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Abstract: Intracranial hemorrhage is a potentially life-threatening condition categorized into four main groups by the location of bleeding: epidural, subdural, subarachnoid, and intraparenchymal. Subdural hematoma (SDH) is increasingly common as the population of older adults increases. Clinicians must recognize the typical presentations and order diagnostic imaging studies to make a timely diagnosis and referral to neurosurgery for definitive treatment. Understanding the pathophysiology and risk factors for chronic or expanding SDH informs decision-making in managing anticoagulants. Emerging treatments offer potential alternatives to the traditional evacuation of SDH by craniotomy, which remains the standard of care for most symptomatic patients., (Copyright © 2024 American Academy of Physician Associates.)

Subdural hemorrhages (SDHs) in the pediatric population are associated with a high mortality and morbidity and may present in the context of abusive head trauma. Diagnostic investigations for such cases often include evaluation for rare genetic and metabolic disorders that can have associated SDH. Sotos syndrome is an overgrowth syndrome associated with macrocephaly and increased subarachnoid spaces and rarely with neurovascular complications. Here, we report two cases of Sotos syndrome, one with SDH during infancy who underwent repeated evaluation for suspected child abuse prior to the Sotos syndrome diagnosis and the other with enlarged extra-axial cerebrospinal fluid spaces, demonstrating a possible mechanism for SDH development in this setting. These cases suggest that some individuals with Sotos syndrome may be at elevated risk of developing SDH in infancy and that Sotos syndrome should be on the differential diagnosis during a medical genetics evaluation in cases of unexplained SDH, especially in the setting of macrocephaly., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Objectives: Seizures and status epilepticus (SE) are frequent complications of acute subdural hematoma (aSDH) associated with increased morbidity and mortality. Therefore, we aimed to evaluate whether invasive subdural electroencephalogram recording leads to earlier seizure detection and treatment initiation in patients with aSDH., Design: Prospective, single-center, cohort trial., Setting: Neurologic and neurosurgical ICUs of one academic hospital in Germany., Patients: Patients with aSDH undergoing surgical treatment. In total, 76 patients were enrolled in this study, 31 patients (40.8%) were assigned to the invasive electroencephalogram (iEEG) monitoring group and 45 patients (59.2%) to control group., Interventions: The electrode group was implanted with a subdural strip electrode providing up to 7 days of real-time electroencephalogram recording in the neurointensive care unit, whereas the control group received regular normal surface electroencephalograms during the 7-day period. The primary outcomes were the prevalence and time to seizures and SE occurrence. Secondary outcomes included neurologic outcomes assessed using the Glasgow Outcome Scale (GOS) at discharge and 6-month follow-up and the prevalence of focal structural epilepsy within 2 years after discharge., Measurements and Main Results: The trial was stopped after a study committee meeting when the prespecified criteria were met. The iEEG and control groups were well-matched for clinical characteristics at admission. Frequencies of seizures and SE detection were significantly higher in the iEEG group than in the control group (61% vs 15.6%; p < 0.001 and 38.7% vs 11.1%; p = 0.005). Time to seizure and SE detection was significantly earlier (median 29.2 vs 83.8 hr; p = 0.018 and 17.2 vs 83.8 hr; p = 0.033) in the iEEG group than in the control group. Favorable outcomes (GOS 4-5) were more frequently achieved in the iEEG group than in the control group (58% vs 31%; p = 0.065). No significant differences were detected in long-term mortality or post-traumatic epilepsy., Conclusions: Invasive subdural electroencephalogram monitoring is valuable and safe for early seizure/SE detection and treatment and might improve outcomes in the neurocritical care of patients with aSDH., Competing Interests: Drs. Rosenow and Strzelczyk received funding from Angelini Pharma and Desitin Arzneimittel. Dr. Rosenow’s institution received funding from Federal State of Hesse; he received funding from Eisai GmbH, Jazz Pharma, UCB Pharma, and Roche Pharma; and he received support for article research from Federal State of Hesse. Dr. Strzelczyk received funding from GW/Jazz Pharmaceuticals, Eisai, Marinus, Takeda, UCB/Zogenix, and UNEEG medical. Dr. Melzer has received honoraria for lecturing and travel expenses for attending meetings from Biogen Idec, GlaxoSmithKline, Teva, Novartis Pharma, Bayer Healthcare, Fenzyme, Alexion Pharmaceuticals, Fresenius Medical Care, Diamed, UCB Pharma, Angelini Pharma, and BIAL; he has received royalties for consulting from USB Pharma and Alexion Pharmaceuticals; and he has received support from Euroimmun Fresenius Medical Care, Diamed, Alexion Pharmaceuticals, and Novartis Pharma. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: This study aimed to investigate the application of deep learning (DL) models for the detection of subdural hematoma (SDH)., Methods: We conducted a comprehensive search using relevant keywords. Articles extracted were original studies in which sensitivity and/or specificity were reported. Two different approaches of frequentist and Bayesian inference were applied. For quality and risk of bias assessment we used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2)., Results: We analyzed 22 articles that included 1,997,749 patients. In the first step, the frequentist method showed a pooled sensitivity of 88.8% (95% confidence interval (CI): 83.9% to 92.4%) and a specificity of 97.2% (95% CI 94.6% to 98.6%). In the second step, using Bayesian methods including 11 studies that reported sensitivity and specificity, a sensitivity rate of 86.8% (95% CI: 77.6% to 92.9%) at a specificity level of 86.9% (95% CI: 60.9% to 97.2%) was achieved. The risk of bias assessment was not remarkable using QUADAS-2., Conclusion: DL models might be an appropriate tool for detecting SDHs with a reasonably high sensitivity and specificity., Competing Interests: Competing interests: AM: Speakers Bureau/Consultant to Cerenovus, Stryker, Wallaby Medical, RapidAI, BALT USA, LLC. This study did not receive funds from these companies/institutes., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists., Objectives: To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs)., Participants and Setting: Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career., Methods: This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons., Results: There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example., Conclusions: Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Multisystem Inflammatory Syndrome in Neonates (MIS-N) can occur following antenatal COVID- 19 infection in the mother. Here we report a rare case of a neonate with Hemophilia A and MIS-N., Case Presentation: A 2-day-old baby presented with an intramuscular hematoma, neonatal seizures, and isolated activated partial thromboplastin time (APTT) prolongation. The neurosonogram showed a subdural hematoma. A diagnosis of Hemophilia A was made and was confirmed by factor 8 assay and genetic analysis. Supportive measures and Factor 8 replacement was initiated. A rising trend of inflammatory markers and an ongoing need for mechanical ventilation were noted. As there was a history of COVID-19 in the mother in the third trimester, MIS-N was diagnosed. The baby was treated with intravenous immunoglobulin (IVIG) and steroids, and there was an improvement in the clinical and laboratory markers. However, the baby developed seizures on day 16. There was an increase in the subdural hemorrhage and a further rise in inflammatory markers. A craniostomy and hematoma evacuation was done and the baby improved., Conclusion: The concurrent occurrence of hemophilia A with intracranial bleed, and MIS-N in a neonate is a diagnostic challenge. It is important to have a high index of suspicion to ensure timely diagnosis and treatment of MIS-N in this pandemic era., (© 2022. The Author(s).)

