The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis.

OBJECTIVE: Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits. METHODS: A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs). RESULTS: Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality. CONCLUSION: With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.

Subdural and epidural hematoma occurrence in relation to the head impact site: An autopsy study.

Blunt head injury is a major public health and socioeconomic problem causing death and disability particularly among the young population throughout the world. The purpose of the present study was to evaluate if the impact site is correlated with the subdural and epidural hematoma occurrence. A retrospective analysis of consecutive autopsy cases submitted to our Department during a 5-year period was performed. The basic criterion for inclusion in the study was death due to blunt head injury. The recorded variables included the circumstances of death, the existence, and location of head injuries, the primary impact site, age, gender, and toxicological results. A total number of 683 fatal head injury cases was recorded, with most of them being male (74.1%). In 424 cases (62.1%) fatal head injuries were due to road traffic accidents. Fall (from height or on the ground) was the cause of death in 220 (32.2%) cases followed by inflicted impact-assault in 26 (3.8%) cases. A subdural hematoma was found more frequently (26.9%) than epidural (5.0%). Epidural hematomas were found only under the primary impact site, whereas subdural hematomas were coup, contrecoup, or bilateral. An epidural hematoma was found to be almost 5 times more frequent in cases in which a subdural hematoma was present. A higher proportion of subdural, as well as epidural hematoma, was found when the site of impact was the temporal region, followed by the parietal one. Sex did not exert any influence on the probability of subdural and epidural hematoma, whereas for age, a 10% increase in the probability of subdural hematoma occurrence was observed with 10-year age increase.

The Incidence of Depressed Skull Fractures Due to the Use of Pin-Type Head Frame Systems in the Adult Population: 10-year Experience of a Single Neurosurgical Center.

OBJECTIVE: Pin-type head frame systems have become a worldwide standard procedure, but they can cause some complications on rare occasions. This study aimed to examine the incidence and associated risk factors of depressed skull fracture and related intracranial hematoma (DSFH) due to the use of head frames in our institute over the past 10 years. METHODS: This study included 1749 patients who underwent neurosurgical surgeries using pin-type head frames, including the Mayfield (Integra NeuroSciences, Plainsboro, NJ) skull clamp (721 cases) and the Sugita (Mizuho Ikakogyo Co., Ltd., Tokyo, Japan) head frame (1028 cases). We retrospectively reviewed hospital records of our institute to identify cases of DSFH, and documented the type of head frame used, as well as patient characteristics. RESULTS: The incidence of DSFH was 0.29% (5 of 1749 cases). All 5 cases had an associated epidural hematoma, with a single case having an additional dural laceration (without subdural damage). All perforation sites, located at the parietal bone near the pterion, occurred by the unilateral horizontal screw of the Sugita head frame. None of the patients experienced postoperative neurological decline. CONCLUSIONS: Even in the adult population, the DSFH by the pin-type head frame can occur infrequently. Based on our results, we recommend that the following factors should be considered when the pin-type head frame is used for neurosurgical procedures: location of pin application, thickness and fragility of the skull, and adequate control of compressive forces exerted by the head frame.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating.

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Occurrence of traumatic brain injury due to short falls with or without a witness by a nonrelative in children younger than 2 years.

OBJECTIVE: There is disagreement about the occurrence of severe traumatic brain injury, especially subdural hematoma, caused by short falls in very young children. To verify intracranial injury due to these falls and examine its characteristics, the authors compared infants and toddlers with head trauma witnessed by a nonrelative with those whose injuries were not witnessed by a nonrelative. METHODS: The authors retrospectively reviewed clinical records of children younger than 2 years with head trauma due to a short fall who visited the emergency department of the National Center for Child Health and Development in Japan between April 2015 and March 2018. Patients were classified into two groups: falls that were witnessed by a nonrelative and falls not witnessed by a nonrelative. The authors compared the age in months, sex, mechanism of injury, fall height, prevalence rate of intracranial injury, skull fracture, type of traumatic brain injury, retinal hemorrhage, rib or long-bone fracture, and outcomes between patients whose fall was witnessed by a nonrelative and those whose fall was not witnessed by a nonrelative. RESULTS: Among 1494 patients included in the present analysis, 392 patients were classified into the group of falls witnessed by a nonrelative, and 1102 patients were classified into the group of falls that were not witnessed by a nonrelative. The prevalence rates of intracranial injury, skull fracture, epidural hematoma, and subarachnoid hemorrhage were equal between the groups. The prevalence rate of subdural hematoma in the group whose falls were witnessed by a nonrelative was significantly lower than that of the other group (p = 0.027). There were no patients with subdural hematoma, retinal hemorrhage, or neurological sequelae in the group whose fall was witnessed by a nonrelative. CONCLUSIONS: Subdural hematoma, retinal hemorrhage, and neurological sequelae due to short falls were not seen after witnessed falls in the present study.

