Traumatic Intracerebral Hematoma Research Articles

CT and clinical criteria for conservative treatment of supratentorial traumatic intracerebral haematomas.

In search of guidelines for the management of traumatic intracerebral haematomas (TICHs) with slight mass effects on computed tomography (CT) scans, the author reviewed the records of 29 patients who did not undergo surgery and 11 patients who did. It is found that patients with a TICH volume of less than 15 ml, a midline shift of less than 5 mm, an open perimesencephalic cistern on CT scans, a Glasgow Coma Scale (GCS) score of 12 or more, and an absence of lateralizing signs may be treated conservatively and expected to make a good recovery. On the other hand, with zero mortality and satisfactory outcomes, the patients under-going early surgery tended to have a TICH volume of more than 15 ml, a midline shift of more than 5 mm, an obliterated perimesencephalic cistern on CT scans, a GCS score of less than 12, and the presence of lateralizing signs. However, the position of such features as the criteria of early operation for a TICH is weakened by the retrospective nature of this study because some surgical patients, free of lateralizing signs in particular, might have managed to do well without craniotomy.

Porphyrinuria Associated with Continuous Intravenous Infusion Therapy of Barbiturate

The authors previously reported a case on barbiturate therapy, complicated with porphyrinuria, and in the present study, confirmed the existence of porphyrinuria during the barbiturate therapy, by determination of porphyrin body in the urine. The subjects were 9 cases on barbiturate therapy, hospitalized for central neuvons system disease during last 4 years. These disease were acute subdural hematoma (4 cases) and traumatic intracerebral hematoma, subarachnoid hemorrhage, arteriovenous malformation, anoxic brain and herpes simplex encephalitis (1 case, each). These subjects averaged 38.9 years and showed mean Glasgow coma scale of 6.5 points on admission. Barbiturate therapy consisted of continuous intravenous infusion of thiamylal at a dose of 1-5mg·kg-1·hr-1. The medication averaged 8.6 days in duration with average total dose of 667.4mg·kg-1. Complicated porphyrinuria, abnormally high urinary coproporphyrin, uroporphyrin and porphobilinogen were noted in 3, 2 and 1 cases, respectively. These 3 cases of complicated porphyrinuria had longer medication and larger total dose of barbiturate and were all compicated with liver dysfunction. The present examination suggests that prophyrinuria should also be kept in mind as a complication of barbiturate therapy.

Acute traumatic intracerebral haematomas: Determinants of outcome in a retrospective series of 202 cases

A retrospective study was carried out of 202 patients with traumatic intracerebral haematomas (TICH) noted on CT, to determine which factors most affected outcome. There were 151 (75%) males and 51 (25%) females, whose ages ranged from 1 to 84 years. One-hundred-and-two (51%) had a good outcome (Glasgow Outcome Score 1 and 2). Thirty-five (17%) were vegetative or severely disabled and 65 (32%) died. Of the 169 with a single haematoma, 98 (58%) had a good outcome, while only 20% of patients with two clots fared well. No patient with three or more haematomas had a good outcome. Single factor logistic regression analysis identified Glasgow Coma Score (GCS), haematoma volume and difficulty with airway maintenance or poor arterial oxygenation as important factors in determining outcome. A four-factor logistic regression analysis model was developed which revealed that, when all other factors had been taken into consideration, craniotomy significantly improved the probability of a good outcome.

Delayed Traumatic Intracerebral Hematoma: Case Report and Review of Literature

Delayed Traumatic Intracerebral Hematoma: Case Report and Review of Literature

Intraparenchymal blood-fluid levels in traumatic intracerebral haematomas.

Blood-fluid levels within the cerebral parenchyma are observed more frequently on CT and MRI in traumatic intracerebral haematomas than in those of other aetiologies. The intraparenchymal blood-fluid interface can be formed without a fluid cavity. It is suggested that the blood-fluid levels represent layering of red blood cells within areas of contusion necrosis as well as extensive contusion oedema. The more extensive the damage to brain tissue, the more often blood-fluid levels formed. A poorer outcome can be therefore predicted when an intraparenchymal blood-fluid interface is seen.

Significance of Magnetic Resonance Imaging in Acute Head Injury

One hundred seventy-seven patients who had incurred head trauma were studied with magnetic resonance imaging (MRI). Patients varied from those with mild injury without any focal neurological deficit to those with severe injury with post-traumatic coma. Altogether, 177 lesions were demonstrated by MRI in 123 of 177 patients within 3 days of injury using T2-weighted (SE2000/40,2000/111) and T1-weighted (IR1500/500/40) multislice sequences. In contrast, computerized tomography (CT) demonstrated 103 lesions in 90 patients. MRI was superior to CT in the diagnosis of nonhemorrhagic contusions demonstrated as a high-intensity area on T2-weighted imaging. MRI provided some information to evaluate the severity of diffuse axonal injury or to predict delayed traumatic intracerebral hematoma (DTICH).

