Cardiac surgery for a right atrial myxoma with traumatic intracranial hemorrhage: a case report.

BACKGROUND: The timing of cardiac surgery with cardiopulmonary bypass (CPB) for intracranial hemorrhage is controversial. CASE PRESENTATION: We report the case of an 82-year-old woman who was transferred to our hospital because of a head injury. Brain computed tomography (CT) revealed traumatic intracranial hemorrhage, and transthoracic echocardiography revealed a giant right atrial myxoma. After confirming the disappearance of intracranial hemorrhage on brain CT, cardiac surgery with CPB was performed, which was uneventful. CONCLUSIONS: For an uneventful surgery, the optimal timing of cardiac surgery with CPB in patients with giant right atrial myxoma and intracranial hemorrhage should be based on brain CT.

Toward rational use of repeat imaging in children with mild traumatic brain injuries and intracranial injuries.

OBJECTIVE: Limited evidence exists on the utility of repeat neuroimaging in children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs). Here, the authors identified factors associated with repeat neuroimaging and predictors of hemorrhage progression and/or neurosurgical intervention. METHODS: The authors performed a multicenter, retrospective cohort study of children at four centers of the Pediatric TBI Research Consortium. All patients were ≤ 18 years and presented within 24 hours of injury with a Glasgow Coma Scale score of 13-15 and evidence of ICI on neuroimaging. The outcomes of interest were 1) whether patients underwent repeat neuroimaging during index admission, and 2) a composite outcome of progression of previously identified hemorrhage ≥ 25% and/or repeat imaging as an indication for subsequent neurosurgical intervention. The authors performed multivariable logistic regression and report odds ratios and 95% confidence intervals. RESULTS: A total of 1324 patients met inclusion criteria; 41.3% of patients underwent repeat imaging. Repeat imaging was associated with clinical change in 4.8% of patients; the remainder of the imaging tests were for routine surveillance (90.9%) or of unclear prompting (4.4%). In 2.6% of patients, repeat imaging findings were reported as an indication for neurosurgical intervention. While many factors were associated with repeat neuroimaging, only epidural hematoma (OR 3.99, 95% CI 2.22-7.15), posttraumatic seizures (OR 2.95, 95% CI 1.22-7.41), and age ≥ 2 years (OR 2.25, 95% CI 1.16-4.36) were significant predictors of hemorrhage progression and/or neurosurgery. Of patients without any of these risk factors, none underwent neurosurgical intervention. CONCLUSIONS: Repeat neuroimaging was commonly used but uncommonly associated with clinical deterioration. Although several factors were associated with repeat neuroimaging, only posttraumatic seizures, age ≥ 2 years, and epidural hematoma were significant predictors of hemorrhage progression and/or neurosurgery. These results provide the foundation for evidence-based repeat neuroimaging practices in children with mTBI and ICI.

Ultrasonic diagnosis of delayed hematoma during emergency removal of traumatic intracranial hematoma: A case report and literature review.

RATIONALE: It is emergency and vital during neurosurgical procedure in traumatic intracranial when an acute intraoperative brain bulge (AIBB) is occurred. It is important to get a diagnosis quickly. PATIENT CONCERNS: A 44-year-old man was undergone a neurosurgical procedure for the left side of traumatic intracranial hematoma. An AIBB was occurred during the surgery. Computed tomography (CT) is always used in diagnosis when an AIBB is occurred, but more time is needed when CT is conducted. DIAGNOSES: We diagnosed the AIBB through bedside real-time ultrasound, and a delayed hematoma which caused the AIBB was found. INTERVENTIONS: A further neurosurgical procedure of right intracranial hematoma was performed for the patient. OUTCOMES: The surgical effect and the patient's prognosis were significantly improved. LESSONS: Through this patient, we should pay more attention to the application of perioperative of real-time ultrasonic monitoring, to provide more convenience for surgical patients, and improve the prognosis of them.

Clinical Utility of Near-Infrared Device in Detecting Traumatic Intracranial Hemorrhage: A Pilot Study Toward Application as an Emergent Diagnostic Modality in a Low-Resource Setting.

