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Hudak A, Sabini R, Moen M, Rothman D. Acute Management of Moderate to Severe Traumatic Brain Injury. Phys Med Rehabil Clin N Am 2024; 35:479-492. [PMID: 38945645 DOI: 10.1016/j.pmr.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
The focus of this article is on the acute management of traumatic brain injury. The article focuses on the classification of traumatic brain injury, general acute management of traumatic brain injury, the role of the physiatrist on this team, and lastly, behavioral and family considerations in the acute care setting. The article includes a focus on physiologic systems, strategies for the management of various aspects of brain injury, and consideration of factors associated with the continuum of care. Overall, the article reviews this critical period of brain injury recovery and provides a primer for the physiatrist.
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Affiliation(s)
- Anne Hudak
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 223 E. Marshall Street Box 980677, Richmond, VA 23284-0667, USA; Central Virginia Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249-4915, USA
| | - Rosanna Sabini
- Department of Physical Medicine & Rehabilitation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, South Shore University Hospital, Bay Shore, NY 11706, USA
| | - Makinna Moen
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 223 E. Marshall Street Box 980677, Richmond, VA 23284-0667, USA
| | - David Rothman
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 223 E. Marshall Street Box 980677, Richmond, VA 23284-0667, USA.
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Encarnación-santos D, Rubenovich-chikava D, Pachev M, Bozkurt I, Chmutin G, Chaurasia B. Acute Subdural Hematoma Regarding Glial Cystic Changes– A Case Report and Literature Review.. [DOI: 10.21203/rs.3.rs-3967434/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Abstract
Background
This report attempts to examine a controversial case of trauma-associated acute subdural hematoma (ASH). In that case, surgical intervention indicates an intraoperative craniectomy with trephine evacuation or, if the patient is eligible, a Decompressive Craniectomy.
Clinical Case Description
A 51-year-old male was referred to our emergency room due to severe dysarthria and left hemiparesis precipitated by a traumatic event to the right frontoparietal region. demonstrated an (ASH) associated with areas of cystic-glial transformation. Confirmed by CT and follow-up.
Conclusion
A case that illustrates and favors surgical intervention for evacuation with priority and recovery by osteoplastic craniotomy as a treatment and approaches to subdural hematoma, hematoma, and postoperative compliance after said procedure.
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Shen H, Liu H, He J, Wei L, Wang S. Risk factors of prognosis in older patients with severe brain injury after surgical intervention. Eur J Med Res 2023; 28:479. [PMID: 37925438 PMCID: PMC10625240 DOI: 10.1186/s40001-023-01473-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Older patients (aged ≥ 60 years) with severe brain injury have a high mortality and disability rate. The objective of this retrospective study was to assess the clinical risk factors of prognosis in older patients with severe brain injury after surgical intervention and to analyze the prognosis of the surviving group of patients 1 year after discharge. METHODS Clinical data of older patients with severe brain injury who were admitted to two neurosurgical centers between January 2010 and December 2020 were collected. Patient age, sex, Glasgow Coma Scale (GCS) score at admission, underlying disease, mechanisms of injury, abnormal pupillary reflex, head computed tomography imaging findings (such as hematoma type),intraoperative brain swelling and other factors were reviewed. All the patients were categorized into a good prognosis (survival) group and a poor prognosis (death) group by the Glasgow Outcome Score (GOS); also, the related factors affecting the prognosis were screened and the independent risk factors were identified by the Binary logistic regression analysis. GOS was used to evaluate the prognosis of the surviving group of patients 1 year after discharge. RESULTS Out of 269 patients, 171 (63.6%) survived, and 98 (36.4%) died during hospitalization. Univariate analysis showed that age, GCS score at admission, underlying diseases, abnormal pupillary reflex, the disappearance of ambient cistern, the midline structure shift, intraoperative brain swelling, oxygen saturation < 90%, and cerebral hernia were risk factors for the prognosis of older patients with severe brain injury after surgical intervention. Multivariate analysis showed that age, underlying diseases, disappearance of ambient cistern, Oxygen saturation < 90% and intraoperative brain swelling were independent risk factors of the prognosis in the population. The effect of surgical intervention differed among various age groups at 1-year follow-up after surgery. CONCLUSIONS The results of this retrospective study confirmed that age, underlying diseases, disappearance of ambient cistern, intraoperative brain swelling, and oxygen saturation < 90% are associated with poor prognosis in older postoperative patients with severe brain injury. Surgical intervention may improve prognosis and reduce mortality in older patients (age < 75 years). But for those patients (age ≥ 75 years), the prognosis was poor after surgical intervention.
