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Purpose The aim of the current study was to investigate the risk factors for post-traumatic epilepsy (PTE) in a large cohort of patients after severe non-penetrating civilian traumatic brain injury (TBI). Methods This was a longitudinal study. All patients with a severe non-penetrating TBI, who were admitted at the neuro-intensive care unit of Shahid Rajaee Trauma Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, Iran, from 2015 until 2019, were studied. Severe TBI was defined as a Glasgow Coma Scale-Motor score below six. Post-traumatic epilepsy was defined as any seizures that occurred after being discharged from the hospital. Results In total, 803 patients with severe non-penetrating TBI were studied; 82 patients (10.2%) reported any late post-traumatic seizures (PTSs). A higher Glasgow outcome scale (extended) at discharge was significantly inversely associated with PTE [Odds Ratio (OR)= 0.76, 95% Confidence Interval (CI): 0.65–0.87; p = 0.0001]. Depressed skull fracture (OR= 1.88, 95% CI: 0.92–3.80; p = 0.081), epi‑dural hematoma (OR= 1.67, 95% CI: 0.93–2.97; p = 0.083), and sub-dural hematoma (OR= 1.64, 95% CI: 0.96–2.78; p = 0.068) were associated with PTE as trends. Conclusion Our study adds to the literature on the risk of PTE after severe non-penetrating civilian TBI. Our large sample size and also the application of a logistic regression analysis model may suggest that other variables (e.g., depressed skull fracture and intracranial hematoma) are indeed associated with the Glasgow outcome scale (extended) at discharge and that is why they lost their significance in the model.

A 6-month-old, previously healthy boy hit the right frontal region of his head against the corner of a plastic toy box. At presentation, a small area with scalp discoloration was noted in the right frontal region. Head computed tomography at the level of discoloration revealed an intracranial hematoma, 5 mm in maximal thickness, below the coronal suture. In addition, there were bony bridges connecting the frontal and parietal bones. Furthermore, a linear crack was found in the diploe of the frontal bone in contact with the coronal suture. Cerebral MRI confirmed linear hyperintensity between the inner tables. We assumed that a kind of ping-pong ball fracture was caused by the head blow, centering on the coronal suture, resulting in rupture of contacting diploic channels and tear of the dura mater, and forming a subdural hematoma. Acute subdural hemorrhage may be caused by an insignificant blow to the coronal suture in infantile patients with underdeveloped cranial bones and sutures, accompanied by subtle external findings.

background Intracranial hypotension due to cerebrospinal fluid (CSF) leak is often associated with secondary chronic subdural hematoma (CSDH). Although epidural blood patch (EBP) treatment for the CSF leak site has been reported to result in spontaneous regression of the CSDH in most cases, it is still debatable whether blocking CSF leak first in the patients with intracranial hematoma is always safe. Case Description A 72-year-old woman presented with orthostatic headache after a head injury and was diagnosed with intracranial hypotension. Computed tomography myelography and radioisotope cisternography failed to reveal the CSF leak point. The overflow leak test, a novel diagnostic method for intracranial hypotension, revealed a leakage at the cervical spine. Bilateral CSDHs were also observed by a computed tomography scan of the head. We performed EBP at the cervical spine and anticipated subsequent regression of the CSDH by normalizing intrathecal pressure. However, the patient became delirious the morning after EBP, and an emergency burr hole trepanation was performed. The patient's consciousness fully recovered, and her orthostatic headache improved as well. Conclusions This case presentation demonstrated that in the case of intracranial hypotension with secondary CSDH, performing EBP and waiting for subsequent spontaneous regression of CSDH are not necessarily safe. Immediate burr hole trepanation should be prepared for the subsequent rapid symptomatic change of the CSDH after EBP.

Background and Objective Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. Methods We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. Results There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. Conclusions EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

Ultrasonography (US) has been used as a reliable imaging modality, providing real-time information during neurosurgical operations. One recent innovative US technique, superb microvascular imaging (SMI), visualizes small vessels and flow, which are not detected with standard US with doppler. We apply SMI to intraoperative US monitoring in emergency surgery for intracerebral hemorrhage (ICH). Eleven consecutive patients with ICH underwent endoscopic emergency surgery under US monitoring with SMI. After performing a small craniotomy, US images were obtained using SMI, a fusion technique, and a contrast agent technique, with the probe on the brain surface during surgery. Fusion images were obtained with the probe on the head before craniotomy in some patients. Animated US images with SMI could differentiate hematoma containing no vessels from brain tissue, and flow images using SMI and contrast agent techniques clarified the borderlines. Animated fusion images of intraoperative US and preoperative CT provided information on the extent of hematoma and residual hematoma during emergency surgery. We made various fusion CT images showing intracranial hematoma with US probes and decided on the skin incision line before beginning surgery, as if we were using a neuronavigation system. US with SMI, contrast agent, and fusion techniques provide information on the extent of intracranial hematoma and residual hematoma with no vessels and no flow. Monitoring by US and fusion CT images is useful for ICH surgery as a next-generation neuronavigator.

Background Traumatic intracranial hemorrhaging associated with revascularization surgery for moyamoya vasculopathy is a potentially devastating problem that requires meticulous management, including surgery. However, only a few studies on this subject have been reported, and the clinical characteristics are poorly understood. We report a case of successful surgical management for a patient with traumatic intracranial hematoma managed with encephalo-duro-arterio-myo-synangiosis (EDAMS). The purpose of this article is to clarify the specific features of clinical scenarios, hemorrhagic sites, and operative techniques by reviewing all published cases. Case Description A 10-year-old Japanese girl with a history of EDAMS for quasi-moyamoya disease was referred to our institution after minor head trauma. Cranial computed tomography scans revealed a right intracranial hematoma overlying the temporal muscle flap. After admission, hematoma developed, and emergency hematoma evacuation was performed. Venous hemorrhaging from the fascia of the temporal muscle flap was confirmed. Collaterals from indirect bypass were preserved in the surgery. Postoperative diffusion-weighted imaging revealed no ischemic complications. She immediately recovered and returned to her preinjury baseline. Conclusion In moyamoya vasculopathy, intrinsic collaterals or de novo anastomoses from revascularization surgery are easily injured, even with mild head trauma. Furthermore, the administration of antiplatelets agents increases the risk of hematoma development. Sacrifice of collaterals can lead to acute cerebral infarction. During emergency surgery for traumatic intracranial hematoma, a careful surgical strategy is needed to preserve the collateral supply.

