Computer-Assisted Measurement of Traumatic Brain Hemorrhage Volume Is More Predictive of Functional Outcome and Mortality than Standard ABC/2 Method: An Analysis of Computed Tomography Imaging Data from the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III Trial.

Hemorrhage volume is an important variable in emergently assessing traumatic brain injury (TBI). The most widely used method for rapid volume estimation is ABC/2, a simple algorithm that approximates lesion geometry as perfectly ellipsoid. The relative prognostic value of volume measurement based on more precise hematoma topology remains unknown. In this study, we compare volume measurements obtained using ABC/2 versus computer-assisted volumetry (CAV) for both intra- and extra-axial traumatic hemorrhages, and then quantify the association of measurements using both methods with patient outcome following moderate to severe TBI. A total of 517 computer tomography (CT) scans acquired during the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III (ProTECTIII) multi-center trial were retrospectively reviewed. Lesion volumes were measured using ABC/2 and CAV. Agreement between methods was tested using Bland-Altman analysis. Relationship of volume measurements with 6-month mortality, Extended Glasgow Outcome Scale (GOS-E), and Disability Rating Scale (DRS) were assessed using linear regression and area under the curve (AUC) analysis. In subdural hematoma (SDH) >50cm3, ABC/2 and CAV produce significantly different volume measurements (p < 0.0001), although the difference was not significant for smaller SDH or intra-axial lesions. The disparity between ABC/2 and CAV measurements varied significantly with hematoma size for both intra- and extra-axial lesions (p < 0.0001). Across all lesions, volume was significantly associated with outcome using either method (p < 0.001), but CAV measurement was a significantly better predictor of outcome than ABC/2 estimation for SDH. Among large traumatic SDH, ABC/2 significantly overestimates lesion volume compared with measurement based on precise bleed topology. CAV also offers significantly better prediction of patient functional outcofme and mortality.

Tranexamic Acid Inhibits Hematoma Expansion in Intracerebral Hemorrhage and Traumatic Brain Injury. Does Blood Pressure Play a Potential Role? A Meta-Analysis from Randmized Controlled Trials.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic agent, which has shown an effect on reducing blood loss in many diseases. Many studies focus on the effect of TXA on cerebral hemorrhage, however, whether TXA can inhibit hematoma expansion is still controversial. Our meta-analysis performed a quantitative analysis to evaluate the efficacy of TXA for the hematoma expansion in spontaneous and traumatic intracranial hematoma. METHOD: Pubmed (MEDLINE), Embase, and Cochrane Library were searched from January 2001 to May 2020 for randomized controlled trials (RCTs). RESULT: We pooled 3102 patients from 7 RCTs to evaluate the efficacy of TXA for hematoma expansion. Hematoma expansion (HE) rate and hematoma volume (HV) change from baseline were used to analyze. We found that TXA led to a significant reduction in HE rate (P = 0.002) and HV change (P = 0.03) compared with the placebo. Patients with moderate or serious hypertension benefit more from TXA. (HE rate: P = 0.02, HV change: P = 0.04) TXA tends to have a better efficacy on HV change in intracerebral hemorrhage (ICH). (P = 0.06) CONCLUSIONS: TXA showed good efficacy for hematoma expansion in spontaneous and traumatic intracranial hemorrhage. Patients with moderate/severe hypertension and ICH may be more suitable for TXA administration in inhibiting hematoma expansion .

Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage.

Recently, minimally invasive techniques, including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, have been used for the treatment of patients with spontaneous cerebellar hemorrhage (SCH). However, credible evidence is still needed to validate the effects of these techniques. To explore the long-term outcomes of both surgical techniques in the treatment of SCH. Fifty-two patients with SCH who received endoscopic evacuation or MIC evacuation were retrospectively reviewed. Six-month mortality and the modified Rankin Scale (mRS) score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of the different surgical techniques on patient outcomes. In the present study, the mortality rate for the entire cohort was 34.6%. Univariate analysis showed that the surgical technique and preoperative Glasgow Coma Scale (GCS) score affected 6-month mortality. However, no variables were found to be correlated with 6-month mRS scores. Further multivariate analysis demonstrated that 6-month mortality in the endoscopic evacuation group was significantly lower than that in the MIC evacuation group (OR = 4.346, 95% CI 1.056 to 17.886). The 6-month mortality rate in the preoperative GCS 9-14 group was significantly lower than that in the GCS 3-8 group (OR = 7.328, 95% CI 1.723 to 31.170). Compared with MIC evacuation, endoscopic evacuation significantly decreased 6-month mortality in SCH patients. These preliminary results warrant further large, prospective, randomized studies.

