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The main treatment strategy for chronic subdural hematoma is surgical intervention. When a conservative pharmacological approach is considered in symptomatic patients, mainly dexamethasone therapy is applied. Recent trials revealed dexamethasone therapy to be an ineffective treatment in symptomatic patients with chronic subdural hematoma. Whether the efficacy of dexamethasone therapy differs in radiological hematoma subtypes is unknown. The aim of this substudy was to identify which hematoma subtype might be favorable for dexamethasone therapy. As part of a randomized controlled trial, symptomatic chronic subdural hematoma patients received 19-days dexamethasone therapy. The primary outcome measure was the change in hematoma size as measured on follow-up computed tomography (CT) after 2 weeks of dexamethasone in six hematoma (architectural and density) subtypes: homogeneous total, laminar, separated and trabecular architecture types, and hematoma without hyperdense components (homogeneous hypodense, isodense) and with hyperdense components (homogeneous hyperdense, mixed density). We analyzed hematoma thickness, midline shift, and volume using multi-variable linear regression adjusting for age, sex and baseline value of the specific radiological parameter. From September 2016 until February 2021, 85 patients were included with a total of 114 chronic subdural hematoma. The mean age was 76 years and 25% were women. Larger decrease in hematoma thickness and midline shift was revealed in hematoma without hyperdense components compared with hematoma with hyperdense components (adjusted [adj.] b -2.2 mm, 95% confidence interval [CI] -4.1 to -0.3 and adj. b -1.3 mm, 95% CI -2.7 to 0.0 respectively). Additional surgery was performed in 57% of patients with the highest observed rate (81%) in separated hematoma. Largest hematoma reduction and better clinical improvement was observed in chronic subdural hematoma without hyperdense components after dexamethasone therapy. Evaluation of these parameters can be part of an individualized treatment strategy.

Age is variably described as a minor or major risk factor for traumatic intracranial lesions after head injury. However, at present, no specific CT decision rule is available for elderly patients with minor head injury (MHI). The aims of this prospective multicenter cohort study were to assess the performance of existing CT decision rules for elderly MHI patients and to compare the clinical and CT characteristics of elderly patients with the younger MHI population. Thirty-day mortality between two age groups (cutoff ≥ 60 years), along with clinical and CT characteristics, was evaluated with four CT decision rules: the National Institute for Health and Care Excellence (NICE) guideline, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and the CT Head Injury Patients (CHIP) rule. Of the 5517 MHI patients included, 2310 were aged ≥ 60 years. Elderly patients experienced loss of consciousness (17% vs. 32%) and posttraumatic amnesia (23% vs. 31%) less often, but intracranial lesions (13% vs. 10%), neurological deterioration (1.8% vs. 0.2%), and 30-day mortality (2.0% vs. 0.1%) were more frequent than in younger patients (all p < 0.001). Elderly patients with age as their only risk factor showed intracranial lesions in 5% (NOC and CHIP) to 8% (CCHR and NICE) of cases. The sensitivity of decision rules in the elderly patients was 60% (CCHR) to 97% (NOC) when age was excluded as a risk factor. Current risk factors considered when evaluating elderly patients show lower sensitivity to identify intracranial abnormalities, despite more frequent intracranial lesions. Until age-specific CT decision rules are developed, it is advisable to scan every elderly patient with an MHI.

Introduction: A computerized tomography (CT) scan is an effective test for detecting traumatic intracranial findings after mild traumatic brain injury (mTBI). However, a head CT is costly, and can only be performed in a hospital., Objective: To determine if the addition of plasma S100B to clinical guidelines could lead to a more selective scanning strategy without compromising safety., Methods: We conducted a single center prospective cohort study at the emergency department. Patients (≥16 years) who received head CT and had a blood draw were included. The primary outcome was the accuracy of plasma S100B to predict the presence of any traumatic intracranial lesion on head CT., Results: We included 495 patients, out of the 74 patients who had traumatic intracranial lesions, 5 patients had a plasma S100B level below the cutoff value of 0.105 ug/L. For the detection of traumatic intracranial injury, S100B had a sensitivity of 0.932 , a specificity of 0.157, a negative predictive value of 0.930, and a positive predictive value of 0.163., Conclusions: Among patients undergoing guideline-based CT scan for mTBI, the use of S100B, would results in a further decrease (14.8%) of CT scans but at a cost of missed injury, without clinical consequence, on CT.

Background and Objectives: The ULTRA trial showed that ultra-early and short-term tranexamic acid treatment after subarachnoid hemorrhage did not improve clinical outcome at 6 months. An expected proportion of the included patients experienced nonaneurysmal subarachnoid hemorrhage. In this post hoc study, we will investigate whether ultra-early and short-term tranexamic acid treatment in patients with aneurysmal subarachnoid hemorrhage improves clinical outcome at 6 months., Methods: The ULTRA trial is a multicenter, prospective, randomized, controlled, open-label trial with blinded outcome assessment, conducted between July 24, 2013, and January 20, 2020. After confirmation of subarachnoid hemorrhage on noncontrast CT, patients were allocated to either ultra-early and short-term tranexamic acid treatment with usual care or usual care only. In this post hoc analysis, we included all ULTRA participants with a confirmed aneurysm on CT angiography and/or digital subtraction angiography. The primary endpoint was clinical outcome at 6 months, assessed by the modified Rankin scale (mRS), dichotomized into good (0-3) and poor (4-6) outcomes., Results: Of the 813 ULTRA trial patients who experienced an aneurysmal subarachnoid hemorrhage, 409 (50%) were assigned to the tranexamic acid group and 404 (50%) to the control group. In the intention-to-treat analysis, 233 of 405 (58%) patients in the tranexamic acid group and 238 of 399 (60%) patients in the control group had a good clinical outcome (adjusted odds ratio [aOR] 0.92; 95% CI 0.69-1.24). None of the secondary outcomes showed significant differences between the treatment groups: excellent clinical outcome (mRS 0-2) (aOR 0.76; 95% CI 0.57-1.03), all-cause mortality at 30 days (aOR 0.91; 95% CI 0.65-1.28), and all-cause mortality at 6 months (aOR 1.10; 95% CI 0.80-1.52)., Discussion: Ultra-early and short-term tranexamic acid treatment did not improve clinical outcomes at 6 months in patients with aneurysmal subarachnoid hemorrhage and therefore cannot be recommended., Trial Registration Information: ClinicalTrials.gov (NCT02684812; submission date February 18, 2016, first patient enrollment on July 24, 2013)., Classification of Evidence: This study provides Class II evidence that tranexamic acid does not improve outcomes in patients presenting with aneurysmal subarachnoid hemorrhage., (© 2022 American Academy of Neurology.)

