Mixed-density extradural hematomas on computed tomography—prognostic significance

Imaging Findings in Acute Traumatic Brain Injury: a National Institute of Neurological Disorders and Stroke Common Data Element-Based Pictorial Review and Analysis of Over 4000 Admission Brain Computed Tomography Scans from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

In 2010, the National Institute of Neurological Disorders and Stroke (NINDS) created a set of common data elements (CDEs) to help standardize the assessment and reporting of imaging findings in traumatic brain injury (TBI). However, as opposed to other standardized radiology reporting systems, a visual overview and data to support the proposed standardized lexicon are lacking. We used over 4000 admission computed tomography (CT) scans of patients with TBI from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study to develop an extensive pictorial overview of the NINDS TBI CDEs, with visual examples and background information on individual pathoanatomical lesion types, up to the level of supplemental and emerging information (e.g., location and estimated volumes). We documented the frequency of lesion occurrence, aiming to quantify the relative importance of different CDEs for characterizing TBI, and performed a critical appraisal of our experience with the intent to inform updating of the CDEs. In addition, we investigated the co-occurrence and clustering of lesion types and the distribution of six CT classification systems. The median age of the 4087 patients in our dataset was 50 years (interquartile range, 29-66; range, 0-96), including 238 patients under 18 years old (5.8%). Traumatic subarachnoid hemorrhage (45.3%), skull fractures (37.4%), contusions (31.3%), and acute subdural hematoma (28.9%) were the most frequently occurring CT findings in acute TBI. The ranking of these lesions was the same in patients with mild TBI (baseline Glasgow Coma Scale [GCS] score 13-15) compared with those with moderate-severe TBI (baseline GCS score 3-12), but the frequency of occurrence was up to three times higher in moderate-severe TBI. In most TBI patients with CT abnormalities, there was co-occurrence and clustering of different lesion types, with significant differences between mild and moderate-severe TBI patients. More specifically, lesion patterns were more complex in moderate-severe TBI patients, with more co-existing lesions and more frequent signs of mass effect. These patients also had higher and more heterogeneous CT score distributions, associated with worse predicted outcomes. The critical appraisal of the NINDS CDEs was highly positive, but revealed that full assessment can be time consuming, that some CDEs had very low frequencies, and identified a few redundancies and ambiguity in some definitions. Whilst primarily developed for research, implementation of CDE templates for use in clinical practice is advocated, but this will require development of an abbreviated version. In conclusion, with this study, we provide an educational resource for clinicians and researchers to help assess, characterize, and report the vast and complex spectrum of imaging findings in patients with TBI. Our data provides a comprehensive overview of the contemporary landscape of TBI imaging pathology in Europe, and the findings can serve as empirical evidence for updating the current NINDS radiologic CDEs to version 3.0.

The importance of additional intracranial injuries in epidural hematomas: detailed clinical analysis, long-term outcome, and literature review in surgically managed epidural hematomas

Objective

Epidural hematomas (EDH) occur in up to 8.2% of all traumatic brain injury patients, with more than half needing surgical treatment. In most patients suffering from this perilous disease, good recovery with an excellent clinical course is possible. However, the clinical course is mainly dependent on the presence of additional intracerebral injuries. Few studies comparing isolated and combined EDH in detail exist.

Methods

We performed a retrospective single-center study from April 2002 to December 2014. The mean follow-up time was more than 6 years. In addition to analyzing diverse clinicoradiological data, we performed a systematic literature review dealing with a detailed comparison of patients with (combined) and without (isolated) additional intracerebral injuries.

Results

We included 72 patients in the study. With increasing age, combined EDH had a higher incidence than isolated EDH. The mortality rate of the patients in the cohort was 10%, of which 0% had isolated EDH and 10% had combined EDH. Good recovery was achieved in 69% of patients, of which 91% had isolated EDH and 50% had combined EDH. A subgroup analysis of the different additional intracerebral injuries in combined EDH demonstrated no significant difference in outcome. A systematic literature review only identified six studies. Patients with isolated EDH had a statistically significantly lower mortality risk [relative risk (RR): 0.22; 95% CI: 0.12-0.39] and a statistically significantly lower risk of unfavorable Glasgow outcome scale score (RR: 0.21; 95% CI: 0.14-0.31) than patients with combined EDH.

