An exploratory study investigating the effect of targeted hyperoxemia in a randomized controlled trial in a long-term resuscitated model of combined acute subdural hematoma and hemorrhagic shock in cardiovascular healthy pigs.

Severe physical injuries and associated traumatic brain injury and/or hemorrhagic shock (HS) remain leading causes of death worldwide, aggravated by accompanying extensive inflammation. Retrospective clinical data indicated an association between mild hyperoxemia and improved survival and outcome. However, corresponding prospective clinical data, including long-term resuscutation, are scarce. Therefore, the present study explored the effect of mild hyperoxemia for 24 hours in a prospective randomized controlled trial in a long-term resuscitated model of combined acute subdural hematoma (ASDH) and HS. ASDH was induced by injecting 0.1 ml × kg-1 autologous blood into the subdural space and HS was triggered by passive removal of blood. After 2 hours, the animals received full resuscitation, including retransfusion of the shed blood and vasopressor support. During the first 24 hours, the animals underwent targeted hyperoxemia (PaO2 = 200 - 250 mmHg) or normoxemia (PaO2 = 80 - 120 mmHg) with a total observation period of 55 hours after the initiation of ASDH and HS. Survival, cardiocirculatory stability, and demand for vasopressor support were comparable between both groups. Likewise, humoral markers of brain injury and systemic inflammation were similar. Multimodal brain monitoring, including microdialysis and partial pressure of O2 in brain tissue, did not show significant differences either, despite a significantly better outcome regarding the modified Glasgow Coma Scale 24 hours after shock that favors hyperoxemia. In summary, the present study reports no deleterious and few beneficial effects of mild targeted hyperoxemia in a clinically relevant model of ASDH and HS with long-term resuscitation in otherwise healthy pigs. Further beneficial effects on neurological function were probably missed due to the high mortality in both experimental groups. The present study remains exploratory due to the unavailability of an a priori power calculation resulting from the lack of necessary data.

Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis.

BACKGROUND: Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management. OBJECTIVE: To investigate inpatient mortality after conservative management of large aSDHs. METHODS: Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale. RESULTS: Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110). CONCLUSION: In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.

Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma.

OBJECTIVE: Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates. RESULTS: Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses. CONCLUSIONS: Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.

Acute spontaneous subdural hematoma as an inaugural presentation of systemic lupus erythematosus with acquired factor XIII deficiency: a case report.

Acute spontaneous subdural hematoma is a rare clinical situation. Among its various etiologies, underlying coagulopathy is associated with a considerable risk of mortality. A 43-year-old female patient with no comorbidity and no personal or family history of bleeding disorders, consulted for acute and intense headache. The brain computed tomography (CT) scan showed a compressive left fronto-parietal acute subdural hematoma. The cerebral magnetic resonance angiography and routine hemostasis workup were normal. Factor XIII activity was low at 41% and the etiological investigation was consistent with the diagnosis of systemic lupus erythematosus. Surgical evacuation of the hematoma, factor XIII supplementation and systemic corticosteroid therapy with hydroxy chloroquine resulted in a favorable outcome. Acquired factor XIII deficiency should be systematically investigated for any acute spontaneous subdural hematoma with a normal hemostasis assessment in an adult with no personal or family history of hemorrhage.

Management of acute subdural hematoma in incarcerated patients.

INTRODUCTION: Incarcerated patients have been documented to have higher rates of mental illness, substance abuse disorders, trauma, and chronic illnesses compared to non-incarcerated populations. In this study, we evaluated the incidence of subdural hematoma (SDH) in incarcerated patients and compared the outcomes of these patients to those of non-incarcerated patients. METHODS: We conducted a retrospective cohort study of incarcerated patients admitted to a hospital with acute SDH using the Nationwide Readmissions Database between 2016-2017. Nearest-neighbor propensity score matching for demographics was implemented to identify non-incarcerated control patients admitted with SDH. Analysis used chi-squared testing, Mann-Whitney U testing, and generalized binomial regression modeling. RESULTS: A total of 962 incarcerated and non-incarcerated patients were identified at primary admission. No significant difference was found between the two cohorts with regards to rates of neurosurgical complications or readmissions. Incarcerated patients were found to receive a significantly lower number of procedures, including respiratory ventilation, intubation, central venous line placement, and imaging, during their primary admission (NPR = 2.7 ± 4.0) compared to non-incarcerated patients (NPR = 3.9 ± 4.9) (p = 0.00050), reduced length of stay (p = 0.0052), and reduced hospital costs (p = 0.00026) compared to non-incarcerated patients. Furthermore, female incarcerated patients with SDH had significantly worse outcomes compared to male patients with SDH, including higher rates of mortality (p = 0.0017) and 30-day readmission rates (p = 0.041). DISCUSSION: Our study suggests that incarcerated patients may receive significantly fewer diagnostic and supportive procedures while admitted for SDH and may be discharged sooner than non-incarcerated patients with SDH. In addition, outcomes following SDH within incarcerated patients may be significantly worse for females.

Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively.

Acute subdural hematomas (ASDHs) are highly morbid and increasingly common. Hematoma expansion is a potentially fatal complication, and few studies have examined whether factors associated with hematoma expansion vary over time. To answer this, we performed a case-control study in a cohort of initially conservatively managed patients with ASDH. Two time periods were considered, early (<72 h from injury) and delayed (>72 h from injury). Cases were defined as patients who developed ASDH expansion in the appropriate period; controls were patients who had stable imaging. Associated factors were determined with logistic regression. We identified 68 cases and 237 controls in the early follow-up cohort. Early ASDH expansion was associated with coagulopathy (adjusted odds ratio [aOR] 2.3, 95 % CI: 1.2-4.5; p = 0.02), thicker ASDHs (aOR 1.1, 95% CI: 1.03-1.2; p = 0.006), additional intracranial lesions (aOR 3, 95% CI: 1.6-6.2; p = 0.002), no/minimal trauma history (aOR 0.4, 95% CI: 0.2-0.9; p = 0.03), and duration between injury and initial scan (aOR 0.9, 95% CI: 0.8-0.97; p = 0.04). In the delayed follow-up cohort, there were 41 cases and 126 controls. Delayed ASDH expansion was associated with older age (aOR 1.3 per 10 years, 95% CI: 1.1-1.6; p = 0.01), systolic blood pressure (SBP) >160 on hospital presentation (aOR 4.5, 95% CI: 1.8-11.3; p = 0.001), midline shift (aOR 1.5 per 1 mm, 95% CI: 1.3-1.9; p < 0.001), and convexity location (aOR 14.1, 95% CI: 2.6-265; p = 0.013). We conclude that early and delayed ASDH expansion are different processes with different associated factors, and that elevated SBP may be a modifiable risk factor of delayed expansion.

Post-Dural Puncture Headache Evolving to a Subdural Hematoma: A Case Report.

INTRODUCTION: Cervical epidural corticosteroid injections are frequently used for the treatment of subacute cervicobrachial pain. This therapy is considered safe, with the vast majority of the complications being minor and transient. CASE REPORT: We present a case of a woman in her fifties who suffered from cervicobrachialgia and received 2 cervical epidural corticosteroid infiltrations. On day 3 after the second infiltration, a new headache appeared and on day 16 a bilateral subdural hematoma was visualized on CT scan. Complete resorption of the hematoma was seen on day 25 without surgical intervention. DISCUSSION: Up until now, only 1 case report of an intracranial subdural hematoma after a cervical epidural steroid injection has been published. But several cases of an intracranial subdural hematoma after spinal, epidural, or combined spinal and epidural anesthesia have been reported. Physicians should be aware of this potentially dramatic complication since post-dural puncture headache after any type of procedure can evolve into a subdural hematoma. Clinical differentiation between the two can be difficult; post-dural puncture headache is characterized by relief of symptoms in the supine position and photophobia/phonophobia. A subdural hematoma should be considered if the headache changes in character, does not respond to treatment, or there are neurological signs such as nausea/vomiting and blurred vision. Immediate medical imaging should then be performed.

Cervical spine subdural hematoma: A rare radiographic abnormality in a trauma patient.

Spinal subdural hematomas (SSDH) are a rare radiographic finding that can lead to significant long-term disability. Many clinicians are unfamiliar with this condition and the available treatment options. This article describes one approach to managing a patient with an SSDH.

Increases in Subdural Hematoma with an Aging Population-the Future of American Cerebrovascular Disease.

