Traumatic Acute Subdural Hematoma Research Articles

Travmatik akut subdural hematomun hızlı rezolüsyonu: olgu sunumu

Akut travmatik subdural hematom nöroşirurji pratiğinde travma sonrası hastalarda görülen önemli bir morbitide ve mortalite sebebidir. Nörolojik kusur varlığında, acil cerrahi tedavi düşünülmelidir. Diğer yandan nörolojik tablonun daha iyi olduğu, dikkatli seçilmiş bazı hastalarda ise cerrahi girişim her zaman gerekmeyebilir. Yakın takip ile akut travmatik subdural hematomlarda spontan hızlı rezolüsyonun olabileceği bildirilmiştir. Boks müsabakasında yüzüne aldığı darbe sonrası akut travmatik subdural hematom tanısı konan hastanın 20. saat kontrol tomografisinde subdural hematomun tamamen gerilediği görüldü. Akut travmatik subdural hematomun hızlı rezolüsyonu için literatürde çeşitli mekanizmalar ve prediktif bulgular öne sürülmüştür fakat patofizyolojiyi açıklamada ileri çalışmalara ihtiyaç duyulmaktadır.

Prognostic Value of Admission Parameters in a Machine Learning Predictive Model in Patients With Severe Traumatic Brain Injury and Acute Subdural Hematomas

Abstract INTRODUCTION Acute subdural hematoma (aSDH) in the context of severe traumatic brain injury (TBI) is a neurosurgical emergency. Predictive models have been used in an attempt to modulate the morbidity and mortality of patient outcomes. We used machine learning (ML) to identify admission risk factors predictive of long-term morbidity in the severe TBI patient population with aSDH. METHODS Between 2013 and 2016, 85 patients with severe TBI and aSDH were included in the analysis. Random forest, ML architecture, was used to create a predictive model of long-term morbidity stratification. About 46 patients were included in the high morbidity group [Glasgow Outcome Scale (GOS) 1-2] and 39 patients were in the low morbidity group (GOS 3-5). We included 30 admission input variables including medical and surgical co-morbidities, neurological examination, laboratory values, and radiographic findings. RESULTS The predictive model showed a 78% precision. The highest scoring input variable was the pupillary examination in predicting high vs low morbidity (bilaterally unreactive vs symmetrically reactive; P < .0001). GCS on admission was higher in the low morbidity group (4 [3-7] vs 7 [3-7]; P < .0101). Rotterdam scores were higher in the high-morbidity group (3 [3-5] vs 4 [4-5]; P < .0032). GCS motor examination on admission was higher in the low-morbidity group (5 [1-5] vs. 2 [1-5]; P < .0106). The basal cisterns were found to be more patent in patients with the low-morbidity group (P = .0012). CONCLUSION ML is an efficient tool that can provide a reasonable level of accuracy in predicting long-term morbidity in patients with severe TBI and aSDH. Monitoring these admission criteria can help with risk-stratification of patients into higher and low risk tracks. Integration of ML into the treatment algorithm may allow the development of more refined guidelines to guide goal-directed therapy.

Unfavorable functional outcome is expected for elderly patients suffering from acute subdural hematoma even when presenting with preserved level of consciousness

Alongside an increase in life expectancy, median age of patients presenting with traumatic acute subdural hematomas (ASDH) has increased as well. Treatment guidelines are based on studies performed on relatively young patients. The optimal management of elderly (>70 years old) patients with ASDH, specifically those with relatively preserved level of consciousness, was not thoroughly investigated so far. We retrospectively examined elderly patients presented to our medical center between the years 2006–2016 with traumatic convexity ASDH and GCS of 13–15. 773 patients were included in the initial cohort and 54 patients were included in the final analysis. The mean age at presentation was 81.5 years and the means of hematoma thickness and midline shift were 15.5 mm and 6.6 mm, respectively. Patients in our cohort had an overall unfavorable outcome (mRS 5–6) of 28% and 56% at discharge and at 1 year following injury, respectively. The results were not significantly different for the subgroups of patients older than 80 years and patients with high ASA-PS. Surgical evacuation of the ASDH was undertaken in 28 patients with focal neurologic deficit and/or worsening on subsequent brain scans. At 1 year, 64% (18 patients) in the surgery group had unfavorable outcome compared to 48% (12 patients) in the conservative group. We believe that these numbers should be taken under consideration when assessing elderly patients with convexity ASDH and relatively preserved level of consciousness.

