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Amorim RL, da Silva VT, Martins HO, Brasil S, Godoy DA, Mendes MT, Gattas G, Bor-Seng-Shu E, Paiva WS. Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series. J Clin Monit Comput 2024; 38:783-789. [PMID: 38381360 DOI: 10.1007/s10877-024-01133-6] [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] [Received: 11/22/2023] [Accepted: 01/28/2024] [Indexed: 02/22/2024]
Abstract
Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.
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Affiliation(s)
- Robson Luís Amorim
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
- Health Sciences Faculty, Federal University of Amazonas, Manaus, Brazil
| | | | | | - Sérgio Brasil
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil.
- Division of Neurosurgery, University of São Paulo, 255. Eneas de Carvalho Aguiar Av., São Paulo, 05403-000, Brazil.
| | - Daniel Agustín Godoy
- Critical Care Department, Division Neurocritical Care, Sanatorio Pasteur, Catamarca, Argentina.
- Neurointensive Care Unit, Sanatorio Pasteur. Chacabuco 747, Catamarca, 4700, Argentina.
| | | | - Gabriel Gattas
- Institute of Radiology, University of São Paulo Medical School, São Paulo, Brazil
| | - Edson Bor-Seng-Shu
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Wellingson Silva Paiva
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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2
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Merakis M, Lewis DP, Weaver N, Balogh ZJ. Time from injury to operative intervention in traumatic intracranial hematoma: A systematic literature review and meta-analysis. World J Surg 2024. [PMID: 39031939 DOI: 10.1002/wjs.12298] [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: 05/20/2024] [Accepted: 07/07/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND The outcomes in traumatic intracranial hematoma (TICH) have not improved significantly despite advances in trauma care. A modifiable factor in TICH management is time to operation room (TOR). TOR has become a key marker in Traumatic brain injury care despite a lack of contemporary evidence. This study aimed to determine the timing of TICH evacuation and its association with mortality and neurological outcomes. METHODS A systematic review of PubMed, OVID MEDLINE, CINAHL, and Web of Science. Included studies reported data on adult patients with acute TICH who underwent surgical evacuation. The primary outcome was TOR and its association with mortality or functional neurological recovery. RESULTS From 1838 articles screened, 17 were included. Eight studies reported TOR as a continuous variable, ranging between 3 and 7.1 h. Three studies found better outcomes with shorter TOR, five found no difference, and one found worse outcomes with shorter TOR. Five articles were included in meta-analysis of mortality in patients undergoing operative decompression less than or greater than 4 h from injury which found lower mortality in the >4-h group, OR = 1.53. Longitudinal regression analysis showed no difference in TOR over the 33-year span of articles included. CONCLUSION There is limited data available on TOR in TICH, with equivocal results on the effect of timing on outcomes. TOR has not decreased over the last 4 decades. The unvalidated 4-h cut-off seems to be associated with better survival. Contemporary assessment of this potentially important performance indicator is required.
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Affiliation(s)
- Michael Merakis
- John Hunter Hospital and University of Newcastle, Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Daniel P Lewis
- Department of Traumatology, John Hunter Hospital, University of Newcastle, New Lambton, New South Wales, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
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3
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Merakis MP, Weaver N, Fischer A, Balogh ZJ. Time to traumatic intracranial hematoma evacuation: contemporary standard and room for improvement. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02573-0. [PMID: 38888792 DOI: 10.1007/s00068-024-02573-0] [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: 09/03/2023] [Accepted: 06/01/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Traumatic intracranial hematoma (TICH) is a neurosurgical emergency with high mortality and morbidity. The time to operative decompression is a modifiable but inconsistently reported risk factor for TICH patients? OUTCOMES We aimed to provide contemporary time to evacuation data and long-term trends in timing of TICH evacuation in a trauma system. METHODS A 13-year retrospective cohort study ending in 2021 at a trauma system with one level-1 trauma center included all patients undergoing urgent craniotomy or craniectomy for evacuation of TICH. Demographics, injury severity and key timeframes of care were collected. Subgroups analyzed were polytrauma versus isolated head injury, direct admissions versus transfers and those who survived versus those who died. Linear regression of times from injury to operating room was performed. RESULTS Seventy-eight TICH patients (Age: 35 (22-56); 58 (74%) males; ISS: 25(25-41); AIS head: 5 (4-5); mortality: 21 (27%) patients) were identified. Initial GCS was 8 (3.25-14) which decreased to 3 (3-7) by arrival in the trauma center. There were 46 (59%) patients intubated prior to arrival. Median time from injury to operation was 4.88 (3.63-6.80) hours. Linear regression of injury to OR showed increasing times to operative intervention for direct admissions to the trauma center over the study period (p=0.04). There was no associated change in mortality or Glasgow outcome score over the same time. CONCLUSION This contemporary data shows timing from injury to evacuation is approaching 5 hours. Over the 13-year study period the time to operative intervention significantly increased for direct admissions. This study will guide our institutions response to TICH presentations in the future. Other trauma systems should critically appraise their results with the same reporting standard.
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Affiliation(s)
- Michael P Merakis
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia
| | - Natasha Weaver
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia
| | - Angela Fischer
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia.
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4
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Fluss R, Ryvlin J, Lam S, Abdullah M, Altschul DJ. Deadliness of Traumatic Subdural Hematomas in the First Quarter of the Year: A Measurement by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Cureus 2023; 15:e50860. [PMID: 38249271 PMCID: PMC10798905 DOI: 10.7759/cureus.50860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Background Traumatic acute subdural hematoma (ASDH) is a surgical emergency and has been associated with high morbidity and mortality. However, it is not known whether mortality from ASDH occurs more frequently in a particular season. Methodology We queried the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) from 2016 to 2019. They were identified in the NSQIP using the International Classification of Diseases (ICD-10) code S06.5 to capture all admissions with a primary diagnosis of traumatic subdural hematoma. Mortality rates were reviewed per season, defined as three consecutive months in the year. Demographics such as age, race, ethnicity, height, and weight were reviewed. Comorbidities such as diabetes, risk factors, including smoking history, and hospitalization characteristics, such as admission year, operation year, and inpatient/outpatient treatment type, were also reviewed. Results A total of 1,656 patients were included in this study. The mean age of all participants was 70.6 years, with 37% (604/1,656) being female. The mortality rate was highest in January, February, and March at 24.5% (104/425, P = 0.045) of admitted patients compared to mortality rates of 18.8% (70/373) in April to June, 18.4% (81/441) in July to September, and 17.5% (73/417) in October to December. Conclusions Mortality is significantly greater during the winter months of January, February, and March among patients with ASDH. Despite better survival rates of ASDH over the past two decades, postoperative mortality rates still remain high.
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Affiliation(s)
- Rose Fluss
- Neurological Surgery, Montefiore Medical Center, Bronx, USA
| | - Jessica Ryvlin
- Neurological Surgery, Albert Einstein College of Medicine, Bronx, USA
| | - Sharon Lam
- Neurological Surgery, Albert Einstein College of Medicine, Bronx, USA
| | - Muhammad Abdullah
- Neurological Surgery, Albert Einstein College of Medicine, Bronx, USA
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5
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van Essen TA, Res L, Schoones J, de Ruiter G, Dekkers O, Maas A, Peul W, van der Gaag NA. Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute? J Neurotrauma 2023; 40:22-32. [PMID: 35699084 DOI: 10.1089/neu.2022.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.
