Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage

INTRODUCTION

Patients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13-15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score - specifically, patients with GCS scores of 13 and 14 - may exhibit poorer neurological outcomes.

METHOD

Between January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis.

RESULTS

During the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13-14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13-14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15.

CONCLUSION

Among SDH patients with mild TBI, those with GCS scores of 13-14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.

Massive spontaneous subdural hemorrhage mimicking dural venous thrombosis in a sickle cell adolescent, a rare case report

INTRODUCTION

Sickle cell disease is one of the most common hemoglobinopathies in Africa. Tanzania alone accounts for about 11,000 sickle cell births annually making it one of the most common disorders in eastern Africa. The affected individuals are prone to several complications since childhood as a result of the defective hemoglobin structure, these include neurological complications such as ischemic stroke due to hypercoagulability state caused by the disease. Spontaneous intracranial hemorrhage such as subdural hemorrhage in the absence of predisposing factors such as trauma, anticoagulant use, or recent blood transfusions is rare. As reported in the previous literature.

CASE PRESENTATION

We report a rare case of acute spontaneous subdural hemorrhage in an adolescent sickle cell patient of African descent.

DISCUSSION

Initial management including early referral and medical treatment is crucial for cases that are suspicious of intracranial hemorrhage. These cases are more common to be missed in resource-limited settings where there are a limited number of neurosurgery interventions.

CONCLUSION

Although few reported cases of spontaneous intracranial hemorrhage in sickle cell patients are reported, it is important to be vigilant as a clinician wherever a sickle cell patient presents with signs of increased intracranial pressure without a history of trauma such as in our patient and order an urgent brain imaging to rule out spontaneous hemorrhagic events which may lead to fatal consequences if missed out.

Cerebral sinovenous thrombosis as a cause of subdural hemorrhage in the pediatric population: Is there a correlation?

PURPOSE

Cerebral sinovenous thrombosis is an increasingly recognized cause of stroke in children and neonates. Its true incidence appears to be underestimated. Despite being a rare event, certain studies have found a correlation between subdural hemorrhage and cerebral sinus thrombosis. The literature suggests that spontaneous cerebral sinovenous thrombosis in the pediatric population may lead to the occurrence of a subdural hemorrhage. In this report, we present a case of cerebral venous thrombosis associated with chronic subdural hematoma and review the literature to highlight the importance of these conditions.

CASE REPORT

An 11-year-old boy was admitted in the neurosurgery department with headache and a neurological examination without changes. The imaging studies identified a heterogeneous subdural collection in the fronto-temporo-parietal region. The patient underwent surgical drainage of the subdural hematoma, and the procedure was performed without complications. The magnetic resonance and angiography showed an extensive thrombosis of the superior sagittal sinus, extending downward to the occipital sinus and partially to the right transverse sinus.

CONCLUSIONS

Appropriate management in the diagnosis and an early treatment of dural sinus thrombosis associated with subdural hemorrhage can reduce the risk of recurrence and improve the clinical outcome.

Subdural hemorrhage in middle cranial fossa arachnoid cysts: a report of two cases at two ends of the spectrum

Arachnoid cysts are usually asymptomatic, benign lesions commonly occurring in the middle cranial fossa. However, the cysts may rupture in rare cases causing intracystic or subdural hemorrhages with significant mass effect. We report two cases of middle cranial fossa arachnoid cyst with subdural hemorrhage with very different clinical course. The first case presented with significant mass effect with cerebral herniation and had significant neurological morbidity post-surgery. The second case had minimal symptoms and was managed conservatively with offer of elective surgery. The report underscores the importance of prompt diagnosis and appropriate surgical intervention in managing arachnoid cysts with hemorrhage, highlighting the potential for diverse clinical presentations and outcomes.

Implications of intracranial hemorrhage associated with stereo-EEG

OBJECTIVE

Intracranial hemorrhage (ICH) is a known complication during stereo-electroencephalography (sEEG) however true rates remain unknown. We provide a comprehensive review of ICH during sEEG regardless of clinical symptoms. Secondly, we analyzed sEEG recordings to identify electrographic correlates of ICH.

METHODS

This is a retrospective study of patients undergoing sEEG between January 2016 and April 2022 at the Mayo Clinic in Rochester. We reviewed medical records and imaging studies to identify ICH. We analyzed ICH by type, electrode trajectories, timing, sEEG findings and outcomes.

RESULTS

There were a total of 201 sEEG implants, of which 23 (11%) cases or 0.9% electrodes implanted had evidence of ICH. The majority of affected patients (82%) were either asymptomatic or had mild clinical neurological manifestations. In 90% of patients who proceeded with surgical treatments, outcomes were favorable. The most common sEEG finding in contacts in proximity of ICH was either focal slowing with interictal discharges or focal electrographic seizures.

CONCLUSIONS

ICH associated with sEEG is likely under-reported in literature. We present electroencephalographic correlates of ICH that may aid identification of ICH in the course of performing sEEG monitoring.

SIGNIFICANCE

Our data provides clinically relevant information on potential risks and outcomes of ICH. Furthermore, our findings aid identification of ICH during sEEG.

Gilteritinib and the risk of intracranial hemorrhage: a case series of a possible, under-reported side effect

Gilteritinib is currently approved for patients with relapsed/refractory AML with FLT3 mutations, based on the positive results of the pivotal ADMIRAL study. In ADMIRAL trial, no increased risk of bleeding was reported, but in the previous dose finding study, a single event of intracranial hemorrhage (ICH) was registered after exposure to subtherapeutic doses of gilteritinib. Here, we report the first case series on five ICHs diagnosed in patients with FLT3-mutated AML, occurred within the first month of exposure to gilteritinib. Our cohort included 24 patients treated in three Italian centers. Most of these ICH cases were non-severe and self-limiting, while one was fatal. This link with ICHs remains in any case uncertain for the presence of active AML. We further reported that an analysis of the post-marketing surveillance data (EudraVigilance) retrieved other 11 cases of ICHs present in the database after gilteritinib treatment. A causality assessment was performed according to the Dx3 method to evaluate the possibility that ICHs might be an actual side effect of gilteritinib. In conclusion, further research is needed to elucidate the potential role of gilteritinib in the pathogenesis of ICHs.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

Middle meningeal artery embolization of septated chronic subdural hematomas

INTRODUCTION

Middle meningeal artery embolization (MMAE) has emerged as a promising new treatment for patients with chronic subdural hematomas (cSDH). Its efficacy, however, upon the subtype with a high rate of recurrence-septated cSDH-remains undetermined.

METHODS

From our prospective registry of patients with cSDH treated with MMAE, we classified patients based on the presence or absence of septations. The primary outcome was the rate of recurrence of cSDH. Secondary outcomes included a reduction in cSDH thickness, midline shift, and rate of reoperation.

RESULTS

Among 80 patients with 99 cSDHs, the median age was 68 years (IQR 59-77) with 20% females. Twenty-eight cSDHs (35%) had septations identified on imaging. Surgical evacuation with burr holes was performed in 45% and craniotomy in 18.8%. Baseline characteristics between no-septations (no-SEP) and septations (SEP) groups were similar except for median age (SEP vs no-SEP, 72.5 vs. 65.5, p = 0.016). The recurrence rate was lower in the SEP group (SEP vs. no-SEP, 3 vs. 16.7%, p = 0.017) with higher odds of response from MMAE for septated lesions even when controlling for evacuation strategy and antithrombotic use (OR = 0.06, CI [0.006-0.536], p = 0.012). MMAE resulted in higher mean absolute thickness reduction (SEP vs. no-SEP, -8.2 vs. -4.8 mm, p = 0.016) with a similar midline shift change. The rate of reoperation did not differ (6.2 vs. 3.1%, p = 0.65).