Purpose: Chronic subdural hematoma (CSDH) is a common neurological disease often affecting the elderly. Long-term excess mortality for patients after CSDH has been suggested but causes of death are unknown. We hypothesize that excess mortality of CSDH patients is related to frailty. In this article, we describe mortality rates and causes of death of CSDH patients compared with the general population and assess the association of frailty with mortality., Methods: A cohort study in which consecutive CSDH patients were compared to the general population regarding mortality rates. Furthermore, the association of six frailty indicators (cognitive problems, frequent falling, unable to live independently, unable to perform daily self-care, use of benzodiazepines or psychotropic drugs, and number of medications) with mortality was assessed., Results: A total of 1307 CSDH patients were included, with a mean age of 73.7 (SD ± 11.4) years and 958 (73%) were male. Median follow-up was 56 months (range: 0-213). Compared with controls CSDH patients had a hazard ratio for mortality of 1.34 (95% CI: 1.2-1.5). CSDH patients more often died from cardiovascular diseases (37% vs. 30%) and falls (7.2% vs. 3.7%). Among CSDH patients frequent falling (HR 1.3; 95% CI: 1.0-1.7), inability to live independently (HR 1.4, 95% CI: 1.1-1.8), inability to perform daily self-care (HR 1.5; 95% CI: 1.1-1.9), and number of medications used (HR 1.0; 95% CI: 1.0-1.1) were independently associated with mortality., Conclusions: CSDH patients have higher mortality rates than the general population. Frailty in CSDH patients is associated with higher mortality risk. More attention for the frailty of CSDH patients is warranted., (© 2022. The Author(s).)

Background: Several prognostic models for outcomes after chronic subdural hematoma (CSDH) treatment have been published in recent years. However, these models are not sufficiently validated for use in daily clinical practice. We aimed to assess the performance of existing prediction models for outcomes in patients diagnosed with CSDH., Methods: We systematically searched relevant literature databases up to February 2021 to identify prognostic models for outcome prediction in patients diagnosed with CSDH. For the external validation of prognostic models, we used a retrospective database, containing data of 2384 patients from three Dutch regions. Prognostic models were included if they predicted either mortality, hematoma recurrence, functional outcome, or quality of life. Models were excluded when predictors were absent in our database or available for < 150 patients in our database. We assessed calibration, and discrimination (quantified by the concordance index C) of the included prognostic models in our retrospective database., Results: We identified 1680 original publications of which 1656 were excluded based on title or abstract, mostly because they did not concern CSDH or did not define a prognostic model. Out of 18 identified models, three could be externally validated in our retrospective database: a model for 30-day mortality in 1656 patients, a model for 2 months, and another for 3-month hematoma recurrence both in 1733 patients. The models overestimated the proportion of patients with these outcomes by 11% (15% predicted vs. 4% observed), 1% (10% vs. 9%), and 2% (11% vs. 9%), respectively. Their discriminative ability was poor to modest (C of 0.70 [0.63-0.77]; 0.46 [0.35-0.56]; 0.59 [0.51-0.66], respectively)., Conclusions: None of the examined models showed good predictive performance for outcomes after CSDH treatment in our dataset. This study confirms the difficulty in predicting outcomes after CSDH and emphasizes the heterogeneity of CSDH patients. The importance of developing high-quality models by using unified predictors and relevant outcome measures and appropriate modeling strategies is warranted., (© 2022. The Author(s).)

Objective: To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI)., Methods: The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic., Results: Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%)., Conclusions: Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate., (Copyright © 2022. Published by Elsevier Ltd.)

The COVID-19 pandemic changed daily practice in a number of ways. In a recent article it was shown that mortality in multitrauma patients with mild to moderate head injury, was higher compared to pre-COVID-19 mortality. The authors describe possible mechanisms for this higher mortality, for instance scarcity of IC beds and changes in Intensive care unit admissions. However, the study only showed mortality data, not the complete range of possible outcomes. In multitrauma patients, mere survival is not necessarily a good outcome. It would be very interesting to know whether the increased mortality is a accompanied by a lower proportion of patients who need daily care. If that is the case, then the conclusion of the authors that the COVID-19 pandemic leads to worse outcomes needs to be nuanced.

