Risk factors predicting operable intracranial hematomas in head injury.

A study was performed to examine the incidence of operable traumatic intracranial hematomas accompanying head injuries of differing degrees of severity, and to see if factors predicting operable mass lesions could be identified. Logistic analysis was used to identify independent predictors of operable traumatic intracranial hematomas. Data were gathered prospectively on 1039 patients admitted with head injury between January, 1986, and December, 1990. Patient age, Glasgow Coma Scale (GCS) score, pupillary inequality, and injury by falling were all independent predictors of the presence of operable intracranial hematomas (p = 0.0000, 0.0000, 0.0182, and 0.0001, respectively). Injury to vehicle occupants was less likely to result in operable mass lesions (p = 0.0001) than injury by other means. The incidence of traumatic intracranial hematomas in patients over 50 years old was three to four times higher than in those under 30 years of age. Not surprisingly, the incidence of operable hematomas increased with decreasing GCS scores. However, even at a GCS score of 13 to 15, patients with other risk factors had a substantial incidence of operable mass lesions. There was a 29% incidence of operable intracranial hematomas for patients with a GCS score of 13 to 15, aged over 40 years and injured in a fall. It is suggested that patients who are middle-aged or older, or those injured in falls, are at particular risk for traumatic intracranial hematomas even if their GCS score is high. These patients should have early definitive investigation with computerized tomography in order to identify operable hematomas and to initiate surgical treatment prior to neurological deterioration from mass effect.     

Severity and outcome of intracranial lesions in pedestrians injured by motor vehicles.

To evaluate the type and severity of intracranial lesions and the prognosis after closed head trauma in pedestrians injured by motor vehicles, we reviewed the cases of 225 consecutive patients who suffered major head injuries in collisions with motor vehicles. Patients in this series were comatose, had intracranial hematomas requiring surgical removal, or both. The initial Glasgow Coma Scale (GCS) score was 9-15 in 24% of patients, 6-8 in 32%, and 3-5 in 43%. Intracranial hypertension occurred in 40%. Diagnostic studies showed subdural hematomas in 45% of patients, epidural hematomas in 8%, intracerebral hematomas in 10%, and cerebral contusions in 9%. Clinically significant mass lesions were evacuated, and intracranial pressure was monitored and treated aggressively if elevated. After 6 months, 51% of the patients had died, 13% were vegetative or severely disabled, and 35% had a good outcome or moderate disability. These major head injuries in pedestrians struck by motor vehicles were usually severe, included a high incidence of intracranial hematomas and increased intracranial pressure, and frequently had poor outcomes.     

Epidural hematoma in infants: a different entity?

BACKGROUND: Epidural hematoma (EDH) in infants may be difficult to diagnose. The mechanism of injury and the clinical presentation are different from those in older children. We characterized the clinical and radiologic parameters of EDH in infants and correlated them with outcome. Because there are no optimal prognostic tools or clear guidelines to perform computed tomography in this unique population, a new approach of neurotrauma scoring is suggested. METHODS: Eleven infants (<2 years old) operated on for EDH were studied. Children's Glasgow Coma Scale (CCS) score was applied, and diagnosis was confirmed by computed tomography. RESULTS: Age was 13+/-5 months. Seven infants (63.6%) fell from less than 1 m. CCS score on admission was 10.7+/-3.9. Five infants (45%) were unconscious, yet two (18.2%) had CCS scores of 15. Pupillary abnormalities were found in two infants and lateralizing signs in five infants. Eight infants (72.7%) had subgaleal hematomas. Mortality and morbidity were 9% each. CONCLUSION: We suggest that a Trauma Infant Neurologic Score be used when dealing with EDH in infants. Lateralizing signs, pupillary abnormalities, mechanism of trauma, and scalp injuries should be included because these are objective relevant parameters.     

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.     

