Traumatic Subarachnoid Hemorrhage and Subdural Hematoma Due to Acute Rebleeding of a Pseudoaneurysm with Dural Arteriovenous Fistula Between Inferolateral Trunk of the Internal Carotid Artery and Middle Cerebral Vein.

BACKGROUND: According to previous reports, pseudoaneurysms that are concomitant with a dural arteriovenous fistula (dAVF) are associated with penetrating trauma, blunt trauma, and skull fractures. Moreover, dAVFs between the inferolateral trunk of the internal carotid artery and middle cerebral vein are a rare disease manifestation. Pseudoaneurysms concomitant with dural arteriovenous fistulas (dAVF) are rare and traumatic pseudoaneurysms with dAVF typically developed slowly with less rebleeding than isolated traumatic aneurysms. CASE DESCRIPTION: Here, we report an extremely rare case of a traumatic pseudoaneurysm with a dAVF between the inferolateral trunk and middle cerebral vein. The traumatic pseudoaneurysm presented with acute pseudoaneurysm formation and rebleeding within 1 day of the trauma and was managed with direct surgery. CONCLUSIONS: The traumatic pseudoaneurysm was completely obliterated by surgical clipping, followed by decompressive craniectomy and postoperative coma therapy with propofol. Resulting from these surgical and postoperative treatments, 56 days after the operation the patient recovered fully and did not present any neurologic deficits.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

How to Remove a Penetrating Intracranial Large Nail.

BACKGROUND: The incidence of penetrating intracranial foreign bodies is rare, and to date, not many relevant studies have been published worldwide. In particular, a nail penetrating intracranially, just near the superior sagittal sinus (SSS), is extremely rare. We treated the case of a large nail that penetrated the middle of the head and strategized its removal. CASE DESCRIPTION: A 70-year-old man had experienced headache lasting a day. Computed tomography of the brain revealed a nail penetrating the middle of his head; in particular, the tip of the nail had penetrated the right ventricle, causing a slight subarachnoid hemorrhage. Angiography showed that the nail was very close to the SSS and that the venous flow was normal. However, there was a risk of the nail penetrating through the SSS or injuring other arteries, and we removed the nail directly from the intracranial view to stop bleeding from the SSS or other vessels. Fortunately, there was no bleeding, and we washed the hole created by the nail penetration and concluded the surgery. CONCLUSIONS: Our technique is useful and safe for removing large nails penetrating the head.

Improving Survival with Tranexamic Acid in Cerebral Contusions or Traumatic Subarachnoid Hemorrhage: Univariate and Multivariate Analysis of Independent Factors Associated with Lower Mortality.

BACKGROUND: Fall with head injury is a pervasive challenge, especially in the aging population. Contributing factors for mortality include the development of cerebral contusions and delayed traumatic intracerebral hematoma. Currently, there is no established specific treatment for these conditions. OBJECT: This study aimed to investigate the impact of independent factors on the mortality rate of traumatic brain injury with contusions or traumatic subarachnoid hemorrhage. METHODS: Data were collected from consecutive patients admitted for cerebral contusions or traumatic subarachnoid hemorrhage at an academic trauma center from 2010 to 2016. The primary outcome was the 30-day mortality rate. Independent factors for analysis included patient factors and treatment modalities. Univariate and multivariate analyses were conducted to identify independent factors related to mortality. Secondary outcomes included thromboembolic complication rates associated with the use of tranexamic acid. RESULTS: In total, 651 consecutive patients were identified. For the patient factors, low Glasgow Coma Scale on admission, history of renal impairment, and use of warfarin were identified as independent factors associated with higher mortality from univariate and multivariate analyses. For the treatment modalities, univariate analysis identified tranexamic acid as an independent factor associated with lower mortality (P = 0.021). Thromboembolic events were comparable in patients with or without tranexamic acid. CONCLUSION: Tranexamic acid was identified by univariate analysis as an independent factor associated with lower mortality in cerebral contusions or traumatic subarachnoid hemorrhage. Further prospective studies are needed to validate this finding.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage.

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. METHODS: This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. RESULTS: Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. CONCLUSIONS: RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury: A meta-analysis.

