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Extradural haematomas (EDH) occur in approximately 2% of all head injuries but account for a significant proportion of fatal head injuries with mortality rates ranging from 1.2 to 33%. The expeditious surgical evacuation of EDH is associated with an excellent prognosis and is considered the most cost-effective operation performed by neurosurgeons. The Brain Trauma Foundation (BTF) has produced informative guidance on the management of EDH. The criteria laid out for conservative management comprises non-comatose patients with EDH less than 30 cm in volume, less than 15 mm thick and causing less than 5 mm midline shift. The BTF recommends that all patients with an EDH volume of greater than 30 cm(3) should undergo surgical evacuation regardless of Glasgow Coma Scale. This recommendation was based upon early case series and cohort studies from two decades. Within an ageing population, we now see many older patients who may accommodate greater extra-axial blood volumes. With this in mind, we believe the indications for surgical evacuation of EDH merit renewed consideration.

Unlabelled: Cerebrovascular resistance is an important parameter of the microcirculation. The main objective of cerebrovascular resistance is to maintain the constancy of cerebral blood flow and protect downstream vessels when changing perfusion pressure. The purpose of the study was to assess cerebrovascular resistance (CVR) in patients with severe combined traumatic brain injury (CTBI) with and without intracranial hematomas (IHs)., Material and Methods: We analyzed treatment outcomes in 70 patients with severe CTBI (42 males and 28 females). The mean age was 35.5 ± 14.8 years (min 15 years; max 73 years). All patients were divided into 2 groups, depending on the presence of intracranial hemorrhage. The first group included 34 patients without IH, and the second group included 36 patients with epidural (6), subdural (26), and multiple (4) hematomas. The GCS score was 10.4 ± 2.6 in the first group and 10.6 ± 2.8 in the second group. The ISS severity injury score was 32 ± 8 in the first group and 31 ± 11 in the second group. All patients were operated on within the first 3 days, with 30 (83.3%) patients being operated on during the first day. Perfusion computed tomography (PCT) of the brain was performed within 1-14 days after TBI in the first group and within 2-8 days after surgical evacuation of hematoma in the second group. After PCT, the mean arterial pressure was measured, and the blood flow rate in the middle cerebral artery was determined using transcranial dopplerography. Cerebrovascular resistance was calculated using the formula modificated by P. Scheinberg. Comparisons between the groups were performed using the Student t-test and χ² criterion., Results: The mean CVR values in each group (both with and without hematomas) were statistically significantly higher than the mean normal value of this parameter. Intergroup comparison of CVR values demonstrated a statistically significant increase in the CVR level in group 2 on the side of removed hematoma compared to group 1 (p=0.037). CVR in the perifocal zone of removed hematoma remained significantly higher compared to the symmetrical zone of the contralateral hemisphere (p=0.0009)., Conclusion: Cerebrovascular resistance in patients with combined traumatic brain injury is significantly increased compared to the normal value. Cerebrovascular resistance in the perifocal zone after evacuation of hematoma in patients with multiple injury remains significantly increased compared to the symmetrical zone in the contralateral hemisphere.

Peculiarities of clinical course and approaches to surgical treatment were studied in patients, suffering isolated cranio-cerebral trauma (CCT); new approaches were elaborated, permitting to improve outcome of epidural hematoma (EG) in surgical treatment of the patients. For isolated CCT 188 patients there were operated on, EG was revealed in 83 (44.1%) of them. The majority of patients were admitted to the hospital in subcompensated stage of clinical course of CCT. EG occurrs in the injured persons in indented cranial fracture, it is diagnosed by KT of the brain. Unfavorable impact on the surgical treatment results causes admittance to the hospital in a rude decompensation stage, in case of preoperative treatment absence, while diagnostic mistake committ- ment, late conduction of the operation, and admittance to the hospital more than 1 day after the trauma. The intensive therapy conduction postoperatively permits to reduce significantly the rate of cerebral and extracerebral complications.

