Traumatic hematomas of the posterior fossa. A clinicopathological spectrum

Eight patients were found to have traumatic hematomas of the posterior fossa during a 6-year period. There were four patients with extradural hematomas, one patient with a subdural hematoma, and four patients with intracerebellar hematomas. In one patient, clinically significant hematomas were found both in the extradural space and in the cerebellum. Clinical or radiologic evidence of skull fracture was present in each case, and computed tomography scans were diagnostic of a posterior fossa hematoma in all cases. In six of the eight patients, there was clinical deterioration prior to surgical treatment, and in three cases, this was abrupt. All patients underwent suboccipital craniectomy. Six patients survived; four made a good recovery. Our experience indicates that early operation is usually indicated for these lesions.     

Delayed traumatic intracerebellar hematoma: correlation between the location of the hematoma and the pre-existing cerebellar contusion--case report.

A rare case of delayed traumatic intracerebellar hematoma (DTIC1H) in a 54-year-old male achieved an excellent outcome without surgery. Analysis of this case and other reported cases suggests that DTIC1H occurs in two types: Group I with hematoma developing in previously contused areas, and Group II with hematoma developing in areas appearing normal on the initial computed tomographic scan. Group I hematomas occurred in the cerebellar cortex, but Group II hematomas occurred in the subcortical region or vermis where direct impact is less likely to have an effect. This suggests different mechanisms of development for DTIC1H.     

Traumatic intracerebellar hemorrhagic contusions and hematomas

BACKGROUND: Traumatic intracerebellar hemorrhagic contusions and hematomas (TIHC) are unusual lesions and their surgical management remains controversial. METHODS: From January 1990 to July, 1998, 3290 patients underwent computed tomography for acute head trauma at our Institution. Eighteen patients (0.54%) were retrospectively identified as harboring TIHC. Patients were divided into two groups. In Group I (n=78) GCS at admission was > or = 9. Seven patients presented with isolated TIHC and one with an associated supratentorial lesion. Three patients exhibited an evolving clinico-radiological course. In Group II patients (n=10) GCS at admission was < or = 7. All but one presented with severe supratentorial lesions and associated brainstem signs. RESULTS: In group I six patients had their TIHC managed conservatively, and two were operated on, and all recovered completely. In group II, two patients were operated on. The outcome was poor in 90% of cases. CONCLUSIONS: TIHC constitute a protean clinico-pathological entity. Non-comatose patients with intracerebellar clots less than 3 cm in diameter should be treated conservatively and expected to make a good recovery. Surgery is indicated for larger hematomas causing cisternal and IV ventricle compression ab initio or as a result of their secondary evolution. In severely ill patients admitted comatose, it is generally the primary brain stem damage and the concomitant severe supratentorial lesions to dictate the prognosis. In these cases obliteration of the posterior fossa cisterns is the most reliable indicator of poor outcome.     

Delayed traumatic intracerebellar hematoma

A case of delayed traumatic intracerebellar hematoma is presented in which the patient survived after diagnosis and surgical intervention. The computed tomographic and clinical features of this entity are reported, and theories of pathogenesis are discussed. We advise a high index of suspicion for delayed intracerebellar hematomas in patients with cerebellar contusion following trauma.     

Nontraumatic subcapsular renal hematoma: report of a case

A case of nontraumatic subcapsular renal hematoma was reported. The patient was a 41-year-old woman. She complained of right flank colic pain. Her excretory pyelography showed right hydronephrosis and ureteral stone, and demonstrated a large mass involving the right kidney and medial displacement of its collecting system. Ultrasonic examination and computed tomography revealed right subcapsular renal hematoma. Since we found no malignancy, we made a puncture and drained the lesion. A bloody aliquot was gained and its cytological examination was negative. Her clinical course was uneventful. After 6 months the hematoma was absorbed clearly. A review was made of 38 cases of nontraumatic subcapsular renal hematoma, including our own case. Of these, the cause was unidentified in 17 cases. Hydronephrosis, mostly associated with calculi, renal infarcts, nephritis and renal cell carcinoma followed. Of 38 cases, 2 (5.3%) were of malignant tumor.     

Acute bilateral epidural hematoma

A case of acute bilateral epidural hematoma with different onsets is presented. The pathogenesis of the two hematomas is discussed. The importance and the limits of computed tomography scanning in these cases are stressed.     

