Search Results (189)

Major traumas result from the application of multiple force components that, in adulthood, can lead to high mortality and morbidity. In forensic practice, pathological consequences arising from the rapid flexion–extension of an adult victim’s soma are observed, with typical intracranial and ophthalmological findings. The totality of these findings allows for a contribution to the definition of the Shaken Adult Syndrome (SAS). A comprehensive review, employing the PRISMA methodology, was conducted on international works pertaining to SAS. This resulted in the identification of six scientific papers, which were analyzed separately. It emerged that, for the diagnosis of SAS, the same diagnostic triad as Shaken Baby Syndrome is valid, comprising subdural hemorrhages, retinal hemorrhages, and encephalopathy. This syndrome appears to encompass a broad spectrum of pathological conditions, ranging from whiplash to diffuse axonal injury (DAI). At the conclusion of this work, we proposed a diagnostic flowchart that allows for suspected predictive diagnosis of SAS, both in live patients presenting to emergency medical services and in post-mortem cadavers. For this purpose, the collection of anamnesis and circumstantial data, the detection of external injuries, and the execution of cranial CT scans will be essential. Ultimately, microscopic examinations of the brain with specific immunomarkers and of ocular structures will enable the identification of pathognomonic findings for SAS. Full article

Background: Venous thromboembolism (VTE) is associated with high morbidity and mortality. The activation of multiple pathways of venous thrombosis occurs after an injury. A prophylaxis protocol is necessary to prevent early and late venous thrombotic complications. Methods: This study aimed to evaluate the outcomes of venous thromboembolism using the Greenfield risk assessment profile score and its association with bleeding complications. This was a retrospective cohort study conducted on trauma cases who were aged 15 years or older. The study was conducted from January 2020 through December 2022. Patients who were admitted to hospital for less than 24 h or those who died during resuscitation or treatment in an emergency room were excluded from this study. Results: We enrolled 580 cases. Among them, 46.6% were categorized as high-risk for developing venous thromboembolism, and 30.4% of these high-risk patients received pharmaco-mechanical thromboprophylaxis. All VTE cases were high risk according to the Greenfield risk assessment profile, accounting for 3% of the entire group and 1.4% of all enrolled cases. All major bleeding complications occurred with a previously diagnosed large subdural hematoma. Conclusions: Assessing VTE risk was crucial for optimal management of prophylaxis. Proper use of pharmacological prophylaxis had to be balanced against the risk of bleeding complications. Full article

Cerebral Amyloid Angiopathy (CAA) is a neurovascular condition characterized by the accumulation of amyloid-beta (Aβ) in the walls of small blood vessels, particularly affecting the leptomeninges and cortical regions in elderly populations. Initially recognized for its association with spontaneous lobar intracerebral hemorrhage, recent studies have highlighted the broader implications of CAA on cognitive decline and vascular health. This narrative review aims to elucidate the mechanisms of dural involvement in CAA, an aspect that has been largely overlooked in existing literature. This paper provides a detailed examination of the potential role of the dura mater and its associated lymphatic system in the clearance of interstitial amyloid and the maintenance of cerebrospinal fluid (CSF) homeostasis. Dural lymphatic vessels may facilitate the efflux of Aβ from the brain, and any impairment in this drainage system could contribute to the pathological accumulation of amyloid, exacerbating CAA and its neurological consequences. Additionally, the significant association between CAA and subdural hematoma (SDH) has been explored, indicating that the presence of SDH may complicate the clinical management of CAA patients by signaling an increased risk of hemorrhagic events. The mechanisms linking CAA and SDH, including vascular fragility and chronic inflammatory processes, are discussed to provide insight into potential pathways for therapeutic intervention. Full article

Background/Objectives: Safe discharge after neurosurgical traumatic brain injury (TBI) depends on documented counseling and appropriate referrals, yet real-world fidelity is uncertain in resource-constrained settings. We quantified discharge process quality and identified digitally actionable gaps. Methods: The sample for this study was a retrospective cohort of 559 consecutive neurosurgical TBI patients discharged from a Brazilian public tertiary center (2012–2022). Data were abstracted from electronic health records. The primary outcome was documentation of warning sign counseling at discharge. Proportions are reported with exact Clopper–Pearson 95% confidence intervals. Results: The median age was 66 years (IQR 47–79.5); 78.5% were male and most received care under the public health system. Subdural hematoma predominated; hematoma drainage was the most frequent procedure. Warning sign counseling was documented in 16.1% of cases (89/559; 95% CI 13.2–19.5), and no palliative care referrals were recorded. Conclusions: A low baseline for a safety-critical discharge element exposes an immediately actionable target. Embedding discharge order sets with mandatory counseling fields in the EHR, clinical decision support prompts for palliative care screening and follow-up, and QR-coded patient handouts represent a pragmatic path to improve discharge quality and end-of-life readiness in the digital era. Full article

