Connection between traumatic frontal intracerebral hemorrhage and lower urinary tract symptoms.

OBJECTIVE: There have been no previous studies of urinary symptoms in patients with traumatic frontal intracerebral hemorrhage. The purpose of this work was to provide first insights into the potential role of traumatic frontal intracerebral hemorrhage in the development of urinary symptoms. This condition is known to cause compression in and around the prefrontal cortex, and we wanted to examine its effect on the micturition center. PATIENTS AND METHODS: Patients with voiding dysfunction (n = 176) were assessed for lower urinary tract symptoms using the International Prostate Symptom Score (IPSS). Out of 176 patients, 52 symptomatic patients with voiding difficulties underwent urodynamic testing. All patients with traumatic frontal intracerebral hemorrhage were treated at the University Medical Center Tuebingen, Germany, and the Azad University of Medical Sciences in Tehran, Iran, between 2017 and 2020. Lower urinary tract symptoms (LUTS) were documented in patients with compression of the frontal lobe due to local hemorrhage. All patients routinely performed Brain CT scans. Brain magnetic resonance (MRI) images of the patients with suspicion of diffuse axonal injuries were additionally performed. Out of 176 treated patients (median age of 49 years), 52 patients with voiding difficulties were evaluated. RESULTS: Urodynamic testing of 52 symptomatic patients revealed detrusor overactivity in 25 (48%), low-compliance bladder in 4 (7.7%), detrusor-sphincter dyssynergia in 20 (38%), and uninhibited sphincter relaxation in 11 patients (21%). There was no significant correlation between the volume of hemorrhage and urinary symptoms (p=0.203, Spearman q=0.726). Frontal intracerebral hemorrhage compressing the pre-frontal cortex influences the micturition center and is responsible for lower urinary tract symptoms. CONCLUSIONS: Hemorrhage of the right or left frontal lobe does have a direct relationship with incontinence which completely disappeared in 85% of the patients within 9 months.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Prevalence and Incidence of Microhemorrhages in Adolescent Football Players.

BACKGROUND AND PURPOSE: SWI is an advanced imaging modality that is especially useful in cerebral microhemorrhage detection. Such microhemorrhages have been identified in adult contact sport athletes, and the sequelae of these focal bleeds are thought to contribute to neurodegeneration. The purpose of this study was to utilize SWI to determine whether the prevalence and incidence of microhemorrhages in adolescent football players are significantly greater than those of adolescent noncontact athletes. MATERIALS AND METHODS: Preseason and postseason SWI was performed and evaluated on 78 adolescent football players. SWI was also performed on 27 adolescent athletes who reported no contact sport history. Two separate one-tailed Fisher exact tests were performed to determine whether the prevalence and incidence of microhemorrhages in adolescent football players are greater than those of noncontact athlete controls. RESULTS: Microhemorrhages were observed in 12 football players. No microhemorrhages were observed in any controls. Adolescent football players demonstrated a significantly greater prevalence of microhemorrhages than adolescent noncontact controls (P = .02). Although 2 football players developed new microhemorrhages during the season, microhemorrhage incidence during 1 football season was not statistically greater in the football population than in noncontact control athletes (P = .55). CONCLUSIONS: Adolescent football players have a greater prevalence of microhemorrhages compared with adolescent athletes who have never engaged in contact sports. While microhemorrhage incidence during 1 season is not significantly greater in adolescent football players compared to adolescent controls, there is a temporal association between playing football and the appearance of new microhemorrhages.

Low Risk of Traumatic Intracranial Hematoma Expansion with Factor Xa Inhibitors without Andexanet Reversal.

BACKGROUND: Andexanet alfa, a novel anticoagulation reversal agent for factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors study established the efficacy of andexanet alfa in reversing factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. The objective of this study was to determine progression rates of patients with traumatic intracranial hemorrhage on factor Xa inhibitors prior to hospitalization who were managed without the use of andexanet alfa. METHODS: A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. RESULTS: We identified 25 patients meeting the inclusion criteria. Two patients were excluded because of a lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 were (48%) on rivaroxaban. On admission CT scan, 14 patients had subdural hematoma, 6 had traumatic intraparenchymal hemorrhage, and 3 had subarachnoid hemorrhage. Anticoagulation reversal was attempted in 17 patients (74%), primarily using 4-factor prothrombin complex concentrate. Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. CONCLUSIONS: Our results indicate that patients on factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after andexanet alfa administration.

Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking. METHODS: This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes. RESULTS: A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. CONCLUSIONS: The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.

Early computed tomography for acute post-traumatic diffuse axonal injury: a systematic review.

PURPOSE: Diffuse axonal injury (DAI) is the rupture of multiple axons due to acceleration and deceleration forces during a closed head injury. Most traumatic brain injuries (TBI) have some degree of DAI, especially severe TBI. Computed tomography (CT) remains the first imaging test performed in the acute phase of TBI, but has low sensitivity for detecting DAI, since DAI is a cellular lesion. The aim of this study is to search in the literature for CT signs, in the first 24 h after TBI, that may help to differentiate patients in groups with a better versus worst prognosis. METHODS: We searched for primary scientific articles in the PubMed database, in English, indexed since January 1st, 2000. RESULTS: Five articles were selected for review. In the DAI group, traffic accidents accounted 70% of the cases, 79% were male, and the mean age was 41 years. There was an association between DAI and intraventricular hemorrhage (IVH) and traumatic subarachnoid hemorrhage (tSAH); an association between the IVH grade and number of corpus callosum lesions; and an association between blood in the interpeduncular cisterns (IPC) and brainstem lesions. CONCLUSION: In closed TBI with no tSAH, severe DAI is unlikely. Similarly, in the absence of IVH, any DAI is unlikely. If there is IVH, patients generally are clinically worse; and the more ventricles affected, the worse the prognosis.

Acute post-traumatic hydrocephalus in children due to aqueductal obstruction by blood clot: a series of 6 patients.

INTRODUCTION: Post-traumatic hydrocephalus following head injury is a well-known entity. Most cases occur in patients with severe head injuries, often following decompressive craniectomy. On the contrary, acute post-traumatic hydrocephalus, caused by aqueductal obstruction by a blood clot, following mild head injury is uncommon. CLINICAL MATERIAL: Six patients aged between 6 and 15 months presented hydrocephalus secondary to a blood clot in the aqueduct. Because of intracranial hypertension at presentation, 4 patients were urgently treated with external ventricular drains (EVDs). Post-operative course was uneventful. In 2 cases, EVDs were removed without further treatments. In 2 cases, hydrocephalus recurred. These patients were successfully treated with endoscopic third ventriculostomy. The remaining two patients developed symptoms a few days after the trauma. One, that presented hydrocephalus at imaging, was managed with a ventriculo-peritoneal shunt; the other, that presented subdural hygroma, was managed with subduro-peritoneal shunt that was removed later. All patients had complete recovery. DISCUSSION AND CONCLUSION: Hydrocephalus secondary to clot in the aqueduct may rarely be the result of mild head injury in young children. Usually, prompt surgical management warrants a very good outcome. Most children may be treated without a permanent shunt, by using external drains and endoscopic third ventriculostomy.

Vessel Wall Magnetic Resonance Imaging in a Case of Post-traumatic Multifocal Striatocapsular Hemorrhagic Infarction.

Post-traumatic striatocapsular infarction is extremely rare and has been described only within the vascular territory of the perforating arteries originating from the middle cerebral artery (MCA). We recently encountered a patient presenting with unilateral multifocal striatocapsular hemorrhagic infarctions following mild head injury. This 25-year-old female was admitted to our trauma center after a motorcycle accident. Initial brain computed tomography and magnetic resonance (MR) imaging showed multifocal acute hemorrhagic infarctions with a clustering in the right caudate head, anterior limb of internal capsule, and globus pallidus. MR angiography and digital subtraction angiography showed suspicious luminal irregularities of the lenticulostriate arteries of the right MCA. Vessel wall MR images (VWI) did neither indicate intramural hematoma nor wall enhancement in the right MCA, suggesting dissection. However, VWI showed the passages of each lenticulostriate artery supplying each infarction site. Therefore, based on both conventional images and VWI, we postulate that this patient's post-traumatic multifocal striatocapsular hemorrhagic infarctions were caused by damage to multiple lenticulostriate arteries.

Traumatic Minor Intracranial Hemorrhage: Management by Non-neurosurgeon Consultants in a Regional Trauma Center is Safe and Effective.

