Recurrent hematomas following craniotomy for traumatic intracranial mass

Traumatic Middle Meningeal Artery Aneurysm: A Rare Cause of Recurrent Acute Epidural Hematoma. A Case Report

Traumatic middle meningeal artery aneurysm (TMMA) is a rare condition and a known cause of several different bleeding patterns after head injury. Once detected, they need to be treated as an emergency due to their potential for morbidity and mortality. Generally, recurrence does not occur in surgery for acute epidural hematoma if adequate hemostasis is achieved. Here, we report a case of atypical postoperative recurrence of an acute epidural hematoma, possibly due to the development and rupture of a TMMA. A 41-year-old man with left acute epidural hematoma after a head injury was referred to our hospital. Emergency craniotomy was performed immediately, and the hematoma was removed. The source of the bleeding was near the fracture site in the middle cranial fossa, and sufficient hemostasis was confirmed. However, a head computed tomography (CT) scan the next day revealed a recurrence of the acute epidural hematoma. Magnetic resonance (MR) angiogram showed an aneurysm with a diameter of approximately 4 mm in the left middle meningeal artery. The recurrence of the acute epidural hematoma appeared to be related to the formation and a rupture of a middle meningeal artery aneurysm, and to prevent subsequent rebleeding, the patient underwent reoperation, and the hematoma and aneurysm were removed. In surgery for acute epidural hematoma, recurrence can be prevented by removing the hematoma and ensuring hemostasis. Although conventional surgery was performed in this case, a repeat of epidural hematoma occurred. A postoperative middle meningeal artery aneurysm had been thought to have developed, ruptured, and caused a repeat epidural hematoma. In treating acute epidural hematoma, a TMMA development should be considered when an atypical clinical course occurs, such as a recurrence of postoperative bleeding.

Outcome and survival of surgically treated acute subdural hematomas and postcraniotomy hematomas - A retrospective cohort study

Background

The morbidity and mortality of acute subdural hematoma (aSDH) remains high. Several factors have been reported to affect the outcome and survival of these patients. In this study, we explored factors potentially associated with the outcome and survival of surgically treated acute subdural hematoma (aSDH), including postcraniotomy hematomas (PCHs).

Methods

This retrospective cohort study was conducted in a single tertiary university hospital between 2008 and 2012 and all aSDH patients that underwent surgical intervention were included. A total of 132 cases were identified for collection of demographics, clinical, laboratory, and imaging data. Univariate and multivariable analyses were performed to assess factors associated with three-month Glasgow Outcome Scale (GOS) and survival at one- and five-year.

Results

In this study, PCH (n = 14, 10.6%) was not associated with a worse outcome according to the 3- month GOS (p = 0.37) or one (p = 0.34) and five-year (p = 0.37) survival. The multivariable analysis showed that the volume of initial hematoma (p = 0.009) and Abbreviated Injury Scale score (p = 0.016) were independent predictors of the three-month GOS. Glasgow Coma Scale (GCS) score (p < 0.001 and p = 0.037) and age (p = 0.048 and p = 0.003) were predictors for one and five-year survival, while use of antiplatelet drug (p = 0.030), neuroworsening (p = 0.005) and smoking (p = 0.026) were significant factors impacting one year survival. In addition, blood alcohol level on admission was a predictor for five-year survival (p = 0.025).

Conclusions

These elucidations underscore that, although PCHs are pertinent, a comprehensive appreciation of multifarious variables is indispensable in aSDH prognosis. These findings are observational, not causal. Expanded research endeavors are advocated to corroborate these insights.

The role of extended coagulation screening in adult cranial neurosurgery

Introduction

Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality.

Research question

We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage.

Methods

A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage.

Results

The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p ​= ​.546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p ​= ​.023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p ​= ​.034). Differences in mean intraoperative blood loss were not significant with 528 ​ml in the study cohort and 486 ​ml in the control cohort (p ​= ​.376).

Conclusion

Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.

The timing and value of early postoperative computed tomography after head surgery in traumatic brain injury patients

OBJECTIVE

To analyze the timing of the early postoperative computed tomography (CT) in traumatic brain injury (TBI) patients, and compare CT and neurological examination (NE) findings.

METHODS

Retrospective analysis included 353 TBI patients admitted to two level 1 trauma centers (2016-2020) who underwent head surgery and postoperative CT within 24 h. Analyzed variables: age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), Abbreviated Injury Scale head (AISh), comorbidities, CT and NE findings and timing, head surgery type, and mortality.

RESULTS

Patients mean age was 61.9 years, ISS 25.1, GCS 11.0, AISh 4.7. Postoperatively, mean time to first positive CT was 6.1 h and to first positive NE was 13.2 h. Positive CT alone was more accurate in identifying need for 2nd head surgery than positive NE alone (21.8 % vs 6.0 %, p = 0.04). There was no difference between patients with CT done earlier than 6 h compared to patients with CT done after 6 h in mortality (26.1 % vs 22.0 %, p = 0.4) or 2nd surgery rate (12.2 % vs 12.2 %, p = 1.0). Reversal of postoperative CT findings occurred in 1/6 of patients and was more common when CT was done earlier than 6 h compared to CT done later (25.7 % vs 0.8 %, p < 0.001). Early CT within 1 h rarely leads to the change of management but often is followed by another CT within 12 h.

CONCLUSION

In TBI patients postoperative CT was more effective than NE in predicting a need for 2nd head surgery. Postoperative head CT at 6 h is recommended to allow timely detection of intracranial deterioration, reduce the number of CTs and reversal findings as it does not increase 2nd surgery rates and mortality.