Background: Accurate volumetry and imaging characterization of chronic subdural hematoma (cSDH) are essential for prognostication and treatment planning, but manual assessment is time-consuming and therefore underutilized. Methods: We retrospectively analyzed preoperative non-contrast CT (NCCT) scans of 257 patients undergoing first-time surgery for uni- or bilateral cSDH. Hematoma volumes were measured manually using a semi-automated area-outlining tool on every second axial slice and compared with the volumes estimated through the ABC/2 formula. Hematoma attenuation patterns and components were categorized, and interrater reliability was assessed for volume, maximum diameter, and imaging features using intraclass correlation coefficients (ICCs) and Cohen’s κ. Results: A total of 339 hematomas were evaluated. Manual and ABC/2 volume measurements correlated strongly (R² = 0.83, ICC [3, 1] = 0.90). The interrater agreement for manual volumetry was excellent (ICC [2, 1] = 0.96). Agreement was also excellent for maximum diameter (ICC [2, 1] > 0.9) and good for midline shift assessment (κ = 0.81). Agreement was moderate for the identification of fresh clots, trabeculations, and laminations (κ = 0.62–0.72) but poor for general attenuation patterns (κ = 0.44). Conclusions: The manual volumetry of cSDH is feasible and highly reproducible between raters of different experience levels. These results provide a robust reference standard for the validation of automated volumetry tools and support the implementation of quantitative hematoma assessment in future clinical trials and routine care. Full article

Background: Moyamoya syndrome is a moyamoya-like cerebrovascular condition associated with an identifiable underlying condition. Although head trauma has historically been considered a possible contributing factor, it is currently excluded from the Japanese diagnostic criteria. We report a rare case of progressive unilateral moyamoya-like vasculopathy that developed on the ipsilateral chronic subdural hematoma (CSDH) following head trauma, with a decade-long imaging follow-up. Anterior circulation basi-parallel anatomical scanning (BPAS) provided unique insights into the progressive vessel narrowing beyond the vascular lumen, suggesting its potential utility in evaluating such rare vasculopathies. Case Presentation: A 40-year-old man developed a left-sided CSDH after head trauma and underwent burr hole drainage. Although his symptoms resolved, serial magnetic resonance angiography (MRA) over the subsequent 10 years revealed progressive stenosis of the left middle cerebral artery (MCA), ultimately culminating in an occlusion-like appearance. BPAS revealed moyamoya-like collateral vessels in the same hemisphere, a significant reduction in the outer diameter of the left MCA, supporting the presence of structural arterial wall changes that were not apparent on conventional MRA. Single-photon emission computed tomography revealed mildly reduced cerebral blood flow on the affected side, with a difference of less than 5% compared to non-affected side. He remained neurologically non-symptomatic, with no history of transient ischemic attacks or overt ischemic stroke. Conclusions: This case highlights a rare clinical course of progressive ipsilateral moyamoya-like vascular changes following head trauma and burr-hole drainage for CSDH, potentially indicating an association between head trauma, CSDH, and subsequent moyamoya-like collateral vessel development, warranting further investigation. The use of the anterior circulation BPAS contributed to the detection of structural arterial changes that were not apparent on conventional MRA, suggesting its potential utility in evaluating such vascular abnormalities. Full article

