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Background and importance Chronic subdural hematoma (cSDH) is a common neurosurgical pathology with a projected increase in prevalence as the elderly population grows. We describe a novel implementation of the IRRAflow irrigating drainage system after burr hole evacuation of bilateral acute-on-chronic subdural hematomas that demonstrates the benefits of this system for common post-operative challenges of these surgeries. Clinical presentation An 83-year-old male presented to the emergency department with 3 weeks of progressive weakness, lethargy, and confusion following an unwitnessed fall. Physical examination was notable for pupillary asymmetry and altered mental status. Computed tomography (CT) of the head showed bilateral acute-on-chronic subdural hematomas. The patient underwent bilateral burr hole evacuation and placement of IRRAflow irrigating drains. Postoperative head CT demonstrated poor brain re-expansion with significant bilateral pneumocephalus. Marked improvement in brain re-expansion occurred with continuous irrigation and drainage, and the patient was discharged on postoperative day (POD) 3 with return to neurological baseline. He followed up on POD13 in stable condition. Conclusion This report described a patient with bilateral subdural hematomas who underwent evacuation and bilateral IRRAflow dual-lumen catheter placement. Significant postoperative pneumocephalus improved rapidly with continuous irrigation and drainage, leading to improved brain re-expansion, hematoma resolution, and excellent neurological recovery.

Acute subdural hematomas (ASDHs) caused by vehicle collisions are common brain injuries that suffers prone to disability and death. However, there is currently no commonly accepted evaluation index...

Objective: To improve the treatment of young children with traumatic intracranial hematomas by improving the diagnosis and use of minimally invasive surgical methods based on calculations of the intracranial hematoma volume index (VICH). Subjects and Methods: An analysis of the clinical course as well as the surgical treatment of 111 patients was carried out. The patients were under the age of 3, with severe traumatic brain injury, and formation of intracranial hematomas. The children were treated at the Department of Pediatric Neurosurgery of the City Children’s Clinical Hospital No.3 in Omsk, Russia, from 2008 to 2018. Three groups were identified: Group A - children with epidural hematomas (n=30), Group B - children with subdural hematomas (n=43), Group C - children with multiple hematomas (n=38). The volume index of intracranial hematomas (VICH) was calculated, and the surgical tactics were determined based on the value of the VICH. Results: Children with a VICH less than 2% received conservative treatments. Those with a VICH from 2 to 4% were treated with minimally invasive methods (puncture, drainage). Children with VICH above 4% underwent decompressive surgery. Conclusion: The effectiveness of the developed differentiated tactics of treatment of young children with traumatic intracranial hematomas (ICH) is characterized by a decrease in the risk of an unfavourable outcome by 74.2% and mortality by 1.2%.

Introduction Nonaccidental trauma (NAT) is considered when pediatric patients present with intracranial injuries and a negative history of an accidental injury or concomitant medical diagnosis. The evaluation of NAT should include the consideration of possible medical causes including coagulation, hematologic, metabolic and other genetic disorders, as well as witnessed and unwitnessed accidental injuries. Case Presentation We present a 7‐month‐old male with spells and incidental findings of bilateral subdural hematomas, retinal hemorrhages, and secondary macrocephaly, leading to investigation for NAT. Biochemical analysis showed excretion of a large amount of D‐2‐hydroxyglutaric in urine consistent with a biochemical diagnosis of D‐2‐hydroxyglutaric aciduria, a rare neurometabolic disorder characterized by developmental delay, epilepsy, hypotonia, and psychomotor retardation. None of these symptoms were present in our patient at the time of diagnosis. Molecular genetic testing revealed a pathogenic splice site variant (c.685‐2A>G) and a variant of uncertain significance (c.1256G>T) with evidence of pathogenicity in the D2HGDH gene, consistent with a molecular diagnosis of D‐2‐hydroxyglutaric aciduria type I (OMIM #600721). Conclusion Since several metabolic disorders, including D‐2‐hydroxyglutaric aciduria type I, can present solely with symptoms suggestive of NAT (subdural and retinal hemorrhages), an early metabolic evaluation by urine organic acid analysis should be included in clinical protocols evaluating NAT. A methodical and nonjudgmental approach coordinated between pediatricians and metabolic specialists is also necessary to ensure that rare genetic conditions are not overlooked to prevent devastating social, legal, and financial consequences of suspected child abuse.

