Outcome of traumatic brain injury in patients on antiplatelet agents: a retrospective 20-year observational study in a single neurosurgery unit.

OBJECTIVE: To evaluate the outcomes after Traumatic Brain Injury (TBI) in patients taking Antiplatelet Agents (APAs). METHODS: We reviewed the clinical records of 934 patients with TBI between 1995 and 2014. Multivariate analysis was performed to correlate patient outcome with various factors, including pre-injury APA intake. Cause of death was compared among groups stratified according to APA dose. RESULTS: Increasing doses of APAs were positively associated with mortality rates, however, differences were primarily due to non-traumatic causes. APA therapy before injury was independent of both overall and non-traumatic mortality. In multivariate analysis, mortality was significantly correlated with the Charlson Comorbidity Index (CCI), pupillary abnormalities, age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (AIS) and additional AIS >2. Conversely, non-traumatic mortality was associated with age, GCS, additional AIS >2 and CCI, though only CCI was correlated with increasing APA dose. Furthermore, no significant difference was observed when comparing mortalities according to CCI score among APA groups. Thus, mortalities were associated with the severity of pre-existing conditions rather than APA dose. CONCLUSIONS: The outcome of patients with TBI, who were on APAs may be determined by the severity of pre-existing conditions. Aggressive TBI treatment should be implemented when tolerable, regardless of pre-existing APA treatment status.

Traumatic hematoma of the posterior fossa.

Posterior fossa injury is rare, occurring in less than 3 % of head injuries. We retrospectively reviewed patients' clinical and radiological findings, management, and outcomes. The aim of the present study was to investigate the features of posterior fossa hematoma, including posterior fossa epidural hematoma (EDH), posterior fossa subdural hematoma (SDH), and intracerebellar hematoma. From January 1995 to January 2009, 4,315 patients with head trauma were hospitalized at our institution. The -present study focused on 41 patients (1.0 %) with traumatic hematomas of the posterior fossa. Eighteen patients had EDH, 10 patients had SDH, and 17 patients had intracerebellar hematomas. In each type of injury, occipital bone fractures were seen in many patients, and hematoma enlargement was often observed within a few days of the injury. In addition, a high frequency of associated lesions and a high poor outcome rate were features of intracerebellar hematomas and -posterior fossa SDH. The present study suggests that repeat CT imaging and careful management are necessary until the lesion is stabilized, and patients showing lesions with mass effects should therefore be immediately treated with surgery.

Traumatic basal ganglia hematomas: an analysis of 20 cases.

Twenty patients with traumatic basal ganglia hematoma (TBGH) were studied. Of the 20 patients, 16 were male and 4 were female, with an age range of 4-89 years (mean, 54.4 years). The causes of injury were traffic accidents in 12 patients and falls in 8. The mean admission GCS score was 7.5. Skull fractures were revealed in five patients (25 %). The hematoma was found in the putamen in 15 patients (80 %), the thalamus in 4, and the caudate in 1. The mean hematoma volume was 10.7 mL. The CT findings indicated focal contusions in 9 patients, subdural hematoma in 5, intraventricular hemorrhage in 4, subarachnoid hemorrhage in 10, and diffuse axonal injury in 5. Six patients (30 %) underwent surgery. The final outcomes were poor: 7 patients (35 %) died, 1 was in a vegetative state, 4 experienced severe disabilities, and 8 patients (40 %) made a favorable recovery. The statistical analysis identified the GCS score and midline shift as prognostic factors.Our study revealed interesting characteristics of TBGH, including a high frequency of putaminal involvement, a low frequency of skull fractures, a high frequency of associated intracranial lesions, and a high poor outcome and mortality rate.

Subacute subdural hematoma.

Subacute subdural hematoma (SASDH) is a rare entity. We retrospectively reviewed 8 patients with SASDH. Four patients were male and 4 were female, with an age range of 45-87 years (mean, 67.8 years). The minimal level of deterioration ranged from 8 to 14 (mean, 10.5). The deterioration of neurological symptoms was confirmed 4-20 days after injury (mean, 12.9). The hematoma volume was increased in 6 patients. Seven patients underwent surgeries (burr-hole irrigation in 6, craniotomy in 1). The Glasgow Outcome Scale indicated a good recovery in 4 patients and moderate disability in 4 patients. Increased cerebral blood flow was observed just below the SDH in 1 patient. We consider that the hypoperfused tissue in the acute phase might become hyperperfused during the subacute phase owing to impaired autoregulation, and the hyperperfusion may be responsible for the development of the SASDH, leading to deterioration. Further investigations in a larger series are needed to elucidate the mechanism underlying the development of SASDH.

