Progressive brain injury

The aim of this study was to evaluate the clinical manifestations and prognostic factors of progressive brain injury following trauma. We reviewed the records of 779 patients with head injury who had an admission Glasgow Coma Scale of 9 or more; 70 (7.0%) developed progressive brain injury as evidenced on serial CT scans. Of these 70 patients, 19 (27.1%) had a subdural hematoma, 19 (27.1%) an epidural hematoma, 16 (22.9%) a cerebral contusion, 13 (18.6%) an intracerebral hematoma, and 3 (4.3%) a diffuse brain swelling. Three months after injury, 36 (51.4%) patients died, 2 (2.9%) were left in a vegetative state and 23 (32.9%) had a favorable outcome. The appearance of progressive brain injury was associated with patient age, admission Glasgow Coma Scale, injury mechanisms, skull fracture and hemorrhagic lesions on the initial CT scan. Patients with the extracerebral lesions deteriorated 4 hours after injury, whereas those with intracerebral lesions deteriorated 8 hours after injury. The outcome based on Glasgow Outcome Scale was significantly associated with age, type of intracranial lesion, Glasgow Coma Scale following deterioration, the mechanism of injury and surgical treatment. It is concluded that early repeated CT scan is indicated in patients with risk factors of developing progressive brain injury.     

Serial computerized tomographic scanning and the prognosis of severe head injury

Serial (two or three) computerized tomographic (CT) scans were performed on a series of 58 patients with severe head injury. The protocol called for scans to be done upon admission and on Days 3 and 7 after injury. New lesions (i.e., lesions not visualized on the initial CT scans but appearing on subsequent scans) were a frequent finding, occurring in over half of all patients. For the purposes of this study a new lesion was classified as edema involving two or more lobes, extra-axial hematoma, parenchymal hemorrhage, or infarction. Significant correlation was found between good outcome and the absence of new lesions and between bad outcome and the development of new lesions (p less than 0.001). Several patients did well in spite of the development of new lesions, but these patients were unique in that most had small, unilateral parenchymal hematomas located at or near the frontal or temporal poles. In most cases, patients who did poorly in spite of not developing new lesions had severe injuried visualized on their initial scans (massive intracerebral hematoma, hemorrhage of the corpus callosum) or succumbed to medical complications. The pertinent literature is reviewed, and other CT findings associated with a poor prognosis are noted. The authors suggest that serial CT scanning may be used to make prognostic assessments in severely head-injured patients and may be of value in increasing the confidence in and accuracy of assessments made on clinical grounds alone. (Neurosurgery, 5: 566--569, 1979).     

Early ischemic lesion on computed tomography: predictor of poor outcome among survivors of aneurysmal subarachnoid hemorrhage

OBJECT: Identifying ischemic lesions after subarachnoid hemorrhage (SAH) is important because the appearance of these lesions on follow-up imaging correlates with a poor outcome. The effect of ischemic lesions seen on computed tomography (CT) scans during the first days of treatment remains unknown, however. METHODS: In 156 patients with SAH, clinical course and outcome, as well as the appearance of ischemic lesions on serial CT scans, were prospectively monitored for 3 months. At 3 months after SAH, magnetic resonance imaging was performed to detect permanent lesions that had not been visible on CT. RESULTS: Of the 53 patients with no lesions on any of the follow-up CT scans, four (8%) had a poor outcome. Of the 52 patients with a new hypodense lesion on the first postoperative day CT, 23 (44%) had a poor outcome. Among the remaining 51 patients with a lesion appearing later than the first postoperative morning, 10 (20%) had a poor outcome (p < 0.001). After adjusting for patient age; clinical condition on admission; amounts of subarachnoid, intracerebral, and intraventricular blood; and plasma glucose and D-dimer levels, a hypodense lesion on CT on the first postoperative morning was an independent predictor of poor outcome after SAH (odds ratio 7.27, 95% confidence interval 1.54-34.37, p < 0.05). CONCLUSIONS: A new hypodense lesion on early postoperative CT seems to be an independent risk factor for poor outcome after SAH, and this early lesion development may be more detrimental to clinical outcome than a later lesion occurrence.     

Early diagnosis of delayed posttraumatic intracerebral hematomas.

