A simple tool to identify elderly patients with a surgically important acute subdural haematoma

Swift Spontaneous Regression of a Pediatric Traumatic Acute Subdural Hematoma

We report the case of a 4-year-old girl with acute subdural hematoma who presented to the emergency department after an unwitnessed fall of the balcony. The hematoma was hyperdense along the left convexity of 9 mm thickness with a consequent mass effect with obliteration of the adjacent sulci, left lateral ventricle compression and a midline shift of 7 mm. During her stay in the emergency department while waiting for transfer to the children intensive care unit elsewhere she slightly deteriorated neurologically. Repeat CT scan of the brain 4 h after initial presentation remarkably showed that the subdural hematoma had now largely disappeared, with a decrease in volume and density. Consequently, the mass effect diminished with a near normalization of the midline shift.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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 or 5.

CONCLUSIONS

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.

Detection and volume estimation of artificial hematomas in the subcutaneous fatty tissue: comparison of different MR sequences at 3.0 T

In legal medicine, reliable localization and analysis of hematomas in subcutaneous fatty tissue is required for forensic reconstruction. Due to the absence of ionizing radiation, magnetic resonance imaging (MRI) is particularly suited to examining living persons with forensically relevant injuries. However, there is limited experience regarding MRI signal properties of hemorrhage in soft tissue. The aim of this study was to evaluate MR sequences with respect to their ability to show high contrast between hematomas and subcutaneous fatty tissue as well as to reliably determine the volume of artificial hematomas. Porcine tissue models were prepared by injecting blood into the subcutaneous fatty tissue to create artificial hematomas. MR images were acquired at 3T and four blinded observers conducted manual segmentation of the hematomas. To assess segmentability, the agreement of measured volume with the known volume of injected blood was statistically analyzed. A physically motivated normalization taking into account partial volume effect was applied to the data to ensure comparable results among differently sized hematomas. The inversion recovery sequence exhibited the best segmentability rate, whereas the T1T2w turbo spin echo sequence showed the most accurate results regarding volume estimation. Both sequences led to reproducible volume estimations. This study demonstrates that MRI is a promising forensic tool to assess and visualize even very small amounts of blood in soft tissue. The presented results enable the improvement of protocols for detection and volume determination of hemorrhage in forensically relevant cases and also provide fundamental knowledge for future in-vivo examinations.

Aggressive operative treatment of isolated blunt traumatic brain injury in the elderly is associated with favourable outcome

Outcome after traumatic brain injury (TBI) in the elderly has not been fully elucidated. The present retrospective observational study investigates the age-dependent outcome of patients suffering from severe isolated TBI with regard to operative and non-operative treatment. Data were prospectively collected in the TraumaRegister DGU. Anonymous datasets of 8629 patients with isolated severe blunt TBI (AISHead≥3, AISBody≤1) documented from 2002 to 2011 were analysed. Patients were grouped according to age: 1-17, 18-59, 60-69, 70-79 and ≥80 years. Cranial fractures (44.8%) and subdural haematomas (42.6%) were the most common TBIs. Independent from the type of TBI the group of patients with operative treatment declined with rising age. Subgroup analysis of patients with critical TBI (AISHead=5) revealed standardised mortality ratios (SMRs) of 0.81 (95% CI 0.75-0.87) in case of operative treatment (n=1201) and 1.13 (95% CI 1.09-1.18) in case of non-operative treatment (n=1096). All age groups ≥60 years showed significantly reduced SMRs in case of operative treatment. Across all age groups the group of patients with low/moderate disability according to the GOS (4 or 5 points) was higher in case of operative treatment. Results of this retrospective observational study have to be interpreted cautiously. However, good outcome after TBI with severe space-occupying haemorrhage is more frequent in patients with operative treatment across all age groups. Age alone should not be the reason for limited care or denial of operative intervention.