Computed tomography after decompressive craniectomy for head injury.

New findings (NF) on postoperative CTs are -occasionally found in patients who undergo surgery for traumatic brain injury (TBI). We conducted a retrospective -registry-based review of the care of 102 patients who underwent decompressive craniectomy (DC) for TBI to investigate the prognostic factors of new findings on CT early after -surgery. Of the 102 patients, the mean age was 50 years and 69.6 % were male. The overall survival was 72.5 %. The primary indication for DC included subdural hematoma in 72 (70.6 %), epidural hematoma in 17 (16.7 %), and intraparenchymal contusion in 13 (12.7 %). New findings on postoperative CTs were observed in 26 patients (25.5 %). The univariate analysis showed that a GCS score ≤8 (P = 0.012) and the absence of a basal cistern (P = 0.012) were significantly associated with NF on postoperative CT. The logistic regression analysis demonstrated that the GCS score ≤8 (P = 0.041; OR, 3.0; 95 % CI, 1.048-8.517) was the only significant factor. TBI patients with a low GCS score who underwent DC should undergo additional CT evaluations immediately after surgery.

Decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage.

Hemispheric hypertensive intracerebral hemorrhage (ICH) has a high mortality rate. Decompressive craniectomy (DC) has generally been used for the treatment of severe traumatic brain injury, aneurysmal subarachnoid hemorrhage, and hemispheric cerebral infarction. However, the effect of DC on hemispheric hypertensive ICH is not well understood. To investigate the effects of DC for treating hemispheric hypertensive ICH, we retrospectively reviewed the clinical and radiological findings of 21 patients who underwent DC for hemispheric hypertensive ICH. Eleven of the patients were male and 10 were female, with an age range of 22-75 years (mean, 56.6 years). Their preoperative Glasgow Coma Scale scores ranged from 3 to 13 (mean, 6.9). The hematoma volumes ranged from 33.4 to 98.1 mL (mean, 74.2 mL), and the hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. Intraventricular extensions were observed in 11 patients. With regard to the complications after DC, postoperative hydrocephalus developed in ten patients, and meningitis was observed in three patients. Six patients had favorable outcomes and 15 had poor outcomes. The mortality rate was 10 %. A statistical analysis showed that the GCS score at admission was significantly higher in the favorable outcome group than that in the poor outcome group (P = 0.029). Our results suggest that DC with hematoma evacuation might be a useful surgical procedure for selected patients with large hemispheric hypertensive ICH.

Hydrocephalus following decompressive craniectomy for ischemic stroke.

Numerous studies on hydrocephalus after decompressive craniectomy (DC) for severe traumatic brain injury have been reported, whereas there have been only two reports on DC for hemispheric cerebral infarction. Here, we present the clinical details of 23 patients who underwent DC for hemispheric cerebral infarction and the incidence of hydrocephalus following DC. Of the 23 patients, 13 were male and 10 were female, with an age range from 34 to 75 years (mean, 60.8 years). The areas of hemispheric infarctions were those of the middle cerebral arteries in 12 patients and of the internal carotid arteries in 11 patients. The mean preoperative GCS score was 6. Nineteen patients (82.6 %) underwent cranioplasty. Pre-cranioplasty hydrocephalus was observed in 11 (47.8 %) patients. Four patients who had precranioplasty hydrocephalus were transferred or died without cranioplasty, and post-cranioplasty hydrocephalus occurred in 7 (36.8 %). Only one patient underwent a shunt procedure after cranioplasty. We consider that the explanation for the discrepancies between our study and the previous studies might lie in the definition of hydrocephalus and the indications for shunting.

Hydrocephalus after decompressive craniectomy for hemispheric cerebral infarction.

The aim of the present study was to investigate the risk factors for hydrocephalus after decompressive craniectomy (DC) for hemispheric cerebral infarction. This study selected 28 patients who underwent DC for malignant hemispheric cerebral infarction. The patients' clinical and radiologic findings were retrospectively reviewed. Fourteen of the 28 patients were male and 14 were female, with an age range from 34 to 80 years (mean, 63.5 years). Eighteen patients (64.3%) underwent DC within 48 hours of stroke onset. The superior limit of DC was <25 mm from the midline in 16 patients (57.1%). Twenty-two patients underwent cranioplasty, and the interval from DC to cranioplasty was within 60 days in 14 patients. Pre- and post-cranioplasty hydrocephalus were observed in 13 and nine patients, respectively. Two patients required shunt procedures for post-cranioplasty hydrocephalus. Patients with DC whose superior limit was <25 mm from the midline had a significantly increased risk of developing not only pre-cranioplasty but also post-cranioplasty hydrocephalus (p=0.008, p=0.010, respectively). In addition, the presence of pre-cranioplasty hydrocephalus was significantly associated with the development of post-cranioplasty hydrocephalus (p=0.001). The presence of pre- and post-cranioplasty hydrocephalus was significantly associated with a poor outcome (p=0.031, p=0.049, respectively). DC with a superior limit <25 mm from the midline should be avoided to prevent the development of hydrocephalus.