CONCLUSION

MMAE appears to be equal to potentially more effective in preventing the recurrence of cSDH in septated lesions. These findings may aid in patient selection.

Risk Factors Associated With Neurosurgical Intervention in Patients With Mild Traumatic Intracranial Hemorrhage

INTRODUCTION

Community centers commonly transfer patients with traumatic intracranial hemorrhage (ICH) to level 1 and 2 trauma centers for neurosurgical evaluation regardless of the degree of injury. Determining risk factors leading to neurosurgical intervention (NSI) may reduce morbidity and mortality of traumatic ICH and the transfer of patients with lower risk of NSI.

METHODS

A retrospective chart review was performed on patients admitted or transferred to a level 1 trauma center from October 2015 to September 2019 with Glassgow Coma Scale score 13-15 and traumatic ICH on initial head computerized tomography (CTH) scan. Bivariate analyses and multivariable regression were used to identify factors associated with progression to NSI.

RESULTS

Of 1542 included patients, 8.2% required NSI. A greater proportion were male (69.1% versus 52.3%, P = 0.0003), on warfarin (37.7% versus 21.6%, P = 0.0023), presented with subdural hemorrhage (98.4% versus 63.3%, P < 0.0001, larger subdural hemorrhage size (median 19 mm [interquartile range {IQR}: 14-25] versus 5 mm [IQR: 3-8], P < 0.0001), and had a worsening repeat CTH (24.4% versus 13%, P < 0.0001). On physical examination, more patients had confusion (40.5% versus 31.4%, P = 0.0495) and hemiparesis (16.2% versus 2.6%, P < 0.0001). CTH findings of midline shift (80.2% versus 10.8%, P < 0.0001) and shift size (median 8.0 mm [IQR: 5.0-12.0] versus 4 mm [IQR: 3-5], P < 0.0001) were significantly associated with NSI.

CONCLUSIONS

Clinical factors and patient characteristics can be used to infer a greater risk of requiring NSI. These factors could reduce unnecessary transfers and hasten the transfer of patients more likely to progress to NSI.

Concomitant Rupture of an Intracranial Aneurysm and a Dural Arteriovenous Fistula: Clinical Image

A patient in his 50s presented with postcoital severe headache. Computed tomography revealed a subarachnoid hemorrhage but also a subdural hematoma at the left convexity. Computed tomography angiography revealed a large irregular anterior communicating artery aneurysm but also cortical serpiginous vessels suggestive of a vascular malformation adjacent to the subdural hematoma in the left convexity. Digital subtraction angiography confirmed the ruptured aneurysm but also revealed a Borden 3 type dural arteriovenous fistula on the left convexity. The fistula had arterial supply mostly from middle meningeal artery branches and venous drainage directly to a left cortical vein adjacent to superior sagittal sinus. Ruptured aneurysm was treated with coiling. The ruptured fistula was treated in the same session with transarterial Onyx embolization. The patient had a favorable outcome. Our case is an important reminder for all clinicians treating patients with intracranial hemorrhages on the necessity of fully reviewing all available preoperative imaging.

Intracranial hemorrhage and Covid-19: A retrospective analysis of 1675 hospitalized Covid-19 Brazilian patients

Background

The present study seeks to overcome the lack of data on Covid-19 associated intracranial hemorrhage (ICH) in Brazil.

Methods

This is a retrospective, single-center case series of consecutive patients. It is a subanalysis of a larger study still in progress, which covers all neurological manifestations that occurred in patients admitted between March 1st, 2020 and June 1st, 2022, with active SARS-CoV-2 infection confirmed by polymerase chain reaction test. All patients with non-traumatic ICH were included.

Results

A total of 1675 patients were evaluated: 917 (54.75 %) had one or more neurological symptoms and 19 had non-traumatic ICH, comprising an incidence of 1.13 %. All patients had one or more risk factors for ICH. The presence of neurological manifestations before the ICH and ICU admission showed a statistically significant relationship with the occurrence of ICH (X² = 6.734, p = 0.0095; OR = 4.47; CI = 1.3-15.4; and FET = 9.13; p = <0.001; OR = 9.15; CI = 3.27-25.5 respectively).

Discussion and conclusion

Our findings were largely congruent with the world literature. We believe that the assessment of risk factors can accurately predict the subgroup of patients at increased risk of ICH, but further studies are needed to confirm these hypotheses.

CLINICAL AND HISTOPATHOLOGICAL FINDINGS OF HEMORRHAGIC ASCENDING AND DESCENDING PROGRESSIVE MYELOMALACIA AFTER LUMBAR TAP IN TWO DOGS: CASE REPORT

Bichon Frise (1) and Boxer (2), both with epileptic seizures, underwent lumbar taps for cerebrospinal fluid collection. After the examination, the first dog became paraplegic, and the second dog did not recover from anesthesia and remained in a coma. Both dogs were euthanatized 12 h after the examination. The dogs were diagnosed with idiopathic epilepsy and fibrillar astrocytoma, respectively, after postmortem examination. They were also diagnosed with hemorrhagic ascending and descending progressive myelomalacia, involving C1-C5 until the L4-S3 spinal segments. Since it was not possible to attribute the development of myelomalacia to the primary diseases observed, the lumbar tap likely caused this severe spinal cord injury. These reports highlight myelomalacia as a possible complication of lumbar taps, even in the presence of intracranial diseases.

Simultaneous presentation of subcortical hemorrhage, subdural hemorrhage, and cerebral infarct in a hemiplegic patient

A 90-year-old, non-hypertensive woman presented gait disturbance followed by falls. She had developed a lacunar infarction in the right frontal lobe 1 month previously that subsequently resulted in subtle motor weakness in the left lower extremity. At presentation, the patient showed motor weakness in the left upper and lower extremities with normal findings on blood test. Cranial computed tomography (CT) revealed a subcortical hemorrhage in the anterior part of the right frontal lobe that was accompanied by perilesional edema. In addition, two small subdural hematomas, apparently in the acute phase, were found. Magnetic resonance imaging performed immediately after the CT revealed hyperacute infarct in the right precentral gyrus adjacent to the previous infarct. It was hyperintense on the diffusion-weighted imaging but indistinct on the fluid-attenuated inversion recovery sequence. In addition, findings suggesting cerebral contusions were not observed. Based on these, we assumed that the patient's symptoms were mainly derived from the infarct and the subdural hemorrhages had developed in association with falls. However, it was unclear whether the infarct had developed before or after the formation of subcortical hemorrhage. Traumatic and non-traumatic intracranial hemorrhage and cerebral infarcts may present simultaneously. When intracranial hemorrhages appearing on CT do not adequately explain the patient's neurological findings, undetected cerebral ischemia should be assumed.

