Remote Postoperative Epidural Hematoma after Subdural Hygroma Drainage

Objective. Subdural hygroma is reported to occur in 5%–20% of all patients with closed head trauma, the treatment is controversial and in symptomatic cases surgical drainage is need. We report on a new case with remote acute epidural hematoma (AEH) after subdural hygroma drainage. Case Presentation. A 38-year-old man suffered blunt head trauma and had diffuse axonal injury grade III in CT scan. A CT scan that was late performed showed an increasing subdural fluid collection with mild mass effect and some effacement of the left lateral ventricle. We perform a trepanation with drainage of a hypertensive subdural collection with citrine aspect. Postoperative tomography demonstrated a large left AEH. Craniotomy and evacuation of the hematoma were performed. Conclusion. The mechanism of remote postoperative AEH formation is unclear. Complete reliance on neurologic monitoring, trust in an early CT scan, and a relative complacency after an apparently successful initial surgery for hygroma drainage may delay the diagnosis of this postoperative AEH

Traumatic Pseudoaneurysm of the Middle Meningeal Artery Causing an Intracerebral Hemorrhage

Traumatic aneurysms comprise less than 1% of all intracranial aneurysms. Most of these aneurysms are actually false aneurysms, or pseudoaneurysms, which are caused by the rupture of entire vessel wall layers, with the wall of the aneurysm being formed by the surrounding cerebral structures. Traumatic pseudoaneurysms of the middle meningeal artery are also rare. Only four cases have been reported in the literature with intracerebral hematoma. In this paper, the authors report a case of a patient with a ruptured traumatic pseudoaneurysm of the MMA who presented with an intracerebral hematoma in the left temporal region immediately after trauma; the patient underwent endovascular treatment

Diffuse Axonal Injury: Epidemiology, Outcome and Associated Risk Factors

Abstract Diffuse axonal injury (DAI), a type of traumatic injury, is known for its severe consequences. However, there are few studies describing the outcomes of DAI and the risk factors associated with it. This study aimed to describe the outcome for patients with a primary diagnosis of DAI six months after trauma and to identify sociodemographic and clinical factors associated with mortality and dependence at this time point. Seventy-eight patients with DAI were recruited from July 2013 to February 2014 in a prospective cohort study. Patient outcome was analyzed using the Extended Glasgow Outcome Scale (GOS-E) within six months of the traumatic injury. The mean Injury Severity Score was 35.0 (SD = 11.9), and the mean New Injury Severity Score (NISS) was 46.2 (SD = 15.9). Mild DAI was observed in 44.9% of the patients and severe DAI in 35.9%. Six months after trauma, 30.8% of the patients had died, and 45.1% had shown full recovery according to the GOS-E. In the logistic regression model, the severity variables—DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with NISS value—had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence

Surgical treatment of a transorbital penetrating brain injury

Penetrating injury of the skull and brain are relatively uncommon events, representing about 0.4% of all head injuries. Transorbital penetrating brain injury is an unusual occurrence in emergency practice and presents with controversial management. We report the case of a 10-year-old boy who fell forward on a bamboo stick while playing with other children, causing a penetrating transorbital injury, resulting in meningitis. We performed a combined surgical approach with neurosurgeons and ophthalmogic surgeons. Upon discharge, the patient had a Glasgow Coma Scale score of 15, no motor deficit and no visual loss. We discuss the management of this case and review current literature

Serum sodium disorders in patients with traumatic brain injury

Sodium disorders are the most common and most poorly understood electrolyte disorders in neurological patients. The aim of this study was to determine the incidence of sodium disorders and its association with different traumatic brain injuries. This prospective study was conducted in 80 patients diagnosed with moderate and severe traumatic brain injuries. All patients underwent cerebral computed tomography. Incidence of sodium disorders, presence of injuries in the first computed tomography after traumatic brain injury, and level of consciousness were analyzed. Patients that presented other potential causes of sodium disorders and systemic trauma were excluded from the study. The incidence of sodium disturbances was 45%: 20 patients presented hypernatremia and 16 hyponatremia. Refers to all patients with sodium disturbances 53% were detected in the first sample. We recorded at least one measurement <125 mEq/L in 50% of the patients with hyponatremia. A greater incidence of sodium disorders was found in patients with subdural, intracerebral hematoma and with diffuse axonal injury. The incidence of sodium disorders among the patients with diffuse lesions was greater than in the group of patients with brain contusion (P = 0.022). The incidence of sodium disorders is higher in patients with diffuse traumatic brain injuries. No association was found between focal lesions and proportion of sodium disorders