Background Level I trauma centers use patient triaging systems to deploy neurosurgical resources and pursue good outcomes; however, data describing the effectiveness these triage systems are lacking. We reviewed the leveling protocol (cases designated urgent and emergent) of a regional Level I trauma center to obtain epidemiologic data about the efficiency of that system and identify areas for improvement. Methods We retrospectively reviewed leveled neurosurgical cases from January 2015 to October 2017, assessing surgery date, neurosurgical procedure, posted surgical urgency level (levels 1–3, with 1 being most urgent), and post-to-room (PTR) time (i.e., the time between initial leveling and admission of the patient to the operating room). Mean PTR times were compared between case types using one-way analysis of variance with post hoc Tukey honestly significant difference analysis. Results Of 1469 cases, 577 (39.3%) were shunt placement or revision, 231 (15.7%) were craniectomy or craniotomy for hematoma, 147 (10.0%) were craniectomy or craniotomy for tumor, and 514 (35.0%) were for other indications. Among level 1 cases, PTR time was lowest for craniotomies to evacuate intracranial hematoma (mean 16.2 minutes) and highest for spinal decompression procedures and wound washouts (mean 36.2 and 42.4 minutes, respectively). Conclusions To our knowledge, this is the first study of variability in PTR timing as a function of surgical urgency or indication. The most common leveled cases were craniectomies or craniotomies to relieve increased intracranial pressure, which were also the most common level 1 cases. Significant variability occurred within each leveling category; thus, further investigation is required.

OBJECTIVE To enhance students' understanding and imagination and improve teachers' teaching quality through the "Hand As Foot" teaching method. METHODS Teachers explained the hierarchical structure of brain and the location of intracranial hematoma through the "Hand As Foot" teaching method. RESULTS Through the "Hand As Foot" teaching method, students can deeply remember the hierarchical structure of brain and the location of intracranial hematoma. CONCLUSION This novel and unique teaching method makes the interaction between teachers and students stronger and improves the teaching quality.

Objective To report our single-center experience in the treatment of dolichoectatic vertebrobasilar aneurysms. Methods We retrospectively reviewed the data, including clinical features, strategies of managing aneurysms, and follow-up results, of 12 patients who were treated at the Tainjin Huanhu Hospital. Results Of the 12 patients, 1 patient was treated with medication, 4 patients were treated using stent reconstruction, and 7 patients were treated via revascularization (open surgery). The clinical symptoms of the patients who were treated with medication and stent reconstruction were stable. The patients who were treated with revascularization suffered from pneumonia, and 1 patient who presented with intracranial hematoma was treated via a second craniotomy. One patient suffered from new cerebral infraction. Postoperative follow-up from 5 to 67 months indicated that 2 patients (16.7%) had died (modified Rankin Scale [mRS] score of 6), and both were treated with revascularization. Seven patients had mRS scores of 0–2, and the other 3 patients had mRS scores of 4–5. Conclusions If the condition of the patients is stable and benign, they can be treated with medication or stent reconstruction. Given the serious complications that can be caused by open surgery, care must be taken when selecting the patients to be treated using open surgery, but more studies are needed to support this conclusion. The key points are to avoid aneurysm thrombosis and maintain patency of the perforators.

Background Acute subdural hematomas are frequently seen in brain trauma−injured patients. However, spontaneous subdural hematomas are uncommon, especially those localized in the posterior fossa, where fewer than 10 case reports have been described in the medical literature. Case Description We describe a patient who suddenly had a headache and progressed rapidly to coma and signs of brainstem compression. She was diagnosed with posterior fossa subdural hematoma after image examinations that were endorsed by surgical findings. A posterior fossa craniectomy was performed and was associated with blood drainage. Conclusions The patient had a great outcome, with no neurologic deficits at hospital discharge and the 1-year follow-up.

Objective Increased attention has been paid to limiting preoperative hemostatic screening because assessment of patient history can be used as an alternative. However, there may be some clinical pitfalls in overlooking acquired coagulopathies. Here, we present a case of newly diagnosed acquired hemophilia A (AHA) that manifested as a massive intracranial hemorrhage without unexplained bleeding history or abnormal hemostatic results. Case Description A 58-year-old man, who had a history of surgical clipping of an anterior communicating artery aneurysm 30 years ago, experienced subarachnoid hemorrhage because of a ruptured middle cerebral artery aneurysm. He underwent surgical clipping and external decompressive craniectomy; 30 days later, cranioplasty was performed without preoperative hemostatic screening because of his normal coagulation status at the time of a previous surgery. Persistent wound bleeding and epistaxis suddenly began 6 hours after surgery. Computed tomography (CT) revealed a massive intracranial hematoma in the damaged parenchyma, although the patient was asymptomatic. At that time, laboratory tests showed isolated prolonged activated partial thromboplastin time and the presence of factor VIII inhibitor, which confirmed AHA. To manage the bleeding, fresh frozen plasma was transfused for 4 consecutive days, and hemostasis was finally achieved. Thereafter, the laboratory test results were normalized in 5 weeks. The patient's clinical course has been uneventful for 7 months without recurrence of AHA. Conclusions Acquired coagulopathies are relatively rare but life-threatening. Because clinical history is insufficient to predict an acquired coagulopathy, preoperative hemostatic screening should be performed before each neurosurgical procedure.

