Traumatic injury of dural venous sinus as cause of epidural hematoma: importance of recognition and adequate surgical planning

Background: Although most traumatic epidural hematomas are secondary to arterial injuries, particularly rupture of the middle meningeal artery, around 9.7% of cases are associated with dural venous sinus injury, leading to poorer prognosis and greater complications. We report a case of a patient presenting cranial trauma with bone fracture and laceration of the transverse sinus producing epidural hematoma, and discuss the main aspects of this condition. Case description: A 47-year-old man struck by a motorcycle was admitted to the Emergency Room with a score of 15 on the Glasgow Coma Scale, evolving over 5 hours with reduced level of consciousness. A cranial CT scan was performed disclosing right parieto- occipital hyperdensity, consistent with acute epidural hematoma, and a parieto-occipital fracture line crossing the path of the ipsilateral transverse sinus. Parietal craniotomy was performed to drain the hematoma, revealing a venous sinus injury requiring immediate repair. Conclusions: This case and discussion highlight the many details and technical specificities to be taken into account by neurosurgeons when encountering intracranial hematoma caused by traumatic injury of the dural venous sinus, and which are pivotal in determining the efficacy of the treatment approach and prognosis of the patient.

Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial

Background The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy. Methods/design Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury. Discussion This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice. Trial registration ClinicalTrials.govNCT 04261673. Registered on 04 February 2020

Application of Endoport-Assisted Neuroendoscopic Techniques in Lateral Ventricular Tumor Surgery

PurposeThe aim of this study was to review the experience of Endoport-assisted neuroendoscopic surgery for lateral ventricular tumors resection, investigate the therapeutic efficiency and discuss the key points. MethodsWe retrospectively reviewed the clinical data of 16 patients suffering from lateral ventricular tumors. All the patients received Endoport-assisted neuroendoscopic surgery from January 2018 to June 2020 in the department of neurosurgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School. ResultsAll the patients received standardized treatment according to the preoperative image data and the postoperative pathology of the tumors. Endoport-assisted Neuroendoscopic surgery achieved complete removal of lateral ventricular tumors in 14 cases (87.5%) and subtotal removal in 2 cases (12.5%, glioma). The perioperative complications were analyzed, 1 acute epidural hematoma occurred during surgery, 1 hemiplegia and 2 obstructive hydrocephalus occurred after surgery. All the complications were managed timely. During the long-time follow up, the patient with glioblastoma died 16 months after surgery, the other patients are still alive with Glasgow outcome scales not less than 4.ConclusionEndoport-assisted neuroendoscopic surgery is suitable for the resection of lateral ventricular tumors. This procedure is simple, effective, minimally invasive, and associated with fast postoperative recovery.

Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial

Background: Expeditiously surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical treatment for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted by the decision to evacuate the hematoma with decompressive craniectomy or craniotomy. Here, we present the protocol for a randomized controlled trial targeted at comparing the outcome and economic benefits of decompressive craniectomy versus craniotomy for the treatment of traumatic brain injury (TBI) patients with cerebral herniation undergoing evacuation of AEDH.Methods/design: Patients of both genders, aged from 18 to 65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, comply with other inclusion and exclusion criteria are enrolled. Clinical information, including diagnosis of AEDH, clinical radiological information and treatment procedures, follow-up data of 1, 3 and 6 months post injury are collected on 120 eligible patients, randomized into groups of decompressive craniectomy versus craniotomy in a 1:1 ratio among 51 centers. The primary outcome is the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes include incidence of post-operative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicator within 6 months post-injury.Discussion: This study is expected to help neurosurgeons make a better decision to evacuate the epidural hematoma with or without a DC, especially for patients with brain herniation, and improve current situation of lack of general evidence.Trial registration: Clinicaltrials.gov: NCT 04261673 (Registration date: 04 February 2020)

Retrospective clinical evaluation of patients undergoing surgery for acute epidural hematoma

We aimed to evaluate mortality-associated factors among patients with acute epidural hematoma due to head trauma. Demographic characteristics, preoperative Glasgow Coma Scale score, epidural hematoma aetiology and radiological findings, accompanying systemic trauma results, hospitalisation duration, sequelae, and mortality features of patients experiencing epidural hematoma between 2014 and 2018 were evaluated. Overall, 79 patients were examined. The most frequent epidural hematoma aetiology was traffic accidents (51.9%), with temporal region being the most common epidural hematoma location (38 [48.2%] patients). Among all, 12 (15.2%) patients died and 67 (84.8%) were discharged. Of them, 57 (85.1%) patients were discharged without and 10 (14.9%) with neurological sequelae. Age>65 years (p=0.001) and low Glasgow Coma Scale score (p<0.05) were significantly associated with higher mortality. Overall mortality rate was 91.7% (p<0.001) in patients with systemic trauma accompanying epidural hematoma, with thoracic (12%) and orthopaedic (9%) trauma being the most common. Cranial injuries included linear fracture, 78.5%; pneumocephalus, 48.1%; cerebral contusion, 44.3%; traumatic subarachnoid haemorrhage, 32.9%; acute subdural hematoma; 26.6%, and collapse fracture, 15%. All cranial injuries except linear fractures were associated with high mortality (p<0.05). Epidural hematoma is associated with high mortality. Aetiology, Glasgow Coma Scale score, cranial pathology, age, and additional trauma are the major predictive mortality-associated factors.

Duret Hemorrhage after Extradural Hematoma Evacuation–A Rare Entity

Traumatic brainstem injury can be classified as primary or secondary. Secondary brainstem hemorrhage that evolves from raised intracranial pressure (ICP) and transtentorial herniation is referred to as Duret hemorrhage. We report a 25-year-old male who underwent emergency craniotomy, with evacuation of acute epidural hematoma, and postoperatively developed fatal Duret hemorrhage. Duret hemorrhage after acute epidural hematoma (EDH) evacuation is a very rare complication and the outcome is grave in most of the cases.

Distant large acute epidural hematoma after closed cerebrospinal fluid tapping through the anterior fontanelle: A case report and its pathogenesis

Background: Cerebrospinal fluid (CSF) infection is one of the most common and serious complications of shunt placement. The CSF shunt infections are preferably treated with intravenous antibiotics, infected shunt removal, repeated tapping (infants) or placement of an external ventricular drainage (EVD) device, and placement of a new shunt once the CSF is sterile. The tapping through the anterior fontanelle is commonly used instead of the EVD in developing countries to manage CSF infection in open anterior fontanelle patients. To the best of our knowledge, this would be considered the first reported case of distant epidural hematoma after closed ventricular tapping. Case Description: We report a case of 6-months child with Chiari malformation (Type II) presenting to us with a shunt infection with possible obstruction. CSF was aspirated for examination through a tap through the anterior fontanelle followed by the development of extradural hemorrhage far from the tapping site. Conclusion: EDH after a transfontanellar ventricular tap can rapidly evolve and lead to patient death. This report raises the awareness of the neurosurgeons to this possible complication that can happen and leads to major complications. Monitoring the conscious level would be needed after ventricular tapping to detect this possible complication.