Traumatic intracranial hemorrhage in pediatrics: Implications of factor XIII deficiency and consumptive coagulopathy in abusive head trauma evaluation.

For infants that present with intracranial hemorrhage in the setting of suspected abusive head trauma (AHT), the standard recommendation is to perform an evaluation for a bleeding disorder. Factor XIII (FXIII) deficiency is a rare congenital bleeding disorder associated with intracranial hemorrhages in infancy, though testing for FXIII is not commonly included in the initial hemostatic evaluation. The current pediatric literature recognizes that trauma, especially traumatic brain injury, may induce coagulopathy in children, though FXIII is often overlooked as having a role in pediatric trauma-induced coagulopathy. We report an infant that presented with suspected AHT in whom laboratory workup revealed a decreased FXIII level, which was later determined to be caused by consumption in the setting of trauma induced coagulopathy, rather than a congenital disorder. Within the Child Abuse Pediatrics Research Network (CAPNET) database, 85 out of 569 (15 %) children had FXIII testing, 3 of those tested (3.5 %) had absent FXIII activity on qualitative testing, and 2 (2.4 %) children had activity levels below 30 % on quantitative testing. In this article we review the literature on the pathophysiology and treatment of low FXIII in the setting of trauma. This case and literature review demonstrate that FXIII consumption should be considered in the setting of pediatric AHT.

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

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

Progression of Intracranial Hemorrhage After Chemical Prophylaxis Using Low-Molecular-Weight Heparin in Patients With Traumatic Brain Injury.

INTRODUCTION: Chemical prophylaxis using low-molecular-weight heparin (LMWH) is considered a standard of care for venous thromboembolism in trauma patients. Our center performs a head computed tomography (CT) scan 24 hours after initiation with prophylactic LMWH in the setting of a known traumatic brain injury (TBI). The purpose was to determine the overall incidence of ICH progression after chemoprophylaxis in patients with a TBI. METHODS: This retrospective study was performed at a Level I trauma center, from 1/1/2014 to 12/31/2017. Study patients were drawn from the institution's trauma registry based on Abbreviated Injury Score codes. RESULTS: 778 patients met all inclusion criteria after initial chart review. The proportion of patients with an observed radiographic progression of intracranial hemorrhage after LMWH was 5.8%. 3.1% of patients had a change in clinical management. Observed radiographic progression after LMWH prophylaxis and the presence of SDH on initial CT, the bilateral absence of pupillary response in the emergency department, and a diagnosis of dementia were found to have statistically significant correlation with bleed progression after LMWH was initiated. CONCLUSION: Over a 4-year period, the use of CT to evaluate for radiographic progression of traumatic intracranial hemorrhage 24 hours after receiving LMWH resulted in a change in clinical management for 3.1% of patients. The odds of intracranial hemorrhage progression were approximately 6.5× greater in patients with subdural hemorrhage on initial CT, 3.1× greater in patients with lack of bilateral pupillary response in ED, and 4.2× greater in patients who had been diagnosed with dementia.

Near-infrared spectroscopy for intracranial hemorrhage detection in traumatic brain injury patients: A systematic review.

PURPOSE: To synthesize evidence of the use of near-infrared spectroscopy (NIRS) to detect intracranial hemorrhage in traumatic brain injury (TBI) patients. METHODS: The literature search was conducted in PubMed and Google Scholar (from inception to July 2021). RESULTS: 216 original articles were found, 197 of which were omitted, and the final review contained 19 original articles covering 2291 patients. CONCLUSION: For patients with TBI, a NIRS test may be useful as a screening tool for intracranial hemorrhage, especially at the prehospital level. Negative results may help rule out intracranial hemorrhage and may remove the need for more head computed tomography (CT) scanning. Prehospital testing may guide the decision of whether the patient should be transferred to a craniotomy-equipped specialized hospital. NIRS can also be useful in situations when CT is not available. For future research, a significant objective is to show whether the effects of NIRS can improve outcomes and lead to meaningful improvements in clinical practice and decision making.

The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review.

BACKGROUND: The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. OBJECTIVE: Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. METHODS: We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. RESULTS: There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. CONCLUSIONS: This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.

Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants.

