Endoscope-Assisted Evacuation of an Acute Subdural Hematoma in an Elderly Patient With Refractory Nonconvulsive Status Epilepticus: An Illustrative Case.

Traumatic brain injuries lead to post-traumatic seizures (PTS), with acute subdural hematomas (ASDH) posing a particularly elevated risk. The development of refractory nonconvulsive status epilepticus (NCSE) in such cases, especially in older patients, requires immediate and effective management. This case report highlights the improvement of refractory NCSE in an elderly patient with ASDH through endoscope-assisted evacuation. An 88-year-old woman was hospitalized for dysarthria and right hemiparesis 3 days after a fall. Computed tomography (CT) revealed a left hemispheric ASDH, 9 mm thick, along with minor traumatic subarachnoid bleeding in the interpeduncular cistern. The initial treatment was conservative, including the administration of lacosamide at 100 mg/day. However, her consciousness deteriorated 4 days after admission, and she experienced convulsions in the right face and arm on day 5. Although the convulsions stopped after the administration of diazepam 10 mg IV and her consciousness temporarily improved, it worsened again on day 6, leading to a diagnosis of NCSE on an electroencephalogram (EEG). Despite aggressive pharmacological interventions with fosphenytoin (750 mg initially followed by 262 mg/day) and phenobarbital (625 mg/day), the patient's cognitive state and EEG findings did not improve. Consequently, on the 13th day, she underwent an endoscopic procedure to remove the SDH, which alleviated her symptoms and ended the seizures. This case demonstrates that even the absence of a significant mass effect from ASDH can trigger NCSE, underscoring the necessity for swift diagnosis and consideration of surgical options when conventional treatment fails. Endoscope-assisted evacuation is a safe and effective treatment option, particularly in older patients.

Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series.

Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.

Traumatic Brain Injury Profile of an Elderly Population in Puerto Rico.

OBJECTIVE: Describe the types of traumatic brain injury secondary to falls sustained by the members of an elderly population who received services at the Puerto Rico Medical Center and the demographic profile of that population. METHODS: A group of 332 adults (60 years and over) assessed for traumatic brain injury secondary to falls suffered in 2013 were included in the analysis. The cases were retrieved from the computerized database of the Neurosurgery Section. We analyzed information such as age, gender, type of traumatic brain injury, mechanism of injury, and the performance of surgery (if applicable). Descriptive analysis was performed to derive a general profile of elderly adults who presented with traumatic brain injury secondary to falls. RESULTS: The sample consisted of 332 elderly adults: 73% were men and 27% were women. The mean age was 76.74 (SD=9.95) years: 75.67 (SD=9.78) for men and 79.13 (SD=10.02) for women. The most common traumatic brain injury was subdural hematoma (51%) and the mechanism of injury most prevalent was the groundlevel fall (83%). Other traumatic brain injuries included traumatic subarachnoid hemorrhages (14%), cerebral contusions (18%) and epidural hematomas (3%). Of all the cases, 52% had were managed surgically. CONCLUSION: The elderly population is growing and the risk of falls increases with advancing age. Recurrent falls are an important cause of morbidity, and mortality rates oscillate from 6 to 18%. Elderly patients have longer rehabilitation times, incur more expenses, and have greater levels of disability. This study provides a platform for future epidemiological studies to help develop strategies for the prevention of traumatic brain injury in older adults.

Are acute subdural hematomas possible without head trauma?

Acute subdural hematomas (ASDHs) are rarely reported in the literature. In general, it is due to head trauma, but if the traumatic event is very mild, it is inadequate to explain the ASDH occurrence. Risk factors for the development of spontaneous ASDH include hypertension, vascular abnormalities and deficit of coagulation. We present two cases of ASDH in patients with the coagulation deficit and review of the literature to understand the coagulation factors role and platelet role in the management of ASDHs.