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Affiliation(s)
- Hanchao Shen
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China
- Department of Neurosurgery, Cangshan Hospital District of the 900th Hospital, Fuzhou, China
| | - Haibing Liu
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China
| | - Jiongzhou He
- Department of Neurosurgery, Cangshan Hospital District of the 900th Hospital, Fuzhou, China
| | - Lianqfeng Wei
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China
| | - Shousen Wang
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China.
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Privitera CM, Neerukonda SV, Aiyagari V, Yokobori S, Puccio AM, Schneider NJ, Stutzman SE, Olson DM, Hill M, DeWitt J, Atem F, Barnes A, Xie D, Kuramatsu J, Koehn J, Swab S. A differential of the left eye and right eye neurological pupil index is associated with discharge modified Rankin scores in neurologically injured patients. BMC Neurol 2022; 22:273. [PMID: 35869429 PMCID: PMC9306158 DOI: 10.1186/s12883-022-02801-3] [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: 09/30/2021] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Automated infrared pupillometry (AIP) and the Neurological Pupil index (NPi) provide an objective means of assessing and trending the pupillary light reflex (PLR) across a broad spectrum of neurological diseases. NPi quantifies the PLR and ranges from 0 to 5; in healthy individuals, the NPi of both eyes is expected to be ≥ 3.0 and symmetric. AIP values demonstrate emerging value as a prognostic tool with predictive properties that could allow practitioners to anticipate neurological deterioration and recovery. The presence of an NPi differential (a difference ≥ 0.7 between the left and right eye) is a potential sign of neurological abnormality.
Methods
We explored NPi differential by considering the modified Rankin Score at discharge (DC mRS) among patients admitted to neuroscience intensive care units (NSICU) of 4 U.S. and 1 Japanese hospitals and for two cohorts of brain injuries: stroke (including subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, and aneurysm, 1,200 total patients) and 185 traumatic brain injury (TBI) patients for a total of more than 54,000 pupillary measurements.
Results
Stroke patients with at least 1 occurrence of an NPi differential during their NSICU stay have higher DC mRS scores (3.9) compared to those without an NPi differential (2.7; P < .001). Patients with TBI and at least 1 occurrence of an NPi differential during their NSICU stay have higher discharge modified Rankin Scale scores (4.1) compared to those without an NPi differential (2.9; P < .001). When patients experience both abnormalities, abnormal (NPi < 3.0) and an NPi differential, the latter has an anticipatory relationship with respect to the former (P < .001 for z-score skewness analysis). Finally, our analysis confirmed ≥ 0.7 as the optimal cutoff value for the NPi differential (AUC = 0.71, P < .001).
Conclusion
The NPi differential is an important factor that clinicians should consider when managing critically ill neurological injured patients admitted to the neurocritical care units.
Trial registration
NCT02804438, Date of Registration: June 17, 2016.
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Klavansky D, Kellner C, Ghatan S, Nelson S. Preventing Poor Outcomes for Neurosurgical Patients. Semin Neurol 2022; 42:611-625. [PMID: 36427527 DOI: 10.1055/s-0042-1758704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ensuring that patients with neurosurgical conditions have the best possible outcome requires early diagnosis, monitoring, and interventions to prevent complications and optimize care. Here, we review several neurosurgical conditions and the measures taken to prevent complications and optimize outcomes. We hope that the practical tips provided herein prove helpful in caring for neurosurgical patients.
