Brain shift, level of consciousness, and restoration of consciousness in patients with acute intracranial hematoma

Recently, Ropper reported that horizontal brain shift caused by acute unilateral mass lesions correlated closely with consciousness, and suggested that recovery of consciousness was unlikely to occur after surgical evacuation if the shift was insufficient to explain the observed diminution of consciousness. The authors have sought to confirm the correlation of pineal shift with level of consciousness and to assess the prognostic value of brain shift measurements in a prospective study. Forty-six patients (19 with subdural hematoma, 14 with intracerebral hematoma, and 13 with epidural hematoma) were accrued to the study group consecutively. A correlation was found between a decrease in the level of consciousness and a significant increase in the mean lateral brain displacement at the pineal gland (from 3.8 to 7.0 mm) and septum (5.4 to 12.2 mm). When outcome was examined in patients who were stuporous or comatose on admission, a significant increase in septal shift was found among patients with a poor outcome, but there was no significant relationship between outcome and degree of pineal or aqueductal shift. A poor outcome was more likely with effacement of both perimesencephalic cisterns or the ipsilateral cistern, but not the contralateral cistern, although this difference did not reach statistical significance. These results do not substantiate the value of brain shift as an independent prognostic factor after evacuation of an acute unilateral mass lesion. The decision to operate and the determination of prognosis should be based rather on established criteria such as the clinical examination, age of the patient, and the mechanism of injury.     

Subperiosteal hematoma of the orbit associated with subfrontal extradural hematoma

Subperosteal hematoma is rarely associated with extradural hematoma and orbital roof fracture. We report a case observed in a 16-year-old boy who developed exophthalmos, diplopia and visual loss after blunt head trauma. Computed tomography demonstrated the subperiosteal hematoma associated with a thin extradural hematoma and an orbital roof fracture. The hematomas were removed during the same procedure via fronto-orbito craniotomy. Surgery led to complete recovery without functional sequelae. We stress the importance of early diagnosis and treatment of post-traumatic exophthalmos.     

Behavior of an extradural pressure monitor in clinical use. Comparison of extradural with intraventricular pressure in patients with acute and chronically raised intracranial pressure

A comparison of intraventricular pressure (IVP) and extradural pressure (EDP) was carried out in 17 patients being investigated for normal-pressure hydrocephalus, and in six patients with acutely raised intracranial pressure following events such as head injury or intracerebral hematoma. Extradural pressure was measured using the CardioSearch monitor. There was a reasonably good correlation between EDP and IVP in the chronic stable group with pressures up to 25 mm Hg. In the acute group there was no predictable relationship between EDP and IVP, and during a 24-hour period the pressures could vary by as much as 30 mm Hg. Subdural pressure, measured with the same instruments, was compared to IVP in both acute and stable situations in eight other patients: there was a close and constant correlation between pressures in these two spaces. The authors conclude that misleading information may be obtained from EDP monitoring, and erroneous management decisions may result from dependence on such a technique. Possible explanations for this are discussed.     

Device for extradural monitoring of intracranial pressure: technical note

An ICP-monitoring device utilizing an extradural method is described. Clinical and laboratory use has shown it to be easily installed, safe, accurate, and reliable. It can be used with currently available transducers and monitoring equipment. It is hoped that this simple device will encourage the increased use of ICP monitoring.     

急性硬膜外血肿手术后颅内压影响因素分析

目的 探讨急性硬膜外血肿患者术后颅内压增高发生的机制及其影响因素和术中去骨瓣减压的指征.方法 将65例急性硬膜外血肿患者分为颅内压显著增高组和颅内压正常或轻度增高组两组.根据患者格拉斯哥昏迷评分(Glasgow Coma Scale,GCS)、瞳孔大小、血肿量、手术时间等进行统计学分析.结果 两组在瞳孔进行性散大的差异有统计学意义(P＜0.01);而在GCS评分、血肿量、手术时间等的差异无统计学意义.结论 急性硬膜外血肿术后颅内压增高主要是急性脑受压造成的脑水肿;脑受压程度越重、时间越长,术后脑水肿越严重;及时手术是避免或减轻术后脑水肿的有效措施,对术后发生颅内压显著增高病例应及时去骨瓣减压.     

