Evacuation Of Acute Subdural Hematoma Research Articles

Comparison of the efficacy of 0.9% normal saline with balanced crystalloid (Plasmalyte) in maintaining the metabolic profile in head injury patients undergoing evacuation of acute subdural haematoma – A randomised controlled trial

Background and Aims: The choice of intravenous fluids is important in patients with traumatic brain injury (TBI), where large volumes may be required for resuscitation. Our study aimed to compare 0.9% normal saline (NS) with balanced crystalloid (Plasmalyte) in TBI patients in terms of metabolic and coagulation profile, brain relaxation score (BRS) and renal functions using serum urea, creatinine and urinary tissue inhibitor of metalloproteinases-2* insulin-like growth factor binding protein-7, [TIMP-2]*[IGFBP7], value to assess the risk of acute kidney injury. Methods: This randomised controlled trial on 90 TBI patients undergoing emergency craniotomy and subdural haematoma evacuation was conducted in a tertiary care institute. The patients were randomised to receive either NS (Group NS) or Plasmalyte (Group P) as the intraoperative maintenance fluid. The primary outcome measures included the potential of hydrogen (pH), base excess (BE) and chloride values from an arterial blood gas. The secondary outcomes were the coagulation profile, BRS and urinary [TIMP-2]*[IGFBP7]. The two groups’ metabolic profile differences were analysed using two-way repeated analysis of variance. BRS was analysed using the Mann–Whitney U test. A P value < 0.05 was considered to be statistically significant. Results: The pH and chloride values were significantly higher, and the BE values were significantly lower in Group P compared to Group NS (P < 0.001). Brain relaxation and coagulation profiles were comparable between the two groups. Serum creatinine (P = 0.002) and urinary [TIMP-2]*[IGFBP7] (P = 0.042) were significantly higher in the NS group. Conclusion: Plasmalyte maintains a more favourable metabolic profile than NS in TBI patients without affecting brain relaxation adversely.

Comparison of Efficacy of Decompressive Craniectomy By Multiple Dural Stabs Versus Open Dural Flap For The Evacuation of Acute Subdural Hematoma

Comparison of Efficacy of Decompressive Craniectomy By Multiple Dural Stabs Versus Open Dural Flap For The Evacuation of Acute Subdural Hematoma

Acute Subdural Hematoma Evacuation

Dr. Prinz performs a craniotomy to gain access to and evacuate a subdural hematoma, relieving pressure that caused a midline shift and a compressed left ve

Letter to the Editor Regarding “Contralateral Subdural Hematoma Following Surgical Evacuation of Acute Subdural Hematoma: Super-Early Intervention and Clinical Implications”

Letter to the Editor Regarding “Contralateral Subdural Hematoma Following Surgical Evacuation of Acute Subdural Hematoma: Super-Early Intervention and Clinical Implications”

Outcomes After the Surgical Evacuation of Traumatic Acute Subdural Hematomas: The tASDH Risk Score

Acute subdural hematoma (ASDH) is a common pathology following traumatic brain injury (TBI). There is sparse data on the prediction of clinical outcomes following traumatic ASDH (tASDH) evacuation. We investigated prognosticators of outcome following evacuation of tASDHs, with subset analysis in a cohort of octogenarians. We developed a scoring system for stratifying the risk of in-hospital mortality for patients undergoing tASDH evacuation. A retrospective chart review was performed to identify all patients who underwent tASDH evacuation. Baseline clinical and demographic data including age, traumatic brain injury mechanism, admission Glasgow Coma Scale (GCS), and Rotterdam computed tomography Scale (RCS) were collected. In-hospital outcomes such as mortality and discharge disposition were collected. A scoring system (tASDH Score) which incorporates RCS (1-2 points), admissions GCS (0-1 points), and age (0-1 point) was created to predict the risk of in-hospital mortality following tASDH evacuation. Being an octogenarian (OR=6.91 [2.20-21.71], P= 0.0009), having a GCS of 9-12 (OR=1.58 [1.32-4.12], P= 0.027) or 3-8 (OR=2.07 [1.41-10.38], P= 0.018), and having an RCS of 4-6 (OR=3.49 [1.45-8.44], P= 0.0055) were independently predictive of in-hospital mortality. The in-hospital mortality rate was lower for those with a tASDH score of 1 (10%), compared to those with a score of 2 (12%), 3 (42%), and 4 (100%). Octogenarians with an RCS of 4-6 and an admission GCS <13 have a high risk of mortality following tASDH evacuation. Knowledge of which patients are unlikely to survive ASDH evacuation may help guide neurosurgeons in prognostication and goals of care discussions.

Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study

Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p<0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre=0.9 [95% CI 0.7-1.1], n=200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n=200]). We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.

Neurosurgical treatment in elderly patients with Traumatic brain injury: A 20-year follow-up study

IntroductionTraumatic brain injury in the elderly population can have a substantial impact on patients’ quality of life. In this regard, successful treatment strategies are hard to define to date. Research questionIn order to facilitate further insight, this study assessed outcomes following acute subdural hematoma evacuation in patients aged ≥65 years in a large patient series. Material and methodsA manual screening of the clinical records of 2999 TBI patients aged ≥65 years, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed. ResultsA total of 149 patients were identified with aSDH, of whom 32 underwent early surgery, 33 underwent delayed surgery and 84 were treated conservatively. Patients who underwent early surgery had the lowest median GCS, poorest Marshall CT scores, longest hospital and ICU stay, and highest intensive care unit admission and redo surgery rates. 30-d mortality was 21.9% in patients undergoing early surgery, 3.0% in patients undergoing late surgery and 16.7% in patients who were treated conservatively. Discussion and conclusionIn conclusion, patients in whom surgery could not be delayed had the worst presentation and poorest outcomes as opposed in patients in whom delay was possible. Surprisingly, patients treated conservatively had worse outcomes than those treated with delayed surgery. These results might indicate that if the GCS at admission is still adequate, an initial strategy of waiting and seeing might be associated with better outcomes. Future prospective studies with sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.

Surgical Modality as a Determinant of Survival and Neurological Outcome Following the Evacuation of Acute Subdural Hematomas

Objective: We designed the present study to compare the clinical outcomes of the craniotomy and the decompressive craniectomy procedures that we had performed in our department for evacuating traumatic acute subdural hematomas.&#x0D; Material and Methods: We retrospectively analyzed the medical data of all the adult patients in whom a craniotomy or a decompressive craniectomy had been performed for evacuating acute traumatic subdural hematoma. The demographic data, the preoperative Glasgow Coma Scale (GCS), and the clinical outcome were studied.&#x0D; Results: A craniotomy had been carried out in five patients for traumatic AcSDH evacuation while in twelve patients a decompressive craniectomy had been performed. The mean preoperative GCS was 9 in the patients that underwent a craniotomy, whereas the mean preoperative GCS in the decompressive craniectomy group was 6.8. The overall mortality was 47%. In the craniotomy group, 4 (80%) patients survived and 1 (20%) patient expired. In the decompressive craniectomy group, 5 (41.7%) patients survived and 7 (58.3%) patients expired. The outcome in all the 9 surviving patients was favorable based on the Glasgow Outcome scale and all of them were independent of follow-up.&#x0D; Conclusion: Better clinical outcome was observed in patients who had undergone a craniotomy compared to those in whom a decompressive craniectomy had been performed. Patients that underwent a craniotomy were also in a better clinical status preoperatively compared to patients who underwent a decompressive craniectomy.

Predictive Factors of Outcomes in Acute Subdural Hematoma Evacuation.

