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.

Initial Factors Affecting 6-month Outcome of Patients Undergoing Surgery for Acute Post-traumatic Subdural and Epidural Hematoma.

INTRODUCTION: The most frequent consequences of a traumatic brain injury are acute subdural (SDH) and epidural hematoma (EDH), which usually require a surgical treatment. Most of the factors affecting the prognosis have been analyzed on a wide group of traumatic brain injuries. Nonetheless, there are few studies analyzing factors influencing the prognosis regarding patients with EDH and SDH. The aim of the study is to identify factors which have prognostic value in relation to 6-month outcome of patients undergoing surgery for acute hematoma. PATIENTS AND METHODS: The study included a group of 128 patients with isolated craniocerebral injuries. The patients were divided into two groups, namely a group of 28 patients operated on due to epidural hematoma and a group of 100 patients operated on due to acute subdural hematoma. All patients were operated and treated in the Department of Neurosurgery at the Medical University in Lublin from 1.10.2014 to 31.08.2017. The following factors from the groups were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics, and time between the trauma and the surgery. All the factors were correlated with six-month outcome in Glasgow outcome scale. RESULTS: The univariate analysis has confirmed the influence of many factors affecting the outcomes. CONCLUSION: It is interesting that the factors such as GSC score, saturation, respiratory rate, and systolic blood pressure were associated with outcome with highly statistically significant differences in both group. These are factors that, with an appropriate treatment, could be normalized at the place of the accident.

Ratio of Optic Nerve Sheath Diameter to Eyeball Transverse Diameter by Ultrasound Can Predict Intracranial Hypertension in Traumatic Brain Injury Patients: A Prospective Study.

BACKGROUND: Measuring optic nerve sheath diameter (ONSD), an indicator to predict intracranial hypertension, is noninvasive and convenient, but the reliability of ONSD needs to be improved. Instead of using ONSD alone, this study aimed to evaluate the reliability of the ratio of ONSD to eyeball transverse diameter (ONSD/ETD) in predicting intracranial hypertension in traumatic brain injury (TBI) patients. METHODS: We performed a prospective study on patients admitted to the Surgery Intensive Care Unit. The included 52 adults underwent craniotomy for TBI between March 2017 and September 2018. The ONSD and ETD of each eyeball were measured by ultrasound and computed tomography (CT) scan within 24 h after a fiber optic probe was placed into lateral ventricle. Intracranial pressure (ICP) > 20 mmHg was regarded as intracranial hypertension. The correlations between invasive ICP and ultrasound-ONSD/ETD ratio, ultrasound-ONSD, CT-ONSD/ETD ratio, and CT-ONSD were each analyzed separately. RESULTS: Ultrasound measurement was successfully performed in 94% (n = 49) of cases, and ultrasound and CT measurement were performed in 48% (n = 25) of cases. The correlation efficiencies between ultrasound-ONSD/ETD ratio, ultrasound-ONSD, CT-ONSD/ETD ratio, and ICP were 0.613, 0.498, and 0.688, respectively (P < 0.05). The area under the curve (AUC) values of the receiver operating characteristic (ROC) curve for the ultrasound-ONSD/ETD ratio and CT-ONSD/ETD ratio were 0.920 (95% CI 0.877-0.964) and 0.896 (95% CI 0.856-0.931), respectively. The corresponding threshold values were 0.25 (sensitivity of 90%, specificity of 82.3%) and 0.25 (sensitivity of 85.7%, specificity of 83.3%), respectively. CONCLUSION: The ratio of ONSD to ETD tested by ultrasound may be a reliable indicator for predicting intracranial hypertension in TBI patients.

Non-Contact Monitoring of Temporal Volume Changes of a Hematoma in the Head by a Single Inductive Coil: A Numerical Study.