Chronic subdural hematomas are complex collections that usually form after a trauma, particularly in elderly patients. This vulnerable population is at increased risk given the current viral pandemic. We share our experience in managing minimally symptomatic, enlarging subdural collections via middle meningeal embolization through the outpatient setting. This approach minimizes inpatient hospitalizations in hopes or reducing nosocomial spread (e.g., of COVID-19).

This study aimed to evaluate the utility of the 11-variable modified Frailty Index (mFI) in prognosticating elderly patients with traumatic acute subdural hematomas (aSDHs). A state-service level 1 trauma center registry was interrogated to investigate consecutive patients ≥65 years of age presenting with traumatic aSDH, with or without major extracranial injury, between January 2013 and December 2017. mFI on admission, demographics, and admission details, including Glasgow Coma Scale (GCS) and pupillary status and radiological findings, were retrospectively retrieved from institutional records. Clinical outcome data were retrieved from medical records and the Victorian State Trauma Registry (VSTR). Outcome measures were 1) 30-day mortality and 2) 6-month unfavorable outcome, defined by the Extended Glasgow Outcome Scale (GOS-E). Five hundred twenty-nine consecutive cases were identified from the registry. Demographic data included: 1) age (median; interquartile range) = 80.46; 74.17-85.89; 2) mFI (mean ± standard deviation) = 1.96 ± 1.42 of 11 variables. Four hundred sixteen cases (79%) had complete outcome data. As mFI increased from 0/11 variables to ≥5/11 variables (≥0.45), 30-day mortality risk increased from 17.72% to 39.29% (

The factors influencing the outcomes of mild/moderate acute subdural hematoma (ASDH) are still unclear. Retrospective analyses were performed to identify such factors. The medical records of all patients who were admitted to Saiseikai Shiga Hospital with mild (Glasgow Coma Scale [GCS] score of 14-15) or moderate (GCS score of 9-13) ASDH between April 2008 and March 2017 were reviewed. Comparisons between the patients who exhibited favorable and poor outcomes were performed. Then, independent factors that contributed to poor outcomes were identified via logistic regression analyses. A total of 266 patients with a mean age of 70.2 were included in this study. The most common concomitant injuries were subarachnoid hemorrhages (SAHs; 56.8%). The patients' Injury Severity Scores (ISS) ranged from 16 to 75 (median: 21). The 66 moderate ASDH patients exhibited significantly higher frequencies of surgery and mortality (24.2% and 13.6%, respectively) than the 200 mild ASDH patients (8.0% and 4.5%, respectively). The factors associated with poor outcomes were age (odds ratio [OR]: 1.06) and the ISS (OR: 1.24) in the mild ASDH patients, and older age (OR: 1.09) and the higher ISS (OR: 1.15) in the moderate group, too.

Middle meningeal artery (MMA) embolization could be an effective method of inhibiting neovascularization of the subdural capsular membrane and preventing hematoma maintenance. We sought to better understand how the MMA might affect subdural hematoma physiology and how this process might be modified by embolization.We performed a retrospective review of 27 patients with 29 subdural hematomas (SDHs) who had undergone MMA embolization from July 2018 to May 2019. Of the 27 patients, 8 had undergone postembolization DynaCT imaging studies and were included in the present study.The average patient age was 75 years. The baseline noncontrast-enhanced cranial computed tomography (CT) scans showed the presence of a hematoma membrane in all 8 patients. The postembolization DynaCT scans of all patients demonstrated enhancement of all 4 components (i.e., dura, capsular membrane, septations, and subdural hematoma fluid). All patients had a minimum of 60-day imaging and clinical follow-up data available. The average decrease in SDH volume at the last follow-up examination was 87% compared with that at baseline. A significant difference was found between the average baseline and average last follow-up SDH volume (P 0.0001, paired t test) in all 8 patients. The average interval from the date of the procedure to the last follow-up scan was 89 days (range, 61-122 days). No patient experienced postembolization complications, subsequent SDH drainage, or mortality.Our data lend support to the theory of contiguous vascular networks between the MMA and SDH membranes. Targeting these leaky vascular networks might remove the source of hematoma accumulation. These data add to the pathophysiological understanding of the disease and suggests potential insights into the mechanism of action of MMA embolization.

