Intravenous Tranexamic Acid for Brain Contusion with Intraparenchymal Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial.

INTRODUCTION: Controlling of secondary traumatic brain injuries (TBI) is necessary due to its salient effect on the improvement of patients with TBI and the final outcomes within early hours of trauma onset. This study aims to investigate the effect of intravenous tranexamic acid (TAX) administration on decreased hemorrhage during surgery. METHODS: This double-blind, randomized, and placebo-controlled trial was conducted on patients referring to the emergency department (ED) with IPH due to brain contusion within 8 h of injury onset. The patients were evaluated by receiving TXA and 0.9% normal saline as a placebo. The following evaluation and estimations were performed: intracranial hemorrhage volume after surgery using brain CT-scan; hemoglobin (Hb) volume before, immediately after, and six hours after surgery; and the severity of TBI based on Glasgow Coma Score (GCS). RESULTS: 40 patients with 55.02 ± 18.64 years old diagnosed with a contusion and intraparenchymal hemorrhage. Although the (Mean ± SD) hemorrhage during surgery in patients receiving TXA (784.21 ± 304.162) was lower than the placebo group (805.26 ± 300.876), no significant difference was observed between two groups (P=0.83). The (Mean ± SD) Hb volume reduction immediately during surgery (0.07 ± 0.001 and 0.23 ± 0.02) and six hours after surgery (0.04 ± 0.008 and 0.12 ± 0.006) was also lower in TXA group but had no significant difference (P = 0.89 and P = 0.97, respectively). CONCLUSION: Using TXA may reduce the hemorrhage in patients with TBI, but this effect, as in this study, was not statistically significant and it is suggested that a clinical trial with a larger population is employed for further investigation.

Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin.

PURPOSE: In 2007, Essentia Health St. Mary's Medical Center (SMMC), a Level II trauma center in northeastern Minnesota, implemented a protocol for patients who presented with blunt head trauma and were receiving warfarin for anticoagulation. The purpose of this study was to determine the incidence and risk factors of early delayed, warfarin-associated intracranial hemorrhage (ICH). METHODS: Adult patients with signs and symptoms of head injury on warfarin who were admitted by protocol to SMMC between March 2007 and June 2015 were included. Patients were observed for neurologic change and received a follow-up head CT scan within 24 h after an initial negative scan. RESULTS: Among the 232 episodes of care studied, there were 204 patients. The average age was 71; 51% of patients were female. Most patients presented with Glasgow Coma Scale score of 15 and had signs of head trauma. The majority of patients (63%) had a therapeutic International Normalized Ratio (INR) for their indicated condition, but 19% of patients had a supratherapeutic INR and 19% had a subtherapeutic INR. The incidence of early delayed ICH was 1.7%; none of these cases required operative intervention or were fatal. CONCLUSIONS: For patients who were anticoagulated with warfarin and had sustained minor traumatic brain injury, implementation of our protocol showed low incidence of early delayed ICH in the first 24 h. We believe withholding warfarin for several days and careful follow-up regarding its resumption is warranted, especially in the setting of supratherapeutic INR.

Predictors of Hypopituitarism in Patients with Traumatic Brain Injury.

Hypopituitarism may often occur in association with traumatic brain injury (TBI). Identification of reliable predictors of pituitary dysfunction is of importance in order to establish a rational testing approach. We searched the records of patients with TBI, who underwent neuroendocrine evaluation in our institution between 2007 and 2013. One hundred sixty-six adults (70% men) with TBI (median age: 41.6 years; range: 18-76) were evaluated at a median interval of 40.4 months (0.2-430.4).Of these, 31% had ≥1 pituitary deficiency, including 29% of patients with mild TBI and 35% with moderate/severe TBI. Growth hormone deficiency was the most common deficiency (21%); when body mass index (BMI)-dependent cutpoints were used, this was reduced to 15%. Central hypoadrenalism occurred in10%, who were more likely to have suffered a motor vehicle accident (MVA, p = 0.04), experienced post-traumatic seizures (p = 0.04), demonstrated any intracranial hemorrhage (p = 0.05), petechial brain hemorrhages (p = 0.017), or focal cortical parenchymal contusions (p = 0.02). Central hypothyroidism occurred in 8% and central hypogonadism in 12%; the latter subgroup had higher BMI (p = 0.03), were less likely to be working after TBI (p = 0.002), and had lower Global Assessment of Functioning (GAF) scores (p = 0.03). Central diabetes insipidus (DI) occurred in 6%, who were more likely to have experienced MVA (p < 0.001) or sustained moderate/severe TBI (p < 0.001). Patients with MVA and those with post-traumatic seizures, intracranial hemorrhage, petechial brain hemorrhages, and/or focal cortical contusions are at particular risk for serious pituitary dysfunction, including adrenal insufficiency and DI, and should be referred for neuroendocrine testing. However, a substantial proportion of patients without these risk factors also developed hypopituitarism.

