Traumatic Subdural Hematoma Research Articles

Application of multi-channel differential optical density on fast detection of degree of traumatic dural hematoma

Due to the advantages of rapid and non-invasive detection of traumatic dural hematoma using near-infrared differential optical density method, this technology has become a hot research topic in tissue optics in recent years and has important applications in clinical emergency treatment. To further improve the detection accuracy of traumatic subdural hematoma degree, in this paper, a multi-channel differential optical density method was used to obtain the bilaterally-symmetric optical density data of brain. A calibration model with the optical absorption coefficient of the brain tissue and the differential optical density was established using the partial least squares method to predict intracranial epidural hematoma. Simulation results show that the average relative error of the absorption coefficient of dural hematoma using the prediction model was 11.16% and the average relative error on hematoma depth prediction was less than 1%. The model meets the demands of noninvasive traumatic subdural hematoma degree detection. By introducing multi-channel differential optical density method into the noninvasive detection of subdural hematoma, the effects of individual differences on the detection result could be eliminated significantly and the detection accuracy of traumatic subdural hematoma degree can be improved.

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

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

Concomitant Overlapping Acute Extradural and Subdural Hematoma

AbstractUsually following traumatic brain injury, extradural hematoma (EDH) and subdural hematoma (SDH) appear in opposite locations, with EDH being a coup injury and SDH being a contrecoup injury. We present a case of 24-year-old male patient who had concomitant overlapping acute EDH and SDH requiring neurosurgical intervention and discuss the clinical relevance of these coexisting lesions. Concomitant overlapping EDH and SDH are uncommon lesions and need close observation and planned follow-up imaging.

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

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

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

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

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

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

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

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

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

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

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

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

Decompressive Cranioplasty (Osteoplastic Hinged Craniectomy): A Novel Technique for Increased Intracranial Pressure—Initial Experience and Outcome

We redesigned decompressive craniectomy and cranioplasty procedures to decrease the inherent risk of complications. This novel technique, called decompressive cranioplasty, not only may decrease the complication rate but also may improve the cosmetic result, obviate the need for artificial skull implant, and increase the decompressive volume compared with traditional craniectomy. In decompressive cranioplasty, the Agnes Fast craniotomy was adopted without cutting the temporalis muscle from the underlying bone flap. After opening the dura with or without removal of intracranial hematomas, duraplasty was performed with an intracranial pressure monitor inserted. Four miniplates were bent into a "Z" shape, and the vascularized bone flap was elevated approximately 1.2-1.5 cm above the outer cortex of the skull and fixed with the miniplates. Subsequent cranioplasty was done with a mini-incision on the miniplate sites and reshaping of the miniplate to align the outer cortex of the bone flap. We successfully performed decompressive cranioplasty in 3 emergent cases-2 traumatic subdural hematomas and 1 malignant middle cerebral artery infarction. Postoperative brain computed tomography demonstrated adequate decompression in all cases. Cosmetic outcome was excellent, and there was no temporal hallowing. Mastication function was not affected. At 6-month follow-up, there was no bone flap shrinkage and no hydrocephalus. Decompressive cranioplasty is a safe and effective method in the management of patients with brain edema and intracranial hypertension. It is simple to perform and may reduce the morbidity associated with traditional decompressive craniectomy and subsequent cranioplasty.

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

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

Epidemiological investigation of 673 patients who resorted to the emergency department for mild head trauma complaints

Aim: Mild head trauma (MHT) or mild traumatic brain injury (MTBI) is an injury whose incidence is increasing in emergency services. This retrospective study carried out an epidemiological evaluation of patients with MHT, who underwent head computed tomography (HCT) with a 15-point score on the Glasgow Coma Scale (GCS).Material and Methods: This study retrospectively evaluated 673 patients with MHT, who were examined by the department of neurosurgery in the emergency department of Istinye University, Canakkale Anatolian Hospital between 2015 and 2019. The cases were evaluated because of age, gender, cause of trauma, HCT findings, duration of admission to the emergency department, and other body traumas associated with head trauma.Results: 390 (57.95%) patients were male, while 283 (42.05%) were female. The mean age and standard deviation were calculated as 23.72 ± 24.87 years. Of the 673 cases, 494 (73.40%) were admitted to the emergency department due to non-high falls. After trauma, 642 (95.39%) patients were admitted to the emergency department within the admitted to the emergency department within the first two hours after injury. 656 (97.48%) of the patients were treated in the emergency department. 105 (15.60%) patients had a scalp incision and underwent a small surgical procedure. The most common accompanying body trauma detected was that of the maxillofacial region in 26 (3.86%) patients. HCT pathology was detected in 20 (2.97%) patients. These pathologies included; 14 (2.08%) non-surgical intracerebral hemorrhage, 2 (0.30%) skull base fractures, 1 (0.15%) traumatic subdural hematoma, 1 (0.15%) traumatic epidural hematoma, 1 (0.15%) pneumocephalus and 1 (0.15%) cerebral edema.Conclusion: Head trauma is an important issue in this country. Brain CT may not be necessary in patients with a GCS score of 15. After a short observation, if patients live near the medical center, they can be sent home to return the next day for further evaluation.

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

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

Factors affecting the prognosis of traumatic acute subdural hematomas

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

Clinical Predictors of outcome in Isolated Traumatic Acute Subdural Hematoma

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

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

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

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

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

Decompressive Craniotomy and Fast-Track Duraplasty in Acute Subdural Hematomas

Background: Traumatic subdural hematoma is one of the severe injuries to brain with high mortality rates. Dural opening is often associated with brain herniation against the dural edges due to associated edema that would lead to venous infarction. Aim: The objective of this study is to describe a technical note that would allow fast and effective closure of the dura after hematoma evacuation via duraplasty with analysis of the safety and competency of the technique. Subjects and Methods: The fast-track technique was implemented in 15 successive cases with acute subdural hematoma where the fascia lata flap was prepared and sutured to the planned dural incision before opening the dura, which allowed fast and effective closure of the dura before brain herniation. Subdural bridges were planned by using Gelfoam to prevent venous compression. Analysis of the technique effectiveness was performed by the operative detection of brain herniation, as well as clinical and radiological follow-up of patients. Results: All patients had a Glasgow coma score (GCS) below six before the operation. Mean time from trauma to surgery was five hours. The dura could be effectively closed with no brain herniation in all cases. Nine patients survived (60%), where five of them ended up in a vegetative state. Of these two recovered and three continued in a persistent vegetative state. The mortality rate was 40%. Post-operative infarction was detected in post-operative imaging of four patients. Conclusion: The fast-track duraplasty technique is fast and effective in prevention of brain herniation during surgery with favorable clinical outcome in comparison with the poor and severely deteriorated preoperative clinical presentation. More studies to evaluate the impact of the technique on the survival rate are warranted.

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

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

The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome.

Objective:Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH.Materials and Methods:The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups.Results:The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome.Conclusions:The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.