Traumatic intracerebellar hemorrhage: clinicoradiological analysis of 81 patients

Traumatic injury to the posterior fossa: a secondary analysis and description of case series from the NEXUS head injury dataset

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.

Traumatic Cerebellar Hematoma: A Tertiary Care Experience of 23 Conservatively Managed Cases

Context:

Traumatic cerebellar hematomas are rare in comparison to nontraumatic cerebellar hematomas.

Aims:

The aim of this study is to evaluate the prognostic factors and outcome determining factors with regard to conservatively managed isolated traumatic cerebellar hematoma.

Settings and Design:

Retrospective cohort study.

Materials and Methods:

A retrospective study of 23 patients of conservatively managed isolated posterior fossa hematoma, admitted between August 2018 and May 2020, was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi. Each of the patients was evaluated in terms of age, sex, mode of injury, clinical presentation, comorbidity, the severity of injury, best motor response, Glasgow Coma Scale (GCS) at admission, computed tomography findings, and Glasgow Outcome Scale at discharge/death.

Statistical Analysis:

Chi-square test and unpaired t-test were used. P < 0.05 was deemed statistically significant.

Results:

Mean volume of posterior fossa contusion was 8.9 ml. The cerebellar hemispheric (60.9%) location of hematoma was more common. Age at presentation (P = 0.0086), best motor response (P < 0.0001), severity of injury (P = 0.0002), GCS at admission (P < 0.0001), effacement of basal cistern (P < 0.0001), fourth ventricular compression and intraventricular hemorrhage (P = 0.0008), presence of hydrocephalus (P = 0.0142), subarachnoid hemorrhage (P = 0.0008), and volume of posterior fossa contusion (P = 0.0002) were significantly associated with outcome of posterior fossa contusion.

Conclusion:

Traumatic cerebellar hematoma is rare. Conservatively managed cerebellar hematoma patients must be monitored closely for neurological and radiological status. Patients who show deterioration in neurological or radiological status require surgical intervention.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Acute Posterior Cranial Fossa Hemorrhage-Is Surgical Decompression Better than Expectant Medical Management?

Background

To compare the in-hospital mortality and institutional morbidity from medical therapy (MT), external ventricular drainage (EVD) and suboccipital decompressive craniectomy (SDC) following an acute hemorrhagic posterior cranial fossa stroke (PCFH) in patients admitted to the neurosciences critical care unit (NCCU). Retrospective observational single-center cohort study in a tertiary care center. All consecutive patients (n = 104) admitted with PCFH from January 1st 2005–December 31st 2011 were included in the study.

Methods

All patients with a PCFH were identified and confirmed by reviewing computed tomography of the brain reported by a specialist neuroradiologist. Management decisions (MT, EVD, and SDC) were identified from operative notes and electronic patient records.

Results

Following a PCFH, 47.8 % (n = 11) patients died after EVD placement without decompression, 45.7 % (n = 16) died following MT alone, and 17.4 % (n = 8) died following SDC. SDC was associated with lower mortality compared to MT with or without EVD (χ² test p = 0.006, p = 0.008). Age, ICNARC score, brain stem involvement, and hematoma volume did not differ significantly between the groups. There was a statistically significant increase in hydrocephalus and intraventricular bleeds in patients treated with EVD placement and SDC (χ² test p = 0.02). Median admission Glasgow Coma Scale scores for the MT only, MT with EVD, and SDC groups were 8, 6, and 7, respectively (ranges 3–15, 3–11 and 3–13) and did not differ significantly (Friedman test: p = 0.89). SDC resulted in a longer NCCU stay (mean of 17.4 days, standard deviation = 15.4, p < 0.001) and increased incidence of tracheostomy (50 vs. 17.2 %, p = 0.0004) compared to MT with or without EVD.

Conclusions

SDC following PCFH was associated with a reduction in mortality compared to expectant MT with or without EVD insertion. A high-quality multicenter randomized control trial is required to evaluate the superiority of SDC for PCFH.