Prognostic factors in patients with primary brainstem hemorrhage.

OBJECTIVE: Primary brainstem hemorrhage (PBH) frequently causes severe disturbances of consciousness, papillary abnormalities, as well as respiratory and motor disturbances. The prognosis has been reported to be highly dependent on the clinical severity at presentation and the presence of certain radiological markers. However, the number of PBH patients enrolled in previous reports tended to be small, and precise statistical analyses were also lacking. The aim of this study was to analyze the impact of clinical or radiologic parameters on the outcome of patients with PBH. METHODS: We retrospectively reviewed 212 consecutive patients with PBH and analyzed the impact of the clinical or radiological parameters on the outcome of patients with PBH. RESULTS: Of the 212 patients, 134 (63.2%) were male and 78 (36.8%) were female, with an age range of 17-97 years (mean, 60.3 years). The median admission GCS score was 4. The outcomes included a good recovery in 13 patients (6.1%), moderate disability in 27 (12.7%), severe disability in 27 (12.7%), a vegetative state in 23 (10.8%), and death in 122 (57.5%). A multivariate analysis demonstrated bilateral hematoma extension, a GCS score ≤8, the presence of hydrocephalus, gender, and the hematoma volume to all be significantly associated with the 3-month mortality, while the GCS score ≤8, the presence of a pupillary abnormality, and the hematoma volume were found to be associated with the 3-month poor outcome. CONCLUSION: The identification of these factors is therefore considered to be useful for managing patients with PBH.

Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage.

OBJECTIVE: The aim of the present study was to investigate factors associated with the development of ventriculomegaly suggestive of hydrocephalus (VSOH) after decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage. METHODS: This study focused on 21 patients who underwent decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage. The patients' clinical and radiological findings were retrospectively reviewed. RESULTS: Eleven patients were male and ten were female, with an age range from 22 to 75 years (mean, 56.6 years). The preoperative Glasgow Coma Scale score ranged from 3 to 13 (mean, 6.9). Hematoma volumes ranged from 33.4 to 98.1 ml (mean, 74.2 ml). Hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. The presence of intraventricular hemorrhage was significantly associated with the development of VSOH (P=0.023). The distance of the decompressive defect to the midline and the presence of meningitis showed a strong trend for association with VSOH (P=0.051, P=0.090, respectively). CONCLUSION: Careful attention should be paid to the occurrence of VSOH after decompressive craniectomy with hematoma evacuation in intracerebral hemorrhage patients with intraventricular extension, meningitis, and/or a short distance of the decompressive defect to the midline.

Postoperative computed tomography after surgery for head trauma.

BACKGROUND: It is well known that intracranial lesions, which are already diagnosed on preoperative computed tomography, often expand after surgery, and the risk factors have been investigated. On the other hand, we have experienced cases in which new lesions, which were not detected on preoperative computed tomography, were found on postoperative computed tomography. However, little is known about the factors associated with such new postoperative lesions. Here, we investigated the predictive factors of new findings (NFs) on computed tomography early after surgery. METHODS: We conducted a retrospective registry-based review of 186 consecutive patients who underwent surgery for traumatic brain injury and investigated the prognostic factors of NFs on computed tomography early after surgery. RESULTS: Mean age was 51 years, and 67.2% were males among the 186 patients. NFs on postoperative computed tomography were observed in 29 patients (15.6%). A univariate analysis showed that Glasgow Coma Scale (GCS) score of 8 or less (p < 0.001), subdural hematoma as the primary indication for surgery (p = 0.012), midline shift (p < 0.001), absence of basal cistern (p < 0.001), and decompressive craniectomy and craniotomy as the surgical procedures (p < 0.001, p = 0.004, respectively) were significantly associated with NFs on postoperative computed tomography. A logistic regression analysis demonstrated that decompressive craniectomy as the surgical procedure (p = 0.001; odds ratio [OR], 8.1; 95% confidence interval [CI], 2.23-28.82), GCS score of 8 or less (p = 0.019; OR, 3.4; 95% CI, 1.23-9.52), and absence of basal cistern (p = 0.023; OR, 3.5; 95% CI, 1.19-10.35) were significant factors. CONCLUSION: Early postoperative computed tomography after surgery for head trauma seems to be warranted in patients presenting with the indicated predictive factors of NFs. LEVEL OF EVIDENCE: Prognostic/therapeutic study, level III.

