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.     

Bilateral frontal extradural haematomas caused by rupture of the superior sagittal sinus: case report.

A 26-year-old male sustained simultaneous massive bilateral frontal extradural haematomas following a head injury as a result of a large tear of the superior sagittal sinus, without fracturing of the skull vault.     

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.     

Acute bilateral extradural haematoma of the posterior cranial fossa

Traumatic haematomas located in the posterior fossa are less frequent than those above the tentorium. Extradural haematomas are the most common type of haematomas in the posterior fossa and are usually unilateral. We present the case of a patient with a bilateral extradural haematomas of the posterior fossa and review eight cases previously reported in the literature.     

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.     

Diffuse Axonal Injury after severe head trauma

Summary Diffuse Axonal Injury (DAI) is a well known entity that affects many patients with severe head trauma. Classically DAI has been considered the pathological substrate of those cases rendered unconscious at the moment of impact and in which the CT scan does not show mass lesions. Diffuse axonal damage is almost always related to mechanisms of injury in which the rotational acceleration produces shear and tensile strains of high magnitude. In this paper we present a group of 24 patients with a severe head injury in whom the postmortem examination demonstrated unequivocal signs of DAI.Widespread axonal retraction balls, located preferentially in the centrum semiovale and internal capsule were the most constant histological finding. We divided the entire series into two subgroups. One group (15 cases), included all the patients in whom the CT scan did not demonstrate mass lesions. In the second group (9 patients) we considered patients with a diffuse axonal injury in whom the CT scan additionally demonstrated a mass lesion (6 acute subdural haematomas, 2 intracerebral and 1 extradural haematoma). The mean age of the entire group was 26 years.Twenty two patients were injured in a road traffic accident, the remaining two fell from a considerable height. All were rendered immediately unconscious on impact. Diffuse brain damage is a common finding in patients with a severe head injury and immediate coma in whom the CT scan does not show mass lesions. Diffuse axonal injury can also appear in connection with a wide spectrum of focal lesions (acute subdural haematoma, basal ganglia haematoma etc.). Associated shear injuries of the brain in this latter group, could justify the poor outcome that certain groups of patients had in spite of the rapid surgical treatment and aggressive control of intracranial pressure.     

Chronic extradural haematomas

Acta Neurochirurgica - We report 17 cases of chronic extradural haematoma out a total of 411 epidural haematomas treated at the Neurosurgical Department of Padua from 1954 to 1980. The definition,...     

Epidemiology and clinical outcomes of neurotrauma in New South Wales

This study of 1161 neurotrauma patients in New South Wales hospitals was designed to examine the role of preventable causes of death and disability in cases of spinal injury, extradural, subdural and multiple intracranial haematomas in order to make recommendations for improvements in accident, emergency, ambulance and hospital services. Methods have been developed for standardizing diagnosis in different classes of hospital for the assessment of severity in terms of the patient's age, sex, physical signs, head and spine injuries and other injuries. Estimates have been made of the number of preventable deaths by a case control study of each category of neurotrauma under study.     

Management of life-threatening blunt head trauma in childhood-A case report

INTRODUCTIONTraumatic head/brain injury (TBI) is a leading cause of death and life-long disability in children. The key to successful management of extradural haematoma is early recognition and evacuation.PRESENTATION OF CASEWe report the successful management of a child with life-threatening traumatic brain injury requiring timely surgical intervention outside of a specialist neurosurgical unit.DISCUSSIONChildren with an operable injury have improved outcomes if their lesion is surgically evacuated within four hours. This can be challenging in regions located a significant distance from paediatric neurosurgical specialist centres.CONCLUSIONThis case supports the recommendation for general surgeons maintaining the skill of burrhole evacuation of extradural haematomas. Whether this will remain feasible in the era of “super-specialisation” is questionable.     

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.     

