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.     

Traumatic extradural haematomas in children: Experience with 62 cases

Summary Sixty-two children with traumatic extradural haematomas are considered. According to the clinical history presented—often atypical— and to the grade of neurological impairment, patients have been divided into different clinical groups. Nearly 50% of patients sustained a minor injury, and 26% did not lose consciousness after trauma. Twenty-four per cent of patients did not show fractures on skull X-rays. Atypical location of the haematoma was noted in 22 cases, mainly in the anterior fossa (19 cases).Sixty patients were operated on, while two patients were conservatively treated, owing to the limited size of the haematomas and to the absence of neurological deficits. Associated brain lesions were discovered at surgery in 40% of cases.The overall mortality rate has been 17%, the operative mortality rate 14%. The morbidity rate has been 6%, with 3% of patients presenting severe disability. Morbidity and mortality have been shown to be affected by age—with better prognosis in patients under 10 years of age, by the clinical history presented, by the preoperative conditions, and, mainly, by the presence of associated brain lesions. As regards location, frontal haematomas have shown a better prognosis and a slower course than convexity haematomas. Finally, prognosis of extradural haematomas in children has improved to some extent in the last years with the advent of the CT scan, possibly due to speed and accuracy of diagnosis.     

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.     

Sequential computerized tomography changes and related final outcome in severe head injury patients

Summary The authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan.92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%).Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes.Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.     

Computerized tomography and prognosis in paediatric head injury

Summary The authors have analysed the computerized tomography (CT) findings and their correlation with the clinical state, early and late outcome in children and adolescents with head injuries (HI). This study represents clinical and CT data of 82 consecutive HI patients under 18 years of age. Among them 51 (62%) were boys and 31 (38%) girls. The application of CT to the evaluation of the morphologic manifestations of HI in children has shown some differences in forms and mechanisms of injury and in outcome compared to adults. In the paediatric HI the most frequent finding was diffuse brain swelling with CT evidence of ventricular and cisternal compression or obliteration. Prognostically the most unfavourable findings were shearing injury, intracerebral and subdural haematomas combined with brain swelling and parenchymal damage. According to the Lidcombe impairment scale, outcome from severe paediatric HI was determined in the 3rd and 6th months, one year and 2 years after the injury. The outcome two years after severe HI varied to a great extent and was better in children than in adults. Although there was long-term disruption of the patient's quality of life, our data show that as there are no predictors of individual outcomes in child HI, no child should be excluded from early and long-term rehabilitation.     

MODERATE HEAD INJURY: A SYSTEM OF NEUROTRAUMA CARE

Background : The aim of the present study was to determine those factors which contribute to a poor outcome and to propose a management plan that is complementary to trauma systems in common use. Methods : A prospective study of 110 consecutive patients with moderate head injury (post-resuscitation Glasgow Coma Scale (GCS) 9–13) was carried out. Results : A total of 75% of the patients sustained multisystem trauma, generally of minor or moderate grade according to the Abbreviated Injury Scale (AIS). However, the death rate increased with the severity of the injury as measured by the Injury Severity Score (ISS). The initial cranial computed tomography (CT) scan was abnormal in 61% and no patient with a normal scan developed a delayed intracranial haematoma or neurological worsening. Those patients who developed a delayed intracerebral haematoma had a worse outcome. Sixteen patients underwent craniotomy for haematoma. The intracranial pressure (ICP) was measured selectively in 20 patients and exceeded 20 mmHg in half, requiring treatment. Nine patients died, four as a result of head injury and all those had an intracranial haematoma. As a group, those who died were older and had a higher ISS. Conclusions : A plan for care of patients with moderate head injury is proposed, complementary to the Early Management of Severe Trauma (EMST) protocol and the Neurosurgical Society of Australasia guidelines for neurotrauma management in rural and remote locations.     

Traumatic interhemispheric subdural haematomas

Summary According to reports in the literature traumatic interhemispheric subdural haematomas (I.S.H.) are supposed to present acutely or subacutely with contralateral monoparesis of a lower extremity or hemiparesis or in bilateral haematomas even with paraparesis, and to need early operative evacuation. In our series of 5 cases none of them followed this classical clinical picture, and three of them recovered without operation.We conclude that the indication for operative evacuation depends on the clinical course and that in patients with spontaneously improving symptomatology non-surgical management under close supervision may be the better solution. Also the C.T. finding of open convexity cisterns may be possible indication for conservative management.     

Epidural haematoma of the posterior fossa with delayed operation

Summary A case of chronic epidural haematoma of the posterior fossa is reported. The lesion was studied with cerebral angiography and computed tomography. The patient was under observation for two weeks before the extradural clot was. removed. The membrane surrounding the haematoma was examined histologically. The importance of computed tomography in the diagnosis of traumatic lesions of the posterior fossa is emphasized.     

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.     

Conservative management of epidural haematomas

Summary Conservative management of epidural haematoma (EDH) depends on a balance between expansion and resorption rate of the clot.15 patients with EDH whose CT scans demonstrated a small EDH and were asymptomatic or with minor symptoms or with a delayed diagnosis were treated conservatively. The thickness of haematoma ranged between 4.9–40.8 mm. In two patients, the haematoma extended from the posterior fossa to the supratentorial region. In 7 patients, additional intracranial pathology was detected. None of the patients had neurological deterioration on follow up. The second CT was performed on second day at the earliest, in fourth week at the latest.We conclude that the patients with EDH who are neurologically stable during the first 24 hours after trauma, with small EDH and with minor or no symptoms or signs, might be candidates for conservative management. An absolute precondition for conservative management is close supervision of the patient.     

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.     

