We present the case of a 23-year-old man who suddenly collapsed during a physical altercation with his friends while in a drunken state. The post-mortem computed tomography (CT) with angiography revealed acute basal subarachnoid hemorrhage with rupture of the left middle cerebral artery. On autopsy, the head, face, mandible and neck showed multifocal hemorrhages with fracture of the hyoid bone, and the pathologic findings of the brain was consistent with CT findings. However, the vascular rupture site was not observed macroscopically. On histologic examination, a microscopic focal rupture was identified at the proximal portion of the middle cerebral artery, and possibility of arteriopathy was considered. This case illustrates that other parts of intracerebral arteries (other than the vertebral arteries) can be the culprit of rupture in the case of traumatic basal subarachnoid hemorrhage, and the post-mortem angiographic findings can be helpful in targeting the site of vascular injury. Furthermore, meticulous sampling of intracranial vessels could help find the vascular rupture site and identify any histologic findings suspicious of arteriopathy. Therefore, we suggest that post-mortem angiography can be an effective and adjunctive tool for a tailored approach in finding the vascular injury, and that histologic examination of both the intracranial and extracranial arteries be important to medicolegally ensure the death of traumatic basal subarachnoid hemorrhage and to examine presence of arteriopathy as a predisposing factor.
Angiography ; Arteries ; Autopsy ; Brain ; Causality ; Forensic Pathology ; Friends ; Head ; Hemorrhage ; Humans ; Hyoid Bone ; Mandible ; Middle Cerebral Artery ; Neck ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic ; Vascular System Injuries ; Young Adult

Cranial nerve palsies are relatively common after trauma, but trochlear nerve palsy is relatively uncommon. Although traumatic trochlear nerve palsy is easy to diagnose clinically because of extraocular movement disturbances, radiologic evaluations of this condition are difficult to perform because of the nerve's small size. Here, we report the case of a patient with delayed traumatic trochlear nerve palsy associated with a traumatic subarachnoid hemorrhage (SAH) and the related radiological findings, as obtained with high-resolution three-dimensional (3D) magnetic resonance imaging (MRI). A 63-year-old woman was brought to the emergency room after a minor head trauma. Neurologic examinations did not reveal any focal neurologic deficits. Brain computed tomography showed a traumatic SAH at the left ambient cistern. The patient complained of vertical diplopia at 3 days post-trauma. Ophthalmologic evaluations revealed trochlear nerve palsy on the left side. High-resolution 3D MRI, performed 20 days post-trauma, revealed continuity of the trochlear nerve and its abutted course by the posterior cerebral artery branch at the brain stem. Chemical irritation due to the SAH and the abutting nerve course were considered causative factors. The trochlear nerve palsy completely resolved during follow-up. This case shows the usefulness of high-resolution 3D MRI for evaluating trochlear nerve palsy.
Brain ; Brain Stem ; Cranial Nerve Diseases ; Craniocerebral Trauma ; Diplopia ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Humans ; Imaging, Three-Dimensional ; Magnetic Resonance Imaging* ; Middle Aged ; Neurologic Examination ; Neurologic Manifestations ; Posterior Cerebral Artery ; Subarachnoid Hemorrhage, Traumatic* ; Trochlear Nerve Diseases* ; Trochlear Nerve*

OBJECTIVE: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. METHODS: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. RESULTS: Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p < 0.001), coexistence of intraventricular hemorrhage (IVH) (p < 0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative findings showing intracranial hypertension combined with brain edema (p < 0.001), and bleeding tendency (p=0.02). An average value of 2.74±1.52 was obtained for these factors for group A, which was significantly different from that for group B (p < 0.001). CONCLUSION: An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.
Brain ; Brain Edema ; Cerebral Hemorrhage, Traumatic ; Craniotomy* ; Decompressive Craniectomy* ; Hematoma ; Hematoma, Subdural ; Hematoma, Subdural, Acute* ; Hemorrhage ; Humans ; Intracranial Hypertension ; Multivariate Analysis ; Reoperation ; Risk Factors

PURPOSETraumatic brain injury (TBI) is a leading cause of death and disability. Intracranial hemorrhage (ICH) secondary to TBI is associated with a high risk of coagulopathy which leads to increasing risk of hemorrhage growth and higher mortality rate. Therefore, antifibrinolytic agents such as tranexamic acid (TA) might reduce traumatic ICH. The aim of the present study was to investigate the extent of ICH growth after TA administration in TBI patients.

METHODSThis single-blind randomized controlled trial was conducted on patients with traumatic ICH (with less than 30 ml) referring to the emergency department of Vali-Asr Hospital, Arak, Iran in 2014. Patients, based on the inclusion and exclusion criteria, were divided into intervention and control groups (40 patients each). All patients received a conservative treatment for ICH, as well as either intravenous TA or placebo. The extent of ICH growth as the primary outcome was measured by brain CT scan after 48 h.

RESULTSAlthough brain CT scan showed a significant increase in hemorrhage volume in both groups after 48 h, it was significantly less in the TA group than in the control group (p = 0.04). The mean total hemorrhage expansion was (1.7 ± 9.7) ml and (4.3 ± 12.9) ml in TA and placebo groups, respectively (p < 0.001).

CONCLUSIONIt has been established that TA, as an effective hospital-based treatment for acute TBI, could reduce ICH growth. Larger studies are needed to compare the effectiveness of different doses.