Chronic bilateral subdural haematoma in adults

Summary Twenty-nine patients with chronic bilateral subdural haematomas were surgically treated during 1966 to 1977. Twenty-four of them (83%) had a history of head injury, which caused unconsciousness in eight cases. The mean interval from trauma to operation was eleven weeks. The mean age of the patients was 60 years. The prevalence of the most commonly encountered symptoms and signs was: headache 72%, mental symptoms 48%, papilloedema 41%, vertigo 31%, nausea 28%, reduced consciousness 28%, walking difficulties 24%, hemiparesis 24%, and paraparesis 14%. The aggregate thickness of haematomas was 34 mm, 36 mm, and 40 mm in age groups of 20–39, 40–59, and over 60 years, respectively. All patients were operated on, four of them only unilaterally. Three patients in the whole series died. Two of them had been operated upon only on one side in the first session, the haematoma of the other side being evacuated 81/2 hours and four days later, respectively. Unilateral operation is likely to cause sever e distortion of the midline structures and the brain stem and thus aggravates the cerebral situation. Therefore the necessity of simultaneous evacuation of the haematomas on both sides is stressed. The reason for the death of the third patient was delay in diagnosis.All three patients who died belonged to the group of eight patients with a reduced level of consciousness before surgery.Twenty-three of the survivors were fully independent in their daily lives, and three needed some help after operative treatment.     

Epidural "sulmycin implant" coverage for local prevention of infection in surgical management of open craniocerebral injuries]

In various series reported in the literature on the operative management of severe head injuries with compound depressed skull fractures and penetrating wounds of the brain, the rates of infection differ from 1 to 17%. In this paper the operative experience with 22 cases of penetrating head injuries is discussed. In conventional operative therapy, depressed skull fracture and lacerated dura were covered by "Sulmycin Implant" containing Gentamycin as a helpful bacteriological barrier. 18 patients survived, 7 patients had severe neurological defects, 5 patients had mild neurological deficits and 6 patients recovered completely. There were no signs of suppurative complications in superficial wounds or in the brain. 4 patients died due to their severe brain damage with multiple contusional lesions. Postoperative complications were as follows: one patient suffered extradural and one patient subdural rebleeding. Another patient with a frontal base skull fracture suffered a pneumatocele because the fracture was not correctly covered. The revision was done successfully using the "Sulmycin Implant". Presently, however, the intradural use of "Sulmycin Implant" is not recommended without further testing for the level of gentamycin in the cerebrospinal fluid which is released by the "Sulmycin Implant".     

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.     

Serum S100B levels in patients with epidural haematomas

Protein S100B is today the most promising biomarker for cerebral injury. A welcomed area for the use of such a marker is in the early stages of head trauma and diagnosis of brain injury, in particular epidural haematomas. We report five consecutive cases of epidural haematoma where serum samples for S100B were drawn at admission. Three of the patients showed low levels of S100B (< or =0.2 microg/l). One patient with a large epidural haematoma with radiological signs of cerebral herniation displayed normal levels (0.14 microg/l) of S100B 3.5 h after the initial head trauma. Normal S100B levels in serum do not predict normal intracranial findings. S100B may be unreliable as a marker for epidural haematomas after closed head injury.     

Traumatic intracerebral haematomas of delayed onset

Summary 25 cases of traumatic intracerebral haematomas of delayed onset were found among 775 cases of acute head injuries. All these 25 cases were analysed both clinically and with computed-tomographical studies. Their clinical features were different from those of classical traumatische Spät-Apoplexie originally described by Bollinger in 1891, in the following aspects; (A) absence of the symptom-free interval and (B) absence of apoplectic onset of symptoms after a relatively long lucid interval. These traumatic intracerebral haematomas of delayed onset were, on the other hand, characterized by the following; (1) the patient was injured when the head was in motion, (2) the injury was not necessarily severe, (3) the onset of signs and symptoms were gradual and insidious, (4) all 25 cases but 4, had cranial vault fractures and/or basal skull fractures, (5) precipitating factors could not be identified, though hypotensive episodes were present in 60% of cases, (6) intracerebral haematomas appeared within 72 hours following the head injury in most of cases, though more than 4 days later in a small number of cases, (7) the appearance of such intracerebral haematomas suggested an unfavourable outcome, (8) cerebral contusion might be a major contributory factor.     

