Acute-on-chronic subdural cranial hematoma in a dog: case report / Hematoma craniano subdural crônico-agudizado em um cão: relato de caso

A ten-month-old male Yorkshire terrier dog was evaluated via CT four months after traumatic brain injury. The head CT scan showed dilated ventricles associated with a peripheral crescent-shaped collection of blood near the right parietal bone with a mineralized area. The visceral layer of the hematoma was hyperattenuating on the native scan and showed moderate contrast enhancement after administration of intravenous iodinated contrast medium. No fractures were identified in the calvarium. These findings were compatible with acute-on-chronic calcified subdural hematoma, which have been described with more detail in humans. This is the first report to include the description of the imaging findings related to this condition using computed tomography in a dog.(AU)

Um cão Yorkshire Terrier, de 10 meses de idade, foi avaliado por tomografia computadorizada, quatro meses após lesão encefálica de origem traumática. A tomografia da cabeça demonstrou dilatação dos ventrículos associada com coleção de sangue periférico, em formato crescente, próxima ao osso parietal direito, com uma área mineralizada interna. A camada visceral do hematoma era hiperatenuante no exame pré-contraste e demonstrou moderado aumento de atenuação radiográfica após a administração de contraste iodado intravenoso. Fraturas no calvário não foram identificadas. Esses achados foram compatíveis com agudização de hematoma subdural crônico calcificado, condição que tem sido descrita com mais detalhes em humanos. Este é o primeiro relato que descreve os achados de imagem, por tomografia computadorizada, em um cão, relacionados a essa condição.(AU)

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project / Análise da custo-efetividade em hernioplastias antes e após a implementação do projeto ACERTO

ABSTRACT Objective: to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital. Methods: retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System. Results: surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction). Conclusion: there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

RESUMO Objetivo: comparar custos hospitalares e desfechos clínicos em hernioplastias inguinal e incisional antes e após a implementação do projeto ACERTO, em hospital universitário. Métodos: estudo retrospectivo com 492 pacientes submetidos à hernioplastias inguinais (n=315) ou incisionais (n=177). A investigação envolveu duas fases: entre janeiro de 2002 e dezembro de 2005, englobando casos internados antes da implantação do protocolo ACERTO (período PRÉ-ACERTO), e outra, com casos operados entre janeiro de 2006 e dezembro de 2011, após a implantação (período ACERTO). A variável de desfecho principal foi o custo médio de internação comparando-se os dois períodos estudados. Como desfecho secundário, analisou-se tempo de internação, infecção de sítio cirúrgico e mortalidade. Foi utilizado o método de custeio do Sistema de Informação de Custos do Setor Público. Resultados: a ocorrência de infecção de sítio cirúrgico foi maior (p=0,039) na primeira fase do estudo tanto para hernioplastias inguinais (2 (1,6%) versus 0 (0%) casos) quanto para incisionais (5 (7,6%) versus 3 (2,7%) casos). O tempo de internação diminuiu em um dia após a implementação do protocolo ACERTO (p=0,005). Houve redução no custo por paciente indo de R$ 4.328,58 por paciente na 1ª fase para R$ 2.885,72 na 2ª fase (redução de 66,7%). Conclusão: o conjunto de dados mostrou que houve redução da morbidade infecciosa, tempo de internação e custos hospitalares em hernioplastias após a implementação do protocolo ACERTO.

Trauma quality indicators: a way to identify attention points in the treatment of elderly trauma patients / Filtros de qualidade: uma maneira de identificar pontos de atenção no atendimento ao idoso traumatizado

ABSTRACT Purpose: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment. Methods: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance. Results: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017). Conclusions: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.