Traumatic brain injury is the most common cause of death and disability in young people, with an annual financial burden of over $50 billion per year in the United States. Traumatic brain injury is defined by both the initial primary injury and the subsequent secondary injuries. Fundamental to emergency department management is ensuring brain perfusion, oxygenation, and preventing even brief or transient episodes of hypotension, hypoxia, and hypocapnia. Cerebral perfusion pressure is a function of intracranial pressure and systemic blood pressure, and it must be monitored and maintained. Current research is devoted towards the prevention and treatment of secondary injury. The emergency clinician must be vigilant in maintaining homeostasis while coordinating the downstream care of the patient, including the intensive care unit and/or the operating room.

A 15-year-old girl sustained a mild isolated traumatic brain injury  following a pedestrian road traffic accident. She was ventilated for head computed tomography (CT) scan which revealed no intracranial abnormalities. Ventilation was not withdrawn until 15 h later when poor neurological recovery prompted urgent repeat CT, which demonstrated a delayed extradural haemorrhage (EDH). She underwent surgical evacuation, and intracranial pressure (ICP) monitoring was initiated postoperatively. She developed persistently raised ICP resistant to medical therapy, prompting further CT. This showed a recurrence of the delayed EDH requiring further surgical drainage. She made a good neurological recovery. There should be a low threshold for repeat CT to exclude delayed EDH when neurological status is poor despite normal CT soon after initial primary injury. ICP monitoring should be undertaken in children and adolescents who have normal initial CT, but in whom serial neurological assessment is not possible owing to sedation.

Objective: The aim of this study was to identify factors contributing to outcomes after severe traumatic brain injury (TBI) associated with epidural hematoma (EDH)., Methods: Between 02/2002 and 4/2010 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Data sets from patients who had severe TBI (=Glasgow Coma Scale score <9) and EDH were selected. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale (GOS) scores were 5 or 4, and were classified as "unfavorable" if GOS scores were 3 or less. The Rotterdam score was used to classify computed tomography (CT) findings; the scores published by Hukkelhoven et al. (J Neurotrauma 22:1025-1039, 2005) were used to estimate predicted rates of death and of unfavorable outcomes. Univariate (Fisher's exact test, t test, Chi(2)-test) and multivariate (logistic regression) statistics were used to identify factors associated with hospital mortality and favorable outcome., Results: Of the 738 patients with severe TBI 159 (21.5 %) had EDH. Of these, 49 (30.8 %) died in the hospital, 21 (13.2 %) survived with unfavorable outcome, 82 (51.6 %) with favorable outcome; long-term outcome was unknown in 7 survivors (4.4 %). Mortality rates predicted by the Rotterdam score showed good correlation with observed mortality rates. According to the Hukkelhoven scores, observed/predicted ratios for mortality and unfavorable outcome were 0.94 and 0.97, respectively. Age, severity of TBI, and neurological status were the main factors influencing outcomes after severe TBI associated with EDH. We were unable to demonstrate significant effects of treatment factors.

Background: Bilateral traumatic basal ganglia haematoma is an extremely rare event in traumatic brain injuries, with only five reported cases. The presumed mechanism is due to shearing forces leading to haemorrhage from the lenticulostriate or anterior choroidal artery. The prognosis appears to be dependent on the extent and severity of underlying brain injury., Case Study: A case of a 38 year old fully conscious male, who presented with bilateral basal ganglia haematoma and extradural haematoma, is presented and the relevant literature is briefly reviewed.

