Risk of Subdural Hematoma Expansion in Patients With End-Stage Renal Disease: Continuous Venovenous Hemodialysis Versus Intermittent Hemodialysis

BACKGROUND AND OBJECTIVES

Subdural hematoma (SDH) patients with end-stage renal disease (ESRD) require renal replacement therapy in addition to neurological management. We sought to determine whether continuous venovenous hemodialysis (CVVHD) or intermittent hemodialysis (iHD) is associated with higher rates of SDH re-expansion as well as morbidity and mortality.

METHODS

Hemodialysis-dependent patients with ESRD who were discovered to have an SDH were retrospectively identified from 2016 to 2022. Rates of SDH expansion during CVVHD vs iHD were compared. Hemodialysis mode was included in a multivariate logistic regression model to test for independent association with SDH expansion and mortality.

RESULTS

A total of 123 hemodialysis-dependent patients with ESRD were discovered to have a concomitant SDH during the period of study. Patients who received CVVHD were on average 10.2 years younger ( P < .001), more likely to have traumatic SDH (47.7% vs 19.0%, P < .001), and more likely to have cirrhosis (25.0% vs 10.1%, P = .029). SDH expansion affecting neurological function occurred more frequently during iHD compared with CVVHD (29.7% vs 12.0%, P = .013). Multivariate logistic regression analysis found that CVVHD was independently associated with decreased risk of SDH affecting neurological function (odds ratio 0.25, 95% CI 0.08-0.65). Among patients who experienced in-hospital mortality or were discharged to hospice, 5% suffered a neurologically devastating SDH expansion while on CVVHD compared with 35% on iHD.

CONCLUSION

CVVHD was independently associated with decreased risk of neurologically significant SDH expansion. Therefore, receiving renal replacement therapy through a course of CVVHD may increase SDH stability in patients with ESRD.

Cerebral Amyloid Angiopathy and Risk of Isolated Nontraumatic Subdural Hemorrhage

Importance

Cerebral amyloid angiopathy (CAA) is a common cause of spontaneous intracerebral hemorrhage in older patients. Although other types of intracranial hemorrhage can occur in conjunction with CAA-related intracerebral hemorrhage, the association between CAA and other subtypes of intracranial hemorrhage, particularly in the absence of intracerebral hemorrhage, remains poorly understood.

Objective

To determine whether CAA is an independent risk factor for isolated nontraumatic subdural hemorrhage (SDH).

Design, Setting, and Participants

A population-based cohort study was performed using a 2-stage analysis of prospectively collected data in the UK Biobank cohort (discovery phase, 2006-2022) and the All of Us Research Program cohort (replication phase, 2018-2022). Participants included those who contributed at least 1 year of data while they were older than 50 years, in accordance with the diagnostic criteria for CAA. Participants with prevalent intracranial hemorrhage were excluded. Data were analyzed from October 2022 to October 2023.

Exposure

A diagnosis of CAA, identified using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code.

Main Outcomes and Measures

The outcome was an isolated nontraumatic SDH, identified using ICD-10-CM codes. Two identical analyses were performed separately in the 2 cohorts. First, the risk of SDH in patients with and without CAA was assessed using Cox proportional hazards models, adjusting for demographic characteristics, cardiovascular comorbidities, and antithrombotic medication use. Second, multivariable logistic regression was used to study the association between CAA and SDH.

Results

The final analytical sample comprised 487 223 of the total 502 480 individuals in the UK Biobank cohort and 158 008 of the total 372 082 individuals in the All of Us cohort. Among the 487 223 participants in the discovery phase of the UK Biobank, the mean (SD) age was 56.5 (8.1) years, and 264 195 (54.2%) were female. There were 649 cases of incident SDH. Of the 126 participants diagnosed with CAA, 3 (2.4%) developed SDH. In adjusted Cox regression analyses, participants with CAA had an increased risk of having an SDH compared with those without CAA (hazard ratio [HR], 8.0; 95% CI, 2.6-24.8). Multivariable logistic regression analysis yielded higher odds of SDH among participants with CAA (odds ratio [OR], 7.6; 95% CI, 1.8-20.4). Among the 158 008 participants in the All of Us cohort, the mean (SD) age was 63.0 (9.5) years, and 89 639 (56.7%) were female. The findings were replicated in All of Us, in which 52 participants had CAA and 320 had an SDH. All of Us participants with CAA had an increased risk of having an SDH compared with those without CAA (HR, 4.9; 95% CI, 1.2-19.8). In adjusted multivariable logistic regression analysis, CAA was associated with higher odds of SDH (OR, 5.2; 95% CI, 0.8-17.6).

Conclusions and Relevance

In 2 large, heterogeneous cohorts, CAA was associated with increased risk of SDH. These findings suggest that CAA may be a novel risk factor for isolated nontraumatic SDH.

Symptomatic subdural hemorrhage following heart valve surgery: a retrospective cohort study

OBJECTIVE

Subdural hemorrhage (SDH) has been reported to be the most frequent intracranial hemorrhagic complication following open heart surgery; however, its clinical features and pathophysiology remain unclear. The aim of this retrospective study was to elucidate the incidence, clinical course, and factors associated with the development of symptomatic SDH following heart valve surgery.

METHODS

A retrospective review of medical records on the development of symptomatic SDH after heart valve surgery involving cardiopulmonary bypass (CPB) from April 2011 to March 2016 was performed. Patients who had undergone preoperative cranial computed tomography (CT) or brain magnetic resonance imaging (MRI) were included in this study, and factors associated with SDH following heart valve surgery were analyzed. When neurological symptoms developed after heart valve surgery, cranial CT or brain MRI was performed.

RESULTS

A total of 556 patients who had undergone heart valve surgery were analyzed. Among these patients, symptomatic SDH occurred in 11 (2.0%). The mean duration of symptomatic onset was 10.1 days (range 2-37 days). Ten of 11 patients (90.9%) developed SDH in the posterior fossa or occipital convexity. Logistic regression analysis revealed longer aortic clamp time (95% CI 1.00-1.10, p = 0.04), higher dose of heparin after surgery (95% CI 1.00-1.02, p = 0.001), and higher pulmonary artery pressure (PAP) just before disconnection of the CPB (95% CI 1.01-1.37, p = 0.04) as significantly associated with the development of SDH.

CONCLUSIONS

The incidence of symptomatic SDH following heart valve surgery was 2.0%. Symptoms due to SDH usually developed a few days to 1 month after surgery. Surprisingly, most SDHs developed in the posterior fossa or occipital convexity following heart valve surgery. A longer aortic clamp time, higher dose of heparin after surgery, and higher PAP just before disconnection of the CPB were related to the development of symptomatic SDH following heart valve surgery.

Prevalence of cerebral sinovenous thrombosis in abusive head trauma

BACKGROUND

Cerebral sinovenous thrombosis (CSVT) has been proposed in legal settings to be an atraumatic mimic of abusive head trauma (AHT).

OBJECTIVE

The objective of this study was to determine the prevalence of CSVT and subdural hemorrhage (SDH) in a large AHT population.

MATERIALS AND METHODS

This retrospective cohort study measured the prevalence of CSVT and SDH on magnetic resonance venograms in 243 patients diagnosed with AHT at a single center. We also reported additional intra- and extracranial injuries, head injury severity and length of hospital stay.