RESUMO Objetivo: analisar a utilidade de "filtros de qualidade" pré-estabelecidos para a identificação de oportunidades de melhora no atendimento ao idoso traumatizado. Método: análise prospectiva dos dados coletados entre 2014-2015 e armazenados em software iTreg (Ecossistemas). Foram revisados vítimas de trauma maiores de 60 anos e filtros de qualidade propostos, baseados naqueles idealizados pela SBAIT em 2013: (F1) Drenagem de hematoma subdural agudo após 4 horas da admissão em pacientes com ECG<9; (F2) transferência da sala de emergência sem via aérea definitiva e ECG<9; (F3) Reintubação em até 48 horas da extubação; (F4) Tempo admissão-laparotomia exploradora maior que 60 min. em pacientes instáveis com foco abdominal; (F5) Reoperação não programada; (F6) Laparotomia após 4 horas da admissão; (F7) Fratura de diáfise de fémur não fixada; (F8) Tratamento não operatório de ferimento abdominal por PAF; (F9) Tempo admissão-tratamento de fraturas expostas de tíbia superior a 6 horas; (F10) Operação após 24 horas da admissão. Foi analisada relação dos filtros com tratamentos, complicações e óbitos, pelo software SPSS, utilizando-se o teste qui-quadrado e Fisher para calcular a relevância estatística. Resultados: dos 92 casos, 36 (39,1%) tiveram complicações e 15 (16,3%) morreram. A frequência da quebra dos filtros foi de 12% em pacientes que sobreviveram e 55,6% nos entre os que faleceram (p=0,005). A incidência de complicações foi de 77,8% (7/9) nos doentes com FQ comprometido, contra 34,9% (28/83) nos não comprometidos (p=0,017). Conclusões: o comprometimento dos filtros de qualidade se relaciona diretamente com a ocorrência de complicações e óbitos em idosos traumatizados.

Epidemiology and Outcomes of Traumatic Brain Injury in Elderly Population : A Multicenter Analysis Using Korean Neuro-Trauma Data Bank System 2010–2014

OBJECTIVE: Although traumatic brain injury (TBI) occurs in people of all age groups, the elderly population is at a particular risk. The proportion of elderly population in the society is markedly increasing and Korea is one of the most rapidly aging societies. Here, we analyzed the data from 904 patients older over 65 years who were registered in the Korean Neuro-Trauma Data Bank System (KNTDBS).METHODS: The Korean Society of Neurotraumatology recorded data from 20 institutions between September 2010 and March 2014. This retrospective study examined the clinical epidemiology, sex difference, outcome epidemiology, sociodemographic variables, and outcomes in the geriatric population related to TBI based on data from the KNTDBS.RESULTS: The study included 540 men and 364 women. The age distributions in the male and female groups were statistically significantly different. The most common cause of trauma was a fall and diagnosis was acute subdural hematoma. The incidence was the highest in men aged 80–84 years and in women aged 75–79 years. The most common time of arrival to hospital after TBI was within 1 hour and 119 rescue team provided first aid earliest to patients with TBI. The mortality rate stratified according to the cause of trauma was significantly different, with mortality rates of 3.77% in fall and 11.65% in traffic accident. The mortality rates according the severity of brain injury, Glasgow Coma Scale score, and treatment were statistically significant.CONCLUSION: To our knowledge, this study is the first to focus on elderly patients with TBI in Korea and particularly investigate mortality and characteristics related to TBI-related death based on data from the KNTDBS. Although the study has some limitations, our results may be used to obtain useful information to study targeted prevention and more effective treatment options for older TBI patients and establish novel treatment guidelines and health polish for the geriatric population.

Epidemiology and Outcomes of Traumatic Brain Injury in Elderly Population : A Multicenter Analysis Using Korean Neuro-Trauma Data Bank System 2010–2014

OBJECTIVE: Although traumatic brain injury (TBI) occurs in people of all age groups, the elderly population is at a particular risk. The proportion of elderly population in the society is markedly increasing and Korea is one of the most rapidly aging societies. Here, we analyzed the data from 904 patients older over 65 years who were registered in the Korean Neuro-Trauma Data Bank System (KNTDBS). METHODS: The Korean Society of Neurotraumatology recorded data from 20 institutions between September 2010 and March 2014. This retrospective study examined the clinical epidemiology, sex difference, outcome epidemiology, sociodemographic variables, and outcomes in the geriatric population related to TBI based on data from the KNTDBS. RESULTS: The study included 540 men and 364 women. The age distributions in the male and female groups were statistically significantly different. The most common cause of trauma was a fall and diagnosis was acute subdural hematoma. The incidence was the highest in men aged 80–84 years and in women aged 75–79 years. The most common time of arrival to hospital after TBI was within 1 hour and 119 rescue team provided first aid earliest to patients with TBI. The mortality rate stratified according to the cause of trauma was significantly different, with mortality rates of 3.77% in fall and 11.65% in traffic accident. The mortality rates according the severity of brain injury, Glasgow Coma Scale score, and treatment were statistically significant. CONCLUSION: To our knowledge, this study is the first to focus on elderly patients with TBI in Korea and particularly investigate mortality and characteristics related to TBI-related death based on data from the KNTDBS. Although the study has some limitations, our results may be used to obtain useful information to study targeted prevention and more effective treatment options for older TBI patients and establish novel treatment guidelines and health polish for the geriatric population.

