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Cooper RJ, Akie TE, Gujral T, Rana S, Bui K, Factora R, Quinones A, Gupta M, Hendey GW, Rodriguez RM, Mower WR. Traumatic injury to the posterior fossa: a secondary analysis and description of case series from the NEXUS head injury dataset. LANCET REGIONAL HEALTH. AMERICAS 2024; 34:100760. [PMID: 38764982 PMCID: PMC11101874 DOI: 10.1016/j.lana.2024.100760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
Background Traumatic brain injuries involving the posterior fossa are rare and case reports indicate they often result in severe outcomes. We seek to describe characteristics and outcomes of traumatic posterior fossa injuries. Methods We performed a planned secondary analysis of all patients with posterior fossa injuries enrolled in the NEXUS head computed tomography (CT) validation study dataset. The dataset includes prospectively collected data on all patients undergoing non-contrast cranial CT following blunt traumatic head injury from April 2006 to December 2015, at four emergency departments comprising community and university sites, as well as urban, suburban and rural settings in California (Antelope Valley Hospital, San Francisco General Hospital, UCLA Ronald Reagan Medical Center, UCSF Fresno Community Regional Medical Center). We classified each patient into one of three injury patterns: Type I-notable traumatic injuries primarily above the tentorium, with minimal posterior fossa involvement; Type II-notable traumatic injuries both above and within the posterior fossa; and Type III-notable traumatic injuries primarily within the posterior fossa. We extracted demographic data for each patient as well as physician assessments of the NEXUS head CT and Canadian Head CT rule clinical criteria, mechanisms of injury, patient outcomes, and the location and types of intracranial injuries sustained. Findings Of 11,770 patients in the database, 184 (1.6%) had posterior fossa injuries on CT imaging. Mean age was 55.4 years (standard deviation 22.5 years, range 2-96 years); 131 (71.2%) were males. We identified 63 patients with Type I injuries, 87 with Type II injuries, and 34 Type III injuries. The most common mechanisms of injury were falls (41%), pedestrian vs automobile (15%), and motor vehicle collisions (13%). On presentation most patients had altered mental status (72%), abnormal behavior (53%), or a neurologic deficit (55%). The majority of individuals, 151 (82%), had clinically important injuries and 111 (60%) required neurosurgical intervention. The dispositions for the subjects included 52 deaths (28%), 49 (27%) patients discharged home, and 48 (26%) discharged to rehabilitation facilities. When compared to individuals with Type I and Type II injuries, patients with Type III injuries had lower mortality (6% vs 30% and 35%) and higher percentage of patients discharged home (60% vs 19% and 21%). Interpretation Patients with Type I and II injury patterns (those that involve both the posterior fossa and supratentorium) experienced high mortality and disability. Patients with Type III injuries (isolated posterior fossa) had a better prognosis. Funding None.
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Affiliation(s)
- Richelle J. Cooper
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Thomas E. Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Tarika Gujral
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shivam Rana
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kyle Bui
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ryan Factora
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexandra Quinones
- Department of Emergency Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - Malkeet Gupta
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- Antelope Valley Hospital, Lancaster, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gregory W. Hendey
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- UCSF-Fresno, Medical Education Program, Fresno, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert M. Rodriguez
- Department of Emergency Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - William R. Mower
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Shafique MA, Mustafa MS, Luke-Wold B, Kumar A, Rangwala BS, Abdullah M, Ali SMS, Iqbal J, Haseeb A. Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy. Acta Neurochir (Wien) 2024; 166:121. [PMID: 38436794 DOI: 10.1007/s00701-024-06013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. MATERIALS AND METHODS We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. RESULTS We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). CONCLUSION Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.
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Affiliation(s)
- Muhammad Ashir Shafique
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan.
| | - Muhammad Saqlain Mustafa
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Brandon Luke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Aashish Kumar
- Department of Neurosurgery, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75010, Pakistan
| | - Burhanuddin Sohail Rangwala
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Muhammad Abdullah
- Department of Neurosurgery, Rai Medical College, Lahore Road, Sargodha City, 40100, Punjab, Pakistan
| | - Syed Muhammad Sinaan Ali
- Department of Neurosurgery, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, 74800, Pakistan
| | - Javed Iqbal
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
| | - Abdul Haseeb
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
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Habibi MA, Kobets AJ, Boskabadi AR, Mousavi Nasab M, Sobhanian P, Saber Hamishegi F, Naseri Alavi SA. A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma. Neurosurg Rev 2024; 47:77. [PMID: 38336894 PMCID: PMC10858084 DOI: 10.1007/s10143-024-02292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/06/2024] [Accepted: 01/14/2024] [Indexed: 02/12/2024]
Abstract
There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.