BACKGROUND: The rates of clinical and radiographic progression and the need for neurosurgical intervention in patients with isolated traumatic subarachnoid hemorrhage (itSAH) after mild traumatic brain injury (Glasgow Coma Scale score, 13-15) has not been well established.The aim of this work was to review the evidence regarding patient outcomes after mild traumatic brain injury with itSAH. METHODS: Two authors independently extracted the data according to a predefined protocol. The proportions of patients who had the outcomes of interest were pooled using random-effects model. The quality of included studies was assessed using the methodological index for nonrandomized studies scale. RESULTS: Thirteen studies reporting on 15,327 patients met inclusion criteria, and outcomes were pooled where available. No patient required neurosurgical intervention on presentation to hospital, and the incidence of need for eventual neurosurgical intervention was 0.0017% (95% confidence interval [CI], 0-0.39%). Moreover, the pooled analyses for all patients with available data showed an incidence of 5.76% (95% CI, 1.18-12.94%) for radiographic progression, 0.75% (95% CI, 0-2.39%) for neurologic deterioration, and 0.60% (95% CI, 0.09-1.41%) for mortality. Only one patient had died due to neurological injury. CONCLUSIONS: These patients experience very low rates of radiographic progression and neurologic deterioration and rarely require neurosurgical intervention or die due to neurological injury. LEVEL OF EVIDENCE: Meta-analysis, level III.

Management of screwdriver-induced penetrating brain injury: a case report.

BACKGROUND: Penetrating brain injury (PBI) can be caused by several objects ranging from knives to chopsticks. However, an assault with long and electric screwdriver is a peculiar accident and is relatively rare. Because of its rarity, the treatments of such injury are complex and nonstandardized. CASE PRESENTATION: We presented a case of a 54-year-old female who was stabbed with a screwdriver in her head and accompanied by loss of consciousness for 1 h. Computer tomography (CT) demonstrated that the screwdriver passed through the right zygomatic bone to posterior cranial fossa. Early foreign body removal and hematoma evacuation were performed and the patient had a good postoperative recovery. CONCLUSIONS: In this study, we discussed the clinical presentation and successful management of such a unique injury caused by a screwdriver. Our goal is to demonstrate certain general management principles which can improve patient outcomes.

Acute left ventricle failure on induction of anesthesia: a case report of reverse stress cardiomyopathy-presentation, diagnosis and treatment.

Reverse takotsubo cardiomyopathy (TCM) is a less common variant of classic TCM that presents within a different patient profile and with its own hemodynamic considerations. A 46-year-old woman was admitted to our hospital for laryngoscopy and possible balloon dilatation for tracheal stenosis under general anesthesia. One year prior to this admission, the patient was admitted after a motor vehicle accident with subdural hematoma, subarachnoid hemorrhage, and fracture of the eighth thoracic vertebra. She underwent uneventful anesthesia for thoracic spine surgery and tracheostomy to help her wean from the ventilator during that admission. Since her previous admission, she developed posttraumatic anxiety and depression (a neuropsychiatric disorder triggered by subdural hematoma and subarachnoid hemorrhage) and was treated with antianxiety and antidepressant medication. At this admission, the patient developed acute left ventricle failure on induction of anesthesia secondary to reverse TCM. We report a case of reverse TCM, where posttraumatic emotional stress of a neuropsychiatric disorder combined with physical stress from anesthesia and laryngoscopy triggered TCM in a patient with previous uneventful anesthesia 1 year earlier.

Epidural Blood Patch Using Manometry for Sinking Skin Flap Syndrome.

We describe here a 55-year-old male patient with a medical history significant for chronic back pain and substance abuse with cocaine who sustained a traumatic subarachnoid hemorrhage after a fall from a roof while acutely intoxicated on cocaine requiring decompressive hemicraniectomy and cranioplasty that was complicated by an epidural abscess requiring a repeat craniectomy. He was diagnosed with sinking skin flap syndrome consistent with altered mental status and a sunken skin flap with increased midline shift. Despite treatment with Trendelenburg positioning and appropriate fluid management, the patient continued to decline, and an epidural blood patch was requested for treatment. After placement of the epidural blood patch using manometry in the epidural space, the patient's neurologic status improved allowing him to ultimately receive a cranioplasty. The patient is now able to perform several of his activities of daily living and communicate effectively.

Airway pressure release ventilation in a patient with refractory intracranial hypertension.

Patients with refractory intracranial hypertension often require short-term mechanical ventilation because they cannot protect their airway. Airway pressure release ventilation (APRV) is less commonly used than other modes because it is thought to increase intracranial pressure. However, this case study describes how APRV improved alveolar recruitment and functional residual capacity in a patient with refractory intracranial hypertension secondary to severe traumatic brain injury.

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.

Traumatic Subarachnoid Hemorrhage Originating from Mid-Cervical Arterial Injury.

BACKGROUND: Subarachnoid hemorrhage (SAH) occasionally originates from extracranial arteries, and SAH caused by cervical trauma is even rarer. CASE REPORT: A 17-year-old male patient was admitted to our emergency department aftera bike accident; he was drowsy and showed left hemiparesis. Initial computed tomography (CT) of the brain showed SAH into the cervicomedullary cistern. A 4-hour follow-up brain CT revealed heavy bleeding into the basal cistern. Because CT angiography did not show any vascular injury, we performed imaging studies of the cervical spine. Magnetic resonance imaging revealed a blood clot located ventral to the C4-C5 level of the spinal cord without any flow void. The patient's condition deteriorated over time, and he was accordingly referred for surgery. Intraoperatively, a thick subarachnoid hematoma ventral to the spinal cord was observed. The hematoma was removed and hemostasis by bipolar cauterization was performed for bleeding from a small branch of the anterior spinal artery. Postoperatively, the weakness of the lower extremity improved considerably. CONCLUSION: In young adult patients with SAH of unexplained origin, we suggest that the cervical region be considered as the bleeding focus; in such cases, surgical evacuation of bleeding can save some patients.