Spontaneous intracranial hypotension typically manifests with orthostatic headaches and is caused by spinal dural tears, ruptured meningeal diverticula, or CSF-venous fistulas. While most patients are diagnosed and treated in the outpatient setting, some patients will occasionally present in the emergent ICU setting due to subdural hematomas, coma, or downward brain herniation. In this review paper, we will discuss the diagnostic and treatment steps that intensivists can undertake to coordinate a team approach to successfully manage these patients. A brief general overview of spontaneous intracranial hypotension will also be discussed.

Objective: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH., Methods: A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables., Results: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures., Conclusions: Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Based on a patient encounter in which genetically confirmed Marfan's syndrome (MFS) underlay a spontaneously resolving subdural hygroma (SDHy) diagnosed in infancy, we review the literature of MFS clinically manifest in early life (early-onset MFS [EOMFS]) and of differential diagnoses of SDHy and subdural hemorrhage (SDHe) at this age. We found that rare instances of SDHy in the infant are associated with EOMFS. The most likely triggers are minimal trauma in daily life or spontaneous intracranial hypotension. The differential diagnosis of etiologies of SDHy include abusive and nonabusive head trauma, followed by perinatal events and infections. Incidental SDHy and benign enlargement of the subarachnoid spaces must further be kept in mind. SDHy exceptionally also may accompany orphan diseases. Thus, in the infant, EOMFS should be considered as a cause of SDHe and/or SDHy. Even in the absence of congestive heart failure, the combination of respiratory distress syndrome, muscular hypotonia, and joint hyperflexibility signals EOMFS. If EOMFS is suspected, monitoring is indicated for development of SDHe and SDHy with or without macrocephaly. Close follow-up is mandatory., Competing Interests: No author has any conflict of interest to declare., (Thieme. All rights reserved.)

Competing Interests: The authors declare no conflict of interest.