Background and Objectives: Few prospective well-designed diagnostic accuracy studies have been performed to study the parameters of infection in patients suspected for external ventricular catheter-associated infection. Our objective was to analyze the diagnostic accuracy of clinical characteristics and biochemical and microbiological parameters in diagnosing external ventricular CSF catheter-associated infection., Methods: From 2014 to 2017, we performed a single-center cohort study in consecutive patients at the intensive care unit who required an external ventricular CSF catheter in the Hague, the Netherlands. CSF was sampled and analyzed daily. Ventricular catheter-associated infection was defined according to the 2017 Infectious Diseases Society of America's Clinical Practice Guidelines. We compared clinical characteristics and biochemical parameters between patients with and without infection from 3 days before to 3 days after the day the CSF sample was collected that grew bacteria., Results: A total of 103 patients were included of whom 15 developed a catheter-associated infection (15%). The median day cultures were positive was 3 days after CSF collection (interquartile range [IQR] +2 to +4). On day 0, none of the tests could differentiate between patients with and without infection. The CSF leukocyte count was increased in patients with ventricular catheter-associated infection as compared with patients without on days +2 and +3. The difference was most prominent on day +2 (1,703 × 10 6 /L [IQR 480-6,296] vs 80 × 10 6 /L [IQR 27-251]; p < 0.001; area under the curve [AUC] 0.87 [95% confidence interval (CI) 0.71-1.00]). Sensitivity for the CSF leukocyte count at a cutoff level >1,000 × 10 6 /L was 67% (95% CI 30-93), and specificity was 100% (95% CI 90-100); the positive predictive value was 100%, and the negative predictive value was 92% (95% CI 83-97). The percentage of polymorphonuclear cells (PMNs) was higher in patients with infection on days +1 and +2 (day +2 89% [IQR 78-94] vs 59% [IQR 39-75]; p < 0.01; AUC 0.91 [95% CI 0.81-1.0])., Discussion: An elevated CSF leukocyte count and increased percentage of PMNs are the strongest indicators for external catheter-associated infections on the days before culture positivity. New CSF markers of drain-associated infection should be studied to enable earlier diagnosis and treatment in patients with an infection and reduce antibiotic treatment in those with no infection., Classification of Evidence: This study provides Class I evidence that in individuals requiring an external ventricular CSF catheter, an elevated CSF leukocyte count and an increased percentage of PMNs are the strongest indicators of catheter-associated infections in the days before CSF culture positivity., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Background: We aimed to quantify the need for additional surgery in patients with chronic subdural hematoma (CSDH) primarily treated with dexamethasone and to identify patient characteristics associated with additional surgery., Methods: Data were retrospectively collected from 283 patients with CSDH, primarily treated with dexamethasone, in 3 hospitals from 2008 to 2018. Primary outcome was the need for additional surgery. The association between baseline characteristics and additional surgery was analyzed with univariable and multivariable logistic regression analysis and presented as adjusted odds ratios (aOR)., Results: In total, 283 patients with CSDH were included: 146 patients (51.6%) received 1 dexamethasone course (DXM group), 30 patients (10.6%) received 2 dexamethasone courses (DXM-DXM group), and 107 patients (37.8%) received additional surgery (DXM-SURG group). Patients who underwent surgery more often had a Markwalder Grading Scale of 2 (as compared with 1, aOR 2.05; 95% confidence interval [CI] 0.90-4.65), used statins (aOR 2.09; 95% CI 1.01-4.33), had a larger midline shift (aOR 1.10 per mm; 95% CI 1.01-1.21) and had larger hematoma thickness (aOR 1.16 per mm; 95% CI 1.09-1.23), had a bilateral hematoma (aOR 1.85; 95% CI 0.90-3.79), and had a separated hematoma (as compared with homogeneous, aOR 1.77; 95% CI 0.72-4.38). Antithrombotics (aOR 0.45; 95% CI 0.21-0.95) and trabecular hematoma (as compared with homogeneous, aOR 0.31; 95% CI 0.12-0.77) were associated with a lower likelihood of surgery., Conclusions: More than one-third of patients with CSDH primarily treated with dexamethasone received additional surgery. These patients were more severely affected amongst others with larger hematomas., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Rationale: Symptoms of chronic subdural hematoma (CSDH) vary widely, including transient neurological deficit(s) (TND). The precise prevalence and the clinical aspects of TND are yet to be determined. Most TNDs are regarded and treated as symptomatic seizures, but the rationale for this decision is not always clear., Methods: Patients with temporary symptoms were selected from a retrospective cohort of CSDH patients. We analyzed the association of TND characteristics with patients being classified as having a symptomatic seizure and with functional outcome using logistic regression analysis., Results: Of the included 1307 CSDH patients, 113 (8.6%) had at least one episode of TND. Most common TNDs were aphasia/dysphasia, impaired awareness or clonic movements. Of these 113 patients, 50 (44%) were diagnosed with symptomatic seizure(s) by their treating physician. Impaired awareness, clonic movements and the presence of 'positive symptoms' showed the strongest association with the diagnosis symptomatic seizure (OR 36, 95% CI 7.8-163; OR 24, 95% CI 6.4-85; and OR 3.1, 95% CI 1.3-7.2). Aphasia/dysphasia lowered the chance of TND being classified as symptomatic seizure together with a longer TND duration (OR 0.2, 95% CI 0.1-0.6; and OR 0.91, 95% CI 0.84-0.99). Treatment with anti-epileptic drugs was related to unfavorable functional outcome (aOR 5.4, 95% CI 1.4-20.7)., Conclusion: TND was not a rare phenomenon in our cohort of CSDH patients. A TND episode of 5 min, aphasia/dysphasia and/or absence of 'positive' symptoms are suggestive of a different TND pathophysiology than symptomatic seizures. Our results further suggest that treatment of TND in CSDH deserves careful consideration as management choices might influence patient outcome., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Patients with chronic subdural hematoma (CSDH) can have transient neurological deficits deficit (TND) mimicking transient ischemic attacks. The prevalence of TNDs in CSDH varies between 1%-24%, depending on TND definition. Despite this high prevalence the pathophysiology of TND in CSDH is not clear in many cases. In this systematic review, we aim to unravel the responsible mechanism. Pubmed and Embase were searched for all articles concerning the pathophysiology of TND as a presenting symptom in patients with CSDH. There were no publication date restrictions for the articles in the search. Two reviewers independently selected studies for inclusion and subsequently extracted the necessary data. Out of 316 identified references, 15 met the inclusion criteria. Several articles mentioned multiple pathophysiological mechanisms. One of the proposed etiologies of TND was epileptic activity, stated by three articles. In contrast, three different studies stated that seizures are unlikely to cause TND. Five papers suggested that obstruction of blood flow, caused by the hematoma or subsequent swelling, might be the cause. Six articles made no definite statement on the responsible pathophysiological mechanism of TND. Different mechanisms have been proposed to be the cause of TNDs in patients with CSDH. Based on this review, the exact pathophysiology of TND remains unclear. We suggest that future studies on this topic should incorporate MRI of the brain (with diffusion-weighted imaging) and EEG, to provide better insight into TND pathophysiology. The knowledge resulting from future studies might contribute to better understanding of TND and optimal treatment in CSDH., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. The optimal treatment strategy is still unknown. The objective of the Dutch Injection versus Surgery TRIal in patients with CTS (DISTRICTS) is to investigate if initial surgery of CTS results in a better clinical outcome and is more cost-effective when compared with initial treatment with corticosteroid injection., Methods and Analysis: The DISTRICTS is an ongoing multicenter, open-label randomised controlled trial. Participants with CTS are randomised to treatment with surgery or with a corticosteroid injection. If needed, any additional treatments after this first treatment are allowed and these are not dictated by the study protocol. The primary outcome is the difference between the groups in the proportion of participants recovered at 18 months. Recovery is defined as having no or mild symptoms as measured with the 6-item carpal tunnel symptoms scale. Secondary outcome measurements are among others: time to recovery, hand function, patient satisfaction, quality of life, additional treatments, adverse events, and use of care and health-related costs., Ethics and Dissemination: The study was approved by the Medical Ethical Committee of the Amsterdam University Medical Centers (study number 2017-171). Study results will be disseminated in peer-reviewed journals and conferences., Trial Registration Number: ISRCTN Registry: 13164336., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The aim of this work was to conduct a systematic review and meta-analysis of studies reporting on the risk of traumatic intracerebral hemorrhage (tICH), the course of tICH, and its treatment and mortality rates in elderly mild traumatic brain injury (mTBI) patients using direct oral anticoagulants (DOACs). We consulted PubMed and Embase for relevant cohort and case-control studies with a control group. Two authors independently selected studies, assessed methodological quality, and extracted outcome data. Estimates were pooled with the Mantel-Haenszel random-effects method. We identified 16 articles comprising 3671 elderly mTBI patients using DOACs. Use of DOACs was associated with a reduced risk of tICH compared to the use of vitamin K antagonists (VKAs; odds ratio [OR], 0.44; 95% confidence interval [CI], 0.29-0.65; I 2  = 22%) and a similar risk compared to the use of antiplatelet therapy (APT; OR, 0.98; 95% CI, 0.39-2.44; I 2  = 0%). Reversal agent use and neurosurgical intervention rate were lower in patients using DOACs compared to patients using VKAs (OR, 0.10; 95% CI, 0.06-0.16; I 2  = 0% and OR, 0.37; 95% CI, 0.21-0.67; I 2  = 0%, respectively). There was no significant difference in neurosurgical intervention rate between patients who used DOACs versus patients who used APT (OR, 0.58; 95% CI, 0.15-2.21; I 2  = 41%) or no antithrombotic therapy (OR, 0.76; 95% CI, 0.20-2.86; I 2  = 23%). ICH progression, risk of delayed ICH, and TBI-related in-hospital mortality were comparable among treatment groups. The present study indicates that elderly patients using DOACs have a lower risk of adverse outcome compared to patients using VKAs and a similar risk compared to patients using APT after mTBI.