Simultaneous multiple hypertensive intracerebral hematoma

Hypertensive intracerebral hemorrhage (HIH) occurring simultaneously in different locations is rare. We encountered 11 such cases between January 1990 and November 2002. The diagnosis of all 11 cases was established by computed tomography, and the location of the hematomas was: cerebellum and basal ganglia in 5 cases, pons and basal ganglia in 4, and subcortex and basal ganglia in 2. Our patients were analyzed with respect to clinical characteristics, pathogenesis of multiple hematomas, and indication of operation. These patients represented 1% of all 1,069 patients we encountered with HIH. As past history, there were no characteristic disorders except hypertension. There were no characteristic initial symptoms suggesting that hemorrhage had occurred simultaneously. Both supra- and infra-tentorial hematomas were observed in 80% of the patients, and the size of the multiple hematomas was proportional in principle. Cerebellar hematomas were often mild, and pontine hematomas were often severe. The outcome in those patients whose neurological grading was 1 to 3 was good with conservative therapy or surgical treatment. The severity, treatment methods, and outcomes in these patients were similar to those in patients with single HIH, which suggests only a slight influence of multiple lesions on outcome. As for the possible mechanism of simultaneous multiple hemorrhages, we speculated that bleeding occurred simultaneously in the different regions, or that the initial bleeding was followed after a short time by secondary bleeding due to high intracranial pressure and circulatory disturbance. In patients with cerebellar hematoma, initial symptoms suggested the development of secondary hemorrhage after primary hemorrhage. The surgical treatment for multiple hematomas should be determined by the location and maximum axis of the hematoma. We proposed that cerebellar hematomas should be removed if the supra-tentorial hematoma is small.     

Subdural hematoma after thoracoabdominal aortic aneurysm repair: an underreported complication of spinal fluid drainage?

OBJECTIVE: Cerebrospinal fluid (CSF) drainage is a commonly used adjunct to thoracoabdominal aortic aneurysm (TAAA) repair that improves perioperative spinal cord perfusion and thereby decreases the incidence of paraplegia. To date, little data exist on possible complications, such as subdural hematoma caused by stretching and tearing of dural veins, should CSF drainage be excessive. We reviewed our experience with patients in whom postoperative subdural hematomas were detected. METHODS: The records of 230 patients who underwent TAAA repair at the Johns Hopkins Hospital between January 1992 and February 2001 were reviewed. RESULTS: Eight patients had subdural hematomas (3.5%). The four men and four women had a mean age of 60.6 years; two of these patients had a connective tissue disorder. All patients had lumbar drains placed before surgery, including one patient who underwent an emergency operation for rupture. Drains were set to allow drainage for CSF pressure greater than 5 cm H(2)O in all but one patient set for 10 cm H(2)O; spinal cooling was not performed in any patient. All drains were removed on the third postoperative day. In patients in whom subdural hematomas developed, the mean amount of CSF removed after surgery was 690 +/- 79 mL, which was significantly greater than the amount drained from patients in whom subdural hematomas did not develop (359 +/- 24 mL; P =.0013, Mann-Whitney U test). Six patients had postoperative subdural hematomas detected during hospitalization (mean postoperative day, 9.3; range, 2 to 16), and two patients were seen in delayed fashion after discharge from the hospital at 1.5 and 5 months. Four patients died of the subdural hematoma (50%); only one of these patients had neurosurgical intervention. All four survivors responded to neurosurgical intervention and are neurologically healthy. Two patients, both of whom were seen in delayed fashion, needed a lumbar blood patch. Multivariate logistic regression identified the volume of CSF drained as the only variable predictive of occurrence of subdural hematoma (P =.01). CONCLUSION: Subdural hematoma is an unusual and potentially catastrophic complication after TAAA repair. Prompt recognition and neurosurgical intervention is necessary for survival and recovery after acute presentation. Epidural placement of a blood patch is recommended if a chronic subdural hematoma is detected. Care should be taken to ensure that excessive CSF is not drained perioperatively, and higher (10 cm H(2)O) lumbar drain popoff pressures may be necessary together with meticulous monitoring of patient position and neurologic status.     

Spontaneous Acute Subdural Hematomas. A Clinical Comparison with Traumatic Acute Subdural Hematomas.

