Risk factors predicting operable intracranial hematomas in head injury

1992 ◽  
Vol 77 (1) ◽  
pp. 9-14 ◽  
Author(s):  
Michael B. Gutman ◽  
Richard J. Moulton ◽  
Irene Sullivan ◽  
Gillian Hotz ◽  
William S. Tucker ◽  
...  
Keyword(s):  
Risk Factors ◽  
Head Injury ◽  
Head Injuries ◽  
Mass Effect ◽  
Content Type ◽  
Logistic Analysis ◽  
Intracranial Hematomas ◽  
Gcs Score ◽  
Mass Lesions ◽  
Fine Print

✓ A study was performed to examine the incidence of operable traumatic intracranial hematomas accompanying head injuries of differing degrees of severity, and to see if factors predicting operable mass lesions could be identified. Logistic analysis was used to identify independent predictors of operable traumatic intracranial hematomas. Data were gathered prospectively on 1039 patients admitted with head injury between January, 1986, and December, 1990. Patient age, Glasgow Coma Scale (GCS) score, pupillary inequality, and injury by falling were all independent predictors of the presence of operable intracranial hematomas (p = 0.0000, 0.0000, 0.0182, and 0.0001, respectively). Injury to vehicle occupants was less likely to result in operable mass lesions (p = 0.0001) than injury by other means. The incidence of traumatic intracranial hematomas in patients over 50 years old was three to four times higher than in those under 30 years of age. Not surprisingly, the incidence of operable hematomas increased with decreasing GCS scores. However, even at a GCS score of 13 to 15, patients with other risk factors had a substantial incidence of operable mass lesions. There was a 29% incidence of operable intracranial hematomas for patients with a GCS score of 13 to 15, aged over 40 years and injured in a fall. It is suggested that patients who are middle-aged or older, or those injured in falls, are at particular risk for traumatic intracranial hematomas even if their GCS score is high. These patients should have early definitive investigation with computerized tomography in order to identify operable hematomas and to initiate surgical treatment prior to neurological deterioration from mass effect.

Head injuries due to falls caused by seizures: a group at high risk for traumatic intracranial hematomas

1997 ◽  
Vol 86 (3) ◽  
pp. 433-437 ◽  
Author(s):  
Thomas J. Zwimpfer ◽  
Jennifer Brown ◽  
Irene Sullivan ◽  
Richard J. Moulton
Keyword(s):  
Head Injury ◽  
Alcohol Intoxication ◽  
Head Injuries ◽  
Chi Square ◽  
Focal Neurological Deficit ◽  
Content Type ◽  
Intracranial Hematomas ◽  
Chi Square Analysis ◽  
Mass Lesions ◽  
Fine Print

✓ This prospective review of adult patients with head injuries examines the incidence of head injuries due to falls caused by seizures, the incidence and severity of intracranial hematomas, and the morbidity and mortality rates in this patient population. A head injury was attributed to a fall caused by a seizure if the seizure was witnessed to have caused the fall, or the patient had a known seizure history, appeared postictal or was found convulsing after the fall, and no other cause for the fall was evident. A total of 1760 adult head-injured patients were consecutively admitted to the authors' service between 1986 and 1993. Five hundred eighty-two head injuries (33.1%) were due to falls and 22 (3.8%) of these were caused by seizures. Based on the prevalence rates for epilepsy in the general population of 0.5 to 2%, these results indicate that epileptics are several times more likely to suffer a head injury due to a fall. Mass lesions were found in 20 (90.9%) of these 22 patients and the remaining two patients suffered mild diffuse head injuries. There was a high incidence of extraaxial mass lesions: 17 (85%) of the 20 intracranial hematomas were either epidural (five cases) or acute subdural (12 cases) hematomas. Eighteen (81.8%) of the 22 patients required evacuation of a hematoma. Both the incidence of intracranial hematomas (90.9% vs. 39.8%; p < 0.001, chi-square analysis) and the rate of hematoma evacuation (81.8% vs. 32.3%; p < 0.001) was significantly greater in patients injured in falls due to seizures (22 cases) than in the group injured in falls from all other causes (560 cases). The higher incidence of hematomas and the need for evacuation were not explained by differences in age, severity of head injury, or incidence of alcohol intoxication. Despite the greater incidence of mass lesions and the need for operative treatment in patients injured because of seizures, their mortality rate was similar to that of patients injured in falls from other causes. On the basis of their review of patients admitted to a neurosurgical center with complaints of head injury, the authors conclude that patients with head injuries due to a fall caused by a seizure should undergo computerized tomography scanning early in their management. Until a mass lesion has been excluded, any decrease in level of consciousness or focal neurological deficit should not be attributed to the seizure itself.