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.

Severe Traumatic Brain Injury Cases among Children Younger than 24 Months.

INTRODUCTION: Accidental head injuries are known to cause serious traumatic brain injury (TBI). Children younger than 2 years of age build a separate group that is more difficult to assess clinically. Investigations targeting TBIs in pediatric cases, particularly in those between 0 and 2 years of age, are limited. OBJECTIVE: In this study, we reviewed a number of severe accidental head injuries in a cohort of children aged 0-2 years to evaluate the relative incidence, distribution, and clinical success in determining the nature of the cases in the Kars Province of Turkey. METHODS: The study targeted 26 -cases who presented to the Emergency Department of Kars Harakani Hospital for TBI between 2017 and 2019 through retrospective chart review. RESULTS AND CONCLUSIONS: Among the children who presented to the emergency clinic, 2 were newborns, 7 were <1 year of age, and the remaining 17 cases were between 1 and 2 years old. The number of male and female patients was equal, and 5 fatality cases were observed. The most frequent cause of head trauma were falls. We deduced that 6 cases had subarachnoid hemorrhage, 2 cases had subdural hemorrhage, 3 cases had epidural hemorrhage, and 4 cases had contusion. We compared the mean level of the two blood parameters hemoglobin (HGB) and hematocrit (HCT) between fatal and surviving cases and detectedthat both values decreased dramatically in exitus cases. The higher fatality rate in the present study could be attributed to the fact that we targeted only the severe TBI cases. Severe TBI in children younger than 2 years results in a life-threating situation. The risk of fatality might be deduced from the reduction of the HGB and HCT levels as it is significantly lower in fatal cases than in surviving cases.

Predicting mortality in traumatic intracranial hemorrhage.

OBJECTIVE: Traumatic intracranial hemorrhage (tICH) is a significant source of morbidity and mortality in trauma patients. While prognostic models for tICH outcomes may assist in alerting clinicians to high-risk patients, previously developed models face limitations, including low accuracy, poor generalizability, and the use of more prognostic variables than is practical. This study aimed to construct a simpler and more accurate method of risk stratification for all tICH patients. METHODS: The authors retrospectively identified a consecutive series of 4110 patients admitted to their institution's level 1 trauma center between 2003 and 2013. For each admission, they collected the patient's sex, age, systolic blood pressure, blood alcohol concentration, antiplatelet/anticoagulant use, Glasgow Coma Scale (GCS) score, Injury Severity Score, presence of epidural hemorrhage, presence of subdural hemorrhage, presence of subarachnoid hemorrhage, and presence of intraparenchymal hemorrhage. The final study population comprised 3564 patients following exclusion of records with missing data. The dependent variable under study was patient death. A k-fold cross-validation was carried out with the best models selected via the Akaike Information Criterion. These models risk stratified the study partitions into grade I (< 1% predicted mortality), grade II (1%-10% predicted mortality), grade III (10%-40% predicted mortality), or grade IV (> 40% predicted mortality) tICH. Predicted mortalities were compared with actual mortalities within grades to assess calibration. Concordance was also evaluated. A final model was constructed using the entire data set. Subgroup analysis was conducted for each hemorrhage type. RESULTS: Cross-validation demonstrated good calibration (p < 0.001 for all grades) with a mean concordance of 0.881 (95% CI 0.865-0.898). In the authors' final model, older age, lower blood alcohol concentration, antiplatelet/anticoagulant use, lower GCS score, and higher Injury Severity Score were all associated with greater mortality. Subgroup analysis showed successful stratification for subarachnoid, intraparenchymal, grade II-IV subdural, and grade I epidural hemorrhages. CONCLUSIONS: The authors developed a risk stratification model for tICH of any GCS score with concordance comparable to prior models and excellent calibration. These findings are applicable to multiple hemorrhage subtypes and can assist in identifying low-risk patients for more efficient resource allocation, facilitate family conversations regarding goals of care, and stratify patients for research purposes. Future work will include testing of more variables, validation of this model across institutions, as well as creation of a simplified model whose outputs can be calculated mentally.