Epidural hematomas which are located at the vertex are rarely seen and form a small percentage of total epidural hematomas. Tearing in the superior sagittal sinus is the usual cause of an epidural hematoma located in the vertex. The clinical features of this entity are non-specific; hence, localization of the lesion is difficult. We report an adult who was hit by a motorcycle and was initially discharged from the hospital as a case of concussional head injury. He returned back with raised intracranial pressure symptoms, so a CT scan was done but was misinterpreted, and he reported one week later with bilateral abducent nerve palsy. Magnetic resonance imaging confirmed vertex EDH for which he was operated.These hematomas are seen rarely and can be interpreted as an artifact. Its recognition is important because it has an excellent prognosis. We concluded that all head injury patients should get high axial cuts on the CT scan, and any degree of suspicion should prompt a neurosurgeon to investigate further with coronal CT scan or MRI.

Object: Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need., Methods: The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded., Results: During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15., Conclusions: Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.

In this article, the neuroradiological evaluation of traumatic brain injury is reviewed. Different imaging strategies in the assessment of traumatic brain injury are initially discussed, and this is followed by a review of the imaging characteristics of both primary and secondary brain injuries. Computed tomography remains the modality of choice for the initial assessment of acute head injury because it is fast, widely available, and highly accurate in the detection of skull fractures and acute intracranial hemorrhage. Magnetic resonance imaging is recommended for patients with acute traumatic brain injury when the neurological findings are unexplained by computed tomography. Magnetic resonance imaging is also the modality of choice for the evaluation of subacute or chronic traumatic brain injury. Mild traumatic brain injury continues to be difficult to diagnose with current imaging technology. Advanced magnetic resonance techniques, such as diffusion-weighted imaging, magnetic resonance spectroscopy, and magnetization transfer imaging, can improve the identification of traumatic brain injury, especially in the case of mild traumatic brain injury. Further research is needed for other advanced imaging methods such as magnetic source imaging, single photon emission tomography, and positron emission tomography.

Traumatic brain injury (TBI) is still the major cause of death under 45 years of age and an important one for children under 15. Its incidence is 332/100,000 inhabitants. It results from an impact with the skull with/without lesion of the brain but at least a short-term neurological disorder. All other injuries to the skull should be called concussion. The duration of unconsciousness defines the severity of TBI. Patients with TBI should be admitted to a surgical ward. Those retaining consciousness and with GCS scores of 15 might be allowed to go home if under surveillance. With GCS of <15 or with risk factors, TBI requires a CT scan and in-hospital surveillance. Acutely life-threatening, i.e. space-occupying, bleeding must be operated on immediately. Epidural or subdural bleeding, especially in comatose patients, is still a vital risk and thus requires immediate surgery.

Epidural hematomas (EDHs) account for 10% of fatal injuries in patients with head trauma. Up to 35% of patients suffering EDHs develop secondary brain injury within days after the initial trauma. Secondary brain injury can profoundly affect a patient's subsequent neurologic recovery and functional status. This case study presents a patient who developed an EDH following severe head trauma with signs and symptoms of secondary brain injury; intravascular temperature modulation was used to treat the secondary injury for a prolonged period of 13 days. The patient showed a complete neurologic recovery with return to work 6 months after her injury.

Background: Subjects with moderate head injury are a particular challenge for the emergency physician. They represent a heterogeneous population of subjects with large variability in injury severity, clinical course and outcome. We aimed to determine the early predictors of outcome of subjects with moderate head injury admitted to an Emergency Department (ED) of a general hospital linked via telemedicine to the Regional Neurosurgical Centre., Patients and Methods: We reviewed, prospectively, 12,675 subjects attending the ED of a General Hospital between 1999 and 2005 for head injury. A total of 309 cases (2.4%) with an admission Glasgow Coma Scale (GCS) 9-13 were identified as having moderate head injury. The main outcome measure was an unfavourable outcome at 6 months after injury. The predictive value of a model based on main entry variables was evaluated by logistic regression analysis., Findings: 64.7% of subjects had a computed tomographic scan that was positive for intracranial injury, 16.5% needed a neurosurgical intervention, 14.6% had an unfavourable outcome at 6 months (death, permanent vegetative state, permanent severe disability). Six variables (basal skull fracture, subarachnoid haemorrhage, coagulopathy, subdural haematoma, modified Marshall category and GCS) predicted an unfavourable outcome at 6 months. This combination of variables predicts the 6-month outcome with high sensitivity (95.6%) and specificity (86.0%)., Interpretation: A group of selected variables proves highly accurate in the prediction of unfavourable outcome at 6 months, when applied to subjects admitted to an ED of a General Hospital with moderate head injury.

