How to Remove a Penetrating Intracranial Large Nail

BACKGROUND

The incidence of penetrating intracranial foreign bodies is rare, and to date, not many relevant studies have been published worldwide. In particular, a nail penetrating intracranially, just near the superior sagittal sinus (SSS), is extremely rare. We treated the case of a large nail that penetrated the middle of the head and strategized its removal.

CASE DESCRIPTION

A 70-year-old man had experienced headache lasting a day. Computed tomography of the brain revealed a nail penetrating the middle of his head; in particular, the tip of the nail had penetrated the right ventricle, causing a slight subarachnoid hemorrhage. Angiography showed that the nail was very close to the SSS and that the venous flow was normal. However, there was a risk of the nail penetrating through the SSS or injuring other arteries, and we removed the nail directly from the intracranial view to stop bleeding from the SSS or other vessels. Fortunately, there was no bleeding, and we washed the hole created by the nail penetration and concluded the surgery.

CONCLUSIONS

Our technique is useful and safe for removing large nails penetrating the head.

Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70

AIM

Mortality and morbidity due to brain injury in the elderly population is a growing clinical problem: among older patients, those >70 years have a considerably higher risk both in terms of mortality and morbidity. Thereafter, the reasons influencing outcome have not been clearly examined: in the present study we addressed these questions considering the main clinical characteristics exerting a significant impact on the outcome of patients aged > 70, with emphasis for the severity of brain injury and anticoagulant (CAW) treatments.

METHODS

We performed a retrospective analysis of 103 consecutive isolated head injury patients older than 70, admitted at our Department in the period November 2004-November 2009. The clinical variables considered were as follow: age, sex, type of TBI, GCS, pre-TBI use of anti-coagulants (aspirin, warfarin, clopidogrel), INR at admission (INR values were subdivided in values >1.25 as at risk for hemorrhagic events and <1.25 as normal), initial CT scan classification looking at the presence of subarachnoid hemorrhage (t-SAH) or mass lesions; the main outcome measure was the Glasgow Outcome Scale.

RESULTS

The most frequent cause of TBI was accidental fall (65%): 39 were in CAW therapies and in 36 cases the cause of falling down injury was recorded due to a sincopal event (arterial hypotension, atrial fibrillation); in the older patients an accidental fall is significantly related to the TBI, while in the patients aged 70-75 years, TBI is related to a traffic accident (P=0.002). Moreover the cause of TBI correlates with the CAW treatment, the accidental fall being significantly more frequent in patients in CAW treatment (P=0.003). Overall mortality rate is significantly related to an elevated INR class, to presence of t-SAH (16/50 patients) and subdural hematoma (26/46).

CONCLUSION

The results of the present study show that in a population of patients aged > 70, TBI is a high risk event if patient has concurrent treatment with CAW therapies and if an accidental fall is the cause of TBI. In these cases the finding of t-SAH represents a high-risk parameter for mortality but not for morbidity.

Cerebral microdialysis: perioperative monitoring and treatment of severe neurosurgical patient

The early signs of brain ischemia are key indicators of secondary brain injury and their recognition on time can ultimately save life. Direct recording of cerebral ischemia is possible using the method of cerebral microdialysis (CM). This paper presents results of the five-year experience in applying this method at University Department of Neurosurgery, Sarajevo University Clinical Center in Sarajevo. In this observational prospective clinical study, the treatment and outcome of 51 patients with subarachnoid hemorrhage (SAH) and traumatic intracranial hemorrhage (tICH) undergoing neurosurgery and consequently treated conservatively at Neurosurgical Intensive Care Unit (NICU) were analyzed. All patients were followed up by unified monitoring at NICU and additionally by the CM method. Between December 2006 and September 2010, CM monitoring was performed in 51 patients: 18 patients with SAH and 33 patients with tICH. In all patients, samples were obtained on 367 occasions, yielding a total of 3314 samples for biochemical parameters (mean 64.98 per patient, range 42-114 samples). Positive correlation was found between glucose level and outcome at one-year follow up (when glucose level was lower, the patient Glasgow Outcome Scale (GOS) score was worse). The correlation coefficient for glycerol was negative (r=-0.81), and so was for the lactate/pyruvate ratio. There was a significant difference in patient outcome in favor of the group of patients monitored by use of CM in terms of poor and good outcome graded according to GOS score 12 months after the injury compared with the group of patients not monitored with CM (P<0.028). According to our experience, we believe that CM enables early initiation of appropriate therapeutic strategies to overcome cerebral ischemia and secondary brain damage, eventually leading to better patient outcome.

Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage

BACKGROUND

Posttraumatic hydrocephalus is a common complication of head injury. However, hydrocephalus after tSAH has seldom been addressed. We present this clinical study to determine the incidence of hydrocephalus and analyze the risk factors for developing hydrocephalus in patients with tSAH.

METHODS

A consecutive series of 301 patients with tSAH were retrospectively reviewed to determine the effects of the admission GCS score, age, sex, decompressive craniectomy, intraventricular hemorrhage, and features of tSAH (according to the initial computerized tomography scans) on the development of hydrocephalus. Risk factors for hydrocephalus were evaluated by using logistic regression analysis.

RESULTS

Of the 301 patients, hydrocephalus was observed in 36 (11.96%). Increasing age (P< .05), intraventricular hemorrhage (P< .05), and thickness (P< .01) or distribution (P< .05) of tSAH were significantly associated with the development of hydrocephalus. No relationship was found between hydrocephalus and sex, admission GCS score, location of tSAH, or decompressive craniectomy.

CONCLUSION

Hydrocephalus frequently occurs in patients with tSAH. Increasing age, low GCS score on admission, intraventricular hemorrhage, and severe SAH could be risk factors for facilitating the development of hydrocephalus.

"Migration" of traumatic subarachnoid hematoma? A case report

BACKGROUND

Traumatic spinal SAH with neurologic deficits is rare and easily misdiagnosed, especially after traumatic intracranial hemorrhage.

CASE DESCRIPTION

We report a case of spinal SAH with root compression occurring after a scooter accident.

CONCLUSIONS

Physicians should be aware of descending migration of intracranial SAH as a possible cause of spinal cord or root compression, especially in the patient with late onset spinal symptoms.

Rapid regrowth of a successfully coiled traumatic pericallosal aneurysm

Regrowth of an intracranial aneurysm is a known complication of endovascular coiling. We report a patient with a traumatic pericallosal aneurysm which was initially treated successfully with endovascular coiling. Six-month follow-up angiography showed aneurysm regrowth with migration of the coils. To our knowledge, recurrence of a coiled pericallosal aneurysm of traumatic etiology has not been previously reported. Endovascular coiling may not be the best primary treatment for traumatic pericallosal artery aneurysms.

Traumatic acute subdural hygroma mimicking acute subdural hematoma

Subdural hygroma is a frequent delayed complication of head trauma. Most hygromas are clinically 'silent' and a few cases have shown slow deterioration in the chronic stage. We report a case of subdural hygroma showing unique radiological findings and rapid deterioration. A 74-years-old female presented with a mild headache and consciousness disturbance after head injury. Computed tomography showed a midline shift as a result of two components piling up in the subdural space; the outer components showed low density, the inner components high density. Magnetic resonance imaging demonstrated that these two subdural components were subdural hygroma and subarachnoid hematoma. Simple burr hole irrigation, rather than large craniotomy, was thought to be more appropriate treatment to reduce the mass effect. Simple burr hole irrigation was performed to remove the subdural hygroma and the patient showed an excellent recovery. Careful examination of the radiological findings prevented an unnecessary procedure in this case. A possible mechanism of this phenomenon is discussed.

Traumatic acute spinal subarachnoid hematoma

This report describes a 66-year-old man who presented with progressive paraparesis after a fall. Magnetic resonance imaging showed an acute spinal hematoma at T11-12 with spinal cord compression. The patient underwent an emergency left T11-12 hemilaminectomy. The hematoma was subarachnoid and the source of bleeding was an injured radicular vein. To the best of our knowledge, this is the first reported case of traumatic spinal subarachnoid hematoma. We discuss the possible mechanism and our case illustrates an injured radicular vein can be a source of traumatic spinal subarachnoid hematoma.

Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders

OBJECTIVE

This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders.

METHOD

Medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. Patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained.

RESULTS

In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases).

CONCLUSION

The early reimplantation of the patient's own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes.

Spinal subarachnoid hematomas: our experience and literature review

STUDY DESIGN

Spinal subarachnoid hematomas are unusual and difficult to diagnose and the outcome of treatment is influenced by the lesions that frequently accompany them.

OBJECTIVES

To clarify the neuroradiological diagnostic aspects of spinal subarachnoid hematoma as well as the results of treatment.

BACKGROUND

Only recently has subarachnoid hematoma been clearly distinguished from more common subarachnoid hemorrhage and its characteristics have still not been dealt with in detail.

METHODS

A total of 69 cases (3 personal case, 66 published cases) were revised in terms of etiology, diagnostic imaging and the results of both surgical and conservative treatment.

