The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis.

OBJECTIVE: Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits. METHODS: A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs). RESULTS: Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality. CONCLUSION: With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.

Traumatic epidural hematomas in the pediatric population: clinical characteristics and diagnostic pitfalls.

BACKGROUND/PURPOSE: The purpose of this study was to review the initial clinical presentation of EDH, identify potential clinical markers and highlight diagnostic pitfalls. METHODS: Retrospective review of all pediatric patients admitted to a Level I Trauma Center diagnosed with blunt traumatic EDH from 2008 to 2018. RESULTS: A total of 699 pediatric patients were identified with blunt traumatic brain injury (TBI); 106 with EDH made up the study population. A skull fracture was present in 84%. Overall, the most common clinical finding was a scalp hematoma (86%), followed by loss of consciousness (66%), emesis (34%), headache (27%), amnesia (18%), and seizures (12%). Importantly, 40% of patients with EDH presented with GCS 15. Four children (4%) had GCS 15 and were completely asymptomatic on admission. In three children (3%) the only symptom was a scalp hematoma. 50% of all EDH required craniotomy, and this was not significantly different if GCS was 15 on presentation (45%, p = 0.192). Mortality was 2%. Fourteen patients (13%) were discharged with cognitive/motor deficits. CONCLUSIONS: Pediatric EDH frequently present with subtle clinical signs, including a normal GCS half the time. Irrespective of asymptomatic presentation, threshold for CT scan or an observation period should be low after head injuries in children. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II/III.

Clinical Outcome of Epidural Hematoma Treated Surgically in the Era of Modern Resuscitation and Trauma Care.

OBJECTIVE: Patients from contemporary populations with traumatic brain injury (TBI) resulting from epidural hematoma (EDH) may differ regarding age, comorbidities, and coagulation status. We therefore analyzed predictors for the clinical outcome of patients with EDH treated surgically regarding modern approaches to resuscitation and trauma care. METHODS: A retrospective observational analysis was carried out. All patients included underwent surgery. The indication for surgery followed international guidelines. Retrospective data evaluation considered data reflecting the effectiveness of trauma care, baseline characteristics, and radiologic findings. In this analysis, we divided patients into 2 groups (isolated EDH vs. EDH plus other intracranial traumatic injuries). The neurologic outcome was assessed at discharge using the Glasgow Outcome Scale. RESULTS: Two hundred and sixty-eight patients with epidural hematoma, of whom 131 underwent surgery, were treated between January 1997 and December 2012 in our level-1 trauma center. The overall mortality was 6.8% (mortality for patients with Glasgow Outcome Scale score <9, 15%). As expected, factors with a highly significant (P < 0.01) impact on outcome were concomitant with other intracranial injuries, brain midline shift, and higher Injury Severity Score. Alcohol intoxication was a significant (P < 0.05) predictor of an unfavorable outcome. Anticoagulants and Glasgow Coma Scale score at admission had no significant impact on the outcome. CONCLUSIONS: The outcome for EDH is more favorable than decades ago, most probably reflecting a well-established chain of trauma care. Therefore, EDH is a treatable disease with a high probability of a favorable outcome.

The pathogenesis of delayed epidural hematoma after posterior fossa surgery.

The purpose of this study was to analyze the pathogenesis of delayed epidural hematoma (EDH) after posterior fossa surgery. Non-traumatic, non-arterial origin delayed EDH after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure. Between April 1997 and June 2016, over 3300 patients underwent microvascular decompression (MVD) for neurovascular compression syndrome. The medical chart of four patients with delayed EDH were retrospectively reviewed. The median time from MVD to re-CT scan was 58 h (range, 33-100). All patients underwent hematoma evacuations. Intraoperative findings during hematoma evacuation revealed only an oozing hemorrhage from the transverse sinus with no definitive bleeding focus. The patients spent a median of 21.5 days (range, 11-39) at the hospital. At the last follow-up, all patients had fully recovered without significant neurological deficits and exhibited complete relief or minimal symptoms from hemifacial spasm (HFS). Postoperative uncontrolled bleeding from the dural venous sinus can sometimes cause an insidious-onset or delayed posterior fossa EDH.

Complications of Head Immobilization Devices in Children: Contact Mechanics, and Analysis of a Single Institutional Experience.