Moderate head injury: a guide to initial management

1992 ◽  
Vol 77 (4) ◽  
pp. 562-564 ◽  
Author(s):  
Sherman C. Stein ◽  
Steven E. Ross
Keyword(s):  
Head Injury ◽  
Head Injuries ◽  
Ct Scanning ◽  
Ct Scans ◽  
Initial Examination ◽  
Content Type ◽  
Injury Group ◽  
Intracranial Lesions ◽  
Gcs Score ◽  
Fine Print

✓ The purpose of this study is to determine the initial treatment of patients who appear to have sustained moderate head injuries when first evaluated. The authors reviewed the records of 341 patients whose initial Glasgow Coma Scale (GCS) scores ranged from 9 to 12, as well as another 106 patients with GCS scores of 13. All patients underwent cranial computerized tomography (CT) at the time of admission. In 40.3% of these patients the CT scans were abnormal (30.6% had intracranial lesions), and 8.1 % required neurosurgical intervention (craniotomies for hematoma in 12, elevation of depressed fractures in five, and insertion of intracranial pressure monitors in 19). Four patients died of their intracranial injuries. A similar incidence of lesions found on CT and at surgery suggests that an initial GCS score of 13 be classified with the moderate head injury group. Skull fractures were found to be poor indicators of intracranial abnormalities. These results suggest that all patients with head injury thought to be moderate on initial examination be admitted to the hospital and undergo urgent CT scanning. Patients with intracranial lesions require immediate neurosurgical consultation, surgery as needed, and admission to a critical-care unit. Scans should be repeated in patients whose recovery is less rapid than expected and in all patients with evidence of clinical deterioration; this was necessary in almost half of the patients in this group, and 32% were found to have progression of radiological abnormalities on serial CT scans.

Acute regional cerebral blood flow changes caused by severe head injuries

1991 ◽  
Vol 74 (3) ◽  
pp. 407-414 ◽  
Author(s):  
Donald W. Marion ◽  
Joseph Darby ◽  
Howard Yonas
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Head Injury ◽  
Brain Stem ◽  
Head Injuries ◽  
Clinical Signs ◽  
Content Type ◽  
Tomography Method ◽  
Gcs Score ◽  
Mass Lesions

