Outcome from severe head injury related to the type of intracranial lesion

A computerized tomography study

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✓ The influence of the type of intracranial lesion on the final outcome in a consecutive series of 277 severely head-injured patients was analyzed. Patients were studied with computerized tomograpy (CT) and underwent continuous measurement of intracranial pressure. They received identical treatment according to a standardized protocol. Outcome of patients with either epidural hematoma (38 cases), subdural hematoma (56 cases), brain contusion (87 cases), or diffuse brain damage (96 cases) was rather heterogeneous, and serial CT scanning allowed the authors to outline eight consistent anatomical patterns in the whole series which have stronger prognostic significance than the four major lesion categories mentioned above. Patients with pure extracerebral hematoma (19 cases), single brain contusion (45 cases), general brain swelling (41 cases), and normal CT scans (28 cases) had a significantly better outcome than patients developing acute hemispheric swelling after operation for a large extracerebral hematoma (27 cases), patients with multiple brain contusion, either unilateral or bilateral (74 cases), and patients with diffuse axonal injury (43 cases). These anatomical patterns are interesting because, in addition to having clinical and physiopathological significance, they provide useful prognostic information and facilitate improved therapeutic decision-making in severely head-injured patients.

Article Information

Address reprint requests to: Ramiro D. Lobato, M.D., Servicio de Neurocirugía, Ciudad Sanitaria “1° de Octubre,” C. Andalucia, Km 5.400, Madrid, Spain.

© AANS, except where prohibited by US copyright law.

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    Pattern 1. Upper: Preoperative view (A) of a large epidural hematoma causing marked midline shift in an 18-year-old man who had a lucid interval. This patient had a Glasgow Coma Scale (GCS) score of 4 and unilateral mydriasis at the time of operation. Following surgery (B), both the intracranial pressure (ICP) and the midline were normal. The patient was fully alert on the 3rd postoperative day. Lower: Preoperative view (C) in a 16-year-old boy who had a lucid interval. The patient had a GCS score of 4 and right-sided mydriasis at the time of evacuation of an acute subdural hematoma. Control scan immediately after surgery (D), when the mean ICP was 12 mm Hg. The patient made a good recovery.

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    Pattern 2. A: Preoperative view of an epidural hematoma in a 45-year-old man operated on 9 hours after trauma. The patient had a Glasgow Coma Scale score of 4 and bilateral mydriasis. B, C, and D: After surgery mean intracranial pressure was 65 mm Hg, and control scans showed persistent midline shift and decreased density of the ipsilateral cerebral hemisphere. The patient died 2 days postoperatively.

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    Pattern 2. Upper Row: Preoperative scan (A) in a 21-year-old man with a monoconvex subdural hematoma who had a Glasgow Coma Scale (GCS) score of 4 and unilateral mydriasis at the time of operation. Following surgery, a general swelling of the ipsilateral hemisphere ensued (B and C), resulting in increased shift and uncontrollable intracranial hypertension. Lower Row: Preoperative view (D) in a 35-year-old man operated on for a subdural hematoma more than 6 hours after trauma. The patient had a GCS score of 5. Following surgery he did not improve and the intracranial pressure rose progressively. Two days later the control scan (E) showed an intracerebral hematoma surrounded by a hypodense halo and persistent midline shift. Control scan after hematoma evacuation (F) shows hemispheric swelling. The patient developed uncontrollable intracranial hypertension and died.

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    Pattern 4. A: Admission scan in a 39-year-old man with multiple unilateral brain contusion. The patient had frontotemporal hemorrhagic contusion and a Glasgow Coma Scale score of 12. B and C: Control scans 36 hours after A when the patient had deteriorated. New hemorrhagic areas with perifocal edema developed, causing marked shift of brain structures. D: Following surgery, intracranial pressure was easily controllable. The patient developed moderate disability.

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    Pattern 4. A: Preoperative scan in a 77-year-old woman who was conscious for 36 hours before becoming comatose and undergoing operation for acute subdural hematoma. B: Following surgery, areas of mixed increased and decreased density appeared at the frontoparietal level. The midline shift persisted, but the intracranial pressure was normal. The patient had a Glasgow Coma Scale score of 7. C: Control scan 19 days after surgery showing cerebral hypodense areas. The patient died from extracranial complications.

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    Pattern 5. A and B: Preoperative scans in a 49-year-old man who was unconscious on admission. The patient had multiple hemorrhagic areas in the frontotemporal lobes, with discrete midline shift from left to right. C and D: Following operation intracranial pressure was very high. The patient died 4 days later.

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    Pattern 5. A and B: Admission scans in a 50-year-old man who complained of cortical blindness after falling backwards from a ladder. The patient had cerebellar contusion (not shown) and discrete occipital contusion. C and D: Intracranial pressure (ICP) monitoring was started when the patient became stuporous 48 hours after entry, at which time control scans showed multifocal intraparenchymal hemorrhages. Rising ICP could not be controlled with high-dose thiopental.

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    Pattern 5. A and B: Scans showing bifrontal hypodense areas with marked mass effect in a 43-year-old man who had a Glasgow Coma Scale score of 7 at admission. Mean intracranial pressure was 50 mm Hg (epidural sensor), but it was easily controlled with mannitol and the patient became conscious 2 days after admission. C: Control scan 7 days after admission. D: Late control scan showing ventricular dilatation. The patient made a good recovery.

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    Pattern 6. Upper Row: Typical appearance of transient general brain swelling in a boy who was alert for 15 minutes following trauma and who had a Glasgow Coma Scale (GCS) score of 5. His score was unchanged for 3 days. Admission scan (A) and a control scan 2 days later (B) show compressed ventricles when the intracranial pressure (ICP) was moderately raised. The compressed cisterns are not visible. The swelling eventually disappeared (C). Middle Row: Small frontal epidural hematoma associated with general brain swelling (D) was found in an 11-year-old boy who had a GCS score of 4 and ipsilateral mydriasis at the time of operation. Swelling persisted for several days postoperatively (E), causing moderately raised ICP. The swelling vanished 1 week after surgery (F). Lower Row: Small epidural hematoma with general brain swelling (G) in a boy with a GCS score of 5 at operation; the septum is minimally displaced. Control scan (H) 1 day after surgery shows a persistent swelling effect. At that time the ICP was almost normal and he had a GCS score of 7. On the 4th postoperative day the patient developed bilateral pneumonia with marked hypoxemia; ICP rose uncontrollably coincident with increased swelling (I).

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    Pattern 7. Sequential scans in a patient with diffuse axonal injury who was in a vegetative state after being in a coma for several weeks. A, B, and C: Multiple small hemorrhages were scattered throughout the deep white matter and the corpus callosum at admission. His intracranial pressure was low. D: A bifrontal hygroma was demonstrated 11 days after admission, but resolved spontaneously. E and F: Late control scans showing diffuse brain atrophy.

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