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Affiliation(s)
- Mohammad Amin Habibi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran
| | - Andrew J Kobets
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | | | - Mehdi Mousavi Nasab
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooria Sobhanian
- Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Seyed Ahmad Naseri Alavi
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA.
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Lim JX, Liu SJ, Cheong TM, Saffari SE, Han JX, Chen MW. Closure intracranial pressure is an objective intraoperative determinant of the adequacy of surgical decompression in traumatic acute subdural haematoma: a multicentre observational study. Acta Neurochir (Wien) 2022; 164:2741-2750. [PMID: 35831725 DOI: 10.1007/s00701-022-05270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/06/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Acute subdural haematoma (ASDH) is associated with severe traumatic brain injury and poor outcomes. Although guidelines exist for the decompression of ASDH, the question of adequate decompression remains unanswered. The authors examined the relationship of intracranial pressure (ICP) on closure with outcomes to determine its utility in the determination of adequate ASDH decompression. METHODS A multicentre retrospective review of 105 consecutive patients with ASDH who underwent decompressive surgery was performed. Receiver operating characteristic (ROC) analysis with internal validation was performed to determine an ICP threshold for the division of patients into the inadequate and good ICP groups. Multivariable analyses were performed for both inpatient and long-term outcomes. RESULTS An ICP threshold of 10 mmHg was identified with a 91.5% specificity, 45.7% sensitivity, and a positive and negative predictive value of 80.8% and 68.4%. There were 26 patients (24.8%) and 79 patients (75.2%) in the inadequate and good ICP groups, respectively. After adjustment, the inadequate ICP group was associated with increased postoperative usage of mannitol (OR 14.2, p < 0.001) and barbiturates (OR 150, p = 0.001). Inadequate ICP was also associated with increased inpatient mortality (OR 24.9, p < 0.001), and a lower rate of favourable MRS at 1 year (OR 0.08, p = 0.008). The complication rate was similar amongst the groups. CONCLUSIONS Closure ICP is a novel, objective, and actionable intraoperative biomarker that correlates with inpatient and long-term outcomes in ASDH. Various surgical manoeuvres can be undertaken to achieve this target safely. Large-scale prospective studies should be performed to validate this ICP threshold.
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Affiliation(s)
- Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.
| | - Sherry Jiani Liu
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Tien Meng Cheong
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Julian Xinguang Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Min Wei Chen
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
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KIKUCHI J, ORITO K, SAKATA K, YAMAMOTO M, HASEGAWA Y, SHOJIMA T, TAYAMA E, MORIOKA M. Neurosurgical Treatment of Patients with Posterior Fossa Acute Subdural Hematoma Right after Cardiac Surgery. Neurol Med Chir (Tokyo) 2022; 62:238-245. [PMID: 35354713 PMCID: PMC9178110 DOI: 10.2176/jns-nmc.2021-0314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
As posterior fossa acute subdural hematoma (ASDH) right after cardiac surgery is extremely rare, the clinical course and optimal treatment strategy remain undetermined. We performed a retrospective analysis of patients with posterior fossa ASDH right after cardiac surgery requiring neurosurgical treatment at our institution over a 7-year period and, in this study, discussed the neurosurgical strategy and clinical course. Collected data included clinical history, laboratory results, time course, symptoms, neurosurgical treatment, outcome at discharge, and imaging studies. All six patients were women who had no history of head trauma and had received antithrombotic therapy during the perioperative period of cardiac surgery. All patients showed lower platelets count and were diagnosed with ASDH within 3 days (longest time 64 h) right after cardiac surgery. After discontinuation of anticoagulation therapy and administration of reversal agents, they underwent emergency hematoma evacuation craniotomy (n = 5) or burr hole drainage surgery (n = 1), which were performed in the prone (n = 4) or lateral (n = 2) positions. Four of these patients showed favorable outcomes, and two showed poor outcomes. One of the poor-outcome patients received three antithrombotic therapies, and another developed rapidly progressive ASDH. Posterior fossa ASDH associated with antithrombotic therapy right after cardiac surgery is frequently found in women, and emergent neurosurgical treatment with anticoagulation discontinuation and reversal agent administration can be performed safely. Burr hole drainage surgery might be acceptable in nonsevere cases. By contrast, we must pay attention to cases receiving both anticoagulant and antiplatelet drugs and rapid progression cases.