Conclusions

An excellent outcome in patients with surgically treated isolated EDH is possible. Furthermore, patients with combined EDH or isolated EDH with a low Glasgow coma scale (GCS) score may have favorable outcomes in 50% of the cases. Therefore, every possible effort for treatment should be made for this potentially lethal injury.

Comparison of different noncontrast computed tomographic markers for predicting early perihematomal edema expansion in patients with intracerebral hemorrhage

OBJECTIVES

Noncontrast computed tomography (NCCT) imaging markers are associated with early perihematomal edema (PHE) growth. The aim of this study was to compare the predictive value of different NCCT markers in predicting early PHE expansion.

METHODS

ICH patients who underwent baseline CT scan within 6 h of symptoms onset and follow-up CT scan within 36 h between July 2011 and March 2017 were included in this study. The predictive value of hypodensity, satellite sign, heterogeneous density, irregular shape, blend sign, black hole sign, island sign and expansion-prone hematoma for early perihematomal edema expansion were assessed, separately.

RESULTS

214 patients were included in our final analysis. After adjusting for ICH characteristics, hypodensity, blend sign, island sign and expansion-prone hematoma are still predictors of early perihematomal edema expansion in multivariable logistics regression analysis (all P < 0.05). The area under the receiver operating characteristic (ROC) curve of expansion-prone hematoma was significantly larger than the area under the ROC curve of hypodensity, blend sign and island sign in predicting PHE expansion (P = 0.003, P < 0.001 and P = 0.002, respectively).

CONCLUSION

Compared with single NCCT imaging markers, expansion-prone hematoma seems to be optimal predictor for early PHE expansion than any single NCCT imaging marker.

The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis

OBJECTIVE

Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits.

METHODS

A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs).

RESULTS

Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality.

CONCLUSION

With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.

A case report of frontal spontaneous epidural hematoma associated with cranial osteomyelitis and epidural abscess due to paranasal sinusitis

Background:

Intracranial epidural hematoma (EDH) is frequently secondary to trauma, but in some rare cases, spontaneous EDH (SEDH) could develop without trauma. Cranial osteomyelitis is an uncommon osseous infection that most frequently presents as a postoperative complication but also rarely originates from paranasal sinusitis and can develop extracranially to form a subperiosteal abscess or intracranially to form an epidural, subdural, or cerebral abscess. Intracranial epidural abscess (EDA) is an uncommon infection that forms in the space between the cranial bone and dura mater. It is rare to have a case of SEDH associated with cranial osteomyelitis and EDA due to paranasal sinusitis.

Case Description:

An 18-year-old male was admitted to the hospital with headache, nausea, and vomiting for 2 days. The patient denied a history of head trauma, operation, and any other infectious and systemic diseases, and he was not taking any medication. CT scan demonstrated a mixed density lenticular mass with some air collection in the frontal region. The axial sinus CT image demonstrated opacification of the left frontal, ethmoid, and maxillary sinuses. An emergency operation confirmed the diagnosis of frontal SEDH associated with EDA and frontal osteomyelitis. The frontal EDH, abscess, and the infected bone were completely removed during the operation without opening the dura. The patient recovered well after receiving 8 weeks of antibiotic therapy, and a cranioplasty was performed 9 months after the craniectomy.

Conclusion:

To the best of our knowledge, SEDH associated with EDA is very rare. It is important to recognize the possibility of SEDH associated with cranial osteomyelitis and EDA due to paranasal sinusitis, and the presence of an EDA should, therefore, be considered in the differential diagnosis of cases of SEDH.

Novel Predictive Markers on Computed Tomography for Predicting Early Epidural Hematoma Growth in Pediatric Patients

Objective  Epidural hematoma (EDH), most often caused by rupture of the middle meningeal artery secondary to head trauma with fracture of the temporal bone, is a potentially fatal condition that can lead to elevated intracranial pressure, herniation, and death within hours following the inciting traumatic incident, unless surgical evacuation is accomplished. Several markers have been found to be associated with hematoma expansion in intracerebral hemorrhage (ICH) patients, including: the CT Blend Sign, Swirl Sign, and Black Hole Sign. This study aims to examine these markers, along with intradural air close to or in the region of an EDH and/or close to a significant fracture, fractures involving the skull base, and complicated (i.e., comminuted or displaced) fractures for possible associations to EDH growth in the pediatric population. Predicting hematoma growth is a crucial part of patient management, as surgery can be a life-saving intervention.