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Affiliation(s)
- Dana Klavansky
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Nelson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Subdural Hematoma. Neurocrit Care 2022. [DOI: 10.1017/9781108907682.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Rodrigues de Souza M, Aparecida Côrtes M, Carlos Lucena da Silva G, Jorge Fontoura Solla D, Garcia Marques E, Luz Oliveira Junior W, Ferreira Fagundes C, Jacobsen Teixeira M, Luis Oliveira de Amorim R, M. Rubiano A, G. Kolias A, Silva Paiva W. Evaluation of Computed Tomography Scoring Systems in the Prediction of Short-Term Mortality in Traumatic Brain Injury Patients from a Low- to Middle-Income Country. Neurotrauma Rep 2022; 3:168-177. [PMID: 35558729 PMCID: PMC9081064 DOI: 10.1089/neur.2021.0067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The present study aims to evaluate the accuracy of the prognostic discrimination and prediction of the short-term mortality of the Marshall computed tomography (CT) classification and Rotterdam and Helsinki CT scores in a cohort of TBI patients from a low- to middle-income country. This is a post hoc analysis of a previously conducted prospective cohort study conducted in a university-associated, tertiary-level hospital that serves a population of >12 million in Brazil. Marshall CT class, Rotterdam and Helsinki scores, and their components were evaluated in the prediction of 14-day and in-hospital mortality using Nagelkerk's pseudo-R2 and area under the receiver operating characteristic curve. Multi-variate regression was performed using known outcome predictors (age, Glasgow Coma Scale, pupil response, hypoxia, hypotension, and hemoglobin values) to evaluate the increase in variance explained when adding each of the CT classification systems. Four hundred forty-seven patients were included. Mean age of the patient cohort was 40 (standard deviation, 17.83) years, and 85.5% were male. Marshall CT class was the least accurate model, showing pseudo-R2 values equal to 0.122 for 14-day mortality and 0.057 for in-hospital mortality, whereas Rotterdam CT scores were 0.245 and 0.194 and Helsinki CT scores were 0.264 and 0.229. The AUC confirms the best prediction of the Rotterdam and Helsinki CT scores regarding the Marshall CT class, which presented greater discriminative ability. When associated with known outcome predictors, Marshall CT class and Rotterdam and Helsinki CT scores showed an increase in the explained variance of 2%, 13.4%, and 21.6%, respectively. In this study, Rotterdam and Helsinki scores were more accurate models in predicting short-term mortality. The study denotes a contribution to the process of external validation of the scores and may collaborate with the best risk stratification for patients with this important pathology.
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Affiliation(s)
| | | | | | - Davi Jorge Fontoura Solla
- Department of Neurology–Division of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | | | | | | | - Manoel Jacobsen Teixeira
- Department of Neurology–Division of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Andres M. Rubiano
- Department of Neurosurgery–Neuroscience Institute, Neurotrauma Group, El Bosque University, Bogotá, Colombia
| | - Angelos G. Kolias
- NIHR Global Health Research Group on Neurotrauma, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neuroscience–Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Wellingson Silva Paiva
- Department of Neurology–Division of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Near-infrared spectroscopy for intracranial hemorrhage detection in traumatic brain injury patients: A systematic review. Am J Emerg Med 2021; 50:758-764. [PMID: 34879500 DOI: 10.1016/j.ajem.2021.09.070] [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: 05/31/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To synthesize evidence of the use of near-infrared spectroscopy (NIRS) to detect intracranial hemorrhage in traumatic brain injury (TBI) patients. METHODS The literature search was conducted in PubMed and Google Scholar (from inception to July 2021). RESULTS 216 original articles were found, 197 of which were omitted, and the final review contained 19 original articles covering 2291 patients. CONCLUSION For patients with TBI, a NIRS test may be useful as a screening tool for intracranial hemorrhage, especially at the prehospital level. Negative results may help rule out intracranial hemorrhage and may remove the need for more head computed tomography (CT) scanning. Prehospital testing may guide the decision of whether the patient should be transferred to a craniotomy-equipped specialized hospital. NIRS can also be useful in situations when CT is not available. For future research, a significant objective is to show whether the effects of NIRS can improve outcomes and lead to meaningful improvements in clinical practice and decision making.