OBJECTIVE: This numerical study was designed to evaluate the feasibility of using an inductive coil for monitoring the changes in the volume of a hematoma in the head in situ and to compare the inductive coil performance to that of a spiral antenna based on the radar principle. METHODS: Numerical analysis was used to solve the complete set of Maxwell's equations in full three-dimensional anatomical model of a head and brain with data on clinical occurrence of hematomas from the clinical literature, for frequencies of 100 MHz, 500 MHz, and 1 GHz. RESULTS: 1) The analysis shows that the spiral radar antenna provides a better resolution when the antenna can be placed exactly facing the center of the volume of blood. Under any other circumstance, the inductive coil has a better resolution at both 500 MHz and 1 GHz. 2) The induction coil is more sensitive to rotation artifacts than the spiral antenna. 3) Single frequency measurements do not provide conclusive results. CONCLUSION: The inductive coil has the ability to monitor small changes in the volume of a hematoma in the head. However, multifrequency measurements are required for correct diagnostic. SIGNIFICANCE: This study provides a new, low-cost alternative to the conventional medical imaging for monitoring the hematoma increase.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage.

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. METHODS: This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. RESULTS: Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. CONCLUSIONS: RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures.

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ±â€Š3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ±â€Š1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.

Prognostic significance of optic nerve sheath diameter on computed tomography scan with severity of blunt traumatic brain injury in the emergency department.

Optic nerve sheath diameter measurement (ONSD) has been associated with identifying the prognosis of traumatic brain injury (TBI) patients. The study was planned to evaluate the prognostic value of ONSD measured on the initial brain computed tomography (CT) scan performed on patients with blunt TBI in the emergency department(ED). This retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of moderate and severe TBI patients from January to December 2014. ONSD for each eye on the initial CT scan and Glasgow Coma Scale (GCS) was measured upon patient presentation. Correlation between presentation GCS and ONSD was done through Pearson's correlation. Receiver operator curve (ROC) analysis was done to measure the predictive values of ONSD for mortality. Of the 276 patients, 211(76%) were males and 65(23%) females. ONSD was measured on 160(58%) patients. The mean ONSD measured on CT scan was 3.8±1. The Pearson's correlation between the severity of brain injury as per GCS at presentation and ONSD was not significant (-0.182). We concluded that ONSD measured on the initial CT brain scan had good association with the severity of blunt TBI in patients presenting to the ED.

[Pathophysiology of intracranial injuries]. / Pathophysiologie intrakranieller Verletzungen.

Traumatic brain injury (TBI) constitutes a heterogeneous condition that affects the most complex organ of the human body. It is commonly classified by its location as focal injury (e.g. epidural hematoma) and diffuse injury (e.g. diffuse axonal shearing injury) as well as by primary and secondary tissue injury. Accordingly, direct mechanical force causes the primary insult. The tissue damage occurring afterwards is subsumed under the term secondary brain damage. Some of these processes are overlapping and include in the early phase local cerebral ischemia resulting in excitotoxicity, which together with the triggered neuroinflammatory cascade causes the formation of cerebral edema and ultimately increased intracranial pressure once the intracranial compliance is exhausted. In survivors the long-term sequelae of the late stage include seizures caused by synaptic reorganization (incidence depending on the severity of TBI), persistent neuroinflammation promoting further neurodegeneration and increased risk for Alzheimer's disease probably because of TBI-related protein misfolding (tauopathy). Acute phase biomarkers of TBI should ideally originate from the injured brain. They should help distinguish disease severity and predict morbidity and mortality; however, the most commonly used biomarkers (S-100ß and neurone-specific enolase) show a low specificity. In theory their successors (i. e. GFAP, pNF-H) seem more specific; however, these "new kids on the block" still need to be thoroughly investigated in large scale studies.

Cerebrovascular Time Constant in Patients with Head Injury.

