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Background Spontaneous intracerebral hemorrhage is a disease with high morbidity, high disability rate, high mortality, and high economic burden. Whether patients can benefit from surgical evacuation of hematomas is still controversial, especially for those with moderate-volume hematomas in the basal ganglia. This study is designed to compare the efficacy of endoscopic surgery and conservative treatment for the moderate-volume hematoma in spontaneous basal ganglia hemorrhage. Methods Patients meet the criteria will be randomized into the endoscopic surgery group (endoscopic surgery for hematoma evacuation and the best medical treatment) or the conservative treatment group (the best medical treatment). Patients will be followed up at 1, 3, and 6 months after initial treatment. The primary outcomes include the Extended Glasgow Outcome Scale and the Modified Rankin Scale. The secondary outcomes consist of the National Institutes of Health Stroke Scale and the mortality. The Barthel Index(BI) will also be evaluated. The sample size is 100 patients. Discussion The ECMOH trial is a randomized controlled trial designed to evaluate if endoscopic surgery is better than conservative treatment for patients with moderate-volume hematomas in the basal ganglia. Trial registration Chinese Clinical Trial Registry: ChiCTR-TRC-11001614 ( http://www.chictr.org/en/proj/show.aspx?proj=1618 )

A middle childhood boy with homozygous sickle cell disease (SCD) on hydroxyurea, previously healthy, presented with acute bilateral limb pain progressing rapidly to altered sensorium and signs of raised intracranial pressure. Cranial CT revealed bilateral epidural haematomas with a large left fronto-parietal epidural haematoma (EDH) and midline shift. He underwent urgent craniotomy, mechanical ventilation, blood transfusion and phenobarbitone coma for autonomic instability. He recovered with initial right hemiparesis that improved to independent ambulation without limitation, with no recurrence on follow-up. This case represents the youngest documented survivor of spontaneous EDH in SCD, emphasising that non-traumatic intracranial bleeding can occur even at early ages in SCD patients. Emergency physicians should remain alert to this rare possibility in young children with SCD.

To identify the most suitable predictive computed tomographic (CT) scoring system for traumatic brain injuries (TBI) patients, they reported that the Stockholm [2] and the Helsinki [3] systems yielded the closest relationship with the actual outcomes. To our best knowledge, a typical epidural hematoma (EDP) prognosis is good if it is discovered quickly and managed. [...]the presence of EDH is considered a positive prognostic sign in the Rotterdam [4], Stockholm [2], and the Helsinki [3] CT scoring systems. Whether one still can interpret EDH as a positive prognostic factor in the Rotterdam CT scoring system is a matter of discussion, because its presence does not make a difference to the risk of mortality.

Background The occurrence of a contralateral acute epidural hematoma (AEDH) following removal of an acute subdural hematoma (ASDH) is a rare but nearly devastating postoperative complication. Here, we describe a series of five patients with contralateral AEDH and provide a review of the literature to elucidate the characteristics and improve management of these patients. Methods A total of 386 patients underwent ASDH evacuations in our hospital between August 2008 and July 2011. Five of these patients (1.3 %) developed AEDH that required surgery. Thirty-two additional patients were identified by a search of the PubMed database. Clinical features, surgical treatment, and outcomes (scored by Glasgow outcome scale, GOS) of the collective 37 AEDH cases were analyzed retrospectively. Results Contralateral AEDH after ASDH evacuation occurred in 27 males (73 %) and 10 females (27 %) (mean age: 35.9 ± 14.2 years). Twenty-six patients (70 %) had unfavorable outcomes (GOS 1–3), and 11 patients (30 %) had favorable outcomes (GOS 4–5). Contralateral skull fractures and intraoperative acute brain swelling occurred in 30 (81 %) and 28 (76 %) patients, respectively. The preoperative Glasgow coma score (GCS) was significantly associated with outcome ( p  < 0.05). Conclusions Lower preoperative GCS score is an independent risk factor for prognosis of contralateral AEDH after ASDH. Postoperative management should include assessment of AEDH in patients treated for contralateral skull fractures and who experienced intraoperative acute brain swelling. We recommend early decompression with a burr-hole craniotomy, immediately followed by a decompressive craniectomy. This strategy provides gradual decompression, while advancing the initial surgical time and preventing the suddle decreased tamponade effect. As such, it may help decrease the risk of contralateral AEDH associated with decompression.

