Conservative management of extradural haematomas

Summary The personal experiences with a series of 57 conservatively treated extradural haematomas (EDH) are presented and the criteria for conservative management outlined. Main preconditions are absence of neurological deficit, close clinical supervision and repeated CT check-ups.     

Asymptomatic or minimally symptomatic traumatic epidural haematomas: Comparison of the results of surgical and conservative management related to SPECT and neuropsychological tests

One hundred and thirteen patients with asymptomatic or minimally symptomatic epidural heamatomas treated surgically or conservatively in our department were collected prospectively. Between 3 and 6 months after the head injury a SPECT (single photon emission computed tomography) study for evaluation of the three-dimensional cerebral blood flow distribution and extensive neuropsychological tests were performed in 22 patients. The preliminary results of this prospective study have demonstrated that minimally symptomatic or asymptomatic EDHs cause no pathologic SPECT findings and that neuropsychological impairment and duration of the haematoma do not affect the results of conservative management.     

Multiple supratentorial epidural haematomas after posterior fossa surgery

Postoperative epidural haematoma distant to a site of craniotomy is a rare but possibly hazardous complication. We report a 31-year-old female who presented with a history of chronic hydrocephalus due to fourth-ventricular plexus papilloma. Following resection of the posterior fossa tumour with intraoperative placement of a ventricular drainage, she consecutively developed four supratentorial epidural haematomas at different locations, all necessitating evacuation. The clinical manifestations ranged from subtle neurological deficits to signs of tentorial herniation; the ultimate outcome was complete recovery. Rapid tapering of CSF pressure after long-standing hydrocephalus and clotting disorders could be implicated as causative factors. We stress the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication.     

Spontaneous spinal epidural haematomas

Summary The spontaneous spinal epidural haematoma (SSEH) is a rarity, but the severe and permanent motor disability underlines its importance.From 1957 seven cases of SSEH have been diagnosed and operated on in the National Institute of Neurosurgery, Budapest. These cases are analysed and discussed.The clinical picture began with local pain of the spine and radicular signs but some hours or days later paraparesis or paraplegia and incontinence developed. In the discussed cases the neurological deficit progressed to complete para- or tetraplegia in 5 cases. Only 2 patients had partial spinal transverse lesions on admission. All patients underwent myelography to detect the spinal space occupying lesion and were operated on soon. Three patients recovered completely, 2 remained partly and 2 totally paralysed.The outcome depended mainly on the timing of neurological deficiency. If the neurological signs existed less than 8 hours the patients recovered completely or fairly well while the prognosis was poor if the transverse lesion persisted longer than 24 hours.The authors stress the importance of correct and fast decisions at the first medical examination for the outcome of this disease, because only immediate transfer to a neurosurgical department gives a chance of good recovery.     

Bilateral supratentorial epidural haematomas occurring independently and consecutively after the removal of a craniospinal meningioma

Summary We report a case of bilateral supratentorial epidural haematomas occurring independently and consecutively after the removal of a craniospinal meningioma. The patient was a 45-year-old female who was treated surgically with complete cure.     

Primary brain stem haematomas. Diagnosis and treatment

Summary Case histories are reported of 18 patients in whom the diagnosis of primary brain stem haematoma⁵ and brain stem haemorrhage¹³ was made by computed tomography (CT).The possibility of an early diagnosis of brain stem haematoma, and the differential diagnosis of brain stem haemorrhage by a combination of clinical and tomodensitometric criteria is emphasized.It is concluded that CT is a highly reliable method for the diagnosis, location, and management of brain stem haematoma.     

Gas bubbles within acute intracranial epidural haematomas

Summary In order to assess the actual incidence of gas bubbles trapped within acute intracranial epidural haematomas, as revealed by computed tomography (CT) of the skull, a series of 204 patients with surgically verified epidural haematomas was retrospectively reviewed. Gas bubbles were observed on CT scan in 22.5% of the cases, with the incidence rising to 37% when CT scanners of the last generation were employed. The available data failed to demonstrate the actual source of intracranial gas. No correlation was found between the presence of gas bubbles and outcome. No patient in the whole series showed any sign of intracranial infection.     

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

Summary Background. The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Method. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). Findings. The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diplo? (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 ± 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4–5) and 8 (26.7%) had poor results (GOS 1–3). Conclusions. Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.     

