Mortality After Trauma Craniotomy Is Decreasing in Older Adults-A Nationwide Population-Based Study.

OBJECTIVE: No evidence-based guidelines are available for operative neurosurgical treatment of older patients with traumatic brain injuries (TBIs), and no population-based results of current practice have been reported. The objective of the present study was to investigate the rates of trauma craniotomy operations and later mortality in older adults with TBI in Finland. METHODS: Nationwide databases were searched for all admissions with a TBI diagnosis and after trauma craniotomy, and later deaths for persons aged ≥60 years from 2004 to 2018. RESULTS: The study period included 2166 patients (64% men; mean age, 70.3 years) who had undergone TBI-related craniotomy. The incidence rate of operations decreased with a concomitant decrease in adjusted mortality (30-day mortality, P < 0.001; 1-year mortality, P < 0.001) and increase in mean patient age (R2 = 0.005; P < 0.001) during the study period. The cumulative mortality was 25% at 30 days and 38% at 1 year. The comorbidities increasing the hazard for 30-day mortality were diabetes, a history of malignancy, peripheral vascular disease, and a history of myocardial infarction. For 1-year mortality, the comorbidities were heart failure and a history of myocardial infarction. Evacuation of an epidural hematoma decreased the hazard for mortality. In contrast, evacuation of an intracerebral hematoma and decompressive craniectomy increased the risk at both 30 days and 1 year. CONCLUSIONS: Among older adults in Finland, the rate of trauma craniotomy and later mortality has been decreasing although the mean age of operated patients has been increasing. This can be expected to be related to an improved understanding of geriatric TBIs and, consequently, improved selection of patients for targeted therapy.

Hematological factors predicting mortality in patients with traumatic epidural or subdural hematoma undergoing emergency surgical evacuation: A retrospective cohort study.

Hematological abnormalities at admission are common after traumatic brain injuries and are associated with poor outcomes. The objective of this study was to identify the predictive factors of mortality among patients who underwent emergency surgery for the evacuation of epidural hematoma (EDH) or subdural hematoma (SDH).This was a single-center retrospective cohort study of 200 patients who underwent emergency surgical evacuation of EDH or SDH between September 2010 and December 2018. Data on hematological parameters and clinical and intraoperative features were collected. The primary end-point was 1-year mortality after surgery. Univariate and multivariate analysis were performed, and the receiver operating characteristic (ROC) curves were assessed.Of the 200 patients included in this study, 102 (51%) patients died within 1 year of emergency surgery. Lymphocyte count at admission, creatinine levels, activated partial thromboplastin time (aPTT), age, intraoperative epinephrine use, and Glasgow Coma Scale (GCS) score were significantly associated with mortality in the multivariate analysis. The areas under the ROC curve for the GCS score, aPTT, and lymphocyte counts were 0.677 (95% confidence interval [CI] 0.602-0.753), 0.644 (95% CI 0.567-0.721), and 0.576 (95% CI 0.496-0.656), respectively.Patients with elevated lymphocyte counts on admission showed a higher rate of 1-year mortality following emergency craniectomy for EDH or SDH. In addition, prolonged aPTT and a lower GCS score were also related to poor survival.

The Predictive Role of Postoperative Neutrophil to Lymphocyte Ratio for 30-Day Mortality After Intracerebral Hematoma Evacuation.