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Jain V, Remley W, Mohan A, Leone EL, Taneja S, Busl K, Almeida L. Nonepileptic, Stereotypical, and Intermittent Symptoms After Subdural Hematoma Evacuation. Cureus 2021; 13:e18361. [PMID: 34725611 PMCID: PMC8555749 DOI: 10.7759/cureus.18361] [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] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Transient neurological deficits can occur in the setting of subdural hemorrhages with subsequent unremarkable electrodiagnostic and radiological evaluation. This scenario is rare and can be difficult for physicians to interpret. These transient neurological deficits are thought to result from relative ischemia, secondary to a lesser-known concept known as cortical spreading depolarization. These transient neurological deficits are thought to result from relative ischemia, secondary to a lesser-known concept known as cortical spreading depolarization, which may present clinically as nonepileptic, stereotypical, and intermittent symptoms (NESIS). In these instances, patients are often misdiagnosed as epileptics and committed to long-term antiseizure drugs. We present a 51-year-old patient developing acute global aphasia following the evacuation of a subdural hematoma, with no significant findings on laboratory, microbiological, electrodiagnostic, or radiological evaluation. The patient experienced spontaneous improvement and returned to baseline in the subsequent weeks. Increased awareness of NESIS as a cortical spreading depolarization phenomenon can improve patient care and prevent both unnecessary, extended medical evaluations and therapeutic trials.
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Affiliation(s)
- Varun Jain
- Neurology, University of Florida, Gainesville, USA
| | - William Remley
- Neurology, Lake Erie College of Osteopathic Medicine, Jacksonville, USA
| | - Arvind Mohan
- Neurosurgery, University of Florida, Gainesville, USA
| | - Emma L Leone
- Neurology, University of Florida, Gainesville, USA
| | - Srishti Taneja
- Neurology, Avalon University School of Medicine, Youngstown, USA
| | - Katharina Busl
- Neurocritical Care, University of Florida, Gainesville, USA
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Gunther M, Witenko CJ, Prust M, Salerno D, Berger K. The Safety and Efficacy of Desmopressin in Patients With Intracranial Hemorrhage and a History of Alcohol Use. J Intensive Care Med 2021; 37:825-832. [PMID: 34286612 DOI: 10.1177/08850666211031494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with a history of alcohol use disorder are at an increased risk of hematoma expansion following intracranial hemorrhage (ICH) due to the effects of alcohol on platelet aggregation. Desmopressin (DDAVP) improves platelet aggregation and may decrease hematoma expansion in patients with ICH. However, DDAVP may also increase the risk of hyponatremia and thrombotic events. Evidence is limited regarding the safety and efficacy of DDAVP in alcohol use (AU)-associated ICH. METHODS This was a retrospective chart review of adult patients with radiographic evidence of ICH and a confirmed or suspected history of alcohol use upon admission. Patients were categorized into groups based on DDAVP administration. Safety outcomes included hyponatremia (serum sodium <135 mEq/L or decrease in serum sodium of ≥ 5 mEq/L for patients with baseline sodium <135 mEq/L) within 24 hours of ICH and thrombotic events within 7 days of ICH. The primary efficacy outcome was the incidence of hematoma expansion, defined as any expansion of the hemorrhage noted on repeat imaging within 32 hours. RESULTS In total, 52 patients were included in the safety analysis (27 DDAVP and 25 non-DDAVP). Although hyponatremia was numerically higher in the DDAVP group, there was no significant difference between groups (19.2% vs 4.2%, P = 0.192). Thrombotic complications were similar between the DDAVP and non-DDAVP groups (11.1% vs. 8%, P = 1.0). Thirty-nine patients met criteria for hemostatic efficacy analysis. There was no difference in hematoma expansion between the DDAVP and non-DDAVP groups (23.1% vs 34.6%, P = 0.71) and these findings were consistent after adjusting for differences in baseline characteristics (OR 0.63, 95% CI 0.1-3.3). CONCLUSION The administration of DDAVP was not associated with adverse safety events, but did not significantly reduce the incidence of hematoma expansion in patients with AU-associated ICH.