Background: Patients undergoing a subdural hematoma (SDH) evacuation can experience transient neurological symptoms (TNS) postoperatively. Electroencephalography (EEG) is used to rule out seizures. We aim to characterize patients with TNS and negative epileptiform activity on EEG and compare them to those with positive epileptiform EEG findings., Methods: We performed a retrospective study of adult patients who underwent EEG for evaluation of TNS after undergoing SDH evacuation. Patients were stratified based on SDH type (acute and non-acute) and whether or not their EEG demonstrated positive epileptiform activity. A multivariate analysis was performed to identify predictors of negative EEG findings., Results: One hundred twenty-nine SDH patients were included (45 (34.9%) acute; 84 (65.1%) non-acute). Overall, 45 (24 acute and 21 non-acute SDH patients) had positive epileptiform EEG findings, and 84 (21 acute and 63 non-acute SDH patients) had a negative EEG. Acute and non-acute SDH patients with positive EEG findings were more likely to suffer from greater than five episodes of TNS, impaired awareness, and motor symptoms, while the negative EEG group was more likely to suffer from negative symptoms. Non-acute SDH patients with positive EEG had longer mean ICU stays (14.6 vs. 7.2; p = 0.005). Both acute and non-acute SDH-positive EEG patients had worse disposition upon discharge (p < 0.05), worse modified Rankin score at discharge (p < 0.05), and 3-month follow-up (p < 0.05) and were more likely to be discharged on more than one antiepileptic drug (p < 0.001)., Conclusion: Postoperative acute and non-acute SDH patients with TNS and negative EEG results are likely to have a favorable clinical picture. This distinction is therapeutically and prognostically important as these patients may not respond to typical antiepileptic drugs and they have better functional outcomes., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Psychogenic nausea refers to nausea symptoms that are experienced outside of the context of obvious general medical pathology and presumably as a result of psychiatric etiology. Although this dichotomy between general medical and psychiatric pathology is somewhat dated according to the focus of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Somatic Symptom Disorders, the psychogenic description of a medically unexplained symptom is still commonly used in the general medical vernacular. This case report involved a 74-year-old man who was presumed to have "psychogenic" nausea symptoms after a negative medical workup. New tremulous symptoms were presumed to be secondary to a benzodiazepine taper. However, the presence of additional focal neurological deficits prompted a computed tomography of the patient's head, which revealed a subdural hematoma. Emergent neurosurgical evacuation and drainage relieved the patient's symptoms and proved to be a life-saving measure. Subdural hematomas are most commonly the result of traumatic tearing of the cortical bridging veins that overlie this subdural space. Subsequent mass effect and ischemia from venous bleeding can cause multiple symptoms, including nausea. This case highlights the importance of ensuring a broad differential for medically unexplained symptoms and close monitoring of symptomatic changes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Subdural hemorrhage (SDH), the accumulation of blood between the dura and arachnoid mater, is one of the most commonly encountered traumatic findings in emergency radiology setting. The purpose of this essay is to review the pitfalls in the diagnosis of SDH including a) mimics on CT imaging and b) etiology other than accidental trauma. We describe several entities that closely mimic SDH on non-contrast CT scans. A knowledge of these mimics is essential in the emergency setting since overdiagnosis of SDH can lead to unnecessary hospital admissions, potentially invasive procedures, or even delay in necessary treatment. The mimics of SDH on non-contrast head CT include: PATHOLOGIC ENTITIES IATROGENIC MIMICS ANATOMIC/PHYSIOLOGIC MIMICS ARTIFACTUAL MIMICSWe also briefly review non-accidental and non-traumatic causes of SDH. Although, the most common cause of SDH is accidental trauma, other routinely encountered causes of SDH include coagulopathy, non-accidental trauma, cranial surgery, vascular malformations etc. CONCLUSION: Clinicians dealing with SDH in the emergency setting should consider SDH mimics and less common etiologies of SDH in order to facilitate appropriate patient management., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Neonatal meningitis is a severe infectious disease of the central nervous system with high morbidity and mortality. Ureaplasma parvum is extremely rare in neonatal central nervous system infection., Case Presentation: We herein report a case of U. parvum meningitis in a full-term neonate who presented with fever and seizure complicated with subdural hematoma. After hematoma evacuation, the seizure disappeared, though the fever remained. Cerebrospinal fluid (CSF) analysis showed inflammation with CSF pleocytosis (1135-1319 leukocytes/μl, mainly lymphocytes), elevated CSF protein levels (1.36-2.259 g/l) and decreased CSF glucose (0.45-1.21 mmol/l). However, no bacterial or viral pathogens in either CSF or blood were detected by routine culture or serology. Additionally, PCR for enteroviruses and herpes simplex virus was negative. Furthermore, the CSF findings did not improve with empirical antibiotics, and the baby experienced repeated fever. Thus, we performed metagenomic next-generation sequencing (mNGS) to identify the etiology of the infection. U. parvum was identified by mNGS in CSF samples and confirmed by culture incubation on mycoplasma identification medium. The patient's condition improved after treatment with erythromycin for approximately 5 weeks., Conclusions: Considering the difficulty of etiological diagnosis in neonatal U. parvum meningitis, mNGS might offer a new strategy for diagnosing neurological infections.