The cerebrovascular time constant (τ) theoretically estimates how fast the cerebral arterial bed is filled by blood volume after a sudden change in arterial blood pressure during one cardiac cycle. The aim of this study was to assess the time constant of the cerebral arterial bed in patients with traumatic brain injury (TBI) with and without intracranial hematomas (IH). We examined 116 patients with severe TBI (mean 35 ± 15 years, 61 men, 55 women). The first group included 58 patients without IH and the second group included 58 patients with epidural (7), subdural (48), and multiple (3) hematomas. Perfusion computed tomography (PCT) was performed 1-12 days after TBI in the first group and 2-8 days after surgical evacuation of the hematoma in the second group. Arteriovenous amplitude of regional cerebral blood volume oscillation was calculated as the difference between arterial and venous blood volume in the "region of interest" of 1 cm(2). Mean arterial pressure was measured and the flow rate of the middle cerebral artery was recorded with transcranial Doppler ultrasound after PCT. The time constant was calculated by the formula modified by Kasprowicz. The τ was shorter (p = 0.05) in both groups 1 and 2 in comparison with normal data. The time constant in group 2 was shorter than in group 1, both on the side of the former hematoma (р = 0.012) and on the contralateral side (р = 0.044). The results indicate failure of autoregulation of cerebral capillary blood flow in severe TBI, which increases in patients with polytrauma and traumatic IH.

[Cerebrovascular resistance in patients with severe combined traumatic brain injury].

UNLABELLED: Cerebrovascular resistance is an important parameter of the microcirculation. The main objective of cerebrovascular resistance is to maintain the constancy of cerebral blood flow and protect downstream vessels when changing perfusion pressure. The purpose of the study was to assess cerebrovascular resistance (CVR) in patients with severe combined traumatic brain injury (CTBI) with and without intracranial hematomas (IHs). MATERIAL AND METHODS: We analyzed treatment outcomes in 70 patients with severe CTBI (42 males and 28 females). The mean age was 35.5 ± 14.8 years (min 15 years; max 73 years). All patients were divided into 2 groups, depending on the presence of intracranial hemorrhage. The first group included 34 patients without IH, and the second group included 36 patients with epidural (6), subdural (26), and multiple (4) hematomas. The GCS score was 10.4 ± 2.6 in the first group and 10.6 ± 2.8 in the second group. The ISS severity injury score was 32 ± 8 in the first group and 31 ± 11 in the second group. All patients were operated on within the first 3 days, with 30 (83.3%) patients being operated on during the first day. Perfusion computed tomography (PCT) of the brain was performed within 1-14 days after TBI in the first group and within 2-8 days after surgical evacuation of hematoma in the second group. After PCT, the mean arterial pressure was measured, and the blood flow rate in the middle cerebral artery was determined using transcranial dopplerography. Cerebrovascular resistance was calculated using the formula modificated by P. Scheinberg. Comparisons between the groups were performed using the Student t-test and χ² criterion. RESULTS: The mean CVR values in each group (both with and without hematomas) were statistically significantly higher than the mean normal value of this parameter. Intergroup comparison of CVR values demonstrated a statistically significant increase in the CVR level in group 2 on the side of removed hematoma compared to group 1 (p=0.037). CVR in the perifocal zone of removed hematoma remained significantly higher compared to the symmetrical zone of the contralateral hemisphere (p=0.0009). CONCLUSION: Cerebrovascular resistance in patients with combined traumatic brain injury is significantly increased compared to the normal value. Cerebrovascular resistance in the perifocal zone after evacuation of hematoma in patients with multiple injury remains significantly increased compared to the symmetrical zone in the contralateral hemisphere.

Invasive and ultrasound based monitoring of the intracranial pressure in an experimental model of epidural hematoma progressing towards brain tamponade on rabbits.

INTRODUCTION: An experimental epidural hematoma model was used to study the relation of ultrasound indices, namely, transcranial color-coded-Doppler (TCCD) derived pulsatility index (PI), optic nerve sheath diameter (ONSD), and pupil constriction velocity (V) which was derived from a consensual sonographic pupillary light reflex (PLR) test with invasive intracranial pressure (ICP) measurements. MATERIAL AND METHODS: Twenty rabbits participated in the study. An intraparenchymal ICP catheter and a 5F Swan-Ganz catheter (SG) for the hematoma reproduction were used. We successively introduced 0.1 mL increments of autologous blood into the SG until the Cushing reaction occurred. Synchronous ICP and ultrasound measurements were performed accordingly. RESULTS: A constant increase of PI and ONSD and a decrease of V values were observed with increased ICP values. The relationship between the ultrasound variables and ICP was exponential; thus curved prediction equations of ICP were used. PI, ONSD, and V were significantly correlated with ICP (r² = 0.84 ± 0.076, r² = 0.62 ± 0.119, and r² = 0.78 ± 0.09, resp. (all P < 0.001)). CONCLUSION: Although statistically significant prediction models of ICP were derived from ultrasound indices, the exponential relationship between the parameters underpins that results should be interpreted with caution and in the current experimental context.