RESULTS

Among 243 patients diagnosed with AHT, 7% (16/243) had CSVT. SDH was present in 94% (15/16) of the CSVT cases. Cytotoxic edema and subarachnoid hemorrhage were in 88% (14/16) and 69% (11/16) of the CSVT cases, respectively. Extracranial signs of abuse were also in 100% (16/16) of the patients with CSVT. Critical to maximal head injury severity (abbreviated injury scale >=5) was in 75% (12/16) of the CSVT population vs. 33% (82/243) in the total AHT population. Length of hospital and pediatric intensive care unit stay was greater in those with CSVT (10 vs. 21.9 and 3.5 vs. 7.3 days).

CONCLUSION

These findings suggest that CSVT is uncommon in AHT and is associated with additional traumatic injuries and greater injury severity.

Infantile subdural hematoma in Japan: A multicenter, retrospective study by the J-HITs (Japanese head injury of infants and toddlers study) group

Objective

Subdural hematoma in infants or toddlers has often been linked to abuse, but it is not clear how many cases actually occur and how many are suspected of abuse. The purpose of this study was to investigate subdural hematoma in infants and toddlers in Japan.

Methods

This multicenter, retrospective study reviewed the clinical records of children younger than 4 years with head trauma who were diagnosed with any finding on head computed tomography (CT) and/or magnetic resonance imaging (MRI), such as skull fracture and/or intracranial injury. A total of 452 children were included. The group suspected to have been abused was classified as nonaccidental, and the group considered to have been caused by an accident was classified as accidental. Subdural hematoma and other factors were examined on multivariate analysis to identify which factors increase the risk of nonaccidental injuries.

Results

Of the 452 patients, 158 were diagnosed with subdural hematoma. Subdural hematoma was the most common finding intracranial finding in head trauma in infants and toddlers. A total of 51 patients were classified into the nonaccidental group, and 107 patients were classified into the accidental group. The age of patients with subdural hematoma showed a bimodal pattern. The mean age of the accidental group with subdural hematoma was significantly older than that in the nonaccidental group (10.2 months vs 5.9 months, respectively. p < 0.001). Multivariate analysis showed that patients under 5 months old, retinal hemorrhage, and seizure were significant risk factors for nonaccidental injury (odds ratio (OR) 3.86, p = 0.0011; OR 7.63, p < 0.001; OR 2.49, p = 0.03; respectively). On the other hand, the odds ratio for subdural hematoma was 1.96, and no significant difference was observed (p = 0.34).

Conclusions

At least in Japanese children, infantile subdural hematoma was frequently observed not only in nonaccidental but also in accidental injuries. In infants with head trauma, age, the presence of retinal hemorrhage, and the presence of seizures should be considered when determining whether they were abused. Subdural hematoma is also a powerful finding to detect abuse, but care should be taken because, in some ethnic groups, such as the Japanese, there are many accidental cases.

Incidence of child abuse with subdural hemorrhage during the first year of the COVID-19 pandemic: a nationwide study in France

The global COVID-19 pandemic prompted governments to impose unprecedented sanitary measures, such as social distancing, curfews, and lockdowns. In France and other countries, the first COVID-19 lockdown raised concerns about an increased risk of child abuse. Abusive head trauma (AHT) is one of the most serious forms of child abuse in children aged 0-24 months and constitutes the leading cause of death in children under 2 years of age. Subdural hemorrhage (SDH) is present in 89% of cases of AHT and constitutes one of the most specific, objective clinical presentations in the diagnosis of child abuse. In a French nationwide study, we sought to evaluate the potential impact of the first year of the COVID-19 pandemic on the incidence of hospital admissions for child abuse with SDH, relative to the two previous years. We conducted a nationwide, retrospective study of data in the French national hospital discharge summary database by applying the International Classification of Diseases (10th Revision) codes for SDH and for child abuse. After including children aged up to 24 months with a diagnosis of child abuse and/or SDH following hospital admission anywhere in France between January 1, 2018, and December 31, 2020, we compared the incidence of child abuse, the incidence of SDH + child abuse, and the demographic data for 2020 with the corresponding values for 2018 and 2019. There were no significant differences in the number of hospital admissions due to child abuse or SDH + child abuse between 2020 and the 2018/2019 control years. The incidence of SDH + child abuse was higher among boys than among girls. There were significantly fewer hospital admissions in May 2020 (p = 0.01) and significantly more in December 2020 (p = 0.03), relative to the same months in the two preceding years. There was a nonsignificant trend toward a lower incidence of hospital admission for child abuse in 2020, relative to 2019 (decrease: 6.4%) and 2018 (decrease: 7.6%).

CONCLUSION

When considering children under the age of 24 months in France, the incidence of hospital admission for SDH in the context of child abuse was not significantly higher in 2020 than in the two previous years.

WHAT IS KNOWN

• The impact of COVID-19 lockdown on child abuse and more specifically on subdural hemorrhage remains unknown.

WHAT IS NEW

• There was no increase in hospitalizations for child abuse and AHT. • We found that boys are more often victims of child abuse and subdural hemorrhage among children aged less than 12 months.

Subdural hemorrhage in a cohort with cerebral sinovenous thrombosis: Application to abusive head trauma

BACKGROUND

Cerebral sinovenous thrombosis (CSVT) is a postulated cause of subdural hemorrhage (SDH) that is hypothesized to mimic abusive head trauma (AHT). Minimal data exists directly investigating this relationship.

OBJECTIVES

To evaluate the frequency of SDH in children with CSVT, identify factors associated with CSVT and SDH, and to assess if any association supports the hypothesis that CSVT causes SDH.

PARTICIPANTS AND SETTING

The International Pediatric Stroke Study (IPSS) prospectively collects data on subjects birth to 19 years of age with intracranial thrombosis.

METHODS

IPSS subjects with CSVT and SDH were compared to those with CSVT and no SDH. For subjects with CSVT and SDH, neuroimaging reports further characterized the findings. In any case with no known risk factors for SDH, neuroimaging studies were reviewed by a pediatric neuroradiologist.

RESULTS

Of 216 subjects with CSVT, 20 (9.3%) had SDH. Those with SDH (median age 0.3 years) were younger than those without SDH (median age 4.2 years), p < 0.001. Subjects with CSVT and SDH more frequently had anoxia (OR = 10.8; 95% CI: 1.4, 81.1), head/neck injury (OR = 4.0; 95% CI: 1.3, 12.6), or abnormal consciousness (OR = 3.0; 95% CI: 1.2, 7.6). Of 20 subjects with CSVT and SDH, 19 had known risk factors for SDH. The remaining subject had a chronic SDH identified concomitantly to a newly symptomatic CSVT with accompanying venous infarctions.

CONCLUSIONS

SDH in the setting of CSVT is typically identified in children with independent risk factors for SDH. This study does not support the hypothesis that CSVT causes SDH.

Decreased number of deaths related to severe traumatic brain injury in intensive care unit during the first lockdown in Normandy: at least one positive side effect of the COVID-19 pandemic

Background

The COVID-19 pandemic has led to severe containment measures to protect the population in France. The first lockdown modified daily living and could have led to a decrease in the frequency of severe traumatic brain injury (TBI). In the present study, we compared the frequency and severity of severe TBI before and during the first containment in Normandy.

Methods

We included all patients admitted in the intensive care unit (ICU) for severe TBI in the two tertiary neurosurgical trauma centres of Normandy during the first lockdown. The year before the containment served as control. The primary outcome was the number of patients admitted per week in ICU. We compared the demographic characteristics, TBI mechanisms, CT scan, surgical procedure, and mortality rate.

