Presence Of Subdural Hematoma Research Articles

Risk factors for posttraumatic hydrocephalus after decompressive hemicraniectomy in pediatric patients with traumatic brain injury.

Traumatic brain injuries (TBIs) play a significant role in pediatric mortality and morbidity. Decompressive hemicraniectomy (DHC) is a treatment option for severe pediatric TBI (pTBI) not amenable to medical management of intracranial pressure. Posttraumatic hydrocephalus (PTH) is a known sequela of DHC that may lead to further injury and decreased capacity for recovery if not identified and treated. The goal of this study was to characterize risk factors for PTH after DHC in patients with pTBI by using the Kids' Inpatient Database (KID). The records collected in the KID from 2016 to 2019 were queried for patients with TBI using International Classification of Diseases, 10th Revision codes. Data defining demographics, complications, procedures, and outcomes were extracted. Multivariate regression was used to identify risk factors associated with PTH. The authors also investigated length of stay and hospital charges. Of 68,793 patients with pTBI, 848 (1.2%) patients underwent DHC. Prolonged mechanical ventilation (PMV) was required in 475 (56.0%) patients with pTBI undergoing DHC. Three hundred (35.4%) patients received an external ventricular drain (EVD) prior to DHC. PTH was seen in 105 (12.4%), and 50 (5.9%) received a ventriculoperitoneal shunt. DHC before hospital day 2 was negatively associated with PTH (OR 0.464, 95% CI 0.267-0.804; p = 0.006), whereas PMV (OR 2.204, 95% CI 1.344-3.615; p = 0.002) and EVD placement prior to DHC (OR 6.362, 95% CI 3.667-11.037; p < 0.001) were positively associated with PTH. PMV (OR 7.919, 95% CI 2.793-22.454; p < 0.001), TBI with subdural hematoma (OR 2.606, 95% CI 1.119-6.072; p = 0.026), and EVD placement prior to DHC (OR 4.575, 95% CI 2.253-9.291; p < 0.001) were independent predictors of ventriculoperitoneal shunt insertion. The mean length of stay and total hospital charges were significantly increased in patients with PMV and in those with PTH. PMV, presence of subdural hematoma, and EVD placement prior to DHC are risk factors for PTH in patients with pTBI who underwent DHC. Higher healthcare resource utilization was seen in patients with PTH. Identifying risk factors for PTH may improve early diagnosis and efficient resource utilization.

Is bridging vein rupture/thrombosis associated with subdural hematoma at birth?

The combination of bridging vein rupture/thrombosis and subdural hematoma in infants has recently gained attention as highly suggestive of abusive head trauma. While subdural hematomas are frequently observed at birth, there are no previous studies of bridging vein rupture/thrombosis prevalence in that context. To evaluate the prevalence of bridging vein rupture/thrombosis in newborns with and without subdural hematoma. This bicentric retrospective study (2012-2019) looked at all brain MRIs performed in neonates. We noted delivery method, demographic data and intracranial injuries and analyzed any clots at the vertex as potential markers of bridging vein rupture/thrombosis. We analyzed 412 MRIs in 412 neonates. Age was (mean ± standard deviation [SD]) 5.4±2.2days and 312 (76%) infants were full term (38.3±2.9weeks from last menstrual period). The delivery method was vaginal birth for 42% (n=174), cesarean section for 43% (n=179), and unknown for 14% (n=59). Subdural hematoma was present in 281 MRIs (68.0%, [95% confidence interval = 63.3-72.5]).Six MRIs showed at least one clot at the vertex, assumed to be possible bridging vein rupture/thrombosis (1.5%, [0.5-3.1%]). Only one MRI showed more than two clots at the vertex, in a context of maternal infection. There was no significant difference in terms of gestational age at birth, delivery method or the presence of subdural hematoma or parenchymal injuries between those 6 infants and the 406 others. Bridging vein rupture/thrombosis at birth is very rare and unlikely to be related to subdural hematoma.