Rapid spontaneous disappearance of an acute extradural hematoma: case report

The authors report the case of a patient presenting with an acute extradural hematoma and diffuse axonal injury. Control CT scan performed 4 hours later showed the complete resolution of the extradural collection together with increased evidence of shearing injuries. The mechanism of the hematoma resolution may probably be related to the concomitant acute brain swelling.     

一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗体会

目的 探讨一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗方法.方法 回顾性分析13例急性颅内血肿术中继发对侧迟发性颅内血肿患者的临床资料,采用一次开颅清除双侧血肿.结果 术后按Glasgow(COS)评定预后,其中良好4例,中残4例,重残2例,植物生存1例,死亡2例.结论 采用一次开颅治疗一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的效果显著,可以提高患者的生存率和生活质量.     

Case of spontaneous intracranial hypotension associated with depressed consciousness

We experienced a case of spontaneous intracranial hypotension (SIH) complicated with depressed consciousness after its treatment. A 56-year-old woman developed postural headache, and her MRI revealed bilateral chronic subdural hematoma (CSH). After treatment with epidural autolongous blood patch, her headache resolved completely. However, two days after, the patient developed depressed conciousness, and MRI showed brain sagging and downward brain displacement. After management with conservative treatment, including second epidural blood patch and hematoma drainage, the patient became alert and other symptoms resolved gradually. We demonstrated that caution should be taken for the management of SIH, especially in the case associated with CSH.     

一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗体会

目的 探讨一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗方法.方法 回顾性分析13例急性颅内血肿术中继发对侧迟发性颅内血肿患者的临床资料,采用一次开颅清除双侧血肿.结果 术后按Glasgow(COS)评定预后,其中良好4例,中残4例,重残2例,植物生存1例,死亡2例.结论 采用一次开颅治疗一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的效果显著,可以提高患者的生存率和生活质量.     

Novel method for emergency craniostomy for rapid control and monitoring of the intracranial pressure in severe acute subdural hematoma

Acute subdural hematoma (ASDH) is a critical condition following the onset of traumatic brain injury, and it is essential to immediately reduce elevated intracranial pressure (ICP). Single burr hole surgery/twist drill craniostomy is commonly performed in patients with ASDH as an emergency surgical intervention, usually preceding decompressive craniotomy. A novel method using a cerebrospinal fluid (CSF) drainage catheter kit for rapid drainage of ASDH is described. Percutaneous twist drill craniostomy using a CAMINO(?) micro ventricular bolt pressure-temperature monitoring kit was performed in the emergency room in 12 patients with severe ASDH. The kit contained a closed-system CSF drainage and pressure-temperature monitoring catheter, which allowed aspiration of the hematoma and monitoring of the ICP. The tip of the catheter was inserted into the hematoma from the forehead. The mean initial ICP was 61 mmHg, with a range of 31 to 120 mmHg. The liquid hematoma was aspirated, and the ICP was temporarily controlled to the normal range. Pupil dilation recovered immediately after aspiration of the hematoma in 3 patients. No complications occurred either during or after the operation. This new method for craniostomy is easy, safe, and effective to monitor and rapidly control ICP in the emergency room. This technique also offers the possibility of evaluating the patient's prognosis and determining indications for further decompressive craniectomy by the continuation of ICP control under ICP monitoring and evaluation of the reversibility of pupillary findings in ASDH patients.     