Results

The incidence of admissions for severe TBI in Normandy decreased by 33% during the containment. The aetiology of TBI significantly changed during the containment: there were less traffic road accidents and more TBI related to alcohol consumption. Patients with severe TBI during the containment had a better prognosis according to the impact score (p=0.04). We observed a significant decrease in the rate of short-term mortality related to severe TBI during the period of lockdown (p=0.02).

Conclusions

Containment related to the COVID-19 pandemic has resulted in a modification of the mechanisms of severe TBI in Normandy, which was associated with a decline in the rate of short-term death in intensive unit care.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Treatment for secondary deterioration in idiopathic normal pressure hydrocephalus in the later course of the disease: a retrospective analysis

BACKGROUND

Cerebrospinal fluid (CSF) shunting is a highly effective treatment for idiopathic normal pressure hydrocephalus (iNPH). However, secondary deterioration can occur at a later time. Thus, the current study aimed to evaluate the incidence rate and causes of secondary deterioration.

METHODS

A retrospective analysis was conducted on all patients with iNPH who were treated with implantation of a CSF shunt since 1993. A meticulous shunt workup was recommended to all patients who presented to our department with secondary deterioration during their follow-up visits. Data about the proportion of patients with such deterioration and its causes, subsequent treatment, and clinical outcome were obtained.

RESULTS

A total of 169 patients were included, and the mean follow-up time was 69.2 months. In total, 119 (70.4%) patients presented with a total of 153 secondary deteriorations. In 9 cases (5.9%), the deterioration was caused by delayed subdural hematoma and in 27 (22.1%) cases, by shunt dysfunction. Invasive shunt testing was commonly required to validate shunt failure. Moreover, 19 of 27 patients experienced a satisfactory improvement after revision surgery. In total, 86 deteriorations were attributed to nonsurgical causes, and the valve pressure was decreased in 79 patients, with only 16.5% presenting with a satisfactory improvement after lowering of valve pressure.

CONCLUSIONS

Most patients with shunted iNPH presented with deterioration in the later course of the disease. Shunt dysfunction was considered a cause of secondary deterioration. Moreover, shunt revision surgery was a highly effective treatment, and patients with deterioration should undergo screening procedures for shunt dysfunction, including invasive shunt testing.

Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2

BACKGROUND

Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study.

METHODS

We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality.

RESULTS

We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47).

CONCLUSION

PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.

Rates of Repeated Operation for Isolated Subdural Hematoma Among Older Adults

IMPORTANCE

Elderly patients who undergo surgery for an isolated nontraumatic subdural hematoma (SDH) are at major risk for SDH reaccumulation, which can cause further injury and disability. Few population-based studies have examined how often nontraumatic SDH reaccumulates and necessitates repeated operation.

OBJECTIVE

To determine the rate of repeated operation after evacuation of nontraumatic SDH.

DESIGN, SETTING, AND PARTICIPANTS

In a cohort study, 2 parallel analyses were performed using data from the National Surgical Quality Improvement Project (NSQIP) from January 1, 2012, through December 31, 2015, and inpatient and outpatient claims data from a 5% nationally representative sample of Medicare beneficiaries from January 1, 2009, to September 30, 2015. In both samples, our cohort comprised patients 65 years or older who underwent surgical evacuation of nontraumatic SDH. Data were analyzed from March 28 to April 13, 2018.

MAIN OUTCOMES AND MEASURES

The outcome variable was repeated operation for SDH after the index operation. Survival analysis and Kaplan-Meier statistics were used to calculate cumulative rates.

RESULTS

Among 2 831 274 cases submitted to the NSQIP registry, 515 patients 65 years or older (mean [SD] age, 76.9 [7.4] years; 177 [34.4%] women; 367 [71.3%] white) who underwent craniotomy or craniectomy for nontraumatic SDH were identified. Within 30 days after the index surgery, 37 patients underwent a repeated operation for SDH. The cumulative 30-day mortality rate was 13.8% (95% CI, 11.0%-17.1%), and the repeated operation rate was 7.8% (95% CI, 5.7%-10.7%). Among a cohort of 1 952 305 Medicare beneficiaries, 1534 patients (mean [SD] age, 77.7 [7.0] years; 498 [32.5%] women; 1244 [81.1%] white) who underwent evacuation of nontraumatic SDH were identified. A total of 103 patients underwent a repeated operation within 90 days. The cumulative 30-day mortality rate was 11.6% (95% CI, 10.1%-13.3%), and the repeated operation rate was 4.9% (95% CI, 3.9%-6.2%); the cumulative 90-day mortality rate was 17.6% (95% CI, 15.7%-19.6%), and the repeated operation rate was 7.5% (95% CI, 6.2%-9.0%). The study found no evidence of a significant difference in cumulative repeated operation rates at 90 days between patients whose index surgery was a burr-hole procedure for chronic SDH (11.7%; 95% CI, 6.3%-21.3%) vs a craniotomy or craniectomy (7.2%; 95% CI, 6.0%-8.8%) (P = .14 by the log-rank test).

CONCLUSIONS AND RELEVANCE

In 2 large cohorts of US patients, approximately 5% to 10% of patients who underwent surgery for nontraumatic SDH were required to undergo repeated operation within 30 to 90 days. These results may inform the design of future prospective studies and trials and help practitioners calibrate their index of suspicion to ensure that patients are referred for timely surgical care.

Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders

BACKGROUND

Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT.

METHODS

We reviewed subjects <4 years of age in the Universal Data Collection database. ICH was categorized on the basis of association with trauma. Prevalence and probability of types of ICH were calculated for each bleeding disorder.

RESULTS

Of 3717 subjects, 255 (6.9%) had any ICH and 206 (5.5%) had nontraumatic ICH. The highest prevalence of ICH was in severe hemophilia A (9.1%) and B (10.7%). Of the 1233 subjects <2 years of age in which the specific location of any ICH was known, 13 (1.1%) had spontaneous SDH (12 with severe hemophilia; 1 with type 1 vWD). The findings in the subject with vWD were not congruent with AHT.

CONCLUSIONS

In congenital bleeding disorders, nontraumatic ICH occurs most commonly in severe hemophilia. In this study, vWD is not supported as a "mimic" of AHT.

Validation of intracranial hemorrhage in the Norwegian Patient Registry

Objectives

Administrative health registries need to have accurate diagnoses and sufficient coverage in the population they serve in order to be useful in research. In this study, we investigated the proportion of discharge diagnoses of intracranial hemorrhage (ICH) that were coded correctly in the Norwegian Patient Registry (NPR).

Materials and Methods

We reviewed the electronic medical records and diagnostic imaging of all admissions to St. Olavs University Hospital, Trondheim, Norway, between January 1, 2008, to December 31, 2014, with a discharge diagnosis of ICH in the NPR, and estimated positive predictive values (PPVs) for primary and secondary diagnoses. Separate calculations were made for inpatient and outpatient admissions.

Results

In total, 1,419 patients with 1,458 discharge diagnoses of ICH were included in our study. Overall, 1,333 (91.4%) discharge diagnoses were coded correctly. For inpatient admissions, the PPVs for primary discharge codes were 96.9% for hemorrhagic stroke, 95.3% for subarachnoid hemorrhage, and 97.9% for subdural hemorrhage. The most common cause of incorrect diagnosis was previous stroke that should have been coded as rehabilitation or sequela after stroke. There were more false-positive diagnoses among outpatient consultations and secondary diagnoses.

Conclusion

Coding of ICH discharge diagnoses in the NPR is of high quality, showing that data from this registry can safely be used for medical research.

