Epidemiology of traumatic epidural hematoma in young age

Conservative therapy of epidural hematoma with atorvastatin combined with glucocorticoids: cases report and literature review

Epidural hematomas (EDH), typically requiring surgery, may be managed conservatively in select patients. We investigated atorvastatin (10 mg/day) combined with dexamethasone (2.25 mg/day) as conservative therapy in six EDH patients (GCS ≥ 13, volume < 30 ml) post-trauma. All patients recovered fully without surgery, and literatures support conservative care for stable EDH. Our findings suggest this combination therapy may promote hematoma absorption. In conclusion, atorvastatin/dexamethasone shows promise as a non-surgical EDH option, warranting further investigation.

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.

Rubiano A, G. Kolias A, Silva Paiva W. Evaluation of Computed Tomography Scoring Systems in the Prediction of Short-Term Mortality in Traumatic Brain Injury Patients from a Low- to Middle-Income Country

The present study aims to evaluate the accuracy of the prognostic discrimination and prediction of the short-term mortality of the Marshall computed tomography (CT) classification and Rotterdam and Helsinki CT scores in a cohort of TBI patients from a low- to middle-income country. This is a post hoc analysis of a previously conducted prospective cohort study conducted in a university-associated, tertiary-level hospital that serves a population of >12 million in Brazil. Marshall CT class, Rotterdam and Helsinki scores, and their components were evaluated in the prediction of 14-day and in-hospital mortality using Nagelkerk's pseudo-R² and area under the receiver operating characteristic curve. Multi-variate regression was performed using known outcome predictors (age, Glasgow Coma Scale, pupil response, hypoxia, hypotension, and hemoglobin values) to evaluate the increase in variance explained when adding each of the CT classification systems. Four hundred forty-seven patients were included. Mean age of the patient cohort was 40 (standard deviation, 17.83) years, and 85.5% were male. Marshall CT class was the least accurate model, showing pseudo-R² values equal to 0.122 for 14-day mortality and 0.057 for in-hospital mortality, whereas Rotterdam CT scores were 0.245 and 0.194 and Helsinki CT scores were 0.264 and 0.229. The AUC confirms the best prediction of the Rotterdam and Helsinki CT scores regarding the Marshall CT class, which presented greater discriminative ability. When associated with known outcome predictors, Marshall CT class and Rotterdam and Helsinki CT scores showed an increase in the explained variance of 2%, 13.4%, and 21.6%, respectively. In this study, Rotterdam and Helsinki scores were more accurate models in predicting short-term mortality. The study denotes a contribution to the process of external validation of the scores and may collaborate with the best risk stratification for patients with this important pathology.

Traumatic epidural hematoma treated with endovascular coil embolization

Background:

Traumatic cerebrovascular injury may result in epidural hematoma (EDH) from laceration of the middle meningeal artery (MMA), which is a potentially life-threatening emergency. Treatment ranges from surgical evacuation to conservative management based on a variety of clinical and imaging factors.

Case Description:

A 14-year-old male presented to our institution after falling from his bicycle with traumatic subarachnoid hemorrhage and a right frontotemporal EDH. The patient did not meet criteria for surgical evacuation and endovascular embolization of the right MMA was performed. Rapid resolution of the EDH was observed.

Conclusion:

This case corroborates the sparse existing literature for the potential role of endovascular embolization to treat acute EDH in carefully selected patients who do not meet or have borderline indications for surgical management.

Management of Traumatic Epidural Hematoma in Infants Younger than One Year: 50 Cases - Single Center Experience

AIM AND BACKGROUND

Traumatic epidural hematoma (EDH) is a rare but possibly fatal complication of head trauma in infants. In this study, infants who were younger than 1 year and followed up and treated for TEDH in our clinic were evaluated. Our series is the largest series consisting only infantile cases in the literature.

MATERIAL AND METHODS

There were 50 patients younger than 1 year followed up and treated in our hospital between January 2011 and December 2019. Their age, gender, hospital admission signs and symptoms, trauma type, localization and thickness of the hematoma, and accompanying skull fracture were noted from their hospital files. Decisions for conservative or surgical treatment were made according to neurological status, Children Coma Scale (CCS) score, and EDH thickness, degree of the midline shift on cranial computerized tomography (CT), and presence of additional intracranial pathology.

RESULTS

Patients' age ranged from 0 day to 12 months (7 months as median), and their male/female ratio was 30/20. Falling from a height (<1 m) was the most frequent trauma mechanism, with a 96% rate. The most common finding was irritability and unusual crying (88%). The CCS score was 5-15 (median 13). The hematoma was located most frequently in the parietal region (48%) and least frequently in the posterior fossa (2%). Linear fracture was observed in 62% of the cases. Thirty-nine (78%) patients were treated conservatively (hematoma thickness ≤17 mm). Eleven (22%) cases were surgically treated (hematoma thickness was between 15 and 40 mm (26.3 ± 6.6 mm, mean ± standard deviation [SD]). The midline shift in the operated cases was between 1.8 and 11.8 mm (6.4 ± 3 mm, mean ± SD). One of them with a hematoma thickness of 15 mm was operated for associated open depression fracture above the hematoma. Other 10 patients were operated for primarily hematoma evacuation. None of the patients treated conservatively worsened neurologically or required operation during or after hospitalization. Two patients died (4%) during hospitalization, and both of them were anisocoric on admission. The hospital stay was between 1 and 10 (median 3) days, and the follow-up period of the living patients was between 1 month and 6 years (median 24 months). All of the living patients were neurologically normal on their last controls.