Background: Traumatic EDHs of the posterior cranial fossa are rare and have a higher mortality than supratentorial localizations. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. Active use of cranial CT scanning has taken a major role in the diagnosis, surgical indication, close observation, and strategy planning. As a result, better prognosis is achieved. In this study, we represent our results and experiences in the management of TEHPCF., Methods: Between 1993 and 2006, 65 patients with TEHPCF were treated in Istanbul University Faculty Of Medicine, Neurosurgery and Emergency Surgery Departments. The hospital records of these patients were analyzed retrospectively., Results: Of 65 patients, whose diagnosis and management decisions were determined by cranial CT scans, 53 were treated through surgery and 12 by conservative methods. Of the 53 surgically treated patients, 2 (3%) patients died, and 2 (3%) other patients remained moderately disabled during their discharge. As a result, 61 (94%) of 65 patients had excellent recovery., Conclusion: When compared with the literature, our mortality rate was superior to other previously reported studies. In our opinion, this is a result of extensive use of the cranial CT scan together with aggressive surgery. Patients with occipital trauma should be evaluated using cranial CT scans, and those showing mass effect should be immediately treated surgically. The patients that have no mass effect on CT scans can be closely observed by planned serial control CT scans.

Objective and Importance: Neonatal subgaleal hematomas (SGHs) are infrequent but underdiagnosed collections of blood beneath the galea, often caused by vacuum delivery. With massive bleeding into the subgaleal space, exsanguination and hypovolemic shock can cause death in 20 to 60% of newborn infants. We report the first two known patients with extracranial cerebral compression caused by SGH. Also, the surgical evacuation of neonatal SGH has not been described previously., Clinical Presentation: One patient was a full-term boy who was delivered via vacuum extraction after an uncomplicated pregnancy. Within a few hours, he developed an expanding fluid collection of the scalp and disseminated intravascular coagulation and shock requiring intubation, inotropic support, and blood transfusions. His head circumference grew from 33 cm at birth to 42 cm. He became progressively lethargic and developed posturing movements. Computed tomography of the head revealed a massive SGH causing gross overlapping of the cranial sutures and diffuse cerebral edema. The other patient was a full-term boy delivered via cesarean section after an unsuccessful attempt at vacuum extraction and forceps delivery. The initial head circumference was 34 cm. Within a few hours, he developed an expanding fluid collection of the scalp and became progressively lethargic with posturing. Magnetic resonance imaging of the head revealed a massive SGH with cranial compromise and diffuse cerebral edema., Intervention: Both children had radiographic features indicative of elevated intracranial pressure as well as neurological decompensation. The first patient was taken to the operating room, and the hematoma was evacuated through a small scalp incision. Initially, approximately 150 ml of blood was removed, and a Jackson-Pratt drain diverted another 200 ml of blood during the next 2 days. The infant made a good recovery. In the second case, the patient remained too unstable for operative intervention and died., Conclusion: Extracranial cerebral compression represents another way by which neonatal SGH may jeopardize the infant's life. Management consists of measures to correct hypovolemic shock and disseminated intravascular coagulation, as well as surgical intervention to control elevated intracranial pressure.

The rapid spontaneous resolution of an acute epidural hematoma within a one hour is reported in a 8 year-old boy. The literature is reviewed and the potential communication between intracranial and epicranial spaces through a fracture is emphasized in very rapid spontaneous resolution of epidural hematomas.