Association Between Serum Sodium Abnormalities and Clinicoradiologic Parameters in Severe Traumatic Brain Injury

Background: Secondary brain insults after traumatic brain injury such as electrolyte dysfunctions are associated with poor outcomes. This study aimed at determining the incidence of serum sodium ion abnormalities and their association with clinicoradiological parameters.&#x0D; Methods: A prospective crosssectional study of one hundred and seventeen patients with severe head injury. Data collected included patient demographics, prehospital interventions, clinical examination findings, computed tomography (CT) scan head findings, serum sodium ion levels (at admission and 48 h later), and outcome (30 days).&#x0D; Results: At admission, 93(79.5%) patients had normal serum sodium ion levels. However, 48 h post-admission, hypernatremia was prevalent in 56(63.6%) patients (p &lt; 0.001). Hypernatremia was significantly associated with the use of mannitol (p = 0.036), lower Glasgow Coma Score (p = 0.047), higher Injury Severity Score (p = 0.015), presence of subdural hematoma (p = 0.044), midline shift &gt;5 mm (p = 0.048), compressed/absent basal cistern (p = 0.010), and higher Rotterdam CT Score (p = 0.003). Hypernatremia reported 48 h postadmission was associated with a high 30-day mortality rate [odds ratio (OR) 3.55, p = 0.0095]. Risk of mortality associated with hyponatremia and hypernatremia at admission was not statistically significant.&#x0D; Conclusion: While both hyponatremia and hypernatremia can occur in serious TBI patients, hypernatremia predominates 48 hours post- admission and is associated with statistically significant increased risk of death.

Classic Metaphyseal Lesions and Abuse

Research Article| September 01 2019 Classic Metaphyseal Lesions and Abuse AAP Grand Rounds (2019) 42 (3): 28. https://doi.org/10.1542/gr.42-3-28 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Classic Metaphyseal Lesions and Abuse. AAP Grand Rounds September 2019; 42 (3): 28. https://doi.org/10.1542/gr.42-3-28 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: abuse, physical, fractures, perpetrator of child and adult abuse, torsion, traction, shoulder region, musculoskeletal torsion, function Source: Adamsbaum C, De Boissieu P, Teglas JP, et al. Classic metaphyseal lesions among victims of abuse. J Pediatr. 2019; 209: 154.e2– 159.e2; doi: https://doi.org/10.1016/j.jpeds.2019.02.013Google Scholar Investigators from multiple institutions in France conducted a retrospective review to better understand the circumstances of injuries in physically abused infants with classic metaphyseal lesion (CML), which is a fracture through immature metaphyseal bone near the growth plate. CML is thought to be caused by torsion or traction and is considered to be highly suggestive of abuse.1 Children included in the study were identified through review of cases of suspected abuse referred by the court system in France for expert medical evaluation. Only children with CML were included; all study participants who were living were examined by one of the authors. Data from medical records, abuse evaluation, police investigations, and court records were abstracted for study participants. Logistic regression was used to assess the association between anatomical location of CML and the presence of subdural hematoma (SDH). The mechanism of injury causing CML was described among a subset of study participants in whom the perpetrator admitted abusing the child. A total of 67 children with CML from physical abuse were identified. The mean age of victims was 3.4 months with no sex predominance; 8 children were born prematurely (gestational age <37 weeks). In addition to CML, all children had other signs of abuse. Concurrent injuries included unusual bruising (30 children) and burns (4 children). CML was identified on routine skeletal surveys in 43 patients (64%). Overall, 44 children had multiple CMLs. CML was more common in lower than upper extremities. There were 27 children with CML in whom the perpetrator admitted abusing the child. Among these were 19 male perpetrators (18 fathers and 1 stepfather) and 8 female perpetrators (3 mothers and 5 nannies). These perpetrators admitted using excessive force on joints by means of torsion, traction, violent compression, and other forced movements. Among male perpetrators, violent handling was described during diapering in 44% of cases, and among all perpetrators the use of excessive force during dressing or undressing the infant occurred in 30% of cases. Perpetrators of both sexes cited crying or feeding as trigger events. There were 24 children with SDH. Compared to CML at other anatomic sites, CML of the shoulder was associated with an increased risk of concurrent SDH (OR, 4.85; 95% CI, 1.16–20.18). The authors conclude that CMLs are caused by violent acts inflicted during routine care of infants. Dr Dubik has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Caffey first described the radiological pattern of metaphyseal injury in abused infants.2 Although no specific fracture type is pathognomonic for physical abuse,3 CML, also known as “corner” or “bucket handle” fracture, is considered a strong indicator of inflicted injury in infants.4 However, iatrogenic causes of CMLs have been documented, including... You do not currently have access to this content.