BACKGROUND: The established clinical risk factors for post-traumatic intracranial bleeding have not been evaluated in patients receiving DOACs yet. AIM: Evaluating the association between clinic and patient characteristics and post-traumatic intracranial bleeding (ICH) in patients with mild traumatic brain injury (MTBI) and DOACs. METHODS: This is a retrospective observational study conducted on three Emergency Departments. Multivariate analysis provided association in terms of OR with the risk of ICH. The performance of the multivariate model, described in a nomogram, has been tested with discrimination and decision curve analysis. RESULTS: Of 473 DOACs patients with MTBI, 8.5% had post-traumatic ICH. On multivariable analysis, major dynamics (odds ratio [OR] 6.255), post-traumatic amnesia (OR 3.961), post-traumatic loss of consciousness (LOC, OR 7.353), Glasgow Coma Scale (GCS) score < 15 (OR 3.315), post-traumatic headache (OR 4.168) and visible trauma above the clavicles (OR 3.378) were associated with a higher likelihood of ICH. The multivariate model, used for the nomogram construction, showed a good performance (AUC bias corrected with 5000 bootstraps resample 0.78). The DCAs showed a net clinical benefit of the prognostic model. CONCLUSIONS: Clinical risk factors can be used in DOACs patients to better define the risk of post-traumatic ICH.

Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage.

BACKGROUND: Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI). METHODS: Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016-12/2018. INCLUSION CRITERIA: head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm). EXCLUSION CRITERIA: GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion. OUTCOMES: pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits. RESULTS: 138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/- 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/- 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring. CONCLUSIONS: ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting.

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

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

Incremental Risk of Intracranial Hemorrhage After Mild Traumatic Brain Injury in Patients on Antiplatelet Therapy: Systematic Review and Meta-Analysis.

BACKGROUND: Mild traumatic brain injury (TBI) is a common event and antiplatelet therapy might represent a risk factor for bleeding. OBJECTIVE: The aim of this study was to evaluate the risk of intracranial hemorrhage (ICH) after mild TBI in patients on antiplatelet therapy through a systematic review and meta-analysis. METHODS: We conducted a systematic review and meta-analysis of prospective and retrospective observational studies on patients with mild TBI on antiplatelet therapy vs. those not on any antithrombotic therapy. The primary outcome was the risk of ICH in patients with mild TBI based on the first computed tomography scan. Secondary outcome was the risk of mortality and neurosurgery. RESULTS: Nine studies and 14,545 patients were included. The incidence of ICH ranged from 3.6% to 29.4% in the antiplatelet group and from 1.6% to 21.1% in the control group. Patients on antiplatelet therapy had a higher risk of ICH after a mild TBI compared with patients that were not on antithrombotic therapy (risk ratio 1.51; 95% confidence interval 1.21-1.88). No difference was found in the composite outcome of mortality and neurosurgery. CONCLUSIONS: Patients on antiplatelet therapy have an increased risk of ICH after mild TBI compared with patients not on antithrombotic therapy. However, the risk is just slightly increased, and the need to perform a computed tomography scan in patients on antiplatelet therapy after a mild TBI should be evaluated case by case, but always considered in patients with other risk factors.

Preinjury Antiplatelet Use Does Not Increase the Risk of Progression of Small Intracranial Hemorrhage.

BACKGROUND: The modified brain injury guidelines (mBIG) provide an algorithm for surgeons to manage some mild traumatic brain injury (TBI) with intracranial hemorrhage (ICH) without neurosurgical consultation or repeat imaging. Currently, antiplatelet use among patients with any ICH classifies a patient at the highest level, mBIG 3. This study assesses the risk of clinical progression among patients taking antiplatelet medications with mild TBI with ICH. METHODS: A retrospective analysis of patients with traumatic ICH over a 5-year period was conducted. Demographics, injury severity, and outcome data were collected for each patient. Patients taking antiplatelet agents were reclassified as if they were not taking these medications. Patients who would have met criteria for a lower classification (mBIG 1 or 2) without antiplatelet agents were designated mBIG 3 Antiplatelet and compared with all other mBIG 1 and 2 patients. RESULTS: 736 patients met the inclusion criteria. 158 patients were taking antiplatelet medications and 53 were reclassified as mBIG 3 Antiplatelet. When comparing mBIG 3 Antiplatelet to the 226 patients originally classified as mBIG 1 and 2, mBIG 3 Antiplatelet patients were more likely to undergo repeat head computed tomography (98.1% vs 76.6%; P < .001) and neurosurgical consultation (94.2% vs 76.5%; P < .001) but had no significant differences in outcomes. No mBIG 3 Antiplatelet patients had a worsening examination or needed operative intervention. DISCUSSION: This data suggests that antiplatelet medication use should not automatically classify a patient as mBIG 3. Adoption of this strategy would better utilize resources and avoid unnecessary costs without sacrificing care.

