Nontraumatic Intracranial Epidural Hematoma: Systematic Review of the Literature / Hematoma epidural intracraniano não traumático: revisão sistemática da literatura

Introduction Epidural hematoma (EDH) is generally a direct sequela of head injury. Spontaneous EDH is rarely described in the literature. Spontaneous EDH can be caused by infections of adjacent regions, vascular malformations of the dura mater, metastases to the bone skull, and disorders of blood coagulation. The preferred treatment is surgical. The prognosis is directly related to the size, location, and Glasgow Coma Scale score on admission and the underlying disease. Methods A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We performed the search in the PubMed/MEDLINE, Embase, and Scopus databases. Abstracts and articles were screened according to our inclusion and exclusion criteria. Results The literature review yielded 1,156 records from the databases, of which a total of 164 full-text articles were included in the final synthesis, plus 22 additional relevant studies. A total of 89 case report studies were included, providing 95 unique patients. There was a predominance of coagulopathies as the main etiology of spontaneous EDH. A total of 45.3% of the patients presented lesions in > 1 brain lobe. The frontal lobe was the most prevalent location of EDH. The most used neuroimaging exam was computed tomography (CT). Surgical intervention was the most common treatment performed. A total of 24.2% of the patients died. Conclusion Nontraumatic EDH represents an uncommon manifestation of several pathologies. Clinical investigation should be aware of such a possibility. Healthcare professionals should value the physical examination and clinical history of the patient. Given the scarcity of information on the pathogenesis of spontaneous EDH, further studies are needed to better define intervention strategies and therapies for these patients.

Introdução Geralmente, o hematoma epidural (HED) é decorrente de traumatismo cranioencefálico. O HED espontâneo tem sido ocasionado por infecção de áreas adjacentes, malformação vascular na dura-máter, metástases para osso do crânio e doenças da coagulação sanguínea. Seu prognóstico está diretamente relacionado com o tamanho, a localização, o escore na escala de coma de Glasgow na admissão e a doença de base. Metodologia Uma revisão sistemática da literatura foi conduzida e seguiu as diretrizes Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA, na sigla em inglês). Realizamos a pesquisa nos bancos de dados PubMed/MEDLINE, Embase e Scopus. Os resumos e artigos foram selecionados de acordo com os nossos critérios de inclusão e exclusão. Resultados A revisão da literatura resultou em 1,156 registros nas bases de dados, dos quais um total de 164 artigos com texto completo foram incluídos na síntese final; mais 22 estudos relevantes foram adicionados. Um total de 89 estudos de caso foi incluído, fornecendo 95 pacientes únicos. Havia uma predominância de coagulopatias como a principal etiologia do HED espontâneo. Um total de 45,3% dos pacientes apresentava lesões em > 1 lobo cerebral. A intervenção cirúrgica foi o tratamento mais comum realizado. Um total de 24,2% dos pacientes morreu. Conclusão Hematoma epidural não traumático representa uma manifestação incomum de várias patologias. A investigação clínica deve estar atenta a tal possibilidade e os profissionais de saúde devem valorizar o exame físico e a história clínica do paciente. Dada a escassez de informações sobre a etiopatogenia do HED, mais estudos são necessários para melhor definir estratégias de intervenção e terapias para estes pacientes.

Adulto con hematoma medular epidural espontáneo

RESUMEN El hematoma espinal es una entidad clínica poco frecuente. Se necesita de una alta sospecha clínica para su diagnóstico precoz y tratamiento oportuno. Habitualmente se presenta en forma de deterioro neurológico súbito debida a la compresión medular mecánica producida por sangre en el canal medular. Presentamos el caso de un paciente de sexo masculino de 53 años, consumidor de bebidas alcohólicas (ron paraguayo) en forma diaria que presenta un deterioro neurológico brusco comprometiendo miembros superiores e inferiores. Con la resonancia magnética se llega al diagnóstico de hematoma epidural a nivel de C4-C5 y mielopatía compresiva de los segmentos adyacentes.

ABSTRACT The spinal hematoma spinal is a infrequent clinical entity. A high clinical suspicion is needed for early diagnosis and timely treatment. It usually presents as a sudden neurological deterioration due to mechanical spinal cord compression caused by blood in the spinal canal. We present the case of a 53-year-old male patient, a daily consumer of alcoholic beverages (Paraguayan rum) who presented sudden neurological deterioration compromising upper and lower limbs. Magnetic resonance imaging leads to a diagnosis of epidural hematoma at the C4-C5 level and compressive myelopathy of the adjacent segments.

