Flexible endoscopically assisted evacuation of acute and subacute subdural hematoma through a small craniotomy: preliminary results.

BACKGROUND: The first choice to treat acute subdural hematoma (SDH) is a large craniotomy under general anesthesia. However, increasing age or comorbid burden of the patients may render invasive treatment strategy inappropriate. These medically frail patients with SDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive and even available under local anesthesia. Although hematoma evacuation with a rigid endoscope for acute or subacute SDHs has been reported in the literature, use of a flexible endoscope may have distinct advantages. In this article, we attempted to clarify the utility of small craniotomy evacuation with a flexible endoscope for acute and subacute SDH in the elderly patients. METHOD: Between November 2013 and September 2016, a total of 17 patients with acute SDH (15 patients), subacute SDH (1 patient), or acute aggravation of chronic SDH (1 patient) underwent hematoma evacuation with a flexible endoscope at our hospital and were enrolled in this retrospective study. Either under local or general anesthesia, the SDH was removed with a flexible suction tube with the aid of the flexible endoscope through the small craniotomy (3 × 4 cm). Hematoma evacuation rate, improvement of clinical symptoms, and procedure-related complications were evaluated. RESULTS: Hematoma evacuation rate was satisfactory, and statistically significant clinical improvement was observed in postoperative Glasgow Coma Scale in all cases compared to the preoperative assessment. No procedure-related hemorrhagic complications were observed. CONCLUSIONS: The results reported here suggest that small craniotomy evacuation with a flexible endoscope is a safe, effective, and minimally invasive treatment for acute and subacute SDH in selected cases.

Omega-3 Fatty Acid Supplementation and Warfarin: A Lethal Combination in Traumatic Brain Injury.

Polyunsaturated fatty acids such as omega-3 eicosapentaenoic acid and omega-6 docosahexaenoic acid, found in over-the-counter fish oil supplements, are often consumed for their beneficial, prophylactic, anti-inflammatory effects. Although the mechanisms of action are not fully known, a diet rich in polyunsaturated fats may reduce the risk of hyperlipidemia, atherosclerosis, high low-density lipoprotein cholesterol levels, hypertension, and inflammatory diseases. Masked by its many benefits, the risks of omega-3 fatty acid supplementation are often underappreciated, particularly its ability to inhibit platelet aggregation and promote bleeding in patients taking anticoagulant medications. The following details the clinical case of an elderly patient taking warfarin and fish oil supplementation whose warfarin-induced coagulopathy could not be reversed after suffering blunt head trauma.

Acupuncture helps regain postoperative consciousness in patients with traumatic brain injury: a case study.

OBJECTIVE: This report of one case illustrates the potential effect of acupuncture therapy in addition to Western medicine for regaining postoperative consciousness in patients with traumatic brain injury (TBI). CLINICAL FEATURES: A 65-year-old man experienced a TBI after being involved in a motor vehicle accident. His initial Glasgow Coma Scale (GCS) score was E1V1M2, and brain computerized tomography showed a right-sided subdural hemorrhage. He received emergency medical treatment and underwent craniotomy to remove the lacerated portions of brain as well as subtemporal decompression, followed by a decompressive craniectomy the following day to remove an intracerebral hematoma due to late-onset temporo-parietal rebleeding. Twelve days after surgery, the patient remained in poor condition due to serious complications and the GCS was E2VeM4. His family then underwent counseling and he subsequently received acupuncture treatment. INTERVENTION AND OUTCOME: This patient was treated with acupuncture three times each week, consisting of strong stimulation at GV26 (Shuigou) and the 12 Well points using the half-needling technique. After 3 weeks of consecutive treatment, his GCS score improved to E4VtM6. In addition, he regained consciousness and could tolerate rehabilitation programs. CONCLUSIONS: We believe that an experienced physician may use acupuncture as complementary therapy in patients with TBI who fail to regain consciousness postoperatively.

Relationships between kinesiotherapy methods used in rehabilitation and the course of lost function recovery following surgical treatment of cranio-cerebral trauma.