BACKGROUND: Head immobilization devices (HIDs) are a staple of neurosurgical procedures, including in the intraoperative magnetic resonance imaging (iMRI) operating rooms (ORs) where material modifications were necessary for compatibility with the magnets utilized. OBJECTIVE: To present the experience in this OR environment and discuss the multifactorial nature of the observed adverse events. METHODS: A retrospective chart review was performed, utilizing the Department of Neurosurgery and iMRI OR databases to identify patients who suffered complications related to HIDs between November 2007 and March 2016. A literature review was also done to identify the magnitude of the problem and the availability of safety guidelines. RESULTS: Nine hundred and forty patients underwent surgery in the iMRI OR requiring head immobilization. Seven (0.7%) suffered complications related to the HID-depressed skull fractures (n = 7) and epidural hematomas (n = 6). Age at surgery ranged from 1.6 to 10.3 yr. All patients had posterior fossa neoplasms and associated obstructive hydrocephalus. Four patients (57%) suffered permanent neurological deficits. Six patients (86%) underwent a surgical procedure to evacuate the epidural hematomas and repair the depressed skull fracture. In contrast, 1 out of 445 patient (0.2%) suffered HID-related adverse events in the conventional ORs, aged 10.2 yr. CONCLUSION: HIDs are important to provide stability and support during neurosurgical procedures. Modifications in the material or the shape of the pins can significantly change the pressure exerted. Most of these complications are preventable if certain precautionary measures are taken especially in certain high-risk patients, and the overall benefits of HIDs continue to outweigh the risks. There is a need for consensus on guidelines for the safe use of these devices.

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.

Intrasylvian/Intracerebral Hematomas Associated with Ruptured Middle Cerebral Artery Aneurysms: A Single-Center Series and Literature Review.

OBJECTIVE: Ruptured middle cerebral artery (MCA) aneurysms usually lead to subarachnoid hemorrhage (SAH), and several cases have shown concomitant intrasylvian or intracerebral hematomas. The objective of this study was to compare the clinical and radiographic characteristics with their different outcomes. METHODS: The charts of 30 consecutive patients with ruptured MCA aneurysm-related intracranial hematoma were retrospectively reviewed. These patients were dichotomized into an intrasylvian hematoma (ISH) group and an intracerebral hematoma (ICH) group by the presence of intrahematomal contrast-enhancing vessel; for patients under open surgery, hematoma type was further confirmed by intraoperative observation. The characteristics were compared between these 2 groups (ie, age, gender, history of hypertension, history of smoking, systolic pressure at admission, hematoma volume, size and side of aneurysms, the angle between the pointing direction of the aneurysm and the MCA trunk [denoted as α], middle line shifting, treatment modality, and outcome). All the angles are measured in the anterior-posterior projection. RESULTS: In our series, only hematoma volume, the angle α, and the middle line shift showed statistical significance regarding prognosis between 2 hematoma groups. An angle α between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range indicates ICH. In our series, patients in the ICH group had a larger hematoma volume compared with the ISH patients (33.3 ± 17.6 vs. 11.5 ± 10.5; P = 0.002). There exists no statistical difference regarding prognosis between these 2 groups, even although there is a trend toward worse recovery for patients in the ISH group (Glasgow Outcome Scale score, 3.0 ± 1.3 vs. 3.8 ± 1.9; P = 0.07). CONCLUSIONS: In our series, the prognosis of patients with ICH was worse than that of patients with ISH. Early discrimination of these 2 types of hematoma helps to predict future outcome; an angle (between the pointing direction of aneurysm and the MCA trunk) between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range suggests ICH.

Stereotactic Electroencephalography Is a Safe Procedure, Including for Insular Implantations.

BACKGROUND: In some cases of drug-resistant focal epilepsy, noninvasive presurgical investigation may be insufficient to identify the ictal onset zone and the eloquent cortical areas. In such situations, invasive investigations are proposed using either stereotactic electroencephalography (SEEG) or subdural grid electrodes. Meta-analysis suggests that SEEG is safer than subdural grid electrodes, but insular implantation of SEEG electrodes has been thought to carry an additional risk of intraparenchymal hemorrhagic complications. Our objectives were to determine whether an insular SEEG trajectory is a risk factor for intracranial hematoma and to report the global safety of the procedure and provide some guidelines to prevent and detect complications. METHODS: In a retrospective analysis of a surgical series of 525 consecutive procedures between 1995 and 2015, all electrodes were classified according to their insular or extrainsular trajectory. All complications were classified as major or minor according to their potential consequences regarding patient neurologic status. RESULTS: Four intraparenchymal hematomas, all related to extrainsular electrodes (4/4974; 0.08%) were reported; no hematoma was found along insular electrodes (0/1042; 0%). There were 8 major complications (1.52%): 7 intracranial hematomas (1.33%) and 1 case of meningitis. Two patients had long-term neurologic impairment (0.38%), and 1 death (not directly related to the procedure) occurred (0.19%). Eleven minor complications (2.09%) were encountered, including broken electrode (1.52%), acute pneumocephalus (0.38%), and local cutaneous infection (0.19%). CONCLUSIONS: SEEG is a safe procedure. Insular trajectories cannot be considered an additional risk of intracranial bleeding.