Background: Chronic subdural hematoma (CSDH) is a frequent pathological entity in daily clinical practice. However, evidence-based CSDH-guidelines are lacking and level I evidence from randomized clinical trials (RCTs) is limited. In order to establish and subsequently implement a guideline, insight into current clinical practice and attitudes toward CSDH-treatment is required. The aim is to explore current practice and attitudes toward CSDH-management in the Netherlands., Methods: A national online survey was distributed among Dutch neurologists and neurosurgeons, examining variation in current CSDH-management through questions on treatment options, (peri)operative management, willingness to adopt new treatments and by presenting four CSDH-cases., Results: One hundred nineteen full responses were received (8% of neurologists, N = 66 and 35% of neurosurgeons, N = 53). A majority of the respondents had a positive experience with burr-hole craniostomy (93%) and with a conservative policy (56%). Around a third had a positive experience with the use of dexamethasone as primary (30%) and additional (33.6%) treatment. These numbers were also reflected in the treatment preferences in the presented cases. (Peri)operative management corresponded among responding neurosurgeons. Most respondents would be willing to implement dexamethasone (98%) if equally effective as surgery and tranexamic acid (93%) if effective in CSDH-management., Conclusion: Variation was found regarding preferential CSDH-treatment. However, this is considered not to be insurmountable when implementing evidence-based treatments. This baseline inventory on current clinical practice and current attitudes toward CSDH-treatment is a stepping-stone in the eventual development and implementation of a national guideline., (© 2022 The Authors. Brain and Behavior published by Wiley Periodicals LLC.)

Background: Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes., Objective: To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH., Methods: We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders., Results: We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4)., Conclusion: Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

A chronic subdural hematoma is a common neurological disorder that occurs mainly in the elderly. The inciting event is often a minor head trauma and subsequent inflammation may play a role in the pathogenesis. The clinical spectrum can present heterogeneously, and symptom onset and progression can vary from days to weeks. To date surgical evacuation of the subdural collection remains the main treatment approach for symptomatic patients. Evidence is still scarce for dexamethasone as an effective primary conservative treatment strategy. Future research is necessary to elucidate the effect of various pharmacological therapies compared to primary surgery on functional outcome.

When acute stroke care is organised using a "drip-and-ship" model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the "direct-to-mothership" model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from "drip and ship" into "direct-to-mothership". Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders., Competing Interests: Declaration of Competing Interest All authors work in the study setting, except for Naomi van der Linden, who currently works at the University of Twente but was employed by AstraZeneca Netherlands, a pharmaceutical company, during this study. Crispijn van den Brand worked in the study setting and is currently employed by the Dutch Institute for Clinical Auditing.The authors declare that they have no competing interests, (Copyright © 2021. Published by Elsevier B.V.)

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients. Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results. Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination. Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lemmens, van der Linden and Jellema.)

Background: Treatment with one standard dose (2 g/kg) of intravenous immunoglobulin is insufficient in a proportion of patients with severe Guillain-Barré syndrome. Worldwide, around 25% of patients severely affected with the syndrome are given a second intravenous immunoglobulin dose (SID), although it has not been proven effective. We aimed to investigate whether a SID is effective in patients with Guillain-Barré syndrome with a predicted poor outcome., Methods: In this randomised, double-blind, placebo-controlled trial (SID-GBS), we included patients (≥12 years) with Guillain-Barré syndrome admitted to one of 59 participating hospitals in the Netherlands. Patients were included on the first day of standard intravenous immunoglobulin treatment (2 g/kg over 5 days). Only patients with a poor prognosis (score of ≥6) according to the modified Erasmus Guillain-Barré syndrome Outcome Score were randomly assigned, via block randomisation stratified by centre, to SID (2 g/kg over 5 days) or to placebo, 7-9 days after inclusion. Patients, outcome adjudicators, monitors, and the steering committee were masked to treatment allocation. The primary outcome measure was the Guillain-Barré syndrome disability score 4 weeks after inclusion. All patients in whom allocated trial medication was started were included in the modified intention-to-treat analysis. This study is registered with the Netherlands Trial Register, NTR 2224/NL2107., Findings: Between Feb 16, 2010, and June 5, 2018, 327 of 339 patients assessed for eligibility were included. 112 had a poor prognosis. Of those, 93 patients with a poor prognosis were included in the modified intention-to-treat analysis: 49 (53%) received SID and 44 (47%) received placebo. The adjusted common odds ratio for improvement on the Guillain-Barré syndrome disability score at 4 weeks was 1·4 (95% CI 0·6-3·3; p=0·45). Patients given SID had more serious adverse events (35% vs 16% in the first 30 days), including thromboembolic events, than those in the placebo group. Four patients died in the intervention group (13-24 weeks after randomisation)., Interpretation: Our study does not provide evidence that patients with Guillain-Barré syndrome with a poor prognosis benefit from a second intravenous immunoglobulin course; moreover, it entails a risk of serious adverse events. Therefore, a second intravenous immunoglobulin course should not be considered for treatment of Guillain-Barre syndrome because of a poor prognosis. The results indicate the need for treatment trials with other immune modulators in patients severely affected by Guillain-Barré syndrome., Funding: Prinses Beatrix Spierfonds and Sanquin Plasma Products., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Emergency departments (EDs) are faced with a growing number of patients with traumatic brain injury (TBI) using direct oral anticoagulants (DOACs). However, there remains uncertainty about the bleeding risk, rate of hematoma expansion, and the efficacy of reversal strategies in these patients., Objective: This study aims to identify the risk of traumatic hemorrhagic complications in patients with TBI using DOACs., Methods: In this retrospective study we included patients with TBI. All TBI patients were using DOACs, attended one of the three EDs of our hospital between January 2016 and October 2019, and received a computed tomography (CT) scan of the brain. The primary outcome was any traumatic intracranial hemorrhage on CT. Secondary outcomes were the use of reversal agents, secondary neurological deterioration, a neurosurgical intervention within 30 days after the injury, length of stay (LOS), Glasgow Outcome Scale (GOS) at discharge, and mortality., Results: Of the included patients (N = 316), 24 patients (7.6%, 95% confidence interval [CI] 4.2-9.8) presented with a traumatic intracranial hematoma (ICH). Seven patients (2.2%, 95% CI 0.6-3.8) received a reversal agent and 1 patient (0.3%, 95% CI -0.3-0.9) underwent a neurosurgical intervention. Of the 24 patients with a traumatic ICH, progression of the lesion was seen in 6 patients (1.9%, 95% CI 0.4-3.4). The mean LOS was 6.5 days (95% CI 3.0-10.1) and the mean GOS at discharge was 4 (95% CI 3.6-4.6). Death occurred in 1 patient (0.3%, 95% CI -0.3-0.9) suffering from an ICH., Conclusion: Based on the present findings it can be postulated that TBI patients using DOACs have a low risk for ICH. Hematoma progression occurred, however, in a substantial number of patients. Considering the retrospective nature of the present study, future prospective trials are needed to confirm this finding., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Chronic subdural hematoma (CSDH) is a frequently occurring neurological disease associated with older age and use of anticoagulants. Symptoms vary from headaches to coma, but cognitive deficits can also be present. However, exact prevalence and severity of cognitive deficits in CSDH are still unknown. In this systematic review, we aim to assess cognitive status of patients with CSDH, at presentation and after treatment. PubMed, Embase and PsycInfo were searched for articles concerning cognition in CSDH. We divided cognitive changes into subjective cognitive deficit (cognitive complaints [CC]) and objective cognitive deficit (cognitive impairment [CI]). Two reviewers independently selected studies for inclusion and subsequently extracted data. Quality assessment was done by means of the Newcastle-Ottawa Scale. Reported prevalence of CC and CI was pooled with random effects meta-analysis. Out of 799 identified references, 22 met inclusion criteria. Twenty-one articles reported on prevalence of CC/CI and one study reported solely on CSDH patients with cognitive deficit. Estimated pooled prevalence of both CC and CI in CSDH at presentation was 45% (95% confidence interval [CI]: 36-54%). Four studies concerned a prospective evaluation of the effect of surgical treatment on cognition. These proved to be of fair to good quality after quality assessment. The estimated pre-treatment prevalence of objectified cognitive impairment was 61% (95% CI: 51-70%) decreasing to 18% (95% CI: 8-32%) post-surgery. From this review it can be concluded that CC and CI are very common in CSDH, with a tendency to improve after treatment. Therefore, we underline the importance of increased attention to cognitive status of these patients, with proper testing methods and treatment-testing intervals.

