The management of “asymptomatic” epidural hematomas

1989 ◽  
Vol 70 (3) ◽  
pp. 392-396 ◽  
Author(s):  
Neville W. Knuckey ◽  
Steven Gelbard ◽  
Mel H. Epstein
Keyword(s):  
Risk Factors ◽  
Epidural Hematoma ◽  
Skull Fracture ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Management Protocol ◽  
Major Vessel ◽  
Low Incidence ◽  
A Prospective Study ◽  
Fine Print

✓ Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma. Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol. It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.

Teratomas of the central nervous system: treatment considerations based on 34 cases

1998 ◽  
Vol 89 (5) ◽  
pp. 728-737 ◽  
Author(s):  
Yutaka Sawamura ◽  
Tsutomu Kato ◽  
Jun Ikeda ◽  
Jun-ichi Murata ◽  
Mitsuhiro Tada ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Radiation Therapy ◽  
Adjuvant Therapy ◽  
Karnofsky Performance Scale ◽  
Content Type ◽  
Treatment Considerations ◽  
Low Incidence ◽  
A Prospective Study ◽  
Fine Print

Object. The optimum clinical management of central nervous system (CNS) teratomas, particularly postsurgical adjuvant therapy, is still unclear, partly as a result of the tumors' low incidence. In this study the authors analyze 34 cases of CNS teratomas so that they may adequately indicate management of these lesions. Methods. The median age of the 34 patients was 13 years. Twenty-seven patients treated between 1970 and 1991 were retrospectively reviewed. Four of these 27 patients died as a result of radical surgery; each of them had a teratoma involving the hypothalamus. After initial treatment, which included radiation therapy, 20 patients (48%) had died. In all seven cases of mature teratomas there was no recurrence. In two cases of immature teratomas in which there was complete surgical resection there was recurrence; however, salvage therapies were effective. Seven of eight patients with highly malignant teratomas died; for these patients salvage therapies, including repeated radiation and chemotherapy, failed. Seven patients who presented with CNS teratomas between 1992 and 1996 received adjuvant chemotherapy and radiation therapy according to a prospective study protocol. All seven patients were free from recurrence with a 70 to 100% Karnofsky Performance Scale score at a median follow-up period of 41 months. Patients with CNS teratomas rarely responded completely to chemotherapy or radiation therapy; an effective adjuvant therapy produced a partial response at best. Conclusions. Because teratomas show various responses to adjuvant therapy, a misdiagnosis of their histological subtype will lead to inadequate therapy. A diverse therapeutic protocol based on histological diagnosis is necessary to plan appropriate management. Treatment recommendations are discussed in detail in the article.

Rapid resolution of acute epidural hematoma

1988 ◽  
Vol 68 (1) ◽  
pp. 149-151 ◽  
Author(s):  
Nobuhiko Aoki
Keyword(s):  
Epidural Hematoma ◽  
Clinical Course ◽  
Skull Fracture ◽  
Fracture Line ◽  
Concomitant Increase ◽  
Content Type ◽  
Rapid Resolution ◽  
Acute Epidural Hematoma ◽  
Fine Print

✓ Two cases of acute epidural hematoma with rapid resolution followed by a benign clinical course are reported. Because of the concomitant increase in the epicranial hematoma over a linear skull fracture in each case, the acute epidural hematoma was presumed to have been decompressed into the epicranial region through the fracture line.

Air in acute epidural hematomas

1986 ◽  
Vol 65 (4) ◽  
pp. 555-556 ◽  
Author(s):  
Nobuhiko Aoki
Keyword(s):  
Temporal Bone ◽  
Clinical Significance ◽  
Epidural Hematoma ◽  
Pediatric Patients ◽  
Skull Fracture ◽  
Air Bubbles ◽  
Content Type ◽  
Air Bubble ◽  
Acute Epidural Hematoma ◽  
Fine Print

✓ Two pediatric patients with acute epidural hematomas containing air bubble(s) are reported. A skull fracture was observed extending to the mastoid cells of the temporal bone in both patients. In one patient the hematoma and air bubbles subsequently increased in volume, requiring a craniotomy. The clinical significance of air in an acute epidural hematoma is discussed.

Inflammation markers and risk factors for recurrence in 35 patients with a posttraumatic chronic subdural hematoma: a prospective study

2004 ◽  
Vol 100 (1) ◽  
pp. 24-32 ◽  
Author(s):  
Alessandro Frati ◽  
Maurizio Salvati ◽  
Fabrizio Mainiero ◽  
Flora Ippoliti ◽  
Giovanni Rocchi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prospective Study ◽  
Inflammatory Cytokines ◽  
Subdural Hematoma ◽  
Traumatic Event ◽  
Chronic Subdural Hematoma ◽  
Local Inflammation ◽  
Content Type ◽  
A Prospective Study ◽  
Fine Print