The use of chemoprophylaxis or not for dvt in spine surgery: a systematic review / O uso da quimioprofilaxia ou não para tvp em cirurgia de coluna: revisão sistemática / El uso de quimioprofilaxis o no para la tvp en la cirugía de columna vertebral: revisión sistemática

ABSTRACT Objective: To compare pharmacological and non-pharmacological prophylaxis in elective spine surgery to determine the risks of DVT, PTE, and epidural hematoma (EH) in both groups, as well as their respective treatment effectiveness. Methods: Systematic review and meta-analysis based on systematically searched articles, using combinations of MeSH terms related to chemoprophylaxis and non-chemoprophylaxis for prevention of deep vein thrombosis and pulmonary embolism in elective spine surgery. Adult patients were eligible for inclusion in the study, except for those with trauma, spinal cord injury, neoplasms, or those using vena cava filters. Results: Five studies were selected for this systematic review and meta-analysis: 3 retrospective studies, 1 prospective study, and 1 case series. Data analysis showed that 4.64% of patients treated with chemoprophylaxis had an unfavorable outcome regarding DVT, while this outcome occurred in 1.14% of patients not treated with chemoprophylaxis (p=0.001). Among patients using chemoprophylaxis, only 0.1% developed epidural hematoma and 0.38% developed PTE. Among those on non-pharmaceutical prophylaxis, 0.04% had EH (p=0.11) and 0.42% had PTE (p=0.45). Conclusions: No benefits were found for chemoprophylaxis as compared to non-chemoprophylaxis in preventing DVT in elective spine surgery, nor was there an increased risk of epidural hematoma or fatal thromboembolic events. Level of evidence III; Therapeutic studies; Investigation of treatment results.

RESUMO Objetivo: Comparar profilaxia farmacológica e não farmacológica em cirurgia eletiva da coluna vertebral, a fim de determinar os riscos de TVP, TEP e hematoma epidural (HE) em ambos os grupos, bem como a respectiva eficácia do tratamento. Métodos: Revisão sistemática e metanálise com base em artigos sistematicamente pesquisados, usando combinações de termos MESH relacionados à quimioprofilaxia e à não quimioprofilaxia para prevenção de trombose venosa profunda e embolia pulmonar em cirurgia eletiva da coluna vertebral. Pacientes adultos foram elegíveis para inclusão no estudo, exceto aqueles com trauma, lesão medular, neoplasias e aqueles que usavam filtros de veia cava. Resultados: Cinco estudos foram incluídos para fazer parte desta revisão sistemática e metanálise: três estudos retrospectivos, um prospectivo e um série de casos. A análise dos dados mostrou que 4,64% dos pacientes tratados com quimioprofilaxia tiveram um resultado desfavorável em relação à TVP, enquanto esse resultado ocorreu em 1,14% dos pacientes não tratados com quimioprofilaxia (p = 0,001). Entre os pacientes em uso de quimioprofilaxia, apenas 0,1% desenvolveram hematoma epidural (HE) e 0,38% desenvolveram TEP. Entre aqueles em profilaxia não medicamentosa, 0,04% apresentaram HE (p = 0,11) e 0,42% tiveram TEP (p = 0,45). Conclusões: Não foram encontrados benefícios para a quimioprofilaxia quando comparada à não quimioprofilaxia na prevenção da TVP em cirurgia eletiva da coluna vertebral, assim como não foi verificado aumento do risco de hematoma epidural ou eventos tromboembólicos fatais. Nível de evidência III; Estudos terapêuticos - Investigação dos resultados do tratamento.

RESUMEN Objetivo: Comparar la profilaxis farmacológica y no farmacológica en la cirugía de columna electiva para determinar los riesgos de TVP, TEP y hematoma epidural (HE) en ambos grupos, así como la respectiva eficacia del tratamiento. Métodos: Revisión sistemática y metanálisis basados en artículos buscados sistemáticamente, utilizando combinaciones de términos MESH relacionados con quimioprofilaxis y no quimioprofilaxis para la prevención de trombosis venosa profunda y embolia pulmonar en cirugía electiva de columna. Se eligieron pacientes adultos para su inclusión en el estudio, excepto aquellos con traumatismos, lesión medular, neoplasias y aquellos que usan filtros de vena cava. Resultados: Se incluyeron cinco estudios para formar parte de esta revisión sistemática y metanálisis: 3 estudios retrospectivos, 1 prospectivo y 1 serie de casos. El análisis de los datos reveló que el 4,64% de los pacientes tratados con quimioprofilaxis tuvieron un resultado desfavorable con respecto a la TVP, mientras que este resultado se produjo en el 1,14% de los pacientes no tratados con quimioprofilaxis (p = 0,001). Entre los pacientes que recibieron quimioprofilaxis, sólo el 0,1% desarrolló hematoma epidural (HE) y el 0,38% desarrolló TEP. Entre los que recibieron profilaxis no farmacológica, el 0,04% desarrolló HE (p = 0,11) y el 0,42% desarrolló TEP (p = 0,45). Conclusiones: No se encontraron beneficios para la quimioprofilaxis en comparación con la no quimioprofilaxis para prevenir la TVP en la cirugía de columna electiva, así como tampoco un mayor riesgo de hematoma epidural o eventos tromboembólicos fatales. Nivel de evidencia - III; Estudios terapéuticos - Investigación de los resultados del tratamiento.

