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Background: Aneurysmal subdural hematoma (aSDH) is a rare complication of aneurysm rupture, affecting between 0.5 and 7.9% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The clinical presentation, course, and outcomes of these patients are largely unknown. Objective: This study aims to systematically review the literature to evaluate the demographics, clinical presentation, aneurysm location, treatment options, and outcomes of patients with aSDH with and without aSAH. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review of three databases (PubMed, EMBASE, and Google Scholar). From identified reports, we extracted data on patients' demographics, clinical presentation, imaging findings, surgical interventions, and clinical outcomes. We compared clinical outcomes, need for surgical treatment, and aneurysm location between patients with aSDH with and without concurrent aSAH using χ2 and Fisher's exact tests. We used simple and multivariable logistic regression models to further examine the association between the presence of aSAH and surgical treatment with clinical outcomes. Results: We identified 112 articles with a total of 270 patients (70% women, mean age 52.8 [± 15.5] years). The most common aneurysm locations were the middle cerebral artery, followed by the posterior communicating artery, and the internal carotid artery. Patients with isolated aSDH fully recovered more frequently than those with concomitant aSAH (38% vs. 6%). The presence of aSAH increased the odds of unfavorable outcome (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.34–5.37). Surgical treatment was inversely associated with unfavorable outcome in the univariable (OR 0.48, 95% CI 0.28–0.84) but not in the multivariable analysis (OR 0.76, 95% CI 0.35–1.66). Conclusion: aSDH occurs infrequently. Simultaneous presence of both aSDH and aSAH from an aneurysmal source is associated with poor outcomes. Surgical treatment is associated with lower rates of unfavorable outcomes including death and severe disability. [ABSTRACT FROM AUTHOR]

Abstract Background Traumatic acute subdural haematoma is a debilitating condition. Laterality intuitively influences management and outcome. However, in contrast to stroke, this research area is rarely studied. The aim is to investigate whether the hemisphere location of the ASDH influences patient outcome. Methods For this multicentre observational retrospective cohort study, patients were considered eligible when they were treated by a neurosurgeon for traumatic brain injury between 2008 and 2012, were > 16 years of age, had sustained brain injury with direct presentation to the emergency room and showed a hyperdense, crescent shaped lesion on the computed tomography scan. Patients were followed for a duration of 3-9 months post-trauma for functional outcome and 2-6 years for health-related quality of life. Main outcomes and measures included mortality, Glasgow Outcome Scale and the Quality of Life after Brain Injury score. The hypothesis was formulated after data collection. Results Of the 187 patients included, 90 had a left-sided ASDH and 97 had a right-sided haematoma. Both groups were comparable at baseline and with respect to the executed treatment. Furthermore, both groups showed no significant difference in mortality and Glasgow Outcome Scale score. Health-related quality of life, assessed 59 months (IQR 43-66) post-injury, was higher for patients with a right-sided haematoma (Quality of Life after Brain Injury score: 80 vs 61, P = 0.07). Conclusions This study suggests patients with a right-sided acute subdural haematoma have a better long-term health-related quality of life compared to patients with a left-sided acute subdural haematoma.

Background Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity. Economic impact is much worse in developing countries like Bangladesh, as victims are frequently male, productive, and breadwinners of the families. Objectives The objective of our study was to highlight the etiological pattern and distribution of varieties of head injuries in Bangladesh and give recommendations regarding how this problem can be solved or reduce to some extent at least. Methods From January 2017 to December 2019, a total of 14,552 patients presenting with head injury at emergency got admitted in Neurosurgery department of Dhaka Medical College and Hospital and were included in this study. Results The most common age group was 21 to 30 years (36%: 5,239) with a male-to-female ratio of 2.6:1. Injury was mostly caused by road traffic accident (RTA[58.3%: 8,484]), followed by fall (25%: 3,638) and history of assault (15.3%: 2,226). The common varieties of head injury were: acute extradural hematoma (AEDH [42.30%: 1,987]), skull fracture either linear or depressed (28.86%: 1,347), acute subdural hematoma (ASDH [12.30%: 574]), brain contusion (10.2%: 476), and others (6.04%: 282). Conclusion RTA is the commonest cause of TBI, and among them motor bike accident is the severe most form of TBI. AEDH is the commonest variety of head injuries. Proper steps taken by the Government, vehicle owners, and drivers, and proper referral system and prompt management in the hospital can reduce the mortality and morbidity from TBI in Bangladesh. [ABSTRACT FROM AUTHOR]