Purpose The incidence of acute subdural hematomas (aSDH) is rising. However, beneficial effects of surgery for the oldest aSDH patients remain unclear. We hence describe the postoperative outcome of octa- and nonagenarians with aSDH in comparison to a younger patient cohort. Methods Patients aged ≥ 80 years surgically treated for traumatic aSDH at a single institution between 2006 and 2016 were retrospectively reviewed. Clinical and imaging variables were assessed, and univariate analysis was performed to identify factors predicting outcome at discharge. Results were compared to a cohort of younger aSDH patients and statistical analysis was performed. Long-term outcome was prospectively evaluated with the GOSE and QOLIBRI. Results 27 aSDH patients aged ≥ 80 years were identified. On admission, 41% were in a comatose state and in-hospital mortality was 33%. At discharge, 22% had a favorable outcome (GOS 4 + 5). In univariate statistical analysis, better neurological status (GCS > 8), ≤ 1 comorbidity and smaller aSDH volumes were significant predictors for a favorable outcome. Comparison to 27 younger aSDH patients revealed significant differences in the prevalence of comorbidities and antithrombotics. At long-term follow-up, quality of life of aSDH patients was reduced (median QOLIBRI 54%). Conclusion Outcome after surgical treatment of aSDH in octa- and nonagenarians is not detrimental per se. Predictors for a favorable outcome are a non-comatose state on admission (GCS > 8), ≤ 1 preexisting comorbidity and a lower aSDH volume in patients aged ≥ 80 years. In individual patients, surgical evacuation of aSDH might remain a treatment option even in high ages.

The aim of the study was to determine the relationship between the effectiveness of treatment of patients with traumatic brain injury complicated by subdural hematoma and the localization of the hematoma. Materials and methods. The medical documentation of 52 patients with traumatic brain injury (TBI) complicated by acute subdural hematoma with a volume of 60-100 cm 3 was retrospectively analyzed. Patients were divided into 3 groups depending on the location of the hematoma: group I consisted of 21 patients (40%) with hematoma localization in the frontotemporal region, group II - 18 patients (35%) with hematoma localization in the parietal - temporal region, group III - 13 patients (25%) with hematoma localization in the frontotemporal - occipital region. When patients are discharged from the hospital, their condition indicators are calculated according to the Rankin scale. Results. More often subdural hematomas were localized in the frontotemporal and parietal-temporal regions, less often in the frontotemporal-occipital region. The severity of the victims' condition, estimated at less than 10 points according to the Glasgow scale, prevailed in patients with TBI complicated by subdural hematoma localized in the frontal-parietal -occipital region. The volume of hematoma localized in the frontal-parietal -occipital region prevailed in comparison with the frontal-temporal and parietal-temporal regions (p

OBJECTIVESubdural hematomas and hygromas (SDHs) are common complications in idiopathic normal pressure hydrocephalus (iNPH) patients with shunts. In this registry-based study, patients with shunted iNPH were screened nationwide to identify perioperative variables that may increase the risk of SDH.METHODSThe Swedish Hydrocephalus Quality Registry was reviewed for iNPH patients who had undergone shunt surgery in Sweden in 2004–2014. Potential risk factors for SDH were recorded preoperatively and 3 months after surgery. Drug prescriptions were identified from a national pharmacy database. Patients who developed SDHs were compared with those without SDHs.RESULTSThe study population consisted of 1457 patients, 152 (10.4%) of whom developed an SDH. Men developed an SDH more often than women (OR 2.084, 95% CI 1.421–3.058, p < 0.001). Patients on platelet aggregation inhibitors developed an SDH more often than those who were not (OR 1.733, 95% CI 1.236–2.431, p = 0.001). At surgery, shunt opening pressures had been set 5.9 mm H2O lower in the SDH group than in the no-SDH group (109.6 ± 24.1 vs 115.5 ± 25.4 mm H2O, respectively, p = 0.009). Antisiphoning devices (ASDs) were used in 892 patients but did not prevent SDH. Mean opening pressures at surgery and the follow-up were lower with shunts with an ASD, without causing more SDHs. No other differences were seen between the groups.CONCLUSIONSiNPH patients in this study were diagnosed and operated on in routine practice; thus, the results represent everyday care. Male sex, antiplatelet medication, and a lower opening pressure at surgery were risk factors for SDH. Physical status and comorbidity were not. ASD did not prevent SDH, but a shunt with an ASD allowed a lower opening pressure without causing more SDHs.