✓ To evaluate the changes in cerebral blood flow (CBF) that occur immediately after head injury and the effects of different posttraumatic lesions on CBF, 61 CBF studies were obtained using the xenon-computerized tomography method in 32 severely head-injured adults (Glasgow Coma Scale score (GCS) ≤ 7). The measurements were made within 7 days after injury, 43% in the first 24 hours. During the 1st day, patients with an initial GCS score of 3 or 4 and no surgical mass had significantly lower flows than did those with a higher GCS score or mass lesions (p < 0.05): in the first 1 to 4 hours, those without surgical mass lesions had a mean CBF of 27 cc/100 gm/min, which rose to 44 cc/100 gm/min by 24 hours. Patients without surgical mass lesions who died tended to have a lower global CBF than did those with better outcomes. Mass lesions were associated with a high global CBF and bihemispheric contusions with the lowest flows. By 24 hours after injury, global blood flow increased in groups that originally had low flows and decreased in those with very high initial flows, such that by 36 to 48 hours, most patients had CBF values between 32 and 55 cc/100 gm/min. Lobar, basal ganglion, and brain-stem blood flow values frequently differed by 25% or more from global averages. Brain-stem CBF varied the most but did not correlate with clinical signs of brain-stem dysfunction. Double studies were performed at two different pCO2 values in 10 patients with various posttraumatic lesions, and the CO2 vasoresponsivity was calculated. Abnormal CO2 vasoresponsivity was found with acute subdural hematomas and defuse cerebral swelling but not with epidural hematomas. In patients without surgical mass lesions, the findings suggest that CBF in the first few hours after injury is often low, followed by a hyperemic phase that peaks at 24 hours. Global CBF values vary widely depending on the type of traumatic brain injury, and brain-stem flow is often not accurately reflected by global CBF values. These findings underscore the need to define regional CBF abnormalities in victims of severe head injury if treatment is intended to prevent regional ischemia.

Quantitative pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury

2003 ◽  
Vol 98 (1) ◽  
pp. 205-213 ◽  
Author(s):  
William R. Taylor ◽  
Jeff W. Chen ◽  
Hal Meltzer ◽  
Thomas A. Gennarelli ◽  
Cynthia Kelbch ◽  
...  
Keyword(s):  
Head Injury ◽  
Healthy Volunteers ◽  
New Technology ◽  
Head Injuries ◽  
Mass Effect ◽  
Midline Shift ◽  
Content Type ◽  
Cardiology Clinic ◽  
Diffuse Brain Swelling ◽  
Fine Print

✓ The authors prospectively used a new hand-held point-and-shoot pupillometer to assess pupillary function quantitatively. Repetitive measurements were initially made in more than 300 healthy volunteers ranging in age from 1 to 87 years, providing a total of 2432 paired (alternative right eye, left eye) measurements under varying light conditions. The authors studied 17 patients undergoing a variety of nonintracranial, nonophthalmological, endoscopic, or surgical procedures and 20 seniors in a cardiology clinic to learn more about the effects of a variety of drugs. Additionally, the authors carried out detailed studies in 26 adults with acute severe head injury in whom intracranial pressure (ICP) was continuously monitored. Finally, five patients suffering from subarachnoid hemorrhage were also studied. Quantitative pupillary measurements could be reliably replicated in the study participants. In healthy volunteers the resting pupillary aperture averaged 4.1 mm and the minimal aperture after stimulation was 2.7 mm, resulting in a 34% change in pupil size. Constriction velocity averaged 1.48 ± 0.33 mm/second. Pupillary symmetry was striking in both healthy volunteers and patients without intracranial or uncorrected visual acuity disorders. In the 2432 paired measurements in healthy volunteers, constriction velocity was noted to fall below 0.85 mm/second on only 33 occasions and below 0.6 mm/second on eight occasions (< one in 310 observations). In outpatients, the reduction in constriction velocity was observed when either oral or intravenous narcotic agents and diazepam analogs were administered. These effects were transient and always symmetrical. Among the 26 patients with head injuries, eight were found to have elevations of ICP above 20 mm Hg and pupillary dynamics in each of these patients remained normal. In 13 patients with a midline shift greater than 3 mm, elevations of ICP above 20 mm Hg, when present for 15 minutes, were frequently associated with a reduction in constriction velocity on the side of the mass effect to below 0.6 mm/second (51% of 156 paired observations). In five patients with diffuse brain swelling but no midline shift, a reduction in constriction velocities did not generally occur until the ICP exceeded 30 mm Hg. Changes in the percentage of reduction from the resting state following stimulation were always greater than 10%, even in patients receiving large doses of morphine and propofol in whom the ICP was lower than 20 mm Hg. Asymmetry of pupillary size greater than 0.5 mm was observed infrequently (< 1%) in healthy volunteers and was rarely seen in head-injured patients unless the ICP exceeded 20 mm Hg. Pupillometry is a reliable technology capable of providing repetitive data on quantitative pupillary function in states of health and disease.