Postoperative Epidural Hematomas in the Lumbar Spine.

Postoperative epidural hematomas are rare complications following lumbar spine surgery, but if they are not quickly identified and treated they can lead to permanent neurological deficits. Epidural hematomas occur in approximately 0.10%-0.24% of all spine surgeries, and despite the fact that multiple large studies have been performed attempting to identify risk factors for this complication, there is still significant debate about the effect of subfascial drains, postoperative anticoagulation, and antiplatelet medication on the incidence of postoperative hematoma. The purpose of this manuscript is to review the epidemiology, etiology, diagnosis, and treatment of patients who develop a postoperative lumbar epidural hematoma.

Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery.

OBJECTIVE: Post-operative extradural hematoma (EDH) is a relatively common complication in patients undergoing intracranial operations. The risk factors associated with the occurrence of EDH are not well described in the literature. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy or the craniectomy site. METHOD: This was a retrospective study of 24 (2.6% of total) patients who underwent extradural hematoma evacuation after primary intracranial supratentorial surgery between January 2005 and December 2011. During this period, 941 intracranial operations were performed. The control group (72 patients) was selected on the basis of having undergone the same pre-operative diagnosis and treatment within 2 months of the operations for the 24 hematoma patients. The Glasgow Coma Scale score and operation character (emergency or elective) of the hematoma and control group were individually matched to minimize pre-operative conditional bias. The ages of both groups were individually matched with similar ages within 10 years of each other to minimize age bias. RESULT: Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were an intra-operative blood loss of greater than 800 mL (p=0.007), maximal craniotomy length of greater than or equal to 100 mm (p=0.001), and craniotomy area of greater than or equal to 71.53 cm2 (p=0.018). In multivariate analysis, intra-operative blood loss exceeding 800 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH. CONCLUSION: The data did not examine established risk factors for post-operative hematoma, such as thrombocytopenia, anti-coagulant and anti-platelet therapy, and a history of heavy alcohol consumption and/or tobacco intake. Recognizing the limitations of the study, large intra-operative blood loss and wide craniotomy area are implicated with an increased risk of post-operative EDH after intracranial surgery.

Epidural Hematoma: A Prospective Analysis of Morbidity and Mortality in 173 Patients / Hematoma epidural: Uma análise prospectiva de morbidade e mortalidade em 173 pacientes

Objectives A few recent studies have focused on epidural hematomas (EDHs) that are routine in emergency rooms. The study was to evaluate the latest situation of affected patients by encephalic trauma associated with EDH in our service. Methods Prospective study between September 1, 2003 and May 30, 2009. Data were computed regarding age, sex, trauma mechanism, qualification by Glasgow coma scale admission, presence of anisocoria, and evaluation by the recovery of Glasgow scale high, with all patients by computed tomography (CT) scan. Results Among the 173 analyzed patients, mortality reached 20 patients (11.5%). Mortality was higher in the subgroup of 76 patients (44%) admitted with Glasgow coma scale (GCS ≤ 8) with 17 deceased, corresponding to 85% of total deaths. Prevalence of male subjects (140 cases, 81%) with bruises located in the temporal, frontal and parietal regions; 147 (85%) patients underwent neurosurgical treatment by craniotomy. The worst prognosis was in patients with hematomas of higher-volume (50 mL), midline structures deviations greater than 1.5 mm and basal cisterns CSF closed. Conclusion The authors emphasize the correct indication of neurosurgery and the postoperative intensive care unit (ICU) as key factors for success in the treatment of patients with EDHs.

