Swirl sign in traumatic acute epidural hematoma: prognostic value and surgical management

Neurosurgical management of the acute phase of adult and pediatric traumatic brain injury

OBJECTIVE

To develop a multidisciplinary French framework addressing neurosurgical management in the initial phase of traumatic brain injury (TBI) in adults and children.

DESIGN

A panel of 29 experts was formed at the request of the French Society of Neurosurgery (SFNC), with the participation of the French Society of Pediatric Neurosurgery (SFNCP), French Society of Private-Practice Neurosurgeons (SFNCL), French-Speaking Neurocritical Care and Neuro-Anesthesiology Society (ANARLF), French Society of Anesthesia, Critical Care and Perioperative Medicine (SFAR), French-Speaking Pediatric Emergency and Intensive Care Group (GFRUP), French Society of Neuroradiology (SFNR), French-Speaking Infectious Diseases Society (SPILF), and the French Society of Physical Medicine and Rehabilitation (SOFMER).

METHODS

Questions were formulated using the PICO (Patients, Intervention, Comparison, Outcome) format, grouped into 7 categories: 1. Factors of poor prognosis, 2. Extradural hematoma, 3. Acute subdural hematoma, 4. Skull-base fracture and dural tear, 5. Penetrating traumatic brain injury, 6. Post-traumatic cerebrospinal fluid disorder, and 7. Pediatric specificities.

RESULTS

Synthesis by the experts and application of the GRADE® method resulted in the formulation of 45 recommendations. Strong consensus was reached for all recommendations at the first round of rating, CONCLUSION: There was a strong consensus among the experts on important interdisciplinary recommendations to improve the neurosurgical management of patients with TBI.

Predicting Epidural Hematoma Expansion in Traumatic Brain Injury: A Machine Learning Approach

IntroductionTraumatic brain injury (TBI) is a leading cause of disability and mortality worldwide, with epidural hematoma (EDH) being a severe consequence. This study focuses on identifying factors predicting EDH volume changes in TBI patients and developing a machine learning (ML) model to predict EDH expansion.MethodsThe study includes patients with traumatic EDH between 2019 and 2021. Data were gathered from CT scans performed at the time of admission and 6 hours later, and subsequently analyzed. The data was divided into three cohorts: all cases, adults, and pediatrics. To predict EDH volume changes, we used Logistic Regression (LR), Random Forest (RF), XGBoost, and K-Nearest Neighbors (KNN) models. Data was divided into an 80% training set and a 20% test set. Through a rigorous process of parameter optimization and K-fold cross-validation, focusing on the area under the receiving operating curve (AUROC), we identified the best models in all cohorts. The best models were evaluated on the test sets, reporting AUROC, recall, precision, and accuracy using the youden index threshold.ResultsResults show that age, initial EDH volume, swirl sign, intra-hematoma air bleb, contusion, otorrhagia, subarachnoid hemorrhage, location, and other side extra-axial hematoma have significant effects on changing EDH volume. Based on test AUROC, the best models were RF for adults (82.4%), KNN for pediatrics (90%), and LR for all cases (81.6%).DiscussionIn this study, we identified key features for predicting EDH expansion as well as developing ML models. Using high sensitive models, can assist clinicians in identifying high-risk patients early. This allows for enhanced monitoring and timely intervention, improving patient outcomes by facilitating quicker decisions for follow-up imaging or treatment.

Computer tomography-based radiomics combined with machine learning for predicting the time since onset of epidural hematoma

Estimation of the age of epidural hematoma (EDH) is a challenge in clinical forensic medicine, and this issue has yet to be conclusively resolved. The advantages of objectivity and non-invasiveness make computing tomography (CT) imaging an potential diagnostic method for EDH in living individuals. Recently, radiomics, the extraction hidden information from medical images, has emerged as a promising method for constructing predictive models. The aim of this study is to explore the feasibility and applicability of CT-based radiomics in predicting the timing of EDH injuries in surviving victims. A cohort of 95 EDH cases with definite injured time (within 12 h since injury) was selected. Clinical characteristics (age, gender, injury time, bleeding location, bleeding volume, and fracture) were recorded. The datasets were divided randomly into training and test cohorts. LIFEx software was used to segment the hematoma area in the CT and extract radiomic features. Machine learning algorithms were applied for features selection and model building. Twenty-three features were selected to calculate the Radscore, a key metric in our analysis. Utilizing this Radscore in conjunction with the time since injury, we constructed an Ordinary Least Squared (OLS) model. Our validation study has shown that mean absolute error (MAE) of the test cohort was 2.42 h, indicating a high degree of accuracy. In order to enhance the accuracy of prediction, the dataset was divided into unstable phase, occurring within the first 5 h post injury, and the stable phases. The Random Forest algorithm presented a significant divergence in predictive performance between the two phases, achieving an area under the curve (AUC) of 0.79, with an accuracy of 75.86%. The MAE of the regression model was 1.05 h for the unstable phase, and 1.23 h for the stable phase. Our findings underscore the potential of CT-based radiomics to offer a novel, convenient, and efficient approach to dating EDH, promising to illuminate new avenues in the field of medical diagnostics.