Background: In patients with aneurysmal subarachnoid haemorrhage, short-term antifibrinolytic therapy with tranexamic acid has been shown to reduce the risk of rebleeding. However, whether this treatment improves clinical outcome is unclear. We investigated whether ultra-early, short-term treatment with tranexamic acid improves clinical outcome at 6 months., Methods: In this multicentre prospective, randomised, controlled, open-label trial with masked outcome assessment, adult patients with spontaneous CT-proven subarachnoid haemorrhage in eight treatment centres and 16 referring hospitals in the Netherlands were randomly assigned to treatment with tranexamic acid in addition to care as usual (tranexamic acid group) or care as usual only (control group). Tranexamic acid was started immediately after diagnosis in the presenting hospital (1 g bolus, followed by continuous infusion of 1 g every 8 h, terminated immediately before aneurysm treatment, or 24 h after start of the medication, whichever came first). The primary endpoint was clinical outcome at 6 months, assessed by the modified Rankin Scale, dichotomised into a good (0-3) or poor (4-6) clinical outcome. Both primary and safety analyses were according to intention to treat. This trial is registered at ClinicalTrials.gov, NCT02684812., Findings: Between July 24, 2013, and July 29, 2019, we enrolled 955 patients; 480 patients were randomly assigned to tranexamic acid and 475 patients to the control group. In the intention-to-treat analysis, good clinical outcome was observed in 287 (60%) of 475 patients in the tranexamic acid group, and 300 (64%) of 470 patients in the control group (treatment centre adjusted odds ratio 0·86, 95% CI 0·66-1·12). Rebleeding after randomisation and before aneurysm treatment occurred in 49 (10%) patients in the tranexamic acid and in 66 (14%) patients in the control group (odds ratio 0·71, 95% CI 0·48-1·04). Other serious adverse events were comparable between groups., Interpretation: In patients with CT-proven subarachnoid haemorrhage, presumably caused by a ruptured aneurysm, ultra-early, short-term tranexamic acid treatment did not improve clinical outcome at 6 months, as measured by the modified Rankin Scale., Funding: Fonds NutsOhra., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Radiographic prognostic factors may identify patients who are prone for recurrence and who might benefit further optimization of therapy. In this meta-analysis, we systematically evaluated pre-operative radiological prognostic factors of recurrence after surgery., Methods: Electronic databases were searched until September 2020 for relevant publications. Studies reporting on CSDH recurrence in symptomatic CSDH patients with only surgical treatment were included. Random or fixed effects meta-analysis was used depending on statistical heterogeneity., Results: Twenty-two studies were identified with a total of 5566 patients (mean age 69 years) with recurrence occurring in 801 patients (14.4%). Hyperdense components (hyperdense homogeneous and mixed density) were the strongest prognostic factor of recurrence (pooled RR 2.83, 95% CI 1.69-4.73). Laminar and separated architecture types also revealed higher recurrence rates (RR 1.37, 95% CI 1.04-1.80 and RR 1.76 95% CI 1.38-2.16, respectively). Hematoma thickness and midline shift above predefined cut-off values (10 mm and 20 mm) were associated with an increased recurrence rate (RR 1.79, 95% CI 1.45-2.21 and RR 1.38, 95% CI 1.11-1.73, respectively). Bilateral CSDH was also associated with an increased recurrence risk (RR 1.34, 95% CI 0.98-1.84)., Limitations: Limitations were no adjustments for confounders and variable data heterogeneity. Clinical factors could also be predictive of recurrence but are beyond the scope of this study., Conclusions: Hyperdense hematoma components were the strongest prognostic factor of recurrence after surgery. Awareness of these findings allows for individual risk assessment and might prompt clinicians to tailor treatment measures.

Objective: A new nationwide guideline for minor head injury was introduced in the Netherlands in 2010. The effect on computed tomography (CT) ratio and hospital admission ratio after introduction of the guideline is unknown. The aim was to reduce these numbers as part of cost-effective health care. Therefore, we assessed the effect on these variables after introduction of the guideline., Methods: We used an interrupted time-series study design. Data selection was done 3 years before (2007-2009) and several years after (2012, 2014, 2015) introduction of the guideline., Results: Data collection was performed for 3880 patients. Introduction of the new guideline was associated with an increase in CT ratio from 24.6% before to 55% after introduction (P < 0.001). This increase is the result of both the new guideline and a secular trend. Besides this, hospital admissions increased from 14.7 to 23.4% (P < 0.001) during the study period. This increase was less clearly associated with the new guideline. After introduction of the guideline there was no significant difference in (intra)cranial traumatic findings (2.6% vs. 3.4%; P = 0.13) and neurosurgical interventions (0.1% vs. 0.2%; P = 0.50)., Conclusion: Between 2007 and 2015, a marked increase in CT ratio and hospital admissions has been observed. The increase in CT ratio seems to be caused both by the new guideline and by a secular trend to perform more CT scans. Adaptations to the guideline should be considered to improve patient care and cost-effectiveness in patients with minor head injury.

The aim of this study was to determine the association between bicycle helmet use in adults (16 years and older) and traumatic brain injury (TBI) in emergency departments (EDs) in the Netherlands.The conducted research was a retrospective case-control study in patients aged 16 years and older who sustained a bicycle accident and therefore visited the EDs of participating hospitals throughout 2016. Cases were patients with TBI; controls were patients without TBI but with other trauma. Exposure was defined as helmet wearing during the accident. In total, 2133 patients were included in the study, 361 case patients and 1772 controls. Within the TBI group (cases) 3.9% of patients wore a helmet compared with 7.7% of patients in the control (non-head injury) group (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.28-0.86). No difference in helmet wearing was observed in patients who sustained accidents that involved motorized vehicles (OR 0.91; 95% CI: 0.29-2.83). In conclusion, adult patients (≥16 years of age) with TBI had a significantly lower odds of wearing a bicycle helmet than adult patients with other trauma, adding more evidence that wearing a bicycle helmet effectively protects against TBI., Competing Interests: S.N. and H.V. are employed by the Consumer Safety Institute, a non-profit organization that collects and analyses the LIS data that were used for this study. For the remaining authors there are no conflicts of interests, no other financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work., (© Crispijn L. van den Brand et al., 2020; Published by Mary Ann Liebert, Inc.)

