Recently, decompressive craniectomy (DC) for refractory intracranial hypertension (IH) has been widely reevaluated, and many researchers support the advantages of early and aggressive DC in the management of severe head trauma. We too applied DC in the early stages of IH, and confirmed its favorable results compared to those of the standard treatment. In patients with evacuate masses (EM), DC was determined based on the intraoperative condition of the brain parenchyma; in those without EM, intracranial pressure (ICP) ≥30 mmHg was considered the criterion for DC. However, in some cases, the expected brain edema (BE) was absent after DC, and DC seemed unnecessary on retrospection. Here, the effectiveness of DC performed at our hospital and its predictive factors were investigated. Of the 26 DCs performed in the past 3.5 years, 9 were ineffective because the expected BEs were absent on postoperative computed tomography. In those 9 cases, the Glasgow coma scale (GCS) scores and D-dimer of fibrinogen degradation product (FDP-DD) were significantly higher and lower, respectively, than those of the control group. Patients with EM showed similar trends regarding the GCS score and FDP-DD, both of which are probable indicators of BE. In patients without EM, the GCS score and FDP-DD were normal, but their base excess at admission was significantly low with increased ICP, requiring DC. GCS score and FDP-DD may represent the extent of mechanically damaged brain, and this may explain their relation with DC effectiveness in patients with EM. In patients without EM and with mild brain damage, base excess that reflects the respiratory or circulatory disorder should be the predictor for BE.
The acute subdural hematoma (ASDH) remains one of the most life-threatening state of all head injuries. We have retrospectively reviewed 469 patients suffering ASDH between 1990 and 2010. The overall mortality rate was 34.1% and 38.6% had good recovery (GR) of Glasgow outcome scale at discharge. The outcome was found to be influenced significantly by the consciousness level at admission. In 198 patients, surgical procedure was performed. Based on the distribution of ASDH, the patients with ASDH only in the interhemispheric space were prone to reach GR state compared to the other locations, namely, unilateral and bilateral lesions. In 469 patients, 28 patients (6%) presented with a mild head injury (JCS 0 – 3) at admission, and then rapidly deteriorated to comatose state in the first 3 hours, they were classified as “talk and deteriorate” (T & D) type. The mortality rate of T & D type was 61%, and the outcome of T & D type was significantly correlated with the operative procedures such as removal via one-burr hole, removal via craniotomy, and decompressive craniotomy and removal. The more degree of decompression, the better outcome is expected for the T & D type. But the independent predictable signs in initial CT scan for T & D type, such as the combination of contusion and/or acute epidural hematoma, in order to evacuate the hematoma promptly before the deterioration falls to the critical level, failed to be identified. Therefore, we conclude that patients who present in good clinical condition with ASDH initially must be prepared for emergency operation.
The patients of traumatic intracranial hemorrhage (TICH) with preinjury antithrombotic therapy are difficult to treat because of two conflicted factors. We experienced two cases, those clinical courses seemed to be unique and useful when considering a management strategy for these patients.
Case 1: A 67 year-old woman suffered from severe head injury by falling down from upstairs. The patient's Glasgow Coma Scale (GCS) score was 5 at transfer to our acute care center. Initial brain computed tomography (CT) scan demonstrated left acute subdural hematoma, and she received emergent decompressive craniectomy and evacuation of hematoma. She also suffered from acute myocardial infarction (AMI) intraoperatively and received percutaneous coronary intervention (PCI) immediately after craniotomy operation, and antiplatelet therapy (APT), aspirin, was started. Twenty-four hours later, she presented anisocoric pupil (left > right) and brain CT scan revealed growth of left temporal contusional hematoma and impending uncal herniation, following emergent left temporal lobe resection including contusional hematoma. Additionally, she received 2nd PCI with BMS stent placement and dual APT (aspirin + clipidogrel) was started six days after head injury. After that, she recovered with dual APT, having no hemorrhagic and ischemic events.