Traumatismo encéfalo-craneano por caída libre en neonatos

Objetivo : Describir las características clínicas del traumatismo encéfalo craneano en neonatos. Materiales y métodos : Se realizó una serie de casos de neonatos con traumatismo encéfalo craneano, todos con diagnóstico clínico y tomográfico atendidos por el Servicio de Neuropediatría y Neonatología del Hospital Cayetano Heredia del 2014 al 2019. Resultados : Se incluyeron 12 neonatos, 67% (8/12) fueron varones, 33% (4/12) menores de cuatro días de edad y 25% (3/12) hijos de madres añosas. La caída libre fue el mecanismo de lesión en todos los casos y tres de ellos se cayeron de coches de paseo para bebés. El lugar más frecuente de la caída fue el hospital, tres neonatos se encontraban en alojamiento conjunto, dos en la sala de espera de la consulta externa y uno en hospitalización. El 83% (10/12) de los casos cayó de ≥ 0.5 m de altura y 33% (4/12) cayó de ≥ 1m. El 58% (7/12) fue sintomático a la caída, cuatro casos con letargia y uno con irritabilidad. Además, se reportaron vómitos y dificultad respiratoria. Cuatro presentaron hematoma epidural y tres de ellos fractura craneal, dos de gravedad por hipertensión endocraneana descompensada que requirieron evacuación quirúrgica de emergencia. Conclusión : El traumatismo encéfalo craneano en neonatos es un problema potencialmente grave. El hematoma epidural fue la lesión intracraneal más frecuente. La letargia e irritabilidad fueron los síntomas más frecuentes en los neonatos que cayeron de ≥ 0.5m de altura.

Objective : To describe clinical characteristics of head trauma in neonates. Material and methods : This is a case series of neonate patients with head trauma. All of them had a clinical diagnosis and computed tomography scans performed. They were taken care of in both Neuropediatrics and Neonatology services in Cayetano Heredia National Hospital in Lima, Peru from 2014 to 2019. Results : Twelve neonates were included, 67% (8/12) were male, 33% (4/12) were less than four days old, and 25% (3/12) were born to mature mothers. Free fall was the mechanism of lesion for all cases, and three of them fell down from baby trolleys. Places where these accidents occurred were at the hospital. Three neonates were in joint housing, two were in the waiting room of the outpatient clinic, and one fall occurred in the hospitalization ward. Eighty- three per cent (10/12) of all cases fell from ≥0.5- m height, and 33% (4/12) fell from 1- m height. Fifty-eight per cent (7/12) developed symptoms after the fall, four had lethargy and one had irritability. Also, vomits and respiratory distress were reported. Four neonates developed epidural hematoma and three had cranial fracture, two of these latter cases were severe because of decompensated cranial hypertension that required emergency surgical decompression. Conclusion : Head trauma in neonates is a potentially severe condition. Epidural hematoma was the most frequent intracranial lesion. Lethargy and irritability were most frequent symptoms in neonates who fell from ≥0.5- m height.

Stroke Mimics：report of 3 Cases and Review of Literature / 中风与神经疾病杂志

@#Objective In order to improve the clinicians’ awareness of stroke mimics and to avoid inappropriate therapy，we described the clinical data of 3 patients with stroke mimics and reviewed the literature.Methods We retrospectively gave a description of the medical history，clinical manifestations，imaging data and treatments of three typical cases of stroke mimics from January 2017 to September 2018 in our hospital.Results Case1 The patient complained of inability to speak in the morning and weakness of the right limbs for several hours. Head CT showed old lacunar infarctions.The primary diagnosis was acute ischemic stroke（AIS）. The patient developed with fever and seizures during the following days. The diagnosis of intracranial subdural empyema was confirmed by head MRI and further surgery was performed. The reason why we didn’t make the right diagnosis was that the resident didn’t ask the medical history in detail and we didn’t check the head MRI in time.Case 2 We describe a 70-year-old man who presented to our emergency department（ED）with acute onset of left arm soreness and left leg weakness for 5 hours. The AIS was considered. The patient was admitted to the ward and we knew his first symptom was back pain which lasted about few minutes. Spinal cord MRI revealed spinal epidural hematoma. Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs，mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms，spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a symptom of pain who is a possible candidate for thrombolytic therapy. Case3 The patient admitted to the ward with a seizure，speech disorder and right limbs paralysis for more than 20 hours. The patient’s head MR angiography showed severe stenosis of the left middle cerebral artery. The diagnosis of AIS was made. But the two head MRI being negative for acute ischemic lesion and three dimensional arterial spin-labeled brain perfusion MRI was normal. The diagnosis of AIS was wavering. Within 5 days from the admission，there was almost a complete remission of the neurological findings. The electroencephalogram examination revealed focal abnormalities and Todd’s paralysis was finally confirmed. The neurological deficits during the postictal seizure phase are usually short lasting，but they may last up to days after the convulsion.Conclusion Stroke mimics term is applied in a clinical evaluation，describing those non-vascular conditions that simulate stroke，namely those presenting with an acute neurological deficit.Careful clinical assessment （clinical history and neurological examination）in association with laboratory evaluation is important for depicting the stroke mimics. Brain imaging is essential for the correct diagnosis of AIS and stroke mimic exclusion. With the use of the clinical，laboratory data and magnetic resonance imaging （MRI） evaluation，the misdiagnosis incidence of stroke mimics will decline to lower degree.