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Affiliation(s)
- Michelle Gunther
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Corey J Witenko
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Morgan Prust
- Department of Neurology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA. Gunther is now with Department of Pharmacy, The Hospital of Central Connecticut, New Britain, CT, USA
| | - David Salerno
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA.,Department of Neurology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA. Gunther is now with Department of Pharmacy, The Hospital of Central Connecticut, New Britain, CT, USA
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Travers B, Jones S, Bastani A, Opsommer M, Beydoun A, Karabon P, Donaldson D. Assessing geriatric patients with head injury in the emergency department using the novel level III trauma protocol. Am J Emerg Med 2020; 45:149-153. [PMID: 33229252 DOI: 10.1016/j.ajem.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/17/2020] [Accepted: 11/14/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Intracranial injury in elderly patients presenting with minor head trauma is often overlooked in the emergency department (ED). Our suburban community-based level II trauma hospital developed and implemented the level III trauma protocol (L3TP) in January 2016 to better evaluate and diagnose intracranial injury in elderly patients presenting with minor head trauma after a fall. The L3TP requires that the ED physician immediately assess all patients meeting the following criteria 1) Age ≥ 65 years old. 2) Currently taking any anticoagulant or antiplatelet agents. 3) Presenting in the ED with a potential head injury after a fall. The ED physician determines if these high-risk patients require emergent imaging, obviating the need for trauma team activation unless an intracranial hemorrhage (ICH) is found. The purpose of this study was to assess the impact of the novel L3TP on resource utilization and patient outcome. METHODS Our retrospective cohort study included patients who met the L3TP inclusion criteria and had an ICH diagnosed by non-contrast computed tomography (CT). We compared patients triaged by the L3TP (January to December 2017) to patients triaged before the L3TP was implemented (January to August 2015) in order to assess the impact of the L3TP on resource utilization and patient outcome. The data was analyzed using two independent samples t-tests and Chi-square tests. RESULTS Patients triaged by the L3TP had a significantly shorter average length of time from arrival in the ED to CT (level III trauma 0.64 h vs control 2.37 h, (d = 1.73; 95% CI = 1.42, 2.04), p ≤ 0.0001) and ED length of stay (level III trauma 2.55 h vs control 4.72 h, (d = 2.17; 95% CI = 1.21, 3.13), p ≤ 0.0001). There was insufficient evidence to conclude that there was any difference in health outcomes between the control and level III trauma groups. CONCLUSION The L3TP is an effective and resource efficient protocol that quickly identifies ICH in elderly patients without activating the trauma team for every elderly patient presenting to the ED with a potential head injury after a fall.