Five clinical case studies (1 normal, 3 brain injured and 1 subject who had a left frontal hematoma) are presented which addressed the effectiveness of EEG biofeedback for auditory memory impairment. A normative QEEG activation database of 59 right-handed subjects was developed, which delineated the QEEG variables which were positively related to auditory memory performance (paragraphs). Persons who had experienced a brain injury underwent the same procedure employed in the development of the database. The person's values on the effective parameters of memory functioning were determined. EEG biofeedback interventions were determined by the individual's deviation from the normative reference group in terms of the relevant QEEG parameters of effective auditory memory (paragraph recall). Improvements ranged from 39% subjects who had a follow up assessment that occurred from one month to one year following termination of treatment.

The findings in three children who died as a consequence of shaking and those in another child who survived are presented. In the three fatal cases, a combination of anatomical lesions were identified at autopsy which appear to indicate the sites where kinetic energy related to the shaking episodes had been applied thus enabling the sequence of events resulting in the fatal head injury to be elucidated. Such patterns of injuries involved the upper limb, the shoulder, the brachial nerve plexus and the muscles close to the scapula; hemorrhages were present at the insertions of the sternocleidomastoid muscles due to hyperextension trauma (the so-called periosteal sign) and in the transition zone between the cervical and thoracic spine and extradural hematomas. Characteristic lesions due to traction were also found in the legs. All three children with lethal shaking trauma died from a subdural hematoma only a few hours after the event. The surviving child had persistant hypoxic damage of the brain following on massive cerebral edema. All the children showed a discrepancy between the lack of identifiable external lesions and severe internal ones.

The authors present four cases of acute epidural hematoma (three supratentorial and one in the posterior fossa), in which non-operative treatment was performed. The conditions to undertake this treatment were: good clinical and neurological state of the patients on admission (GCS equal or more than 14), absence or mild focal symptoms and possibility to observe the patients and to perform CT follow-up. All patients had a good recovery. The authors discuss these cases and present the review of the literature concerning the problem.

Object: This study was conducted to determine whether proton magnetic resonance spectroscopy (MRS) is a sensitive method for detecting diffuse axonal injury, which is a primary sequela of traumatic brain injury (TBI). Diffuse axonal injury is characterized by selective damage to white matter tracts that is caused in part by the severe inertial strain created by rotational acceleration and deceleration, which is often associated with motor vehicle accidents. This axonal injury is typically difficult to detect by using conventional imaging techniques because it is microscopic in nature. The splenium was selected because it is a site vulnerable to shearing forces that produce diffuse axonal injury., Methods: The authors used proton MRS to evaluate the splenium, the posterior commissure of the corpus callosum, in normal control volunteers and in patients with TBI. Proton MRS provided an index of neuronal and axonal viability by measuring levels of N-acetyl aspartate (NAA)., Conclusions: A majority of mildly brain injured patients, as well as those more severely injured, showed diminished NAA/creatine (Cr) levels in the splenium compared with normal control volunteers. The patients displaying lowered NAA/Cr in the splenium were also likely to exhibit lowered NAA/Cr in lobar white matter. Also, the levels of NAA/Cr in the splenium of normal volunteers were higher compared with those found in lobar white matter. Decreases in NAA/Cr levels in the splenium may be a marker for diffuse injury. A proton MRS examination may be particularly useful in evaluating mildly injured patients with unexplained neurological and cognitive deficits. It is concluded that MRS is a sensitive tool in detecting axonal injury.

