Influence of operative timing on prognosis of patients with acute subdural hematoma

Objective: To study the influence of operative timing on the prognosis of patients with acute subdural hematoma (ASDH) in order to provide theoretical basis for clinical treatment.Methods: The clinical data of 202 patients with ASDH undergoing operations were collected, and the mortalities and functional survival rates were analyzed 2, 4, 6, and 8 hours after injury.Results: No significant difference was found in mortalities and functional survival rates at different operative timings. However, there was a clear trend that the shorter the operative timing was, the lower the mortality and the higher functional survival rate were. In addition, the mean time from injury to operation of non-survivors was significantly longer than that of survivors.Conclusions: Operative timing has potential influences on the prognosis of patients with ASDH. Surgical evacuation of ASDH should be performed as soon as possible once the operation indication emerges.     

急性硬膜下血肿手术时机对预后的影响

目的 研究手术时机对急性硬膜下血肿预后的影响.方法 收集了202例接受手术治疗的急性硬膜下血肿患者,统计分析伤后2、4、6、8h等时间为界限的死亡率和功能生存率.结果 各个时间界限的死亡率和功能生存率差异无统计学意义,但是随着受伤至手术间隔时间的延长,死亡率呈现出逐渐增加、功能生存率逐渐降低的趋势.并且,死亡患者的受伤至手术时间要显著大于生存患者.结论 急性硬膜下血肿手术时机对预后有潜在的影响.符合有手术指征的患者,急性硬膜下血肿需要尽早手术清除血肿.     

Iatrogenic acute subdural hematoma due to drainage catheter

BACKGROUND

Insertion of a catheter for drainage of a cavity is a routine step in many surgical practices. In neurosurgery, catheters are commonly placed in the subdural, subgaleal, or epidural spaces to prevent haematoma formation.

CASE DESCRIPTION

We present three cases of iatrogenic acute subdural hematoma. These were all related to the drainage catheters. In the first case, a subgaleal redivac suction catheter was used after craniotomy for brain abscess. The other two patients had ordinary ventricular catheters placed in the subdural space after burr hole drainage of chronic subdural hematoma. The drainage catheter was removed on postoperative day 5 in the first case and two days after the initial operation in the other two cases. Shortly after the removal of the drains, the conditions of the patients deteriorated rapidly due to the development of acute subdural hematoma.

CONCLUSION

Although they are extremely uncommon, life-threatening complications related to a drainage catheter are a real possibility. Therefore, the procedure should not be taken lightly.     

急性硬膜下血肿清除术后迟发性硬膜下积液的诊治

目的 探讨急性硬膜下血肿清除术后硬膜下积液的原因、早期诊断、手术治疗方法和疗效。方法 对急性硬膜下血肿后硬膜下积液29例进行回顾性分析。结果 痊愈14例，占48．7％；轻残5例，占17．2％；重残4例，占13．8％；植物状态3例，占10．3％，死亡3例，占10．3％。引流效果良好，无一例颅内感染。结论 急性硬膜下血肿清除后可能发生硬膜下积液；术后意识无改善或意识好转后又加重、出现颅内压增高征象、神经系统定位体征、减压区膨隆、瞳孔及生命体征改变应予CT检查可明确诊断：积液区颅骨钻孔或减压区小切口置管引流简便易行，有效满意疗效。     

Acute subdural hematoma: morbidity, mortality, and operative timing

Traumatic acute subdural hematoma remains one of the most lethal of all head injuries. Since 1981, it has been strongly held that the critical factor in overall outcome from acute subdural hematoma is timing of operative intervention for clot removal; those operated on within 4 hours of injury may have mortality rates as low as 30% with functional survival rates as high as 65%. Data were reviewed for 1150 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3 to 7) treated at a Level 1 trauma center between 1982 and 1987; 101 of these patients had acute subdural hematoma. Standard treatment protocol included aggressive prehospital resuscitation measures, rapid operative intervention, and aggressive postoperative control of intracranial pressure (ICP). The overall mortality rate was 66%, and 19% had functional recovery. The following variables statistically correlated (p less than 0.05) with outcome; motorcycle accident as a mechanism of injury, age over 65 years, admission GCS score of 3 or 4, and postoperative ICP greater than 45 mm Hg. The time from injury to operative evacuation of the acute subdural hematoma in regard to outcome morbidity and mortality was not statistically significant even when examined at hourly intervals although there were trends indicating that earlier surgery improved outcome. The findings of this study support the pathophysiological evidence that, in acute subdural hematoma, the extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome; therefore, the ability to control ICP is more critical to outcome than the absolute timing of subdural blood removal.     

Unilateral subdural hematoma without midline shift

Two cases of radiographically isodense subdural hematoma are presented in which absence of displacement of midline cerebral structures was due not to bilateral lesions, but rather to “balancing” of the volumetric effect of a unilateral lesion by preexisting encephalomalacia. Attention to the past medical history and the computed tomography scan which showed evidence of unilateral loss of brain substance led to the proper diagnosis.     

