Traumatic extradural haematomas in pediatric age group

Summary A series of 75 children with traumatic extradural haematomas operated on at our Department between 1982 and 1988 were analysed in detail. The overall mortality rate was 17%. CT scan constituted a valuable tool for an early and correct diagnosis, and the mortality rate declined to 9% in the post-CT era. The outcome was found to be predominantly affected by the preoperative neurological status, by the duration of the time interval between onset of coma and surgical intervention, and mainly by the presence of associated brain lesions.     

Severe traumatic coma in infancy and childhood: results after surgery and resuscitation.

This study deals with 390 cases of severe traumatic coma in infancy, childhood and youth, aged between 4 months and 19 years. Cases in which unconsciousness lasted less than 24-48 hours have not been considered here. 161 patients were operated upon for intracranial space-occupying lesions or for open head injury: extradural haematomas 60; extradural haematomas + brain lacerations and/or subdural haematomas 16; acute subdural haematomas 18; brain laceration 36; open head injuries 17; decompressive operations, hydromas and contusions 14. 102 patients recovered and 59 died. 229 subjects were given only to resuscitation treatment. 164 recovered and 65 died. Recovery and mortality rate are discussed in relation to the pathologicial lesions and to the clinical picture (severity, evolution and duration of coma). Overall mortality rate was 31%. Mortality was higher in operated patients (36.6%) and lower in patients in whom space-occupying lesions were not demonstrated by angiography and who underwent only resuscitation treatment (28%). The lowest rate was observed in cases of extradural haematoma (25.4%) and open head injury (23%). Highest mortality rate have been observed in cases of decerebrated coma (with or without signs of low brain stem impairment). Complete recovery can be achieved even after prolonged decerebration. 31 patients showed the typical picture of the "apallic syndrome": in 28 cases after prolonged decerebrated coma, in 3 cases after coma without decerebration. Of our 31 cases, 4 died, 4 are still in a chronic apallic state and 23 recovered. Of these, 10 patients had a remarkable recovery and 13 remained severely disabled.     

DELAYED TRAUMATIC EXTRADURAL HAEMATOMAS

A total of 76 patients with traumatic extradural haematoma were treated within a period of 3 years. Four patients developed delayed extradural haematomas. These cases are reported in view of the unusual sequence and the importance of early diagnosis.     

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.     

Spinal angiolipoma: case report and review of the literature

Summary Spinal angiolipomas are rare lesions usually found in the epidural space of the thoracic spine. This report presents a case of and reviews the literature on this rare entity. The etiology, clinical presentation, imaging, and treatment are discussed. In 92 reported cases of spinal angiolipoma 56 occurred in women (61%), and 36 in men (39%). Mean age of occurrence is 42.9 years (range 10 days–85 years) with most patients presenting with slowly progressive symptoms of spinal cord compression. Most cases occur in the extradural compartment, and are of the non-invasive subtype. This rare clinical entity must be considered in the differential diagnosis of spinal epidural lesions. In most cases complete removal is possible, however, prognosis is good even for infiltrating lesions. Thus, one must not risk neurological damage to attain complete resection.     

ANALYSIS OF MORTALITY OF EXTRADURAL HAEMATOMA IN A GENERAL SURGICAL UNIT

Extradural haematoma complicating head injury still has a formidable mortality despite recent advances in neurological surgery. The experience of 60 cases of extradural haematoma treated in a general surgical unit was reviewed retrospectively. The mortality was 35%. Analysis of the 21 deaths showed that 13 (62%) of them were possibly avoidable. Lack of index of suspicion, delay in instituting surgical treatment and inadequate surgical intervention were the main causes of the avoidable motality.     

Epidural haematoma at the vertex

Summary We report 14 cases of vertex epidural haematomas among 478 cases of epidural haematomas that were hospitalized in the Neurosurgical Department of the University Hospital of Padova during the period 1953–1980.We discuss the clinical, diagnostic, and prognostic features. The mortality rate was 50%. In this type of traumatic haematoma prompt surgical treatment is not always followed by good recovery.     

Pure subdural haematomas of arteriolar origin

Summary Fifteen consecutive cases of subdural haematomas (SDHs) of arteriolar origin operated on during the last twenty years in the Neurosurgical Clinic of the University of Genoa are reported. These SDHs are rare and form as a result of a rupture of a cortical arteriolar branch typically on the vicinity of the Sylvian fissure. They are always in a pure form and never associated with parenchymal lesions. Their aetiology is spontaneous, as in the 40% of our series, or more frequently related to minor traumas. These SDHs are often encountered in elderly patients generally presenting with severe clinical conditions (in the 60% of our patients GCS on admission was <8). Prompt surgical treatment is required in all cases before further worsening of their neurological condition, even if CT scanning does not reveal parenchymal lesions. The mortality rate is over 50% and mainly relates to the pre-operative GC score. Clinical features, neuroradiological aspects and treatment are discussed and literature reviewed.     