Incidence of child abuse with subdural hemorrhage during the first year of the COVID-19 pandemic: a nationwide study in France

The global COVID-19 pandemic prompted governments to impose unprecedented sanitary measures, such as social distancing, curfews, and lockdowns. In France and other countries, the first COVID-19 lockdown raised concerns about an increased risk of child abuse. Abusive head trauma (AHT) is one of the most serious forms of child abuse in children aged 0-24 months and constitutes the leading cause of death in children under 2 years of age. Subdural hemorrhage (SDH) is present in 89% of cases of AHT and constitutes one of the most specific, objective clinical presentations in the diagnosis of child abuse. In a French nationwide study, we sought to evaluate the potential impact of the first year of the COVID-19 pandemic on the incidence of hospital admissions for child abuse with SDH, relative to the two previous years. We conducted a nationwide, retrospective study of data in the French national hospital discharge summary database by applying the International Classification of Diseases (10th Revision) codes for SDH and for child abuse. After including children aged up to 24 months with a diagnosis of child abuse and/or SDH following hospital admission anywhere in France between January 1, 2018, and December 31, 2020, we compared the incidence of child abuse, the incidence of SDH + child abuse, and the demographic data for 2020 with the corresponding values for 2018 and 2019. There were no significant differences in the number of hospital admissions due to child abuse or SDH + child abuse between 2020 and the 2018/2019 control years. The incidence of SDH + child abuse was higher among boys than among girls. There were significantly fewer hospital admissions in May 2020 (p = 0.01) and significantly more in December 2020 (p = 0.03), relative to the same months in the two preceding years. There was a nonsignificant trend toward a lower incidence of hospital admission for child abuse in 2020, relative to 2019 (decrease: 6.4%) and 2018 (decrease: 7.6%).

CONCLUSION

When considering children under the age of 24 months in France, the incidence of hospital admission for SDH in the context of child abuse was not significantly higher in 2020 than in the two previous years.

WHAT IS KNOWN

• The impact of COVID-19 lockdown on child abuse and more specifically on subdural hemorrhage remains unknown.

WHAT IS NEW

• There was no increase in hospitalizations for child abuse and AHT. • We found that boys are more often victims of child abuse and subdural hemorrhage among children aged less than 12 months.

A case of subdural hemorrhage due to ruptured cerebral aneurysm presenting with atypical imaging features

Acute subdural hemorrhage caused by ruptured cerebral aneurysms is rare. Herein, we report an atypical case of subdural hemorrhage caused by ruptured anterior communicating artery aneurysm in a 49-year-old woman. Computed tomography revealed subarachnoid, intracerebral, and subdural hemorrhages. After the treatment with endovascular coiling significantly decreased the patient's subdural hemorrhage. However, the subdural hemorrhage revealed and became iso-attenuation compared with the white matter on the 11th day, and hypo-attenuation on the 19th day. On the 33rd day, this subdural hemorrhage completely resolved after discontinuation of dual antiplatelet therapy. Due to rapid changes in the radiologic features of SDH, frequent computed tomography scans at least once a week may be needed especially in patients who receive antiplatelet therapy during the vasospasm phase.

Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight

BACKGROUND

Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI.

OBJECTIVE

To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions.

METHODS

A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted.

RESULTS

Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033).

CONCLUSION

RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

[Nonaccidental traumatic brain injury in infants and children]

Violent traumatic brain injury (TBI) can cause brain dysfunction and injury. Accidental and nonaccidental trauma are still the leading cause of childhood death worldwide. It is assumed that about 20% of TBI in children under 2 years of age are nonaccidentally caused. In all cases, nonaccidental TBI is caused by the violent impact on the brain and spinal cord by the massive shaking of the child held by the upper arms or body. This can lead to a rupture of blood vessels, especially bridge veins, as well as axonal shear injuries to the nerve connections and brain swelling. Involvement of the brain stem can lead to initial short-term respiratory arrest. The resulting clinical symptoms include poor drinking, drowsiness, apathy, cerebral seizures, breathing disorders, temperature disorders, and vomiting as a result of increased intracranial pressure. Long-term disorders can include neurological and neuropsychological disorders, hearing disorders, visual disorders up to blindness, and poor school performance. In addition, there are metaphyseal fractures and rib fractures of various forms, also of different ages. Since shaking trauma has a poor prognosis, preventive measures are useful: education!

Subdural hemorrhage in a cohort with cerebral sinovenous thrombosis: Application to abusive head trauma

BACKGROUND

Cerebral sinovenous thrombosis (CSVT) is a postulated cause of subdural hemorrhage (SDH) that is hypothesized to mimic abusive head trauma (AHT). Minimal data exists directly investigating this relationship.

OBJECTIVES

To evaluate the frequency of SDH in children with CSVT, identify factors associated with CSVT and SDH, and to assess if any association supports the hypothesis that CSVT causes SDH.

PARTICIPANTS AND SETTING

The International Pediatric Stroke Study (IPSS) prospectively collects data on subjects birth to 19 years of age with intracranial thrombosis.

METHODS

IPSS subjects with CSVT and SDH were compared to those with CSVT and no SDH. For subjects with CSVT and SDH, neuroimaging reports further characterized the findings. In any case with no known risk factors for SDH, neuroimaging studies were reviewed by a pediatric neuroradiologist.

RESULTS

Of 216 subjects with CSVT, 20 (9.3%) had SDH. Those with SDH (median age 0.3 years) were younger than those without SDH (median age 4.2 years), p < 0.001. Subjects with CSVT and SDH more frequently had anoxia (OR = 10.8; 95% CI: 1.4, 81.1), head/neck injury (OR = 4.0; 95% CI: 1.3, 12.6), or abnormal consciousness (OR = 3.0; 95% CI: 1.2, 7.6). Of 20 subjects with CSVT and SDH, 19 had known risk factors for SDH. The remaining subject had a chronic SDH identified concomitantly to a newly symptomatic CSVT with accompanying venous infarctions.

CONCLUSIONS

SDH in the setting of CSVT is typically identified in children with independent risk factors for SDH. This study does not support the hypothesis that CSVT causes SDH.

Pitfalls in the diagnosis of subdural hemorrhage - Mimics and uncommon causes

PURPOSE

Subdural hemorrhage (SDH), the accumulation of blood between the dura and arachnoid mater, is one of the most commonly encountered traumatic findings in emergency radiology setting. The purpose of this essay is to review the pitfalls in the diagnosis of SDH including a) mimics on CT imaging and b) etiology other than accidental trauma. We describe several entities that closely mimic SDH on non-contrast CT scans. A knowledge of these mimics is essential in the emergency setting since overdiagnosis of SDH can lead to unnecessary hospital admissions, potentially invasive procedures, or even delay in necessary treatment. The mimics of SDH on non-contrast head CT include: PATHOLOGIC ENTITIES IATROGENIC MIMICS ANATOMIC/PHYSIOLOGIC MIMICS ARTIFACTUAL MIMICSWe also briefly review non-accidental and non-traumatic causes of SDH. Although, the most common cause of SDH is accidental trauma, other routinely encountered causes of SDH include coagulopathy, non-accidental trauma, cranial surgery, vascular malformations etc. CONCLUSION: Clinicians dealing with SDH in the emergency setting should consider SDH mimics and less common etiologies of SDH in order to facilitate appropriate patient management.

Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse

BACKGROUND/PURPOSE

Accurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations.

METHODS

Electronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH.

RESULTS

Two hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated.

CONCLUSIONS

Children under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse.

