Factors predicting early deterioration in mild brain trauma: a prospective study

Airway obstruction resulting from massive subgaleal hematoma caused by superficial temporal artery injuries in an adult patient with liver cirrhosis

Subgaleal hematoma, characterised by blood accumulation between the galea aponeurosis and the periosteum, is rarely reported in adults. A man with liver cirrhosis experienced airway obstruction secondary to an extensive subgaleal hematoma due to superficial temporal artery injuries. Within 6 hours after injury, swelling of the patient's head and neck was noted, which was associating with inspiratory wheezing and paradoxical breathing, thus necessitating emergency intubation. The branches of the superficial temporal artery were identified as the bleeding source via angiography. Subsequently, endovascular embolisation was successfully performed. This case highlights a rare association between airway obstruction and subgaleal hematoma, originating from injuries of the superficial temporal artery in an adult patient with severe coagulopathy. Airway obstruction was secondary to the hematoma progression into the facial and neck regions. It is crucial to identify and address alternative bleeding sources if conservative treatments or initial interventions for subgaleal hematomas are proven ineffective.

Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series

OBJECTIVE

To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI).

METHODS

The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic.

RESULTS

Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%).

CONCLUSIONS

Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.

Tranexamic acid to reduce operative blood loss in brain tumor surgery: A meta-analysis

Background:

Major blood loss during neurosurgery may result in a variety of complications, such as potentially fatal hemodynamic instability. Brain tumor and skull base surgery is among the high bleeding risk procedures. Tranexamic acid (TXA) has been found to reduce bleeding events in various fields of medicine.

Methods:

We searched for all randomized controlled trials published in English or Bahasa which compared the use of TXA with placebo in brain tumor surgery. The studies should include adult patients with intracranial tumor who received TXA before skin incision. The primary and secondary outcomes are intraoperative blood loss and the need of transfusion.

Results:

This meta-analysis included a total of 200 patients from three studies. TXA resulted in less blood loss with pooled mean difference of −292.80 (95% CI, −431.63, −153.96, P<0.05). The need of transfusion was not significant between TXA and control group (pooled mean difference −85.36, 95% CI, −213.23 – (42.51), P=0.19).

Conclusion:

TXA reduced the volume of blood loss but did not reduce the need of blood transfusion.

Enlarging acute tentorial subdural hematoma evacuated by surgery

Acute intracranial subdural hematomas (SDHs) of tentorial type generally pose no serious clinical threats, and unlike other variants of SDH, rarely require surgical intervention. Herein, we present an exceedingly rare case of tentorial SDH, marked by gradual enlargement and eventually calling for surgical evacuation. A 55-year-old man presented to the emergency department after sustaining head trauma. Initially, he was alert, fully oriented, and neurologically stable. Although computed tomography (CT) of the brain revealed an acute SDH scantily distributed along right tentorium, brain swelling or midline shift was negligible. On the following day, he became confused, but pupil size and light reflex remained normal. A follow-up CT scan showed considerable enlargement of the acute SDH, with midline shift. In a matter of hours, he deteriorated to a stuporous state, as the SDH enlarged even more. We performed a craniotomy and completely evacuated the SDH on an emergency basis. As a result, the midline shift improved, and he again became alert, soon recovering without any new neurologic deficit. This illustrative case demonstrates that even a tentorial SDH may ultimately deteriorate, forcing surgical evacuation. We, therefore, feel that close observation is mandatory for such events, even if the initial volume is small.

Subarachnoid versus Nonsubarachnoid Traumatic Brain Injuries: The Impact of Decision-Making on Patient Safety

Introduction

Traumatic intracranial hemorrhages (ICHs) are high priority injuries. Traumatic brain bleeds can be categorized as traumatic subarachnoid hemorrhage (SAH) versus non-SAH-ICH. Non-SAH-ICH includes subdural, epidural, and intraventricular hematomas and brain contusions. We hypothesize that awake patients with SAH will have lower mortality and needless interventions than awake patients with non-SAH-ICHs.

Study Design and Methods

A review of data collected from our Level I trauma center was conducted. Awake was defined as an initial Glasgow coma score (GCS) 13-15. Patients were divided into two cohorts: awake SAH and awake non-SAH-ICH. Chi-square and t-test analyses were used with statistical significance defined as P < 0.05.