Limited computed tomography (CT) availability in low- and middle-income countries frequently impedes life-saving neurosurgical decompression for traumatic brain injury. A reliable, accessible, cost-effective solution is necessary to detect and localize bleeds. We report the largest study to date using a near-infrared device (NIRD) to detect traumatic intracranial bleeds. Patients with confirmed or suspected head trauma who received a head CT scan were included. Within 30 min of the initial head CT scan, a blinded examiner scanned each patient's cranium with a NIRD, interrogating bilaterally the frontal, parietal, temporal, and occipital quadrants Sensitivity, specificity, accuracy, and precision were investigated. We recruited 500 consecutive patients; 104 patients had intracranial bleeding. For all patients with CT-proven bleeds, irrespective of size, initial NIRD scans localized the bleed to the appropriate quadrant with a sensitivity of 86% and specificity of 96% compared with CT. For extra-axial bleeds >3.5mL, sensitivity and specificity were 94% and 96%, respectively. For longitudinal serial rescans with the NIRD, sensitivity was 89% (< 4 days from injury: sensitivity: 99%), and specificity was 96%. For all patients who required craniectomy or craniotomy, the device demonstrated 100% sensitivity. NIRD is highly sensitive, specific, and reproducible over time in diagnosing intracranial bleeds. NIRD may inform neurosurgical decision making in settings where CT scanning is unavailable or impractical.

Emergent surgical evacuation of traumatic intracranial hematoma in patients with preoperative thrombocytopenia: surgical risk and early outcome.

BACKGROUND: Surgical evacuation of intracranial hematoma, including epidural, subdural, intracerebral, and intraventricular hematoma, is recommended in patients with traumatic brain injury (TBI) for prevention of cerebral herniation and possible saving of life. However, preoperative coagulopathy is a major concern for emergent surgery on patients with severe TBI. METHODS: We reviewed 65 consecutive patients with severe TBI who underwent emergency craniotomy for intracranial hematomas. RESULTS: Univariate analysis showed preoperative pupil abnormality, absence of pupil light reflex, respiratory failure, preoperative thrombocytopenia (< 100 × 109/L), increased activated partial thromboplastin time (> 36 s), low fibrinogen (< 150 mg/dL), platelet transfusion, red cell concentrate transfusion, and presence of brain contusion and traumatic subarachnoid hemorrhage (SAH) on computed tomography were correlated with poor outcome (death or vegetative state). Multivariate analysis revealed that pupil abnormality (p = 0.001; odds ratio [OR] 0.064, 95% confidence interval [CI] 0.012-0.344), preoperative thrombocytopenia (p = 0.016; OR 0.101, 95% CI 0.016-0.656), and traumatic SAH (p = 0.021; OR 0.211, 95% CI 0.057-0.791) were significant factors. Investigation of the 14 patients with preoperative thrombocytopenia found the emergency surgery was successful, with no postoperative bleeding during hospitalization. However, half of the patients died, and almost a quarter remained in the vegetative state mainly associated with severe cerebral edema. CONCLUSIONS: Emergent craniotomy for patients with severe TBI who have preoperative thrombocytopenia is often successful, but the prognosis is often poor. Emergency medical care teams and neurosurgeons should be aware of this discrepancy between successful surgery and poor prognosis in these patients. Further study may be needed on the cerebral edema regulator function of platelets.

Therapeutic Strategies in Traumatic Intracranial Hemorrhage and Outcomes.