LEVEL OF EVIDENCE

III (Diagnostic Test).

Spinal subdural hemorrhage in abusive head trauma: a pictorial review

A growing body of evidence links abusive head trauma (AHT) to patterns of direct and indirect spinal injuries, such as spinal subdural hemorrhage (SDH). Identification of evidence of spinal injury such as spinal SDH plays a crucial role in the diagnosis and subsequent management of the index child with AHT and his or her siblings. In a value-based practice of medicine, it can be argued that adding spine imaging to identify spinal SDH in the workup of AHT adds value to both the short- and long-term management of the patient. This pictorial review describes the normal appearance of spinal SDH and challenges of identifying spinal SDH, and it explores the mechanism of spinal SDH development in AHT.

Macrocephaly and subdural collections

Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.

Genetic causes of fractures and subdural hematomas: fact versus fiction

Genetic disorders are in the differential diagnosis when young children present with unexplained fractures or intracranial hemorrhage. For medical and legal reasons, it is imperative to make the correct diagnosis and provide clear, evidence-based explanations of how alternative diagnoses were ruled out. A genetics consultation in cases of suspected child physical abuse should synthesize the history of present illness, medical history, family history, physical examination, and radiologic and laboratory findings in consultation with other specialists. The medical geneticist highlights how these disorders truly present. When the natural history of a genetic disorder is understood, it becomes clear that genetic disorders are not mysterious or difficult to diagnose. As highlighted in this case-based review, mainstream medical practice allows for differentiation among the intracranial and skeletal manifestations of osteogenesis imperfecta, Menkes disease, glutaric acidemia type 1 and child physical abuse. This review also highlights how a genetic disorder, Ehlers-Danlos syndrome, can be misused in a courtroom. Finally, this review summarizes when genetic testing is appropriate in cases of suspected child physical abuse.

Neuroradiologic timing of intracranial hemorrhage in abusive head trauma

Determining the timing of intracranial injuries in general, and abusive head trauma (AHT) in particular, is important to the care of children with traumatic brain injury. Additionally, identifying the time of the injury provides important information as to who might have, and who did not, inflict the trauma. Understanding the appearance and evolution of intracranial findings on neuroimaging has been an important factor in assessing the time of the injury. However, a number of studies in the last two decades have both suggested greater uncertainty about the reliability of this process and advanced our knowledge in this area. In this review, the authors consider the biophysical factors that contribute to the appearance and evolution of intracranial hemorrhage and, in particular, subdural hemorrhage (SDH). The traditional view of SDH is predicated largely on prior studies of intracerebral hemorrhage, although a number of variables make this comparison untenable. Moreover, more recent studies have suggested a number of factors that could alter the density (CT) or signal intensity (MRI) and produce mixed density/intensity SDH. These factors need to be considered in interpreting neuroimaging studies. A number of these recent studies evaluating serial neuroimaging in children with AHT have modified our understanding of intracranial hemorrhage and its evolution in this context. Taken together, the studies to date, having important limitations, provide only broad ranges over which to time injuries. The authors conclude that neuroimaging studies at this time are not likely, in isolation, to be able to accurately pinpoint a specific time of injury; rather, neuroimaging can only provide a range of possible times and should instead be used as a means to supplement or corroborate timing based on clinical presentation and other imaging findings.

A perfect storm: The distribution of tissue damage depends on seizure duration, hemorrhage, and developmental stage in a gyrencephalic, multi-factorial, severe traumatic brain injury model

The pathophysiology of extensive cortical tissue destruction observed in hemispheric hypodensity, a severe type of brain injury observed in young children, is unknown. Here, we utilize our unique, large animal model of hemispheric hypodensity with multifactorial injuries and insults to understand the pathophysiology of this severe type of traumatic brain injury, testing the effect of different stages of development. Piglets developmentally similar to human infants (1 week old, “infants”) and toddlers (1 month old, “toddlers”) underwent injuries and insults scaled to brain volume: cortical impact, creation of mass effect, placement of a subdural hematoma, seizure induction, apnea, and hypoventilation or a sham injury while anesthetized with a seizure-permissive regimen. Piglets receiving model injuries required overnight intensive care. Hemispheres were evaluated for damage via histopathology. The pattern of damage was related to seizure duration and hemorrhage pattern in “toddlers” resulting in a unilateral hemispheric pattern of damage ipsilateral to the injuries with sparing of the deep brain regions and the contralateral hemisphere. While “infants” had the equivalent duration of seizures as “toddlers”, damage was less than “toddlers”, not correlated to seizure duration, and was bilateral and patchy as is often observed in human infants. Subdural hemorrhage was associate with adjacent focal subarachnoid hemorrhage. The percentage of the hemisphere covered with subarachnoid hemorrhage was positively correlated with damage in both developmental stages. In “infants”, hemorrhage over the cortex was associated with damage to the cortex with sparing of the deep gray matter regions; without hemorrhage, damage was directed to the hippocampus and the cortex was spared. “Infants” had lower neurologic scores than “toddlers”. This multifactorial model of severe brain injury caused unilateral, wide-spread destruction of the cortex in piglets developmentally similar to toddlers where both seizure duration and hemorrhage covering the brain were positively correlated to tissue destruction. Inherent developmental differences may affect how the brain responds to seizure, and thus, affects the extent and pattern of damage. Study into specifically how the “infant” brain is resistant to the effects of seizure is currently underway and may identify potential therapeutic targets that may reduce evolution of tissue damage after severe traumatic brain injury.

Surgical treatment of spontaneous intracranial hemorrhage in patients with cancer: Analysis of prognostic factors

BACKGROUND

Intracranial hemorrhage (ICH) is the most common cerebrovascular event in patients with cancer. We sought to evaluate the outcomes of surgical treatment for ICH and to determine possible pre-operative outcome predictors.

METHODS

We retrospectively reviewed surgical procedures for the treatment of ICH in patients with cancer. Analysis included clinical and radiological findings of the patients. Primary endpoints were survival and mortality in index hospitalization.

RESULTS

Ninety-four emergency neurosurgeries were performed for ICH in 88 different patients with cancer over ten years. 51 patients had chronic subdural hematomas (CSDH: 54.3%), 35 with intraparenchymal hemorrhage (37.2%), 6 with acute subdural hematoma (ASDH: 6.4%), and only 2 with epidural hemorrhages (2.1%). Median patient follow-up was 63 days (IQR = 482.2). 71 patients (75.5%) died at follow-up, with a median survival of 33 days. Overall 30-day mortality was 38.3%; 27.5% for patients with CSDH. Lower survival was associated to higher absolute leucocyte count (HR 1.06; 95%CI 1.04-1.09), higher aPTT ratio (HR 3.02; 95% CI 1.01-9.08), higher serum CRP (HR 1.01; 95%CI 1.01-1.01), and unresponsive pupils (each unresponsive pupil - HR 2.65; 95%CI 1.50-4.68).

CONCLUSION

Outcomes following surgical treatment of ICH in patients with cancer impose significant morbidity and mortality. Type of hematoma, altered pupillary reflexes, coagulopathies, and increased inflammatory response were predictors of mortality for any type of ICH.

The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis

BACKGROUND

Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH.

METHODS

Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home.

RESULTS

Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis.

CONCLUSIONS

iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.