Frequency of and Risk Factors for Chronification in Traumatic Acute Subdural Hematoma following Conservative Therapy

In an aging society, traumatic head injuries, such as acute subdural hematomas (aSDHs), are increasingly common because the elderly are prone to falls and are often undergoing anticoagulation treatment. Especially in advanced age, cranial surgery such as craniotomies may put patients in further jeopardy. But if treatment is conservative, a chronic subdural hematoma (cSDH) may develop, requiring surgical evacuation. Existing studies have reported a correlation between several risk factors contributing to the frequency of chronification. To improve the prediction of the course of disease and to aid counseling patients and relatives, this study aimed to determine the frequency and the main risk factors influencing the process of chronification of an aSDH following conservative treatment. We identified patients presenting between January 2012 and September 2017 at our neurosurgical department with an aSDH. All patients treated conservatively were selected retrospectively, and the following parameters were documented: age, sex, chronification status, Glasgow Coma Scale score on admission and discharge, hematoma thickness and density, the degree of midline shift (MLS), prior anticoagulants and administration of procoagulants, thrombosis management, other coagulopathies, initial length of hospital stay, interval between discharge and readmission, and interval between initial injury and date of surgery and last follow-up. The cohort was divided into patients with complete resolution of their aSDH, and patients who needed surgery due to chronification. A total of 75 conservatively treated patients with aSDH were included. A chronification was observed in 24 cases (32%). The process of chronification takes an average of 18 days (range: 10-98 days). The following factors were significantly associated with the process of chronification: age (p = 0.001), anticoagulant medication (acetylsalicylic acid [ASA], Coumadin, and novel anticoagulants [NOACs]) before injury (p = 0.026), administration of procoagulants (p = 0.001), presence of other coagulopathies such as thrombocytopenia (p = 0.002), low hematoma density at discharge (p = 0.001), hematoma thickness on admission and discharge (p = 0.001), and the degree of MLS (p = 0.044). Chronification occurred in a third of all patients with conservatively treated aSDH, on average within 3 weeks. The probability of developing a cSDH is 0.96 times higher with every yearly increase in age, resulting in 56% chronification in patients ≥ 70 years. Hematoma thickness and impairment of the coagulation system such as anticoagulant medication (ASA, Coumadin, and NOACs) or thrombocytopenia are further risk factors for chronification.

Traumatic Acute Subdural Haematoma: Management and Outcome

Traumatic Acute Subdural Haematoma: Management and Outcome

Idarucizumab to revert the anticoagulant effect of dabigatran in traumatic acute subdural haematoma: a case report of first use in Latin America.

Background Direct oral anticoagulants (DOAC) are an attractive alternative over vitamin K antagonists. They have several advantages in primary and secondary prevention of thromboembolisms due to atrial fibrillation, as well as in prevention and treatment of thromboembolic venous disease. They have fast onset action, do not need laboratory controls in patients with normal renal function, and they have practically no interference with the patient’s diet or medications. The strongest objection to their use was the lack of reversal agents that could be used in case of life-threatening haemorrhage or the need for emergency surgery. Dabigatran was the first DOAC to have its own specific reversal agent: idarucizumab, a monoclonal antibody.Case summary We report here the case of a patient undergoing treatment with dabigatran that suffered an expansive subdural haematoma secondary to a cranial injury. The condition was life-threatening and required emergency surgery. Anticoagulation was successfully reversed with idarucizumab.Discussion Emergency surgery in patients in treatment with DOAC is associated with an increased risk of bleeding. With the use of a specific antidote to block the action of the anticoagulant, as in the case of idarucizumab with dabigatran, the risk of complications during and after emergency surgery is reduced. This is the first case report with which the successful use of idarucizumab in Latin America is documented.

Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review

BackgroundA large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review.Case presentationA total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients’ baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30–120 min). The mean distance of midline shift was 14.6 mm (10–20 mm). The preoperative GCS in all patients ranged from 4 to 13(median, 9). The mean duration of the operation was 14.4 min (6–19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0–2) at 6 months after surgery.ConclusionsTASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

BackgroundThe decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness.MethodsThis study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)–specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation.ResultsOut of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13–15), 19 a moderate (GCS 9–12), and 49 a severe (GCS 3–8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4–5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580).ConclusionsAlthough this study confirms that outcome is often “unfavorable” after t-ASDH, it also shows that “favorable” outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.

