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Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity with a significant loss of functional capacity and a huge socioeconomic burden. Road traffic accidents are the most common (60%) cause followed by falls and violence in India and worldwide. This case discusses the story of a 23-year-old man with severe TBI–subdural haematoma, who presented in a comatose state. The patient was a purported candidate for emergency decompressive surgery as per Brain Trauma Foundation (BTF) guidelines but was managed conservatively. This case questions the plausibility of the BTF guidelines for severe TBI, particularly in rural hospitals in India and how such cases are often managed with clinical judgement based on the review of literature. The patient recovered well with a perfect 8/8 on Glasgow Outcome Scale Extended Score.

A 51-year-old woman with no significant medical history was found collapsed at work having sustained a head strike. She was evaluated at her local hospital. Glasgow Coma Scale was 12 (E3 V3 M6). Pupils were equal and reactive. Eye movements were normal. CT of the brain revealed a large left-sided

There is good evidence that pupil reactivity is useful for prognostication in acute head injuries. Despite this, most pupil assessments are subjective and are performed by physicians who may not be experts. They can therefore be unreliable. We present a case of a patient with seemingly irreversible demise from an acute traumatic subdural haematoma. This was determined by assessment of his pupils, which were non-reactive to light at the time of arrival to the neurosurgical theatre. He was transferred to the neurointensive care for brainstem death testing, where assessment by objective pupillometry determined that his pupils were in fact reactive. He made a good recovery following subsequent surgery to evacuate his subdural haematoma. We propose the widespread adoption of objective pupillometers in the assessment of acute head-injured patients and offer our case as an example of how an objective and accurate assessment can make a difference to patients' outcome.

Delayed de novo left ventricular apical thrombus following a distant antero-apical myocardial infarction has to our knowledge not been previously reported. Herein we describe a patient who developed an apical thrombus 18 months after his initial infarct following cessation of dual anti-platelet therapy for a traumatic subdural haematoma requiring surgical evacuation.

Percutaneous dilatational tracheostomy (PDT) is associated with a number of life-threatening complications. We present a case of massive and fatal arterial haemorrhage that occurred in the intensive care unit during an elective PDT on an 86-year-old woman following earlier evacuation of a traumatic subdural haematoma. An avulsed right subclavian artery was found at post mortem. Previous thyroid surgery and aberrant arterial anatomy contributed to the fatal outcome. Br J Anaesth 2003; 90: 517–20

A Parkinson's disease patient with deep brain stimulation (DBS) implantation experienced an acute subdural haematoma (SDH) after a fall. The DBS electrodes and brain parenchyma were shifted. Fortunately, the patient recovered after craniectomy and removal of SDH, and the DBS was re-activated with the same parameters. Patients with DBS implants who suffer a traumatic brain injury do not necessarily incur permanent implant failure; there is every chance that the DBS may continue to work as reported here.

This is a report of a case of a subdural haematoma in infancy of possible non-accidental aetiology with raised pericerebral pressure, which we postulate has eroded the inner table of the cranial bones and resulted in leakage of marrow precursor cells into the extradural space. Subdural tapping via the fontanelle has created a channel allowing subsequent ingress of nucleated red cell precursors into the subdural space. This addition to the subdural collection has prolonged its course necessitating subduro-peritoneal shunting.

The author has reviewed the outcome of 27 patients aged 75 years and over who had an operation for acute traumatic subdural haematoma at Frenchay Hospital, Bristol, over a 10-year period. There were 15 men and 12 women with a mean age of 79.2 years. The outcome at 6 months was determined using the Glasgow Outcome Score. Of the patients, 15 per cent made a good recovery, 15 per cent a poor recovery and 70 per cent died. The influence of age, sex, mechanism of injury, preoperative Glasgow Coma Score (GCS), pupillary reactivity to light, skull and limb fractures, clinical course, CT scan appearance and timing of operation were analysed in relation to the outcome. The results showed that a preoperative GCS of 4 or less and unilateral pupillary dilatation and non-reactivity to light were not compatible with good survival in the very elderly patient with acute subdural haematoma. Under these circumstances, operation is not justified. The prognosis was worse in patients who were unconscious immediately after injury and with a CT scan showing a subdural haematoma and a haemorrhagic contusion which required urgent early intervention. The prognostic indicators present may prove useful in the selection of patients for active surgical intervention.

Post-traumatic acute subdural haematoma (ASDH) is a life threatening condition. The traditional approach is urgent surgery in haematomas with a mass effect. We report a case with a large post-traumatic ASDH whose haematoma disappeared markedly within 2 hours. A 19 year old man sustained a head trauma at 22:30 and presented with Glasgow Coma Scale (GCS) score of 9 to the state hospital. CT scan showed a right hemispheric ASDH and …

Acute traumatic subdural haematoma suspected of extending over an entire hemisphere must be treated with all speed. To obviate unnecessary skin incisions and subsequent craniectomies and craniotomies during the operation, we think it advantageous to plan a series of burrholes at set points in order to; a) begin to clear the haematoma; b) assess its extent and possible origin; c) decide whether a hemicranial or smaller craniotomy is called for.

Publisher Summary Neurosurgical procedures influence the course of intracranial haemorrhages by surgical closure of the source of haemorrhage in many cases; and by removing the blood clot which is space occupying and the cause of perifocal oedema at the same time. Indication to surgery is then closely related to pathogenesis. These facts of a predilection site and a combination with other space occupying lesions seem to be of importance for roentgenology and echoencephalography in the diagnostic process of epidural and acute and chronic subdural encapsulated haematoma. The fact of a predilection site of the subdural encapsulated haematoma is now better understood since one has a better insight into pathogenesis, where one distinguishes between two forms: a primary degenerative process of the dura, in the old-age group, called the true “pachymeningitis” or “pachymeningosis” of Virchow and the post traumatic subdural haematoma which is later encapsulated and is more common in younger people. Cerebral haemorrhages mainly due to extracranial factors like Hypertensive-striate-haemorrhages and Atypical haemorrhages are discussed. Only the study of pathogenesis can lead to a rational therapy particularly if this is neurosurgical—thatconsists of removal of the blood clot, because it can show the predilection site, the source of the bleeding vessel and the cause for its rupture.

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