Predictions of neonatal porcine bridging vein rupture and extra-axial hemorrhage during rapid head rotations

When the head is rotated rapidly, the movement of the brain lags that of the skull. Intracranial contents between the brain and skull include meninges, cerebrospinal fluid (CSF), and cerebral vasculature. Among the cerebral vasculature in this space are the parasagittal bridging veins (BVs), which drain blood from the brain into the superior sagittal sinus (SSS), which is housed within the falx cerebri, adhered to the inner surface of the skull. Differential motion between the brain and skull that may occur during a traumatic event is thought to stretch BVs, causing damage and producing extra-axial hemorrhage (EAH). Finite element (FE) modeling is a technique often used to aid in the understanding and prediction of traumatic brain injury (TBI), and estimation of tissue deformation during traumatic events provides insight into kinematic injury thresholds. Using a FE model of the newborn porcine head with neonatal porcine brain and BV properties, single and cyclic rapid head rotations without impact were simulated. Measured BV failure properties were used to predict BV rupture. By comparing simulation outputs to observations of EAH in a development group of in vivo studies of rapid non-impact head rotations in the piglet, it was determined that failure of 16.7% of BV elements was associated with a 50% risk of EAH, and showed in a separate validation group that this threshold predicted the occurrence of EAH with 100% sensitivity and 100% specificity for single rapid non-impact rotations. This threshold for failed BV elements performed with 90% overall correct prediction in simulations of cyclic rotational head injuries. A 50% risk of EAH was associated with head angular velocities of 94.74 rad/s and angular accelerations of 29.60 krad/s² in the newborn piglet. Future studies may build on these findings for BV failure in the piglet to develop predictive models for BV failure in human infants.

A ruptured posterior communicating artery aneurysm presenting as tentorial and spinal isolated subdural hemorrhage: a case report and literature review

Background

Ruptured intracranial aneurysms are often associated with subarachnoid or intraparenchymal hemorrhage. However, the prevalence of subdural hemorrhage post aneurysmal rupture is low and rarely reported in scientific studies. Here, we report an unusual case of a ruptured posterior communicating artery aneurysm resulting in an isolated subdural hematoma located in the tentorial and spinal canal without subarachnoid or intraparenchymal hemorrhage.

Case presentation

In this case, a 34-year-old woman with no history of trauma or coagulopathy was diagnosed with a subdural hematoma in the tentorium cerebellum tracing to the subdural space of the spinal column. Computed tomography angiography was used to identify the source of the bleeding, which revealed a ruptured left-sided posterior communicating artery saccular aneurysm. The aneurysm was clipped, and the hematoma was evacuated. The patient recovered without any neurological complications.

Conclusions

Our results suggest that a diagnosis of ruptured intracranial aneurysm should be considered in patients with nontraumatic subdural hematoma. Prompt diagnostic imaging and interventional diagnostic procedures are required to ensure proper management of these patients and to avoid unnecessary complications.

Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants

BACKGROUND

Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited.

METHODS

We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30 months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included.

RESULTS

A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment.

CONCLUSIONS

These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.

Characteristics associated with spine injury on magnetic resonance imaging in children evaluated for abusive head trauma

BACKGROUND

Spine injuries are increasingly common in the evaluation for abusive head trauma (AHT), but additional information is needed to explore the utility of spine MRI in AHT evaluations and to ensure an accurate understanding of injury mechanism.

OBJECTIVE

To assess the incidence of spine injury on MRI in children evaluated for AHT, and to correlate spine MRI findings with clinical characteristics.

MATERIALS AND METHODS

We identified children younger than 5 years who were evaluated for AHT with spine MRI. Abuse likelihood was determined a priori by expert consensus. We blindly reviewed spine MRIs and compared spinal injury, abuse likelihood, patient demographics, severity of brain injury, presence of retinal hemorrhages, and pattern of head injury between children with and without spine injury.

RESULTS

Forty-five of 76 (59.2%) children had spine injury. Spine injury was associated with more severe injury (longer intensive care stays [P<0.001], lower initial mental status [P=0.01] and longer ventilation times [P=0.001]). Overall abuse likelihood and spine injury were not associated. Spinal subdural hemorrhage was the only finding associated with a combination of retinal hemorrhages (P=0.01), noncontact head injuries (P=0.008) and a diagnosis of AHT (P<0.05). Spinal subdural hemorrhage was associated with other spine injury (P=0.004) but not with intracranial hemorrhage (P=0.28).

CONCLUSION

Spinal injury is seen in most children evaluated for AHT and might be clinically and forensically valuable. Spinal subdural hemorrhage might support a mechanism of severe acceleration/deceleration head injury and a diagnosis of AHT.

Subdural hemorrhage rebleeding in abused children: frequency, associations and clinical presentation

BACKGROUND

Limited documentation exists about how frequently radiologically visible rebleeding occurs with abusive subdural hemorrhages (SDH). Likewise, little is known about rebleeding predispositions and associated symptoms.

OBJECTIVE

To describe the frequency of subdural rebleeding after abusive head trauma (AHT), its predispositions and clinical presentation.

MATERIALS AND METHODS

We evaluated children with SDHs from AHT who were reimaged within a year of their initial hospitalization, retrospectively reviewing clinical details and imaging. We used the available CT and MR images. We then performed simple descriptive and comparative statistics.

RESULTS

Fifty-four of 85 reimaged children (63.5%) with AHT-SDH rebled. No child had new trauma, radiologic evidence of new parenchymal injury or acute neurologic symptoms from rebleeding. From the initial presentation, macrocephaly was associated with subsequent rebleeding. Greater subdural depth, macrocephaly, ventriculomegaly and brain atrophy at follow-up were associated with rebleeding. No other radiologic findings at initial presentation or follow-up predicted rebleeding risk, although pre-existing brain atrophy at initial admission and initial chronic SDHs barely missed significance. Impact injuries, retinal hemorrhages and clinical indices of initial injury severity were not associated with rebleeding. All rebleeding occurred within chronic SDHs; no new bridging vein rupture was identified. The mean time until rebleeding was recognized was 12 weeks; no child had rebleeding after 49 weeks.

CONCLUSION

Subdural rebleeding is common and occurs in children who have brain atrophy, ventriculomegaly, macrocephaly and deep SDHs at rebleed. It usually occurs in the early months post-injury. All children with rebleeds were neurologically asymptomatic and lacked histories or clinical or radiologic findings of new trauma. Bleeds did not occur outside of chronic SDHs. We estimate the maximum predicted frequency of non-traumatic SDH rebleeding accompanied by acute neurological symptoms in children with a prior abusive SDH is 3.5%.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification of clinical characteristics and factors predicting favorable treatment outcomes in elderly patients with traumatic brain injury

Age is an important prognostic factor for patients with traumatic brain injury (TBI), and worse treatment outcomes have been reported in elderly patients. Therefore, proper treatment is needed for the increasing number of elderly patients with TBI. We aimed to analyze predictive factors of favorable treatment outcomes (FTO) in elderly patients. Clinical and radiological data from 493 patients with TBI who visited a single institute were retrospectively collected from January 2014 to December 2015. We compared the characteristics of the elderly group (individuals above 65 years) and younger group (16-65 years). We analyzed the characteristics and outcomes in both groups and the factors related to the Glasgow outcome scale-extended score at 6 months after injury in 170 elderly patients. The treatment outcomes were dichotomized into favorable and unfavorable groups. In the elderly group, the proportion of female patients and the incidence of subdural hemorrhage (SDH) were higher than in the younger group. Among the 170 elderly patients, 62 had pure SDH, and 21 of the 62 with pure SDH had undergone surgical treatment. Compared with other types of intracranial hemorrhage, FTO was as high as 85.5%, and mortality was as low as 11.3% in patients with pure SDH. High initial Glasgow coma scale score, low injury severity score, and normal pupillary reflex were significantly related to FTO in multivariate analysis. Therefore, active therapeutic strategies, including surgery should be considered for elderly patients with pure SDH without intra-parenchymal injury.

