Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma.

OBJECTIVE: Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score. METHODS: Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome. RESULTS: Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels. CONCLUSIONS: The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

[Severe traumatic brain injury]. / Schweres Schädel-Hirn-Trauma.

Traumatic brain injury is a leading cause of morbidity and mortality, especially under 45 years of age. The primary brain injury occurs at the moment of trauma and is defined by the direct damage to tissue. In contrast, secondary brain injury develops over time and is accessible to therapeutic interventions. Patients with severe traumatic brain injury have to be transferred to a specialized trauma centre in order to perform appropriate diagnostic and therapeutic procedures. These include surgical management of lesions (e.g. haematoma evacuation) as well as specific neurointensive care. Neurointensive care medicine principles such as treatment of increased intracranial pressure and advanced invasive neuromonitoring of brain tissue have to be followed.

Retinal hemorrhages: advances in understanding.

Retinal hemorrhage is a cardinal manifestation of abusive head injury characterized by repetitive acceleration-deceleration with or without blunt head impact. Detailed description of the hemorrhages and documentation are critical to diagnosis. Vitreoretinal traction appears to be the major causative factor. Outcome is largely dependent on brain and optic nerve injury.

A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed.

BACKGROUND: Patients with minimal head injury (MHI) and intracranial bleed (ICB) detected on cranial computed tomography (CT) scan routinely undergo a repeat cranial CT within 24 hours after injury to assess for progression of intracranial injuries. While this is clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination. The goal of this study was to prospectively assess the value of a repeat cranial CT in patients with a MHI and an ICB who have a normal neurologic examination. METHODS: A prospective analysis of all adult patients admitted to a Level I trauma center after blunt trauma causing a MHI (defined as the loss of consciousness or posttraumatic amnesia with a Glasgow Coma Scale (GCS) score of greater or equal to 13) and an ICB on the initial cranial CT during a 12-month period (July 2002 through July 2003) was performed. All patients with MHI were prospectively evaluated and followed until discharge. Data collected included demographics, neurologic examination and findings on the initial and repeat cranial CT scan. Outcome data included neurologic deterioration, neurosurgical intervention, and Glasgow Outcome Scale (GOS) on discharge. RESULTS: In all, 161 consecutive patients with MHI and a positive cranial CT scan were identified. The initial cranial CT lead to a neurosurgical intervention (1 craniotomy, 4 intracranial pressure monitors) in 4% of cases. The remaining 130 patients who met inclusion criteria, underwent a repeat cranial CT scan within 24 hours postadmission. Ninety nine (76%) patients had a normal neurologic examination at the time of their repeat cranial CT. After the repeat cranial CT none required immediate neurosurgical intervention or had delayed neurologic deterioration related to their head injury. Fifteen patients underwent additional neuroradiologic studies but none showed further progression of their ICB or lead to a change in management. One patient died from non-traumatic brain injury related causes and of the remaining 26 patients, 98% had an overall favorable GOS score (> 3) on discharge. In this group of patients with MHI and ICB, the negative predictive value of a normal neurologic examination was 100%. CONCLUSIONS: Repeat cranial CT, in patients with a MHI and a normal neurologic examination, resulted in no change in management or neurosurgical intervention and is therefore not indicated. A multicenter prospective study would further validate these conclusions, reduce unnecessary CT scans, and likely improve our current standard of care in these patients.

Traumatic intracranial hemorrhage in newborns.

INTRODUCTION: Neonatal traumatic head injuries (NTHI) can be life-threatening and require aggressive treatment. The indications, techniques, and results of brain decompression are not well defined in the literature. METHODS: We studied prospectively cases of NTHI with intracranial traumatic lesions; skull fractures without underlying lesions were not included. We treated 17 cases of NTHI: 7 patients had a subdural hematoma, 3 had an extradural hematoma, and the others had subarachnoid hemorrhage. Surgical evacuation of intracranial clots was performed in 7 cases, by needle aspiration in 5 and by craniotomy in 2 patients with extradural hematomas. RESULTS: The outcome was favorable in all but one patient, who had hemophilia A, and died of rebleeding at the age of 2 months. CONCLUSION: Surgical decompression of intracranial hematomas due to NTHI is often unnecessary; however, it may be required in emergency because of poor clinical tolerance. Whenever possible, percutaneous needle aspiration is the treatment of choice.

[Brain and head injury. Part 1: Clinical classification, imaging modalities, extra-axial injuries, and contusions]. / Schädel- und Hirntrauma. Teil 1: Klinische Klassifikationen, bildgebende Methoden, extraaxiale Verletzungen und Kontusionen.

This article describes the imaging tools for efficient diagnostic management of head trauma victims. The basic mechanisms of brain injuries are explained and the imaging features are described. Computed tomography remains the most important method for the initial screening and follow-up investigation. Though magnetic resonance imaging has a higher sensitivity to most traumatic lesions, it does not play an important role in the acute phase of head trauma patients. In the first part of this paper clinical classifications, imaging modalities, extra-axial injuries, and contusions are described. In the second part of this paper intra-axial and secondary injuries are discussed.