Neutrophil to lymphocyte ratio predicts early growth of traumatic intracerebral haemorrhage.

OBJECTIVE: The neutrophil to lymphocyte ratio (NLR) has been proposed to capture the inflammatory status of patients with various conditions involving the brain. This retrospective study aimed to explore the association between the NLR and the early growth of traumatic intracerebral haemorrhage (tICH) in patients with traumatic brain injury (TBI). METHODS: A multicentre, observational cohort study was conducted. Patients with cerebral contusion undergoing baseline computed tomography for haematoma volume analysis within 6 h after primary injury and follow-up visits within 48 h were included. Routine blood tests were performed upon admission, and early growth of tICH was assessed. Prediction accuracies of the NLR for the early growth of tICH and subsequent surgical intervention in patients were analysed. RESULTS: There were a total of 1077 patients who met the criteria included in the study cohort. Univariate analysis results showed that multiple risk factors were associated with the early growth of tICH and included in the following multivariate analysis models. The multivariate logistic regression analysis results revealed that the NLR was highly associated with the early growth of tICH (p < 0.001) while considering other risk factors in the same model. The prediction accuracy of the NLR for the early growth of tICH in patients is 82%. INTERPRETATION: The NLR is easily calculated and might predict the early growth of tICH for patients suffering from TBI.

The Effect of Antithrombotics on Hematoma Expansion in Small- to Moderate-Sized Traumatic Intraparenchymal Hemorrhages.

BACKGROUND: Although pre-injury antithrombotic agents, including antiplatelets and anticoagulants, are historically associated with expansion of traumatic intraparenchymal hemorrhage (tIPH), the literature has poorly elucidated the actual risk of hematoma expansion on repeat computed tomography (CT). The objective was to determine the effect of antithrombotic agents on hematoma expansion in tIPH by comparing patients with and without pre-injury antithrombotic medication. METHODS: The volume of all tIPHs over a 5-year period at an academic Level 1 trauma center was measured retrospectively. The initial tIPH was divided into 3 equally sized quantiles. The third tercile, representing the largest subset of tIPH, was then removed from the study population because these patients reflect a different pathophysiologic mechanism that may require a more acute and aggressive level of care with reversal agents and/or operative management. Per institutional policy, all patients with small- to moderate-sized hemorrhages received a 24-hour stability CT scan. Patients who received reversal agents were excluded. RESULTS: Of the 105 patients with a tIPH on the initial head CT scan, small- to moderate-sized hemorrhages were <5 cm3. The size of tIPH on initial imaging did not statistically significantly differ between the antithrombotic cohort (0.7 ± 0.1 cm3) and the non-antithrombotic cohort (0.5 ± 0.1 cm3) (P = 0.091). Similarly, the volume of tIPH failed to differ on 24-hour repeat imaging (1.0 ± 0.2 cm3 vs. 0.6 ± 0.1 cm3, respectively, P = 0.172). Following a multiple linear regression, only history of stroke, not antithrombotic medications, predicted increased tIPH on 24-hour repeat imaging. CONCLUSIONS: In small- to moderate-sized tIPH, withholding antithrombotic agents without reversal may be sufficient.

The profile of blunt traumatic supratentorial cranial bleed types.

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ±â€¯6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage.

Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.

Contrecoup Traumatic Intracerebral Hemorrhage: A Geometric Study of the Impact Site and Association with Hemorrhagic Progression.

Traumatic intracerebral hemorrhage (TICH) represents 13-48% of the lesions after a traumatic brain injury (TBI). The frequency of TICH-hemorrhagic progression (TICH-HP) is estimated to be approximately 38-63%. The relationship between the impact site and TICH location has been described in many autopsy-based series. This association, however, has not been consistently demonstrated since the introduction of computed tomography (CT) for studying TBI. This study aimed to determine the association between the impact site and TICH location in patients with moderate and severe TBI. We also analyzed the associations between the TICH location, the impact site, the production mechanism (coup or contrecoup), and hemorrhagic progression. We retrospectively analyzed the records of 408 patients after a moderate or severe TBI between January 2010 and November 2014. We identified 177 patients with a total of 369 TICHs. We found a statistically significant association between frontal TICHs and impact sites located on the anterior area of the head (OR 5.8, p < 0.001). The temporal TICH location was significantly associated with impact sites located on the posterior head area (OR 4.9, p < 0.001). Anterior and lateral TICHs were associated with impact sites located at less than 90 degrees (coup) (OR 1.64, p = 0.03) and more than 90 degrees (contrecoup), respectively. Factors independently associated with TICH-HP obtained through logistic regression included an initial volume of <1 cc, cisternal compression, falls, acute subdural hematoma, multiple TICHs, and contrecoup TICHs. We demonstrated a significant association between the TICH location and impact site. The contrecoup represents a risk factor independently associated with hemorrhagic progression.