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Affiliation(s)
- Thomas Arjan van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk Res
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Jan Schoones
- Directorate of Research Policy (Walaeus Library), and Leiden University Medical Center, Leiden, The Netherlands
| | - Godard de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Olaf Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Niels Anthony van der Gaag
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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6
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Park JS, Sin EG. Clinical Importance of Prophylactic Ligation of the Bridging Vein in Acute Subdural Hematoma: A Case Report. Korean J Neurotrauma 2023; 19:103-108. [PMID: 37051041 PMCID: PMC10083443 DOI: 10.13004/kjnt.2023.19.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/02/2022] [Accepted: 10/17/2022] [Indexed: 02/25/2023] Open
Abstract
Acute subdural hematoma (ASDH) induced by a bridging vein (BV) rupture is considered a catastrophic head injury, especially in the elderly. Epidemiological studies have shown a much higher incidence rate of BV-induced ASDH in the elderly compared to younger adults, along with elevated morbidity and mortality, and poor outcomes. Brain atrophy can be a risk factor contributing to the increased risk of ASDH in elderly trauma patients. Considering this, prophylactic ligation of the impending breakage in the BV may reduce the risk of rebleeding and treat the ASDH. Here, we report a relevant case.
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Affiliation(s)
- Jun Seok Park
- Department of Neurosurgery, Konyang University Hospital, Daejeon, Korea
| | - Eui Gyu Sin
- Department of Neurosurgery, Konyang University Hospital, Daejeon, Korea
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7
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Dincer A, Stanton AN, Parham KJ, Carr MT, Opalak CF, Valadka AB, Broaddus WC. The Richmond Acute Subdural Hematoma Score: A Validated Grading Scale to Predict Postoperative Mortality. Neurosurgery 2022; 90:278-286. [PMID: 35113829 DOI: 10.1227/neu.0000000000001786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 09/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Traumatic acute subdural hematomas (aSDHs) are common, life-threatening injuries often requiring emergency surgery. OBJECTIVE To develop and validate the Richmond acute subdural hematoma (RASH) score to stratify patients by risk of mortality after aSDH evacuation. METHODS The 2016 National Trauma Data Bank (NTDB) was queried to identify adult patients with traumatic aSDHs who underwent craniectomy or craniotomy within 4 h of arrival to an emergency department. Multivariate logistic regression modeling identified risk factors independently associated with mortality. The RASH score was developed based on a factor's strength and level of association with mortality. The model was validated using the 2017 NTDB and the area under the receiver operating characteristic curve (AUC). RESULTS A total of 2516 cases met study criteria. The patients were 69.3% male with a mean age of 55.7 yr and overall mortality rate of 36.4%. Factors associated with mortality included age between 61 and 79 yr (odds ratio [OR] = 2.3, P < .001), age ≥80 yr (OR = 6.3, P < .001), loss of consciousness (OR = 2.3, P < .001), Glasgow Coma Scale score of ≤8 (OR = 2.6, P < .001), unilateral (OR = 2.8, P < .001) or bilateral (OR = 3.9, P < .001) unresponsive pupils, and midline shift >5 mm (OR = 1.7, P < .001). Using these risk factors, the RASH score predicted progressively increasing mortality ranging from 0% to 94% for scores of 0 to 8, respectively (AUC = 0.72). Application of the RASH score to 3091 cases from 2017 resulted in similar accuracy (AUC = 0.74). CONCLUSION The RASH score is a simple and validated grading scale that uses easily accessible preoperative factors to predict estimated mortality rates in patients with traumatic aSDHs who undergo surgical evacuation.
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Affiliation(s)
- Alper Dincer
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Amanda N Stanton
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kevin J Parham
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Matthew T Carr
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Charles F Opalak
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - William C Broaddus
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
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8
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Tandon PN. Unsolved Problems of Brain Trauma. Neurol India 2020; 68:534-539. [PMID: 32643658 DOI: 10.4103/0028-3886.288988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Prakash N Tandon
- National Brain Research Centre, Manesar, Gurugram, Haryana, India
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9
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Rossini Z, Nicolosi F, Kolias AG, Hutchinson PJ, De Sanctis P, Servadei F. The History of Decompressive Craniectomy in Traumatic Brain Injury. Front Neurol 2019; 10:458. [PMID: 31133965 PMCID: PMC6517544 DOI: 10.3389/fneur.2019.00458] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023] Open
Abstract
Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.
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Affiliation(s)
- Zefferino Rossini
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Federico Nicolosi
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | | | - Franco Servadei
- Research Hospital, Humanitas University, Pieve Emanuele, Italy
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10
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Bus S, Verbaan D, Kerklaan BJ, Sprengers MES, Vandertop WP, Stam J, Bouma GJ, van den Munckhof P. Do older patients with acute or subacute subdural hematoma benefit from surgery? Br J Neurosurg 2018; 33:51-57. [PMID: 30317874 DOI: 10.1080/02688697.2018.1522418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE According to the international guidelines, acute subdural hematomas (aSDH) with a thickness of >10 mm, or causing a midline shift of >5 mm, should be surgically evacuated. However, high mortality rates in older patients resulted in ongoing controversy whether elderly patients benefit from surgery. We identified predictors of outcome in a single-centre cohort of elderly patients undergoing surgical evacuation of aSDH or subacute subdural hematoma (saSDH). MATERIALS AND METHODS This retrospective study included all patients aged ≥65 years undergoing surgical evacuation of aSDH/saSDH from 2000 to 2015. One-year outcome was dichotomized into favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3). Predictors of outcome were identified by analysing patient characteristics. RESULTS Eighty-four patients aged ≥65 years underwent craniotomy for aSDH/saSDH during the 16 year time period. Twenty-five percent regained functional independence, 11% survived severely disabled, and 64% died. Most patients died of respiratory failure following withdrawal of artificial respiration or following restriction of treatment. Age of the SDH or Glasgow Coma Scores ≤8/intubation did not predict unfavourable outcome. All patients with bilaterally absent pupillary light reflexes died, also those who still exhibited one normal-sized pupil. CONCLUSION The low number of operated patients per year probably suggests that this cohort represents a selection of patients who were judged to have good chances of favouring from surgery. Functional independence at one-year follow-up was reached in 25% of patients, 64% died. Patients with bilaterally absent pupillary light reflexes did not benefit from surgery. The tendency to restrict treatment because of presumed poor prognosis may have acted as a self-fulfilling prophecy.
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Affiliation(s)
- Sander Bus
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Dagmar Verbaan
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Bertjan J Kerklaan
- b Department of Neurology , Onze Lieve Vrouwe Gasthuis, Amsterdam, and Zaans Medical Centre , Zaandam , The Netherlands
| | | | - William P Vandertop
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Jan Stam
- d Department of Neurology , Academic Medical Centre , Amsterdam , The Netherlands
| | - Gerrit J Bouma
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
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11
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Wang HC, Tsai JC, Lee JE, Huang SJ, Po-Hao Huang A, Lin WC, Hsieh ST, Wang KC. Direct visualization of microcirculation impairment after acute subdural hemorrhage in a novel animal model. J Neurosurg 2017; 129:997-1007. [PMID: 29219760 DOI: 10.3171/2017.5.jns162579] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Direct brain compression and secondary injury due to increased intracranial pressure are believed to be the pathognomic causes of a grave outcome in acute subdural hemorrhage (aSDH). However, ischemic damage from aSDH has received limited attention. The authors hypothesized that cerebral microcirculation is altered after aSDH. Direct visualization of microcirculation was conducted in a novel rat model. METHODS A craniectomy was performed on each of the 18 experimental adult Wistar rats, followed by superfusion of autologous arterial blood onto the cortical surface. Changes in microcirculation were recorded by capillary videoscopy. Blood flow and the partial pressure of oxygen in the brain tissue (PbtO2) were measured at various depths from the cortex. The brain was then sectioned for pathological examination. The effects of aspirin pretreatment were also examined. RESULTS Instantaneous vasospasm of small cortical arteries after aSDH was observed; thrombosis also developed 120 minutes after aSDH. Reductions in blood flow and PbtO2 were found at depths of 2-4 mm. Blood-brain barrier disruption and thrombi formation were confirmed using immunohistochemical staining, while aspirin pretreatment reduced thrombosis and the impairment of microcirculation. CONCLUSIONS Microcirculation impairment was demonstrated in this aSDH model. Aspirin pretreatment prevented the diffuse thrombosis of cortical and subcortical vessels after aSDH.