Severe traumatic brain injury in adults.

Traumatic brain injury is the most common cause of death and disability in young people, with an annual financial burden of over $50 billion per year in the United States. Traumatic brain injury is defined by both the initial primary injury and the subsequent secondary injuries. Fundamental to emergency department management is ensuring brain perfusion, oxygenation, and preventing even brief or transient episodes of hypotension, hypoxia, and hypocapnia. Cerebral perfusion pressure is a function of intracranial pressure and systemic blood pressure, and it must be monitored and maintained. Current research is devoted towards the prevention and treatment of secondary injury. The emergency clinician must be vigilant in maintaining homeostasis while coordinating the downstream care of the patient, including the intensive care unit and/or the operating room.

Delayed extradural haemorrhage: a case for intracranial pressure monitoring in sedated children with traumatic brain injury within tertiary centres.

A 15-year-old girl sustained a mild isolated traumatic brain injury  following a pedestrian road traffic accident. She was ventilated for head computed tomography (CT) scan which revealed no intracranial abnormalities. Ventilation was not withdrawn until 15 h later when poor neurological recovery prompted urgent repeat CT, which demonstrated a delayed extradural haemorrhage (EDH). She underwent surgical evacuation, and intracranial pressure (ICP) monitoring was initiated postoperatively. She developed persistently raised ICP resistant to medical therapy, prompting further CT. This showed a recurrence of the delayed EDH requiring further surgical drainage. She made a good neurological recovery. There should be a low threshold for repeat CT to exclude delayed EDH when neurological status is poor despite normal CT soon after initial primary injury. ICP monitoring should be undertaken in children and adolescents who have normal initial CT, but in whom serial neurological assessment is not possible owing to sedation.

The lucid interval associated with epidural bleeding: evolving understanding.

The aim of this paper was to elucidate the evolution of our understanding of the term "lucid interval." A number of texts were reviewed to assess their suitability for analysis. The primary requirement was that the text contain detailed descriptions of a series of patients. Details of the clinical course, the findings and timing of surgery, and, when relevant, the time of death and postmortem findings were required. Books written by Henri-François Le Dran, Percival Pott, and James Hill fulfilled these criteria. Surgical findings included the presence and type of fractures, changes in the bone, separation of periosteum, malodorous or purulent material, tense brain, and hematoma. Postmortem findings supplemented and/or complemented the surgical findings. The courses of the patients were then tabulated, and the correlation between different clinical and operative findings was thereby determined. Our understanding of a lucid interval began in the early 18th century with the work of Henri-François Le Dran and Percival Pott in London. They did not, however, demonstrate an interval without symptoms between trauma and deterioration in patients with epidural hematomas (EDHs). The interval they described was longer than usually expected with EDHs and occurred exclusively in patients who had a posttraumatic infection. In 1751, James Hill, from Dumfries, Scotland, described the first hematoma-related lucid interval in a patient with a subdural hematoma. The first case of a lucid interval associated with an EDH was described by John Abernethy. In the 19th century, Jonathan Hutchinson and Walter Jacobson described the interval as it is known today, in cases of EDH. The most recent work on the topic came from studies in Cincinnati and Oslo, where it was demonstrated that bleeding can separate dura mater and that hemorrhage into the epidural space can be shunted out via the veins. This shunting could delay the accumulation of a hematoma and thus the rise in intracranial pressure, which in turn would delay the development of symptoms. The lucid interval as previously conceived was not properly understood by the French school or by Percival Pott and Benjamin Bell, who all described a symptom-free period prior to the development of infection. The first to have a proper understanding of the interval in relation to an EDH was John Abernethy. The modern description and definition of the lucid interval was the work of Hutchinson and Jacobson in the latter half of the 19th century. Understanding of the pathophysiology of the lucid interval has been advanced by the work of Ford and McLaurin in Cincinnati and a group in Oslo, with the demonstration of what it takes to loosen dura and how an arteriovenous shunt slows down for a while the accumulation of an EDH.