OBJECTIVELarge interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.METHODSA prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.RESULTSTwenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.CONCLUSIONSiSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic. A 14-year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school. ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.

Background Acute traumatic posterior fossa subdural hematomas are rare lesions in adult. Data on its physiopathology are limited. Timely surgical evacuation is the mainstay of treatment, particularly in selected cases with large volume hematomas compressing the posterior fossa neural elements. The outcome is generally poor and the overall mortality rate is high. The outcome depends on the clinical status of the patient and the timing of surgery. Results We report a case of a 22-years old patient admitted after a severe traumatic brain injury, with a Glasgow coma scale (GCS) of 12. The CT scan showed a right acute subdural hematoma of the cerebellar hemisphere, extending to right the cerebellar pontine angle (CPA) with compression of the posterior fossa neural elements. The patient had surgery within four hours from the trauma with a good recovery. Conclusion Despite the high rate of mortality related to posterior fossa subdural hematomas, our case report and literature analysis highlight the importance of early surgical management in ensuring a better clinical outcome.

Background: A complication after surgical intervention for chronic and subacute subdural hematoma drainage is the recurrence of hematoma, often requiring repeat surgical management. Recurrence rates varied widely across the published series, which may partially be due to different technical strategies used by the surgeons involved in the study. We decided to review our patients with chronic and subacute subdural hematomas that were surgically managed with a burr hole procedure by a single surgeon to compare recurrence rates with the evidence available. Methods: A retrospective review of the medical records was performed on the patients who underwent burr hole surgical intervention to drain a chronic or subacute subdural hematoma between April 1995 and March 2020. All patients were under the care of a single surgeon at an academic institution. Variables analyzed included age, sex, laterality of the hematoma, and recurrence. Results: During the selected timeframe, 610 cases were identified. There were 35 cases of recurrence of the hematoma. The recurrence rate after burr hole drainage was 5.73%. Conclusion: Surgical drainage of chronic and subacute subdural hematoma via burr hole using consistent stepwise management is associated with a relatively low recurrence rate in our single surgeon patient cohort.

Road traffic collisions are a major cause of traumatic brain injury. However, the relationship between road traffic collision dynamics and traumatic brain injury risk for different road users is unknown. We investigated 2065 collisions from Great Britain’s Road Accident In-depth Studies collision database involving 5374 subjects (2013–20). Five hundred and ninety-five subjects sustained a traumatic brain injury (20.2% of 2940 casualties), including 315 moderate–severe and 133 mild–probable injuries. Key pathologies included skull fracture (179, 31.9%), subarachnoid haemorrhage (171, 30.5%), focal brain injury (168, 29.9%) and subdural haematoma (96, 17.1%). These results were extended nationally using >1 000 000 police-reported collision casualties. Extrapolating from the in-depth data we estimate that there are ∼20 000 traumatic brain injury casualties (∼5000 moderate–severe) annually on Great Britain’s roads, accounting for severity differences. Detailed collision investigation allows vehicle collision dynamics to be understood and the change in velocity (known as delta-V) to be estimated for a subset of in-depth collision data. Higher delta-V increased the risk of moderate–severe brain injury for all road users. The four key pathologies were not observed below 8 km/h delta-V for pedestrians/cyclists and 19 km/h delta-V for car occupants (higher delta-V threshold for focal injury in both groups). Traumatic brain injury risk depended on road user type, delta-V and impact direction. Accounting for delta-V, pedestrians/cyclists had a 6-times higher likelihood of moderate–severe brain injury than car occupants. Wearing a cycle helmet during a collision was protective against overall and mild-to-moderate-to-severe brain injury, particularly skull fracture and subdural haematoma. Cycle helmet protection was not due to travel or impact speed differences between helmeted and non-helmeted cyclist groups. We additionally examined the influence of the delta-V direction. Car occupants exposed to a higher lateral delta-V component had a greater prevalence of moderate–severe brain injury, particularly subarachnoid haemorrhage. Multivariate logistic regression models created using total delta-V value and whether lateral delta-V was dominant had the best prediction capabilities (area under the receiver operator curve as high as 0.95). Collision notification systems are routinely fitted in new cars. These record delta-V and automatically alert emergency services to a collision in real-time. These risk relationships could, therefore, inform how routinely fitted automatic collision notification systems alert the emergency services to collisions with a high brain injury risk. Early notification of high-risk scenarios would enable quicker activation of the highest level of emergency service response. Identifying those that require neurosurgical care and ensuring they are transported directly to a centre with neuro-specialist provisions could improve patient outcomes.