Nine cases of delayed posttraumatic intracerebral hematomas (DTICH) were found retrospectively among 656 patients with closed head injuries admitted to the Hennepin County Medical Center in a 12-month period. All cases had severe head injuries sustained with the head in motion. The interval from cranial injury to diagnosis of DTICH by computerized tomography (CT) varied from 8 hours to 13 days. Eight patients were comatose on admission, three had focal seizures, and three had focal findings. The diagnosis was made on repeat CT scans obtained because of the development of focal findings in four cases, lack of improvement in four cases, and general neurological deterioration in one case. Four patients had initially negative CT scans. Four demonstrated only extracerebral hematomas on initial CT scan. One patient showed intracerebral hematoma on the initial scan followed by new hematomas on repeat study. The cases presented are discussed in light of pertinent literature.     

Reimaging in pediatric neurotrauma: factors associated with progression of intracranial injury

Purpose: The purpose of this study was to characterize the radiologic changes that are seen in the first 24 to 48 hours after head injury and to correlate those changes with clinical findings, to determine which children are at greatest risk for progression of their neurologic injury. Methods: The authors identified 104 children ([le ]17 years of age) who had a second computed tomography (CT) scan of the head within 24 to 48 hours of admission. CT scans were evaluated systematically in a blinded fashion. Mechanism of injury, findings on physical examination, therapeutic measures, and changes in management were recorded from hospital medical records. The 50 children whose second CT scan showed progression of injury were compared with the 54 patients whose intracranial injuries were unchanged or improved on their second CT. Results: Twenty-six percent of patients (13 of 50) with radiographic progression of injury had an admission Glasgow coma score of 15. Progression of injury was more common, however, in patients with lower Glasgow coma scores, averaging 9 on admission and 10 at the time of the second CT. Progression of injury also was more common if the initial head CT showed 3 or more intracranial injuries, mass effect, intraventricular hemorrhage, or an epidural hematoma. Conclusions: Children with an intracranial injury identified on their initial head CT scan should undergo a second scan 24 hours after injury, especially if the initial CT shows 3 or more intracranial injuries, mass effect, intraventricular hemorrhage, or an epidural hematoma.     

Computerized tomography findings of acute traumatic epidural hematoma

During four year period from April, 1977 to March, 1981, 53 cases with acute traumatic epidural hematoma had been encountered out of 430 acute head injured patients examined by computerized tomography (CT) within 24 hours after incurring the trauma at the Department of Neurosurgery and Critical Care Medicine of Nippon Medical School, Sendagi, Tokyo, Japan. Besides the initial CT, the authors performed contrast enhanced CT (41 cases) and serial CT scanning (31 cases). There were 49 cases of epidural hematoma existing in the supratentorial region, Two cases infratentorial region and 2 cases in the both regions. Two cases of vertex epidural hematoma had been encountered, one of them required vertical scan technique. In 22 (41%) of the 53 patients, the initial CT showed evidence of other cerebral lesions. The most frequent lesion was pneumocephalus (11 cases), 3 cases of them existed in the epidural hematoma. There were also intracerebral hematoma (6 cases), subdural hematoma (4 cases), cerebral contusion (2 cases), intraventricular hemorrhage (2 cases) and 2 cases of them demonstrated "diffuse traumatic cerebral injury" (Zimmerman, 1979). During contrast enhanced CT, 11 cases out of 41 cases indicated several enhancement pattern. There were total enhancement of epidural hematoma (2 cases), partial enhancement of hematoma (2 cases) and enhancement of internal margin of hematoma (2 cases). Serial CT scans was performed in 36 out of the 53 patients. Common findings on the serial CT scans were decreased density collection in the subdural space such as subdural effusions or chronic subdural hematomas (8 cases) and enlargement of small epidural hematomas (3 cases).(ABSTRACT TRUNCATED AT 250 WORDS)     

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation

BACKGROUND: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS: Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS: Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS: Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.     

Minimal head injury: is admission necessary?