To study the utility of fluid attenuated inversion recovery (FLAIR)MR images in the evaluation of traumatic head injury, 56 patients with traumatic head injuries were examined with long TR/TE spin-echo(SE)sequences and FLAIR sequences. In 40 of them, long TR/short TE images were added to those sequences. Careful readings of MR images were done by two well-trained neuroradiologists. The chi square test was used for statistical evaluation of our results. The relative sensitivities of FLAIR images were significantly better than those of long TR/TE, long TR/short TE images for the detection of diffuse axonal injury (p < 0.01), cortical contusion (p < 0.01), and subdural hematoma (p < 0.01) for long TR/TE, p < 0.05 for long TR/short TE). The number of cases of epidural hematoma and brainstem injury was too small for statistical significance to be determined. In 9 patients with corpus callosum injuries. FLAIR images demonstrated the lesions as abnormally high signal intensity in the septum pellucidum and fornix. Only sagittal FLAIR images could definitely discriminate the traumatic lesions of the fornix from the surrounding CSF. In addition, FLAIR images could easily discriminate DAI of the corpus callosum from CSF of the cavum velli interpositi. MR FLAIR images were found to be useful for detecting traumatic head injuries.

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.

The author makes a concise review of the imagiology of acute head trauma. The relative value of the various imaging techniques and the present importance of skull radiography are discussed; the role of computed tomography (CT) is emphasized. The most important aspects of traumatic lesions, as evaluated by CT, are presented.

115 traumatic extradural haematoma cases who were treated surgically at Cerrahpasa Medical Faculty Neurosurgery Department between 1987 and 1992 are evaluated. When factors affecting the outcome were examined, a strong correlation was found between the result and Glasgow coma scale (GCS) (p < 0.00001). The existence of a fracture, the interval between onset of haematoma symptoms and intervention and the existence of an intracerebral haematoma together with contusion accompanying intradural haematoma, affect the outcome in a negative direction. There was no statistical correlation between the outcome and the age of patient, localization of the haematoma and aetiology.

During an 8-year period, fifteen patients with subacute or chronic epidural haematoma were seen among 110 treated cases of extradural haematoma corresponding to a frequency of 13.6%. Increasing headache, nausea, vomiting, mild drowsiness and cranial nerve palsy were the symptoms resulting in the correct diagnosis in most cases. Clinical and pathological findings are described, and the factors influencing the course of events are discussed. The most important factors are cerebral atrophy, age, source of bleeding and location. By means of early CT (computed tomography) diagnosis of haematoma, fatal outcome could be prevented in most of the cases.

To assess the efficacy of magnetic resonance (MR) imaging for detection of associated brain injuries in cases with extradural hematoma (EDH), 32 patients of EDH were examined by MR. CT detected associated lesion in eleven patients (34%), while MR detected them in 24 patients (75%). MR is more sensitive than CT in detecting associated lesions, especially when T2 weighted imaging is used. Non-hemorrhagic contusions adjacent to EDH, and near the cranial base were well shown by MR, however they tended to be missed by CT. EEG findings were clearly related to abnormalities detected by MR. Coupling between functional change and organic change was confirmed. The improved detection and anatomic localization of associated brain injuries by MR should allow more accurate assessment of brain injuries, and sophisticated management of EDH patient. The authors also discussed on the cardiorespiratory monitoring and support during MRI examination in critically ill patients.

Penetrating head trauma in children causes uncommon and potentially life-threatening injuries. We report on a case of penetrating cranial stab wound to the right parietal region of the head to a 29-week fetus. The child was delivered by emergency Caesarian section. Neurosurgical intervention after birth was necessary. The injury caused a posthaemorrhagic hydrocephalus. Real-time ultrasound examination visualises the brain damage and the development of a hydrocephalus e vacuo.

Using the method digital analysis of CT image (ASOT programme) the cerebrospinal brain index was analysed in a group of 78 patients after past craniocerebral trauma. The studied subjects had had craniocerebral trauma complicated with focal brain contusions and intracerebral and paracerebral haematomas, as well as posttraumatic multiple changes. The control group comprised 12 subjects who had had cerebral concussion. A significant statistically increase of the index was found in the groups with past craniocerebral trauma complicated with intracerebral haematoma or multiple posttraumatic lesions.

