Surgical management of traumatic supra and infratentorial extradural hematomas: our experience and systematic literature review.

Post-traumatic supra and infratentorial acute extradural hematomas (SIEDHs) are an uncommon type of extradural hematoma with only few small series published. In this scenario, the purposes of the present study are to present our experience in the management of 8 patients with acute SIEDH and to perform a systematic literature review. The clinical and radiological data of 8 patients operated for SIEDH at our department were analyzed retrospectively. Using the PRISMA guidelines, we reviewed the articles published from January 1990 to January 2018 reporting data about SIEDH. A total of 3 articles fulfilled the inclusion criteria and were analyzed. The incidence of SIEDHs is very rare constituting < 2% of all traumatic extradural hematomas (EDH). SIEDHs are associated with non-specific symptoms. Only 20% of patients were in coma (GCS < 8) at admission. A "lucid interval" was not reported. The source of bleeding of SIEDH was venous in all cases due to the following: bone fracture with diploe bleeding (50%), transverse/sigmoid sinus injury (22%), oozing meningeal venous vessel (8%), detachment of transverse sinus without wall injury (6%), and unknown in the other cases. Due to the venous nature of the source of hemorrhage, the clinical manifestation of a SIEDH may develop in a slow way, but once a critical volume of hematoma is reached, the deterioration can become rapid and fatal for acute brain stem compression. Surgery is the mainstay of SIEDHs treatment: among 42 cases with SIEDH included in this review, 40 (95.23%) patients were treated with surgery while only two were managed conservatively. Also in our series, all patients underwent surgery. A combined supratentorial craniotomy and suboccipital craniotomy leaving in a bone bridge over the transverse sinus for dural tenting sutures resulted the most used and safe surgical approach. SIEDH is a rare type of EDH. Early diagnosis of SIEDH and prompt surgical evacuation with a combined supratentorial and suboccipital approach provide excellent recovery.

Atypical Manifestation of Direct Low-Flow Carotid-Cavernous Fistula: Case Report and Review of the Literature.

BACKGROUND: Carotid cavernous fistula (CCF) is a rare type of arteriovenous shunt that develops within the cavernous sinus (CS). Direct CCFs entail a direct communication between the cavernous internal carotid artery and the CS and are typically high-flow lesions. Most CCFs drain into the ophthalmic veins (typical venous drainage pattern), leading to the pathognomic ocular clinical triad associated with a CCF. When an obstruction of the typical venous outflow is present, the arterial pressure generated by the fistula is transmitted into the cerebral venous system via the sphenoparietal sinus, which might lead to intracerebral hemorrhage. We present a rare case of posttraumatic, direct, low-flow CCF associated with cerebral hemorrhage, a typical venous drainage pattern, and without ocular symptoms at presentation. CASE DESCRIPTION: A 76-year-old woman was hospitalized for a posttraumatic frontotemporopolar hemorrhage associated with multiple fractures of the maxillofacial and cranial base skeleton and midline shift >10 mm. On neurologic examination the Glasgow Coma Scale was 8 and right anisocoria was present. Immediate surgical evacuation of the hematoma was performed. Severe arterial bleeding from the anterior third of the middle cranial fossa floor was controlled intraoperatively. Postoperative brain angio-magnetic resonance imaging and digital subtraction angiography showed a direct CCF without theft phenomenon. Ocular symptoms, and ultimately loss of function of the right eye, appeared 2 weeks from surgery. Endovascular treatment of the CCF was attempted attaining partial closure of the shunt using coils. CONCLUSIONS: Direct low-flow CCFs are exceedingly rare lesions. Five cases have been described in the literature, 4 of which were associated with spontaneous rupture of a cavernous carotid aneurysm while only 1 case was associated with posttraumatic rupture of a cavernous internal carotid artery pseudoaneurysm. In addition, despite our patient having developed an intraparenchymal hemorrhage most probably correlated to the CCF, the latter was associated with a typical venous drainage via the superior ophthalmic vein, which is uncommonly correlated to intraparenchymal bleeding.

Traumatic Minor Intracranial Hemorrhage: Management by Non-neurosurgeon Consultants in a Regional Trauma Center is Safe and Effective.