BACKGROUND: Subdural hematomas (SDHs) are a common and dangerous condition, with potential for a rapid rise in incidence given the aging U.S. population, but the magnitude of this increase is unknown. Our objective was to characterize the number of SDHs and practicing neurosurgeons from 2003-2016 and project these numbers to 2040. METHODS: Using the National Inpatient Sample years 2003-2016 (nearly 500 million hospitalizations), all hospitalizations with a diagnosis of SDH were identified and grouped by age. Numerical estimates of SDHs were projected to 2040 in 10-year increments for each age group using Poisson modeling with population estimates from the U.S. Census Bureau. The number of neurosurgeons who billed the Centers for Medicare and Medicaid Services from 2012 to 2017 was noted and linearly projected to 2040. RESULTS: From 2020-2040, SDH volume is expected to increase by 78.3%, from 135,859 to 208,212. Most of this increase will be seen in the elderly, as patients 75-84 years old will experience an increase from 37,941 to 69,914 and patients older than 85 years old will experience an increase from 31,200 to 67,181. The number of neurosurgeons is projected to increase from 4675 in 2020 to 6252 in 2040. CONCLUSIONS: SDH is expected to increase significantly from 2020-2040, with the majority of this increase being concentrated in elderly patients. While the number of neurosurgeons will also increase, the ability of current neurosurgical resources to properly handle this expected increase in SDH will need to be addressed on a national scale.

Clinical Characterization of Traumatic Acute Interhemispheric Subdural Hematoma.

OBJECT: Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH. METHODS: This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected. RESULTS: Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient. CONCLUSION: IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.

Recurrent Acute Subdural Hematoma Due to Middle Meningeal Artery Bleeding Treated by Embolization.

BACKGROUND: Recurrent acute subdural hematomas (ASDHs) are a common complication of neurosurgical operations. However, ASDHs associated with middle meningeal artery (MMA) injury are extremely rare. We encountered a rare case of recurrent ASDH due to MMA bleeding after craniotomy for a nontraumatic ASDH and successfully performed MMA embolization for treatment of it. CASE DESCRIPTION: A 56-year-old woman was admitted to our department with progressively worsening headache and vomiting approximately 1 week. She had no history of head trauma and illness. A head computed tomography (CT) scan revealed an ASDH on the right hemisphere. The patient underwent a right-sided craniotomy for evacuation of the hematoma. Two days later, she exhibited impaired consciousness and a repeat CT scan showed a recurrent ASDH. To clarify the cause, we performed cerebral digital subtraction angiography for the patient. Obvious contrast extravasation from the anterior branch of the right MMA was noticed. It was considered to be related to the recurrent ASDH. Embolization of the MMA was performed using Onyx 18 (Micro Therapeutics, Inc., Irvine, California, USA). Follow-up CT scans showed progressive resolution of the ASDH and no recurrence. The patient was discharged without any neurologic deficits. CONCLUSIONS: In our case, the relationship between the recurrent ASDH and MMA was observed via angiography and MMA embolization was successfully performed to avoid surgery for reevacuation, suggesting that active bleeding of MMA may be a cause of recurrent ASDH after neurosurgical operations and endovascular exploration, and possible treatment is necessary for an unexplained ASDH.

Predictors of subacute hematoma expansion requiring surgical evacuation after initial conservative treatment in patients with acute subdural hematoma.

BACKGROUND: The aim of this study was to clarify the factors associated with requiring subacute surgery in patients with acute subdural hematoma (ASDH) treated conservatively at admission. METHODS: Among the patients with ASDH admitted to our hospital from 2007 to 2018, we retrospectively reviewed data for 200 patients initially treated conservatively. We compared patients' characteristics, medical history, radiological findings, and clinical outcomes and differences between patients undergoing subacute surgery or no surgery. RESULTS: Of the 200 patients treated conservatively, 17 (8.5%) patients underwent subacute surgery due to deterioration of their clinical and/or computed tomography (CT) findings, while 183 (91.5%) patients did not undergo subacute surgery. There were significant differences in the presence of focal neurological deficits, modified Rankin Scale scores, degree of midline shift, hematoma thickness, hematoma volume, cella media index, Sylvian fissure ratio, and hematoma density between the two groups. CONCLUSIONS: Large hematoma, brain atrophy, and hematoma density may be useful predictors for the need for subacute surgery in patients with ASDH treated conservatively at admission. Intensive investigation of clinical findings or CT images is warranted in patients with adverse prognostic factors, even if their initial symptoms are mild.

Comparative effectiveness of surgery in traumatic acute subdural and intracerebral haematoma: study protocol for a prospective observational study within CENTER-TBI and Net-QuRe.

