Outcome of Nonoperative Management of Selected Cases of Acute Traumatic Intracranial Hematomas in a Rural Neurosurgical Service of a Developing Country

OBJECTIVE

In resource-limited settings, the standard of care prescribed in developed countries for either operative or nonoperative management of traumatic intracranial hematomas (TICHs) frequently has to be adapted to the economic and infrastructural realities. This study aims to present the outcome of selected cases of TICHs managed nonoperatively without routine intensive care unit admission, repeated cranial computed tomography (CT) scan or intracranial pressure monitoring at a rural neurosurgical service in a developing country.

METHODS

This was a retrospective analysis of a cohort of our patients with cranial CT-confirmed TICHs selected for nonoperative treatment from our prospective head injury (HI) register over a 42-month period.

RESULTS

There were 67 patients (51 males) in this study with a mean age of 38.6 (standard deviation, 17.6) years, having mild HI in >half, (55.2%, 37/67) and anisocoria in 22.4% (15/67). Road traffic accident was the most common (50/67, 74.7%) trauma etiology. Isolated acute-subdural hematoma, intracerebral hemorrhage, and epidural hematoma occurred in 29.9%, 25.4%, and 22.4% of the patients respectively. Only 2 of 8 patients in whom intensive care unit admission was deemed necessary could afford admission. Repeat cranial CT scan was requested in 8 patients (8/67, 11.9%); only 5 of these could afford the investigation. The outcome of care was good in 82.1% patients (55/67). Increasing severity of the HI (P < 0.01) and presence of pupillary abnormality (P = 0.03) were significant predictors of poor outcome.

CONCLUSIONS

In a Nigerian rural neurosurgery practice, nonoperative management of a well-selected cohort of TICHs was attended by acceptable level of favorable outcome.

Diagnostic value of protein S100b as predictor of traumatic intracranial haemorrhage in elderly adults with low-energy falls: results from a retrospective observational study

PURPOSE

The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF).

METHODS

We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH.

RESULTS

We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH.

CONCLUSION

In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required.

Clinical Utility of Near-Infrared Device in Detecting Traumatic Intracranial Hemorrhage: A Pilot Study Toward Application as an Emergent Diagnostic Modality in a Low-Resource Setting

Limited computed tomography (CT) availability in low- and middle-income countries frequently impedes life-saving neurosurgical decompression for traumatic brain injury. A reliable, accessible, cost-effective solution is necessary to detect and localize bleeds. We report the largest study to date using a near-infrared device (NIRD) to detect traumatic intracranial bleeds. Patients with confirmed or suspected head trauma who received a head CT scan were included. Within 30 min of the initial head CT scan, a blinded examiner scanned each patient's cranium with a NIRD, interrogating bilaterally the frontal, parietal, temporal, and occipital quadrants Sensitivity, specificity, accuracy, and precision were investigated. We recruited 500 consecutive patients; 104 patients had intracranial bleeding. For all patients with CT-proven bleeds, irrespective of size, initial NIRD scans localized the bleed to the appropriate quadrant with a sensitivity of 86% and specificity of 96% compared with CT. For extra-axial bleeds >3.5mL, sensitivity and specificity were 94% and 96%, respectively. For longitudinal serial rescans with the NIRD, sensitivity was 89% (< 4 days from injury: sensitivity: 99%), and specificity was 96%. For all patients who required craniectomy or craniotomy, the device demonstrated 100% sensitivity. NIRD is highly sensitive, specific, and reproducible over time in diagnosing intracranial bleeds. NIRD may inform neurosurgical decision making in settings where CT scanning is unavailable or impractical.

Toward rational use of repeat imaging in children with mild traumatic brain injuries and intracranial injuries

OBJECTIVE

Limited evidence exists on the utility of repeat neuroimaging in children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs). Here, the authors identified factors associated with repeat neuroimaging and predictors of hemorrhage progression and/or neurosurgical intervention.

METHODS

The authors performed a multicenter, retrospective cohort study of children at four centers of the Pediatric TBI Research Consortium. All patients were ≤ 18 years and presented within 24 hours of injury with a Glasgow Coma Scale score of 13-15 and evidence of ICI on neuroimaging. The outcomes of interest were 1) whether patients underwent repeat neuroimaging during index admission, and 2) a composite outcome of progression of previously identified hemorrhage ≥ 25% and/or repeat imaging as an indication for subsequent neurosurgical intervention. The authors performed multivariable logistic regression and report odds ratios and 95% confidence intervals.

RESULTS

A total of 1324 patients met inclusion criteria; 41.3% of patients underwent repeat imaging. Repeat imaging was associated with clinical change in 4.8% of patients; the remainder of the imaging tests were for routine surveillance (90.9%) or of unclear prompting (4.4%). In 2.6% of patients, repeat imaging findings were reported as an indication for neurosurgical intervention. While many factors were associated with repeat neuroimaging, only epidural hematoma (OR 3.99, 95% CI 2.22-7.15), posttraumatic seizures (OR 2.95, 95% CI 1.22-7.41), and age ≥ 2 years (OR 2.25, 95% CI 1.16-4.36) were significant predictors of hemorrhage progression and/or neurosurgery. Of patients without any of these risk factors, none underwent neurosurgical intervention.

CONCLUSIONS

Repeat neuroimaging was commonly used but uncommonly associated with clinical deterioration. Although several factors were associated with repeat neuroimaging, only posttraumatic seizures, age ≥ 2 years, and epidural hematoma were significant predictors of hemorrhage progression and/or neurosurgery. These results provide the foundation for evidence-based repeat neuroimaging practices in children with mTBI and ICI.

ABO blood groups do not predict progression of traumatic intracranial hemorrhage

ABO blood groups are associated with genetically predisposed variations in von Willebrand factor (VWF) resulting in higher risks of thrombotic events in non-O blood types and bleeding complications in blood type O. The role of ABO blood groups in progression of traumatic intracranial hemorrhage (TICH) is unknown. Given statistically lower VWF levels in blood type O in the general population, we hypothesized that blood type O patients have a higher risk of such progression. A retrospective review of adult trauma patients with isolated TICH admitted to a Level 1 trauma center over eight years was conducted. Patients were categorized with blood type O and non-O (types A, B, AB) delineation. The primary outcome was radiological progression of TICH during the first 24 h. Secondary outcomes included surgical intervention after follow-up computed tomography (CT), complications, days on mechanical ventilation (DMV), intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Of 949 patients, 432 (45.5%) had blood type O. When comparing O and non-O groups, no significant differences were found in gender, age, race, admission vital signs, Glasgow Coma Scale, coagulation profile, TICH type, or Injury Severity Score. No difference in TICH progression was found between O and non-O groups: 73 (17%) vs 80 (15%), respectively, p = 0.55. Blood type O mortality was 12 (3% vs. 23 (4%), p = 0.174). Rate of TICH surgical intervention after follow-up CT, DMV, complications, and ICU and hospital LOS did not differ. No association between ABO blood types and radiological progression of TICH was identified.