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Affiliation(s)
- Jin KIKUCHI
- Department of Neurosurgery, Kurume University School of Medicine
| | - Kimihiko ORITO
- Department of Neurosurgery, Kurume University School of Medicine
| | - Kiyohiko SAKATA
- Department of Neurosurgery, Kurume University School of Medicine
| | | | - Yu HASEGAWA
- Department of Neurosurgery, Kurume University School of Medicine
| | - Takahiro SHOJIMA
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine
| | - Eiki TAYAMA
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine
| | - Motohiro MORIOKA
- Department of Neurosurgery, Kurume University School of Medicine
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Acute traumatic posterior fossa subdural hematoma: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Shibahashi K, Sugiyama K, Okura Y, Hoda H, Hamabe Y. Traumatic Posterior Fossa Subdural Hemorrhage: A Multicenter, Retrospective Cohort Study. World Neurosurg 2018; 119:e513-e517. [PMID: 30075270 DOI: 10.1016/j.wneu.2018.07.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Traumatic posterior fossa subdural hemorrhage (SDH) is a rare subtype of subdural hemorrhage in head injuries. Existing data on its pathophysiology and outcome are currently limited; therefore, the condition is not yet fully understood. The present study aimed to determine the incidence, outcome, and prognostic factors for traumatic posterior fossa SDH. METHODS We performed a retrospective cohort study using the nationwide trauma registry Japan Trauma Data Bank. We identified adult patients (i.e., aged ≥18 years) who had posterior fossa SDH after blunt head trauma from 2004 to 2015. The primary endpoint was in-hospital mortality. We compared patients with and without posterior fossa SDH and adjusted for confounders using a multivariate logistic regression model. RESULTS A total of 75,838 patients had blunt head injuries. Of these, 266 (0.35%) had posterior fossa SDH, and 177 (median age, 69 years; interquartile range, 55-76) were eligible for analysis. The distribution of the Glasgow Coma Scale (GCS) score was bimodal, and the median score was 14 (interquartile range, 9-15). The mortality rate was 16.9% (95% confidence interval [CI], 11.7%-23.3%). A large posterior fossa SDH (>30 cm3; >1 cm thick), low GCS score on arrival, and the presence of a skull fracture were significantly associated with mortality, with an adjusted odds ratio of 4.51 (95% CI, 1.46-13.9), 0.82 (95% CI, 0.73-0.92), and 4.59 (95% CI, 1.52-13.9), respectively. CONCLUSIONS Traumatic posterior fossa SDH was extremely rare in our data set. Mortality correlated with the size of the SDH, GCS score on admission, and the presence of a skull fracture.
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Affiliation(s)
- Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yoshihiro Okura
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Phan K, Moore JM, Griessenauer C, Dmytriw AA, Scherman DB, Sheik-Ali S, Adeeb N, Ogilvy CS, Thomas A, Rosenfeld JV. Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: Systematic Review and Meta-Analysis. World Neurosurg 2017; 101:677-685.e2. [DOI: 10.1016/j.wneu.2017.03.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 01/01/2023]
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Al-Qazzaz MA, Jabor MAM. Medico-legal study of intracranial causes of death. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2014. [DOI: 10.1016/j.ejfs.2014.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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10
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de Amorim RLO, Stiver SI, Paiva WS, Bor-Seng-Shu E, Sterman-Neto H, de Andrade AF, Teixeira MJ. Treatment of traumatic acute posterior fossa subdural hematoma: report of four cases with systematic review and management algorithm. Acta Neurochir (Wien) 2014; 156:199-206. [PMID: 24009046 DOI: 10.1007/s00701-013-1850-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 08/17/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Traumatic posterior fossa subdural hematomas (SDHs) are rare lesions. Despite improvements in intensive care and surgical management of traumatic brain injuries over the last decades, the outcome for posterior fossa subdural hematomas remains poor. METHODS We conduct a retrospective study over a 2-year period of patients sustaining traumatic brain injury and posterior fossa SDH. Additionally, a systematic review of case series published to date was performed. RESULTS The incidence of posterior fossa SDH was 0,01% (4/326). All patients in this current series had poor prognosis. Three out of four exhibited ischemic/edema lesions in postoperative CT scans leading to fourth ventricle effacement and persistent brainstem compression. Our literature review retrieved 57 patients from only seven case series. Unfavorable outcomes were seen in 63% of patients. CONCLUSIONS Our data and data from the literature do not provide sufficient evidence to establish an optimal treatment strategy for posterior fossa SDH. However, based on lessons learned with these four cases, together with results from review of the literature, we propose an algorithm for the management of this rare condition.