The records of 138 patients admitted a Glasgow Coma Score (GCS) of 14 or 15 following head injury were reviewed to assess the need for hospital observation and to determine whether obtaining a normal computerized tomography (CT) scan in the emergency department could have avoided admission. GCS was 15 in 103 patients (74%) and 14 in 35 (26%). Eighty-three patients were admitted for their head injury alone, and 55 had other injuries but would have required admission for their head injury. Loss of consciousness was documented in 51 per cent and suspected in another 29 per cent and was distributed equally regardless of GCS. Seven per cent (5/71) of skull x rays were positive and were associated with CNS pathology in three patients. Skull x rays in an additional four patients with positive CT findings were negative including a patient with an epidural hematoma (EDH). Seventeen per cent (13/75) of CT scans were positive (contusions 5, subdural hematoma 3, subarachnoid hemorrhage 2, edema 2, EDH 1). Only the patient with the EDH required operative treatment. No patient with a normal CT scan went on to develop any neurosurgical problems, and 78 per cent of the patients admitted with isolated head injuries were discharged within 48 hours. Significant CNS pathology does occur following "minimal" head injuries. Skull x rays are not helpful. The use of CT scanning appears to triage those patients requiring admission and in hospital observation.     

Bilateral Traumatic Intracranial Hematomas and its Outcome: a Retrospective Study

The objective of this study was to evaluate the age distribution, mode of injury, type of hematomas, and their surgical outcome in patients with bilateral traumatic head injuries. The present study included 669 cases of traumatic head injury who presented at the neurosurgery emergency out of which 94 cases had bilateral head injuries from the period of August 2009 to April 2014. The data from the hospital computerized database were retrospectively analysed. Cases of bilateral traumatic head injury included 94 patients out of which 88.29 % (n?=?83) were males and 11.70 % (n?=?11) were females. Commonest mode of injury was road traffic accident in 56.38 % (n?=?53) followed by fall from height in 29.78 % (n?=?28). In our study, 25.53 % patients had epidural hematoma (EDH) with intracerebral hematoma (ICH) or contusion (n?=?24), followed by EDH with subarachnoid hemorrhage (SAH) in 18.08 % (n?=?17). At the time of discharge, all those patients managed conservatively had good Glasgow outcome scale (GOS) while with surgical intervention 58 % patients had good GOS, 19 % had moderate disability, and 9 % remained with severe disability. In cases of bilateral hematomas, EDH is most common and should be managed in neurosurgical emergency. Other combinations of bilateral intracranial hematomas should be managed according to the surgical indication and serial CT imaging.     

The value of serial computerized tomography in the management of severe head injury

A consecutive series of 107 comatose patients with head injury was studied with regard to the proper role of serial computerized tomography for clinical management and as a research tool for studying the pathophysiology of severe head trauma. In this prospective study patients had serial CT scans on days 1, 3, 5, 7, 14, at 3 months, and at 1 year (day 1 is the day of admission). In seven instances CT scanning was responsible for detection of late intracranial lesions requiring surgical decompression two weeks to one year after injury. No surgically significant lesions were, however, detected by routine scanning on the pre-determined days in the early post-trauma period that had not already been signalled by changes in the neurological status, intracranial pressure, or volume pressure response. It is concluded that for purposes of clinical management, additional scans should be obtained in the following circumstances: 1) 1 day post-craniotomy, 2) no improvement by day 3, 3) at 2-3 weeks, and 4) at 3 months. All other scans should be obtained as needed. As a research tool, serial CT scanning is of value in studying post-traumatic hydrocephalus, delayed intracerebral hematomas, and intraventricular hemorrhage.     

Intraventricular hemorrhage in severe head injury

A series of 30 patients suffering posttraumatic intraventricular hemorrhage (IVH) after closed head injury is reviewed. Clotted blood and a mixture of blood and cerebrospinal fluid could be distinguished by computerized tomography (CT). Posttraumatic IVH was associated with diffuse brain lesions in most cases; intracerebral lesions with contusion, and subdural hematomas coexisted with posttraumatic IVH in eight and four instances, respectively. In two more cases, no CT abnormality other than IVH was noted. All patients in this series were in deep coma at the time of CT examination, and only seven survived. The early clinical findings, the site of ventricular hematoma, and the final outcome are analyzed.     