Acute Subdural Hemorrhage Associated With Both Metastatic Adenocarcinoma of the Dura and Minor Head Trauma: A Case Report and Review of the Literature

While reportedly a relatively common finding at the autopsy of decedents with metastatic neoplasms, dural metastases are infrequently described in the medical literature and only 55 cases of subdural hemorrhage associated with dural metastases have been described, with only one of these cases associated with head trauma. We report a 50-year-old incarcerated male who died as the result of acute and chronic subdural hemorrhage associated with recent minor head trauma and dural metastases, which were most likely of pancreatic origin. He had sustained a fall, possibly due to a seizure in his jail cell, developed an acute subdural hemorrhage, and died, necessitating an autopsy. Metastatic tumor in the dura and other organs was identified upon histologic examination and found to be CK7 and CK20 positive and TTF-1 and CDX2 negative, consistent with a pancreatic adenocarcinoma. In addition, marantic endocarditis was identified, which can occur in individuals with mucinous tumors, such as a pancreatic neoplasm. This case report offers the second description of a subdural hemorrhage occurring in association with both dural metastases and recent head trauma and confirms the importance of histologic examination of the subdural hemorrhage and adjacent dura at autopsy for reasons other than just timing of the event.

Short- and Long-Term Geriatric Mortality After Acute Traumatic Subdural Hemorrhage

BACKGROUND

Acute subdural hemorrhage often occurs in those ≥65 years of age after trauma and tends to yield poor clinical outcomes. Previous studies have demonstrated a propensity toward high in-hospital mortality rates in this population; however, postdischarge mortality data are limited. The objective of the present study was to analyze short- and long-term mortality data after acute traumatic subdural hemorrhage in the geriatric population as well as review the impact of associated clinical variables including mechanism of injury, pre-morbid antithrombotic use, and need for surgical decompression on mortality rates.

METHODS

We retrospectively reviewed 455 patients who presented with an isolated traumatic acute subdural hemorrhage to our level-1 trauma center over a 5 year period using our data registry. Patients were then cross-referenced in the National Social Security Death Index for postdischarge mortality rates. United States life tables were used for peer-controlled actuarial comparisons.

RESULTS

Acute traumatic subdural hemorrhage is often a fatal injury in the geriatric population, especially if taking antithrombotics or requiring surgical decompression. Specifically, they have greater in-hospital mortality rates than adults with similar injuries and have significantly lower survival rates for several years following discharge compared with their peer-matched controls.

CONCLUSIONS

Here, we found that age is a significant predictor of both short- and long-term survival after acute traumatic subdural hemorrhage. Moreover, the present study corroborates that the need for surgical decompression or the use of pre-morbid antithrombotic medications is associated with increased overall mortality.

Non-traumatic subdural hemorrhage: beware of ruptured intracranial aneurysm

Acute subdural hemorrhage (SDH) is commonly encountered by emergency radiologists in the setting of trauma. When history or imaging evidence of trauma is absent, the differential diagnosis for SDH should be expanded. Intracranial aneurysm rupture is a rare and underrecognized cause of SDH which may present without concurrent subarachnoid hemorrhage. The mechanism of aneurysmal SDH is controversial, but understanding the anatomic microenvironment of the aneurysm provides insight and clarifies aneurysm features predisposing to subdural compartment rupture. Aneurysmal SDH is a neurosurgical emergency and its treatment strategies differ from traumatic SDH. Outcomes are poor if treatment is delayed; thus, radiologists play a central role in recognizing this uncommon but potentially devastating complication of aneurysm rupture. The goal of this article is to familiarize radiologists with clinical and imaging characteristics of aneurysmal SDH and review pertinent anatomy, risk factors, and potential etiologies. Aneurysmal rupture can easily be overlooked in the routine workup of atraumatic SDH, and radiologists must know when to recommend vascular imaging to avoid the catastrophic consequences of a missed diagnosis.

Frequency of macroscopic intradural hemorrhage with and without subdural hemorrhage in early childhood autopsies

Some authors have suggested that in the fetus, neonate and infant, intradural hemorrhage (IDH) is relatively common and often presents alongside subdural hemorrhage (SDH). These authors have theorized that pediatric SDH may result from an IDH due to blood leakage from a dural vascular plexus. In this study, we report the inter-observer variation for detection of IDH from a retrospectively collected series of pediatric autopsy photographs, with and without SDH. Autopsy photographs of the falx and tentorium from 27 neonatal, infant and early childhood autopsies were assessed by two independent consultant forensic pathologists blinded to all case histories for the presence and extent (focal or diffuse) of IDH. Inter-observer agreement between the pathologists was calculated using Cohen’s kappa coefficient. The occurrence of subdural hemorrhage was also recorded at autopsy. A kappa coefficient value of 0.669 (p = 0.001), indicated a substantial level of agreement for the presence/absence of IDH between the pathologists. For the extent of IDH a kappa coefficient value of 0.6 (p = 0.038) indicated a moderate level of agreement. The pathologists agreed on the presence of IDH in 10 of the 27 cases. Subdural hemorrhage was recorded for 8 out of 27 cases. Of these 8 cases, it was agreed that 4 had IDH. Using standardized methods of image capture and assessment, inter-observer agreement for the presence/absence of IDH was substantial. In this paper, we report a much lower frequency of macroscopic IDH occurring alongside SDH than previous studies, which included both gross observation of IDH and histological examination.

Non-Traumatic Acute Subdural Hemorrhage Due To Cranial Venous Hypertension

Acute subdural hemorrhage is typically associated with a history of head trauma, and as such it is a finding with significant potential medicolegal consequences. In this article, 37 adult and post-infantile pediatric sudden death autopsy cases with small volume ("thin film" or "smear") acute subdural hemorrhage are presented-in which there is either no further evidence of head trauma or only features of minor head injury. The possible underlying pathophysiological mechanisms are explored, and it is concluded that a common thread in many of these cases is likely to have been cranial venous hypertension at around the time of death. These findings may have implications in instances where small volume subdural hemorrhage is identified in the absence of other evidence of significant head injury.

Spontaneous Intracranial Hemorrhage in Pregnancy: A Systematic Review of the Literature

Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6 weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.

T2-blackout effect on DWI as a sign of early bone infarct and sequestration in a patient with sickle cell disease

Differentiation of bone infarct from osteomyelitis is one of the most challenging issues in the evaluation of acute bone pain in sickle cell patients. The imaging modalities that are currently being used for assessment of bone marrow in this population have several limitations. We present a case of an 18-year-old male with a history of sickle cell disease, who was transferred to our emergency department with progressively severe headache and jaw pain for one-week. Initial evaluation was concerning for osteomyelitis and epidural abscess formation. Due to the lack of response to the current antibiotic treatment, he was transferred to our institution. On further review of the images, atypical DWI findings that were identified in the early phase of presentation helped to differentiate bone infarct from osteomyelitis. Radiologists should be aware of this phenomenon, as it can help in the differentiation between these two pathologies and can affect the patient's management overall.