Effects of hypothermia on intracranial pressure and brain edema formation: studies in a rat acute subdural hematoma model

Acute subdural hematoma (SDH) is the most common mass lesion in severe head injury, and brain ischemia is the leading pathophysiological mechanism in the development of secondary brain damage following SDH. Hypothermia has been employed as an effective neuroprotective procedure in clinical and laboratory studies on cerebral ischemic and contusional injuries. In the present study, we used a rat acute SDH model to assess the effect of hypothermia on the intracranial pressure (ICP) and also on the brain edema formation at 4 h after hematoma induction. Mild (34 degrees C) and moderate (32 degrees C) hypothermia did not significantly affect the ICP or cerebral perfusion pressure, but they were associated with a significant lower cortical brain edema formation beneath the hematoma (81.09 +/- 0.49%, p<0.05; and 80.88 +/- 0.17%, p<0.01) when compared with the normothermic control group (81.65 +/- 0.52%). This reduction in brain edema formation was comparable to the results of MK-801 treatment (80.95 +/- 0.35%, p<0.01). The present findings indicate that hypothermia represents a potent neuroprotective strategy. The possible protective mechanisms of hypothermic protection afforded in this rat acute SDH model are discussed.     

Intentional hypotension therapy induced by nitroglycerin and the changes in the intracranial pressure for acute hemorrhagic intracranial lesions]

It is reported that nitroglycerin (NTG) induces the elevation of intracranial pressure (ICP). Because of it, the use of NTG in patients exhibiting the increased ICP especially in the neurosurgical field is thought to be avoided. However, these reported cases dealt with normal patients. Few cases under the condition of exactly increased intracranial pressure were studied. Our 31 patients of the hemorrhagic intracranial lesion (subarachnoid hemorrhage and hypertensive intracranial hemorrhage) at the acute stage were treated by NTG infusion as an antihypertensive drug, and the ICP was measured using the epidural pressure transducer. The 31 patients were divided into three groups. Group 1 consists of the 14 patients exhibiting normal ICP (< 15mmHg). Group 2 consists of 9 patients showing elevated ICP (15mmHg < or =). Group 3 consists of 8 patients treated with glycerol before the NTG infusion. Group 1 demonstrates a statistically significant elevation of ICP corresponding with the blood pressure depression. Group 2 showed no significant elevation of it. Group 3 disclosed no remarkable elevation of it both in the elevated ICP cases and the normal ICP cases. As mentioned above, the intravenous NTG caused a remarkable increase of ICP in the normal compliance of the intracranial contents and no elevation of ICP in the poor compliance. We conclude that NTG can be used for blood pressure control at an acute stage even in hemorrhagic intracranial lesion as anti-depressor.     

A case of coup and contrecoup extradural hematoma

We report an unusual type of a bilateral extradural hematoma: one due to direct injury and another due to the contrecoup effect. The second evolved after the first hematoma was evacuated.     

The influence and outcome of acute infantile intracranial hematoma with hypoxemia

Unusually broad areas of cerebral infarction were demonstrated by CT scan in three head injured infants with acute intracranial hematoma. They revealed very characteristic CT findings including contralateral hemispheric ischemic zone. Case 1 is a 5-month-old boy who had hit his head 4 days before. On admission he was semicomatose and his respiration had suffered from generalized seizures with arterial PO2 value of 43 mmHg. CT scan revealed right subdural hematoma, and bihemispheric ischemic low density was also demonstrable. Hematoma clot weighing 10 grams was removed through emergency craniotomy, followed by external decompression. There was a marked atrophic change in the right cerebral hemisphere and contralateral frontal base during the following few months, but the basal ganglionic region, brainstem and cerebellum were hardly affected. The patient developed comparatively well mentally for the next one and a half years. Case 2 was a 2-year-old boy who had a previous history of moderate head trauma 8 hours before admission. After a lucid interval, sudden epileptic attacks hospitalized him in a condition of cardiopulmonary arrest. CT scan revealed severe epidural hematoma on the patient's right cerebrum. Emergency craniotomy was performed and hematoma 95 g in weight was removed followed by decompression. Postoperative CT showed broad ipsilateral ischemic edema including the contralateral cerebral hemisphere and brainstem. One and a half years later, the patient shows decorticated posture with ataxic respiration and negative light reflexes. Case 3 was an 8-month-old boy who had fallen down and hit his head on the floor. Status epilepticus had attacked him, causing him to be admitted in a dyspneic state.(ABSTRACT TRUNCATED AT 250 WORDS)