Study Objectives: To investigate (1) the effect of different scoring rules on leg movement (LM) classification in patients with obstructive sleep apnea (OSA); (2) determinants of respiratory event related leg movements (rLM); and (3) to relate LM parameters to clinical outcomes., Methods: (1) LM classification was compared between the World Association of Sleep Medicine (WASM) 2006 and the WASM 2016 rules in 336 participants with apnea hypopnea index (AHI) ≥ 5; (2) determinants and features of rLM were investigated with logistic mixed regression in 172 participants with AHI ≥ 10 and respiratory disturbance index (RDI) ≥ 15, and (3) LM parameters were compared for patients with and without cardiovascular events and related to continuous positive airway pressure (CPAP) adherence., Results: WASM-2016 scoring significantly reduced periodic limb movements of sleep (PLMS) frequency in OSA participants even when only considering the new periodicity criteria. Probability of rLM was strongly increased when respiratory events ended with an arousal, but rLM probability was lower for hypopneas and respiratory effort-related sleep arousal (RERAs) than for obstructive apneas. In participants with frequent non-respiratory PLMS, rLM were more frequent and behaved more PLMS-like. In participants without PLMS, rLM probability mostly depended on respiratory event features. LM parameters were neither related to cardiovascular event risk nor to CPAP-adherence., Conclusions: It is likely that the PLMS frequency in OSA populations has been previously overestimated. Our results suggest that there are two types of rLM, true periodic ones that happen to synchronize with the respiratory events, and periodic appearing but respiratory driven LM, and that the presence of non-respiratory PLMS is instrumental in distinguishing between the two., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI)., Methods: A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers., Main Measures: Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning., Results: Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level., Discussion: Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

Emergency departments (EDs) are eerily quiet for illnesses apart from COVID-19. In this short communication, we assessed the effect of COVID-19 on ED attendance rates for traumatic brain injury (TBI). Data were collected from all consecutive patients with TBI attending our hospital (Haaglanden Medical Center, The Hague, The Netherlands) during the first 3 weeks of the Dutch lockdown (from March 18 to April 6) and for the same period last year. We observed a 36% decrease in ED attendance for TBI since the beginning of the SARS-CoV-2 pandemic (91 vs. 143). Patients who presented during the lockdown were significantly older compared with the patients who visited the ED in the previous year (72 vs. 57, p  = 0.01). No other significant differences were found., Competing Interests: No competing financial interests exist., (© Juliette A.L. Santing et al., 2020; Published by Mary Ann Liebert, Inc.)

Objective: Surgery and specifically burr hole craniostomy is the most common first choice treatment of patients with Chronic Subdural Hematoma (CSDH). However, several aspects of neurosurgical and peri-operative management are still a subject of research, such as how to treat bilateral CSDH and the anesthetic approach. We aim to investigate the effect of the surgical approach to bilateral CSDH and the effect of anesthesia modality on outcome of CSDH patients. Methods: We retrospectively included surgically treated CSDH patients between 2005 and 2019 in three hospitals in the Netherlands. The effect of the surgical approach to bilateral CSDH (unilateral vs. bilateral decompression) and anesthesia modality (general vs. local anesthesia) on outcome (complications, recurrence, and length of hospital stay over 4 days) was studied with logistic regression adjusting for potentially confounding radiological and clinical characteristics. Results: Data of 1,029 consecutive patients were analyzed, mean age was 73.5 years (±11) and 75% of patients were male. Bilateral CSDH is independently associated with an increased risk of recurrence within 3 months in logistic regression analysis (aOR 1.7, 95% CI: 1.1-2.5) but recurrence rate did not differ between primary bilateral or unilateral decompression of bilateral CSDH. (15 vs. 17%, p = 0.775). Logistic regression analysis showed that general anesthesia was independently associated with an increased risk of complications (aOR 1.8, 95% CI: 1.0-3.3) and with a length of hospital admission of over 4 days (aOR 8.4, 95% CI: 5.6-12.4). Conclusions: Bilateral CSDH is independently associated with higher recurrence rates. As recurrence rates in bilateral CSDH are similar for different surgical approaches, the optimal choice for primary bilateral decompression of bilateral CSDH could vary per patient. General anesthesia for surgical treatment of CSDH is associated with higher complication rates and longer hospital admission., (Copyright © 2020 Blaauw, Jacobs, den Hertog, van der Gaag, Jellema, Dammers, Lingsma, Naalt, Kho and Groen.)

Introduction : 9-20% of the patients with an external ventricular drain develop a catheter-associated infection. Areas covered : This review summarizes the diagnostic process and management of bacterial external ventricular catheter-associated infection. Expert commentary : Current literature shows that no single CSF-, blood- or microbiological measure can be used to differentiate between an infection and sterile inflammation. The gold standard of diagnosis remains CSF culture. Empiric antimicrobial treatment consists of vancomycin combined with an anti-pseudomonal β-lactam. The increase in multi-drug resistant Gram-negative bacteria is an emerging problem in the treatment. Preventive measures and antibiotic-impregnated drains have shown to contribute to reducing incidence of external ventricular drain-associated infections.

Worldwide, different strategies are being applied for symptomatic chronic subdural hematoma (CSDH). The aim of this study was to evaluate the efficacy of two treatment strategies for symptomatic CSDH: initial dexamethasone (DXM) therapy versus primary surgery by burr hole craniostomy (BHC). We retrospectively collected data for 120 symptomatic CSDH patients in two neurotrauma centers between 2014 and 2016, each with their own treatment protocol. Sixty patients received primary BHC (center A), and another 60 initial DXM therapy (center B). Primary outcome was evaluated by dichotomized modified Rankin Scale (mRS) score (0-3 and 4-6) and Markwalder Grading Scale (MGS) score at 3 months. Secondary outcomes were additional interventions, CSDH recurrence, mortality, complications, and duration of hospital stay. Baseline characteristics were similar in both groups. At 3 months, a favorable mRS score (0-3) was observed in 70% and 76% of patients in cohort A and B, respectively (odds ratio [OR] 0.77, 95% CI 0.30-1.98; p  = 0.59). A favorable MGS score (0-1) was observed in 96% of patients in both groups (OR 0.98, 95% CI 0.45-2.15; p  = 0.95). CSDH recurrence was 12% in cohort A and 22% in cohort B ( p  = 0.15). Mortality was 10% in both cohorts. In cohort B, additional surgery was performed in 83% at a median of 6 days, and significantly more patients had complications (55% vs. 35%, p  = 0.02), a prolonged hospitalization (10 vs. 5 days; p  = 0.02), and one or more follow-up cranial CT's (85% vs. 48%; p  < 0.001). To achieve a favorable clinical outcome, initial DXM therapy was associated with a high rate of crossover to surgery, significantly longer overall hospital stay, and more complications compared with primary surgery.

