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.     

微创幕上血肿抽吸引流术后患者死亡相关因素分析

目的探讨幕上脑出血患者行微创血肿抽吸引流术预后的影响因素。方法回顾性分析2009年1月~2013年1月我科采用微创颅内血肿抽吸引流术治疗的129例幕上脑出血患者的临床资料,并对可能影响其预后及死亡的相关因素进行单因素和多因素分析。结果术后死亡16例(12.4%)。单因素分析结果显示患者术前血肿体积(P=0.021或P=0.013)、GCS评分(P=0.011)、糖尿病史(P=0.045)及高血压病史(P=0.039)是影响预后的相关因素,多因素分析显示术前GCS评分(≤8)是患者术后死亡的独立危险因素。结论术前GCS评分≤8是预测幕上脑出血患者血肿抽吸引流术术后死亡风险的独立危险因素,应根据患者意识状态合理选择治疗方案。     

Clinical course in poor grade patients with ruptured intracranial aneurysms and extensive subarachnoidal clot]

Three hundred and eight cases with ruptured intracranial aneurysms and variable amounts of subarachnoidal clot were evaluated clinically with special emphasis on the natural course of poor grade patients. Clinical severity was classified according to the Glasgow Coma Scale (GCS); severe cases (score 3-8) and mild cases (score 9-15). Patients were further divided into four groups based on the preoperative clinical course, and on whether radical surgery was performed or not. Group A, severe cases without radical surgery (17 patients, mean GCS score 4.2); group B, severe cases (which had undergone) radical surgery (24 cases, mean GCS score 5.5); group C, patients considered as severe cases on admission that had improved to mild cases before radical surgery (3 patients, mean GCS score 11.7); group D, mild cases which had undergone radical surgery (254 cases, mean GCS score 14.3). CT findings after their last bleeding episode were evaluated in each group using subarachnoid hemorrhage (SAH) score from "0"-"3" according to the severity of SAH. In addition, the SAH-B (brainstem) score ("0"-"9") was also evaluated. In this score, the amount of SAH in each perimesencephalic cistern (a. prepontine or interpeduncular cistern, b. ambient cistern, c. quadrigeminal cistern) was considered with a possible score of "0"-"3" for each cistern. (No patient had a concurrent intracerebral or intraventricular hematoma causing a mass effect on CT scan). All cases in group A died except one patient that remained in a vegetative state. All of them had severe subarachnoidal clot (mean SAH score 2.9, SAH-B score 8.2). In group B, in patients with same scores (mean SAH score 2.8, mean SAH-B score 7.3), the outcome was as follows: 6 patients (33.3%) had full recovery or were capable of self-management, 6 patients (33.3%) were partially or fully dependent, and 12 patients (50%) were either in vegetative state or died. Patients in groups C and D with good outcome had significantly less amount of SAH, especially in the perimesencephalic cistern (group C--mean SAH score 2.3, mean SAH-B score 3.7, group D--mean SAH score 1.9, mean SAH-B score 3.3). It is concluded that duration and level of unconsciousness in the cases of SAH without concurrent hematoma causing mass effect, has a good correlation with the severity of SAH in the perimesencephalic cisterns.(ABSTRACT TRUNCATED AT 400 WORDS)     

硬膜外血肿穿颅清除术24例临床体会

目的总结穿颅清除术治疗急性外伤性硬膜外血肿的临床体会。方法回顾性分析24例急性外伤性硬膜外血肿实施选择性穿颅清除术的临床资料,采用弦距定位法确定穿刺点,选用颅内血肿粉碎穿刺针进行穿刺、抽吸、冲洗、粉碎、液化及引流。结果本组平均治疗时间3.4(2~5)d,无一例再出血或死亡,亦无中转开颅手术,CT复查示血肿清除率达85%~95%,随访3~6个月,本组GOS评分均为良好。结论选择性穿颅清除术治疗急性外伤性硬膜外血肿方法简易、有效、安全、经济,值得推广。     

Acute subdural hematoma: Outcome and outcome prediction

Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome.Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively.Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9–15) and 23% of patients with a low GCS score (3–8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21–40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion.Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.     