OBJECTIVE: To evaluate whether the postoperative neutrophil-to-lymphocyte ratio (NLR) is a prognostic marker for patients with intracerebral hemorrhage (ICH) undergoing surgical hematoma evacuation. METHODS: This retrospective cohort study was conducted to identify patients with ICH who underwent hematoma evacuation between January 2013 and December 2018. Data on demographics, clinical features, laboratory tests (admission and postoperative), and imaging information were collected. The associations between variables and 30-day mortality were assessed by multivariable logistic regression analysis. The predictive power of independent predictors was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 380 patients were included. Multivariable analysis identified admission Glasgow Coma Scale score (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.53-0.70; P < 0.001) and initial hematoma volume (OR, 1.01; 95% CI, 1.01-1.02; P = 0.022) were independently associated with 30-day mortality. With regard to laboratory biomarkers, postoperative NLR (OR, 1.04; 95% CI, 1.01-1.08; P = 0.014) was independently correlated with 30-day death, but admission NLR (OR, 1.00; 95% CI, 0.97-1.03; P = 0.944) was not. The best predictive cutoff point of 12.97 for postoperative NLR (area under the ROC curve, 0.606; P = 0.006) for predicting 30-day mortality was determined by ROC analysis. CONCLUSIONS: In patients with ICH undergoing hematoma evacuation, admission Glasgow Coma Scale score, initial hematoma volume, and postoperative NLR were independently associated with 30-day mortality. Postoperative NLR may be a prognostic marker in surgical ICH patients, and future studies are needed to confirm this finding.

Traumatic Pediatric Extradural Hematoma: An Institutional Study of 228 Patients in Tertiary Care Center.

BACKGROUND: Extradural hematoma (EDH) is one of the most common causes of mortality and morbidity after traumatic brain injury in pediatric patients. Early surgical intervention in these patients produces excellent results. OBJECTIVE: We reviewed surgical experience at our center, examining and presenting symptomatology and outcome analysis. MATERIALS AND METHODS: A retrospective study of 228 pediatric patients of EDH from July 2007 to August 2017 was performed. Patients were evaluated in terms of demographic profile, clinical features, pupillary size and reaction, computed tomography findings, operative measures, and several other parameters. Neurological status was assessed using motor component (M) of Glasgow Coma Scale score. Best motor response was considered as a criterion to classify severity of traumatic brain injury and for the assessment of outcome. RESULTS: Most of the patients were in the age group of 13-18 years (n = 122, 53.5%). Majority of them were male (n = 182, 79.8%). The commonest mode of injury was fall from height (n = 116, 50.9%) followed by road traffic accident (n = 92, 40.4%). Most common site of hematoma was frontal region (n = 66, 28.9%) followed by parietal region (n = 54, 23.7%). The volume of hematoma was between 30 and 50 mL in majority of the patients (n = 186, 81.6%), and most of the patients had a motor responses of M5 (n = 88, 38.6%) and M6 (n = 108, 47.4%). The association between hematoma site and volume was not significant (χ2 = 5.910, p = 0.749), whereas statistically significant association was noted between volume of hematoma and motor response (χ2 = 93.468, p ≤ 0.001), volume and age (χ2 = 7.380, p ≤ 0.05), and volume to time between trauma and surgery (χ2 = 8.469, p ≤ 0.05). Maximum mortality was in patients of low motor (M1-M3) response and who were operated 24 h after injury. CONCLUSION: Mortality in patients of EDH can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH.

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.

SHORT-TERM OUTCOME OF OPERATED TRAUMATIC BRAIN INJURY PATIENTS FOR INTRACRANIAL HEMORRHAGE AT TIKUR ANBESSA SPECIALIZED TEACHING HOSPITAL (TASTH), ADDIS ABABA, ETHIOPIA.

