Progressive brain injury

The aim of this study was to evaluate the clinical manifestations and prognostic factors of progressive brain injury following trauma. We reviewed the records of 779 patients with head injury who had an admission Glasgow Coma Scale of 9 or more; 70 (7.0%) developed progressive brain injury as evidenced on serial CT scans. Of these 70 patients, 19 (27.1%) had a subdural hematoma, 19 (27.1%) an epidural hematoma, 16 (22.9%) a cerebral contusion, 13 (18.6%) an intracerebral hematoma, and 3 (4.3%) a diffuse brain swelling. Three months after injury, 36 (51.4%) patients died, 2 (2.9%) were left in a vegetative state and 23 (32.9%) had a favorable outcome. The appearance of progressive brain injury was associated with patient age, admission Glasgow Coma Scale, injury mechanisms, skull fracture and hemorrhagic lesions on the initial CT scan. Patients with the extracerebral lesions deteriorated 4 hours after injury, whereas those with intracerebral lesions deteriorated 8 hours after injury. The outcome based on Glasgow Outcome Scale was significantly associated with age, type of intracranial lesion, Glasgow Coma Scale following deterioration, the mechanism of injury and surgical treatment. It is concluded that early repeated CT scan is indicated in patients with risk factors of developing progressive brain injury.     

Computerized tomography findings of acute traumatic epidural hematoma

During four year period from April, 1977 to March, 1981, 53 cases with acute traumatic epidural hematoma had been encountered out of 430 acute head injured patients examined by computerized tomography (CT) within 24 hours after incurring the trauma at the Department of Neurosurgery and Critical Care Medicine of Nippon Medical School, Sendagi, Tokyo, Japan. Besides the initial CT, the authors performed contrast enhanced CT (41 cases) and serial CT scanning (31 cases). There were 49 cases of epidural hematoma existing in the supratentorial region, Two cases infratentorial region and 2 cases in the both regions. Two cases of vertex epidural hematoma had been encountered, one of them required vertical scan technique. In 22 (41%) of the 53 patients, the initial CT showed evidence of other cerebral lesions. The most frequent lesion was pneumocephalus (11 cases), 3 cases of them existed in the epidural hematoma. There were also intracerebral hematoma (6 cases), subdural hematoma (4 cases), cerebral contusion (2 cases), intraventricular hemorrhage (2 cases) and 2 cases of them demonstrated "diffuse traumatic cerebral injury" (Zimmerman, 1979). During contrast enhanced CT, 11 cases out of 41 cases indicated several enhancement pattern. There were total enhancement of epidural hematoma (2 cases), partial enhancement of hematoma (2 cases) and enhancement of internal margin of hematoma (2 cases). Serial CT scans was performed in 36 out of the 53 patients. Common findings on the serial CT scans were decreased density collection in the subdural space such as subdural effusions or chronic subdural hematomas (8 cases) and enlargement of small epidural hematomas (3 cases).(ABSTRACT TRUNCATED AT 250 WORDS)     

Delayed post-traumatic epidural hematoma. A review

Post-traumatic acute epidural hematoma (EDH) is generally visible on the CT scan done immediately after admission: occasionally, it only comes to light at a later scan and is then termed delayed (DEDH). Since the introduction of CT, the frequency of this occurrence has gone up from 6–13% to 30%.The mechanisms responsible for the delayed appearance of the epidural hematoma a tamponade effect are usually increased endocranial pressure and post-traumatic arterial hypotension as well as, in a limited number of cases, coagulopathy, CSF drainage, and arterio-venous shunt.The authors report 5 of their own cases and 45 published cases and discuss the characteristics of this particular form of hematoma and its outcome.     

Delayed epidural hematoma without neurologic deficit

Six patients with delayed epidural hematoma demonstrated by serial computed tomography scan are presented. Three of the patients had no neurologic deficit but suffered from severe headache. We suggest routinely performing repeat CT, before discharge, in patients having sustained head trauma with or without skull fracture, who suffer non-resolving headache, even when there is no neurologic deterioration. Serious symptomatology that may have occurred due to the development of delayed intracranial hematomas is thereby anticipated.     