Prognostic factors in acute subdural hematoma and the significance of serum FDP measurement

Sixty-two cases of acute subdural hematoma were clinically analyzed with special reference to such prognostic factors as age, Glasgow Coma Scale (GCS) score on admission, pupillary signs, decerebration, and initial computed tomography (CT) findings. Intraparenchymal lesions demonstrated by CT were evaluated according to Yamaura's classification. In 19 cases, serum fibrin and fibrinogen degradation products (FDP) were measured at the time of admission. Emergency surgery was performed in 46 cases, and the remaining 16 patients were treated conservatively. The final outcome was judged according to the Glasgow Outcome Scale, and patients were divided into a "good outcome" group (good recovery or moderate disability) and a "poor outcome" group (severe disability, vegetative state, or death). In general, the outcomes proved to be unsatisfactory. Forty-four patients (71%) had a poor outcome, with 32/62 (52%) mortality, and only 18 (29%) had a good outcome. The clinical factors associated with a poor outcome were age over 64 years, a GCS score on admission of less than 7, decerebration, and absence of pupillary reaction to light. Initial CT scans showed brain damage in 46 patients (74%), 39 (85%) of whom had a poor outcome. This indicates that the outcome was significantly related to brain injury complicating the acute subdural hematoma. A high serum FDP level was similarly related to a poor outcome, which suggests that the serum FDP level reflects the degree of both primary and secondary brain injury. Thus, measurement of serum FDP may be valuable both in assessing clinical status and in evaluating the extent of brain injury in acute subdural hematoma.     

The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study

A prospective study was conducted to validate the retrospective finding that adolescents (11 to 15 years old) with skull fractures were prone to develop acute traumatic intracranial hematoma (ICH). Over a 4-year period, 1178 consecutive adolescents attended the emergency room directly, of whom 760 were discharged well and 418 were admitted. All underwent skull x-ray studies. Immediate computerized tomography (CT) scans were performed in patients with Glasgow Coma Scale (GCS) scores of less than 15, in those with radiological and/or clinical evidence of skull fracture, and whenever clinically indicated. Of the 418 admitted patients, only 26 had skull fractures; 13 of these developed ICH. Four patients without skull fracture developed diffuse brain swelling. The remaining 401 patients were discharged after observation periods of up to 48 hours. Of the 13 patients with ICH, 10 had admission GCS scores of 15; however, four deteriorated rapidly and required urgent operation, and four remained stable but were operated on due to their large ICH. Two required conservative treatment only and both made good recovery. Three patients were in coma (GCS score less than or equal to 8) on admission. One patient had an epidural hematoma and made good recovery after surgery. Two developed delayed ICH after operations for associated systemic injuries despite initial CT showing diffuse brain swelling only, and both died despite evacuation of the ICH. Multivariate analysis showed that skull fracture was the only independent significant risk factor in predicting ICH in adolescents (sensitivity of 100% and specificity of 97%). A routine skull x-ray study is therefore mandatory in all head-injured adolescents and, if a skull fracture is detected, immediate CT may be performed for early detection of ICH.     