Background: Traumatic Brain Injury (TBI) represents a growing cause of medical emergencies globally. Objective: This study evaluates whether healthcare outcomes for TBI patients differ between daytime and on-call (after-hours) admissions. Methods: A retrospective analysis was conducted using data from a hospital database spanning January 2015 to December 2019. Of the 670 cases reviewed, 45 patients over the age of 65 were admitted with head trauma. Data were analyzed using SPSS. Results: Surgical interventions were significantly less frequent during on-call hours. Admission type (elective vs. emergent) showed a statistically significant difference (p < 0.05). Postoperative ICU length of stay (LOS) was markedly longer for on-call admissions (p = 0.002). Due to a controlled sample size, p-value interpretations would need some discretion. TBI patients admitted during on-call hours had a 9.9-fold increase in ICU stay, a 2.5-fold increase in total hospital LOS, and a 475% higher complication rate compared to daytime admissions. Complication rates were 20% for daytime admissions versus 92% for on-call admissions. Furthermore, patients treated during on-call hours were 11 times more likely to be discharged in an unconscious state (GCS < 8). Conclusions: TBI outcomes are significantly worse during on-call hours. Enhancing imaging availability and staffing during these periods may help improve patient outcomes. Full article

Background: Chronic subdural hematoma (cSDH) is a common condition, particularly in individuals over 65 years of age. Its pathophysiology involves traumatic and inflammatory processes, culminating in hematoma formation. Although surgical drainage is the primary treatment of choice, its significant recurrence rates have prompted exploration of non-surgical options. This study evaluates the effectiveness of middle meningeal artery (MMA) embolization as an alternative or adjunctive treatment in asymptomatic or paucisymptomatic cSDH patients. Methods: This two-center retrospective study analyzed 93 patients treated with MMA embolization at two hospitals between 2020 and 2024. Patients exhibited either asymptomatic or mild symptomatic cSDH (Markwalder score 0 or 1), with hematoma thickness >10 mm. Pre- and post-treatment CT scans were compared to assess hematoma thickness, with follow-ups conducted at three months. Statistical analysis included ANCOVA and Mann–Whitney U tests for outcome evaluation. Results: Of the 93 patients, 44 underwent bilateral embolization, and 49 underwent unilateral embolization. Treatment reduced hematoma thickness by an average of 59% at three months follow-up. The trabecular subtype showed the greatest thickness reduction compared to other subtypes (p < 0.05). No significant differences were found between embolization materials. Only 3.2% of patients experienced technical complications, and three patients experienced rebleeding during follow-up. Conclusions: MMA embolization appears to be a safe and effective treatment for cSDH, providing a minimally invasive alternative to surgery. The technique shows promise in reducing hematoma size, especially in the trabecular subtype. Further research is needed to confirm these findings and establish their role in routine clinical practice. Full article

Intraoperative ultrasound (IOUS) is an increasingly adopted adjunctive intraoperative visualization method in spinal tumor surgery, offering real-time imaging that improves lesion localization, exposure planning, and resection control. This paper focuses on IOUS findings in rare intradural entities (neuroenteric/respiratory cysts, chronic spinal subdural hematoma, tethered cord/scarring, intradural extramedullary hemangioblastomas, and arachnoid cysts) where evidence remains limited. Across these lesions, IOUS typically depicts cysts as anechoic or hypoechoic cavities with definable walls and occasional septations; CSSDH is also delimited by hypoechoic subdural collections bounded by echogenic membranes; hemangioblastomas, as well as circumscribed, homogeneous nodules often with cystic components; and arachnoid webs/cysts with their boundaries and subtle subarachnoid communications. Doppler and micro-Doppler can delineate feeding and draining vessels in highly vascular tumors, while shear wave elastography provides quantitative stiffness changes that support effective detethering. IOUS complements preoperative MRI, shortens exposure, helps tailor bone and dural openings, and allows immediate assessment of residual disease. Taken together, current data and our experience support IOUS as a safe, cost-effective, and versatile intraoperative tool for rare intradural spinal pathology, while underscoring the need for prospective studies to refine sonographic criteria and validate outcome benefits. Full article