Prognostic value of computed tomography and magnetic resonance imaging findings in acute traumatic brain injury in prediction of poor neurological outcome and mortality: a systematic review and meta-analysis

Traumatic brain injury (TBI) is a major cause of morbidity and mortality, impacting healthcare systems and economies. Early identification of poor outcomes is crucial for effective treatment. This systematic review assesses the prognostic value of computed tomography (CT) and magnetic resonance imaging (MRI) findings in predicting poor neurological outcomes and mortality in the acute phase of TBI. A comprehensive search of Scopus, MEDLINE, and Web of science databases was performed to identify studies examining CT and MR-based imaging findings and their association with poor outcomes as assessed by Glasgow outcome score as well as mortality within the early acute phase of TBI following injury/admission. Qualitative evaluation of included studies revealed several imaging sequences that modify the outcome of the patients, including extra-axial and intra-axial hemorrhage, swirl sign, contrast extravasation, midline shift, closed and open cranial cisterns, signs of edema, presence of cranial fractures, intracranial hemorrhage, cerebral microbleeds, diffuse axonal injury, apparent diffusion coefficient and fractional anisotropy in diffusion tensor imaging, as well as, concentrations of brain metabolites(N-acetyl aspartate, Creatinine, Choline, Myo-inositol, glutamate, and glutamine) in magnetic resonance spectroscopy. Among these markers, subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) emerged as the most predictive of poor outcomes based on meta-analysis findings. SAH was significantly associated with an increased risk of mortality (OR: 3.35, 95% CI: 2.41-4.65, I²=51.3%) and poor outcomes (OR: 2.69, 95% CI: 2.44-2.96, I²=0%). Similarly, SDH correlated with higher mortality risk (OR: 2.44, 95% CI: 2.14-2.78, I²=0%) and worse outcomes (OR: 2.00, 95% CI: 1.12-3.59, I²=60.9%). In contrast, epidural hematoma (EDH) was linked to better outcomes (OR: 0.60, 95% CI: 0.52-0.68, I²=0%) but not significantly associated with mortality (OR: 0.38, 95% CI: 0.09-1.65, I²=73.7%). The results of this systematic review and meta-analysis provide an overview of clinically feasible imaging markers of prognostic value and may inform clinical decision-making in the future.

I saw the swirl sign: Acute extravasation of blood within a hematoma

The swirl sign is a finding on non-contrast computed tomography (CT) scans that represents an acute extravasation of blood into a hematoma filled with clotted blood. In it, a "swirl" of active bleeding within a body of acutely clotted blood is noted as a hypodense accumulation within a hyperdense fluid collection. Here, we describe a case in which a 35-year-old female presents unresponsive with a Glasgow Coma Scale score of 3 and is ultimately found to have a large frontal intraparenchymal hematoma with intraventricular extension and an area of low attenuation within the hyperattenuating fluid collection on CT, otherwise known as the swirl sign. This radiographic sign has been associated with hematoma expansion, worse clinical outcomes as measured by the Glasgow Outcome Scale, and higher mortality rates. As such, all patients suspected to have intracranial bleeds should have CT imaging done as soon as possible. When the swirl sign is identified on CT, providers are clued in to the risk of clinical deterioration and the urgent need for surgical evaluation.