BACKGROUND: Traumatic intracranial hemorrhage (TICH) and its progression have historically resulted in poor prognosis and functional disability. Such outcomes can impact the daily lives and financial condition of patients' families as well as add burden to the health care system. This review examines the diverse therapeutic intervention that were observed in randomized clinical trials (RCT) on various outcomes. Many demographic and clinical risk factors have been identified for poor prognosis after a TICH. Among the many therapeutic strategies studied, few found to have some beneficial effect in minimizing the progression of hemorrhage and reducing the overall mortality. METHODS: A literature review was conducted of all relevant sources using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include articles that were RCTs for patients aged 18 years and above to include a total of 19 articles. RESULTS: Across studies, many therapies have been assessed; however, only few findings including infusion of tranexamic acid (TXA), use of ß-blocker, and early operative evacuation of TICH yielded favorable results. Use of steroid and blood transfusion to target higher hemoglobin levels showed evidence of adversely impacting the outcome. CONCLUSION: Of the many therapeutic strategies available for TICH, very few therapies have proven to be beneficial.

Incidence of traumatic intracranial hemorrhage expansion after stable repeat head imaging: A retrospective cohort study.

INTRODUCTION: Patients with traumatic intracranial hemorrhage (tICH) often require intensive care unit (ICU) admission until bleeding stability is demonstrated through interval head computed tomography (HCT). The brain injury guidelines (BIG) suggest a minimum 24-h ICU admission for severe patients (BIG 3) regardless of repeat CT stability. We sought to evaluate the rate of tICH expansion after an initial stable interval scan was obtained. METHODS: A single-center retrospective cohort study at a level 1 trauma center was performed. All adult patients with tICH evaluated using BIG criteria were included. The primary endpoint was incidence of tICH expansion after initial stability on interval HCT performed at approximately 6 h. Secondary endpoints included time to tICH stability, frequency of neurosurgical intervention, and time to surgical intervention. RESULTS: A total of 1517 patients met inclusion criteria. Of the 1121 patients with repeat imaging, 288 (25.7%) experienced progression with 94.4% detected on the initial 6-h interval scan. Of all patients with initially stable repeat imaging (n = 833), progression occurred in 16 (1.9%) patients. Of these patients, 5 required neurosurgical intervention, 4 received increased monitoring, 2 transitioned to comfort measures and 5 had no change in management. The median time from initial scan to expansion in these patients was 42.2 h. Median time to surgical intervention after post-stability expansion was 102 h. CONCLUSION: Patients who demonstrate bleeding stability on first interval HCT after tICH rarely experience expansion. Consideration should be given to discharging patients from the ICU when initial interval HCT shows no progression.

Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review.

BACKGROUND: Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS: A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS: Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS: Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.

[Surgical Management of a Post-traumatic Intracranial Hematoma].

Surgery is one of the primary options for the management of traumatic brain injury(TBI). We focused on operative techniques, additional options, and potential pitfalls of surgical intervention for intracranial hematomas, such as acute subdural hematoma(ASDH), acute epidural hematoma(AEDH), cerebral contusion, and intracerebral hematoma. A wide craniotomy covering the hematoma was recommended for a case of AEDH to evacuate the hematoma, control bleeding, and prevent blood reaccumulation. Combined multiple craniotomies leaving a bone bridge over the sinus for dural tenting sutures enabled safe surgical intervention in a case of AEDH with sinus injuries. Different surgical techniques have been advocated for the evacuation of ASDH. Large craniotomy is often chosen as it can easily be shifted to decompressive craniectomy in case of brain swelling. It is important to pay attention to injuries of dural sinuses and bridging veins, and to expose the floor of the middle cranial fossa. Small craniotomy or endoscopic burr-hole evacuation of ASDH has been accepted as a way to avoid large craniotomies and additional morbidity, particularly for patients who are poor surgical candidates. Contusion necrotomy is performed for satisfactory control of progressive elevation in intracranial pressure and clinical deterioration.

Effects of STC on postoperative recovery of disturbance of consciousness in traumatic multiple intracranial hematoma patients.