Endoscopic surgery for thalamic hemorrhage: a technical note

BACKGROUND: Approximately 10% to 15% of cases of ICH involve the thalamus. Evacuation of a thalamic hematoma by craniotomy is associated with high rates of mortality and morbidity. Evacuation by endoscopic surgery is less invasive but is relatively inefficient because of limited visualization of the surgical field. Therefore, a procedure using a polypropylene endoscopic sheath was developed to improve endoscopic visualization and the efficiency of endoscopic evacuation of thalamic hematoma. METHODS: From September 2004 to September 2005, 7 patients underwent endoscopic evacuation of posterial-lateral type thalamic hemorrhage that had ruptured into the lateral ventricle of the trigum and caused acute hydrocephalus. The clinical evaluation included pre- and postoperative Glasgow Coma Scale (GCS) score, 30-day mortality rate, and Glasgow Outcome Scale score 6 months later. The surgical procedure was performed with the patient in the supine position while under general anesthesia. A 3-cm incision was made across the occipital-parietal scalp ipsilateral to the thalamic hematoma. A burr hole, 1 cm in diameter, was drilled on the Keen's point, which is located 3 cm posterior and 3 cm superior to the pinna. A transcortical intraventricular puncture was made with a rigid endoscopic tube. A 2.7-mm endoscope and the necessary surgical instruments were then inserted through this tube, permitting the simultaneous removal of hematoma in the intraventricular space and thalamus. A surgical demonstration of this technique to evacuate thalamic hemorrhage in a patient with acute hydrocephalus is provided herein. RESULTS: The preoperative mean GCS score was 8.4 and the postoperative mean GCS score was 9.4. The 30-day mortality rate was 15% and none of the patients developed shunt-dependent hydrocephalus. The average Glasgow Outcome Scale score was 3.7 six months later. CONCLUSION: Use of a rigid endoscopic sheath in combination with an endoscope and an approach from Keen's point to the collateral trigone of the lateral ventricle improves the efficiency of evacuating thalamic hematomas and prevents shunt-dependent hydrocephalus.     

Management of spontaneous cerebellar hematomas: a prospective treatment protocol

OBJECTIVE: To identify easily applicable guidelines for the surgical and conservative management of spontaneous cerebellar hematomas. METHODS: A treatment protocol was developed and prospectively applied for the management of 50 consecutive cases of cerebellar hematomas. The appearance of the fourth ventricle, adjacent to the hematoma, on computed tomographic scans was divided into three grades (normal, compressed, or completely effaced). The degree of fourth ventricular compression was correlated with the size and volume of the hematoma and the presenting Glasgow Coma Scale (GCS) score. The hematoma was surgically evacuated for all patients with Grade III compression and for patients with Grade II compression when the GCS score deteriorated in the absence of untreated hydrocephalus. Patients with Grade I or II compression were initially treated with only ventricular drainage in the presence of hydrocephalus and clinical deterioration. RESULTS: The degree of fourth ventricular compression was classified as Grade I in 6 cases, Grade II in 26, and Grade III in 18. The degree of fourth ventricular compression was significantly correlated with the volume of the hematoma (r(s) = 0.67, P < 0.0001), hydrocephalus (r(s) = 0.44, P = 0.001), the preoperative GCS score (r(s) = 0.43, P = 0.001), the maximal diameter of the hematoma (r(s) = 0.43, P = 0.001), and a midline location of the hematoma (chi(2) = 6.84, P < 0.009). Acute deterioration in GCS scores occurred for 6 (43%) of 14 patients with Grade III ventricular compression who were conscious at presentation. Thirteen patients with Grade I or II ventricular compression and stable GCS scores of more than 13 were treated conservatively. Nine patients were treated with ventricular drainage only, and 28 underwent posterior fossa craniectomy and evacuation of the hematoma with ventricular drainage. The mortality rate at 3 months was 40%. None of the patients with Grade III fourth ventricular compression and GCS scores of less than 8 at the time of treatment experienced good outcomes. Overall, 15 (60%) of 25 patients with hematomas with maximal diameters of more than 3 cm and Grade I or II compression did not require clot evacuation. CONCLUSION: Conscious patients with Grade III fourth ventricular compression should undergo urgent clot evacuation before deterioration. Surgical evacuation of the clot may not be required for large hematomas (>3 cm) if the fourth ventricle is not totally obliterated at the level of the clot.     