CONCLUSIONS

Because the symptoms and signs in infants are nonspecific, it is difficult to diagnose EDH clinically. Cranial CT should be performed in cases with irritability, swelling of the scalp, pallor, deterioration of consciousness, and anisocoria after head trauma. Traumatic EDHs with normal neurological examination, high CCS score, hematoma thickness below 20 mm, no apparent shift, and without associated brain pathology can be treated conservatively. None of those patients treated conservatively required operation after that.

Incidence and Age Distribution of Hospitalized Presumptive and Possible Abusive Head Trauma of Children Under 12 Months Old in Japan

Background

Abusive head trauma (AHT) is the leading cause of fatal maltreatment among young children. The incidence of AHT in Japan, however, remains unknown. This study examined the incidence and distribution of age in months among young children under 12 months of age hospitalized with intracranial injury in Japan.

Methods

We conducted a multicenter cross-sectional study of children under 36 months old admitted with intracranial injury to hospitals that employed the Diagnostic Procedure Combination (DPC) payment system between 2010 and 2013. Presumptive and possible AHT were defined using the combination of ICD-10 codes modified from the coding system recommended by the United States Centers for Disease Control and Prevention.

Results

The average incidence was 7.2 (95% confidence interval [CI], 7.18–7.26) for presumptive and 41.7 (95% CI, 41.7–41.8) for possible AHT per 100,000 children less than 12 months old from 2010 to 2013. The distributions of age in months for both presumptive AHT and possible AHT had peaks at around 2 and 8 months.

Conclusions

This is the first study to report the incidence of hospitalized children with presumptive and possible AHT using population-based data. Further datasets are needed to evaluate the incidence and specific preventive strategies to prevent AHT in infants during the months of highest risk.

The profile of blunt traumatic supratentorial cranial bleed types

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

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.

Trauma-induced Acute Epidural Hematoma: The Rising Sun in a Progressively Lethargic Man

A young adult, 18 years of age, presented to the emergency department with severe traumatic brain injury (TBI) resulting from a bicycle versus vehicle head-on collision. The patient initially presented in a promising condition but quickly deteriorated into a state of unconsciousness with no meaningful responses to stimuli or coordinated voluntary movement. Stat computed tomography (CT) revealed a large, right-sided, acute epidural hematoma (EDH) with mass-effect and a severe midline shift indicative of immediate surgery. This case highlights the importance of closely monitoring traumatic brain injury patients regardless of initial presentation and neurological exam results, as the patient's condition may drastically and rapidly change without much warning. Additionally, it is key to utilize regular radiological studies on these patients, to detect any neurological changes as close to onset as possible. Lastly, it is imperative that neurosurgeons closely monitor the patients/ state of consciousness as a rapid decline serves as a key diagnostic indicator of the need for immediate surgery.

Clinicopathological Characteristics of Traumatic Head Injury in Juvenile, Middle-Aged and Elderly Individuals

BACKGROUND Traumatic head injury is a leading cause of death and disability worldwide. How clinicopathological features differ by age remains unclear. This epidemiological study analyzed the clinicopathological features of patients with head injury belonging to 3 age groups. MATERIAL AND METHODS Data of patients with traumatic head injury were obtained from the Department of Cerebral Surgery of the Affiliated Hospital of Guizhou Medical University and the Guizhou Provincial People's Hospital in 2011-2015. Their clinicopathological parameters were assessed. The patients were divided into 3 age groups: elderly (≥65 years), middle-aged (18-64 years), and juvenile (≤17 years) individuals. RESULTS Among 3356 hospitalizations for traumatic head injury (2573 males and 783 females, 654 died (19.49%), the highest and lowest mortality rates were in the elderly and juvenile groups, respectively. Fall was the most common cause in juvenile and elderly individuals (32.79% and 43.95%, respectively), while traffic injury was most common in the elderly group (35.08%). The manners of injury differed considerably among the 3 age groups. Scalp injury, skull fracture, intracranial hematoma, and cerebral injury were the most common mechanisms in juvenile (67.32%), middle-aged (63.50%), elderly (69.56%) and middle-aged (90.44%) individuals, respectively. Scalp injury and skull fracture types differed among the groups. Epidural, subdural, and intracerebral hematomas were most common in juvenile, middle-aged, and elderly individuals, respectively. Cerebral contusion showed the highest frequency in the 3 groups, and concussion the lowest. CONCLUSIONS Patients with traumatic HI show remarkable differences in clinicopathological features among juvenile, middle-aged, and elderly individuals.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment

BACKGROUND

Although some pediatric patients with small traumatic epidural hematoma (EDH) are observed without surgical drainage, clinical practice remains variable.

OBJECTIVES

Create a prediction rule to identify patients with EDH unlikely to fail hospital observation.