BACKGROUND: There is debate concerning the need for specialist neurosurgical transfer of patients presenting to Level II trauma centers with a minimal head injury (Glasgow Coma Scale ≥13) and a small non-progressive intracranial bleeding (ICB). METHODS: A retrospective chart analysis was performed assessing the outcomes of adult patients presenting with a minor traumatic ICB on initial CT scan (minimal subarachnoid hemorrhage; small-width subdural hematoma without shift; punctate cerebral contusion). Patients with extradural hematomas and those patients on antiplatelet or anticoagulant therapy were excluded from the protocol. RESULTS: Overall 291 cases were assessed (mean age 69.9 years) with 75% of cases presenting after a fall. There was deterioration of neurological status in 11 patients (3.8%) with 8 hospital transfers and 5 with an abnormal neurological examination (NE). Two patients with an abnormal INR and a worsening head CT were transferred without neurosurgical intervention. Of the 8 transferred cases there were 2 deaths (both >90 years of age with multiple comorbidities) with one craniotomy performed for a subdural hematoma (with full recovery). Three patients meeting transfer criteria were not transferred with one death (patient >90 years of age with severe dementia). The remaining 2 patients were discharged with normal neurological outcomes. CONCLUSIONS: Patients with a minimal traumatic brain injury and a non-progressive minor ICB may be safely managed in a Level II trauma center by an acute care consultant with neurosurgical consultation but without the need for neurosurgical transfer. LEVEL OF EVIDENCE: Retrospective analysis: Level IV.

Akinetic mutism following prefrontal injury by an electrical grinder a case report: A diffusion tensor tractography study.

RATIONALE: A 72-year-old male had suffered from head trauma resulting from injury to his frontal area by an electrical grinder while working at his home. PATIENT CONCERNS: He lost consciousness for approximately 10 minutes and experienced continuous post-traumatic amnesia. DIAGNOSES: He was diagnosed as traumatic intracerebral hemorrhage in both frontal lobes, intraventricular hemorrhage, and subarachnoid hemorrhage, and underwent decompressive craniectomy and hematoma removal. INTERVENTIONS: The patient's Glasgow Coma Scale score was 5. At 2 months after onset, when starting rehabilitation, he showed no spontaneous movement or speech; he remained in a lying position all day with no spontaneous activity. OUTCOMES: On 2-month diffusion tensor tractography, decreased neural connectivity of the caudate nucleus to the medial prefrontal cortex (PFC, Broadmann area [BA]: 10 and 12) and orbitofrontal cortex (BA 11 and 13) was observed in both hemispheres. LESSONS: Akinetic mutism following prefrontal injury.

Increased Transfusion of Fresh Frozen Plasma is Associated with Mortality or Worse Functional Outcomes After Severe Traumatic Brain Injury: A Retrospective Study.

BACKGROUND: The fresh frozen plasma (FFP) transfusion threshold and timing for traumatic brain injury (TBI)-associated coagulopathy are controversial. Thus, a multicenter retrospective study was conducted to determine whether or not FFP transfusion is associated with poor outcomes after severe TBI. METHODS: Data from decompressive craniotomy after blunt force trauma that took place between December 2013 and June 2016 were collected in a multicenter chart. The primary outcomes were mortality and survival, as well as worse outcomes (defined as a Glasgow Outcome Scale [GOS] score ≤3) and better outcomes (GOS score ≥4). Secondary outcomes included 90-day survival rates in all patients with or without FFP transfusion, as well as length of hospital stay in patients with a better prognosis (GOS score ≥4). Univariate analysis, bivariate logistic regression, Spearman rank correlation, and Kaplan-Meier analysis were performed to account for the association between perioperative FFP transfusion and different outcomes. RESULTS: Bivariate logistic analysis showed that mortality and worse outcomes were correlated with FFP transfusion and Glasgow Coma Scale score (P < 0.05). Kaplan-Meier analysis suggested that mortality was statistically higher in the FFP transfusion groups compared with the no FFP transfusion groups, regardless of the severity of TBI (P < 0.05). The overall complications, acute respiratory distress syndrome, and pneumonia rate were significantly higher for patients receiving FFP transfusion (P < 0.05). CONCLUSIONS: Increased perioperative FFP infusion was independently associated with mortality or worse outcomes across a spectrum of surgical risk profiles.