Background Chronic subdural hematoma (CSDH) is a common intracranial hematoma. The number of patients who undergo anticoagulant therapy including a direct oral anticoagulant (DOAC) is expected to increase. Recently, idarucizumab, the antidote for dabigatran, which is a DOAC, has been developed. We successfully treated CSDH with dabigatran using emergency burr hole surgery and idarucizumab. Case Description A 79-year-old Japanese man severely hit his head and visited the emergency department. Computed tomography (CT) showed tiny traumatic acute subdural hematoma, for which he was admitted. At that time, atrial fibrillation was newly detected, for which dabigatran, having a specific antidote (idarucizumab), was chosen and started 2 weeks after the discharge. Two months after the trauma episode, he revisited the emergency department because of acute left upper and lower limb motor weakness. CT revealed a midline shifted CSDH. Considering rush course of motor weakness and shifted brain, we performed emergency surgery using an antidote for dabigatran, idarucizumab. He was discharged 5 days after surgery without any complications or excessive perioperative hemorrhage. Conclusion Dabigatran should be used for atrial fibrillation detected after head trauma. Emergency surgery can be safely performed for CSDH with dabigatran using idarucizumab.

Background Stroke causes death and disability throughout the world and recurrent stroke events are more likely to be disabling or fatal. We conducted a hospital-based study to investigate the frequency and influence factors of stroke recurrence in China. Methods Data from patients hospitalized with stroke between January 2007 and December 2010 of 109 tertiary hospitals in China were used. Stroke recurrence and associated factors were ascertained. The zero-inflated model was used to evaluate the factors of recurrence. Results Of 101,926 discharged patients, the cumulative 2-year stroke recurrence rate was 3.80% for subarachnoid hemorrhage (SAH), 5.31% for intracerebral hemorrhage (ICH), and 8.71% for ischemic stroke (IS), respectively. Among patients with stroke recurrence, 54.11% with SAH, 60.42% with ICH, and 92.92% with IS relapsed for the same type of the first-onset stroke. For discharged patients with SAH with middle cerebral artery aneurysm clipping or artery aneurysm embolization, it was less likely to stroke relapse, but the times of recurrence would increase if 1 recurrence appeared. Cerebral artery aneurysms and hypertension were risk factors for recurrence frequency. For ICH, protective factors for recurrence were trepanation and drainage of intracranial hematoma, cerebral angiography, puncture and drainage of intracranial hematoma, and length of stay (LOS). But rheumatic heart disease and atrial fibrillation would further the relapse frequency. For IS, age and LOS were protective factors, but recurrence frequency would increase if the first recurrence happened. Cervical spondylopathy, male gender, and diabetes were risk factors for frequency of relapse. Conclusions Associated factors were different for recurrence frequency among different stroke types.

Objective Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score. Methods Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome. Results Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels. Conclusions The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

Objective Ruptured middle cerebral artery (MCA) aneurysms usually lead to subarachnoid hemorrhage (SAH), and several cases have shown concomitant intrasylvian or intracerebral hematomas. The objective of this study was to compare the clinical and radiographic characteristics with their different outcomes. Methods The charts of 30 consecutive patients with ruptured MCA aneurysm-related intracranial hematoma were retrospectively reviewed. These patients were dichotomized into an intrasylvian hematoma (ISH) group and an intracerebral hematoma (ICH) group by the presence of intrahematomal contrast-enhancing vessel; for patients under open surgery, hematoma type was further confirmed by intraoperative observation. The characteristics were compared between these 2 groups (ie, age, gender, history of hypertension, history of smoking, systolic pressure at admission, hematoma volume, size and side of aneurysms, the angle between the pointing direction of the aneurysm and the MCA trunk [denoted as α], middle line shifting, treatment modality, and outcome). All the angles are measured in the anterior-posterior projection. Results In our series, only hematoma volume, the angle α, and the middle line shift showed statistical significance regarding prognosis between 2 hematoma groups. An angle α between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range indicates ICH. In our series, patients in the ICH group had a larger hematoma volume compared with the ISH patients (33.3 ± 17.6 vs. 11.5 ± 10.5; P = 0.002). There exists no statistical difference regarding prognosis between these 2 groups, even although there is a trend toward worse recovery for patients in the ISH group (Glasgow Outcome Scale score, 3.0 ± 1.3 vs. 3.8 ± 1.9; P = 0.07). Conclusions In our series, the prognosis of patients with ICH was worse than that of patients with ISH. Early discrimination of these 2 types of hematoma helps to predict future outcome; an angle (between the pointing direction of aneurysm and the MCA trunk) between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range suggests ICH.

Highlights • Remote intracranial hemorrhage (RICH) in patients during spinal surgery is rare. • Our case was a man with subarachnoid hemorrhage due to cervical spinal surgery. • The pathomechanism leading to RICH is probably due to rapid leak of CSF. • Treatment for RICH depends on the size of hematoma and symptoms., Introduction The incidence of remote intracranial hemorrhage (RICH) in patients during spinal surgery is rare and the detailed mechanism remains unclear. Presentation of case A 55-year-old man had undergone cervical discectomy and fusion at C5–6 and C6–7 due to herniated disc and secondary spinal canal stenosis. He had severe headache 20 h postoperatively and his drain output increased from 100 to 350 mL in the second 10 h after surgery. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed and he was diagnosed with acute subarachnoid hemorrhage in the ventral medulla oblongata. The drainage tube was quickly removed. Infusion of hypertonic saline was used to reduce intracranial pressure and nimodipine prevented vasospasm around the brainstem. The patient made a gradual, satisfactory recovery with conservative treatment. Discussion The most likely pathomechanism leading to RICH is venous bleeding due to rapid leak of a large amount of cerebral spinal fluid (CSF) after spinal surgery. If the patient has a headache or neurological complaints after spinal surgery, immediate imaging is recommended to confirm the diagnosis. Treatment depends on the amount and location of intracranial hemorrhage. Conclusion RICH is a serious but rare complication of spinal surgery and cerebellar hemorrhage is the most common. The most important pathomechanism leading to RICH after spinal surgery is venous bleeding due to rapid leak of a large amount of CSF. Timely CT is necessary to exclude RICH. Treatment of RICH depends on the size of the intracranial hematoma and the patient’s symptoms.