Patients with traumatic subarachnoid hemorrhage are at low risk for deterioration or neurosurgical intervention.

BACKGROUND: Current standard of care for patients with traumatic intracranial hemorrhage (TIH) includes neurosurgical consultation and/or transfer to a trauma center with neurosurgical backup. We hypothesize that a set of low-risk criteria can be applied to such patients to identify those who may not require neurosurgical evaluation. METHODS: This is a cross-sectional study of consecutive emergency department patients in 2009 and 2010 with TIH on computerized tomographic scan owing to blunt head trauma. Patients presented to an urban academic Level I trauma center (volume, 92,000) were older than 15 years and had a Glasgow Coma Scale (GCS) score of 13 or greater. Charts were abstracted using a standardized data form by two emergency physicians. Our principal outcome was deterioration represented by a composite of neurosurgical intervention, clinical deterioration, or worsening computerized tomographic scan result. RESULTS: During the study period, 404 patients were seen with TIH and met our inclusion criteria, and 48 of those patients (11.8%) deteriorated. Patients with isolated subarachnoid hemorrhage, were less likely to deteriorate (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.011-0.58). Characteristics associated with deterioration were subdural hematomas (OR, 2.63; 95% CI, 1.198-5.81) or presenting GCS of less than 15 (OR, 2.12; 95% CI, 1.01-4.43).The use of anticoagulant medications or antiplatelet agents were not associated with deterioration for warfarin, aspirin, or clopidogrel; however bleeding diatheses were corrected with vitamin K, fresh frozen plasma, and platelets as necessary. CONCLUSION: Patients with isolated traumatic subarachnoid hemorrhage are at low risk for deterioration. These individuals may not need neurosurgical consultation or transfer to a trauma center where neurosurgical backup is available. Those patients with subdural hematoma or a GCS of less than 15 have a higher risk of deterioration and require neurosurgical evaluation. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70.

AIM: Mortality and morbidity due to brain injury in the elderly population is a growing clinical problem: among older patients, those >70 years have a considerably higher risk both in terms of mortality and morbidity. Thereafter, the reasons influencing outcome have not been clearly examined: in the present study we addressed these questions considering the main clinical characteristics exerting a significant impact on the outcome of patients aged > 70, with emphasis for the severity of brain injury and anticoagulant (CAW) treatments. METHODS: We performed a retrospective analysis of 103 consecutive isolated head injury patients older than 70, admitted at our Department in the period November 2004-November 2009. The clinical variables considered were as follow: age, sex, type of TBI, GCS, pre-TBI use of anti-coagulants (aspirin, warfarin, clopidogrel), INR at admission (INR values were subdivided in values >1.25 as at risk for hemorrhagic events and <1.25 as normal), initial CT scan classification looking at the presence of subarachnoid hemorrhage (t-SAH) or mass lesions; the main outcome measure was the Glasgow Outcome Scale. RESULTS: The most frequent cause of TBI was accidental fall (65%): 39 were in CAW therapies and in 36 cases the cause of falling down injury was recorded due to a sincopal event (arterial hypotension, atrial fibrillation); in the older patients an accidental fall is significantly related to the TBI, while in the patients aged 70-75 years, TBI is related to a traffic accident (P=0.002). Moreover the cause of TBI correlates with the CAW treatment, the accidental fall being significantly more frequent in patients in CAW treatment (P=0.003). Overall mortality rate is significantly related to an elevated INR class, to presence of t-SAH (16/50 patients) and subdural hematoma (26/46). CONCLUSION: The results of the present study show that in a population of patients aged > 70, TBI is a high risk event if patient has concurrent treatment with CAW therapies and if an accidental fall is the cause of TBI. In these cases the finding of t-SAH represents a high-risk parameter for mortality but not for morbidity.

[Odontoid fracture: Long-term subarachnoid hemorrhage after anterior screw fixation. Case report and literature review]. / Fracture de l'odontoïde : hémorragie sous-arachnoïdienne à distance d'un vissage odontoïdien. À propos d'un cas et revue de la littérature.