Predictive Factors for Regression versus Progression of Nonevacuated Posttraumatic Acute Extradural Hematoma

Study Design  This study was a retrospective study conducted from October 2020 to October 2022 on 106 posttraumatic patients with acute extradural hematomas (EDHs) who were initially planned for conservative treatment. 74 patients had spontaneous EDH regression (EDHR), while 32 patients developed EDH progression (EDHP) and were shifted for surgery. The two groups were statistically compared regarding the different demographic, clinical, and radiographic factors to identify the significant predictors for regression versus progression of acute posttraumatic EDH. Objectives  Conventionally, urgent evacuation is the accepted management for EDH. However, several recent reports have described successful conservative management in selected patients. There are no adequate clues to verify patients who will have spontaneous EDHR from those at risk for EDHP and delayed surgery. The main objective of this study was to identify the significant predictors for possible regression versus progression of acute posttraumatic EDH initially planned for nonsurgical treatment. Materials and Methods  A retrospective study conducted over 2 years, included 106 head trauma patients with acute EDH, who were admitted to our department and were initially planned for conservative treatment. Various demographic, clinical, and radiographic factors were analyzed to verify the significant predictors for spontaneous EDHR (EDHR group) versus EDHP and subsequent surgical evacuation (EDHP group). Results  The mean age was 20.37 ± 12.712 years and the mean Glasgow Coma Scale score (GCS) was 12.83 ± 2.113. Total 69.8% of patients showed spontaneous EDHR, while 30.2% developed EDHP and were shifted for surgical evacuation. Statistical comparison showed that higher GCS ( p  = 0.002), frontal location ( p  = 0.022), and concomitant fissure fracture ( p  =  0.014) were the significant predictors for EDHR, while younger age ( p  = 0.006), persistent nausea/vomiting ( p  = 0.046), early computed tomography (CT) after trauma ( p  = 0.021), temporal location ( p  < 0.001), and coagulopathy ( p  = 0.001) were significantly associated with EDHP. Conclusion  Patients with traumatic EDH fitting the criteria of initial nonsurgical treatment necessitates 48 hours of close observation and serial CT scans at 6, 12, 24, and 48 hours to confirm the regression or early detect the EDHP. Patients with high GCS, frontal hematomas, and associated fissure fracture are at low risk for EDHP. Increased alertness is mandatory for young age and patients with persistent nausea/vomiting, early CT scan, temporal hematomas, or coagulopathy.

Swirl sign score system: a novel and practical tool for predicting hematoma expansion risk after spontaneous intracerebral haemorrhage

OBJECTIVE

To methodically analyse the swirl sign and construct a scoring system to predict the risk of hematoma expansion (HE) after spontaneous intracerebral haemorrhage (sICH).

METHODS

We analysed 231 of 683 sICH patients with swirl signs on baseline noncontrast CT (NCCT) images. The characteristics of the swirl sign were analysed, including the number, maximum diameter, shape, boundary, minimum CT value of the swirl sign, and the minimum distance from the swirl sign to the edge of the hematoma. In the development cohort, univariate and multivariate analyses were used to identify independent predictors of HE, and logistic regression analysis was used to construct the swirl sign score system. The swirl sign score system was verified in the validation cohort.

RESULTS

The number and the minimum CT value of the swirl sign were independent predictors of HE. The swirl sign score system was constructed (2 points for the number of swirl signs >1 and 1 point for the minimum CT value ≤41 Hounsfield units). The area under the curve of the swirl sign score system in predicting HE was 0.773 and 0.770 in the development and validation groups, respectively.

CONCLUSIONS

The swirl sign score system is an easy-to-use radiological grading scale that requires only baseline NCCT images to effectively identify subjects at high risk of HE.

ADVANCES IN KNOWLEDGE

Our newly developed semiquantitative swirl sign score system greatly improves the ability of swirl sign to predict HE.

The importance of additional intracranial injuries in epidural hematomas: detailed clinical analysis, long-term outcome, and literature review in surgically managed epidural hematomas

Objective

Epidural hematomas (EDH) occur in up to 8.2% of all traumatic brain injury patients, with more than half needing surgical treatment. In most patients suffering from this perilous disease, good recovery with an excellent clinical course is possible. However, the clinical course is mainly dependent on the presence of additional intracerebral injuries. Few studies comparing isolated and combined EDH in detail exist.

Methods

We performed a retrospective single-center study from April 2002 to December 2014. The mean follow-up time was more than 6 years. In addition to analyzing diverse clinicoradiological data, we performed a systematic literature review dealing with a detailed comparison of patients with (combined) and without (isolated) additional intracerebral injuries.