Objectives intracranial pressure (ICP) monitoring has now been a standard technique for the treatment of severe traumatic brain injury (sTBI), while the effect of ICP monitoring for moderate traumatic brain injury (mTBI) is not clear. Moreover, evidence comparing the two types of ICP monitoring: ventricular drainage (VD) catheter and intraparenchymal (IP) catheter is scarce. Patients and methods 91 patients with mTBI were reviewed retrospectively. They were divided into VD, IP and Non-ICP group. Baseline parameters were recorded. The clinical outcome was reflected by Glasgow Outcome Scale (GOS) and mortality at discharge and six months after injury. The rate of surgical decompression, refractory intracranial hypertension, neuroworsening, dose of mannitol and cranial CT were recorded. Meningitis and intracranial hematoma, two major complications of ICP monitoring, were also collected. Results the three groups showed no significant difference in GOS at discharge and six months after injury. The mortality was similar among the three groups at six months after injury, while the Non-ICP group had the highest mortality at discharge. The Non-ICP group was administered the most mannitol while the VD group was administered the least. The Non-ICP group also received the most cranial CT scans among the three groups. Incidence of meningitis and intracranial hematoma were not significantly different among the VD and IP group. Conclusion use of ICP monitoring could hardly improve the functional outcome of mTBI, but may possibly reduce the in-hospital mortality. By using ICP monitoring, the dose of mannitol and cranial CT scan for mTBI patients may be decreased.

Background Cranioplasty is considered as a routine procedure in everyday neurosurgical practice for the patient with cranial defect, however, there is no established consensus on optimal surgical timing. Objective To compare the effect of early cranioplasty (1–3 months after DC) and late cranioplasty (3–6 months after DC) on the complications and recovery of neurological function in the management of patients who received decompressive craniotomy. Methods In this paper, the authors report a systematic review and meta-analysis of operative time, complications and neurological function outcomes on different timing of cranioplasty. Randomized or non-randomized controlled trials of early cranioplasty and late cranioplasty surgery were considered for inclusion. Results Nine published reports of eligible studies involving 1209 participants meet the inclusion criteria. Compared with late cranioplasty, early cranioplasty had no significant difference in overall complications [RR=1.14, 95%CI (0.83, 1.55), p >0.05], infection rates [RR=0.87, 95%CI (0.47, 1.61), p >0.05], intracranial hematoma [RR=1.09, 95%CI (0.53, 2.25), p >0.05]; subdural fluid collection [RR=0.47, 95%CI (0.15, 1.41), p >0.05]. However, early CP significantly reduced the duration of cranioplasty [mean difference=−13.46, 95%CI (−21.26, 5.67), p p Conclusion Early CP can only reduce the duration of operation, but cannot reduce the complications of patients and even increase the risk of hydrocephalus. More evidence from advanced multi-center studies is needed to provide illumination for the timing selection of CP surgery.

Intracranial electroencephalographic monitoring with subdural and/or depth electrodes is widely used for the surgical localization of epileptic foci in patients with intractable partial epilepsy; however, data on safety and surgical outcome with this technique are still inadequate. The aims of this study were to assess the morbidity of intracranial recordings and the surgical outcomes in epileptic children. We retrospectively reviewed the clinical data for 137 children with epilepsy (mean age at implantation: 12.6 ± 3.8 years) who underwent intracranial monitoring with the implantation of strip or grid subdural electrodes and/or intracerebral depth electrodes from September 2004 to September 2011 at a tertiary epilepsy center in China. Complications were classified using five grades of severity (including mortality) and were further classified as either minor or severe. Outcome was classified according to Engel's classification. Regression analysis was performed to identify risk factors for complications. The mean duration of implantation was 5.3 ± 1.3 days. Among the 133 patients who underwent resection, 65 (48.9%) were seizure free (Engel Class I) at last known follow-up, which was >2 years after surgery for all patients. Also, 31 (23.3%) patients had a significant reduction in seizures (Engel Class II). Complications of any type were documented in 29 (21.7%) patients; 15 of these patients had intracranial hematoma. The results of multivariate analysis showed that the only independent risk factor for intracranial hematoma was number of electrode contacts. The most common pathologic diagnosis was focal cortical dysplasia (n=58). Our results showed that intracranial electroencephalographic monitoring in children provides good surgical outcomes and the level of risk is acceptable. When using this technique strategies such as using as few electrode contacts as possible should be adopted to minimize the risk of intracranial hematoma.

A 79-year-old lean man with a height of 157cm and weight of 42kg (body mass index, 17.2kg/m(2)) receiving rivaroxaban developed an intracranial subdural hematoma and was treated conservatively. Because he had a reduced creatinine clearance of 44mL/min, his dosage of rivaroxaban was reduced from 15 to 10mg daily according to official Japanese prescribing information. However, he developed bilateral intracranial subdural hematomas 2weeks later. Plasma rivaroxaban concentration on anti-factor Xa chromogenic assay was elevated at 301ng/mL, suggesting excessive accumulation. He underwent burr hole drainage and resumed anticoagulation with warfarin. Subsequently, he developed a lumbosacral hematoma. He was treated conservatively and discharged without neurological sequelae. The main cause of the increased concentration of rivaroxaban was believed to be his older age and low body weight. The etiology of the spinal hematoma was suspected to be the migration of intracranial hematoma to the spinal subdural space.

Ventriculo-peritoneal shunt (VPS) continues to remain the main diverted method to drain the cerebrospinal fluid (CSF) from the ventricles to the peritoneal cavity. It has some complications that must be managed promptly to avoid any eventual fatal evolution. The association of delayed intracerebral and subdural hematomas after VPS insertion is a very rare complication and has, to our knowledge, never previously been reported in the literature. We report a very uncommon association of this entity occurring 11months after a shunt placement in a 13-year-old boy and discuss the likely pathogenesis, as well as the clinical and the radiological data.

The intracerebral hemorrhage in pregnancy is a rare event, but can have catastrophic consequences for both mother and fetus. The management of non-ruptured arteriovenous malformations in pregnancy is not free of controversy in the current literature, as there is the possibility of spontaneous bleeding and becoming a true emergency. We report the case of a pregnant patient of 35 weeks with a diagnosis of a cerebral arteriovenous malformation, who developed a sudden onset of headache, generalized tonic-clonic seizures, loss of consciousness, and hemiparesis with radiological images of an intracranial hematoma with a mass effect, and signs of herniation. The multidisciplinary management is discussed, emphasizing perioperative cesarean approach plus craniotomy and drainage of the hematoma, and subsequent management in intensive care, and definitive management by neuroradiology, with a successful outcome.