Prophylactic phenytoin in severe head injuries

1979 ◽  
Vol 51 (4) ◽  
pp. 507-509 ◽  
Author(s):  
Richard N. W. Wohns ◽  
Allen R. Wyler
Keyword(s):  
Retrospective Study ◽  
Head Injury ◽  
High Probability ◽  
Late Onset ◽  
Head Injuries ◽  
Content Type ◽  
Posttraumatic Epilepsy ◽  
Fine Print

✓ We are reporting a retrospective study of 62 patients whose head injury was sufficiently severe to cause a high probability of posttraumatic epilepsy. Of 50 patients treated with phenytoin, 10% developed epilepsy of late onset. Twelve patients not treated with phenytoin but who had head injuries of equal magnitude had a 50% incidence of epilepsy. These data from a highly selected group of patients with severe head injuries confirm the bias that treatment with phenytoin decreases the incidence of posttraumatic epilepsy.

The outcome of severe closed head injury

1991 ◽  
Vol 75 (Supplement) ◽  
pp. S28-S36 ◽  
Author(s):  
Lawrence F. Marshall ◽  
Theresa Gautille ◽  
Melville R. Klauber ◽  
Howard M. Eisenberg ◽  
John A. Jane ◽  
...  
Keyword(s):  
Head Injury ◽  
Mortality Rate ◽  
Severe Head Injury ◽  
Closed Head Injury ◽  
Data Bank ◽  
Content Type ◽  
Severity Of Injury ◽  
Gcs Score ◽  
Fine Print ◽  
Overall Mortality

✓ The outcome of severe head injury was prospectively studied in patients enrolled in the Traumatic Coma Data Bank (TCDB) during the 45-month period from January 1, 1984, through September 30, 1987. Data were collected on 1030 consecutive patients admitted with severe head injury (defined as a Glasgow Coma Scale (GCS) score of 8 or less following nonsurgical resuscitation). Of these, 284 either were brain-dead on admission or had a gunshot wound to the brain. Patients in these two groups were excluded, leaving 746 patients available for this analysis. The overall mortality rate for the 746 patients was 36%, determined at 6 months postinjury. As expected, the mortality rate progressively decreased from 76% in patients with a postresuscitation GCS score of 3 to approximately 18% for patients with a GCS score of 6, 7, or 8. Among the patients with nonsurgical lesions (overall mortality rate, 31%), the mortality rate was higher in those having an increased likelihood of elevated intracranial pressure as assessed by a new classification of head injury based on the computerized tomography findings. In the 276 patients undergoing craniotomy, the mortality rate was 39%. Half of the patients with acute subdural hematomas died — a substantial improvement over results in previous reports. Outcome differences between the four TCDB centers were small and were, in part, explicable by differences in patient age and the type and severity of injury. This study describes head injury outcome in four selected head-injury centers. It indicates that a mortality rate of approximately 35% is to be expected in such patients admitted to experienced neurosurgical units.

High-risk mild head injury

1997 ◽  
Vol 87 (2) ◽  
pp. 234-238 ◽  
Author(s):  
John N. K. Hsiang ◽  
Theresa Yeung ◽  
Ashley L. M. Yu ◽  
Wai S. Poon
Keyword(s):  
Head Injury ◽  
High Risk ◽  
Mild Head Injury ◽  
Radiographic Findings ◽  
Content Type ◽  
Head Injured ◽  
Definition Of ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

