Naeimi A, Aghajanian S, Jafarabady K, Aletaha R, Maroufi SF, Khorasanizadeh M, Stippler M.
Prognostic value of computed tomography and magnetic resonance imaging findings in acute traumatic brain injury in prediction of poor neurological outcome and mortality: a systematic review and meta-analysis.
Neurosurg Rev. 2024 Nov 6;47(1):837. doi: 10.1007/s10143-024-03071-y. Epub 2024 Nov 6.
Abstract/Text
Traumatic brain injury (TBI) is a major cause of morbidity and mortality, impacting healthcare systems and economies. Early identification of poor outcomes is crucial for effective treatment. This systematic review assesses the prognostic value of computed tomography (CT) and magnetic resonance imaging (MRI) findings in predicting poor neurological outcomes and mortality in the acute phase of TBI. A comprehensive search of Scopus, MEDLINE, and Web of science databases was performed to identify studies examining CT and MR-based imaging findings and their association with poor outcomes as assessed by Glasgow outcome score as well as mortality within the early acute phase of TBI following injury/admission. Qualitative evaluation of included studies revealed several imaging sequences that modify the outcome of the patients, including extra-axial and intra-axial hemorrhage, swirl sign, contrast extravasation, midline shift, closed and open cranial cisterns, signs of edema, presence of cranial fractures, intracranial hemorrhage, cerebral microbleeds, diffuse axonal injury, apparent diffusion coefficient and fractional anisotropy in diffusion tensor imaging, as well as, concentrations of brain metabolites(N-acetyl aspartate, Creatinine, Choline, Myo-inositol, glutamate, and glutamine) in magnetic resonance spectroscopy. Among these markers, subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) emerged as the most predictive of poor outcomes based on meta-analysis findings. SAH was significantly associated with an increased risk of mortality (OR: 3.35, 95% CI: 2.41-4.65, I²=51.3%) and poor outcomes (OR: 2.69, 95% CI: 2.44-2.96, I²=0%). Similarly, SDH correlated with higher mortality risk (OR: 2.44, 95% CI: 2.14-2.78, I²=0%) and worse outcomes (OR: 2.00, 95% CI: 1.12-3.59, I²=60.9%). In contrast, epidural hematoma (EDH) was linked to better outcomes (OR: 0.60, 95% CI: 0.52-0.68, I²=0%) but not significantly associated with mortality (OR: 0.38, 95% CI: 0.09-1.65, I²=73.7%). The results of this systematic review and meta-analysis provide an overview of clinically feasible imaging markers of prognostic value and may inform clinical decision-making in the future.
© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
一般社団法人JPTEC協議会編：JPTECガイドブック改訂第2版、へるす出版、2017.
日本外傷学会・日本救急医学会監修：外傷初期診療ガイドラインJATEC改訂第6版、へるす出版、2021.
日本脳神経外科学会編：頭部外傷治療・管理のガイドライン（第4版）,医学書院,2019.
Holzschuh M, Schuknecht B.
Traumatic epidural haematomas of the posterior fossa: 20 new cases and a review of the literature since 1961.
Br J Neurosurg. 1989;3(2):171-80. doi: 10.3109/02688698909002792.
Abstract/Text
Twenty patients with an epidural haematoma of the posterior fossa (EPIPF) among a total number of 359 patients with an epidural haematoma are reported (5.6%). Nine patients obtained a good outcome, four patients had a moderate disability and seven patients died (mortality 35%). Mortality of the acute cases was 50%, of the subacute cases 20%. In general, the clinical features were uncertain. Sixteen cases showed an occipital skull fracture or diastasis of the lambdoid suture respectively. A total number of 127 cases with EPIPF from the literature since 1961 was studied. The mortality in the CT-diagnosed group ran to 21.7% and to 25.9% in the group without CT. None of the patients showing a subacute course died when the diagnosis was made by CT, in the group without CT, however, four patients out of 11 subacute cases died. Head injured patients with an occipital trauma should therefore undergo CT scanning to detect a surgically significant lesion before clinical deterioration occurs.