Parasagittal vertex clots on head CT in infants with subdural hemorrhage as a predictor for abusive head trauma

BACKGROUND

Abusive head trauma (AHT) is the most common cause of subdural hemorrhage (SDH) in infants younger than 12 months old. Clot formation in the parasagittal vertex seen on imaging has been associated with SDH due to AHT. There have been very few studies regarding these findings; to our knowledge, no studies including controls have been performed.

OBJECTIVE

To describe parasagittal vertex clots on head computed tomography (CT) in infants with SDH and AHT compared to patients with SDH and accidental trauma, and to evaluate for parasagittal vertex clots in the absence of SDH in the setting of known accidental head trauma.

MATERIALS AND METHODS

All infants younger than 12 months old with SDH present on CT scan were retrospectively identified from 2004 to 2014. Blinded, independent review of all CT scans for clot formation at the parasagittal vertex was performed by a pediatric neuroradiologist.

RESULTS

Ninety-nine patients were eligible for analysis. Mean age was 4 months. Fifty-seven (57.6%) were male. Fifty-five (55.6%) patients were identified as having AHT and 22 (22.2%) had accidental trauma. Forty-five (81.2%) patients with AHT had parasagittal vertex clots present on CT scan compared to 8 (36.4%) patients with accidental trauma. Compared to patients without parasagittal vertex clots, those with parasagittal vertex clots were more likely to have AHT (66.2% vs. 32.3%, P=0.001), no known mechanism of injury (69.1% vs. 32.3%, P=0.015), retinal hemorrhage (75% vs. 35.5%, P=0.002) and hypoxic-ischemic changes (25% vs. 0%, P=0.002). Patients with parasagittal vertex clots have eight times the odds of AHT compared to patients without parasagittal vertex clots. Age-matched control patients who underwent head CT scan due to a history of accidental head injury without SDH were identified (n=87); no patient in the control group had parasagittal vertex clots.

CONCLUSION

The finding of parasagittal vertex clots on CT scans should raise suspicion for abuse and prompt further investigation, especially in the setting of no known, uncertain or inconsistent mechanism of injury.

Traumatic Posterior Fossa Subdural Hemorrhage: A Multicenter, Retrospective Cohort Study

BACKGROUND

Traumatic posterior fossa subdural hemorrhage (SDH) is a rare subtype of subdural hemorrhage in head injuries. Existing data on its pathophysiology and outcome are currently limited; therefore, the condition is not yet fully understood. The present study aimed to determine the incidence, outcome, and prognostic factors for traumatic posterior fossa SDH.

METHODS

We performed a retrospective cohort study using the nationwide trauma registry Japan Trauma Data Bank. We identified adult patients (i.e., aged ≥18 years) who had posterior fossa SDH after blunt head trauma from 2004 to 2015. The primary endpoint was in-hospital mortality. We compared patients with and without posterior fossa SDH and adjusted for confounders using a multivariate logistic regression model.

RESULTS

A total of 75,838 patients had blunt head injuries. Of these, 266 (0.35%) had posterior fossa SDH, and 177 (median age, 69 years; interquartile range, 55-76) were eligible for analysis. The distribution of the Glasgow Coma Scale (GCS) score was bimodal, and the median score was 14 (interquartile range, 9-15). The mortality rate was 16.9% (95% confidence interval [CI], 11.7%-23.3%). A large posterior fossa SDH (>30 cm³; >1 cm thick), low GCS score on arrival, and the presence of a skull fracture were significantly associated with mortality, with an adjusted odds ratio of 4.51 (95% CI, 1.46-13.9), 0.82 (95% CI, 0.73-0.92), and 4.59 (95% CI, 1.52-13.9), respectively.

CONCLUSIONS

Traumatic posterior fossa SDH was extremely rare in our data set. Mortality correlated with the size of the SDH, GCS score on admission, and the presence of a skull fracture.

Spontaneous pneumocephalus and subdural hemorrhage after sneezing

Spontaneous pneumocephalus is defined as the presence of air in the absence of intracranial factors. The management of spontaneous pneumocephalus can be conservative or surgical, and surgical intervention could be urgently required if clinical deterioration is rapid. Here, we report a case of pneumocephalus and subdural hemorrhage after sneezing. A 24-year-old male reported to our emergency department with a chief complaint of headache and dizziness. The patient gave a history of onset of headache and dizziness after 2 episodes of heavy sneezing. There was neither a history of recent traumatic episode or previous surgery, nor any signs and symptoms of recent fever or upper respiratory tract infections. Physical examination showed no specific findings. Computed tomography was performed, which showed subdural hemorrhage and PNC in the left occipital lobe, left hemomastoid, and maxillary hemosinus. A neurosurgeon was consulted, who suggested admission in the intensive care unit. An otolaryngologist was then consulted for the left ear otorrhea and hearing impairment. Otoscopic examination showed hemotympanum of the left ear, for which pain control and conservative treatment was suggested. The patient was transferred to general ward 4 days later, since the following brain computed tomography showed resolution of the hemorrhage, and discharged 6 days later because of the improved signs and symptoms. Pneumocephalus and intracranial hemorrhage can occur without a history of trauma or surgery. Special attention is required if headache, dizziness, or other neurologic signs and symptoms occur immediately after sneezing. Intracranial hemorrhage and penumocephalus should be considered in the differential diagnosis.

Cerebral venous thrombosis presenting like a subdural hemorrhage at magnetic resonance imaging: An Italian case report

Cerebral venous sinus thrombosis (CVST) is responsible for 1–2% of all strokes in adults. Venous occlusive disease is a less common condition than the arterial one, but probably underestimated in the past [1]. Its early detection is crucial to ensure appropriate therapy, to prevent irreversible brain injury. The neuroradiological study is crucial to formulate the diagnosis.

Unenhanced computed tomography (CT) is usually the first imaging study performed on an emergency basis.

We report the case of a woman who present a migrant headache, resistant to the therapy. It was at first performed an axial CT scan of the brain that was negative.

Afterwards the Patient did an MRI which proves the presence of a hyperintensity rhyme, localized in the left temporal region, in the subdural space, diagnosed like a subdural hemorrhage.

Considering the type and increase of headache, neurologist suggest to perform a venography PC sequence that finally demonstrate the correct diagnosis of a filling defect of left spheno-parietal sinus.

Pediatric abusive head trauma in Taiwan: clinical characteristics and risk factors associated with mortality

PURPOSE

To report the clinical characteristics of abusive head trauma (AHT) in Taiwan and identify the risk factors associated with mortality of these patients.

METHODS

Children with clinically diagnosed AHT from January 1, 2000, to October 31, 2015 were reviewed. The demographic data, clinical features, and associated retinal and radiologic findings were analyzed. The multivariable logistic regression model analysis was performed to identify the risk factors associated with in-hospital mortality.

