Contralateral acute subdural hematoma following traumatic acute subdural hematoma evacuation

Outcomes of Repeat Surgery in Pediatric Severe Traumatic Brain Injury: An Analysis from Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial

BACKGROUND

Early operative intervention, craniotomy, and/or craniectomy are occasionally warranted in severe traumatic brain injury (TBI). Persistent increased intracranial pressure or accumulation of intracranial hematoma postsurgery can result in higher mortality and morbidity. There is a gap in information regarding the outcome of repeat surgery (RS) in pediatric patients with severe TBI.

METHODS

An observational cohort study titled Approaches and Decisions in Acute Pediatric TBI Trial data was obtained from the Federal Interagency Traumatic Brain Injury Research Informatics System. All pediatric patients who underwent craniotomy or decompressive craniectomy, survived more than 44 hours and were found to have persistent elevated intracranial pressure >20 mmHg for 2 consecutive hours were included in the study. The purpose of the study was to find the outcomes of RS in pediatric severe TBI. Propensity based matching was used to find the outcomes. The primary outcome was 60-day mortality.

RESULTS

Out of 1000 total patients enrolled in the Approaches and Decisions in Acute Pediatric Trial, 160 patients qualified for this study. Propensity score matching created 13 pairs of patients. There were no significant differences found between the groups who had RS versus those who did not have repeat surgery on baseline characteristics. There were no significant differences found between the groups regarding 60-day mortality, median hospital days, median intensive care unit days, and 6-month favorable outcome on Glasgow Outcome Scale Extended score.

CONCLUSIONS

There was no difference in mortality between patients who underwent a second surgery and patients who did not have to undergo a second surgery.

The timing and value of early postoperative computed tomography after head surgery in traumatic brain injury patients

OBJECTIVE

To analyze the timing of the early postoperative computed tomography (CT) in traumatic brain injury (TBI) patients, and compare CT and neurological examination (NE) findings.

METHODS

Retrospective analysis included 353 TBI patients admitted to two level 1 trauma centers (2016-2020) who underwent head surgery and postoperative CT within 24 h. Analyzed variables: age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), Abbreviated Injury Scale head (AISh), comorbidities, CT and NE findings and timing, head surgery type, and mortality.

RESULTS

Patients mean age was 61.9 years, ISS 25.1, GCS 11.0, AISh 4.7. Postoperatively, mean time to first positive CT was 6.1 h and to first positive NE was 13.2 h. Positive CT alone was more accurate in identifying need for 2nd head surgery than positive NE alone (21.8 % vs 6.0 %, p = 0.04). There was no difference between patients with CT done earlier than 6 h compared to patients with CT done after 6 h in mortality (26.1 % vs 22.0 %, p = 0.4) or 2nd surgery rate (12.2 % vs 12.2 %, p = 1.0). Reversal of postoperative CT findings occurred in 1/6 of patients and was more common when CT was done earlier than 6 h compared to CT done later (25.7 % vs 0.8 %, p < 0.001). Early CT within 1 h rarely leads to the change of management but often is followed by another CT within 12 h.

CONCLUSION

In TBI patients postoperative CT was more effective than NE in predicting a need for 2nd head surgery. Postoperative head CT at 6 h is recommended to allow timely detection of intracranial deterioration, reduce the number of CTs and reversal findings as it does not increase 2nd surgery rates and mortality.

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

Context

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

Objective

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

Methods

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

Results

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

Conclusion

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

High fibrin/fibrinogen degradation product value as a risk factor for progressive remote traumatic intracranial haemorrhage following neurosurgery