Factors Influencing Readmission Rates of Acute Traumatic Subdural Hematoma in the Elderly

Factors Influencing Readmission Rates of Acute Traumatic Subdural Hematoma in the Elderly

Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P= 0.03) and ASDH thickness ≥20 mm (P=0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or5. The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.

Scandinavian Multicenter Acute Subdural Hematoma (SMASH) Study: Study Protocol for a Multinational Population-Based Consecutive Cohort.

Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved. To evaluate postoperative (30-d) mortality in younger vs elderly (≥70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables. This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (≥18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190. We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified. An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.

P16 Relation of timing of surgery to outcome from traumatic acute subdural haematoma

ObjectivesAcute subdural haemorrhage (ASDH) is a neurosurgical emergency with high mortality and morbidity rates. Time to surgical intervention is implicated as an important factor affecting patient outcomes, however, more recent studies do not support this. We aimed to determine the correlation between time interval to surgery and outcome of patients with traumatic ASDH.MethodsWe retrospectively reviewed consecutive ASDH patients who underwent haematoma evacuation in the period between 2010 and 2016 at this tertiary neurosurgical centre. 49 patients were included for the analysis. Patient data was extracted from theatre records, patient notes and electronic records.ResultsThe median time interval from injury to surgery was 403 min (6 hours 43 min) with road traffic accident being the commonest mechanism of injury. 20 of 49 (34.7%) patients underwent evacuation within five hours from time of injury. Of these, 12 (41.4%) had good recovery (GOS 5), versus 15 (51.7%) amongst the 29 patients who underwent operation after five hours. Spearman rank correlation test (rs=0.07375) showed no statistically significant correlation between time interval to surgery and patient outcomes as measured by GOS. The overall mortality rate of evacuated patients at JCUH was 8.16% and the majority had good functional status, 55.1% with GOS 5.ConclusionsLonger time interval of more than four hours from injury to surgical intervention was not associated with higher mortality rate, or worse functional outcome.

Risk Factors for Recurrent Hematoma After Surgery for Acute Traumatic Subdural Hematoma

The development of postcraniotomy hematoma (PCH) after surgery for acute traumatic subdural hematoma (aSDH) has been associated with an increased risk of a poor outcome. The risk factors contributing to PCH remain poorly understood. Our aim was to study the potential risk factors for PCH in a consecutive series of surgically evacuated patients with aSDH. A total of 132 patients with aSDH treated at Turku University Hospital (Turku, Finland) from 2008 to 2012 were enrolled in the present retrospective cohort study. The demographic, clinical, laboratory, and imaging data were collected from the medical records. A comprehensive analysis of the data using 6 different univariate methods, including machine learning and multivariate analyses, was conducted to identify the factors related to PCH. The incidence of PCH after primary surgery for traumatic aSDH was 10.6%. The patients experiencing PCH were younger (P= 0.04). No difference was found in the use of anticoagulant or antiplatelet medication for the patients with and without PCH. Multivariate analyses identified alcohol inebriation at the time of injury (odds ratio [OR], 12.67; P= 0.041) and hypocapnia (OR, 26.09; P= 0.003) as independent risk factors for PCH. The patients with PCH had had hyponatremia (OR, 0.08; P= 0.018) less often, and their maximal systolic blood pressure was lower (OR, 0.94; P= 0.009). The area under the curve for the multivariate model was 0.96 (P= 0.049), with a Youden index of 0.88. The results suggest that alcohol inebriation at the time of injury and hypocapnia during hospitalization are risk factors for the development of PCH.

Factors affecting the prognosis of traumatic acute subdural hematomas

Background Trauma is the most frequent cause of young adult (under 45 years of age) fatalities worldwide, and traumatic brain injury accounts for up to 50% of these deaths. The incidence of traumatic brain injuries is increasing globally, largely due to an increase in motor vehicle use in low-income and middle-income countries. Purpose The aim of study was to investigate the factors that modulate the prognosis of patients with traumatic acute subdural hematoma. Patients and methods This study was conducted on 30 patients with acute traumatic subdural hematoma managed in the Department of Neurosurgery, ER, and Surgical ICU, Al-Azhar University Hospitals. All the data collected were statistically analyzed and the results were compared with the international results. Our recommendations were based on that comparison. Results Mortality rate was 53.3% (16 patients) in our study. The mean and SD of age in our study was 46.3±20.6 years. The range of age was 64 years (21–85 years). There was no statistical difference between sexes as regards age (P=0.393). The entire study population was subjected to logistic regression analysis, severity of injury, presence of a secondary injury especially hypoxia or both hypoxia and hypotension. Polytrauma, status of conscious level at admission, anemia, thickness of hematoma, and necessity for endotracheal intubation were enrolled. The hypoxia and lower Glasgow coma scale at admission were found to be significant predictors of mortality. Conclusion Traumatic acute subdural hematoma still has a high mortality rate despite all developments in neurosurgical interventions. Initially low Glasgow coma scale and hypoxia are important parameters that correlate with the mortality rate.