Traumatic Brain Injury Profile of an Elderly Population in Puerto Rico

OBJECTIVE

Describe the types of traumatic brain injury secondary to falls sustained by the members of an elderly population who received services at the Puerto Rico Medical Center and the demographic profile of that population.

METHODS

A group of 332 adults (60 years and over) assessed for traumatic brain injury secondary to falls suffered in 2013 were included in the analysis. The cases were retrieved from the computerized database of the Neurosurgery Section. We analyzed information such as age, gender, type of traumatic brain injury, mechanism of injury, and the performance of surgery (if applicable). Descriptive analysis was performed to derive a general profile of elderly adults who presented with traumatic brain injury secondary to falls.

RESULTS

The sample consisted of 332 elderly adults: 73% were men and 27% were women. The mean age was 76.74 (SD=9.95) years: 75.67 (SD=9.78) for men and 79.13 (SD=10.02) for women. The most common traumatic brain injury was subdural hematoma (51%) and the mechanism of injury most prevalent was the groundlevel fall (83%). Other traumatic brain injuries included traumatic subarachnoid hemorrhages (14%), cerebral contusions (18%) and epidural hematomas (3%). Of all the cases, 52% had were managed surgically.

CONCLUSION

The elderly population is growing and the risk of falls increases with advancing age. Recurrent falls are an important cause of morbidity, and mortality rates oscillate from 6 to 18%. Elderly patients have longer rehabilitation times, incur more expenses, and have greater levels of disability. This study provides a platform for future epidemiological studies to help develop strategies for the prevention of traumatic brain injury in older adults.

Injuries Associated with Subdural Hematoma: A Study of the National Trauma Data Bank

Of 92030 patients with subdural hematoma (SDH) in the National Trauma Data Bank (NTDB), 55729 had fall mechanisms of injury (61%), while 36301 had other traumatic mechanisms (nonfall, 39%). For nonfall mechanisms, the three associated injuries with the highest incidence were: skull fractures (43.3%), rib/sternum injuries (25.0%), and thoracic organ injuries (24.0%). For fall mechanisms, the three associated injuries with the highest incidence were: skull fractures (19.0%), spinal injuries (7.1%), and upper extremity fractures (6.8%). Mortality was associated with age and most studied associated injuries (odds ratios ofup to 2.04). 'This study conveys an important clinical point: even though traditional teaching highlights the risk of noncontiguous spine fractures in patients with a known spine fracture, the risk of a noncontiguous spine fracture is higher when dealing with a patient with SDH. This is underscored by the fact that mortality is higher for SDH patients with other associated injuries.

Association of Antithrombotic Drug Use With Subdural Hematoma Risk

IMPORTANCE

Incidence of subdural hematoma has been reported to be increasing. To what extent this is related to increasing use of antithrombotic drugs is unknown.

OBJECTIVES

To estimate the association between use of antithrombotic drugs and subdural hematoma risk and determine trends in subdural hematoma incidence and antithrombotic drug use in the general population.

DESIGN, SETTING, AND PARTICIPANTS

Case-control study of 10 010 patients aged 20 to 89 years with a first-ever subdural hematoma principal discharge diagnosis from 2000 to 2015 matched by age, sex, and calendar year to 400 380 individuals from the general population (controls). Subdural hematoma incidence and antithrombotic drug use was identified using population-based regional data (population: 484 346) and national data (population: 5.2 million) from Denmark. Conditional logistic regression models were used to estimate odds ratios (ORs) that were adjusted for comorbidity, education level, and income level.

EXPOSURES

Use of low-dose aspirin, clopidogrel, a vitamin K antagonist (VKA), a direct oral anticoagulant, and combined antithrombotic drug treatment.

MAIN OUTCOMES AND MEASURES

Association of subdural hematoma with antithrombotic drug use, subdural hematoma incidence rate, and annual prevalence of treatment with antithrombotic drugs.

RESULTS

Among 10 010 patients with subdural hematoma (mean age, 69.2 years; 3462 women [34.6%]), 47.3% were taking antithrombotic medications. Current use of low-dose aspirin (cases: 26.7%, controls: 22.4%; adjusted OR, 1.24 [95% CI, 1.15-1.33]), clopidogrel (cases: 5.0%, controls: 2.2%; adjusted OR, 1.87 [95% CI, 1.57-2.24]), a direct oral anticoagulant (cases: 1.0%, controls: 0.6%; adjusted OR, 1.73 [95% CI, 1.31-2.28]), and a VKA (cases: 14.3%, controls: 4.9%; adjusted OR, 3.69 [95% CI, 3.38-4.03]) were associated with higher risk of subdural hematoma. The risk of subdural hematoma was highest when a VKA was used concurrently with an antiplatelet drug (low-dose aspirin and a VKA: 3.6% of cases and 1.1% of controls; adjusted OR, 4.00 [95% CI, 3.40-4.70]; clopidogrel and a VKA: 0.3% of cases and 0.04% of controls; adjusted OR, 7.93 [95% CI, 4.49-14.02]). The prevalence of antithrombotic drug use increased from 31.0 per 1000 individuals from the general population in 2000 to 76.9 per 1000 individuals in 2015 (P < .001 for trend). The overall subdural hematoma incidence rate increased from 10.9 per 100 000 person-years in 2000 to 19.0 per 100 000 person-years in 2015 (P < .001 for trend). The largest increase was among older patients (>75 years; n = 4441) who experienced an increase from 55.1 per 100 000 person-years to 99.7 per 100 000 person-years (P < .001 for trend).

CONCLUSIONS AND RELEVANCE

In Denmark, antithrombotic drug use was associated with higher risk of subdural hematoma; and the highest odds of subdural hematoma was associated with combined use of a VKA and an antiplatelet drug. The increased incidence of subdural hematoma from 2000 to 2015 appears to be associated with the increased use of antithrombotic drugs, particularly use of a VKA among older patients.

Incidence and risk factors of subdural hematoma after intraoperative cerebrospinal fluid leakage during the transsphenoidal approach

PURPOSE

The transsphenoidal approach (TSA) is regarded as the first line of treatment for sellar and suprasellar lesions. There are only few case reports of postoperative subdural hematoma after TSA and extended transsphenoidal approach (eTSA), and the detailed incidence and risk factors for this complication are still unknown. We reviewed the incidence and risk factors for subdural hematoma after TSA and eTSA.

METHODS

Between January 1, 2013 and December 31, 2014, 165 consecutive patients underwent TSA or eTSA at Nagoya University Hospital and Nagoya Daini Red Cross Hospital. Fifty-one patients experienced intraoperative CSF leakage. Postoperative subdural hematoma was observed in 10 patients, all of whom experienced intraoperative CSF leakage. We reviewed clinical data including CT and MR images and examined factors related to subdural hematoma among patients with intraoperative CSF leakage.

RESULTS

In univariate statistical analyses, risk factors for postoperative subdural hematoma were advanced age, high Evans' index, and preoperative hypopituitarism. These factors were also significant in the multivariate logistic regression analysis. There were no statistical differences in sex, tumor size, approach methods, preoperative diabetes insipidus, or degree of intraoperative CSF leakage.

CONCLUSIONS

The incidence of postoperative subdural hematoma after intraoperative CSF leakage during TSA and eTSA was higher than the incidence reported in patients after craniotomy. Intraoperative CSF leakage should be avoided as much as possible, especially in patients with brain atrophy and/or enlargement of the ventricular system, even if the intent of the reconstruction technique is authenticity. In addition, patients with hypopituitarism should be carefully followed up after surgery.