Results

We included 72 patients in the study. With increasing age, combined EDH had a higher incidence than isolated EDH. The mortality rate of the patients in the cohort was 10%, of which 0% had isolated EDH and 10% had combined EDH. Good recovery was achieved in 69% of patients, of which 91% had isolated EDH and 50% had combined EDH. A subgroup analysis of the different additional intracerebral injuries in combined EDH demonstrated no significant difference in outcome. A systematic literature review only identified six studies. Patients with isolated EDH had a statistically significantly lower mortality risk [relative risk (RR): 0.22; 95% CI: 0.12-0.39] and a statistically significantly lower risk of unfavorable Glasgow outcome scale score (RR: 0.21; 95% CI: 0.14-0.31) than patients with combined EDH.

Conclusions

An excellent outcome in patients with surgically treated isolated EDH is possible. Furthermore, patients with combined EDH or isolated EDH with a low Glasgow coma scale (GCS) score may have favorable outcomes in 50% of the cases. Therefore, every possible effort for treatment should be made for this potentially lethal injury.

A brief review of dural venous sinus injury with a short case series

Background

Dural venous sinus injury results in torrential hemorrhage and exsanguination. The initial review by Harvey Cushing had shown high mortality. The depressed fractures over sinuses were managed conservatively, because of the risk of massive hemorrhage during elevation. The consequences of sinus injury are hemorrhage, intracranial hypertension, brain swelling and venous infarct. Topical hemostatic agents such as gelatin sponge, oxidized cellulose, hemostatic matrix, bioresorbable plate, tissue-glue-coated collagen sponge, and fibrin glue help in controlling bleeding during surgery. The aim of the study is to analyze five cases of traumatic dural venous sinus injury. The literature review was done from Pubmed, Scopus and Google Scholar. A retrospective and descriptive analysis is done.

Case presentation

Among the five cases described, four had injury to superior sagittal sinus and one had injury to the transverse sinus. Two patients had open wounds. Three patients had continuous bleeding and two had intracranial hypertension. Decompressive craniectomy was done in three patients, wound hemostasis and closure in one, and craniotomy and evacuation of hematoma in one. Compression with Gelfoam was the main method for hemostasis and thrombin–gelatin hemostatic matrix had to be applied in two patients, with continued pressure for one hour.

Conclusions

Injury to the dural venous sinus should be suspected in fracture over the venous sinus. Surgery is indicated in active bleeding, expanding hematoma, compression or occlusion of the sinus and intracranial hypertension. Topical hemostatic agents help in controlling the bleed. Morbidity and mortality are more with involvement of middle and posterior third of superior sagittal sinus.

Prognostic Value of Swirl Sign in Acute Epidural Hemorrhage

Objective  The purpose of this study is to analyze and evaluate the incidence, prognostic value, and impact of swirl sign on the outcome of patients who underwent surgical treatment for epidural hematoma. Materials and Methods  A retrospective analytical study on 307 acute epidural hematoma (AEDH) patients with and without swirl sign was conducted at our hospital between 2015 and 2019. All the patients in this study were treated initially as per the protocols of advanced trauma life support and surgically treated by craniotomy and evacuation of epidural hematoma. Patients with other concomitant intracerebral injuries such as subdural hematoma and contusion and those who were managed conservatively were excluded from the study. Various factors such as age, sex, mechanism of injury, Glasgow Coma Scale (GCS) score at admission, time from injury to surgery, preoperative mydriasis, location of bleed, midline shift, location of fracture, volume of hematoma, duration of stay in the hospital, and GCS score at discharge were taken into consideration and compared in between patients with and without swirl sign. Outcomes were assessed at the end of 6 months using the Glasgow Outcome Scale. Results  Of the 307 patients who were operated for epidural hemorrhage, 92 had swirl sign (29.96%) and the rest had no swirl sign. Univariate analysis revealed a significant correlation between the presence of swirl sign and age, preoperative mydriasis, and time from injury to surgery. The patients with the swirl sign had an unfavorable outcome at the end of 6 months which was statistically significant. Conclusion  It can be concluded that those patients with swirl sign in AEDH had an unfavorable outcome compared to those without swirl sign. Therefore, aggressive treatment and early surgery play an important role in the outcomes of the patients.

The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis

OBJECTIVE

Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits.

METHODS

A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs).

RESULTS

Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality.

CONCLUSION

With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.