OBJECTIVE: The study explored the therapeutic value of standard trauma craniectomy (STC) for the treatment of traumatic multiple intracranial hematoma. METHODS: Clinical data of traumatic multiple intracranial hematoma patients who underwent surgical treatment in 2014 and 2015 were collected. The STC group and a control group according to the surgical mode, 48 and 30 cases were randomly selected from each group, respectively. Statistical analysis was performed on the change in the Glasgow coma scale (GCS) score from before the operation to 1 day, 1 week and 1 month postoperatively through repeated analysis of variance and Wilcoxon rank-sum analysis. RESULTS: Significant differences in the GCS were observed at different time points for the two operative modes (P < .01), and an interaction was observed between time and treatment groups (P < .05). The rates of change of the GCS score for the two surgical modes were most obviously different at 3 days and 1 week postoperatively (P ≤ .001, P < .01). No statistically significant differences were observed in the rates of change of the GCS at 1 month postoperatively (P > .05). CONCLUSIONS: Compared to conventional craniotomy, STC has obvious effects on the recovery after disturbance of consciousness at 1 week postoperatively but does not result in a significant improvement in recovery at 1 month postoperatively.

High fibrin/fibrinogen degradation product value as a risk factor for progressive remote traumatic intracranial haemorrhage following neurosurgery.

INTRODUCTION: Remote traumatic intracranial haemorrhage (RTIH) may develop after neurosurgery. Recognition of the risk factors for RTIH before surgery might be of great value. The purpose of this study was to verify if the fibrin/fibrinogen degradation product (FDP) value may be a risk factor for RTIH. METHODS: This was a retrospective study of the data of 56 patients with traumatic intracranial hematomas shown on initial computed tomography (CT) who were treated with craniotomy or decompressive craniectomy and underwent a follow-up CT at a single centre over a period of approximately 10.5 years. We divided the patients into 2 groups: those who developed RTIH (Positive: P-group) and those who did not (Negative: N-group). We compared the 2 groups in terms of not only the laboratory data before surgery, but also patient age, sex, antiplatelet/antithrombotic medications received, cause of injury, and GCS score on arrival. RESULTS: RTIH was observed in 22 patients (P-group, 39.3%). The FDP value was the only significant risk factor identified in this study (p = 0.00076). The cut-off value was estimated on the basis of the area under the receiver operating characteristic (ROC) curve. The cut-off FDP value was 120 µg/mL (63.6% sensitivity and 85.3% specificity). CONCLUSIONS: FDP levels over 120 µg/mL were determined to be a risk factor for progressive RTIH after neurosurgery. We suggest the FDP level be checked before surgery for traumatic intracranial haemorrhage and follow-up CT be done as soon as possible after the surgery if the serum FDP level is over 120 µg/mL.

Surgical outcomes in traumatic brain injuries with bilateral mass occupying lesions. Analysis of prognostic factors.

INTRODUCTION: Traumatic brain injury is a silent epidemic with major impacts on national productivity as it affects the economically productive age group. Bilateral injuries are usually severe with no clearly defined predictors of outcome as per current available literature. METHODS: We retrospectively assessed 102 consecutive cases of post traumatic intracranial mass lesions operated bilaterally, either simultaneously or sequentially, between January 2011 and April 2019. The primary and secondary end points of the study were to assess mortality and GCS at discharge respectively. RESULTS: The cohort included 102 patients. 91(89.2 %) were males, mean age was 40(±13.6) years. Median GCS at presentation was 9 with 47(46.07 %) having moderate head injury. EDH with contusion was seen in 38(37.3 %), SDH with contusion in 24(23.5 %) and 4 patients (3.9 %) had EDH, SDH and contusion. On univariate analysis, female gender(p = 0.001), poor GCS at presentation(p < 0.001), higher Rotterdam grade on initial CT scan(p < 0.001), need for blood transfusions(p = 0.026) and intraoperative hypotension(p = 0.007) were associated with significantly higher mortality. On multivariate analysis female gender(p = 0.034), poor GCS(p = 0.026) and worse Rotterdam score(p = 0.038) were associated with mortality. Among the subgroup of survivors, GCS at presentation(p < 0.001), Rotterdam grading(p = 0.003), time to surgery after trauma(p = 0.032), duration of hospital stay(<0.001), intraoperative brain bulge(p=.003) and craniotomy instead of craniectomy(p = 0.001) were associated with clinical outcome at discharge. CONCLUSION: Traumatic brain injuries with bilateral mass lesions requiring surgery have been rarely reported. In this study we have elucidated management strategies and have further studied the factors influencing mortality and clinical outcome. Careful considerations are required in decision making in such cases. Larger multicentric studies would throw more light on outcomes of this rare variety of traumatic brain injury.