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Affiliation(s)
- Huan-Chih Wang
- 1Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu.,2Division of Neurosurgery, Department of Surgery
| | | | - Jing-Er Lee
- 3Department of Neurology, Taipei Medical University-Wan Fang Hospital, Taipei; and
| | | | | | | | - Sung-Tsang Hsieh
- 5Department of Neurology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei.,6Department of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan
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12
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Yoon JH, Shim YB, Gwak HS, Kwon JW, Lee SH. Acute Spontaneous Subdural Hematoma of Arterial Origin. ACTA ACUST UNITED AC 2017. [DOI: 10.21129/nerve.2017.3.1.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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13
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Lenzi J, Caporlingua F, Caporlingua A, Anichini G, Nardone A, Passacantilli E, Santoro A. Relevancy of positive trends in mortality and functional recovery after surgical treatment of acute subdural hematomas. Our 10-year experience. Br J Neurosurg 2016; 31:78-83. [PMID: 27596026 DOI: 10.1080/02688697.2016.1226253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Among traumatic brain injuries, acute subdural hematoma (aSDH) is considered one of the most devastating still retaining poor surgical outcomes in a considerable percentage of affected patients. However, according to results drawn from published samples of aSDH patients, overall mortality and functional recovery have been progressively ameliorating during the last decades. METHODS We present a retrospective analysis of 316 consecutive cases of post-traumatic aSDH operated on between 2003 and 2011 at our institution. RESULTS Mortality was 67% (n = 212); a useful recovery was achieved in 16.4% cases (n = 52). Age >65 years, a preoperative Glasgow coma scale (GCS) ≤ 8, specific pre-existing medical comorbidities (hypertension, heart diseases) were found to be strong indicators of unfavorable outcomes and death during hospitalization. CONCLUSION Our results, compared with those of the inherent literature, led the authors to question both the "aggressiveness" of neurosurgical care indications in certain subpopulations of patients being known to fare worse or even die regardless of the treatment administered and the relevance of the results concerning mortality and functional recovery reported by third authors.
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Affiliation(s)
- Jacopo Lenzi
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy
| | - Federico Caporlingua
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy
| | - Alessandro Caporlingua
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy
| | - Giulio Anichini
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy.,b Department of Neurosurgery , Charing Cross Hospital, Imperial College of London , London , United Kingdom
| | - Antonio Nardone
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy
| | - Emiliano Passacantilli
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy
| | - Antonio Santoro
- a Department of Neurology and Psychiatry, Neurosurgery , "Sapienza" University of Rome , Rome , Italy
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deRoux SJ, Sgarlato A. Subdural Hemorrhage, a Retrospective Review with Emphasis on a Cohort of Alcoholics. J Forensic Sci 2015; 60:1224-8. [PMID: 26174954 DOI: 10.1111/1556-4029.12792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/10/2014] [Accepted: 08/18/2014] [Indexed: 11/28/2022]
Abstract
Subdural hemorrhage (SDH) is a common cause of death. As external evidence of injury may be absent, an autopsy is frequently needed to detect it. We conducted a 3-year review of SDH from the New York City Office of Chief Medical Examiner, with emphasis on a cohort of alcoholics. Our study population of 1942 included 1588 alcoholics. Of the alcoholics, c. 8% had SDH (26% of the total number of SDH). Of the alcoholics with SDH, 57% had associated brain injuries. As alcohol intoxication is frequently associated with aggressive and violent behavior, we are concerned that 6% of alcoholics in our review had no autopsy or imaging studies. It is possible that a portion of these may have had a SDH due to an unrecognized inflicted injury. We recommend that autopsies be performed on all alcoholics without a clear cause or mechanism of death.
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Affiliation(s)
- Stephen J deRoux
- New York City Office of Chief Medical Examiner and Department of Forensic Medicine, New York University School of Medicine, New York, 10016, NY
| | - Anthony Sgarlato
- Office of Chief Medical Examiner of the City of New York, 520 First Ave, New York, 10016, NY
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15
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Miller JD, Nader R. Acute subdural hematoma from bridging vein rupture: a potential mechanism for growth. J Neurosurg 2014; 120:1378-84. [DOI: 10.3171/2013.10.jns13272] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Most acute subdural hematomas (ASDHs) develop after rupture of a bridging vein or veins. The anatomy of the bridging vein predisposes to its tearing within the border cell layer of the dura mater. Thus, the subdural hematoma actually forms within the dura. The hematoma grows by continued bleeding into the border cell layer. However, the venous pressure would not be expected to cause a large hematoma. Therefore, some type of mechanism must account for the hematoma's expansion.
Cerebral venous pressure (CVP) has been demonstrated in animal models to be slightly higher than intracranial pressure (ICP), and CVP tracks the ICP as pressure variations occur. The elevation of CVP as the ICP increases is thought to result from an increase in outflow resistance of the terminal portion of the bridging veins. This probably results from a Starling resistor model or, less likely, from a muscular sphincter.
A hypothesis is derived to explain the mechanism of ASDH enlargement. Tearing of one or more bridging veins causes these vessels to bleed into the dural border cell layer. Subsequent ICP elevation from the ASDH, cerebral swelling, or other cause results in elevation of the CVP by increased outflow resistance in the intact bridging veins. The increased ICP causes further bleeding into the hematoma cavity via the torn bridging veins. Thus, the ASDH enlarges via a positive feedback mechanism.
Enlargement of an ASDH would cease as blood within the hematoma cavity coagulates. This would stop the dissection of the dural border cell layer, and pressure within the hematoma cavity would equalize with that in the torn bridging vein or veins.
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Affiliation(s)
- Jimmy D. Miller
- 1Division of Neurosurgery, Greenwood Leflore Hospital, Greenwood, Mississippi
| | - Remi Nader
- 2Division of Neurosurgery, University of Texas Medical Branch, Galveston; and
- 3Texas Center for Neurosciences, Beaumont, Texas
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16
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Cook RJ, Fearnside MR, McDougall P, McNeil RJ. The Westmead head injury project: Outcome prediction in acute subdural haematoma. J Clin Neurosci 2012; 3:143-8. [PMID: 18638857 DOI: 10.1016/s0967-5868(96)90008-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/1994] [Accepted: 05/19/1995] [Indexed: 10/26/2022]
Abstract
A prospective two year study of a consecutive sample of patients with an acute subdural haematoma who were admitted to Westmead Hospital, New South Wales, Australia was undertaken. There were 103 patients with an acute subdural haematoma admitted in the period. Twenty-four of these scored 9 or greater on the Glasgow Coma Scale (GCS) and of these all made a functional recovery, i.e. Glasgow Outcome Scale (GOS 1 or 2). The remaining 79 patients scored 8 or less on admission and of these 30% made a functional recovery. Of the 70% remaining, 4% were moderately or severely disabled (GOS 3 or 4) while 66% died (GOS 5). Age, hypoxia, hypotension, response to intracranial pressure control and two CT scan features, midline shift as measured from the septum pellucidum and cerebral oedema, were all significant in predicting outcome. Time from injury to treatment, initial pupil response, lucid interval and compression of brainstem cisterns on CT scans statistically failed to predict outcome. The data were analysed using logistic regression which showed age and midline shift to predict death or disability with an accuracy of 80% at twelve months after the injury (sensitivity 58%, specificity 89%).