Background: The aim of this study was to raise the awareness of all healthcare personnel, primarily Emergency Department physicians, forensic physicians, and paediatricians about cases of shaken baby syndrome (SBS), which can be difficult to diagnose, require a high level of suspicion in diagnosis and there is a high likelihood of missed diagnosis., Methods: A retrospective examination was made of 3400 forensic cases applied with autopsy between 2012 and 2018 to the Forensic Medicine Institution of Malatya Group Directorate., Results: Of the total cases, 113 were aged < 2 years and head trauma was determined in 35. Eight cases were determined as SBS. Of the 8 cases that resulted in death, 75% were male and the mean age was 8.3 months. The trauma had been perpetrated by the father in 50% of cases. There was a history of seizure in 67.5% of the infants and 75% were taken to the Emergency Department with cardiopulmonary arrest. Subdural hematoma and subarachnoid hemorrhage were determined in 37.5% of the cases, subdural hematoma, subarachnoid hemorrhage and intracranial hemorrhage in 50%, and epidural hemorrhage and subarachnoid hemorrhage in 12.5%. In the microscopic examination of the medulla spinalis, focal subdural fresh bleeding was seen in 50% of cases. Bleeding around the optic nerves was determined in 37.5% of cases bilaterally and in 37.5% unilaterally. Retinal hemorrhage was determined in all the cases, which was bilateral in 75%., Conclusions: The actual worldwide incidence of SBS is not known, and in Turkey, it is thought to be much higher than has been determined. The most important reason for this is thought to be that the diagnosis of child abuse is difficult and physicians do not have a sufficient level of knowledge.

The work is based on the results of a retrospective analysis of the medical records of 56 patients with traumatic brain injury complicated by acute subdural hematoma with a volume of 60-100 cm3. The patients were divided into 2 groups according to their age: the 1st group included 29 patients aged 22-29 years, the 2nd group consisted of 27 patients aged 61-69 years. The degree of impaired consciousness in the victims at admission to the clinic was evaluated on the Glasgow scale, the effectiveness of the treatment at discharge from the hospital was performed on the Rankin scale, assessing the degree of independence and disability. Elderly patients were found to have a more severe condition upon admission to the clinic. Upon discharge from the hospital, the assessment of the degree of independence and disability on the Rankin scale revealed a statistically significant predominance of scores in the group of elderly patients (p<0,01), which indicates less effective treatment in comparison with young patients. The results of this study can serve as a basis for the development of additional recommendations in outpatient practice for the care and care of patients in the older age group and a personalized approach to neurosurgical patients taking into account their age.

Viscoelastic monitoring (VEM) tools, such as rotational thrombelastometry, have been used extensively to measure coagulopathy in adults but have received less attention in paediatric care. The presented case involves a 5-year-old boy who was brought to the emergency department after a motor vehicle collision with a Glasgow Coma Scale score of 6T and extensive injuries, including a subdural hematoma. VEM was used to monitor the patient's coagulopathy and to inform treatment measures by allowing real-time visualisation of the patient's coagulation status. VEM was additionally used to direct blood product replacement in preparation for neurosurgical intervention, and 4-factor prothrombin complex concentrate (PCC) was used to help reverse the coagulopathy. The patient underwent successful hemicraniectomy after improvement of his coagulopathy. In paediatrics, VEM and PCC are increasingly being used for post-trauma coagulopathy, and this case highlights their potential promise and the need for further research., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH., Methods: Case report., Case Description: We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed., Discussion: The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain., Conclusion: Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH., (© 2020 American Headache Society.)