Applying Pediatric Brain Injury Guidelines at a Level I Adult/Pediatric Safety-Net Trauma Center.

BACKGROUND: Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC. METHODS: A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included. RESULTS: Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I. CONCLUSIONS: Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.

Successful Surgical Management of Traumatic Intracranial Hemorrhaging After Revascularization Surgery for Moyamoya Vasculopathy: A Case Report and Review of Literature.

BACKGROUND: Traumatic intracranial hemorrhaging associated with revascularization surgery for moyamoya vasculopathy is a potentially devastating problem that requires meticulous management, including surgery. However, only a few studies on this subject have been reported, and the clinical characteristics are poorly understood. We report a case of successful surgical management for a patient with traumatic intracranial hematoma managed with encephalo-duro-arterio-myo-synangiosis (EDAMS). The purpose of this article is to clarify the specific features of clinical scenarios, hemorrhagic sites, and operative techniques by reviewing all published cases. CASE DESCRIPTION: A 10-year-old Japanese girl with a history of EDAMS for quasi-moyamoya disease was referred to our institution after minor head trauma. Cranial computed tomography scans revealed a right intracranial hematoma overlying the temporal muscle flap. After admission, hematoma developed, and emergency hematoma evacuation was performed. Venous hemorrhaging from the fascia of the temporal muscle flap was confirmed. Collaterals from indirect bypass were preserved in the surgery. Postoperative diffusion-weighted imaging revealed no ischemic complications. She immediately recovered and returned to her preinjury baseline. CONCLUSION: In moyamoya vasculopathy, intrinsic collaterals or de novo anastomoses from revascularization surgery are easily injured, even with mild head trauma. Furthermore, the administration of antiplatelets agents increases the risk of hematoma development. Sacrifice of collaterals can lead to acute cerebral infarction. During emergency surgery for traumatic intracranial hematoma, a careful surgical strategy is needed to preserve the collateral supply.

Repeat Surgery After Decompressive Craniectomy for Traumatic Intracranial Hemorrhage: Outcomes and Predictors.

INTRODUCTION: Repeat surgery (RS) after decompressive craniectomy/craniotomy (DC) for traumatic intracranial hemorrhage (TICH) is a devastating complication. In patients undergoing DC for TICH, we sought to 1) describe the population requiring RS, 2) compare outcomes of those requiring RS with those who did not, and 3) discern RS predictors. METHODS: A single-institution retrospective case-control study was conducted from 2000 to 2015. Inclusion criteria were DC for acute supratentorial TICH (subdural hemorrhage, epidural hemorrhage, and intraparenchymal hemorrhage) and ≥7 day survival. Patients underwent RS within 7 days of DC; controls did not require RS. Outcomes and predictors of RS were evaluated with univariate and multivariate logistic regression (MLR). RESULTS: Of 201 patients requiring DC, 28 (14%) underwent RS. Common mechanisms were ground-level fall (45%) and motor vehicle collision (29%). Anticoagulation/antiplatelet medication was used by 44 patients (21%). Subdural hemorrhage was the most common hemorrhage (64%). Using MLR, those requiring RS were more likely to experience major complications (odds ratio [OR], 22.6; 95% confidence interval [CI], 5.06-101.35; P < 0.001) and in-hospital mortality (OR, 2.76; 95% CI, 1.02-7.43; P = 0.045) and be dead/dependent at 6 months (OR, 2.50; 95% CI, 1.08-5.82; P = 0.033) and 2 years (OR, 2.44; 95% CI, 0.99-6.00; P = 0.051). Predictors of undergoing RS identified by MLR were smaller hemorrhage (OR, 0.32; 95% CI, 0.13-0.78; P = 0.012), larger midline shift (OR, 4.40; 95% CI, 1.43-13.51; P = 0.010), and better preoperative Glasgow Coma Scale score (OR, 1.28; 95% CI, 1.13-1.46; P < 0.001). CONCLUSIONS: Patients requiring RS after DC represent a heterogenous population with worse outcomes. Although the identified risk factors for RS are not modifiable, surgeons should be aware of these factors during the initial surgery.