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Affiliation(s)
- R J Cook
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth WA, Australia; Department of Neurosurgery, Westmead Hospital, Westmead NSW, Australia
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Walcott BP, Nahed BV, Sheth SA, Yanamadala V, Caracci JR, Asaad WF. Bilateral hemicraniectomy in non-penetrating traumatic brain injury. J Neurotrauma 2012; 29:1879-85. [PMID: 22452418 DOI: 10.1089/neu.2012.2382] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury is a heterogeneous entity that encompasses both surgical and non-surgical conditions. Surgery may be indicated with traumatic lesions such as hemorrhage, fractures, or malignant cerebral edema. However, the neurological exam may be clouded by the effects of medications administered in the field, systemic injuries, and inaccuracies in hyperacute prognostication. Typically, neurological injury is considered irreversible if diffuse loss of grey/white matter differentiation or if brainstem hemorrhage (Duret hemorrhage) exists. We aim to characterize a cohort of patients undergoing bilateral hemicraniectomy for severe traumatic brain injury. A retrospective consecutive cohort of adult patients undergoing craniectomy for trauma was established between the dates of January 2008 and November 2011. The primary outcome of the study was in-hospital mortality. Secondary outcomes were ICU length of stay, surgical complications, and Glasgow Outcome Score at most recent follow-up. During the study period, 210 patients undergoing craniectomy for traumatic mass-occupying lesion (epidural hematoma, subdural hematoma, or parenchymal contusion) were analyzed. Of those, 9 met study criteria. In-hospital mortality was 67% (6 of 9 patients). The average ICU length of stay was 12 days. The GOS score was 3 in surviving patients. Bilateral hemicraniectomy is a heroic intervention for patients with severe TBI, but can be a life-saving procedure.
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Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Cho CB, Park HK, Chough CK, Lee KJ. Spontaneous bilateral supratentorial subdural and retroclival extradural hematomas in association with cervical epidural venous engorgement. J Korean Neurosurg Soc 2009; 46:172-5. [PMID: 19763223 DOI: 10.3340/jkns.2009.46.2.172] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Revised: 02/22/2009] [Accepted: 08/04/2009] [Indexed: 11/27/2022] Open
Abstract
We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patient's symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.
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Affiliation(s)
- Chul Bum Cho
- Catholic Neuroscience Center, Department of Neurosurgery, St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Senft C, Schuster T, Forster MT, Seifert V, Gerlach R. Management and outcome of patients with acute traumatic subdural hematomas and pre-injury oral anticoagulation therapy. Neurol Res 2009; 31:1012-8. [PMID: 19570326 DOI: 10.1179/174313209x409034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Acute subdural hematomas (aSDHs) are found in up to one-third of patients with severe traumatic brain injury and are associated with an unfavorable outcome in the majority of cases. Mortality ranges between 40 and 60%, but was reported to be even higher in patients undergoing oral anticoagulation therapy (OAT) at the time of injury. The objective of this study is to specifically report on the peri-operative management and outcome of patients with aSDH and pre-injury OAT. MATERIAL AND METHODS From June 2002 to June 2006, all patients with OAT who underwent surgical treatment of aSDH were retrospectively analysed. Results of pre-operative blood tests, the peri-operative and surgical management and the clinical courses were assessed. Patient outcome is reported according to the Glasgow Outcome Scale (GOS) at 6 months. RESULTS Eleven (10.3%) out of 107 patients with aSDH were on OAT. Patients with OAT were significantly older than patients without OAT (72.4 +/- 9.3 versus 59.9 +/- 17.5 years; p<0.05, Mann-Whitney U-test). Intensity of head trauma was moderate in four and severe in seven patients with a median pre-operative Glasgow Coma Scale (GCS) of 8. Median pre-treatment prothrombin time and international normalized ratio were 23% (range: 10-65%) and 3.3 (range: 1.5-10.6), respectively. Replacement therapy consisted of administration of prothrombin complex concentrates, vitamin K and FFP (fresh frozen plasma). In four patients, antithrombin was additionally given to prevent disseminated intravascular coagulation. Surgical treatment consisted of craniotomy (n=10) or craniectomy (n=1) and hematoma evacuation with intracranial pressure probe placement. Low molecular weight heparin was administered as pharmacological prophylaxis of thrombembolic events in an increasing dose post-operatively. At 6 months, six out of 11 patients survived with a median GOS of 4. All-cause mortality was 45.5%. A pre-operative GCS of < or = 8 was not associated with an increased risk of mortality (p>0.5, Fisher's exact test). No relevant rebleedings or thrombembolic complications were observed. The mortality rate of patients who did not undergo OAT was 50%. CONCLUSION A large number of patients with aSDH are on pre-injury OAT. Specific replacement therapy facilitates successful clot evacuation without bleeding complications. The overall outcome of these patients does not seem to differ from historical cohorts with aSDH without OAT, but a large prospective multicenter study is warranted to answer that question.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe University, Frankfurt, Germany.
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Kim KH. Predictors for functional recovery and mortality of surgically treated traumatic acute subdural hematomas in 256 patients. J Korean Neurosurg Soc 2009; 45:143-50. [PMID: 19352475 DOI: 10.3340/jkns.2009.45.3.143] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 02/22/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the reliable factors influencing the surgical outcome of the patients with traumatic acute subdural hematoma (ASDH) and to improve the functional outcome of these patients. METHODS A total of 256 consecutive patients who underwent surgical intervention for traumatic ASDH between March 1998 and March 2008 were reviewed. We evaluated the influence of perioperative variables on functional recovery and mortality using multivariate logistic regression analysis. RESULTS Functional recovery was achieved in 42.2% of patients and the overall mortality was 39.8%. Age (OR=4.91, p=0.002), mechanism of injury (OR=3.66, p=0.003), pupillary abnormality (OR=3.73, p=0.003), GCS score on admission (OR=5.64, p=0.000), and intraoperative acute brain swelling (ABS) (OR=3.71, p=0.009) were independent predictors for functional recovery. And preoperative pupillary abnormality (OR=2.60, p=0.023), GCS score (OR=4.66, p=0.000), and intraoperative ABS (OR=4.16, p=0.001) were independent predictors for mortality. Midline shift, thickness and volume of hematoma, type of surgery, and time to surgery showed no independent association with functional recovery, although these variables were correlated with functional recovery in univariate analyses. CONCLUSION Functional recovery was more likely to be achieved in patients who were under 40 years of age, victims of motor vehicle collision and having preoperative reactive pupils, higher GCS score and the absence of ABS during surgery. These results would be helpful for neurosurgeon to improve outcomes from traumatic acute subdural hematomas.