Background: The incidence of traumatic acute subdural hematomas (ASDH) in the elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays no clear role as a predictor. We investigated whether the timing of surgery had a major role in influencing the outcome in these patients. Methods: We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 year period in five Italian hospitals. Patients were divided into three surgical timing groups from hospital arrival: ultra-early (within 6 h); early (6–24 h); and delayed (after 24 h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at the Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed. Results: We included 136 patients. About 33% died as a result of the consequences of ASDH and among the survivors, only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting the Glasgow Outcome Scale (GCS), which was on average lower in the ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared to be neither associated with survival nor with functional outcome, also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor. Conclusions: An earlier surgery was offered to patients with worse clinical-radiological findings. Additionally, after stratification for GCS, it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor. [ABSTRACT FROM AUTHOR]

Background: Traumatic acute subdural haematoma is a debilitating condition. Laterality intuitively influences management and outcome. However, in contrast to stroke, this research area is rarely studied. The aim is to investigate whether the hemisphere location of the ASDH influences patient outcome.Methods: For this multicentre observational retrospective cohort study, patients were considered eligible when they were treated by a neurosurgeon for traumatic brain injury between 2008 and 2012, were > 16 years of age, had sustained brain injury with direct presentation to the emergency room and showed a hyperdense, crescent shaped lesion on the computed tomography scan. Patients were followed for a duration of 3-9 months post-trauma for functional outcome and 2-6 years for health-related quality of life. Main outcomes and measures included mortality, Glasgow Outcome Scale and the Quality of Life after Brain Injury score. The hypothesis was formulated after data collection.Results: Of the 187 patients included, 90 had a left-sided ASDH and 97 had a right-sided haematoma. Both groups were comparable at baseline and with respect to the executed treatment. Furthermore, both groups showed no significant difference in mortality and Glasgow Outcome Scale score. Health-related quality of life, assessed 59 months (IQR 43-66) post-injury, was higher for patients with a right-sided haematoma (Quality of Life after Brain Injury score: 80 vs 61, P = 0.07).Conclusions: This study suggests patients with a right-sided acute subdural haematoma have a better long-term health-related quality of life compared to patients with a left-sided acute subdural haematoma. [ABSTRACT FROM AUTHOR]

Acute subdural hematoma (ASDH) caused by bridging vein (BV) rupture is a frequent and lethal brain injury, especially in the elderly. Brain atrophy has been hypothesized to be a primary pathogenesis associated with the increased risk of ASDH in the elderly. Although decades of biomechanical endeavors have been made to elucidate the potential mechanisms, a thorough explanation for this hypothesis appears lacking. Therefore, a recently improved finite element head model, in which the brain–skull interface was modeled using a fluid-structure interaction (FSI) approach with special treatment of the cerebrospinal fluid as arbitrary Lagrangian–Eulerian fluid formulation, is used to partially address this understanding gap. Models with various degrees of atrophied brains and thereby different subarachnoid thicknesses are generated and subsequently exposed to experimentally determined loadings known to cause ASDH or not. The results show significant increases in the cortical relative motion and BV strain in the atrophied brain, which consequently exacerbates the ASDH risk in the elderly. Results of this study are suggested to be considered when developing age-adapted protecting strategies for the elderly in the future. [ABSTRACT FROM AUTHOR]

Background Rapidly resolving acute subdural hematomas (RRASDHs) have been described in case reports and case series but are still poorly understood. We hypothesized that a cohort analysis would confirm previously reported predictors of RRASDH including coagulopathy, additional intracranial hemorrhage, and low-density band on imaging. We also hypothesized that rapid resolution would be associated with improved trauma outcomes. Methods We reviewed all nonoperative acute subdural hematomas (ASDHs) treated at our center from 2011 to 2015. Inclusion criteria were ASDH on computed tomography (CT), admission Glasgow coma score >7, and repeat CT to evaluate ASDH change. RRASDH was defined as reduced hematoma thickness by 50% within 72 h. Clinical data, CT findings, and trauma end points were analyzed for the RRASDH and nonresolving groups. Results There were 154 ASDH patients included, with 29 cases of RRASDH. The RRASDH group had a lower rate of comorbidities than the nonresolving group (58.6% versus 78.4%, P = 0.03) and a lower rate of prehospital anticoagulation (7.7% versus 37.1%, P = 0.004). Previously reported predictors of RRASDH did not differ between the groups, nor did any clinical outcome measures. When compared with patients who experienced rapid growth (>50% increased width in 72 h), the RRASDH group had lower mortality (3.4% versus 23.5%, P = 0.04). Conclusions To our knowledge, this is the largest review of RRASDHs. We identified two previously unrecognized factors that may predict resolution; however, previously reported predictors were not associated with resolution. We also found no relationship between RRASDHs and improved standard trauma outcomes, calling into question the clinical significance of RRASDH. [ABSTRACT FROM AUTHOR]