Introduction: Remote traumatic intracranial haemorrhage (RTIH) may develop after neurosurgery. Recognition of the risk factors for RTIH before surgery might be of great value. The purpose of this study was to verify if the fibrin/fibrinogen degradation product (FDP) value may be a risk factor for RTIH.Methods: This was a retrospective study of the data of 56 patients with traumatic intracranial hematomas shown on initial computed tomography (CT) who were treated with craniotomy or decompressive craniectomy and underwent a follow-up CT at a single centre over a period of approximately 10.5 years. We divided the patients into 2 groups: those who developed RTIH (Positive: P-group) and those who did not (Negative: N-group). We compared the 2 groups in terms of not only the laboratory data before surgery, but also patient age, sex, antiplatelet/antithrombotic medications received, cause of injury, and GCS score on arrival.Results: RTIH was observed in 22 patients (P-group, 39.3%). The FDP value was the only significant risk factor identified in this study (p = 0.00076). The cut-off value was estimated on the basis of the area under the receiver operating characteristic (ROC) curve. The cut-off FDP value was 120 µg/mL (63.6% sensitivity and 85.3% specificity).Conclusions: FDP levels over 120 µg/mL were determined to be a risk factor for progressive RTIH after neurosurgery. We suggest the FDP level be checked before surgery for traumatic intracranial haemorrhage and follow-up CT be done as soon as possible after the surgery if the serum FDP level is over 120 µg/mL.

Remote Supratentorial Subdural Hematoma Following Craniectomy and Evacuation of Hypertensive Cerebellar Hematoma

Remote acute subdural hematoma following a decompressive craniotomy or craniectomy is a rare phenomenon. Only few cases of postoperative contralateral acute subdural hematomas have been reported in the literature review till date. This case report details a case of a 32-year-old hypertensive male who presented with severe headache, multiple episodes of vomiting, slurring of speech, nystagmus and ataxic gait for one day. Computed tomography (CT) scan of head revealed a right sided cerebellar hemorrhage with effacement of fourth ventricle and upstream hydrocephalus. A right suboccipital craniectomy and hematoma evacuation were performed. A repeat CT scan of head was done at six hours post surgery; which revealed a contralateral (left-sided) subdural hematoma involving the fronto-parieto-temporal region. The patient improved following conservative management.

Contralateral acute subdural hematoma following evacuation of hematoma is a rare, but a potentially life-threatening complication; therefore, we should try to detect such contralateral hematoma and prevent clinical deterioration.

Repeat Surgery After Decompressive Craniectomy for Traumatic Intracranial Hemorrhage: Outcomes and Predictors

INTRODUCTION

Repeat surgery (RS) after decompressive craniectomy/craniotomy (DC) for traumatic intracranial hemorrhage (TICH) is a devastating complication. In patients undergoing DC for TICH, we sought to 1) describe the population requiring RS, 2) compare outcomes of those requiring RS with those who did not, and 3) discern RS predictors.

METHODS

A single-institution retrospective case-control study was conducted from 2000 to 2015. Inclusion criteria were DC for acute supratentorial TICH (subdural hemorrhage, epidural hemorrhage, and intraparenchymal hemorrhage) and ≥7 day survival. Patients underwent RS within 7 days of DC; controls did not require RS. Outcomes and predictors of RS were evaluated with univariate and multivariate logistic regression (MLR).

RESULTS

Of 201 patients requiring DC, 28 (14%) underwent RS. Common mechanisms were ground-level fall (45%) and motor vehicle collision (29%). Anticoagulation/antiplatelet medication was used by 44 patients (21%). Subdural hemorrhage was the most common hemorrhage (64%). Using MLR, those requiring RS were more likely to experience major complications (odds ratio [OR], 22.6; 95% confidence interval [CI], 5.06-101.35; P < 0.001) and in-hospital mortality (OR, 2.76; 95% CI, 1.02-7.43; P = 0.045) and be dead/dependent at 6 months (OR, 2.50; 95% CI, 1.08-5.82; P = 0.033) and 2 years (OR, 2.44; 95% CI, 0.99-6.00; P = 0.051). Predictors of undergoing RS identified by MLR were smaller hemorrhage (OR, 0.32; 95% CI, 0.13-0.78; P = 0.012), larger midline shift (OR, 4.40; 95% CI, 1.43-13.51; P = 0.010), and better preoperative Glasgow Coma Scale score (OR, 1.28; 95% CI, 1.13-1.46; P < 0.001).