Serum D-dimer level as a predictor of neurological functional prognosis in cases of head injuries caused by road traffic accidents

Background

The number of traffic fatalities is declining in Japan; however, a large proportion of head injuries are still attributable to traffic accidents. Severe head trauma may cause progressive and devastating coagulopathy owing to exacerbated coagulation and fibrinolysis, which results in massive bleeding and poor patient outcomes. D-dimer is a fibrinolytic marker, which remarkably increases in severe coagulopathy due to the exacerbated fibrinolytic system. Because the degree of coagulopathy is associated with patient outcomes, the D-dimer level is a useful prognostic predictor in patients with head trauma. However, the usefulness of D-dimer in cases of head trauma caused by road traffic accidents remains inadequately explored. In this study, we investigated the relationship between D-dimer levels and outcomes in head injuries caused by traffic accidents.

Methods

We extracted data on traffic injuries from Japan Neuro-Trauma Data Bank Project 2015, which is a prospective multicenter registry of head injuries. The analysis included 335 individuals with no missing data. The outcome variable was the score of the Glasgow Outcome Scale (GOS), a neurological outcome index. The participants were categorized into the favorable outcome (GOS score ≥ 4) and poor outcome (GOS score ≤ 3) groups. The serum D-dimer levels at the time of admission were divided into four categories at the quartiles, and the reference category was less than the first quartile (< 17.4 µg/mL). We performed a logistic regression analysis with GOS as the dependent variable and D-dimer as a predictor and performed a multivariate analysis that was adjusted for 10 physiological parameters.

Results

In the univariate analysis, all groups with serum D-dimer values ≥ 17.4 μg/dL showed significantly poorer outcomes than those of the reference group. In the multivariate analysis, after adjusting for other factors, D-dimer levels ≥ 89.3 μg/dL were an independent predictor of poor outcome.

Conclusion

After adjusting for physiological parameters, high serum D-dimer levels can be an independent factor for predicting neurological prognosis in head trauma caused by road traffic accidents.

The utility of routine head CT for hemorrhage surveillance in post-craniotomy patients undergoing anticoagulation for venous thromboembolism

Anticoagulation for postoperative venous thromboembolism (VTE) may infer a higher risk of intracranial hemorrhage. We treat patients with VTE using slowly titrating intravenous heparin drip without bolus. When PTT is greater than 60 s, a head CT is obtained to monitor for the development of a intracranial hemorrhage before transition to oral anticoagulation. We evaluated the utility of routine surveillance head CT to monitor for intracranial hemorrhage during anticoagulation. This is a case series of neurosurgical patients in an academic quaternary hospital who developed a VTE after cranial procedures between 2007 and 2017. Over 11,000 patients were screened for the study. Patients' demographics data, surgical indication, PTT at the time of surveillance CT head, surveillance CT head findings, and patient's clinical course were reviewed. A total of 83 patients were included. Three patients (3.6%) developed a new subclinical hemorrhage on CT head imaging while on heparin drip. Interval CT head showed stable hemorrhage in all patients. Heparin drip was stopped in two patients and they both progressed from DVT to pulmonary embolism: one patient died due to cardiac arrest, the other patient was transitioned to oral anticoagulation. In the third patient heparin drip was continued uneventfully and transitioned to oral anticoagulation with no further clinical sequalae. Surveillance CT while on heparin drip for VTE management detected subclinical intracranial hemorrhage in a small subset of patients. Patients whose anticoagulation was stopped had progression of VTE. Undertreatment of VTE in the presence of subclinical hemorrhage may lead to significant morbidity and mortality.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.

Biomechanics of a novel reversibly expandable dynamic craniotomy bone flap fixation plate

OBJECTIVE

Biomechanical evaluation of a novel expandable cranial fixation plate was assessed in cadavers. The dynamic craniotomy procedure uses low-profile reversibly expandable plates that allow cranial decompression by providing for intracranial volume expansion without removal of the bone flap. The plates allow reversible outward movement of the bone flap upon an increase in intracranial pressure (ICP) and also retract the bone flap and prevent it from sinking inside the cranium once the ICP normalizes.

METHODS

A comparative evaluation of the extent of ICP control with an increase in intracranial volume between various bone flap fixation techniques was undertaken along with testing of the expandable plate compliance. Static compression tests of the plates were performed to assess bone flap fixation and prevention of sinking. Quasi-static shear tension testing of the plates was undertaken to test the tolerance of the plates for expansion. Fatigue shear tension evaluation of the plates was undertaken to assess tolerance for repetitive expansion and contraction.

RESULTS

The dynamic craniotomy provided superior control of ICP with an increase in intracranial volume compared to the hinged craniotomy and standard craniotomy techniques (p < 0.001). Static compression results revealed that the plates withstood bone flap sinkage with a mean peak load of 643.3 ± 26.1 N and a mean inward bone flap displacement of 1.92 ± 0.09 mm. Static shear tension results indicated that the plates could withstand a peak expansion of 71.6 mm. Dynamic shear tension testing of the plates with repetitive 15-mm outward expansion and retraction for a total of up to 500 cycles revealed no cracking and no failure points.

CONCLUSIONS

The reversibly expandable plates provide for a low-profile bone flap fixation with rigid restriction of bone flap sinking and also enable cranial decompression with a high tolerance for repetitive expansion and contraction.

Spot sign as a predictor of rebleeding after endoscopic surgery for intracerebral hemorrhage

OBJECTIVE

In patients with spontaneous intracerebral hemorrhage (sICH), postoperative recurrent hemorrhage (PRH) is one of the most severe complications after endoscopic evacuation of hematoma (EEH). However, no predictors of this complication have been identified. In the present study, the authors retrospectively investigated whether PRH can be preoperatively predicted by the presence of the spot sign on CT scans.

METHODS

In total, 143 patients with sICH were treated by EEH between June 2009 and March 2017, and 127 patients who underwent preoperative CT angiography were included in this study. Significant correlations of PRH with the patients' baseline, clinical, and radiographic characteristics, including the spot sign, were evaluated using multivariable logistic regression models.