A prognostic scoring system for operated acute epidural hematoma based on gray-white matter ratio

ABSTRACT

To determine the prognostic risk factors of patients with acute epidural hematoma (AEDH), a scoring system was established based on gray-white matter ratio (GWR) and internal verification was performed.All patients with AEDH who underwent surgical treatment in Qinghai Provincial People's Hospital from January 2013 to June 2019 were continuously collected. The clinical and imaging data of the patients were collected. According to Glasgow Outcome Scale at 3 months after operation, the patients were divided into poor and good prognosis groups, respectively. The GWR value of the nonhematoma side was measured at the inner capsule area. Univariate and multivariate analyses were used. Independent predictors significantly related to the prognosis of AEDH were screened out and a nomogram was established based on these factors.A total of 170 cases were included in this study, the Glasgow Coma Score (severe and moderate), cerebral hernia, midline shift, preoperative GWR, postoperative GWR, hematoma thickness/midline shift, time from coma to surgery, and decompression of bone flap were the independent risk factors for predicting the poor prognosis of AEDH. Moreover, the prediction ability of nomogram was higher than any other independent predictive factors.The nomogram model established represents the most effective factor to predict the prognosis of operated AEDH. The scoring system is characterized by high accuracy, simplicity and feasibility, with a wide range of clinical application prospects.

The 'swirl sign' as a marker for haematoma expansion and outcome in intra-cranial haemorrhage: A meta-analysis

The 'swirl sign' is a CT imaging finding associated with haematoma expansion and poor prognosis. We performed a systematic review and meta-analysis to determine its prognostic value. PubMed/MEDLINE and EMBASE were searched until 16/12/2020 for related articles. Articles detailing the relationship between the swirl sign and any of haematoma expansion (HE), neurological outcome in the form of Glasgow Outcome Score (GOS) or mortality were included. A meta-analysis was performed and the pooled sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated for each of HE, GOS and mortality. 15 papers were assessed. Nine papers related to HE, for which the pooled sensitivity was 50% (95% CI 30-71), specificity was 77% (95%CI 67-85) and PLR was 2.16 (95%CI 1.89-2.42). There was significant heterogeneity (I² = 70%, Q = 26.9). Three papers related to GOS, for which the pooled sensitivity was 45% (95%CI 20-74), specificity was 78.3% (95%CI 40-95.2) and PLR was 1.77 (95%CI 1.04-2.62). Three papers related to mortality, for which the pooled sensitivity was 65% (95% CI 32-88), specificity was 75% (95%CI 42-92) and pooled PLR was 2.64 (95%CI 1.60-4.13). Our findings indicated that the swirl sign is a useful prognostic marker in the radiological evaluation of intracranial haemorrhage. However, more research is needed to assess its independence from other risk factors for haematoma expansion.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Surgical resection of a large posttraumatic middle meningeal artery pseudoaneurysm with associated epidural hematoma

Background:

Middle meningeal artery (MMA) pseudoaneurysms are rare but can occur secondary to trauma with an associated skull fracture and can present with a variety of hemorrhage patterns. Epidural, subdural, subarachnoid, and intraparenchymal hematomas have all been reported. Given the wide range of clinical presentations and radiographic findings, multiple treatment strategies have been employed, including surgical removal, endovascular intervention, and conservative treatment. MMA pseudoaneurysms typically range from 2 to 5 mm in size and have been shown to have unpredictable growth patterns.

Case Description:

A 54-year-old male identifying as a Jehovah’s Witness presented after a fall and was found to have an epidural hematoma with an accompanying temporal bone fracture. Imaging demonstrated a traumatic pseudoaneurysm of the MMA. Given the patient’s religious preferences, the emphasis was made during surgical planning for the minimization of blood loss. The epidural hematoma was evacuated, and the MMA pseudoaneurysm was directly visualized and surgically excised after ligation of its tributaries. The patient tolerated the procedure well without significant blood loss and made a complete neurological recovery.

Conclusion:

A well-circumscribed hypodensity on CT within a surrounding hyperintense collection should raise suspicion of MMA pseudoaneurysm in the setting of overlying temporal bone fracture as supported by previous imaging findings of large MMA pseudoaneurysms. The early detection of MMA pseudoaneurysm is imperative, as the presence may dictate more urgent intervention and changes in operative technique. Although not much is known about the nature and progression of these lesions, surgical excision has remained a safe, reliable method of treatment.

Risk Factors and Prognostic Value of Swirl Sign in Traumatic Acute Epidural Hematoma

Objective: Acute epidural hematoma (AEDH) is one of the deadliest lesions in patients after traumatic brain injury. AEDH with swirl sign progresses rapidly and requires timely surgical treatment. This study aims to investigate the risk factors for the occurrence of AEDH with swirl sign and its prognostic value.