Methods  Scans from all pediatric patients with EDH from 2012 to 2019 across two separate health systems were examined and measurements were taken to determine whether these additional factors are of predictive value. Specifications such as length, transverse, and height measurements were taken from CT images.

Statistical Analysis  The average percent change in the hematoma measurements was used to determine which predictive factors were associated with a “noteworthy increase,” namely, an increase of greater than 25%. Additionally, the average percent change in hematoma size was evaluated for patients whose original imaging showed either all three CT signs or intradural air in all three specified locations.

Results  Most of the proposed markers were associated with EDH growth in this cohort. The established CT signs were also supported. This is notable, as most of the research on these signs has been in adult populations rather than pediatric.

Conclusions  Adding these novel imaging signs could aid in the decision to operate on versus observe PEDH patients, thereby preventing unnecessary procedures or preserving brain function quickly when surgery is indicated. This study serves as a starting point for several other investigations into the validity of the proposed markers as well as a reevaluation of the current signs in the pediatric population.

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.

Development and external validation of a novel multihematoma fuzzy sign on computed tomography for predicting traumatic intraparenchymal hematoma expansion

Acute traumatic intraparenchymal hematoma (tICH) expansion is a devastating neurological complication that is associated with poor outcome after cerebral contusion. This study aimed to develop and validate a novel noncontrast computed tomography (CT) (NCCT) multihematoma fuzzy sign to predict acute tICH expansion. In this multicenter, prospective cohort study, multihematoma fuzzy signs on baseline CT were found in 212 (43.89%) of total 482 patients. Patients with the multihematoma fuzzy sign had a higher frequency of tICH expansion than those without (90.79% (138) vs. 46.71% (71)). The presence of multihematoma fuzzy sign was associated with increased risk for acute tICH expansion in entire cohort (odds ratio [OR]: 16.15; 95% confidence interval (CI) 8.85-29.47; P < 0.001) and in the cohort after propensity-score matching (OR: 9.37; 95% CI 4.52-19.43; P < 0.001). Receiver operating characteristic analysis indicated a better discriminative ability of the presence of multihematoma fuzzy sign for acute tICH expansion (AUC = 0.79; 95% CI 0.76-0.83), as was also observed in an external validation cohort (AUC = 0.76; 95% CI 0.67-0.84). The novel NCCT marker of multihematoma fuzzy sign could be easily identified on baseline CT and is an easy-to-use predictive tool for tICH expansion in the early stage of cerebral contusion.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ± 3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ± 1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.

Heterogeneity Signs on Noncontrast Computed Tomography Predict Hematoma Expansion after Intracerebral Hemorrhage: A Meta-Analysis

Background and Purpose

Hematoma expansion (HE) is related to clinical deterioration after intracerebral hemorrhage (ICH) and noncontrast computed tomography (NCCT) signs are indicated as predictors for HE but with inconsistent conclusions. We aim to clarify the correlations of NCCT heterogeneity signs with HE by meta-analysis of related studies.

Methods

PubMed, Embase, and Cochrane library were searched for eligible studies exploring the relationships between NCCT heterogeneity signs (hypodensity, mixed density, swirl sign, blend sign, and black hole sign) and HE. Poor outcome and mortality were considered as secondary outcomes. Odds ratio (OR) and its 95% confidence intervals (CIs) were selected as the effect size and combined using random effects model.

Results

Fourteen studies were included, involving 3240 participants and 435 HEs. The summary results suggested statistically significant correlations of heterogeneity signs with HE (OR, 5.17; 95% CI, 3.72–7.19, P < 0.001), poor outcome (OR, 3.60; 95% CI, 1.98–6.54, P < 0.001), and mortality (OR, 4.64; 95%, 2.96–7.27, P < 0.001).