Objective: There is little evidence to guide patient selection for subdural hemorrhage (SDH) evacuation. This study was designed to assess the benefit of surgical evacuation of SDH, identify predictors of functional outcome, and create a bedside score to guide the clinical management of SDH., Methods: A cohort of 331 patients presenting to a single center from 2010 to 2014 with a principal diagnosis of subdural hemorrhage was identified. Clinical and radiographic information were extracted from the medical record. Outcomes of interest were (1) the occurrence of surgical evacuation of SDH, and (2) an unfavorable 90-day functional status represented by a modified Rankin score (mRS) ≥ 3. Propensity score matching and adjustment techniques were employed to assess the benefit of surgery accounting for confounding by indication. Multivariable logistic regression models predicting follow-up functional outcome were generated and bootstrapped separately among those with acute SDH and those with either subacute or chronic SDH. Clinical scores were created using model coefficients., Results: In this cohort [65% male, mean age 67 years], 47% underwent surgery. Age, focal neurologic deficit, SDH thickness > 10 mm, midline shift > 5mm, and SDH acuity predicted undergoing surgery. Propensity score matching analysis demonstrated that operated patients overall were less likely to have unfavorable 90-day mRS outcome (OR 0.35, 95% C.I. 0.15-0.82). Among patients with acute SDH, age, female sex, pre-admission mRS, focal neurologic deficit, and neuropsychiatric symptoms predicted 90-day functional outcome (c-statistic 0.89, optimism-corrected c-statistic 0.87) and were incorporated into an acute SDH score (range 1-10). Patients with SDH score > 4 were significantly more likely to have an unfavorable outcome if treated medically versus surgically; there was no difference in 90-day functional status by treatment strategy among patients with SDH score ≤ 4. No difference in outcome was seen by surgical status across the spectrum of chronic SDH scores., Conclusions: Surgical evacuation of subdural hematomas overall is associated with favorable outcome. Patient selection for evacuation is enhanced by the application of the acute SDH score. Future studies are necessary to validate the SDH score in an external cohort., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Many physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high., Methods: Infants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions., Results: All identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma., Conclusions: The present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors., Competing Interests: Ingemar Thiblin, Ulf Högberg, Knut Wester and Johan Wikström have written statements and appeared in court in child abuse cases both on the request of the prosecutor and the defence. Göran Högberg has written statements and appeared in court in child abuse cases on the request of the defence. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Transient neurological symptoms (TNS) are frequent in patients with subdural hematomas (SDH) and many will receive a diagnosis of epilepsy despite a negative workup., Objective: To explore if patients with TNS and a negative epilepsy workup (cases) evolved differently than those with a positive EEG (controls), which would suggest the existence of alternative etiologies for TNS., Methods: We performed a single-center, retrospective, case-control study of patients with TNS post-SDH. The demographics and clinical and semiological features of cases and controls were compared. The outcome and response to antiepileptic drugs were also assessed and a scoring system developed to predict negative EEG., Results: Fifty-nine patients with SDH-associated TNS were included (39 cases and 20 controls). Demographic characteristics were comparable in both groups. Dysphasia and prolonged episodes were associated with a negative EEG. Clonic movements, impaired awareness, positive symptomatology, complete response to antiepileptic drugs, and mortality were associated with a positive EEG. Using semiological variables, we created a scoring system with a 96.6% sensitivity and 100% specificity in predicting case group patients. The differences observed between both groups support the existence of an alternative etiology to seizures in our case group. We propose the term NESIS (NonEpileptic, Stereotypical, and Intermittent Symptoms) to refer to this subgroup and hypothesize that TNS in these patients might result from cortical spreading depolarization., Conclusion: We describe NESIS as a syndrome experienced by SDH patients with specific prognostic and therapeutic implications. Independent validation of this new entity is now required., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers., Competing Interests: Conflicts of interest The author declares no conflict of interest., (Copyright © 2020 Chang Gung University. Published by Elsevier B.V. All rights reserved.)