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Affiliation(s)
- Benjamin Travers
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
| | - Shanna Jones
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Aveh Bastani
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Michael Opsommer
- Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Ali Beydoun
- Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - David Donaldson
- Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
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Shin DS, Hwang SC. Neurocritical Management of Traumatic Acute Subdural Hematomas. Korean J Neurotrauma 2020; 16:113-125. [PMID: 33163419 PMCID: PMC7607034 DOI: 10.13004/kjnt.2020.16.e43] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucehon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucehon, Korea
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Whiting MD, Dengler BA, Rodriguez CL, Blodgett D, Cohen AB, Januszkiewicz AJ, Rasmussen TE, Brody DL. Prehospital Detection of Life-Threatening Intracranial Pathology: An Unmet Need for Severe TBI in Austere, Rural, and Remote Areas. Front Neurol 2020; 11:599268. [PMID: 33193067 PMCID: PMC7662094 DOI: 10.3389/fneur.2020.599268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Severe traumatic brain injury (TBI) is a leading cause of death and disability worldwide, especially in low- and middle-income countries, and in austere, rural, and remote settings. The purpose of this Perspective is to challenge the notion that accurate and actionable diagnosis of the most severe brain injuries should be limited to physicians and other highly-trained specialists located at hospitals. Further, we aim to demonstrate that the great opportunity to improve severe TBI care is in the prehospital setting. Here, we discuss potential applications of prehospital diagnostics, including ultrasound and near-infrared spectroscopy (NIRS) for detection of life-threatening subdural and epidural hemorrhage, as well as monitoring of cerebral hemodynamics following severe TBI. Ultrasound-based methods for assessment of cerebrovascular hemodynamics, vasospasm, and intracranial pressure have substantial promise, but have been mainly used in hospital settings; substantial development will be required for prehospital optimization. Compared to ultrasound, NIRS is better suited to assess certain aspects of intracranial pathology and has a smaller form factor. Thus, NIRS is potentially closer to becoming a reliable method for non-invasive intracranial assessment and cerebral monitoring in the prehospital setting. While one current continuous wave NIRS-based device has been FDA-approved for detection of subdural and epidural hemorrhage, NIRS methods using frequency domain technology have greater potential to improve diagnosis and monitoring in the prehospital setting. In addition to better technology, advances in large animal models, provider training, and implementation science represent opportunities to accelerate progress in prehospital care for severe TBI in austere, rural, and remote areas.
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Affiliation(s)
- Mark D Whiting
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Stephens Family Clinical Research Institute, Carle Foundation Hospital, Urbana, IL, United States
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Carissa L Rodriguez
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - David Blodgett
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - Adam B Cohen
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States.,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Todd E Rasmussen
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David L Brody
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Laboratory of Functional and Molecular Imaging, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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Wang C, Xian L, Chen X, Li Z, Fang Y, Xu W, Wei L, Chen W, Wang S. Visualization of cortical cerebral blood flow dynamics during craniotomy in acute subdural hematoma using laser speckle imaging in a rat model. Brain Res 2020; 1742:146901. [PMID: 32445715 DOI: 10.1016/j.brainres.2020.146901] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/25/2020] [Accepted: 05/18/2020] [Indexed: 02/05/2023]
Abstract
Mass evacuation with decompressive craniotomy is considered a standard intervention for acute subdural hematoma (ASDH). However, hemispheric swelling complicates the intraoperative and postoperative management of ASDH patients, and previous studies have revealed that this approach can damage ischemic/reperfusion (I/R) injury. Few studies have focused on the cerebrovascular response following traumatic brain injury (TBI). To characterize the relative cerebral blood flow (rCBF) before and after removal of the hematoma, rats were injured by a subdural infusion of 400 μL of venous blood or paraffin oil. MRI scans were performed. Then, we monitored cortical rCBF during hematoma removal in real time using laser speckle imaging (LSCI) in ASDH rats. The CBF of arteriovenous and capillary regions were quantified and normalized to their own baseline values via a custom algorithm. In the sham group, the cortical CBF was higher post-craniotomy than pre-craniotomy. However, in the hematoma injection group, the CBF of arteries and capillaries was higher while the venous CBF was lower post-craniotomy than pre-craniotomy. The difference in the changes in vein CBF that occurred between the two groups was statistically significant. The three components of the vascular system showed heterogeneous responses to craniotomy, which may be the basis for secondary brain injury.
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Affiliation(s)
- Cheng Wang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, PR China
| | - Liang Xian
- Bengbu Medical College, Bengbu, Anhui, PR China
| | - Xiangrong Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, PR China
| | - Zuanfang Li
- Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, PR China
| | - Yi Fang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, PR China
| | - Weiming Xu
- Department of Neurosurgery, The Hospital of Changle, Fuzhou, PR China
| | - Liangfeng Wei
- Department of Neurosurgery, 900th Hospital, Fuzhou, PR China
| | - Weiqiang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, PR China
| | - Shousen Wang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, PR China; Department of Neurosurgery, 900th Hospital, Fuzhou, PR China.
