Extradural Haematoma: Protocol Needs Revision for Conservative Management

Background: Brain Trauma Foundation recommends EDH volume of greater than 30 cm3 warrants surgical evacuation irrespective of Glasgow Coma Scale. Often it is observed that Not all cases of acute EDH require immediate surgical evacuation, cases with lesser than 5 mm midline shift, no focal neurological deficits and GCS>8 and can be managed conservatively provided the patients are closely observed for any deterioration in GCS. For EDH with a volume more or less than 30ml in the supratentorial space and, a midline shift 6-10 mm, with a GCS score > 10, was attempted non-surgical management, with close observation and serial CT scanning. Aim: The aim of this study was to discover the most important factors influencing the management strategy and outcome of EDH. Methods: 70 adult patients treated for EDH were included in this retrospective study, 26 cases (37%) underwent urgent surgery, 44 cases (62.8%) were managed conservatively out of which one third of patient required delayed surgery. Results: Our study showed that out of 62 % of the patients who  were conservatively managed, 72 % had a favorable outcome despite the presence of a midline shift of 6- 10 mm and an EDH volume of >30 ml but having a good GCS score. Conservatively managed patients with GCS >10, 77% had Good Recovery. Those with high EDH volume, 61% had a good outcome. 84 % of the patients having a midline shift between 6-10 mm had a good recovery. Patients with GCS < 8 had a poorer outcome than patients in good neurological status, regardless of the therapy. Conclusions: Hence we conclude, EDH must be promptly diagnosed by CT scan and considered as an emergency lest misdiagnosed and should be admitted into a neurosurgical care unit. Close neurological monitoring, appropriate follow up CT scans in the setting of improved GCS score resulting in   good outcome in patient  on conservative management.

Managing Subacute Subperiosteal Hematoma with High Intraocular Pressure: A Case Report

Subperiosteal haematoma of the orbit is an uncommon complication of maxillofacial trauma, hence easily missed. It usually presents subacutely with proptosis and diplopia. In our case, the subperiosteal haematoma is complicated with high intraocular pressure, necessisating measures to reduce the intraocular pressure. Unresponsive to only medical treatment, surgical evacuation was carried out in this patient. Removal of the clot finally relieved the intraocular pressure and simultaneously improved the proptosis and the cumbersome diplopia.

A Prospective Study on Effect of Stress on Sleep Quality in Young Medical Students in a Tertiary Hospital

Objective: The objectives of this study was to evaluate the sleep disruption risk enhancement among the young Medical students due to increasing the demand of clinical and academic duties and Studying the relation between sleep quality and psychological stress  which can be useful in implementing an organized mental health program in medical colleges. The main aim is to study the prevalence and the effect of stress on sleep quality in young medical students. Methods: This Prospective cross sectional study was conducted on Medical students of Teerthanker Mahaveer Medical College & Research Centre to recognize the effect of stress on sleep quality among 75 medical students. The instruments used for data collection were a self-report Pittsburg Sleep Quality Index (PSQI) and the General Health Questionnaire (GHQ). Results: Results of present study showed that 59% of subjects were poor sleepers. Furthermore, there was a significant correlation between general health status and sleep quality of students (r = 0.5118, p = 0.0001). Conclusions: A considerable proportion of medical students are affected by poor sleep quality. Sleep disruption acts as a barrier for students’ performance in examinations. So, it is important to implement health promotion and educational programs for them.

Bifrontal Extradural Hematoma (EDH) Causing Isolated Right 3rd Nerve Palsy with Spontaneous Partial Recovery

All neurosurgeons are aware of traumatic intracranial hematomas presenting with oculomotor nerve palsy which requires immediate surgical intervention. Isolated third nerve palsy with no other neurological signs due to head injury is a rare occurrence. We report a case of head injury with bifrontal extradural hematoma presenting as  isolated right sided  third nerve palsy which partially improved with nonsurgical management. We also discuss the possible causes of such involvement.

Remote Acute Extradural Hematoma Formation after Ventriculoperitoneal Shunt - A Rare Occurrence

Formation of acute epidural hematoma after Ventriculoperitoneal shunt insertion is rare in adults, more so at a site remote from the site of shunt insertion. We are presenting such a rare occurrence and discussing possible factors involved in this complication. A 35-year-old male was diagnosed with a third ventricular colloid cyst with hydrocephalus. A Ventriculoperitoneal medium pressure shunt was placed through right Keen point burr hole and the patient developed a right frontal extradural hematoma on the 4th post-operative day which was subsequently evacuated by craniotomy and the patient recovered fully thereafter. Acute extradural hematoma is a potentially life threatening complication. High index of suspicion, precautions during shunt insertion and early detection can prevent mortality and severe morbidity in these cases.

Outcome of Surgically Treated Traumatic Extradural Hematoma.

Summary: Extradural hematoma (EDH) has been seen as a neurosurgical emergency since eighteenth century. Efforts have been on since then to reduce the mortality associated with this entity. The mortality has dropped from around 80% in late nineteenth and early twentieth centuries to below 20% in many centers now. Improving quality of care and, constant assessment of outcome and factors affecting outcome are the driving forces leading to reduction in mortality. Objectives: To determine the functional outcome and the effect of level of consciousness on traumatic extradural hematoma patients who had surgery in our centers. Patients and Methods: It was a prospective observational study carried out on forty three patients with traumatic extradural hematoma who had surgical evacuation of the hematomas in our centers over a five year period. Data were collected using structured proforma in accident and emergency, theater, intensive care unit, wards and in outpatient clinic. The data were analyzed using Environmental Performance Index (EPI) info 2007 software. Results: Forty three patients had surgery for traumatic extradural hematoma during the five year period. There were thirty eight males (88.37%) and five females (11.63%). Road traffic accident was the most common aetiology. The functional outcome was 83.72% and mortality was 13.95%. Glasgow Coma Score prior to surgery and age significantly affected the outcome, P = .002 and P = .00 respectively. Conclusion: The favorable functional outcome from our study (83.72%) was within the current range in the world. Level of consciousness prior to surgery and age significantly affected outcome.