Subdural Haematoma in Patients With Spontaneous Intracranial Hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.

Seizure Correlates with Prolonged Hospital Stay, Increased Costs, and Increased Mortality in Nontraumatic Subdural Hematoma

BACKGROUND

Nontraumatic subdural hematoma (NTSDH) is a common neurosurgical disease process, with mortality reported as high as 13%. Seizure has a known association with NTSDH, although patient outcomes have not previously been well studied in this population. The purpose of this study was to examine the relationship between in-hospital seizure and inpatient outcomes in NTSDH.

METHODS

Using the University HealthSystem Consortium (UHC) database, we performed a retrospective cohort study of adults with a principal diagnosis of NTSDH (International Classification of Diseases, Ninth Revision code 43.21) between 2011 and 2015. Patients with in-hospital seizure (International Classification of Diseases, Ninth Revision codes 34500-34591, 78033, 78039) were compared with those without. Patients with a history of seizure before arrival were excluded. Patient demographics, hospital length of stay (LOS), intensive care unit stay, in-hospital mortality, and direct costs were recorded.

RESULTS

A total 16,928 patients with NTSDH were identified. Mean age was 69.2 years, and 64.7% were male. In-hospital seizure was documented in 744 (4.40%) patients. Hospital LOS was 17.64 days in patients with seizure and 6.26 days in those without (P < 0.0001). Mean intensive care unit stay increased from 3.36 days without seizure to 9.36 days with seizure. In-hospital mortality was 9.19% in patients without seizure and 16.13% in those with seizure (P < 0.0001). Direct costs were $12,781 in patients without seizure and $38,110 in those with seizure (P < 0.0001).

CONCLUSIONS

Seizure in patients with NTSDH correlates with significantly increased total LOS and increased mortality. Direct costs are similarly increased. Further studies accounting for effects of illness severity are necessary to validate these results.

Computerized tomographic pattern of stroke seen in University of Portharcourt Teaching Hospital

BACKGROUND

Data on Computed tomographic (CT) pattern of stroke abound in literature but they are predominantly from studies done in the Western world. Though most of the reports agree that ischaemic rather than haemorrhagic stroke is prevalent in most climes,no strictly radiology based study can be quoted in the Port Harcourt area. Thus there is the need for accurate data on stroke pattern in Nigerians of the South-South region.

AIMS

This study was done to establish the CT pattern of stroke seen in University of Port Harcourt Teaching Hospital (UPTH) and to determine the relationship between the different stroke patterns and age, sex, including time of presentation.

METHODOLOGY

A prospective study of 203 subjects with clinical diagnosis of stroke who had CT of the brain performed during a 12month period (November 2012 to November 2013).A 2-slice helical CT was used to obtain images in the axial plane. Images were classified as normal or abnormal scans. Abnormal scans were analyzed as ischaemic infarcts, intracerebral haemorrhage, subarachnoid haemorrhage (SAH), subdural haematoma, abscess, neoplasm, meningitis, and cerebral atrophy. The clinical diagnosis, age, sex and time of presentation of the patients were recorded. Statistical analysis was done with the Statistical Package for the Social Sciences (SPSS) software version 20.0.Means were compared using Student's t test. Pearson's correlation coefficient was used to correlate CT findings with clinical diagnosis ,age, and sex.P values < 0.05 were considered significant.

RESULTS

The age distribution of the study population ranged from 6-90 years with a mean of 58.3+14.9years. The over 70 age group was most frequent with 24.1% of the subjects. Males were predominant at 51.7% of the sample size. Findings of ischaemic cerebrovascular disease (CVD) were more common than haemorrhagic CVD at 63.2%.

CONCLUSION

This study revealed a higher incidence of ischaemic stroke compared to haemorrhagic stroke.

Recurrence of Subdural Haematoma in a Population-Based Cohort - Risks and Predictive Factors

Objectives

To estimate the risks of and identify predictors for recurrent subdural haematoma in surgically and conservatively treated patients.

Methods

The cohort comprised all individuals diagnosed with a first-time subdural hematoma in Denmark 1996–2011. Information on potential predictors was retrieved from the Danish health registers. Cumulative recurrence risks were estimated using the Aalen-Johansen estimator. Rate ratios (RR) were estimated using Poisson regression.

Results

Among 10,158 individuals with a subdural hematoma, 1,555 had a recurrent event. The cumulative risk of recurrent subdural hematoma was 9% at 4 weeks after the primary bleeding, increasing to and stabilising at 14% after one year. Predictors associated with recurrence were: Male sex (RR 1.60, 95% CI:1.43–1.80), older age (>70 years compared to 20–49 years; RR 1.41, 95% CI: 1.21–1.65), alcohol addiction (RR 1.20, 95% CI:1.04–1.37), surgical treatment (RR 1.76, 95% CI:1.58–1.96), trauma diagnoses (RR 1.14, 95% CI:1.03–1.27), and diabetes mellitus (RR 1.40, 95% CI:1.11–1.74). Out of a selected combination of risk factors, the highest cumulative 1-year recurrence risks for subdural hematoma of 25% (compared to 14% for all patients) was found in surgically treated males with diabetes mellitus.

Conclusions

The recurrence risk of subdural hematoma is largely limited to the first year. Patient characteristics including co-morbidities greatly influence the recurrence risk of SDH, suggesting that individualized prognostic guidance and follow-up is needed.

Risk factors for subdural bleeding in elderly population

In the elderly, a larger proportion of the intracranial bleeds is related to non-traumatic causes or is caused by slight trauma--such that in a younger patient would not be expected to cause a bleed. In clinical practice, there is a prevailing impression that these bleeds, especially subdural hematomas of chronic and sub-chronic duration with or without acutization (evidence of "fresh" bleeding) are in many cases related directly to the use of anticoagulant therapy. A retrospective survey of medical documentation was performed for patients treated at the Neurosurgery Clinic of KBC Rijeka during the period of 2011 and 2012. Statistical analysis showed a significantly greater incidence of spontaneous SDH (subdural hematoma) in patients taking oral anticoagulation therapy (Fisher exact test, p < 0.01). In the article 3 typical cases of such patients are also presented. This survey confirmed the existence of a relationship between oral anticoagulant therapy and SDH, in particular the subgroup of "spontaneous" SDH. A larger study is planned.

Postoperative anticoagulation in patients with mechanical heart valves following surgical treatment of subdural hematomas

BACKGROUND

Thromboembolic events and anticoagulation-associated bleeding events represent frequent complications following cardiac mechanical valve replacement. Management guidelines regarding the timing for resuming anticoagulation therapy following a surgically treated subdural hematoma (SDH) in patients with mechanical valves remains to be determined.

OBJECTIVE

To determine optimal anticoagulation management in patients with mechanical heart valves following treatment of SDH.

METHODS

Outcomes were retrospectively reviewed for 12 patients on anticoagulation therapy for thromboembolic prophylaxis for mechanical cardiac valves who underwent surgical intervention for a SDH at the Johns Hopkins Hospital between 1995 and 2010.

RESULTS

The mean age at admission was 71 years. All patients had St. Jude's mechanical heart valves and were receiving anticoagulation therapy. All patients had their anticoagulation reversed with vitamin K and fresh frozen plasma and underwent surgical evacuation. Anticoagulation was withheld for a mean of 14 days upon admission and a mean of 9 days postoperatively. The average length of stay was 19 days. No deaths or thromboembolic events occurred during the hospitalization. Average follow-up time was 50 months, during which two patients had a recurrent SDH. No other associated morbidities occurred during follow-up.