INTRODUCTION AND AIM: This paper aims to outline the relationships between kinesiotherapy methods used in rehabilitation and the recovery of the patient's ability to perform activities of daily living (ADLs), improvement of functional condition, regression of pareses and improvement of conscious state following surgical treatment of traumatic subdural haematomas. MATERIALS AND METHODS: The study was conducted on 84 patients treated surgically for traumatic subdural haematomas, divided into two groups. The key differentiating factor was the kinesiotherapy method used in rehabilitation. Patients were assessed using the International Scale of Muscle Weakness (ISMW), Barthel Index and modified Rankin Scale, while their conscious state was assessed using the Glasgow Coma Scale. RESULTS: A significant improvement of the assessed features was observed in all patients. However, patients treated with proprioceptive neuromuscular facilitation (PNF) and elements of the Bobath concept regained lost function significantly faster than patients treated with traditional kinesiotherapy. No significant differences were observed in the course of improvement of conscious state between the two groups. CONCLUSIONS: Treatment using functional elements may significantly accelerate the return of the ability to perform ADLs, improvement in functional condition and regression of pareses in comparison with traditional kinesiotherapy.

Prospective analysis of bedside percutaneous subdural tapping for the treatment of chronic subdural haematoma in adults.

OBJECTIVES: Although there is general agreement that surgery is the best treatment for chronic subdural haematoma (CSDH), the extent of the surgical intervention is not well defined. METHODS: The less invasive surgical technique of bedside percutaneous subdural tapping and spontaneous haematoma efflux after twist drill craniostomy under local anaesthesia was prospectively analysed in 118 adult patients, 99 with unilateral and 19 with bilateral CSDH. RESULTS: The mean number of subdural tappings was 3.2. Ninety two of the patients with unilateral CSDH were successfully treated by up to five subdural tappings, 95% of the patients with bilateral CSDH were successfully treated by up to 10 subdural tappings. The mean duration of inpatient treatment was 12 days. In 11 patients (9%) the treatment protocol had to be abandoned because of two acute subdural bleedings, two subdural empyemas, and seven cases of insufficient haematoma efflux and no neurological improvement. The only significant predictor for failure of the described treatment protocol was septation visible on preoperative CT. CONCLUSIONS: The described therapy protocol is-apart from a purely conservative treatment-the least invasive presently available surgical technique for treating chronic subdural haematoma. Its results are comparable with other modern treatment protocols. Thus, it can be recommended in all patients as a first and minimally invasive therapy, especially in patients in a poor general condition. Patients with septation visible on preoperative CT should be excluded from this form of treatment.

The fate of the cerebrospinal fluid after neuroendoscopic third ventriculostomy.

This paper describes the case of a 9-year-old girl with a posterior thalamic/pineal region lesion and secondary obstructive hydrocephalus. The hydrocephalus was treated by neuroendoscopic third ventriculostomy (NTV), and she underwent simultaneous transendoscopic biopsy. The tumour biopsy was haemorrhagic, but the bleeding settled with constant irrigation. The patient remained neurologically unchanged, but subsequent imaging revealed an asymptomatic thoracolumbar spinal subdural haematoma thought to be due to blood flowing out through the NTV into the subdural space. This demonstrates the subdural location of the cerebrospinal fluid after NTV.

Is sedation necessary for demented patients under infiltration anesthesia?

BACKGROUND: Sedation for intraoperative patients under infiltration anesthesia is often used, however, disadvantages of sedation for demented patients may sometimes exceed its advantages because some of the demented patients are already apathetic about their surroundings. The authors prospectively investigated whether sedation for alert or demented patients receiving surgery under infiltration anesthesia is useful and safe for intraoperative management. METHODS: Sixty patients undergoing irrigation and drainage of chronic subdural hematoma under infiltration anesthesia were divided into four groups. Patients in Group A were non-sedated alert patients. Patients in Group B were non-sedated demented patients. Patients in Group C were sedated alert patients. Patients in Group D were sedated demented patients. Intraoperative variables, adverse effects, and the postoperative satisfaction represented by five-point score were recorded. RESULTS: The heart rate in group A during operation was significantly faster than the control value. The postoperative satisfaction score in group A was significantly lower than any other groups. A patient in group D required a nasal airway to improve respiration during operation. CONCLUSIONS: These results suggest that there is no evidence to show that advantages of sedation for demented surgical patients under infiltration anesthesia excel the disadvantages although sedation for alert patients may be an effective and rational conduct in intraoperative management.