Traumatic injury to the posterior fossa

Traumatic injury to the posterior fossa is a complex pathologic condition because of the great heterogeneity of lesions present. Treatment of primary brain injuries and prevention of secondary brain injuries is the mainstay of management. It is imperative to recognize traumatic lesions of the posterior fossa early because of the occurrence of rapid neurologic decline. The decision regarding whether or not to proceed with surgical intervention depends on the patient's clinical condition, neurologic status, and imaging findings. Nonoperative management should be considered only if the patient is fully conscious and the associated posterior fossa lesions are small with little or no mass effect.

Quantitative studies of caspase-3 catalyzed αII-spectrin breakdown

Under various physiological and patho-physiological conditions, spectrin breakdown reactions generate several spectrin breakdown products (SBDPs)-in particular SBDPs of 150 kDa (SBDP150) and 120 kDa (SBDP120). Recently, numerous studies have shown that reactions leading to SBDPs are physiologically relevant, well regulated, and complex. Yet molecular studies on the mechanism of the SBDP formation are comparatively scarce. We have designed basic systems to allow us to follow the breakdown of αII-spectrin model proteins by caspase-3 in detail with gel electrophoresis, fluorescence and mass spectrometry methods. Amongst the predicted and reported sites, our results show that caspase-3 cleaves after residues D1185 and D1478, but not after residues D888, D1340 and D1475. We also found that the cleavage at these two sites is independent of each other. It may be possible to inhibit one site without affecting the other site. Cleavage after residue D1185 in intact αII-spectrin leads to SBDP150, and cleavage after D1478 site leads to SBDP120. Our results also show that the cleavage after the D1185 residue is unusually efficient, with a kcat/KM value of 40,000 M(-1) s(-1), and the cleavage after the D1478 site is more similar to most of the other reported caspase-3 substrates, with a kcat/KM value of 3000 M(-1) s(-1). We believe that this study lays out a methodology and foundation to study caspase-3 catalyzed spectrin breakdown to provide quantitative information. Molecular understanding may lead to better understanding of brain injuries and more precise and specific biomarker development.

Traumatic hematoma of the posterior fossa

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.

Management of Spontaneous Intracerebral Haemorrhage

BACKGROUND

Management of spontaneous intracerebral haemorrhage (SICH) is still an enigma. The study was conducted to find out the most appropriate mode of treatment and other possible inclusion criteria's in addition to clot size.

METHODS

Sixty consecutive patients of SICH excluding bleeds due to arteriovenous malformations/aneurysm were included in the study. Patients with moderate and large bleeds, progressive neurological deficit and glasgow coma scale (GCS) of more than five were included in the surgical group and rest treated conservatively.

RESULT

Location of the bleed, other co-morbid conditions and GCS at presentations were more important guidelines than size of the bleed. Mortality was more in surgically treated group where cerebellar bleed fared well after evacuation.

CONCLUSION

Surgery is preferred in superficially located bleeds and cerebellar bleeds. Intra cranial pressure monitoring will help in categorizing the mode of treatment better than mere clot size.

Surgical Management of Posterior Fossa Mass Lesions

RECOMMENDATIONS (see Methodology)

Indications

Timing

Methods

[Post-traumatic temporal lobe lesions: surgical decision making based on CT scan findings]

BACKGROUND

The indication for surgical treatment of post-traumatic parenchymal lesions in the temporal lobe remains controversial.

OBJECTIVE

We reviewed the tomographic parameters that might be useful in making surgical decisions.

METHOD

The tomographic findings of 69 patients were analyzed in a retrospective manner considering: 1) the effects of the lesion (classified into 4 variables: midline shift, status of the cisterns, status of the ventricles, and status of the peripheral sulci); and 2) the characteristics of the lesion: anterior, posterior or anteroposterior location (as defined by a coronal plane tangent to the cerebral peduncles) and its mediolateral diameter.

RESULTS

When none or only one of the aforementioned variables was found to be altered, conservative treatment was instituted (22 out of 38 lesions). In two cases, all four variables were altered, and surgery was performed in both. Anterior, anteroposterior and posterior lesions measuring 21, 23 and 28 mm in diameter, respectively, had a 50% chance of surgical removal.

CONCLUSION

Amongst the patients who underwent surgical intervention, the more anterior the location of the temporal lobe lesion, the smaller the diameter.