Seizure incidence in the acute postneurosurgical period diagnosed using continuous electroencephalography.

Delay in diagnosis and subsequent treatment of nonconvulsive seizures can lead to worsened outcomes. The gold standard in detecting nonconvulsive seizures is continuous video-electroencephalography (cEEG). Compared to routine, 30-minute EEG, the use of cEEG increases the likelihood of capturing intermittent nonconvulsive seizures. Studies of critically ill patients in intensive care units demonstrate a particularly high rate of nonconvulsive seizures. Some of these studies included postneurosurgical patients, but often subanalyses of specific populations were not done. In particular, few studies have specifically evaluated postneurosurgical patients by using cEEG in the acute postoperative setting. Therefore, the incidence and predictors of acute postneurosurgical seizures are unclear. In this study, the authors focused on patients who were admitted to the neurological critical care unit following neurosurgery and who underwent cEEG monitoring within 72 hours of surgery. A total of 105 cEEG studies were performed in 102 patients. Twenty-nine patients demonstrated electrographic (subclinical) seizures, of whom 10 had clinical seizures clearly documented either before or during cEEG monitoring. Twenty-two patients had subclinical seizures only detected on cEEG, 19 of whom did not have clinical seizure activity at any point during hospitalization. Those with seizures were more likely to have had a history of epilepsy (p = 0.006). The EEG studies of patients with seizures were more likely to show lateralized periodic discharges (p = 0.012) and lateralized rhythmic delta activity (p = 0.012). The underlying neuropathological disorders most associated with seizure risk were lobar tumor on presentation (p = 0.048), subdural hematoma (SDH) requiring craniotomy for evacuation (p = 0.002), subarachnoid hemorrhage (SAH) (p = 0.026), and perioperative SAH (p = 0.019). In those undergoing craniotomy, the presence of SDH (p = 0.032), particularly if requiring evacuation (p = 0.003), increased the risk of seizures. In those without preoperative intracranial bleeding, perioperative SAH after craniotomy was associated with a higher incidence of seizures (p = 0.014). There was an additive effect on seizure incidence when perioperative SAH as well as concomitant intraparenchymal hemorrhage and/or stroke were present. The clinical examination of the patient, including the presence or absence of altered mental status and the presence or absence of repetitive movements, was not predictive of subclinical seizures. In postneurosurgical patients referred for cEEG monitoring, there is a high rate of both clinical and subclinical seizures in the early postoperative period. Seizures are particularly common in patients with SDH or lobar tumor and perioperative SAH. There was an additive effect on seizure incidence when more extensive brain injury was present. As expected, those with a history of epilepsy also demonstrated higher seizure rates. Further studies are needed to evaluate the time period of maximum seizure incidence after surgery, and the effects acute postneurosurgical seizures have on long-term outcomes.

Lesión hepática severa inducida por carbamazepina asociado a necrolisis epidérmica tóxica. Reporte de un caso.

La necrolisis epidérmica toxica y el síndrome de Stevens- johnson son trastornos raros y mortales, caracterizado por una lesión severa de la piel y mucosa. Estos trastornos son una misma condición, se diferencia por el grado de afección de la superficie corporal total. La reacción de hipersensibilidad de los fármacos es la etiología más frecuente de estas dos entidades; por otro lado, el hígado es también una diana de las lesiones causadas por medicamentos, pudiendo conducir hasta una hepatitis severa y hasta en peor de los casos falla hepática aguda, llevando a ictericia, encefalopatía y coagulopatia. El presente caso es un paciente que sufre un trauma craneoencefálico con presencia de hematoma subdural, días después inicia el consumo de carbamazepina como profilaxis anticonvulsivante y acetaminofén para el dolor, generando lesión en piel que comprometían más de un 30% de la superficie corporal, lesión hepática severa con elevación marcada de transaminasas y encefalopatía, que bien podría corresponder al hematoma subdural o a la lesión hepática; esto genero gran interés.