Background: Traumatic brain injury is the leading cause of death and disability in people younger than 40 years of age worldwide. Objective: The study primarily aims at assessing the short-term outcome of patients operated for traumatic intracranial hemorrhage. Patients and Methods: This is a hospital based cross sectional study on patients with traumatic brain injury at Tikur Anbessa Specialized Teaching Hospital in Addis Ababa, Ethiopia, between February 2013 and February 2014. Standardized and structured questionnaire was used to collect sociodemographic data. All patients with traumatic brain injury operated following intracranial hemorrhage were included. Glasgow Coma Scale was used to determine the outcome. Difference in proportions was examined using Chi-square test. Results: The study reviewed 91 patients with traumatic brain injury. Their age ranged from 13 to 60 years with a mean (SD) of 32.3 (±12.1). Eighty-seven (95.6%) of the cases were males and 4(4.4%) females and 34(37.4%) of them cases had mild and 30(33%) had severe traumatic brain injury. Acute Epidural Hematoma was seen in 79(86.8%), Acute Subdural hematoma had the highest proportion, 4/11(36.4%), of deaths and it was also significantly associated with unfavorable Glasgow Outcoma Scale at 3 months (p=0.03). Overall, the proportion patients who died was 18.7% with older patients (>50 years) had a significantly higher proportion of death (p=0.01). Most of the patients had favorable Glasgow Outcoma Scale ,unfavorable was seen in 22/30 (73.3%) and 17/30 (56.7%) of patients with severe traumatic brain injury at 3 and 6 months, respectively. Conclusion: In conclusion, male predominance was substantially high. Acute Subdural hematoma and old patients had high death rates and unfavorable outcome. Overall the death rate was not different from global figures.

[Surgical techniques for severe brain injury : With special emphasis on polytrauma]. / Operationstechniken beim Schädel-Hirn-Trauma : Unter besonderer Berücksichtigung des Polytraumas.

CLINICAL ISSUE: In Austria approximately 2000 people suffer from severe brain injury per year. Brain trauma is the most common cause of death under the age of 45 years. In polytrauma patients the treatment and management of severe brain injury is particularly challenging because the life-threatening injuries of other organ systems significantly influence the timing of surgery and the outcome. The sequence of the necessary surgery is an interdisciplinary decision already made in the emergency room. The evacuation of space-occupying intracranial hemorrhage can be of secondary importance. STANDARD TREATMENT: The standard approach for acute subdural hematoma is a craniotomy using a large question mark-shaped incision (trauma flap) and decompression. In acute epidural hematoma and impression fractures the localization of the lesion determines the surgical approach and evacuation. A variety of access procedures are available. Frontobasal injuries are extremely rarely an indication for an emergency operation for life-threatening injuries. Decompressive craniotomy is performed as for craniotomy for acute subdural hematoma by the standard trauma flap. DIAGNOSTIC WORK-UP: Emergency room computed tomography provides fast and accurate information about the localization and extent of brain injury. PERFORMANCE: The mortality of acute subdural hematoma ranges between 50-90% despite an adequate evacuation. Outcome of epidural hematoma has a much better prognosis (10% mortality). The results of decompressive craniectomy versus conservative treatment for moderate disability and good recovery are quite similar according to the randomized evaluation of surgery with craniectomy for uncontrolled elevation of intracranial pressure (RESCUE-ICP) study. PRACTICAL RECOMMENDATION: Interdisciplinary cooperation and communication and well-trained trauma surgeons with experience in brain trauma are key factors in the treatment of severe brain injury in polytrauma patients.

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.

Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center.

BACKGROUND: Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children. HYPOTHESIS: We hypothese that due to adequate treatment of EDH in children and adolescence excellent clinical and functional outcome can be reached. PURPOSE: To evaluate retrospectively our treatment process of EDH and to elucidate the relationship between trauma mechanism, injury pattern, radiological presentation, subsequent therapy and functional outcome. PATIENTS AND METHODS: Hundred and twenty infants and children with traumatic brain injuries (TBI) were treated between 1992 and 2009 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow Outcome Scale (GOS) scores at hospital discharge and at follow-up visits were used. EDH was classified according to the Rotterdam score. RESULTS: Finally, 41 cases were diagnosed with an EDH and therefore included in our study. Twenty-one cases were treated surgically; however of these in 11 patients delayed surgery was necessary. Twenty patients were treated conservatively. Two patients (5%) died within 24hours, 39 patients (95%) survived. One of the operatively treated patients (2%) presented in a vegetative state, another one had severe disability, and however, 32 patients (78%) showed good recovery at latest follow-up. DISCUSSION: Age, severity of TBI, and neurological status were the main factors influencing outcome after TBI due to acute EDH. We found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases - however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached.

