Evaluation of Head Computed Tomography Assessment of Brain Swelling after Acute Traumatic Brain Injury: A Pilot study

Objective To evaluate the interobserver reliability of a new scale created for quantitatively assessing brain swelling in traumatic brain injury (TBI) patients using the computed tomography (CT) findings in three levels. Methods Computed tomography scans of severe head injury patients were randomly selected from a tertiary hospital image database and evaluated by independent groups of neurosurgeons, neurosurgery residents, radiologists, and intensivists from the same hospital. Each specialist assessed the tomographic findings, applying zero to six points in a new scale. The Kappa coefficient was calculated to assess interobserver agreement. Results The highest reliability coefficient was obtained by the neurosurgeons group (0.791; 95% confidence interval [CI]: 0.975­0.607; p < 0.001), followed by the neurosurgery residents group (0.402; 95%CI: 0.569­0.236; p < 0.001) and by the radiologists group (0.301; 95%CI: 0.488­0.113; p < 0.002). The lowest coefficient was found among the intensivists (0.248; 95%CI: 0.415­0.081; p » 0.004). Conclusion The proposed scale showed good reliability among neurosurgeons, and moderate overall reliability. This tomographic classification might be useful to better assist severe TBI victims, allowing to identify the worsening or amelioration of brain swelling, which should be further investigated. The scale seems to be feasible, even in low income countries,where the costof intracranial pressure (ICP)monitoring is higher than thatofCTs.

Chronic subdural hematoma with sudden clinical uncal herniation and coma: case report

Context: Chronic subdural hematomas are frequent diseases in neurosurgery units. Decreased level of consciousness is observed in 28 to 100 percent of cases, nevertheless in rare cases are seen comatous patients. We describe a case of a patient with clinical uncal herniation elapsed by a chronic subdural hematoma. Case report: Patient with previous diagnosis of breast cancer, presented sudden occurrence of a headache followed by decreasing level of consiousness the day before reaching our service. The patient was taken than to another Hospital at 1:00 AM in Glasgow Coma Scale (GCS) 13, with isochonic pupils. At 7:00 AM the GCS went to 7 and the pupils became anisochonic L > R and than transferred to our Unit and immediatly submitted to a computed tomohraphy scanning of the head that showed a chronic subdural hematoma with midline shift. The patient promptly was taken to surgical room and treated with a single burr hole with drainage of hypertensive chronic subdural hematoma. The level of consiousness increased few hours after surgery, being in GCS 15 just 6 hours after, without motor deficits. Conclusion: In spite of commonly progressive evolution chronic subdural hematomas can present with herniation, becoming itself a neurosurgical emergency.