This study aimed to elucidate the surgical experience of medullary hemangioblastoma (MH) at a single institution. We reviewed 34 consecutive patients with MH operated on between January 2005 and June 2012 in the neurosurgery department of the Beijing Tiantan Hospital. There were 14 men and 20 women. The patients were aged from 17 to 60 years with an average age of 38 years. Tumors were cystic in 12 patients (Type A), and solid in 22 patients. The solid tumors were of a small size in six patients (3 cm, Type B), large in 12 (3.1-5 cm, Type C), and giant in four (5 cm, Type D). Radical tumor removal was achieved in all patients. Tracheotomy was performed in 10 patients (one Type B patient, seven Type C, two Type D) postoperatively. Pneumonia secondary to lower cranial nerve palsy occurred in six patients (all Type C). Complications including intracranial infection (n=5), gastrointestinal bleeding (n=2), and intracranial hematoma (n=1) also occurred in this group. Follow-up (range, 2-82 months; mean, 30 months) was available in all patients. At follow-up, 29 patients (85.3%) had a good outcome. Twenty-eight of these (82.4%) had an excellent outcome postoperatively (Karnofsky Performance Status ⩾ 80). Although transient surgical complications are possible especially for large solid tumors, total surgical resection can be performed with favorable long-term outcomes with meticulous microsurgical technique and understanding of the vascular pattern of the tumor. Postoperative management of MH is as important as the operation.

Purpose To assess the role of MRI DWI in detection and characterization of ICH. Patients and methods 61 patients with intracranial hemorrhage who underwent MRI (including DWI, ADC, and GRE) and CT were retrospectively included in this study. MRI DWIs were analyzed for age, type, (primary parenchymal hemorrhage or hemorrhagic lesion) and location of the hemorrhage. The results were compared with conventional MRI sequences, GRE, and CT to assess the diagnostic accuracy of DWI in assessment of patients with intracranial hematoma. Results We had 61 patients with intracranial hemorrhage, six cases were missed by DWI. MRI DWI was accurate for the detection of hyperacute, medium, large sized acute, early and late sub acute, subdural, hemorrhagic components of arterial and venous infarction, intraventricular hemorrhage. DWI showed low sensitivity in detection of subarachnoid and small intraparenchymal hemorrhage The ADC measurements in hyperacute, acute, early and late subacute hematoma were statistically equivalent and were significantly less than the late subacute hematoma as well as the contralateral white matter. Conclusion MRI DWI was accurate in detection, characterization and staging hyperacute, acute, subacute hemorrhage as well as hemorrhagic components of arterial and venous infarctions and of low diagnostic accuracy in subarachnoid and small parenchymal hemorrhage.

Extrahepatic biliary atresia (EHBA) is a rare disease characterized by progressive and obliterative cholangiopathy in infants and is one of the major causes of secondary vitamin K deficiency bleeding (VKDB) due to cholestasis-induced fat malabsorption. Breast feeding increases the tendency of bleeding in EHBA patients because breast milk contains low amounts of vitamin K. A 2-month-old female infant unexpectedly died, with symptoms of vomiting and jaundice prior to death. She had been born by uncomplicated vaginal delivery and exhibited normal growth and development with breastfeeding. There was no history of trauma. She received vitamin K prophylaxis orally. In an emergency hospital, a CT scan showed a right intracranial hematoma and mass effect with midline shift to the left. In the postmortem examination, severe atresia was observed in the whole extrahepatic bile duct. Histologically, cholestasis, periductal fibrosis, and distorted bile ductules were noted. The gallbladder was not identified. A subdural hematoma and cerebellar tonsillar herniation were found; however, no traumatic injury in any part of the body was observed. Together, these findings suggest that the subdural hemorrhage was caused by secondary vitamin K deficiency resulting from a combination of cholestasis-induced fat malabsorption and breastfeeding. Subdural hemorrhage by secondary VKDB sometimes occurs even when vitamin K prophylaxis is continued. This case demonstrated that intrinsic factors, such as secondary VKDB (e.g., EHBA, neonatal hepatitis, chronic diarrhea), should also be considered in infant autopsy cases presenting with subdural hemorrhage.

Background The administration of epinephrine by the intramuscular route can be life-saving in cases of anaphylaxis or severe allergic reactions. However, the use of this drug can lead to a rapid rise in blood pressure, which theoretically could lead to deleterious effects in patients of any age, with elderly patients at greatest risk. Objectives To present a rare case of intracranial hemorrhage potentially resulting from the administration of intramuscular epinephrine in an elderly patient with an allergic reaction. Case Report We present a case report of a 65-year-old woman who developed an intracranial hemorrhage after a single, therapeutic, intramuscular dose of epinephrine for a wasp sting to the tongue. The patient underwent successful craniotomy with evacuation of the intracranial hematoma. Conclusions In circumstances where the severity of the allergic reaction remains unclear (lack of airway compromise, cardiovascular collapse, or true anaphylaxis), careful consideration of the potential risks of intramuscular epinephrine, such as a rapid rise in blood pressure leading to intracranial hemorrhage, should be undertaken when using this medication in elderly patients.