Background/Objectives: Chronic subdural hematoma (CSDH) predominantly affects the elderly population. To optimize care and quality in this demographic, tailored, age-specific counseling and therapeutic decision-making are imperative. Accordingly, this study aimed to identify risk factors for in-hospital mortality and functional outcome at discharge following surgery using an age-stratified approach. Methods: We conducted a retrospective analysis of symptomatic CSDH patients who underwent surgery at our institution between June 2012 and December 2023. Subjects were categorized into three age cohorts: younger adults (18–64 years), older adults (65–79 years), and the oldest old (≥80 years). Clinical and neurological statuses at admission and discharge were evaluated using the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS), with mRS scores > 3 indicating poor functional outcomes. Results: Among 879 CSDH patients (mean age 75 ± 11.9 years), the sex ratio shifted progressively from a male predominance in younger adults (1:3.2) to a more balanced ratio in the oldest old (1:1.7). In the multivariate analysis, poor admission mRS and GCS score ≤ 7 predicted in-hospital mortality for older adults, while atrial fibrillation and postoperative pneumonia were significant in the oldest old. Poor admission mRS and multimorbidity consistently forecast unfavorable outcomes alongside other predictors, such as preoperative altered state of consciousness, epilepsy, dementia, unilateral CSDH, postoperative seizure, bleeding, and pneumonia varying by age cohort. Recurrence-free intervals were significantly extended with increasing age. Conclusions: This large-scale, age-stratified analysis delineates critical predictors of in-hospital mortality and unfavorable functional outcomes in surgically treated CSDH patients. These findings offer valuable guidance for neurosurgeons in preoperative risk assessment and inform age-specific counseling strategies to better communicate prognosis and tailor treatment plans. Full article

Prompt reversal of anticoagulation in the elderly population with subdural hematoma (SDH) is critical to reduce morbidity and facilitate timely surgical intervention. In patients receiving dabigatran, idarucizumab provides rapid anticoagulation reversal. We evaluated clinical and radiological outcomes of dabigatran-treated SDH patients receiving idarucizumab, including those undergoing surgical management. We conducted a single-center retrospective observational study of dabigatran-treated patients who received idarucizumab reversal for traumatic or spontaneous SDH between 2016 and 2024. Hematoma evolution was monitored using follow-up computed tomography. Clinical and neurological outcomes were recorded. Of eleven included patients (mean age 80.8 ± 6.7 years; 36% female), falls were the primary cause (64%). SDH was chronic in 64% and acute in 36%, with associated traumatic lesions in 33%. Surgical evacuation was performed in 82% of cases. Anticoagulation was resumed in 27% of patients within 3–4 weeks post-discharge. The median Glasgow Outcome Scale Extended (GOSE) score was 5, indicating moderate disability. In-hospital mortality was 9.1%. Idarucizumab enabled rapid and safe dabigatran reversal in this high-risk elderly cohort, supporting both surgical and conservative SDH management. Functional outcomes were moderate and mortality was low, underscoring its clinical utility. Targeted reversal strategies remain essential, and further research should refine long-term anticoagulation management. Full article

Targeted temperature management (TTM), particularly the avoidance of hyperpyrexia, is a cornerstone of intensive care, especially in conditions such as cerebral edema and increased intracranial pressure. Management becomes more complex in pregnancy, where maternal neuroprotection must be weighed against fetal safety. Both invasive and noninvasive methods for temperature control have been described, but evidence regarding their safety in pregnancy remains limited. We present the case of a 24-year-old pregnant woman admitted to the ICU with cerebral edema due to subdural empyema. The Arctic Sun surface cooling system was employed for fever control, with continuous maternal and fetal monitoring. The system effectively maintained normothermia without immediate adverse effects on either the mother or the fetus. However, on the third day of its use, the patient experienced a spontaneous preterm delivery of a stillborn fetus. Although a causal link between surface cooling and preterm labor cannot be established from this single case, the event underscores the need for caution and further investigation. This case highlights both the feasibility and the uncertainties of using advanced TTM devices in critically ill pregnant patients. It emphasizes the importance of multidisciplinary monitoring and the urgent need for evidence-based guidelines to balance maternal benefits with fetal safety. Full article

Background/Objectives: While epidural and periradicular corticosteroid injections are well-established treatments for degenerative spinal conditions, intrathecal administration of glucocorticoids remains uncommon and under-researched. To our knowledge, this is the first large contemporary dataset on intrathecal triamcinolone in degenerative lumbar disorders. This study retrospectively analyzes clinical outcomes and complication rates associated with this treatment. Methods: We reviewed patients who received intrathecal injections of triamcinolone for lumbar degenerative spinal diseases between May 2023 and June 2024. Data were extracted from electronic records and included demographics, indication, application method (freehand or CT-guided), dosage, symptom relief, and complications. Results: A total of 722 intrathecal injections were performed (499 patients). The most common indication was lumbar spinal canal stenosis (94.0%). Punctures were performed freehand in 68.4% of the injections; 80 mg of triamcinolone was administered in 71.2%. Follow-up data were available for 528 injections. After 87.3% of these, symptom improvement (binary yes/no) after injection was reported. Duration of benefit was documented after 144 injections: 39.6% reported a relief lasting up to six months, and 25% up to one month. Four complications (0.6%) occurred: one post-puncture headache, one pain aggravation, one case of shortness of breath, and one intracranial subdural hygroma. All were managed conservatively. Conclusions: Despite limited data quality, including missing/non-standardized follow-up and the lack of standardized pain scales for follow-up, this large retrospective cohort provides preliminary evidence that intrathecal triamcinolone may be a safe and effective treatment option for lumbar degenerative spinal disorders, with pain relief observed in the majority of cases. Given the inherent limitations of retrospective Level IV evidence, prospective controlled studies are warranted to further evaluate its role compared to other interventional pain therapies. Full article