Impact of Antithrombotic Agents on Radiological Lesion Progression in Acute Traumatic Brain Injury: A CENTER-TBI Propensity-Matched Cohort Analysis

An increasing number of elderly patients are being affected by traumatic brain injury (TBI) and a significant proportion are on pre-hospital antithrombotic therapy for cardio- or cerebrovascular indications. We have quantified the impact of antiplatelet/anticoagulant (APAC) agents on radiological lesion progression in acute TBI, using a novel, semi-automated approach to volumetric lesion measurement, and explored the impact of use on clinical outcomes in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We used a 1:1 propensity-matched cohort design, matching controls to APAC users based on demographics, baseline clinical status, pre-injury comorbidities, and injury severity. Subjects were selected from a pool of patients enrolled in CENTER-TBI with computed tomography (CT) scan at admission and repeated within 7 days of injury. We calculated absolute changes in volume of intraparenchymal, extra-axial, intraventricular, and total intracranial hemorrhage (ICH) between scans, and compared volume of hemorrhagic progression, proportion of patients with significant degree of progression (>25% of initial volume), proportion with new ICH on follow-up CT, as well as clinical course and outcomes. A total of 316 patients were included (158 APAC users; 158 controls). The mean volume of progression was significantly higher in the APAC group for extra-axial (3.1 vs. 1.3 mL, p = 0.01), but not intraparenchymal (3.8 vs. 4.6 mL, p = 0.65), intraventricular (0.2 vs. 0.0 mL, p = 0.79), or total intracranial hemorrhage (ICH; 7.0 vs. 6.0 mL, p = 0.08). More patients had significant hemorrhage growth (54.1 vs. 37.0%, p = 0.003) and delayed ICH (4 of 18 vs. none; p = 0.04) in the APAC group compared with controls, but this was not associated with differences in length of stay (LOS), rates of neurosurgical intervention, mortality or Glasgow Outcome Scale Extended (GOS-E) score at 6 months. Pre-injury use of antithrombotic agents was associated with greater expansion of extra-axial lesions, higher rates of significant hemorrhagic progression, and higher risk of delayed traumatic ICH, but this was not associated with worse clinical course or functional outcomes.

Relationship Between Measures of Cerebrovascular Reactivity and Intracranial Lesion Progression in Acute TBI Patients: an Exploratory Analysis

BACKGROUND

Failure of cerebral autoregulation and progression of intracranial lesion have both been shown to contribute to poor outcome in patients with acute traumatic brain injury (TBI), but the interplay between the two phenomena has not been investigated. Preliminary evidence leads us to hypothesize that brain tissue adjacent to primary injury foci may be more vulnerable to large fluctuations in blood flow in the absence of intact autoregulatory mechanisms. The goal of this study was therefore to assess the influence of cerebrovascular reactivity measures on radiological lesion expansion in a cohort of patients with acute TBI.

METHODS

We conducted a retrospective cohort analysis on 50 TBI patients who had undergone high-frequency multimodal intracranial monitoring and for which at least two brain computed tomography (CT) scans had been performed in the acute phase of injury. We first performed univariate analyses on the full cohort to identify non-neurophysiological factors (i.e., initial lesion volume, timing of scan, coagulopathy) associated with traumatic lesion growth in this population. In a subset analysis of 23 patients who had intracranial recording data covering the period between the initial and repeat CT scan, we then correlated changes in serial volumetric lesion measurements with cerebrovascular reactivity metrics derived from the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC (correlation coefficient between the pulse amplitude of intracranial pressure and cerebral perfusion pressure). Using multivariate methods, these results were subsequently adjusted for the non-neurophysiological confounders identified in the univariate analyses.

RESULTS

We observed significant positive linear associations between the degree of cerebrovascular reactivity impairment and progression of pericontusional edema. The strongest correlations were observed between edema progression and the following indices of cerebrovascular reactivity between sequential scans: % time PRx > 0.25 (r = 0.69, p = 0.002) and % time PAx > 0.25 (r = 0.64, p = 0.006). These associations remained significant after adjusting for initial lesion volume and mean cerebral perfusion pressure. In contrast, progression of the hemorrhagic core and extra-axial hemorrhage volume did not appear to be strongly influenced by autoregulatory status.

CONCLUSIONS

Our preliminary findings suggest a possible link between autoregulatory failure and traumatic edema progression, which warrants re-evaluation in larger-scale prospective studies.

Dual-Energy Computed Tomography Imaging of Head: Virtual High-Energy Monochromatic (190 keV) Images Are More Reliable Than Standard 120 kV Images for Detecting Traumatic Intracranial Hemorrhages

High-energy monochromatic (190 keV) images may be more reliable than standard 120 kV Images for detecting intracranial hemorrhages. We aimed to retrospectively compare virtual high monochromatic (190 keV) and standard 120 kV images from dual-energy computed tomography (CT; DECT) for the diagnosis of intracranial hemorrhages in traumatic brain injury (TBI). We analyzed admission CT studies in 100 trauma patients. Three radiologists independently reviewed four image sets: 120 kV and 190 keV (thin [1 mm] and thick [5 mm] section) images for the presence of various types of intracranial hemorrhages. The proportions of positive variables were compared and differences calculated by McNemar test and sensitivities determined by contingency tables. Randomly selected hemorrhagic lesions were analyzed for contrast index (CI). Thin-section 190 keV images were superior in the detection of subdural hematomas (SDH) (p < 0.0001), supratentorial contusions (p < 0.0001), and epidural hematomas (EDH) (p = 0.014), when compared with standard 120 kV images. However, 190 keV images were inferior to standard 120 kV images in diagnosis of subarachnoid hemorrhage (SAH) (thin-sections, p = 0.059; thick-sections, 0.0075). The 190 keV images yielded moderate increase in CI of contusions (Cohen's d > 0.53) and a large increase in CI of extra-axial hematomas (Cohen's d > 0.86). Our results indicate that virtual high monochromatic (190 keV, thin-section) images combined with standard 120 kV images may provide optimal diagnostic performance for evaluation of patients suspected of TBI.

