Acute subdural hematoma: morbidity and mortality related to timing of operative intervention

In spite of major advances in the management of severe head injury (HI) acute subdural hematoma (ASDH) continues to be one of the most lethal of all intracranial injuries. Of 1,150 consecutive severe HI patients, 137 (12%) had ASDH. The following variables were assessed in regards to outcome morbidity/mortality from ASDH: mechanism of injury, age, sex, neurologic presentation, postoperative intracranial pressure (ICP), and timing from injury to operative evacuation of the ASDH. The only variables found to statistically correlate with outcome were presenting neurologic condition (p = 0.001) and elevated postoperative ICP greater than 45 mm Hg (p = 0.001). The timing from injury to operative evacuation of the ASDH in regards to outcome morbidity/mortality was not statistically significant even when examined at hourly intervals (p = 0.418).     

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.     

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.     

Basal ganglia haemorrhages: efficacy and limits of different surgical strategies

To assess the role of surgery in patients with spontaneous basal ganglia haemorrhages, we evaluated poor outcome (mortality and prolonged unawareness) one month after 'open' surgery in patients with haematomas larger than 30 cm(3). One hundred and twenty-seven patients were traced over a 5-year period. Excluding deeply comatose patients (Glasgow Coma Scale [GCS] 3-4, n?=?39), we analysed the remaining 88 patients, dividing them into two homogeneous groups according to the modality of treatment: aggressive or palliative. Multivariate analysis was applied both to the overall population and to the two groups in order to determine factors prognostic for poor outcome. Aggressive treatment was defined as surgery as the first-choice treatment modality aimed at 'complete' evacuation. Palliative treatment was defined as delayed surgery and/or surgery aimed at clot removal only to obtain internal decompression. Efficacy was assessed in patients having the same initial GCS score in both groups. Factors significantly associated with outcome were preoperative complications, volume, timing of operation, residual clots and postoperative complications. Outcomes were significantly better for aggressive surgery (17% vs. 68%, p?相似文献   

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.     

Treatment of acute subdural hematoma with low GCS score

In order to clarify the present problems in the treatment of acute subdural hematoma with low GCS score (5 or less), we studied the difference of the outcomes from two different surgical treatments for these patients. The present series included 30 patients who had GCS scores of 3, 4 or 5, and they were divided into two groups: 16 in DH group who had decompressive hemicraniectomy and 14 in HITT group who had hematoma irrigation with trephination therapy. The mean age of the patients was 47 years. They all had an intensive medical management including barbiturate therapy under intracranial pressure (ICP) monitoring after the operation. Time course of ICP after operation was classified as controlled, high but reduced and uncontrollable, based on the ICP level of 30 mmHg. The outcomes of the patients were determined by use of Glasgow outcome scale and classified into good, poor and dead. In these patients, the outcome was good in 13.3%, poor in 23.3% and dead in 63.4%. There was no survived case in those with GCS score of 3. The mortality rate in older patients over 60 years was high as 81.8%. ICP was well controlled in 2 patients (12.4%) in DH group. But there is no such case in HITT group. Uncontrollable ICP was more frequently seen in HITT group than in DH group. The patients showed different outcomes in the two types of treatment. Good outcome was found in 18.7% and the mortality rate was 56.3% in DH group. On the other hand, only one patient (7.1%) showed good outcome and the mortality rate of 71.4% in HITT group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy of large decompressive craniectomy in severe traumatic brain injury

Objective： To investigate the role of large decompres- sive craniectomy （LDC） in the management of severe and very severe traumatic brain injury （TBI） and compare it with routine decompressive craniectomy （RDC）.
Methods： The clinical data of 263 patients with severe TBI （GCS~8） treated by either LDC or RDC in our department were studied retrospectively in this article. One hundred and thirty-five patients with severe TBI, including 54 patients with very severe TBI （GCS ≤ 5）, underwent LDC （LDC group）. The other 128 patients with severe TBI, including 49 patients with very severe TBI, underwent RDC （RDC group）. The treatment outcome and postoperative complications of the two treatment methods were compared and analyzed in a 6-month follow-up period.
Results： Ninety-six patients （71.7 %） obtained satisfactory treatment outcome in the LDC group, while only 75 cases （58.6 %） obtained satisfactory outcome in the RDC group （P〈 0.05）. Moreover, the efficacy of LDC in treating very severe TBI was higher than that of RDC （63.0 % vs. 36.7 %, P 〈 0.01）. The chance of reoperation due to refractory intracranial pressure （ICP） in the LDC group was significantly lower than that of the RDC group （P 〈 0.05）, while the incidences of delayed intracranial hematoma and subdural effusion were significantly higher than those of the RDC group （ P 〈 0.05）.
Conclusions： LDC is superior to RDC in improving the treatment outcome of severe TBI, especially the very severe ones. LDC can also efficiently reduce the chances of reoperation due to refractory ICP. However, it increases the incidences of delayed intracranial hematoma and contralateral subdural effusion.     