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

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

Development and Implementation of a Pilot Radiation Reduction Protocol for Pediatric Head Injury.

BACKGROUND: Traumatic brain injury is the leading cause of morbidity and mortality for children in the United States. The aim of this study was to develop and implement a guideline to reduce radiation exposure in the pediatric head injury patient by identifying the patient population where repeat imaging is necessary and to establish rapid brain protocol magnetic resonance imaging as the first-line modality. METHODS: A retrospective chart review of trauma patients between 0 and 14 y of age admitted at a pediatric level 2 trauma center was performed between January 2013 and June 2019. The guideline established the appropriateness of repeat scans for patients with Glasgow Coma Scale >13 with clinical neurological deterioration or patients with Glasgow Coma Scale ≤13 and intracranial hemorrhagic lesion on initial head computed tomography (CT). RESULTS: Our trauma registry included 592 patients during the study period, 415 before implementation and 161 after implementation. A total of 132 patients met inclusion criteria, 116 pre-guideline and 16 post-guideline. The number of patients receiving repeat head CTs significantly decreased from 34.5% to 6.3% (P < 0.02). There was also a significant decrease in the mean number of head CT/patient pre-guideline 1.63 (range 1-7) compared with post-guideline 1.06 (range 1-2) (P < 0.02). CONCLUSIONS: CT head imaging is invaluable in the initial trauma evaluation of pediatric patients. However, it can be overused, and the radiation may lead to long-term deleterious effects. Establishing a head imaging guideline which limits use with clinical criteria can be effective in reducing radiation exposure without missing injuries.

Therapeutic anticoagulation in patients with traumatic brain injuries and pulmonary emboli.

BACKGROUND: Patients with traumatic intracranial hemorrhage (ICH) and concomitant pulmonary embolus (PE) have competing care needs and demand a careful balance of anticoagulation (AC) versus potential worsening of their ICH. The goal of this study is to determine the safety of therapeutic AC for PE in patients with ICH. METHODS: This is a retrospective single-center study of patients older than 16 years with concomitant ICH and PE occurring between June 2013 and December 2017. Early AC was defined as within 7 days of injury or less; late was defined as after 7 days. Primary outcomes included death, interventions for worsening ICH following AC, and pulmonary complications. Multivariate logistic regression was used to evaluate for clinical and demographic factors associated with worsening traumatic brain injury (TBI), and recursive partitioning was used to differentiate risk in groups. RESULTS: Fifty patients met criteria. Four did not receive any AC and were excluded. Nineteen (41.3%) received AC early (median, 4.1; interquartile range, 3.1-6) and 27 (58.7%) received AC late (median, 14; interquartile range, 9.7-19.5). There were four deaths in the early group, and none in the late cohort (21.1% vs. 0%, p = 0.01). Two deaths were due to PE and the others were from multi-system organ failure or unrecoverable underlying TBI. Three patients in the early group, and two in the late, had increased ICH on computed tomography (17.6% vs. 7.4%, p = 0.3). None required intervention. CONCLUSION: This retrospective study failed to find instances of clinically significant progression of TBI in 46 patients with computed tomography-proven ICH after undergoing AC for PE. Therapeutic AC is not associated with worse outcomes in patients with TBI, even if initiated early. However, two patients died from PE despite AC, underlining the severity of the disease. Intracranial hemorrhage should not preclude AC treatment for PE, even early after injury. LEVEL OF EVIDENCE: Care management, Level IV.

Impact of Antithrombotic Agents on Radiological Lesion Progression in Acute Traumatic Brain Injury: A CENTER-TBI Propensity-Matched Cohort Analysis.