Acute traumatic vertex epidural haematomas surgically treated

Summary Eleven consecutive cases of acute traumatic vertex epidural haematomas (VEDHs) among 416 epidural haematomas (EDHs) operated on during the same period in the Neurosurgical Clinic of the University of Genoa, are reported. Clinical features, neuroradiological aspects (X-ray, angiography and CT scan) and results are discussed, in order to point out the problems encountered in the diagnosis, expecially due to the mystifying clinical picture and the unsuitability of the axial CT scan in the detection of these lesions. In this series mortality rate was 18%, against 50% reported in the literature.     

The CT criteria for conservative treatment — but under close clinical observation — of posterior fossa epidural haematomas

Summary In order to assess whether the indications for conservative treatment of supratentorial epidural haematomas are applicable also to posterior fossa epidural haematomas (PFEDH), the author reviewed the records of 25 patients. With a PFEDH volume of no more than 10 ml, a thickness of no more than 15 mm, a midline shift of no more than 5 mm, and in the absence of a significant intracranial haematoma elsewhere on computed tomography (CT) scans, the patients undergoing conservative treatment achieved the same excellent outcome as those undergoing early surgery. These CT criteria for conservative treatment of PFEDHs are similar to those of supratentorial epidural haematomas except the volume factor, namely, 10 ml in the former against 30 ml in the latter. That means a PFEDH of 10 ml or larger in the small posterior fossa may produce the same degree of midline shift and compression, and be as dangerous as an epidural haematoma of 30 ml or larger in the more capacious supratentorial compartment. But also for epidural haematomas of the posterior fossa, which initially are smaller than 10 ml, the general rule remains valid that they should be under close clinical supervision     

Clinical and CT scan assessment of benign versus fatal spontaneous cerebellar haematomas

Summary We have studied 15 cases of spontaneous intracerebellar haematomas in 9 males and 6 females. A significant correlation between the clinical presentation and the CT scan features of benign and fatal haemorrhages of the cerebellum is presented.Diagnostic computerized tomographic studies were performed in a mean interval of 31 hours after the initial symptoms. 60% were diagnosed and treated in less than 24 hours; 11 patients had haematomas larger than 3 cm, and 5 (45%) of these cases died with evidence of irreversible brain-stem damage. Twelve (80%) showed compression of the fourth ventricle, 9 (60%) obliteration of the brainstem cisterns and 8 (53%) ventricular dilatation.8 cases were treated with surgery; 50% of them showed neurological improvement, including two cases with signs of brain-stem compression. 7 patients who were treated conservatively were followed closely with repeated CT scans, which showed that resolution of the mass effect and isodensity of the haematomas occurred within 9 to 15 days, with a mean of 11 days, after the initial CT scan. An increased mortality was observed with haematomas larger than 3cm (73%), hydrocephalus (45%) and intraventricular haemorrhage (40%). Smaller haematomas without CT scan evidence of obliteration of the brain-stem cisterns or hydrocephalus had a better outcome.     

Chronic expanding epidural haematoma

Summary An encapsulated fluid epidural haematoma in a 9-year-old boy was successfully evacuated by a simple burr hole procedure 5 months after a minor head injury. Clinicopathological findings suggested that chronic expansion of an initially unsuspected epidural haematoma occurred as a result of repeated haemorrhages from the haematoma membrane, resulting in an unusually long delayed appearance of clinical evidence. This case demonstrates that a chronic expanding process similar to that seen in chronic subdural haematoma needs to be considered as a possible complication of epidural haematoma and indicates an important role for the haematoma membrane in the chronic expansion of epidural haematoma.     

Traumatic interhemispheric subdural haematomas

Summary According to reports in the literature traumatic interhemispheric subdural haematomas (I.S.H.) are supposed to present acutely or subacutely with contralateral monoparesis of a lower extremity or hemiparesis or in bilateral haematomas even with paraparesis, and to need early operative evacuation. In our series of 5 cases none of them followed this classical clinical picture, and three of them recovered without operation.We conclude that the indication for operative evacuation depends on the clinical course and that in patients with spontaneously improving symptomatology non-surgical management under close supervision may be the better solution. Also the C.T. finding of open convexity cisterns may be possible indication for conservative management.     

Efficacy of subdural saline injection during surgery for acute epidural haematomas

Primary objective: The purpose of this study was to investigate the efficacy of subdural space saline injection surgery in the management of large acute epidural haematomas (EDHs).

Methods and procedures: Over a period of 6 years, the authors employed the technique of subdural space saline injection to facilitate elevation of dura after evacuation of supratentorial epidural haematomas.