The outcome from acute subdural haematoma following decompressive hemicraniectomy

Summary Retrospective analysis of 15 cases with acute subdural haematoma receiving decompressive hemicraniectomy was carried out in an effort to clarify the beneficial effect and limitation of this operative procedure. The patients in this series were divided into three groups according to postoperative intracranial pressure (ICP). Decompressive hemicraniectomy was effective in lowering ICP in all patients except for the cases that developed acute brain swelling. Overall mortality rate was 66.7% in this series. Preoperative clinical status, and intra- and postoperative ICP and CT findings obtained within 24 hours of operation were correlated with the operative outcome.The summary of this paper was presented at the 6th European Congress of Neurosurgery (Paris, 1979).     

Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma

Mortality due to epidural hematoma is virtually restricted to patients who undergo surgery for that condition while in coma. The authors have analyzed the factors influencing the outcome of 64 patients who underwent epidural hematoma evacuation while in coma. These patients represented 41% of the 156 patients operated on for epidural hematoma at their centers after the introduction of computerized tomography (CT). Eighteen patients (28.1%) died, two (3.1%) became severely disabled, and 44 (68.8%) made a functional recovery. The mortality rate for the entire series was 12%, significantly lower than the 30% rate observed when only angiographic studies were available. A significant correlation was found between the final result and the mechanism of injury, the interval between trauma and surgery, the motor score at operation, the hematoma CT density (homogeneous vs. heterogeneous), and the hematoma volume. The patient's age, the course of consciousness before operation (whether there was a lucid interval), and the clot location did not correlate with the final outcome. The mortality rate was significantly higher in patients operated on within 6 hours or between 6 and 12 hours after injury than in those undergoing surgery 12 to 48 hours after injury. Compared with the patients operated on later, the patients undergoing surgery in the early period were, on the average, older and had more rapidly developing symptoms, more pupillary changes, lower motor scores at surgery, larger hematomas, a higher incidence of mixed CT density clots, more severe associated intracranial lesions, and higher postoperative intracranial pressure (ICP). The mechanism of trauma seems to influence the course of consciousness before and after surgery. Passengers injured in traffic accidents had a lower incidence of a lucid interval and longer postoperative coma than patients with low-speed trauma, suggesting more frequent association of diffuse white matter-shearing injury. The duration of postoperative coma correlated with the morbidity rate in survivors. Forty-eight patients (75%) had one or more associated intracranial lesions, and 70% of these required treatment for elevation of ICP after hematoma evacuation. An ICP of over 35 mm Hg strongly correlated with poor outcome; administration of high-dose barbiturates was the only effective means for lowering ICP in nine of 15 patients who developed severe intracranial hypertension after surgery. This study attempts to identify patients at greater risk for presenting postoperative complications and to define a strategy for control CT scanning and ICP monitoring.     

Hyperacute measurement of intracranial pressure, cerebral perfusion pressure, jugular venous oxygen saturation, and laser Doppler flowmetry, before and during removal of traumatic acute subdural hematoma

OBJECT: The poor prognosis for traumatic acute subdural hematoma (ASDH) might be due to underlying primary brain damage, ischemia, or both. Ischemia in ASDH is likely caused by increased intracranial pressure (ICP) leading to decreased cerebral perfusion pressure (CPP), but the degree to which these phenomena occur is unknown. The authors report data obtained before and during removal of ASDH in five cases. METHODS: Five patients who underwent emergency evacuation of ASDH were monitored. In all patients, without delaying treatment, a separate surgical team (including the senior author) placed an ICP monitor and a jugular bulb catheter, and in two patients a laser Doppler probe was placed. The ICP prior to removing the bone flap in the five patients was 85, 85, 50, 59, and greater than 40 mm Hg, resulting in CPPs of 25, 3, 25, 56, and less than 50 mm Hg, respectively. Removing the bone flap as well as opening the dura and removing the blood clot produced a significant decrease in ICP and an increase in CPP. Jugular venous oxygen saturation (SjvO2) increased in four patients and decreased in the other during removal of the hematoma. Laser Doppler flow also increased, to 217% and 211% compared with preevacuation flow. CONCLUSIONS: Intracranial pressure is higher than previously suspected and CPP is very low in patients with ASDH. Removal of the bone flap yielded a significant reduction in ICP, which was further decreased by opening the dura and evacuating the hematoma. The SjvO2 as well as laser Doppler flow increased in all patients but one immediately after removal of the hematoma.     