Postoperative spinal epidural hematoma at a site distant from the main surgical procedure: a case report and review of the literature

Background ContextPostoperative spinal epidural hematomas are known complications of spinal surgery. However, to our knowledge, there are no known cases of postoperative spinal epidural hematoma that occurred distant from the portion of the procedure that breached the spinal canal.PurposeTo report a case and review the literature on the development of postoperative spinal epidural hematoma at a site distant from the portion of the surgical procedure that breached the spinal canal.Study DesignCase report and review of the literature.MethodsOne patient at our institution developed a hematoma at a site distant from the surgical procedure that breached the spinal canal. We retrospectively reviewed the patient's clinical charts, radiographs, and computed tomography scans.ResultsA 57-year-old woman with adult scoliosis and junctional kyphosis underwent a pedicle subtraction osteotomy and long spinal fusion from T3 to the sacrum. Three hours postoperatively, she developed paraplegia with a neurologic deficit at a level distant from the site at which the spinal canal was surgically breached. A computed tomography myelogram revealed a spinal epidural hematoma that was causing compression of the spinal cord in the upper thoracic spine. The patient was returned to the operating room emergently and underwent laminectomy and hematoma evacuation. She had near-complete recovery 5 months after surgery.ConclusionSpinal epidural hematomas are rare but dangerous complications that can result in severe neurologic deficits. A neurologic examination should always be conducted in the operating room immediately after surgery; if it is abnormal, spinal epidural hematoma should be suspected. If the examination indicates a deficit at a site distant from the original surgery, then diagnostic reimaging (magnetic resonance imaging or computed tomography myelogram) is indicated.     

Spontaneous non-traumatic mediastinal hematoma associated with oral anticoagulant therapy: A case report and literature review

IntroductionMediastinal hematoma is usually caused by thoracic trauma or a ruptured aortic aneurysm. Spontaneous non-traumatic mediastinal hematomas are rare but potentially life-threatening conditions that can occur in patients taking anticoagulants.Presentation of caseWe report a case of 72-year-old man with a massive mediastinal hematoma associated with anticoagulant therapy. He had complained of acute chest discomfort and subsequent tarry diarrhea. Because he had been taking warfarin for paroxysmal atrial fibrillation, an upper gastrointestinal hemorrhage was initially suspected, but no bleeding was detected by upper endoscopy. A computed tomography scan revealed a massive posterior mediastinal hematoma and markedly compressed surrounding structures. The compression of the left atrium caused a congested lung and exacerbated respiratory and hemodynamic status despite conservative therapy. Therefore, we surgically removed the hematoma. Immediately after removal, the respiratory and hemodynamic conditions improved, and the postoperative course was uneventful.DiscussionSpontaneous mediastinal hematoma is rare but can occur in patients who are administered anticoagulants regardless of the therapeutic level of anticoagulation. Although conservative therapy is commonly effective, active surgical intervention should be considered for cases in which the hematoma is symptomatic or conservative therapy is ineffective.ConclusionTo facilitate prompt and proper management, clinicians should be aware of this condition as a potential complication of anticoagulant therapy.     

Intracranial hematomas following aneurysmal rupture: experience with 309 cases

Three hundred and nine consecutive cases of intracranial hematomas due to aneurysmal rupture--representing 34% of the total number of patients with aneurysms observed in a 12-year period--were evaluated; of these, 211 were submitted to computed tomography scan. Hematomas were present on admission in 71% of patients and occurred at rebleeding in 29%. Ruptured middle cerebral artery aneurysms caused an intracranial hematoma more frequently than aneurysms in other locations. Ventricular hematomas were frequently observed--especially at rebleeding--in cases with anterior communicating artery aneurysms. Basal ganglia hematomas were detected in eight cases with internal carotid bifurcation aneurysms and in three with middle cerebral artery aneurysms. Subdural hematomas were observed in 32 cases, mainly due to ruptured middle-cerebral-artery and internal-carotid-artery aneurysms. As for clinical evolution, a rapid deterioration was observed in 39% of cases and a chronic course in 46%; a subacute deterioration was far less frequent. Delayed deterioration from vasospasm was observed in 8% of cases, and appeared to be related to the amount of subarachnoid bleeding associated with the hematoma. One hundred and forty-two patients were submitted to surgical treatment (evacuation of hematoma together with exclusion of aneurysm); deep coma, poor medical condition, stabilized neurological disability, or combinations of these factors accounted for the high number of patients not operated upon. Regardless of treatment, 24% of patients showed good results and 58% died. Presence of a large hematoma, ventricular hemorrhage, and shift of the ventricles represented significant risk factors, associated with a poor prognosis. A comparison between two groups of patients admitted within 3 days of hemorrhage--47 operated on early, and 149 with delayed treatment--showed that better results were achieved by early operations, especially for cases in Hunt's grades IV and V.     