Decreasing the Cerebral Edema Associated with Traumatic Intracerebral Hemorrhages: Use of a Minimally Invasive Technique.

Traumatic brain injury (TBI) is a major public health problem worldwide that affects all age groups. In the United States alone, there are approximately 50,000 deaths from severe traumatic brain injuries each year. In most studies, about 40 % of severe TBI have associated traumatic intracerebral hemorrhages (tICHs). The surgical treatment of tICH is debated largely because of its invasive nature, particularly in reaching deep tICHs. tICHs have a clear contribution to mass effect and exacerbate cerebral edema and ICP because of the break-down products of hemorrhage. We introduce a modification of the Mi SPACE technique (Minimally Invasive Subcortical Parafascicular Transsulcal Access for Clot Evacuation) that is applicable to tICH. In brief, this technique utilizes a trans-sulcal, stereotactic-guided technique in which a specially designed cannula is used to introduce a 13.5-mm-diameter tube into the epicenter of the tICH. We identified eight tICHs that were treated entirely or in part with the modified Mi SPACE technique during the time period from August 15, 2014 to December 15, 2014. This modified technique was readily deployed safely and efficaciously with significant removal of the tICH as demonstrated by postoperative CT scans. The removal of tICH using this minimally invasive technique may help with the control of ICP and cerebral edema.

Delayed Deterioration in Isolated Traumatic Subarachnoid Hemorrhage.

BACKGROUND: Isolated traumatic subarachnoid hemorrhage (SAH) in association with mild traumatic brain injury is considered to be a less severe finding that is not likely to require surgical intervention. No previous reports have described cases warranting craniotomy for isolated traumatic SAH by itself. CASE DESCRIPTION: We report 2 cases of minor head trauma with isolated traumatic SAH that showed delayed clinical deterioration requiring immediate surgical intervention. Initial computed tomography showed isolated traumatic SAH in the basal cistern and Sylvian fissure in both cases. Angiography showed no aneurysmal source. Within 24 hours of each accident, both disturbance of consciousness and hemiparesis deteriorated. Follow-up computed tomography showed formation of intracerebral hematoma adjacent to the Sylvian fissure. Intraoperative findings showed abruption injury of a perforating branch arising from the middle cerebral artery (MCA) as the cause of bleeding. Impact at the time of injury could have caused traction on the MCA in the Sylvian fissure, resulting in abruption of the perforator. CONCLUSIONS: Isolated traumatic SAH seen in the basal cistern and Sylvian fissure carries a risk of late deterioration. A possible cause of hematoma expansion is abruption of a perforating branch arising from the MCA at the time of head injury. When hematoma expansion is identified, surgical evacuation of the hematoma is indicated. Surgical evacuation should be safely performed with the knowledge of the point of bleeding in such patients.

Surgical Trial In Traumatic intraCerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment.