In Vivo Demonstration of Traumatic Rupture of the Bridging Veins in Abusive Head Trauma

ObjectiveIn victims of abusive head trauma, bridging vein thrombosis is a common finding on magnetic resonance imaging. We aimed to evaluate the utility of high-resolution coronal susceptibility-weighted imaging (SWI) in depicting bridging vein thrombosis as well as to verify the morphology of the bridging vein thrombosis on axial SWI. We additionally analyzed the correlations between bridging vein thrombosis or bridging vein deformation and other magnetic resonance imaging findings that often occur in association with abusive head trauma. MethodsSeventeen patients with abusive head trauma were retrospectively evaluated for the presence of thrombosis on axial SWI. The affected veins were localized on coronal SWI, and the strength of association between the presence of bridging vein thrombosis on axial versus high-resolution coronal SWI was determined. ResultsOf 11 patients identified with thrombosis on axial SWI, high-resolution coronal SWI verified bridging vein thrombosis in four individuals (36%). The previously reported “tadpole sign” on axial images did not predict bridging vein thrombosis on coronal SWI (odds ratio = 0.3 [0.02, 5.01], P = 0.538). Volumetric coronal SWI disclosed additional irregularities of the bridging vein walls which was associated with the presence of subdural hematoma on magnetic resonance imaging (P = 0.03), suggesting traumatic injury. ConclusionCoronal SWI confirmed thrombosis of the bridging veins only in a minority of cases. Diffusely irregular contours of the veins observed on high-resolution coronal SWI was a major finding in our study. Disruption of the normal anatomy of the bridging veins in abusive head trauma further supports the traumatic nature of the disease.

Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury.

OBJECTIVE Early radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models. METHODS The authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present. RESULTS In general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3-8). CONCLUSIONS In these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.

Subdural hematoma and mycotic aneurysm bleed.

A subdural hematoma is a common neurosurgical problem. Easy identification, relatively safe and simple treatment, and positive neurological outcome are hallmarks of the issue. While in most cases of acute or chronic subdural hematoma, the exact cause cannot be identified, in extremely rare situations, causes such as aneurysm (as in the case presented) and arteriovenous fistulae are identified. It is crucial that the surgeon is aware of the possibility of such causative factors such that correct and timely treatment can be initiated. In this regard, prefect analysis of the clinical events and presenting deficits is necessary. The presence of subdural hematoma in proximity to major vessels such as close to Sylvian fissure and interhemispheric fissure can assist in identifying the need to investigate to identify and treat the incriminating cause. The presence of flow voids in or in the vicinity of the clot can suggest the presence of arteriovenous fistula. Mycotic aneurysms are significantly rare and more frequently involve distal arterial branch. The authors have managed the case well[1] and as per the contemporary norms.

Early neurological wake-up test in intubated brain-injured patients: A long-term, single-centre experience

BackgroundIn prehospital setting, a severe traumatic brain injury (TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test (ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure. MethodsWe conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure. ResultsDuring 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients (39.5%), mostly due to neurological deterioration in 27 cases (71%) or respiratory distress in 10 cases (26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness >5mm on first imagery (OR=3.2; 95%CI [1.01–10.28]), and an initial GCS score <5 (OR=7.4; 95%CI [1.92–28.43]). Prevalence of poor outcome at 1year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49% (p<0.0001). ConclusionsThe ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness >5mm or an initial GCS score <5, an ENWT failure may be expected.