Mecanismos de lesão cerebral no traumatismo cranioencefálico

O traumatismo cranioencefálico (TCE) é a principal causa de morte e sequela em crianças e adultos jovens nos países industrializados ocidentais. A lesão encefálica definitiva que se estabelece após o TCE é o resultado de mecanismos fisiopatológicos que se iniciam com o acidente e estendem-se por dias ou semanas. As lesões encefálicas no TCE podem ser classificadas em difusas e focais. Esses dois mecanismos costumam associar-se em um mesmo paciente, embora, geralmente exista o predomínio de um tipo. O conhecimento dos mecanismos fisiopatológicos da lesão cerebral no traumatismo cranioencefálico é fundamental para o estabelecimento de medidas terapêuticas clínicas e cirúrgicas. Neste artigo, realizamos uma revisão crítica da literatura sobre os princípios fisiopatológicos da lesão cerebral no paciente com traumatismo cranioencefálico.Traumatic brain injury is the main cause of death and disability in children and adults in Western Countries. The definitive brain injury is a consequence of pathophysiological mechanisms that begin at the moment of an accident and may extend for days or weeks. Traumatic brain injury may be classified as diffuse or focal. These two mechanisms are commonly associated in a patient, however one is generally predominant. Therefore knowledge of the pathophysiological mechanisms of brain injury in head trauma is important to establish the therapeutic, clinical and surgical measures. In this paper the authors present a critical review of the literature on the pathophysiological principles of traumatic brain injury

Coma e outros estados de consciência

As alterações do nível de consciência podem variar entre dois extremos, desde uma desorientação têmporo-espacial até um estado de coma profundo. Na prática clínica é extremamente comum o médico se deparar frente a um paciente com alteração do nível de consciência. Em hospitais gerais, estudos indicam o alcoolismo, o traumatismo cranioencefálico e as doenças cardiovasculares como as principais causas de coma (82%). O médico deve saber reconhecer as principais causas de alteração da consciência, seus diagnósticos diferenciais, identificar o paciente grave e tratar as possíveis alterações emergenciais que possam levar aum dano neurológico secundário. Nesta revisão destacamos os principais pontos no exame neurológico para determinar as diferentes alterações do nível de consciência.The alterations of the level of conscience can vary among two ends, from a mental confusion to a state of deep coma. In clinical practice it is extremely common apatient with alteration of the level of conscience without diagnosis. In general hospitals, studies indicate that the alcoholism, the brain trauma and the cardiovascular diseases are the main causes of coma (82%). Its necessary know how to recognize the main causes of unconsciousness of and their differential diagnosis, aimed to identify the severe ill patient and to treat the possible emergency states that take to a secondary neurological damage. In this revision, we emphasized the key points in the neurological exam to determine the different alterations ofthe level of consciousness

Propostas para revisão dos critérios clínicos de morte encefálica

Atualmente, quase 70 mil pessoas aguardam doação de órgãos no Brasil. O Hospital das Clínicas da Universidade de São Paulo – HCFMUSP é referência em transplantes de órgãos e tecidos e, ao mesmo tempo que se realizam cirurgias de alta complexidade, capacita os profissionais de saúde, sendo um facilitador para a integração dos mesmos. A morte encefálica hoje deve ser considerada uma emergência médica, pois pode salvar várias vidas. O seu diagnóstico é realizado de acordo com a Resolução do Conselho Federal de Medicina nº 1.480/97 e, baseado nessa resolução e em nossa experiência com todo o processo de captação até o transplante, apresentamos neste artigo propostas para evitar a perda de potenciais doadores.Almost 70 thousand people await donation of organs in Brazil. The Hospital das Clínicas of the University of São Paulo is reference center in transplants of organs and woven and, at the same time that you/they take place surgeries of high complexity, it qualifies the professionals of health, being a facilitator for the integration of the same ones. Brain death today should be considered a medical emergency, because its diagnosis can save several lives. Its diagnosis is accomplished in agreement with the Brazilian Medicine Federal Council number 1.480/97 and, based on that resolution and in our experience with whole transplant process, we presented in this paper proposed to avoid the potentials donors’ loss