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Takeuchi S, Wada K, Takasato Y, Masaoka H, Hayakawa T, Yatsushige H, Shigeta K, Momose T, Otani N, Nawashiro H, Shima K. Traumatic hematoma of the posterior fossa. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 118:135-8. [PMID: 23564119 DOI: 10.1007/978-3-7091-1434-6_24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Posterior fossa injury is rare, occurring in less than 3 % of head injuries. We retrospectively reviewed patients' clinical and radiological findings, management, and outcomes. The aim of the present study was to investigate the features of posterior fossa hematoma, including posterior fossa epidural hematoma (EDH), posterior fossa subdural hematoma (SDH), and intracerebellar hematoma. From January 1995 to January 2009, 4,315 patients with head trauma were hospitalized at our institution. The -present study focused on 41 patients (1.0 %) with traumatic hematomas of the posterior fossa. Eighteen patients had EDH, 10 patients had SDH, and 17 patients had intracerebellar hematomas. In each type of injury, occipital bone fractures were seen in many patients, and hematoma enlargement was often observed within a few days of the injury. In addition, a high frequency of associated lesions and a high poor outcome rate were features of intracerebellar hematomas and -posterior fossa SDH. The present study suggests that repeat CT imaging and careful management are necessary until the lesion is stabilized, and patients showing lesions with mass effects should therefore be immediately treated with surgery.
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Affiliation(s)
- Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan.
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Li LM, Kolias AG, Guilfoyle MR, Timofeev I, Corteen EA, Pickard JD, Menon DK, Kirkpatrick PJ, Hutchinson PJ. Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy. Acta Neurochir (Wien) 2012; 154:1555-61. [PMID: 22752713 DOI: 10.1007/s00701-012-1428-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/12/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute subdural haematomas (ASDH) occur commonly following traumatic brain injury and may be evacuated by either craniotomy (CR) or decompressive craniectomy (DC). We reviewed a series of consecutive patients undergoing evacuation of a traumatic ASDH at a regional centre, comparing observed clinical outcomes (assessed by Glasgow Outcome Scale at six months) with those predicted by the CRASH-CT prognostic model. METHODS Retrospective review of prospectively collected data. RESULTS Ninety-one patients were identified (51 DC and 40 CR ). Eighty-five had available admission data sets from which predicted outcome could be calculated. The DC group were younger than the CR group (p = 0.015). The DC group also had a greater proportion of patients whose pre-intubation GCS was ≤8 (p = 0.001), with significant extracranial injuries (p = 0.001) and obliterated basal cisterns (p = 0.001) on their pre-operative CT scan. Bone flaps in the DC group (n = 45) were longer (mean 11.6 cm; 95 % CI: 11.1-12.1) in comparison to bone flaps in the CR (n = 34) group [(mean 10.2 cm; 95 % CI: 9.35 - 10.9); p = 0.0024] The mean CRASH-CT predicted risk of 14-day mortality and of unfavourable outcome at six months was significantly higher in the DC group compared with the CR group. Eighty-eight patients had available 6-month Glasgow Outcome Scale scores. Favourable outcomes were observed in 42 % of DC versus 45 % of CR (p = 0.83). The overall mortality rate was 38 % in DC versus 32 % in CR (p = 0.65). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95 % CI: 0.51-1.07) for DC and 0.90 (95 % CI: 0.57-1.35) for CR. CONCLUSIONS CR and DC for traumatic ASDH are both commonly used for primary evacuation of ASDH. Primary DC may be more effective than CR for selected patients with ASDH. Class I evidence is required in order to refine the indications for DC following evacuation of ASDH.