Background: Guidelines for management of intracranial hemorrhage do not account for bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to convexity SDH, is a distinct clinical entity and these patients do not benefit from critical care monitoring or repeat imaging., Methods: We identified patients presenting to a single level I trauma center with isolated head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH., Results: Demographics, comorbidities, and use of antiplatelet and anticoagulant agents were similar between the groups. As compared to patients with convexity SDH, patients with parafalcine SDH had a significantly lower incidence of radiographic progression, and had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all P < 0.005). Compared to patients admitted to the intensive care unit, patients with parafalcine SDH admitted to the floor had a shorter length of stay (2.0 ± 1.6 versus 3.8 ± 2.9 d, P < 0.005) with no difference in outcomes., Conclusions: Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Patients with hematologic disorders who present with subdural hematomas (SDH) present a surgical decision-making challenge. Because of intrinsic coagulopathy, platelet dysfunction, and immunosuppression, surgical intervention poses a unique set of risks., Objective: To describe a clinical sample of patients with hematologic disorders and concurrent SDH, to compare baseline and outcome variables, including complication rates and survival, in surgical versus nonsurgical management, and to identify clinical variables that may predict outcomes., Methods: A 12-year retrospective case-control study was carried out of 50 adult patients with hematologic malignancies and SDH. Patients underwent surgical evacuation for SDH. Controls did not. Outcomes included discharge disposition, Glasgow Outcome Scale score, 30-day mortality, and overall survival. Complications included seizure, reoperation, and readmission. A Fisher exact test or χ 2 analysis compared categorical variables; continuous outcomes were compared with a Student t test. A Kaplan-Meier survival analysis was performed and multivariable Cox logistic regression evaluated variables associated with overall mortality., Results: Surgical and nonsurgical groups differed only by Glasgow Coma Scale score, with slightly lower Glasgow Coma Scale scores in the surgical group. Complication rates did not differ; however, the 30-day reoperation rate was 35% for the surgical cohort. Overall, seizure incidence was 18%, readmission was 30%, 30-day mortality was 38%, median survival was 140.5 days, and 75% had a Glasgow Outcome Scale score of 1-3 at censorship. Increased age, low hemoglobin levels, and low platelet levels were associated with increased risk of mortality., Conclusions: Low platelet and hemoglobin levels are consistent markers of poor prognosis and surgical intervention, either as a proxy of or as a cause for clinical deterioration, is associated with increased mortality risk., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intracranial hypotension is an underrecognized cause of spontaneous subdural hematoma. Failure to identify this entity and treat the underlying etiology can result in profoundly dangerous clinical consequences, prolonged and costly hospitalization, and caregiver fatigue, as seen in the case presented here., Case Description: We present a case of intracranial hypotension associated with a spontaneous cerebrospinal fluid (CSF) leak in the cervical spine leading to consistently reproducible herniation syndrome with head of bed elevation, and bilateral subdural hematomas as a result of a pressure gradient favoring downward migration of intracranial contents resulting in traction on bridging veins. This gradient promoted transtentorial herniation with resultant brainstem compression, leading to a prolonged intensive care unit stay, recurrent respiratory failure, and severe deconditioning. An exhaustive diagnostic workup uncovered a cervical root CSF leak with a nuclear medicine CSF flow study, which was successfully treated with nerve root ligation and dural closure. The patient recovered well postprocedurally and was able to return to baseline level of function., Conclusions: This case demonstrates the importance of considering intracranial hypotension in cases of positional herniation syndrome and the necessity for early and aggressive attempts at identifying and treating the underlying cause to prevent unnecessary neurologic dysfunction and protracted medical care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Posterior fossa subdural hemorrhage (PFSDH) in term neonates is rare and unknown in the absence of obvious trauma. Its management is challenging and decided case to case basis. Here we report two cases of posterior fossa subdural hemorrhage in term babies with normal transition at birth and presenting later with neonatal encephalopathy. First baby was born by elective caesarean section and the second baby by assisted vaginal delivery. They presented at 60 h and 48 h respectively. Both babies had similar clinical presentation in the form of poor feeding, shrill cry and posturing. But they had contrasting clinical course with features of brainstem compression in the first baby requiring ventilation. Coagulation workup was normal in the first baby but fibrinogen level was low in the second baby. Magnetic resonance imaging of the first baby showed PFSDH with tonsillar herniation while in the second baby, there was no midline shift or herniation associated with the PFSDH. Management was tailor made to suit the clinical course and imaging findings. Craniotomy and clot evacuation was done in the first case and in the second baby, management was conservative. Neurological examination was normal at discharge. Both are developmentally normal on follow up. There is no evidence of hydrocephalus in both. Management of PFSDH depends on clinical course and MRI findings. Timely intervention leads to good outcome., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by disruption of normal collagen formation resulting in varying degrees of ligamentous laxity and skeletal vulnerability; the low bleeding potential is easily overlooked. Subdural hematoma (SDH) is a common neurosurgical condition, classically related to the rupture of bridging cortico-dural veins after trauma. In the pediatric population, the age distribution shows a massive preponderance for children in their early first decade. We report a very unusual case of SDH in a 10-year-old boy with OI type I, with history of minor trauma. SDH remains exceedingly rare in OI, and its pathophysiology is unclear. To the best of our knowledge, this is the first report of a unilateral subacute SDH associated with OI in a child of such advanced age. These cases may also carry legal ramifications, including misdiagnosis of child abuse in ambiguous situations that are not thoroughly investigated.

Background and Purpose: Differentiating Abusive Head Trauma (AHT) from Non-abusive Head trauma (NAHT) has profound clinical prognostic and legal implications, as certain imaging findings can individually be more suggestive of NAHT, while others are more suggestive of AHT. This study was set out to evaluate for an association between the various imaging findings in AHT with outcome., Material and Methods: Over 7-years, 55 children (age 0-4 years') with head trauma and magnetic resonance imaging (MRI) were included as either: abusive (n = 16), non-abusive (n = 35), or indeterminate (n = 4). Two pediatric neuroradiologists jointly reviewed the imaging. The frequency of imaging findings and their association with ≥6 months' outcome were calculated., Results: Comparing abusive versus non-abusive head trauma, complex subdural hematoma was present in 81% (n = 13/16) and 29% (n = 10/35), hypoxic-ischemic injury in 44% (n = 7/16) and 6% (n = 2/35), and diffuse axonal injury in 12% (n = 2/16) and 26% (n = 9/35), respectively. Susceptibility-weighted imaging (SWI) retinal hemorrhages were absent in non-abusive trauma (0/35), but present in 44% (n = 7/16) of the abusive group. In abuse, simple subdural hematomas were absent. Significant associations were found between the presence of abusive trauma with both hypoxic ischemic insult (OR = 12.83, p = 0.0024) and complex subdural hematoma (OR = 10.83, p = 0.0007). The presence of hypoxic ischemic injury (HII) did correlate significantly with clinical outcome (p = 0.017), while retinal hemorrhages on SWI and complex subdural hematoma did not (p = 0.1696-p = 0.2496)., Conclusion: Neuroimaging findings can be helpful in discriminating these two conditions on presentation, as well as in helping solidify the suspicion of AHT. Regarding eventual outcome in AHT, the most important predictor is clearly HII.