Clinical evaluation of the InnerSpace fibreoptic intracranial pressure monitoring device

Objective : The aim of this study is the clinical evaluation of the intraparenchymal ICP monitor InnerSpace OPX 100. Methods : Sixty four Inner Space OPX 100 transducers in 51 patients with severe head injury 42 , intracranial spontaneous bleeding 6 or hypoxia 3 were studied. The transducer was placed in the frontal white matter. Thirty nine patients received one catheter, eleven patients two catheters and one patient three catheters. The study period ranged from 10 hours-25 days; total study time was 421.5 days mean duration 6.6 days . Results : In nine cases 14.1 an inadequate location of the ICP transducer was found, but the accuracy of the measurement was not influenced. Dislocation of the transducer occurred in eight cases 12.5 due to inadequate handling. A failed transducer was observed in four cases 6.3 because of a damaged optical fibre 1 or inadequate handling 3 . In one patient 1.9 a minor local infection developed. In eleven cases 17 a haematoma around the ICP sensor was observed. Six haematomas were small; five haematomas were larger than 1cm in diameter. In two patients a large frontal haematoma developed after exchange of the transducer. Operative evacuation was necessary in both cases. Zero shift was below 2mmHg in all catheters. Conclusion : It is concluded that the InnerSpace intraparenchymal ICP monitor is a reliable device: the rate of catheter related intracerebral haematomas, however, is not acceptable. This could be improved by a better fixation of the catheter in the burr hole in order to avoid micromovements of the transducer.     

Hématome extra-dural de la fosse postérieure

Summary A case history of an extradural haematoma of the posterior cerebral fossa is presented. The most important findings were rapidly developing papilloedema, an ipsilateral hemiplegia, and the angiographic evidence of a pronounced hydrocephalus. Operation resulted in a cure.Based on the cases in the literature and on this individual observation, the authors refer to the importance of recognizing an occipital fracture as well as to the diagnostic possibilities of angiography. They stress the necessity for bilateral burr-holes in the posterior fossa when, for other reasons, an angiogram cannot be performed, but an occipital fracture has been recognized and the clinical situation is deteriorating. The possibility of the simultaneous development of multiple haematomas (21% of the cases in the literature) must be considered.     

Craniocerebral epidermoids and dermoids

Summary We review 40 epidermoids and 4 dermoids of the skull and brain treated surgically in our Department between 1976 and 1987. Fourteen were extradural and 30 intradural. The mean duration of symptoms was 3 years for extradural and 10 years for intradural tumours. Symptoms varied with tumour site, in some sites being helpful in differential diagnosis. Skull X-rays and CT were the key diagnostic investigations in extradural and CT in intradural lesions, the latter, with few exceptions, presenting a characteristic CT scan. In 7 cases MRI supplied important details on the tumour boundaries. All the diploic and orbital lesions were removed totally, with a good outcome. Twelve of the intradural lesions were removed totally, 9 subtotally and 9 partially, with a good outcome in 21 patients and a poor outcome in 4; 5 patients died. Outcome was unrelated to degree of removal.     

Frontal extradural hematomas.

In a series of 1841 severe head injuries, 97 cases of epidural hematomas were observed. Among these there were 13 in the frontal area, i.e. 13.4%. The nine cases of frontal extradural hematomas not previously reported are described. Five of them had "pure" extradural frontal clots. In four cases the epidural hematoma was associated with intradural lesions. The "pure" frontal epidural cases presented a subacute to chronic course of a benign character. All of these patients survived and made a complete recovery after operation. A malignant, stormy and fatal course was observed in the "mixed" cases.     

Comparison of management outcome of primary and secondary referred patients with traumatic extradural haematoma in a neurosurgical unit

A total of 104 patients with a traumatic extradural haematoma in a 5-year period were studied. The mortality of the 71 patients managed primarily by the neurosurgical unit was less than that of the 33 patients secondarily transferred from the district general hospital: 4 per cent vs 24 per cent. This better result was associated with a shorter delay between the time of conscious level deterioration and decompressive operation: 0.7 +/- 1.0 h vs 3.2 +/- 0.5 h. Direct admission of all head injured patients to a neurosurgical unit resulted in significant reduction in mortality and morbidity in patients with an extradural haematoma.