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Background Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood. Methods An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases. Results A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed. Conclusion IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed.

OBJECTIVEA recent retrospective study of severe traumatic brain injury (TBI) in pediatric patients showed similar outcomes in those with a Glasgow Coma Scale (GCS) score of 3 and those with a score of 4 and reported a favorable long-term outcome in 11.9% of patients. Using decision tree analysis, authors of that study provided criteria to identify patients with a potentially favorable outcome. The authors of the present study sought to validate the previously described decision tree and further inform understanding of the outcomes of children with a GCS score 3 or 4 by using data from multiple institutions and machine learning methods to identify important predictors of outcome.METHODSClinical, radiographic, and outcome data on pediatric TBI patients (age < 18 years) were prospectively collected as part of an institutional TBI registry. Patients with a GCS score of 3 or 4 were selected, and the previously published prediction model was evaluated using this data set. Next, a combined data set that included data from two institutions was used to create a new, more statistically robust model using binomial recursive partitioning to create a decision tree.RESULTSForty-five patients from the institutional TBI registry were included in the present study, as were 67 patients from the previously published data set, for a total of 112 patients in the combined analysis. The previously published prediction model for survival was externally validated and performed only modestly (AUC 0.68, 95% CI 0.47, 0.89). In the combined data set, pupillary response and age were the only predictors retained in the decision tree. Ninety-six percent of patients with bilaterally nonreactive pupils had a poor outcome. If the pupillary response was normal in at least one eye, the outcome subsequently depended on age: 72% of children between 5 months and 6 years old had a favorable outcome, whereas 100% of children younger than 5 months old and 77% of those older than 6 years had poor outcomes. The overall accuracy of the combined prediction model was 90.2% with a sensitivity of 68.4% and specificity of 93.6%.CONCLUSIONSA previously published survival model for severe TBI in children with a low GCS score was externally validated. With a larger data set, however, a simplified and more robust model was developed, and the variables most predictive of outcome were age and pupillary response.

Introduction: Traumatic brain injury (TBI) is common, and the frequency of patients taking oral anticoagulants is increasing. However the optimal initial triage, management, and long term care plans of hemorrhagic TBI patients taking oral anticoagulants is not clear. Objectives: To determine the usage pattern of reversal agents for hemorrhagic TBI patients taking oral anticoagulants, and examine their characteristics and outcomes as compared to hemorrhagic TBI patients not taking these medications. Methods: This was a single-center, retrospective, observational study. Included were adults with trauma categorization and traumatic intracranial hemorrhage (ICH) between April 1, 2017 and December 31, 2019. Patient age, type of ICH, initial Glasgow Coma Scale (GCS) score, oral anticoagulant prescribed pre-injury, anticoagulation reversal agent given, and hospital discharge disposition were recorded. Results: For the entire sample size (n=111), the mean age and GCS were 71.6 years old and 13.8, respectively. Compared to patients not taking oral anticoagulants, patients taking oral anticoagulants were older (76.7 years old versus 69.1; p

Pneumorrhachis (PR) is the presence of free air within the spinal canal. It is generally benign and improves with conservative management. Case reports and a literature review exist documenting the existence and potential pathogenesis of this phenomenon, but no evidence-based guidelines exist documenting what treatment, if any, is indicated for this condition. We present a case of a 21-year-old male who developed PR after a preceding upper respiratory tract infection. His symptoms improved with expectant management and administration of high-flow oxygen. The purpose of this case report is to add to the scarce existing literature reporting this condition and to provide a short review of literature detailing the pathogenesis of PR.

Introduction Mild traumatic brain injury (TBI) is common but its management is variable. Objectives To describe the acute natural history of isolated hemorrhagic mild TBI. Methods This was a single-center, retrospective chart review of 661 patients. Inclusion criteria were consecutive patients with hemorrhagic mild TBI. Exclusion criteria were any other acute traumatic injury and significant comorbidities. Variables recorded included neurosurgical intervention and timing, mortality, emergency room disposition, intensive care unit (ICU) length of stay (LOS), discharge disposition, repeat computed tomography head (CTH) indications and results, neurologic exam, age, sex, Glasgow Coma Scale (GCS) score, and hemorrhage type. Results Overall intervention and unexpected delayed intervention rates were 9.4% and 1.5%, respectively. The mortality rate was 2.4%. A 10-year age increase had 26% greater odds of intervention (95% CI, 9.6-45%; P

Rosai-Dorfman disease is an uncommon lymphoproliferative disorder, and multiple intracranial involvement in disseminated disease is exceedingly rare. We present a case of a 52 year-old female who presented with intractable headaches and a history of Rosai-Dorfman disease unresponsive to chemo- and radiation therapies. She was found to have new multiple intracranial masses that were treated with surgical excision. Pathology confirmed a diagnosis of intracranial Rosai-Dorfman. The disease presentation, radiographic appearance, histology, treatment, and prognosis are briefly reviewed.

Traumatic intracranial aneurysms are rare lesions that occur after blunt or primarily penetrating mechanisms. These are extremely fragile vessel injuries associated with significant morbidity and mortality, especially after rupture. Disease natural history, surveillance strategies, and management are based on small case series. Here we present a case of a 29-year-old male with a large epidural hematoma after blunt trauma, who underwent emergent surgical intervention. Three months postoperatively, he presented with unusual cerebral bleeding. Clinical suspicion prompted a conventional angiogram, which diagnosed a ruptured cortical traumatic intracranial aneurysm. The patient was urgently treated by surgical clipping with a good outcome.

Pituitary carcinomas are defined as pituitary tumors with craniospinal and/or systemic metastasis. These are rare and highly aggressive lesions. We present an unusual case of a 52-year-old male who had a pituitary adenoma removed via craniotomy. The tumor recurred three years post-op near the surgical tract, and slowly enlarged before removal two years later. Technically, this lesion was defined as a pituitary carcinoma, even though the histology and clinical course were atypical. There is no standardized grading system for pituitary tumors and ideal criteria should correlate clinically. Treatment for pituitary carcinoma is multimodal and largely empiric. We believe this case illustrates that current definitions of pituitary carcinoma are incomplete.

A 19-year-old Caucasian male presented with complaints of headaches and syncope. Suspicion of hydrocephalus prompted computed tomography (CT) and magnetic resonance imaging (MRI), which revealed pineal and suprasellar prominences with diffuse, thick, nodular subependymal enhancement of the lateral and third ventricles. Based on imaging, the differential diagnosis consisted primarily of malignancy, such as lymphoma, with inflammatory and infectious etiologies not excluded. Cerebrospinal fluid (CSF) samples were non-specific, and neuroendoscopic tissue biopsy histologically confirmed the diagnosis of pure germinoma. The patient was treated with radiation, and follow-up MRIs at one, three, six, and 12 months demonstrated progressive resolution of tumor burden with marked clinical improvement. Germinomas are rare germ cell tumors that are more frequently diagnosed in Asian countries. They uncommonly seed into the lateral ventricles, and only two other cases have been described with diffuse subependymal involvement. Unlike other malignant germ cell tumors, germinomas have marker negative CSF samples that are important in the normal diagnostic workup of diffuse subependymal lesions. Histopathologic correlation is required for definitive diagnosis in the United States and can be achieved with endoscopic tissue sampling. Germinomas are highly radio- and chemotherapy sensitive and have a fair prognosis with modern therapeutic techniques. Germinoma should be considered with simultaneous midline and diffuse ventricular lesions.