Management of mild traumatic brain injury-trauma energy level and medical history as possible predictors for intracranial hemorrhage

Purpose

Head trauma is common in the emergency department. Identifying the few patients with serious injuries is time consuming and leads to many computerized tomographies (CTs). Reducing the number of CTs would reduce cost and radiation. The aim of this study was to evaluate the characteristics of adults with head trauma over a 1-year period to identify clinical features predicting intracranial hemorrhage.

Methods

Medical record data have been collected retrospectively in adult patients with traumatic brain injury. A total of 1638 patients over a period of 384 days were reviewed, and 33 parameters were extracted. Patients with high-energy multitrauma managed with ATLS™ were excluded. The analysis was done with emphasis on patient history, clinical findings, and epidemiological traits. Logistic regression and descriptive statistics were applied.

Results

Median age was 58 years (18–101, IQR 35–77). High age, minor head injury, new neurological deficits, and low trauma energy level correlated with intracranial hemorrhage. Patients younger than 59 years, without anticoagulation or antiplatelet therapy who suffered low-energy trauma, had no intracranial hemorrhages. The hemorrhage frequency in the entire cohort was 4.3% (70/1638). In subgroup taking anticoagulants, the frequency of intracranial hemorrhage was 8.6% (10/116), and in the platelet-inhibitor subgroup, it was 11.8% (20/169).

Conclusion

This study demonstrates that patients younger than 59 years with low-energy head trauma, who were not on anticoagulants or platelet inhibitors could possibly be discharged based on patient history. Maybe, there is no need for as extensive medical examination as currently recommended. These findings merit further studies.

Prognostic significance of optic nerve sheath diameter on computed tomography scan with severity of blunt traumatic brain injury in the emergency department

Optic nerve sheath diameter measurement (ONSD) has been associated with identifying the prognosis of traumatic brain injury (TBI) patients. The study was planned to evaluate the prognostic value of ONSD measured on the initial brain computed tomography (CT) scan performed on patients with blunt TBI in the emergency department(ED). This retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of moderate and severe TBI patients from January to December 2014. ONSD for each eye on the initial CT scan and Glasgow Coma Scale (GCS) was measured upon patient presentation. Correlation between presentation GCS and ONSD was done through Pearson's correlation. Receiver operator curve (ROC) analysis was done to measure the predictive values of ONSD for mortality. Of the 276 patients, 211(76%) were males and 65(23%) females. ONSD was measured on 160(58%) patients. The mean ONSD measured on CT scan was 3.8±1. The Pearson's correlation between the severity of brain injury as per GCS at presentation and ONSD was not significant (-0.182). We concluded that ONSD measured on the initial CT brain scan had good association with the severity of blunt TBI in patients presenting to the ED.

Lesson of the month 2: Contusion confusion

This lesson of the month highlights that certain radiology terminology may be used to report bleeding on head computerised tomography (CT) reports. On-call junior doctors should not be expected to interpret CT head images, so often their decisions will be based on the written report. The wording used can change the clinical decision and therefore the treatment given by a junior doctor. Clinical teams and junior doctors should be educated on terminology in relation to bleeding on CT head reports.

Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma

OBJECTIVE

Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score.

METHODS

Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome.

RESULTS

Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels.

CONCLUSIONS

The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

Osteopathic Manipulative Treatment for Somatic Dysfunction After Acute Severe Traumatic Brain Injury

Somatic dysfunction caused by traumatic brain injury (TBI) may be managed by osteopathic manipulative treatment (OMT). In this case report, the authors describe 2 patients with severe TBI who were each treated with OMT in a level-1 regional trauma center. Both patients received OMT beginning in the acute care phase of injury. Somatic dysfunction improved during the course of treatment, and no adverse effects of OMT were noted. More comprehensive research may clarify the efficacy and adverse effects of OMT as part of multimodal acute care of patients with severe TBI.

Superficial Echogenic Lesions Detected on Neonatal Cranial Sonography: Possible Indicators of Severe Birth Injury

OBJECTIVES

The purpose of this study was to evaluate the characteristics and importance of superficial echogenic lesions around cranial sutures on neonatal cranial sonography.

METHODS

We retrospectively reviewed the clinical records and neuroimaging studies of 40 neonates who had superficial echogenic lesions around sutures on neonatal cranial sonography. Magnetic resonance imaging (n = 18) and computed tomography (n = 2) were performed within 2 weeks after sonography. We correlated sonographic findings with computed tomographic and magnetic resonance imaging findings and analyzed them. We also evaluated the associated lesions, neurologic signs, and follow-up changes.

RESULTS

Sonographically, the superficial echogenic lesions involved both sulci and perisulcal parenchyma in 39 neonates and were located in the frontal and parietal areas around the sagittal suture in 38 neonates. Magnetic resonance imaging revealed a pattern of hypoxic ischemic encephalopathy in 9 neonates, birth trauma in 3 neonates, a mixed pattern of hypoxic ischemic encephalopathy and trauma in 3 neonates, nonspecific single infarctions in 2 neonates, and lack of a defined lesion in 1 neonate. The associated lesions were subdural hemorrhage (n = 12), epidural hematoma (n = 4), germinal matrix hemorrhage (n = 3), intraventricular hemorrhage (n = 2), and periventricular leukomalacia (n = 1). All epidural hematomas were associated with scalp hematoma, and 2 patients had skull fractures. One neonate with epidural hematoma associated with a hypoxic ischemic encephalopathy pattern showed mild spasticity in both ankles until 16 months.

CONCLUSIONS

Superficial echogenic lesions detected around cranial sutures on neonatal sonography may be an indicator of more serious intracranial lesions such as more extensive hypoxic ischemic encephalopathy and intracranial hematomas, including epidural hematoma.

Fall from a car driving at high speed: A case report

In cases of falls, the key issue for forensic scientists is to determine the manner of death. They must distinguish between accidental falls, suicidal falls, falls including blows and falls caused by a blow. Several strategies have been proposed in the literature to help explain injury patterns. Here, we report an original case of a man who died after jumping from a car moving at high speed. A mathematical and modeling approach was developed to reconstruct the trajectory of the body in order to understand the injury pattern and apparent discrepancy between the high speed of the car from which the victim jumped and the topography of the bone fractures, which were limited to the skull. To define the initial values of the model's parameters, a technical vehicle evaluation and several test jumps at low speed were carried out. We studied in greater detail the trajectory of three characteristic points corresponding to the dummy's center of gravity, head and right foot. Calculations were made with and without the air friction effect to show its influence. Finally, we were successful in modeling the initial trajectory of the body and the variation of its head energy over time, which were consistent with the injuries observed.

Clinical Decision Rules for Paediatric Minor Head Injury: Are CT Scans a Necessary Evil?