Delayed traumatic intracerebral hematomas: "Sp?t-Apoplexie". Report of two cases

Two patients who suffered a head trauma experienced sudden clinical deterioration more than 1 week after their injury. The initial computerized tomography (CT) scan demonstrated a small hematoma underlying a depressed skull fracture in one patient and a small interhemispheric subdural hematoma in the other. Both patients had made a complete recovery and follow-up CT scans were normal when clinical deterioration suddenly occurred. Both patients developed a large intracerebral hematoma and underwent emergency evacuation of the mass. The first patient recovered with the exception of a moderate hemiparesis and dysphasia, but the second patient died. Delayed traumatic intracerebral hematomas have been described in the literature. Since the advent of CT scanning, the incidence of this phenomenon has been estimated as between 1.7% and 7.4% of closed head injuries. In 1891, Otto Bollinger described four patients who suffered head injury, followed days to weeks later by death from an apoplectic event. His criteria for diagnosis of "traumatische Sp?t-Apoplexie" included the absence of preexisting vascular disease, a definite history of trauma, an asymptomatic interval of at least several days, and an apoplectic episode. These two cases reemphasize the existence of Sp?t-Apoplexie as a rare clinical condition. In the presence of CT findings of even small traumatic intracerebral or extracerebral hematomas, the possibility of this late complication should be kept in mind.     

A guide to initial management of minor head injury

We reviewed the records of 1,335 minor head injury patients with initial Glasgow Coma Scale (GCS) scores of 15 treated by our neurosurgery service between January 1998 and December 2000. Skull X-ray was performed in 945 patients (71%), and Computed tomography (CT) was performed in 590 patients (44%). Skull fracture was shown radiographically in 24 patients (2.5%), and abnormalities on the initial CT were seen in 29 patients (4.9%). The most frequent intracranial lesion on CT was acute epidural hematoma with skull fracture. Significantly more intracranial lesions were found in those with a fracture than in those without by chi2 analysis. Post-traumatic vomiting was significantly associated with radiographical abnormalities, but headache and nausea did not increase the risk of skull fracture and intracranial lesions on the CT. Patients required neurosurgical intervention in 4 cases, and all of those were acute epidural hematoma with skull fracture. In this study, the first thing we should do for asymptomatic minor head injury patients with a GCS score of 15 is to investigate the presence of a skull fracture by skull X-ray. Head trauma patients with a skull fracture and post-traumatic vomiting should undergo CT to facilitate detection of intracranial lesions, even when there are no abnormal neurological signs.     

迟发性外伤性颅内血肿30例分析

目的总结迟发性外伤性颅内血肿(DTICH)的诊治经验。方法患者均头部CT检查,首次检查于伤后1～3 h。正常8例,脑挫裂伤伴血肿9例,硬膜下血肿6例,硬膜外血肿7例,颅内积气5例。复查头部CT发现血肿时间22例于伤后3～6 h,4例于伤后3～7 d,4例伤后7d以后发现。其中脑内血肿22例(额叶10例、颞叶12例),硬膜下血肿6例,硬膜外血肿2例。血肿与受力点关系,直接着力12例,对冲部位18例。迟发性颅内血肿指首次检查(CT扫描)未发现,经过一定时间后复查发现的血肿,或手术、尸检在原无血肿部位发现血肿。其产生的机理尚不清楚。结果 30例中14例有颅骨骨折及硬脑膜中动脉破裂,5例原发血肿,11例迟发性血肿发生在颅骨骨折部位。可能与血肿清除后填塞现象解除及骨折线渗血加速有关。结论对有颅骨骨折的颅内血肿患者,如血肿不在骨折线附近,或骨折线较长,原发血肿位于骨折线的一端,血肿清除后,颅内压仍高或脑膨出者,首先应排除远隔部位骨折线附近迟发血肿的可能。     

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation

BACKGROUND: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS: Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS: Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS: Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.     