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.

Subdural hematomas (SDHs) are increasingly common and can cause ischemic brain injury. Previous work has suggested that this is driven largely by vascular compression from herniation, although this work was done before the era of magnetic resonance imaging (MRI). We thus sought to study SDH-related ischemic brain injury by looking at patterns of cytotoxic edema on diffusion-weighted MRI. To do so, we identified all SDH patients at a single institution from 2015 to 2019 who received an MRI within 2 weeks of presentation. We reviewed all MRIs for evidence of restricted diffusion consistent with cytotoxic edema. Cases were excluded if the restricted diffusion could have occurred as a result of alternative etiologies (e.g., cardioembolic stroke or diffuse axonal injury). We identified 450 SDH patients who received an MRI within 2 weeks of presentation. Twenty-nine patients (∼6.5% of all MRIs) had SDH-related cytotoxic edema, which occurred in two distinct patterns. In one pattern (N = 9), patients presented as comatose with severe midline shift and were found to have cytotoxic edema in the vascular territories of the anterior and posterior cerebral artery, consistent with herniation-related vascular compression. In the other pattern (N = 19), patients often presented as awake with less midline shift and developed cytotoxic edema in the cortex adjacent to the SDH outside of typical vascular territories (peri-SDH cytotoxic edema). Both patterns occurred in 1 patient. The peri-SDH cytotoxic edema pattern is a newly described type of secondary injury and may involve direct toxic effects of the SDH, spreading depolarizations, or other mechanisms.

Inadvertent dural puncture with subsequent post-dural puncture headache (PDPH) is the most typical complication of labour epidural analgesia. Subdural hematoma (SDH) is a rare but late neurological complication of this procedure. The intracranial hypotension created by the cerebrospinal fluid (CSF) leakage through the dural defect can lead to the rupture of the bridging veins to produce a subdural hematoma. A change in the character from postural to a non-postural headache is a warning sign of subdural hematoma. We describe a case of post-dural puncture headache followed by the development of cranial SDH in a patient who refused a blood patch and opted for conservative treatment. We conclude that a high index of suspicion must be maintained with a witnessed dural puncture or even without it but having persistent headache, to detect any severe complications like an intracranial subdural hematoma. An epidural blood patch is to be considered when the headache does not subside with conservative management. Early employment of MRI or CT head imaging studies should be considered to exclude, diagnose, or treat any serious complication without unnecessary delay.

The Cheiro-Oral (COS) Syndrome is a rare neurologic condition characterized by sensory disturbances involving the peri-oral area and the upper extremity, typically isolated to the hand or fingers. The thalamus contralateral to the symptomatic side is the brain region most commonly involved. Most cases are caused by ischemic or hemorrhagic strokes, although other structural lesions have been implicated. These include tumors, subdural hematomas, aneurysms, and infections. The unusual and seemingly unrelated nature of the symptoms may contribute to misdiagnosis and incomplete workup for potentially serious conditions. We are unable to identify a report of this condition in the emergency medicine literature despite the emergency department being the likely point of presentation for patients with COS. In this report, we describe two patients with COS who presented to our emergency department and review the features of COS as described in published case reports.