Conclusions

Our findings suggested that hematoma heterogeneity signs on NCCT were positively associated with the increased risk of HE, poor outcome, and mortality rate in ICH.

Blend Sign on Computed Tomography

Background and Purpose—

Early hematoma growth is not uncommon in patients with intracerebral hemorrhage and is an independent predictor of poor functional outcome. The purpose of our study was to report and validate the use of our newly identified computed tomographic (CT) blend sign in predicting early hematoma growth.

Methods—

Patients with intracerebral hemorrhage who underwent baseline CT scan within 6 hours after onset of symptoms were included. The follow-up CT scan was performed within 24 hours after the baseline CT scan. Significant hematoma growth was defined as an increase in hematoma volume of >33% or an absolute increase of hematoma volume of >12.5 mL. The blend sign on admission nonenhanced CT was defined as blending of hypoattenuating area and hyperattenuating region with a well-defined margin. Univariate and multivariable logistic regression analyses were performed to assess the relationship between the presence of the blend sign on nonenhanced admission CT and early hematoma growth.

Results—

A total of 172 patients were included in our study. Blend sign was observed in 29 of 172 (16.9%) patients with intracerebral hemorrhage on baseline nonenhanced CT scan. Of the 61 patients with hematoma growth, 24 (39.3%) had blend sign on admission CT scan. Interobserver agreement for identifying blend sign was excellent between the 2 readers (κ=0.957). The multivariate logistic regression analysis demonstrated that the time to baseline CT scan, initial hematoma volume, and presence of blend sign on baseline CT scan to be independent predictors of early hematoma growth. The sensitivity, specificity, positive and negative predictive values of blend sign for predicting hematoma growth were 39.3%, 95.5%, 82.7%, and 74.1%, respectively.

Conclusions—

The CT blend sign could be easily identified on regular nonenhanced CT and is highly specific for predicting hematoma growth.

Hypodensity of extradural hematomas in children: an ominous sign

OBJECT

The aim of this study was to analyze the correlation of hypodensity in extradural hematomas on CT with the clinical profile in pediatric patients. This is the only study available in this age group.

METHODS

This was a prospective study conducted over a period of 3 years in which all children 18 years old or younger with a diagnosis of cranial extradural hematoma were included. The patients were allocated to 2 groups: those with mixed-density clots (17 cases) and those with classically hyperdense clots (52 cases). A comparative analysis between the 2 groups was conducted.

RESULTS

Patients with mixed-density clots presented earlier to the hospital, had poor Glasgow Coma Scale scores at admission, exhibited large clot volumes, had a high incidence of active bleeding at surgery, and had increased morbidity and mortality as compared with the patients with hyperdense extradural hematomas.

CONCLUSIONS

Early recognition and rapid evacuation of the mixed-density clot with restoration of hemostasis may result in a decline in morbidity and death in children with this entity.

Head trauma

Worldwide, an estimated 10 million people are affected annually by traumatic brain injury (TBI). More than 5 million Americans currently live with long-term disability as a result of TBI and more than 1.5 million individuals sustain a new TBI each year. It has been predicted that TBI will become the third leading cause of death and disability in the world by the year 2020. This article outlines the classification of TBI, details the types of lesions encountered, and discusses the various imaging modalities available for the evaluation of TBI.

Head computed tomography interpretation in trauma: a primer

Noncontrast computed tomography (CT) provides important diagnostic information for patients with traumatic brain injury. A systematic approach to image interpretation optimizes detection of pathologic air, fractures, hemorrhagic lesions, brain parenchymal injury, and abnormal cerebrospinal fluid spaces. Bone and brain windows should be reviewed to enhance injury detection. Findings of midline shift and mass effect should be noted as well as findings of increased intracranial pressure such as hydrocephalus and cerebral edema, because these may immediately influence management. Compared with CT, magnetic resonance imaging may provide more sensitive detection of diffuse axonal injury but has no proven improvement in clinical outcomes. This article discusses key CT interpretation skills and reviews important traumatic brain injuries that can be discerned on head CT. It focuses on imaging findings that may deserve immediate surgical intervention. In addition, the article reviews the limits of noncontrast CT and discusses some advanced imaging modalities that may reveal subtle injury patterns not seen with CT scan.