Endoscopic removal of organized chronic subdural hematoma

An endoscopic surgical approach to organized chronic subdural hematoma is described. Advantages of the endoscopic approach include access to virtually the entire hematoma cavity through a small craniectomy performed with local-standby anesthesia. Two illustrative cases are presented.     

Traumatic subdural hydroma developing into chronic subdural hematoma

Objective: To probe the incidence, pathogenesis and clinical characteristics of traumatic subdural hydroma (TSH) developing into chronic subdural hematoma(CSDH). Methods: We retrospectively analyzed the clinical data of 32 patients with TSH developing into CSDH and reviewed related literature. Results: 16.7 % of TSH developed into CSDH in this study. The time of evolution was from 22 to 100 days after head injury. All the patients were cured with hematoma drainage. Conclusions : TSH is one of the origins of CSDH. The clinical characteristics of TSH developing into CSDH follow that the ages of the patients are polarized, that the evolution often happens in the patients with small chronic hydromas and being treated conservatively, that the patients are usually injured deceleratedly and that the accompanying cerebral damage is often very mild.     

Acute subdural hematoma: morbidity and mortality related to timing of operative intervention

In spite of major advances in the management of severe head injury (HI) acute subdural hematoma (ASDH) continues to be one of the most lethal of all intracranial injuries. Of 1,150 consecutive severe HI patients, 137 (12%) had ASDH. The following variables were assessed in regards to outcome morbidity/mortality from ASDH: mechanism of injury, age, sex, neurologic presentation, postoperative intracranial pressure (ICP), and timing from injury to operative evacuation of the ASDH. The only variables found to statistically correlate with outcome were presenting neurologic condition (p = 0.001) and elevated postoperative ICP greater than 45 mm Hg (p = 0.001). The timing from injury to operative evacuation of the ASDH in regards to outcome morbidity/mortality was not statistically significant even when examined at hourly intervals (p = 0.418).     

外伤性硬膜下积液演变的慢性硬膜下血肿

目的 探讨外伤性硬膜下积液演变为慢性硬膜下血肿的几率、机理和临床特点。方法 回顾性分析32例外伤性硬膜下积液演变为慢性硬膜下血肿患者的临床资料及有关文献。结果 本组16.7%的外伤性硬膜下积液病例演变为慢性硬膜下血肿;积液演变为血肿的时间为伤后22－100d;经钻颅血肿引流均治愈。结论 外伤性硬膜下积液是慢性硬膜下血肿的来源之一。发病年龄两极化,常发生在积液量少、保守治疗的慢性型病例中,致病方式常为减速性损伤及合并的颅脑损伤很轻微是外伤性硬莫膜下积液演变为慢性硬膜下血肿患者的临床特点。     

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

Summary A medline search back to 1975 was undertaken to identify relevant papers published on subdural haematomas. The search was restricted, whenever possible, to adult age and comatose patients. Forty relevant reports were identified. Only 3 papers reported results on multivariate analysis. In terms of prognosis, the following parameters were found to be significant: age, time from injury to treatment, presence of pupillary abnormalities, GCS/motor score on admission, immediate coma or lucid interval, CT findings (haematoma volume, degree of midline shift, associated intradural lesion, compression of basal cisterns), post-operative ICP and the type of surgery. Improving the outcome of patients with acute subdural haematoma's is a difficult task. A small subpopulation of patients may have a benign course without surgical haematoma evacuation, but all comatose patients with an acute subdural haematoma should be treated in Centers where neurosurgical facilities and appropriate monitoring are available.     

Significance of consecutive bilateral surgeries for patients with acute subdural hematoma who develop contralateral acute epi- or subdural hematoma

BACKGROUND: Although rare, patients with acute subdural hematoma (ASDH) because of severe head injury can develop contralateral acute epi- or subdural hematoma, requiring consecutive surgical procedures. The choice of treatment strategies for such patients is clinically important. METHODS: Among 88 patients with ASDH who were surgically treated over 13 years, we encountered and studied 5 patients who developed contralateral acute epi- or subdural hematoma (5.7%). RESULTS: All 5 patients were male, ranging in age from 17 to 40. According to the Glasgow Coma Scale on admission, 1 patient was rated 3, 1 was 4, 1 was 5, and 2 were 6. All patients underwent consecutive surgical procedures for ASDH and contralateral ASDH and/or acute epidural hematoma, and were given postoperative supportive therapy with barbiturates and mild hypothermia. Patients' outcomes according to the Glasgow Outcome Scale were as follows: 1 patient, good recovery (20.0%); 1, mild disability (20.0%); 2, severe disability (40.0%), and 1, persistent vegetative state (20.0%). No patients died. Although decompressive craniectomy and evacuation of hematoma may lead to contralateral acute epi- or subdural hematoma in patients with ASDH, this therapy is justified because hematoma irrigation with trephination therapy has a poor outcome for comatose patients. CONCLUSION: Awareness of intraoperative brain swelling is important, as it suggests the development of contralateral hematoma. Immediate computed tomography and a rapid return to the operating room are therefore critical.     