BACKGROUND: While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic intracerebral haemorrhage (TICH) is controversial. There is no evidence to support Early Surgery in this condition. OBJECTIVES: There have been a number of trials investigating surgery for spontaneous intracerebral haemorrhage but none for TICH. This study aimed to establish whether or not a policy of Early Surgery for TICH improves outcome compared with a policy of Initial Conservative Treatment. DESIGN: This was an international multicentre pragmatic parallel group trial. Patients were randomised via an independent telephone/web-based randomisation service. SETTING: Neurosurgical units in 59 hospitals in 20 countries registered to take part in the study. PARTICIPANTS: The study planned to recruit 840 adult patients. Patients had to be within 48 hours of head injury with no more than two intracerebral haematomas greater than 10 ml. They did not have a SDH or EDH that required evacuation or any severe comorbidity that would mean they could not achieve a favourable outcome if they made a complete recovery from their head injury. INTERVENTIONS: Patients were randomised to Early Surgery within 12 hours or to Initial Conservative Treatment with delayed evacuation if it became clinically appropriate. MAIN OUTCOME MEASURES: The Extended Glasgow Outcome Scale (GOSE) was measured at 6 months via a postal questionnaire. The primary outcome was the traditional dichotomised split into favourable outcome (good recovery or moderate disability) and unfavourable outcome (severe disability, vegetative, dead). Secondary outcomes included mortality and an ordinal assessment of Glasgow Outcome Scale and Rankin Scale. RESULTS: Patient recruitment began in December 2009 but was halted by the funding body because of low UK recruitment in September 2012. In total, 170 patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes were obtained for 99% of 168 eligible patients (82 Early Surgery and 85 Initial Conservative Treatment patients). Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment [odds ratio 0.65; 95% confidence interval (CI) 0.35 to 1.21; p = 0.17]. Mortality was significantly higher in the Initial Conservative Treatment group (33% vs. 15%; absolute difference 18.3%; 95% CI 5.7% to 30.9%; p = 0.006). The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = 0.047 and p = 0.043 respectively). CONCLUSIONS: This is the first ever trial of surgery for TICH and indicates that Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intraCerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intraCerebral Haemorrhage (STICH II). Further research is clearly warranted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 19321911. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 70. See the NIHR Journals Library website for further project information.

[Delayed Traumatic Intracerebral Hematoma during Antiplatelet Therapy after Operations for Ruptured Left ICPC Aneurysm and Right Traumatic Epidural Hematoma: A Case Report].

Delayed traumatic intracerebral hematoma (DTICH) is a rare complication of head injury that appears suddenly after an interval of several days or months. Here, we report a case of DTICH during antiplatelet therapy for vasospasm following surgeries for a ruptured left internal carotid-posterior communicating (ICPC) aneurysm and right acute epidural hematoma (EDH). A 77-year-old man with no medical history was diagnosed with a subarachnoid hemorrhage (SAH) due to rupturing of a left ICPC aneurysm and a right linear fracture of the right parietal bone due to a head injury following the rupture. On day 2, the patient underwent successful clipping of the left ICPC aneurysm. Computed tomography (CT) performed post-clipping revealed a right acute EDH below the linear fracture of the right parietal bone, which was removed immediately. A next-day CT revealed minor contusions in both temporal poles. Fasudil, ozagrel, and cilostazol were administered from Day 3 post-clipping and EDH evacuation to prevent vasospasm. The contusions did not enlarge until Day 10. On Day 11, the patient became comatose, and a huge hematoma was identified in the right temporal lobe to frontal lobe. Although the hematoma was removed immediately, the patient died on Day 13. The hematoma was considered to be a rare case of DTICH that developed from a minor contusion of the right temporal lobe during antiplatelet therapy for vasospasm. In cases of aneurysmal SAH with head injury and contusion, we must pay attention to DTICH and select more deliberate treatment for vasospasm.

Early Surgery versus Initial Conservative Treatment in Patients with Traumatic Intracerebral Hemorrhage (STITCH[Trauma]): The First Randomized Trial.

Intraparenchymal hemorrhages occur in a proportion of severe traumatic brain injury TBI patients, but the role of surgery in their treatment is unclear. This international multi-center, patient-randomized, parallel-group trial compared early surgery (hematoma evacuation within 12 h of randomization) with initial conservative treatment (subsequent evacuation allowed if deemed necessary). Patients were randomized using an independent randomization service within 48 h of TBI. Patients were eligible if they had no more than two intraparenchymal hemorrhages of 10 mL or more and did not have an extradural or subdural hematoma that required surgery. The primary outcome measure was the traditional dichotomous split of the Glasgow Outcome Scale obtained by postal questionnaires sent directly to patients at 6 months. The trial was halted early by the UK funding agency (NIHR HTA) for failure to recruit sufficient patients from the UK (trial registration: ISRCTN19321911). A total of 170 patients were randomized from 31 of 59 registered centers worldwide. Of 82 patients randomized to early surgery with complete follow-up, 30 (37%) had an unfavorable outcome. Of 85 patients randomized to initial conservative treatment with complete follow-up, 40 (47%) had an unfavorable outcome (odds ratio, 0.65; 95% confidence interval, CI 0.35, 1.21; p=0.17), with an absolute benefit of 10.5% (CI, -4.4-25.3%). There were significantly more deaths in the first 6 months in the initial conservative treatment group (33% vs. 15%; p=0.006). The 10.5% absolute benefit with early surgery was consistent with the initial power calculation. However, with the low sample size resulting from the premature termination, we cannot exclude the possibility that this could be a chance finding. A further trial is required urgently to assess whether this encouraging signal can be confirmed.