Bilateral remote cerebellar haemorrhage after spinal surgery: a case study and review of the literature.

BACKGROUND: Remote cerebellar haemorrhage is a rare and unpredictable complication after intracranial and spinal surgery, although less frequently found in the latter. The physiopathology of this phenomenon has not been definitely explained. OBJECTIVES: To describe and discuss the potential implications and pathomechanism of a bilateral remote cerebellar haemorrhage case after spinal surgery and review the literature related to this rare phenomenon. CASE REPORT: A 75 year-old man developed bilateral remote cerebellar haemorrhage after a lumbar laminectomy. Brain CT and MRI examinations showed chronic bilateral remote cerebellar haemorrhage, right haemoventricle and bilateral supratentorial subarachnoid haemorrhage. Subsequently, the patient underwent rehabilitation therapy with improvement of symptoms. CONCLUSION: When large cerebrospinal fluid loss is observed during spinal surgery, brain imaging study should be carried out. The pathogenetic hypothesis of microcirculation vessels tearing, the role of previous spinal surgery and of cerebellar atrophy should be considered and validated with further investigation.

Late intracranial haemorrhage and subsequent carotid-cavernous sinus fistula after fracture of the facial bones.

Carotid-cavernous sinus fistula is an arteriovenous fistula between the internal carotid artery and the cavernous sinus, and is usually caused by a traumatic tear or a ruptured aneurysm of the cavernous segment of the internal carotid artery. We describe a rare case of delayed intracranial haemorrhage and carotid-cavernous sinus fistula that presented 3 weeks after fracture of the facial bones. The patient developed orbital apex syndrome including ptosis of upper eyelid, pulsatile exophthalmos, chemosis, loss of ocular motility, monocular blindness on the right, and numbness of the right infraorbital region. After transcatheter intra-arterial embolisation, the ptosis and chemosis improved.

A rare complication: aorta-cutaneous fistula with abundant bleeding.

Pseudoaneurysm and aorto-cutaneous fistula following surgical procedures of the aorta are rare complications with potentially catastrophic results that require rapid diagnosis and urgent surgical treatment. We performed a successful life-saving operation using hypothermic circulatory arrest with femoral artery and vein cannulation. The patient had undergone open heart surgery in our clinic twice, and there was active and abundant bleeding from aorta-cutaneous fistula that occured 5 years after the last surgery.

Does ventricular opening promote remote cerebellar haemorrhage?

Cerebellar haemorrhage after supratentorial craniotomy is a rare complication Because of its significant morbidity and mortality rates, being aware of this complication is important for early diagnosis. In a 30-year-old male with multiple intracranial cavernomas, remote cerebellar haemorrhage (RCH) was observed after removal of symptomatic left temporal lesion. The lateral wall of the temporal horn that was tightly attached to the cavernoma was also opened and excessive drainage of the CSF occurred. The haemorrhage is attributed to opening of the ventricle wall and excessive drainage of cerebrospinal fluid (CSF) during the procedure.

Complications in auditory brainstem implant surgery in adults and children.