Extradural hematoma following double valve replacement under cardiopulmonary bypass: A rare complication.

The primary mechanisms responsible for acute neurological deterioration following cardiopulmonary bypass (CPB) include cerebral embolism, cerebral hypoperfusion and/or inflammatory process triggered by CPB. Extradural hematoma (EDH) following CPB is rare but associated with significant mortality and morbidity. We present a case of EDH following double valve replacement in an adolescent boy.

Epidemiological analysis of 189 cases of traumatic intracranial extradural hematoma treated by surgery / Análisis epidemiológico de 189 casos de hematoma epidural tratados quirúrgicamente

Objective: To analyze the epidemiology, clinical and radiological presentation of patients with extradural hematoma (EDH) who underwent surgery in our service and their neurological status at the time of discharge. Method: We reviewed the charts of 189 patients who were admitted to our service with EDH and were treated surgically, during the period of August 1998 to January 2007. Results: In 49.2 percent the mechanism of trauma was falling; 49.7 percent of the cases had GCS between 13-15; 45.0 percent had skull fractures; 32.8 percent had associated intracranial injuries. Conclusion: We observed that 76.2 percent of surgically treated patients were discharged with minimum or no neurological deficits.

Acute Simultaneous Bilateral Extradural Hematoma.

Bilateral extradural hematomas are uncommon consequence of head injury with many unique features .In our case the fracture line over the skull was extending across the sagittal sinus.This case report emphasizes the specific features as to their etiopathology, clinical presentation, diagnosis and management principles.

Diagnosis and treatment of contrecoup contusion and laceration in frontal lobe / 中国基层医药

Objective To discuss the clinical characteristics and therapeutic strategy of contrecoup contusion and laceration in frontal lobe. Methods 48 cases with contrecoup contusion and laceration in frontal lobe were analysed retrospectively with their imaging feature. Results In accordance with the GOS,36 cases survived well, 8 suffered from moderate disability. One keept in persistent vegetative state and one was dead. Conclusion Contrecoup contusion and laceration in frontal lobe merged with occipital extradural hematoma and diffuse brain swelling. Early diagnosis and treatment for the delayed occipital extradural hematoma, and standard large trauma craniotomy in treatment of heavy contrecoup contusion and laceration with diffuse brain swelling in frontal lobe were the key measures to improve the rate of success rescue.

Spontaneous Bilateral Supratentorial Subdural and Retroclival Extradural Hematomas in Association with Cervical Epidural Venous Engorgement

We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patient's symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.

Bilateral cortical atrophy after severe brain trauma and extradural homatoma

We report the case of a severe head injured 43-year old male patient with a large extradural hematoma, Glasgow Coma Scale 3 and dilated fixed pupils. Patient was promptly submitted to surgical evacuation of the lesion, but remained in persistent vegetative state in the post-operative time. Head computed tomography scans performed before surgery, and at early and late post-operative periods comparatively revealed extreme bilateral cortical atrophy. Late consequences of severe head trauma drastically affect the prognosis of patients, being its prevention, and neuroprotection against secondary injury still a therapeutical challenge for neurosurgeons.

Relatamos o caso de um paciente de 43 anos, com traumatismo cranioencefálico grave, com grande hematoma extradural, Escala de Coma de Glasgow 3 e pupilas fixas e dilatadas. O paciente foi prontamente submetido à evacuação cirúrgica da lesão mas permaneceu em estado vegetativo persistente no período pós-operatório. As TC de crânio realizadas antes da cirurgia e nos períodos pós-operatórios precoce e tardio revelaram comparativamente extrema atrofia cerebral bilateral. As conseqüências tardias do traumatismo craniano grave afetam drasticamente o prognóstico dos pacientes, sendo sua prevenção, e a neuroproteção contra a injúria secundária ainda um desafio terapêutico para os neurocirurgiões.

Acute Expanding Venous Extradural Hematoma: Pitfall of Early Brain CT Scan

A case of a acute expanding venous extradural hematoma was treated. Initial CT scan was favorable, but delayed bleeding & its expansion was developed. The bleeding points were left transverse sinus and superior petrosal sinus. Serial neurologic examination & serial CT scan in patients with head injuries are recommended.

Delayed Post-traumatic Extradural Hematomas: Delayed Bleeding & Delayed Expansion

Delayed traumatic extradural hematoma is a new pathological dimension. Thirteen patients with delayed traumatic extradural hematoma were seen 70 treated cases of extradural hematomas for a frequency of 18.6%. The hematomas were insignificant or not present on the initial CT scanning. All patients had a skull fracture at the site of delayed extradural hematoma formation. Ten hematomas were surgically evacuated and three were reabsorbed spontaneously. Repeated CT scanning was performed if the patient has any new focal neurological deficits or clinical status was not improved despite of minimal extradural hematoma after head injury. Delayed extradural hematoma were classified into two groups based on the presence of hematoma in initial CT scan : delayed bleeding type(newly formed xtradural hematoma/4 cases : 5.7%) & delayed expansion type(enlargement of initial thin hematoma/9 cases : 12.6%).