Primary intracerebellar hematomas: surgical indications, prognosis

Intracerebellar primary hematoma are produced by spontaneous hemorrhages in the cerebellar parenchima and usually present an sudden onset. In the present study we analyzed a serie of 34 cases of primary intracerebellar hematoma, in patients of both genders, between 35 and 80 years old. Taking in account the incidence of symptoms, the clinical picture was dominated by the gait disturbances, headache and consciousness disorders. From the analyzed cases, 50% had had surgical indication and 50% benefits on conservative treatment. Even though the evolution was favorable in the great majority of cases,the mortality in the surgical treated group was lesser (5,88%) comparative to the conservative treated group (17,64%). The main criteria for surgical treatment were represented by GCS (Glasgow Coma Scale) score < or =13 or blood collections exceeding 3 cm in diameter.     

Nontraumatic intracerebellar hematomas: Prognostic value of volumetric evaluation by computed tomography

Thirty-two consecutive cases of nontraumatic intracerebellar hematomas detected by computed tomography are reviewed. A strong correlation was found between the clinical course and the volumetrically calculated size of the hematomas. Prompt evacuation has the best prognosis in cases that have an acute or subacute course (hematoma size, 22.5 to 66 cm³). Conservative treatment was most successful in chronic cases (hematoma size, 8 to 16 cm³). Surgical treatment should be the treatment of choice in very acute cases also (hematoma size, over 70 cm³) if the hematoma is diagnosed immediately after the onset of bleeding. Early detection and volumetric evaluation by computed tomography have great prognostic value for managing nontraumatic intracerebellar hematomas.     

Traumatic intracerebellar hemorrhage: clinicoradiological analysis of 81 patients

OBJECTIVE: We report 81 patients with a traumatic intracerebellar hemorrhagic contusion or hematoma managed between 1996 and 1998 at 13 Italian neurosurgical centers. METHODS: Each center provided data about patients' clinicoradiological findings, management, and outcomes, which were retrospectively reviewed. RESULTS: A poor result occurred in 36 patients (44.4%). Forty-five patients (55.6%) had favorable results. For the purpose of data analysis, patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (39/81 cases; GCS score, > or =8), the outcome was favorable in 95% of cases. In Group 2 (42/81 cases; GCS score, <8), the outcome was poor in 81% of cases. Twenty-seven patients underwent posterior fossa surgery. Factors correlating with outcome were GCS score, status of the basal cisterns and the fourth ventricle, associated supratentorial traumatic lesions, mechanism of injury, and intracerebellar clot size. Multivariate analysis showed significant independent prognostic effect only for GCS score (P = 0.000) and the concomitant presence of supratentorial lesions (P = 0.0035). CONCLUSION: This study describes clinicoradiological findings and prognostic factors regarding traumatic cerebellar injury. A general consensus emerged from this analysis that a conservative approach can be considered a viable, safe treatment option for noncomatose patients with intracerebellar clots measuring less than or equal to 3 cm, except when associated with other extradural or subdural posterior fossa focal lesions. Also, a general consensus was reached that surgery should be recommended for all patients with clots larger than 3 cm. The pathogenesis, biomechanics, and optimal management criteria of these rare lesions are still unclear, and larger observational studies are necessary.     

Traumatic intracranial hematomas in hemophiliac children

Three cases of traumatic acute subdural hematoma in hemophilia A children underwent surgical interventions. There were two functional survivors and one death. The management of intracranial hematoma in hemophiliac patients is discussed.     

Traumatic epidural hematomas of the posterior cranial fossa

BACKGROUND: Traumatic EDHs of the posterior cranial fossa are rare and have a higher mortality than supratentorial localizations. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. Active use of cranial CT scanning has taken a major role in the diagnosis, surgical indication, close observation, and strategy planning. As a result, better prognosis is achieved. In this study, we represent our results and experiences in the management of TEHPCF. METHODS: Between 1993 and 2006, 65 patients with TEHPCF were treated in Istanbul University Faculty Of Medicine, Neurosurgery and Emergency Surgery Departments. The hospital records of these patients were analyzed retrospectively. RESULTS: Of 65 patients, whose diagnosis and management decisions were determined by cranial CT scans, 53 were treated through surgery and 12 by conservative methods. Of the 53 surgically treated patients, 2 (3%) patients died, and 2 (3%) other patients remained moderately disabled during their discharge. As a result, 61 (94%) of 65 patients had excellent recovery. CONCLUSION: When compared with the literature, our mortality rate was superior to other previously reported studies. In our opinion, this is a result of extensive use of the cranial CT scan together with aggressive surgery. Patients with occipital trauma should be evaluated using cranial CT scans, and those showing mass effect should be immediately treated surgically. The patients that have no mass effect on CT scans can be closely observed by planned serial control CT scans.     