Burden of blood pressure-related alleles is associated with larger hematoma volume and worse outcome in intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) is the acute manifestation of a progressive disease of the cerebral small vessels. The severity of this disease seems to influence not only risk of ICH but also the size of the hematoma. As the burden of high blood pressure-related alleles is associated with both hypertension-related end-organ damage and risk of ICH, we sought to determine whether this burden influences ICH baseline hematoma volume. METHODS: Prospective study in subjects of European descent with supratentorial ICH who underwent genome-wide genotyping. Forty-two single nucleotide polymorphisms associated with high blood pressure were identified from a publicly available database. A genetic risk score was constructed based on these single nucleotide polymorphisms. The score was used as the independent variable in univariate and multivariate regression models for admission ICH volume and poor clinical outcome (modified Rankin Scale, 3-6). RESULTS: A total of 323 ICH cases were enrolled in the study (135 deep and 188 lobar intracranial hematomas). The blood pressure-based genetic risk score was associated with both baseline hematoma volume and poor clinical outcome specifically in deep ICH. In multivariate regression analyses, each additional SD of the score increased mean deep ICH volume by 28% (or 2.7 mL increase; ß=0.28; SE=0.11; P=0.009) and risk of poor clinical outcome by 71% (odds ratio, 1.71; 95% confidence interval, 1.05-2.80; P=0.03). CONCLUSIONS: Increasing numbers of high blood pressure-related alleles are associated with mean baseline hematoma volume and poor clinical outcome in ICH. These findings suggest that the small vessel vasculopathy responsible for the occurrence of the hemorrhage also influences its volume.

Bilateral supratentorial epidural hematomas: a rare complication in adolescent spine surgery.

A 14-year-old girl presented with a rare case of spontaneous bilateral supratentorial epidural hematomas which developed rapidly following cervical surgery. The hematomas presumably resulted from dural dynamics changes secondary to cerebrospinal fluid loss and intracranial hypotension. Intracranial epidural hemorrhage after spinal surgery is extremely uncommon with only one previous case report. Spontaneous intracranial epidural hematoma is an extremely rare complication, but should be considered as a possible complication of spine surgery, especially in adolescents complicated by delayed consciousness and breathing restoration from anesthesia. This case report expands the presently known clinical spectrum of this uncommon complication.

Spontaneous slow drainage of epidural hematoma into the subgaleal space through a skull fracture in an infant--case report.

A 4-month-old girl fell off a table onto the floor. Computed tomography performed 4 hours after the trauma showed a left parietal epidural hematoma (EDH) with an omega-shaped fracture line in the left parietal region. The EDH was enlarged after another 4 hours. However, the EDH showed drainage into the subgaleal space through the skull fracture 2 days after the trauma and was almost completely discharged into the subgaleal space by 5 days after trauma. Both the EDH and the subgaleal hematoma had resolved completely by 12 days after the trauma. No symptoms or signs were observed during the course. This case suggests that EDH can drain slowly and spontaneously into the subgaleal space through a skull fracture in an infant.

Abducens nerve palsy associated with a clival epidural hematoma.

A clival epidural hematoma is a rare lesion that usually develops after a hyperflexion or hyperextension injury of the neck, often in a child. A 5-year-old girl presented after a motor vehicle accident with multiple cranial neuropathies, including bilateral abducens nerve pareses and right facial, glossopharyngeal, and hypoglossal cranial nerve palsies. Neuroimaging identified a clival epidural hematoma. The child was observed and the hematoma resolved. The abducens nerve palsies resolved during the ensuing 14 months.