Delayed epidural bleeding caused by traumatic pseudoaneurysm of the middle meningeal artery: case report

A 16-year-old man who presented with delayed bleeding of epidural hematoma is reported. Computed tomography (CT) on admission demonstrated a small amount of right epidural hematoma and a small fracture of the right lateral orbital wall. He was treated conservatively. Repeated CT scans and magnetic resonance (MR) imaging revealed no growth in the epidural hematoma, but demonstrated flow void sign at the medial side of the hematoma on MR images. After 8 days, CT scan presented the regrowth of the hematoma, so we planned the removal of hematoma. Epidural hematoma due to the rupture of a traumatic pseudoaneurysm of the middle meningeal artery is rare. Especially, since traumatic lesions were diagnosed by CT, it was unusual to be able to diagnose the pseudoaneurysm of middle meningeal artery preoperatively. The cases of epidural hematoma treated conservatively should be followed up by MR imaging and MR angiography using the fat suppression technique.     

Is computed tomographic scanning necessary in patients with tentorial herniation? Results of immediate surgical exploration without computed tomography in 100 patients

Computed tomographic (CT) scans are performed on virtually all patients with severe head injury at the time of admission. Because of the time involved in obtaining these studies, the evacuation of significant intracranial mass lesions is delayed. To avoid such delays, the authors performed burr-hole exploration for the diagnosis of intracranial hematomas before CT scans were obtained in 100 consecutive head-injured patients with clinical signs of tentorial herniation or upper brain stem dysfunction upon admission to the emergency room. Patients in whom a hematoma was discovered had a craniotomy for evacuation of the clot; those in whom the exploration was negative had a CT brain scan immediately after operation. Burr-hole exploration revealed extracerebral mass lesions in 56 patients. In 38 patients, the exploration was negative, and postoperative CT scanning showed no significant hematoma. Of 6 patients in whom the CT scan demonstrated extraaxial hematomas requiring surgical evacuation, 4 had subdural hematomas that were missed because the exploration was incomplete; 1 patient had an epidural hematoma and 1 had a subdural hematoma contralateral to a craniotomy on the side of a positive initial burr-hole exploration. Our results indicate that the relatively small subgroup of head-injured patients with early tentorial herniation or upper brain stem compression have a high incidence of immediate extraaxial hematomas and a low incidence of intracerebral hematomas. This is particularly true of patients over 30 years of age and those who suffer low speed trauma, such as falls and vehicle-pedestrian accidents.     

Chronic epidural hematoma of the vertex: problems in detection with computed tomography

A vertex epidural hematoma of a 21-year-old man was diagnosed by angiography 1 month after head trauma. Two axial computed tomography scans did not reveal the lesion, whereas a coronal computed tomography scan demonstrated the hyperdense hematoma. The problems of detecting vertex lesions with axial computed tomography scans are discussed.     

Early seizures after mild closed head injury.

The authors review the seizure incidence in 4232 adult patients with mild closed head injury who did not receive prophylactic anticonvulsant agents. One hundred patients (2.36%) experienced seizures within 1 week after head injury; 43 of these (1.02% of the series) had seizures within 24 hours after trauma. Most of the seizures (84%) that developed during the 1st week after injury were of the generalized tonic-clonic type. The incidence of generalized tonic-clonic seizures was higher than that of partial seizures with motor symptoms both within 24 hours (91% vs. 9%) and during the Day 2 to 7 period (79% vs. 21%). No definite intracranial pathological findings were detected by computerized tomography (CT) in 53% of patients with early posttraumatic seizures; six patients had intracranial hemorrhage without intracranial parenchymal damage (three with epidural hematoma and three with subarachnoid hemorrhage). The most common positive CT findings in the early posttraumatic-seizure group were intracerebral hemorrhage (24%), followed by acute subdural hematoma with intracerebral hemorrhage (17%). Intracerebral parenchymal damage could be identified on CT scans in 41 (48.8%) of 84 patients with generalized tonic-clonic seizures and five (31%) of 16 patients with partial seizures with motor symptoms. The intracerebral parenchymal damage was most commonly detected in the frontal lobe (21%) and the temporal lobe (19%). Seven patients with early posttraumatic seizures received emergency craniotomy to remove an intracranial hematoma (epidural in three, subdural and intracerebral in four) because the mass effect resulted in significant midline shift as seen on CT scans. This review suggests that early posttraumatic seizures after mild closed head injury have a high incidence (53%) in patients with normal CT scan findings. Although the possibility of surgically correctable intracranial hemorrhage is low (7%), the condition may be devastating if not treated properly.     