[...]of admission, the patient was in shock (systolic blood pressure 60 mmHg), and was comatose (Glasgow Coma Scale E1M2V1). The scoring criteria based on the global coagulation tests (platelet count, prothrombin time, fibrin-related markers, and fibrinogen levels) revealed a score of [4] However, the presence of splinter hemorrhages in the retina, multiple punctuate areas of hemorrhage in the brain, and the epidural spinal hematoma was suggestive of coagulopathy (nonovert), in all likelihood, due to septicemia. [5] Though the coagulation abnormality is generalized, bleeding manifestations occurs locally in areas with dysfunctional vasculature. [...]septicemia produces alteration in the blood flow to vital organs, thereby resulting in cytopathic hypoxia, thus adding to the injury.

To identify factors that favour spontaneous recovery in patients who suffered a spontaneous spinal epidural hematoma (SSEH). The literature was reviewed regarding non-operative cases of SSEH (SSEH(cons)). Sixty-two cases from the literature and 2 of our own cases were collected, focusing on sex, age, medical history, position of the hematoma, segmental distribution and length of the hematoma, diagnostic imaging, neurological condition and outcome. Those data were analysed and compared with the data from a literature review of 474 cases operated on because of a SSEH (SSEH(oper)). The mean length of the hematoma was significantly higher in SSEH(cons), compared to SSEH(oper) (5.4 versus 4.2 vertebral segments; [standard error of the difference (SED) is 0.38 vertebral segments; 95% confidence limits for the difference are 0.45 to 1.95]). Also after exclusion of patients with coagulopathy, mean length of the hematoma was significantly higher in SSEH(cons) (4.7 versus 3.9 vertebral segments [SED is 0.39 vertebral segment; 95% confidence limits for the difference are 0.04 to 1.56]). Neurological signs and symptoms in SSEH(cons) were significantly less severe (P<0.005) and diagnosis was based on Magnetic Resonance Imaging (MRI) in the majority of cases (P<0.0005), when compared to SSEH(oper). All other patient characteristics showed no correlation with spontaneous recovery. The recent increase of publications of SSEH(cons) has to be explained by the introduction of MRI in daily medical practice. As a result, more patients with a mild or benign clinical course are being diagnosed. In earlier times those patients would have escaped medical attention. The mean length of the hematoma in SSEH(cons) appears to be significantly higher compared to SSEH(oper). This suggests that spontaneous regression of neurological symptoms may result from decompression of the neural structures by spreading of the (liquid) hematoma along the spinal epidural space in the early stages after haemorrhage. Based on the present review, there appear to be no factors which promote conservative treatment in SSEH. In the majority of cases with SSEH, the mainstay of treatment will remain surgical decompression of the neural structures and removal of the hematoma. The decision for conservative treatment has to be based on the severity of the neurological deficit and on the clinical course. Retrospectively, the length of the hematoma seems to give a clue to the spontaneous recovery which occurs in some cases of SSEH. Nevertheless, hematoma-length can not be used as a guide to treatment.

Secondary massive cerebral infarction (MCI) is the predominant prognostic factor for cerebral herniation from epidural hematoma (EDH) and determines the need for decompressive craniectomy. In this study, we tested the clinical feasibility and reliability of a novel pre-operative risk scoring system, the EDH-MCI scale, to guide surgical decision making. It is comprised of six risk factors, including hematoma location and volume, duration and extent of cerebral herniation, Glasgow Coma Scale score, and presence of preoperative shock, with a total score ranging from 0 to 18 points. Application of the EDH-MCI scale to guide surgical modalities for initial hematoma evacuation surgery for 65 patients (prospective cohort, 2012.02-2014.01) showed a significant improvement in the accuracy of the selected modality (95.38% vs. 77.95%; p = 0.002) relative to the results for an independent set of 126 patients (retrospective cohort, 2007.01-2012.01) for whom surgical modalities were decided empirically. Results suggested that simple hematoma evacuation craniotomy was sufficient for patients with low risk scores (≤9 points), whereas decompressive craniectomy in combination with duraplasty were necessary only for those with high risk scores (≥13 points). In patients with borderline risk scores (10–12 points), those having unstable vital signs, coexistence of severe secondary brainstem injury, and unresponsive dilated pupils after emergent burr hole hematoma drainage had a significantly increased incidence of post-traumatic MCI and necessity of radical surgical treatments. In conclusion, the novel pre-operative risk EDH-MCI evaluation scale has a satisfactory predictive and discriminative performance for patients who are at risk for the development of secondary MCI and therefore require decompressive craniectomy.

