Importance of a Reliable Admission Glasgow Coma Scale Score for Determining the Need for Evacuation of Posttraumatic Subdural Hematomas

Servadei, Franco; Nasi, Maria Teresa; Cremonini, Anna Maria; Giuliani, Giuliano; Cenni, P.; Nanni, Andrea

doi:10.1097/00005373-199805000-00021

Cited by 111 publications

(49 citation statements)

References 28 publications

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“…The pertinent medical literature mentions no randomized trials which might have compared neurosurgical decompression with conservative medical management for patients with SDHs, but limited observational data suggest that neurologically-stable patients with acute SDH who have small hematomas can be managed nonsurgically [22][23][24] . Non-operative conservative treatment has been recommended for acute SDHs.…”

Section: Discussionmentioning

confidence: 99%

Akut Posterior Fossa Subdural Hematom

Amin¹

2014

Cukurova Medical Journal

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Acute posterior fossa subdural hematomas are rare and most of them are trauma-related. Non-traumatic ones have been reported in patients who had idiopathic thrombocytopenic purpura or those who had been receiving anticoagulant therapy. We report on the case of 57-year-old Iranian man who developed sudden severe occipital headache, drowsiness, repeated vomiting, and instability of stance and gait. He was neither hypertensive nor diabetic. No history of head trauma was obtained and he denied illicit drug or alcohol ingestion. A preliminary diagnosis of acute intracerebellar hemorrhage was made. His CT brain scan revealed an acute right-sided, extra-axial, crescent-shaped hyperdense area at the posterior fossa. His routine blood tests, platelets count, bleeding time, and coagulation profile were unremarkable. The patient had spontaneous acute infratentorial subdural hematoma. He was treated conservatively and discharged home well after 5 days. Since then, we could not follow-up him, clinically and radiologically because he went back to Iran. Our patient's presentation, clinical course, and imaging study have called for conservative management, as the overall presentation was relatively benign. Unless the diagnosis is entertained and the CT brain scan is well-interpreted, the diagnosis may easily escape detection. Key Words: acute subdural hematoma; posterior fossa; cerebellar compression; ataxia; spontaneous ÖZET Akut posterior fossa subdural hematom nadir olarak gözlenir ve çoğu travmaya bağlıdır. Travmatik olmayanlar ise antikoagulan tedavi görmüş yada idiopatik trombositopenik purpura hastalarında rapor edilmiştir. Çalışmamızda ani ve ciddi oksipital baş ağrısı ile birlikte halsizlik, tekrarlayan kusmalar, dengesiz duruş ve yürüyüşü olan iranlı 57 yaşındaki bir erkek rapor edilmiştir. Bu kişi hipertansiyon veya diabet hastası değildir. Başında travma geçmişi bulunmamaktadır ve kişi uyuşturucu yada alkol kullanmadığını söylemektedir. Akut intra serebral hemoraji için ön bir tanı yapıldı. CT beyin taraması, posterior fossa bölgesinde sağ taraflı, ekstra aksiyal hilal şeklinde yoğunlaşmış bir alan olduğunu gösterdi.Rutin kan testleri, kanama zamanı, koagülasyon durumu ve trombosit sayımı normaldi. Hastada spontan gelişen akut infratentoryal subdural hematom vardı. Hasta tedavi edildi ve 5 gün sonra iyi bir şekilde taburcu edildi. O zamandan beri hasta klinik olarak veya radyolojik olarak takip edilemedi, çünkü hasta irana geri döndü. Hastanın durumu, klinik seyiri ve görüntüleri konservatif bir yönetim gerektirmiştir. Dolayısıyla genel anlamda hastanın durumu nispeten iyi olsada, CT beyin taramasını iyi yorumlanmadıkça ve olası teşhis konusunda önceden fikir sahibi olunmadıkca hastalık kolayca gözden kaçabilir.Anahtar Kelimeler: Akut subdural hematom, posterior fossa, serebral basınç, spontan, ataksi

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Section: Discussionmentioning

confidence: 99%

Akut Posterior Fossa Subdural Hematom

Amin¹

2014

Cukurova Medical Journal

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“…A drop of 2 or more points in the GCS score is considered significant and should raise an index of suspicion for an expanding intracranial mass lesion. 135 In a series of 81 patients with initial field GCS scores of 13 or 14 who subsequently deteriorated and required prehospital intubation, 31% had an abnormal CT scan and 21% had evidence of an intracranial hemorrhage. 54 The development of an oval or irregular pupil is the first sign of uncal herniation.…”

Section: Management Of Suspected Raised Icpmentioning

confidence: 99%

Prehospital management of traumatic brain injury

Stiver¹,

Manley²

2008

FOC

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The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.

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“…The authors dealt with the evidence that the use of sedative drugs precluded accurate GCS assessment during the first 24 h in most cases (Livingston et al, 2000). Dealing with posttraumatic subdural hematomas, Servadei et al (1998), underlined the importance of accurate and repeated GCS ratings, and advocated the avoidance of long-lasting sedatives and paralyzing medications.…”

Section: Inaccurate Early Neurological Assessment In Head Injurymentioning

confidence: 99%

Inaccurate Early Assessment of Neurological Severity in Head Injury

Stocchetti¹,

Pagan²,

Calappi³

et al. 2004

J Neurotrauma

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Intubation, which requires sedation and myorelaxants, may lead to inaccurate neurological evaluation of severely head-injured patients. Aims of this study were to describe the early clinical evolution of traumatic brain injured (TBI) patients admitted to intensive care unit (ICU), to identify cases of over-estimated neurological severity, and to quantify the risk factors for this over-estimation. A total of 753 TBI patients consecutively admitted to ICU of three academic neurosurgical hospitals (NSH) were assessed. Cases whose severity was potentially over-estimated were identified by four criteria and indicated as "mistakenly severe" (MS): (1) no surgical intracranial masses; (2) could not follow commands at neurological assessment; (3) were dismissed from the ICU in Յ3 days to a regular ward; and (4) had regained the ability to obey commands. A total of 675 patients were intubated and/or sedated-paralyzed at the post-stabilization evaluation. In all, 304 patients had surgically treated intracranial masses. Among the 449 non-surgical cases, 58 patients fulfilling the criteria for MS were identified. The main features distinguishing MS from truly severe cases were younger age, higher Glasgow Coma Scale (GCS) score at all time points, Marshall classification of Computerized Tomographic (CT) scan mostly Diffuse Injury I and II, fewer pupillary abnormalities, and a lower frequency of hypoxia, hypotension, and extra-cranial injuries. In a certain proportion of non-surgical TBI patients, mostly intubated and sedated, neurological examination is difficult and severity can be over-estimated. Risk factors for this inaccurate evaluation can be identified, and clinical decisions should be based on further examination.

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Importance of a Reliable Admission Glasgow Coma Scale Score for Determining the Need for Evacuation of Posttraumatic Subdural Hematomas

Cited by 111 publications

References 28 publications

Akut Posterior Fossa Subdural Hematom

Akut Posterior Fossa Subdural Hematom

Prehospital management of traumatic brain injury

Inaccurate Early Assessment of Neurological Severity in Head Injury

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