Traumatic peritentorial subdural hematomas: a study of 32 cases.

AIM: This study aimed to investigate the clinicoradiological features in patients with traumatic peritentorial subdural hematomas (SDHs). MATERIAL AND METHODS: We retrospectively reviewed the clinical and radiological findings, management criteria, and outcomes in 32 patients with peritentorial SDHs. The outcomes were classified as favorable (good recovery or moderate disability) or poor (severe disability, vegetative state, or death). RESULTS: Of the 32 patients, 19 were male and 13 were female. The patients' ages ranged from 10-92 years (mean age, 60.9 years). Coagulopathies were observed in 23 patients. Twenty-four patients presented with associated intracranial lesions. Eighteen patients had favorable outcomes and 14 had poor outcomes. All patients were treated conservatively. The presence of coagulopathy (p = 0.024) and presence of convexity SDH (p = 0.008) correlated with the outcome. CONCLUSION: The patients with traumatic peritentorial SDHs were predominantly male and relatively elderly, and had a high incidence of coagulopathy, associated intracranial lesions (especially falx SDHs), a high rate of impact in the occipital or frontal regions, and a low incidence of skull fractures. The factors that were correlated with outcome in patients receiving conservative therapy were the presence of coagulopathy and the presence of convexity SDH.

Traumatic posterior fossa subdural hematomas.

BACKGROUND: Traumatic hematomas in the posterior fossa are rare, especially traumatic posterior fossa subdural hematomas (SDHs), which account for <1% of head injured patients. The aim of this study was to investigate the features of traumatic posterior fossa SDHs. METHODS: We retrospectively reviewed clinical and radiologic findings, management, and outcomes of patients with traumatic posterior fossa SDH. RESULTS: Ten patients with traumatic posterior fossa SDHs were admitted to our hospital. There were seven males and three females, with an age range of 3 years to 97 years (mean, 57.5 years). Coagulopathies were observed in five patients. The causes of injury were motor vehicle crash in three patients, falls in six patients, and being hit by an iron plate in one patient. The mean admission Glasgow Coma Scale score was 8.3. Skull fractures were revealed in six patients. Hematoma sizes ranged from 5 mm to 20 mm (mean, 7.7 mm). Two patients presented with isolated posterior fossa SDHs, and eight patients presented with associated intracranial lesions. Only one patient was treated surgically for posterior fossa SDHs associated with intracerebellar hematomas. The poor outcome rate was 90% and the mortality was 50%. CONCLUSIONS: A review of the literature revealed the following characteristics of posterior fossa SDHs: (1) a relatively high frequency of occipital impacts and fractures, (2) a low Glasgow Coma Scale score, (3) a high frequency of associated intracranial lesions, especially supratentorial lesions and intracerebellar hematomas, (4) a potential for lesion evolution, especially within 2 days, and (5) a high poor outcome rate and mortality. LEVEL OF EVIDENCE: IV.

Analysis of DWI ASPECTS and recanalization outcomes of patients with acute-phase cerebral infarction.

In order to rapidly judge the response to intravenous tissue plasminogen activator (Ⅳ tPA) treatment, we retrospectively analyzed clinical data, such as MRI diffusion-weighted images (DWI), and treatment outcomes in 73 patients who developed anterior circulation disorders. The patients with favorable outcomes (modified Rankin Scale [mRS]: 2 or less) at discharge accounted for 32.9%. In these patients, the National Institutes of Health Stroke Scale (NIHSS) value, DWI Alberta Stroke Programme Early CT Score (ASPECTS), and the incidence of large artery (internal carotid artery [ICA]/sphenoidal segment of the middle cerebral artery [M1]) occlusion at their hospital visit were lower, higher, and lower, respectively (all P < 0.05 in univariate analysis). Multivariate analysis showed significant differences in DWI ASPECTS and the incidence of large artery occlusion. A DWI ASPECTS of at least 8 was found to be predictive of favorable outcomes. However, subclass analysis in the group with a DWI ASPECTS of 8 or higher predicting favorable outcome revealed 13 patients (41.9%) with unfavorable (mRS, 3-6) outcome. The factor associated with unfavorable outcomes is ICA occlusion. The combination of DWI ASPECTS and MRA appeared to be useful for predicting outcomes of Ⅳ tPA.

Simultaneous multiple hypertensive intracranial hemorrhages.