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Affiliation(s)
- Kyu-Hong Kim
- Department of Neurosurgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine, Masan, Korea
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21
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Turtz AR, Goldman HW. Head Injury. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Raju S, Gupta DK, Mehta VS, Mahapatra A. Predictors of outcome in acute subdural hematoma with severe head injury- A prospective study. INDIAN JOURNAL OF NEUROTRAUMA 2004. [DOI: 10.1016/s0973-0508(04)80008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
The management of pediatric head injuries has evolved over the past decade,and a number of significant advances have been made. Evidence-based guide-lines and algorithms for the management of severe pediatric head injuries have recently been published, and all pediatricians who care for children with severe head injuries should be familiar with these guidelines. It is hoped the guidelines will streamline the clinical management of these children and stimulate future research into the many areas that require further investigation.
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Affiliation(s)
- Mark S Dias
- Department of Pediatric Neurosurgery, Penn State University College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.
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Abstract
BACKGROUND Acute subdural hematoma in infants is distinct from that occurring in older children or adults because of differences in mechanism, injury thresholds, and the frequency with which the question of nonaccidental injury is encountered. The purpose of this study is to analyze the clinical characteristics of acute subdural hematoma in infancy, to discover the common patterns of this trauma, and to outline the management principles within this group. METHODS Medical records and films of 21 cases of infantile acute subdural hematoma were reviewed retrospectively. Diagnosis was made by computed tomography or magnetic resonance imaging. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome. RESULTS Twenty-one infants (9 girls and 12 boys) were identified with acute subdural hematoma, with ages ranging from 6 days to 12 months. The most common cause of injury was shaken baby syndrome. The most common clinical presentations were seizure, retinal hemorrhage, and consciousness disturbance. Eight patients with large subdural hematomas underwent craniotomy and evacuation of the blood clot. None of these patients developed chronic subdural hematoma. Thirteen patients with smaller subdural hematomas were treated conservatively. Among these patients, 11 developed chronic subdural hematomas 15 to 80 days (mean = 28 days) after the acute subdural hematomas. All patients with chronic subdural hematomas underwent burr hole and external drainage of the subdural hematoma. At follow-up, 13 (62%) had good recovery, 4 (19%) had moderate disability, 3 (14%) had severe disability, and 1 (5%) died. Based on GCS on admission, one (5%) had mild (GCS 13-15), 12 (57%) had moderate (GCS 9-12), and 8 (38%) had severe (GCS 8 or under) head injury. Good recovery was found in 100% (1/1), 75% (8/12), and 50% (4/8) of the patients with mild, moderate, and severe head injury, respectively. Sixty-three percent (5/8) of those patients undergoing operation for acute subdural hematomas and 62% (8/13) of those patients treated conservatively had good outcomes. CONCLUSIONS Infantile acute subdural hematoma if treated conservatively or neglected, is an important cause of infantile chronic subdural hematoma. Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality.
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MESH Headings
- Diagnosis, Differential
- Female
- Follow-Up Studies
- Hematoma, Subdural, Acute/diagnosis
- Hematoma, Subdural, Acute/etiology
- Hematoma, Subdural, Acute/surgery
- Hematoma, Subdural, Chronic/diagnosis
- Hematoma, Subdural, Chronic/etiology
- Hematoma, Subdural, Chronic/surgery
- Humans
- Infant
- Infant, Newborn
- Magnetic Resonance Imaging
- Male
- Neurologic Examination
- Risk Factors
- Shaken Baby Syndrome/diagnosis
- Shaken Baby Syndrome/prevention & control
- Shaken Baby Syndrome/surgery
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- Joon-Khim Loh
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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25
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Abstract
According to European Brain Injury Consortium (EBIC) and American Brain Injury Consortium (ABIC) guidelines for severe head injuries, decompressive craniectomy is one therapeutic option for brain edema that does not respond to conventional therapeutic measures. As a result of the failure of all recently developed drugs to improve outcome in this patient group, decompressive craniectomy has experienced a revival during the last decade. Although class I studies of this subject are still lacking, there is strong evidence from prospective, uncontrolled trials that such an operation improves outcome in general and also has beneficial effects on various physiologic parameters that are known to be independent predictors for poor outcome. Whether this operation should be performed in a protocol-driven or in a prophylactic manner remains unclear. Decompressive craniectomy may, however, be the only method available in developing countries with limited ICU and monitoring resources. Prospectively controlled and randomized studies to definitively evaluate the effect of this old neurosurgical method on outcome in patients with traumatic brain injury (TBI) are forthcoming.
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Affiliation(s)
- Jürgen Piek
- Neurosurgical Clinic, Ernst-Moritz-Arndt-University Greifswald, Greifswald, Germany.
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Münch E, Horn P, Schürer L, Piepgras A, Paul T, Schmiedek P. Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery 2000; 47:315-22; discussion 322-3. [PMID: 10942004 DOI: 10.1097/00006123-200008000-00009] [Citation(s) in RCA: 224] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The beneficial effect of decompressive craniectomy in the treatment of head trauma patients is controversial. The aim of our study was to assess the value of unilateral decompressive craniectomy in patients with severe traumatic brain injury. METHODS We retrospectively investigated 49 patients who underwent decompressive craniectomy. Intracranial pressure, cerebral perfusion pressure, therapy intensity level, and cranial computed tomographic scan features (midline shift, visibility of ventricles, gyral pattern, and mesencephalic cisterns) were evaluated before and after craniectomy. The gain of intracranial space was calculated from cranial computed tomographic scans. Patient outcome was graded using the Glasgow Outcome Scale. RESULTS Thirty-one patients (63.3%) underwent rapid surgical decompression within 4.5 +/- 3.8 hours after trauma; in 18 patients (36.7%), delayed surgical decompression was performed 56.2 +/- 57.0 hours after injury. Patients younger than 50 years or patients who underwent rapid surgical decompression had a significantly better outcome than older patients or patients who underwent delayed surgical decompression. Craniectomy significantly decreased midline shift and improved visibility of the mesencephalic cisterns. The state of the mesencephalic cisterns correlated with the distance of the lower border of the craniectomy to the temporal cranial base. Alterations in intracranial pressure, cerebral perfusion pressure, and therapy intensity level were not significant. The overall mortality of the patients corresponded to the reports of the Traumatic Coma Data Bank (1991). CONCLUSION Although there was a significant decrease in midline shift after craniectomy, this did not translate into decompressive craniectomy demonstrating a beneficial effect on patient outcome.
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Affiliation(s)
- E Münch
- Department of Anesthesiology, Klinikum Mannheim, University of Heidelberg, Mannheim, Germany.
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27
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The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Age. J Neurotrauma 2000; 17:573-81. [PMID: 10937903 DOI: 10.1089/neu.2000.17.573] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Age is a strong factor influencing both mortality and morbidity. Despite some contradictions, most literature supports children faring better than adults who have severe brain injury. The significant influence of age upon outcome is not explained by the increased frequency of systemic complications or intracerebral hematomas with age. Increasing age is a strong independent factor in prognosis, with a significant increase in poor outcome above 60 years of age.
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Koç RK, Akdemir H, Oktem IS, Meral M, Menkü A. Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev 1998; 20:239-44. [PMID: 9457718 DOI: 10.1007/bf01105894] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome. Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively. Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9-15) and 23% of patients with a low GCS score (3-8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21-40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion. Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.