RESULTS

The incidence of and risk factors for PRH were assessed in 127 patients with available data. PRH occurred in 9 (7.1%) patients. Five (21.7%) cases of PRH were observed among 23 patients with the spot sign, whereas only 4 (3.8%) cases of PRH occurred among 104 patients without the spot sign. The spot sign was the only independent predictor of PRH (OR 5.81, 95% CI 1.26-26.88; p = 0.02). The following factors were not independently associated with PRH: age, hypertension, poor consciousness, antihemostatic factors (thrombocytopenia, coagulopathy, and use of antithrombotic drugs), the location and size of the sICH, other radiographic findings (black hole sign and blend sign), surgical duration and procedures, and early surgery.

CONCLUSIONS

The spot sign is likely to be a strong predictor of PRH after EEH among patients with sICH. Complete and careful control of bleeding in the operative field should be ensured when surgically treating such patients. New surgical strategies and procedures might be needed to improve these patients' outcomes.

Postoperative subdural hematoma with blood flow from an epidural hematoma through a tear at the suture point of an artificial dura substitute

OBJECTIVE

We have recently seen cases of postoperative epidural and subdural hematomas after duraplasty with an artificial dura substitute. In these cases, the epidural hematoma flowed into the subdural space through a tear at the suture point of the artificial dura substitute. In this study, whether such hematomas are specific to a certain artificial dura substitute was investigated, and the cause and risk factors were examined.

METHODS

In our institute, 46 patients underwent brain tumor extirpation with duraplasty with an artificial dura substitute; Gore-Tex and SEAMDURA were used as the artificial dura substitutes. Patients with postoperative hemorrhage after brain tumor extirpation with duraplasty with an artificial dura substitute were retrospectively analyzed. Moreover, suture strength was compared experimentally between Gore-Tex and SEAMDURA.

RESULTS

In patients who underwent brain tumor extirpation with duraplasty with an artificial dura substitute, the rate of postoperative hemorrhage was 8.6%. Epidural and subdural hematomas were seen in four patients after tumor extirpation with duraplasty with SEAMDURA, but there were none with Gore-Tex. Exposure of the superior sagittal sinus at craniotomy, older age, and longer operative time were seen more frequently in patients with hematoma than in patients without hematoma. The strength of the suture point was significantly weaker with SEAMDURA than with Gore-Tex (P = 0.00016).

CONCLUSIONS

Postoperative epidural and subdural hematomas seem to be specific for SEAMDURA and may be caused by the weak suture strength of SEAMDURA. In cases of duraplasty, a nonabsorbable artificial dura substitute may be suitable.

Complications in Patients Undergoing Microsurgical Clipping of Intracranial Aneurysms with Pre-existing Ventriculoperitoneal Shunts Following a Cranial Procedure

INTRODUCTION

Patients with ventriculoperitoneal/pleural (VP) shunts occasionally must undergo subsequent craniotomy, craniectomy, or cranioplasty. Due to changes in pressure dynamics following shunt placement, we hypothesized that such patients may have an increased risk of developing symptomatic collections of extra-axial blood, fluid, and/or air postoperatively, leading to longer stays and worse outcomes compared to those undergoing cranial operations without a VP shunt.

METHODS

From a retrospective cohort of patients who underwent cranial operations for management of cerebral aneurysms in 2005-2014, we identified patients who previously had a VP shunt placed, determined the temporal relationship between shunt placement and cranial operation, and investigated outcomes in those with and without a shunt.

RESULTS

Of 818 patients who underwent cranial operations, 28 (3.4%) had a VP shunt. Four of these 28 (14.3%, 95% confidence interval [CI] 4.0%-32.7%) developed postoperative complications, compared to 42 of 790 (5.3%, 95% CI 4.0%-7.1%) without a history of VP shunt (P = .07). In addition, patients with a shunt were more likely to have longer cranial procedures (P = .04), longer hospital stays (P = .05), and more computed tomography scans during their craniotomy-associated admission (P = .002). Multivariate analysis, though not significant, demonstrated that the presence of a shunt contributed to the development of complications (odds ratio [OR] 2.24, 95% CI .70-7.13, P = .17). Length of surgery (OR 1.17, 95% CI 1.04-1.31, P = .01) and length of stay (OR 1.04, 95% CI 1.01-1.07, P = .01) were significantly longer in those with a postoperative complication.

CONCLUSION

We found a nonsignificant trend toward increased postoperative complications in patients with a VP shunt who underwent a subsequent cranial operation.

Mild hemophilia A presaged by recurrent postoperative hemorrhagic complications in an elderly patient

Background:

Mild hemophilia without spontaneous bleeding can remain undiagnosed for a lifetime. However, intracranial hemorrhage is one of the most serious complications for patients with hemophilia. In addition, hemorrhagic complications after emergency surgery tend to arise from coagulopathy.

Case Description:

An 80-year-old man was admitted with left hemiparesis and disturbed consciousness. He had no history of trauma, fever, or drug and alcohol intake. Computed tomography imaging upon admission disclosed a hemispheric subdural hematoma with a midline shift. No vascular abnormalities were identified as a source of the hemorrhage. The hematoma was removed on an emergency basis with external decompression. However, a large subcutaneous hematoma was again evident on the following day. Insufficient hemostatic maneuvers during surgery were considered the cause of this hemorrhagic complication. A second operation was performed to achieve hemostasis of the subcutaneous and muscle tissue. Thereafter, he was rehabilitated without treatment for hemophilia as he had no bleeding episodes. Cranioplasty proceeded using artificial bone at 40 days after the first operation. However, epidural hematoma developed again on postoperative day 1. His neurological status did not worsen so a repeat procedure was unnecessary. Close scrutiny uncovered a diagnosis of mild hemophilia A.

Conclusions:

Accurate diagnosis is important for the management of postoperative hemorrhagic complications caused by pathologies of the coagulation system. Sufficient hemostasis of hemorrhage from subcutaneous and muscle tissue is essential even during emergency surgery to avoid postoperative complications. A diagnosis of hemophilia should be considered in the face of prolonged activated partial thromboplastin time (APTT).

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study

OBJECTIVE

We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders.