99TCm-HMPAO SPECT studies in traumatic intracerebral haematoma.

Traumatic intracerebral haematomas are a common neurosurgical emergency. Their management, particularly the role of surgical removal, is controversial. Deterioration often occurs late, and is unpredictable. Eight patients with traumatic intracerebral haematomas were admitted to the neurosurgical unit to monitor their clinical state. All were studied within 48 hours of admission with single photon emission computerised tomography (SPECT), using the recently introduced radionuclide 99Technetiumm-Hexamethyl propylene amine oxime (99Tcm-HMPAO). At the time of the SPECT study, all the patients had been clinically stable. Three patients remained so; in the other five, the conscious level deteriorated, necessitating craniotomy and evacuation of the haematoma. In all the patients, the SPECT studies demonstrated perfusion defects that corresponded to the location of the haematoma, as demonstrated by computerised tomography (CT). However, in the five patients who subsequently deteriorated, the perfusion defects seen on the SPECT scan appeared larger than the haematoma, as seen on the CT scan. In addition, there was widespread poor retention of 99Tcm-HMPAO in the ipsilateral hemisphere. These differences were quantifiable. Interestingly, these differences were present at a time when the patients were clinically stable, before their deterioration. It is concluded that SPECT studies with 99Tcm-HMPAO are of possible use as predictors of late deterioration in the management of traumatic intracerebral haematomas.

Diffuse Axonal Injury and Early Intracranial Sequelae in Severe Head Injury

The importance of diffuse axonal injury (DAI) and early intracranial sequelae was studied in 107 patients with diffuse and focal brain injuries. Comprehensive neuropathological study was also undertaken in 24 fatal patients. The mortality rate was clearly the highest in traumatic subarachnoid hemorrhage, followed by acute subdural hematoma, cerebral contusion with delayed hematoma formation, traumatic intracerebral hematoma, diffuse cerebral swelling, DAI with classical features, and finally nearly normal on computed tomographic scans. The mean flow velocities in the middle cerebral artery recorded by transcranial Doppler ultrasound were variable in diffuse brain injury, but commonly decreased on the hematoma side depending on increased intracranial pressure and decreased cerebral perfusion pressure in focal brain injury. Deep-seated hemorrhagic lesions did not expand in diffuse brain injury, but sizable hematoma developed within 24 hours in focal brain injury. The platelet count was significantly lower in patients with poor outcomes in focal brain injury. Histological evidence of classical DAI was found in eight (50%) of 16 cases with focal brain injury. DAI of varying severity is the common subjacent lesion in patients with severe head injury, but the final outcome varies greatly with different lesion types.

Delayed traumatic intracerebral hematoma

Although delayed traumatic intracerebral hematomas (DTICHs) have been frequently reported since 1970, the time interval from trauma to hemorrhage and diagnosis has not been well defined. Eight patients with DITCH were found among 1,320 head-injured patients admitted to the neurosurgical service through the emergency department from March 1989 to March 1990. The mean time interval between initial and follow-up CT scan was 22 h. The mean time interval between initial trauma and diagnosis of DITCH was 24 h. One patient was diagnosed incidentally by magnetic resonance imaging. Three patients underwent operation and five patients were managed conservatively. Three patients died, resulting in a case mortality rate of 37.5%. The time interval for DTICHs' development and pitfalls in its diagnosis were discussed.

Delayed Traumatic Intracerebral Hematoma: Case Report and Review of Literature

Delayed Traumatic Intracerebral Hematoma: Case Report and Review of Literature

Delayed traumatic intracerebral hematomas: “Spät-Apoplexie”

Two patients who suffered a head trauma experienced sudden clinical deterioration more than 1 week after their injury. The initial computerized tomography (CT) scan demonstrated a small hematoma underlying a depressed skull fracture in one patient and a small interhemispheric subdural hematoma in the other. Both patients had made a complete recovery and follow-up CT scans were normal when clinical deterioration suddenly occurred. Both patients developed a large intracerebral hematoma and underwent emergency evacuation of the mass. The first patient recovered with the exception of a moderate hemiparesis and dysphasia, but the second patient died. Delayed traumatic intracerebral hematomas have been described in the literature. Since the advent of CT scanning, the incidence of this phenomenon has been estimated as between 1.7% and 7.4% of closed head injuries. In 1891, Otto Bollinger described four patients who suffered head injury, followed days to weeks later by death from an apoplectic event. His criteria for diagnosis of "traumatische Spät-Apoplexie" included the absence of preexisting vascular disease, a definite history of trauma, an asymptomatic interval of at least several days, and an apoplectic episode. These two cases reemphasize the existence of Spät-Apoplexie as a rare clinical condition. In the presence of CT findings of even small traumatic intracerebral or extracerebral hematomas, the possibility of this late complication should be kept in mind.