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Affiliation(s)
- R K Koç
- Department of Neurosurgery, Erciyes University, Medical School, Kayseri, Turkey
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30
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Abstract
This article reviews the neuroradiological evaluation of acute head injury with an emphasis on CT and MR imaging. Subacute and chronic head injury are not discussed. CT remains the modality of choice in the emergency setting, permitting rapid, comprehensive assessment of the great majority of head injuries. MR is most useful in patients in whom there is a discrepancy between clinical symptoms and CT findings. In addition, MR is the imaging modality of choice in the subacute and chronic setting. The superior contrast resolution of MR permits optimal evaluation of nonhemorrhagic (and hemorrhagic) white matter shearing injuries, and the lack of beam-hardening artifact permits a more thorough evaluation of the brain stem, posterior fossa, and cortical surface.
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Affiliation(s)
- J G Murray
- University of California, San Francisco 94110, USA
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31
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de Figueiredo Neto N, Martins JW, Farage Filho M, da Motta LA, de Mello PA, Pereira RS. [Acute traumatic subdural haematomas: study of 110 cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 1996; 54:238-44. [PMID: 8984982 DOI: 10.1590/s0004-282x1996000200011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report a series of 110 patients with acute traumatic subdural hematoma (ASDH) admitted at HBDF emergency within 1994 (January 1st to December 1st). All patients were treated according to the same protocol. There was a predominance of males (79%), with ages ranging from 14 to 70, being car accidents (20%) and car-pedestrian accidents (34%) the most frequent causes. The majority of patients (85.7%) was admitted in very serious condition, with a score of 8 points on the Glasgow Coma Scale (GCS) or lesser, which directly influenced the mortality rates. CT scan was the diagnostic procedure of choice, and it showed contusion and brain swelling to be the most frequent associated intracranial lesions. Surgery was carried out in 45.1% of cases and, in most instances, through an ample fronto-temporo-parietal craniotomy, with hematoma drainage and dural reconstitution. In 54.9% of cases, clinical conditions did not allow surgery and in this group, 69.6%.
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Massaro F, Lanotte M, Faccani G, Triolo C. One hundred and twenty-seven cases of acute subdural haematoma operated on. Correlation between CT scan findings and outcome. Acta Neurochir (Wien) 1996; 138:185-91. [PMID: 8686543 DOI: 10.1007/bf01411359] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Traumatic acute subdural haematoma is one of the most lethal of all head injuries: the mortality rate is reported to be between 50 and 90%. We reviewed the clinical records of 1688 head injured patients admitted to the Department of Neurosurgery at C.T.O. hospital between 1982 and 1992. In 127 cases (7,5%) CTscan on admission showed acute subdural haematoma requiring surgery because the midline shift was greater than 5 mm. The overall mortality rate was 57% and 23% had functional recovery. The following variables were assessed with regard to morbidity and mortality: mechanism of injury, age, neurological presentation, time delay from injury to intervention, CTscan finding on admission. GCS and CTscan findings were found to be the most important prognostic variable. Timing of operative intervention for clot removal with regard to outcome was not statistically significant. But no conclusions regarding the importance of early haematoma evacuation can be drawn from such an oversimplifying statement, because it does not take into account factors like rapidity of haematoma development and related brain decompensation as well as additional direct brain lesions. The results of this study suggest that the extent of primary brain injury underlying the subdural haematoma is the most important factor affecting outcome.
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Affiliation(s)
- F Massaro
- Department of Neurosurgery, C.T.O. Hospital, Torino, Italy
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33
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Snoey ER, Levitt MA. Delayed diagnosis of subdural hematoma following normal computed tomography scan. Ann Emerg Med 1994; 23:1127-31. [PMID: 8185112 DOI: 10.1016/s0196-0644(94)70115-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We report the cases of three patients with subdural hematoma following minor closed-head trauma in whom the initial neurologic examinations and cranial computed tomography (CT) scans were normal. In each case, the patient was re-evaluated clinically several times (average of four times) due to persistence of post-traumatic symptoms. The development of focal neurologic signs, which eventually led to a correct diagnosis, was significantly delayed in all three cases (average of 47 days). All three patients had large subdural hematomas requiring surgical drainage. The timely diagnosis of subdural hematoma may be difficult despite the appropriate use of CT scan in the immediate post-traumatic period. Repeat CT scan may be indicated in patients suffering minor head trauma with persistent symptoms. These patients seem to recover without deficit following neurosurgical treatment despite a significant delay in diagnosis.
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Affiliation(s)
- E R Snoey
- Department of Emergency Medicine, Highland General Hospital, Oakland, California
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Kotwica Z, Brzeziński J. Acute subdural haematoma in adults: an analysis of outcome in comatose patients. Acta Neurochir (Wien) 1993; 121:95-9. [PMID: 8512021 DOI: 10.1007/bf01809257] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The authors analysed a series of 200 adult patients admitted to the Department of Neurosurgery, Medical University of Lódź with a diagnosis of acute subdural haematoma (ASDH). 63% of them were surgically treated within the first 4 hours after head injury, the others were operated on 4 to 16 hours after trauma. All patients had GCS below 10 for the whole time period from trauma to surgery. Younger patients 18-30 year old had lower mortality-25%, while patients above 50 revealed 75% mortality. Analysis of operative timing and outcome, no benefit revealed when surgery was performed within first 4 hours. However, the patients operated on later than 4 hours after trauma had smaller midline shift and less pronounced brain contusion. It must be taken into account that some patients who could benefit from early surgery-those with quickly developing haematomas and intracranial hypertension-had no chance to arrive and died in peripheral hospitals. Despite our results we advocate an urgent evacuation of haematoma, as early as possible after trauma. Significant correlation was found between midline shift, cerebral contusion on CT scans and results of surgery. Patients with bigger midline shift or presence of focal cerebral contusion revealed higher mortality and worse outcome than patients with smaller shift and no cerebral contusion visible on CT pictures.
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Affiliation(s)
- Z Kotwica
- Department of Neurosurgery, Medical University of Lódź, High School of Medicine, Poland
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Abstract
A teenager with a history of sudden onset of headache and vomiting is described. Computed tomography revealed an acute subdural hematoma in the right temporoparietal region, causing marked compression of the right ventricular system and a shift of midline structures to the left. No operation was carried out because the symptoms and neurological signs were slight enough to allow monitoring by means of close clinical and neuroradiological investigations. Within 18 days the hematoma resolved spontaneously and completely. There was no history of trauma or any objective sign of trauma about the face or head, and radiography of the skull showed no fracture. We are not aware of any other report of a spontaneous subdural hematoma which did not require surgery. This feature makes our case unique. In addition, comparable cases in the literature are reviewed and the etiological possibilities of spontaneous subdural hematoma are discussed.