Reporte de caso: hematoma epidural supra e infratentorial en paciente pediátrico / Case report: supra and infratentorial epidural hematoma in a pediatric patient

El traumatismo craneoencefálico es una causa común de morbi-mortalidad en la población pediátrica, sus lesiones secundarias como los hematomas epidurales son frecuentemente hallados, pero en su localización de la fosa posterior solo representa el 5% y son de alto riesgo de presentar complicaciones; además el hematoma supra e infratentorial simultáneo es muy poco frecuente. En el presente trabajo daremos a conocer el manejo quirúrgico de alto riesgo de un paciente con un hematoma supra e infratentorial de gran volumen, describiendo las posibles complicaciones y observando la evolución. Se realizó craneotomía supratentorial y una craniectomía sub-occipital para evacuación de hematoma. El paciente se recuperó satisfactoriamente mostrando mejoría en el postoperatorio inmediato, siendo dado de alta recuperando la función global(AU)

Traumatic Head Injury is a common cause of morbidity and mortality in the pediatric population. Its secondary lessons, such as epidural hematomas, are frequently found, but in the posterior fossa it only represents 5% and they are at high risk of complications; in addition, simultaneous supra and infratentorial hematoma is very rare. In the present work, we will present the high-risk surgical management of a patient with a large volume supraand infratentorial hematoma, describing the possible complications and observing the evolution. Supratentorial craniotomy and sub-occipital craniectomy were performed to evacuate the hematoma. The patient recovered satisfactorily showing improvement in the immediate postoperative period, being discharged recovering global function(AU)

Hematoma epidural supra e infratentorial en paciente pediátrico

El traumatismo craneoencefálico es una causa común de morbi-mortalidad en la población pediátrica, sus lesiones secundarias como los hematomas epidurales son frecuentemente hallados, pero en su localización de la fosa posterior solo representa el 5% y son de alto riesgo de presentar complicaciones; además el hematoma supra e infratentorial simultáneo es muy poco frecuente. En el presente trabajo daremos a conocer el manejo quirúrgico de alto riesgo de un paciente con un hematoma supra e infratentorial de gran volumen, describiendo las posibles complicaciones y observando la evolución. Se realizó craneotomía supratentorial y una craniectomía sub-occipital para evacuación de hematoma. El paciente se recuperó satisfactoriamente mostrando mejoría en el postoperatorio inmediato, siendo dado de alta recuperando la función global.

Traumatic Head Injury is a common cause of morbidity and mortality in the pediatric population. Its secondary lessons, such as epidural hematomas, are frequently found, but in the posterior fossa it only represents 5% and they are at high risk of complications; in addition, simultaneous supra and infratentorial hematoma is very rare. In the present work, we will present the high-risk surgical management of a patient with a large volume supra- and infratentorial hematoma, describing the possible complications and observing the evolution. Supratentorial craniotomy and sub-occipital craniectomy were performed to evacuate the hematoma. The patient recovered satisfactorily showing improvement in the immediate postoperative period, being discharged recovering global function.

Modified surgical method for supra- and infratentorial epidural hematoma and related anatomical study of the squamosal part of the occipital bone / 西安交通大学学报(医学版)

Objective: To explore the modified surgical method of supra- and infratentorial epidural hematoma (SIEDH) and analyze the related anatomy of the occipital bone. Methods: CT scan data of 30 adult patients with no history of craniocerebral trauma were collected in our hospital from January to August 2019. The median sagittal plane was taken to define line A (from lambdoid suture to the extraoccipital turbercle) and line B (from extraoccipital turbercle to the posterior edge of the foramen magmun). The angle θ was defined between the two lines. The mean value of θ was analyzed for comparison between genders and for exploration of the anatomical basis of single supratentorial craniotomy for SIEDH. Eight patients with SIEDH were recruited in the same period to analyze the procedure and results of the modified surgical method. Results: The average angle of the θ was (117.4±4.3)° for men and (130.0 ±4.9)° for women; the minimum was 108.3° for men and the maximum was 138.7 ° for women. The θ was smaller in men than in women (P<0.001). The smaller the angle was, the more conductive it was to detect the lesions from superior to inferior tentorial apartment. The bone flaps of the eight patients were designed above the transverse sinus. During the operation, epidural hematoma was completely removed, and no skull defects occurred like in conventional supra-inferior tentorial craniotomy. Conclusion: The supratentorial craniotomy above the tranverse sinus has reliable anatomical basis and is an effective surgical method for SIEDH.