RESULTS

A total of 75 children were included. The mean age was 7.31 ± 6.57 months (range, 1-36 months). Retinal hemorrhages were detected in 69 children with AHT (92%). The majority of retinal hemorrhages were characterized by hemorrhagic numbers higher than ten (74.7%), multi-layered (54.7%), and extension beyond the posterior pole to the peripheral retina (73.3%). Twenty children (26.7%) had macular retinoschisis. As a direct result of AHT, ten children died in the hospital (13.3%). Logistic regression showed that respiratory distress or apnea (adjusted odds ratio [OR] = 22.46; 95% confidence interval [CI], 2.24-225.33; P = .0082), vomiting (adjusted OR = 11.94; 95% CI, 1.31-108.403; P = .0276), retinal finding of macular retinoschisis (adjusted OR = 8.9; 95% CI, 1.01-78.65; P = .0493), and the presence of subarachnoid hemorrhage (SAH) (adjusted OR = 15.17; 95% CI, 1.40-64.84; P = .0255) were independently associated with mortality.

CONCLUSIONS

Respiratory distress or apnea, vomiting, SAH, and macular retinoschisis are independently associated with mortality in abusive head trauma. A complete ophthalmologic examination with the immediate visualization of intraocular injury should be performed to clarify the likelihood of child abuse and predict a potential poor neurologic outcome.

Intracranial hemorrhage in term neonates

BACKGROUND

Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates; currently, ICH is more frequently diagnosed because of improved neuroimaging techniques.

PURPOSE

The study aims to evaluate the clinical characteristics and neuroimaging data (pattern, size, distribution) of neonatal ICH.

METHODS

We reviewed MRI data from July 2004 to June 2015 for 42 term neonates with ICH who were less than 1 month old. We recorded clinical data and manifestations, mode of delivery, Apgar score at 1 and 5 min, associated hypoxic insult, birth trauma, neurological symptoms, EEG results, extent and site of hemorrhage, neurosurgical intervention, and developmental outcomes. The clinical outcome was determined for 27 neonates. Risk factors were assessed in relation to ICH.

RESULTS

A total of 42 neonates who presented with ICH underwent MR imaging 2 to 22 days postnatally (mean age 9.3 days). The majority of clinical symptoms were present in patients within the first 24 h of life (n = 31), but symptoms appeared until day 10 postnatally (mean 4.9 days, n = 11). Seizure or seizure-like activity was the most common presenting symptom (17/42, 40.5%), with apnea seen in another seven infants (7/42, 16.7%). The majority of infants had a normal prenatal course. Two patients had antenatally detected hydrocephalus. Ten had infratentorial hemorrhage, and two had supratentorial hemorrhage. A total of 30 infants had a combination of infratentorial and supratentorial hemorrhage. Subdural hemorrhage (SDH) was the most common type of hemorrhage (40/42, 95.2%), followed by nine cases of parenchymal hemorrhage, seven of subarachnoid hemorrhage, three of germinal matrix hemorrhage (GMH), and one of epidural hemorrhage (EDH). A total of 16 infants had two or more types of hemorrhage. SDH was identified along the tentorium (n = 38) as well as over the cerebellar hemispheres (n = 39), along the interhemispheric fissure (n = 10), and over the occipital (n = 13) or parietooccipital (n = 11) lobes. Intraparenchymal hemorrhage involved either the frontal (n = 4), parietal (n = 3), or cerebellar (n = 2) lobes. Traumatic delivery was suspected in 20 patients (47.6%), and perinatal asphyxia was present in 21 patients (50.0%). A low Apgar score at 5 min and a history of perinatal asphyxia were the factors that most predicted poor clinical outcomes (n = 12/27). Logistic regression analysis revealed that a history of perinatal asphyxia resulted in poor outcomes. No patients died. One infant required burr hole drainage of a right parietal EDH, one infant needed a subcutaneous reservoir, and three infants required a ventriculoperitoneal shunt for obstructive hydrocephalus.

CONCLUSION

SDH was the most common type of ICH in term infants. Combined supratentorial and infratentorial hemorrhage was more common than isolated infratentorial hemorrhage in these infants. A total of 44.4% of patients had poor outcomes, with perinatal asphyxia the most common statistically significant cause.

Subdural Hemorrhage from Cerebral Amyloid Angiopathy-Related Intracerebral Hemorrhage: A Risk Factor for Postoperative Hemorrhage

OBJECTIVE

Surgical treatment for cerebral amyloid angiopathy (CAA)-related intracerebral hemorrhage (ICH) is controversial. A subset of CAA-related ICH with associated subdural hemorrhage (SDH) has been reported. This study aimed to evaluate clinical results and surgical outcomes of this type of ICH with associated SDH.

METHODS

Study participants included 98 patients with CAA-related ICH who met Boston criteria. Patients were divided into an SDH group and a control (no SDH) group. Clinical and neuroimaging features and surgical outcomes of the 2 groups were compared.

RESULTS

Lobular shape of hematoma was found significantly more often in the SDH group (65.7% [23/35]) compared with the control group (25.4% [16/63]; P < 0.001). Subarachnoid hemorrhage was found significantly more often in the SDH group (34.3% [12/35]) compared with the control group (7.9% [5/63]; P = 0.001). The rate of postoperative hemorrhage was significantly higher in the SDH group (61.5% [8/13]) than in the control group (16.2% [6/37]; P = 0.006). The frequency of occurrence of postoperative hemorrhage was significantly higher in the SDH group (13/13) than in the control group (6/37; P = 0.017). A good surgical outcome occurred in none (0/12) of the patients in the SDH group, whereas a good surgical outcome occurred in 51.9% (14/27) of patients in the control group (P = 0.006).

CONCLUSIONS

Patients with CAA-related ICH with associated SDH more frequently have postoperative hemorrhage and have a worse surgical outcome. These findings are useful in choosing therapeutic methods and preoperative planning of surgical strategy.

Early rebleeding of intracranial dural arteriovenous fistulas after an intracranial hemorrhage

BACKGROUND

The aim of this study was to evaluate the clinical and angiographic characteristics of dural arteriovenous fistulas (DAVF) presenting with intracranial hemorrhage (ICH), with a focus on early rebleeding according to the initial hemorrhage type.

METHOD

The clinical and radiologic features of 21 dAVFs that presented with intracranial hemorrhage were retrospectively reviewed. The hemorrhage type was classified as pure intraparenchymal hemorrhage (pIPH) and subarachnoid or subdural hemorrhage with IPH (non-pIPH).

RESULTS

There were 13 patients with pIPH and 8 with non-pIPH. The median follow-up period was 30 months (range, 1-116 months), and the median interval from hemorrhage to treatment was 4 days (range, 0-72 days). Rebleeding occurred in 8 (38.1%) of 21 patients. Four (50%) of eight patients with non-pIPH suffered from early rebleeding within 3 days, while there was no early rebleeding in patients with pIPH. There was a significantly higher rate of early rebleeding in the non-pIPH group (p = 0.012). Angiographically, venous ectasia (p = 0.005) and direct cortical venous drainage (dCVD) (p = 0.008) showed a significantly higher proportion in the non-pIPH group than in the pIPH group.

CONCLUSIONS

DAVFs with ICH is likely to rebleed after the first hemorrhage. Thus, early treatment can be needed in all DAVFs with ICH. In addition, DAVFs that presenting with non-pIPH and containing venous ectasia or dCVD on initial angiography may have a higher risk of early rebleeding. Therefore, cautious attention and urgent treatment are necessary for these patients.