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Affiliation(s)
- A Kulah
- Clinic of Neurosurgery, Dicle University School of Medicine, Diyarbakir, Turkey
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Kotwica Z, Jakubowski JK. Acute head injuries in the elderly. An analysis of 136 consecutive patients. Acta Neurochir (Wien) 1992; 118:98-102. [PMID: 1456109 DOI: 10.1007/bf01401293] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
136 patients older than 70 years, admitted to our neurosurgical ward directly after head trauma, were analysed. 40% of them were admitted with low GCS, below 9 points, and showed a mortality of 85%. 45 patients had intracranial mass lesions--the commonest was subdural haematoma, with a low incidence of epidural haematomas. In patients admitted with GCS above 12, mortality was 20%, mainly due to pneumonia. Satisfactory results were achieved in 30% of trauma victims. From patients with intracranial space occupying lesions and GCS below 9 points on admission practically all died, despite aggressive surgical treatment and intensive care. Thus, especially in departments with limited resources, therapy can be limited, or even no therapy may be introduced in this group. Surgical treatment can be limited only to patients who are conscious on admission. In patients with non-surgical lesions, low GCS--below 9 points--leads to mortality of 80%, and in this group we propose aggressive intensive care for 24 hours and the limitation of further "maximal" therapy only to those, who significantly improve within this period of time. If the patient has a non-surgical lesion and is conscious after trauma, aggressive treatment of extracranial complication is the most important, because brain injury can usually be well tolerated by these patients. If pneumonia or heart complications do not occur this group of old patients often have a good prognosis.
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Affiliation(s)
- Z Kotwica
- Department of Neurosurgery, School of Medicine, Medical University of Lódź, Poland
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Crooks DA. Pathogenesis and biomechanics of traumatic intracranial haemorrhages. VIRCHOWS ARCHIV. A, PATHOLOGICAL ANATOMY AND HISTOPATHOLOGY 1991; 418:479-83. [PMID: 2058082 DOI: 10.1007/bf01606496] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Intracranial haemorrhage is frequently seen by the general pathologist in the context of neural trauma. Thus, the differential diagnosis, pathogenesis and biomechanics are of practical interest in the routine work. Extradural haematomas are produced when branches of the middle meningeal vessels are lacerated. They are commonly located in the temporal fossa, and other intracranial haematomas may be present. Skull fractures occur in a high percentage of cases and play a key role in the pathogenesis of this type of bleeding. Acute subdural haematomas commonly arise from tearing of the bridging veins. They are often located in the temporal and frontal regions, and the morbidity and mortality are related to the extent of the underlying brain damage. The visco-elastic behaviour of the bridging veins and their lack of reinforcement by arachnoid trabecula in the subdural space explains why they tear under high rates of acceleration during trauma. Subacute and chronic subdural haematomas are weakly correlated with trauma. The less striking onset of symptoms may be related to the rate of blood accumulation and the capacity of the brain to accommodate the mass effect of the bleeding. Intracerebral haematomas are probably due to the direct rupture of the intrinsic cerebral vessels. The mortality rate shows no correlation with location, but those located in the basal ganglia are compatible with a good recovery when occurring in isolation. Traumatic subarachnoid haemorrhage, when in isolation, is usually associated with evidence of injury elsewhere, such as the neck muscles or the ligamentary system of the cervical spinal column. It may be secondary to intraventricular bleeding due to tearing of the tela choroidea, or associated with contusions.
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Affiliation(s)
- D A Crooks
- Department of Morbid Anatomy, Royal London Hospital, UK
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Wilberger JE, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 1991; 74:212-8. [PMID: 1988590 DOI: 10.3171/jns.1991.74.2.0212] [Citation(s) in RCA: 265] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Traumatic acute subdural hematoma remains one of the most lethal of all head injuries. Since 1981, it has been strongly held that the critical factor in overall outcome from acute subdural hematoma is timing of operative intervention for clot removal; those operated on within 4 hours of injury may have mortality rates as low as 30% with functional survival rates as high as 65%. Data were reviewed for 1150 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3 to 7) treated at a Level 1 trauma center between 1982 and 1987; 101 of these patients had acute subdural hematoma. Standard treatment protocol included aggressive prehospital resuscitation measures, rapid operative intervention, and aggressive postoperative control of intracranial pressure (ICP). The overall mortality rate was 66%, and 19% had functional recovery. The following variables statistically correlated (p less than 0.05) with outcome; motorcycle accident as a mechanism of injury, age over 65 years, admission GCS score of 3 or 4, and postoperative ICP greater than 45 mm Hg. The time from injury to operative evacuation of the acute subdural hematoma in regard to outcome morbidity and mortality was not statistically significant even when examined at hourly intervals although there were trends indicating that earlier surgery improved outcome. The findings of this study support the pathophysiological evidence that, in acute subdural hematoma, the extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome; therefore, the ability to control ICP is more critical to outcome than the absolute timing of subdural blood removal.
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Affiliation(s)
- J E Wilberger
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Singounas EG, Sfakianos G, Sourtzis I, Karvounis PC. "Benign" acute subdural haematomas. Analysis of 12 cases. Acta Neurochir (Wien) 1990; 106:140-4. [PMID: 2284989 DOI: 10.1007/bf01809457] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Twelve cases of acute subdural haematomas, who had a benign course, were studied. During the same period of 8 years, 132 patients with acute subdural haematomas were treated in our unit, an incidence of 9%. From our study it becomes evident that the fate of the patients is determined by the type of injury and especially the conscious level of the patients on admission and their evolution. It also becomes evident from the world literature, that the term "acute" was used in an arbitrary way in most papers and more strict criteria should be used for using this term and for evaluating the ultimate course of these patients.
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Affiliation(s)
- E G Singounas
- Evangelismos Medical Center, Neurosurgical Department, Athens, Greece
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Raftopoulos C, Reuse C, Chaskis C, Brotchi J. Acute subdural hematoma of the posterior fossa. A case report and a review of the relevant literature. Clin Neurol Neurosurg 1990; 92:57-62. [PMID: 2154356 DOI: 10.1016/0303-8467(90)90008-s] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute subdural hematoma of the posterior fosa (ASDH-PF) is a clinical rarity with a poor prognosis in teenagers or adults (mortality rate: 71%). We report the third case operated upon with success. The relevant literature is analysed and the characteristics of ASDH-PF are discussed, particularly in connection with the patient's age.
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Affiliation(s)
- C Raftopoulos
- Department of Neurosurgery, Erasmus Hospital, Université Libre de Bruxelles, Belgium
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Abstract
Reports prior to 1980 describe overall mortality rates for acute subdural hematomas (SDH's) ranging from 40% to 90% with poor outcomes observed in all age groups. Recently, improved results have been reported with rapid diagnosis and surgical treatment. A relatively large number of older patients (34 patients over 65 years old) were treated recently at Harborview Medical Center, enabling a retrospective comparison with similarly treated younger patients (33 patients aged 18 to 40 years). Clinical information and computerized tomography morphometric data were obtained. Patients in the younger group were most often injured in motor-vehicle accidents (15 cases), whereas falls were most frequent in the older group (19 cases). Patients in both groups were rapidly resuscitated in the field; more than 30% were treated within 1 hour after the time of injury. Injury severity, determined by the admission Glasgow Coma Scale score, was similar for the two groups. Mean acute SDH volume was significantly larger in the older patients than in the younger group (mean +/- standard deviation: 96.2 +/- 117.2 vs. 21.6 + 27.7 cu cm), as was the amount of midline shift (1.2 +/- 1.69 vs. 0.6 +/- 0.75 cm). Surgical treatments were similar, but outcomes were dramatically different for the younger and older patients. Mortality rates were more than four times higher in older patients than in younger ones (74% vs. 18%). Three older patients and 25 younger patients were functional survivors. Old age, a larger SDH volume, and a larger midline shift all correlated with a poor outcome. The results of this study suggest that the pathophysiology of acute SDH varies with age, and that currently employed resuscitation and treatment methods have differentially improved the outcome for younger patients.