Intracranial hypotension with subdural hematoma following lumbar puncture: case report

BACKGROUND AND PURPOSE: Lumbar puncture is a common procedure highly contributive to neurological diagnosis. It can also cause serious adverse side effects including subdural hematoma and intracranial hypotension as illustrated by this case report. CASE REPORT: A 38-year-old women presented severe intracranial hypotension after a lumbar puncture. Magnetic resonance imaging was compatible with intracranial hypotension and revealed an acute subdural hematoma with midline deviation. A first blood patch was unsuccessful. Symptom relief was achieved with a second patch. The patient was, then, discharged but developed recurrent headache subsequent to the transformation from acute to chronic subdural hematoma. Surgical drainage was required. The postoperative imaging and physical examination returned to normal and the patient was discharged with no recurrence. CONCLUSION: The serious adverse effects of lumbar puncture is an easy and common medical procedure that must be kept in mind.     

Oculomotor palsy with pupillary sparing in a patient with chronic subdural hematoma

A patient with adult-onset diabetes mellitus developed an oculomotor palsy with pupillary sparing. Five days after her initial evaluation, she presented in a confused state with a complete oculomotor palsy. Computed cranial tomography revealed a chronic subdural hematoma. We recommend that noninvasive radiographic intracranial investigation be considered in elderly patients with adultonset diabetes mellitus who present with headache and pupil-sparing oculomotor palsy.     

重症急性胰腺炎手术时机和手术方式的探讨

目的 探讨重症急性胰腺炎(SAP)手术时机和手术方式。方法 对1986~1998年收治的59例SAP患者手术时机、术式及病死率进行回顾性分析。结果 (1)手术病死率为20.3%,其中66.7%为40~60岁患者。性别及病因分类无差异。1992年以前早期手术为主,病死率26.7%,并发症发生率40.0%;1992年以后延期手术为主,病死率13.8%,并发症发生率24.1%。(2)随手术距发病时间延长,病死率逐渐降低,但差异无显著性(P>0.05)。(3)随胰腺坏死程度增加,手术病死率显著增加(P<0.05)。(4)休克、Ⅲ级胰坏死及多脏器功能衰竭的相关病死率分别为42.9%、40.0%和71.4%(P均<0.05)。(5)术式以胆胰联合手术及单纯胰病灶清除引流为主。结论 SAP手术时机是影响手术病死率的重要因素,应采用延期与个体化相结合的处理原则。术式选择应以简单有效,充分引流,清除病灶,去除病因为基本原则。     

Coagulopathy and inhospital deaths in patients with acute subdural hematoma

OBJECT: Acute subdural hematoma (SDH) is one of the most lethal forms of intracranial injury; several risk factors predictive of a worse outcome have been identified. Emerging research suggests that patients with coagulopathy and intracerebral hemorrhage have a worse outcome than patients without coagulopathy but with intracerebral hemorrhage. The authors sought to determine if such a relationship exists for patients with acute SDH. METHODS: The authors conducted a retrospective analysis of consecutive patients admitted to a neurosciences intensive care unit with acute SDH over a 4-year period (January 1997-December 2001). Demographic data, laboratory values, admission source, prior functional status, medical comorbidities, treatments received, and discharge disposition were recorded, as were scores on the Acute Physiology, Age, and Chronic Health Evaluation III (APACHE III). Coagulopathy was defined as an internal normalized ratio>1.2 or a prothrombin time>or=12.7 seconds. Univariate and multivariate analyses were performed on 244 patients to determine factors associated with worse short-term outcomes. RESULTS: The authors identified 248 patients with acute SDH admitted to the neurointensive care unit during the study period, of which 244 had complete data. Most were male (61%), and the mean age of the study population was 71.3+/-15 years (range 20-95 years). Fifty-three patients (22%) had coagulopathy. The median APACHE III score was 43 (range 11-119). Twenty-nine patients (12%) died in the hospital. Independent predictors of inhospital death included APACHE III score (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.4-13.4, p=0.011) and coagulopathy (OR 2.7, 95% CI 1.1-7.1, p=0.037). Surgical evacuation of acute SDH was associated with reduced inhospital deaths (OR 0.2, 95% CI 0.1-0.6, p=0.003). CONCLUSIONS: Coagulopathy is independently associated with inhospital death in patients with acute SDH. Time to treatment to correct coagulopathy using fresh frozen plasma and/or vitamin K was prolonged.     

Radiology of acute subtemporal subdural hematomas

Four cases of acute subtemporal hematoma are presented. The diagnostic appearance of this lesion on axial and coronal computed tomographic (CT) scans and at angiography is described.     

Spontaneous disappearance of a middle fossa arachnoid cyst associated with subdural hematoma

The case of a 7-year-old boy with a middle fossa arachnoid cyst that spontaneously disappeared is presented. Computed tomography (CT) scan revealed an arachnoid cyst in the right middle fossa with a thin subdural hematoma on the same side. As the subdural hematoma spontaneously resolved, the cyst became smaller and finally disappeared without surgical intervention after 18 months on the follow-up CT scans. Possible mechanisms of the spontaneous disappearance of an arachnoid cyst are discussed.