A prospective study of 315 consecutive patients with a severe head injury was undertaken to study factors contributing to mortality and morbidity, both in the pre-hospital and hospital phases. Entry criteria were a Glasgow Coma Scale (GCS) score of 8 or less after non-surgical resuscitation within 6 h of the injury, or a deterioration to that level within 48 h. Patients with gunshot wounds or who were dead on arrival were excluded. End points of the study were either death or at 6 months after the injury. Predictors of mortality were increasing age, the presence of hypotension, a low GCS, abnormal motor responses and pupillary non-reactivity. In the 167 patients in whom intracranial pressure (ICP) was measured, raised ICP and failure to respond to treatment for raised ICP also predicted mortality. Three CT predictors of mortality were the presence of cerebral oedema, intraventricular blood and the degree of midline shift. When analysed using logistic regression, the most accurate model (accuracy 84.4%) included increasing age, abnormal motor responses and the three CT indicators. Analysis of the data for 'good' (Glasgow Outcome Score (GOS) 1 and 2) vs 'poor' (GOS 3 and 4) survival at 6 months was also performed using logistic regression. The model which provided the most accurate prediction of poor outcome included age, hypotension and three different CT characteristics, subarachnoid blood, intracerebral haematoma or intracerebral contusion (accuracy 72.5%).

The clinical course was studied as were potentialities of certain methods of diagnosis in 91 patients with traumatic intracranial hematomas of rare localization: hematomas of the posterior cranial fossa, epidural hematomas of the anterior cranial fossa and occipital pole, and those seated above the upper longitudinal sinus, interhemispheric subdural hematomas and basal subdural hematomas. The authors' and reported data are summarized.

Forty patients with severe head injury were classified on the basis of initial CT findings into 2 groups of focal injury (n = 20, mean age = 55.2 years), and diffuse injury (n = 20, mean age = 45.0 years). Glasgow Outcome Scale (GOS) status at 2 post-injury intervals (at discharge and 1 year after injury) of the 2 groups were compared and prognostic factors examined. At discharge (less than 3 months after injury), there were slight differences between the 2 groups in GOS score distribution, with nearly half of the patients in each group being independent. One year after injury, mean GOS score of the focal injury group was relatively more favorable, with about 60% of patients being independent, while no significant improvement was observed in the diffuse injury group. With the exception of brainstem signs, in both groups, the parameters of type of lesion detected on initial CT, modality of treatment, patient age, and operative timing all proved of little prognostic value. Brainstem injury due to intracranial mass lesions or postoperative brain edema was presumably a critical factor affecting prognosis in the focal injury group, while both primary and secondary brainstem injuries could have been major factors affecting prognosis in the diffuse injury group. In the prognosis of patients with severe head injuries, not only the parameter of initial CT findings but also time course of changes in brainstem signs, serial CT findings, MRI, and electrophysiological analyses such as motor evoked response should be considered.

A case of epidural haematoma in the fronto-temporo-parietal region with ipsilateral exophthalmus is presented. In the light of 10 cases reported in literature and one own case, and on the basis of neuroanatomical data the possible causes of this rare sign are discussed. The aetiology of this exophthalmus is still unclear and subject to discussion.

In the course of 5 years (1983-1987) in the North Bohemian region 88 patients were operated on account of epidural haematoma (EDH). The majority of patients (71%) were treated in a regional hospital. Computed tomography made it possible to divide the group into associated and simple EDH. In the submitted paper the authors discuss only simple EDH, as associated injuries modify the clinical picture. Of 34 simple EDH 85.3% had an atypical course. Alcohol, different localizations of the haematoma or concurrent polytraumatism were the most frequent cause of an atypical course and thus a late diagnosis. These are in the authors' opinion the most frequent causes of failure. Supporting factors were shortcomings in the organization and restricted transport facilities. The finding of an ipsilateral cranial fracture was more typical for the diagnosis of EDH than the presence of the classical triad. The mortality in simple EDH was 26.5% and the morbidity also 26.5%. Only those patients died who were operated in areactive motor unconsciousness--i.e. late.

