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Background The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH Methods In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. Discussion The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. Trial registration Nederlands Trial Register (NTR), Trial NL9012 . ClinicalTrials.gov, Trial NCT04648436 .

Purpose Infantile acute subdural hematoma (IASDH) has a limited age distribution and mostly benign clinical features. Mild-type IASDH has a stereotypical clinical course which, however, has been described in only a few studies. Methods Four male infants (aged 6–10 months; mean age: 7.5 months) were diagnosed as mild-type IASDH associated with retinal hemorrhage (RH) after suffering from occipital impact in a fall. The present case series reviews their clinical features and neuroimaging findings, including CT and MRI findings. Results All the infants fell backwards from a standing or sitting position onto a soft surface, striking the occipital region. They began crying on impact and then soon afterwards exhibited seizure-like activity or recurrent vomiting. CT and MRI revealed a thin, unclotted subdural hematoma (SDH) without mass effect or brain parenchymal abnormality. Various degrees of bilateral RH were observed. On the day of symptom onset, all infants returned to baseline, and follow-up more than 5 years revealed normal development with no deficits. Conclusions Mild-type IASDH with retinal hemorrhage presents with seizure-like activity or recurrent vomiting preceded by crying after an occipital impact on a soft surface. The clinical course of IASDH is followed by rapid recovery on the day of symptom onset. CT and MRI findings reveal a small, unclotted SDH without a mass effect or cerebral parenchymal abnormality.

Background and Objective: The study’s aim is to identify a subgroup of patients who would benefit from primary decompressive craniectomy (pDC) after acute subdural hematoma (aSDH) evacuation. Materials and Methods: A retrospective analysis of 290 patients undergoing aSDH evacuation between 2016 and 2021 was conducted. Osteoplastic craniotomy (OC) was performed in 213 cases (73.4%), whereas 77 individuals underwent pDC. Preoperative characteristics, such as age, initial GCS score, hematoma thickness, midline shift, and cisternal effacement score (CES), were used to predict outcome at discharge by the Glasgow Outcome Scale (GOS). Results: Older age, lower initial GCS, and higher CES preoperatively were independently associated with lower GOS scores at discharge. Age and degree of cisternal compression remained significant predictors of GOS score in the pDC subgroup. Survivors who underwent pDC were younger in comparison to deceased individuals receiving OC (mean age 55.43 ± 14.58 vs. 72.28 ± 14.63, p < 0.001). Patients who achieved favorable outcomes after pDC were significantly younger compared to those who had poor outcomes after OC (mean age 49.20 ± 12.05 vs. 72.28 ± 14.32, p < 0.001). Conclusions: Younger patients (<55 years old) with initial GCS scores of 4–6, midline shifts of 1 to 2 cm, subdural hematoma thickness of 1 to 2.5 cm, and CES in a range of 7–12 may benefit from pDC as it could potentially improve survival and functional outcomes after aSDH evacuation.

Several recent global traumatic brain injury (TBI) initiatives rely on practice variation in diagnostic and treatment methods to answer effectiveness questions. One of these scientific dilemmas, the surgical management of the traumatic acute subdural hematoma (ASDH) might be variable among countries, among centers within countries, and even among neurosurgeons within a center, and hence be amenable for a comparative effectiveness study. The aim of our questionnaire, therefore, was to explore variations in treatment for ASDH among neurosurgeons in similar centers in a densely populated geographical area. An online questionnaire, involving treatment decisions on six case vignettes of ASDH, was sent to 93 neurosurgeons in The Netherlands and Belgium. Clinical and radiological variables differed per case. Sixty neurosurgeons filled out the questionnaire (response rate 65%). For case vignettes with severe TBI and an ASDH, there was a modest variation in the decision to evacuate the hematoma and a large variation in the decision to combine the evacuation with a decompressive craniectomy. The main reasons for operating were “neurological condition” and “mass effect.” For ASDH and mild/moderate TBI, there was large variation in the decision of whether to operate or not, whereas “hematoma size” was the predominant motivation for surgery. Significant inter-center variation for the decision to evacuate the hematoma was observed (p = 0.01). Most pronounced was that 1 out of 7 (14%) neurosurgeons in one region chose a surgical strategy compared with 9 out of 10 (90%) in another region for the same scenario. In conclusion, variation exists in the neurosurgical management of TBI within an otherwise homogeneous setting. This variation supports the methodology of the international Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) initiative, and shaped the Dutch Neurotraumatology Quality Registry (Net-QuRe) initiative.