A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury.

OBJECTIVE: Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS: A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS: No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS: FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.

Consequences of pre-injury utilization of direct oral anticoagulants in patients with traumatic brain injury: A systematic review and meta-analysis.

BACKGROUND: The rapid adoption and widespread use of direct oral anticoagulants (DOACs) has outpaced research efforts to establish their effects in bleeding trauma patients. In patients with complicated traumatic brain injury (TBI) caused by intracranial hemorrhage, DOAC use may be associated with higher bleeding volume and potentially more disastrous sequelae than use of vitamin K antagonists (VKAs). In the current systematic review and meta-analysis we set out to evaluate the literature on the relationship between preinjury DOAC use and course of the intracranial hemorrhage. (ICH), its treatment and mortality rates in TBI patients, and to compare these outcomes to those of patients with preinjury VKA use. METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched using a search strategy including three main terms: "traumatic brain injury," "direct oral anticoagulants," and "vitamin K antagonists." There were 1,446 abstracts screened, and ultimately, six included articles. Random effects modeling meta-analysis was performed on in-hospital mortality, ICH progression and neurosurgical intervention rate. RESULTS: All cohorts had similar baseline and emergency department parameters. Within individual studies surgery rate, reversal agents used, ICH progression and in-hospital mortality differed significantly between DOAC and VKA cohorts. Meta-analysis showed no significant difference in in-hospital mortality (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.23-4.06; I = 76%; p = 0.97), neurosurgical interventions (OR, 0.48; 95% CI, 0.14-1.63; p = 0.24), or ICH progression rates (OR, 1.86; 95% CI, 0.32-10.66; p = 0.49) between patients that used preinjury DOACs versus patients that used VKAs. CONCLUSION: Direct oral anticoagulant-using mild TBI patients do not appear to be at an increased risk of in-hospital mortality, nor of increased ICH progression or surgery rates, compared with those taking VKAs. LEVEL OF EVIDENCE: Systematic review, level III.

Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas.

INTRODUCTION: Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making. METHODS: A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon. RESULTS: Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline. CONCLUSION: Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.

Use of Anticoagulation Agents After Traumatic Intracranial Hemorrhage.

OBJECTIVE: Anticoagulant therapy (ACT) after traumatic intracranial hemorrhage may lead to progression of hemorrhage, but in the presence of thromboembolic events, the clinician must decide if the benefits outweigh the risks. Currently, no data exist to guide therapy in the acute setting. METHODS: We retrospectively identified all patients admitted to our institution with traumatic intracranial hemorrhage that received intravenous heparin, full-dose enoxaparin, or warfarin during their initial hospitalization over a 3-year period. We reviewed their demographics, hospital course, clinical indication and timing for initiation of ACT, and complications. RESULTS: A total of 112 patients were identified. The median age and Glasgow Coma Scale score of these patients was 50.5 years and 9.5, respectively. Twenty-two patients required neurosurgical procedures for their presenting injury, including intracranial pressure monitors and/or open surgeries. Fifty-four patients had deep vein thrombosis or pulmonary embolism prior to initiation, and the remaining 20 patients had preexisting conditions or other indications for initiating ACT. The median time from injury to starting ACT was 8 days. Immediate complications occurred in 6 patients; however, none of these patients required a neurosurgical intervention. Delayed complications included progression of acute to chronic subdural hematoma that required intervention in 2 patients. One patient died from delayed hemorrhage. CONCLUSIONS: For this patient population, the risk of immediate and delayed intracranial hemorrhages from initiating ACT therapy in intracranial injury must be weighed against the morbidity of delaying treatment. Although further studies are needed, our review provides the first rates of complications for this patient population.