We retrospectively reviewed the clinical and radiological findings, management, and factors correlated with outcomes in 20 patients with simultaneous multiple hypertensive intracranial hemorrhages (ICH). The mean admission Glasgow Coma Scale score was 7.8. The most common hematoma location was the putamen, while putamen-brainstem hematomas were the most common combination. The mean hematoma volume was 27.5 mL. Eight patients had favorable outcomes and 12 had poor outcomes. Statistical analysis identified that the GCS score on admission, hematoma distribution (unilateral supratentorial hematomas were the most favorable), and total hematoma volume were prognostic factors. This study provides important information on the clinicoradiological findings and prognosis in patients with simultaneous multiple hypertensive ICH.

Clinical characteristics and surgical outcomes of patients with aneurysmal subarachnoid hemorrhage and acute subdural hematoma undergoing decompressive craniectomy.

OBJECTIVE: This report presents 12 consecutively managed patients with aneurysmal subarachnoid hemorrhage (SAH) associated with acute subdural hematoma (ASDH) who underwent decompressive craniectomy (DC) with special attention to their clinical characteristics and surgical outcomes. METHODS: We retrospectively reviewed medical charts, radiologic findings, surgical notes, and video records. RESULTS: Among these 12 patients (mean age 59.1 years, 4 men, 8 women), the Hunt and Kosnik clinical grade was grade V in 7 patients (58.3%), grade IV in 2 patients (16.7%), grade III in 2 patients (16.7%), and grade II in 1 patient (8.3%). The aneurysms were located on the internal carotid artery in four patients, the middle cerebral artery in six patients, and the anterior communicating artery in two patients. Computed tomography findings on admission revealed ASDH in all patients. In addition, SAH was seen in 11 patients. An intracerebral hematoma was found in eight patients, intraventricular hemorrhaging occurred in four, and an acute hydrocephalus was seen in one patient. All patients underwent a microsurgical clipping procedure and an additional DC. Symptomatic vasospasm was confirmed in six (50%), and eight patients with chronic hydrocephalus received a ventriculoperitoneal shunt (67%). The Glasgow Outcome Scale at discharge showed good recovery in five patients (41.7%), severe disability in four (33.3%), vegetative state in two (16.7%), and death in one patient (8.3%). A favorable outcome was achieved in five patients (41.7%). CONCLUSIONS: We suggest that the DC was effective for reducing morbidity and mortality in poor grade patients with SAH presenting with ASDH.

Traumatic intra-cerebellar haematoma: study of 17 cases.

PURPOSE: We report on 17 patients with traumatic intra-cerebellar haematomas. METHODS: We retrospectively reviewed patients' clinical and radiological findings, management criteria and outcomes. RESULTS: Ten patients had poor outcomes. Glasgow Coma Scale (GCS) score at admission was significantly higher in the favourable outcome group than in the poor outcome group (p = 0.010). The haematoma volume was significantly smaller in the favourable outcome group than in the poor outcome group (p = 0.025). There were also significant differences between the two groups in terms of types of haematoma location, the status of the brainstem cisterns, the status of the fourth ventricle, and the presence of associated subarachnoid haemorrhage (SAH) (p = 0.035, 0.002, 0.010, 0.003, respectively). CONCLUSIONS: The factors correlated with outcome were GCS score, the status of the brainstem cisterns and the fourth ventricle, the presence of associated SAH, haematoma volume and haematoma location. Further studies are needed to investigate the factors relevant to the management of traumatic intra-cerebellar haematomas.

Traumatic interhemispheric subdural haematoma: Study of 35 cases.

The clinical and radiological findings, management, and outcomes in 35 patients with traumatic interhemispheric subdural haematoma (ISH) were reviewed retrospectively. Twenty-five patients had favourable outcomes and 10 had poor outcomes. All patients were treated conservatively for ISH. Univariate analysis found that the Glasgow Coma Scale (GCS) score (p < 0.001), hypovolemic shock (p = 0.018), skull fracture (p = 0.008), convexity or posterior fossa subdural haematoma (p = 0.008), and subarachnoid haemorrhage (SAH) were correlated with outcome (p < 0.001). Multivariate analysis showed that GCS score (p = 0.031; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3-0.9) and the presence of SAH (p = 0.023; OR, 14.2; 95% CI, 1.5-138.2) were significantly related to poor outcome. This study provides important information on the clinicoradiological findings and prognoses in patients with traumatic ISH.

Middle cerebral artery occlusion resulting from hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is a rare disorder that can cause ischemic stroke. We present a patient with middle cerebral artery (MCA) occlusion resulting from HES. Transarterial thrombolysis resulted in MCA recanalization and adjuvant therapy may have contributed to stabilization of the underlying HES in our patient.