Case 2: A 76 year-old man was transfered from near hospital to our center because of acute subdural hematoma in spite of no apparent episode of head injury. He had received anticoagulation therapy (ACT) for long periods and his PT-INR was over 14 at transfer. Conservative therapy with rapid injection of Vitamin K was performed, then, there was no enlargement of intracranial hematoma. However, he presented left hemiparesis two days later, and Magnetic Resonance Imaging (MRI) demonstrated right temporo-occipital cortical infarction and also right internal capsule infarction. The mechanism of this ischemic event was unclear, maybe not a cardiogenic embolism, but poor control of ACT was considered to be one of the causes of this infarction.
Intensive systemic management, especially strict control of blood pressure within acute stage, at intensive care unit (ICU) seemed to lead to good result in case 1. Case 2 indicated that treatment of traumatic injury with poor control of ACT became more difficult and complicated. The important step in the management of TICH with preinjury antithrombotic agents is thought to be an exact evaluation and assessment of hemorrhagic and thrombotic factors. Additionally, even though when unexpected emergent event occur, for example hematoma enlargement or cerebral ischemic event, prompt and reasonable treatment, we think, will lead to better clinical outcomes.
Objective. To investigate the cause of poor prognosis of traumatic acute subdural hematoma in patients undergoing renal hemodialysis we reviewed our own cases at our institution.
Materials and methods. From 2001 to 2010 we experienced six patients with traumatic acute subdural hematoma on renal hemodialysis. Five were male, 1 female. The average age of injury was 65 years old. The mechanisms of injury, the use of antiplatelets and/or anticoagulants, outcomes and duration of dialysis were retrospectively analyzed.
Results. The mechanisms of injury included fall on the same level due to faintness immediately after hemodialysis in five patients, fall down the stairs in 1 patient. All of these patients received antiplatelets. No patient received anticoagulants. A mean score of Glasgow Coma Scale on admission was 5.6. Craniective decompression, evacuation of hematoma, placement of external ventricular drainage and intracranial pressure monitoring and normothermia were carried out on acute stage. Outcomes at discharge were severely disabled in two cases, persistent vegetative status in 2 and dead in 2. Duration of dialysis was less than one year in four cases, three years in 1 and thirteen years in 1.
Conclusions. Traumatic acute subdural hematoma in patients undergoing intermittent renal hemodialysis appeared to occur at early phase after hemodialysis initiated. Faintness might be the major cause of head trauma while severe high energy trauma is quite rare. Vulnerability of brain on dialytic patient against head trauma and common use of pre-injury antiplatelets and/or anticoagulants therapy are thought to be responsible for poor prognosis.
With increasingly frequent use of CT scanning in less severely head injured conscious patients, the demonstration of minimal “asymptomatic” acute subdural hematoma (ASDH) is becoming an increasingly frequent finding, and this sometimes presents the neurosurgeon with a difficult management decision. We have studied about the pathogenesis of the mild ASDH through three patients who demonstrate relatively few neurological abnormalities with ASDH on admission. All patients were managed conservatively in the first instance, but rapid deterioration emerged in sub-acute phase after injuries. They required operation for their residual and/or enlarged ASDH and the midline shift in emergency though the craniotomy or the burr-hole surgery. The outcome was uniformly excellent for all patients. On the basis of this study, we recommend that the attention against the rapid deterioration in sub-acute phase after the head injury should be paid continuously for the initially conscious patients with minimal ASDH.
In general, subacute subdural hematomas are treated surgically. However, patients who do not show any symptoms are often treated conservatively, despite of the lack of effective medicine. Sairei-tou, a Kampo medicine, promotes endogenous steroid secretion and is considered to have diuretic and anti-inflammatory actions. Recently, the effect of Sairei-tou in reduction of chronic subdural hematomas was reported. Because of similarities in the growing mechanisms of chronic subdural hematomas and subacute subdural hematomas, we considered the effect of Sairei-tou in reducing subacute subdural hematomas.
We observed reduction in hematomas in 3 patients with asymptomatic or symptomatic subacute subdural hematomas who were administered Sairei-tou. Therefore, Sairei-tou could be considered as a medication for reducing subacute subdural hematomas.
The incidence of dementia increases with age. Chronic subdural hematoma is also a common disease in elderly people. It is difficult to diagnose chronic subdural hematoma in patients with dementia.
