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

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

A Standardized Classification for Subdural Hematomas- I.

Subdural hematomas are a frequent and highly heterogeneous traumatic disorder, with significant clinical and socioeconomic consequences. In clinical and medicolegal practice, subdural hematomas are classified according to its apparent age, which significantly influences its intrinsic pathogenic behavior, forensic implications, clinical management, and outcome. Although practical, this empirical classification is somewhat arbitrary and scarcely informative, considering the remarkable heterogeneity of this entity. The current research project aims at implementing a comprehensive multifactorial classification of subdural hematomas, allowing a more standardized and coherent assessment and management of this condition. This new method of classification of subdural hematomas takes into account its intrinsic and extrinsic features, using imaging data and histopathological elements, to provide an easily apprehensible and intuitive nomenclature. The proposed classification unifies and organizes all relevant details concerning subdural hematomas, hopefully improving surgical care and forensic systematization.

Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Factors Influencing Functional Outcome--A Single-Center Series.

OBJECTIVE: Patients presenting with poor-grade aneurysmal subarachnoid hemorrhage (SAH) have commonly been reported to have a poor prognosis; however, several reports suggest a favorable outcome in a subgroup of patients. We analyzed our database to identify factors determining functional outcome after poor-grade SAH. METHODS: During the period 2004-2014, 248 patients with poor-grade SAH were treated in our institution. Poor-grade SAH was defined as World Federation of Neurological Surgeons grades IV-V on admission. Data including patient characteristics, treatment modality, radiologic features, and functional neurologic outcome were assessed and further analyzed. Outcome was assessed according to the modified Rankin Scale after 6 months and stratified into favorable (modified Rankin Scale score 0-2) versus unfavorable (modified Rankin Scale score 3-6). A multivariate analysis was performed to identify predictors of functional outcome. RESULTS: A favorable outcome was achieved in 24% of patients with poor-grade SAH. Patients with a favorable outcome were significantly younger (P = 0.005), harbored significantly smaller aneurysms (P = 0.004), and had a lower initial World Federation of Neurological Surgeons grade (P < 0.0001). An unfavorable outcome was significantly more frequent in patients with additional space-occupying hematoma compared with patients without additional space-occupying hematoma (P = 0.0009). On multivariate analysis, patient age, World Federation of Neurological Surgeons grade V, signs of cerebral herniation, aneurysm size, and presence of space-occupying hematoma were identified as significant predictors of unfavorable outcome in patients with poor-grade SAH. CONCLUSIONS: A favorable outcome was achieved in 24% of severely ill patients with poor-grade SAH. Therefore, treatment of patients with poor-grade SAH should not be omitted. Careful individualized decision making is necessary for each patient.

[Usefulness of selected microscopic morphological changes in determining the age of subdural hematomas]. / Wybrane cechy budowy mikroskopowej jako element dodatkowy w ocenie wieku krwiaków podtwardówkowych.

The objective of the study was to assess the usefulness of selected microscopic changes for determining the age of subdural hematoma (SDH). The research was based on microscopic examination of histopathological preparations representing SDHs collected in the course of 76 forensic autopsies performed in the Chair and Department of Forensic Medicine, Warsaw Medical University, Poland. The deceased had SDH after head injuries and the time of injury was known. H.E. and Masson's staining was employed for qualitative and quantitative determinations. The presence of hematoma capsules, as well as hematoidin and hemosiderine deposits were analyzed. The results suggest that microscopic SDH examinations based on the afore-said features is a helpful method for determining the age of SDHs. Additionally, the results of this study indicate that qualitative techniques of SDHs dating are more accurate than quantitative ones.

Shaken baby syndrome in New Zealand, 2000-2002.

AIM: To describe the epidemiology of subdural haemorrhage (SDH) in New Zealand infants. METHODS: Prospective enrollment of all cases of infantile SDH from 2000 to 2002. Retrospective analysis of national discharge and death data for the same period. RESULTS: Seventy-seven cases of infantile SDH were identified prospectively, and a further 49 cases retrospectively. Of these 126 cases, 92 resulted from non-birth-related trauma. Forty-eight of these were attributed to abuse and 28 to accidental injury. Sixteen cases were undetermined. The 'minimum' annual incidence of inflicted infantile SDH in New Zealand is 14.7 per 100,000 (95% confidence interval(CI) 10.8-19.4), and the 'maximum' 19.6 per 100,000 (95% CI 15.1-25.0). Among Maori, the 'minimum' is 32.5 per 100,000 (95% CI 21.4-47.3), and the 'maximum' 38.5 per 100,000 (95% CI 26.3-54.4). CONCLUSIONS: The epidemiology of infantile subdural haemorrhage in New Zealand is similar to that described elsewhere. Non-accidental head injury is a significant child health issue in New Zealand, and the incidence is particularly high among Maori.

[Brain and head injury. Part 1: Clinical classification, imaging modalities, extra-axial injuries, and contusions]. / Schädel- und Hirntrauma. Teil 1: Klinische Klassifikationen, bildgebende Methoden, extraaxiale Verletzungen und Kontusionen.