Intraventricular hemorrhage on initial computed tomography as marker of diffuse axonal injury after traumatic brain injury.

Intraventricular hemorrhage (IVH) on initial computed tomography (CT) was reported to predict lesions of diffuse axonal injury (DAI) in the corpus callosum (CC) on subsequent magnetic resonance imaging (MRI). We aimed to examine the relationship between initial CT findings and DAI lesions detected on MRI as well as the relationship between the severity of IVH (IVH score) and severity of DAI (DAI staging). A consecutive 140 patients with traumatic brain injury (TBI) who underwent MRI within 30 days after onset were revisited. We reviewed their initial CT for the following six findings: Status of basal cistern, status of mid-line shift, epidural hematoma, IVH, subarachnoid hemorrhage, and volume of hemorrhagic mass and IVH score were assigned in each patient. Based on MRI findings, patients were divided into DAI and non-DAI groups and were assigned a DAI staging. Then, to confirm that the IVH on initial CT predicts DAI lesions on MRI, we used multi-variate analysis of the six CT findings, including IVH, and examined the relationship between IVH score and DAI staging. The IVH detected on CT was the only predictor of DAI (p=0.0139). The IVH score and DAI staging showed significant positive correlation (p<0.0003). IVH score in DAI stage 3 (with DAI involving the brain stem; p=0.0025) or stage 2 (with DAI involving CC; p=0.0042) was significantly higher than that of DAI stage 0 (no DAI lesions). In conclusion, IVH on initial CT is the only marker of DAI on subsequent MRI, specifically severe DAI (stage 2 or 3).

Neuropeptide proenkephalin A is associated with in-hospital mortality in patients with acute intracerebral hemorrhage.

High plasma proenkephalin A (PENK-A) levels are associated with poor clinical outcome after ischemic stroke. However, not much is known regarding the change of its level in acute intracerebral hemorrhage. Thus, we sought to determine PENK-A in plasma of patients with acute spontaneous basal ganglia hemorrhage and evaluate its relation with disease severity and in-hospital mortality. One hundred and two patients and 100 healthy controls were recruited. Plasma samples were obtained on admission for patients and at study entry for controls. Its concentration was measured by chemoluminescence sandwich immunoassay. Plasma PENK-A levels were substantially higher in patients than in healthy controls (235.5±85.4 pmol/L vs. 90.1±31.3 pmol/L; P<0.0001). A forward stepwise logistic regression selected plasma PENK-A as an independent predictor for in-hospital mortality of patients (odds ratio 1.080, 95% confidence interval 1.018-1.147, P<0.001). A multivariate linear regression demonstrated that plasma PENK-A level was positively associated with National Institutes of Health Stroke Scale (NIHSS) score (t=6.189, P<0.001) and hematoma volume (t=5.388, P<0.001). A receiver operating characteristic curve identified a plasma PENK-A level>267.1 pmol/L predicted in-hospital mortality of patients with 80.0% sensitivity and 74.7% specificity (area under curve, 0.836; 95% confidence interval, 0.750-0.902). Its predictive value was similar to NIHSS score's and hematoma volume's (both P>0.05). However, it did not statistically significantly improve the predictive values of NIHSS score and hematoma volume (both P>0.05). Thus, increased plasma PENK-A levels are associated with disease severity and in-hospital mortality after acute intracerebral hemorrhage.

Fatal gunshot wound to the head with lack of immediate incapacitation.

Investigation of deaths caused by penetrating gunshot wounds to the head often raises the possibility of foul play. The forensic pathologist may be asked if the victim was able to perform certain acts after the gunshot, and how quickly this person might have become incapacitated. The possibility of a suicidal act can depend on these answers. We report the case of a 45-year-old woman whose body was found with a right temporal entrance wound. A shotgun was found 60 ft from the body location. The question of knowing if this woman had been able to shoot herself in the head and then walk a distance of 60 ft before dying was essential for the investigation, as suicide was the first hypothesis. The autopsy and a careful neuropathology investigation allowed to answer this question. In the literature, multiple publications report cases of victims who were able to act following penetrating ballistic head injury.

Hemorrhagic progression of a contusion after traumatic brain injury: a review.