Background:Subjects with moderate head injury are a particular challenge for the emergency physician. They represent a heterogeneous population of subjects with large variability in injury severity, clinical course and outcome. We aimed to determine the early predictors of outcome of subjects with moderate head injury admitted to an Emergency Department (ED) of a general hospital linked via telemedicine to the Regional Neurosurgical Centre.Patients and methods:We reviewed, prospectively, 12 675 subjects attending the ED of a General Hospital between 1999 and 2005 for head injury. A total of 309 cases (2.4%) with an admission Glasgow Coma Scale (GCS) 9–13 were identified as having moderate head injury. The main outcome measure was an unfavourable outcome at 6 months after injury. The predictive value of a model based on main entry variables was evaluated by logistic regression analysis.Findings:64.7% of subjects had a computed tomographic scan that was positive for intracranial injury, 16.5% needed a neurosurgical intervention, 14.6% had an unfavourable outcome at 6 months (death, permanent vegetative state, permanent severe disability). Six variables (basal skull fracture, subarachnoid haemorrhage, coagulopathy, subdural haematoma, modified Marshall category and GCS) predicted an unfavourable outcome at 6 months. This combination of variables predicts the 6-month outcome with high sensitivity (95.6%) and specificity (86.0%).Interpretation:A group of selected variables proves highly accurate in the prediction of unfavourable outcome at 6 months, when applied to subjects admitted to an ED of a General Hospital with moderate head injury.

Retroclival collections are rare lesions reported almost exclusively in children and strongly associated with trauma. We examine the incidence and imaging characteristics of retroclival collections in young children with abusive head trauma. We conducted a database search to identify children with abusive head trauma ≤3 years of age with brain imaging performed between 2007 and 2013. Clinical data and brain images of 65 children were analyzed. Retroclival collections were identified in 21 of 65 (32%) children. Ten (48%) were subdural, 3 (14%) epidural, 2 (10%) both, and 6 (28%) indeterminate. Only 8 of 21 retroclival collections were identifiable on CT and most were low or intermediate in attenuation. Eighteen of 21 retroclival collections were identifiable on MRI: 3 followed cerebral spinal fluid in signal intensity and 15 were bloody/proteinaceous. Additionally, 2 retroclival collections demonstrated a fluid-fluid level and 2 enhanced in the 5 children who received contrast material. Sagittal T1-weighted images, sagittal fluid-sensitive sequences, and axial FLAIR (fluid-attenuated inversion recovery) images showed the retroclival collections best. Retroclival collections were significantly correlated with supratentorial and posterior fossa subdural hematomas and were not statistically correlated with skull fracture or parenchymal brain injury. Retroclival collections, previously considered rare lesions strongly associated with accidental injury, were commonly identified in this cohort of children with abusive head trauma, suggesting that retroclival collections are an important component of the imaging spectrum in abusive head trauma. Retroclival collections were better demonstrated on MRI than CT, were commonly identified in conjunction with intracranial subdural hematomas, and were not significantly correlated with the severity of brain injury or with skull fractures.

Background The occurrence of remote epidural hematoma as a postoperative complication after intracranial tumor resection is rare. This study reviewed experiences treating these hematomas and speculated on the causes of this disease. This study reviewed the treatment experience of 14 such cases. Methods The 14 patients included 10 males and 4 females, with an age range of 19 to 65 years old. Six cases of tumors occurred in the sellar region, two cases in the lateral ventricle, one case in the fourth ventricle, one case in a cerebellar hemisphere, and four cases in other sites. Among them, five cases were complicated with supratentorial hydrocephalus. The tumors included five cases of meningioma tumors, two cases of pituitary adenomas, three cases of ependymomas, two cases of craniopharyngiomas, one case of astrocytoma, and one case of tuberculosis tumor. For the cases complicated with hydrocephalus, ventricular drainage was provided if needed, and the tumor resection was then performed, with close observation for postoperative changes. If neurological symptoms and disturbance of consciousness occurred, computed tomography (CT) examination was immediately performed. If a remote epidural hematoma was found, the hematoma was evacuated by craniotomy. The patients were followed up after surgery. In the five cases complicated with hydrocephalus, ventricular drainage was first provided for three cases. Results All of the 14 cases underwent total tumor resection, and postoperative remote epidural hematoma occurred in all cases, including eight cases on the ipsilateral side and adjacent to the supratentorial operative field; two cases occurred on the contralateral side; two cases occurred on bilateral sides; and two cases occurred in distant areas (with infratentorial surgery, the hematoma occurred on the supratentorial area). Postoperative remote epidural hematoma usually occurred 0.5–5 h after the tumor resection, when the tentorial hernia had already occurred. Following tumor resection and epidural hematoma evacuation, 13 patients were discharged with good recovery, and one patient died. Conclusions The reduced intracranial pressure due to the intracranial tumor resection may be the cause of this hematoma. This type of epidural hematoma is acute and often occurs before hernia. Thus, the risk of remote epidural hematoma after intracranial tumor resection needs to be made known. Aggressive hematoma evacuation can often result in satisfactory outcomes for patients.