Acute subdural hematoma caused by mild head trauma in the aged]

We encountered 8 cases of acute subdural hematoma caused by mild head trauma in the aged. In this report, these cases were analyzed, taking into consideration clinical symptoms, CT scan, operative findings and outcome. The age ranged from 70 to 92 years (mean age of 79.7 years). 4 patients were male and 4 female. Head trauma was caused by falls in 4 patients, but in the other 4 patients the causes were unknown. Initial symptoms were headache, nausea and vomiting in 5 patients and mild disturbance of consciousness with lucid intervals in 3 patients. Seven patients had more than 100 on JCS and less than 9 on GCS on admission. Small craniotomy (HITT) was performed in 4 patients. Large craniotomy was performed in 2 patients, and decompressive craniectomy was carried out in 2 patients. The bleeding focus came from the cortical artery of the middle cerebral artery in 4 patients, cerebral contusion in 2 patients, and was unknown in 2 patients for HITT. CT scan on admission showed mixed density area of acute subdural hematoma in all of the patients, and intraventricular hemorrhage, intracerebral hemorrhage and subarachnoid hemorrhage in 3 patients. CT scan after operation revealed a new area of cerebral contusion in 3 patients, delayed traumatic intracerebral hematoma (DTICH) in 2 patients, and hypertensive intracerebral hemorrhage in 1 patient. Two patients recovered to good and fair without general complication. But the outcome in 5 patients with general complication was poor for 3 patients and fatal for 2 patients. In conclusion, large craniotomy is recommended because of bleeding from the cortical artery of the middle cerebral artery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Spontaneous intracerebral hemorrhage with antiplatelets/anticoagulants/none: a comparison analysis

Background

Problems that the risk of using antiplatelet/anticoagulant may overwhelm its benefits have been raised. We analyzed patients with spontaneous intracerebral hemorrhage who had received antiplatelet/anticoagulant therapy.

Method

A consecutive series of patients with spontaneous intracerebral hemorrhage who underwent brain computed tomographic (CT) scans within 48 h from attack. We analyzed the clinical manifestations and radiologic findings of the patients according to antiplatelet/anticoagulant therapy: Antiplatelet group, Anticoagulant group, and None group.

Results

A total of 338 patients were included in the study. The initial volume of hematoma was 46.8 ml in the Anticoagulant group, and 24.1 ml in the None group. There were significant differences among the groups in terms of intraventricular hemorrhage (Antiplatelet group: 45.6 %, Anticoagulant group: 20 %, None: 26.4 %, p?=?0.008), and the proportion of hydrocephalus in the Antiplatelet group was higher than in another group (p?=?0.017). Also, herniation and expansion of spontaneous intracerebral hemorrhage had significant differences among the groups. The prognoses of the None group were the best among the groups. There was also significant difference in the mortality among the groups.

Conclusions

In comparison with the None group, the spontaneous intracerebral hemorrhages of the Antiplatelet/Anticoagulant group were a little more extensive and they had more intraventricular hemorrhage, hydrocephalus, herniation, and expansion of spontaneous intracerebral hemorrhage that would come to poor prognosis. Therefore, antiplatelets and anticoagulants should be used under strict indications.     

Pathology of intracerebral hemorrhage in ruptured aneurysms of the posterior communicating artery at its origin from the internal carotid artery

There were thirty-two autopsied cases of ruptured aneurysms at the junction of the internal carotid and posterior communicating arteries in the file of Montefiore Medical Center from 1948 to 1983 (Table 1). The age range of the patients was 11-83 years. Seven were men and twenty-five were women. Fifteen had previous surgery; either clipping of the neck of the aneurysm or ligation of the common carotid artery. Analysis of the hemorrhage associated with the ruptured aneurysms revealed two distinct patterns. One is subarachnoid hemorrhage alone (18 cases) and another is subarachnoid hemorrhage and intraventricular rupture through the temporal horn (14 cases). These aneurysms did not produce a large intracerebral hematoma in the temporal lobe because they ruptured into the temporal horn. Among the post-operative cases (14 cases), only 3 cases had intraventricular hemorrhage. Correlation of these autopsy findings with CT Scans revealed that an intraventricular hematoma in the temporal horn could be interpreted as a large intracerebral hematoma in the temporal lobe.     