✓ The generally accepted definition of mild head injury includes Glasgow Coma Scale (GCS) scores of 13 to 15. However, many studies have shown that there is a heterogeneous pathophysiology among patients with GCS scores in this range. The current definition of mild head injury is misleading because patients classified in this category can have severe sequelae. Therefore, a prospective study of 1360 head-injured patients with GCS scores ranging from 13 to 15 who were admitted to the neurosurgery service during 1994 and 1995 was undertaken to modify the current definition of mild head injury. Data regarding patients' age, sex, GCS score, radiographic findings, neurosurgical intervention, and 6-month outcome were collected and analyzed. The results of this study showed that patients with lower GCS scores tended to have suffered more serious injury. There was a statistically significant trend across GCS scores for percentage of patients with positive acute radiographic findings, percentage receiving neurosurgical interventions, and percentage with poor outcome. The presence of postinjury vomiting did not correlate with findings of acute radiographic abnormalities. Based on the results of this study, the authors divided all head-injured patients with GCS scores ranging from 13 to 15 into mild head injury and high-risk mild head injury groups. Mild head injury is defined as a GCS score of 15 without acute radiographic abnormalities, whereas high-risk mild head injury is defined as GCS scores of 13 or 14, or a GCS score of 15 with acute radiographic abnormalities. This more precise definition of mild head injury is simple to use and may help avoid the confusion caused by the current classification.

Low-dose aspirin prophylaxis and risk of intracranial hemorrhage in patients older than 60 years of age with mild or moderate head injury: a prospective study

2003 ◽  
Vol 99 (4) ◽  
pp. 661-665 ◽  
Author(s):  
Sergey Spektor ◽  
Samuel Agus ◽  
Vladimir Merkin ◽  
Shlomo Constantini
Keyword(s):  
Head Injury ◽  
Intracranial Hemorrhage ◽  
Ct Scanning ◽  
Treated Group ◽  
Control Group ◽  
Content Type ◽  
Significant Difference ◽  
Traumatic Intracranial Hemorrhage ◽  
Gcs Score ◽  
Fine Print

Object. The goal of this paper was to investigate a possible relationship between the consumption of low-dose aspirin (LDA) and traumatic intracranial hemorrhage in an attempt to determine whether older patients receiving prophylactic LDA require special treatment following an incidence of mild-to-moderate head trauma. Methods. Two hundred thirty-one patients older than 60 years of age, who arrived at the emergency department with a mild or moderate head injury (Glasgow Coma Scale [GCS] Scores 13–15 and 9–12, respectively), were included in the study. One hundred ten patients were receiving prophylactic LDA (100 mg/day) and these formed the aspirin-treated group. One hundred twenty-one patients were receiving no aspirin, and these formed the control group. There was no statistically significant difference between the two groups with respect to age, sex, mechanism of trauma, or GCS score on arrival at the emergency department. Most of the patients sustained the head injury from falls (88.2% of patients in the aspirin-treated group and 85.1% of patients in the control group), and had external signs of head trauma such as bruising or scalp laceration (80.9% of patients in the aspirin-treated group and 86.8% of patients in the control group). All patients underwent similar neurological examinations and computerized tomography (CT) scanning of the head. The CT scans revealed evidence of traumatic intracranial hemorrhage in 27 (24.5%) patients in the aspirin-treated group and in 31 patients (25.6%) in the control group. Surgical intervention was required for five patients in each group (4.5% of patients in the aspirin-treated group and 4.1% of patients in the control group). A surprising number of the patients who arrived with GCS Score 15 were found to have traumatic intracranial hemorrhage, as revealed by CT scanning (11.5% of patients in the aspirin-treated group and 16.5% of patients in the control group). Surgery, however, was not necessary for any of these patients. Conclusions. There was no statistically significant difference in the frequency or types of traumatic intracranial hemorrhage between patients who had received aspirin prophylaxis and those who had not. The authors conclude that LDA does not increase surgically relevant parenchymal or meningeal bleeding following moderate and minor head injury in patients older than 60 years of age.