Delayed Operation of Acute Subdural Hematoma in Subacute Stage by Trephine Drainage using Urokinase / 대한신경손상학회지

OBJECTIVE: The principle operation of acute subdural hematoma (ASDH) is a craniotomy with hematoma removal, but a trephination with hematoma evacuation may be another method in selected cases. Trephine drainage was performed for ASDH patients in subacute stage using urokinase (UK) instillation, and its results were evaluated. METHODS: Between January 2016 and December 2018, the trephine evacuation using UK was performed in 9 patients. The interval between injury and operation was from 1 to 2 weeks. We underwent a burr hole trephination with drainage initially, and waited until the flow of liquefied hematoma stopped, then instilled UK for the purpose of clot liquefaction. RESULTS: The mean age of patients was 71.6 years (range, 38–90 years). The cause of ASDH was trauma in 8 cases, and supposed a complication of anticoagulant medication in 1 case. Four out of 8 patients took antiplatelet medications and one of them was a chronic alcoholism. The range of the Glasgow Coma Scale score before surgery was from 13 to 15. Most of patients, main symptom was headache at admission. The Glasgow Outcome Scale score was 5 in 8 cases and 3 in 1 case. CONCLUSION: It is thought to be a useful operation method in selected patients with ASDH that the subdural drainage in subacute stage with UK instillation. This method might be another useful option for the patients with good mental state regardless of age and the patients with a risk of bleeding due to antithrombotic medications.

Gauze Packing for the Massive Venous Sinus Bleeding in a Patient with Acute Subdural Hematoma of Posterior Fossa / 대한신경손상학회지

A 57-year-old male had cardiac arrest during an operation of traumatic acute subdural haematoma (ASDH) and intraparenchymal haemorrhage in the infratentorium due to a great amount of bleeding from the pre-injured venous sinus. After effective bleeding control using a gauze, the patient recovered without additional neurological sequelae. The operation of traumatic ASDH in the infratentorium always poses a risk of excessive bleeding from the injured venous sinus that could be life-threatening to the patient. This risk could be avoided with the effective first method that can immediately control the bleeding.

Burr Hole Drainage with Urokinase Irrigation for the Treatment of Acute Subdural Hematoma: A Case Report / 대한신경손상학회지

We describe the case of a patient with an acute subdural hematoma (SDH) that was removed using urokinase irrigation after burr hole trephination in a limited situation where craniotomy was not possible. A 90-year-old woman was admitted to our hospital with a stuporous mental status. Computed tomography (CT) scans revealed a chronic SDH, and a burr hole procedure was performed. The patient's postoperative progression was good until the third day after surgery when we found that the acute SDH had increased on CT scans. The patient's guardian refused further surgery, and thus we drained the blood from the hematoma by injecting urokinase through a drainage catheter. We used urokinase for two days, and removed the catheter after confirming via CT scans that the hematoma was almost alleviated. The patient recovered gradually; she was discharged with few neurological deficits.

Tracheal Infection Resulting from High Endotracheal Tube Cuff Pressure in an Unconscious Patient with Brain Trauma / 대한신경손상학회지

Deep neck infections (DNIs) are mainly caused by dental caries, tonsillitis, and pharyngitis; however, DNIs can also occur after head and neck trauma. A 79-year-old male patient underwent a craniectomy due to an acute subdural hematoma. The patient was unconscious and continued to have a fever, but no clear cause was found. On postoperative day 9, he suddenly showed redness and swelling on the anterior neck. Enhanced computed tomography of the pharynx revealed tracheal necrosis and an abscess in the surrounding area. An incision and drainage were performed and Enterobacter aerogenes and E. faecalis were identified. The infection was controlled after antibiotic treatment. High endotracheal tube cuff pressure was suspected as the cause of the tracheal infection. Although DNIs are difficult to predict in patients who cannot report their symptoms due to unconsciousness, prevention and rapid diagnosis are important, as DNIs have serious side effects.