Extradural haematomas: an analysis of the changing characteristics of patients admitted from 1980 to 1986. Diagnostic and therapeutic implications in 158 cases

From January to June 1986, 158 patients with extradural haematoma were admitted to our neurosurgical unit. They were divided into four groups, reflecting their clinical features: A. 46 cases (GCS less than or equal to 12) in whom a condition of coma/stupor had occurred at the time of injury and persisted to the time of surgical decompression; B. 41 cases showing deterioration of consciousness (GCS less than or equal to 12) after a lucid interval; C. 46 cases of 'asymptomatic' patients (GCS consistently greater than or equal to 13, no neurological deficits, no signs of increased intracranial pressure); D. 25 cases arriving at our unit in a conscious state, but restless and/or with neurological deficits. The location of the haematoma (temporal in only 35%), the incidence of associated lesions such as cerebral lacerations and/or subdural effusion (30.3%), and the age of the patients (28.4 +/- 18.4 years were similar in the four groups. The size of the haematoma and the displacement of the midline structures were significantly greater in comatose/stuporose patients (groups A and B). The overall mortality was 12% (19 patients), with a morbidity of 14% (22 patients). Factors statistically significant in determining mortality and morbidity were: degree of coma as assessed by GCS; displacement of midline structures: age of the patient; size of the haematoma. There was no mortality or morbidity in those patients who remained conscious (groups C and D). A pronounced increase in the number of CT examinations performed in patients with head injury in our area of referral has caused profound changes in the population of patients admitted to our centre, resulting in a greater proportion of extradural haematomas detected in patients who are still conscious, and in whom operative mortality and morbidity are negligible. One further therapeutic implication of the increase in the number of patients with EDH admitted while asymptomatic may be the option of conservative management in those patients who remain in a good clinical condition, with haematomas of less than 1 cm in thickness and no displacement of midline structures.     

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.     

EXTRADURAL MALIGNANT LYMPHOMA ASSOCIATED WITH SPINAL CORD COMPRESSION

Cord compression was noted in 26 patients with extradural malignant lymphoma. There were 19 cases of non-Hodgkin's lymphoma and seven cases of Hodgkin's disease. Eighteen cases of non-Hodgkin's lymphoma had intermediate or high grade malignancy types according to the Working Formulation Lymphoma Classification. These patients represented 28% of all extradural malignant tumours seen at the Royal Adelaide Hospital (RAH) and 2.5% of all patients with malignant lymphoma, during an 11 year period. The patients were classified in three presenting groups: Group A, six patients with primary extranodal extradural lymphoma; Group B, nine patients with bolh extradural lymphoma and disseminated disease at initial presentation; and Group C, 11 patients who developed extradural lymphoma during the course of established disease. Only classification by groups appeared to affect survival time. Group A had the most favourable prognosis, with a 5 year survival of 83%. Five of the Group A patients had a relapse of lymphoma; four at distant sites and one in the retroperitoneum. Laminectomy was essential to provide a diagnosis in Group A patients. The most useful warning symptom of impending spinal cord compression was back and/or radicular pain, which preceded neurological deficit either by days or by up to 5 years. Plain spinal X-rays were abnormal in 64% of cases, emphasizing the value of this simple procedure.     

Prognosis after acute subdural or epidural haemorrhage

Summary In a series of 171 patients suffering acute subdural haemorrhage (SDH) (111 patients) or epidural haemorrhage (EDH) (60 patients) after closed head injury accumulated during the years 1978–1985 at the University Hospital of Graz, the mortality rate and the grade of clinical recovery were evaluated. The overall mortality in acute SDH was 57%, in acute EDH 25%, the percentages of good recoveries—full recovery and minimal neurologic deficit—25 and 58%, respectively. Outcome was found to be predominantly influenced by the preoperative state of consciousness, associated brain lesions, and, in comatose patients, the duration of the time interval between onset of coma and surgical decompression. When this interval exceeded two hours, mortality from SDH rose from 47 to 80% (good outcomes 32 and 4%, respectively). In acute EDH an interval under two hours lead to 17% mortality and 67% of good recoveries compared to 65% mortality and 13% of good recoveries after an interval of more than two hours. Age and concomitant injuries of other body regions proved to be of secondary importance.     

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.     

Traumatische intrakranielle Hämatome

Zusammenfassung In einem Bericht über 9000 cranio-cerebrale Traumen mit 1271 traumatischen intrakraniellen Hämatomen [Chirurgie Gießen (n = 291) 1942–1974 und Neurochirurgie Gießen (n = 980) 1953–1974] wird zur Verteilung, Diagnose, Therapie und Prognose der Hämatome Stellung genommen. Unter 26 % Hämatomen lagen 6,4 %. extradural, 17,2 % subdural und 2,4 % intracerebral. Die Mortalität ist von 84 % in den 40er Jahren auf ca. 40% im letzten Jahrzehnt zurückgegangen, am geringsten mit 64 % bei den intracerebralen Hämatomen. Die einzelnen Blutungsformen werden hinsichtlich Lokalisation, Klinik und Behandlung besprochen. Die Computer-Tomographie hat die Diagnose perfektioniert und gewährleistet Indikation, zeitgerechte Operation und Verlaufskontrolle. Ihr Fehlen in den meisten chirurgi-schen und traumatologischen Abteilungen, damit der weiterhin notwendige Einsatz der Angiographie und die mangelnde Ausbildung in der Neurotraumatologie sind die wesentlichen Gründe für die immer noch ungünstige Prognose.