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15
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Abecassis ZA, Nistal DA, Abecassis IJ, Sen RD, Levitt MR. Ghost Aneurysms in Acute Subdural Hematomas: A Report of Two Cases. World Neurosurg 2020; 139:e159-e165. [PMID: 32272269 PMCID: PMC10947780 DOI: 10.1016/j.wneu.2020.03.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Acute subdural hematoma (aSDH) is a common pathology encountered in neurosurgery. Although most cases are associated with trauma and injuries to draining veins, traumatic aSDH from injury to arteries or spontaneous aSDH because of a ruptured intracranial aneurysm can occur. For some patients without a clear clinical history, it can be difficult to distinguish between these etiologies purely based on radiography. The objective of this research was to describe a case series in which imaging was suggestive of the presence of distal cortical intracranial aneurysm associated with aSDH, but operative management demonstrated no evidence of aneurysm. METHODS We retrospectively reviewed 2 patients known to have aSDH with suspicion for associated aneurysm between May 2019 and September 2019 at our institution. Data collected included demographic, clinical, and operative course, including age, gender, past medical history, presenting symptoms, and pre and postoperative imaging. RESULTS In 2 patients presenting with aSDH with preoperative radiographic imaging suggesting distal middle cerebral artery aneurysms, surgical exploration revealed no aneurysm. In both cases, noniatrogenic active arterial bleeding from an injured cortical middle cerebral artery branch was identified. CONCLUSIONS Although there are prior reports of arterial aSDH, to our knowledge, this is the first to describe the radiographic "ghost aneurysm" sign. It is important for clinicians to be aware of this potential misleading radiographic sign, which indicates active extravasation into a spherical cast of clot.
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Affiliation(s)
- Zachary A Abecassis
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dominic A Nistal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington, USA.
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Al Shaikh RH, Hasan TF, Becker TL, Ng Tucker LK, Meschia JF, Tawk RG, Ayala E, Freeman WD. Rapidly Resolving and Recurrent Contralateral Subdural Hematoma From Disseminated Intravascular Coagulation. J Stroke Cerebrovasc Dis 2020; 29:104872. [PMID: 32434727 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104872] [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: 01/20/2020] [Revised: 03/20/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Acute, recurrent subdural hematoma (SDH) is a rare entity in the absence of trauma. Atraumatic SDH may be due to vascular disorders, coagulopathies, or intracranial hypotension. It is a rare complication of disseminated intravascular coagulation (DIC), with no prior reports in patients with intracranial metastatic colon cancer (MCC). Rapid resolution of the initial acute SDH with contralateral recurrence has not yet been reported in the literature. We present a case of rapidly resolving and recurrent, contralateral acute SDH from DIC secondary to MCC. CASE DESCRIPTION A 77-year-old woman with MCC presented with severe, acute onset headache. She progressed to unresponsiveness, dilated right pupil, and Glasgow Coma Scale (GCS) score of 4T. Initial computed tomography (CT) of the head demonstrated a right, 17-mm SDH with a right-to-left midline shift. Repeat CT head 8 hours later revealed resolution of the right SDH. She was extubated with notable clinical improvement. Laboratory examination showed international normalized ratio of 3.4, leukocytosis, and thrombocytopenia. The next morning, she became lethargic, GCS score of 3, with bilateral fixed pupils and dilated to 5-mm, and she was then reintubated. Repeat CT head demonstrated a new left SDH with bilateral uncal herniation. A small hyperdense focus in the left parietal region was suspicious for intraparenchymal hematoma versus a hemorrhagic metastatic focus. Shortly after, she was extubated due to do not resuscitate status, and she then passed away. CONCLUSIONS To our knowledge, this is the first case illustrating rapidly resolving and recurrent, contralateral acute SDH from DIC in a patient with MCC. Clinical recognition of this phenotypic pattern should raise the question of an underlying coagulopathy.
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Affiliation(s)
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport 71103, Louisiana, United States.
| | - Tara L Becker
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
| | - Lauren K Ng Tucker
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States.