Clinical Outcome of Epidural Hematoma Treated Surgically in the Era of Modern Resuscitation and Trauma Care.

OBJECTIVE: Patients from contemporary populations with traumatic brain injury (TBI) resulting from epidural hematoma (EDH) may differ regarding age, comorbidities, and coagulation status. We therefore analyzed predictors for the clinical outcome of patients with EDH treated surgically regarding modern approaches to resuscitation and trauma care. METHODS: A retrospective observational analysis was carried out. All patients included underwent surgery. The indication for surgery followed international guidelines. Retrospective data evaluation considered data reflecting the effectiveness of trauma care, baseline characteristics, and radiologic findings. In this analysis, we divided patients into 2 groups (isolated EDH vs. EDH plus other intracranial traumatic injuries). The neurologic outcome was assessed at discharge using the Glasgow Outcome Scale. RESULTS: Two hundred and sixty-eight patients with epidural hematoma, of whom 131 underwent surgery, were treated between January 1997 and December 2012 in our level-1 trauma center. The overall mortality was 6.8% (mortality for patients with Glasgow Outcome Scale score <9, 15%). As expected, factors with a highly significant (P < 0.01) impact on outcome were concomitant with other intracranial injuries, brain midline shift, and higher Injury Severity Score. Alcohol intoxication was a significant (P < 0.05) predictor of an unfavorable outcome. Anticoagulants and Glasgow Coma Scale score at admission had no significant impact on the outcome. CONCLUSIONS: The outcome for EDH is more favorable than decades ago, most probably reflecting a well-established chain of trauma care. Therefore, EDH is a treatable disease with a high probability of a favorable outcome.

Epidemiology of traumatic brain injury in the elderly over a 25 year period. / Epidemiología del traumatismo craneoencefálico en la población mayor de 65 años a lo largo de 25 años.

OBJECTIVE: To identify the changes in the epidemiology of traumatic brain injury (TBI) in a cohort of patients older than 65 years old admitted in the Intensive care unit of a third-level hospital over a 25 year period. MATERIAL AND METHODS: A retrospective cohort study conducted on patients over 65 years-old admitted with the diagnosis of TBI into an intensive care unit of a Spanish university hospital. The demographic, clinical variables were collected at the time of admission, including comorbidities, injury mechanisms, and injuries presented, and days of stay in ICU. A statistical analysis was carried out by five-year periods. RESULTS: A total of 446 TBI in patients over 65 years were included. In the analysis, an increase was observed in the proportion of patients presenting with epidural haematoma (1.39% in the period 1990-1995 vs. 9.46% in 2010-2015), with a significant linear tendency (P=.018). Falls from own height have increased from 8.33% (1991-1995) to currently more than 70% (2011-2015), P<.001. The percentage of traffic accidents declined from 26.39% to 3.95% in the last period, P<.001. CONCLUSIONS: In the last 25 years there seems to be evidence of a change in the origins of TBI in the elderly in our field.

SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations.

Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.

Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury.

OBJECTIVE Early radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models. METHODS The authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present. RESULTS In general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3-8). CONCLUSIONS In these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.

The pathogenesis of delayed epidural hematoma after posterior fossa surgery.