Simultaneous multiple hypertensive intracerebral hematoma

Hypertensive intracerebral hemorrhage (HIH) occurring simultaneously in different locations is rare. We encountered 11 such cases between January 1990 and November 2002. The diagnosis of all 11 cases was established by computed tomography, and the location of the hematomas was: cerebellum and basal ganglia in 5 cases, pons and basal ganglia in 4, and subcortex and basal ganglia in 2. Our patients were analyzed with respect to clinical characteristics, pathogenesis of multiple hematomas, and indication of operation. These patients represented 1% of all 1,069 patients we encountered with HIH. As past history, there were no characteristic disorders except hypertension. There were no characteristic initial symptoms suggesting that hemorrhage had occurred simultaneously. Both supra- and infra-tentorial hematomas were observed in 80% of the patients, and the size of the multiple hematomas was proportional in principle. Cerebellar hematomas were often mild, and pontine hematomas were often severe. The outcome in those patients whose neurological grading was 1 to 3 was good with conservative therapy or surgical treatment. The severity, treatment methods, and outcomes in these patients were similar to those in patients with single HIH, which suggests only a slight influence of multiple lesions on outcome. As for the possible mechanism of simultaneous multiple hemorrhages, we speculated that bleeding occurred simultaneously in the different regions, or that the initial bleeding was followed after a short time by secondary bleeding due to high intracranial pressure and circulatory disturbance. In patients with cerebellar hematoma, initial symptoms suggested the development of secondary hemorrhage after primary hemorrhage. The surgical treatment for multiple hematomas should be determined by the location and maximum axis of the hematoma. We proposed that cerebellar hematomas should be removed if the supra-tentorial hematoma is small.     

Bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient

Purpose

Interhemispheric subdural hematomas (ISH) are rare in adults and occur most often after cranial trauma. We describe a parturient who developed bilateral acute ISH after inadvertent dural puncture associated with placement of an epidural catheter for labour analgesia. We discuss the features, pathophysiology, and management of this type of subdural hematoma.

Clinical features

A 38-yr-old woman requested epidural analgesia for relief of labour pain. An inadvertent dural puncture occurred during placement of a 17G Tuohy needle. After labour and delivery, the patient developed symptoms of a postdural puncture headache, which responded only partially to an epidural blood patch. The patient??s headache subsequently became less position-dependent and was associated with episodes of sharp pain radiating down her legs and paresthesias on the left side of her body. A computed tomography (CT) scan showed right frontal and left parietal acute ISH without an intracranial mass effect. The patient was monitored in the intensive care unit and treated conservatively because of the relatively small size of the ISH and the absence of progressive neurological deficits on serial examinations. Daily CT scans showed gradual decreases in the size of the ISH concomitant with improvement of the headache.

Conclusions

Rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. Nearly one-quarter of patients with ISH do not survive, although those with smaller hematomas have a better outcome. If the hematoma is?相似文献   

Contralateral development of chronic subdural hematoma after evacuation of chronic subdural hematoma. A case report

Contralateral acute complications such as acute epi/subdural hematomas can be encountered after evacuation of a chronic subdural hematoma, though they are rare. We found only one case of chronic subdural hematoma following the surgery for contralateral chronic subdural hematoma, have been published in English language literature. A 73-year-old male admitted to our hospital with a right-sided subdural hematoma. The subdural hematoma was evacuated through a burr-hole. A left-sided subdural higroma appeared after operation and turned into classical subdural hematoma in the course of time. After evacuation of contralateral chronic subdural hematoma, the patient recovered completely. All stages of the development of contralateral chronic subdural hematomas were shown by serial computed tomograms. It was suggested that traumatic chronic subdural hematomas develop from mostly subdural higromas. If contralateral subdural higroma is seen after surgical evacuation of a chronic subdural hematoma, the possibility of development of contralateral chronic subdural hematoma must be kept on mind.     