Background Head injury is a critical public health problem responsible for up to 50% of fatalities among trauma patients and for a large component of continuing care among survivors. Intracranial hematomas are among the most common clinical entities encountered by any neurosurgical service and have a very high mortality rate and extremely poor prognosis among traumatic brain injuries. Objective The purpose of this study was to investigate reliable factors influencing the functional outcome of the patients with traumatic intracranial hematomas (ICHs). Methods A retrospective analysis was conducted of consecutive patients presenting at the Kenyatta National Hospital between January 2000 and December 2009. Following ethical approval, the records of patients admitted to the neurosurgical unit and diagnosed with traumatic ICH were retrieved and reviewed. The outcome measure was the Glasgow Outcome Scale (GOS) score at discharge. Data were collected in preformed questionnaires, and the coding and analysis were carried out using SPSS, version 11.5. Results Of the 608 patients diagnosed with intracranial hematomas during the study period, there was a clear male predominance, with 89.3% male and 10.7% female patients. Majority of the patients (49%) were aged between 26 and 45 years, whereas 5.6% and 9.4% were younger than age 13 years and older than age 61 years, respectively. The most common cause of injury was assault (48%). Good functional recovery was achieved by 280 (46.1%) of the patients in our series, whereas moderate and severe disability accounted for 27% and 6.9%, respectively. Males were more likely to have functional recovery (46.4%) than were females (43.1%), though this finding was not statistically significant (P = 0.069). The proportion of patients who achieved functional recovery seemed to decrease with increasing age. Patients who were involved in motor vehicle accidents were less likely to have functional recovery (33.7%, P = 0.003) than those who fell (53.6%). There was a statistically significant difference in the proportion of patients who achieved functional recovery, with 65.2% of those who had mild head injury as compared to 46% and 15.1% (P ≤ 0.001) for those with moderate and severe head injury, respectively. Patients who had surgical intervention were more likely to achieve functional outcome (51.2%) as compared to 31.7% in those managed conservatively. Furthermore, the time elapsed from initial trauma to surgery significantly influenced outcome. The type of surgery done was not found to significantly influence patient outcome (P = 0.095). Conclusion An increased risk of poor outcome occurs in patients who are older than age 61 years, have lower preoperative GCS scores, pupillary abnormalities, and a long interval between trauma and decompression. The findings would help clinicians determine management criteria and improve survival.

p f c n t d t n n T he treatment of giant and complex aneurysms often involves redirection of flow and removal of the aneurysm from circulation. In their study, Zhu et al. review their xperience with complex internal carotid aneurysms and reorted outcomes for patients treated with parent vessel occluion (PVO) alone or with intracranial bypass. Zhu et al. retrospecively reviewed their experience in treating 49 patients with omplex aneurysms over a 7-year period. The investigators used n institutionally standardized protocol of balloon-test occlusion BTO) with computed tomographic perfusion to evaluate the eed for extracranial-intracranial bypass before deconstructive arent vessel occlusion (PVO). With a follow-up range of 5 to 12 onths, 10 patients “passed” BTO and underwent direct interal carotid artery (ICA) sacrifice with no ischemic-related compliations; 39 patients underwent bypass after “failing” BTO, with follow-up range of 3 to 64 months. Graft patency was high 90.7% of all bypasses). In the bypass group, complications ncluded 5 occurrences of minor hemispheric ischemia, from hich all but 1 recovered, 1 intracranial hematoma requiring vacuation, and 4 episodes of graft occlusion. Overall Glasgow utcome Scale values were high; 74% achieved a score of 5 at ast follow-up.

To report a series of patients with aneurysmal subarachnoid hemorrhage (SAH) and associated intracranial hematoma (ICH) who underwent coiling of the aneurysm followed immediately by open surgical decompression with evacuation of the hematoma.With the hypothesis that aneurysm coiling before hematoma evacuation may simplify surgery, prospectively collected data at two neurovascular institutions were retrospectively reviewed. Patients with aneurysmal SAH and associated ICH who underwent combined endovascular and open surgery were identified; only cases of coiling before open surgery were analyzed. Relevant information was collected from medical records and imaging studies for analysis. The Glasgow Outcome Scale (GOS) was used to evaluate clinical outcome.There were 30 patients who were treated with endovascular obliteration of aneurysms followed by surgical decompression (9 men and 21 women; mean age 50 years). Patients presented with Hunt and Hess (HH) grade 3 or higher except for one patient who presented initially with grade 1 and deteriorated to grade 5 after rerupture and before treatment. At discharge, GOS scores were as follows: 1 in 5 patients, 2 in 1 patient, 3 in 22 patients, and 4 in 2 patients. At a mean follow-up of 18 months (range 3-60 months), 28 patients had an outcome that could be evaluated, and GOS scores were as follows: 1 in 6 patients, 3 in 5 patients, 4 in 8 patients, and 5 in 9 patients. One patient required retreatment for aneurysm recurrence; no patient had aneurysm rerupture.In selected patients with aneurysmal SAH and associated ICH, reasonable outcomes can be achieved using aggressive control of intracranial pressure (ICP) with combined endovascular and open surgical techniques. Endovascular aneurysm obliteration before surgical decompression represents a paradigm in the management of ruptured aneurysms associated with ICH and can transform surgery to a simple decompression. In expert hands, consecutive procedures can be performed rapidly with 60.7% of patients having a favorable outcome (GOS score of 4 or 5) and becoming independent.

Physicians evaluate computed tomography (CT) of the brain to quantitatively and qualitatively identify various types of intracranial hematomas for patients with neurological emergencies. We propose a novel method that can perform this task in a totally automatic fashion, based on a multiresolution binary level set method. The skull regions are segmented in downsized images generated with a maximum filter. The intracranial regions are located using the average gray levels and connectivity. These regions compose the regions of interest (ROIs) for segmenting the hematoma from the normal brain. The gray levels of the voxels within these ROIs are generated with an averaging filter in a multiresolution fashion. After identifying the candidate hematoma voxels using adaptive thresholds and connectivity, binary level set algorithm is applied repeatedly until the original resolution is reached. We apply our method to non-volumetric non-contrast CT images of 15 surgically proven intracranial hematomas and the results were quantitatively evaluated by a human expert. The correlation coefficient between the volumes measured manually and automatically is 0.97. The overlap metrics ranged from 0.97 to 0.74, with an average of 0.88. The average precision and recall are 0.89 and 0.87, respectively. We use decision rules to classify these hematomas and were able to make correct diagnoses in all cases.