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Affiliation(s)
- Lucia M Li
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
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Interdural haemorrhage of the posterior fossa due to infraclinoidal carotid artery aneurysm rupture. Acta Neurochir (Wien) 2010; 152:1543-6. [PMID: 20577887 DOI: 10.1007/s00701-010-0720-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
Abstract
Several anatomical studies indicate that the intracranial pachimeninges consist of two dural layers joined together, which divide while bordering the venous sinuses, therefore located in an interdural space. We present here an uncommon case of haematoma due to rupture of an infraclinoidal internal carotid artery aneurysm. The dome of the aneurysm leaned against the posterior wall of the cavernous sinus and, following laceration, pierced the inner dural layer and caused its detachment from the periosteal layer, thus determining a truly interdural haematoma which progressively involved the whole posterior fossa. A 42-year-old female was admitted to our institution with a recent history of thunderclap headache and right ophthalmoparesis. Two cerebral computerised scan tomographies performed elsewhere tested negative for subarachnoid haemorrhage. A cerebral magnetic resonance imaging (MRI) showed a thin collection of blood adjacent to the clivus and all along the wall of the posterior fossa and foramen magnum. A right infraclinoid internal carotid artery aneurysm was also diagnosed, subsequently better highlighted on angiography. The patient underwent surgery with aneurysm clipping. Post-operative course was uneventful, and control angiography showed complete exclusion of the aneurysm from blood circulation. The patient was discharged 5 days later. At 3 months follow-up ophthalmoplegia had disappeared, and the patient had fully recovered. The possibility of a truly interdural location, particularly in cases of non-traumatic parasellar or clival haematomas, must be included in the differential diagnosis of posterior fossa extra-axial haemorrhages. MRI is the test of choice for diagnostic purposes.
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Gulsen S, Sonmez E, Yilmaz C, Altinors N. Traumatic acute subdural hematoma extending from the posterior cranial fossa to the cerebellopontine angle. J Korean Neurosurg Soc 2009; 46:277-80. [PMID: 19844633 DOI: 10.3340/jkns.2009.46.3.277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Revised: 06/15/2009] [Accepted: 08/31/2009] [Indexed: 11/27/2022] Open
Abstract
Posterior cranial fossa subdural hematomas and extension of the subdural hematoma to the cerebellopontine angle is rarely seen and the concurrent development of acute peripheral facial palsy and the management strategy have not previously been reported in this pathology because of its rarity. We present this case to emphasize that minor head trauma may lead to a posterior cranial fossa hematoma extending to the cerebellopontine angle and cause peripheral facial palsy in patients using aspirin (acetylsalicylic acid). In addition, partial evacuation and waiting for the resorption of the hematoma may help to prevent damage to the 7th and 8th cranial nerves.
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Affiliation(s)
- Salih Gulsen
- Department of Neurosurgery, Baskent University, Ankara, Turkey
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Xu XY, Liu WG, Yang XF, Li LQ. Evaluation of models that predict short-term outcome after traumatic brain injury. Brain Inj 2009; 21:575-82. [PMID: 17577708 DOI: 10.1080/02699050701426881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE This study aimed to identify models that predicted the short-term outcome after traumatic brain injury (TBI) from the literature and to evaluate their clinical significance. METHODS Literatures from PubMED were reviewed. Regression coefficients and intercepts were extracted. A group of 229 cases was used for validation and the unfavourable rate was calculated to assess the validity of these models by the area under receiver operating. Characteristic curve (AUC), C-statistic and Brier score. MAIN RESULTS In total, 13 studies of 18 different models were included. Data from the validation group were in accordance with the indicators of the studies reviewed. All models got an AUC value ranging from 0.644-0.890 except two (AUC value <0.6) and their Brier scores were near zero. However, the calibration of most studies was insufficient (p < 0.05). CONCLUSIONS Most of the models included in this study have a good discriminatory power while lacking sufficient calibration. However, they all predict with relative accuracy at the level of individuals. Therefore, current models can be used to predict the survival rate of individual patients and may be useful to inform patients and relatives about the likelihood of a beneficial outcome.
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Affiliation(s)
- Xiao Yan Xu
- Department of Neurosurgery, Zhejiang University, Hangzhou, Zhejiang Province, PR China
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