Traumatic intracerebral hematoma—Which patients should undergo surgical evacuation? CT scan features and ICP monitoring as a basis for decision making

When a patient presents to the neurosurgeon with a traumatic intracerebral hematoma and has not deteriorated or developed new neurological deficit since the injury, the decision to remove the hematoma may be difficult. Of 244 patients with traumatic intracerebral hematomas, 85 were selected for intracranial pressure monitoring to assist in deciding whether surgical evacuation was indicated. None had deteriorated in conscious level or developed new neurological deficit since injury. Fifty-five patients (65%) demonstrated high intracranial pressure and underwent craniotomy. In 30 patients, intracranial pressure remained under 30 mm Hg, and their hematomas were not initially removed. Five of these 30 patients suddenly deteriorated or died 6 to 11 days after injury, with features of high intracranial pressure clinically or at postmortem. Intracranial pressure monitoring therefore failed to predict a late rise in intracranial pressure in 16.6% of those with low intracranial pressure initially. An analysis of computed tomography scanning and clinical features was therefore carried out to search for better predictors of the need for surgery. Our data suggest that basal cistern status, coma score, and the severity of edema surrounding the intracerebral hematoma should be used, in addition to intracranial pressure monitoring, to improve management of patients with traumatic intracerebral hematoma.

Follow-up of computerized tomography findings in traumatic intracerebral hematomas

CT controls and follow-ups were conducted in 27 patients who had suffered traumatic intracerebral hemorrhage. Only such patients were included who did not die before the 14th day after the trauma and in whom operation did not become necessary during this period. In these patients the volume of the hematoma and perifocal edema was determined via CT and clinical parameters were measured or recorded such as state of consciousness at the time of admission and the neurological outcome. It was found that the hematoma had attained its maximum size on about the fourth posttraumatic day. However, even the size of the freshly CT-detected hematoma shows good correlation to the outcome of the patients. Examination of the edema size points to the existence of two groups: one with only slight edema formation in the early posttraumatic stage, and another with an immediate considerable edematic border. From approximately the 8th posttraumatic day the hematoma/edema ratio is approximately the same in both groups, namely, 0.3. Anisocoria, or inequality of the pupils, occurred early in patients with an average hematoma volume of 37.7 cm. Of these, none left the hospital without neurologic signs, so that anisocoria must be considered as a prognostically unfavorable sign.

Two types of delayed traumatic intracerebral hematoma: differential forms of treatment.

Two types of delayed traumatic intracerebral hematoma: differential forms of treatment.

Chronological evaluation of the occurrence and growth of the traumatic intracerebral hematoma.

Chronological evaluation of the occurrence and growth of the traumatic intracerebral hematoma.

Clinical Value of Bedside Ultrasonography in Craniectomized Patients

Twenty-five patients underwent bedside ultrasonographic examination through a postoperative skull defect, and the images were compared with axial computed tomography (CT) scans. The patients included 12 with cerebrovascular disease, two with brain tumor, one with a brain abscess, and 10 with head injury. Clear ultrasonographic images were obtained in all patients except one who had undergone a suboccipital craniectomy. Ultrasound was most useful when hydrocephalus was present, in which cases, regardless of the cause, hypo-echoic dilated third and lateral ventricles were demonstrated. In one case, it was decided to emplace a ventriculoperitoneal shunt on the basis of the results of serial sonography, which documented ventricular enlargement. Intracerebral hematomas also were identified by ultrasonography. Acute hematomas, such as subarachnoid blood clots persisting after clipping of an aneurysm, appeared as hyper-echoic images, whereas, late hematomas were depicted as hypo-echoic images. In one case, a recurrent brain tumor was depicted as a hyper-echoic mass. In multiple-trauma patients with head injury who were too unstable to be moved for CT scanning, ultrasound was extremely useful. So-called "delayed traumatic intracerebral hematoma" was identified in two cases subsequent to removal of an acute subdural hematoma. These results that serial ultrasonographic examination of the lateral ventricles through a craniectomy can supplement CT scanning in the evaluation of hydrocephalus and is also useful in evaluating cerebrovascular disease, brain tumors, infection, and head injury.

Diagnosis and management of delayed traumatic intracerebral haematomas.