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.     

Traumatic intracerebral hematomas: timing of appearance and indications for operative removal

Immediate and delayed traumatic intracerebral hematomas (ICH) can produce devastating secondary brain damage after severe head injury. The relationship between the initial injury and eventual occurrence, size, and time of appearance of such hematomas is not well understood, but has great importance since delayed appearance may necessitate delayed surgical decompression of developing lesions not present on early CT scans. We reviewed the records of 35 consecutive patients with operated post-traumatic ICH to document when these lesions appeared on CT, what were the indications for surgery, and what was eventual outcome. Time between injury and ICH appearance was categorized as immediate (0-3 hours), intermediate (3-6), delayed (6-24) or very delayed (later than 24 hours). ICH appearance was immediate in 20%, intermediate in 6%, delayed in 29%, and very delayed in 46%. Half of the patients were not comatose at the time of admission (GCS greater than or equal to 8). Hematoma removal was prompted by clinical deterioration or failure to improve in half the patients and by uncontrolled intracranial hypertension in the other half. Half the patients died, generally those in traumatic coma immediately after injury although advanced age also was associated with poor outcome. Only about one quarter of patients who require surgical removal of ICH can be shown to have their lesions soon after injury. Most operable intraparenchymal clots develop after initial CT scanning and trauma surgeons must be prepared to recognize and treat this delayed complication of brain injury. Even with aggressive management, ICH contribute significantly to poor outcome and improved treatment must be sought.     

Traumatic extradural hematomas in infancy and childhood. Experience with 144 cases

The authors report a series of 144 children with traumatic extradural hematomas operated on at the Lille Department of Neurosurgery between 1969 and 1982. The patients are divided into different groups according to age, and clinical findings were recorded for each age group. The overall mortality rate was 9%. The authors demonstrate that prognosis is related to age, neurological status at time of surgery, and duration of postoperative coma.     

Post-operative expansion of hemorrhagic contusions after unilateral decompressive hemicraniectomy in severe traumatic brain injury

Decompressive hemicraniectomy is commonly performed in patients with traumatic brain injury (TBI) with diffuse brain swelling or refractory raised intracranial pressure. Expansion of hemorrhagic contusions in TBI patients is common, but its frequency following decompressive hemicraniectomy has not been well established. The aim of this retrospective study was to determine the rate of hemorrhagic contusion expansion following unilateral hemicraniectomy in severe TBI, to identify factors associated with contusion expansion, and to examine whether contusion expansion is associated with worsened clinical outcomes. Computed tomography (CT) scans of 40 consecutive patients with non-penetrating TBI who underwent decompressive hemicraniectomy were analyzed. Hemorrhagic contusion volumes were measured on initial, last pre-operative, and first post-operative CT scans. Mortality and 6-month Glasgow Outcome Scale (GOS) score were recorded. Hemorrhagic contusions of any size were present on the initial head CT scan in 48% of patients, but hemorrhagic contusions with a total volume of >5 cc were present in only 10%. New or expanded hemorrhagic contusions of >or=5 cc were observed after hemicraniectomy in 58% of patients. The mean volume of increased hemorrhage among these patients was 37.1+/-36.3 cc. The Rotterdam CT score on the initial head CT was strongly associated with the occurrence and the total volume of expanded hemorrhagic contusions following decompressive hemicraniectomy. Expanded hemorrhagic contusion volume greater than 20 cc after hemicraniectomy was strongly associated with mortality and poor 6-month GOS even after controlling for age and initial Glasgow Coma Scale (GCS) score. Expansion of hemorrhagic contusions is common after decompressive hemicraniectomy following severe TBI. The volume of hemorrhagic contusion expansion following hemicraniectomy is strongly associated with mortality and poor outcome. Severity of initial CT findings may predict the risk of contusion expansion following hemicraniectomy, thereby identifying a subgroup of patients who might benefit from therapies aimed at augmenting the coagulation system.