This article describes the imaging tools for efficient diagnostic management of head trauma victims. The basic mechanisms of brain injuries are explained and the imaging features are described. Computed tomography remains the most important method for the initial screening and follow-up investigation. Though magnetic resonance imaging has a higher sensitivity to most traumatic lesions, it does not play an important role in the acute phase of head trauma patients. In the first part of this paper clinical classifications, imaging modalities, extra-axial injuries, and contusions are described. In the second part of this paper intra-axial and secondary injuries are discussed.

[The morphological characteristics of chronic subdural hematomas]. / Morfologicheskaia kharakteristika khronicheskikh subdural'nykh gematom.

Preparations of chronic subdural hematomas (CSH) obtained during surgery from 29 patients aged 19-50 years are studied. Histological sections were stained with hematoxylin-eosin after van Gieson. Morphological criteria of CSH variants are defined, permitting forensic medical experts to make well-based conclusions on the nature (traumatic or not) of CSH (two types of capsules) and the time when it occurred.

Importance of a reliable admission Glasgow Coma Scale score for determining the need for evacuation of posttraumatic subdural hematomas: a prospective study of 65 patients.

BACKGROUND: Patients who have an acute subdural hematoma with a thickness of 10 mm or less and with a shift of the midline structures of 5 mm or less often can be treated nonoperatively. We wonder whether the knowledge of the clinical status both in the prehospital determination and on admission to the neurosurgical center can predict the need for evacuation of subdural hematomas as well as the computed tomographic (CT) parameters. METHODS: From January 1, 1994, to May 31, 1996, 65 comatose patients harboring an acute subdural hematoma of 5 mm or more and not brain dead were admitted to our intensive care unit. Of the 65 patients, 15 patients were initially managed conservatively according to a protocol based on clinical, CT, and intracranial pressure parameters. During the study period, the use of long-lasting paralytic agents has been eliminated to allow detection of clinical deterioration in the Glasgow Coma Scale (GCS) score from the prehospital determination to the hospital admission assessment. RESULTS: Of the 15 patients initially managed conservatively, two were subsequently operated on because of evolving parenchymal hematomas. When comparing demographic, clinical, and CT parameters between the surgical group of patients and the patients initially conservatively treated, hematoma thickness (mean, 17.1 mm vs. 7.5 mm, p < 0.0001) and shift of the midline structures (mean, 12.8 mm vs. 4.7 mm, p < 0.008) were predictive of the need for surgery. A statistically significant change in the GCS score between prehospital determination and admission assessment was shown in the surgical group of patients (mean GCS score, 8.4 vs. 6.7, p < 0.01), and it was not present (mean GCS score, 7.3 vs. 7.2) in the patients initially conservatively treated. Functional outcomes were present in 23 cases (35.4%); functional outcomes in the initially conservatively treated patients were reached by 10 patients (66.7%). CONCLUSIONS: Nonoperative management for selected cases of acute subdural hematomas is at least as safe as surgical management. GCS scoring at the scene and in the emergency room combined with early and subsequent CT scanning is crucial when making the decision for nonoperative management. This strategy requires that administration of long-lasting sedatives and paralytic medications be avoided before the patient arrives at the neurosurgical center.

Clinicopathological classification of chronic subdural hematoma.

Clinicopathological classification of chronic subdural hematoma was made, based on a study of 135 cases; chronic subdural hematoma with a visible inner membrane (type I: 123 cases), acute subdural hematoma in chronic healing stage (type II: 8 cases), and chronic subdural effusion of hemorrhagic type (type III: 4 cases). Type I is an expanding lesion, due to repetitive hemorrhage from outer membrane. It is a traditional hematoma with a distinct inner membrane. Type II is a late healing stage of a previously unrecognized or unoperated acute subdural hematoma, and not an expanding lesion. It has a subdural granulation tissue of irregular thickness with little rebleeding tendency, but it lacks a visible inner membrane. Type III is a variant of chronic subdural effusion, in which a minimum amount of fresh blood is added to a maximum amount of xanthochromic fluids. The latter contains an extremely low level of LDH.

[CT findings in chronic subdural hematomas (author's transl)]. / Zur Diagnose des chronischen subduralen Hämatomas im Computer-Tomogramm

CT findings of 46 patients with operatively confirmed chronic subdural hematomas are reviewed. The analysis of the EMI scans resulted in three different types of CT findings. Type 1 is characterized by decreased attenuation of the hematoma contents compared to brain tissue. The hematoma is visualized as a lens-shaped low density area between the skull and the surface of the brain. Type 2 apart from low density areas contains zones of increased attenuation due to recent bleeding into a watery chronic subdural hematoma. In many cases sedimentation causes a well-defined horizontal borderline between the thin fluid parts in the anterior portion and the blood debris in the posterior portion of the hematoma sac. Type 3 shows the same average absorption values as normal brain tissue, a direct visualization is not possible. However , the presence of a midline displacement in combination with ventricular compression and absence of a circumscript lesion even after contrast enhancement, allows the diagnosis of a unilateral chronic subdural hematoma in these cases too. Bilateral chronic subdural hematomas may cause considerable diagnostic difficulties if only one or none of the hematomas is visualized. A relatively small midline displacement points to a second bleeding on the opposite side. Most frequent were hematomas of type 1 (37%), type 2 and 3 could be observed in 30,5% resp. 32,5% of cases respectively.