Traumatic delayed epidural hematoma

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

Delayed progressive intracranial bleeding in pediatric acute epidural hemorrhage treated expectantly

INTRODUCTION AND IMPORTANCE

Progressive epidural hematoma (PEDH) after traumatic brain injury is usually found in the first 24 h after accident. However, EDH enlargement on day six after admission is rarely observed.

PRESENTATION OF CASE

We present the case of a 14-year-old boy who presented to the emergency room after a car accident with only a headache without any neurological deficit. The computed tomography (CT) scan revealed a slight epidural hematoma, which then treated expectantly. On day 6, the patient developed severe headache. CT-Scan showed enlarged epidural hematoma with significant mass effect. The emergency clot evacuation was completed successfully.

CLINICAL DISCUSSION

Progressive intracranial hemorrhage is any increase in pre-existing intracranial bleeding or the presence of a new hematoma on a CT scan. Young age and cranial fracture have been identified as risk factors for PEDH morbidity and mortality. Coagulation parameters may be a predictor of progressive intracranial bleeding, but their accuracy remains unclear. Still, the decision to conduct a CT scan as a follow-up is debatable, but it should be performed when neurological deterioration occurs.

CONCLUSION

Although rare, PEDH could still be occurred six days after trauma. Linear fracture and young age are among the risk factors. A thorough routine neurological examination is crucial in treating this condition.

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.

Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010–2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13–15), and median head Abbreviated Injury Scale score was 3 (2–4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay ( P = 0.02) and longer intensive care unit length of stay ( P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.

Risk factors for delayed neuro-surgical intervention in patients with acute mild traumatic brain injury and intracranial hemorrhage

Background

Mild traumatic brain injury (TBI) patients with initial traumatic intracranial hemorrhage (tICH) and without immediate neuro-surgical intervention require close monitoring of their neurologic status. Progressive hemorrhage and neurologic deterioration may need delayed neuro-surgical intervention. This study aimed to determine the potential risk factors of delayed neuro-surgical intervention in mild TBI patients with tICH on admission.

Methods

Three hundred and forty patients with mild TBI and tICH who did not need immediate neuro-surgical intervention on admission were evaluated retrospectively. Their demographic information, clinical evaluation, laboratory data, and brain CT was reviewed. Delayed neuro-surgical intervention was defined as failure of non-operative management after initial evaluation. Risk factors of delayed neuro-surgical intervention on admission were analyzed.

Results

Delayed neuro-surgical intervention in mild TBI with tICH on initial brain CT accounted for 3.8 % (13/340) of all episodes. Higher WBC concentration, higher initial ISS, epidural hemorrhage (EDH), higher volume of EDH, midline shift, and skull fracture were risk factors of delayed neuro-surgical intervention. The volume of EDH and skull fracture is independent risk factors. One cubic centimeter (cm3) increase in EDH on initial brain CT increased the risk of delayed neurosurgical intervention by 16 % (p = 0.011; OR: 1.190, 95 % CI:1.041–1.362).

Conclusions

Mild TBI patients with larger volume of EDH have higher risk of delayed neuro-surgical interventions after neurosurgeon assessment. Longer and closer neurological function monitor and repeated brain image is required for those patients had initial larger EDH. A large-scale, multi-centric trial with a bigger study population should be performed to validate the findings.

The Clinic of Neurosurgery at the Clinical Center of Serbia in Belgrade--building on the past

Neurosurgery as an independent discipline in Serbia has a distinguished history, beginning in 1938 when Dr. Milivoje Kostic, Professor and Chairman of Surgery, opened the Department of Neurosurgery within the Clinic of Surgery in Belgrade. Since then, thanks to the founding fathers' efforts and their successors' work, the Clinic for Neurosurgery in Belgrade has become a highly specialized health, scientific, and educational institution that is part of the University of Belgrade and is a referral center for all neurosurgical clinics in Serbia. Currently, the Clinic for Neurosurgery, with 160 patient beds, is one of the largest European institutions of its kind. Neurosurgery at the Clinical Center of Serbia (CCS) involves a wide range of patients and resources, with an average daily inpatient census of 15 to 20 patients. Each year, there are more than 3000 admissions at the neurosurgical service. Approximately 3500 operations per year are performed in the main campus neurosurgical operating rooms of CCS, while approximately 15,000 patients alone are evaluated in emergency room or inpatient consultations. Despite economic restraints, the department continues to grow in strength, and we remain optimistic of exciting times ahead for neurosurgery at the CCS.

Progressive epidural hematoma in patients with head trauma: incidence, outcome, and risk factors

Progressive epidural hematoma (PEDH) after head injury is often observed on serial computerized tomography (CT) scans. Recent advances in imaging modalities and treatment might affect its incidence and outcome. In this study, PEDH was observed in 9.2% of 412 head trauma patients in whom two CT scans were obtained within 24 hours of injury, and in a majority of cases, it developed within 3 days after injury. In multivariate logistic regression, patient gender, age, Glasgow Coma Scale (GCS) score at admission, and skull fracture were not associated with PEDH, whereas hypotension (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17-0.84), time interval of the first CT scanning (OR 0.42, 95% CI 0.19-0.83), coagulopathy (OR 0.36, 95% CI 0.15-0.85), or decompressive craniectomy (DC) (OR 0.46, 95% CI 0.21-0.97) was independently associated with an increased risk of PEDH. The 3-month postinjury outcome was similar in patients with PEDH and patients without PEDH (χ(2) = 0.07, P = 0.86). In conclusion, epidural hematoma has a greater tendency to progress early after injury, often in dramatic and rapid fashion. Recognition of this important treatable cause of secondary brain injury and the associated risk factors may help identify the group at risk and tailor management of patients with TBI.