Acute epidural hematoma in the posterior fossa in patients with hemophilia A--report of two surgically treated cases

Case I: A 9-year-old boy, diagnosed as having hemophilia A at 8 months, was admitted complaining of slight headache and nausea one day after a minor head trauma. Neurological deficits were absent but CT scan revealed an epidural hematoma in the posterior fossa. Shortly afterwards, he lapsed into coma with apnea and dilated pupils. Following resuscitation, emergency suboccipital craniectomy and total removal of the bilateral supra- and infratentorial extradural hematoma was performed under AHG administration. The patient gradually regained consciousness, but during the subsequent nine weeks he underwent three major operations (laparotomy): the first two for hemostasis of gastrointestinal bleeding, and the last one for strangulated intestinal obstruction. Although this patient necessitated 16 weeks of AHG administration, he was discharged without any side effects after 4 months of hospitalization. Case II: A 10-year-old boy, diagnosed earlier as having hemophilia A, experienced a minor head trauma and was admitted because of headaches and nausea. CT scan revealed an epidural hematoma in the posterior fossa. Removal of the hematoma was successfully completed under AHG administration. The patient was discharged without any neurological deficits. In the above hemophilic cases, we used a high concentrated AHG and maintained at 70% of the plasma concentration of the VIII factor during the first 14 postoperative days. The high concentrated AHG was safe for long term administration, so one should not hesitate operation even in the case of intracranial hemorrhage of hemophilic patients. CT scan should be recommended to the patient of hemophilia A even in minor head trauma.     

Spontaneous epidural hematoma after open heart surgery: case report

Acute epidural hematoma not associated with head injury is rarely encountered and is known as spontaneous epidural hematoma. To our knowledge, only five cases with epidural hematoma after open-heart surgery have been published. Pathogenesis and preventive measures have not yet been determined. We report a case of such spontaneous epidural hematoma and consider the possible pathogenesis. A 12-year-old female received a radical operation for severe subaortic stenosis. The intraoperative course was uneventful except for massive hemorrhage which was adequately controlled. Postoperatively, she was moved to the CCU still not having aroused from anesthesia. Eleven hours later, it was found that her pupils were fixed and dilated. CT scan demonstrated a huge bifrontal epidural hematoma with disappearance of the basal cistern. Even though immediate emergency evacuation was performed, the patient died of acute brain swelling four days after the operation.     

The management of "asymptomatic" epidural hematomas. A prospective study

Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma. Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol. It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.     

Delayed epidural hematoma. Apropos of a series of 8 cases

The authors report 8 patients who developed an epidural hematoma after having been submitted to 1 or 2 computed tomographies (CT) which did not yet show the hematoma. The initial CT was done 1 to 6 hours after the accident. The delayed hematoma was diagnosed 3 and a half hours to 7 days after the accident. Secondary clinical deterioration occurred in 6 patients and was dramatic in 4 of them. Delayed epidural hematoma seems to be a frequent event; our 8 cases represent 10 % of all epidural hematomas operated during the period under consideration. This has to be taken into account when taking care of head injured patients after negative CT. The authors propose a list of indications for repeating CT. The current views on mechanisms of formation of epidural hematomas are discussed in the light of the increasing number of reported cases of delayed epidural hematoma.     