This comparative cross-sectional study was conducted in the Departments of Trauma and Neurosurgery, Ayub Teaching Hospital,Abbottabad, Pakistanfrom September 2021 to February 2022to study predictive factors of outcomes in acute subdural hematoma evacuation. A total of 101 patients with confirmed diagnosis of acute subdural hematoma (ASDH) who underwent surgical evacuation by consultant neurosurgeon were included in the study. A detailed clinical proforma was designed to document all the clinical and demographic details of these patients at the time of admission. Glasgow Coma Scale outcome score (GOS)was used to assess the outcome of patients after the surgery. Sociodemographic and clinical parameters were associated withoutcome of surgery in our study participants. Out of 101 patients, 55 (54.5%) were males and 46 (45.5%) were females. Mean age was 43.66±19.66 years with 7.39 as mean Glasgow Coma Scale (GCS) at presentation. Road traffic accident (RTA) 62 (61.4%) was most frequent mechanism of injury followed by fall from height (19.8%) and history of assault (13.9%). In our study, 59 patients had poor outcomes while 42 had good outcomes. Elder age, low GCS at presentation, and use of oral anticoagulant were associated with poor outcomes while pupillary reaction had no effect on the outcome after application of test of significance. More than half of the patients managed with surgical evacuation for acute subdural hematoma as per guidelines at our neurosurgical unit had poor outcomes according toGlasgow Coma Scale. In this study, advancing age (>60 years), low GCS score at presentation, and use of oral anticoagulation therapy emerged as significant risk factors for poor outcomes in participants. Pupillary reaction had no effect on outcomes as per this study but this needsfurther evaluation in future studies.

Primary Decompressive Craniectomy After Traumatic Brain Injury: A Literature Review.

Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC)remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).

Endoscope-Assisted Evacuation of Acute-on-Chronic Subdural Hematomas: A Single-Center Series.

Purpose: Acute subdural hematomas are frequent, highly morbid, and affect all age groups. The most common mechanism of injury is a low-velocity fall, and the incidence of the disease is growing due to increasingly aggressive antithrombotic and anticoagulant therapies. In this study, we aimed to share our experience with the endoscopic-assisted evacuation of acute subdural hematoma, a less invasive procedure compared to standard craniotomy.Methods: We retrospectively reviewed data of all consecutive patients aged 18 years and older who underwent endoscopic-assisted evacuation of acute-on-chronic subdural hematoma at our institution from 2015 to 2019. Preoperative, intraoperative, postoperative, and follow-up data were collected and reported. Statistical tests were done using Python statistical packages.Results: Of the 35 patients that underwent this procedure, 32 were 18 years and older. The median age was 69.5 years and 37.5% were female. Twenty patients (62.5%) were on antiplatelet therapy, and six patients (18.75%) were on anticoagulants upon presentation. A fall was the most common cause of trauma (71.88%). The median operative time was 107 minutes. The median length of stay in days and Glasgow Coma Scale (GCS) at discharge were 8.5 and 15, respectively. There were no surgical site infections or in-hospital mortality in this series. At the latest follow-up, the median GCS and modified Rankin Scale were 15 and 1, respectively.Conclusion: Evacuation of acute-on-chronic subdural hematomas can be performed safely and efficiently via a smaller craniotomy and with the assistance of an endoscope. This may represent a less invasive alternative than standard craniotomy/craniectomy in selected patients.

Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma

Loss to follow-up (LTF) and unplanned readmission are barriers to recovery after acute subdural hematoma evacuation. The variables associated with these postdischarge events are not fully understood. To determine factors associated with LTF and unplanned readmission, emphasizing socioeconomic status (SES). A retrospective analysis was conducted of surgical patients with acute subdural hematoma managed operatively from 2009 to 2019 at a level 1 regional trauma center. Area Deprivation Index (ADI), which is a neighborhood-level composite socioeconomic score, was used to measure SES. Higher ADI corresponds to lower SES. To decrease the number of covariates in the model, principal components (PCs) analysis was used. Multivariable logistic regression analyses of PCs were performed for LTF and unplanned readmission. A total of 172 patients were included in this study. Thirty-six patients (21%) were LTF, and 49 (28%) patients were readmitted; 11 (6%) patients were both LTF and readmitted ( P = .9). The median time to readmission was 10 days (Q1: 4.5, Q3: 35). In multivariable logistic regression analyses for LTF, increased ADI and distance to hospital through PC2 (odds ratio [OR] 1.49; P = .009) and uninsured/Medicaid status and increased length of stay through PC4 (OR 1.73; P = .015) significantly contributed to the risk of LTF. Unfavorable discharge functional status and nonhome disposition through PC3 were associated with decreased odds of unplanned readmission (OR = 0.69; P = .028). Patients at high risk for LTF and unplanned readmissions, as identified in this study, may benefit from targeted resources individualized to their needs to address barrier to follow-up and to ensure continuity of care.

The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study.

Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score, GOS, 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH. We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1st 2016 and December 31st 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index-CCI, antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and Chi-squared tests and logistic regression models were used to assess differences in and associations between clinicalradiological characteristics and functional outcomes. We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other posttraumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group. A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.

Changing epidemiology of traumatic brain injury among the working-aged in Finland: Admissions and neurosurgical operations.

Recent studies from Finland have highlighted an increase in the incidence of traumatic brain injuries (TBI) in older age groups and high overall mortality. We performed a comprehensive study on the changing epidemiology of TBI focusing on the acute events in the Finnish working-age population. Nationwide databases were searched for all emergency ward admissions with a TBI diagnosis for persons of 16-69years of age during 2004-2018. In the Finnish working-age population, there were 52,487,099 person-years, 38,810TBI-related hospital admissions, 4664 acute neurosurgical operations (ANO), and 2247 cases of in-hospital mortality (IHM). The TBI-related hospital admission incidence was 94/100,000 person-years in men, 44/100,000 in women, and 69/100,000 overall. The incidence rate of admissions increased in women, while in men and overall, the rate decreased. The incidence rate increased in the group of 60-69years in both genders. Lowest incidence rates were observed in the age group of 30-39years. Occurrence risk for TBI admission was higher in men in all age groups. Trends of ANOs decreased overall, while decompressive craniectomy was the only operation type in which a rise in incidence was found. Evacuation of acute subdural hematoma was the most common ANO. Mean length of stay and IHM rate halved during the study years. In Finland, the epidemiology of acute working-aged TBI has significantly changed. The rates of admission incidences, ANOs, and IHM nowadays represent the lower end of the range of these acute events reported in the western world.

Extracting the communication profile of a patient who underwent right Fronto-Temporo-Parietal decompressive craniotomy post Traumatic brain injury

Traumatic brain injury is one of the leading causes for cognitive-linguistic impairments in individuals. Considering cerebral lateralization, the type of communication impairments does depend on the hemisphere that is damaged. The current study reports about a 26-year-old female who has underwent right fronto-temporo-parietal (FTP) craniotomy and evacuation of acute subdural hematoma, followed by left FTP decompressive craniotomy and conservative evacuation of the left temporal contusion. A detailed assessment focussing on the linguistic, cognitive, and speech skills were done using formal and informal measures. Bangladesh Journal of Medical Science Vol. 21 No. 02 April’22 Page : 422-425

Comparison of Mortality and Glasgow Outcome Scale Extended (GOSE) between Craniotomy and Decompressive Craniectomy in Patients with Traumatic Acute Subdural Hematoma at Sanglah General Hospital, Bali