INTRODUCTION: Controversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this practice variation on patient outcome is unknown. Here, we present the protocol for a prospective multicentre observational study aimed at comparing the effectiveness of different treatment strategies in patients with ASDH and/or t-ICH. Specifically, the aims are to compare (1) an acute surgical approach to an expectant approach and (2) craniotomy to decompressive craniectomy when evacuating the haematoma. METHODS AND ANALYSIS: Patients presenting to the emergency room with an ASDH and/or an t-ICH are eligible for inclusion. Standardised prospective data on patient and injury characteristics, treatment and outcome will be collected on 1000 ASDH and 750 t-ICH patients in 60-70 centres within two multicentre prospective observational cohort studies: the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Neurotraumatology Quality Registry (Net-QuRe). The interventions of interest are acute surgery, defined as surgery directly after the first CT at presentation versus late or no surgery and craniotomy versus decompressive craniectomy. The primary outcome measure is the Glasgow Outcome Score-Extended at 6 months. Secondary outcome measures include in-hospital mortality, quality of life and neuropsychological tests. In the primary analysis, the effect of treatment preference (eg, proportion of patients in which the intervention under study is preferred) per hospital will be analysed with random effects ordinal regression models, adjusted for casemix and stratified by study. Such a hospital-level approach reduces confounding by the indication. Sensitivity analyses will include propensity score matching, with treatment defined on patient level. This study is designed to determine the best acute management strategy for ASDH and t-ICH by exploiting the existing between-hospital variability in surgical management. ETHICS AND DISSEMINATION: Ethics approval was obtained in all participating countries. Results of surgical management of ASDH and t-ICH/contusion will separately be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02210221 and NL 5761.

Low-Dose, Early Fresh Frozen Plasma Transfusion Therapy After Severe Trauma Brain Injury: A Clinical, Prospective, Randomized, Controlled Study.

BACKGROUND: To investigate role of Low-dose, Early Fresh frozen plasma Transfusion (LEFT) therapy in preventing perioperative coagulopathy and improving long-term outcome after severe traumatic brain injury (TBI). METHODS: A prospective, single-center, parallel-group, randomized trial was designed. Patients with severe TBI were eligible. We used a computer-generated randomization list and closed opaque envelops to randomly allocate patients to treatment with fresh frozen plasma (5 mL/kg body weight; LEFT group) or normal saline (5 mL/kg body weight; NO LEFT group) after admission in the operating room. RESULTS: Between January 1, 2018, and November 31, 2018, 63 patients were included and randomly allocated to LEFT (n = 28) and NO LEFT (n = 35) groups. The final interim analysis included 20 patients in the LEFT group and 32 patients in the NO LEFT group. The study was terminated early for futility and safety reasons because a high proportion of patients (7 of 20; 35.0%) in the LEFT group developed new delayed traumatic intracranial hematoma after surgery compared with the NO LEFT group (3 of 32; 9.4%) (relative risk, 5.205; 95% confidence interval, 1.159-23.384; P = 0.023). Demographic characteristics and indexes of severity of brain injury were similar at baseline. CONCLUSIONS: LEFT therapy was associated with a higher incidence of delayed traumatic intracranial hematoma than normal fresh frozen plasma transfusion in patients with severe TBI. A restricted fresh frozen plasma transfusion protocol, in the right clinical setting, may be more appropriate in patients with TBIs.

Initial Results of Empirical Cryoprecipitate Transfusion in the Treatment of Isolated Severe Traumatic Brain Injury: Use of In-house-produced Cryoprecipitate.

Acute coagulopathy is common after traumatic brain injury (TBI), particularly in severe cases of acute subdural hemorrhage (ASDH). Although acute coagulopathy is associated with poor outcomes, the optimal treatment strategy remains unknown. Here, we report the initial results of an empirical cryoprecipitate transfusion strategy that we developed as an early intervention for acute coagulopathy after TBI. We performed chart reviews of adult patients (aged ≥18 years) who received early cryoprecipitate transfusion after admission to our institution with a diagnosis of severe TBI (Glasgow Coma Scale ≤8) and ASDH from March 2013 to December 2016. We compared the outcomes of these patients with those who were treated before the implementation of the cryoprecipitate transfusion strategy (January 2011-February 2013). During the study period, 33 patients received early cryoprecipitate transfusion and no acute transfusion-related adverse event was reported. The rate of coagulopathy development within 24 h after admission was lower in these patients (23%) than in the controls (49%), but the difference was not significant (P = 0.062). The in-hospital mortality rate was 36% in patients receiving early cryoprecipitate transfusion and 52% in controls. After adjusting for confounding factors, the in-hospital mortality rate was significantly lower in the intervention period [adjusted odds ratio: 0.25, 95% confidence interval (CI): 0.08-0.78, P = 0.017]. In summary, we analyzed initial results of a cryoprecipitate transfusion strategy in patients with severe isolated TBI and ASDH. No acute transfusion-related adverse event was observed, and early transfusion of the in-house-produced cryoprecipitate may have reduced rates of coagulopathy development and in-hospital mortality.