Objetivos Poucos estudos atuais tem focado os hematomas epidurais que são rotina nos serviços de emergência. O estudo teve por objetivo avaliar a situação mais recente dos doentes acometidos por traumatismo crânio ancefálico associado a hematoma epidural no nosso serviço. Métodos Estudo prospectivo entre 1 de setembro de 2003 a 30 de maio de 2009. Foram computados dados referentes a idade, sexo, mecanismo do traumatismo, qualificação pela escala de coma de Glasgow` a admissão, presença de anisocoria e avaliação pela escala de recuperação de Glasgow na alta, tendo todos os pacientes realizado tomografia de crânio. Resultados Dentre os 173 pacientes analisados encontramos mortalidade de 20 pacientes (11,5%). No subgrupo de 76 pacientes (44%) admitidos em escala de coma de Glasgow (ECGLa) ≤ 8 pontos, a mortalidade foi superior com 17 óbitos, correspondendo a 85% do total de óbitos. Prevaleceram indivíduos do sexo masculinos (140 casos, 81%) com hematomas localizados na região temporal, seguido pelas regiões frontal e parietal; 147 (85%) foram submetidos a tratamento neurocirúrgico por craniotomia. O prognóstico foi pior nos pacientes com hematomas de volume superior a 50 mL, desvios de estruturas de linha mediana maiores que 1,5 mm e cisternas liquóricas basais fechadas. Conclusões Os autores enfatizam a correta indicação da neurocirurgia e o pósoperatório na unidade de terapia intensiva como fatores chave para o bom resultado no tratamento dos doentes com hematomas epidurais.

The challenges of managing acute extradural hematoma in a Nigerian neurosurgical center--still a long way to go.

BACKGROUND: Acute extradural hematoma (EDH) is the collection of blood in the potential space between the dura mater and endocranium within 3 days of an incident. It is usually, but not always, a neurosurgical emergency, and early treatment reduces morbidity and mortality, although the outcome is still affected by some other determinants. In Nigeria, the National Health Insurance Scheme does not cover neurosurgical cases, and patients have to pay for all of their treatment regardless of the emergency status. We evaluate epidemiologic patterns, management protocols, and outcome, especially in relation to timely operative intervention, in patients with acute extradural hematoma who presented to our recently established neurosurgical service. METHODS: This prospective study comprised cases managed in our center from May 2006 to July 2013. Data of all patients with acute EDH were collected on Microsoft Excel software and complemented with hospital charts and operative records. Demographic data, etiologic factors, time interval from injury to presentation in our service, time interval from presentation to definitive treatment, and outcome were collected and analyzed. RESULTS: Within the 86-month study period, 1648 patients presented to our service with head injuries. Acute EDH constituted 3.03%, with a mean of 7.14 cases per year. Among the cases of acute EDH, 92% involved male patients (male-to-female ratio, 11.5:1). Peak age incidence (42%) was 21-30 years (mean, 23 years), and motorcycle road traffic accident was the most common etiologic factor (72%). Operative treatment was performed in 84% of the cases (in 57.1%, operative treatment occurred within 1 week of presentation). Conservative management was employed in 10% of cases. Mortality was 14.9%; most (10%) had severe head injury, although 2.1% had mild injury known to be associated with 0% mortality. CONCLUSIONS: Acute EDH is a potentially fatal condition that is easily treatable if presentation, diagnosis, and treatment occur promptly. Our outcomes could be improved if the present logistics associated with the cash-and-carry health care delivery system in Nigeria could be reduced or obviated.

Postoperative epidural hematoma covering the galeal flap in pediatric patients with moyamoya disease: clinical manifestation, risk factors, and outcomes.