Acute subdural hematoma in infancy

BACKGROUND: Acute subdural hematoma in infants is distinct from that occurring in older children or adults because of differences in mechanism, injury thresholds, and the frequency with which the question of nonaccidental injury is encountered. The purpose of this study is to analyze the clinical characteristics of acute subdural hematoma in infancy, to discover the common patterns of this trauma, and to outline the management principles within this group. METHODS: Medical records and films of 21 cases of infantile acute subdural hematoma were reviewed retrospectively. Diagnosis was made by computed tomography or magnetic resonance imaging. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome. RESULTS: Twenty-one infants (9 girls and 12 boys) were identified with acute subdural hematoma, with ages ranging from 6 days to 12 months. The most common cause of injury was shaken baby syndrome. The most common clinical presentations were seizure, retinal hemorrhage, and consciousness disturbance. Eight patients with large subdural hematomas underwent craniotomy and evacuation of the blood clot. None of these patients developed chronic subdural hematoma. Thirteen patients with smaller subdural hematomas were treated conservatively. Among these patients, 11 developed chronic subdural hematomas 15 to 80 days (mean = 28 days) after the acute subdural hematomas. All patients with chronic subdural hematomas underwent burr hole and external drainage of the subdural hematoma. At follow-up, 13 (62%) had good recovery, 4 (19%) had moderate disability, 3 (14%) had severe disability, and 1 (5%) died. Based on GCS on admission, one (5%) had mild (GCS 13-15), 12 (57%) had moderate (GCS 9-12), and 8 (38%) had severe (GCS 8 or under) head injury. Good recovery was found in 100% (1/1), 75% (8/12), and 50% (4/8) of the patients with mild, moderate, and severe head injury, respectively. Sixty-three percent (5/8) of those patients undergoing operation for acute subdural hematomas and 62% (8/13) of those patients treated conservatively had good outcomes. CONCLUSIONS: Infantile acute subdural hematoma if treated conservatively or neglected, is an important cause of infantile chronic subdural hematoma. Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality.     

Endoscopic findings in chronic subdural hematoma

On the genesis of chronic subdural hematoma (CSH), it is one of the possible explanations that a head injury triggers uncertain cause off for the formation of the hematoma membrane, where the bleeding occurs to form and enlarge the hematoma. Although some reports on the staging classification based on computed tomography (CT) findings are available the natural course or history of the hematoma formation is not yet known. As previously reported, we have been using an endoscopically guided method in which a drainage tube is placed in the most frontal area of the cavity so as to evacuate the residual air efficiently. In this study, we analyzed the endoscopic findings in hematoma cavities and compared them with the clinical data, focusing on the post-trauma interval and recurrence of the hematoma. Between January 1999 and October 2000, we had an opportunity to observe the inner aspect of 60 hematomas in 48 patients. A trabecular structure was found in 39 hematoma cavities (65%), whereas apparent clot formation was observed in 18 cavities (30%). Septum formation leading to a multi-loculated hematoma was observed in 10 cavities (17%). Twenty-six patients with 32 hematomas with the obvious history of head injury were classified into 4 groups according to the post-traumatic interval to the surgery, which are stage I; less than 30 days, stage II; 31 to 60 days, stage III; 61 to 90 days and stage IV; more than 91 days. Clot formation and a trabecular structure were frequently seen in stages II and III. Clot formation was statistically and significantly seen in the recurrent group. The results suggest that CSHs increase in size in stages II and III, when clot formation and a trabecular structure are frequently observed. Endoscopic observation of hematomas may assist to know hematomas, and clot formation may be a warning of hematoma recurrence.     

Extradural hematoma of the posterior cranial fossa

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological findings are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86% of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2%, but only patients with an acute course died (20%). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality. According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.     

Local and Systemic Consequences of Large Retroperitoneal Clot Burdens

Background  There is a paucity of data regarding the impact of retroperitoneal hematoma (RPH) volumes, as detected by computed tomography (CT) scanning, on patient morbidity and mortality. Therefore, we wanted to determine the natural history of RPHs and the effect of size on local and systemic outcomes. Methods  We performed a volumetric analysis of CT-documented RPHs managed at our institution between 1985 and 2006 along with a retrospective chart review. Results  We included 81 cases of RPH in this study. The mean Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score was 12.8 ± 0.72 (score ± SE). By univariate analysis, the size of the hematoma showed a significant correlation with the development of local mass effects, delayed mass effects, 6-month mortality, major morbidity, pulmonary complications, fluid overload, and the requirement for operative evacuation (p < 0.05). Receiver operating characteristic analysis revealed that a size ≥1600 cm³ was >80% sensitive and specific for predicting a delayed mass effect or an increase in 6-month mortality. Multivariate analysis controlling for factors such as APACHE II and packed red blood cells transfused showed that the volume of the RPH was an independent predictor for the development of local mass effects, pulmonary insufficiency, and fluid overload. Conclusions  Large RPHs are clearly associated with worse patient outcomes. Surgical intervention may be warranted for the treatment of RPHs ≥1600 cm³.     