Summary  A comparison was made between factors influencing survival in patients operated on for acute spontaneous subdural hematomas (ASSH) and other groups of patients operated for acute, post-traumatic, subdural hematoma reported in the literature.  The data of 17 patients operated on for ASSH were collected. Four variables: early surgical treatment, high Glasgow Coma Scale score on admission, pupillary reactivity and age were statistically analyzed.  The most significant factors for good outcome, in order of importance, were early surgical treatment, a high Glasgow Come Scale score on admission, good pupillary reactivity and younger age.  The prognostic factors in non-traumatic and traumatic acute subdural hematomas were found to be identical.     

Efficacy of and morbidity associated with stereoelectroencephalography using computerized tomography--or magnetic resonance imaging-guided electrode implantation

OBJECT: The purpose of this paper was to define the general efficacy of and morbidity associated with stereoelectroencephalography using modem methods of imaging and to particularize the risks related to specific lobes of the brain. METHODS: All patients admitted to the Montreal Neurological Institute who had undergone either computerized tomography- or magnetic resonance imaging-guided electrode implantation by one surgeon (A.O.) were reviewed. The procedure was considered efficient if the obtained information was sufficient to make a decision either in support of or against surgery. Two hundred seventeen patients underwent 224 implantations with 3022 electrodes. Complications related to each lobe were as follows: temporal lobe, two abscesses (0.54%); frontal lobe, one abscess and three hematomas (1.4%); and occipital lobe, one hypointense lesion found 1 week after electrode explantation (2.6%). Significant risk factors associated with hematomas were implantation in the frontal lobe (p < 0.05) and the use of four or more implanted electrodes (p < 0.025). General complications included the following: 26 patients, psychiatric symptoms during monitoring; one patient, meningitis; four patients, scalp cellulitis; and two patients, hemiparesis during angiography in the early 1980s. One of these latter patients maintained a mild hemiparesis and represents the only case of permanent neurological sequela in the entire series. Data obtained during recordings supported an indication for surgery in 178 patients (79.5%), excluded a surgical option in 37 patients (16.5%), and were unsatisfactory in nine patients (4%). Thus, the overall efficacy as defined previously was 96%. CONCLUSIONS: Stereoelectroencephalography is an efficient procedure with low associated morbidity. Bilateral exploration of the temporal lobes has a morbidity rate of approximately 1%. A higher risk of hematomas occurs with the implantation of four or more electrodes in the frontal lobes.     

Spontaneous resolution of subdural hematomas.

From a series of 35 cases of subdural hematomas in a 12 months span, 6 cases of subdural hematomas which spontaneously resolved were found. The sizes of these hematomas ranged from the relatively small to the huge. All of these cases displayed little if any neurological deficit when seen by us. It is thought that the mechanisms of resorption are: co-mingling with CSF and redistribution in the more acute variety and in instances of subdural hydromas; and thru the healing and reparative process in the chronic type.     

Clinical features of temporal tip epidural hematomas

OBJECT: The purpose of this paper was to clarify the clinical features of temporal tip epidural hematomas (EDHs). METHODS: A retrospective chart review was conducted for 53 patients who had suffered an EDH. They were divided into two groups, those whose hematoma occurred in the temporal tip (23 patients) and others (30 patients). The following variables were analyzed: age, sex, Glasgow Coma Scale score, systolic blood pressure on admission, Injury Severity Score, incidence of hematomas in intracerebral regions, location of skull fracture, incidence of cranial nerve injury, type of operation, and Glasgow Outcome Scale (GOS) score at 3 months postinjury. RESULTS: A greater incidence of zygomatic arch or lateral orbital cavity fracture was found in the "temporal tip" group than in the "other" group. There was a greater incidence of cranial nerve injury in the temporal tip (26.0%) than in the other group (6.6%; p < 0.05). Surgery to treat the EDH was more frequently performed in the other group (36.6%) than in the temporal tip group (two patients, 8.6%; p = 0.01). There were no significant differences between the groups in terms of the GOS score. CONCLUSIONS: A temporal tip hematoma is not a rare injury among patients with EDHs. This hematoma tends to be induced by lateral orbital cavity and/or zygomatic arch fractures. It tends to be associated with cranial nerve injury, but it rarely requires an operation. The outcome of patients with this hematoma depends on the associated intracerebral lesions, thus indicating it to be similar to an EDH in other places.     

Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases

The indications for surgery in hypertensive intracerebral hematoma are still controversial. The reason for this may be: 1) lack of adequate and comparable data in conservative and surgical therapy from the same institution; 2) lack of adequate close follow-up monitoring over an extended period of time; or 3) lack of proper classification of hematomas for comparison of results from different institutions. The authors have treated 459 cases of hypertensive intracerebral hematoma between October, 1975, and July, 1983. The hematomas have been classified according to their mode of extension on computerized tomography. The long-term outcome was assessed on the basis of activity of daily living. Putaminal hematomas were classified as mild, moderate, severe, and very severe. In general, there was no significant difference in outcome between the surgical and nonsurgical cases; however, the outcome in the moderate and severe hematomas was found to be a little better for the surgical cases in some restricted areas. Thalamic and pontine hemorrhages were classified as mild, moderate, or severe. If the hematoma is localized to the thalamus or pons, and if it extends to the midbrain, there is no indication for surgery; however, in patients with moderate hematomas, the prognosis showed a variable outcome, and the indications for surgery were questionable. In cerebellar hematomas, the authors propose that even a hematoma with a diameter greater than 3 cm might show a good outcome with nonsurgical therapy.     

Acute subdural hematoma in infancy

BACKGROUND: Acute subdural hematoma in infants is distinct from that occurring in older children or adults because of differences in mechanism, injury thresholds, and the frequency with which the question of nonaccidental injury is encountered. The purpose of this study is to analyze the clinical characteristics of acute subdural hematoma in infancy, to discover the common patterns of this trauma, and to outline the management principles within this group. METHODS: Medical records and films of 21 cases of infantile acute subdural hematoma were reviewed retrospectively. Diagnosis was made by computed tomography or magnetic resonance imaging. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome. RESULTS: Twenty-one infants (9 girls and 12 boys) were identified with acute subdural hematoma, with ages ranging from 6 days to 12 months. The most common cause of injury was shaken baby syndrome. The most common clinical presentations were seizure, retinal hemorrhage, and consciousness disturbance. Eight patients with large subdural hematomas underwent craniotomy and evacuation of the blood clot. None of these patients developed chronic subdural hematoma. Thirteen patients with smaller subdural hematomas were treated conservatively. Among these patients, 11 developed chronic subdural hematomas 15 to 80 days (mean = 28 days) after the acute subdural hematomas. All patients with chronic subdural hematomas underwent burr hole and external drainage of the subdural hematoma. At follow-up, 13 (62%) had good recovery, 4 (19%) had moderate disability, 3 (14%) had severe disability, and 1 (5%) died. Based on GCS on admission, one (5%) had mild (GCS 13-15), 12 (57%) had moderate (GCS 9-12), and 8 (38%) had severe (GCS 8 or under) head injury. Good recovery was found in 100% (1/1), 75% (8/12), and 50% (4/8) of the patients with mild, moderate, and severe head injury, respectively. Sixty-three percent (5/8) of those patients undergoing operation for acute subdural hematomas and 62% (8/13) of those patients treated conservatively had good outcomes. CONCLUSIONS: Infantile acute subdural hematoma if treated conservatively or neglected, is an important cause of infantile chronic subdural hematoma. Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality.     

Management of traumatic retroperitoneal hematoma.

The management of retroperitoneal hematomas remains confusing to many surgeons because the available literature frequently groups patients with blunt and penetrating etiologies together. Because the underlying injuries and their treatment may differ considerably, the nonoperative or operative approach to the common hematomas is based on mechanism of injury coupled with hemodynamic status of the patient and extent of associated injuries. After blunt trauma, selected retroperitoneal hematomas in the lateral perirenal and pelvic areas do not require operation and should not be opened if discovered at operation. Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are opened after proximal vascular control has been obtained, if appropriate. Retrohepatic hematomas without obvious active hemorrhage are not opened. After penetrating trauma, most retroperitoneal hematomas are still opened. Exceptions include isolated lateral perirenal hematomas that have been carefully staged by CT and some lateral pericolonic hematomas. As with blunt trauma, retrohepatic hematomas without obvious active hemorrhage are not opened.     

Revised screening scale to predict survival after insertion of a left ventricular assist device

BACKGROUND: We previously calculated a risk factor summation score that successfully predicted survival after insertion of a left ventricular assist device. We sought to validate our previous score by using a single center's clinical experience and to determine emerging risk factors for mortality after device insertion. METHODS: The clinical records of 130 consecutive patients who received the HeartMate VE left ventricular assist device (Thoratec Corp, Pleasanton, Calif) at our institution between June 1996 and March 2001 as a bridge to transplantation were reviewed. Univariate and multivariable analyses were performed to determine the predictors of operative mortality after device insertion. Using the relative risks for each identified variable, we devised a new risk factor summation score. The new and old scores were then compared by using linear regression analyses to determine whether the revised score improved statistical accuracy. RESULTS: Overall operative mortality was 25% (n = 33). The old score successfully predicted operative mortality in the current patient population (operative mortality of 38% for score >5 vs 13% for score < or =5). However, the revised score improved risk discrimination (operative mortality of 46% for a score >5 vs 12% for a score < or = to 5). Statistical accuracy was comparable between scores, but the relationship between observed and predicted outcomes was improved with the revised score. CONCLUSIONS: The changing demographic profile and management of patients presenting for mechanical circulatory support has led to a change in the predictors of mortality after device insertion. Periodic remodeling and recalibration of risk indices helps to accurately predict outcomes in high-risk patient groups and identifies emerging risk factors for mortality.     

Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery?

BACKGROUND: Compressive hematoma after thyroidectomy is a rare complication (1%) but can potentially be severe. The aim of this study was to search for risk factors, in particular the use of anticoagulants or antiplatelet medication, and to see if the delay of hematoma formation would require 1-day surgery performed in a careful manner. MATERIALS AND METHODS: Retrospective review of 6,830 patients undergoing thyroidectomy in a single institution (1991 to 2006) identified 70 patients with hematomas requiring reoperation. Case controls (210 patients) were matched for age, gender, year of operation, type of thyroid disease, and type of operation. The notion of anticoagulant or antiplatelet medication was particularly studied. The delay of hematoma formation and the cause of bleeding were studied in univariate analysis by a chi-squared test and a Fischer's test. RESULTS: In univariate analysis, the formation of hematoma is not related to age, gender, type of thyroid disease, or type of bleeding. The pre or intraoperatory administration of anticoagulant or antiplatelet medication did not influence hematoma formation. Thirty-seven hematomas (53%) presented within 6 h postoperatively, 26 (37%) between 7 and 24 h and seven (10%) beyond 24 h. CONCLUSION: Patients undergoing anticoagulant or antiplatelet treatment are not a high-risk population for hematoma formation. Forty-seven percent of the patients presented postoperative hematomas beyond 6 h postoperatively, leading to the conclusion that 1-day surgery is not safe.     

Implications of systemic hypotension for the neurological examination in patients with severe head injury

Thirty-six patients admitted with severe head injury and various degrees of systemic hypotension were studied to determine the effect of hypotension on the validity of the neurological examination in reflecting mechanical brain compression. All patients had clinical signs of transtentorial herniation or upper brainstem compression and underwent immediate bilateral placement of exploratory burr holes for the diagnosis and removal of intracranial hematomas. All patients were initially hypotensive: 10 were in cardiac arrest, 7 had a systolic blood pressure (SBP) < 60 torr, and 19 had SBP of 60–90 torr. The median score on the Glascow coma scale was 3 (range 3–8). Although 4 of the 10 cardiac arrest patients had anisocoria, only one (10%) had an intracranial hematoma. Among the seven patients with severe hypotension, only two had anisocoria and neither had an intracranial hematoma; one patient in this group (14%) had a hematoma that was diagnosed at autopsy. In contrast, intracranial hematomas were discovered by burr-hole placement and evacuated in 13 (68%) of 19 patients with initially moderate hypotension, including seven (78%) of nine patients with anisocoria. Anisocoria was associated with mechanical brain compression from an intracranial hematoma significantly more often in patients with an initial SBP of 60–90 torr than in those with initial cardiac arrest or SBP < 60 torr (chi-square p < 0.05). Intracranial hematomas were significantly more frequent among patients with SBP of 60–90 torr than among those with a lower SBP or initial cardiac arrest (p < 0.01). Thirty-three of 36 patients died; each of the three survivors had an initial SBP of 60–90 torr, and hematomas were removed in two. In head-injured patients with SBP > 60 torr, clinical signs of tentorial herniation or upper brainstem dysfunction remain valid indicators of possible mechanical compression; the high percentage of patients with acute intracranial hematomas in this group warrants immediate diagnostic burr-hole exploration. In patients with severe initial hypotension (SBP < 60 torr) or cardiac arrest, clinical findings of brainstem dysfunction cannot be relied upon to indicate mechanical compression, and computed tomography scanning should be done immediately after resuscitation to determine the need for surgical exploration.     