INTRODUCTION

High performing clinical decision rules (CDRs) have been derived to predict which head-injured child requires a computed tomography (CT) of the brain. We set out to evaluate the performance of these rules in the Singapore population.

MATERIALS AND METHODS

This is a prospective observational cohort study of children aged less than 16 who presented to the emergency department (ED) from April 2014 to June 2014 with a history of head injury. Predictor variables used in the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) and Pediatric Emergency Care Applied Research Network (PECARN) CDRs were collected. Decisions on CT imaging and disposition were made at the physician's discretion. The performance of the CDRs were assessed and compared to current practices.

RESULTS

A total of 1179 children were included in this study. Twelve (1%) CT scans were ordered; 6 (0.5%) of them had positive findings. The application of the CDRs would have resulted in a significant increase in the number of children being subjected to CT (as follows): CATCH 237 (20.1%), CHALICE 282 (23.9%), PECARN high- and intermediate-risk 456 (38.7%), PECARN high-risk only 45 (3.8%). The CDRs demonstrated sensitivities of: CATCH 100% (54.1 to 100), CHALICE 83.3% (35.9 to 99.6), PECARN 100% (54.1 to 100), and specificities of: CATCH 80.3% (77.9 to 82.5), CHALICE 76.4% (73.8 to 78.8), PECARN high- and intermediate-risk 61.6% (58.8 to 64.4) and PECARN high-risk only 96.7% (95.5 to 97.6).

CONCLUSION

The CDRs demonstrated high accuracy in detecting children with positive CT findings but direct application in areas with low rates of significant traumatic brain injury (TBI) is likely to increase unnecessary CT scans ordered. Clinical observation in most cases may be a better alternative.

Blood pressure regulation to prevent progression of blunt traumatic intracranial hemorrhage in stable patients

BACKGROUND

Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients.

METHODS

A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval.

RESULTS

Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD.

CONCLUSIONS

A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated.

LEVEL OF EVIDENCE III

Prognostic, Level II study.

[Peculiarities of clinical course and factors impacting the results of surgical treatment of intracerebral hematoma in isolated cranio-cerebral trauma]

Peculiarities of clinical course of intracerebral hematoma (ICH) in isolated cranio-cerebral trauma (CCT), and factors, influencing the surgical treatment results, were analyzed. Medical histories of 188 injured persons, suffering isolated CCT, were analyzed, in 14 of them ICH was revealed. In isolated CCT the brain contusion focus, revealed in first hours after trauma, in accordance to CT of the brain data, during 10 - 12 h may be transformed into ICH, with increase of the brain oedema severity, what constitutes bad prognostic sign. There are following unfavorable factors: severe state of the injured person while his admittance to hospital, decompensation of the CCT course, elderly age, absence of treatment on prehospital stage, the operation performance later than in 1 - 2 h after admittance to hospital, occurrence of cerebral and extracerebral complications postoperatively, including focus of encephalomalacia, meningoencephalitis, and pulmonary complications as well.

ED disposition of the Glasgow Coma Scale 13 to 15 traumatic brain injury patient: analysis of the Transforming Research and Clinical Knowledge in TBI study

OBJECTIVE

Mild traumatic brain injury (mTBI) patients are frequently admitted to high levels of care despite limited evidence suggesting benefit. Such decisions may contribute to the significant cost of caring for mTBI patients. Understanding the factors that drive disposition decision making and how disposition is associated with outcomes is necessary for developing an evidence-base supporting disposition decisions. We evaluated factors associated with emergency department triage of mTBI patients to 1 of 3 levels of care: home, inpatient floor, or intensive care unit (ICU).

METHODS

This multicenter, prospective, cohort study included patients with isolated head trauma, a cranial computed tomography as part of routine care, and a Glasgow Coma Scale (GCS) score of 13 to 15. Data analysis was performed using multinomial logistic regression.

RESULTS

Of the 304 patients included, 167 (55%) were discharged home, 76 (25%) were admitted to the inpatient floor, and 61 (20%) were admitted to the ICU. In the multivariable model, admission to the ICU, compared with floor admission, varied by study site, odds ratio (OR) 0.18 (95% confidence interval [CI], 0.06-0.57); antiplatelet/anticoagulation therapy, OR 7.46 (95% CI, 1.79-31.13); skull fracture, OR 7.60 (95% CI, 2.44-23.73); and lower GCS, OR 2.36 (95% CI, 1.05-5.30). No difference in outcome was observed between the 3 levels of care.

CONCLUSION

Clinical characteristics and local practice patterns contribute to mTBI disposition decisions. Level of care was not associated with outcomes. Intracranial hemorrhage, GCS 13 to 14, skull fracture, and current antiplatelet/anticoagulant therapy influenced disposition decisions.

The role of repeat head computed tomography in the management of mild traumatic brain injury patients with a positive initial head CT

This was a prospective observational study done to evaluate the role of a repeat head CT in patients with mild traumatic brain injury. The aim was to evaluate wether the repeat head CT were useful in providing information that leads to any neurosurgical intervention. 279 adult patients with a mild head injury (GCS 13-15) were enrolled, and these comprised of patients with an initial traumatic intracranial haemorrhage not warranting any surgical intervention. All patients were subjected to a repeat head CT within 48 hours of admission and these showed no change or improvements of the brain lesion in 217 patients (79.2%) and worsening in 62 patients (20.8%). In thirty-one patients, surgical intervention was done following the repeat head CT. All of these patients had a clinical deterioration prior to the repeat head CT. Even if a repeat head CT had not been ordered on these patients, they would have had a repeat head CT due to deteriorating neurological status. When the 62 patients with a worsening repeat head CT were compared with the 217 patients with an improved or unchanged repeat head CT, they were found to have older age, lower GCS on admission, presenting symptoms of headache, higher incidence of multiple traumatic intracranial pathology and lower haemoglobin level on admission. On stepwise multiple logistic regression analysis, three factors were found to independently predict a worse repeat head CT (Table IV). This includes age of 65 years or older, GCS score of less than 15 and multiple traumatic intracranial lesion on initial head CT. As a conclusion, we recommend that, in patients with a MTBI and a normal neurological examination, a repeat cranial CT is not indicated, as it resulted in no change in management or neurosurgical intervention. Close monitoring is warranted in a subset of patients with risk factors for a worsening repeat head CT.