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.

[Special aspects of the emergency medical care of head and neck injuries]. / Besonderheiten der notärztlichen Versorgung von Kopf-/Halsverletzten.

The overall incidence of severe head, face and neck injuries as seen from the German Trauma Registry of the National Association of German Trauma Surgeons is 81.3%. The leading causes of death among these patients are hemorrhage and severe traumatic brain injury. The aim of prehospital emergency medical care is to stabilize vital functions in order to ensure primary survival and to reduce morbidity with appropriate prehospital treatment of the individual injuries within the overall injury pattern. In this review, special aspects as well as pitfalls of the prehospital management of patients with head, face and neck injuries are demonstrated. Prehospital airway management concepts as well as concepts for stopping bleeding in the head, face and neck region are discussed in detail.

Skull fracture and haemorrhage pattern among fatal and nonfatal head injury assault victims - a critical analysis.

BACKGROUND: The global incidence of fatal head injuries as the result of assault is greater than the number of non-fatal cases. The important factors that determine the outcome in terms of survival of such head injury cases include the type of weapon used, type and site of skull fracture, intra cranial haemorrhage and the brain injury. The present study aims to highlight the role of skull fractures as an indirect indicator of force of impact and the intra cranial haemorrhage by a comparative study of assault victims with fatal and nonfatal head injuries. METHODS: 91 head injury cases resulting from assault were studied in the Department of Forensic Medicine, IMS, BHU Varanasi over a period of 2 years from which 18 patients survived and 73 cases had a lethal outcome. Details of the fatal cases were obtained from the police inquest and an autopsy while examination of the surviving patients was done after obtaining an informed consent. The data so obtained were analyzed and presented in the study. RESULTS: Assault with firearms often led to fatality whereas with assault involving blunt weapons the survival rate was higher. Multiple cranial bones were involved in 69.3% cases while comminuted fracture of the skull was common among the fatal cases. Fracture of the base of the skull was noted only in the fatal cases and a combination of subdural and subarachnoid haemorrhage was found in the majority of the fatal cases. CONCLUSIONS: The present study shows skull fractures to be an important indicator of severity of trauma in attacks to the head. Multiple bone fracture, comminuted fracture and base fractures may be considered as high risk factors in attempted homicide cases.

Decompressive craniectomy as the primary surgical intervention for hemorrhagic contusion.

The standard surgical treatment of hemorrhagic cerebral contusion is craniotomy with evacuation of the focal lesion. We assessed the safety and feasibility of performing decompressive craniectomy and duraplasty as the primary surgical intervention in this group of patients. Fifty-four consecutive patients with Glasgow Coma Scale (GCS) scores of less than or equal to 8, a frontal or temporal hemorrhagic contusion greater than 20 cm(3) in volume, and a midline shift of at least 5 mm or cisternal compression on computer tomography (CT) scan were studied. Sixteen (29.7%) underwent traditional craniotomy with hematoma evacuation, and 38 (70.4%) underwent craniectomy as the primary surgical treatment. Mortality, reoperation rate, Glasgow Outcome Scale-Extended (GOSE) scores, and length of stay in both the acute care and rehabilitation phase were compared between these two groups. Mortality (13.2% vs. 25.0%) and reoperation rate (7.9% vs. 37.5%) were lower in the craniectomy group, whereas the length of stay in both the acute care setting and the rehabilitation phase were similar between these two groups. The craniectomy group also had better GOSE score (5.55 vs. 3.56) at 6 months. Decompressive craniectomy is safe and effective as the primary surgical intervention for treatment of hemorrhagic contusion. This study also suggests that patient with hemorrhagic contusion can possibly have better outcome after craniectomy than other subgroup of patients with severe traumatic brain injury.