Background The role of acute coagulopathy after traumatic brain injury (TBI) on outcome has gained increasing appreciation over the recent years. This study was conducted to assess the frequency, outcome, and risk factors associated with this complication. Patients and Methods Using the large, multi-center population-based Trauma Registry of the German Society for Trauma Surgery (TR-DGU), we retrospectively analyzed adult patients with isolated blunt TBI (intracranial AIS HEAD  ≥ 3 and extracranial AIS scores <3) for the presence of acute post-traumatic coagulopathy upon emergency room (ER) arrival. Coagulopathy was defined as prothrombin time test (Quick’s value) <70% and/or platelets < 100,000/μl. Results From a total of 3,114 eligible patients with isolated TBI, 706 (22.7%) presented with coagulopathy upon ER arrival. Coagulopathy was associated with higher rates of craniotomies ( P  = 0.02), of single and multiple organ failure and with less intubation-free days. In surviving patients, ICU length of stay and hospital length of stay were significantly longer, if coagulopathy had been present at admission. The overall hospital mortality was 50.4% ( n  = 356) in patients with coagulopathy vs. 17.3% ( n  = 417) in non-coagulopathic patients (all P  < 0.001). Multivariate analysis identified AIS HEAD severity grade, GCS ≤ 8 at scene, the presence of hypotension at scene and/or at ER, pre-hospital i.v.-fluids ≥2,000 ml and age ≥75 years as independent risk factors for coagulopathy after TBI. Acute coagulopathy in TBI had an adjusted odds ratio for hospital mortality of 2.97 (CI 95 : 2.30–3.85; P  < 0.001). Conclusion Coagulopathy upon ER admission is frequent after isolated blunt TBI and represents a powerful, independent predictor related to prognosis. Future research should aim to determine the beneficial effects of early treatment of TBI-associated coagulopathy.

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.

The authors report a 61-year-old female patient with a giant cavernous aneurysm in the right internal carotid artery (ICA) leading to acute subdural hematoma (ASDH) 7 days after the occurrence of abducens nerve palsy. She underwent ICA occlusion associated with high-flow bypass. In all five reported patients with a cavernous ICA aneurysm causing ASDH, the size of the aneurysm was giant and cranial nerve signs preceded the rupture. When a patient with a symptomatic cavernous ICA giant aneurysm experiences sudden-onset headache and/or consciousness disturbance, rupture of the aneurysm should be differentiated, even though a cavernous ICA aneurysm rarely causes ASDH.

PurposeMycobacterium abscessus, and rapidly growing mycobacteria in general, are rare but increasing causes of central nervous system (CNS) infections. The aim of this study is to highlight the importance of considering these microorganism in the differential diagnosis of CNS infections, obtaining a prompt diagnosis, and improving clinical outcomes.MethodsCase report and literature review.ResultsWe report a case of meningeal infection in a patient who underwent decompressive craniectomy after a craniofacial trauma. The diagnosis was made analyzing a sample obtained during a second operation of cranioplasty. A regimen of amikacin, clarithromycin, and imipenem/cilastatin was started. In the following days, the patient experienced a variety of side effects. So, first clarithromycin was replaced with linezolid, then amikacin was stopped and cefoxitin added to the therapy and at the end all the antibiotics were withdrawn. The patient was discharged in good conditions and a clinical interdisciplinary follow-up was started. After 12 months, the patient is still doing well. After a literature analysis, 15 cases of M. abscessus CNS infections were identified. Various modes of acquisition, underlying disease and therapeutic schemes were evident.ConclusionsConsidering the results of the literature analysis and the increasing incidence of M. abscessus, all specialists involved in the management of CNS infection should be aware of the importance of atypical microorganisms in differential diagnosis.

The removal of headgear in amateur boxing from 2013 onwards has coincided with marked increase in the number of scalp and facial cuts among boxers. 3-5 When mandatory helmet use was first introduced in amateur boxing in 1984, there was a threefold reduction in the 'referee stopped contest-injury' decisions as well as a reduction in the rate of 'knock outs' suggesting that helmets may play a role in preventing brain injury.\\n9 to 11.9 m/s with impact force of punches ranging from 1.4 to 4.8 kN. 6-9 Across all studies, the impact forces generated by professional boxers were higher than amateurs and higher weight divisions in both types of boxing had higher impact forces than lower divisions and experienced boxers generate greater impact forces than novices. [...]the wrapping of the fist inside the glove by professional boxers increases the rigidity of the hand. 10 The greater thickness of the wrap in professional boxing, as compared to amateurs, increases the impact forces generated in a punch. [...]the use or non-use of headgear is not the only issue influencing head injury rates in Boxing.

Background Acute subdural haematoma (aSDH) is a rare complication of aneurysmal subarachnoid haemorrhage (SAH) and is associated with poor clinical condition on admission and poor outcome. Objective The aim of this study was to assess whether aneurysmal aSDH is an independent risk factor for poor outcome. Methods In a series of 1632 patients retrieved from our prospectively collected single centre SAH database and fulfilling prespecified inclusion criteria, we found 53 patients with aSDH on the initial CT scan. From the same series, we collected 660 patients in whom aSDH was ruled out by reviewing the initial CT scan. We compared the risk of poor outcome at discharge and at 3 months between patients with and without aSDH by calculating crude risk ratios (RRs) with corresponding 95% CIs, and adjusting for age, sex, location and treatment modality of the aneurysm that bled, clinical condition on admission, intracerebral haemorrhage, intraventricular haemorrhage and hydrocephalus, with Poisson regression. Results Patients with aSDH had a higher risk of poor outcome at discharge (crude RR 1.59; 95% CI 1.35 to 1.86) and at 3 months (crude RR: 2.17, 95% CI 1.79 to 2.62) than patients without aSDH. After simultaneous adjustment for five characteristics that affected the crude RR, the RR for poor outcome for patients with aSDH at discharge was 1.15 (95% CI 0.97 to 1.37) and at 3 months 1.30 (95% CI 1.04 to 1.62). Conclusions The presence of aSDH in patients with aneurysmal SAH is an independent risk factor for poor outcome at 3 months.