Satellite effusion sign: an important CT sign of epidural hematoma / 中华神经医学杂志

Objective:To investigate the CT imaging features of epidural hematoma (EDH) surrounding subdural effusion (satellite effusion sign) and its application value in diagnosis of EDH.Methods:A retrospective analysis of clinical and imaging data of 30 patients with EDH and 122 patients with acute subdural hematoma (SDH), admitted to our hospitals from December 2017 to February 2020, was performed. The frequencies of satellite effusion sign were compared in the two groups, and the differences between the correct diagnosis rate of traditional CT performance and the correct diagnosis rate of traditional CT performance+satellite effusion sign were compared in the two groups; the specific characteristics of satellite effusion sign was clarified and its relations with morphological characteristics and distribution of hematoma were analyzed.Results:Among 30 patients with acute EDH, the occurrence rate of satellite effusion sign was 63.3% (19/30); among 122 patients with acute SDH, the occurrence rate of satellite effusion sign was 2.5% (3/122); the difference was statistically significant ( χ2=67.248, P=0.000). Among the 30 patients with acute EDH, the correct diagnosis rate of traditional CT manifestation was 86.7% (26/30), and the correct diagnosis rate of traditional CT manifestation+satellite effusion sign was 93.3% (28/30), without statistically significance ( χ2=0.185, P=0.667). The length of the satellite effusion sign was (1.1±0.9) cm, ranged from 0.2 cm-3.1 cm; the width was (3.6±2.0) mm, ranged from 1.4 mm-7.5 mm. The incidence of satellite effusion sign in the frontotemporal EDH patients (73.9%) was significantly increased as compared with that in the occipitoparietal EDH patients (28.6%, P<0.05); that of patients with clinically diagnosed cerebral contusion, laceration, cerebral hernia or other severe to extremely severe craniocerebral injuries (22.2%) was significantly reduced as compared with that of patients with mild to moderate craniocerebral injuries (81.0%, P<0.05). Conclusion:Satellite effusion sign is an important new CT sign in the diagnosis of EDH, which is closely related to the locations of hematoma and severities of craniocerebral injury.

Large Vertex Epidural Hematoma: Case Report and Review of Surgical Approaches

Vertex epidural hematomas (VEHs) are a special clinical entity due to their clinical presentation, vascular etiology and options of surgical approach. The clinical suspicion involves recognizing the mechanism of the injury and the correct visualization of the hematoma in computed tomography (CT) coronal sequences. In the present article, we describe a case of a very large (146 mL) VEH with central brain herniation, and provide a technical note on the surgical planning and treatment. A 34-year-old male patient was admitted to the hospital after an injury on the left superior parietal region. The Glasgow coma scale score was 6, and the left pupil of the patient was dilated. The CT scan showed a large epidural hematoma on the vertex between the coronal e lambdoid sutures, and a fracture over the sagittal suture. During the surgery, multiple burr holes were made laterally to the sagittal suture, and after inspection and no visualization of bleeding in the superior sagittal sinus (SSS), we performed a standard biparietal craniotomy. The patient was discharged three days after the surgery without any deficits. Currently, with the improvement in imaging modalities,more cases of VEH are being identified. Identifying the etiology prior to the craniotomy is challenging in severe cases. Tears in the SSS can bleed profusely, and they demand strategies during the craniotomy.With multiple burr holes parallel to the sagittal suture, we can visualize whether there is bleeding in the SSS and design a craniotomy with or without a central osseous bridge to anchor the dura. Neurosurgeons must be prepared to plan a surgical strategy in cases of large VEHs. Due to its rare frequency and bleeding risks, VEHs are considered challenging.

Epidural hematoma after total knee arthroplasty in a patient receiving rivaroxaban: A case report

Rivaroxaban, a factor Xa inhibitor, is one of the newly developed direct oral anticoagulants (DOAC). In recent times, it has been increasingly used in the prevention of pulmonary embolism in patients undergoing orthopedic surgery. This report describes a case of epidural hematoma in an elderly patient who underwent combined spinal epidural anesthesia for total knee arthroplasty; the patient received rivaroxaban postoperatively for 7 days to prevent pulmonary embolism. Additionally, the epidural hematomas developed on the 5th postoperative day but the patient recovered well with conservative treatment. Although rivaroxaban has a low need for monitoring and is easily administered, the guidelines should be carefully checked for the postoperative administration schedule in patients undergoing regional anesthesia. In addition, rivaroxaban should be used with caution, especially in elderly patients.

Traumatic Cervical Epidural Hematoma without Osseous Fracture Presenting as Hemiparesis / 대한신경손상학회지

Traumatic cervical epidural hematoma (EDH) with no osseous fracture or underlying hematological abnormalities is a rare disorder that sometimes requires emergent surgical decompressive therapy. A 47-year-old woman was admitted to our emergency room due to severe neck pain and rapid onset hemiparesis after a car accident. Plain cervical radiographs and computed tomography scan did not reveal any abnormality. However, magnetic resonance imaging (MRI) revealed a large posterior EDH compressing the spinal cord extensively from C3 to C5. Emergent hematoma removal was performed following laminectomy, and subsequently the patient showed substantial clinical improvement. Complete removal of the hematoma was confirmed by MRI at 10 days after surgery. Here, the authors present a discussion of the etiology, pathogenesis, and prognosis of this rare pathologic entity.