Rivas JJ, Lobato RD, Sarabia R, Cordobés F, Cabrera A, Gomez P.
Extradural hematoma: analysis of factors influencing the courses of 161 patients.
Neurosurgery. 1988 Jul;23(1):44-51. doi: 10.1227/00006123-198807000-00010.
Abstract/Text
The clinical and computed tomographic (CT) findings in a series of 161 consecutive patients operated upon for postraumatic extradural hematoma are analyzed. Thirteen (8%) patients had delayed epidural hematoma formation. The overall mortality for the series was 12%, significantly lower than that observed during the prior "angiographic" period at the same unit (30%). Because all but 1 of the deaths occurred among the 66 patients unconscious at the time of operation (27% mortality in this subgroup), the authors sought differential factors between comatose and noncomatose patients at operation. There were no significant differences between these groups in age, sex, mechanism of injury, preoperative course of consciousness (lucid interval or not), or epidural hematoma location and shape. In contrast, significant differences were seen between the two subgroups in trauma-to-operation interval, hematoma volume, CT hematoma density (mixed low-high CT density vs. homogeneous hyperdensity), midline displacement, severity of associated intracranial lesions, and postoperative intracranial pressure (ICP). Patients comatose at operation usually evidenced a more rapid clinical deterioration (a shorter trauma-to-operation interval) and tended to have a large hematoma volume, a higher incidence of mixed CT density clot (hyperacute bleeding), more marked shift of midline structures, more severe associated lesions, and higher postoperative ICP levels.
CRASH-3 trial collaborators.
Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial.
Lancet. 2019 Nov 9;394(10210):1713-1723. doi: 10.1016/S0140-6736(19)32233-0. Epub 2019 Oct 14.
Abstract/Text
BACKGROUND: Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI.
METHODS: This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat. This trial was registered with ISRCTN (ISRCTN15088122), ClinicalTrials.gov (NCT01402882), EudraCT (2011-003669-14), and the Pan African Clinical Trial Registry (PACTR20121000441277).
RESULTS: Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86-1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80-1·00]). The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64-0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91-1·07]; p value for heterogeneity 0·030). Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74-1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90-1·33]).
INTERPRETATION: Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.
FUNDING: National Institute for Health Research Health Technology Assessment, JP Moulton Charitable Trust, Department of Health and Social Care, Department for International Development, Global Challenges Research Fund, Medical Research Council, and Wellcome Trust (Joint Global Health Trials scheme).
TRANSLATIONS: For the Arabic, Chinese, French, Hindi, Japanese, Spanish and Urdu translations of the abstract see Supplementary Material.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
日本神経学会監修：てんかん診療ガイドライン2018追補版．2021. Available from: https://www.neurology-jp.org/guidelinem/tenkan_tuiho_2018.html
山浦 晶，ほか編：神経外傷 感染・炎症性疾患．脳神経外科学体系12．中山書店，2005.
Jamjoom AB, Kane N, Sandeman D, Cummins B.
Epilepsy related to traumatic extradural haematomas.
BMJ. 1991 Feb 23;302(6774):448. doi: 10.1136/bmj.302.6774.448.
Abstract/Text
Zimmerman RA, Bilaniuk LT.
Computed tomographic staging of traumatic epidural bleeding.
Radiology. 1982 Sep;144(4):809-12. doi: 10.1148/radiology.144.4.7111729.
Abstract/Text
Guo C, Liu L, Wang B, Wang Z.
Swirl sign in traumatic acute epidural hematoma: prognostic value and surgical management.
Neurol Sci. 2017 Dec;38(12):2111-2116. doi: 10.1007/s10072-017-3121-4. Epub 2017 Sep 11.