OBJECTIVE: Surgery for hearing restoration with auditory brainstem implantation (ABI) in patients with neurofibromatosis type 2 (NF2) is considered safe, as no increase in postoperative complications related to surgery or device implantation has been observed. Over the last 10 years, we have extended the use of ABI to nontumor (NT) adults and children with cochlear or cochlear nerve malfunctions who would not or did not benefit from a cochlear implant (CI). This article examines the complications encountered in ABI surgery in all patient groups. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: : One hundred fourteen ABI operations were performed in Verona (Italy) from 1997 to 2008 in 83 adults and 31 children. Thirty-six had NF2 (34 adults and 2 children), and 78 (49 adults and 29 children) had NT cochlear and cochlear nerve disorders. INTERVENTION: A retrosigmoid-transmeatal approach was used in the NF2 cases, and a simple retrosigmoid approach was used in the NT patients. MAIN OUTCOME MEASURES: Surgical complications are tabulated according to standard reporting categories and are presented separately and analyzed statistically for NF2, NT adults, and NT children. Complication rates are compared with those of CI and microvascular decompression surgery. RESULTS: ABI surgery has a very low major complication rate, particularly in non-NF2 patients. Minor complications were easily controlled with complete resolution in all cases. Although the potential complications of intradural ABI implantation are more severe than those of a transmastoid approach for CIs, the actual observed complication rates in ABI candidates without NF2 tumors are comparable to those of CI surgery in both adults and children. CONCLUSION: This study demonstrates that the ABI is a safe procedure when performed by an experienced surgical and rehabilitation team, and its benefits can be extended to a larger population of deaf patients.

Complex craniofacial trauma resulting from fireworks blast.

The authors report the case of a patient who sustained a complex craniofacial trauma secondary to a recreational fireworks blast. Initial assessment and management were performed with a multidisciplinary approach to achieve control of cerebral hemorrhage, debridement of wounds and brain, isolation of the brain from the external environment, reconstruction of the cranial base floor, and orbital and facial reconstruction. Modification of multiple conventional approaches, along with a multispecialty surgical team, were used to deal effectively with this unusual patient who was treated by single-stage immediate management. Reconstruction of both the intracranial and extracranial compartments was considered successful with a satisfactory cosmetic result.

Cerebellar hemorrhage caused by remote neurological surgery.

INTRODUCTION: Intracranial hemorrhage usually occurs as a complication of hypertension, coagulopathy, or trauma. In rare instances, remote cerebellar hemorrhage (RCH) may complicate supratentorial or spinal surgery. METHODS: Retrospective case series study. RESULTS: We describe three cases of RCH complicating spinal and cranial surgical procedures associated with cerebrospinal fluid hypotension. CONCLUSIONS: Remote cerebellar intracranial hemorrhage may complicate neurosurgical procedures in which cerebrospinal fluid hypotension occurs.

Remote cerebellar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review.

OBJECTIVE AND IMPORTANCE: This report presents a case in which cerebellar hemorrhage occurred after lumbar decompression surgery that was complicated by dural tear and prolonged cerebrospinal fluid leakage. Remote cerebellar hemorrhage after spinal surgery is extremely rare. Our objective is to describe this unusual complication, discuss the possible mechanisms of remote cerebellar hemorrhage, and review the literature. CLINICAL PRESENTATION: A 73-year-old woman underwent surgery for lumbar spinal stenosis. A dural tear occurred during decompression, and the patient developed remote cerebellar hemorrhage on postoperative Day 2. INTERVENTION: The cerebellar hemorrhage was treated surgically, and a biopsy of hemorrhagic brain parenchyma revealed an arteriovenous malformation. CONCLUSION: Although it is an extremely rare complication, remote cerebellar hemorrhage should be kept in mind as a possible complication of spinal surgery, especially in operations complicated by dural tears.

Cerebellar haemorrhage following supratentorial craniotomy.

Distant cerebellar haemorrhage is a rare complication occurring in approximately 0.3-0.6% of all supratentorial craniotomy. A Medline and Pubmed search revealed only 98 cases in the English literature. We report three cases from our institution. An overall review of these 101 cases demonstrated that this complication commonly presented early in the postoperative course as decreased level of consciousness following aneurysm repair surgery or lobectomy for epilepsy. Asymptomatic presentation due to small haemorrhage was not uncommon. A transtentorial pressure gradient set up by excessive CSF loss is generally held responsible for disrupting the cerebellar venous blood flow and consequently leading to venous haemorrhage. Perioperative hypertension may also play a role. The outcome of patients who survived the complications was generally good, though not infrequently fatality resulted from the mass effect of extensive cerebellar haemorrhage demanded vigilance in its management.