OBJECT: Postoperative epidural hematoma (EDH), a blood collection between the inserted galeal flap and the overlying skull flap (epigaleal flap hematoma), is a frustrating complication of the surgical treatment of moyamoya disease (MMD) in pediatric patients. The symptoms of postoperative EDH are often similar to those of postoperative cerebral ischemia, and may cause confusion during clinical decision making. The authors designed this study to evaluate the incidence, clinical presentation, risk factors, and treatment outcomes of postoperative EDH in pediatric patients with MMD. METHODS: A retrospective review of 148 pediatric patients with 250 craniotomies who underwent indirect bypass revascularization surgery between January 2002 and December 2006 was performed. This group consisted of 60 male and 88 female patients, and the mean age at surgery was 7.5 years (range 1-18 years). RESULTS: Of the 250 craniotomies, postoperative EDH was detected in 32 cases. In 12 cases of EDH, surgical treatment was necessary (4.8% of 250 craniotomies). During the same period, 743 non-MMD craniotomy operations were performed. In 6 of these 743 operations, patients developed postoperative EDH that required surgical treatment, significantly less than the percentage of EDH requiring postoperative treatment in patients with MMD (0.8%, p < 0.001). The average interval between craniotomy surgery and the detection of EDH was 1.8 days (range 0-5 days) in patients with MMD and 0.5 days (range 0-2 days; p = 0.018) in the non-MMD craniotomy group. Postoperative EDH was observed in significantly fewer cases (17 of 191) when a subcutaneous drain (SCD) was inserted over the bone flap than in cases in which an SCD was not inserted (14 of 55; p = 0.001). The mean international normalized ratio of prothrombin time in the immediate postoperative blood test was 1.27 ± 0.17 in the EDH group and 1.20 ± 0.11 in the non-EDH group (values are expressed as the mean ± SD; p = 0.008). Central galeal flap tenting suture and immediate postoperative platelet count were not related to the incidence of postoperative EDH following pediatric MMD surgery. CONCLUSIONS: Postoperative EDH is more likely to be found following craniotomy in patients with MMD than in those without MMD, and may occur in a delayed fashion. Insertion of an SCD and immediate correction of an abnormal value for international normalized ratio of prothrombin time can decrease the incidence of postoperative EDH following surgery for pediatric MMD.

Análise epidemiológica de 210 casos de hematoma extradural traumático tratados cirurgicamente / Epidemiological analysis of 210 cases of surgically treated traumatic extradural hematoma

OBJETIVO: Analisar aspectos da epidemiologia, apresentação clínica e radiológica de pacientes com hematoma extradural traumático (HED) submetidos a procedimento neurocirúrgico. MÉTODOS: Foi realizada a revisão de prontuários de 210 pacientes admitidos no Serviço de Emergência com HED diagnosticados através de tomografia computadorizada, tratados cirurgicamente no período de agosto de 1998 a janeiro de 2008. Foram analisados: idade, sexo, apresentação clínica e radiológica, mecanismo de trauma e status neurológico no momento da alta hospitalar. RESULTADOS: Em 49,2% o mecanismo de trauma foi queda; 89,2% dos pacientes eram do gênero masculino; 49,7% dos casos tinham Escala de Coma de Glasgow (ECG) entre 13-15; 61% dos pacientes tinham idade entre 20-49 anos; A localização do HED em 26,5% e 19,6% dos casos foi têmporo-parietal e temporal, respectivamente; 32,8% tinham lesões intracranianas associadas, sendo a fratura craniana evidenciada em cerca de 45% dos casos; 76,2% dos pacientes tratados cirurgicamente tiveram alta com déficit mínimo ou ausência de déficit neurológico. CONCLUSÃO: Observamos que o HED, na população de estudo, apresenta-se mais frequentemente no gênero masculino, na quarta década de vida, mais relacionado às quedas. Na admissão, observamos uma ECG entre 13 e 15, sendo pertinente mencionar o envolvimento da região têmporo-parietal na maioria dos casos. Acreditamos que o conhecimento da epidemiologia do hematoma extradural traumático pode auxiliar na elaboração de medidas de saúde pública, visando à prevenção e identificação precoce desta doença em determinada população.

OBJECTIVE: To assess the epidemiology, clinical and radiological presentation of patients with traumatic extradural hematoma (EDH) undergoing neurosurgical procedures. METHODS: We performed a chart review of 210 patients admitted to the emergency department with EDH diagnosed by CT scan and surgically treated between August 1998 and January 2008. Variables analyzed were: age, gender, clinical and radiological presentation, mechanism of injury and neurological status at discharge from hospital. RESULTS: In 49.2% trauma mechanism was fall; 89.2% of patients were male, 49.7% of cases had a Glasgow Coma Scale (GCS) between 13 and 15; 61% of patients had age between 20 and 49 years; the location of EDH was the temporo-parietal and temporal in 26.5% and 19.6% of the cases, respectively; 32.8% had associated intracranial lesions, with skull fractures seen in around 45% of cases; 76.2% of surgically treated patients were discharged with minimal or no neurologic deficit. CONCLUSION: We observed that, in the study population, EDH appears more often in males, in the fourth decade of life, and is more related to falls. On admission, GCS was observed between 13 and 15 and it is appropriate to mention the involvement of the temporo-parietal region in most cases. We believe that knowledge of the epidemiology of traumatic epidural hematoma can assist in developing public health measures aimed at prevention and early identification of this disease in the population.