Objective: To determine the diagnostic value of clinical factors and biochemical or microbiological measures for diagnosing a drain-associated ventriculitis, we summarized the available evidence., Methods: We performed a systematic review and meta-analysis of studies of patients with external ventricular CSF drains who developed drain-associated ventriculitis by searching MEDLINE, EMBASE, and CENTRAL electronic database. We reported the occurrence of abnormal test results in patients with and without drain-associated ventriculitis. For continuous variables, we recalculated mean values presented in multiple studies., Results: We identified 42 articles published between 1984 and 2018 including 3,035 patients with external CSF drains of whom 697 (23%) developed drain-associated bacterial ventriculitis. Indications for drain placement were subarachnoid, intraventricular or cerebral hemorrhage or hemorrhage not further specified (69%), traumatic brain injury (13%), and obstructive hydrocephalus secondary to a brain tumor (10%). Fever was present in 116 of 162 patients with ventriculitis (72%) compared with 80 of 275 (29%) patients without ventriculitis. The CSF cell count was increased for 74 of 80 patients (93%) with bacterial ventriculitis and 30 of 95 patients (32%) without ventriculitis. CSF culture was positive in 125 of 156 episodes classified as ventriculitis (80%), and CSF Gram stain was positive in 44 of 81 patients (54%). In patients with ventriculitis, PCR on ribosomal RNA was positive on 54 of 78 CSF samples (69%)., Conclusion: Clinical factors and biochemical and microbiological measures have limited diagnostic value in differentiating between ventriculitis and sterile inflammation in patients with external CSF drains. Prospective well-designed diagnostic accuracy studies in drain-associated ventriculitis are needed., (© 2019 American Academy of Neurology.)

In the emergency department, we see many patients with minor head injury (MHI). To help physicians decide which patient should have a CT scan, decision rules have been developed that calculate the risk of intracranial complications based on a number of criteria. One of those decision rules is the CT in Head Injury Patients (CHIP) decision rule on which the Dutch national MHI guideline is based. In a recent hospital-based study in the Netherlands, the CHIP decision rule and three other decision rules were investigated. The different decision rules showed a variation in the percentage of unnecessary CT scans and failure to identify traumatic abnormalities on CT. The CHIP decision rule performed the best, but an update of the decision rule is needed. We expect that the results of our study and future update of the CHIP decision rule can contribute to an effective decision rule for clinical practice.

Objective: The objective of this study was to assess the incidence and characteristics of patients presenting with physical symptoms that remain medically unexplained at the emergency department (ED)., Patients and Methods: A retrospective chart study was carried out in three hospitals in The Netherlands and Belgium. All patients (age > 18 years) visiting the ED in 4 selected weeks in 2013 at the Erasmus University Medical Center (Erasmus MC) in Rotterdam, The Netherlands, and 1 selected week in 2013 at the Haaglanden Medical Center, Westeinde HMC in The Hague, The Netherlands, and the University Hospital Ghent (UZG), Belgium, were included. Descriptive statistics were used for data analysis., Results: A total of 2869 patients (Erasmus MC 1674, HMC 691, UZG 504) were included. Medically unexplained physical symptoms in the emergency department (EDMUPS) were present in 13.4% of all ED visits (Erasmus MC 12.5%, HMC 18.7%, UZG 9.1%). No EDMUPS were identified in trauma patients. When excluding trauma patients, EDMUPS were present in 18.5% (Erasmus MC 16.8%, HMC 26.5%, UZG 13.3%) of the visits. The characteristics of patients with and without EDMUPS differed significantly; patients with EDMUPS were more often younger, female, self-referred, frequent visitors, were prescribed less medication and more often had a psychiatric disease. Dutch and Belgian Hospital differed in the distribution of patients in triage categories and in the incidence of psychiatric illnesses., Conclusion: Physical symptoms remain unexplained in a significant number of patients at the time of ED assessment.

Background: There is an ongoing debate on the role of corticosteroids in the treatment of chronic subdural hematoma (CSDH). This study aims to evaluate the effectiveness of corticosteroids for the treatment of CSDH compared to surgery., Method: A systematic search was performed in relevant databases up to January 2019 to identify RCTs or observational studies that compared at least two of three treatment modalities: the use of corticosteroids as a monotherapy (C), corticosteroids as an adjunct to surgery (CS), and surgery alone (S). Outcome measures were good neurological outcome, need for reintervention, mortality, and complications. Effect estimates were pooled and presented as relative risk (RR) with 95% confidence interval (95%CI)., Results: Of 796 initially identified studies, 7 were included in the meta-analysis. Risk of bias was generally high. There were no differences in good neurological outcome between treatment modalities. The need for reintervention varied between 4 and 58% in C, 4-12% in CS, and 7-26% in S. The need for reintervention was lower in CS compared with C (RR 3.34 [95% CI 1.53-7.29]; p < 0.01) and lower in CS compared with S (RR 0.44 [95% CI 0.27-0.72]; p < 0.01). Mortality varied between 0 and 4% in C, 0-13% in CS, and 0-44% in S. Mortality was lower in CS compared with S (RR 0.39 [95% CI 0.25-0.63]; p < 0.01). There were no differences in complications between treatment modalities., Conclusions: This meta-analysis suggests that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH.

A lumbar puncture (LP) is often essential for the diagnosis of bacterial meningitis. An LP can worsen brain displacement in case of a space-occupying lesion. Therefore, in selected patients a CT scan of the brain is made prior to performing the LP. However, the level of agreement between experts in diagnosing a contraindication for LP on CT scan is low. More importantly, in a substantial part of patients, empirical treatment with antibiotics was delayed due to the CT scan being performed first. The only effective treatment for patients with bacterial meningitis is early administration of antibiotics. Therefore, delay in administrating antibiotics should be prevented. Thus, should a CT scan of the brain be indicated, antibiotic treatment should be started before said imaging diagnostics and/or a potential LP procedure.

Background: Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. The effects of epidemiological changes such as ageing of the population and increased traffic safety on the incidence of TBI are unknown., Objective: The objective of this study was to evaluate trends in TBI-related emergency department (ED) visits, hospitalization and mortality in the Netherlands between 1998 and 2012., Design: This was a retrospective observational, longitudinal study., Main Outcome Measures: The main outcome measures were TBI-related ED visits, hospitalization and mortality., Results: Between 1998 and 2012, there were 500 000 TBI-related ED visits in the Netherlands. In the same period, there were 222 000 TBI-related admissions and 17 000 TBI-related deaths. During this period, there was a 75% increase in ED visits for TBI and a 95% increase for TBI-related hospitalization; overall mortality because of TBI did not change significantly. Despite the overall increase in TBI-related ED visits, this increase was not evenly distributed among age groups or trauma mechanisms. In patients younger than 65 years, a declining trend in ED visits for TBI caused by road traffic accidents was observed. Among patients 65 years or older, ED visits for TBI caused by a fall increased markedly. TBI-related mortality shifted from mainly young (67%) and middle-aged individuals (<65 years) to mainly elderly (63%) individuals (≥65 years) between 1998 and 2012. The conclusions of this study did not change when adjusting for changes in age, sex and overall population growth., Conclusion: The incidence of TBI-related ED visits and hospitalization increased markedly between 1998 and 2012 in the Netherlands. TBI-related mortality occurred at an older age. These observations are probably the result of a change in aetiology of TBI, specifically a decrease in traffic accidents and an increase in falls in the ageing population. This hypothesis is supported by our data. However, ageing of the population is not the only cause of the changes observed; the observed changes remained significant when correcting for age and sex. The higher incidence of TBI with a relatively stable mortality rate highlights the importance of clinical decision rules to identify patients with a high risk of poor outcome after TBI.