Objective: To investigate a temporal association between vaccination and subdural hematoma, the main feature of abusive head trauma., Study Design: From a prospective population-based survey carried out in 1 administrative district in France between January 2015 and April 2017, including all infants between 11 and 52 weeks old who underwent a first cerebral imaging (computerized tomography scan or magnetic resonance imaging), we conducted a nested case-control study. Vaccine exposure was compared between cases (infants with subdural hematoma) and 2-3 paired controls, without subdural hematoma or any other imaging findings compatible with abusive head trauma. Cases and controls were matched on chronological (±7 days) and gestational (≤33 vs >33 weeks) ages, respectively. Vaccination status was collected in the personal national pediatric health booklet., Results: Among the 228 prospectively surveyed infants, 28 had subdural hematoma including 22 with abusive head trauma. The mean chronological age at imaging was 5.3 months among the 28 cases and the 62 controls, who did not differ significantly in median time since last vaccination (1.4 vs 1.3 months, P = .62) or frequency of at least 1 vaccination since birth (86% vs 89%; matched-pairs OR 0.77, 95% CI 0.17-3.86) or within 7 days (0.94, 0.08-6.96), 14 days (0.70, 0.12-2.92), or 21 days (0.48, 0.08-1.98) before cerebral imaging., Conclusions: We found no significant temporal association between vaccination and subdural hematoma diagnosis, which must continue to be considered a red flag for abusive head trauma and child abuse., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Metastatic subdural hematoma with dural metastasis in the setting of an underlying malignancy is a rare condition that is difficult to diagnose and associated with a poor prognosis. Knowledge of this rare entity is of a paramount importance to neurosurgeons, as its diagnosis may affect the management plan and overall survival. Here, we report a rare case of atraumatic subdural hematoma with dural metastasis in a patient with poorly differentiated adenocarcinoma of unknown origin., Case Description: A 34-year-old man presented with an insidious onset of headaches, severe light headedness, progressive low back pain, and generalized weakness for 2 weeks. On imaging, he was found to have left-sided acute on chronic subdural hematoma with midline shift. The patient underwent surgical evacuation of the hematoma and the subdural membrane was biopsied. Histopathologic examination revealed metastatic poorly differentiated adenocarcinoma of unclear origin. A full metastatic workup was unremarkable., Conclusions: Metastatic subdural hematoma with dural metastasis should be included in differential diagnosis of subdural hematoma, especially in patients with atypical presentation and in the presence of an underlying malignancy, as it may affect the management plan and overall survival., (Copyright © 2019. Published by Elsevier Inc.)

Of the multitude of neurologic injuries related to roller-coaster rides, a majority of them are reported about adults. In this case, we present a patient who presented to the pediatric emergency department with new-onset seizure and hemiplegia 2 days after a roller-coaster ride. She was ultimately diagnosed with a subdural hematoma. The acceleration and G forces of roller coasters are hypothesized to cause enough stress and shearing forces that are thought to directly cause subdural hemorrhage.Advances in roller-coaster technology may surpass the passenger's physical capacity for acceleration and rotary forces, and we may see an increased number of medical complications after these rides. We recommend that emergency and pediatric health care providers consider amusement park thrill rides as a possible cause of subdural hematomas in previously healthy patients with new neurologic complaints.

Background: One of the most severe traumatic brain injuries, the subdural haematoma, is related to damage and rupture of the bridging veins, generating an abnormal collection of blood between the dura mater and arachnoid mater. Current numerical models of these vessels rely on very simple geometries and material laws, limiting its accuracy and bio-fidelity., Methods: In this work, departing from an existing human head numerical model, a realistic geometry for the bridging veins was developed, devoting special attention to the finite elements type employed. A novel and adequate constitutive model including damage behavior was also successfully implemented., Findings: Results attest that vessel tearing onset was correctly captured, after comparison against experiments on cadavers., Interpretation: Doing so, the model allow to precisely predict the individual influence of kinematic parameters such as the pulse duration, linear and rotational accelerations in promoting vessel tearing., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects., (© 2019 by American Journal of Neuroradiology.)

Timing of the intervention for intracranial hematomas is critical for its success, specifically since expansion of the hemorrhage can result in debilitating and sometimes fatal outcomes. Led by Britton Chance, we and an extended team from University of Pennsylvania, Baylor and Drexel universities developed a handheld brain hematoma detector for early triage and diagnosis of head trauma victims. After obtaining de novo Food and Drug Administration clearance, over 200 systems are deployed in all Marine battalion aid stations around the world. Infrascanner, a handheld brain hematoma detection system, is based on the differential near-infrared light absorption of the injured versus the noninjured part of brain. About 12 independent studies have been conducted in the USA, Canada, Spain, Italy, the Netherlands, Germany, Russia, Poland, Afghanistan, India, China, and Turkey. Here, we outline the background and design of the device as well as clinical studies with a total of 1293 patients and 203 hematomas. Infrascanner demonstrates high sensitivity (adults: 92.5% and children: 93%) and specificity (adults: 82.9% and children: 86.5%) in detecting intracranial hematomas >3.5  mL in volume and <2.5  cm from the surface of the brain. Infrascanner is a clinically effective screening solution for head trauma patients in prehospital settings where timely triage is critical.