The magnitude of damage to cerebral tissues following head trauma is determined by the primary injury, caused by the kinetic energy delivered at the time of impact, plus numerous secondary injury responses that almost inevitably worsen the primary injury. When head trauma results in a cerebral contusion, the hemorrhagic lesion often progresses during the first several hours after impact, either expanding or developing new, non-contiguous hemorrhagic lesions, a phenomenon termed hemorrhagic progression of a contusion (HPC). Because a hemorrhagic contusion marks tissues with essentially total unrecoverable loss of function, and because blood is one of the most toxic substances to which the brain can be exposed, HPC is one of the most severe types of secondary injury encountered following traumatic brain injury (TBI). Historically, HPC has been attributed to continued bleeding of microvessels fractured at the time of primary injury. This concept has given rise to the notion that continued bleeding might be due to overt or latent coagulopathy, prompting attempts to normalize coagulation with agents such as recombinant factor VIIa. Recently, a novel mechanism was postulated to account for HPC that involves delayed, progressive microvascular failure initiated by the impact. Here we review the topic of HPC, we examine data relevant to the concept of a coagulopathy, and we detail emerging data elucidating the mechanism of progressive microvascular failure that predisposes to HPC after head trauma.

Traumatic carotid cavernous fistula complicated with intracerebral hemorrhage: case report.

A 45-year-old woman presented with a rare case of traumatic carotid cavernous fistula (CCF) complicated with intracerebral hemorrhage after injury in a car accident. She had multiple injuries including facial bone fracture and slight subarachnoid hemorrhage around the left sylvian fissure. Emergent plastic surgery for the facial deformity was performed. Next day, she suffered intracerebral hemorrhage in the left frontal lobe. Angiography revealed CCF, predominantly draining to the left superficial sylvian vein. The left internal carotid artery was occluded by endovascular treatment. The clinical triad of traumatic CCF is orbital bruit, exophthalmos, and chemosis. Hemorrhagic complication such as subarachnoid hemorrhage, epistaxis, and otorrhagia may occur according to the venous drainage pattern. Traumatic CCF may be accompanied by intracerebral hemorrhage.

[Measurement of intracranial hematoma volume by personal computer].

OBJECTIVE: To explore the method for intracranial hematoma volume measurement by the personal computer. METHODS: Forty cases of various intracranial hematomas were measured by the computer tomography with quantitative software and personal computer with Photoshop CS3 software, respectively. the data from the 2 methods were analyzed and compared. RESULTS: There was no difference between the data from the computer tomography and the personal computer (P>0.05). CONCLUSION: The personal computer with Photoshop CS3 software can measure the volume of various intracranial hematomas precisely, rapidly and simply. It should be recommended in the clinical medicolegal identification.

Computed tomography and outcome in moderate and severe traumatic brain injury: hematoma volume and midline shift revisited.

Intracranial lesion volume and midline shift are powerful outcome predictors in moderate and severe traumatic brain injury (TBI), and therefore they are used in TBI and computed tomography (CT) classification schemes, like the Traumatic Coma Data Bank (TCDB) classification. In this study we aimed to explore the prognostic value of lesion volume and midline shift in moderate and severe TBI as measured from acute cranial CT scans. Also, we wanted to determine interrater reliability for the evaluation of these CT abnormalities. We included all consecutive moderate and severe TBI patients admitted to our hospital who were aged ≥16 years, over an 8-year period, as part of the prospective Radboud University Brain Injury Cohort Study. Six months post-trauma we assessed outcomes using the Glasgow Outcome Scale-Extended (GOS-E). We analyzed 605 patients and found an association of both lesion volume and midline shift with outcome; increases were associated with a higher frequency of patients with an unfavorable outcome or death. A cut-off value, such as that used in the TCDB CT classification (lesion volume 25 mL and midline shift 5 mm), was not found. The average interrater difference in volume measurement was 6.8 mL, and it was 0.2 mm for the determination of degree of shift. Using lesion volume and midline shift as continuous variables in prognostic models might be preferable over the use of threshold values, although an association of these variables with outcome in relation to other CT abnormalities was not tested. The data provided here will be useful for stratification of patients enrolled in clinical trials of neuroprotective therapies.

Traumatic intraventricular hemorrhage with a good prognosis.