Epidemiological analysis of 189 cases of traumatic intracranial extradural hematoma treated by surgery / Análisis epidemiológico de 189 casos de hematoma epidural tratados quirúrgicamente

Objective: To analyze the epidemiology, clinical and radiological presentation of patients with extradural hematoma (EDH) who underwent surgery in our service and their neurological status at the time of discharge. Method: We reviewed the charts of 189 patients who were admitted to our service with EDH and were treated surgically, during the period of August 1998 to January 2007. Results: In 49.2 percent the mechanism of trauma was falling; 49.7 percent of the cases had GCS between 13-15; 45.0 percent had skull fractures; 32.8 percent had associated intracranial injuries. Conclusion: We observed that 76.2 percent of surgically treated patients were discharged with minimum or no neurological deficits.

Extradural hematoma in children: case series of 33 patients.

BACKGROUND: Conservative management of extradural hematomas (EDH) is relatively recent in the literature and there are few papers reporting on the pediatric population. OBJECTIVE: We conduct a 20-month assessment of the treatment administered for EDH at a pediatric intensive care unit (PICU). METHODS: A retrospective case series in the period described above. The main variables studied were the weight and age of the patients, the Pediatric Trauma Score, the mechanism of injury, clinical features, CT findings and the Glasgow Coma Scale score on arrival, and after 12 and 24 h. Also analyzed was whether during primary care either surgical intervention or initial conservative management was recommended. RESULTS: In the 20 months analyzed, 33 EDH patients were admitted to the PICU. Patients had a mean age of 7.42 ± 4.66 years, mean weight of 31.16 ± 16.16 kg and mean Pediatric Trauma Scores of 7.03 ± 3.71. Out of the total sample, surgery was indicated in 12 patients (36.4%) in primary care and 21 patients (63.6%) were treated with initial conservative management. Most of the patients who were given conservative treatment had a Glasgow Coma Scale score of 15 on arrival and maintained this level throughout the hospital stay. The most prevalent sites of the hematomas were the temporal and parietal regions and the most common associated injury was skull fracture. CONCLUSION: In this case series, conservative treatment of EDH was most frequent; however, which factors are involved in this decision has to be better studied.

[Pediatric head injuries, retrospective analysis of 851 patients: an epidemiological study]. / Çocukluk çagi kafa travmalari, 851 olgunun retrospektif degerlendirilmesi: Epidemiyolojik bir çalisma.

BACKGROUND: The aim of this study was to contribute to the epidemiological database of our country about pediatric head injuries. METHODS: We retrospectively analyzed 851 patients younger than 14 years old with head injury, treated in the Neurosurgery Department of Samsun Mehmet Aydin Education and Research Hospital between January 2003 and June 2008. RESULTS: Five hundred and fifty (65%) patients were male and 301 (35%) were female. Falls (70%) were the most common cause of head injury. According to Glasgow Coma Score (GCS), 74% of patients had mild (13-15), 22% moderate (9-12) and 4% severe (3-8) head injury. Eighty-seven (10.5%) patients were operated. The commonest operations were performed for depressed fractures and epidural hematomas. The mortality rate was 3.8% (33). Common causes of mortality were traffic accidents and falls from heights. CONCLUSION: Other reported studies and this study show that the majority of pediatric head injuries occur as a result of preventable causes. It is important to have local epidemiological studies and data about head injuries in order to prevent these traumas before their occurrence.

Predictors of functional recovery in African patients with traumatic intracranial hematomas.