METHODS

Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only).

RESULTS

The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy.

CONCLUSIONS

POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH.

Routine early CT scanning after craniotomy: is it effective for the early detection of postoperative intracranial hematoma?

BACKGROUND

Postoperative intracranial hematoma (POIH) is a frequent sequela secondary to cranial surgery. The role of routine early postoperative computed tomography (CT) scanning in the detection of POIH remains controversial. The study was aimed at analyzing the effect of routine early CT scanning after craniotomy for the early detection of POIH.

METHODS

Routine early postoperative CT scanning was performed at our institute, and a retrospective study was conducted to analyze the data. POIH was defined as an intracranial hematoma requiring surgical management.

RESULTS

A total of 1,148 patients undergoing craniotomy were included in this study; 28 of these patients developed POIH. The majority of POIH cases (15/28, 54 %) were detected during the first 6 h following craniotomy. A routine CT scan was performed on all included patients but two; however, CT scans detected only 16 POIH cases. During the first 6 h, the rate at which CT scans detected POIH was 1.9 % (15/786); subsequently, the rate decreased to only 0.3 % (1/360; p < 0.05, compared with the rate during the first 6 h). Among patients without clinical manifestations, the rate at which the routine post-craniotomy CT scan detected POIH was only 0.7 % (5/721) (p < 0.05, compared with the incidence of POIH). Finally, among high-risk POIH patients, the POIH-positive rate of routine CT scanning was elevated.

CONCLUSIONS

It appears that routine early CT scan is ineffective for the detection of POIH in patients undergoing craniotomy. However, if the strategy for routine scanning can be improved, its effect may be beneficial.

Complications of Neurosurgery

PURPOSE OF REVIEW

This article provides an overview of the major neurologic complications of common neurosurgical and endovascular procedures.

RECENT FINDINGS

Brain edema, seizures, postoperative hemorrhage, and cerebral ischemia can complicate neurosurgical procedures and produce neurologic decline. The high variability of reporting, types of operations, patient characteristics, and acuity of cases make estimating the incidence and severity of complications difficult. Overall, the complication rate of neurosurgical procedures is approximately 14%, but these are commonly systemic complications (eg, bleeding requiring transfusion, need for mechanical ventilation). In addition to intracranial hemorrhage, ischemia, and seizures after craniotomies, additional characteristic complications include hyperperfusion syndrome and cranial nerve palsies after carotid endarterectomy, cerebrospinal fluid leaks and aseptic meningitis after posterior fossa surgery, and arterial dissections or groin hematomas after endovascular procedures.

SUMMARY

Neurologic decline can be caused by a variety of causes in the postoperative period. The indication for surgery, type of surgery, and time of decline is helpful in narrowing the differential diagnosis. Brain edema, elevated intracranial pressure (ICP), seizures, intracranial hemorrhage, ischemic infarction, and cranial nerve palsies are some of the more common complications in patients that neurologists may be asked to evaluate or comanage in the postoperative setting.

Postoperative care of the neurosurgical patient

PURPOSE OF REVIEW

Monitoring and therapy of patients in neurocritical care are areas of intensive research and the current evidence needs further confirmation.

RECENT FINDINGS

A consensus statement of the Neurocritical Care Society and the European Society of Intensive Care Medicine provided pragmatic guidance and recommendations for multimodal monitoring in neurocritical care patients. Only a minority of these recommendations have strong evidence. In addition, recent multicenter randomized controlled trials concerning the therapy of subarachnoidal hemorrhage and traumatic brain injury could not show decreased mortality or improved functional neurologic outcome after the interventions. The current evidence for monitoring and medical therapy in patients after traumatic brain injury and aneurysmal subarachnoid hemorrhage is highlighted in this review.

SUMMARY

Although strong evidence is lacking, multimodal monitoring is of great value in neurocritical care patients and may help to provide patients with the optimal therapy based on the individual pathophysiological changes.

Incidence of Intracranial Hemorrhage After a Cranial Operation

Objective

To describe the characteristics of patients who underwent a cranial operation and postoperatively suffered an intracranial hemorrhage significant enough to require evacuation.

Materials & methods 

3,109 cranial operations were performed at Houston Methodist Hospital (Texas Medical Center campus) between January 2009 and December 2013. Of these, 59 cases required a second operation for evacuation of an intracranial hemorrhage. The information gathered included the patients’ age, gender, past medical history, medications and laboratory data, initial diagnosis, date/type of first and second operations, duration of hospitalization, discharge condition, and discharge destination.

Results

The study found a 1.90% rate of a postoperative hemorrhage significant enough to require evacuation after a cranial operation. The average age in the cohort requiring reoperation was 63 +/- 14 years with 42 male and 17 female. Hematoma evacuations were performed at various time intervals depending on the pathology treated at the initial operation. The time to second operation was 2.7 days after intraparenchymal hematoma evacuation, 6.0 days after cerebrovascular surgery, 6.2 days after tumor surgery and 9.7 days after subdural hematoma evacuation. The rate of postoperative hematoma development was 9.1% after a subdural hematoma evacuation, while it was only 1.1% in all other operations. Overall, those requiring hematoma evacuation had a 15% mortality rate, 64% were non-ambulatory, and 54% were discharged to long-term acute care facility, skilled nursing facility, rehabilitation facility or hospice.

Conclusions 

Neurological outcomes were poor in patients who underwent a cranial operation and required a second operation to remove a hematoma. This study suggests close observation of elderly males after a cranial operation, especially after subdural hematoma evacuation, and longer observation time for patients undergoing subdural hematoma evacuation than intraparenchymal hematoma evacuation, tumor surgery or cerebrovascular surgery.

An Improved One-Stage Operation of Cranioplasty and Ventriculoperitoneal Shunt in Patient with Hydrocephalus and Large Cranial Defect

Objective

The risk of complications is high for patients with a large cranial defect and hydrocephalus, undergoing cranioplasty and ventriculoperitoneal (VP) shunt operation. The purpose of this study is to examine retrospectively such cases with complications and contrive an operative technique to reduce complications.