Surgical management of traumatic supra and infratentorial extradural hematomas: our experience and systematic literature review

Post-traumatic supra and infratentorial acute extradural hematomas (SIEDHs) are an uncommon type of extradural hematoma with only few small series published. In this scenario, the purposes of the present study are to present our experience in the management of 8 patients with acute SIEDH and to perform a systematic literature review. The clinical and radiological data of 8 patients operated for SIEDH at our department were analyzed retrospectively. Using the PRISMA guidelines, we reviewed the articles published from January 1990 to January 2018 reporting data about SIEDH. A total of 3 articles fulfilled the inclusion criteria and were analyzed. The incidence of SIEDHs is very rare constituting < 2% of all traumatic extradural hematomas (EDH). SIEDHs are associated with non-specific symptoms. Only 20% of patients were in coma (GCS < 8) at admission. A “lucid interval” was not reported. The source of bleeding of SIEDH was venous in all cases due to the following: bone fracture with diploe bleeding (50%), transverse/sigmoid sinus injury (22%), oozing meningeal venous vessel (8%), detachment of transverse sinus without wall injury (6%), and unknown in the other cases. Due to the venous nature of the source of hemorrhage, the clinical manifestation of a SIEDH may develop in a slow way, but once a critical volume of hematoma is reached, the deterioration can become rapid and fatal for acute brain stem compression. Surgery is the mainstay of SIEDHs treatment: among 42 cases with SIEDH included in this review, 40 (95.23%) patients were treated with surgery while only two were managed conservatively. Also in our series, all patients underwent surgery. A combined supratentorial craniotomy and suboccipital craniotomy leaving in a bone bridge over the transverse sinus for dural tenting sutures resulted the most used and safe surgical approach. SIEDH is a rare type of EDH. Early diagnosis of SIEDH and prompt surgical evacuation with a combined supratentorial and suboccipital approach provide excellent recovery.     

Traumatic epidural haematoma of the posterior cranial fossa

A posterior fossa epidural haematoma (EDH) is uncommon and the diagnosis is difficult because the clinical symptoms are non-specific. Therefore, a computed tomography scan is important for the early diagnosis and management. Thirty-four patients with a posterior fossa EDH were admitted between 2001 and 2008. A retrospective analysis of the clinical and radiographic findings with regard to outcome and prognostic factors was carried out. The Glasgow Coma Scale (GCS) score on admission was recorded to be: one in 3-5, five in 6-8, six in 9-12 and 22 patients in 13-15. The admission GCS score was the most valuable prognostic factor. Among the 28 patients with a GCS score of more than 9, 27 patients survived with good results; for the six patients with a GCS score of less than eight, two patients had good recovery and four patients had unfavourable outcome. The 15 patients that were conservatively treated and 14 out of the 19 patients surgically treated had a good recovery. Among the other surgically treated patients, two were moderately disabled, two remained in a vegetative state and one died (overall mortality 2.9%). An occipital fracture was present in 28 cases. Six patients with a diastatic fracture of the lambdoid suture had a more complicated venous sinus injury requiring early surgery compared to those with a simple linear fracture. The patients admitted with associated intracranial injuries, such as a contrecoup injury including subdural haemorrhage or traumatic subarachnoid haemorrhage had a poor outcome. The initial GCS score on admission and the presence of associated intracranial injuries were important factors associated with the patient prognosis. A diastatic fracture of the lambdoid suture was associated with complicated venous sinus injuries making surgery more difficult.     

Spontaneous intracerebral haematomas: surgical versus conservative treatment based on Glascow Coma Scale score and computer tomography data

Eighty cases of spontaneous intracerebral haematomas were studied retrospectively in order to find clinical and computer tomography parameters; such parameters would be useful for the neurosurgeon, as criteria in the process of deciding surgical or conservative treatment. We found Glascow Coma Scale (GCS) score on admission an excellent criterion. Scores between 3-5 and 12-14 were a contraindication for surgery. Scores between 6-8 indicated surgery, while scores between 9-11 indicated an increased level of readiness. Up to a haematoma size of 16 cm2, size had no influence on GCS score and surgical mortality. For haematoma size larger than 16 cm2, the percentage of patients with low GCS score had increased substantially as well as the surgically mortality. This study has not revealed any lethal haematoma size. No effect of midline shift on mortality was found when shift did not exceed 5 mm. Hypertension was found in 40% of the patients and increased mortality in both types of treatment.     