Age thresholds for increased mortality of three predominant crash induced head injuries.

Trauma in the US's increasingly aged population will pose medical, engineering, and legislative challenges in the coming decade. This study sought to identify the age threshold of maximal risk for patients with the three most common isolated types of head injuries from motor vehicle crashes (MVCs). Receiver-operator characteristic analysis was used to identify the quantitative age threshold associated with increased mortality for the three most common MVC-induced types of head injuries. For each injury, an algorithm using multivariable logistic regression modeling was implemented to examine mortality as a function of age, adjusted for the GCS motor score and patient gender. The age threshold that maximized the area under the receiver operator characteristic curve (AUROC) was identified and the curve examined. The increased adjusted odds ratio (AOR) for death associated with each threshold was estimated along with 95% confidence intervals. Data used was from the American College of Surgeons National Trauma Data Bank (NTDB) version 7, Motor Vehicle Crash cases from Jan 1, 2001 to Dec 31, 2006. Three types of head injuries were of a sufficiently high incidence and severity level to be included in the study; the AIS 140684.3 (Cerebrum, Subarachnoid Hemorrhage, n=499), AIS 140650.4 (Cerebrum, Subdural Hematoma NFS, n=273), and AIS 140629.4 (Hematoma/Hemorrhage, Not Further Specified, n=123). The age thresholds are 58 (AOR=4.12, 95% CI 1.21-14.07, p=0.024), 54 (AOR=4.71, 95% CI 1.08-20.46, p=0.039) and 47 (AOR=15.44, 95% CI 2.94-81.2, p=0.001), respectively. Maximal AUROC values ranged from 0.89-0.93. This data along with data on injury mechanism has been used to provide information on the ideal 'threshold' beyond which age becomes an important factor for these three types of head injuries. This is the first study to quantitatively estimate the mortality threshold age for common isolated head injuries. This study has potential implications in the arena of safety design for the elderly, automated crash notification, and auto safety legislation.

The impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with hemorrhagic brain injury.

BACKGROUND: More elderly trauma patients are identified with preinjury use of clopidogrel, aspirin, or warfarin (CAW). The purpose of this study was to determine whether preinjury CAW use was an important predictor of mortality in patients aged >or=50 years with blunt, hemorrhagic brain injury (HBI). METHODS: A retrospective review of patients with blunt, HBI aged >or=50 years with subgroup analysis for older (>70 years) and younger (50-70 years) patients was performed. CAW use was analyzed for differences in age, gender, hospital length of stay (LOS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), mechanism of injury (MOI), platelet transfusion therapy (PLT), disposition at discharge, and in-hospital mortality. RESULTS: From January 2003 to October 2005, 416 patients were identified. The mean age was 69+/-1 years. No differences were found for ISS (24 +/- 0.5), GCS (12 +/- 0.2), or LOS (8 +/- 0.4 days). CAW use was present in 40% of patients and significantly higher in older patients. Mortality was not different between older and younger CAW(+) patients, but it significantly increased for older CAW(-) patients. Significant predictors of death included age, ISS, and GCS (P<.02). CONCLUSIONS: Preinjury CAW use in older blunt, HBI patients is not associated with increased mortality. Age was a significant predictor of mortality independent of CAW use.

Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma.

BACKGROUND: Most studies of traumatic intraventricular hemorrhage (tIVH) contain fewer than 25 subjects and are retrospective in design, providing minimal information about the entity and its clinical significance. METHODS: We prospectively enrolled trauma patients from 18 centers in North America in the National Emergency X-Radiography Utilization Study (NEXUS) II if they received an emergent head computed tomography (CT) scan, as determined by the managing physician. Clinical data were collected at the time of enrollment and CT reports were compiled at least 1 month later. We calculated prevalence and demographics of tIVH from the 18 sites, while outcome data were gathered from medical records of patients with tIVH who were seen at any of six sites that participated in the follow-up portion of the study. We considered patients who underwent a neurosurgical intervention or who had a "poor outcome" (Glasgow Outcome Scale score of 1 to 3, death, persistent vegetative state, or severe disability) to have suffered a "combined outcome." RESULTS: Prevalence of tIVH among all trauma patients who received a head CT was 118 in 8,374, or 1.41%. Among tIVH patients, 70% had a "poor outcome" and 76% had a "combined outcome." A poor outcome appeared to be associated with an abnormal presenting Glasgow Coma Scale score and involvement of the third or fourth ventricle, whereas age appeared to be unrelated. Patients with tIVH and no major associated injury on CT tended to do well; only one patient with isolated tIVH had a poor outcome. CONCLUSIONS: Traumatic IVH is rare and is associated with poor outcomes that seem to be the consequence of associated injuries. Isolated tIVH patients who are clinically well appear to have a functional outcome; we were unable to identify a case of isolated tIVH, combined with a normal neurologic examination, resulting in a poor or combined outcome.

