomas with the majority detected in non-comatose patients. The early mortality rate in severe head injury fell from 45 per cent to 34 per cent despite referral of large numbers of patients with multiple injuries and a substantial proportion (12 per cent) of patients aged more than 70 years in whom outcome did not improve. Total occupied bednights and bednights occupied per surviving patient with severe head injury fell over the period of study. Care for patients with significant head injury should be based on regional neurosurgical units associated with trauma services.

The association between skull fracture, intracranial pathology and outcome in pediatric head injury

We prospectively studied 653 consecutive head-injured children (less than or equal to 14 years old) treated over a 54-month period (1984-88) at the Department of Neurosurgery of the Rambam Medical Center (Haifa, Israel). Demographic and clinical data were collected, the patients were divided into five age groups (birth to 2 years, 169; 3-5 years, 194; 6-9 years, 164; 10-12 years, 77; and 13-14 years, 49), and the information relative to each was then compared. All patients (except three who died on the operating table) underwent computed tomography (CT) scans; 225 (34.6%) had intracranial pathology, e.g. focal mass lesions, diffuse axonal injury, and subarachnoid haemorrhage. The rate of detected pathology increased with age. Skull fracture was documented in 468 (72%) patients. Craniotomies were done on 114 (17.5%) patients. After 3 months, the patients were classified as having good recovery (84.8%), moderate disability (5.5%), or severe disability (2.3%); 0.9% were in a vegetative state. The mortality was 6.6% (43 patients); of these, 39 (90.7%) had admission Glasgow Coma Scale scores below 8. In our area the annual incidence of neurosurgical hospitalization due to head injury in the pediatric group was 37.6 per 100,000 inhabitants per year. This study substantiates the findings of other series on the effects of prognosis of factors such as associated trauma, admission Glasgow Coma Score, mass lesions with persistent intracranial pressure elevation, or diffuse axonal injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural hematoma: an unusual presentation

The authors present a patient with a traumatic epidural hematoma who complained only of headache and presented to the emergency department 48 hours after a fall. Mental status and neurological examination were normal. This delayed presentation is more commonly seen when a subdural hematoma is present but may result from epidural bleeding. Delayed formation of a traumatic epidural hematoma may occur when the following are present: elevated intracranial pressure, hypovolemic shock, a concomitant mass lesion, coagulopathy, bleeding from dural or diploic veins, a dural sinus laceration, a traumatic pseudoaneurysm, or an arteriovenous fistula. Although criteria for computed tomography of patients with head injuries remain variable in the literature, delayed presentation of epidural bleeding must be considered in the differential diagnosis of posttraumatic headache irregardless of the time interval or neurological presentation.

Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries

OBJECTIVE

To determine the factors influencing the risk of an acute traumatic intracranial haematoma in children and adults with a recent head injury.

DESIGN

Prospective study of incidence of risk factors in samples of patients attending accident and emergency departments and in all patients having an acute traumatic intracranial haematoma evacuated in one regional neurosurgical unit during 11 years.

SETTING

Accident and emergency departments in Scotland or Teesside and regional neurosurgical centre in Glasgow.

PATIENTS

8406 Adults and children (less than or equal to 14 years) who attended accident and emergency departments and 1007 consecutive patients who had an operation for an acute traumatic intracranial haematoma. Data were complete in 8366 and 960 patients respectively.

RESULTS

Overall, children were less at risk than adults (one in 2100 v one in 348 respectively). In both age groups the presence of a skull fracture and changes in conscious level permitted identification of subgroups of patients with widely differing degrees of risk. In children the absolute risk ranged from one in almost 13,000 without a fracture or altered conscious level to one in 12 for a child in a coma and with a fracture; the pattern was similar in adults, the risks in corresponding groups ranging from one in almost 7900 to one in four.

CONCLUSIONS

Although children attending hospital after a head injury have a lower overall risk of a traumatic haematoma, the main indicators of risk, a skull fracture and conscious level, are the same as in adults, and the pattern of their combined effect is similar. Guidelines for managing adults with recent head injury may therefore be applied safely to children; with the increasing provision of facilities for computed tomography they should be revised to ensure early scanning of more patients with head injury.