The purpose of this study was to analyze the pathogenesis of delayed epidural hematoma (EDH) after posterior fossa surgery. Non-traumatic, non-arterial origin delayed EDH after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure. Between April 1997 and June 2016, over 3300 patients underwent microvascular decompression (MVD) for neurovascular compression syndrome. The medical chart of four patients with delayed EDH were retrospectively reviewed. The median time from MVD to re-CT scan was 58 h (range, 33-100). All patients underwent hematoma evacuations. Intraoperative findings during hematoma evacuation revealed only an oozing hemorrhage from the transverse sinus with no definitive bleeding focus. The patients spent a median of 21.5 days (range, 11-39) at the hospital. At the last follow-up, all patients had fully recovered without significant neurological deficits and exhibited complete relief or minimal symptoms from hemifacial spasm (HFS). Postoperative uncontrolled bleeding from the dural venous sinus can sometimes cause an insidious-onset or delayed posterior fossa EDH.

Complications of Head Immobilization Devices in Children: Contact Mechanics, and Analysis of a Single Institutional Experience.

BACKGROUND: Head immobilization devices (HIDs) are a staple of neurosurgical procedures, including in the intraoperative magnetic resonance imaging (iMRI) operating rooms (ORs) where material modifications were necessary for compatibility with the magnets utilized. OBJECTIVE: To present the experience in this OR environment and discuss the multifactorial nature of the observed adverse events. METHODS: A retrospective chart review was performed, utilizing the Department of Neurosurgery and iMRI OR databases to identify patients who suffered complications related to HIDs between November 2007 and March 2016. A literature review was also done to identify the magnitude of the problem and the availability of safety guidelines. RESULTS: Nine hundred and forty patients underwent surgery in the iMRI OR requiring head immobilization. Seven (0.7%) suffered complications related to the HID-depressed skull fractures (n = 7) and epidural hematomas (n = 6). Age at surgery ranged from 1.6 to 10.3 yr. All patients had posterior fossa neoplasms and associated obstructive hydrocephalus. Four patients (57%) suffered permanent neurological deficits. Six patients (86%) underwent a surgical procedure to evacuate the epidural hematomas and repair the depressed skull fracture. In contrast, 1 out of 445 patient (0.2%) suffered HID-related adverse events in the conventional ORs, aged 10.2 yr. CONCLUSION: HIDs are important to provide stability and support during neurosurgical procedures. Modifications in the material or the shape of the pins can significantly change the pressure exerted. Most of these complications are preventable if certain precautionary measures are taken especially in certain high-risk patients, and the overall benefits of HIDs continue to outweigh the risks. There is a need for consensus on guidelines for the safe use of these devices.

Traumatic Brain Injury Profile of an Elderly Population in Puerto Rico.

OBJECTIVE: Describe the types of traumatic brain injury secondary to falls sustained by the members of an elderly population who received services at the Puerto Rico Medical Center and the demographic profile of that population. METHODS: A group of 332 adults (60 years and over) assessed for traumatic brain injury secondary to falls suffered in 2013 were included in the analysis. The cases were retrieved from the computerized database of the Neurosurgery Section. We analyzed information such as age, gender, type of traumatic brain injury, mechanism of injury, and the performance of surgery (if applicable). Descriptive analysis was performed to derive a general profile of elderly adults who presented with traumatic brain injury secondary to falls. RESULTS: The sample consisted of 332 elderly adults: 73% were men and 27% were women. The mean age was 76.74 (SD=9.95) years: 75.67 (SD=9.78) for men and 79.13 (SD=10.02) for women. The most common traumatic brain injury was subdural hematoma (51%) and the mechanism of injury most prevalent was the groundlevel fall (83%). Other traumatic brain injuries included traumatic subarachnoid hemorrhages (14%), cerebral contusions (18%) and epidural hematomas (3%). Of all the cases, 52% had were managed surgically. CONCLUSION: The elderly population is growing and the risk of falls increases with advancing age. Recurrent falls are an important cause of morbidity, and mortality rates oscillate from 6 to 18%. Elderly patients have longer rehabilitation times, incur more expenses, and have greater levels of disability. This study provides a platform for future epidemiological studies to help develop strategies for the prevention of traumatic brain injury in older adults.

Models of Mortality and Morbidity in Severe Traumatic Brain Injury: An Analysis of a Singapore Neurotrauma Database.