BACKGROUND: There is debate concerning the need for specialist neurosurgical transfer of patients presenting to Level II trauma centers with a minimal head injury (Glasgow Coma Scale ≥13) and a small non-progressive intracranial bleeding (ICB). METHODS: A retrospective chart analysis was performed assessing the outcomes of adult patients presenting with a minor traumatic ICB on initial CT scan (minimal subarachnoid hemorrhage; small-width subdural hematoma without shift; punctate cerebral contusion). Patients with extradural hematomas and those patients on antiplatelet or anticoagulant therapy were excluded from the protocol. RESULTS: Overall 291 cases were assessed (mean age 69.9 years) with 75% of cases presenting after a fall. There was deterioration of neurological status in 11 patients (3.8%) with 8 hospital transfers and 5 with an abnormal neurological examination (NE). Two patients with an abnormal INR and a worsening head CT were transferred without neurosurgical intervention. Of the 8 transferred cases there were 2 deaths (both >90 years of age with multiple comorbidities) with one craniotomy performed for a subdural hematoma (with full recovery). Three patients meeting transfer criteria were not transferred with one death (patient >90 years of age with severe dementia). The remaining 2 patients were discharged with normal neurological outcomes. CONCLUSIONS: Patients with a minimal traumatic brain injury and a non-progressive minor ICB may be safely managed in a Level II trauma center by an acute care consultant with neurosurgical consultation but without the need for neurosurgical transfer. LEVEL OF EVIDENCE: Retrospective analysis: Level IV.

Evacuación de hematoma subdural crónico: hemorragia de Duret postoperatoria y restitución ad-integrum. A propósito de un caso / Evacuation of chronic subdural hematoma: postoperative Duret hemorrhage and ad-integrum replacement. About a case

El tratamiento de elección para la evacuación de hematoma subdural crónico es la evacuación mediante orificio de trépano. Las complicaciones más frecuentes son recurrencia, neumoencefalo, convulsiones, hemorragia intracraneal y en otros sitios. La hemorragia del tronco cerebral secundaria a la cirugía es extremadamente rara. Aquí presentamos un paciente masculino de 72 años, que ingresa con GSC 9/15, hemiparesia izquierda 2/5. Con HSD crónico bilateral con desplazamiento de línea media de 1.5 cm. hacia izq. Al cual se realiza evacuación de HSD derecho. Y en el POP se detecta GSC 12/15, lado izquierdo fuerza 5/5, con hemiparesia derecha a predominio braquial. TC control POP: adecuada evacuación de HSD y lesión hiperdensa protuberancial. Es externado al 6to día POP con GSC 14/15 sin déficit motor. Este reporte, además de abordar la bibliografía actual y fisiopatología; agrega otro caso para reafirmar la posibilidad de pronóstico favorable en ésta patología

ABSTRACT The treatment of choice for the evacuation of chronic subdural hematoma is evacuation through a trepan orifice. The most frequent complications are recurrence, re-accumulation of the hematoma, pneumoencephalus, seizures, intracranial hemorrhage and elsewhere. Brainstem hemorrhage secondary to surgery is extremely rare. Here we present a 72-year-old male patient, admitted with GSC 9/15, left hemiparesis 2/5. Without obeying orders. With bilateral chronic HSD with midline displacement of 1.5 cm. to left; to which evacuation of right HSD is performed. And in the POP GSC 12/15 is detected, left side force 5/5, with right hemiparesis to brachial predominance. POP control CT: adequate evacuation of HSD and hyperdense pontine lesion. It is extership to the 6th day POP with GSC 14/15 without motor deficit. This report, besides addressing the current bibliography and physiopathology; adds another case to reaffirm the possibility of favorable prognosis in this pathology

Low Glasgow Coma Score in Traumatic Intracranial Hemorrhage Predicts Development of Cerebral Vasospasm.

BACKGROUND: The exact mechanism, incidence, and risk factors for cerebral vasospasm after traumatic intracranial hemorrhage (ICH) continue to be poorly characterized. The incidence of post-traumatic vasospasm (PTV) varies depending on the detection modality. OBJECTIVE: We aimed to shed light on the predictors, associations, and true incidence of cerebral vasospasm after traumatic ICH using digital subtraction angiography (DSA) as the gold standard. METHODS: We examined a prospectively maintained database of traumatic brain injury (TBI) patients to identify patients with ICH secondary to TBI enrolled between 2002 and 2015 at our trauma center. Patients with TBI-associated ICH and evidence of elevated velocities on transcranial Doppler and computed tomography angiograms, confirmed with DSA were included. The diagnostic cerebral angiograms were evaluated by 2 blinded neurointerventionalists for cerebral vasospasm. Statistical analyses were conducted to determine predictors of PTV. RESULTS: Twenty patients with ICH secondary to TBI and evidence of vasospasm underwent DSAs. Seven patients (7/20; 35%) with traumatic ICH developed cerebral vasospasm and of those, 1 developed delayed cerebral ischemia (1/7; 14%). Of these 7 patients, 6 presented with subarachnoid hemorrhage (6/7; 85%). Vasospasm was substantially more common in patients with a Glasgow Coma Scale <9 (P = 0.017) than in all other groups. CONCLUSIONS: PTV as demonstrated by DCA may be more common than previously reported. Patients who exhibit PTV were more likely to have a Glasgow Coma Scale <9. This subgroup of patients may benefit from more systematic screening for the development of PTV, and earlier monitoring for signs of delayed cerebral ischemia.