Is computed tomographic scanning necessary in patients with tentorial herniation? Results of immediate surgical exploration without computed tomography in 100 patients

Computed tomographic (CT) scans are performed on virtually all patients with severe head injury at the time of admission. Because of the time involved in obtaining these studies, the evacuation of significant intracranial mass lesions is delayed. To avoid such delays, the authors performed burr-hole exploration for the diagnosis of intracranial hematomas before CT scans were obtained in 100 consecutive head-injured patients with clinical signs of tentorial herniation or upper brain stem dysfunction upon admission to the emergency room. Patients in whom a hematoma was discovered had a craniotomy for evacuation of the clot; those in whom the exploration was negative had a CT brain scan immediately after operation. Burr-hole exploration revealed extracerebral mass lesions in 56 patients. In 38 patients, the exploration was negative, and postoperative CT scanning showed no significant hematoma. Of 6 patients in whom the CT scan demonstrated extraaxial hematomas requiring surgical evacuation, 4 had subdural hematomas that were missed because the exploration was incomplete; 1 patient had an epidural hematoma and 1 had a subdural hematoma contralateral to a craniotomy on the side of a positive initial burr-hole exploration. Our results indicate that the relatively small subgroup of head-injured patients with early tentorial herniation or upper brain stem compression have a high incidence of immediate extraaxial hematomas and a low incidence of intracerebral hematomas. This is particularly true of patients over 30 years of age and those who suffer low speed trauma, such as falls and vehicle-pedestrian accidents.     

X-ray computed tomography in a series of aneurysms of the circle of Willis

During four years, 80 patients with intracranial aneurysms were examined by a CT scanner. The CT was helpful for: The rapid and easy diagnosis of subarachnoid hemorrhage. Direct visualization of intracranial aneurysms. Detecting intracerebral or intraventricular hematoma and distribution of subarachnoid clots. The limitations and pitfalls of CT were: No abnormality was seen on 16 scans (20%). The identification of the source of bleeding in multiple intracranial aneurysms.     

Clinical significance of intracranial hemorrhage caused by cerebral arteriovenous malformations: with special reference to intraventricular hemorrhage

Forty-two cases with intracranial hemorrhage caused by cerebral arteriovenous malformation (AVM), which was diagnosed by CT scan, were reviewed with regard to the clinical significance of intracranial hemorrhage, especially intraventricular hemorrhage (IVH). Twenty-one patients were defined as poor risk cases whose level of consciousness at admission was 100 to 300 according to the Japan Coma Scale, whereas the remaining 21 patients were defined as good risk cases. Surgical excision of AVM was undertaken in 35 out of the 42 cases. Urgent surgical removal of intracerebral hematoma and AVM within 24 hours following onset was undertaken in 11 cases. In 14 patients, urgent continuous ventricular drainage was carried out. The effects of the following factors on the level of consciousness at admission, and on the result of AVM treatment were investigated to clarify the clinical significance of intracranial hemorrhage; 1) cast formation of 3rd and/or 4th ventricle, 2) volume of intraventricular hematoma, 3) accompanying intracerebral hematoma and 4) acute hydrocephalus. It was confirmed that all these factors significantly contributed to the development of serious disturbance of consciousness in the acute stage following intracranial hemorrhage. For good risk cases, the rate of patients who showed a good recovery or only moderate disability according to the Glasgow Outcome Scale reached 91%, whereas for poor risk cases, it was only 43%. The presence of large intracerebral hematomas of more than 4 cm in diameter accompanied with IVH was significantly correlated with the result of AVM treatment. The presence or absence of cast formation of 3rd and/or 4th ventricle, volume of intraventricular hematoma and acute hydrocephalus were not significantly related to the result of AVM treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study