We performed a retrospective review of 108 patients with chronic subdural hematoma who were treated in our hospital between January 2004 and December 2010; we analyzed the clinical characteristics of the patients and compared the surgical outcome of patients with dementia and those without dementia. Data such as age, gender, clinical symptoms, surgical result, and recurrence rate were obtained from the patients' profiles. The surgical outcome and recurrence rate of the patients with dementia and those without dementia were statistically analyzed.
Of the 108 patients, 69% were men and the mean age was 77.8 years (average, 42-98 years). The most frequent symptom was hemiparesis, followed by disturbance of consciousness. Thirty patients developed dementia before the onset of chronic subdural hematoma, and 63 patients had a definite history of head injury. All the patients were treated using the burr hole procedure with closed system drainage; 5 patients with dementia showed poor recovery, and 3 patients without dementia died in the hospital.
Pre-existing dementia was the potential risk for chronic subdural hematoma and was observed to significantly correlate with a poor outcome (p<0.05). Chronic subdural hematoma should be considered when a patient with dementia exhibits different behavioral characteristics.
Chronic subdural hematoma is thought to be an easily treatable disease. However, its recurrence rate is approximately 10%, and such cases require re-operation. We compared the recurrance rate of chronic subdural hematoma with irrigation using either saline or the artificial cerebrospinal fluid Artcereb®.
Cases: We divided the patients into 2 groups. A total of 60 patients in the normal saline group (hematoma, n=58; bilateral hematoma, n=2) underwent irrigation with saline between March 2007 and July 2009. A total of 61 patients in the Artcereb group (hematoma, n=54; bilateral hematoma, n=7) underwent irrigation using Artcereb® between August 2009 and May 2011.
Methods: We performed irrigation via 1 burr hole with 500 – 1000 ml of either normal saline or Artcereb® under local anesthesia and observed until recurrence or disappearance of the hematomas on CT scan. We researched the recurrence rate of the hematomas.
Results: Recurrence of the hematomas were observed in 8 cases (13%) in the normal saline group and 5 cases (8.2%) in the Artcereb group. No statistically significant differences were observed. Among those patients who did not receive anticoagulants, the recurrence rate was 6/54 (11%) in the normal saline group and 1/49 (2.0%) in the Artcereb group (p<0.10).
Conclusion: Our study showed the posibility that the postoperative recurrence rate of chronic subdural hematoma was lower using Artcereb® than saline for irrigation.
To determine the influence of antithrombotic (anticoagulant and antiplatelet) agents on patients with chronic subdural hematoma (CSDH), the authors retrospectively analyzed 103 patients with CSDH who underwent surgical treatment for CSDH at our institution from January 1998 through June 2011. Of theses 103 patients, 18 patients received antithrombotic agents (warfarin in 10 patients and aspirin in 8), and were compared with 85 other patients who did not take antithrombotic agents. All patients were treated with burr hole irrigation, drainage, or irrigation with drainage. Warfarin was restarted 3 weeks after the surgical treatment. Cessation of aspirin was needed for up to 2 weeks prior to surgery. None of the 18 patients had a recurrence and their outcomes were comparable to the patients who did not take antithrombotic agents. One patient who discontinued warfarin died of acute myocardial infarction three days after surgery.
Discontinuation of warfarin for 3 weeks after surgery may result in a low probability of CSDH recurrence and aspirin could be restarted early after surgery under careful perioperative management.
Objective: This study investigated the efficacy of coil embolization of the injured vertebral artery associated with fracture-dislocation of the cervical spine for the prevention of embolic stroke.
Material and Method: Between 2001 and 2010, 27 patients underwent reduction of the dislocation fracture of the cervical spine. In 4 cases, preoperative MRI revealed disappearance of the flow-void signal of the unilateral vertebral artery in the foramen transversarium, and we performed further investigation of the injury of the vertebral artery with digital subtraction angiography.
Result: In all 4 cases, digital subtraction angiography revealed occlusion of the unilateral vertebral artery. After conviction of the existence of colateral cerebral blood flow from the contralateral vertebral arteries or external carotid arteries, we embolized the proximal part of the occluded vertebral arteries in endovascular procedures with detachable coils for the prevention of the embolic stroke associated with orthopedical procedures. All patients underwent reduction of the cervical dislocation after coil embolization, and the operations were performed uneventfully. During the follow-up period (66.8 months on the average), there were no episodes of vertebro-basilar infarction. Perioperative and postoperative antiplatelet or anticoagulant therapies were not necessary.