Linear fractures invisible on routine axial computed tomography: a pitfall at radiological screening for minor head injury

Computed tomography (CT) is now widely used as the only screening method for fractures in patients with head injury. However, clear depiction of a fracture requires a discontinuity in the skull, so linear fractures parallel to the CT slice may not be visualized. We retrospectively evaluated 302 patients with minor head injuries aged from 0 to 91 years, who had undergone routine skull radiography (anteroposterior and lateral views) and head CT to study these types of fracture and discuss the risk of nondetection. Three patients had linear fractures (0.99%) that were invisible on bone window axial CT but detected on skull radiography, which all ran parallel to the scan slice. Two patients developed acute epidural hematoma or traumatic subarachnoid hemorrhage. Evaluation of head injury by only axial CT may miss such fractures and result in sequelae, so diagnosticians should be alert to the possible presence of this type of fracture.     

Repeat CT scan in closed head injury

BACKGROUND: Cranial CT scans are often repeated to observe the progress of an intracranial injury. This prospective observational study analyses the effect of repeat CT scans with the aim of formulating a guideline for their use. METHODS: One hundred and seventy-five patients with blunt head injury presenting to the trauma unit and undergoing CT scan were included. Unstable patients with polytrauma were excluded. There was no standard protocol for ordering the repeat cranial CT scans. This decision was purely based on the discretion of neurosurgeons. RESULTS: CT scan was repeated in 53 (30%) patients. The clinical indications for the repeat CT scan could be grouped into three: (i) clinical deterioration, (ii) failure of improvement, and (iii) as a follow-up scan. Nine underwent surgical intervention based on the repeat CT scan findings. They were associated with clinical deterioration and had a better survival after surgery. In others the repeat CT scan findings did not alter the management. CONCLUSION: When a head injured patient shows clinical deterioration, it is necessary to repeat the CT scan to pick up a surgically treatable lesion; which is likely in a significant number of patients. Repeat CT scan as a matter of "routine" follow-up when the patient is clinically status-quo or improving, is unlikely to yield any further information necessitating change in treatment. This guideline may be useful in settings where CT scan facility is not easily available or expenditure is an issue.     

Post-traumatic exophthalmos caused by a subperiosteal hematoma of the orbit

We report a case of a 27-year-old man who developed major exophthalmos associated with ophthalmoplegia occurring 48 hours after head trauma. CT scan showed an orbital roof fracture and a subperiosteal hematoma. Surgical evacuation of the hematoma and reconstruction of the orbital roof was performed via a frontal craniotomy. Two months later, the ophthalmologic examination was normal. We stress the importance of early diagnosis and prompt surgical treatment in such an unusual complication of head trauma.     

Intraoperative development of contralateral epidural hematoma during evacuation of traumatic extraaxial hematoma

Intraoperative development of an epidural hematoma contralateral to a craniotomy for acute traumatic extraaxial hematoma has been previously reported. This entity, however, has never been distinctly defined and differentiated from either the delayed or the bilateral acute epidural hematoma. We present 3 new cases of intraoperative contralateral acute epidural hematoma and review the 14 previously reported cases. The typical clinical presentation is a severe head injury with an acute extraaxial hematoma and severe ipsilateral brain displacement during craniotomy. If brain displacement is not noted at craniotomy, then the contralateral hematoma is manifested by immediate postoperative neurological deterioration or intractable elevated intracranial pressure. The presence of any of these signs makes an immediate postoperative CT scan or burr holes contralateral to the original craniotomy mandatory for early diagnosis. In addition to defining "intraoperative contralateral epidural hematoma," stricter definitions of the terms "delayed epidural hematoma" (no hematoma present on the initial CT scan but one present on a later scan) and "bilateral epidural hematomas" (present on the initial scan) are proposed.