We studied the effect of stereotactic surgery in cases of alcohol dependence. Twelve patients with a psychological dependence on alcohol (treated systematically with medication for detoxification 3–8 times in various rehabilitation centers before, but had relapsed within 2 weeks after withdrawal) were treated by ablating the nucleus accumbens (NA C ) bilaterally using stereotactic surgery. The therapeutic effect and safety evaluation index of the surgery were analyzed. The timing of the conducted evaluations was preoperatively and in the sixth postoperative month. Currently, relapse has not occurred in 9 cases. Relapse occurred in 3 cases after surgery. The prevalence of relapse was 16.7% within 6 months, and 25% within 12 months. Non-specific complications of this type of surgery (e.g., intracranial hematoma, infection) were not observed. One case in 12 patients suffered dysosmia, but he recovered completely 4 months later after surgery. The full-scale intelligence quotient (FSIQ) and memory quotient (MQ) of these patients were significantly improved 6 months postoperatively compared with preoperatively. The severity of alcohol dependence scale and a scale measuring alcohol craving in these patients were significantly decreased. There were also significant changes over time in the Minnesota multiphasic personality inventory (MMPI) profile, suggesting a decrease in depression, irritability, and psychopathy. Ablating specified targets (NA C ) using stereotactic surgery is a safe method to alleviate alcohol craving, reduce relapse rates and improve quality-of-life in patients with psychological dependence on alcohol.

314 cases of combined cerebro-cranial trauma and posttraumatic intracranial hematomas were identified of which ethanol was detected in 114 hematomas. The other investigative group was 103 hospitalized patients who had hematomas evacuated during neurosurgical procedures. In 62 of these cases ethanol was detected. Blood and urine samples were also collected and the alcohol concentration was determined in all specimens by GC and ADH. The ethanol elimination rate for autopsy and operative intracranial hematomas was approximately 0.07–0.08‰/h(±0.034‰/h). The elimination rate of ethanol from blood (β60) was about two or three times greater as that from hematomas. Because of the different water content of intracranial hematomas from blood, it was necessary to adjust the ethanol concentration for water content. On the basis of the corrected ethanol concentrations and the elimination rates for both tissues it was possible to estimate the ethanol concentration at the time of injury. Intracranial hematomas are tissues of possible value in the determination of alcohol intoxication especially in alcoholism. Ethanol can be found in hematomas even after 72 h from head injury.

Danhong Injection (DHI), a Chinese Materia Medica standardized product extracted from Radix Salviae Miltiorrhizae and Flos Carthami tinctorii, has the actions of promoting blood circulation and resolving stasis to promote regeneration. The clinical therapeutic effects of DHI on traumatic intracranial hematoma (TICH) were observed. Eighty patients with TICH were randomly assigned to trial group and a control group (40 patients per group), and all were administered with routine medication. Additionally, DIH was administered intravenously to patients in the trial group. Pre and post-treatment GCS was observed in the two groups, along with GOS after therapy. The intracranial hematoma absorption, hemorheological changes, and changes in coagulation indexes pre- and post-treatment were evaluated. The results indicated that GCS and GOS after therapy for the trial group were superior to those for the control group (p

Background Left ventricular assist devices (LVADs) are increasingly used as bridges to transplantation or as destination therapy. As sicker and older patients are more frequently considered for mechanical support, general surgical problems are expected to increase in these patients. Methods Anesthesia records and clinical charts were reviewed for 11 recipients of LVADs undergoing 12 general surgical procedures between January 1988 and March 2007. Results Eight patients underwent major surgical procedures: 1 intracranial hematoma drainage, 1 right hemicolectomy with ileocolostomy, 1 splenectomy, 1 surgical repair of an iliac-femoral artery pseudoaneurysm, 2 cholecystectomies, 1 pyelolithotomy, and 1 coil embolization of a femoral side-branch disruption. Four patients underwent minor surgical procedures. The mean duration of LVAD support before surgery was 58.7 ± 45.6 days. All patients survived the procedures. Conclusion Noncardiac surgery in LVAD recipients is feasible, without significant morbidity or mortality. Intraoperative coagulation management has a key role in safely performing these procedures.

We report a case of spontaneous subdural haematoma due to ruptured intracranial infectious aneurysm, presenting with bilingual aphasia and illustrating differential language recovery. A 62-year-old right-handed bilingual gentleman, with a diagnosis of infective endocarditis, developed headache and became expressively aphasic in the English language. Three days later he was receptively and expressively aphasic in both English and Arabic. Cranial MRI scans showed a left-sided acute subdural haematoma with mass effect and midline shift. Contrast CT brain scans showed an enhancing speck adjacent to the clot and cerebral angiogram confirmed a distal middle cerebral artery aneurysm. He underwent image-guided craniotomy, evacuation of the subdural haematoma and excision of the aneurysm. Histopathological examination was consistent with an infectious intracranial aneurysm. Postoperatively his aphasia did not improve immediately. He had widened pulse pressure due to severe aortic regurgitation, confirmed on echocardiography. He underwent aortic valve replacement and mitral valve repair, following which his aphasia recovered gradually. Initially the recovery of his language was limited to Arabic. About a week later he recovered his English language as well. At 3-year follow-up he is doing well and has no neurological deficits. His aphasia has recovered completely. The present case is unique because of (a) presence of pure subdural haematoma, and (b) the differential susceptibility and recovery of native (L1) and acquired language (L2) in presence of a common pathology. The neurology of language in a bilingual is analysed and possible mechanisms discussed.

ObjectiveTo investigate the role of large decompressive craniectomy (LDC) in the management of severe and very severe traumatic brain injury (TBI) and compare it with routine decompressive craniectomy (RDC).MethodsThe clinical data of 263 patients with severe TBI (GCS≤8) treated by either LDC or RDC in our department were studied retrospectively in this article. One hundred and thirty-five patients with severe TBI, including 54 patients with very severe TBI (GCS≤5), underwent LDC (LDC group). The other 128 patients with severe TBI, including 49 patients with very severe TBI, underwent RDC (RDC group). The treatment outcome and postoperative complications of the two treatment methods were compared and analyzed in a 6-month follow-up period.ResultsNinety-six patients (71.7%) obtained satisfactory treatment outcome in the LDC group, while only 75 cases (58.6%) obtained satisfactory outcome in the RDC group (P

Background and purpose Lumbar puncture is a common procedure highly contributive to neurological diagnosis. It can also cause serious adverse side effects including subdural hematoma and intracranial hypotension as illustrated by this case report. Case report A 38-year-old women presented severe intracranial hypotension after a lumbar puncture. Magnetic resonance imaging was compatible with intracranial hypotension and revealed an acute subdural hematoma with midline deviation. A first blood patch was unsuccessful. Symptom relief was achieved with a second patch. The patient was, then, discharged but developed recurrent headache subsequent to the transformation from acute to chronic subdural hematoma. Surgical drainage was required. The postoperative imaging and physical examination returned to normal and the patient was discharged with no recurrence. Conclusion The serious adverse effects of lumbar puncture is an easy and common medical procedure that must be kept in mind.