Expanding Subdural Hematomas in the Subacute Stage and Treatment via Catheter Drainage / 대한신경손상학회지

OBJECTIVE: Rapid expansion of subacute subdural hematomas (saSDHs) is an uncommon complication in the course of acute subdural hematomas (SDHs). The current study evaluated relevant factors and treatment methods for saSDHs with neurologic deterioration and mass effect. METHODS: A saSDHs was chronologically defined as an SDH occurring 4 to 21 days after head trauma. All cases of surgically treated SDHs were retrieved from the head trauma bank at our institution. Twenty-three patients with expanding saSDHs who met the following criteria were enrolled in the study: defined age of the hematoma, clinical deterioration, and radiological expansion of the hematoma. Cases were analyzed according to demographic factors, trauma mechanism, medical co-morbidity, and surgical method. RESULTS: Expanding saSDHs occurred more often in older (≥60 years old) than in younger patients (69.6% vs. 30.4%, respectively); they also occurred more often in men than in women (64% vs. 36%, respectively). Antiplatelet or anticoagulant therapy was used in 52% of patients. The Glasgow Coma Scale score was 13 at the time of the trauma and deteriorated to 11 at the time of surgery. The mean time from the trauma to development of the expanding saSDH from an SDH was 13.3 days. Regarding surgical methods, closed-system drainage was performed in 22 patients, and only one patient underwent craniotomy with hematoma removal. All patients exhibited neurological improvements after surgery. CONCLUSION: An expanding saSDH usually occurs around 13 days after trauma in older adults. Minimal trephination with closed-system drainage can be used to manage an expanding saSDHs.

Predictable Values of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: Comparison between Decompressive Craniectomy after Craniotomy Group and Craniotomy Only Group / 대한신경손상학회지

OBJECTIVE: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. METHODS: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. RESULTS: Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p 1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.

Development of Delayed Acute Subdural Hematoma after Mild Traumatic Brain Injury: A Case Report / 대한신경손상학회지

We report a case involving the development of a delayed acute subdural hematoma (ASDH) after trauma, with the absence of any abnormal radiological and clinical findings at initial examination. A 54-year-old male visited the emergency department after a minor trauma. The patient only complained of mild headache after head injury. He presented no abnormal findings on neurological examination, and brain computed tomography (CT) did not show any intracranial lesion or skull fractures. However, he developed seizure with disorientation eight hours after trauma, and ASDH with midline shift was found during a follow-up CT. He recovered without neurological deficits after immediate primary care and admission to the neurosurgery department. On serial follow-up CT images, a gradually increasing mass effect of hematoma was detected, and removed by craniotomy. The patient recovered without neurologic deficits.

Arachnoid Cyst with a Non-traumatic Acute Subdural Hematoma in an Eleven-year-old Patient

A non-traumatic intra-cystic hemorrhage in an arachnoid cyst is a rare event, with few cases reported in the literature. We present a case of an eleven-year-old boy patient, which presented a spontaneous acute subdural hematoma and intra-cystic hemorrhage after a strong headache episode. The results were evidenced by a computed tomography (CT) scan and surgical findings. We perform a brief literature review on the arachnoid cyst and its suggested treatments. In our case, the patient underwent a surgical treatment with a complete resolution of the case.

Sabe-se que uma hemorragia intracística não traumática em um cisto aracnoide é um acontecimento raro, com poucos casos relatados na literatura. Nós apresentamos o caso de um menino de onze anos de idade, o qual apresentou espontaneamente um hematoma subdural agudo acompanhado de hemorragia intracística após um forte episódio de dor de cabeça. Os resultados foram evidenciados através de uma tomografia computadorizada e dos achados cirúrgicos. Foi feita uma breve revisão da literatura sobre cisto aracnoide e seus respectivos tratamentos sugeridos.

Spontaneous Acute Subdural Hemorrhage in a Patient with a Tick Borne Bunyavirus-Induced Severe Fever with Thrombocytopenia Syndrome / 대한신경손상학회지

We report the first case of severe fever with thrombocytopenia syndrome (SFTS) and a spontaneous acute subdural hematoma (SDH) in Korea. A 79-year-old male presented with fever and thrombocytopenia. On the third day of hospitalization, his mental changed from drowsy to semi-coma. Brain computed tomography indicated an acute subdural hemorrhage on the right convexity. He was given early decompressive craniectomy, but did not survive. Real-time reverse transcription polymerase chain reaction analysis of a blood sample indicated the presence of SFTS virus (SFTSV). This is the first reported case with intracranial hemorrhage and SFTS. This case report describes our treatment of a patient with acute SDH and an infection from a tick-borne species of Bunyaviridae.

