Progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage: characteristics, risk factors and impact on management

BACKGROUND

Progressive hemorrhagic injury (PHI) is a common occurrence in clinical practice; however, how PHI affects clinical management remains unclear. We attempt to evaluate the characteristics and risk factors of PHI and also investigate how PHI influences clinical management in traumatic intracerebral hemorrhage (TICH) patients.

METHODS

This retrospective study included a cohort of 181 patients with TICH who initially underwent conservative treatment and they were dichotomized into a PHI group and a non-PHI group. Clinical data were reviewed for comparison. Multivariate logistic regression analysis was applied to identify predictors of PHI and delayed operation.

RESULTS

Overall, 68 patients (37.6%) experienced PHI and 27 (14.9%) patients required delayed surgery. In the PHI group, 17 patients needed late operation; in the non-PHI group, 10 patients received decompressive craniectomy. Compared to patients with non-PHI, the PHI group was more likely to require late operation (P = 0.005, 25.0 vs 8.8%), which took place within 48 h (P = 0.01, 70.6 vs 30%). Multivariate logistic regression identified past medical history of hypertension (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 2.04-10.45), elevated international normalized ratio (INR) (OR = 20.93; 95% CI 7.72-71.73) and linear bone fracture (OR = 2.11; 95% CI = 1.15-3.91) as independent risk factors for PHI. Hematoma volume of initial CT scan >5 mL (OR = 3.80; 95% CI = 1.79-8.44), linear bone fracture (OR = 3.21; 95% CI = 1.47-7.53) and PHI (OR = 3.49; 95% CI = 1.63-7.77) were found to be independently associated with delayed operation.

CONCLUSIONS

Past medical history of hypertension, elevated INR and linear bone fracture were predictors for PHI. Additionally, the latter was strongly predictive of delayed operation in the studied cohort.

Perinatal brain damage causation

The search for causes of perinatal brain damage needs a solid theoretical foundation. Current theory apparently does not offer a unanimously accepted view of what constitutes a cause, and how it can be identified. We discuss nine potential theoretical misconceptions: (1) too narrow a view of what is a cause (causal production vs. facilitation), (2) extrapolating from possibility to fact (potential vs. factual causation), (3) if X, then invariably Y (determinism vs. probabilism), (4) co-occurrence in individuals vs. association in populations, (5) one cause is all that is needed (single cause attribution vs. multicausal constellations), (6) drawing causal inferences from very small numbers of observations (the tendency to generalize), (7) unstated causal inferences, (8) ignoring heterogeneity, and (9) failing to consider alternative explanations for what is observed. We hope that our critical discussion will contribute to fruitful research and help reduce the burden of perinatal brain damage.

[Emergency ward management of traumatic head injury in children]

BACKGROUND

The controversial situation relating to assessment and management of the traumatic head injury (THI) in children inspired us to study our own patient pool. The aims were to find a significant correlation between skull fracture or clinical symptom and intracranial lesion as well as to determine the importance of each radiological diagnostic method in the initial management of the pediatric THI.

PATIENTS AND METHODS

In 1 year 1,637 children had been treated in the emergency room of pediatric surgery with the diagnosis of THI. Age, sex, injury pattern, symptoms, radiological diagnostic methods, diagnosis, and clinical follow-up had been registered.

RESULTS

A significant correlation between skull fracture or clinical symptom and the intracranial injury in children could not be found, but risk factors exist. Cranial computed tomography is the imaging method of choice. X-ray, ultrasound, and MRI of the head are reserved for a few indications.

CONCLUSION

A management plan for pediatric head and brain injury in the emergency room based on our own and published international results is introduced.

Routine repeat head CT for minimal head injury is unnecessary

BACKGROUND

Patients with MHI and a positive head computed tomography (CT) scan frequently have a routine repeat head CT (RRHCT) to identify possible evolution of the head injury requiring intervention. RRHCT is ordered based on the premise that significant injury progression may take place in the absence of clinical deterioration.

METHODS

In a Level I urban trauma center with a policy of RRHCT, we reviewed the records of 692 consecutive trauma patients with Glasgow Coma Scale scores of 13-15 and a head CT (October 2004 through October 2005). The need for medical or surgical neurologic intervention after RRHCT was recorded. Patients with a worse and unchanged RRHCT were compared, and independent predictors of a worse RRHCT were identified by stepwise logistic regression.

RESULTS

There were 179 patients with MHI and RRHCT ordered. Of them, 37 (21%) showed signs of injury evolution on RRHCT and 7 (4%) required intervention. All 7 had clinical deterioration preceding RRHCT. In no patient without clinical deterioration did RRHCT prompt a change in management. A Glasgow Coma Scale score less than 15 (13 or 14), age higher than 65 years, multiple traumatic lesions found on first head CT, and interval shorter than 90 minutes from arrival to first head CT predicted independently a worse RRHCT.

CONCLUSIONS

RRHCT is unnecessary in patients with MHI. Clinical examination identifies accurately the few who will show significant evolution and require intervention.

Expanding traumatic intracerebral contusion/hematoma

BACKGROUND AND AIMS

Delayed traumatic hematomas and expansion of already detected hematomas are not uncommon. Only few studies are available on risk factors of expanding hematomas. A prospective study was aimed to find out risk factors associated with such traumatic lesions.