Chronic extradural hematomas of the posterior cranial fossa

During the past 6 years, seven patients with chronic extradural hematomas have been observed at these hospitals. All had a history of occipital injury. Occipital fracture was demonstrated in five cases (by skull x-ray in three cases, at operation in two). The diagnosis was obtained by computed tomography scan in six cases and by iodoventriculography in one. One patient had an associated cerebral lesion, namely, a contralateral temporoparietal contusion. The interval between injury and operation ranged from 27 to 13 days with a mean of 19 days. Only one patient was not operated on, because he was free from symptoms and the hematoma was small. The course was excellent in all seven cases.     

Extradural hematomas of the posterior cranial fossa. Observations on a series of 32 consecutive cases treated after the introduction of computed tomography scanning

A series of 32 patients with posterior fossa epidural hematoma treated after the introduction of computed tomography scanning between 1975 and March 1988 is presented. Sixteen patients harbored "pure" epidural hematomas, whereas 16 had other infratentorial or supratentorial traumatic lesions. Glasgow Coma Scale on admission was 7 or less in 10 patients, 8-12 in 11, and 13-14 in 11. Only six patients had a lucid interval. Thirty patients were treated surgically; two patients with small hematomas were treated conservatively. Overall mortality was 15.6%, with 0% for "pure" and 31.2% for "complicated" posterior fossa epidural hematomas. The value of routine computed tomography scanning is emphasized in cases with occipital skull fracture or when such fracture is found in patients undergoing emergency evacuation of supratentorial hematomas. The pertinent literature is addressed with special regard to the delayed occurrence, associated lesions, and mortality of posterior fossa epidural hematomas and to the role of computed tomography scanning.     

Multilocular encapsulated intracerebral hematoma; a case report

Encapsulated intracerebral hematomas mimicking a brain tumor have been reported as a rare occurrence. An additional case with a characteristic feature found on computed tomography (CT), and a clinical course is described. CT scans revealed a high density mass with peripheral low density in the brain. A hematoma was successfully removed and found to have a thick and multilobular fibrous capsule associated with cavernous hemangioma. Repeated hemorrhage due to vascular malformation was considered to have contributed to the formation of the capsule. Increasing awareness of the possibility of an encapsulated intracerebral hematoma as a clinical and pathological entity, would enable us to make a correct diagnosis and to select proper treatment. A thorough survey of occult vascular malformation is necessary in surgery.     

Primary Enlarged Craniotomy in Organized Chronic Subdural Hematomas

The aim of the study is to evaluate the efficacy of craniotomy and membranectomy as initial treatment of organized chronic subdural hematoma (OCSH). We retrospectively reviewed a series of 34 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or contrast computer tomography (CCT) in order to establish the degree of organization and determine the intrahematomal architecture. The indication to perform a primary enlarged craniotomy as initial treatment for non-liquefied chronic subdural hematoma (CSDH) with multilayer loculations was based on the hematoma MRI appearance—mostly hyperintense in both T₁- and T₂-weighted images with a hypointense web- or net-like structure within the hematoma cavity. The reason why some hematomas evolve towards a complex and organized architecture remains unclear; the most common aspect to come to light was the “long standing” of the CSDHs which, in our series, had an average interval of 10 weeks between head injury and initial scan. Recurrence was found to have occurred in 2 patients (6% of cases) in the form of acute subdural hematoma. One patient died as the result of an intraventricular and subarachnoid haemorrhage, while 2 patients (6%) suffered an haemorrhagic stroke ipsilateral to the OCSH. Eighty-nine percent of cases had a good recovery, while 11% remained unchanged or worsened. In select cases, based on the MRI appearance, primary enlarged craniotomy seems to be the treatment of choice for achieving a complete recovery and a reduced recurrence rate in OCSH.