CONCLUSION

Interruptions in anticoagulation therapy for up to 3 weeks pose minimal thromboembolic risk in patients with mechanical heart valves. Close follow-up after discharge is highly recommended, as recurrent hemorrhages can occur several weeks after the resumption of anticoagulation.

Prevalence of subdural collections in children with macrocrania

BACKGROUND AND PURPOSE

The relationship between enlarged subarachnoid spaces and subdural collections is poorly understood and creates challenges for clinicians investigating the etiology of subdural collections. The purpose of this study was to determine the prevalence of subdural collections on cross sectional imaging in children with macrocephaly correlating with subarachnoid space enlargement.

MATERIALS AND METHODS

The radiology information system of a large pediatric medical center was reviewed for "macrocrania" and "macrocephaly" on reports of cranial MRI/CT examinations in children <24 months of age, over a 24-month period. Head circumference was obtained from the clinical record. Studies were reviewed blindly for subdural collection presence and subarachnoid space size. Children with prior cranial surgery, parenchymal abnormalities, hydrocephalus, or conditions predisposing to parenchymal volume loss were excluded. Chart review was performed on those with subdural collections.

RESULTS

Imaging from 177 children with enlarged head circumference was reviewed. Nine were excluded, for a final cohort of 168 subjects (108 with enlarged subarachnoid space). Subdural collections were identified in 6 (3.6%), all with enlarged subarachnoid space (6/108, 5.6%). In 4, subdural collections were small, homogeneous, and nonhemorrhagic. In 2, the collections were complex (septations or hemorrhage). Two children were reported as victims of child abuse (both with complex collections). No definitive etiology was established in the other cases.

CONCLUSIONS

The prevalence of subdural collections in imaged children with macrocrania was 3.6%, all occurring in children with enlarged subarachnoid space. Our results suggest that enlarged subarachnoid space can be associated with some subdural collections in this cohort. Despite this, we believe that unexpected subdural collections in children should receive close clinical evaluation for underlying causes, including abusive head trauma.

Clinical clues for head injuries amongst Malaysian infants: accidental or non-accidental?

Identifying the differences between infants with non-accidental head injuries (NAHI) and accidental head injuries (AHI) may help alert clinicians to recognize markers of abuse. A retrospective review of infants <1 year of age admitted to a tertiary referral centre in Malaysia over a two year period with a diagnosis of head injury or abnormal computed tomography head scans was conducted to identify the clinical features pointing towards a diagnosis of NAHI by comparing the socio-demographics, presenting complaints, clinical features and the extent of hospital investigations carried out. NAHI infants were more likely to be symptomatic, under a non-related caregiver's supervision, and presented with inconsistent or no known mechanism of injury. Subdural haemorrhages were more common in NAHI infants. The history, mechanism of injury, presenting signs and symptoms as well as the nature of the injuries sustained are all valuable clues as to whether a head injury sustained during infancy is likely to be accidental or not.

Traumatic brain injury in older adults: characteristics, causes and consequences

INTRODUCTION

Traumatic brain injury is of particular concern in the older population. We aimed to examine the trends in hospitalisations, causes and consequences of TBI in older adults in New South Wales, Australia.

METHODS

TBI cases from 1 July 1998 to 30 June 2011 were identified from hospitalisation data for all public and private hospitals in NSW. Direct aged standardised admission rates were calculated. Negative binomial regression modelling was used to examine the statistical significance of changes in trend over time.

RESULTS

There were 12,564 hospitalisations for TBI over the 13 year study period. Hospitalisation rates for TBI among the older population increased by 7.2% (95% CI 6.4-8.0, p<.0001) per year from 65.3/100,000 to 151.8/100,000. [corrected]. Males had a consistently higher hospitalisation rate. Just under one third of all hospitalisations were for adults aged 85 years and over. Traumatic subdural haemorrhage (42.9%), concussive injury (24.1%) and traumatic subarachnoid haemorrhage (12.7%) were the most common type of injury. Falls were the most common cause of TBI (82.9%). Rates of fall-related TBI increased by 8.4% (95% CI 7.5-9.3, p<.001) per year, whilst non-fall related head injury increased by 2.1% (95% CI 0.9-3.3, p<.0001) per year. The majority of falls were as a result of a fall on the same level and occurred at home. 13% of hospitalisations resulted in death, and the majority occurred in those who sustained a traumatic subdural haemorrhage.

CONCLUSIONS

The rapid increase in hospitalised TBI is being predominantly driven by falls in the oldest old and the greatest increase predominantly in intracranial haemorrhages, highlighting the need for future research to quantify the risk versus benefit of anticoagulant therapies.

Does intracranial venous thrombosis cause subdural hemorrhage in the pediatric population?

Unexplained SDH in infants and children is an accepted marker for AHT. It has been proposed that IVT may be the initiating event leading to the development of acute SDH, mimicking the appearance of traumatic SDH. Our study aims to investigate if nontraumatic IVT causes SDH in the pediatric population. We retrospectively identified 36 patients with IVT and reviewed neuroimaging studies for the concurrent presence of SDH. In our 36 patients with IVT, no associated SDH was observed. Even with extensive IVT, no SDH was present. Three false-positive diagnoses of IVT were identified in the setting of mastoiditis and traumatic SDH, demonstrating pitfalls in imaging. In conclusion, our findings do not support the previous AHT literature stating that IVT is associated with, or leads to, SDH in neonates, infants, or children.

Subdural hematomas: an analysis of 1181 Kashmiri patients

BACKGROUND

We endeavored to analyze patients of subacute and chronic subdural hematomas studied in a 4-year period at the Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India.

METHODS

The study was a retrospective analysis of 1181 patients of subdural hematomas. Demographic characteristics, clinico-radiologic features, operative modalities, and outcome were studied. Acute subdural hematomas were excluded from the study.

RESULTS

The mean age was 60.4 ± 12.4 and males outnumbered females. Chronic subdural collections were more common than subacute subdural hematomas and left side predominated. Two burr holes with closed-system drainage was used in most patients. Incidence of postoperative seizures is very low. Overall recurrence rates were low; however, multilocular hematomas had the highest incidence of recurrence. Morbidity and mortality were 7.53% and 2.96%, respectively. Preoperative neurologic grade correlated with outcome.

CONCLUSIONS

Subdural hematomas are common in elderly males. Preoperative neurologic grade dictates the outcome. Multilocular hematomas have a higher chance of recurrence. Craniotomy should be reserved for recurrent hematomas, and there may be a scope of craniotomy for multilocular chronic subdural hematomas at the outset. Antiepileptic prophylaxis is not routinely recommended.

Cognitive performance in late adolescence and the subsequent risk of subdural hematoma: an observational study of a prospective nationwide cohort

BACKGROUND

There are few identified risk factors for traumatic brain injuries such as subdural hematoma (SDH). The aim of the present study was to investigate whether low cognitive performance in young adulthood is associated with SDH later in life. A second aim was to investigate whether this risk factor was associated with education and physical fitness.