Hematoma subdural crónico en paciente joven / Chronic subdural hematoma in young patient

Entre julio de 1984 y junio de 1989 en el I.N.C. e I.C. Dr. A. Asenjo, se operaron de hematoma subdural crónico, H.S.D.Cr, 140 pacientes, 14 de los cuales eran menores de 30 años, 10 por ciento, representando un promedio de 2,8 pacientes por año. 10 pacientes fueron varones, 71,4 por ciento, y 4 mujeres, 28,6 por ciento. En 12 encontramos antecedente de trauma craneal, 85,7 por ciento, pero en solo 8 ésta databa de por lo menos 3 semanas antes del ingreso. En 2 habían antecedentes mórbidos: un hidrocefálico y un niño con un anemia y desnutrición severas. El tiempo entre el inicio de la clínica y el diagnóstico fluctuó entre los 2 meses y 1 día, haciéndose en 4 el diagnóstico de tumor cerebral. En el 71,4 por ciento hubo cefalia con atributos de hipertensión intracraneal, 10pacs.; 42,9 por ciento, 6pac signos focales deficitarios; 21,4 por ciento, 3pac compromiso de conciencia y 7,1 por ciento, 1pac fue asintomático. El tratamiento fue en todos quirúrgico. En 2 hubo complicaciones respiratorias, 14,2 por ciento. Al alta: 13 se encontraban normales, 92,3 por ciento, y 1 falleció, 7,1 por ciento

Percutaneous subdural tapping for the treatment of chronic subdural haematoma in adults.

Chronic subdural haematoma in adults has been treated by percutaneous subdural tapping using a subdural needle. In order to prevent recurrence, the procedure including replacement of the haematoma with oxygen, irrigation using relatively small amounts of saline, and additional drainage for one hour proved to be simple and reliable. The detailed technique is illustrated, and sequential computed tomography scans in six patients treated with this procedure are presented.

[Subdural tension pneumocephalus after trephination for chronic subdural hematoma].

Symptomatic tension pneumocephalus developed after an evacuation of chronic subdural hematoma is reported. In this 71 year-old man, a rapid deterioration of consciousness was noted 5 days after a trephination for bilateral chronic subdural hematomas. An evacuation of hematoma was performed under a local anesthesia, and the preoperative and immediate postoperative course was uneventful. Subdural tension pneumocephalus was confirmed by typical CT findings and treated by re-trephination and drainage. The literature on the tension subdural pneumocephalus was reviewed, and the mechanism of its development was briefly discussed.

Pathophysiology, treatment and outcome following severe head injury in children.

The pathophysiology and outcome following severe head injury in 85 children are presented. The commonest initial CT diagnosis was of acute brain swelling. This swelling was associated with an increased white matter density on the CT scan which decreased to normal concomitant with recovery and increased ventricular size. CBF measurements in 6 of these patients revealed an increased blood flow despite a decreased CMRO2 and clinical coma. This CT pattern of diffuse swelling is believed to be due to acute cerebrovascular congestion and hyperemia and not to edema. Because of this, all children were treated with endotracheal intubation and controlled hyperventilation as part of the initial management. Mass lesions were uncommon, 20%. ICP was monitored in 40 children. The ICP rose above 20 Torr despite therapy in 80% of children with decerebrate or flaccid coma and in only 20% of children with spontaneous motor function. The ICP was at its highest between the second and fifth day. Aggressive therapy to control the ICP, with barbiturates if necessary, was successful in 80% of the patients. The overall results were useful recovery in 87.5% of the children, 3.5% were left vegetative or severely disabled and 9% died.