Cerebral blood flow and metabolism in severely head-injured children

1989 ◽  
Vol 71 (1) ◽  
pp. 63-71 ◽  
Author(s):  
J. Paul Muizelaar ◽  
Anthony Marmarou ◽  
Antonio A. F. DeSalles ◽  
John D. Ward ◽  
Richard S. Zimmerman ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Head Injury ◽  
Severe Head Injury ◽  
Cerebral Blood Volume ◽  
Closed Head Injury ◽  
Volume Index ◽  
Content Type ◽  
Gcs Score ◽  
Fine Print

✓ The literature suggests that in children with severe head injury, cerebral hyperemia is common and related to high intracranial pressure (ICP). However, there are very few data on cerebral blood flow (CBF) after severe head injury in children. This paper presents 72 measurements of cerebral blood flow (“CBF15”), using the 133Xe inhalation method, with multiple detectors over both hemispheres in 32 children aged 3 to 18 years (mean 13.6 years) with severe closed head injury (average Glasgow Coma Scale (GCS) score 5.4). In 25 of the children, these were combined with measurements of arteriojugular venous oxygen difference (AVDO2) and of cerebral metabolic rate of oxygen (CMRO2). In 30 patients, the first measurement was taken approximately 12 hours postinjury. In 18 patients, an indication of brain stiffness was obtained by withdrawal and injection of ventricular cerebrospinal fluid and calculation of the pressure-volume index (PVI) of Marmarou. The CBF and CMRO2 data were correlated with the GCS score, outcome, ICP, and PVI. Early after injury, CBF tended to be lower with lower GCS scores, but this was not statistically significant. This trend was reversed 24 hours postinjury, as significantly more hyperemic values were recorded the lower the GCS score, with the exception of the most severely injured patients (GCS score 3). In contrast, mean CMRO2 correlated positively with the GCS score and outcome throughout the course, but large standard deviations preclude making predictions based on CMRO2 measurements in individual patients. Early after injury, there was mild uncoupling between CBF and CMRO2 (CBF above metabolic demands, low AVDO2) and, after 24 hours, flow and metabolism were completely uncoupled with an extremely low AVDO2. Consistently reduced flow was found in only four patients; 28 patients (88%) showed hyperemia at some point in their course. This very high percentage of patients with hyperemia, combined with the lowest values of AVDO2 found in the literature, indicates that hyperemia or luxury perfusion is more prevalent in this group of patients. The three patients with consistently the highest CBF had consistently the lowest PVI: thus, the patients with the most severe hyperemia also had the stiffest brains. Nevertheless, and in contrast to previous reports, no correlation could be established between the course of ICP or PVI and the occurrence of hyperemia, nor was there a correlation between the levels of CBF and ICP at the time of the measurements. The authors argue that this lack of correlation is due to: 1) a definition of hyperemia that is too generous, and 2) the lack of a systematic relationship between CBF and cerebral blood volume. The implications of these findings for therapeutic modes of controlling ICP in children, such as hyperventilation and the use of mannitol, are discussed.

Pitfalls in the angiographic diagnosis of serious head injury

1980 ◽  
Vol 53 (1) ◽  
pp. 53-57 ◽  
Author(s):  
Edward R. Savolaine ◽  
Arthur M. Gerber ◽  
Stephen F. Nowak
Keyword(s):  
Head Injury ◽  
Anterior Cerebral Artery ◽  
Emergency Situation ◽  
Middle Meningeal Artery ◽  
Apparent Displacement ◽  
Content Type ◽  
Mass Lesions ◽  
Angiographic Diagnosis ◽  
Meningeal Artery ◽  
Fine Print

✓ The problems in interpretation of emergency cerebral arteriograms are discussed with relation to the apparent displacement of “landmark” vessels that is actually produced by rotation or by the type of anteroposterior projection of the vessels, rather than by mass lesions. Anterior cerebral artery, middle meningeal artery, and pineal displacements are reviewed, along with possible pitfalls of diagnosis and attempts at correction. Utilization of dried skulls afforded depth visualization of middle meningeal artery grooves as well as the radiographic projection. The most reliable region on each different type of anteroposterior projection is discussed with regard to the emergency situation where repeat angiographic detections or special views may not be possible.

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