[The effect of platelet transfusion on traumatic intracranial hemorrhage among patients treated with aspirin]

BACKGROUND

Head trauma represents a serious medical and socio-economical problem owing to its related morbidity and mortality. One of its serious complications is traumatic intracranial hemorrhage (TICH). There is evidence that TICH has a tendency to expand, especially during the first hours following injury. Aspirin has a central role in preventing thromboembolic complications in atherosclerotic conditions. This effect is mediated through the inhibition of platelet activity. There is a theoretical concern that treatment prior to the head injury with aspirin may expand the size of TICH. The purpose of the current study was to evaluate the effect of platelet transfusion on the extent of TICH expansion among patients treated with aspirin.

METHODS

This retrospective study includes patients admitted to the Tel-Aviv Medical Center and the Tel-Hashomer Medical Center between 1/12/2004 and 31/10/2008. Patients were included if they underwent closed head injury, were treated regularly with aspirin prior to the injury, and had radiological evidence of an intraparenchymal hemorrhage or contusion (IPHC) or an acute subdural hematoma (ASDH]. The interval between the injury and the first computed tomography [CT] scan was not longer than 12 hours, and the interval between the first CT scan and the control CT scan was not longer than 24 hours. The effect of platelet transfusion administered between these two CT scans on the radiological and clinical outcomes was evaluated by a comparison between a group of patients treated with platelet transfusion (group A) and a group of patients who weren't treated with it (group B).

RESULTS

A total of 44 patients were included in the study: 14 patients had IPHC, 40 had ASDH and 10 had both IPHC and ASDH. In the IPHC group the frequency of hemorrhagic expansion and the extent of expansion were greater in group A than in group B. Possibly, an earlier first CT, longer duration between both CT scans and a larger hemorrhage volume on CT1 in group A may explain these differences. In the ASDH group the frequency of hemorrhagic expansion was lower in group A than in group B, but without statistical significance. There was no significant difference in the extent of hemorrhagic expansion between the two treatment groups.

CONCLUSIONS

From this study it appears that platelet transfusion within 36 hours post injury for patients with TICH who were treated with aspirin prior to the head injury does not reduce the rate or extent of hemorrhagic expansion. However, owing to the limitations of the present study, this conclusion should be considered with caution. We recommend evaluating this issue in a prospective, randomized, multi-center study.

Classification and prediction of outcome in traumatic brain injury based on computed tomographic imaging

Traumatic brain injury (TBI) is a common and potentially devastating problem. The classification of TBI is necessary for accurate diagnosis and the prediction of outcomes. The increased use of early sedation, intubation and ventilation in more severely injured patients has decreased the value of the Glasgow Coma Scale for the purposes of classification. An alternative is the classification of TBI according to morphological criteria based on computed tomography (CT) investigations. This article reviews the current classification and prediction of outcomes in TBI based on CT imaging. Classifications based on the presence or absence of intracranial local lesions, diffuse injury, signs of subarachnoid or intra-ventricular haemorrhage and fractures or foreign bodies are considered, and their predictive value is discussed. Future studies should address the complicated issue of how optimally to combine CT characteristics for prognostic purposes and how to improve on currently used CT classifications to predict outcomes more accurately.

A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy

Trauma patients on prescribed warfarin therapy sustaining intracranial hemorrhage can be difficult to manage. Rapid normalization of coagulopathy is imperative to operative intervention and may affect outcomes. To identify and expedite warfarin reversal, we designed a protocol to administer a prothrombin complex concentrate. A Proplex T protocol was instituted in May 2004. It dictated that trauma patients with an International Normalized Ratio (INR) greater than 1.5, history of prescribed warfarin therapy, and intracranial hemorrhage on CT scan receive a prothrombin complex concentrate for reversal of their coagulopathy. Neither the protocol nor the factor concentrate was validated for use in this subset of trauma patients; therefore, adherence to the protocol and use of the factor concentrate was not mandatory. Patients not administered the prothrombin complex concentrate received vitamin K and fresh-frozen plasma. The protocol resulted in an increased number of patients receiving Proplex T (54.3% vs 35.4%, P = 0.047). Protocol patients had improved times to normalization of INR (331.3 vs 737.8 minutes, P = 0.048), number of patients with reversal of coagulopathy (73.2% vs 50.9%, P = 0.026), and time to operative intervention (222.6 vs 351.3 minutes, P = 0.045) compared with control subjects. There were no differences in intensive care unit (ICU) days, hospital days, or mortality. The Proplex T protocol increased the number of patients who received prothrombin complex concentrate, provided rapid normalization of INR, and improved time to operative intervention.

The role of early follow-up computed tomography imaging in the management of traumatic brain injury patients with intracranial hemorrhage

BACKGROUND

The purpose of this study was to investigate whether routine follow-up computed tomography (CT) for patients with head injury, in the absence of clinical indications, alters patient management.

METHODS

Nonpenetrating head injury patients admitted to San Francisco General Hospital during an 18-month period were reviewed. Patients not surgically treated at presentation and with a routine follow-up head CT within 24 hours were included. Surgical and nonsurgical interventions after repeat CT were assessed. Clinical and imaging parameters were correlated with progressive hemorrhagic injury (PHI) and with delayed development of surgical lesions.

RESULTS

PHI was identified in 49 (42%) of 116 patients. None of these patients required a nonoperative intervention in response to the PHI. Six of these patients developed a neurologic change concurrent with routine follow-up imaging and required operative intervention. Thus, no patient underwent an intervention in response to a worsening head CT in the absence of clinical findings. Of the six patients who developed a surgical lesion, two had increased intracranial pressure, one had a change in pupillary examination, three had worsening mental status, and one had change in the motor examination. Univariate risk factors for development of a delayed surgical lesion included 5 to 10 mm of midline shift (p = 0.001), basal cistern effacement (p = 0.01), and higher Marshall score (p = 0.01) on initial CT imaging.

CONCLUSIONS

Although PHI is common with head injury, delayed interventions in the absence of clinical indicators are uncommon. Our data suggest that early follow-up CT imaging in the setting of head trauma is not routinely indicated. We suggest that assessment, based on the severity of findings on initial brain imaging and serial clinical examinations, should guide the need for follow-up imaging in the setting of head trauma.

Intra-operative diagnosis and image-guided management of an intracerebral haemorrhage occurring during ultrasound-guided biopsy

Haemorrhagic complications occurring after burr-hole procedures are diagnosed only in symptomatic patients or when postoperative imaging is performed routinely. We report the development of an intracerebral haematoma which occurred during ultrasound-guided burr-hole biopsy. Real-time ultrasound through the same burr-hole enabled us to determine the dynamics of the bleeding and its terminal volume. The operation was finished without further complications and the patient did not experience an impairment of her neurological state. Intra-operative ultrasound is capable of detecting "invisible" complications during burr-hole procedures.