Differences of acute and chronic epidural hematoma]

Standard neurosurgical management demands prompt evacuation of all extradural hematomas to obtain a low incidence of mortality and morbidity. In selected cases some authors have suggested that moderate hematomas can be managed conservatively without risk to the patient and with a normal outcome. The goal of this study was to analyze the differences in preoperative clinical parameters between a group of acute and a group of chronic extradural hematomas (chronic extradural hematoma was defined as a delay of more than 72 h from the accident to diagnosis). One hundred fifteen (115) patients with extradural hematomas underwent a standard evaluation, documentation and neurosurgical management (prompt evacuation of all extradural hematomas through a craniotomy). Ninety-five patients (83%) had an acute extradural hematoma. Twenty patients (17%) had a chronic extradural hematoma. We analyzed the following parameters: age, cause of accident, clinical findings, Glasgow Coma Score, morphology of hematoma, location of hematoma, cause of bleeding and clinical outcome. The mean age (chronic 30/acute 32) and age distribution were not significantly different between groups. There were no differences in the cause of accident. All patients in both groups had skull fractures. There was no difference between groups regarding hematoma location, most of there being located in the temporal fossa. In the group of acute extradural hematomas, 62% of patients had a Glasgow Coma Score of less than 8 and 47% had pupillary dilation. In the group of chronic extradural hematomas, moderate clinical symptoms were found, with headache and discrete psychological changes most common. Eighty percent (80%) of the patients had a Glasgow Coma Score of greater than 13 and no patients had pupillary dilation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical experience of the management for the most severely head—injured patients with GCS score of 3

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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.     

Extradural hematoma of the posterior fossa

Extradural hematoma of the posterior fossa (EDHPF) is considered to be a rare complication of head injuries. In early reports, diagnosis was made only at the time of autopsy. Today, CT scanning prompts early diagnosis leading to better outcome. We report 20 consecutive patients observed over the last ten years who underwent surgery for EDHPF. This localization was found in 14,3% of all trauma patients operated for extradural hematoma. In our experience, EDHPF occurs in young adults with a clear male predominance. Vehicle accidents are the most frequent mechanism of injury. The main clinical presentation is subacute onset of signs (50% of our cases). Postoperative outcome was favorable in 19 of our patients (95%). We propose mandatory CT scanning that may have to be repeated as needed, to prevent delay in diagnosis and decision for surgery. Surgical removal of the EDHPF must be carried out as soon as possible as this is the only way to reduce morbidity and mortality.     

Outcomes of blunt head trauma without intracranial pressure monitoring

Although guidelines exist for intracranial pressure (ICP)-guided treatment after head trauma, no conclusive data exist that support routine ICP monitoring. A retrospective case series was reviewed of all patients admitted to the intensive care unit with a diagnosis of blunt head trauma between January 1, 1999 and December 31, 2004. None of the patients in the final analysis had ICP monitoring. Data collected included age, sex, mechanism of injury, Glasgow Coma Score (GCS) at admission, injury severity score, disposition, and length of stay. One hundred thirty-one patients with a median age of 41 years were included. There were 104 men (79%). The median GCS at admission was 12. There were 22 deaths (17% mortality). Stepwise logistic regression analysis identified older age, higher injury severity score, and lower GCS to be predictors of death. The mortality rate was higher in patients with GCS < or =8 compared with GCS >8 (33% vs 8%, respectively; P < 0.001). Ten of 23 patients with a GCS of 3 died (43% mortality). The median time to death for patients with a GCS of 3 was 2 days. Although the Brain Trauma Foundation has published guidelines advocating routine ICP monitoring, no large randomized prospective studies are available to determine its effect on outcome. None of the patients in this study had ICP monitoring. Our overall survival rate of 83 per cent is relatively high. Patients with a low GCS and, specifically, those with a GCS of 3 may not benefit from ICP monitoring because of early and irreversible trauma. Variability in the use of ICP monitoring will remain until ICP monitoring can be conclusively proven to improve outcome.     