Traumatic Brain Injury in Children under Age 24 Months: Analysis of Demographic Data, Risk Factors, and Outcomes of Post-traumatic Seizure

OBJECTIVE: Traumatic brain injury (TBI) in children under age 24 months has characteristic features because the brain at this age is rapidly growing and sutures are opened. Moreover, children this age are completely dependent on their parents. We analyzed the demographic data and risk factors for outcomes in TBI patients in this age group to elucidate their clinical characteristics. METHODS: We retrospectively reviewed the medical records and radiological films of children under 24 months who were admitted to Kyungpook National University Hospital from January 2004 to December 2013 for TBI. Specifically, we analyzed age, cause of injury, initial Glasgow coma scale (GCS) score, radiological diagnosis, seizure, hydrocephalus, subdural hygroma, and Glasgow outcome scale (GOS) score, and we divided outcomes into good (GOS 4–5) or poor (GOS 1–3). We identified the risk factors for post-traumatic seizure (PTS) and outcomes using univariate and multivariate analyses. RESULTS: The total number of patients was 60, 39 males and 21 females. Most common age group was between 0 to 5 months, and the median age was 6 months. Falls were the most common cause of injury (n=29, 48.3%); among them, 15 were falls from household furniture such as beds and chairs. Ten patients (16.7%) developed PTS, nine in one week; thirty-seven patients (61.7%) had skull fractures. Forty-eight patients had initial GCS scores of 13–15, 8 had scores of 12–8, and 4 had scored 3–7. The diagnoses were as follows: 26 acute subdural hematomas, 8 acute epidural hematomas, 7 focal contusional hemorrhages, 13 subdural hygromas, and 4 traumatic intracerebral hematomas larger than 2 cm in diameter. Among them, two patients underwent craniotomy for hematoma removal. Four patients were victims of child abuse, and all of them had PTS. Fifty-five patients improved to good-to-moderate disability. Child abuse, acute subdural hematoma, and subdural hygroma were risk factors for PTS in univariate analyses. Multivariate analysis found that the salient risk factor for a poor outcome was initial GCS on admission. CONCLUSION: The most common cause of traumatic head injury in individuals aged less than 24 months was falls, especially from household furniture. Child abuse, moderate to severe TBI, acute subdural hematoma, and subdural hygroma were risk factors for PTS. Most of the patients recovered with good outcomes, and the risk factor for a poor outcome was initial mental status.

Radiologic Findings and Patient Factors Associated with 30-Day Mortality after Surgical Evacuation of Subdural Hematoma in Patients Less Than 65 Years Old

OBJECTIVE: The purpose of this study is to evaluate the associations between 30-day mortality and various radiological and clinical factors in patients with traumatic acute subdural hematoma (SDH). During the 11-year study period, young patients who underwent surgery for SDH were followed for 30 days. Patients who died due to other medical comorbidities or other organ problems were not included in the study population. METHODS: From January 1, 2004 to December 31, 2014, 318 consecutive surgically-treated traumatic acute SDH patients were registered for the study. The Kaplan–Meier method was used to analyze 30-day survival rates. We also estimated the hazard ratios of various variables in order to identify the independent predictors of 30-day mortality. RESULTS: We observed a negative correlation between 30-day mortality and Glasgow coma scale score (per 1-point score increase) (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.52–0.70; p<0.001). In addition, use of antithrombotics (HR, 2.34; 95% CI, 1.27–4.33; p=0.008), history of diabetes mellitus (HR, 2.28; 95% CI, 1.20–4.32; p=0.015), and accompanying traumatic subarachnoid hemorrhage (hazard ratio, 2.13; 95% CI, 1.27–3.58; p=0.005) were positively associated with 30-day mortality. CONCLUSION: We found significant associations between short-term mortality after surgery for traumatic acute SDH and lower Glasgow Coma Scale scores, use of antithrombotics, history of diabetes mellitus, and accompanying traumatic subarachnoid hemorrhage at admission. We expect these findings to be helpful for selecting patients for surgical treatment of traumatic acute SDH, and for making accurate prognoses.