MATERIALS AND METHODS

Present study is based on 262 cases of intracerebral hematomas / contusions out of which 43 (16.4%) hematomas expanded in size. computerized tomography (CT) scan was done in all the patients at the time of admission and within 24 hours of injury. Repeat CT scan was done within 24 hours, 4 days and 7 days. Midline shift if any, prothrombin time, activated partial thromboplastin time, bleeding time, clotting time and platelet counts, Glasgow coma scale at admission and discharge and Glasgow outcome score at 6 months follow up were recorded.

RESULTS

Twenty six percent, 11.3 and 0% patients developed expanding hematoma in Glasgow Coma scale (GCS) of 8 and below, 9-12 and 13-15 respectively. The chances of expanding hematomas were higher in patients with other associated hematomas (17.4%) as compared to isolated hematoma (4.8%) (Fisher's exact results P =0.216). All the cases of expanding hematoma had some degree of midline shift and considerably higher proportion had presence of coagulopathy. The results of logistic regression analysis showed GCS, midline shift and coagulopathy as significant predictors for the expanding hematoma. Thirty nine patients (90.7%) of the total expanding hematomas developed within 24 hours of injury.

CONCLUSIONS

Enlargement of intracerebral hematomas is quite common and majority of them expand early after the injury. These lesions were common in patients with poor GCS, associated hematomas, associated coagulopathy and midline shift.

Prospective cohort study of the association between use of low-dose oral contraceptives and stroke in Chinese women

PURPOSE

To clarify the association between use of widely distributed low-dose combined oral contraceptives (COCs) in China and the risk of stroke in order to decrease adverse reactions to COCs.

METHODS

A prospective surveillance cohort study was undertaken in 25 towns in two counties in Jiangsu Province, China. Women (44,408 ) on hormonal contraceptives (HC) and 75,230 women with an intrauterine device (IUD) were followed up from July 1997 to June 2000 to study the difference in the incidence of stroke.

RESULTS

The incidence of haemorrhagic stroke (age- and county-standardised rate) was far higher than that of ischaemic stroke (34.74 vs. 11.25 per 100,000 person years) among HC cohort. The relative risk (RR) of incidence of haemorrhagic stroke in the HC cohort (52 cases) was 2.72 times compared with that in the IUD cohort (23 cases). Compared with IUD users, the current users of HC had a higher RR of 4.20 (95%CI, 2.11-8.36) of haemorrhagic stroke, and still reached 2.17 (95%CI, 1.16-4.06) among past users after they stopped taking COCs for more than 10 years. The RR of haemorrhagic stroke was 3.09 (95%CI, 1.26-7.57) among women who had last used low-dose COCs during the previous 5 years. In women aged less than 45 years, compared to IUD users, the haemorrhagic stroke was strongly associated with current use of low-dose combined norethisterone pills, with RR being 19.06 (95%CI, 3.08-118.03).

CONCLUSIONS

There is an increased risk of haemorrhagic stroke among Chinese users of long-term low-dose oral contraceptives, which appears to persist long after discontinuation.

Catastrophic injuries in high school and college baseball players

BACKGROUND

There are few epidemiologic studies of catastrophic baseball injuries.

PURPOSE

To develop a profile of catastrophic injuries in baseball players and to describe relevant risk factors.

STUDY DESIGN

Retrospective cohort study.

METHODS

The authors reviewed 41 incidents of baseball injuries reported to the National Center for Catastrophic Sports Injury Research from 1982 until 2002.

RESULTS

There were an estimated 1.95 direct catastrophic injuries per year, or 0.43 injuries per 100,000 participants. The most common mechanisms of injury were a collision of fielders (9) or of a base runner and a fielder (8), a pitcher hit by a batted ball (14), and an athlete hit by a thrown ball (4). Catastrophic injuries included 23 severe head injuries, 8 cervical injuries, 3 cases of commotio cordis, and 2 cases each of a collapsed trachea and facial fractures. Three athletes sustained a severe head injury and facial fractures. Ten of the 41 injuries were fatalities.

CONCLUSIONS

Suggestions for reducing catastrophic injuries in baseball include teaching proper techniques to avoid fielding and baserunning collisions, protecting the pitcher via a combination of screens and/or helmets with faceguards, continued surveillance and modifications of the bat and ball, eliminating headfirst slides, and continued analysis of chest protectors and automatic external defibrillators for commotio cordis.

Is head injury a risk factor for schizophrenia?

BACKGROUND

The few studies that have examined whether head injury is a risk factor for later schizophrenia have had important methodological problems.

METHOD

We examined the rates of head injury among 8288 persons in the 15 years up to their first admission with schizophrenia and compared them with 82880 age- and gender-matched controls. We used hospitalization for concussion or severe head injury as a definition of head injury. We controlled for any generally altered accident proneness prior to schizophrenia by also comparing the groups with respect to exposition to fractures not involving the skull or spine.

RESULTS

Males with schizophrenia had significantly reduced exposure to concussion (OR = 0.864, p = 0.024), whereas females had significantly increased exposure (OR = 1.322, p = 0.025). No differences were found as regards severe head injury. Males had significantly reduced risk of other fractures (OR = 0.616, p < 0.0001), whereas the risk in females did not differ from controls (OR = 1.154, p = 0.189). After adjusting head injury with the risk for other fractures, both concussion and severe head injury were significantly increased in males (OR = 1.501, p < 0.001 and OR = 1.516. p < 0.001, respectively) but not in females (OR = 1.15, p = 0.413 and OR = 0.819, p = 0.442, respectively).

CONCLUSION

Our results do not exclude that for males, head injury may contribute to the risk for schizophrenia in a limited number of cases. This relation may also exist for females, but it is paralleled by an increased liability to traumas in general. Premorbid general accident proneness requires consideration when studying this association.