An increasing number of elderly patients are being affected by traumatic brain injury (TBI) and a significant proportion are on pre-hospital antithrombotic therapy for cardio- or cerebrovascular indications. We have quantified the impact of antiplatelet/anticoagulant (APAC) agents on radiological lesion progression in acute TBI, using a novel, semi-automated approach to volumetric lesion measurement, and explored the impact of use on clinical outcomes in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We used a 1:1 propensity-matched cohort design, matching controls to APAC users based on demographics, baseline clinical status, pre-injury comorbidities, and injury severity. Subjects were selected from a pool of patients enrolled in CENTER-TBI with computed tomography (CT) scan at admission and repeated within 7 days of injury. We calculated absolute changes in volume of intraparenchymal, extra-axial, intraventricular, and total intracranial hemorrhage (ICH) between scans, and compared volume of hemorrhagic progression, proportion of patients with significant degree of progression (>25% of initial volume), proportion with new ICH on follow-up CT, as well as clinical course and outcomes. A total of 316 patients were included (158 APAC users; 158 controls). The mean volume of progression was significantly higher in the APAC group for extra-axial (3.1 vs. 1.3 mL, p = 0.01), but not intraparenchymal (3.8 vs. 4.6 mL, p = 0.65), intraventricular (0.2 vs. 0.0 mL, p = 0.79), or total intracranial hemorrhage (ICH; 7.0 vs. 6.0 mL, p = 0.08). More patients had significant hemorrhage growth (54.1 vs. 37.0%, p = 0.003) and delayed ICH (4 of 18 vs. none; p = 0.04) in the APAC group compared with controls, but this was not associated with differences in length of stay (LOS), rates of neurosurgical intervention, mortality or Glasgow Outcome Scale Extended (GOS-E) score at 6 months. Pre-injury use of antithrombotic agents was associated with greater expansion of extra-axial lesions, higher rates of significant hemorrhagic progression, and higher risk of delayed traumatic ICH, but this was not associated with worse clinical course or functional outcomes.

Clinically significant traumatic intracranial hemorrhage following minor head trauma in older adults: a retrospective cohort study.

OBJECTIVES: The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial hemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. METHODS: This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. RESULTS: From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). CONCLUSIONS: In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study.

OBJECTIVES: Emergency department (ED) visits among older adults are frequently instigated by a fall at home. Some of these patients develop intracranial bleeding. The aim of this study was to identify the incidence of intracranial bleeding and the associated clinical features in older adults who present to the ED after falling. DESIGN: Prospective cohort study. SETTING: Three Canadian EDs. PARTICIPANTS: A total of 2 176 patients age 65 years or older who presented to the ED with a fall were assessed, and 1753 were included. Inclusion criteria were a fall on level ground, off a bed, chair, or toilet, or from one or two steps within 48 hours. MEASUREMENTS: Emergency physicians recorded predefined clinical findings on initial assessment. The primary outcome was intracranial bleeding, diagnosed either by computed tomography at the index visit or within 42 days. Associations between baseline clinical findings and the presence of intracranial bleeding were assessed with multivariable logistic regression. RESULTS: A total of 1753 patients (median age = 82 y) were enrolled, of whom 39% were male, 35% were on antiplatelet therapy, and 25% were on an anticoagulant. The incidence of intracranial bleeding was 5.0% (95% confidence interval [CI] = 4.1-6.1). Overall, 76 patients were diagnosed at the index ED visit, and 12 were diagnosed during follow-up. Multivariable regression identified four clinical variables that were independently associated with intracranial bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4). CONCLUSION: The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between intracranial bleeding and antiplatelet or anticoagulant use. J Am Geriatr Soc 68:970-976, 2020.

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

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

Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding.

BACKGROUND: Guidelines for management of intracranial hemorrhage do not account for bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to convexity SDH, is a distinct clinical entity and these patients do not benefit from critical care monitoring or repeat imaging. METHODS: We identified patients presenting to a single level I trauma center with isolated head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH. RESULTS: Demographics, comorbidities, and use of antiplatelet and anticoagulant agents were similar between the groups. As compared to patients with convexity SDH, patients with parafalcine SDH had a significantly lower incidence of radiographic progression, and had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all P < 0.005). Compared to patients admitted to the intensive care unit, patients with parafalcine SDH admitted to the floor had a shorter length of stay (2.0 ± 1.6 versus 3.8 ± 2.9 d, P < 0.005) with no difference in outcomes. CONCLUSIONS: Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission.