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Traumatic intracranial hemorrhage is a leading cause of morbidity and mortality in the United States. CT remains the primary imaging modality for initial evaluation of patients who have sustained head trauma. MR imaging, which has always been important for the evaluation of subacute and chronic head trauma, has been gaining popularity and recognition as an alternative primary imaging modality.
BACKGROUND: Recent literature on elderly patients with traumatic intracranial hemorrhage receiving preinjury antiplatelet agents shows a mortality rate of 47%. METHODS: In a retrospective analysis, patients older than 50 years presenting to the hospital over the past 4 years with traumatic intracranial hemorrhage and the use of aspirin, clopidogrel, or a combination were compared with a control group that had hemorrhage but no antiplatelet medications. Patient demographics, mechanism of injury, and injury scores were recorded. RESULTS: No significant differences were found between the 90 study patients and the 89 control subjects in terms of demographics, mechanism of injury, Injury Severity Score, Glasgow Coma Score, or hospital length of stay. Patients receiving antiplatelet therapy had significantly more comorbid conditions (71% vs. 35%; p < 0.001). In this series, 21 study patients and 8 control patients died (23% vs. 8.9%; p = 0.016). Age older than 76 years and a Glasgow Coma Score lower than 12 were correlated significantly with increased mortality. CONCLUSIONS: The use of antiplatelet agents with elderly trauma patients significantly increases the risk of mortality when head injury involves intracranial hemorrhage.
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The development of acute traumatic intracranial bleedings after severe head injuries is a dramatic manifestation. A great part in the timely discovery and successful treatment is equally played by the surgeon and by the radiologist, who make an inseparable diagnostic and therapeutic team. Therefore, they have an equal share in the glory of success and disappointment of failure.
This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anticoagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.
INTRODUCTION: Neonatal traumatic head injuries (NTHI) can be life-threatening and require aggressive treatment. The indications, techniques, and results of brain decompression are not well defined in the literature. METHODS: We studied prospectively cases of NTHI with intracranial traumatic lesions; skull fractures without underlying lesions were not included. We treated 17 cases of NTHI: 7 patients had a subdural hematoma, 3 had an extradural hematoma, and the others had subarachnoid hemorrhage. Surgical evacuation of intracranial clots was performed in 7 cases, by needle aspiration in 5 and by craniotomy in 2 patients with extradural hematomas. RESULTS: The outcome was favorable in all but one patient, who had hemophilia A, and died of rebleeding at the age of 2 months. CONCLUSION: Surgical decompression of intracranial hematomas due to NTHI is often unnecessary; however, it may be required in emergency because of poor clinical tolerance. Whenever possible, percutaneous needle aspiration is the treatment of choice.
We reviewed the records of all patients with recurrent seizures and severe head injury-induced traumatic intracranial hemorrhage (TIH) between 1989 and 2003 in three Israeli medical centers. We identified 52 cases (44 males, mean age=43+/-19 years, range=8-84; 8 females; mean age=74+/-12 years, range=48-85). Twenty-seven (52%) had additional known risk factors for TIH, e.g., older age, alcohol abuse, and anticoagulant use. All five children and adolescents had mental retardation. Approximately one-half of patients with seizures and TIH have additional risk factors for TIH. Non-mentally retarded children and adolescents with seizures are probably at low risk of developing TIH. Women less than 70 years old with seizures are much less prone to TIH than men. In young "otherwise healthy" patients with epilepsy, suboptimal treatment seems to be an important factor in the occurrence of TIH.
Maxillofacial trauma may mask intracranial injuries prompting intensive care treatment. The purpose of this study was to identify whether craniofacial fracture patterns predispose patients with maxillofacial fractures to different types of intracranial hemorrhages. Within 7 years, 6649 patients with craniomaxillofacial injuries were admitted for treatment. The charts of the patients were analyzed according to age, sex, cause and mechanism of injury, type and location of facial injury, and intracranial trauma; 2195 sustained maxillofacial fractures. Statistical analyses were followed by logistic regression analyses for the four main types of intracranial hemorrhage to determine the impact of the different maxillofacial fractures. Intracranial hemorrhages in 212 patients (9.7%) occurred as epidural (2.5%), subdural (4.3%), subarachnoid (5.3%), and intracerebral hemorrhages (6.3%). Le Fort, orbit, nose, zygoma, and maxillary fractures increased the risk for accompanying intracranial hemorrhage by two- to fourfold (P < 0.05). Basal skull fractures caused a multiplication of the risk up to 17-fold, while fractures of the cranial vault were associated with a risk up to 14-fold. Nearly 10% of patients with craniomaxillofacial fractures sustain intracranial hemorrhages requiring frequently immediate neurosurgical intervention. Those patients, suffering from central midface fractures and skull base fractures, are prone to highly significant elevated risks of intracranial hemorrhage.
BACKGROUND: A prospective cohort study at our institution demonstrated a 48% mortality rate in warfarin anticoagulated trauma patients sustaining intracranial hemorrhage (ICH) compared with a 10% mortality rate in nonanticoagulated patients. Forty percent of patients demonstrated progression of their ICH, despite anticoagulation reversal, with a resultant 65% mortality rate. Seventy-one percent of these patients initially presented with a Glasgow Coma Scale (GCS) score > or = 14 and a 'minor' ICH. We postulated that early diagnosis of ICH and rapid anticoagulation reversal would reduce ICH progression rates and mortality. METHODS: All anticoagulated patients with known or suspected head trauma were entered into the Coumadin protocol. The protocol ensured immediate triage and physician evaluation, head computed tomography (CT) scan, and fresh frozen plasma administration in patients with documented ICH. RESULTS: Eighty-two patients were entered into the protocol with ICH documented in 19 (23%). Sixteen of 19 patients (84%) presented with GCS > or = 14. Median international normalized ratio (INR) for treated patients with ICH was 2.7 versus 2.5 for patients without ICH (p = 0.546). Mean time to initiate warfarin reversal was 1.9 hours for protocol patients versus 4.3 hours for preprotocol patients (p < 0.001). Two of 19 (10%) protocol patients with ICH died. However, both patients presented >10 hours after injury with a severe ICH. This 10% mortality rate is significantly less than the 48% mortality rate seen previously (p < 0.001) and is now consistent with that observed in similarly injured patients not on anticoagulation. CONCLUSION: Neither the initial GCS nor INR in anticoagulated trauma patients reliably identifies patients with ICH. Rapid confirmation of ICH with expedited head CT scan combined with prompt reversal of warfarin anticoagulation with fresh frozen plasma decreases ICH progression and reduces mortality.
Wakeboarding is a relatively new and exciting sporting activity which is similar to water-skiing. While there have been several reports of water-skiing-related injuries, there has been nothing reported in the literature so far concerning injuries in wakeboarding. We present the case of a 14-year-old male who sustained an unusual intracranial subdural hemorrhage while wakeboarding and postulate on the mechanisms which could have resulted in the injury.
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