Results

A total of 12,482 trauma patients were admitted during the study period, of which 225 had a SAH and GCS of 13-15 while 826 had a non-SAH-ICH with a GCS of 13-15. There was no significant difference in demographics between the two groups. Predicted survival between the two groups was similar (97.3 vs. 95.7%, P > 0.05). Mortality rates were, however, significantly lower in SAH patients compared to the non-SAH-ICH (4/225 [1.78%] vs. 22/826 [2.66%], P < 0.05). The need for neurosurgical intervention was significantly different comparing the SAH group versus non-SAH-ICH (2/225 [0.89%] vs. 100/826 [12.1%], P < 0.05).

Conclusion

Despite similar predicted mortality rates, awake patients with a SAH are associated with a significantly lower risk of death and need for neurosurgical intervention when compared to other types of awake patients with a traumatic brain bleed.

Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum

BACKGROUND

Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk.

METHODS

Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression.

RESULTS

Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes.

CONCLUSIONS

Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.

Risk Factors Contributing to Higher Mortality Rates in Elderly Patients with Acute Traumatic Subdural Hematoma Sustained in a Fall: A Cross-Sectional Analysis Using Registered Trauma Data

Background: We aimed to explore the risk factors that contribute to the mortality of elderly trauma patients with acute subdural hematoma (SDH) resulting from a fall. Mortality rates of the elderly were compared to those of young adults. Methods: A total of 444 patients with acute traumatic subdural hematoma resulting from a fall, admitted to a level I trauma center from 1 January 2009 to 31 December 2016 were enrolled in this study. Patients were categorized into two groups: elderly patients (n = 279) and young adults (n = 165). The primary outcome of this study was patient mortality in hospital. The adjusted odds ratio (AOR) with 95% confidence interval (CI) for mortality was calculated according to gender and pre-existing comorbidities. Univariate and multivariate logistic regression analyses were performed to identify factors related to mortality in the elderly. Results: The odds ratio for mortality caused by falls in the elderly patients was four-fold higher than in the young adults, after adjusting for gender and pre-existing comorbidities. In addition, the presence of pre-existing coronary artery disease (OR 3.2, 95% CI 1.09–9.69, p = 0.035), end-stage renal disease (OR 4.6, 95% CI 1.48–14.13, p = 0.008), hematoma volume (OR 1.2, 95% CI 1.11–1.36, p < 0.001), injury severity score (OR 1.3, 95% CI 1.23–1.46, p < 0.001), and coagulopathy (OR 4.0, 95% CI 1.47–11.05, p = 0.007) were significant independent risk factors for mortality in patients with acute traumatic SDH resulting from a fall. Conclusions: In this study, we identified that pre-existing CAD, ESRD, hematoma volume, ISS, and coagulopathy were significant independent risk factors for mortality in patients with acute traumatic SDH. These results suggest that death following acute SDH is influenced both by the extent of neurological damage and the overall health of the patient at the time of injury.

Complicated Mild Traumatic Brain Injury and the Need for Imaging Surveillance

OBJECTIVE

To evaluate the need for repeat head computed tomography (CT) in patients with complicated mild traumatic brain injury (TBI) determined nonoperative after the first head CT.

METHODS

A total of 380 patients with mild TBI and a positive head CT not needing surgery were included. Changes between first and second head CT were categorized as decreased, increased, or stable.

RESULTS

Three patients required neurosurgical intervention (0.8%) after the second CT. There were no significant differences in demographics including age, gender, alcohol consumption, anticoagulation status, time between first and second CT, Glasgow Coma Scale score at admission and discharge, and incidence of subarachnoid hemorrhage, epidural hematoma, contusion, or skull fractures between the operated and nonoperated groups. All patients in the operated group had subdural hematoma compared with 40.8% in the nonoperated group (P = 0.07). All operated patients showed symptoms of neurologic worsening after initial head CT, compared with 2.7% in the nonoperated group (P < 0.001). Moreover, patients who showed neurologic worsening were more likely to show increased intracranial bleeding on repeat head CT, whereas patients who did not show neurologic worsening were more likely to show decreased or stable intracranial bleeding (P = 0.04).

CONCLUSIONS

Routine repeat head CT in patients with complicated mild TBI is very low yield to predict need for delayed surgical intervention. Instead, serial neurologic examination and observation over the first 8 hours after the injury is recommended. A second CT scan should be obtained only in patients who have neurologic worsening.

Does distracting pain justify performing brain computed tomography in multiple traumas with mild head injury?