We report a 10-year-old girl with an isolated traumatic intraventricular hemorrhage following a traffic accident, who had a good prognosis. Her neurological examination upon arrival was normal and she had no complaint other than headache and vomiting. Computed tomography on admission showed a hemorrhage in the lateral and fourth ventricles. She had a Glasgow Coma Score of 15, and she was thus given only antiepileptic drugs for prophylaxis and followed. Computed tomography that was repeated 5 days after admission showed no blood and all ventricles were of normal size. There was no vascular pathology on magnetic resonance imaging and magnetic resonance angiography. The patient remains well 5 months after her accident. Intraventricular hemorrhage does not always have a poor prognosis.

D-dimer as a predictor of progressive hemorrhagic injury in patients with traumatic brain injury: analysis of 194 cases.

This study sought to describe and evaluate any relationship between D-dimer values and progressive hemorrhagic injury (PHI) after traumatic brain injury (TBI). In patients with TBI, plasma D-dimer was measured while a computed tomography (CT) scan was conducted as soon as the patient was admitted to the emergency department. A series of other clinical and laboratory parameters were also measured and recorded. A logistic multiple regression analysis was used to identify risk factors for PHI. A cohort of 194 patients with TBI was evaluated in this clinical study. Eighty-one (41.8%) patients suffered PHI as determined by a second CT scan. The plasma D-dimer level was higher in patients who demonstrated PHI compared with those who did not (P < 0.001. Using a receiver-operator characteristic curve to predict the possibility by measuring the D-dimer level, a value of 5.00 mg/L was considered the cutoff point, with a sensitivity of 72.8% and a specificity of 78.8%. Eight-four patients had D-dimer levels higher than the cut point value (5.0 mg/L); PHI was seen in 71.4% of these patients and in 19.1% of the other patients (P < 0.01). Factors with P < 0.2 on bivariate analysis were included in a stepwise logistic regression analysis to identify independent risk factors for TBI coagulopathy. Logistic regression analysis showed that the D-dimer value was a predictor of PHI, and the odds ratio (OR) was 1.341 with per milligram per liter (P = 0.020). The stepwise logistic regression also identified that time from injury to the first CT shorter than 2 h (OR = 2.118, P = 0.047), PLT counts lesser than 100 x 109/L (OR = 7.853, P = 0.018), and Fg lower than 2.0 g/L (OR = 3.001, P = 0.012) were risk factors for the development of PHI. When D-dimer values were dichotomized at 5 mg/L, time from injury to the first CT scan was no longer a risk factor statistically while the OR value of D-dimer to the occurrence of PHI elevated to 11.850(P < 0.001). The level of plasma D-dimer after TBI can be a useful prognostic factor for PHI and should be considered in the clinical management of patients in combination with neuroimaging and other data.

Are serial brain imaging scans required for children who have suffered acute intracranial injury secondary to blunt head trauma?

In most instances, infants and children with moderate to severe head trauma undergo a head computed tomography (CT) scan as part of their initial evaluation. Several authors have advocated a routine second head CT after traumatic brain injury (TBI) to identify progressive lesions that may require surgical intervention. However, recent studies have challenged the need for a routine second brain imaging study after TBI. In addition, recent reports have raised concerns about the potential for malignancy following CT scanning, especially in pediatric patients. The authors performed a retrospective case series of all patients, aged 0 to 21 years, who presented to their 2 emergency departments (EDs) and received an International Classification of Disease-9th revision code related to intracranial injury. Out of 47 children, 5 (11%) underwent neurosurgical intervention following their second imaging study, and 1 of these interventions was unplanned after the first study. Compared with children who did not require an intervention following their second scan, children who received an intervention were more likely to have been subjected to nonaccidental trauma and to have presented to the ED more than 4 hours after the injury. Most children with intracranial injury following blunt trauma who did not require immediate neurosurgical intervention but instead underwent a follow-up brain imaging study did not require subsequent unplanned neurosurgical intervention. Serial brain imaging may not be required for all children with intracranial injury.

Spontaneous resolution of calcified cephalhematomas of infancy: report of two cases.

Cephalhematoma (CH) is less commonly encountered problem of infancy with an incidence of 1 % however calcified CHs are seldom. The exact reason of calcification remains unclear. We report two cases of calcified CHs that developed as a complication of vacuum extraction during vaginal delivery. Calcified CHs generally present with cosmetic reasons like skull asymmetry and calvarial mass. Although Doppler ultrasonography is useful in the diagnosis of CHs, computerized tomography or direct X-rays help more in the detection of calcified ones. Follow-up should be considered for cases below 2 years of age since the cranium continues to grow and there appears to be a chance of spontaneous resolution. Surgical intervention should be reserved for cases with neurological deficits or persistent lesions on follow-up.