Comparison of frame-based and frameless stereotactic hematoma puncture and subsequent fibrinolytic therapy for the treatment of supratentorial deep seated spontaneous intracerebral hemorrhage.

OBJECTIVE: This study compared the technical implications and clinical outcome of patients treated for an intracerebral hemorrhage using two minimally invasive procedures: frame-based stereotactic hematoma aspiration and frameless navigation-guided hematoma aspiration followed by fibrinolysis. METHODS: Thirty patients with a spontaneous supratentorial intracerebral hemorrhage, which was treated by a frame-based (n=15) and frameless (n=15) hematoma aspiration followed by subsequent fibrinolysis with urokinase, were retrospectively reviewed. The data for the two subsets of patients were analyzed with regard to hematoma reduction, Glasgow Coma Scale (GCS), and degree of weakness. RESULTS: In the frame-based stereotactic hematoma aspiration group, the volume of the hematoma was 15.4-100.0 mL (mean: 40.7+/-24.4), the GCS upon admission was 4-15 (mean: 10.1+/-3.0), and the grade of weakness upon admission was 1-5 (mean: 2.1+/-0.9). On the other hand, in the frameless navigation-guided hematoma aspiration group, the hematoma volume was 15.2-62.0 mL (mean: 30.0+/-15.2), the GCS upon admission was 7-15 (mean: 13.0+/-2.4), and the grade of weakness upon admission was 1-4 (mean: 2.3+/-1.2). The drainage catheter was in place for a mean duration of 5.1+/-2.4 days (range: 1-12 days). In the frame-based group, the initial hematoma was reduced by -115-88.5% (mean: 52+/-31.5) immediately after surgery, and 90.5% (41-100%) of the initial volume 14 days after surgery. In the frameless group, the initial hematoma was reduced by 11.7-90.8% (mean 57.3+/-25.1) immediately after surgery and 95.8% (87.7-100%) 14 days after surgery. The GCS score and the degree of weakness were evaluated 14 days after surgery, and the Glasgow outcome scale (GOS) score was evaluated at discharge. There were no statistically significant differences between the two groups. CONCLUSION: The frame-based group and the frameless group followed by fibrinolysis had similar outcomes, and both procedures effectively reduced the intracerebral hemorrhage volume within a short period of time. In addition, these procedures are simple, precise, safe, and brief with a very low rebleeding rate and mortality.     

Urgent reoperation for major regional complications after removal of intracranial tumors: outcome and prognostic factors in 100 consecutive cases

Outcome of urgent reoperation for major regional complication after removal of intracranial tumor was evaluated retrospectively in 100 consecutive patients treated since 1983. Urgent reoperation was performed from 3 to 240 hours (mean 74 hours) after primary surgery for 32 meningiomas, 23 pituitary adenomas, 22 gliomas, 13 vestibular schwannomas, and 10 other intracranial neoplasms. Mean Glasgow Coma Scale (GCS) score before reoperation was 8. Brain edema was the most frequent operative finding at reoperation (31 patients), followed by extradural hematoma (25) and brain ischemia (24). Removal of various types of intracranial hematomas was the most common surgical procedure at reoperation (47 cases). Final outcome was considered favorable in 54 patients, who were discharged without major neurological deficit, and unfavorable in 46, with severe disability or vegetative state in four and death in 42. Multivariate analysis showed statistically significant association with the outcome for histological type of the tumor (p < 0.0001), clinical state at admission (p < 0.001), GCS score before urgent reoperation (p = 0.001), time interval between primary surgery and urgent reoperation (p < 0.01), and patient age (p < 0.05). Therefore, the outcome after urgent reoperation due to major regional complications after removal of intracranial tumor is determined mainly by the clinical condition of the patient and characteristics of the tumor, and less influenced by the type of complication.     

Outcome of traumatic extradural haematoma in Hong Kong

AIM: Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001-2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined. RESULTS: Two thousand and two hundred and eight patients were in the trauma registry for 2001-2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13-15, 9 (10%) GCS 9-12 and 18 (20%) GCS 3-8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS<8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days. CONCLUSION: Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.