Methods

Nineteen patients underwent cranioplasty and VP shunt operation due to large cranial defects and hydrocephalus. These patients were divided into two groups: Group A with 10 patients who underwent staged-operations, and Group B with 9 patients who underwent one-stage operation. Their complications in each group were retrospectively reviewed. Another five patients underwent a one-stage operation with temporary occlusion of the distal shunt catheter to improve on the technique and were categorized as Group C. Complications in these groups were compared and analyzed.

Results

The results of the data analysis revealed that complications related to anesthesia (40%) and those related to antibiotic prophylaxis (30%) were high in Group A, while non-infectious delayed complications (45%) and perioperative complications such as intracranial hematoma (33%) were high in Group B. However, for patients in Group C, it showed less complication with the operative technique devised by these authors, as opposed to two previous procedures.

Conclusion

In patients with hydrocephalus and a large cranial defect, complications arising from existing one-stage operation or staged-operations can be reduced by implementing the technique of "one-stage operation with temporary occlusion of the distal shunt catheter."

Hemostatic and hemorrhagic problems in neurosurgical patients

BACKGROUND

Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years.

METHOD

The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery.

FINDINGS

According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided.

CONCLUSIONS

Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.

Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases

BACKGROUND

Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications.

METHODS

From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed.

FINDINGS

Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the "syndrome of the trephined" and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications.

CONCLUSIONS

The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

[Management of severe traumatic brain injury]

Severe brain injuries, most often occurring in young subjects, are a major source of lost work years. These injuries are medical and surgical emergencies. Prehospital management of severe brain injuries requires intubation and mechanical ventilation aimed at normal arterial carbon dioxide pressure. Signs of transtentorial herniation: Uni- or bilateral mydriasis requires immediate perfusion of 20% mannitol or hypertonic sodium chloride. Neurological disorders after head injury justify emergency cerebral computed tomography. The presence of a mass syndrome or signs of transtentorial herniation are in principle indications for surgery. Specialized hospital management is essential. In the case of refractory intracranial hypertension, the cerebral perfusion pressure and osmotherapy should be adapted to the volume of the cerebral contusion. The use of deep hypothermia and barbiturates should be minimized as much as possible. Magnetic resonance imaging makes it possible to identify the cerebral lesions.

The effect of fresh frozen plasma in severe closed head injury

OBJECTIVE

Traumatic brain injury (TBI) is one of the most common causes of morbidity and mortality. Coagulopathy, commonly occurring after severe TBI, is associated with poor outcome and secondary complications, especially delayed traumatic intracerebral hematoma (DTICH). In this study we evaluated the effect of fresh frozen plasma (FFP) on the reduction in the incidence of DTICH in severe closed head injury victims.

METHODS

This study was carried out as a double-blind randomized clinical trial. Ninety patients were entered in two parallel groups taking either FFP or normal saline (N/S). Patients' selection criteria for both groups were: severe closed head injury (Glasgow coma scale < or =8), no mass lesion required evacuation and no history of coagulopathy. The clinical findings, laboratory data, computed tomography (CT) scans and Glasgow outcome scale after 1 month were assessed and compared in two groups.

RESULTS

Out of 90 patients, 44 received FFP and 46 received N/S. The development of new intracerebral hematoma in follow-up CT scans were more common in the FFP group than the N/S group (p=0.012). Both groups showed similar frequency of poor outcome (p=0.343). The mortality was significantly more common in the FFP group than in the N/S group (63% versus 35%, p=0.006).

CONCLUSION

The result of this study revealed that early empirical infusion of FFP in patients with severe head injury may lead to adverse effects, such as an increase in the frequency of DTICH and an increase in the mortality.

A review of the current management of severe traumatic brain injury

Traumatic brain injury accounts for up to half of trauma related fatalities. This review describes current management practices including pre-hospital care, surgical interventions and various treatment modalities for intracranial hypertension. The lack of class I evidence for the majority of interventions is highlighted.

Pathophysiology of posttraumatic temporal lobe lesions

BACKGROUND

Posttraumatic parenchymal lesions in the temporal lobe may cause neurologic deterioration. An analysis was made of the natural evolution of this type of lesion, with emphasis on its 2 components: hemorrhage (hyperdense on computed tomography [CT]), and edema and necrosis (hypodense on CT). The clinical repercussions were studied, and the factors that might influence such evolution were investigated.

METHODS

Forty head-injured patients with temporal lobe lesions admitted within 12 hours after the injury were selected in a prospective manner. Computed tomography scans were systematically repeated within the first 36 hours and at 7 and 30 days postinjury. Factors such as interval between injury and the first CT scan, age, velocity of the injury, alcohol consumption, coagulation abnormalities, and the presence of decompressive measures were compared between the patients that had enlargement of the hemorrhage and those who did not. Increase in hypodensity was compared with that in hyperdensity.

RESULTS

Fourteen patients showed enlargement of the hemorrhage. In all cases but one, the interval between injury and admission was 3 hours or less. Other factors had no statistical significance as predisposing causes for such enlargement. In approximately half of the cases, the hypodense component increased in the first 36 hours and continued increasing until the end of the first week. Evolution of the hypodense component was not dependent on behavior of the hemorrhage, surgical drainage, or diameter of the hemorrhagic lesion.

CONCLUSIONS

The natural evolution of the hyperdense component of temporal lobe lesions was to enlarge within the first few hours after the injury. Edema and necrosis developed more slowly and with no significant clinical manifestations.

Subsequent Development of Thrombocytopenia and Coagulopathy in Moderate and Severe Head Injury: Support for Serial Laboratory Examination

BACKGROUND

Patients with moderate and severe traumatic brain injury (TBI) are at risk for secondary brain insults such as thrombocytopenia and coagulopathy. This study assessed the development of thrombocytopenia and coagulopathy at admission and within the subsequent 72 hours after TBI.