In a retrospective study of 888 consecutive patients with traumatic intracranial haematomas, we identified 23 (2.6%) who had developed a delayed intracerebral haematoma after admission to hospital. The initial CT scan within 48 h of injury had been abnormal in all 23 cases; a haematoma had been evacuated in eight (35%) and intracranial pressure (ICP) had been monitored in 14 (61%). A delayed intracerebral haematoma had been diagnosed by repeat CT scan between 4 h and 10 days later, and nine of these had been evacuated on clinical grounds. Patients with persistently elevated ICP were rescanned more quickly than those who deteriorated clinically or failed to improve. Seven patients (30%) died, and the main cause of death was severe primary brain damage. Overall outcome was better in this series than in other reported series of delayed haematomas. We conclude that delayed haematomas occur only when the initial CT scan has been abnormal, and that clinically important ones are uncommon. ICP monitoring offers earlier diagnosis, but it remains to be established that this affects outcome.

Delayed Traumatic Intracerebral Hematoma (DTICH) and the Determination of the Manner of Death. A Case Report and Review of the Literature

The concept of a traumatic incident resulting in death when there has been a prolonged interval between the two events raises questions for medical examiners. A case is presented in which a 33-year-old man was found dead in his locked home. Although there was no evidence of foul play at the scene, the death was subsequently found to be directly related to an episode of head trauma sustained in an altercation approximately 1 1/2 months before. The fatal lesion was a large intraparenchymal hematoma in the right frontal lobe of the brain which had developed in an area of contusion identified by computerized tomography (CT) scan while he was hospitalized following the trauma. The literature regarding delayed traumatic intracerebral hematoma (DTICH) is reviewed and its relevance to cases coming under the jurisdiction of a medical examiner is discussed.

Endoscopic neurosurgery.

This paper describes an ultrasound-guided, laser-assisted, and TV-controlled endoscopic technique which has been used so far in 133 patients for a variety of intracranial lesions. Following CT or MRI image reconstruction, and a decision on the placement of a 1 cm or a 2 cm burrhole, a 1 cm 5.0 mHz or 7.5 mHz intraoperative ultrasound probe is used to direct the endoscope from the burrhole to the target area. A 22.5 cm long rigid endoscope tube with an outer diameter of 6 mm with an inbuilt suction irrigation system, Neodymium Yag laser with 600 micron Quartz glass-fibre and an inlet for various microinstruments is then introduced. The attachment of a TV camera to the ocular lens allows the operator to control further surgical steps in the target area via the TV screen and thus warrants sterility in the operating field. The technique has been used for evacuation of 77 spontaneous intracerebral haematomas (lobar, putaminal, thalamic), 8 traumatic intracerebral haematomas, 13 ventricular haematomas, 8 cerebellar haematomas and 1 brainstem haematoma. Total or subtotal evacuation was achieved in 33% of intracerebral haematomas, removal of more than 50% of the clot in 55%. Twenty-four brain tumours (12 ventricular, 12 cystic cerebral or cerebellar tumours) were operated on for biopsy, evacuation of cyst, resection or removal of the cyst wall and/or laser irradiation of solid tumour or the inner cyst wall of cystic tumours. The complication rate probably related to surgery was 1.6%, morbidity 1.6%, mortality 0%. This high-tec endoscopic technique with its minimal surgical trauma and short operation time can be recommended as a low-risk alternative to conventional neurosurgical techniques.

Characteristics of Traumatic Intracerebral Hematomas in Children

The authors retrospectively compared various features of traumatic intracerebral hematoma (TICH) in 15 children and 25 adults. The patients were divided into two groups according to the hematoma site, i.e., cortical/subcortical and central, and their clinical courses, neurological findings and, in particular, computed tomography (CT) scans were analyzed. Most of hematomas in the cortical/subcortical group developed as a result of cerebral contusion. The majority of children in this group were males and trauma was mainly incurred in traffic accidents. On the other hand, falls as well as traffic accidents were the primary causes of TICH in the adults. Most cortical/subcortical hematomas developed soon after head injury, although some evolved gradually in an area that had appeared isodense on the initial CT scan. Completion of this type of hematoma took longer in children than in adults. In pediatric patients, TICHs often were located in the occipital and parietal lobes, whereas most of the adult TICHs developed in the frontal and anterior temporal lobes. TICHs and their causative contusions were generally smaller in the pediatric population and less frequently required surgery, the operative rates being 22.2% among children and 85.7% among adults. In children, the outcome of cortical/subcortical TICH was favorable. Small hematomas in the corpus callosum, basal ganglia, and paraventricular region were included in the central hematoma group. These hematomas were believed to have developed through shearing strain. The incidence of central hematoma was significantly higher in children than in adults, and the adults in this group tended to be young. The outcome in children was somewhat better than that in adults.