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Affiliation(s)
- M A Howard
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle
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Abstract
Presently virtually all patients with acute head trauma are computed tomography (CT) scanned and transferred to a neurosurgical operating room before any surgical intervention. The time required for this, especially if the patient is transferred to another institution, may lead to a significant delay in treatment. In a patient with an expanding intracranial hematoma and evidence of brainstem compromise this delay may produce a worse outcome. Cranial burr hole placement can rapidly, safely, and accurately find and partially decompress most extracerebral intracranial hematomas. A burr hole placed rapidly before CT and transfer could prevent further damage to the brain by an expanding hematoma. The case of a child with a preterminal epidural hematoma whose outcome was excellent because of a burr hole placed in the emergency department (ED) is presented. In light of this case and a complete literature review, it is suggested that more frequent attempts to decompress intracranial hematomas in the ED may be warranted.
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Affiliation(s)
- M F Springer
- Department of Emergency Medicine, University of Chicago Hospitals and Clinics, IL 60637
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Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien) 1988; 90:111-6. [PMID: 3354356 DOI: 10.1007/bf01560563] [Citation(s) in RCA: 182] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In a series of 171 patients suffering acute subdural haemorrhage (SDH) (111 patients) or epidural haemorrhage (EDH) (60 patients) after closed head injury accumulated during the years 1978-1985 at the University Hospital of Graz, the mortality rate and the grade of clinical recovery were evaluated. The overall mortality in acute SDH was 57%, in acute EDH 25%, the percentages of good recoveries--full recovery and minimal neurologic deficit--25 and 58%, respectively. Outcome was found to be predominantly influenced by the preoperative state of consciousness, associated brain lesions, and, in comatose patients, the duration of the time interval between onset of coma and surgical decompression. When this interval exceeded two hours, mortality from SDH rose from 47 to 80% (good outcomes 32 and 4%, respectively). In acute EDH an interval under two hours lead to 17% mortality and 67% of good recoveries compared to 65% mortality and 13% of good recoveries after an interval of more than two hours. Age and concomitant injuries of other body regions proved to be of secondary importance.
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Verlooy P, Lamers BJ, de Haan GJ, Noach LA. Successful treatment of acute subdural haematoma associated with severe bleeding disorder. J Neurol 1987; 234:254-6. [PMID: 3612197 DOI: 10.1007/bf00618260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A 76-year-old man suffering from myelofibrosis with thrombocytopenia sustained an acute subdural haematoma with severe neurological deficit. He was treated initially by bedrest and dexamethasone. Craniotomy was contraindicated because his bleeding time exceeded 20 min in spite of multiple infusions of platelet concentrate. After 3 weeks his condition deteriorated with increase of the fluid collection shown by CT. Partial drainage of the haematoma by subdural puncture with a 22-gauge spinal needle resulted in complete recovery from the neurological deficit and complete resorption of the effusion. The case shows that it is possible to avoid craniotomy in the acute phase of a subdural haematoma in patients with bleeding disorders and that it may be advantageous to use needle evacuation instead of burr-hole drainage in the chronic phase.
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Jones NR, Blumbergs PC, North JB. Acute subdural haematomas: aetiology, pathology and outcome. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1986; 56:907-13. [PMID: 3469984 DOI: 10.1111/j.1445-2197.1986.tb01853.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The aetiology, mechanisms of haemorrhage and results of treatment of a series of 63 consecutive cases of acute subdural haematoma are presented. Forty-six cases were due to trauma (46% mortality) and 17 cases were non-traumatic (41% mortality). Only 15 patients overall (24%) made a good recovery. The various mechanisms of venous and arterial bleeding leading to subdural haematoma are reviewed and the importance of brain swelling as a determinant of fatal outcome is stressed.
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47
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Stening WA, Berry G, Dan NG, Kwok B, Mandryk JA, Ring I, Sewell M, Simpson DA. Experience with acute subdural haematomas in New South Wales. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1986; 56:549-56. [PMID: 3461777 DOI: 10.1111/j.1445-2197.1986.tb07098.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A retrospective survey of head injuries in NSW in 1977 and 1978 was conducted by the Trauma Subcommittee of the Neurosurgical Society of Australasia. Two hundred and ninety patients, who were found to have acute or subacute subdural haematomas, were considered. The mortality rate was 76%, with 19% making a satisfactory recovery. Several factors were found to produce significant improvement in outcome. The availability of neurosurgical facilities at the time of admission made a significant difference. Those patients who had decompressive operations also fared better. No patient survived without operation. Shock, defined as a systolic blood pressure lower than 90 mmHg for more than 60 min was associated with significantly increased mortality. The chance of developing a significant hypotensive episode was greater if two or more other parts of the body were injured. If three other areas were injured, the mortality was 100%. A case control study suggested that some 35 (16%) of all deaths could have resulted from preventable causes, notably delay in instituting definitive treatment and/or inadequate treatment of shock.
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48
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Klun B, Fettich M. Factors influencing the outcome in acute subdural haematoma. A review of 330 cases. Acta Neurochir (Wien) 1984; 71:171-8. [PMID: 6741634 DOI: 10.1007/bf01401312] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A series of 330 consecutive patients with acute subdural haematomas has been selected to analyze the clinical signs which influence the outcome. To assure a uniformity, the material dates from before the CT era. Four main factors have been selected: age, pupillary changes, dynamics of the clinical development, and the state of consciousness. The importance and the characteristics of different factors are discussed. A simple grading system, which was used as a prognostic orientation guide, is presented. Finally, some prognostic conclusions are made.
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Lobato RD, Cordobes F, Rivas JJ, de la Fuente M, Montero A, Barcena A, Perez C, Cabrera A, Lamas E. Outcome from severe head injury related to the type of intracranial lesion. A computerized tomography study. J Neurosurg 1983; 59:762-74. [PMID: 6619928 DOI: 10.3171/jns.1983.59.5.0762] [Citation(s) in RCA: 187] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The influence of the type of intracranial lesion on the final outcome in a consecutive series of 277 severely head-injured patients was analyzed. Patients were studied with computerized tomography (CT) and underwent continuous measurement of intracranial pressure. They received identical treatment according to a standardized protocol. Outcome of patients with either epidural hematoma (38 cases), subdural hematoma (56 cases), brain contusion (87 cases), or diffuse brain damage (96 cases) was rather heterogeneous, and serial CT scanning allowed the authors to outline eight consistent anatomical patterns in the whole series which have stronger prognostic significance than the four major lesion categories mentioned above. Patients with pure extracerebral hematoma (19 cases), single brain contusion (45 cases), general brain swelling (41 cases), and normal CT scans (28 cases) had a significantly better outcome than patients developing acute hemispheric swelling after operation for a large extracerebral hematoma (27 cases), patients with multiple brain contusion, either unilateral or bilateral (74 cases), and patients with diffuse axonal injury (43 cases). These anatomical patterns are interesting because, in addition to having clinical and physiopathological significance, they provide useful prognostic information and facilitate improved therapeutic decision-making in severely head-injured patients.
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50
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Abstract
During an eleven year period, 123 patients with acute subdural haematoma were treated in our unit. The first 63 patients were managed by general surgeons with a mortality rate of 80.9 per cent. Good recovery among survivors was 4.7 per cent. The subsequent 60 patients were managed by neurosurgeons. The mortality rate then dropped to 60 per cent and the rate of good recovery rose to 21.6 per cent. This improvement in outcome is statistically significant (P less than 0.02 and P less than 0.05 respectively). Early operation plus thorough evacuation of haematoma by craniectomy or craniotomy were the main factors found responsible for the improvement.
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