Traumatic brain injury in anticoagulated patients.

BACKGROUND: Coumadin is widely used in the elderly population. Despite its widespread use, little is known about its effect on the outcome of elderly traumatic brain-injured patients. This study was undertaken to describe the outcomes of such a cohort. METHODS: Clinical material was identified from a Level I trauma center prospective head injury database, and a database obtained from the American College of Surgeons Committee on Trauma Verification and Review Committee from 1999 to 2002. Both databases contain many relevant variables, including age, sex, Glasgow Coma Scale (GCS) score, mechanism of injury, Injury Severity Score, International Normalized Ratio (INR), computed tomography (CT) findings, operative procedure, time to operating room, complications, length of stay, and outcome at hospital discharge. RESULTS: For patients with GCS scores less than 8, average INR was 6.0, with almost 50% having an initial value greater than 5.0. Overall mortality was 91.5%. For the 77 patients with GCS scores of 13 to 15, average INR was 4.4. Overall mortality for this group was 80.6%. A subset of patients deteriorated to a GCS score of less than 10 just hours after injury, despite most having normal initial CT scans. Mortality in this group was 84%. CONCLUSIONS: All patients on warfarin should have an INR performed, and a CT scan should be done in most anticoagulated patients. All supratherapeutically anticoagulated patients, as well as any anticoagulated patient with a traumatic CT abnormality, should be admitted for neurologic observation and consideration given to short term reversal of anticoagulation. Routine repeat CT scanning at 12 to 18 hours or when even subtle signs of neurologic worsening occur is a strong recommendation. A multi-institutional, prospective trial using these guidelines would be a first step toward demonstrating improved outcomes in the anticoagulated patient population after head trauma.

Violence is not necessary to produce subdural and retinal haemorrhage: a reply to Punt et al.

In this article we reply to the recent critique by Punt et al. in Pediatric Rehabilitation. Our hypothesis about the pathogenesis of intracranial bleeding in infants has three important implications. First, in the case of an infant with a swollen brain, subdural and retinal haemorrhage but no objective evidence of trauma, the findings by themselves are not certain evidence of abuse; second, violence is not necessary to produce subdural and retinal haemorrhage; and lastly, non-traumatic events producing apnoea with a catastrophic rise in intracranial pressure could produce a clinical picture identical to that seen in trauma.

Traumatic intracranial aneurysms.

Traumatic intracranial aneurysms are rare, occurring in fewer than 1% of patients with cerebral aneurysms. They can occur following blunt or penetrating head trauma and are more common in the pediatric population. Traumatic aneurysms can be categorized histologically as true, false, or mixed, with false aneurysms being the most common. These aneurysms can present in a variety of ways, but are typically associated with an acute episode of delayed intracranial hemorrhage with an average time from initial trauma to aneurysm hemorrhage of approximately 21 days. The mortality rate for patients harboring these aneurysms may be as high as 50%. Prompt diagnosis based on arteriography and aggressive surgical management are associated with better outcome than conservative treatment. The authors describe a classification scheme for traumatic aneurysms based on their anatomical location and conclude that 1) posttraumatic aneurysm must be considered in patients with acute neurological deterioration following closed head injury; 2) they can occur following mild closed head injury; 3) they occur more commonly in children than in adults; and 4) surgical clipping and/or endovascular occlusion is the definitive treatment.