METHODS AND FINDINGS

Word recollection, logical, visuospatial, and technical performances were tested at a mean age of 18.5 years in a prospective nation-wide cohort of 440,742 men. An estimate of global intelligence was calculated from these four tests. Associations between cognitive performance, education, physical fitness, and SDH during follow-up were explored using Cox regression analyses. During a median follow-up of 35 years, 863 SDHs were diagnosed in the cohort. Low global intelligence was associated with an increased risk of SDH during follow-up (hazard ratio [HR]: 1.33, per standard deviation decrease, 95% CI = 1.25-1.43). Similar results were obtained for the other measures of cognitive performance (HR: 1.24-1.33, p<0.001 for all). In contrast, a high education (HR: 0.27, comparing more than 2 years of high school and 8 years of elementary school, 95% CI = 0.19-0.39), and a high level of physical fitness (HR: 0.76, per standard deviation increase, 95% CI = 0.70-0.83), was associated with a decreased risk of suffering from a SDH.

CONCLUSIONS

The present findings suggest that reduced cognitive function in young adulthood is strongly associated with an increased risk of SDH later in life. In contrast, a higher level of education and a higher physical fitness were associated with a decreased risk of SDH.

Medical, social and societal issues in infants with abusive head trauma

Abusive head trauma (AHT) is the leading cause of death from traumatic brain injury in under 2 year olds. AHT presents with acute encephalopathy, subdural hemorrhages and retinal hemorrhages occurring in the context of an inappropriate or inconsistent history. We retrospectively analyzed, over a 10 year period, admissions and transfers to our hospital with suspected AHT to assess patterns of presentation, presenting symptoms, investigations, subsequent confirmation, social work input and both neurological and social outcomes. We analyzed all suspected AHT infants and children looking for the time of presentation, presenting symptoms, caregivers concerns prior to presentation, a family profile including stressors, investigations (in particular neuroradiology and ophthalmology assessments), treatment in hospital, length of stay in hospital, social work involvement, subsequent discharge, neurological outcome and subsequent social work follow up. Data was collected from the hospital HIPE system, RIS (radiology reports system) and records from the social work department from a period October 1998 to January 2009 inclusive. Of 22 patients with confirmed AHT, ages seizures and irritability followed by vomiting, poor feeding, a bulging fontanelle and lethargy. The father was the sole minder in 5 cases. There was a delayed history in 4 cases. One had multiple visits to his GP. All cases had subdural hemorrhages proven by either CT or MRI scans and retinal hemorrhages diagnosed by ophthalmology. One infant presented with a torn frenulum. Four had suspicious bruising. All had normal coagulation profiles, skeletal surveys and extensive metabolic tests. Hospital stays ranged from 1 to 124 days (the median was 28 days and mean 33 days). Ten (45%) infants required ventilatory support. Sixteen infants had social work involvement within 4 days of admission (7 of these were interviewed immediately). Outcomes after case conferences were that 6 returned home with parents, 9 were placed in foster care. Four parents (18%) admitted to shakng their infants. There was 1 death. Thirteen (60%) were normal on follow up. Two had ADHD. Two had language delay. Two had motor delay. One criminal prosecution has ensued as yet Children with suspected AHT should undergo appropriate investigations which should include brain imaging, ophthalmic examination, skeletal survey and blood investigations. Early social work assessment is a priority as part of the multidisciplinary approach. A prospective national study of AHT is required.

Chronic subdural haematoma in patients with Huntington's disease

We studied the frequency of patients who had chronic subdural haematomas (CSDH) and Huntington's disease (HD) in a 1-year study period. In our department a total of 58 patients with CSDH were treated. Four patients (6.9% of them) had HD. Surgical evacuation of the haematoma was performed in all four cases with the use of a twist drill trepanation without a drainage system.

[Diagnosis and expert evaluation of non-radical outcomes of surgical treatment of unencapsulated traumatic subdural hematomas]

Outcomes of surgical treatment of 197 unencapsulated supraperitoneal traumatic subdural hematomas (UTSH) are analysed. The causal relationship between the occurrence and the volume of residual postoperative subdural hematomas (RSH) and the localization ofprimary hemorrhage is validated. Nomograms for the identification of belonging of blood accumulations to the groups of residual and recurrent hemorrhages are developed. A method for comprehensive assessment of the accuracy of clinical and instrumental characteristic of outcomes of the surgical treatment of unencapsulated traumatic subdural hematomas is proposed

[Influence of anticoagulants on the appearance of chronic subdural hematoma]

In recent years in the Department of Neurotraumatology in Cracow it has been noticed the frequent connection between appearance of chronic subdural hematoma (CSDH) and treatment by anticoagulant medications. The aim of this study is to draw attention to the problem of insufficient control of anticoagulants consumption, especially by patients treated for cardiovascular system diseases that increases the risk of bleeding and CSDH development. The paper is based on data from questionnaires that was sent to patients with CSDH, cured in the Department of Neurotraumatology form 2004 to 2005. Analyzed was the group of 51 patients with chronic subdural hematoma; 37 individuals (72.5%) confirmed taking acetylsalicylic acid in the period of 3 months before admission to the Department, 9 (17.6%) patients answered that they were taking low-molecular weight heparin. One patient (1.9%) was taking chronically derivative of cumarin. The authors would inform that anticoagulant treatment might favour increase of chronic subdural hematoma incidence. It's especially important, because the average life expectancy has been prolonged in Poland and there are more people taking acetylsalicylic acid. This can be an epidemiological problem in future.

Demographics, injury characteristics and outcome of traumatic brain injuries in northern Sweden

OBJECTIVES - To describe demographics, injury characteristics and outcome of traumatic brain injury (TBI) in northern Sweden over 10 years. MATERIAL AND METHODS - Data were retrospectively collected on those individuals (n = 332) in Norrbotten, northern Sweden, with a TBI who had been transferred for neurosurgical care from 1992 to 2001. RESULTS - A majority were older men with a mild TBI and an acute or chronic subdural hematoma following a fall. Younger individuals were fewer but had more often a severe TBI from a traffic accident. Most individuals received post-acute care and brain injury rehabilitation. A majority had a moderate or severe disability, but many were discharged back home with no major changes in their physical or social environment. CONCLUSIONS - Our data confirm the relationship between age, cause of injury, injury severity and outcome in relation to TBI and underscore the need for prevention as well as the importance of TBI as a cause of long-term disability.

Traumatic head injury in infants and toddlers

AIM

To describe the presenting characteristics, type of injury and hospital course in young children with traumatic head injury, and to identify characteristics indicating that the trauma was inflicted.

METHODS

A retrospective medical record review of 91 children less than 3 years of age who were admitted to a tertiary teaching hospital in Norway from 1995 through 2005 with a traumatic head injury. Patients were identified by diagnostic codes, and categorized by type of injury as skull fractures (n = 39), epidural haemorrhage (EDH) (n = 12), subdural haemorrhage (n = 27) and parenchymal brain injury (n = 13). Further the cases were classified as inflicted injury (n = 17), accident (n = 35) or indeterminate (n = 39).

RESULTS

The mechanism of injury was similar for EDHs and isolated skull fractures, and none were classified as inflicted. Sixty-three percent of the cases with subdural haematoma were classified as inflicted. When compared to the accident group, children in the inflicted group more frequently had subdural haemorrhage without a skull fracture (OR = 6.9, CI = 1.7-28.2), and seizures (OR = 9.5, CI = 2.1-43.3).

CONCLUSIONS

Inflicted and accidental head injuries differed in presenting characteristics and injury type. Nearly two-third of the subdural haemorrhages were classified as inflicted, but none of the epidural EDHs or skull fractures. Inflicted injuries tended to present with seizures.

Subdural hematomas in chronic dialysis patients: significant and increasing

BACKGROUND AND OBJECTIVES

Subdural hematoma is a known complication of long-term hemodialysis.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

The US Renal Data System was used to determine the occurrence rate of nontraumatic subdural hematoma in long-term dialysis patients and to evaluate time trends.