Traumatic brain injury (TBI) is a significant health concern classified as mild, moderate, and severe. Although the indications to perform brain computed tomography (CT) are clear in moderate and severe cases, there still exists controversy in mild TBI (mTBI). We designed the study to evaluate the significance of distracting pain in patients with mTBI. The study population included patients with mild traumatic brain injury (GCS ≥13). Moderate and high risk factors including age <18 months or ≥60 years, moderate to severe or progressive headache, ≥2 episodes of vomiting, loss of consciousness (LOC), post-traumatic amnesia, seizure or prior antiepileptic use, alcohol intoxication, previous neurosurgical procedures, uncontrolled hypertension, anticoagulant use, presence of focal neurologic deficits, deformities in craniofacial region, and penetrating injuries were excluded. The patients were then grouped based on presence (DP+) or absence (DP-) of another organ fracture with severe pain (based on VAS). The primary outcome was any abnormal findings on brain CT scans; 330 patients were enrolled (184 DP+ and 146 DP-). Overall, two DP+ and one DP- patients had mild cerebral edema in brain CT (p > 0.99). No patients had any neurologic symptoms or signs in follow-up. Our results show that in the absence of any other risk factors, distracting pain from other organs (limbs, pelvis, and non-cervical spine) cannot be regarded as a brain CT indication in patients with mild TBI, as it is never associated with significant intracranial lesions.

Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank

Introduction

Patients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14–15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.

Methods

The National Trauma Databank (2007–2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14–15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.

Results

The study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.

Conclusions

We found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.

Assessment of pedicle screw placement accuracy in thoracolumbosacral spine using freehand technique aided by lateral fluoroscopy: results of postoperative computed tomography in 114 patients

BACKGROUND CONTEXT

Pedicle screw fixation is currently widely used in spine surgery for various pathologies. Increasing screw placement accuracy would improve the outcomes.

PURPOSE

To determine the accuracy rate of screw placement in a group of patients who underwent pedicle screw fixation with conventional techniques.

STUDY DESIGN

A case series.

PATIENT SAMPLE

It includes patients undergoing posterior spinal fixation with pedicle screw insertion. Outcome measures include the accuracy of screw placement in pedicles defined by postoperative computed tomography (CT).

METHODS

After surgery, an axial thin-cut CT scan was performed in all patients. Screw position was classified as correct when the screw was completely surrounded by the pedicle cortex and incorrect when any part of the screw was outside the pedicle boundaries.

RESULTS

Seven hundred seventy screws were inserted at vertebral levels T7-S1 of 114 patients between March 2012 and December 2012. There were three wound infections and one death. Eighteen screws were diagnosed as having an incorrect position (2.3%). The highest accuracy was observed in levels L4 and L5 (0.8% inaccuracy rate for each), whereas the highest inaccuracy rate was observed in T9. The mean inaccuracy rate was 10.5% for levels T7-T9, 3.5% for levels T10-L2, and 0.9% for levels L3-S1. The differences were statistically significant. Only one screw (5%) needed revision.

CONCLUSIONS

The results of our study show that conventional methods for pedicle screw placement remain safe and accurate, with best results obtained in the lumbosacral spine, followed by the thoracolumbar junction. Nonetheless, results are less accurate in the midthoracic spine.

Comparison of Levetiracetam and sodium Valproate in migraine prophylaxis: A randomized placebo-controlled study

Background:

Migraine is a chronic and disabling disorder. Treatment of migraine often comprises of symptomatic (abortive) and preventive (prophylactic) treatment. The current drugs used in migraine prophylaxis include antidepressant drugs (Serotonin Reuptake Inhibitors, Tricyclic antidepressants), and anti-epileptic drugs (valproate, gabapentin, etc).

Objective:

The objective of our study was to assess the efficacy and tolerability of levetiracetam in adult migraine prophylaxis, compared to valproate and placebo.

Materials and Methods:

We conducted a prospective, randomized, placebo-controlled study. A total of 85 patients were randomized to receive levetiracetam 500 mg/d (n = 27), valproate 500 mg/d (n = 32) or placebo (n = 26). The patients were evaluated for treatment efficacy after 6 months. Efficacy was assessed as a more than 50% decrease in headache frequency.

Results:

In levetiracetam group, 17 (63.0%) patients experienced a more than 50% decrease in headache frequency, while this efficacy number was 21 (65.6%) for valproate group and 4 (15.4%) for placebo group. The difference was not statistically significant between levetiracetam and valproate, while it was significant when comparing either levetiracetam or valproate to placebo.

Conclusion:

Compared to placebo, levetiracetam offers improvement in headache frequency in patients with migraine. The efficacy of levetiracetam in migraine prophylaxis is comparable to currently used drugs such as valproate.