Surgical Treatment of Traumatic Bifrontal Contusions: When and How?

OBJECTIVE: The study aimed to investigate optimal surgical timing, methods, and clinical efficacy of bifrontal decompression craniotomy (BDC) on traumatic bifrontal contusions (TBC). METHODS: A retrospective analysis was performed of 98 patients with TBC who underwent BDC of 2510 patients with traumatic brain injury. The operation-timing score was used to determine surgical timing. RESULTS: Ninety-eight cases (19%) underwent amended BDC. Initial Glasgow Coma Score was 13-15 in 52 cases (61%). Initial computed tomography showed hematoma volumes of 15.1 ± 5.2 mL in 73 cases (74%). Preoperative hematoma (80.2 ± 20.5 mL; P < 0.05) was significantly enlarged. Fluctuation in the surgery-timing curve is timing for surgery. Average operation time was 4.5 ± 3.4 days after admission. Hematoma was totally evacuated and Glasgow Coma Score significantly increased (P < 0.05) in all cases. In the follow-up Glasgow Outcome Score, 79 patients (81%) recovered well. CONCLUSIONS: TBC progressed gradually and deteriorated rapidly; this should be strictly and dynamically observed, and patients should be operated on in a timely manner. Changing the operation-timing score is the gold standard for surgery. Amended BDC can significantly improve the prognosis of patients.

The impact of major trauma centre implementation on the pathways and outcome of traumatic intracranial extradural haematoma in a regional centre.

INTRODUCTION: A new trauma care system with regional major trauma centres (MTC) was implemented on 1st April 2012 across England. We aimed to assess whether this has affected the referral pathways and mortality of patients undergoing emergency craniotomy for extradural haematoma (EDH), where clinical outcome is correlated with the time to intervention. MATERIALS AND METHODS: This was a retrospective cohort comparison study. All patients who had undergone evacuation of EDH from January 2011 to December 2013 were identified. Only those in whom a decision for emergency craniotomy had been made at the time of referral to the on-call neurosurgeon were included. The CRASH predicted risk of mortality was calculated for individual patients. Mortality was assessed at 14 days in order to compute standardised mortality ratios (SMR). RESULTS: Overall, 65 patients underwent EDH evacuation during the study period (21 pre-MTC and 44 post-MTC). Of those, 43 emergency procedures according to the aforementioned definition were included for further analysis (13 pre-MTC, 30 post-MTC). The mean CRASH predicted risk of mortality was 0.21 for the pre-MTC cohort (95% CI: 0.07-0.34) and 0.094 for the post-MTC cohort (95% CI: 0.039-0.15; p = 0.052). There was no significant difference in the rate of secondary transfers before and after MTC implementation (9/13 vs. 23/30, p = 0.71). The mean interval from referral to operation was 198 min for the pre-MTC cohort (95% CI: 123-273) and 201 min for the post-MTC cohort (95% CI: 141-262; p = 0.95). The SMR was 0.37 for the pre-MTC cohort (95% CI: 0.02-1.81; 1 death) and 0.71 for the post-MTC cohort (95% CI: 0.12-2.34; 2 deaths). CONCLUSIONS: MTC implementation has not affected the time to operation or the mortality following EDH evacuation.

In-hospital mortality after pre-treatment with antiplatelet agents or oral anticoagulants and hematoma evacuation of intracerebral hematomas.