Computer-Assisted Categorizing of Head Computed Tomography Reports for Clinical Decision Rule Research

STUDY OBJECTIVE

To develop software that categorizes electronic head computed tomography (CT) reports into groups useful for clinical decision rule research.

METHODS

Data were obtained from the Second National Emergency X-Radiography Utilization Study, a cohort of head injury patients having received head CT. CT reports were reviewed manually for presence or absence of clinically important subdural or epidural hematoma, defined as greater than 1.0 cm in width or causing mass effect. Manual categorization was done by 2 independent researchers blinded to each other's results. A third researcher adjudicated discrepancies. A random sample of 300 reports with radiologic abnormalities was selected for software development. After excluding reports categorized manually or by software as indeterminate (neither positive nor negative), we calculated sensitivity and specificity by using manual categorization as the standard. System efficiency was defined as the percentage of reports categorized as positive or negative, regardless of accuracy. Software was refined until analysis of the training data yielded sensitivity and specificity approximating 95% and efficiency exceeding 75%. To test the system, we calculated sensitivity, specificity, and efficiency, using the remaining 1,911 reports.

RESULTS

Of the 1,911 reports, 160 had clinically important subdural or epidural hematoma. The software exhibited good agreement with manual categorization of all reports, including indeterminate ones (weighted kappa 0.62; 95% confidence interval [CI] 0.58 to 0.65). Sensitivity, specificity, and efficiency of the computerized system for identifying manual positives and negatives were 96% (95% CI 91% to 98%), 98% (95% CI 98% to 99%), and 79% (95% CI 77% to 80%), respectively.

CONCLUSION

Categorizing head CT reports by computer for clinical decision rule research is feasible.

A Prospective Evaluation of the Value of Repeat Cranial Computed Tomography in Patients With Minimal Head Injury and an Intracranial Bleed

BACKGROUND

Patients with minimal head injury (MHI) and intracranial bleed (ICB) detected on cranial computed tomography (CT) scan routinely undergo a repeat cranial CT within 24 hours after injury to assess for progression of intracranial injuries. While this is clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination. The goal of this study was to prospectively assess the value of a repeat cranial CT in patients with a MHI and an ICB who have a normal neurologic examination.

METHODS

A prospective analysis of all adult patients admitted to a Level I trauma center after blunt trauma causing a MHI (defined as the loss of consciousness or posttraumatic amnesia with a Glasgow Coma Scale (GCS) score of greater or equal to 13) and an ICB on the initial cranial CT during a 12-month period (July 2002 through July 2003) was performed. All patients with MHI were prospectively evaluated and followed until discharge. Data collected included demographics, neurologic examination and findings on the initial and repeat cranial CT scan. Outcome data included neurologic deterioration, neurosurgical intervention, and Glasgow Outcome Scale (GOS) on discharge.

RESULTS

In all, 161 consecutive patients with MHI and a positive cranial CT scan were identified. The initial cranial CT lead to a neurosurgical intervention (1 craniotomy, 4 intracranial pressure monitors) in 4% of cases. The remaining 130 patients who met inclusion criteria, underwent a repeat cranial CT scan within 24 hours postadmission. Ninety nine (76%) patients had a normal neurologic examination at the time of their repeat cranial CT. After the repeat cranial CT none required immediate neurosurgical intervention or had delayed neurologic deterioration related to their head injury. Fifteen patients underwent additional neuroradiologic studies but none showed further progression of their ICB or lead to a change in management. One patient died from non-traumatic brain injury related causes and of the remaining 26 patients, 98% had an overall favorable GOS score (> 3) on discharge. In this group of patients with MHI and ICB, the negative predictive value of a normal neurologic examination was 100%.

CONCLUSIONS

Repeat cranial CT, in patients with a MHI and a normal neurologic examination, resulted in no change in management or neurosurgical intervention and is therefore not indicated. A multicenter prospective study would further validate these conclusions, reduce unnecessary CT scans, and likely improve our current standard of care in these patients.

Effects of Recombinant Activated Factor VII in Traumatic Nonsurgical Intracranial Hemorrhage

OBJECTIVE

To determine whether treatment with recombinant activated factor VII (rFVIIa) will prevent progression of bleeding in nonsurgical hemorrhagic traumatic brain injury (TBI).

METHODS

Chart review from the trauma registry of a level 1 trauma center between January 1, 2002 and December 31, 2004 identified 2 patients who received rFVIIa for progressive hemorrhagic TBI. These patients were given a single dose of rFVIIa (120 mcg/kg) after a repeat head computed tomography (CT) scan showed worsening of intracranial bleeding. Pre-rFVIIa and post-rFVIIa coagulation parameters and postintervention CT scans were performed. A matched convenience sample was drawn from the institution's trauma registry reflecting similar injury patterns.

RESULTS

The 2 patients who received rFVIIa were ages 61 and 79 years; the patients in the matched convenience sample were 57 and 63 years. Both sets of patients comprised 1 man and 1 woman who had suffered blunt trauma, including hemorrhagic TBI, and were matched according to age, gender, and injury severity score (ISS). During their hospital course, repeat CT scans documented worsening of intracranial hemorrhage in both cohorts. In the rFVIIa patients, follow-up CT showed overall improvement of head injury compared with the convenience sample. The rFVIIa patients also saw an appreciable decrease in both prothrombin time (PT) and international normalized ratio (INR).

CONCLUSIONS

In hemorrhagic TBI, rFVIIa has the potential to limit or even halt the progression of bleeding that would otherwise place growing pressure on the brain. A prospective, randomized multicenter trial is planned to elucidate this hypothesis.

[Local fibrinolytic technique in surgery of traumatic inctracranial hemorrhages]

The emergence of neuroimaging techniques and new surgical technologies (neuroendocopy, navigation systems) in neurosurgery has substantially changed views of surgery for traumatic intracranial hematomas. The local fibrinolytic technique that has been applied to 40 victims aged 18 to 67 years (mean age 42.1 +/- 2 years) who had 18-to-97-cm3 hematomas is a promising direction of mini-invasive surgery for traumatic intracranial hematomas in patients in the compensated and subcompensated state. There were 32 males and 8 females. The procedure of the surgical intervention involves drainage of intracranial hematoma, followed by clot lysis and liquid blood aspiration along the drainage. A good outcome with a complete hematoma removal and clinical symptom regression was observed in 26 patients, a fair result with preservation of moderate neurological symptoms at hospital discharge was noted in 2 patients; 3 victims died. Recurrent bleedings were seen in 4 patients with epidural hematomas. A morphological study revealed the typical features of the morphogenesis of traumatic hematomas and perifocal brain tissue during local fibrinolytic therapy, which suggests that the area of damaging effect of bleeding on the adjacent brain tissue is decreased. Local fibrinolysis in surgery of traumatic intracranial hematomas may be considered to be one of the promising lines of treatment policy along with the existing traditional and current techniques and may be used as the method of choice in surgery of traumatic intracranial hematomas in patients in the compensated state. Removal of epidural hematomas through local fibrinolysis should be limited due to a high risk of recurrent hemorrhage and may be made only in a restricted contingent of patients with severe concomitant injury and concurrent somatic diseases when the risk of combined anesthesia and that of a longer operation are rather high. Moreover, of promise is that subtentorial epidural hematomas may be aspirated without trepanation of the posterior cranial fossa and the surgery may be performed under local anesthesia.