OBJECT: Only limited data exist addressing the long-term outcome of patients with ganglionic hemorrhage complicated by intraventricular hemorrhage (IVH) and hydrocephalus that requires an external ventricular drain (EVD). The aim of this study was to compare the long-term outcome of patients with pure ganglionic hemorrhage and those requiring an EVD due to additional IVH and hydrocephalus. METHODS: For this study, 116 patients with supratentorial ganglionic hemorrhage and occlusive hydrocephalus were screened. To avoid any bias the authors excluded all patients with nonprimary intracerebral hemorrhage as well as those who received no treatment. Forty patients with IVH and subsequent hydrocephalus were examined, and 40 more patients with pure ganglionic hematomas were matched with regard to age, sex, Glasgow Coma Scale score, need for mechanical ventilation, and, in particular, hematoma volume. Outcome analysis was performed using the Barthel Index and the modified Rankin Scale (mRS). The mean hematoma volume was 25.3 +/- 15.2 ml. The overall long-term outcome was unfavorable (mRS Score 4-6) in 59% of all patients. Good outcome (mRS score < 4) was observed in 25 (62.5%) of 40 patients with hematoma volumes less than 25 ml, compared with eight (20%) of 40 who had hematoma volumes greater than 25 ml (p < 0.05, chi-square test). The need for an EVD was not associated with a worse long-term outcome in patients with comparable hematoma volumes. In contrast, the duration of treatment in the intensive care unit was longer for patients with EVDs than for those who had pure ganglionic hematomas (16 [range 5-29] days compared with 8 [range 2-19] days; p < 0.05, Mann-Whitney U-test), regardless of hematoma volume. CONCLUSIONS: The long-term outcome of treated patients with supratentorial ganglionic hemorrhage with ventricular involvement and occlusive hydrocephalus is comparable to that of patients with similar hematoma volumes but no IVH.     

Unfavorable outcome following early surgical repair of ruptured cerebral aneurysms--a critical review of 238 patients

Among 238 consecutive patients admitted early with ruptured cerebral aneurysms, surgical repair within 48-72 hours was feasible in 200 cases. Unfavorable outcomes among the latter 200 patients are analyzed and discussed in this paper. Preoperatively, 148 patients were in Hunt and Hess grades I-III, 33 were in grade IV, and 19 in grade V. After clipping of the aneurysm, all patients received a regimen of topical intracisternal and intravenous/peroral medication with the calcium antagonist nimodipine. The overall rate of unfavorable outcomes was 25%, ie, outcome with moderate or severe deficit or lethal outcome. The reasons for unfavorable outcomes among these 49 patients were the devastating effect of the bleed (severe subarachnoid hemorrhage or additional intracerebral hemorrhage) in 31 patients (15% of the 200 patients), a surgical complication in 11 (5.5%), preoperative rebleeding in three (1.5%), delayed ischemia from vasospasm in one (0.5%), and various others in three further patients (1.5%). Unfavorable outcome occurred in 11% of patients with preoperative grades I-III, in 52% of patients with grade IV, and in 16 of 19 patients with grade V. Among the 141 patients with subarachnoid hemorrhage but not intracerebral or intraventricular hematoma, 16 made an unfavorable outcome, ie, 11% versus 56% among patients with intracerebral hematoma/intraventricular hematoma on preoperative computed tomography scan. The present data seem to speak in favor of early surgery. Since half of the patients with intracerebral hematoma and poor outcome had suffered previous warning leaks, it appears to be a continuing challenge to diagnose warning leaks before a massive hemorrhage occurs.     

Delayed traumatic intracerebral hematomas: "Sp?t-Apoplexie". Report of two cases

Two patients who suffered a head trauma experienced sudden clinical deterioration more than 1 week after their injury. The initial computerized tomography (CT) scan demonstrated a small hematoma underlying a depressed skull fracture in one patient and a small interhemispheric subdural hematoma in the other. Both patients had made a complete recovery and follow-up CT scans were normal when clinical deterioration suddenly occurred. Both patients developed a large intracerebral hematoma and underwent emergency evacuation of the mass. The first patient recovered with the exception of a moderate hemiparesis and dysphasia, but the second patient died. Delayed traumatic intracerebral hematomas have been described in the literature. Since the advent of CT scanning, the incidence of this phenomenon has been estimated as between 1.7% and 7.4% of closed head injuries. In 1891, Otto Bollinger described four patients who suffered head injury, followed days to weeks later by death from an apoplectic event. His criteria for diagnosis of "traumatische Sp?t-Apoplexie" included the absence of preexisting vascular disease, a definite history of trauma, an asymptomatic interval of at least several days, and an apoplectic episode. These two cases reemphasize the existence of Sp?t-Apoplexie as a rare clinical condition. In the presence of CT findings of even small traumatic intracerebral or extracerebral hematomas, the possibility of this late complication should be kept in mind.