T raumaTic subdural hematomas (SDHs) are a common pathological entity in neurosurgical practice. Between 12% and 29% of patients admitted with a severe traumatic brain injury (TBI) have an acute SDH. When combining all patients with TBI, 11% present with an SDH. 10 Acute traumatic SDH has been traditionally considered a lesion that should be treated surgically, although some might be approached conservatively. In a study by Wong, 17 a midline shift greater than 5 mm in patients with a Glasgow Coma Scale (GCS) score below 15 was associated with deterioration and the need for surgical evacuation. In another study, 11 it was the initial thickness of the SDH that was predictive of the need for surgery, with all SDHs greater than 10 mm in thickness requiring surgical evacuation. Based on these findings, Servadei et al.12 attempted to establish a treatment protocol for comatose patients with SDH. They selected 15 comatose patients with abbreviatioNs AUC = area under the curve; BCR = bicaudate ratio; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ISS = Injury Severity Score; ROC = receiver operating characteristic; SDH = subdural hematoma; SFR = sylvian fissure ratio; TBI = traumatic brain injury. obJect The Brain Trauma Foundation has published guidelines on the surgical management of traumatic subdural hematoma (SDH). However, no data exist on the proportion of patients with SDH that can be selected for conservative management and what is the outcome of these patients. The goals of this study were as follows: 1) to establish what proportion of patients are initially treated conservatively; 2) to determine what proportion of patients will deteriorate and require surgical evacuation; and 3) to identify risk factors associated with deterioration and delayed surgery. methods All cases of acute traumatic SDH (869 when inclusion criteria were met) presenting over a 4-year period were reviewed. For all conservatively treated SDH, the proportion of delayed surgical intervention and the Glasgow Outcome Scale score were taken as outcome measures. Multiple factors were compared between patients who required delayed surgery and patients without surgery. results Of the 869 patients with acute traumatic SDH, 646 (74.3%) were initially treated conservatively. A good outcome was achieved in 76.7% of the patients. Only 6.5% eventually required delayed surgery, and the median delay for surgery was 9.5 days. Factors associated with deterioration were as follows: 1) thicker SDH (p < 0.001); 2) greater midline shift (p < 0.001); 3) location at the convexity (p = 0.001); 4) alcohol abuse (p = 0.0260); and 5) history of falls (p = 0.018). There was no significant difference in regard to age, sex, Glasgow Coma Scale score, Injury Severity Score, abnormal coagulation, use of blood thinners, and presence of cerebral atrophy or white matter disease. coNclusioNs The majority of patients with SDH are treated conservatively. Of those, only 6.5% later required surgery, for raised intracranial pressure or SDH pr...

Backround:The American Academy of Neurology recommended using phenytoin or carbamazepine to prevent early post-traumatic seizures (PTS) in severe traumatic brain injuries (TBI). In this study, we examined the effects of using phenytoin prophylaxis on mild, moderate, and severe TBIs. There have been no studies looking at compliance rate and side effects of systematic use of phenytoin at a large population scale. The goal of this study is to determine 1) the proportion of TBI patients receiving phenytoin prophylaxis; 2) which parameters decided when to decide administer phenytoin; 3) prophylaxis efficacy and complication rate.Methods:We retrospectively studied all patients admitted with a TBI over a two year-period and collected the following information: age, GCS score, CT-scan Marshall grade, incidence of early PTS, incidence of phenytoin use and time delay, side effects, and incidence of over-dosage or under-dosage.Results:1008 patients were included. 5.4 % had early PTS, 2.3 % while on prophylaxis and 3.1% while not on prophylaxis, 1.9% before reaching the hospital and 1.2% prior to phenytoin administration while in hospital. Delay of administration was 5 hours. 64.8% received prophylaxis and physicians used positive CT scan as the primary decision-making parameter (p<.001). Compliance with guidelines was 99.7%. Adverse reactions occurred in 0.5%. Levels were drawn in 42.2% (52% therapeutic, 41% low, 7% high).Conclusions:Phenytoin is used according to guidelines, with CT scan being the main decision factor for its use. The frequency of early PTS rate is low and side effects are rare. However, earlier administration of phenytoin and adequate levels could further prevent early PTS.