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Traumatic intracranial haematomas

Summary Based on 9,000 craniocerebral traumas with 1,271 intracranial haematomas [Gießen General Surgery (n = 291) 1942–1974, Gießen Neurosurgery (n = 980) 1953–1974] distribution, diagnosis, therapy, and prognosis of traumatic haematoma has been discussed. Among 26 % of the haematomas, 6.4% were extradural, 17.2% were subdural, and 2.4% were intracerebral. Mortality has decreased from 84 % in the 1940's to 40 % in the last decades; the least decrease (64 %) being among the intracerebral haematomas. Distribution, site and size, symptomatology, and special diagnostic procedures were reported for the different types and forms of haematomas. Computertomography has proved to be the most decisive progress for the diagnosis, indication, timely and appropriate surgery, and follow up. The most important reasons for the still unfavourable results are lack of sufficient experience, among general surgeons and traumatologists, the lack of computer-tomographs, and the need for separate clinical and angiographic diagnosis.

     

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.     

Asymptomatic extradural haematomas. Results of a multicenter study of 158 cases in minor head injury

Summary The authors report a study conducted in three Italian neurosurgical centres on 158 patients admitted after a minor head injury and with CT findings of a hitherto asymptomatic significant extradural haematoma.All patients were examined both prospectively by means of a computerized record containing 18 clinical and radiological parameters, and retrospectively by logistical regression analysis, in order to ascertain which factors influenced most the choice of surgical vs. conservative management.The size of the haematoma, rather than its location, and the degree of midline shift were the factors most influential in deciding in favour of surgical treatment, with a specificity of 0.83 and a sensitivity of 0.92. Conservative management of haematomas having a maximum thickness of less than 10 mm with a midline shift of less than 5 mm appears as safe. Outcome was good recovery in both the surgical and the nonsurgical patients, with only one death in the whole series, unrelated to the extradural lesion. This study focusses attention on a group of patients who are seldom examined by CT scan, but who can harbour potentially lethal lesions. Extension of CT scan examination to all adult patients with a minor head injury and a skull fracture can be recommended in order to identify significant haematomas in an asymptomatic phase.     

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.     

Evacuation of traumatic intracerebral haematomas using a simplified stereotactic procedure

Summary The autors present a serie of 37 traumatic intracerebral haematomas (ICH) evacuated by a simplified stereotatic surgical procedure.The mortality rate was 80% in patients with Glasgow coma scale (G.C.S.) scores of 3–5 and 25% in patients with scores of 6–7. There were no deaths in patients with G.C.S. of 8 or more. With the exception of the first group of patients, the results were better than those archieved by wide craniotomy. The importance of reduced operative trauma in patients with ICH, which often are associated with multifocal or diffuse brain injuries, are discussed.     

Extradural haematoma of the posterior fossa. Twelve years experiences with CT-scan

Summary 18 cases of an extradural haematoma of the posterior fossa (EDHPF) are presented and the clinical and radiological findings are demonstrated. The onset of symptoms was acute in 10 patients and subacute in the other 8 patients. The overall mortality was 22%, but only acute course patients died (40%). All subacute cases survived. The most important factors influencing mortality were the level of consciousness immediately before the operation and the presence of hydrocephalus prior to surgery. Other coexisting intracranial lesions had no influence on mortality but on the quality of survival. Compared with the literature there is a certain decrease in mortality in the subacute course patients since the introduction of computed tomography.     

Influence of neomembranous organisation,cortical expansion and subdural pressure on the post-operative course of chronic subdural haematoma—an analysis of 201 cases

Summary The post-operative clinical course of a series of 201 patients with chronic subdural haematoma has been analyzed with respect to neomembranous organisation, cortical expansion and subdural pressure in the form of a prospective (53 cases) and retrospective (148 cases) study. With the exception of one patient (primary craniotomy and membranectomy) all other 200 cases were treated according to a standarized treatment protocol consisting of burr-hole craniotomy with (170 cases) or without (30 cases) closed-system drainage.Post-operative mortality (within one month after surgery) was 2%. There was a 4.5% recurrency rate and a 2% infection rate. Morbidity solely related to chronic subdural haematoma was 2% and was characterized by a mild neurological deficit. The level of subdural pressure had no influence on the post-operative clinical course, whereas marked intra-operative cerebral re-expansion favoured a more rapid clinical improvement. Although standard deviations were within a broad range, a nearly linear inverse relation could be assumed between the amount of peri-operative cerebral expansion and the degree of neomembranous organisation of the haematomas. Subdural neomembranes seem to represent the crucial opponents to cerebral re-expansion and they prolong the duration of neurological restitution.The results were presented at the Meeting of the Swiss Neurosurgical Society, Bern, November 17, 1984.