Natural course of non-surgical acute traumatic subdural hematomas: Retrospective analysis of 92 patients

Aim: In the present study, we aimed todiscuss the natural course of acute subdural hematoma (ASDH) patients who were not operated according to the admisssion findings.Material and Methods: In this study patients who admittedwith a diagnosis of traumatic ASDH and underwent conservative treatment according to the admission findings at the neurosurgery clinic of Adiyaman University between 2013 and April 2019 were identified. Patients who had a diagnosis of ASDH less than 10 mm, a midline shift of less than 5 mm and had a repeat computed tomography (CT) scan were included in this study.Two groups were formed with and without increase in the hematoma size according to thecontrol CT. Age, gender, anticoagulation status, comorbidities of the patients, type of trauma, size of the hematoma, GCS scores and presence or absence of a “low-density band” on CT were evaluated. Results: We identified 92 patients who had coded as “traumatic ASDH” and managed nonoperatively according to the findings of the initial CT.32.6% of patients had hematoma growth according to the control CT and68.4% had either decreased or the same size.According to the statistical analysis results, anticoagulant drug use(p=0.001) and comorbidity status(p=0.03) were found to be related with the increase of the hematoma size. Also there was no statistically significant difference (p=0.07) between the two groups about the low density band but it was seen more differencein the non-increased group. Conclusion: Conservative treatment is one of the treatment methods of traumatic acute subdural hematomas. Patients who have under 10 mm hematoma size and 5mm midline shift can be followed up by non-surgical methods. But increased headache in these patients may be a sign that should be considered in terms of increased hematoma. Furthermore, the use of anti-coagulant drugs and the presence of comorbidity make patients more risky.

A retrospective analysis of factors influencing readmission rates of acute traumatic subdural hematoma in the elderly: A cohort study

ObjectiveAcute traumatic subdural hematomas (TSDH) readmission rate is high (27.8%) with an increase in morbidity and cost for the elderly. This study identifies risk factors affecting readmission rates for these patients and presents strategies to reduce it. MethodsA retrospective analysis was conducted including patients with TSDH admitted to our Community Hospital and followed subsequently for two years regarding readmission within 6 months of initial discharge. The following factors were compared for patients readmitted versus not readmitted: patient age, sex, number of comorbidities, anticoagulation status, surgical intervention, ICU length of stay, injury severity score, and discharge disposition. ResultsA total of 167 patients were included in the study. Overall, 75 patients (44.9%) were readmitted within 6 months. Readmitted patients had an overall higher mean age (74.1 vs. 65.4, p = 0.001). Readmission with recurrent subdural hematoma was diagnosed in 32.2% of readmitted patients vs. 67.8% (p < 0.0005) with readmission for other medical complications. 80.0% of readmitted patients had more than four comorbid conditions (p < 0.0001). ConclusionThis study identifies risk factors that affect readmission rates for patients with TSDH and establishes strategies that may help to decrease readmission.

Clinical Predictors of outcome in Isolated Traumatic Acute Subdural Hematoma

Head injury is the major cause of death in young adult population worldwide with associated high morbidity. The objective of this study is to find out the outcome and factors affecting the outcome in isolated traumatic acute subdural hematoma.&#x0D; All patients with isolated acute subdural hematoma presenting within 24 hours of trauma and admitted over a period of 1 year were included in this study. Patient was classified according to Glasgow Coma Scale(GCS) after resuscitation in the emergency department. The outcome of the patient was recorded according to the Glasgow Outcome Scale at the time of discharge and at 3 months after the trauma in follow-up. Statistical analysis was performed to find the correlation between GCS, papillary changes and radiological finding in the form of midline shift and hematoma volume to dichotomized outcome.&#x0D; Out of 38 patients enrolled in the study, 33 patients had favorable outcome. Surgery was performed in 12 patients out of whom 4 patients had unfavorable outcome. GCS score, papillary changes, midline shift and hematoma volume were found to have significant association with the outcome in isolated traumatic acute subdural hematoma.&#x0D; Clinical parameters and radiological parameters can gauge the outcome in isolated traumatic brain injury.

Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study

BackgroundNeurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe.MethodsA survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP).ResultsThe survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions.ConclusionDespite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.

The Use of Hinged Craniotomy in Comparison to Cisternostomy for Avoiding Bone Flap Replacement Second Surgery in Cases of Decompressive Craniotomy in Traumatic Brain Injury

Introduction: Acute post traumatic subdural hematoma is a clinical condition with increased morbidity and mortality despite the developments in neurosurgery and urgent intervention is required to have best clinical outcome. We will evaluate hinged craniotomy technique in terms of offering adequate brain decompression plus avoiding removal of bone flap which requires second replacement surgery in comparison to cisternostomy effect. Material and Methods: A prospective study was conducted over 30 patients with traumatic acute subdural hematoma presented to neurotrauma unit in Cairo University hospitals from January 2017 to February 2018, operated by hinged craniotomy plus evacuation of hematoma and duroplasty. We avoid rapping the head with elastic bandage post-operative. Generous subcutaneous dissection (5 - 7 cm) all around skin flap was done routinely. Effect of brain decompression was evaluated by measuring the level of brain in relation to skull in post-operative computerized topography. Results: Twenty-one patients operated with initial GCS less than eight. Ten cases (33%) show that cortical surface in relation to skull bone was at inner table, nine cases (30%) at diploid layer and two cases (6.7%) at outer table in post-operative CT brain. Twenty patients died (66.7%); eight patients (26.6%) became fully conscious and two patients (6.7%) had vegetative outcome. No re-operation was done in any of our patients. Conclusion: Hinged craniotomy may be a safe and effective alternative technique with comparable results to cisternotomy in cases of traumatic brain injury that require decompression to avoid second surgery, especially in centres lacking cisternostomy experience. Although gaining cisternostomy experience may help in other indications, future prospective studies with larger number are required.

Comparative Study between Bone Flap Insertion in Abdominal Wall Versus Flail Replacement in Decompressive Craniectomy of Acute Subdural Hematoma

AbstractBackground: Traumatic acute subdural hematoma remains one of the most lethal of all head injuries patients with Acute Subdural Hematomas (ASDHs) having higher mortality and lower functional recovery rates compared with those of other head-injured patients.Decompressive Craniectomy (DC) for management of ASDH with accompanying brain edema and midline shift has become one of the standard guidelines in many centers. DC remains to be the standard of surgical modality for patients with poor clinical status.Subcutaneous preservation of autologous bone flap is an inexpensive option that preserves the viability of the bone flap, resulting in good cosmetic results and the very low infection rate.Aim of Study: To compare results of (ASDHs) managed with DC with consequent subcutaneous bone flap insertion in the abdominal wall vs subcutaneous hinged flail placement in the craniectomy site.Patients and Methods: A retrospective review of 61 patients with (ASDHs) operated at the Department of Neuro-surgery, Cairo University and Beni Souf University Hospital during the period from Jan. 2012 – Dec. 2015. Patients were divided into:Group (A): 31 patients operated upon with subcutaneous abdominal bone flap insertion, (22 males and 9 females) median age was 42 years. On admission there were 19 patients with Glasgow Coma Score (GCS) below 8, and 12 patients with GCS 8 or above 8.Group (B): 30 patients operated upon with subcutaneous hinged flail bone flap replacement in the craniectomy site, (22 males and 8 females) median age 44 years. On admission there were 18 patients with GCS blew 8, and 12 patients with GCS 8 or above 8.Early surgical evacuation, dural fenestration, intensive care management to monitor intra cranial pressure and follow-up CT brain were done for all patients.Results: Group (A) 14 patients died in the hospital, 4 survived with unfavorable outcome (vegetative state), and 13 survived with favorable outcome.Group (B) 17 patients died in the hospital, 4 survived with unfavorable outcome (vegetative state), and 9 survived with favorable outcome.Conclusion: Analysis of the obtained data reveals that subcutaneous abdominal bone flap insertion shows a statisti-cally significant better prognosis as compared to subcutaneous hinged flail bone flap replacement at the craniectomy site which may be due to better decompression of the brain and allowing for more roomfor expansion.