Pre-treatment with antiplatelet agents is described to be a risk factor for mortality after spontaneous intracerebral hemorrhage (ICH). However, the impact of antithrombotic agents on mortality in patients who undergo hematoma evacuation compared to conservatively treated patients with ICH remains controversial. This analysis is based on a prospective registry for quality assurance in stroke care in the State of Hesse, Germany. Patients' data were collected between January 2008 and December 2012. Only patients with the diagnosis of spontaneous ICH were included (International Classification of Diseases 10th Revision codes I61.0-I61.9). Predictors of in-hospital mortality were determined by univariate analysis. Predictors with P<0.1 were included in a binary logistic regression model. The binary logistic regression model was adjusted for age, initial Glasgow Coma Score (GCS), the presence of intraventricular hemorrhage (IVH), and pre-ICH disability prior to ictus. In 8,421 patients with spontaneous ICH, pre-treatment with oral anticoagulants or antiplatelet agents was documented in 16.3% and 25.1%, respectively. Overall in-hospital mortality was 23.2%. In-hospital mortality was decreased in operatively treated patients compared to conservatively treated patients (11.6% versus 24.0%; P<0.001). Patients with antiplatelet pre-treatment had a significantly higher risk of death during the hospital stay after hematoma evacuation (odds ratio [OR]: 2.5; 95% confidence interval [CI]: 1.24-4.97; P=0.010) compared to patients without antiplatelet pre-treatment treatment (OR: 0.9; 95% CI: 0.79-1.09; P=0.376). In conclusion a higher rate of in-hospital mortality after pre-treatment with antiplatelet agents in combination with hematoma evacuation after spontaneous ICH was observed in the presented cohort.

The Effect of ß-blockade on Survival After Isolated Severe Traumatic Brain Injury.

BACKGROUND: Several North American studies have observed survival benefit in patients exposed to ß-blockers following traumatic brain injury (TBI). The purpose of this study was to evaluate the effect of ß-blockade on mortality in a Swedish cohort of isolated severe TBI patients. METHODS: The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between 1/2007 and 12/2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS)≥3 excluding extra-cranial injuries AIS≥3. Multivariable logistic regression analysis was used to determine the effect of ß-blocker exposure on mortality. Also, a subgroup analysis was performed to investigate the risk of mortality in patients on pre-admission ß-blocker versus not and the effect of specific type of ß-blocker on the overall outcome. RESULTS: Overall, 874 patients met the study criteria. Of these, 33% (n=287) were exposed to ß-blockers during their hospital admission. The exposed patients were older (62±16 years vs. 49±21 years, p<0.001), and more severely injured based on their admission GCS, ISS, and head AIS scores (GCS≤8: 32% vs. 28%, p=0.007; ISS≥16: 71% vs. 59%, p=0.001; head AIS≥4: 60% vs. 45%, p<0.001). The crude mortality was higher in patients who did not receive ß-blockers (17% vs. 11%, p=0.007) during their admission. After adjustment for significant confounders, the patients not exposed to ß-blockers had a 5-fold increased risk of in-hospital mortality (AOR 5.0, CI 95% 2.7-8.5, p=0.001). No difference in survival was noted in regards to the type of ß-blocker used. Subgroup analysis revealed a higher risk of mortality in patients naive to ß-blockers compared to those on pre-admission ß-blocker therapy (AOR 3.0 CI 95% 1.2-7.1, p=0.015). CONCLUSIONS: ß-blocker exposure after isolated severe traumatic brain injury is associated with significantly improved survival. We also noted decreased mortality in patients on pre-admission ß-blocker therapy compared to patients naive to such treatment. Further prospective studies are warranted.

Epidural Hematoma: A Prospective Analysis of Morbidity and Mortality in 173 Patients / Hematoma epidural: Uma análise prospectiva de morbidade e mortalidade em 173 pacientes