OBJECTIVE: Current prognostic models for traumatic brain injury (TBI) are developed from diverse historical data sets. We aimed to construct a prognostication tool for patients with severe TBI, as this group would benefit most from an accurate model. METHODS: Model development was based on a cohort of 300 patients with severe TBI (Glasgow Coma Scale score ≤8) consecutively admitted to a neurosurgical intensive care unit at the National Neuroscience Institute (NNI), Singapore, between February 2006 and December 2009. We analyzed prospectively collected data of admission characteristics using univariate and multivariate logistic regressions to predict 14-day and 6-month mortality and 6-month unfavorable outcome. Comparison with Corticosteroid Randomization After Significant Head Injury (CRASH) and Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) models was done using Akaike information criterion. RESULTS: Two prediction models, NNI Clinical (age, Glasgow Coma Scale score, pupillary reactivity) and NNI+ (NNI Clinical model with addition of obliteration of third ventricle or basal cisterns, presence of subdural hemorrhage, hypoxia, and coagulopathy), were derived from this data set. Both models predicted well across 3 outcome measures with area under the curve values of 0.84-0.91, with adequate calibration. Comparison with CRASH and IMPACT models showed better performance by both derived models with lower Akaike information criterion and higher area under the curve values. CONCLUSIONS: Two accurate prognostic models, NNI Clinical and NNI+, were developed from our cohort of patients with severe TBI. Both models are specific to severe TBI and could be better alternatives to current available models. External validation is required to assess performance of models in a different setting.

Venous Sinus Thrombosis in Blunt Trauma: Incidence and Risk Factors.

PURPOSE: The aim of our study was to determine the incidence and risk factors of dural venous sinus thrombosis and epidural hemorrhage in the setting of a blunt trauma causing a calvarial fracture crossing a dural venous sinus. METHODS: A retrospective review of 472 blunt trauma patients with calvarial fracture crossing a dural venous sinus was performed. Two hundred ten patients who underwent computed tomography venography were identified and evaluated for the presence of dural venous sinus thrombosis and/or epidural hemorrhage. Site and displacement of fractures, as well as age, sex, Glasgow Coma Scale (GCS) score, and mechanism of injury, were considered for potential predictive value of thrombosis and/or epidural hemorrhage. RESULTS: We found a 23% incidence of dural venous sinus thrombosis in patients with a fracture traversing a dural venous sinus. Significant predictors of thrombosis included temporal fracture (38% incidence) and skull base fracture (31% incidence). Occipital fracture not involving the skull base was associated with a significantly decreased risk of thrombosis, with an incidence of 9%. Decreased GCS score and fall from height greater than 10 feet additionally predicted dural venous sinus thrombosis. Significant predictors of epidural hemorrhage included parietal fractures and displaced fractures, although a large percentage of nondisplaced fractures in other bones demonstrated epidural hemorrhage as well. CONCLUSIONS: Dural venous sinus thrombosis in the setting of blunt trauma with a calvarial fracture crossing a dural venous sinus has an incidence of 23%. Increased suspicion for thrombosis is warranted in patients with temporal or skull base fractures, low GCS score, and recent fall from great height.

Impact of Helmet Use on Severity of Epidural Hematomas in Cambodia.

BACKGROUND: Traumatic brain injury is a major cause of morbidity and mortality worldwide, often necessitating neurosurgical intervention to evacuate intracranial bleeding. Since the early 2000s, Cambodia has been undergoing a rapid increase in motorcycle transit and in road traffic accidents, but the prevalence of helmet usage remains low. Epidural hematomas are severe traumatic brain injuries that can necessitate neurosurgical intervention. METHODS: This is a retrospective cohort study of patients with epidural hematoma secondary to motorcycle accidents who presented to a major national tertiary care center in Phnom Penh, Cambodia, between November 2013 and March 2016. All patients were diagnosed with computed tomography of the head. RESULTS: In this cohort, 21.6% of patients in motorcycle accidents presented with epidural hematoma and 89.1% of patients were men, 47.6% were intoxicated, and were 87.8% were not wearing helmets at the moment of impact. Not wearing a helmet was associated with a 6.90-fold increase in odds of presenting with a moderate-to-severe Glasgow coma scale score and a 3.76-fold increase in odds of requiring craniotomy or craniectomy for evacuation of hematoma. Male sex was also associated with increased odds of higher clinical severity at presentation and indication for craniotomy or craniectomy, and alcohol intoxication at the time of accident was not associated with either. CONCLUSIONS: Helmet usage is protective in reducing the severity of presentation and need for neurosurgical intervention for patients with epidural hematoma secondary to motorcycle accidents.