Conclusion: Dislocation fracture of the cervical spine is frequently associated with injuries of vertebral artery, and the management of the risk for cerebral infarction remains controversial. Preoperative embolization of the injured vertebral artery can be an effective procedure in preventing the embolic stroke caused by orthopedical procedures.
We report herein the case of a 38-year-old man who presented with right upper and lower extremities intractable pain caused by traumatic brain contusion. The main pain region was lower extremity and the pain produced his gait disorder. The patient underwent spinal cord stimulation (SCS). Four electrodes were placed in spinal epidural space, two electrodes were placed in Th10 – 11 level, and the others were C4 – 6 level. SCS achieved >70% pain relief and improved his gait disorder. SCS proved effective for central neuropathic pain caused by brain contusion. The method of SCS using four electrodes is effective for pain of upper and lower extremities, especially the main pain region is lower extremity.
A 34-year-old man fell down after his head was hit by a big metalic mass toward the wall. The patient had headache, nausea, and amnesia at arrival to our hospital. A Computed Tomography (CT) scan showed diffuse pneumocephalus, hematoma surrounding the sella turcica, a linear bone fracture on the right vault, and multiple sphenoid fractures. The patient underwent diabetes insipidus (DI) 10 days after admission. Treatment using desmopressin was started, but the patient was discharged with DI. Two years and 4 months after discharge, the patient still had DI. We report a rare case of a late onset permanent DI following skull base fracture. When the lesion near the pituitary stalk is suspected, DI has to be considered.
Authors report rapid resolution of an 8-year-old boy's subgaleal hematoma with skull fractures by taking “Jidabokuippo” orally. He was hospitalized for the treatment for brain contusion, depressed skull fractures, and subgaleal hematoma. He underwent the reconstruction of the skull 9 days after the injury. The temporal muscle and scalp were fixed to the skull with sutures through screws and V-shaped holes in the skull. However, the subgaleal hematoma worsened on the next day of the surgery. He began to take Jidabokuippo on the third day of the surgery. The hematoma nearly disappeared on the fifth day of surgery. It is said that Jidabokuippo has anti-congestive and anti-inflammatory action. Authors think that this action of Jidabokuippo caused the resolution of hematoma.
Pseudoaneurysms on the peripheral part of the anterior cerebral artery (ACA) are sometimes caused by head injury. We have encountered a case of pseudoaneurysm of the ACA caused by ventricular tapping during a shunt operation.
A 67-year-old woman had aneurysmal clipping surgery at the onset of subarachnoid hemorrhage due to ruptured left middle cerebral artery aneurysm. She developed normal pressure hydrocephalus and ventriculoperitoneal shunt surgery was performed. During the operation, we tried to tap the anterior horn of the right lateral ventricle, but, the ventricular needle did not run smoothly. Removing the inner cylinder, active arterial bleeding was observed. Postoperative CT images showed intraventricular hematoma and intracerebral hematoma in the right frontal lobe. Immediately, external ventricular drainage was performed via the left anterior horn of the lateral ventricle. An angiogram showed an aneurysm at the non-bifurcation portion of the distal right ACA. Radical treatment of the aneurysm was performed. A clot was observed on the right side of the bifurcation of the peripheral ACA. After removing the clot, it was clear that all layers of the vessel wall were perforated suggesting a pseudoaneurysm. Suturing and wrapping was performed at the orifice. The intraoperative angiogram did not show the distal part of the ACA from the pseudoaneurysm. Postoperative CT images did not show a cerebral infarction. The patient underwent ventriculoperitoneal shunt surgery 1 month later. She was discharged without any neurological deficits.
It is important to avoid injury of the ACA when tapping the lateral ventricle. If injury of the cerebral artery is suspected because of bleeding, the cerebral artery should be immediately investigated and the injury should be treated to prevent further bleeding. Neck clipping for pseudoaneurysm is often difficult and surgeons should also be prepared for vascular anastomosis.