A 9-month-old child presented with frequent crying and delayed developmental milestones. Computed tomography of the skull showed chronic subdural hematoma caused by playing with a rattle toy. Conservative treatment was decided with good results. The main differential diagnosis in these traumatic brain injuries is abuse, although in these cases subdural hematomas are usually multiple and have specific locations.

Spontaneous subdural hematoma (SDH) in cirrhotic patients is a rarely described condition in the literature and carries a high mortality rate. Several factors can potentially contribute to SDH development in cirrhosis, including coagulation cascade defects, thrombocytopenia, arteriovenous malformations, and cerebral atrophy. Clinicians should always keep spontaneous development of SDH in the differential diagnosis of acute encephalopathy in patients with end-stage liver disease, and prompt head imaging should be considered. We report a unique case of a 64-year-old patient with cryptogenic liver cirrhosis who was found to have spontaneous, bilateral SDHs while undergoing workup for acute encephalopathy.

BACKGROUND Asterion is identified as the connection point of sutura parietomastoidea, sutura occipitomastoidea, and sutura lambdoidea. The location of asterion, which is primarily preferred as a landmark during posterolateral surgical approach for intracranial operations, shows many variables. The aim of this study was to identify the surface location of the asterion and determine the distances between intracranial anatomical structures and asterion. METHODS At this present study, 11 hemicraniums (22 asterion points), situated at the laboratory of Department of Anatomy, Faculty of Medicine, Bursa Uludag University, were used. The asterion points which the sesamoid bone located were classified as type I and the ones which sesamoid bone did not locate were classified as type II. According to the proximity of asterion with sinus transversus, 3 groups were classified. About 19 parameters were measured related to asterion. The obtained data were analyzed in SPSS 22. RESULTS As a result of findings, while sesamoid bone was seen at 7 asterion points (type I), at 15 points sesamoid bone was not detected (type II) (respectively, 31.81%, 68.19%). It was identified that 15 asterion points were at the surface, 5 ones were average 3.42 ± 2.52 mm over, 2 ones average 3.21 ± 2.26 mm below of the projection of sinus transversus. Statistically significance was not seen between the measurements taken from left and right sides. DISCUSSION AND CONCLUSION Asterion is an important landmark for the retrosigmoid approaches. The surface and intracranial location of the asterion and proximity with dural sinuses are important for surgeons not to cause fatal subdural hematomas during the approaches using "Burr Hole" technic in neurochirurgie operations.

Key Clinical Message A neonatal parietal bone fracture was complicated by subgaleal and subdural hematomas after a vacuum extraction delivery. Low‐dose computer tomography visualized a comminuted skull fracture. Close observation of infants delivered by vacuum extraction, conservative management after a skull fracture, and further studies on vacuum traction monitoring are warranted., A neonatal parietal bone fracture was complicated by subgaleal and subdural hematomas after a vacuum extraction delivery. Low‐dose computer tomography visualized a skull fracture. Close observation of infants delivered by vacuum extraction, conservative management after a skull fracture, and further studies on vacuum traction monitoring are warranted.

Currently, clinical practice recommendations regarding patients in need of emergent lumbar puncture who are taking direct oral anticoagulants (DOACs) are based upon expert opinion, as evidence-based guidelines are unavailable. We present the case of an 80-year-old Caucasian lady who underwent diagnostic lumbar puncture for presumed meningitis while on therapeutic apixaban for nonvalvular atrial fibrillation. She was subsequently found to have bilateral subdural hematomas. This case report reviews both the current criteria for computerized tomography brain imaging prior to lumbar puncture as well as the bleeding risks of lumbar puncture while on a DOAC.