Object. To evaluate the role of local inflammation in the pathogenesis and postoperative recurrence of chronic subdural hematoma (CSDH), the authors conducted an investigation in a selected group of patients who could clearly recall a traumatic event and who did not have other risk factors for CSDH. Inflammation was analyzed by measuring the concentration of the proinflammatory and inflammatory cytokines interleukin (IL)-6 and IL-8. The authors also investigated the possible relationship between high levels of local inflammation that were measured and recurrence of the CSDH. Methods. A prospective study was performed between 1999 and 2001. Thirty-five patients who could clearly recall a traumatic event that had occurred at least 3 weeks previously and who did not have risk factors for CSDH were enrolled. All patients were surgically treated by burr hole irrigation plus external drainage. The concentration of inflammatory cytokines was very high in the lesion, whereas it was normal in serum. In five cases in which recurrence occurred, concentrations of both IL-6 and IL-8 were significantly increased (p < 0.01) in comparison with cases without a recurrence. In a layering hematoma, the IL-6 and IL-8 concentrations were significantly higher (p < 0.05). Layering CSDHs were also significantly correlated with recurrence. Trabecular hematoma had the lowest cytokine levels and the longest median interval between trauma and clinical onset. The interval from trauma did not significantly influence recurrence, although it did differ significantly between the trabecular and layering CSDH groups. Concentrations of IL-6 and IL-8 in the CSDHs did not differ significantly in relation to either the age of the hematoma (measured as the interval from trauma) or the age of the patient. Conclusions. Brain trauma causes the onset of an inflammatory process within the dural border cell layer; high levels of inflammatory cytokines were significantly correlated with recurrence and layering CSDH. A prolonged postoperative antiinflammatory medicine given as prophylaxis may help prevent the recurrence of a CSDH.

Late results of radical excision of craniopharyngiomas in children

1975 ◽  
Vol 42 (1) ◽  
pp. 86-90 ◽  
Author(s):  
Edward L. Katz
Keyword(s):  
High Mortality ◽  
Surgical Excision ◽  
Late Results ◽  
Radical Excision ◽  
Initial Operation ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Fine Print

✓ The results of radical surgical excision of craniopharyngiomas in children operated on by Dr. Donald Matson beginning in 1950 are presented. The patients are analyzed in regard to survival and quality of survival. While 22 of 34 children so treated at the initial operation are presently alive and tumor-free, high mortality and morbidity followed in cases where reoperation was performed. Properly treated endocrinological deficits need not be a serious problem, but persistent hyperosmolality carried a grave prognosis. No predictive criteria are yet available to determine which tumors are amenable to radical surgical excision.

Brain-stem tumors in childhood: a prospective randomized trial of irradiation with and without adjuvant CCNU, VCR, and prednisone

1987 ◽  
Vol 66 (2) ◽  
pp. 227-233 ◽  
Author(s):  
R. Derek T. Jenkin ◽  
Carl Boesel ◽  
Inta Ertel ◽  
Audrey Evans ◽  
Robert Hittle ◽  
...  
Keyword(s):  
Adjuvant Chemotherapy ◽  
Brain Stem ◽  
Radiation Treatment ◽  
Risk Of Infection ◽  
Content Type ◽  
Standard Methods ◽  
Increased Risk ◽  
Brain Stem Tumors ◽  
A Prospective Study ◽  
Fine Print

✓ Seventy-four children with a brain-stem tumor diagnosed between 1977 and 1980 were entered into a prospective study in which exploration and assessment for resection were optional, radiation treatment using standard methods was required, and randomization occurred with regard to the use of adjuvant chemotherapy (l-(2-chloroethyl)-l-nitrosourea, vincristine, and prednisone) or no further treatment. The overall 5-year survival rate was 20% and was not improved by the adjuvant chemotherapy program. An increased risk of infection was associated with the adjuvant therapy.

Terson's syndrome: a reversible cause of blindness following subarachnoid hemorrhage

1992 ◽  
Vol 76 (5) ◽  
pp. 766-771 ◽  
Author(s):  
Andrew M. Garfinkle ◽  
Irena R. Danys ◽  
David A. Nicolle ◽  
Austin R. T. Colohan ◽  
Steven Brem
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Vitreous Hemorrhage ◽  
Initial Examination ◽  
Content Type ◽  
Breakthrough Bleeding ◽  
Intraocular Hemorrhage ◽  
Terson’S Syndrome ◽  
Terson's Syndrome ◽  
A Prospective Study ◽  
Fine Print

✓ Terson's syndrome refers to the occurrence of vitreous hemorrhage with subarachnoid hemorrhage (SAH), usually due to a ruptured cerebral aneurysm. Although it is a well-described entity in the ophthalmological literature, it has been only rarely commented upon in the neurosurgical discussion of SAH. Fundus findings are reported in a prospective study of 22 consecutive patients with a computerized tomography- or lumbar puncture-proven diagnosis of SAH. Six of these patients had intraocular hemorrhage on initial examination. In four patients vitreous hemorrhage was evident on presentation (six of eight eyes). In the subsequent 12 days, vitreous hemorrhage developed in the additional two patients (three of four eyes) due to breakthrough bleeding from the original subhyaloid hemorrhages. The initial amount of intraocular hemorrhage did not correlate with the severity of SAH. Two of the six patients with intraocular hemorrhage died, whereas five of the 16 remaining SAH patients without intraocular hemorrhage died. Of the four survivors with intraocular hemorrhage, three showed gradual but significant improvement in their visual acuity by 6 months. The fourth underwent vitrectomy at 8 months after presentation and had a good visual result. With modern and aggressive medical and microsurgical management, Terson's syndrome should be recognized as an important reversible cause of blindness in patients surviving SAH.