Background: Post-traumatic epilepsy (PTE) is a recognized complication of traumatic brain injury (TBI), yet its risk following mild and moderate TBI remains underappreciated. Although mild TBI represents the majority of cases in clinical practice, a subset of patients develop unprovoked seizures months or even years post-injury. This review aims to synthesize current evidence on the incidence and predictors of PTE in mild and moderate TBI and to propose a clinically actionable decision-support tool for early risk stratification. Methods: We performed a narrative review of peer-reviewed studies published between 1985 and 2024 that reported on the incidence, risk factors and predictive models of PTE in patients with mild (Glasgow Coma Scale [GCS] 13–15) and moderate (GCS 9–12 or imaging-positive) TBI. Data from 24 studies were extracted, focusing on neuroimaging findings, early post-traumatic seizures, EEG abnormalities and clinical risk factors. These variables were integrated into a rule-based algorithm, which was implemented using Streamlit to enable real-time clinical decision-making. The decision-support tool incorporated five domains: injury severity, early post-traumatic seizures, neuroimaging findings (including contusion location and hematoma type), clinical and demographic variables (age, sex, psychiatric comorbidities, prior TBI, neurosurgical intervention) and EEG abnormalities. Results: PTE incidence following mild TBI ranged from <1% to 10%, with increased risk observed in patients presenting with intracranial hemorrhage or early seizures. From moderate TBI, incidence rates were consistently higher (6–12%). Key predictors included early seizures, frontal or temporal contusions, subdural hematoma, multiple contusions and midline shift. Additional risk-enhancing factors included prolonged loss of consciousness, male sex, psychiatric comorbidities and abnormal EEG patterns. Based on these features, we developed a decision-support tool that stratifies patients into low-, moderate- and high-risk categories for developing PTE. Conclusions: Even in non-severe cases, patients with mild and moderate TBI who exhibit high-risk features remain vulnerable to long-term epileptogenesis. Our proposed tool provides a pragmatic, evidence-based framework for early identification and follow-up planning. Prospective validation studies are needed to confirm its predictive accuracy and optimize its clinical utility. Full article

Background/Objectives: Subarachnoid cysts in children, while often linked to trauma, can also rupture spontaneously without any apparent injury. Their etiology remains complex, involving congenital, traumatic, and infectious factors. This article explores the risks, pathophysiology, and management strategies related to spontaneous rupture in pediatric cases reported in the literature through the means of a systematic review. Materials and Methods: A systematic review of Web of Science, Scopus, PubMed and the Virtual Health Library (BVS, for its acronym in Spanish) was conducted; the online software Ryyan was used to manage the references and conduct the filtering process. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was used to assess bias for each type of study. Results: We analyzed the data of 101 articles; in total we found that 331 pediatric patients with arachnoid cyst were diagnosed with intracranial hemorrhage and 1030 patients had an unruptured arachnoid cyst. The most common cyst diameter was between 5–7 cm in the bleeding group vs. 3–4.5 cm in the non-bleeding group. A head trauma trigger was identified in 36.25% of cases of bleeding and 10.6% were sports related. Most of the hemorrhages were subdural, followed by a mixed pattern between subdural and intracystic. In both groups the arachnoid cyst was mostly located in the middle cranial fossa in the left side. The bleeding arachnoid cysts were mostly treated with surgery, but conservative treatment was also effective; the outcome was good in the majority of cases. Conclusions: Further research is required to elucidate the pathophysiological mechanisms underlying hemorrhage associated with arachnoid cysts in the pediatric population. Nevertheless, upon identification of an arachnoid cyst, neurosurgical follow-up is warranted. Bleeding tends to occur only in the presence of high-risk features and can be precipitated by traumatic events. Full article