Background: Craniotomy and decompressive craniectomy and are surgical modalities for the evacuation of acute subdural hematoma (SDH). These two techniques show different outcomes in various existing studies. The superiority between either techniques remains controversial. Objective: To determine the outcome comparison of mortality and Glasgow Outcome Scale Extended (GOSE) craniotomy with decompressive craniectomy in patients with traumatic acute SDH. Methods: This is a historical cohort study. Samples of the study were collected from January 2018 to March 2020 at Sanglah General Hospital. All patients with acute traumatic SDH who underwent SDH evacuation with craniotomy and decompressive craniectomy were assessed for mortality status at discharge and GOSE 3 months after surgery. Independent T-test will be carried out if the numerical variable were all normally distributed, while Mann-Whitney U test will be performed if otherwise. A Chi-square test will be performed on all unpaired categorical variables. Statistical analysis was performed with SPSS 25 with 95% confidence intervals. Results: As many as 40 subjects with traumatic acute SDH who underwent craniotomy and 40 subjects with traumatic acute SDH who underwent decompressive craniectomy were included in this study. There was no significant difference in mortality (RR: 1; 95% CI 0.67-1.87; p=0.651) and GOSE score (p=0.718) in traumatic acute SDH who underwent craniotomy or decompressive craniectomy. Conclusion: There was no difference in mortality and GOSE outcomes between a craniotomy and decompressive craniectomy for management of traumatic acute SDH.

Preexisting Ventricular Shunts Are Associated with Failed Evacuation of Acute Subdural Hematomas: Single-Institution Case Series of Complications and Management Strategies

The effect of ventricular shunts on radiographic outcomes after evacuation of acute subdural hematomas (aSDHs) has not yet been established. We studied a series of patients who had undergone craniotomy for aSDH, exploring a possible relationship between the occurrence of a postoperative extra-axial collection (EAC) and the presence of a ventricular shunt. We reviewed all craniotomies for convexity aSDH performed between July 2015 and June 2020. The medical record review included perioperative coagulation studies, platelet counts, and antiplatelet and anticoagulation agent use. Univariate and multivariate analyses were conducted to identify the factors associated with postoperative EACs and reevacuation. A total of 58 patients had undergone craniotomy for aSDHs, including 9 with ventricular shunts. The median age was 67 years (interquartile range, 54-78 years), and 40% of the patients were women. Of the 58 patients, 16 were taking antiplatelet agents, and 6 were taking anticoagulation agents. Ten patients had developed perioperative thrombocytopenia (platelet count, <100,000/μL). Twelve patients had perioperative coagulopathy (international normalized ratio, ≥1.5). A postoperative EAC >10 mm occurred in 17 patients (29.3%). Eight patients (13.8%) had undergone reevacuation. The presence of a shunt and an increasing preoperative aSDH size were independently associated with an EAC >10 mm (P= 0.013 and P= 0.003, respectively). Only the presence of a shunt predicted for the need for reevacuation (P= 0.001). The shunts were explanted (n= 3) or valves were adjusted (n= 3) in all but 3 cases. We found that a lack of brain reexpansion after aSDH evacuation worsens radiographic outcomes and was more common in patients with shunts. Increasing shunt valve resistance might help prevent the formation of large EACs after aSDH evacuation.

Hypothermia for Patients Requiring Evacuation of Subdural Hematoma: A Multicenter Randomized Clinical Trial