Clinical features of spontaneous spinal epidural hematoma / Journal of Rural Medicine

Objective: Spontaneous spinal epidural hematoma is rare and therefore difficult to diagnose. This study evaluated the clinical features of this condition in patients admitted to our hospital.Patients and Methods: We evaluated 12 patients with spontaneous spinal epidural hematoma who were treated at our hospital. We investigated the following variables in these patients: underlying diseases, medications used, initial symptoms, spinal level affected, whether transported to the hospital by ambulance, department where first evaluated, mass lesion on computed tomography with soft tissue window settings, time interval between symptom onset and diagnosis, treatment received, and Frankel classification on arrival and when last observed.Results: Five patients reported the use of antiplatelet or anticoagulant drugs. All patients in this study reported acute onset of severe pain as the initial symptom, and 10 patients reported some degree of paralysis accompanying the pain. With respect to the morbidity level, the cervical region was the most common site of involvement (n=7). Ten patients were transported to the hospital at night via ambulance. Five patients first visited the Department of Internal Medicine. Seven patients presented with a mass lesion on computed tomography with soft tissue window settings. The time interval between symptom onset and diagnosis ranged from 2 hours to 6 days. Three and 9 patients received conservative and surgical treatments, respectively. No patient showed worsening of Frankel classification.Conclusion: Acute onset of severe pain was the most characteristic clinical symptom. Spontaneous spinal epidural hematoma should be included in the differential diagnosis. Computed tomography with soft tissue window settings may rule out cerebrovascular disease and cardiovascular disease, and specifically detect a hematoma. Subsequent magnetic resonance imaging can diagnose a spontaneous spinal epidural hematoma at an early stage.

Delayed-Onset Leg Weakness Caused by Posterior Migration of a Herniated Disc to the Thecal Sac Mimicking Epidural Hematoma in a Flexion-Distraction Injury of the Lumbar Spine: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: To document the first known case of posterior migration of a herniated disc in a lumbar flexion-distraction injury. SUMMARY OF LITERATURE REVIEW: Lumbar disc herniation is sometimes confused with epidural hematoma, especially when the disc migrates posterior to the thecal sac. There has been no report of posterior migration of a herniated disc after a lumbar flexion-distraction injury. MATERIALS AND METHODS: A 47-year-old woman with no pertinent medical history was diagnosed with a flexion-distraction injury of the L2–L3 vertebrae after a motor vehicle accident. The patient had no neurological deficit initially. Magnetic resonance imaging (MRI) showed a space-occupying lesion with T2 hyperintensity and T1 isointensity on the dorsal side of the thecal sac at L2–L3. After posterior lumbar fixation and fusion, progressive leg weakness occurred 1 week postoperatively. RESULTS: A second operation revealed no evidence of epidural hematoma, but a sequestrated disc. Decompression and sequestrectomy were performed, and the patient's neurological status had recovered fully at 4 months postoperatively. CONCLUSIONS: This case highlights the potential for posterior migration of a herniated disc with flexion-distraction injuries of the thoracolumbar spine. Discontinuity of the posterior annulus fibrosus on MRI may aid the distinction of posterior migration of a herniated disc from epidural hematoma. Because posterior migration of a herniated disc is associated with progressive neurological deficits, surgeons must consider decompression surgery when such herniation is suspected, even in the absence of neurological symptoms.

Acute and Delayed Epidural Hematoma After Total Spondylectomy for a Metastatic Spinal Tumor: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: We report a case of recurrent spinal epidural hematoma after total spondylectomy for a metastatic spinal tumor. SUMMARY OF LITERATURE REVIEW: Postoperative epidural hematoma is rare, and no case of delayed epidural hematoma after hematoma removal has been reported. MATERIALS AND METHODS: A 74-year-old woman experienced a ninth thoracic vertebral (T9) pathologic fracture caused by a metastatic spinal tumor and underwent total spondylectomy. Immediate postoperative epidural hematoma occurred and neurological symptoms appeared. After hematoma removal, the symptom improved. Ten days after surgery, the neurological symptoms worsened again. Spine magnetic resonance imaging showed delayed epidural hematoma. Hematoma removal was done again. RESULTS: The patient's neurological symptoms improved after delayed hematoma removal. CONCLUSIONS: Delayed hematoma that cause neurological symptoms may occur after primary hematoma removal. If neurological symptoms recur after hematoma removal, the surgeon should consider the possibility of hematoma recurrence. Before total spondylectomy surgery, preoperative embolization is recommended.

Influencing factors of expanding regional brain injury in patients with acute traumatic epidural hematoma after surgical evacuation / 中华神经医学杂志

Objective To investigate the risk factors,mechanism and treatment strategies of expanding regional brain injury (traumatic intracerebral contusion or hematoma) in patients with acute traumatic epidural hematoma (ATEDH) after surgical evacuation.Methods Fifty-nine patients with ATEDH,admired to and accepted surgical evacuation in our hospital from February 2013 to September 2018,were chosen in this study;their clinical data and CT imaging data were retrospectively analyzed.The volume ofintracranial hematoma was measured by 3D Slicer software.According to the progress of local brain injury revealed by first CT examination after surgical evacuation,patients with ATEDH were divided into progressive group and non-progressive group.Risk factors of patients with expanding regional brain injury after surgery were analyzed by univariate and multivariate Logistic regression analyses.Results After surgery,22 showed expanding regional brain injury,accounting for 37.29％:9 occurred expanding intracerebral hematoma,and 2 of them died after conservative treatment;two had both expanding intracerebral contusion and hematoma;11 expanding intracerebral contusion patients developed into hematoma,and three of them occurred delayed intracerebral hematoma adjacent to the area of ATEDH,and two underwent secondary craniotomy with good recovery.As compared with patients from the non-progressive group,progressive group had significantly higher percentages of patients with preoperative hyperglycemia (＞9.1 mmol/L),patients with preoperative abnormal coagulation and patients accepted decompressive craniectomy (P＜0.05).Multivariate Logistic regression analysis revealed that preoperative abnormal coagulation was an independent risk factor for expanding intracerebral contusion or hematoma after surgery (OR=6.498,95％CI:1.076-39.253,P=0.041).Conclusion Expanding regional brain injury has high morbidity in patients with ATEDH after surgery evacuation;preoperative abnormal coagulation is an independent risk factor for its occurrence.