METHODS

Blunt trauma patients with moderate or severe TBI and an extracranial Abbreviated Injury Scale score less than 3 were reviewed. Data collection included initial and subsequent prothrombin time, partial thromboplastin time, and platelet values.

RESULTS

On initial evaluation, thrombocytopenia was present in 14% and coagulopathy in 21% of patients. By the third day, thrombocytopenia and coagulopathy increased to 46% and 41%, respectively. Of patients who died, 67% had thrombocytopenia and 62% had coagulopathy.

CONCLUSION

Patients with moderate and severe TBI are at risk for thrombocytopenia and coagulopathy, not only at admission but also on subsequent laboratory examination. Repeat laboratory evaluation is warranted even if initial results are normal in this population.

Epidural haematoma after evacuation of contralateral subdural haematoma

BACKGROUND

Sequentially evolving intracranial bilateral haematomas, where the second haematoma develops after the surgical removal of the first one is rarely reported.

AIM

To report a patient who developed an epidural haematoma after evacuation of a contralateral subdural haematoma.

METHODS

A 49-year-old male was admitted to our department after head injury. A brain computerized tomography (CT) scan revealed an acute subdural haematoma in the right temporal area which was evacuated. During his stay in the intensive care unit, he was submitted to intracranial pressure monitoring, which soon rose.

RESULTS

A new CT scan showed an acute epidural haematoma in the contralateral parietal area that was also evacuated.

CONCLUSIONS

While rising intracranial pressure after the evacuation of a traumatic haematoma is usually attributed to brain oedema or recurrent haematoma at the craniotomy site, the development of a contralateral epidural haematoma requiring surgical treatment should not be overlooked.

High intraoperative blood loss may be a risk factor for postoperative hematoma

The authors studied the incidence of postoperative intracranial hematoma to improve care after intracranial surgery. Five years (1995-1999) of surgical records were analyzed retrospectively. Patients were included if evacuation of an intracranial postoperative hematoma was reported. A control group was randomly selected. Forty-nine patients (0.8%) had postoperative hematomas requiring evacuation. The amount of intraoperative blood loss was significantly larger in the hematoma group (762 +/-735 mL [median 500 mL]) than in the control group (415 +/-403 mL; median 300 mL) (P = 0.004). Clinical deterioration occurred within the first 24 hours in 80%, within 6 hours in 51%, and within 1 hour in 12% of the patients. Those who deteriorated within 24 hours had a faster and more life-threatening deterioration than those who had a hematoma after 24 hours. A decreased level of consciousness was found in 61% and increased focal neurologic signs were found in 33% of the patients. An elevated intracranial pressure was seen significantly more often in the hematoma group (9/10 patients, 90%) than in the control group (1/8 patients, 12.5%) (P = 0.001). In this study, a large amount of intraoperative blood loss and elevated intracranial pressure were warning signs of postoperative hematoma and should alert the clinician to the increased risk. Most hematomas occurred within 24 hours after surgery, and in this time period the deterioration was more severe compared with the hematomas that occurred later.

Risk factors for intraoperative hypotension in traumatic intracranial hematoma

Patients suffering from traumatic intracranial hemorrhage (TICH) may experience an episode of catastrophic intraoperative hypotension (IHT), after decompression of the brain. The aim of this study was to investigate the risk factors for IHT during emergency craniotomy A total of 67 patients, who underwent emergency craniotomy due to TICH, were divided into two groups: IHT ( n=31 ) or without IHT ( n=36 ). Data concerning (1) age; (2) gender; (3) mechanism of injury; (4) Glasgow Coma Scale (GCS) on admission; (5) abnormality of the pupils (anisocoria or mydriasis); (6) mean arterial blood pressure; (7) heart rate; (8) time elapsed before craniotomy from injury; (9) initial brain CT scans; (10) duration of craniotomy; and (11) total infusion or urine volume until craniotomy were collected prospectively as IHT risk factors. Low GCS score (<5), tachycardia (heart rate >112min(-1)) and hypertension (mean blood pressure >131mmHg) before emergency craniotomy were strongly ( P<0.05 ) associated with IHT. Delayed surgery (>173min until craniotomy) also had a significant ( P<0.005 ) effect on IHT. The risk factors for IHT were considered as a low GCS score on admission, tachycardia, hypertension before emergency craniotomy and delayed surgery. These results suggested the patients with IHT had a high sympathetic tone before emergency craniotomy A sudden reduction in sympathetic tone after surgical decompression of the brain might cause IHT. We concluded that an important factor in the occurrence of IHT was not only the injury severity, but also the balance between sympathetic and parasympathetic activity before decompression surgery.

Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity: implications of a prospective study

BACKGROUND AND PURPOSE

The functional integrity of the hemostatic system is a prerequisite for the safe performance of neurosurgical procedures. To monitor the individual coagulation capacity of each patient, standard tests are effective to detect deficiencies involving the generation of fibrin. However, fibrin clot strength depends primarily on coagulation factor XIII, which cross-links fibrin monomers and enhances clot resistance against fibrinolysis. Therefore, factor XIII is functionally involved in both the hemostatic and fibrinolytic systems. The objective of this prospective study was to determine the incidence and clinical relevance of perioperative decreased factor XIII with respect to standard coagulation parameters and the occurrence of postoperative hematoma.

METHODS

In 876 patients, 910 neurosurgical procedures were performed. Prothrombin time (PT), partial thromboplastin time (PTT), platelet count, fibrinogen, and factor XIII were tested in each patient preoperatively and postoperatively.