Spontaneous Intracranial Hypotension: Characteristics of the Serious Form in a Series of 24 Patients

Recommended treatments for spontaneous intracranial hypotension (SIH) range from bed rest only to neurosurgery. However, the serious form of SIH is poorly defined. A better description of patient characteristics and their outcome may help define therapeutic options. We reviewed 24 cases of patients with SIH and separated them into 2 groups according to whether or not they presented with signs of severity at admission: disturbance of consciousness, subdural hematomas (SDHs), and cerebral venous thrombosis. Nine patients (37%) were classified as having a serious form of SIH: six (25%) presented SDHs; three (12%) disturbance of consciousness; and one (4%) cerebral venous thrombosis. Bed rest and epidural blood patches (EBPs) were sufficient to treat all patients in the nonserious form group and 4 patients in the serious form group. Two patients (8%) had to undergo cerebrospinal fluid leak repair, and 3 others (12%) evacuation of SDHs. Outcome was good in both groups, with only one (4%) death due to extensive SDHs. Times to diagnosis in the serious form group (63 vs. 35 days, P = 0.052) and to recovery (9 months vs. 5 months, P = 0.088) tended to be higher without reaching difference. The presence of SDHs, disturbance of consciousness, and a trend toward a longer time to diagnosis and recovery seem to define the serious form of SIH. These patients may require exploration and surgical repair of cerebrospinal fluid leak, only after failure of conservative measures--bed rest and time--and EBP, with good outcome.

Imaging abusive head trauma: why use both computed tomography and magnetic resonance imaging?

Abusive head trauma is the leading cause of death in child abuse cases. The majority of victims are infants younger than 1 year old, with the average age between 3 and 8 months, although these injuries can be seen in children up to 5 years old. Many victims have a history of previous abuse and the diagnosis is frequently delayed. Neuroimaging is often crucial for establishing the diagnosis of abusive head trauma as it detects occult injury in 37% of cases. Several imaging patterns are considered to be particularly associated with abusive head trauma. The presence of subdural hematoma, especially in multiple locations, such as the interhemispheric region, over the convexity and in the posterior fossa, is significantly associated with abusive head trauma. Although CT is the recommended first-line imaging modality for suspected abusive head trauma, early MRI is increasingly used alongside CT because it provides a better estimation of shear injuries, hypoxic-ischemic insult and the timing of lesions. This article presents a review of the use and clinical indications of the most pertinent neuroimaging modalities for the diagnosis of abusive head trauma, emphasizing the newer and more sensitive techniques that may be useful to better characterize the nature and evolution of the injury.

Hyperglycemia During Craniotomy for Adult Traumatic Brain Injury

Hyperglycemia after traumatic brain injury (TBI) is associated with poor outcome, but previous studies have not addressed intraoperative hyperglycemia in adult TBI. In this study, we examined glucose value variability and risk factors for hyperglycemia during craniotomy in adults with TBI. A retrospective cohort study of patients ≥18 years who underwent urgent or emergent craniotomy for TBI at Harborview Medical Center (level 1 adult and pediatric trauma center) between October 2007 and May 2010 was performed. Preoperative (within 24 hours of anesthesia start) and intraoperative (during anesthesia) glucose values for each patient were retrieved. The prevalence of intraoperative hyperglycemia (glucose ≥200 mg/dL), hypoglycemia (glucose <60 mg/dL), and glycemic trends was determined. Generalized Estimating Equations was used to determine the independent predictors of intraoperative hyperglycemia. Data are presented as adjusted odds ratio (AOR) (95% confidence interval [CI]), and P < 0.05 reflects significance. Intraoperative hyperglycemia was common (26 [15%]) and intraoperative hypoglycemia was not observed. Independent risk factors of intraoperative hyperglycemia were age ≥65 years (AOR 3.9 [95% CI: 1.4-10.3]; P = 0.007), Glasgow Coma Scale score <9 (AOR 4.9 [95% CI: 1.6-15.1]; P = 0.006), preoperative hyperglycemia (AOR 4.4 [95% CI: 1.7-11.6]; P = 0.003), and subdural hematoma (AOR 5.6 [95% CI: 1.4-22.2]; P = 0.02). Mean intraoperative glucose was highest in severe TBI patients (P = 0.02). There was both between-patient (79.5% variance; P < 0.001) and within-patient (20.5% variance; P < 0.001) intraoperative glucose value variability. Patients with intraoperative hyperglycemia had higher in-hospital mortality (8 [31%] vs 20 [13%]; P < 0.02). Intraoperative hyperglycemia was common in adults undergoing urgent/emergent craniotomy for TBI and was predicted by severe TBI, the presence of subdural hematoma, preoperative hyperglycemia, and age ≥65 years. However, there was significant variability in intraoperative glucose values.