[Pediatric multiple trauma]. / Polytrauma des Kindes.

Multiple trauma in children is rare so that even large trauma centers will only treat a small number of cases. Nevertheless, accidents are the most common cause of death in childhood whereby the causes are mostly traffic accidents and falls. Head trauma is the most common form of injury and the degree of severity is mostly decisive for the prognosis. Knowledge on possible causes of injury and injury patterns as well as consideration of anatomical and physiological characteristics are of great importance for treatment. The differences compared to adults are greater the younger the child is. Decompression and stopping bleeding are the main priorities before surgical fracture stabilization. The treatment of a severely injured child should be carried out by an interdisciplinary team in an approved trauma center with expertise in pediatrics. An inadequate primary assessment involves a high risk of early mortality. On the other hand children have a better prognosis than adults with comparable injuries.

Memory impairment caused by cerebral hematoma in the left medial temporal lobe due to ruptured posterior cerebral artery aneurysm.

BACKGROUND: Cognitive disorders, such as memory disturbances, are often observed following a subarachnoid hemorrhage. We present a very rare case where rupture of a posterior cerebral artery aneurysm caused restricted damage to the hippocampus unilaterally, and caused memory disturbances. CASE PRESENTATION: A 56-year-old, right-handed man, with a formal education history of 16 years and company employees was admitted to our hospital because of a consciousness disturbance. He was diagnosed as having a subarachnoid hemorrhage due to a left posterior cerebral artery dissecting aneurysm, and coil embolization was performed. Subsequently, he had neither motor paresis nor sensory disturbances, but he showed disorientation, and both retrograde and anterograde amnesia. Although immediate recall and remote memory were almost intact, his recent memory was moderately impaired. Both verbal and non-verbal memories were impaired. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed a cerebral hematoma in the left temporal lobe involving the hippocampus and parahippocampal gyrus, and single-photon emission computed tomography (SPECT) demonstrated low perfusion areas in the left medial temporal lobe. CONCLUSIONS: We suggest that the memory impairment was caused by local tissue destruction of Papez's circuit in the dominant hemisphere due to the cerebral hematoma.

Attitudes to intracranial pressure monitoring of traumatic intracerebral haemorrhage.

INTRODUCTION: Recent research has been equivocal regarding the usefulness of intracranial pressure (ICP) monitoring for traumatic intracerebral haemorrhage (ICH). We aimed to investigate attitudes of clinicians from as wide an international audience as possible. MATERIALS AND METHODS: A SurveyMonkey(®) questionnaire was distributed to individuals, including members of the Society of British Neurological Surgeons, the European Brain Injury Consortium, the neurotrauma committee of the Euroacademia Multidisciplinaria Neurotraumatologica and the World Federation of Neurosurgical Societies. RESULTS: N = 98 completed the survey (surgeons n = 86) from at least 25 different countries. ICP was routinely monitored by 76% and would be monitored by 5% more if they had equipment. ICP monitoring was valued (0 = not at all important, 10 = critically important) as 10 by 21% (median = 8, Q1 = 7, Q3 = 9). Triggers to begin ICP monitoring included midline shift (n = 48), contusion (n = 47), ICH (n = 46), subdural haemorrhage (n = 42), Glasgow coma scale reduction of median 2 for eye, verbal or motor, and one reactive pupil (30%). Responders stated that intervention would begin for adults with an ICP median of 25 mmHg and for children 20 mmHg. Most favourable treatments of raised ICP included Mannitol and ventriculostomy, which were ranked as most favourable (out of 10) by n = 31 each. Responders claimed to be aware of 16 different trials that investigated the value of ICP monitoring in neurotrauma, including BEST TRIP (n = 35), Rescue ICP (n = 13) and DECRA (n = 8). CONCLUSION: ICP monitoring continues to be a highly valued and clinically desirable technique for managing traumatic ICH patients.