Investigating the Relationship between Cerebrospinal Fluid and Magnetic Induction Phase Shift in Rabbit Intracerebral hematoma expansion Monitoring by MRI.

In a prior study of intracerebral hemorrhage monitoring using magnetic induction phase shift (MIPS), we found that MIPS signal changes occurred prior to those seen with intracranial pressure. However, the characteristic MIPS alert is not yet fully explained. Combining the brain physiology and MIPS theory, we propose that cerebrospinal fluid (CSF) may be the primary factor that leads to hematoma expansion being alerted by MIPS earlier than with intracranial pressure monitoring. This paper investigates the relationship between CSF and MIPS in monitoring of rabbit intracerebral hemorrhage models, which is based on the MIPS measurements data, the quantified data on CSF from medical images and the amount of injected blood in the rabbit intracerebral hemorrhage model. In the investigated results, a R value of 0.792 with a significance of 0.019 is observed between the MIPS and CSF, which is closer than MIPS and injected blood. Before the reversal point of MIPS, CSF is the leading factor in MIPS signal changing in an early hematoma expansion stage. Under CSF compensation, CSF reduction compensates for hematoma expansion in the brain to keep intracranial pressure stable. MIPS decrease results from the reducing CSF volume. This enables MIPS to detect hematoma expansion earlier than intracranial pressure.

Missing the point: self-inflicted traumatic brain injury in psychosis.

A 36-year-old man was brought to the emergency department by emergency medical services after being found acting unusually at a gas station with blood on his head and clothing. He presented acutely psychotic and reported that he had a pen in his head. Medical evaluation was notable for a superficial puncture wound to the right temple, and he was medically cleared for psychiatric evaluation. After he developed nausea and headache later that evening, the CT scan revealed a temporal bone fracture, pneumocephalus, intraparenchymal haemorrhage and the presence of a metal pen tip lodged in the brain parenchyma. The full nature of the injury went undiscovered in the emergency department for 16 hours due to the superficial appearance of the injury and his acute psychosis with prominent delusional thought content and disorganisation. He underwent craniotomy with removal of the pen and subsequent hospitalisation for intravenous antibiotics, followed by a prolonged psychiatric hospitalisation for psychosis.

Developing, Implementing, and Evaluating a Nurse-Driven Rapid Reversal Protocol for Patients With Traumatic Intracerebral Hemorrhage in the Presence of Preinjury Warfarin.

Warfarin-related traumatic intracerebral hemorrhage (ICH) is often fatal, yet timely evaluation and treatment can improve outcomes. Our study describes the process of developing and implementing a protocol to guide the care of patients with traumatic brain injury (TBI) on preinjury warfarin developed by nurses across several service lines at our Level I trauma center over a 6-month period. Further, we evaluated its efficacy by examining records of adult patients with TBI on preinjury warfarin admitted 1 year before and after protocol implementation. Efficacy was defined as activation rates, receipt and time to head computed tomography (CT) scan and international normalization ratio (INR), and receipt and time to fresh frozen plasma (FFP) administration in patients with ICH with an INR more than 1.5, as per protocol. A subset analysis examined patients with and without an ICH. Outcomes were compared using univariate analyses. One hundred seventy-eight patients were included in the study; 90 (50.6%) were admitted before and 88 (49.4%) after implementation. After implementation, there were improvements in activation rates (34.4% vs. 65.9%; p < .001), the frequency of head CT scans (55.6% vs. 83.0%; p < .001), time to INR (24.0 min vs. 15.0 min; p < .05), and, for patients with ICH with an INR 1.5 or more, decreased time to FFP (157.0 vs. 90.5; p < .05). In conclusion, our protocol led to a more efficient process of care for patients with TBI on warfarin. We believe the implementation process, managed by a dedicated group of nurses across several service lines, substantially contributed to the success of the protocol.