The natural history of brain contusion: an analysis of radiological and clinical progression

Although brain contusions are a common neurosurgical condition, surprisingly little has been written about their natural history. The purpose of this study was to identify factors that predict radiological and clinically significant progression of this pattern of traumatic brain injury in patients who did not initially require surgery. On the basis of their results and the available literature, the authors suggest a management algorithm. The authors performed a retrospective review of clinical and radiological records of consecutive patients with brain contusions who initially underwent conservative treatment. Significant radiological progression was defined as a 30% increase in contusion size on CT scans. Statistical analysis was performed to identify clinical and radiological predictors of CT contusion progression, the significance of progression, and predictors of clinical outcome. Of 98 patients identified with brain contusions who initially received conservative treatment, 44 (45%) had significant progression on CT, and 19 (19%) required surgical intervention. The initial size of the contusion and the presence of subdural hematoma were the only statistically significant predictors of CT progression in the multivariate analysis (p = 0.0212 and 0.05, respectively). Four patients required delayed contusion evacuation (3 had radiological progression on follow-up scans). Good Glasgow Coma Scale (GCS) scores on presentation and younger age were predictors of eventual discharge from the hospital (OR 1.471, CI 1.233-1.755, p < 0.001 and OR 0.949, CI 0.912-0.988, p = 0.011, respectively). No patients with an initial GCS score of 15 or an initial contusion size < 14 ml required delayed evacuation. Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.

Mortality in Late Post-Traumatic Seizures

The objective of this study was to examine the mortality rates in individuals with traumatic brain injury (TBI) who were classified as having experienced late post-traumatic seizures (LPTS) in the first 2 years post-TBI compared to those who were seizure-free (non-LPTS). Participants were a pooled sample (n = 508) from two studies which enrolled individuals with TBI who were injured between March 31, 1992 and December 20, 1999. The first sample was made up of individuals enrolled in a study of risk factors for LPTS development; the second sample was composed of individuals enrolled in the TBI National Database from a single rehabilitation center. Seventy-one (14%) participants had LPTS, of which 27% had died at 8-15 years post-injury, as compared to 10% of non-LPTS participants. Individuals with LPTS died at a younger age (54.1 versus 67.7 years; p = 0.01), but there were no statistically significant differences in either time from date of injury to death or highest GCS score in the first 24 h. Causes of death were variable and not specifically related to epilepsy. Of those with LPTS, risk factors for death include advanced age at time of injury and presence of subdural hematoma. The higher mortality rate and death at younger age with variable causes in TBI individuals with LPTS warrant close medical evaluation and monitoring of these individuals, particularly accessibility and compliance with ongoing general medical care, and education of primary care colleagues of the unique needs of this at-risk population.

Subdural Haematoma in Patients With Spontaneous Intracranial Hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.

Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors

Subdural haematomas are thought to be uncommon in babies born at term. This view is mainly based on findings in symptomatic neonates and babies in whom subdural haemorrhages are detected fortuitously. We aimed to establish the frequency of subdural haemorrhages in asymptomatic term neonates; to study the natural history of such subdural haematomas; and to ascertain which obstetric factors, if any, are associated with presence of subdural haematoma. We did a prospective study in babies who were born in the Jessop wing of the Central Sheffield University Hospitals between March, 2001, and November, 2002. We scanned neonates with a 0.2 T magnetic resonance machine. 111 babies underwent MRI in this study. 49 were born by normal vertex delivery without instrumentation, 25 by caesarean section, four with forceps, 13 ventouse, 18 failed ventouse leading to forceps, one failed ventouse leading to caesarean section, and one failed forceps leading to caesarean section. Nine babies had subdural haemorrhages: three were normal vaginal deliveries (risk 6.1%), five were delivered by forceps after an attempted ventouse delivery (27.8%), and one had a traumatic ventouse delivery (7.7%). All babies with subdural haemorrhage were assessed clinically but no intervention was needed. All were rescanned at 4 weeks and haematomas had completely resolved. Presence of unilateral and bilateral subdural haemorrhage is not necessarily indicative of excessive birth trauma.