Bacterial meningitis caused by the use of ventricular or lumbar cerebrospinal fluid catheters

2005 ◽  
Vol 102 (2) ◽  
pp. 229-234 ◽  
Author(s):  
Rogier P. Schade ◽  
Janke Schinkel ◽  
Leo G. Visser ◽  
J. Marc C. van Dijk ◽  
Joan H. C. Voormolen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Bacterial Meningitis ◽  
Clinical Symptoms ◽  
External Drainage ◽  
Content Type ◽  
Ventricular Catheters ◽  
Independent Risk Factors ◽  
Lumbar Cerebrospinal Fluid ◽  
Fine Print

Object. In the present study the authors compared the incidence and risk factors for external drainage—related bacterial meningitis (ED-BM) by using ventricular and lumbar catheters. Methods. A cohort of 230 consecutive patients with ED was evaluated. Cerebrospinal fluid samples were obtained daily for microbiological culture, and ED-BM was defined based on culture results in combination with clinical symptoms. The incidence of ED-BM was 7% in lumbar and 15% in ventricular drains. Independent risk factors included site leakage, drain blockage, and most importantly duration of ED. Despite a higher infection rate, ventricular catheters did not have a significant higher risk of infection after correcting for duration of drainage. Conclusions. Analysis of data in the present study showed that the incidence of ED-associated death is low (0.45%) in patients who do not receive continuous antibiotic prophylaxis during ED.

Chorea as a manifestation of epidural hematoma

1984 ◽  
Vol 60 (4) ◽  
pp. 856-857 ◽  
Author(s):  
John R. Adler ◽  
Ken R. Winston
Keyword(s):  
Epidural Hematoma ◽  
Content Type ◽  
Fine Print

✓ A child with epidural hematoma presented with choreiform movements which promptly resolved following the evacuation of the hematoma.

Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury

2002 ◽  
Vol 96 (1) ◽  
pp. 109-116 ◽  
Author(s):  
Matthias Oertel ◽  
Daniel F. Kelly ◽  
David McArthur ◽  
W. John Boscardin ◽  
Thomas C. Glenn ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ct Scan ◽  
Ct Scanning ◽  
Older Age ◽  
Ct Scans ◽  
Female Ratio ◽  
Content Type ◽  
Male Sex ◽  
Time From Injury ◽  
Fine Print

Object. Progressive intracranial hemorrhage after head injury is often observed on serial computerized tomography (CT) scans but its significance is uncertain. In this study, patients in whom two CT scans were obtained within 24 hours of injury were analyzed to determine the incidence, risk factors, and clinical significance of progressive hemorrhagic injury (PHI). Methods. The diagnosis of PHI was determined by comparing the first and second CT scans and was categorized as epidural hematoma (EDH), subdural hematoma (SDH), intraparenchymal contusion or hematoma (IPCH), or subarachnoid hemorrhage (SAH). Potential risk factors, the daily mean intracranial pressure (ICP), and cerebral perfusion pressure were analyzed. In a cohort of 142 patients (mean age 34 ± 14 years; median Glasgow Coma Scale score of 8, range 3–15; male/female ratio 4.3:1), the mean time from injury to first CT scan was 2 ± 1.6 hours and between first and second CT scans was 6.9 ± 3.6 hours. A PHI was found in 42.3% of patients overall and in 48.6% of patients who underwent scanning within 2 hours of injury. Of the 60 patients with PHI, 87% underwent their first CT scan within 2 hours of injury and in only one with PHI was the first CT scan obtained more than 6 hours postinjury. The likelihood of PHI for a given lesion was 51% for IPCH, 22% for EDH, 17% for SAH, and 11% for SDH. Of the 46 patients who underwent craniotomy for hematoma evacuation, 24% did so after the second CT scan because of findings of PHI. Logistic regression was used to identify male sex (p = 0.01), older age (p = 0.01), time from injury to first CT scan (p = 0.02), and initial partial thromboplastin time (PTT) (p = 0.02) as the best predictors of PHI. The percentage of patients with mean daily ICP greater than 20 mm Hg was higher in those with PHI compared with those without PHI. The 6-month postinjury outcome was similar in the two patient groups. Conclusions. Early progressive hemorrhage occurs in almost 50% of head-injured patients who undergo CT scanning within 2 hours of injury, it occurs most frequently in cerebral contusions, and it is associated with ICP elevations. Male sex, older age, time from injury to first CT scan, and PTT appear to be key determinants of PHI. Early repeated CT scanning is indicated in patients with nonsurgically treated hemorrhage revealed on the first CT scan.

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