Rapid resolution of acute subdural hematoma in child with severe head injury: a case report

Cost Associated with Geriatric Traumatic Brain Injury in Developing Countries: An Observational Study

BACKGROUND

Traumatic brain injury (TBI) in the geriatric population is a serious public health problem and has a huge impact on mortality and morbidity.

METHODS

A retrospective cohort study including patients aged above 65 admitted to a tertiary specialized trauma center, in the period from January 2016 to 31 December 2019. The data collected include patients' demographics, diagnosis, Glasgow Coma Scale (GCS) on arrival, length of stay, investigations, and type of surgery done.

RESULTS

Total number of TBI cases in our study is 145. The most frequent single diagnosis was subdural hematoma (85). Subsequently, it was the costliest diagnosis with an average cost of 3569 USD per patient. Length of stay on average was 17.11 ± 41 hours, with the majority (109 patients) having nonprolonged hospital stay (<14 days). Most of those managed by observation have below-average costs compared to other patients (P < 0.001). Complete blood count was the highly requested test with a total cost 5070 $ in the study period. And head computed tomography had the highest total cost 58,864 $. 21 craniotomies and 30 burr holes were made with a total cost of 30,000 and 25,325 respectively. Patients with lower GCS (64.6%) have below-average hospitalization costs compared to those who got high GCS scores (P < 0.001).

CONCLUSIONS

This study provides the first estimates of the financial burden of Geriatric TBI in the region, which signifies the importance of developing strategies to prevent TBIs and help in resource allocation and healthcare policy formation.

Rapid Spontaneous Resolution of Large Acute Subdural Hematoma

Usually, acute subdural hematomas (ASDHs) result from head trauma and require urgent surgical treatment. However, there have been many reports of rapid spontaneous resolution of ASDHs since 1986. Recently, we experienced a case of a massive ASDH that resolved spontaneously within 1.5 days. A 76-year-old man was admitted to a local hospital after a head injury. According to his clinical records, his initial neurologic status was good (Glasgow Coma Scale score of 14). However, his head computer tomography (CT) scan demonstrated a massive ASDH to the right, with a significant midline shift. Based on his neurological status and general condition, surgery was not considered, and the patient was closely monitored in the intensive care unit. The next day, the patient was transferred to our hospital as requested by his family, after which his neurological state stabilized, and the customary follow-up brain CT was performed. It was about 32 hours after the patient's head injury, and it revealed an unexpected finding, near-total resolution of the ASDH. Herein, we review previously reported similar cases and relevant mechanisms of rapid resolution of the ASDH. We believe that neurosurgeons should comprehensively assess the patient's condition and CT findings and provide appropriate treatment, especially when surgical intervention is unnecessary.

Rapid Spontaneous Resolution of the Acute Subdural Hematoma: Case Series and Review of Literature

Background:

Traumatic acute subdural hematoma (ASDH) is an oft encountered entity in neurosurgery. While resolution of such thick SDHs usually takes time, certain cases of rapid spontaneous resolution have also been reported. This article attempts to review the pathophysiology, clinical and radiological features of such cases, as well as provide an insight into decision making for their management.

Methods:

Electronic literature search was done to look for similar cases of spontaneous rapid resolution of ASDH. Five of authors cases have been described. Their clinical and radiological features along with those of cases from literature search were tabulated and analyzed.

Results:

A total of 44 relevant cases were included for analyses. Of these, 39 cases were from 33 articles found in existing literature and 5 cases were from author's collection. The M:F ratio was 25:19 with a mean age was 41.84(SD-4.094) years. Twenty -six patients showed “Rapid” neurological improvement (</= 24 hours) while “gradual” neurological improvement (>24 hours) occurred in 10 patients. The mean hematoma resolution time on CT scan was 13.78 hours (SD 16.46) ranging from 1- 72 hours. Twenty-nine patients showed redistribution of hematoma, most commonly to tentorium and falx cerebelli. CT scan findings were classified into 5 types as per the nature of hypodensity around hematoma. The geometric mean time to resolution of hematoma was least for type 2 (7.27 hours) and type 1(7.52 hours) patients.

Conclusion:

Selected patients of ASDH with rapid neurological improvement and specific CT findings may show spontaneous resolution of ASDH. Multicentric studies with larger study population may provide better insight into the nature and outcomes of such entities.