Influencing factors of secondary brain injury adjacent to acute epidural hematoma after surgical evacuation / 中华神经医学杂志

Objective To explore the risk factors,mechanism and treatment strategies of secondary brain injury (cerebral hemorrhage or cerebral infarction/encephaledema) adjacent to acute epidural hematoma after surgical evacuation.Methods Forty-four patients with acute epidural hematoma underwent craniotomy in our hospital from March 2013 to December 2018 were chosen in this study.According to postoperative CT or MR imaging examination results,patients were divided into group of secondary brain injury (n=11) and group of non-secondary brain injury (n=33).The clinical data of the two groups were compared,and the significance of epidural hematoma thickness in assessing secondary brain injury was analyzed by receiver operating characteristic (ROC) curve.Binary Logistic regression analysis was used to analyze the independent risk factors affecting secondary brain injury.Results After surgery,11 showed secondary brain injury:3 occurred cerebral hemorrhage,one of whom was diagnosed as having cerebral venous hemorrhage in the cortical vein drainage area caused by traumatic cerebral venous circulation disorder;6 had cerebral infarction/encephaledema,and 2 occurred hemorrhagic cerebral infarction/encephaledema;two underwent secondary craniotomy and both achieved satisfactory effect.As compared with patients from the non-secondary brain injury group,patients fromsecondary brain injury group had significantly higher percentage of patients with epidural hematoma thickness ≥ 33.5 mm (P＜0.05).ROC curve analysis showed that the thickness of epidural hematoma had predictive value in secondary brain injury after surgery (P＜0.05),and area under the curve was 0.722 and diagnostic threshold was 33.5 mm.Binary Logistic regression analysis revealed that epidural hematoma thickness ≥33.5 mm was an independent risk factor for secondary brain injury adjacent to epidural hematoma after surgery (odds ratio=7.367,P=0.024,95％CI=1.298-41.797).Conclusions Acuteepidural hematoma thickness ≥33.5 mm is a high-risk factor associated with secondary brain injury adjacent to epidural hematoma after surgery.Intracranial venous circulatory disorders have non-negligible effect on occurrence of secondary brain injury.

Correlación de la leucocitosis y lesión intracraneal en pacientes con traumatismo craneoencefálico / Correlation of leukocytosis and intracranial injury in patients with traumatic brain injury / Correlação de leucocitose e lesão intracraniana em pacientes com traumatismo crânioencefálico

Resumen: El daño microvascular difuso se asocia a pérdida de la autorregulación vascular cerebral y a pérdida de integridad de la barrera hematoencefálica. El TCE (traumatismo craneoencefálico) está asociado a un aumento en los niveles séricos de catecolaminas. Las catecolaminas son responsables de los depósitos de neutrófilos. Las catecolaminas aumentan la cuenta leucocitaria, introduciendo las células marginadas al pool circulante. La respuesta de fase aguda también se caracteriza por leucocitosis al ingreso, por lo que es probable que la cuenta de células blancas sirva como indicador adicional al diagnóstico y pronóstico del trauma de cráneo. Material y métodos: Estudio de cohorte prospectivo longitudinal. Se incluyeron pacientes atendidos con TCE, se recopilaron estudios de imagen y de laboratorio. Resultados: De los pacientes atendidos con hemorragia subaracnoidea (HSA), se encontró a su ingreso una media de leucocitos de 17,718 10^3/µl y de 13,970 10^3/µl a las 24 horas del trauma, con una p = 0.000 y 0.001, respectivamente. En pacientes con hematoma subdural (HSD) se observó a su ingreso una media de leucocitos de 18,212 10^3/μl y de 13,319 10^3/µl a las 24 horas, con una p = 0.000 y 0.003, respectivamente. En pacientes con contusión hemorrágica se detectó a su ingreso una media de leucocitos de 13,225 10^3/µl y de 12,501 10^3/µl a las 24 horas, una p = 0.091 y 0.027, respectivamente. En pacientes con hematoma epidural (HE) se observó a su ingreso una media de leucocitos de 16,527 10^3/µl y de 13,240 10^3/µl a las 24 horas, con una p = 0.000 y 0.019, respectivamente.