重型颅脑损伤后高血糖的临床意义分析

目的探讨重型颅脑损伤（SBI）后高血糖的临床意义。方法回顾性收集了128例重型闭合性颅脑损伤（GCS≤8分）患者的临床资料,应用统计学方法分析不同颅脑损伤损伤类型、入院时GCS水平、瞳孔光反应、近期预后与术后24小时内血糖水平的关系。颅脑损伤类型分为硬膜外血肿、硬膜下血肿、脑内血肿/脑挫裂伤3组;入院时GCS水平分成3-4分组、5-6分组、7-8分组;瞳孔对光反应情况分成双侧瞳孔光反应存在、单侧瞳孔光反应消失、双侧瞳孔光反应消失3组。近期预后分为预后良好和预后不良2组。结果重型颅脑损伤组血糖水平明显高于中型颅脑损伤组（P〈0.05）,3-4分组血糖水平（16.11±2.85）mmol/L明显高于7-8分组（12.33±2.23）mmol/L和5-6分组（14.11±2.85）mmol/L,而5-6分组血糖水平也明显高于7-8分组,各组间差异均有统计学意义（P〈0.05）;双侧瞳孔光反应消失组术后24小时内血糖水平（19.29±3.87）mmol/L,明显高于双侧瞳孔光反应存在组（15.69±2.83）mmol/L和单侧瞳孔光反应消失组（17.84±3.89）mmol/L,单侧瞳孔光反应消失组血糖水平明显高于双侧瞳孔光反应存在组,各组间差异均有统计学意义（P〈0.05）;预后不良组术后24小时内血糖水平明显高于预后良好组（P〈0.05）。血糖16.7mmol/L组的预后明显差于≤16.7mmol/L组（P〈0.05）。结论重型颅脑损伤后血糖水平明显增高。颅脑损伤伤情越重,血糖水平越高。高血糖是严重影响重型颅脑损伤预后的重要指标。     

Influence of operative timing on prognosis of patients with acute subdural hematoma

Objective: To study the influence of operative timing on the prognosis of patients with acute subdural hematoma (ASDH) in order to provide theoretical basis for clinical treatment.Methods: The clinical data of 202 patients with ASDH undergoing operations were collected, and the mortalities and functional survival rates were analyzed 2, 4, 6, and 8 hours after injury.Results: No significant difference was found in mortalities and functional survival rates at different operative timings. However, there was a clear trend that the shorter the operative timing was, the lower the mortality and the higher functional survival rate were. In addition, the mean time from injury to operation of non-survivors was significantly longer than that of survivors.Conclusions: Operative timing has potential influences on the prognosis of patients with ASDH. Surgical evacuation of ASDH should be performed as soon as possible once the operation indication emerges.     

Influence of operative timing on prognosis of patients with acute subdural hematoma

Objective: To study the influence of operative timing on the prognosis of patients with acute subdural hematoma (ASDH) in order to provide theoretical basis for clinical treatment.Methods: The clinical data of 202 patients with ASDH undergoing operations were collected, and the mortalities and functional survival rates were analyzed 2, 4, 6, and 8 hours after injury.Results: No significant difference was found in mortalities and functional survival rates at different operative timings. However, there was a clear trend that the shorter the operative timing was, the lower the mortality and the higher functional survival rate were. In addition, the mean time from injury to operation of non-survivors was significantly longer than that of survivors.Conclusions: Operative timing has potential influences on the prognosis of patients with ASDH. Surgical evacuation of ASDH should be performed as soon as possible once the operation indication emerges.     