Frequency of and Risk Factors for Chronification in Traumatic Acute Subdural Hematoma following Conservative Therapy.

BACKGROUND: In an aging society, traumatic head injuries, such as acute subdural hematomas (aSDHs), are increasingly common because the elderly are prone to falls and are often undergoing anticoagulation treatment. Especially in advanced age, cranial surgery such as craniotomies may put patients in further jeopardy. But if treatment is conservative, a chronic subdural hematoma (cSDH) may develop, requiring surgical evacuation. Existing studies have reported a correlation between several risk factors contributing to the frequency of chronification. To improve the prediction of the course of disease and to aid counseling patients and relatives, this study aimed to determine the frequency and the main risk factors influencing the process of chronification of an aSDH following conservative treatment. METHODS: We identified patients presenting between January 2012 and September 2017 at our neurosurgical department with an aSDH. All patients treated conservatively were selected retrospectively, and the following parameters were documented: age, sex, chronification status, Glasgow Coma Scale score on admission and discharge, hematoma thickness and density, the degree of midline shift (MLS), prior anticoagulants and administration of procoagulants, thrombosis management, other coagulopathies, initial length of hospital stay, interval between discharge and readmission, and interval between initial injury and date of surgery and last follow-up. The cohort was divided into patients with complete resolution of their aSDH, and patients who needed surgery due to chronification. RESULTS: A total of 75 conservatively treated patients with aSDH were included. A chronification was observed in 24 cases (32%). The process of chronification takes an average of 18 days (range: 10-98 days). The following factors were significantly associated with the process of chronification: age (p = 0.001), anticoagulant medication (acetylsalicylic acid [ASA], Coumadin, and novel anticoagulants [NOACs]) before injury (p = 0.026), administration of procoagulants (p = 0.001), presence of other coagulopathies such as thrombocytopenia (p = 0.002), low hematoma density at discharge (p = 0.001), hematoma thickness on admission and discharge (p = 0.001), and the degree of MLS (p = 0.044). CONCLUSION: Chronification occurred in a third of all patients with conservatively treated aSDH, on average within 3 weeks. The probability of developing a cSDH is 0.96 times higher with every yearly increase in age, resulting in 56% chronification in patients ≥ 70 years. Hematoma thickness and impairment of the coagulation system such as anticoagulant medication (ASA, Coumadin, and NOACs) or thrombocytopenia are further risk factors for chronification.

PET/CT to Assess Prognosis after a Brain Injury. / Positronenemissionstomografie/Computertomografie zur Prognoseabschätzung bei Tumornachweis in der Traumaspirale: Fallbericht beim bewusstlosen Patienten.

In a comatose patient with acute subdural haematoma, the polytrauma spiral indicated pulmonary metastasising renal carcinoma, which limited therapeutic possibilities. Whole-body positron-emission tomography/computer tomography (PET/CT) was performed with fluorodesoxyglucose. Renal carcinoma with pulmonary, nodal and parotidal metastases was proved. A cerebral metastasis could not be excluded because of perifocal hypermetabolism. There were few therapeutic possibilities. PET/CT is possible and sensible in the unconscious patient to differentiate the results of polytrauma-CT.

Mycotic intracranial aneurysms rupture presenting as pure acute subdural hematoma in infectious endocarditis. Report of 2 cases and review of the literature.