Acupuncture helps regain postoperative consciousness in patients with traumatic brain injury: a case study.

OBJECTIVE: This report of one case illustrates the potential effect of acupuncture therapy in addition to Western medicine for regaining postoperative consciousness in patients with traumatic brain injury (TBI). CLINICAL FEATURES: A 65-year-old man experienced a TBI after being involved in a motor vehicle accident. His initial Glasgow Coma Scale (GCS) score was E1V1M2, and brain computerized tomography showed a right-sided subdural hemorrhage. He received emergency medical treatment and underwent craniotomy to remove the lacerated portions of brain as well as subtemporal decompression, followed by a decompressive craniectomy the following day to remove an intracerebral hematoma due to late-onset temporo-parietal rebleeding. Twelve days after surgery, the patient remained in poor condition due to serious complications and the GCS was E2VeM4. His family then underwent counseling and he subsequently received acupuncture treatment. INTERVENTION AND OUTCOME: This patient was treated with acupuncture three times each week, consisting of strong stimulation at GV26 (Shuigou) and the 12 Well points using the half-needling technique. After 3 weeks of consecutive treatment, his GCS score improved to E4VtM6. In addition, he regained consciousness and could tolerate rehabilitation programs. CONCLUSIONS: We believe that an experienced physician may use acupuncture as complementary therapy in patients with TBI who fail to regain consciousness postoperatively.

Surgical trial in traumatic intracerebral hemorrhage (STITCH(Trauma)): study protocol for a randomized controlled trial.

BACKGROUND: Intracranial hemorrhage occurs in over 60% of severe head injuries in one of three types: extradural (EDH); subdural (SDH); and intraparenchymal (TICH). Prompt surgical removal of significant SDH and EDH is established and widely accepted. However, TICH is more common and is found in more than 40% of severe head injuries. It is associated with a worse outcome but the role for surgical removal remains undefined. Surgical practice in the treatment of TICHs differs widely around the world. The aim of early surgery in TICH removal is to prevent secondary brain injury. There have been trials of surgery for spontaneous ICH (including the STICH II trial), but none so far of surgery for TICH. METHODS/DESIGN: The UK National Institutes of Health Research has funded STITCH(Trauma) to determine whether a policy of early surgery in patients with TICH improves outcome compared to a policy of initial conservative treatment. It will include a health economics component and carry out a subgroup analysis of patients undergoing invasive monitoring. This is an international multicenter pragmatic randomized controlled trial.Patients are eligible if: they are within 48 h of injury; they have evidence of TICH on CT scan with a confluent volume of attenuation significantly raised above that of the background white and grey matter that has a total volume >10 mL; and their treating neurosurgeon is in equipoise.Patients will be ineligible if they have: a significant surface hematoma (EDH or SDH) requiring surgery; a hemorrhage/contusion located in the cerebellum; three or more separate hematomas fulfilling inclusion criteria; or severe pre-existing physical or mental disability or severe co-morbidity which would lead to poor outcome even if the patient made a full recovery from the head injury.Patients will be randomized via an independent service. Patients randomized to surgery receive surgery within 12 h. Both groups will be monitored according to standard neurosurgical practice. All patients have a CT scan at 5 days (+/-2 days) to assess changes in hematoma size. Follow-up is by postal questionnaire at 6 and 12 months. The recruitment target is 840 patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN19321911.

Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years.

OBJECT: Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural, subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several decades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage. METHODS: A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial hematoma following closed head trauma between 2006 and 2009 was identified. Using multivariable logistic regression models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications, intensive care unit stay, hospital stay, morbidity, and mortality. RESULTS: Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29-25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13-9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status. CONCLUSIONS: The findings suggest that in comparison with younger patients, patients over 80 years of age may be similarly able to return to preinjury functional baselines but may require increased postoperative medical attention in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly patients with intracranial hemorrhage.