BackgroundHypothermia is neuroprotective in some ischemia–reperfusion injuries. Ischemia–reperfusion injury may occur with traumatic subdural hematoma (SDH). This study aimed to determine whether early induction and maintenance of hypothermia in patients with acute SDH would lead to decreased ischemia–reperfusion injury and improve global neurologic outcome.MethodsThis international, multicenter randomized controlled trial enrolled adult patients with SDH requiring evacuation of hematoma within 6 h of injury. The intervention was controlled temperature management of hypothermia to 35 °C prior to dura opening followed by 33 °C for 48 h compared with normothermia (37 °C). Investigators randomly assigned patients at a 1:1 ratio between hypothermia and normothermia. Blinded evaluators assessed outcome using a 6-month Glasgow Outcome Scale Extended score. Investigators measured circulating glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 levels.ResultsIndependent statisticians performed an interim analysis of 31 patients to assess the predictive probability of success and the Data and Safety Monitoring Board recommended the early termination of the study because of futility. Thirty-two patients, 16 per arm, were analyzed. Favorable 6-month Glasgow Outcome Scale Extended outcomes were not statistically significantly different between hypothermia vs. normothermia groups (6 of 16, 38% vs. 4 of 16, 25%; odds ratio 1.8 [95% confidence interval 0.39 to ∞], p = .35). Plasma levels of glial fibrillary acidic protein (p = .036), but not ubiquitin C-terminal hydrolase L1 (p = .26), were lower in the patients with favorable outcome compared with those with unfavorable outcome, but differences were not identified by temperature group. Adverse events were similar between groups.ConclusionsThis trial of hypothermia after acute SDH evacuation was terminated because of a low predictive probability of meeting the study objectives. There was no statistically significant difference in functional outcome identified between temperature groups.

Surgical Management of a Post-traumatic Intracranial Hematoma

Surgery is one of the primary options for the management of traumatic brain injury(TBI). We focused on operative techniques, additional options, and potential pitfalls of surgical intervention for intracranial hematomas, such as acute subdural hematoma(ASDH), acute epidural hematoma(AEDH), cerebral contusion, and intracerebral hematoma. A wide craniotomy covering the hematoma was recommended for a case of AEDH to evacuate the hematoma, control bleeding, and prevent blood reaccumulation. Combined multiple craniotomies leaving a bone bridge over the sinus for dural tenting sutures enabled safe surgical intervention in a case of AEDH with sinus injuries. Different surgical techniques have been advocated for the evacuation of ASDH. Large craniotomy is often chosen as it can easily be shifted to decompressive craniectomy in case of brain swelling. It is important to pay attention to injuries of dural sinuses and bridging veins, and to expose the floor of the middle cranial fossa. Small craniotomy or endoscopic burr-hole evacuation of ASDH has been accepted as a way to avoid large craniotomies and additional morbidity, particularly for patients who are poor surgical candidates. Contusion necrotomy is performed for satisfactory control of progressive elevation in intracranial pressure and clinical deterioration.

Comparison of Early vs. Late Tracheostomy in Subdural Hematoma Operated at GCS Six or Below

Objectives:To compare the outcomes of early tracheostomy vs. late tracheostomy in post-operative patients after acute subdural hematoma at receiving GCS (Glasgow comma scale) of six or below.&#x0D; Method: A quasi observational study was conducted on 30 patients with acute subdural hematoma after RTA (road traffic accident) and were operated in The Department of Neurosurgery Unit 2, Punjab Institute of Neurosciences, LGH, Lahore. The age range was 20 – 65 years. All patients were operated upon within 12 hours of RTA.&#x0D; Results: In Group A, 12 (40%) patients, decompressive craniectomy with the evacuation of acute subdural hematoma and early tracheostomy were performed. In Group B, 8 (26%) patients’ craniotomy and evacuation of acute subdural hematoma were done along with early tracheostomy. In 6(20%) patients, decompressive craniectomy and evacuation were done and their tracheostomies were done at the 10th post-operative day. In 4 (13.33%) patients’ craniotomy and evacuation of hematoma done and their tracheostomies were also done at 10th post-operative day. In Group A, on 5th postoperative day GCS of 16 (53.33%) patients with early tracheostomies and fewer comorbidities improved, they were extubated, while 2 (6.67%) patients did not improve and 2 (6.67%) patients died. In Group B, in 30 patients with late tracheostomies, only 4 (13.33%) patients were improved. On 10th post-op day, GCS of 4 (13.33%) patients improved, GCS of 3 (10%) patients not improved and 3 (10%) patients died.&#x0D; Conclusion: Early tracheostomy in patients with acute subdural hematoma yields good results as compared to late tracheostomy.