Clinical Features and Outcomes of Bilateral Decompression Surgery for Immediate Contralateral Hematoma after Craniectomy Following Acute Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Immediate contralateral epidural hematoma (EDH) and traumatic intracerebral hematoma (T-ICH) after craniectomy for traumatic subdural hematoma (SDH) are rare but devastating post-operative complications. Their clinical features and outcomes are not well studied. In this report, we present the clinical features and outcomes of immediate contralateral acute hematoma cases requiring a second operation. METHODS: This study includes 10 cases of immediate contralateral EDH and T-ICH following bilateral craniectomy for the evacuation of traumatic SDH and contralateral hematoma between 2004 and 2015. Their medical records and radiographic findings were reviewed and analyzed retrospectively. RESULTS: Ten of the 528 patients (1.89%) who underwent craniectomy for the evacuation of traumatic SDH developed post-operative EDH (n=5), T-ICH (n=5). The trauma was caused by a fall in 5 patients and by a traffic accident in 5 patients. The patients who suffered trauma due to pedestrian accidents died. Seven patients had a low admission Glasgow Coma Scale (GCS; GCS≤8) score in the preoperative state (average admission GCS, 7.7; average discharge GCS, 3.4; and average discharge Glasgow Outcome Scale, 2.0). Severe intra-operative brain swelling was noted in all patients, while skull fracture was observed in 8. Multiple associated injuries and medication for heart disease were characteristic of patients who died. CONCLUSION: The prognosis of delayed contralateral hematoma was very poor. Multiple associated injuries, past medical history and traffic accidents, especially pedestrians were seemed to be associated with higher mortality rates. Finally, contralateral skull fractures can indicate high risk of delayed contralateral acute intracranial hematoma.

Remote Hemorrhage after Burr Hole Drainage of Chronic Subdural Hematoma / 대한신경손상학회지

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.

Postoperative Subarachnoid Hemorrhage and Multipunctate Intracerebral Hemorrhages Following Evacuation of Bilateral Chronic Subdural Hematomas / 대한신경손상학회지

Chronic subdural hematoma (CSDH) can be easily treated by burr hole surgery. However, several complications including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and acute subdural hematoma are rare after evacuation of a CSDH. A 77-year-old man was admitted with right hemiparesis and dysarthria. A brain computed tomography (CT) scan revealed a bilateral CSDH with midline shifting toward the right side. The patient got the burr hole trephination with the catheters insertion in the both sides of parietal area under the local anesthesia. After burr hole surgery immediately, he developed left side weakness and decreased level of consciousness. Repeat CT scans detected a diffuse SAH and multiple small ICHs. He was treated conservatively and fully recovered at discharge after 1 month. To avoid these complications, slow and gradual drainage of the CSDH is needed. The authors report a rare case of SAH and multipunctate ICHs in both cerebral hemispheres after evacuation of a bilateral CSDH.

Smartphone Fundus Photography in an Infant with Abusive Head Trauma

PURPOSE: To report fundus photography using a smartphone in an infant with abusive head trauma. CASE SUMMARY: An 8-month-old male infant presented to the emergency room with decreased consciousness and epileptic seizures that the parents attributed to a fall from a chair. He had no external wounds or fractures to the skull or elsewhere. However, computerized tomography of the brain revealed an acute subdural hematoma in the right cranial convexity and diffuse cerebral edema, leading to a midline shift to the left and effacement of the right lateral ventricle and basal cistern. The attending neurosurgeon promptly administered a decompressive craniectomy. Immediately after the emergency surgery, a fundus examination revealed numerous multi-layered retinal hemorrhages in the posterior pole extending to the periphery in each eye. He also had white retinal ridges with cherry hemorrhages in both eyes. We acquired retinal photographs using the native camera of a smartphone in video mode. The photographer held the smartphone with one hand, facing the patient's eye at 15–20 cm, and held a 20 diopter condensing lens at 5 cm from the eye in the other hand. Our documentation using a smartphone led to a diagnosis of abusive head trauma and to obtain the criminal's confession, because the findings were specific for repetitive acceleration-deceleration forces to an infant`s eye with a strong vitreoretinal attachment. CONCLUSIONS: This ophthalmic finding had a key role in the diagnosis of abusive head trauma. This case presented the diagnostic use of a smartphone for fundus photography in this important medicolegal case.