Alongside an increase in life expectancy, median age of patients presenting with traumatic acute subdural hematomas (ASDH) has increased as well. Treatment guidelines are based on studies performed on relatively young patients. The optimal management of elderly (>70 years old) patients with ASDH, specifically those with relatively preserved level of consciousness, was not thoroughly investigated so far. We retrospectively examined elderly patients presented to our medical center between the years 2006–2016 with traumatic convexity ASDH and GCS of 13–15. 773 patients were included in the initial cohort and 54 patients were included in the final analysis. The mean age at presentation was 81.5 years and the means of hematoma thickness and midline shift were 15.5 mm and 6.6 mm, respectively. Patients in our cohort had an overall unfavorable outcome (mRS 5–6) of 28% and 56% at discharge and at 1 year following injury, respectively. The results were not significantly different for the subgroups of patients older than 80 years and patients with high ASA-PS. Surgical evacuation of the ASDH was undertaken in 28 patients with focal neurologic deficit and/or worsening on subsequent brain scans. At 1 year, 64% (18 patients) in the surgery group had unfavorable outcome compared to 48% (12 patients) in the conservative group. We believe that these numbers should be taken under consideration when assessing elderly patients with convexity ASDH and relatively preserved level of consciousness.

Background Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. Methods This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. Results Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2–7.2 95 CI) had neurological decline, 73 (7.5% 5.9–9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5–7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1–0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. Conclusions RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Serious complications following spinal anesthesia (SA) are rare. However, surgeons and neurologist need to be aware that postsurgery headache refractory to conservative treatment or change in headache's characteristics could be due to serious intracranial complications such as a subdural hematoma. Any delay in diagnosis and treatment can be fatal. We report and discuss a case of a patient who suffered repeated subdural bleeds following SA.

Background and purpose Isodense and hypodense acute subdural hematomas have been reported in the literature in anemic patients. The purpose of this study is to see if there is a statistically significant difference between the Hounsfield unit measurements of acute subdural hematomas in anemic and nonanemic patients. Methods A total of 109 patients were analyzed. We measured the most hyperdense component of the subdural hematoma and compared these measurements for both anemic and nonanemic patients. Results All patients with anemia had a hyperdense component to their subdural hematomas during the acute period. No statistically significant difference was found in the density of the subdural hematomas between the two groups. More heterogeneous subdural hematomas were found in the anemic group than the nonanemic group, which suggests that anemia alone is not a sufficient explanation for acute homogenous isodense and hypodense subdural hematomas. Conclusion A hyperdense subdural component was present in all acute subdural hematomas in anemic patients. Therefore, anemia alone is not a sufficient explanation for a homogenous low-density acute subdural hematoma.

To evaluate correlation between the lateral ventricle ratio (LVR) and the risk of conservative treatment failure (CTF) among patients with acute subdural hematoma (ASDH) after non-severe traumatic brain injury (TBI), we retrieved from the hospital database and performed a retrospective analysis of 1339 cases with TBI treated during the 2008-2016 period.112 patients with ASDH, GCS≥ 9 and initial conservative treatment were enrolled. They were divided according to the final treatment method applied (surgical or conservative). Clinical and radiological data was evaluated. We used ROC curve analysis and multivariate logistic regression model to identify risk factors of CTF.LVR higher than 1.48 calculated on admission CT scans was the strongest predictor of CTF, with sensitivity of 78.9% and specificity of 93.5% (AUC: 0.774-0.994). LVR, prolonged prothrombin time and coexisting traumatic subarachnoid hemorrhage were independent risk factors.Despite limitations, study results support the view that patients after non-severe TBI with ASDH and with lateral ventricle asymmetry, defined as LVR 1.48, require surgical treatment. LVR seems to be indirect, but still the closest method to quantify intracranial compliance. Thus, in the selected group of patients without clinical symptoms of critically diminished compensatory reserve, LVR could indicate those who need a surgical decompression.

Background Acute subdural hematomas are frequently seen in brain trauma−injured patients. However, spontaneous subdural hematomas are uncommon, especially those localized in the posterior fossa, where fewer than 10 case reports have been described in the medical literature. Case Description We describe a patient who suddenly had a headache and progressed rapidly to coma and signs of brainstem compression. She was diagnosed with posterior fossa subdural hematoma after image examinations that were endorsed by surgical findings. A posterior fossa craniectomy was performed and was associated with blood drainage. Conclusions The patient had a great outcome, with no neurologic deficits at hospital discharge and the 1-year follow-up.