Odontoid fractures have been classified by Anderson and D'Alonzo into three main categories. The most unstable injuries, type II fractures involve the base of the odontoid peg at the junction with the C2 body. Due to the proximity of vital neural structures, fracture of the odontoid process may result in instability and fatal neurological damage. Treatment aims to re-establish stability of the atlanto-axial complex by restoring the odontoid process. This may be achieved by conservative or surgical treatment. Anterior screw fixation of the odontoid peg is an interresting alternative surgical option but this technique has a significant complication rate. However, vascular injury is very rare with three case reported in the literature: one case of an intracranial vertebral artery (VA) injury, one case of a cervical internal carotid artery (ICA) injury and one case of anterior pseudoaneurysm of the spinal artery branch. We report a new case of long term vascular injury after screw fixation revealed by a subarachnoid hemorrhage. We discuss the incidence, the mechanisms of injury and the conditions necessary for the occurrence of this complication.

Cerebral microdialysis: perioperative monitoring and treatment of severe neurosurgical patient.

The early signs of brain ischemia are key indicators of secondary brain injury and their recognition on time can ultimately save life. Direct recording of cerebral ischemia is possible using the method of cerebral microdialysis (CM). This paper presents results of the five-year experience in applying this method at University Department of Neurosurgery, Sarajevo University Clinical Center in Sarajevo. In this observational prospective clinical study, the treatment and outcome of 51 patients with subarachnoid hemorrhage (SAH) and traumatic intracranial hemorrhage (tICH) undergoing neurosurgery and consequently treated conservatively at Neurosurgical Intensive Care Unit (NICU) were analyzed. All patients were followed up by unified monitoring at NICU and additionally by the CM method. Between December 2006 and September 2010, CM monitoring was performed in 51 patients: 18 patients with SAH and 33 patients with tICH. In all patients, samples were obtained on 367 occasions, yielding a total of 3314 samples for biochemical parameters (mean 64.98 per patient, range 42-114 samples). Positive correlation was found between glucose level and outcome at one-year follow up (when glucose level was lower, the patient Glasgow Outcome Scale (GOS) score was worse). The correlation coefficient for glycerol was negative (r=-0.81), and so was for the lactate/pyruvate ratio. There was a significant difference in patient outcome in favor of the group of patients monitored by use of CM in terms of poor and good outcome graded according to GOS score 12 months after the injury compared with the group of patients not monitored with CM (P<0.028). According to our experience, we believe that CM enables early initiation of appropriate therapeutic strategies to overcome cerebral ischemia and secondary brain damage, eventually leading to better patient outcome.

[Injuries to the upper cervical medulla in severe brain injuries]. / Verletzungen des oberen zervikalen Myelons beim schweren Schädel-Hirn-Trauma.

BACKGROUND: Cranial magnetic resonance imaging (MRI) was performed in 250 patients who had been unconscious post-trauma for at least 24 hours. The frequency and the characteristics of injuries to the upper cervical myelon were determined. PATIENTS AND METHODS: Between 1996 and 2009, MRI was carried out within 8 days of trauma. RESULTS: No lesions of the upper cervical medulla were found without accompanying damage to the medulla oblongata. Two groups were found to have a lesion in the upper cervical myelon. (i) In 3.2 % of the patients in a state of deep coma MRI revealed lesions in the entire brain stem. These died without waking from coma. (ii) 2 % of the patients were found to have additional damage to the distal medulla oblongata. These victims of high-speed traumas awoke from coma after 2-3 days. They revealed frontal contusions of the brain and traumatic subarachnoidal hemorrhages. Injuries to the bony upper cervical spine and/or the skull base were frequent. Four of them died, one patient survived with severe disabilities. CONCLUSION: Two types of lesions involving the upper cervical myelon could be differentiated, both of which occur only in association with lesions in the medulla oblongata.

Blister-like supraclinoid internal carotid artery pseudoaneurysm in a 15-year-old male: case report and review of the literature.

With an incidence of less than 1-3 per million, pediatric aneurysms are rare clinical entities. A traumatic etiology is implicated in a large proportion of these cases, leading to the formation of both 'false' and 'true' aneurysms. These occur most often in the distal circulation, but have also been described in the supraclinoid distal internal carotid artery (ICA). Blood blister aneurysms are also found in this location; however, they have not been described in the pediatric population. We report the case of a 15-year-old male who presented following cranial trauma with diffuse basal subarachnoid hemorrhage and limited additional intracranial pathology. Computed tomography angiography demonstrated a small, 2-mm blister-like aneurysm arising from the dorsal surface of the left supraclinoid ICA at a non-branching site. Despite early endovascular treatment with Guglielmi detachable coils, the lesion continued to grow over subsequent studies, necessitating open surgical clipping. At the time of surgery, gross pathology of the native ICA was observed, raising the possibility of a preexisting blood-blister aneurysm. We review the epidemiology, pathophysiology and diagnostic considerations of these lesions. The endovascular and surgical management of these complex non-branching supraclinoid ICA aneurysms is also discussed.