Spinal Subdural Hematomas in a Normal Child without Trauma History: A Case Report

Acute Spinal Subdural Hematoma (ASSH) is a rarely recognized condition that may result in severe irreversible neurologic complication. A 7-yr old girl presented to Neurology Department, Mofid Hospital, ShahidBeheshti University of Medical Sciences, Tehran, Iran with limping and pain in lower extremities and acute paraplegia without history of direct trauma. The patient had muscle weakness in lower limbs and was unable to bear weight. Deep Tendon Reflexes (DTR) in lower extremities had increased. Her MRI showed spinal subdural hematoma we reextended from T2 to T6. We performed laminectomy from T2 to T5 and about 70 cc of subdural hematoma was evacuated. One month after the surgery, the patient's neurological deficit resolved completely. The results showed the pivotal role of attention to clinical manifestation in acute spinal subdural hematoma and early diagnosis to prevent irreversible neurologic complication.

Rapid Spontaneously Resolving Acute Subdural Hematoma

Introduction:

This study reports a rare patient of a rapid spontaneously resolving acute subdural hematoma. In addition, an analysis of potential clues for the phenomenon is presented with a review of the literature.

Patient Presentation:

A 1-year-and-2-month-old boy fell from a height of approximately 2 m. The patient was in a superficial coma with a Glasgow Coma Scale of 8 when he was transferred to the authors’ hospital. Computed tomography revealed the presence of an acute subdural hematoma with a midline shift beyond 1 cm. His guardians refused invasive interventions and chose conservative treatment. Repeat imaging after 15 hours showed the evident resolution of the hematoma and midline reversion. Progressive magnetic resonance imaging demonstrated the complete resolution of the hematoma, without redistribution to a remote site.

Conclusions:

Even though this phenomenon has a low incidence, the probability of a rapid spontaneously resolving acute subdural hematoma should be considered when patients present with the following characteristics: children or elderly individuals suffering from mild to moderate head trauma; stable or rapidly recovered consciousness; and simple acute subdural hematoma with a moderate thickness and a particularly low-density band in computed tomography scans.

Traumatic brain injury: Comparison between autopsy and ante-mortem CT

PURPOSE

The aim of this study was to compare pathological findings after traumatic brain injury between autopsy and ante-mortem computed tomography (CT). A second aim was to identify changes in these findings between the primary posttraumatic CT and the last follow-up CT before death.

METHODS

Through the collaboration between clinical radiology and forensic medicine, 45 patients with traumatic brain injury were investigated. These patients had undergone ante-mortem CT as well as autopsy. During autopsy, the brain was cut in fronto-parallel slices directly after removal without additional fixation or subsequent histology. Typical findings of traumatic brain injury were compared between autopsy and radiology. Additionally, these findings were compared between the primary CT and the last follow-up CT before death.

RESULTS

The comparison between autopsy and radiology revealed a high specificity (≥80%) in most of the findings. Sensitivity and positive predictive value were high (≥80%) in almost half of the findings. Sixteen patients had undergone craniotomy with subsequent follow-up CT. Thirteen conservatively treated patients had undergone a follow-up CT. Comparison between the primary CT and the last ante-mortem CT revealed marked changes in the presence and absence of findings, especially in patients with severe traumatic brain injury requiring decompression craniotomy.

CONCLUSION

The main pathological findings of traumatic brain injury were comparable between clinical ante-mortem CT examinations and autopsy. Comparison between the primary CT after trauma and the last ante-mortem CT revealed marked changes in the findings, especially in patients with severe traumatic brain injury. Hence, clinically routine ante-mortem CT should be included in the process of autopsy interpretation.

Spontaneous rapid resolution of acute subdural hematoma in children

BACKGROUND

Spontaneous rapid resolution of acute subdural hematoma developing secondary to trauma has been reported in the literature, yet it is very rare in pediatric population. The aim of the present review is to analyze mechanisms, characteristics, and outcomes of pediatric acute subdural hematoma cases with spontaneous rapid resolution in conjunction with an exemplary case of ours.

CASE DESCRIPTION

A 3-year-old boy was admitted to our emergency department following mild head trauma secondary to a fall from 2 m. He was alert and has a GCS of 15. He had no motor or sensorial deficit on neurological examination. On the emergent brain computed tomography image, an acute subdural hematoma over left frontoparietal lobe was observed. There was a midline shift of 8.3 mm and the width of the hematoma at the thickest portion was 11.2 mm. Surgery was postponed with a close neurological follow-up of the patient in pediatric intensive care unit, due to his well neurological status without any increased ICP findings. On the fourth hour follow-up head CT image, amount of midline shift and hematoma thickness were observed to have regressed dramatically. At the second week, the hematoma resorbed totally with only conservative approach, and he was discharged to home in well status.

DISCUSSION AND CONCLUSION

Analysis of 12 pediatric patients revealed a mean and median ages of 6.87 and 3.9 years, respectively (range = 8 months-18 years). Causes for ASH development were fall, traffic accident, struggle, and child abuse. Main clinical presentations were with depressed sensorium, coma, stupor, drowsiness, headache, motor weakness, lethargy, and seizure. Close follow-up with conservative treatment should be mode of approach in pediatric patients with ASH, if neurological and radiological findings are favorable. However, if patients' neurological status deteriorates after admission to hospital, surgery should be conveyed with no further delay.