CONCLUSIONS

Patients requiring RS after DC represent a heterogenous population with worse outcomes. Although the identified risk factors for RS are not modifiable, surgeons should be aware of these factors during the initial surgery.

Determinants of reoperation after decompressive craniectomy in patients with traumatic brain injury: A comparative study

OBJECTIVES

Reoperation after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) remains a dilemma and the risk factors are to be identified. The aim of the current study was to determine the determinants and risk factors of reoperation after DC in patients with TBI.

PATIENTS AND METHODS

This retrospective case-controlled study was conducted during a 4-year period from September 2013 to October 2017 in a level I trauma center affiliated with Shiraz University of Medical Sciences in southern Iran. We included all the adult (≥18 years) patients with TBI who underwent primary or secondary DC in our center during the study period. Those who underwent reoperation were compared to those who underwent DC only regarding the demographic findings, clinical features and neuroimaging findings. A univariate and multivariate logistic regression analysis was performed to determine the determining factors of reoperation.

RESULTS

Overall we included 371 patients with mean age of 36.45 ± 14.18 years. Among the patients there were 325 (87.6%) men and 46 (12.4%) women. The reoperation in patients undergoing DC due to TBI was associated with primary DC (p = 0.039) and higher Marshall grade (p = 0.027). Those who underwent reoperation after DC for TBI had significantly higher ICU (p = 0.007) and hospital LOS (p = 0.001) and lower 6-month GOSE (p = 0.010). Age (p < 0.001), GCS (p < 0.001) and pupils (p = 0.027) were predictors of outcome in reoperation group. Reoperation in primary DC group was associated with pupil reactivity (p = 0.002) and number of episodes with INR above 1.5 (p = 0.037) Conclusion: Reoperation after DC for TBI is associated with primary DC, and Marshall grade. The reoperation after DC is associated with worse outcome and longer ICU and hospital stay. The age, GCS and pupil reactivity are the main predictors of outcome in those with reoperation after DC for TBI.

Extradural Hematoma Following Decompressive Craniectomy for Acute Subdural Hematoma: Two Case Reports Illustrating Different Mechanisms

The occurrence of extradural hematoma (EDH) after decompressive craniectomy (DC) for traumatic brain injury is uncommon. We report two cases, one developing ipsilateral EDH and another developing contralateral simultaneous EDH and subdural hematoma after DC. The strategies to anticipate the occurrence of such concurrent hematomas (CH) are highlighted. We propose a subclassification of CH into “immediate” and “delayed,” based on their difference in clinical presentation, image findings, pathogenesis, and surgical management.

Contralateral Subdural Hematoma Following Surgical Evacuation of Acute Subdural Hematoma: Super-Early Intervention and Clinical Implications

BACKGROUND

Contralateral acute subdural hematoma (ASDH) is an uncommon but devastating complication during craniotomy and hematoma evacuation. It can lead to extremely poor outcomes if not treated properly and promptly.

CASE DESCRIPTION

We present a case of a 49-year-old male who suffered contralateral ASDH during surgical evacuation of ASDH on the left side. Before the operation, we noticed slight contralateral ASDH on preoperative cranial computed tomography and were aware of its enlargement during operation. Decompression with a burr-hole craniotomy promptly followed by a decompressive craniectomy was performed to prevent contralateral ASDH. Unfortunately, we found intraoperative brain swelling, which indicated the development of a contralateral hematoma. The patient was reoperated and eventually had a poor prognosis.

CONCLUSIONS

We highlight that super-early intervention of contralateral hematoma is important to improve the prognosis of these patients.

A case of loss of consciousness with contralateral acute subdural haematoma during awake craniotomy

We are reporting the case of a 56-year-old woman who developed loss of consciousness during awake craniotomy. A thin subdural haematoma in the contralateral side of the craniotomy was identified with intraoperative magnetic resonance imaging and subsequently removed. Our case indicates that contralateral acute subdural haematoma could be a cause of deterioration of the conscious level during awake craniotomy.