BACKGROUND: Head injury is a critical public health problem responsible for up to 50% of fatalities among trauma patients and for a large component of continuing care among survivors. Intracranial hematomas are among the most common clinical entities encountered by any neurosurgical service and have a very high mortality rate and extremely poor prognosis among traumatic brain injuries. OBJECTIVE: The purpose of this study was to investigate reliable factors influencing the functional outcome of the patients with traumatic intracranial hematomas (ICHs). METHODS: A retrospective analysis was conducted of consecutive patients presenting at the Kenyatta National Hospital between January 2000 and December 2009. Following ethical approval, the records of patients admitted to the neurosurgical unit and diagnosed with traumatic ICH were retrieved and reviewed. The outcome measure was the Glasgow Outcome Scale (GOS) score at discharge. Data were collected in preformed questionnaires, and the coding and analysis were carried out using SPSS, version 11.5. RESULTS: Of the 608 patients diagnosed with intracranial hematomas during the study period, there was a clear male predominance, with 89.3% male and 10.7% female patients. Majority of the patients (49%) were aged between 26 and 45 years, whereas 5.6% and 9.4% were younger than age 13 years and older than age 61 years, respectively. The most common cause of injury was assault (48%). Good functional recovery was achieved by 280 (46.1%) of the patients in our series, whereas moderate and severe disability accounted for 27% and 6.9%, respectively. Males were more likely to have functional recovery (46.4%) than were females (43.1%), though this finding was not statistically significant (P = 0.069). The proportion of patients who achieved functional recovery seemed to decrease with increasing age. Patients who were involved in motor vehicle accidents were less likely to have functional recovery (33.7%, P = 0.003) than those who fell (53.6%). There was a statistically significant difference in the proportion of patients who achieved functional recovery, with 65.2% of those who had mild head injury as compared to 46% and 15.1% (P ≤ 0.001) for those with moderate and severe head injury, respectively. Patients who had surgical intervention were more likely to achieve functional outcome (51.2%) as compared to 31.7% in those managed conservatively. Furthermore, the time elapsed from initial trauma to surgery significantly influenced outcome. The type of surgery done was not found to significantly influence patient outcome (P = 0.095). CONCLUSION: An increased risk of poor outcome occurs in patients who are older than age 61 years, have lower preoperative GCS scores, pupillary abnormalities, and a long interval between trauma and decompression. The findings would help clinicians determine management criteria and improve survival.

Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury.

AIM: Debate continues as to whether decompressive craniectomy (DC) is an effective treatment for severe traumatic brain injury (STBI). DC is mostly used as a second tier treatment option. The aim of this study was determined whether early bilateral DC is effective as a first tier treatment option in patients with STBI. MATERIAL AND METHODS: The study compared two groups. Group 1 comprised 36 STBI patients for whom control of intracranial pressure (ICP) was not achieved with conservative treatment methods according to radiological and neurological findings. These patients underwent bilateral or unilateral DC as a second tier treatment. Group 2 comprised 40 STBI patients who underwent early bilateral DC as a first tier treatment. RESULTS: Group 2 patients had a mean better outcome than Group 1 patients especially for patients with a GCS 6-8. Postoperative ICP was lower in Group 2 patients than Group 1 patients. CONCLUSION: This study indicates that early bilateral DC can be effective for controlling ICP in STBI patients. It is likely the favorable outcome results for Group 2 patients reflects the relatively short time between trauma and surgery. Therefore, these data indicate early bilateral DC can be considered as a first tier treatment in STBI patients.

The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study.

BACKGROUND: The purpose of this paper is to review the population-based epidemiology of surgically treated post-traumatic epidural hematomas (EDHs) and/or subdural hematomas (SDHs) among patients who presented to the single neurosurgical centre in Nova Scotia. METHODS: We included all patients aged 16 years or older who presented to the tertiary care hospital with acute post-traumatic EDHs and/or SDHs between May 23, 1996, and May 22, 2005, and who were surgically treated. We generated an initial cohort from the provincial trauma registry and reviewed a total of 152 charts for possible inclusion; 70 (46%) patients met the study criteria. We performed a blinded, explicit chart review using a standardized data collection form, and we generated descriptive statistics. RESULTS: Of the patients who had surgery, 34 (49%) presented with SDHs, 23 (33%) presented with EDHs and 13 (19%) presented with both conditions. The median age was 45 years, and 80% of the cohort was male. The major mechanisms of injury were falls (51%), motor vehicle collisions (30%) and assault (11%). More than half (61%) of patients were transferred from referring hospitals while the remainder (39%) arrived directly without an intermediate facility. There were 18 postoperative deaths (26%). Forty-four of 70 patients (63%) had associated good outcomes at 6 months (Glasgow Outcome Scale). CONCLUSION: Acute post-traumatic EDHs and/or SDHs are relatively rare (0.83/100,000 population per annum) and are generally associated with good outcomes. Death was more likely among older, more severely injured patients and among those who required surgery for SDH rather than EDH.