Head injuries lead to changes in cerebral blood flow velocity (BFV)--measured with the transcranial Doppler ultrasonography--in 19 out of 31 patients, i.e. 61%. In 12 cases there was an immediate increase of BFV following the injury or within the first 7 days, often parallel with an increase of the intracranial pressure. On the other hand in 2 out of 4 cases with chronic subdural haemorrhage there was a decrease of the BFV. With routine use of transcranial doppler ultrasound in neurosurgical intensive care, acute changes in BFV along with clinical deterioration may indicate the need for a repeat CT and eventually a surgical intervention.

The evaluation and treatment of minor head injuries are reviewed, with particular emphasis on those problems of head injury commonly seen by family physicians. Clinical history, physical examination, and radiologic studies that are of value in diagnosing minor head injuries are highlighted.

In a large series of head-injured patients (132 cases), we have selected 30 patients (mean age 43 years) with only primary school education: they have been investigated with isotope cisternography and psycodiagnostic tests. 19 underwent neurosurgical procedures (6 extradural haematomas, 8 subdural haematomas, 5 cerebral lacerations). These investigations have been carried at least six months after the head injury. We have used for isotopic cisternography RISA and In111-DTPA. Raven's Progressive Coloured Matrices and Immediate Memory Tests were performed. Cisternographic pictures were classified as 1) normal, 2) with asymmetrical diffusion, 3) with ventricular reflux and were correlated with the neuropsychological data. We have found ventricular reflux in 10 patients (5 underwent surgical procedures), asimmetrical diffusion in 15 patients (11 operated); in 5 cases cisternographic pictures were normal. Neuropsychological tests give quantitative data about progressive mental deterioration, in full agreement with cisternographic results.

The authors report their experience in 8 cases of cranial post-traumatic superficial collections, studied by US. Traumatic cranial injuries with superficial collections are not rare in newborns; their early and complete diagnosis is necessary for a correct therapeutic approach. Sonography could be used as a first choice procedure but presents some limitations in the study of the posterior fossa. Therefore CT remains the technique of choice.

25 cases of traumatic intracerebral haematomas of delayed onset were found among 775 cases of acute head injuries. All these 25 cases were analysed both clinically and with computed- tomographical studies. Their clinical features were different from those of classical " traumatische Spät- Apoplexie " originally described by Bollinger in 1891, in the following aspects; absence of the symptom-free interval and absence of apoplectic onset of symptoms after a relatively long lucid interval. These traumatic intracerebral haematomas of delayed onset were, on the other hand, characterized by the following; the patient was injured when the head was in motion, the injury was not necessarily severe, the onset of signs and symptoms were gradual and insidious, all 25 cases but 4, had cranial vault fractures and/or basal skull fractures, precipitating factors could not be identified, though hypotensive episodes were present in 60% of cases, intracerebral haematomas appeared within 72 hours following the head injury in most of cases, though more than 4 days later in a small number of cases, the appearance of such intracerebral haematomas suggested an unfavourable outcome, cerebral contusion might be a major contributory factor.

Our study is based on the analysis of traumatic I.C.H. 38 cases observed since we have had a C.T. Scan at our disposal (1975). Those cases (recorded in the departments of Paillas, Vigouroux, Sedan, Combalbert) represent 2,3% of the brain traumas, 6,5% of the traumatic intra-parenchymatous lesions and 9,5% of the traumatic intra-cranial hematomas. Most of the cases reported deal with male patients, with on average age of 46, who are often victims of traffic accidents. In half the cases of skull fractures, the hematoma is located in the opposite side of the fracture. In almost all cases, initial loss of consciousness is observed, followed by consciousness alterations, with few free intervals and with neurological focal signs depending on the site of the lesion. The C.T. Scan data of the those traumatic hematoma have been studied.