Objectives A few recent studies have focused on epidural hematomas (EDHs) that are routine in emergency rooms. The study was to evaluate the latest situation of affected patients by encephalic trauma associated with EDH in our service. Methods Prospective study between September 1, 2003 and May 30, 2009. Data were computed regarding age, sex, trauma mechanism, qualification by Glasgow coma scale admission, presence of anisocoria, and evaluation by the recovery of Glasgow scale high, with all patients by computed tomography (CT) scan. Results Among the 173 analyzed patients, mortality reached 20 patients (11.5%). Mortality was higher in the subgroup of 76 patients (44%) admitted with Glasgow coma scale (GCS ≤ 8) with 17 deceased, corresponding to 85% of total deaths. Prevalence of male subjects (140 cases, 81%) with bruises located in the temporal, frontal and parietal regions; 147 (85%) patients underwent neurosurgical treatment by craniotomy. The worst prognosis was in patients with hematomas of higher-volume (50 mL), midline structures deviations greater than 1.5 mm and basal cisterns CSF closed. Conclusion The authors emphasize the correct indication of neurosurgery and the postoperative intensive care unit (ICU) as key factors for success in the treatment of patients with EDHs.

Objetivos Poucos estudos atuais tem focado os hematomas epidurais que são rotina nos serviços de emergência. O estudo teve por objetivo avaliar a situação mais recente dos doentes acometidos por traumatismo crânio ancefálico associado a hematoma epidural no nosso serviço. Métodos Estudo prospectivo entre 1 de setembro de 2003 a 30 de maio de 2009. Foram computados dados referentes a idade, sexo, mecanismo do traumatismo, qualificação pela escala de coma de Glasgow` a admissão, presença de anisocoria e avaliação pela escala de recuperação de Glasgow na alta, tendo todos os pacientes realizado tomografia de crânio. Resultados Dentre os 173 pacientes analisados encontramos mortalidade de 20 pacientes (11,5%). No subgrupo de 76 pacientes (44%) admitidos em escala de coma de Glasgow (ECGLa) ≤ 8 pontos, a mortalidade foi superior com 17 óbitos, correspondendo a 85% do total de óbitos. Prevaleceram indivíduos do sexo masculinos (140 casos, 81%) com hematomas localizados na região temporal, seguido pelas regiões frontal e parietal; 147 (85%) foram submetidos a tratamento neurocirúrgico por craniotomia. O prognóstico foi pior nos pacientes com hematomas de volume superior a 50 mL, desvios de estruturas de linha mediana maiores que 1,5 mm e cisternas liquóricas basais fechadas. Conclusões Os autores enfatizam a correta indicação da neurocirurgia e o pósoperatório na unidade de terapia intensiva como fatores chave para o bom resultado no tratamento dos doentes com hematomas epidurais.

Evidence-based assessment of well-established interventions: the parachute and the epidural hematoma.

BACKGROUND: The methods of evidence-based medicine are a relatively recent development in the understanding of clinical practice. They are criticized as not providing support for interventions long held to be highly effective based on experience that predated the availability of evidence-based analysis. OBJECTIVE: To determine if the methods of evidence-based medicine can be successfully applied to interventions established before those methods were developed. METHODS: Systematic review of English language literature on the natural history and treated prognosis of acute epidural hematoma and analysis of existing data on mortality associated with parachute use. DATA SOURCES: Sources of data included Medline, Old Medline, Science Citation Index, British and US Parachute Associations, and Federal Aviation Administration and National Transportation Safety Board databases (both of the United States). Also included were national databases reporting mortality and total number of parachute uses. RESULTS: The estimated mortality of falling from an airplane with an ineffective parachute is 74% (69-79). Mortality associated with effective parachute deployment is between 0.0011% and 0.0017%. For acute epidural hematoma, estimated mortality is 98.54% (95.1-99.9) without treatment and 12.9% (10.5-15.3) with treatment. The number needed to treat to prevent 1 death for the parachute is estimated to be 1.35 (1.27-1.45) and for epidural hematoma 1.17 (1.13-1.22) (95% binomial confidence intervals in parentheses). CONCLUSION: The methods of evidence-based medicine are robust and can deal with interventions of great face validity and those considered well established before such methods were well developed. We propose initial criteria for evaluating the quality of evidence supporting long-established interventions.

Traumatic subarachnoid hemorrhage due to motor vehicle crash versus fall from height: a 4-year epidemiologic study.

BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage (TSAH). Although TSAH after trauma is associated with poor prognoses, the impact of mechanism of injury (MOI) and the pathophysiology remains unknown. We hypothesized that outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based on the MOI. METHODS: Data were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012. All patients presented with head trauma and TSAH were included. Patient data included age, gender, nationality, mechanism of injury, injury severity score (ISS), types of head injuries, and associated injuries. Ventilator days, intensive care unit length of stay, pneumonia, and mortality were also studied. RESULTS: A total of 1665 patients with TBI were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were male patients and 86% were expatriates. MVC (53%) and FFH (35%) were the major mechanisms of injury. The overall mean ISS and head abbreviated injury score were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in MVC group sustained severe TSAH, had significantly greater head abbreviated injury score (3.5 ± 0.9 vs. 3.2 ± 0.9; P = 0.009) and ISS (21.6 ± 10.6 vs. 15.9 ± 9.5; P = 0.001), and lower scene Glasgow coma scale (10.8 ± 4.8 vs. 13.2 ± 3.4; P = 0.001) compared with the FFH group. In addition, the MVC group sustained more intraventricular hemorrhage (4.7 vs. 0.7; P = 0.001) and diffuse axonal injury (4.2 vs. 2.9; P = 0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; P = 0.008) was higher in the FFH group. Lower extremities (14% vs. 4.3%; P = 0.004) injury was mainly associated with the MVC group. The overall mortality was 19 % among patients with TSAH. The mortality rate was higher in the MVC group when compared with the FFH group (24% vs. 10%; P = 0.001). In both groups, ISS and Glasgow coma scale at the scene were independent predictors of mortality. CONCLUSIONS: Patients with TSAH have a higher mortality rate. In this population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the incidence and severity of TBI in Qatar.

[Peculiarities of clinical course and approaches to surgical treatment of patients with epidural hematoma in isolated cranio-cerebral trauma].

Peculiarities of clinical course and approaches to surgical treatment were studied in patients, suffering isolated cranio-cerebral trauma (CCT); new approaches were elaborated, permitting to improve outcome of epidural hematoma (EG) in surgical treatment of the patients. For isolated CCT 188 patients there were operated on, EG was revealed in 83 (44.1%) of them. The majority of patients were admitted to the hospital in subcompensated stage of clinical course of CCT. EG occurrs in the injured persons in indented cranial fracture, it is diagnosed by KT of the brain. Unfavorable impact on the surgical treatment results causes admittance to the hospital in a rude decompensation stage, in case of preoperative treatment absence, while diagnostic mistake committ- ment, late conduction of the operation, and admittance to the hospital more than 1 day after the trauma. The intensive therapy conduction postoperatively permits to reduce significantly the rate of cerebral and extracerebral complications.

Contralateral haematoma secondary to decompressive craniectomy performed for severe head trauma: a descriptive study of 15 cases.

BACKGROUND: Contralateral haematoma is an infrequent but severe complication of decompressive craniectomy for head trauma. METHOD: A retrospective study was performed of patients developing this complication after decompressive craniectomy for head trauma in the institute. Demographics, mechanism of trauma, time interval between trauma and first operation, time interval between first operation and onset of contralateral haematoma and patients' outcomes were recorded for further analysis. RESULTS: Fifteen patients developed this complication in the study; most had epidural haematomas, which appeared within the first 12 hours after decompressive craniectomy in 13 patients, including three haematomas that developed during surgical decompression. Contralateral cranial fracture is a major risk factor for this condition. Only one patient recovered to mild disability. All remaining patients had poor outcomes, with Glasgow coma scale scores ≤3, except for one patient who was lost to follow-up. A literature review of similar studies including 36 patients revealed similar characteristics. CONCLUSION: Contralateral haematoma secondary to surgical decompression in head trauma can lead to a poor outcome. The prompt detection and removal of the haematoma are keys to management and routine recurrent computed tomography is recommended after the first operation.