Acute subdural hematoma (ASDH) revealing mycotic aneurysm (MA) is an exceptional occurrence. We report 2 cases of MA-related pure ASDH in the course of infective endocarditis (IE) without history of head trauma, hypertension or coagulopathy. Case 1: A 54-year-old man presented with a 10-day history of headache, fever. At admission neurologic examination and Brain-CT were normal. Blood cultures showed Streptococcus bovis. MRI 5 days later revealed ischemic spots and minime ASDH over the right convexity. Cerebral angiography, revealed a 3 mm saccular aneurysm at the bifurcation of a distal branch of the right posterior cerebral artery (PCA). Case 2: A 42-year-old man presented with a 8-day history of fever, and worsening headache. Mitral regurgitation was evidenced. A methicillin-sensitive staphylococcus aureus left-sided IE was diagnosed. Pre- and post-contrast Brain-CT were normal. He presented 15 days later a secondarily generalized status epilepticus. Brain CT showed an ASDH over the convexity with falco-tentorial extension, midline shift and temporal herniation. It was removed in emergency. Cerebral angiography revealed a MA of a peripheral branch of the left PCA. The 2 patients were successfully treated by endovascular glue embolization and recovered without complications. Even rare, ruptured MA should be considered as a cause of pure ASDH of unknown origin. As MA can be missed on CT- and MR-Angiography because of mass effect, cerebral angiography may be mandatory.

Efficacy of platelet transfusion in the management of acute subdural hematoma.

OBJECTIVE: Oral Antithrombotic Therapy has become a well documented predisposing risk factor in the development of traumatic intracranial hemorrhage. Currently, a reversal protocol for antiplatelet therapy remains ill-defined in the management of non-surgical traumatic subdural hematoma and there is no evidence to suggest a clear benefit of platelet transfusion to mitigate the effect of antiplatelet agents. This study aims to establish parameters in which platelet transfusion would be of benefit in patients with non-surgical traumatic subdural hematoma with preinjury antiplatelet therapy. PATIENTS AND METHODS: This study is a retrospective chart review of patents from 2015 to 2018 at two Level II trauma centers identifying consecutive patients with non-surgical acute traumatic subdural hematomas. Patients with use of aspirin and/or clopidogrel were categorized into subgroups based on transfusion of platelets for antiplatelet reversal therapy, and were compared to a control group. The primary outcome measure was the presence of subdural hematoma expansion. RESULTS: A total of 72 patients met the criteria for inclusion in this study. The average age of the cohort was 75.4 with a median of 77.5. There were 40 males and 32 females. Chi-square analysis was performed which demonstrated statistical significance for difference between the aspirin and clopidogrel group for percent of hematoma expansion (p = 0.0284). Patients on antiplatelet therapy (n = 36) were grouped together and compared to patients without antiplatelet therapy (n = 36), this demonstrated that the transfusion of platelets for patients on antiplatelet agents (n = 19/36) still resulted in a significant hematoma expansion in (n = 7/19, 36.8%) compared to patients not on antiplatelet therapy (n = 3/36, 8.3%) (p = 0.0001). CONCLUSION: The results of this study suggest that patients with non-surgical traumatic subdural hematomas on presentation are less likely to expand, however the risk of expansion is greater when the patient is on antiplatelet therapy. There is no clear benefit in the use of platelet transfusion as a reversal agent to mitigate the effects of antiplatelet therapy in the setting of non-surgical traumatic subdural hematomas.

Patientem Fortuna Adiuvat: The Delayed Treatment of Surgical Acute Subdural Hematomas-A Case Series.

BACKGROUND: Current guidelines prescribe emergent decompression of acute subdural hematomas (aSDHs) with width 10 mm or larger or midline shift 5 mm or larger. A subset of patients who meet these criteria, including those with high Glasgow Coma Scale (GCS) scores and coagulopathy because of medication or multiple medical comorbidities, may be treated conservatively until the hematoma can be removed by burr hole drainage. We present a series of conservatively managed surgical patients with aSDH, examining their hospital course and outcomes. METHODS: Patients were included who met guidelines for surgery on admission but who had decompression delayed until it could be accomplished by burr hole drainage. Charts were reviewed for presentation, computed tomography scan findings, and outcomes. Patients were classified according to outcome and whether their eventual surgery was scheduled or emergent. RESULTS: Eighteen patients were included with a mean age of 70.2 years. Average GCS score at presentation was 14.6 ± 0.6. Most patients were using some form of blood-thinning medication at presentation (72.2%). Admission CT scan revealed aSDH with a mean width of 13.6 mm and midline shift of 6.6 mm. Average total length of stay was 28.4 ± 17.0 days, of which 14.2 ± 9.2 days were spent in the intensive care unit. Outcomes were generally acceptable, with an average Glasgow Outcome Scale score at discharge of 3.8 ± 1.4. There were only 2 deaths, neither of which was related to the initial trauma or a neurologic process. CONCLUSIONS: Delayed treatment of aSDH by burr hole drainage is an effective option in certain patients who are suboptimal craniotomy candidates. Acceptable outcomes may be achievable with this conservative approach, when applied in appropriate patients.