Stereotactic Electroencephalography Is a Safe Procedure, Including for Insular Implantations.

BACKGROUND: In some cases of drug-resistant focal epilepsy, noninvasive presurgical investigation may be insufficient to identify the ictal onset zone and the eloquent cortical areas. In such situations, invasive investigations are proposed using either stereotactic electroencephalography (SEEG) or subdural grid electrodes. Meta-analysis suggests that SEEG is safer than subdural grid electrodes, but insular implantation of SEEG electrodes has been thought to carry an additional risk of intraparenchymal hemorrhagic complications. Our objectives were to determine whether an insular SEEG trajectory is a risk factor for intracranial hematoma and to report the global safety of the procedure and provide some guidelines to prevent and detect complications. METHODS: In a retrospective analysis of a surgical series of 525 consecutive procedures between 1995 and 2015, all electrodes were classified according to their insular or extrainsular trajectory. All complications were classified as major or minor according to their potential consequences regarding patient neurologic status. RESULTS: Four intraparenchymal hematomas, all related to extrainsular electrodes (4/4974; 0.08%) were reported; no hematoma was found along insular electrodes (0/1042; 0%). There were 8 major complications (1.52%): 7 intracranial hematomas (1.33%) and 1 case of meningitis. Two patients had long-term neurologic impairment (0.38%), and 1 death (not directly related to the procedure) occurred (0.19%). Eleven minor complications (2.09%) were encountered, including broken electrode (1.52%), acute pneumocephalus (0.38%), and local cutaneous infection (0.19%). CONCLUSIONS: SEEG is a safe procedure. Insular trajectories cannot be considered an additional risk of intracranial bleeding.

Intrasylvian/Intracerebral Hematomas Associated with Ruptured Middle Cerebral Artery Aneurysms: A Single-Center Series and Literature Review.

OBJECTIVE: Ruptured middle cerebral artery (MCA) aneurysms usually lead to subarachnoid hemorrhage (SAH), and several cases have shown concomitant intrasylvian or intracerebral hematomas. The objective of this study was to compare the clinical and radiographic characteristics with their different outcomes. METHODS: The charts of 30 consecutive patients with ruptured MCA aneurysm-related intracranial hematoma were retrospectively reviewed. These patients were dichotomized into an intrasylvian hematoma (ISH) group and an intracerebral hematoma (ICH) group by the presence of intrahematomal contrast-enhancing vessel; for patients under open surgery, hematoma type was further confirmed by intraoperative observation. The characteristics were compared between these 2 groups (ie, age, gender, history of hypertension, history of smoking, systolic pressure at admission, hematoma volume, size and side of aneurysms, the angle between the pointing direction of the aneurysm and the MCA trunk [denoted as α], middle line shifting, treatment modality, and outcome). All the angles are measured in the anterior-posterior projection. RESULTS: In our series, only hematoma volume, the angle α, and the middle line shift showed statistical significance regarding prognosis between 2 hematoma groups. An angle α between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range indicates ICH. In our series, patients in the ICH group had a larger hematoma volume compared with the ISH patients (33.3 ± 17.6 vs. 11.5 ± 10.5; P = 0.002). There exists no statistical difference regarding prognosis between these 2 groups, even although there is a trend toward worse recovery for patients in the ISH group (Glasgow Outcome Scale score, 3.0 ± 1.3 vs. 3.8 ± 1.9; P = 0.07). CONCLUSIONS: In our series, the prognosis of patients with ICH was worse than that of patients with ISH. Early discrimination of these 2 types of hematoma helps to predict future outcome; an angle (between the pointing direction of aneurysm and the MCA trunk) between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range suggests ICH.