Methods: Retrospective analysis was performed on 131 AEDH patients, who were divided into swirl sign group and non-swirl sign group based on the brain computed tomographic (CT) scan. Patient information, including gender, age, hypertension, mechanism of injury, Glasgow Coma Scale (GCS) score on admission, time from injury to CT scan, pupillary light reactivity on admission, midline shift, location of hematoma, hematoma volume on admission, oral anticoagulation, and Glasgow Outcome Scale (GOS) score at 3 months were collected. Univariate analysis was used to determine the risk factors for the occurrence of swirl sign. The factors with P < 0.05 were recruited into the multivariate logistic regression analysis and predictive receiver operating characteristic (ROC) curve model.

Results: Univariate analysis demonstrated that the GCS score on admission (P = 0.007), pupillary light reactivity (P = 0.003), location of hematoma (P < 0.0001), and GOS score at 3 months (P = 0.007) were risk factors for the occurrence of swirl sign. Multivariate logistic regression model revealed that the location of hematoma (OR = 0.121; 95% CI: 0.019–0.786; P = 0.027) was an independent risk factor for swirl sign, and the occurrence of swirl sign was a significant predictor of unfavorable neurological outcomes (OR = 0.100; 95% CI: 0.016–0.630; P = 0.014). ROC curves demonstrated that the GCS score on admission (AUC = 0.655; 95% CI: 0.506–0.804), pupillary light reactivity (AUC = 0.625; 95% CI: 0.474–0.777) and location of hematoma (AUC = 0.788; 95% CI: 0.682–0.893) can predict the occurrence of swirl sign, respectively. Remarkably, the combination of these three factors (AUC = 0.829; 95% CI: 0.753–0.906) provided a greater power to predict the swirl sign.

Conclusion: GCS score on admission, pupillary light reactivity, and location of hematoma are risk factors for the occurrence of swirl sign, respectively. The combination of these three factors might be used to predict whether there is swirl sign in AEDH after traumatic brain injury. Furthermore, swirl sign can be used as an effective predictor of poor prognosis in patients.

Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review

PURPOSE OF REVIEW

The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers.

RECENT FINDINGS

To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.

Application of Absolute Alcohol in the Treatment of Traumatic Intracranial Hemorrhage via Interventional Embolization of Middle Meningeal Artery

Background: Traumatic brain injury is a common condition in neurosurgery. Traditional methods of treatment include conservative treatment and surgical evacuation using burr-holes or craniotomy; however, studies have reported problems such as high re-expansion rates after conservative treatment of epidural hematoma and high postoperative recurrence rates of subdural hematoma. Solutions to these problems are lacking, and research into new treatment methods is ongoing. Among the potential new treatments, middle meningeal arterial embolization is an option. This study involved patients with acute epidural hematoma and chronic subdural hematoma. The purpose was to evaluate the use and effects of absolute alcohol to embolize the middle meningeal artery to treat intracranial hematoma. Material and Methods: A retrospective description study was 12 cases of intracranial hematoma who treated with absolute alcohol interventional therapy from our hospital between June 2018 and October 2019. Five patients with acute epidural hematoma and seven patients with chronic subdural hematoma were treated using absolute alcohol to embolize the middle meningeal artery. Patients' clinical data, imaging results, surgical results, and prognosis were recorded and analyzed. Results: All patients underwent absolute alcohol embolization of the middle meningeal artery, in combination with burr-hole drainage. All imaging data were confirmed preoperatively. We successfully used absolute alcohol to embolize the middle meningeal artery intraoperatively and confirmed these results by postoperative angiography. All patients achieved symptomatic relief without complications, and no recurrence or re-expansion was seen with follow-up computed tomography. Our study has been registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn, ChiCTR1800018714). Conclusion: The use of absolute alcohol to embolize the middle meningeal artery could be used as an attempt to treat acute epidural hematoma and chronic subdural hematoma.

"Swirl Sign" in Extradural Hematoma

"Swirl sign" is a relatively uncommon sign, seen on noncontrast CT scan in patients of head trauma who develop extradural hematoma. It has 2 components: hyperacute, which represents ongoing active intracranial bleed, and acute, which comprises surrounding hyperattenuated clotted blood. The importance of early identification of this sign by surgeons and aggressive surgical management might have a bearing on the prognosis and survival of the patients, as emphasized here by 2 clinical scenarios. The clinical implication is that identification of the swirl sign suggests expanding extradural hematoma with ongoing active bleed, warranting aggressive surgical management.