Main outcomes and results. Eighty patients with supratentorial epidural haematomas underwent the procedure. Infusion of saline in the subdural space not only helps elevation of the dura, facilitate haemostasis and application of suspension stitches during operation, it also avoids ICP fluctuations during the operations. Post-operative CT scans showed rapid disappearance of saline and reposition of cerebral structure. No patient required re-operation for residual haematoma.

Conclusions: Subdural saline injection is an effective operative technique in the management of large epidural haematoma.     

Conservative management of Dieterich disease: case report

Dieterich disease is characterized by avascular necrosis of the metacarpal head. The recent literature has described surgical management of this condition relatively soon after its presentation. We present a case treated conservatively with a satisfactory outcome at 28 months.     

Intracranial epidural haematomas in elderly patients: observations in 14 patients

Summary Backgrounds. Up to now, extra-dural haematomas (EDH) in elderly patients have been known for their poor prognosis and few studies have focused on the particularity of EDH in the elderly. Most clinical studies relating to EDH have generally focused on its occurrence in children and the middle-aged, grouping people of over 50 and 60 years together as the elderly. The purpose of this paper is to present a series of EDH cases in the elderly. Method. 500 EDH patients (of all ages) were admitted to our Department from January 1990 to December 2003 and this is a retrospective study of 14 of those patients who were aged 70 years and over. Findings. The study consists of 8 women and 6 men with an average age of 74 years. A high incidence of disease predisposes elderly to falls, which are the most frequent cause of head trauma. The elderly are less likely to manifest signs or symptoms of increased intracranial pressure due to cerebral atrophy, and almost all haematomas occurred in the parietal area. Post-operative results were satisfactory and only one death was recorded. Conclusion. This study shows that the elderly, presenting EDH after a fall, have a better prognosis than is often feared.     

Prognostic factors in severely head injured adult patients with epidural haematoma's

Summary A medline search back to 1975 was undertaken to identify relevant papers published on epidural haematomas. The search was restricted, whenever possible, to adult age and to comatose patients. Forty four relevant reports were identified. Only 4 papers reported results on multivariate analysis. In terms of prognosis, the following parameters were found to be significant: age, time from injury to treatment, immediate coma or lucid interval, presence of pupillary abnormalities, GCS/motor score on admission, CT findings (haematoma volume, degree of midline shift, presence of signs of active haematoma bleeding, associated intradural lesion) and post-operative ICP. To compare different casistics we need more informations about patients's outcome in the referral area of the neurosurgical centers, about the number of direct admissions and about the number of patients showing clinical deterioration.     

Chronic lumbar epidural haematoma presenting with acute paraparesis

Summary ¶Chronic spinal epidural haematomas are very rare and have been reported to occur only in the lumbar region. They usually become symptomatic through radicular pain or neurogenic claudication. The epidural bleeding is thought to originate from a rupture of an epidural vein due to a sudden increase in intra-abdominal pressure or due to trauma.The patient reported on here developed acute paraparesis about 8 weeks after a mild fall on the buttocks. MRI showed a spinal epidural mass located dorsolaterally at the level of L3–L5. The mass was surgically removed. Histological and immunohistological studies disclosed an organised haematoma.The clinical, radiological and intra-operative features of this case are described, and the relevant literature is analysed.Published online October 20, 2003     

Medical and surgical treatment of intracerebellar haematomas

Summary 15 cases of intracerebellar haematomas [11 spontaneous, 2 traumatic and 2 unclear] were presented. Hypertension was thought to be a main risk factor in 91 % in 11 of the spontaneous cases. 11 cases were treated medically. They were usually conscious, scoring not less than 13 in GCS with subacute or chronic picture of illness and harbouring small haematomas below 3 cm in diameter situated almost always in the hemisphere and with no signs of ventricular dilation. Mortality in medically treated patients was 9% [1 case].The remainder were discharged in good state, usually with no or only slight neurological deficit. Complete haematoma absorption took about 14 days. There were no signs of delayed hydrocephalus in subsequent CT scans.When the haematoma was large, more than 3 cm in diameter, located usually in the vermis or in the vermis and cerebellar hemisphere, sometimes with ventricular involvement, the clinical presentation was acute and required CT diagnosis and surgical evacuation without delay due to low and deteriorating conscious level.Postoperative mortality was 25%, but delayed mortality was 100%. Vertebral angiography was performed in all cases of spontaneous haemorrhage and was normal in 54%, revealed atheromatous changes in 36% and the signs of cerebellar haematoma in only 10%.Arteriovenous malformations were excluded from this study. The authors believe, that the benign course of intracerebellar haematomas is more frequent than it was considered previously and needs no surgical treatment in many cases.