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States.
| | - Ernesto Ayala
- Department of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, United States.
| | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States.
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17
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Ciochon UM, Steuble Brandt EG, Stavngaard T. Acute Tentorial Subdural Hematoma Caused by Rupture of the Posterior Cerebral Artery after Minor Trauma-A Case Report. Diagnostics (Basel) 2020; 10:diagnostics10030175. [PMID: 32210036 PMCID: PMC7151171 DOI: 10.3390/diagnostics10030175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 12/02/2022] Open
Abstract
Acute subdural hematoma (aSDH) is a common pathology encountered after head trauma. Only a minority of aSDHs have an arterial source. In this article, we report a case of aSDH originating from a traumatic pseudoaneurysm of the distal segment of posterior cerebral artery (PCA), diagnosed several days after the initial minor trauma and successfully treated with endovascular coiling. This case emphasizes the importance of searching for vascular pathology when the localization, severity or relapsing course of the intracranial hemorrhage does not fully correspond to the severity of initial trauma and when the bleeding has a delayed onset. Characteristics, diagnostics and treatment possibilities of traumatic cerebral aneurysms, an important cause of arterial aSDH, are described in the article.
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Affiliation(s)
- Urszula Maria Ciochon
- Department of Diagnostic Radiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; (E.G.S.B.); (T.S.)
- Correspondence:
| | - Erik Gudmann Steuble Brandt
- Department of Diagnostic Radiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; (E.G.S.B.); (T.S.)
- Department of Radiology, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark
| | - Trine Stavngaard
- Department of Diagnostic Radiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; (E.G.S.B.); (T.S.)
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Chrastina J, Šilar Č, Zeman T, Svoboda M, Krajsa J, Musilová B, Novák Z. Reoperations after surgery for acute subdural hematoma: reasons, risk factors, and effects. Eur J Trauma Emerg Surg 2019; 46:347-355. [DOI: 10.1007/s00068-019-01077-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/18/2019] [Indexed: 11/30/2022]
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Repair of damaged cortical artery by direct micro-suture in surgical treatment of acute subdural hematoma: technical note. Acta Neurochir (Wien) 2018; 160:1931-1937. [PMID: 30066190 DOI: 10.1007/s00701-018-3634-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND In surgical treatment of acute subdural hematoma (ASDH), neurosurgeons frequently encounter bleeding from cortical arteries, which is usually controlled with bipolar coagulation. However, bipolar coagulation is associated with a risk of sacrificing the cortical artery, which may affect the prognosis of neurological symptoms when these cortical arteries supply critical areas. In this article, we describe microsurgical repair of damaged cortical arteries using a 10-0 nylon micro-suture in patients with arterial-origin ASDH. METHODS After removal of the subdural hematoma, the exact bleeding point of the cortical artery was identified, and the 10-0 nylon suture stitches were placed on the arterial tear under a microscope. After completion of the micro-suture, vascular patency was confirmed by indocyanine green (ICG) videoangiography. RESULTS From June 2015 through February 2017, microsurgical repair was performed for seven cortical arteries in six patients. All damaged arteries were located near the Sylvian fissure, and all tears were pinhole tears. The average blood flow occlusion time was 8 min (range, 0-15 min). The patency of all seven repaired arteries was successfully confirmed by ICG videoangiography. Postoperative cerebral infarction was not observed except in one patient with cerebral contusion and a history of severe head trauma. CONCLUSIONS The present report demonstrates that repair of a cortical artery by the 10-0 nylon micro-suture is a simple and safe method with a low risk of sacrificing the artery. This technique may be a good option in the surgical treatment of arterial-origin ASDH, especially when the accompanying cerebral contusion is minimal.
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Özevren H, Hattapoğlu S. Akut Subdural Hematomlu 106 Olgunun Retrospektif Değerlendirilmesi. DICLE MEDICAL JOURNAL 2018. [DOI: 10.5798/dicletip.410849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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