RESULTS

The occurrence rate of subdural hematoma in long-term dialysis patients is 10 times higher than that of the general population. From 1991 to 2002, the occurrence rate of subdural hematoma in hemodialysis patients doubled, whereas it did not change in peritoneal dialysis patients.

CONCLUSIONS

This high occurrence rate of subdural hematoma and its recent increase may be related to increased use of anticoagulants in long-term hemodialysis patients.

Catastrophic head injuries in high school and college football players

BACKGROUND

Catastrophic head injuries in football are rare but tragic events.

PURPOSE

To update the profile of catastrophic head injuries in high school and college football players and to describe relevant risk factors.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We reviewed 94 incidents of severe football head injuries reported to the National Center for Catastrophic Sports Injury Research during 13 academic years (September 1989 through June 2002).

RESULTS

In the study period there were an average of 7.23 (standard deviation = 2.05) direct high school and college catastrophic head injuries in scholastic football participants per year. There were 0.67 injuries per 100 000 (95% confidence interval: 0.54, 0.81 per 100 000) high school and 0.21 injuries per 100 000 (95% confidence interval: 0.0, 0.49 per 100 000) college participants for a risk ratio of 3.28 (95% confidence interval: 0.81, 13.3). The injuries resulted in subdural hematoma in 75 athletes, subdural hematoma with diffuse brain edema in 10 athletes, diffuse brain edema in 5 athletes, and arteriovenous malformation or aneurysm in 4 athletes. Fifty-nine percent of the contacts reported that the athlete had a history of a previous head injury, of which 71% occurred within the same season as the catastrophic event. Thirty-nine percent of the athletes (21 of 54) were playing with residual neurologic symptoms from the prior head injury. There were 8 (9%) deaths as a result of the injury, 46 (51%) permanent neurologic injuries, and 36 (40%) serious injuries with full recovery. Most players sustained a major impact to the head either from tackling or being tackled.

CONCLUSION

The incidence of catastrophic head injuries in football has remained low since the advent of the modern day football helmet in the early 1970s. The incidence of catastrophic head injuries in football is dramatically higher at the high school level than at the college level. Although the reason for this discrepancy is unclear, an unacceptably high percentage of high school players were playing with residual symptoms from a prior head injury. Coaches, athletes, athletic trainers, and medical personnel need to adhere to the guideline that an athlete with any neurologic symptoms from a head injury should be strongly discouraged from returning to play.

Non-accidental subdural haemorrhage in Hong Kong: incidence, clinical features, management and outcome

OBJECTIVE

We aim to identify the incidence and the characteristics of non-accidental subdural haemorrhage in Hong Kong in children under the age of 5 years.

METHOD

Eighteen children aged below 5 years presented with subdural haemorrhage without a history of significant trauma were studied. Clinical features and the work-up process for probable child abuse were analysed.

RESULTS

Sixteen combined case conferences were held, and eleven cases were concluded to be genuine child abuse cases of non-accidental head injury (incidence=1.5 per 100,000 children <5 years old per year). Among these cases, the most common presentation in the younger age group (age<1 year) was seizure (5/7), whilst that in the older age group (age 1-4 years) was coma (4/4, two of these patients also had seizure). One patient in the younger age group and three (3/4) of the older age group were found to have multiple unexplained bruises, suggesting that, in older children, direct impact injury played an important role. Five (5/7) children in the younger age group and all four children in the older age group had retinal haemorrhage. Coma on admission was associated with an unfavourable outcome (6/7 vs 0/4, p=0.015).

CONCLUSIONS

Sixty-one percent of childhood subdural haemorrhage (11/18) without a history of significant trauma were genuine child abuse cases and should all be investigated for probable "non-accidental injury". An organised protocol involving a multi-disciplinary team is mandatory.

Operative techniques and morbidity with subthalamic nucleus deep brain stimulation in 100 consecutive patients with advanced Parkinson's disease

OBJECTIVE

Subthalamic nucleus (STN) stimulation for patients with medically refractory Parkinson disease (PD) is expanding. Reported experience has provided some indication of techniques, efficacy, and morbidity, but few centres have reported more than 50 patients. To expand this knowledge, we reviewed our experience with a large series of consecutive patients.

METHODS

From March 1999 to September 2003, 191 subthalamic stimulator devices (19 unilateral) were implanted in 100 patients with PD at New York Presbyterian Hospital/Columbia University Medical Center. Sixteen patients had undergone a prior surgery for PD (pallidotomy, thalamotomy, or fetal transplant). Microelectrode guided implantations were performed using techniques similar to those described previously. Electrode implantation occurred 1-2 weeks before outpatient pulse generator implantation.

RESULTS

Reductions of dyskinesias and off severity/duration were similar to prior published reports. Morbidity included: 7 device infections (3.7%), 1 cerebral infarct, 1 intracerebral haematoma, 1 subdural haematoma, 1 air embolism, 2 wound haematomas requiring drainage (1.0%), 2 skin erosions over implanted hardware (1.0%), 3 periprocedural seizures (1.6%), 6 brain electrode revisions (3.1%), postoperative confusion in 13 patients (6.8%), and 16 battery failures (8.4%). Of the 100 patients, there were no surgical deaths or permanent new neurological deficits. The average hospital stay for all 100 patients was 3.1 days.

CONCLUSION

Subthalamic stimulator implantation in a large consecutive series of patients with PD produced significant clinical improvement without mortality or major neurological morbidity. Morbidity primarily involved device infections and hardware/wound revisions.

Subdural haematoma and effusion in infancy: an epidemiological study

AIM

To determine incidence, aetiology, and clinical features of subdural haematoma and effusion (SDH/E) in infancy throughout the British Isles.

METHODS

Cases were notified to the British Paediatric Surveillance Unit over 12 months by paediatricians, neurosurgeons, and paediatric and forensic pathologists.

RESULTS

A total of 186 infants (121 boys, 65 girls) aged 0-2 years were identified. Annual incidence of SDH/E for the UK and Republic of Ireland is 12.54/100,000 aged 0-2 (95% CI 10.3 to 14.62) and 24.1/100,000 aged 0-1 (95% CI 20.89 to 28.18). A total of 106 infants suffered non-accidental head injury (NAHI), 7 accidental head injury, 26 a perinatal cause, 7 a non-traumatic medical condition, 23 meningitis, and in 17 the cause was undetermined; 35 infants died. Significant differences were found in injury pattern, body weight, and Townsend score between NAHI and SDH/E from other cause. There were fewer diagnostic investigations in non-NAHI cases. Delay in diagnosis of greater than a week occurred in 48/181.

CONCLUSION

SDH/E is a significant cause of morbidity and mortality in infancy. NAHI is the predominant cause of SDH/E. SDH/E can present in a non-specific and varied way and must be considered in any infant who is unwell. Determining the cause of the SDH/E in some cases continues to present a diagnostic challenge.

Recent research and views on shaking baby syndrome

Primary care physicians and psychiatrists should be aware of the incidence, causes, diagnosis, and prognosis of the conditions of Shaking Baby Syndrome (SBS). This article discusses both accidental and non-accidental head injury, and also addresses the legal aspects of SBS. Incidence, potential causes, explanations, prevention, and treatment of the condition, both for the perpetrators and the unfortunate victims, are considered. Of special importance is the fact that SBS is difficult to diagnose with absolute certainty. Hence the identification of a potential perpetrator can be difficult and injustices can occur.