Abstract/Text
The swirl sign is identified as a small area of low attenuation within an intracranial hyperattenuating clot on non-enhanced computed tomography (CT) scans of the brain, which represents active bleeding. The purpose of this study was to evaluate the incidence of the swirl sign among patients with acute epidural hematoma (AEDH) and to identify its prognostic value and impact on surgical treatment. A retrospective review was performed of patients with a diagnosis of traumatic EDH by CT scan who were surgically treated at the Department of Neurosurgery of the First People's Hospital of Jingmen between January 2010 and January 2014. Patients with combined or open craniocerebral injuries and those who did not undergo surgical treatment were excluded. Of the 147 patients evaluated, 21 (14%) exhibited the swirl sign on non-enhanced CT scans of the brain. Univariate analysis revealed a significant correlation between the occurrence of the swirl sign and preoperative Glasgow coma scale scores, preoperative mydriasis, time from injury to CT scan, and intraoperative hematoma volume. Compared with patients without this sign, those exhibiting the swirl sign had a higher mortality rate (24 vs. 6%, respectively; P = 0.028) and a worse outcome (Glasgow Outcome Scale score ≤ 3: 38 vs. 15%, respectively; P = 0.027) at 3 months. An adjusted analysis showed that the occurrence of the swirl sign was an independent predictor of poor outcome (death: odds ratio (OR) = 4.61; 95% confidence interval (CI): 1.34-15.82; P < 0.05; 3-month Glasgow Outcome Scale score ≤ 3: OR = 3.47; 95% CI: 1.27-9.49; P < 0.05). In conclusion, the occurrence of the swirl sign on the head CT scan of patients with AEDH was found to be significantly associated with poor outcome. Therefore, early identification of this sign and aggressive management with early surgical evacuation is crucial for improving patient outcome.
Wang X, Ge R, Yuan J, Xu S, Fang X, Dai Y, Jiang X.
Risk Factors and Prognostic Value of Swirl Sign in Traumatic Acute Epidural Hematoma.
Front Neurol. 2020;11:543536. doi: 10.3389/fneur.2020.543536. Epub 2020 Nov 9.
Abstract/Text
Objective: Acute epidural hematoma (AEDH) is one of the deadliest lesions in patients after traumatic brain injury. AEDH with swirl sign progresses rapidly and requires timely surgical treatment. This study aims to investigate the risk factors for the occurrence of AEDH with swirl sign and its prognostic value. Methods: Retrospective analysis was performed on 131 AEDH patients, who were divided into swirl sign group and non-swirl sign group based on the brain computed tomographic (CT) scan. Patient information, including gender, age, hypertension, mechanism of injury, Glasgow Coma Scale (GCS) score on admission, time from injury to CT scan, pupillary light reactivity on admission, midline shift, location of hematoma, hematoma volume on admission, oral anticoagulation, and Glasgow Outcome Scale (GOS) score at 3 months were collected. Univariate analysis was used to determine the risk factors for the occurrence of swirl sign. The factors with P < 0.05 were recruited into the multivariate logistic regression analysis and predictive receiver operating characteristic (ROC) curve model. Results: Univariate analysis demonstrated that the GCS score on admission (P = 0.007), pupillary light reactivity (P = 0.003), location of hematoma (P < 0.0001), and GOS score at 3 months (P = 0.007) were risk factors for the occurrence of swirl sign. Multivariate logistic regression model revealed that the location of hematoma (OR = 0.121; 95% CI: 0.019-0.786; P = 0.027) was an independent risk factor for swirl sign, and the occurrence of swirl sign was a significant predictor of unfavorable neurological outcomes (OR = 0.100; 95% CI: 0.016-0.630; P = 0.014). ROC curves demonstrated that the GCS score on admission (AUC = 0.655; 95% CI: 0.506-0.804), pupillary light reactivity (AUC = 0.625; 95% CI: 0.474-0.777) and location of hematoma (AUC = 0.788; 95% CI: 0.682-0.893) can predict the occurrence of swirl sign, respectively. Remarkably, the combination of these three factors (AUC = 0.829; 95% CI: 0.753-0.906) provided a greater power to predict the swirl sign. Conclusion: GCS score on admission, pupillary light reactivity, and location of hematoma are risk factors for the occurrence of swirl sign, respectively. The combination of these three factors might be used to predict whether there is swirl sign in AEDH after traumatic brain injury. Furthermore, swirl sign can be used as an effective predictor of poor prognosis in patients.