Objective: A substantial part of non-traumatic intracerebral haemorrhages (ICH) arises from a macrovascular cause, but there is little guidance on selection of patients for additional diagnostic work-up. We aimed to develop and externally validate a model for predicting the probability of a macrovascular cause in patients with non-traumatic ICH., Methods: The DIagnostic AngioGRAphy to find vascular Malformations (DIAGRAM) study (n=298; 69 macrovascular cause; 23%) is a prospective, multicentre study assessing yield and accuracy of CT angiography (CTA), MRI/ magnetic resonance angiography (MRA) and intra-arterial catheter angiography in diagnosing macrovascular causes in patients with non-traumatic ICH. We considered prespecified patient and ICH characteristics in multivariable logistic regression analyses as predictors for a macrovascular cause. We combined independent predictors in a model, which we validated in an external cohort of 173 patients with ICH (78 macrovascular cause, 45%)., Results: Independent predictors were younger age, lobar or posterior fossa (vs deep) location of ICH, and absence of small vessel disease (SVD). A model that combined these predictors showed good performance in the development data (c-statistic 0.83; 95% CI 0.78 to 0.88) and moderate performance in external validation (c-statistic 0.66; 95% CI 0.58 to 0.74). When CTA results were added, the c-statistic was excellent (0.91; 95% CI 0.88 to 0.94) and good after external validation (0.88; 95% CI 0.83 to 0.94). Predicted probabilities varied from 1% in patients aged 51-70 years with deep ICH and SVD, to more than 50% in patients aged 18-50 years with lobar or posterior fossa ICH without SVD., Conclusion: The DIAGRAM scores help to predict the probability of a macrovascular cause in patients with non-traumatic ICH based on age, ICH location, SVD and CTA., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Patients with acute headache increasingly undergo CT-angiography (CTA) to evaluate underlying vascular causes. The aim of this study is to determine clinical and non-contrast CT (NCCT) criteria to select patients who might benefit from CTA., Methods: We retrospectively included patients with acute headache who presented to the emergency department of an academic medical center and large regional teaching hospital and underwent NCCT and CTA. We identified factors that increased the probability of finding a vascular abnormality on CTA, performed multivariable regression analyses and determined discrimination with the c-statistic., Results: A total of 384 patients underwent NCCT and CTA due to acute headache. NCCT was abnormal in 194 patients. Among these, we found abnormalities in 116 cases of which 99 aneurysms. In the remaining 190 with normal NCCT we found abnormalities in 12 cases; four unruptured aneurysms, three cerebral venous thrombosis', two reversible cerebral vasoconstriction syndromes, two cervical arterial dissections and one cerebellar infarction. In multivariable analysis abnormal NCCT, lowered consciousness and presentation within 6 hr of headache onset were independently associated with abnormal CTA. The c-statistic of abnormal NCCT alone was 0.80 (95% CI: 0.75-0.80), that also including the other two variables was 0.84 (95% CI: 0.80-0.88). If NCCT was normal no other factors could help identify patients at risk for abnormalities., Conclusions: In patients with acute headache abnormal NCCT is the strongest predictor of a vascular abnormality on CTA. If NCCT is normal no other predictors increase the probability of finding an abnormality on CTA and diagnostic yield is low., (© 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

Background: Patients with acute severe headache, normal neurological examination, and a normal noncontrast head computed tomography (NCCT) may still have subarachnoid hemorrhage, cerebral venous thrombosis (CVT), cervical arterial dissection, or reversible cerebral vasoconstriction syndrome (RCVS). Computed tomography angiography (CTA) is used increasingly in the emergency department for evaluating this, but its added value remains controversial., Methods: We retrospectively collected data on the diagnostic yield of CTA in patients with acute severe headache, normal neurological examination, and normal NCCT who received additional CTA in the acute phase in 2 secondary referral centers for vascular neurology. We combined data of our patients with those from the literature and performed a meta-analysis., Results: We included 88 patients from our hospital files and 641 patients after literature search. Of 729 patients 54 had a vascular abnormality on CTA (7.4%; 95% confidence interval [CI] 5.5%-9.3%). Abnormalities consisted of aneurysms (n = 42; 5.4%; 95% CI 3.8%-7.0%), CVT (n = 3, .5%), RCVS (n = 4, .5%), Moyamoya syndrome (n = 2, .3%), arterial dissection (n = 2, .3%), and ischemia (n = 1, .1%). Because most of the aneurysms were probably incidental findings, only 12 (1.6%) patients had a clear relation between the headache and CTA findings. The number needed to scan to find an abnormality was 14 overall, and 61 for an abnormality other than an aneurysm., Conclusion: Diagnostic yield of CTA in patients with acute headache, normal neurological examination, and normal NCCT is low, but because of the possible therapeutic consequences, its use might be justified in the emergency setting. Prospective studies confirming these results including cost-effectiveness analyses are needed., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Emergency departments (EDs) worldwide face crowding, which hampers patient flow. In this study, the impact of a dedicated neurologist present at the ED on patient flow during out-of-office hours was assessed., Methods: A cross-sectional, mixed methods study was undertaken at a Dutch ED, including a pre-post analysis of data of patients who had a primary neurological disease (n = 458) and staff surveys (n = 152). Descriptive statistics and content analysis were used for analyses., Results: Despite a 36% increase in the number of neurological patients (control period: n = 194, intervention period n = 264), a 30 min per patient decrease in ED median length of stay (LOS) was reached during the intervention period. Furthermore, the admission percentage decreased significantly (57.7% in the control period vs. 47.7% in the intervention period, p = 0.03). During half of the shifts neurologists stated that their presence had been valuable. Perceived reasons for this added value mentioned were improved quality of care, enhanced throughput of patients, and quicker consultations with other medical specialists., Conclusions: In our hypothesis-generating study, a dedicated neurologist present at the ED during out-of-office hours was associated with decreased patients' LOS and a decreased admission percentage, indicating increased decisiveness when the neurologist is present at the ED.

Background: Periodic leg movements during sleep (PLMS) have been associated with an increased risk for cardiovascular diseases and there is a high prevalence of PLMS found in patients with obstructive sleep apnea syndrome (OSAS). We evaluated patients with transient ischemic attack (TIA) for PLMS and respiratory related leg movements (RRLM), versus a control group without TIA., Methods: Twenty-five patients with TIA and 34 patients with no vascular diagnosis were referred for polysomnography. Diagnosis of PLMS was made if the periodic leg movement index (PLMI) was ≥5 and clinical significant as PLMI ≥15., Results: There was no significant difference in PLMI ≥5 and ≥15 between patients with and without TIA. In the absence of OSAS, 2 out of 5 TIA patients (40%) had a PLMI ≥15 compared to 1 of the 19 patients without TIA (5%; p = 0.037). There was no increase in RRLMs when OSAS was present., Conclusions: TIA patients did not have higher PLMI compared to controls, and in the presence of OSAS, there was no increase in RRLMs compared to patients without TIA. In selective patients, PLMS could be associated with cardiovascular diseases, since PLMS was clinically more often found in the TIA group without OSAS., (© 2018 S. Karger AG, Basel.)

Cerebral venous sinus thrombosis is a rare cause of stroke, which is routinely treated with systemic heparin. Unfavourable outcome is often seen in severe cases. Therefore alternative treatment methods should be explored in these patients. Due to the risk of haemorrhagic complications, treatment without administration of thrombolytics is of particular interest. This report presents a case of successful mechanical thrombectomy, without the use of thrombolytics, in a comatose patient with cerebral venous sinus thrombosis.