CT and clinical criteria for conservative treatment of supratentorial traumatic intracerebral haematomas

Summary In search of guidelines for the management of traumatic intracerebral haematomas (TICHs) with slight mass effects on computed tomography (CT) scans, the author reviewed the records of 29 patients who did not undergo surgery and 11 patients who did.It is found that patients with a TICH volume of less than 15 ml, a midline shift of less than 5 mm, an open perimesencephalic cistern on CT scans, a Glasgow Coma Scale (GCS) score of 12 or more, and an absence of lateralizing signs may be treated conservatively and expected to make a good recovery. On the other hand, with zero mortality and satisfactory outcomes, the patients undergoing early surgery tended to have a TICH volume of more than 15 ml, a midline shift of more than 5 mm, an obliterated perimesencephalic cistern on CT scans, a GCS score of less than 12, and the presence of lateralizing signs. However, the position of such features as the criteria of early operation for a TICH is weakened by the retrospective nature of this study because some surgical patients, free of lateralizing signs in particular, might have managed to do well without craniotomy.     

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.     

The influence of concomitant intradural pathology on the presentation and outcome of patients with acute traumatic extradural haematoma

Summary The pre-operative and early postoperative CT scans of 120 patients who had surgery for acute extradural haematoma were reviewed. 88 cases (73%) had an extradural haematoma alone (Group 1) while 32 cases (27%) had an additional intradural abnormality (Group 2). The abnormalities were a subdural haematoma in eight, a haemorrhagic contusion in 16 and hemisphere swelling in eight. The two groups were compared with regard to the findings that an additional intradural abnormality is likely to be associated with an older age, an injury following a road traffic accident, a GCS<7 at operation, additional extracranial injuries and a poorer outcome. The increase in the percentage of patients who were unconscious from the onset and the decrease in those who were always conscious with a concomitant intradural damage was without statistical significance.     

Treatment of chronic subdural hematoma by burr-hole craniostomy in adults: influence of some factors on postoperative recurrence

Summary Background. The study was conducted to determine the causative factors in the postoperative recurrence (PR) of chronic subdural haematomas (CSDHs) and to evaluate the efficacy of surgery in adults enrolled in this trial. Methods. 99 patients with 121 CSDHs, who were operated on between January 1999 and December 2001, were studied. We evaluated the PR rate related to anamnestic, clinical, surgical and neuroradiological imaging variables. In addition, we reviewed the number and the type of repeated operations, complications of surgery and the outcomes at one, three and 12 months. Findings. 82.6% of lesions were successfully treated following the initial evacuation, and 95.9% of lesions following a second procedure. The PR rate was 14.9%. A significantly high PR rate was found to be associated with separated type, frontal base type, a midline displacement >5 mm and the presence of acute subdural clots in cranial base type on CT scans obtained within four days postsurgery. The interval from head trauma to initial surgery <60 days, the maximum width of subdural space >10 mm and massive collection of air in the subdural space tended to give a high PR rate. The PR rate associated with the homogeneous type of CSDHs was significantly low. Age, sex, cause of CSDH, anticoagulant therapy, preoperative neurological presentation, concomitant disease, variables on preoperative CT scans, and surgical factors such as the extent of the surgical procedure, use of drainage, duration and volume of drainage were not significantly associated with PR rate. Conclusions. It is important to identify factors leading to a high or a low PR rate in the treatment of CSDHs because this may help to select appropriate surgical procedures and postoperative management to treat this condition efficiently.     

Extradural haematoma

Summary The availability of CT scanning has considerably improved the results in patients with extradural haematoma (EDH). However, only few reports referred the zero-mortality which today could be considered as possible. This goal was achieved by us recently even in those patients suffering from rapidly developing EDH.A series of 37 consecutive patients with EDH operated on during the last years is presented. 27 patients were comatose GCS 3–8 on admission (within 6 hours after the injury) and underwent surgery immediately; in 7 cases the operation was performed 6 to 25 hours after the injury, soon after the worsening of the level of consciousness; 3 patients were awake at time of surgery and were operated on later than 24 hours after the injury when signs of neurological deterioration apeared. All of our patients survived and 35 of them (95%) fully recovered.We believe that the duration of brain compression is the main factor strongly correlated with outcome. Therefore, in our opinion the primary prerequisite in order to obtain a good result is the prompt evacuation of EDH; furthermore, in this was it is possible to try to prevent brain ischaemia due to clot pressure, mostly the infarction on deeply situated territories.     

DELAYED CEREBROSPINAL FLUID RHINORRHOEA: A CASE REPORT

Post-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a well recognized complication of closed head injury. Most cases occur soon after injury and a delay in presentation of more than 1 month is unusual. A case is reported of CSF rhinorrhoea presenting 15 years after initial trauma which was complicated by meningitis after 12 months. The management of this condition is reviewed.     

PRIMARY EXTRADURAL NEOPLASMS CAUSING SPINAL CORD COMPRESSION

Thirteen patients presented primary extradural neoplasms compressing the spinal cord and/or roots in a four year period. Laminectomy and tumour excision or biopsy were carried out in twelve patients and transthoracic resection in the one remaining. Six tumours were benign; two were neurofibromata associated with von Recklinghausen's disease; two were osteochondromata; and there were single cases of cavernous haemangioma and aneurysmal bone cyst. All patients are alive and well; follow-up ranges between 1.3 an 8.5 years post-operation. Among the malignant neoplasms there were three malignant lymphomata, two Ewing's sarcoma and single instances of mesenchymal chondrosarcoma and chondrosarcoma of the classical type. Four patients are alive, having been followed up between 3.5 to 5 years.