Management of migrating intracranial bullets: lessons learned from surviving an AK-47 bullet through the lateral brainstem.

OBJECTIVE: Survival after a gunshot wound (GSW) to the head is becoming more common, with an accompanying increase in spontaneous migration of these intracranial bullet fragments. This phenomenon is well described in current literature and is a potentially life-threatening delayed complication of GSW to the head. METHODS: We present the case of a 17-year-old boy who survived a penetrating GSW to the cranium and cerebellum after an accident involving an AK (Automatic Kalashnikov)-47 (7.62 mm). RESULTS: Following initial attempts to remove the bullet and associated hematoma from the cerebellar hemisphere, intraoperative fluoroscopy revealed that the bullet had migrated to lie within the right middle cerebellar peduncle with the development of intraoperative cardiac arrhythmia. The bullet could not be retrieved without risk of damage to the superior and inferior cerebellar arteries. The patient then developed bacterial meningitis, and further imaging revealed the bullet had again migrated under the cerebellar cortex to an accessible location. The infection was treated with aggressive antibiotic therapy and the bullet was removed from the posterior fossa, thus preventing recurrence of infection and further migration. The patient regained full motor, speech, and proprioceptive function within months after injury. CONCLUSION: The potential for spontaneous migration exists with any penetrating brain injury involving a retained foreign body. When a retained intracranial foreign body is unable to be safely extracted during initial debridement, close clinical evaluation is essential and plain-film or computed tomographic imaging should be considered in order to enhance the early detection of delayed-onset life-threatening deterioration, such as meningitis and occlusion of cerebrospinal fluid drainage, because of spontaneous migration.

Traumatic brain injury: review of current management strategies.

Head injury is a common condition with a high morbidity and mortality. Serious intracranial haematomas require early recognition and evacuation to maximise chances of independent outcomes. Recent organisational changes have promoted the development of trauma units and major trauma centres where patients can go through triage and be managed in an appropriate environment, and the development of management pathways in intensive treatment units has resulted in improvements in the outcome of traumatic brain injuries. Evidence for the treatment of cerebral perfusion pressure, and management of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) has accumulated during the last decade and is important in the management of patients in all clinical settings. Since head injury is commonly associated with maxillofacial injuries, this review will be relevant to all who deal with this aspect of trauma.

Post-traumatic frontal and parieto-occipital extradural haematomas: a retrospective analysis of 41 patients and review of the literature.

BACKGROUND: The purpose of this study was to analyse the differences between patients with frontal (FEDH) or parieto-occipital (POEDH) epidural haematomas and evaluate possible statistically significant prognostic factors. MATERIAL AND METHODS: In this retrospective study of a group of 41 patients with a FEDH (17) or POEDH (24 individuals), the authors analysed the influence of gender, age, type of injury, clinical presentation, Glasgow coma scale (GCS) score on admission, radiological findings, and time interval from trauma to surgery on outcomes. A good recovery and moderate disability were considered a "good" or "favourable outcome", whereas severe disability, a vegetative state or death was a "poor outcome". RESULTS: In the POEDH subgroup, a higher GCS score on admission and a younger age were statistically significant prognostic factors for a better outcome (p=0.006, rs=0.702). In the subgroup of patients with FEDHs, the results were not significant. However, patients with FEDHs more frequently had "good outcomes" than members of the POEDH subgroup (88.2 vs. 70.9%). Children (≤ 18 years old) constituted a smaller portion of the POEDH subgroup (12.5%) than those in the FEDH subgroup (41.2%). The evaluation of time intervals between the accident and surgery (≤ 24 h vs. > 24 h) showed no significant influence on outcomes in any of the studied subgroups. However, patients undergoing surgery within 24 h of their injury had a less favourable GCS score on admission than those operated on more than 24 h after their injury. Subacute and chronic clinical courses predominated in patients with a FEDH (10/17 FEDH vs. 11/22 POEDH). Different accompanying intradural lesions occurred in 12 patients of the POEDH subgroup, but only in 2 of the FEDH subgroup (50 vs. 11.8%). However, the presence of such lesions did not significantly deteriorate surgical outcomes in either of the subgroups.