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Within a group of 315 epidural haematomas treated surgically 8 (2.5%) were located within the midline or at the vertex. The clinical symptoms may be small in frontally located haematomas. Paraparesis is caused by a haematoma localized at the vertex. The latter may be misinterpreted as a spinal trauma. The recognition of the hyperdense blood within the last slices of normal CT scans needs experience. It has been misinterpreted as hyperostosis of the skull. We present a group of eight personal cases. The sagittal skull suture was fractured in seven patients. One patient already had an 11-month history. Four cases were primary and had not been recognized. The prognosis depends on concomitant primary brain injuries. Early diagnosis with operative treatment given the best chance. Polytraumatized patients with concomitant injuries die. Slowly developing haematomas do not require acute surgery by in experienced surgeons. Sagittal sinus laceration must be treated by experienced neurosurgeons. It can be closed by suturing the dura to the bone with implanted collagen. In subacute cases the stiffness of the dura allows no normalization of the dura position. A dural graft is necessary for repositioning.

In medical services where acute accident patients are encountered, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the Department of Surgery at the University Hospital in Munich, we have been performing neurotraumatological treatment since 1983. We had 162 patients with severe head and brain injuries, 95 intracerebral contusional bleeding, 8 depression fractures, and 3 hygromas. All these patients underwent surgical treatment. Osteoplastic trepanation was performed in 68 patients and osteoclastic trepanation in 65. Further interventions were elevation of the 8 depression fractures and evacuation of the 3 hygromas. Comparison with other investigations in departments of neurosurgical surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1 cured; 2 slightly; 3 severely handicapped; 4 vegetative state; 5 expired). The Traumatic Coma Data Bank (1991) recorded the outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.

A prospective study was performed to analyze the particular injuries of 76 cyclists who required in-patient treatment in our department in 1994. There were 50 male and 26 female cyclists, with a median age of 33 years (range: 4-87 years). The most frequent diagnosis, in 50% (n = 38), was head injury. The series included 63 cyclist (83%) who had not been wearing helmets, and 33 of these sustained a head injury; in the helmet group head injury was found in only 38% (5 out of 13). It is remarkable that more serious head injuries did not occur in the helmet group. In 24 of these 33 head-injured patients (73%) without helmets additional intra- and extracranial diagnoses were made: pathologic EEG in 18 patients (55%), skull fracture in 13 patients (39%), intracerebral haemorrhagic contusion in 4 patients (12%) and an increase in intracerebral pressure (edema) in 3 patients (9%). In contrast to these findings, only 2 of the 5 head-injured patients (40%) in the helmet group showed slight changes in the EEG. In our opinion the bicycle helmet can reduce the incidence and the grade severity of head injuries significantly, particularly as we had 2 deaths in the non-helmet group and none in the helmet group. The use of a bicycle helmet is therefore strongly advocated.

In acute medical service, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the department of surgery of the University Hospital in Munich, we have been performing neurotraumatological treatment since 1982. Within 10 years we saw 138 patients with severe head and brain injury. We had 48 cases of epidural hematoma. 81 of acute subdural hematoma. 84 of intracerebral contusional bleeding, 5 of depression fractures and 3 of hygromas. All these patients underwent surgical treatment. Osteoplastic trepanation was performed in 49 patients and osteoclastic trepanation in 60. Further interventions were elevation of the 5 depression fractures and evacuation of the 3 hygromas. Comparison with other investigations in departments of neurological surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1, cured; 2, slightly handicapped; 3 severely handicapped; 4, vegetative state; 5, expired). The Traumatic Coma Data Bank (1991) recorded outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 36%; and our own results were: 1, 24%; 2, 17%; 3, 15%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.