Hemorrhagic complications of microelectrode-guided deep brain stimulation

BACKGROUND: The incidence of intracranial hemorrhage occurring during microelectrode-guided implantation of deep brain stimulators (DBS) for movement disorders has not been well defined. We report the incidence of hemorrhage in a large series of DBS implants into the subthalamic nucleus (STN), thalamus (VIM) and internal globus pallidus (GPi). METHODS: All DBS procedures performed by a single surgeon (P.A.S.) between June 1998 and April 2003 were included in this study. Patients had postoperative imaging (MRI or CT) 4-24 h following surgery, and all hematomas >0.2 cm(3) in volume were noted and scored as symptomatic (associated with any new neurologic deficit lasting >24 h) or asymptomatic. RESULTS: The total number of lead implants was 357. There were 5 symptomatic hematomas and 6 asymptomatic hematomas. The relative risk of hematoma (any type) per lead implant was 3.1%. The incidence of hematoma by target site was 2.5% per lead for STN-DBS, 6.7% for GPi-DBS and 0% for VIM-DBS. CONCLUSION: The overall risk of intraoperative or early postoperative symptomatic hemorrhage with microelectrode-guided DBS, over all targets, was 1.4% per lead implant. The brain target had a significant effect on the risk of hemorrhage.     

Nonoperative management of acute epidural hematomas: a "no-brainer"

BACKGROUND: Acute epidural hematomas are generally considered to require urgent operation for clot evacuation and bleeding control. It has become increasingly apparent, however, that many epidural hematomas will resolve with nonoperative management. The purpose of the current study was to review our experience with nonoperative management of acute epidural hematomas. METHODS: Patients admitted to our busy urban level I trauma center with an epidural hematoma were identified using our trauma registry. Patients were excluded if they suffered other significant intracranial injury mandating operative intervention. Patient records were reviewed and relevant data collected. Patients who required subsequent craniotomy were compared to those who did not in order to identify risk factors for failure of nonoperative treatment. RESULTS: Between January 1995 and June 2004, 84 patients were identified. The mean age was 27 +/- 1.6 years and 68 (81%) were male. Mean Glasgow Coma Scale in the emergency department was 13.7 +/- 0.3. The most common mechanism of injury was a fall. Fifty-four (64%) patients were initially managed nonoperatively and 30 (36%) were taken directly to the operating room for craniotomy. Nonoperative management was successful in 47/54 (87%) patients. Failure of initial nonoperative management was not associated with adverse outcome. There were no deaths in patients managed operatively or nonoperatively. Seventy-two (86%) patients were discharged to home with excellent neurologic outcome. CONCLUSIONS: Epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome.     

Long-term follow-up review of patients with acute and subacute subdural hematomas

The authors present 149 patients suffering from acute (112) and subacute (37) subdural hematomas admitted during the 10-year period 1965 to 1974, with a follow-up period of 2 to 12 years. During the time of observation, 104 patients died and 45 survived; 73% of the patients with acute and 27% with subacute subdural hematomas died. Of the patients with an acute subdural hematoma, 11% went back to work, as against 32% of those with subacute subdural hematomas. The 5-year survival rate was 28% in patients with acute and 76% in patients with subacute subdural hematomas.     

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.