Object : Although contact sport-related head injuries are frequently reported, golf cart accidents may have significant consequences including severe traumatic brain injury (TBI) or head injury. As no standardized regulations exist, this mechanism may be underreported. Methods : A retrospective review of TBI or cranial trauma after a golf cart accident at a level I trauma center over 5 years were performed. Data regarding age, sex, race, initial Glasgow Coma Scale score, alcohol status, type and location of the injury, and outcomes were analyzed and reported in terms of Modified Rankin Scale (MRS). Results : A total of 23 patients with TBI or cranial trauma following golf cart accident were identified. The mean age was 36 years old with the most common injury being skull fracture followed by acute subdural hematoma. Most patients had good outcomes, MRS 0-3, at discharge, but like most forms of TBI, surgical interventions, intracranial pressure monitoring, post-traumatic seizures, hydrocephalus, and death did occur. Conclusions : Head injuries sustained by golf cart accidents are not insignificant and may be underreported. More awareness of these injuries and safety guidelines are needed.

Background : Seizures are a complication of subdural hematoma (SDH), and there is substantial variability in the use of seizure prophylaxis for patients with SDH. However, the incidence of seizures in patients with SDH without severe neurotrauma is not clear. The objective of this study was to assess the frequency of and factors associated with seizures in patients with isolated SDH (iSDH) without severe neurotrauma. Methods : In this retrospective, observational study, we identified adults with Glasgow Coma Score (GCS) ≥13 and computed tomography (CT)-documented iSDH. The primary outcome was clinical seizure frequency. Seizure medication use was also assessed. Fisher's exact test and logistic regression were used to assess association. Results : Of 643 patients with iSDH, 14 (2.2%) had seizures during hospitalization. Of 630 patients (98%) not receiving seizure medication prior to SDH, 522 (82.9%) received levetiracetam. Of the patients who received a seizure medication, 12 (2.3%) had a seizure, while of the 121 patients who did not receive seizure medications, 2 (1.9%) had a seizure (p = .49). In multivariable regression, the only variable significantly associated with seizure was thickness of subdural hematoma (OR 1.16, p = .005). Conclusion : In patients with iSDH and preserved consciousness, in-hospital seizures were rare regardless of seizure medications use.

Background: Recovery of patients with traumatic brain injury largely depends on the reduction in secondary brain damage. The present study aims at investigating the effect of Tranexamic Acid (TXA) administration within the first hours of brain trauma in the emergency department (ED)., Methods: This randomized, double-blind, placebo-controlled clinical trial was carried out in patients with subdural and epidural hemorrhage. Patients with any type of bleeding were assigned into two groups of TXA and 0.9% normal saline as placebo. The rate of intracranial hemorrhage after surgery was assessed by CT-scan and amount of hemoglobin (Hb) was measured immediately before surgery and after 6 hours of surgery., Results: A total of 80 participants were randomly assigned into four groups of 20 people. There was a significant difference in the mean of intraoperative bleeding during surgery in patients receiving TXA and placebo in both SDH (Subdural hematoma) and EDH (Epidural Hemorrhage) groups (P= 0.012). The Hb drop amount had no significant difference with placebo (P< 0.0001). No complications were observed in any of the intervention and control groups during the study as well., Conclusion: The use of TXA may reduce bleeding, however, based on the results of this study, such effect was not statistically significant in controlling the epidural and subdural hemorrhage, but clinical trials with a higher sample size are suggested for further investigation in this regard., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Subdural hematoma (SDH) in the elderly is an increasingly common entity because of increased use of antithrombotic medications, an aging population, and increasing frequency of geriatric trauma. The present study describes the functional outcomes and mortality of SDH in an elderly population and to identify potential prognostic factors., Methods: Patients >65 years of age with SDH who were treated at our institution from 2005 to 2015 were identified. Patients with a history of preceding high-velocity trauma were excluded. Electronic medical records were retrospectively reviewed. The outcomes of interest were mortality, length of stay, and discharge Glasgow Outcome Score., Results: A total of 671 patients were included in final statistical analyses. For patients with acute SDH, survival was 74.9%, 72.3%, and 69.8% at 30, 60, and 100 days, respectively. With respect to chronic SDH, survival was 87.0%, 83.7%, and 80.3% at 30, 60, and 100 days, respectively. On multivariate analysis, admission Glasgow Coma Scale (GCS) score was significantly predictive of mortality in both the acute and chronic populations. In the acute cohort, admission GCS score was a significant predictor of increased length of stay, whereas age >80 years, admission GCS score, contusion volume >10 cm 3 , SDH volume >50 cm 3 , and antiplatelet use were significant predictors of discharge functional status., Conclusions: SDH in the elderly carries high morbidity and mortality and several prognostic factors were identified. These results can be used to guide discussions with family regarding prognosis and perhaps aid in treatment decisions., (Copyright © 2018 Elsevier Inc. All rights reserved.)