Objective To analyze the occurrence and outcome of new-onset stroke in critically ill patients admitted to a medical intensive-care unit. Material and Methods We reviewed the medical records of patients admitted to the medical intensive-care units of two hospitals between 1985 and 1995. In addition, computed tomographic scans or scan reports were assessed. Results We identified 19 patients with a critical medical illness and a new-onset stroke. Of this study group, ischemic stroke developed in 10 patients, 8 of whom were found to have bihemispheric infarction. A single territory infarct (the middle cerebral artery territory) was noted in two patients. The presumed mechanisms for ischemic stroke were disseminated intravascular coagulation (N = 6), cholesterol embolization (N = 1), discontinuation of warfarin therapy before an invasive procedure (N = 1), septic emboli (N = 1), and cardioversion (N = 1). In nine patients, an intracranial hemorrhage developed. Seven patients had a single lobar hematoma, whereas multiple intracerebral hematomas were found in two patients. Disseminated intravascular coagulation and rupture of a mycotic aneurysm in proven infective endocarditis were the most common mechanisms for hemorrhagic stroke. In all patients with an ischemic stroke, sudden hemiparesis rapidly progressed to coma. In patients with an intracranial hematoma and sudden onset of coma, unilateral fixed pupil was the most common initial manifestation. Of the 19 patients, 17 died and 2 remained severely disabled. Conclusion Coma is a common initial manifestation of stroke in patients with a critical medical illness,. and disseminated intravascular coagulation has a major etiologic role. New-onset stroke in the setting of critical medical illness generally is a complication in a terminally ill patient.

This article reviews the diagnosis and management of athletic-related head injury. Cerebral concussion, diffuse axonal injury, brain contusion, and the spectrum of intracranial hematoma is discussed. Emphasis is placed on the need to evaluate when it is prevented from further participation.

Background The management of head-injured patients admitted to emergency departments is not standardized. Methods The authors performed a retrospective analysis of 10,000 head-injured patients admitted to the Emergency Department of our hospital in a 21-month period and, on the basis of a statistical correlation between each clinical parameter (symptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse or radiologic examinations and yet identify patients with possible life-threatening complications. Results On the basis of this correlation the patients have been divided into four groups. In the first group (called group alpha) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They can be released into the care of relatives who are given a special instruction sheet (X rays unnecessary). No patient in group alpha had complications of any kind. The second group (group beta) is made up of patients with at least one of the following features: transient loss of consciousness, post-traumatic amnesia, a single episode of vomiting or significant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is needed. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be performed promptly. No patient in group beta with normal skull X rays developed intracranial lesions. The third group (group gamma) contains patients with at least one of the following symptoms: impaired consciousness, repeated episodes of vomiting, neurologic deficits, otorrhagia, otorrhea, rhinorrea, signs of basal skull fracture, seizures, penetrating or perforating wounds, lack of cooperation for varying reasons, patients who have undergone previous intracranial operations or been affected by coagulopathy or submitted to anticoagulant therapy, and finally, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group gamma with GCS = 15 upon admission were operated on for intracranial hematoma. The fourth group (group delta) is composed of comatose patients. Immediately following resuscitation maneuvers and prior to any surgical intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated. Conclusions The present protocol stresses the importance of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries.

To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury.This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator.Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P.0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%.There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.

Patients who "talk and deteriorate" are defined as those who utter recognizable words at some time after head injury and then deteriorate to a severe head-injured condition (Glasgow Coma Scale score of 8 or less) within 48 hours of injury. They represent a very small but important subgroup of patients with brain injury. In approximately 75% of these patients, the cause of this deterioration is intracranial hematoma. Despite the fact that talking indicates nonlethal impact brain injury, deterioration is a marker of poor prognosis. Outcome depends on early recognition of deterioration and rapid removal of mass lesions. The challenge for emergency physicians is to distinguish patients at risk for deterioration from the many patients evaluated after head injury.

Introduction: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation. Setting: Academic Level I trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team. Methods: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t -tests ( p = 0.05). Results: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than ground patients. Conclusion: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.

The causes and circumstances of intracerebral hematoma after kidney transplantation have been poorly studied. No data are available on its impact on outcome after a successful renal grafting.We used the Mayo Clinic medical diagnostic index to identify the patients with a diagnosis of intracerebral hematoma among the 1573 patients who received a renal transplant at the Mayo Clinic between 1966 and 1998.Ten intracranial hematomas occurred in 9 patients and were the cause of death in 6 (1%) of the 530 patients known to have died. The interval from renal transplantation to intracranial hematoma ranged from 12 to 114 months (average, 57 months). All patients with intracranial hemorrhage had poorly controlled hypertension. Intracranial hematoma was more frequently and significantly associated with autosomal dominant polycystic kidney disease (4/146 [2.7%]; P.01) and with diabetes mellitus (3/410 [0.7%]; P.01) than with other underlying causes of renal failure (2/1017 [0.2%]).In this preliminary study, the risk of cerebral hemorrhage may have increased 10-fold in patients with autosomal dominant polycystic kidney disease and 4-fold in patients with diabetes mellitus, when compared with the population of patients having other causes of renal failure. Most cerebral hemorrhages were catastrophic and fatal but appeared to be responsible for only 1% of the deaths after renal transplantation.

Intracranial hematoma in pediatric equestrians is rare, notwithstanding the lack of uniform standards and requirements for the use of protective headgear during equestrian events. We report two teenage helmeted equestrians who sustained severe head trauma with intracranial hematoma due to falls during equestrian events. Current recommendations for the use of equestrian headgear are reviewed.