Acute spontaneous subdural hematoma of arterial origin

BACKGROUND: Acute subdural hematoma is usually associated with cerebral contusion or laceration of the bridging veins following a head injury. However, several cases of acute subdural hematoma without head injury (acute spontaneous subdural hematoma) have been reported. METHODS: Among 162 cases of acute subdural hematoma admitted to our departments between 1996 and 2003, we repoort eight cases of acute spontaneous subdural hematoma. These cases fulfilled the following criteria. 1) Head injury was either trivial or absent. 2) Neither aneurysm nor arteriovenous malformation was apparent. 3) CT scan revealed neither brain contusion nor traumatic subarachnoid hemorrhage. 4) At operation, laceration of the cortical artery was observed. In this article, we describe the clinical feature (age, sex, Glasgow Coma Scale [GCS] Score on admission, past history, CT appearance, and outcome) associated with this condition. RESULTS: Patients ranged in age from 68 to 85 years (average 74.8 years), and were comprised of 3 males and 5 females. Previous medical history included cerebral infarction in 6 of the 8 patients and myocardial infarction in 1 patient. These seven patients were taking antiplatelet manifestation. GCS on admission ranged from 4 to 13. Five of the 7 patients on antiplatelet medication had secondary insults, such as hypoxia. On CT, hematoma thickness ranged from 13.2mm to 42.5mm (average 22.6mm), and midline shift ranged from 10.0mm to 24.0mm (average 16.5mm). Neurological outcome evaluated using the Glasgow Outcome Scale was as follows, good recovery n = 2, moderate disability n = 2, severe disability n = 3, persistent vegetative state n = 1. CONCLUSION: The mechanism of acute spontaneous subdural hematoma is influenced by the presence of pre-existing cerebrovascular disease and by the use of antiplatelet agents. In such cases, the possibility of cortical arterial bleeding should be taken into account, and craniotomy should be performed.     

Justification for evacuating acute subdural haematomas in patients above the age of 75 years

The author has reviewed the outcome of 27 patients aged 75 years and over who had an operation for acute traumatic subdural haematoma at Frenchay Hospital Bristol over a 10-year period. There were 15 men and 12 women with a mean age of 79.2 years. The outcome at 6 months was determined using the Glasgow Outcome Score. Of the patients, 15 per cent made a good recovery, 15 per cent a poor recovery and 70 per cent died. The influence of age, sex, mechanism of injury, preoperative Glasgow Coma Score (GCS), pupillary reactivity to light, skull and limb fractures, clinical course, CT scan appearance and timing of operation were analysed in relation to the outcome. The results showed that a preoperative GCS of 4 or less and unilateral pupillary dilatation and non-reactivity to light were not compatible with good survival in the very elderly patient with acute subdural haematoma. Under these circumstances, operation is not justified. The prognosis was worse in patients who were unconscious immediately after injury and with a CT scan showing a subdural haematoma and a haemorrhagic contusion which required urgent early intervention. The prognostic indicators present may prove useful in the selection of patients for active surgical intervention.     

Hemicraniectomy in the treatment of acute subdural hematoma: a re-appraisal.

Although acute subdural hematoma continues to be one of the more common conditions neurosurgeons are called upon to treat, mortality rates continue to be quite unsatisfactory. Hemicraniectomy with wide decompression of the swollen brain was devised for the condition in 1971 (JNS 34:70-76). Initial results were quite encouraging with a 40% overall survival rate, 28% of the patients returning to normal activity. Since this original report, an additional 50 patients have been treated with only a 10% total survival rate and a 4% functional survival rate. Retrospective analysis of our cases over the past three years reveals that patient's age, status of preoperative neurologic examination, angiographic findings and appearance of the brain at operation, all have no statistical correlation with survival. These statistics will be presented and discussed. The failure of hemicraniectomy and extensive clot removal to significantly increase the functional survival rate in this condition implies that in a majority of patients with "acute subdural hematoma," primary brain stem and possibly subcortical injury are present, neither of which is amenable to radical therapy. The operation of hemicraniectomy should be restricted to those patients who enter hospital, obtunded but without demonstrable brain stem dysfunctionn, only to deteriorate subsequently because of increasing hemispheric edema and/or subdural clot.     

The influence of large decompressive craniectomy on the outcome of surgical treatment in spontaneous intracerebral haematomas

Summary The outcome of a series of 73 patients with spontaneous intraparenchymatous haematomas treated by surgical evacuation of the clot and decompressive craniectomy has been described.Comparing postoperative mortality of this series with another series of patients (54 cases) treated only with surgical removal of the clot without decompressive craniectomy a statistically significant improvement in the mortality rate after craniectomy could be observed in acute cases demanding surgical intervention for preservation of life in the first 24 hours.If signs of brain-stem suffering appear surgical mortality increases proportionally to the duration of this symptomatology. In these cases surgery, if it is to be useful, has to be performed as soon as possible.The morbidity of the surviving patients is not greater in this series with decompressive craniectomy than in series without decompression.     

Prognostic value of early computerized tomography scanning following craniotomy for traumatic hematoma.