Abstract: Diffuse microvascular damage is associated with loss of cerebral vascular self-regulation and loss of integrity of the blood-brain barrier. Traumatic brain injury is associated with an increase in serum levels of catecholamines. Catecholamines are responsible for neutrophil deposits. Catecholamines increase the leukocyte count by introducing the marginal cells into the circulating pool. The acute phase response is also characterized by leukocytosis on admission. Therefore, the white cell count is likely to serve as an additional indicator to the diagnosis and prognosis of TBI. Material and methods: Longitudinal prospective cohort study. Patients treated in the emergency room with TBI were included, blood test and imaging studies were collected. Results: Of the patients treated with subarachnoid hemorrhage (SAH), a mean of leukocytes on entry of 17,718 10^3/µl on admission and 13,970 10^3/µl on 24 hours of trauma, with p = 0.000 and 0.001. In patients with subdural hematoma, a mean number of leukocytes was found at 18,212 10^3/µl and 13,319 10^3/µl at 24 hours, with p = 0.000 and 0.003. For patients with hemorrhagic contusion, leukocytes were found on admission on average 13,225 10^3/µl and at 12,501 10^3/µl at 24 hours, a p = 0.091 and 0.027. In patients with epidural hematoma, a mean of 16,527 10^3/µl leukocytes was found on admission, at 24 hours 13,240 10^3/µl, with p = 0.000 and 0.019.

Resumo: O dano microvascular difuso está associado à perda da autorregulação vascular cerebral e à perda da integridade da barreira hematoencefálica. O TCE está associado a um aumento nos níveis séricos de catecolaminas. As catecolaminas são responsáveis pelos depósitos de neutrófilos. As catecolaminas aumentam a contagem de leucócitos introduzindo as células marginais no pool circulante. A resposta de fase aguda também é caracterizada por leucocitose na admissão. Assim, a contagem de células brancas provavelmente servirá como um indicador adicional do diagnóstico e prognóstico do trauma craniano. Material e metodos: Estudo de coorte prospectivo longitudinal. Incluiram-se pacientes atendidos com TCE, foram coletados estudos de imagem e laboratório. Resultados: Dos pacientes atendidos com hemorragia subaracnoide (HSA), uma média de leucócitos de 17,718 10^3/µl na admissão e 13,970 10^3/µl em 24 horas após o trauma. Com P = 0.000 e 0.001, respectivamente. Em pacientes com hematoma subdural (HSD), encontramos uma média de leucócitos na admissão de 18,212 10^3/µl e 13,319 10^3/µl às 24 horas, com p = 0.000 e 0.003. Para os pacientes com contusão hemorrágica, encontramos na admissão uma média de leucócitos de13,225 10^3/µl e às 24 horas de 12,501 10^3/µl, com p = 0.091 e 0.027. Nos pacientes com hematoma epidural (HE) foi encontrada uma média de 16,527 10^3/µl leucócitos à admissão, às 24 horas 13,240 10^3/µl, com p = 0.000 e 0.019.

Effects of preoperative use of parecoxib sodium on perioperative pain and coagulation in patients with epidural hematoma / 中国基层医药

Objective@#To investigate the effect of preoperative use of paracetin sodium on epidural pain and coagulation in patients with epidural hematoma.@*Methods@#80 brain trauma patients with epidural hematoma underwent surgery were selected, and they were randomly divided into two groups according to the digital table, 40cases in each group.30min before surgery, the observation group was given parecoxib sodium, and the control group was treated with the same volume of 0.9% saline.Then, the changes of the visual analogue scale (VAS score) and PCIA compression times were compared between the two groups at 6h, 12h, 24h and 48h after operation.The coagulation changes were observed.@*Results@#6h, 12h, 24h and 48h after operation, the VAS scores of the pain in the observation group were (4.1±0.3)points, (4.0±0.2)points, (3.0±0.3)points and (2.3±0.3)points, respectively, which were lower than those in the control group(t=17.541, 3.508, 7.589 and 28.284, all P<0.05).6h, 12h, 24h and 48h after operation, the PCIA times in the observation group were (1.9±0.4)times, (1.8±0.3)times, (1.1±0.2)times and (0.7±0.1)times, respectively, which were lower than those in the control group (t=4.939, 3.795, 12.279 and 16.000, all P<0.05). The PT, TT, APTT and Fib between the two groups had no statistically significant differences (t=0.407, 0.000, 1.491 and 0.331, all P>0.05).@*Conclusion@#Preoperative use of parecoxib sodium can effectively reduce the perioperative pain in patients with epidural hematoma, and it has no effect on coagulation function with high safety.

Epidural hematoma ossification after craniocerebral injury: A case report and literature review / 吉林大学学报(医学版)

Objective: To analyze the clinical data of a patient with epidural hematoma ossification after craniocerebral injury, and to improve the understanding and treatment level of the disease by combing the literature review. Methods: A 36-year-old man with headache and dizziness for 3 months was performed general physical examination and related imaging examination to identify the location and size of the lesion and its relationships with skull and endocranium. The patient with multiple myeloma was treated with chemotherapy for 4 months. The changes of imaging features of the intracranial lesions were judged. The diagnosis was confirmed by biopsy pathology result after operation and the patient was given the corresponding treatment Results: The diagnosis was regarded as epidural hematoma ossification after craniocerebral injury according to the patient' s imaging examination and the pathological results after operation. The diagnosis results of skull osteoma and multiple myeloma metastasis were excluded. The lesion was stable during the foUow-up of two years. Conclusion : For the patient with epidural hematoma ossification after craniocerebral injury, the skull osteoma should be considered, and other bone diseases should be excluded. The imaging evidence is needed for the diagnosis. The results of biopsy pathology should be taken if necessary.