Clinical characteristics of postoperative contralateral intracranial hematoma after traumatic brain injury

OBJECTIVES

To investigate the clinical characteristics of contralateral intracranial hematoma (ICH) after traumatic brain injury.

METHODS

The subjects included 149 patients with traumatic ICH treated by hematoma evacuation. The patients were retrospectively divided into a bilateral ICH (B-ICH) group and unilateral ICH (U-ICH) group after craniotomy using brain CT scans for comparison of the following parameters: complicated expanded brain bulk from the cranial window, hypotension during craniotomy, and outcome.

RESULTS

Post-craniotomy brain CT scans revealed U-ICH in 106 patients and B-ICH in 43 patients. Average Glasgow Coma Scale on arrival did not differ between the groups, but a higher proportion of patients in the B-ICH group deteriorated after admission (p = 0.02). The B-ICH patients also exhibited a significantly higher rate of expanded brain bulk from the cranial window (p < 0.05). No significant difference was observed between the groups with hypotension during craniotomy. The B-ICH group exhibited a lower rate of favorable outcome (p < 0.05) and higher mortality (p < 0.05).

CONCLUSION

The B-ICH patients had a worse outcome than the U-ICH patients. Contralateral ICH was difficult to forecast based on pre- and intraoperative clinical conditions. Subdural hematoma or contusional ICH was frequently observed as a contralateral ICH.

Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality

BACKGROUND

A prospective cohort study at our institution demonstrated a 48% mortality rate in warfarin anticoagulated trauma patients sustaining intracranial hemorrhage (ICH) compared with a 10% mortality rate in nonanticoagulated patients. Forty percent of patients demonstrated progression of their ICH, despite anticoagulation reversal, with a resultant 65% mortality rate. Seventy-one percent of these patients initially presented with a Glasgow Coma Scale (GCS) score > or = 14 and a 'minor' ICH. We postulated that early diagnosis of ICH and rapid anticoagulation reversal would reduce ICH progression rates and mortality.

METHODS

All anticoagulated patients with known or suspected head trauma were entered into the Coumadin protocol. The protocol ensured immediate triage and physician evaluation, head computed tomography (CT) scan, and fresh frozen plasma administration in patients with documented ICH.

RESULTS

Eighty-two patients were entered into the protocol with ICH documented in 19 (23%). Sixteen of 19 patients (84%) presented with GCS > or = 14. Median international normalized ratio (INR) for treated patients with ICH was 2.7 versus 2.5 for patients without ICH (p = 0.546). Mean time to initiate warfarin reversal was 1.9 hours for protocol patients versus 4.3 hours for preprotocol patients (p < 0.001). Two of 19 (10%) protocol patients with ICH died. However, both patients presented >10 hours after injury with a severe ICH. This 10% mortality rate is significantly less than the 48% mortality rate seen previously (p < 0.001) and is now consistent with that observed in similarly injured patients not on anticoagulation.

CONCLUSION

Neither the initial GCS nor INR in anticoagulated trauma patients reliably identifies patients with ICH. Rapid confirmation of ICH with expedited head CT scan combined with prompt reversal of warfarin anticoagulation with fresh frozen plasma decreases ICH progression and reduces mortality.

Is repeated head computed tomography necessary for traumatic intracranial hemorrhage?

This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anticoagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.

Characteristics of parietal-parasagittal hemorrhage after mild or moderate traumatic brain injury

The aim of this study is to clarify the clinical characteristics of parietal-parasagittal traumatic intracranial hemorrhage (TICH) after mild or moderate traumatic brain injury (TBI). METHODS; Subjects were 105 patients with mild or moderate TBI. The patients with parietal-parasagittal TICH were clinically analyzed based on the initial brain CT findings, hematoma sites and the clinical course as compared to those with TICH at other sites.

RESULTS

Hematoma was located in the frontal or temporal lobes in 89.5% of the subjects and the parietal-parasagittal in 10.5%. Ten of the 11 patients suffering parietal-parasagittal TICH had skull fractures (7 depressed and 3 linear) but no depressed fracture observed in patients with frontal or temporal lobe hemorrhage. Neurological deterioration leading to a comatose state more frequently occurred in 63.6% of patients with parietal-parasagittal TICH than in those with frontal or temporal lobe hemorrhage (19.1%, p < 0.01). The incidence of hematoma growth was significantly higher in patients with parietal-parasagittal TICH (63.6%) than in those with frontal or temporal lobe hemorrhage (31.9%, p < 0.05).

DISCUSSION

The incidence of parietal-parasagittal TICH is low, but the risk of neurological deterioration due to hematoma enlargement is significantly high. Parietal-parasagittal TICH may differ clinically from frontal-temporal TICH.

[Gastric myoelectric activity disturbance in patients with traumatic lesions of the brain stem]

The aim of the study was to evaluate effects of cranio-cerebral trauma on gastric myoelectric activity. Twenty four patients hospitalized in the Department of Neurotraumatology, Collegium Medicum of the Jagiellonian University were compared with a control group of 16 healthy volunteers matched for gender and age. Their gastric myoelectric activity was measured using standard cutaneous electrodes with Synectics, a Swedish system of data storage and analysis. Results of the study were analyzed at the Department of Pathophysiology, Collegium Medicum, Jagiellonian University. In the electrogastrography (EGG) recording of the control group the proportions of time with bradygastria (0.5-2 cpm), normogastria (2-4 cpm) and tachygastria (4-10 cpm) were 11.6 +/- 8%, 86.2 +/- 9% and 2.16 +/- 1.5% respectively. The signal amplitude was 181 +/- 11.5 microV2. In patients with a severe head injury followed by intracranial hypertension III degree and cerebral coma (the Glasgow Coma Scale score 4-7 points), the proportion of bradygastria in the total recording time amounted to 46.5 +/- 8%. In these patients also the signal amplitude was found to increase up to 766 microV2 (p = 0.0007). Our results indicate that in patients comatose due to a posttraumatic brainstem injury, the function of the brain-gut link is altered. There is a severe disorder of the upper gut motility, associated with gastric dysrhythmia--bradygastria resulting from an increased cholinergic output. This leads to intestinal feeding intolerance.

Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies

Does an expanded subarachnoid space predispose to subdural bleeding? What does heterogeneity in the appearance of a subdural collection on CT or MRI imaging indicate? Spontaneous rebleeding? Minor re-injury? Major re-injury? In some specific cases, answers to these questions have important forensic implications. To conclude objectively that an infant's intracranial hemorrhage or rebleeding resulted from inflicted injury or re-injury requires an in-depth understanding of the pathogenesis of posttraumatic subdural and subarachnoid collections. The authors present two cases of indoor, accidental, pediatric, closed-head trauma that resulted in intracranial rebleeding. Both accidental cranial impacts occurred in medical settings and were independently witnessed by medical personnel. In addition, the authors summarize the relevant medical literature regarding pediatric intracranial bleeding and rebleeding.

Imaging of traumatic intracranial hemorrhage

Traumatic intracranial hemorrhage is a leading cause of morbidity and mortality in the United States. CT remains the primary imaging modality for initial evaluation of patients who have sustained head trauma. MR imaging, which has always been important for the evaluation of subacute and chronic head trauma, has been gaining popularity and recognition as an alternative primary imaging modality.

[Acute head trauma: diagnostic imaging]

Computed tomography (CT) ist the primary modality of choice for imaging patients with acute head trauma. Lesions of the soft tissues and of the bones can be assessed more precisely than with other imaging modalities. With magnetic resonance imaging (MRI) additional information may be gained especially in subacute and chronic posttraumatic conditions. Urgent indication to perform a CT examination depends on the patient's history and on the mechanism of trauma. Image interpretation has been performed in the context of typical pathologic effects of trauma and with respect to potential therapy.

Computed tomography of the brain in predicting outcome of traumatic intracranial haemorrhage in Malaysian patients

Head injury is a significant economic, social and medical problem all over the world. Road accidents are the most frequent cause of head injury in Malaysia with highest risk in the young (15 to 24 years old). The associated outcomes include good recovery, possibility of death for the severely injured, which may cause disruption of the lives of their family members. It is important to predict the outcome as it will provide sound information to assist clinicians in Malaysia in providing prognostic information to patients and their families, to assess the effectiveness of different modes of treatment in promoting recovery and to document the significance of head injury as a public health problem.

RESULTS

A total of 103 cases with intracranial haemorrhage i.e. intracerebral haemorrhage, extradural haemorrhage, subdural haemorrhage, intraventricular haemorrhage, haemorrhagic contusion and subarachnoid haemorrhage, following motor vehicle accidents was undertaken to study factors contributing to either good or poor outcome according to the Glasgow Outcome Scale. Patients below 12 years of age were excluded. The end point of the study was taken at 24 months post injury. The selected variables were incorporated into models generated by logistic regression techniques of multivariate analysis to see the significant predictors of outcome as well as the correlation between the CT findings with GCS.

CONCLUSION

Significant predictors of outcome were GCS on arrival in the accident emergency department, pupillary reflex and the CT scan findings. The CT predictors of outcome include ICH, EDH, IVH, present of SAH, site of ICH, volumes of EDH and SDH as well as midline shift.

Melanotic neuroectodermal tumor of infancy discovered after head trauma

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare neoplasm that generally arises in the maxilla during the first year of life. Involvement of bones of the cranial vault or brain is extremely rare. We describe a 7-month-old black female who presented after falling out of bed onto a concrete floor. Subsequently, she developed an anterior frontal mass that enlarged over several days. Radiographs of the skull at her local hospital showed a depressed right frontal skull fracture. However, computerized tomography of the head (reviewed at our institution) revealed a slightly hyperdense extra-axial mass which crossed the anterior frontal midline, widening the metopic suture and extending into the anterior subgaleal scalp. Hyperostosis of the adjacent frontal calvarium was also present. A craniotomy revealed a dark, 1.5-cm calcified epidural lesion with some features of an unusual hematoma. Microscopic evaluation revealed a chronic hematoma and MNTI. The tumor recurred within a year. MNTI should be included in the differential diagnosis of epidural and skull lesions in infants.

Traumatic intracerebellar hemorrhagic contusions and hematomas

BACKGROUND

Traumatic intracerebellar hemorrhagic contusions and hematomas (TIHC) are unusual lesions and their surgical management remains controversial.

METHODS

From January 1990 to July, 1998, 3290 patients underwent computed tomography for acute head trauma at our Institution. Eighteen patients (0.54%) were retrospectively identified as harboring TIHC. Patients were divided into two groups. In Group I (n=78) GCS at admission was > or = 9. Seven patients presented with isolated TIHC and one with an associated supratentorial lesion. Three patients exhibited an evolving clinico-radiological course. In Group II patients (n=10) GCS at admission was < or = 7. All but one presented with severe supratentorial lesions and associated brainstem signs.

RESULTS

In group I six patients had their TIHC managed conservatively, and two were operated on, and all recovered completely. In group II, two patients were operated on. The outcome was poor in 90% of cases.

CONCLUSIONS

TIHC constitute a protean clinico-pathological entity. Non-comatose patients with intracerebellar clots less than 3 cm in diameter should be treated conservatively and expected to make a good recovery. Surgery is indicated for larger hematomas causing cisternal and IV ventricle compression ab initio or as a result of their secondary evolution. In severely ill patients admitted comatose, it is generally the primary brain stem damage and the concomitant severe supratentorial lesions to dictate the prognosis. In these cases obliteration of the posterior fossa cisterns is the most reliable indicator of poor outcome.

[Cranial gunshot injuries and treatment approaches]

21 patients with gunshot wounds were retrospectively evaluated. They were 19 male and 2 female, age range was 9-24. All of the patients underwent a plain x-ray and computed tomography evaluation. 9 patients had intracerebral hematoma, 4 had subdural hematoma, 1 had epidural hematoma and 1 had intraventricular hematoma. 9 patients were observed to have bullet in the cranium. All the patients with glasgow coma scale 3-5 at the admittance died. 15 patients underwent surgical treatment. 3 patients had cerebrospinal fluid fistula postoperatively and underwent reoperation. Extensivity of the lacerated brain, localization of the lesion and the glasgow coma scale at the admittance affect the outcome in gunshot wounds.