RESULTS

Postoperative intracranial hematoma (defined as requiring surgical evacuation) occurred after 39 (4.3%) of 910 surgical procedures. Patients with postoperative hematoma had significantly lower factor XIII and fibrinogen levels preoperatively and postoperatively than patients without hematoma. In patients with postoperative hematoma, PT and platelets differed significantly only postoperatively, whereas PTT was different neither preoperatively nor postoperatively. Of the 39 patients with a postoperative hematoma, 13 (33.3%) had a postoperative factor XIII <60% compared with 61 (7%) of 867 patients without hematoma (P<0.01, Fisher's exact test). The relative risk of developing a postoperative hematoma is therefore increased 6.4-fold in patients with postoperative factor XIII <60%. The risk is increased 12-fold in patients who additionally have postoperative decreased fibrinogen levels (<1.5 g/L) and 9-fold in patients with platelet count <150x10(9)/L and factor XIII <60%.

CONCLUSIONS

This is the first prospective study that demonstrates the association of decreased perioperative factor XIII with an increased risk of postoperative hematoma in neurosurgical patients. The risk is further increased in those patients with low factor XIII and additional abnormalities of fibrinogen, PT, platelets, and PTT. Factor XIII testing and specific replacement, as accepted for other clotting factors, may reduce the risk of postoperative hematoma.

Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury

OBJECT

Progressive intracranial hemorrhage after head injury is often observed on serial computerized tomography (CT) scans but its significance is uncertain. In this study, patients in whom two CT scans were obtained within 24 hours of injury were analyzed to determine the incidence, risk factors, and clinical significance of progressive hemorrhagic injury (PHI).

METHODS

The diagnosis of PHI was determined by comparing the first and second CT scans and was categorized as epidural hematoma (EDH), subdural hematoma (SDH), intraparenchymal contusion or hematoma (IPCH), or subarachnoid hemorrhage (SAH). Potential risk factors, the daily mean intracranial pressure (ICP), and cerebral perfusion pressure were analyzed. In a cohort of 142 patients (mean age 34 +/- 14 years; median Glasgow Coma Scale score of 8, range 3-15; male/female ratio 4.3: 1), the mean time from injury to first CT scan was 2 +/- 1.6 hours and between first and second CT scans was 6.9 +/- 3.6 hours. A PHI was found in 42.3% of patients overall and in 48.6% of patients who underwent scanning within 2 hours of injury. Of the 60 patients with PHI, 87% underwent their first CT scan within 2 hours of injury and in only one with PHI was the first CT scan obtained more than 6 hours postinjury. The likelihood of PHI for a given lesion was 51% for IPCH, 22% for EDH, 17% for SAH, and 11% for SDH. Of the 46 patients who underwent craniotomy for hematoma evacuation, 24% did so after the second CT scan because of findings of PHI. Logistic regression was used to identify male sex (p = 0.01), older age (p = 0.01), time from injury to first CT scan (p = 0.02), and initial partial thromboplastin time (PTT) (p = 0.02) as the best predictors of PHI. The percentage of patients with mean daily ICP greater than 20 mm Hg was higher in those with PHI compared with those without PHI. The 6-month postinjury outcome was similar in the two patient groups.

CONCLUSIONS

Early progressive hemorrhage occurs in almost 50% of head-injured patients who undergo CT scanning within 2 hours of injury, it occurs most frequently in cerebral contusions, and it is associated with ICP elevations. Male sex, older age, time from injury to first CT scan, and PTT appear to be key determinants of PHI. Early repeated CT scanning is indicated in patients with nonsurgically treated hemorrhage revealed on the first CT scan.

Complications of head injury

Management of head injury is based on two concepts, proper treatment of the acute insult and the prevention and treatment of secondary insults. The head injured patient is subject to both intracranial and extracranial secondary insults. This paper will review complications related to the central nervous system as well as the pulmonary, infectious, gastrointestinal, and psychiatric complications frequently seen following traumatic brain injury. Complications following head trauma lead to significant acute and chronic morbidity and mortality. It is essential that clinicians be able to recognize and treat these complications in order to more effectively manage head trauma, improve outcome, and care for patients.

Ethanol reduces metabolic uncoupling following experimental head injury

Previous investigations have shown that ethanol is neuroprotective following experimental traumatic brain injury (TBI). This study sought to determine if the neuroprotective effects of ethanol in a controlled cortical impact (CCI) injury model are related to its effects on cerebral glucose metabolism and blood flow. Adult rats were given ethanol (1.0 g/kg) or saline by intraperitoneal injection followed 40 min later by injury. Regional cerebral blood flow (CBF) and cerebral metabolic rates of glucose (CMRglc) were determined immediately, and at 3, 6, 12, 24, and 72 h postinjury using quantitative autoradiography. Immediately after injury, CMRglc in the contusion core and penumbra was reduced in the ethanol group compared to the saline group: (core CMRglc: 52.2 +/- 16.0 versus 94.2 +/- 14.1 micromol/100 g/min, respectively,p < 0.001; penumbral CMRglc: 58.2 +/- 12.8 versus 82.8 +/-19.7 micromol/100 g/min, respectively; p < 0.05) However, at 24 and 72 h postinjury, penumbral CMRglc in the ethanol group was increased compared to the saline group (p < 0.05 and p < 0.001, respectively). Regarding CBF, contusion core values in the ethanol group were elevated compared to the saline group immediately postinjury, (70.4 +/- 17.1 versus 31.5 +/- 27.8 mL/100 g/min, respectively (p < .05), and at 6, 12, and 24 h postinjury (p < 0.05). Penumbral CBF was also higher at 6 and 72 h in the ethanol group compared to the saline group (p < 0.05). These results indicate that low-dose ethanol is associated with a marked attenuation of immediate postinjury hyperglycolysis and with more normal glucose metabolism in the injury penumbra over the ensuing 3 days. Simultaneously, the reduction in CBF typically seen within the contusion core and penumbra after CCI is less severe when ethanol is present. The net effect of these changes is a decreased degree of uncoupling between glucose metabolism and CBF that otherwise occurs in the absence of ethanol. These changes may likely explain the neuroprotective effect of ethanol.