RESULTS

The most common causes of spinal subarachnoid hematoma are coagulopathies (either pharmacologically-induced or resulting from systemic diseases) (40.5%), lumbar puncture for diagnostic or anesthesiological purposes (44.9%) and traumatic injuries (15.9%): these factors may be present singly or variously combined. They may be spontaneous (17.3%) or, in rare cases, associated with aortic coarctation or degenerative vascular diseases. Overall mortality is 25.7%. In the 50 cases in whom long-term follow-up was possible, the outcome of treatment, which is almost exclusively always surgical, was good in 93.5% of 31 patients in whom neurological status on admission was satisfactory and in 15.8% of 19 cases with severe neurological deficits.

CONCLUSIONS

MRI and CT are not usually diagnostic because they are not able to differentiate between a subarachnoid lesion and a subdural one. However, diagnosis may be possible when these investigations detect the CSF or the contrast medium surrounding the hematoma. Although the risks of producing spinal subarachnoid hematoma as a result of LP are remote, this is, in fact, the primary cause in patients with coagulopathies. The results of treatment depend on the patient's initial neurological condition, the severity of any concomitant pathologies, the position of the hematoma and the eventual association of a subdural hematoma.

Traumatic subarachnoid hemorrhage: demographic and clinical study of 750 patients from the European brain injury consortium survey of head injuries

OBJECTIVE

Previous reports identified the presence of traumatic subarachnoid hemorrhage (tSAH) on admission computed tomographic (CT) scans as an independent prognostic factor in worsening outcomes. The mechanism underlying the link between tSAH and prognosis has not been clarified. The aim of this study was to investigate the association between CT evidence of tSAH and outcomes after moderate or severe head injuries.

METHODS

In a survey organized by the European Brain Injury Consortium, data on initial severity, treatment, and subsequent outcomes were prospectively collected for 1005 patients with moderate or severe head injuries who were admitted to one of the 67 European neurosurgical units during a 3-month period in 1995. The CT findings were classified according to the Traumatic Coma Data Bank classification system, and the presence or absence of tSAH was recorded separately in the initial CT scan forms.

RESULTS

Complete data on early clinical features, CT findings, and outcomes at 6 months were available for 750 patients, of whom 41% exhibited evidence of tSAH on admission CT scans. There was a strong, highly statistically significant association between the presence of tSAH and poor outcomes. In fact, 41% of patients without tSAH achieved the level of good recovery, whereas only 15% of patients with tSAH achieved this outcome. Patients with tSAH were significantly older (median age, 43 yr; standard deviation, 21.1 yr) than those without tSAH (median age, 32 yr; standard deviation, 19.5 yr), and there was a significant tendency for patients with tSAH to exhibit lower Glasgow Coma Scale scores at the time of admission. A logistic regression analysis of favorable/unfavorable outcomes demonstrated that there was still a very strong association between tSAH and outcomes after simultaneous adjustment for age, Glasgow Coma Scale Motor Scores, and admission CT findings (odds ratio, 2.49; 95% confidence interval, 1.74-3.55; P < 0.001). Comparison of the time courses for 164 patients with early (within 14 d after injury) deaths demonstrated very similar patterns, with an early peak and a subsequent decline; there was no evidence of a delayed increase in mortality rates for either group of patients (with or without tSAH).

CONCLUSION

These findings for an unselected series of patients confirm previous reports of the adverse prognostic significance of tSAH. The data support the view that death among patients with tSAH is related to the severity of the initial mechanical damage, rather than to the effects of delayed vasospasm and secondary ischemic brain damage.

Late detection of supraclinoid carotid artery aneurysm after traumatic subarachnoid hemorrhage and occlusion of the ipsilateral cervical internal carotid artery

BACKGROUND AND PURPOSE

We report the first case of traumatic aneurysm of the supraclinoid internal carotid artery (ICA), which we speculate may have developed or grown after traumatic occlusion of the ipsilateral cervical ICA.

CASE DESCRIPTION

A 26-year-old man presented with severe traumatic subarachnoid hemorrhage (SAH) and occlusion of the right cervical ICA after a motor vehicle accident. Three-dimensional CT angiography on admission showed no aneurysm. However, cerebral angiography 3 weeks after the injury showed a large aneurysm of the right supraclinoid ICA. The aneurysm was trapped, and pathological examination showed that it was a traumatic aneurysm.

CONCLUSIONS

In this case we cannot be sure that the aneurysm was not present on admission. In view of the significant SAH, a lesson of this case may be to suspect such an aneurysm early on and perform early diagnostic cerebral angiography.