Several recent global traumatic brain injury (TBI) initiatives rely on practice variation in diagnostic and treatment methods to answer effectiveness questions. One of these scientific dilemmas, the surgical management of the traumatic acute subdural hematoma (ASDH) might be variable among countries, among centers within countries, and even among neurosurgeons within a center, and hence be amenable for a comparative effectiveness study. The aim of our questionnaire, therefore, was to explore variations in treatment for ASDH among neurosurgeons in similar centers in a densely populated geographical area. An online questionnaire, involving treatment decisions on six case vignettes of ASDH, was sent to 93 neurosurgeons in The Netherlands and Belgium. Clinical and radiological variables differed per case. Sixty neurosurgeons filled out the questionnaire (response rate 65%). For case vignettes with severe TBI and an ASDH, there was a modest variation in the decision to evacuate the hematoma and a large variation in the decision to combine the evacuation with a decompressive craniectomy. The main reasons for operating were 'neurological condition' and 'mass effect.' For ASDH and mild/moderate TBI, there was large variation in the decision of whether to operate or not, whereas 'hematoma size' was the predominant motivation for surgery. Significant inter-center variation for the decision to evacuate the hematoma was observed ( p = 0.01). Most pronounced was that 1 out of 7 (14%) neurosurgeons in one region chose a surgical strategy compared with 9 out of 10 (90%) in another region for the same scenario. In conclusion, variation exists in the neurosurgical management of TBI within an otherwise homogeneous setting. This variation supports the methodology of the international Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) initiative, and shaped the Dutch Neurotraumatology Quality Registry (Net-QuRe) initiative. [ABSTRACT FROM AUTHOR]

It is well established that the probability of occurrence of acute subdural hematomas in traumatic situations increases with age, since the main cause of such hematomas is the mechanical failure of cerebral blood vessels known as bridging veins. This research aims to determine whether there is an effect of age on the mechanical properties of these cerebral vessels, because previous reported studies were conflicting. This study used mechanical tests blue of cerebral bridging veins from post-mortem human subjects. In particular, a series of in vitro tensile tests were performed on a balanced sample of bridging veins from different human subjects. The mechanical parameters measured from the tests were analyzed by means of regression analysis looking for age related effects. The results show that there is a significant effect on both the ultimate strength, maximum stress and strain that the specimens can withstand. The quantitative analysis shows reductions of nearly 50% in ultimate stress, and almost 35% in ultimate strain. Mechanical deterioration of the mechanical strength of cerebral blood vessels seems to be a major factor involved in the increase of frequency of acute subdural hematoma in elderly people in a wide range of life-threatening traumatic situations. • Cerebral Blood Vessels present a deterioration with age. • Mechanical stregnth of Cerebral Blood Vessels become lower as the age increases. • Ultimate stress and strain of Cerebral Blood Vessels are lower for elderly people. [ABSTRACT FROM AUTHOR]

Objective Despite recent progress, prognosis for the elderly (defined as aged ≥70 years) afflicted by traumatic brain injury (TBI) is unfavorable and surgical intervention remains controversial. Research during the past decade on the mortality rates or prognostic factors for survival in the elderly is limited. Methods We analyzed 97 patients aged ≥70 years who were treated surgically for closed TBI at our neurosurgical unit between January 1, 2003 and December 31, 2012. In addition, we analyzed 22 patients aged ≥70 years who had sustained a closed TBI and on whom no neurosurgical intervention was performed. Outcome in both groups was measured as 30-, 90- and 180-day mortality. Results Surgically treated patients: median age, 76 years' 30-day overall mortality rate, 36%. Higher mortality was seen with lower level of consciousness, high energy trauma, one pupil fixed and dilated, and more extensive intracranial pathology. Presence of warfarin, more advanced age, or degree of midline shift were not associated with worsened outcome. Patients not treated neurosurgically: median age. 81.5 years; 30-day overall mortality rate, 23%. Mortality for patients with Glasgow coma scale (GCS) 10–15 was 6%, GCS 6–9 67%, and GCS 3–5 100%. Conclusions Selected patients aged ≥70 years can benefit from surgical intervention for closed TBI. Level of consciousness, radiologic type of injury, mechanism of injury, and pupil abnormalities should be carefully evaluated. There also seems to exist a group of patients in whom surgical intervention offers little benefit, as mortality rate is low without surgical intervention. [ABSTRACT FROM AUTHOR]