Paradoxical effects of acute ethanolism in experimental brain injury

Acute ethanol intoxication is a frequent complicating factor in human head injury, yet its impact on neurological outcome remains poorly defined. This study was undertaken to assess the effect of varying levels of preinjury ethanol on early postinjury mortality, recovery of motor function, and degree of neural degeneration after cortical contusion injury in the rat. Adult rats were pretrained on a beam-walking task, then randomized to one of five groups: low-dose ethanol and injury (1 g/kg, 16 animals); moderate-dose ethanol and injury (2.5 g/kg, 11 animals); high-dose ethanol and injury (3 g/kg, 17 animals); no ethanol and injury (nine animals); or ethanol and sham injury (seven animals). Forty minutes after intraperitoneal injection of ethanol or saline, the rats received a pneumatic piston-induced contusion injury of the left primary motor cortex. Their beam-walking ability was assessed daily for the next 7 days. At 4 weeks postinjury, the brains were sectioned and the dimensions of the cortical lesions were determined. Preinjury ethanol administration was associated with an acute postinjury mortality rate of 29.5% (p < 0.05); the highest mortality rate (47.1%) occurred in the high-dose ethanol group, whereas no deaths occurred in the animals in the no ethanol or sham-injured groups (p < 0.01). However, injured animals receiving low- and moderate-dose ethanol had significantly less severe beam-walking impairment initially, and a more rapid return to normal beam-walking ability, compared to the no and high-dose ethanol groups (p < 0.05). Additionally, the mean lesion volumes were significantly smaller in the low- and moderate-dose ethanol treatment groups compared to the no and high-dose ethanol groups (23.2 +/- 8 mm3 and 29 +/- 6.7 mm3 vs. 52 +/- 8.8 mm3 and 53.7 +/- 10.9 mm3, respectively, p < 0.01). In this cortical contusion model, the presence of ethanol before injury appears to exert a potent neuroprotective effect when administered in low or moderate doses. This action is postulated to result from ethanol-induced inhibition of N-methyl-D-aspartate receptor-mediated excitotoxicity. The loss of neuroprotection and increased mortality rates observed with high-dose ethanol may be related to ethanol-induced hemodynamic and respiratory depression.

Sequential computerized tomography changes and related final outcome in severe head injury patients

The authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan. 92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%). Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes. Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.

Alcohol and head injury: an issue revisited

The pathophysiologic changes associated with acute and chronic alcohol exposure in the setting of traumatic brain injury are complex. Experimental data indicate that ethanol intoxication can exacerbate brain injury through several mechanisms including hemodynamic and respiratory depression, blood-brain barrier disruption, and derangements in hemostasis. Alcohol, however, is also a potent inhibitor of N-methyl-D-aspartate (NMDA) receptor-mediated excitotoxicity, and thus is neuroprotective. In contrast to the effects of acute intoxication, chronic alcohol exposure appears to result in upregulation of NMDA receptor activity and downregulation of gamma-aminobutyric acid (GABA) receptor function. This imbalance, it is hypothesized, can result in a surge of excitotoxicity following alcohol withdrawal. Trauma-related excitotoxic cell damage may be significantly potentiated by this alcohol-induced receptor imbalance that is unmasked as withdrawal occurs. Clinical and epidemiologic investigations of alcohol and outcome after head injury have not consistently demonstrated a measurable effect from either acute or chronic alcohol use. Multiple factors including the timing of intoxication in relation to time of injury, the degree and chronicity of intoxication, as well as the influence of other secondary injury processes appear to determine the net effect of alcohol in a given individual. Further clinical and experimental investigations aimed at defining the impact of alcohol use on outcome after head injury are warranted.

Early detection of delayed traumatic intracranial hematomas using near-infrared spectroscopy

Delayed intracranial hematomas are an important treatable cause of secondary brain injury in patients with head trauma. Early identification and treatment of these lesions, which appear or enlarge after the initial computerized tomography (CT) scan, may improve neurological outcome. Serial examinations using near-infrared spectroscopy (NIRS) to detect the development of delayed hematomas were performed in 167 patients. The difference in absorbance of light (delta OD) at 760 nm between the normal and the hematoma side was measured serially during the first 3 days after injury. Twenty-seven (16%) of the patients developed a type of late hematoma: intracerebral hematoma in eight, extracerebral hematoma in six, and postoperative hematoma in 13 patients. Eighteen of the delayed hematomas caused significant mass effect and required surgical evacuation. The hematomas appeared between 2 and 72 hours after admission. In 24 of the 27 patients, a significant increase (> 0.3) in the delta OD occurred prior to an increase in intracranial pressure, a change in the neurological examination, or a change on CT scan. A favorable outcome occurred in 67% of the patients with delayed hematomas, which suggests that early diagnosis using NIRS may allow early treatment and reduce secondary injury caused by delayed hematomas.

A new application for near-infrared spectroscopy: detection of delayed intracranial hematomas after head injury

Clinical studies have documented the importance of secondary brain insults in determining neurologic outcome after head injury. Delayed intracranial hematomas are one of the most easily remediable causes of secondary injury if identified early, but can cause significant disability or death if not promptly recognized and treated. Early identification and treatment of these lesions that appear or enlarge after the initial CT scan may improve neurological outcome. Serial examinations using near-infrared spectroscopy (NIRS) to detect the development of delayed hematomas were obtained in 167 patients. The difference in absorbance of light (deltaOD) at 760 nm between the normal and the hematoma side was measured serially during the first 3 days after injury. Twenty-seven (16%) of the patients developed some type of late hematoma: an intracerebral hematoma in 8 patients, an extracerebral hematoma in 6 patients, and a postoperative hematoma in 13 patients. Eighteen of the delayed hematomas caused significant mass effect and required surgical evacuation. The hematomas appeared between 2 and 72 h after admission. In 24 of the 27 patients, a significant increase (>0.3) in the deltaOD occurred prior to an increase in intracranial pressure or a change in the neurological examination, or a change on CT scan. Early diagnosis using MRS may allow early treatment and reduce secondary injury caused by delayed hematomas.