METHODS

Retrospective review at a level I pediatric trauma center between 2003 and 2014. Presenting clinical and radiographic features were compared between those successfully to failed observation.

RESULTS

Two hundred twenty-two patients with EDH whose initial management strategy was observation were analyzed; 196 (88%) were successfully observed. The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed = 5.6mm versus failed observation = 10.9mm, p<0.01), median bleed volume (observed = 2.1ml versus failed observation = 15.7ml, p<0.01), and mass effect (RR 3.7; 95% CI 1.8-7.7). No mass effect, EDH volume<15ml, and no neurologic deficits predicted patients at low risk of failing observation with a positive predictive value of 98% (95% CI 93-99%). There was no difference in median discharge Glasgow outcome scores (5 in both groups, p=0.20).

CONCLUSION

Patients with no mass effect and EDH volume <15ml on initial CT scan and no neurologic deficit are at low risk of failing observation.

LEVEL OF EVIDENCE

Retrospective cohort level I.

Thermal Regulation of the Brain-An Anatomical and Physiological Review for Clinical Neuroscientists

Humans, like all mammals and birds, maintain a near constant core body temperature of 36–37.5°C over a broad range of environmental conditions and are thus referred to as endotherms. The evolution of the brain and its supporting structures in mammals and birds coincided with this development of endothermy. Despite the recognition that a more evolved and complicated brain with all of its temperature-dependent cerebral circuitry and neuronal processes would require more sophisticated thermal control mechanisms, the current understanding of brain temperature regulation remains limited. To optimize the development and maintenance of the brain in health and to accelerate its healing and restoration in illness, focused, and committed efforts are much needed to advance the fundamental understanding of brain temperature. To effectively study and examine brain temperature and its regulation, we must first understand relevant anatomical and physiological properties of thermoregulation in the head-neck regions.

Emergency department visits for head trauma in the United States

Background

Head trauma affects millions of Americans each year and has significant morbidity and economic costs to society. The objective of this study is to describe the epidemiology of head traumas presenting to emergency departments in the United States.

Methods

The National Electronic Injury Surveillance System-All Injury Program was queried to conduct a retrospective analysis of head traumas treated in U.S. emergency departments. 207,159 cases of nonfatal head trauma from January 1, 2007 to December 31, 2011 were included in this study.

Results

An estimated 10,746,629 (95 % confidence interval: 8,368,720-13,124,537) head traumas were treated in U.S. emergency departments (EDs) during the study period, averaging 2,149,326 cases annually. The annual injury rate per 10,000 population increased from 55.2 in 2007 to 85.4 in 2011, with the largest increases seen in children ≤11 years of age and in adults >65 years of age. Traffic-related head trauma accounted for an estimated 1,819,824 visits to U.S. EDs over the study period and was associated with a 1.74 times greater risk of a hospital admission compared to injuries due to non-traffic-related causes. Assaults (95.9 %) were the most common reason for head trauma in cases where injury intent was documented, and 16.9 % of assault-related head trauma occurred in children 0-17 years of age. When analyzed separately from other head traumas, concussions increased by 37.5 % over the study period, and nearly a third (29.9 %) of all concussions were sports-related.

Conclusions

The increase in the number and rate of head traumas treated in U.S. EDs warrants continued injury prevention efforts and improvements in injury nomenclature and surveillance.

Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature

Patient: Male, 30

Final Diagnosis: Acute epidural hematoma

Symptoms: —

Medication: —

Clinical Procedure: Observation

Specialty: Neurosurgery

Traumatic extradural hematoma in childhood

OBJECTIVE

This study was undertaken to assess the clinical and radiological characteristics of children with traumatic extradural hematoma (TEDH), and factors affecting the initial neurological status and outcome.

METHODS

Medical records of 269 consecutive children with TEDH from 2005 to 2012 were retrospectively reviewed, factors affecting the initial neurological status and outcomes were explored using univariate and multivariate analysis.

RESULTS

There were 166 boys and 103 girls (average age: 7.0 years). Fall from a height (59 %) was the most common mechanism of head injury. With increasing age, an increase of motor-vehicle accident and assault was noted. Among the children 85.5 % experienced a Glasgow Coma Scale (GCS) of 13-15, 9.7 % with GCS 9-12, and 4.8 % with GCS 3-8. The main clinical manifestations were headache, vomiting and nausea, and conscious disturbance. The main locations were the temporal, temporoparietal, and frontal regions. The 97.4 % saw a favorable outcome, whereas 2.6 % had a poor outcome (overall mortality: 1.1 %).

CONCLUSION

Many factors influenced the prognosis; the most important factors affecting prognosis were the initial neurological condition and secondary brain edema, while the initial neurological status were associated with pupillary abnormality, clinical progression, the number and volume of TEDH, and midline shift. Although the outcome was excellent in most cases, early diagnosis and surgical evacuation before irreversible brain damage was important to lower mortality for those massive TEDHs.

Utility of clinical and radiographic findings in the management of traumatic epidural hematoma

BACKGROUND

There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups.

METHODS

We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center.

RESULTS

Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation.

CONCLUSIONS

Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.