Ruptured middle cerebral artery aneurysm and bilateral chronic subdural hematomas

BACKGROUND While rupture of a cerebral aneurysm into the subdural space is rare, aneurysmal subarachnoid hemorrhage in the presence of subdural hematoma(s) is much more uncommon. Such a patient requires changes in routine perioperative management. CASE DESCRIPTION A patient with a ruptured middle cerebral artery bifurcation aneurysm and bilateral subdural hematomas is presented. He underwent successful aneurysm clipping and subdural hematoma evacuations. At the time of surgery, measures commonly used to obtain brain relaxation were avoided. The patient was kept normovolemic, normocarbic, and normotensive. He recovered completely and resumed his prior occupation. CONCLUSIONS Changes in standard techniques for a patient undergoing a pterional craniotomy for a ruptured cerebral aneurysm are required when bilateral extra-axial mass lesions are present.

The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment.

The records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank were reviewed. Thirty-four severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less were identified. Of those 34 patients, 18 died or were left vegetative and 16 recovered. While there were certain common factors between those who talked and died and those who talked and recovered, there were also significant differences. The common factors between the two groups were the length of time to deterioration or operative intervention (16 versus 18 hours, respectively), and the initial GCS scores (12.6 versus 12.4, respectively). The primary differences between the groups included the mean age, the degree of midline shift seen on computerized tomography (CT), and the presence of subdural hematoma. Those who talked at some point postinjury, but who subsequently died, had a mean age of 50 years. Those who talked, deteriorated, and then recovered were found to have a mean age of 32 years. Seven of the 18 patients who talked and died had a shift of greater than 15 mm on CT, while this degree of shift was demonstrated in only one of 16 patients who talked, deteriorated, and recovered. Subdural hematomas were significantly more common in the "talk and die" group, as was the overall need for operation. Since the overwhelming majority of patients with marked shift on CT have surgical lesions, early operative intervention is strongly recommended in these patients, prior to their inevitable deterioration.

CLINICAL CONFERENCE

Dr. Ransohoff: I want to draw your attention to a group of infants with chronic subdural hematoma. The distinctive feature of these patients is marked enlargement of the skull. This megalocephaly was of such a degree in eight patients we treated that they were all admitted to the hospital with a tentative diagnosis of internal hydrocephalus. The presence of subdural hematoma was only discovered in these children at the time of tipping the subdural space through the enlarged anterior fontanelle prior to carrying out ventriculography. When air is injected into the subdural space in these patients, roentgenograms reveal fairly normal-sized cerebral hemispheres surrounded by hugely distended subdural spaces. We believe that it is this disproportion between the size of the boney vault and the size of the underlying brain which makes this group a special therapeutic problem (Fig. 1). When a surgeon drains blood and fluid from the subdural space, he expects the underlying compressed brain to re-expand and obliterate the remaining cavity. If the lesion is of long standing, he may find it necessary to remove the inner membrane of the subdural hematoma, which is covering the surface of the brain, before the expected re-expansion can occur. However, when the cranium has been so enlarged by bilateral subdural collections that it is considerably larger than the normal-sized brain, the brain cannot be expected to re-expand sufficiently to fill the entire cavity. We became aware of this therapeutic dilemma after applying the usual techniques of treatment to a 3-month-old infant admitted in 1952 with a definite history of trauma. After the removal of about 350 ml of subdural fluid by daily subdural taps, we made bone flaps, bilateral and frontoparietal, and removed the inner membranes of the subdural hematomas, 1 week apart.