Blunt and rotational head impacts due to vehicular collisions, falls and contact sports cause relative motion between the brain and skull. This increases the normal and shear stresses in the (skull/brain) interface region consisting of cerebrospinal fluid (CSF) and subarachnoid space (SAS) trabeculae. The relative motion between the brain and skull can explain many types of traumatic brain injuries (TBI) including acute subdural hematomas (ASDH) and subarachnoid hemorrhage (SAH) which is caused by the rupture of bridging veins that transverse from the deep brain tissue to the superficial meningeal coverings. The complicated geometry of the SAS trabeculae makes it impossible to model all the details of the region. Investigators have compromised this layer with solid elements, which may lead to inaccurate results. In this paper, the failure of the cerebral blood vessels due to the head impacts have been investigated. This is accomplished through a global/local modelling approach. Two global models, namely a global solid model (GSM) of the skull/brain and a global fluid model (GFM) of the SAS/CSF, were constructed and were validated. The global models were subjected to two sets of impact loads (head injury criterion, HIC = 740 and 1044). The relative displacements between the brain and skull were determined from GSM. The CSF equivalent fluid pressure due to the impact loads were determined by the GFM. To locally study the mechanism of the injury, the relative displacement between the brain and skull along with the equivalent fluid pressure were implemented into a new local solid model (LSM). The strains of the cerebral blood vessels were determined from LSM. These values were compared with their relevant experimental ultimate strain values. The results showed an agreement with the experimental values indicating that the second impact (HIC = 1044) was strong enough to lead to severe injury. The global/local approach provides a reliable tool to study the cerebral blood vessel ruptures leading to ASDH and/or SAH. [ABSTRACT FROM AUTHOR]

In plant and microorganisms, aspartate semialdehyde dehydrogenase (ASDH) produces the branch point intermediate between the lysine and threonine/methionine pathways. In this study, we report the first cDNA cloning, purification, and characterization of a plant ASDH. The Arabidopsis thaliana ASDH is an homodimeric enzyme composed of subunits of 36 kDa. The plant enzyme exhibited a specific activity of 26 μmol NADPH oxidized min−1 mg−1 of protein with a KM value for NADPH of 92 μM. ASDH showed cooperative behavior for aspartyl phosphate with a K0.5 value of 37 μM. [Copyright &y& Elsevier]

Objective To discuss the pathologic mechanism of subacute subdural hematoma (sASDH). Methods Three typical cases of sASDH were reported, and related literature in Chinese published in the past 15 years was reviewed. Results Intervals from onset of acute subdural hematoma to surgery or symptom deterioration resulting in sASDH were 12.5–15.5 days (mean 14.1 days). Delayed liquefaction of hematoma clots occurred in all 3 reported cases. One patient achieved good curative effect after administration of dexamethasone, and another patient relapsed owing to poor drainage after evacuation of hematoma. Conclusions The conversion of acute subdural hematoma to sASDH is an inflammatory reaction process with very regular in time, and it is speculated that the pathologic mechanism may be a delayed hypersensitivity reaction. Antigen released during the liquefaction process of blood clot, with subdural neomembrane cells as antigen-presenting cells, is presented to the T lymphocytes released from the capillaries in the neomembrane and forms sensitized T lymphocytes. When the subsequent antigen is released from the blood clots with a delayed liquefaction and is exposed to sensitized T lymphocytes, the delayed hypersensitivity process occurs. [ABSTRACT FROM AUTHOR]

The principal aim in the management of patients with cerebral contusion (CC) following severe traumatic brain injury (TBI) is the prevention, amelioration, and treatment of secondary neuronal dysfunction and pathology. Distinguishing between irreversibly damaged and surviving tissue could have considerable therapeutic and prognostic implications for patients. To characterize structurally the neuronal compartment of the contused region in samples derived from patients who suffered severe TBI and were subjected to decompressive craniectomy, we used NeuN, a neuronal marker. We determined that NeuN "patches", sectors with loss of NeuN immunoreactivity (NeuN-IR), represented 25% of the area among the analyzed cases. We also found a 67% decrease in NeuN levels via Western blot. Tissue adjoining patches of NeuN-IR were considered "preserved" due to the apparent normal density of neurons and conservation of the six cortical layers. Nevertheless, these sectors retained only 39% of their neurons with the classical pattern described for normal NeuN-IR. Using Fluorojade we identified a 16-fold increase in density of moribund neurons in "preserved" sectors when compared to controls. Additionally these abnormalities were enhanced 5-fold in "patches" of NeuN-IR when compared to preserved regions. Therefore, NeuN/Fluorojade abnormalities are indicative of different cell fates characteristic of CC tissue. This analysis addressed exclusively the neuronal compartment and provides new insights into the degenerative state of neurons in the contused region that is likely to contribute to clinical outcome and differentiate TBI from ischemia., (© 2013 Elsevier B.V. All rights reserved.)