Copyright © 2020 Wang, Ge, Yuan, Xu, Fang, Dai and Jiang.
Amoo M, Henry J, Alabi PO, Husien MB.
The 'swirl sign' as a marker for haematoma expansion and outcome in intra-cranial haemorrhage: A meta-analysis.
J Clin Neurosci. 2021 May;87:103-111. doi: 10.1016/j.jocn.2021.02.028. Epub 2021 Mar 19.
Abstract/Text
The 'swirl sign' is a CT imaging finding associated with haematoma expansion and poor prognosis. We performed a systematic review and meta-analysis to determine its prognostic value. PubMed/MEDLINE and EMBASE were searched until 16/12/2020 for related articles. Articles detailing the relationship between the swirl sign and any of haematoma expansion (HE), neurological outcome in the form of Glasgow Outcome Score (GOS) or mortality were included. A meta-analysis was performed and the pooled sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated for each of HE, GOS and mortality. 15 papers were assessed. Nine papers related to HE, for which the pooled sensitivity was 50% (95% CI 30-71), specificity was 77% (95%CI 67-85) and PLR was 2.16 (95%CI 1.89-2.42). There was significant heterogeneity (I2 = 70%, Q = 26.9). Three papers related to GOS, for which the pooled sensitivity was 45% (95%CI 20-74), specificity was 78.3% (95%CI 40-95.2) and PLR was 1.77 (95%CI 1.04-2.62). Three papers related to mortality, for which the pooled sensitivity was 65% (95% CI 32-88), specificity was 75% (95%CI 42-92) and pooled PLR was 2.64 (95%CI 1.60-4.13). Our findings indicated that the swirl sign is a useful prognostic marker in the radiological evaluation of intracranial haemorrhage. However, more research is needed to assess its independence from other risk factors for haematoma expansion.
Copyright © 2021 Elsevier Ltd. All rights reserved.
Sugi K, Kikuchi J, Yoshitomi M, Orito K, Kajiwara S, Nakamura Y, Takeshige N, Takeuchi Y, Abe T, Morioka M.
Leakage Sign Is a Reliable Predictor of Hematoma Expansion in Acute Epidural Hematoma.
World Neurosurg. 2024 Sep;189:e674-e680. doi: 10.1016/j.wneu.2024.06.144. Epub 2024 Jun 29.
Abstract/Text
BACKGROUND: Hematoma expansion (H-Ex) in small-/medium-sized acute epidural hematoma (AEDH) cases upon emergency admission is critical. Predicting H-Ex can lead to early surgical interventions, improving outcomes, and eliminating the need to check for expansion via computed tomography (CT). This study aimed to identify the most reliable predictors of AEDH expansion.
METHODS: We retrospectively collected data from patients with pure AEDH not requiring surgical treatment upon emergency admission from 2012 to 2022. We assessed clinical and laboratory data, time from injury to the first CT, and time to follow-up CT. Factors predictive of H-Ex on the second follow-up CT, including the leakage sign (LS), were analyzed.
RESULTS: A total of 23 patients with pure AEDH without surgery at admission were included, and LS was positive in 18. Thirteen patients showed H-Ex. The H-Ex group showed a significantly higher rate of positive LS and a lower mean platelet count than the group without H-Ex. LS's predictive value for AEDH expansion showed 100% sensitivity and 50% specificity. All patients with negative LS and normal platelet counts showed no H-Ex. Analyzing the time from injury to the first CT suggested that LS (+) within 120 minutes strongly predicted H-Ex. Reconstructed three-dimensional images of the leakage point on the skull revealed multiple mottled bleeding points on the dural surface.
CONCLUSIONS: LS can predict H-Ex in patients with pure AEDH for whom emergency surgery is unnecessary at admission. The time from injury and platelet counts must also be considered.
Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.