A calvarial acute subdural hematoma migrating into the spinal canal in a young male

It is not common for an acute subdural hematoma (SDH) in the supratentorial region to show rapid resolution or migration during the clinical course. In this report, we present a rare case where the SDH in the supratentorial region was observed to rapidly migrate into the lumbar spinal canal, leading to severe radiculopathy. A 20-year-old male patient was admitted to the emergency department with severe headache after head trauma. The patient's overall condition was good, whereas his Glasgow Coma Scale score was 15 and blood pressure was normal. He had vomited 3 times after the onset of pain. No stiff neck was found, and the computed tomography showed an ASDH over the outer layer of the right hemisphere, causing a 7- to 8-mm shift. During the follow-up, the headache regressed and eventually resolved after 12 hours; however, another severe pain occurred in the lumbar region and in both legs. The pain worsened over time, progressing to sciatica in both legs. Acute SDH associated with a minor head trauma may migrate from the supratentorial compartment into the spinal canal by the help of elastic cerebral tissues in young adults and children.

Preoperative trepanation and drainage for acute subdural hematoma: Two case reports

Craniotomy is frequently used for the treatment of acute subdural hematoma; however, it the procedure exhibits a high mortality rate. Preoperative trepanation and drainage in an emergency ward may reduce intracranial pressure, shorten operation time and lower patient mortality, and is thus applicable to the treatment of acute subdural hematoma. The present study reports the cases of two elderly patients that benefitted from trepanation and drainage of an acute subdural hematoma. In each case, the family members of the patients refused to consent to a craniotomy; thus, burr-hole drainage was selected as an alternative option for relieving intracranial pressure. The risks require careful evaluation when considering whether trepanation with drainage is an option for a patient. Following treatment, the two cases were cured and discharged on days 48 and 18 after admission, respectively. The present case studies indicate that trepanation with drainage may be a promising approach for reducing craniotomy-associated mortality and closely monitoring condition variation in elderly patients. Following trepanation with drainage, certain patients do not undergo a craniotomy.

Smaller but denser: postmortem changes alter the CT characteristics of subdural hematomas

PURPOSE

The aim of this study was to investigate if (1) the volume of subdural hematomas (SDH), midline shift, and CT density of subdural hematomas are altered by postmortem changes and (2) if these changes are dependent on the postmortem interval (PMI).

MATERIALS AND METHODS

Ante mortem computed tomography (AMCT) of the head was compared to corresponding postmortem CT (PMCT) in 19 adults with SDH. SDH volume, midline shift, and hematoma density were measured on both AMCT and PMCT and their differences assessed using Wilcoxon-Signed Rank Test. Spearman's Rho Test was used to assess significant correlations between the PMI and the alterations of SDH volume, midline shift, and hematoma density.

RESULTS

Mean time between last AMCT and PMCT was 109 h, mean PMI was 35 h. On PMCT mean midline displacement was decreased by 57% (p < 0.001); mean SDH volume was decreased by 38% (p < 0.001); and mean hematoma density was increased by 18% (p < 0.001) in comparison to AMCT. There was no correlation between the PMI and the normalization of the midline shift (p = 0.706), the reduction of SDH volume (p = 0.366), or the increase of hematoma density (p = 0.140).

CONCLUSIONS

This study reveals that normal postmortem changes significantly affect the extent and imaging characteristics of subdural hematoma and may therefore affect the interpretation of these findings on PMCT. Radiologists and forensic pathologists who use PMCT must be aware of these phenomena in order to correctly interpret PMCT findings in cases of subdural hemorrhages.

Fluctuation of intra-parenchymal cerebral pressure may drive the rapid spontaneous resolution of acute subdural hematoma

Acute subdural hematoma (ASDH) is a severe insult with a high mortality rate, and emergent surgical evacuation is recommended in the vast majority of such cases. Generally, resolution of the hemorrhage requires weeks and months in patients treated conservatively. However, numerous cases of rapid spontaneous resolution of ASDH, occurring within 72h after the trauma, have been reported to date in the literature. Several possible hypotheses have been suggested, primarily involving redistribution and dilution, or washing out the ASDH. In this study, we present the relevant images of such a case, review the mechanisms of the rapid spontaneous resolution in the literature, and also propose a new hypothesis to explain the occurrence of the rapid spontaneous resolution of ASDH. We indicate that the fluctuation of intra-parenchymal cerebral pressure that drives the rapid spontaneous resolution of ASDH.