OBJECT: Patients with head injuries traditionally were categorized on the basis of whether their lesions appeared to be diffuse, focal, or mass lesions on admission computerized tomography (CT) scanning. In the classification of Marshall, et al., the presence of a hematoma (evacuated or not evacuated) is more significant than any diffuse injury (DI). The CT scan appearance after evacuation of a mass lesion has not been analyzed previously in relation to outcome. The authors have investigated the importance of: 1) neurological assessment at hospital admission; 2) the status of the basal cisterns and associated intracranial lesions on the admission CT scan; and 3) the degree of DI on the early CT scan obtained after craniotomy to identify patients at risk for development of raised intracranial pressure (ICP) and lowered cerebral perfusion pressure (CPP) and to discover the influence of the postoperative CT appearance of the lesion on patient outcome. METHODS: The authors prospectively studied 82 patients with isolated, severe closed head injury (Glasgow Coma Scale [GCS] score < or = 8), all of whom had intracranial hematoma. Both ICP and CPP were continuously monitored, and a CT scan was obtained within 2 to 12 hours after craniotomy. The CT images were categorized according to the classification of Marshall, et al. The mortality rate during the hospital stay was 37%, and 50% of the patients achieved a favorable outcome. Compression of the basal cistern on the admission (preoperative) CT scan was associated with raised ICP and a CPP of less than 70 mm Hg but not with any other features or with poor patient outcome. In 53 patients the postoperative CT scan revealed DIs III or IV and 29 patients had DIs I or II. The percentages of time during the hospital stay in which ICP was higher than 20 mm Hg and CPP was lower than 70 mm Hg as well as unfavorable outcome were higher in the group of patients in whom DI III or IV was present (p < 0.001). Raised ICP, CPP lower than 70 mm Hg, DI III or IV, and unfavorable outcome were more frequently observed in patients who presented with a motor (m)GCS score of 3 or less, bilateral unreactive pupils, associated intracranial injuries, and hypotension (p < 0.001). When logistic regression analysis was performed, an mGCS score of 3 or less (p = 0.0013, odds ratio [OR] 10.8), bilateral unreactive pupils (p = 0.0047, OR 31.8), and DI III or IV observed on CT scanning after surgery (p = 0.015, OR 8.9) were independently associated with poor outcome. CONCLUSIONS: Features on CT scans obtained shortly after craniotomy constitute an independent predictor of outcome in patients with traumatic hematoma. Patients in whom DI III or IV appears on postoperative CT scanning, who often present with an mGCS score of 3 or less and nonreactive pupils, are at high risk for the development of raised ICP and lowered CPP.     

Acute epidural hematoma following evacuation of chronic subdural hematoma with continuous closed system drainage]

The authors report a case of acute epidural hematoma occurring after evacuation of chronic subdural hematoma with continuous closed system drainage. Laboratory data of the patient including bleeding time were within normal limits. The cause of the postoperative intracranial hematoma was the rapid surgical decompression of the initial lesion, and we considered that it could be prevented if chronic subdural hematoma was treated using closed system drainage and slow decompression. But acute epidural hematoma occurred after this operative procedure and it was accelerated by evacuation of the chronic subdural hematoma through the drain. An emergent craniotomy and removal of the hematoma was performed, so the patient was discharged from hospital with satisfactory neurological recovery. A careful check of the evacuated hematoma volume is very important, and CT scanning should be immediately performed if postoperative hematoma is suspected.     

Contralateral subdural effusion related to decompressive craniectomy performed in patients with severe traumatic brain injury

BackgroundContralateral subdural effusion caused by decompressive craniectomy (DC) is not uncommon. However, it has rarely been reported.MethodFrom 2004 to 2008, 123 severe traumatic brain injury (TBI) patients were identified as having undergone DC for increased intracranial pressure (IICP) with or without removal of a blood clot or contused brain. Of these 123 patients, nine developed delayed contralateral subdural effusion. Demographics, clinical presentations, treatment and outcome were reported.ResultsThe overall incidence of contralateral subdural effusion was 7.3%. On average, this complication was found 23 days after DC. Of the nine patients, six had neurological deterioration and received drainage through a burr hole. One patient needed a subsequent subduro-peritoneal shunting because of recurrent subdural effusion.ConclusionContralateral subdural effusions may be not uncommon and need more aggressive treatment because of their tendency to cause midline shift. Surgical intervention may be warranted if the patients develop deteriorating clinical manifestations or if the subdural effusion has an apparent mass effect.