Adult ; Antifibrinolytic Agents ; therapeutic use ; Brain Injuries, Traumatic ; diagnostic imaging ; drug therapy ; Cerebral Hemorrhage, Traumatic ; drug therapy ; Female ; Humans ; Male ; Middle Aged ; Single-Blind Method ; Tomography, X-Ray Computed ; Tranexamic Acid ; therapeutic use

PURPOSE: An increase in optic nerve sheath diameter (ONSD) has been associated with elevated intracranial pressure due to brain lesions, such as hemorrhage, infarction, and tumor. The aim of this study was to evaluate whether the difference of both ONSDs can predict surgical treatment in patients with traumatic brain hemorrhage. METHODS: A prospective analysis of the data acquired between September 2016 and November 2016 was performed. We included 155 patients with traumatic brain hemorrhage undergoing computed tomography in the emergency room. We performed an ultrasonography to measure ONSDs for all included patients. The primary outcome of this study was operation indication in patients with traumatic brain hemorrhage. RESULTS: The average age was 63.4±17.0 years (male 60.3±17.3, female 69.8±14.4). There were 61 (39.35%) patients with an indication for operation and 94 (60.65%) patients with an indication for no operation. Indications for operation showed a strong association with the difference of both ONSDs in patients with subdural hemorrhage (p<0.001), no association between them in patients with epidural and intracerebral hemorrhage. In patients with subdural hemorrhage, the area under the curve was 0.988 (0.653-0.998), and the cut-off value for the difference of ONSDs with respect to determining the indications for operation was 0.295 mm f maximizing the sum of the sensitivity (96.9%) and specificity (90.7%) using the receiver operating curve. CONCLUSION: A difference of both ONSDs above 0.295 mm was useful in predicting the indications for operation in patients with traumatic subdural hemorrhage, but not in patients with epidural and intracerebral hemorrhage.
Brain ; Brain Hemorrhage, Traumatic* ; Cerebral Hemorrhage ; Emergency Service, Hospital ; Female ; Hematoma, Subdural ; Hemorrhage ; Humans ; Infarction ; Intracranial Hypertension ; Optic Nerve* ; Prospective Studies ; Sensitivity and Specificity ; Ultrasonography*

Traumatic pseudoaneurysms of middle meningeal artery (MMA) and medial sphenoid wing dural arteriovenous fistula (dAVF) are rare. These lesions usually result from traumatic brain injury, and associated with skull fracture. In this paper, the authors report a case of a patient with a ruptured traumatic pseudoaneurysm of MMA and medial sphenoid wing dAVF presented with an intracerebral hemorrhage in the left temporal region and subarachnoid hemorrhage. These lesions were completely obliterated by endovascular treatment, and the patient was recovered without any neurologic deficit. However, 18-day after the procedure, delayed neurologic deficits were developed due to cerebral vasospasm.
Aneurysm, False* ; Arteriovenous Fistula ; Brain Injuries ; Central Nervous System Vascular Malformations* ; Cerebral Hemorrhage ; Humans ; Meningeal Arteries* ; Neurologic Manifestations ; Skull Fractures ; Subarachnoid Hemorrhage* ; Subarachnoid Hemorrhage, Traumatic ; Temporal Lobe ; Vasospasm, Intracranial

OBJECTIVE: This study evaluated whether emergency medical service (EMS) use was associated with early arrival and admission for definitive care among intracerebral hemorrhage (ICH) patients. METHODS: Patients with ICH were enrolled from 29 hospitals between November 2007 and December 2012, excluding those patients with subarachnoid hemorrhage, traumatic ICH, and missing information. The patients were divided into four groups based on visit type to the definitive hospital emergency department (ED): direct visit by EMS (EMS-direct), direct visit without EMS (non-EMS-direct), transferred from a primary hospital by EMS (EMS-transfer), and transferred from a primary hospital without EMS (non-EMS-transfer). The outcomes were the proportions of participants within early (<1 hr) definitive hospital ED arrival from symptom onset (pS2ED) and those within early (<4 hr) admission from symptom onset (pS2AD). Adjusted odds ratios were calculated to determine the association between EMS use and outcomes with and without inter-hospital transfer. RESULTS: A total of 6,564 patients were enrolled. The adjusted odds ratios (95% confidence intervals) for pS2ED were 22.95 (17.73–29.72), 1.11 (0.67–1.84), and 7.95 (6.04–10.46) and those for pS2AD were 5.56 (4.70–6.56), 0.96 (0.71–1.30), and 2.35 (1.94–2.84) for the EMS-direct, EMS-transfer, and non-EMS-direct groups compared with the non-EMS-transfer group, respectively. Through the interaction model, EMS use was significantly associated with early arrival and admission among direct visiting patients but not with transferred patients. CONCLUSION: EMS use was significantly associated with shorter time intervals from symptom onset to arrival and admission at a definitive care hospital. However, the effect disappeared when patients were transferred from a primary hospital.
Cerebral Hemorrhage* ; Emergencies* ; Emergency Medical Services* ; Emergency Service, Hospital ; Hospitals ; Humans ; Intracranial Hemorrhages ; Observational Study* ; Odds Ratio ; Patient Admission ; Subarachnoid Hemorrhage, Traumatic

We report a case of multiple symptomatic cerebral infarctions from a traumatic vertebral artery dissection (VAD) after cervical fractures. A 73-year-old man was admitted with stuporous mentality and left hemiparesis after a motor-vehicle accident. A brain computed tomography (CT) scan at admission showed a traumatic subarachnoid hemorrhage on the left parietal lobe. A cervical CT scan showed left lateral mass fractures on C2, C5, and C6, involving the transverse foramen. Cervical spine magnetic resonance imaging (MRI) revealed loss of signal void on the left vertebral artery. Neck CT angiography showed left VAD starting at the C5 level. Brain MRI revealed acute, multiple cerebral infarctions involving the pons, midbrain, thalamus, corpus callosum, and parietal and frontal lobes on diffusion weighted images. The patient was treated conservatively at the intensive care unit in the acute stage to prevent extent of stroke. Aspirin was started for antiplatelet therapy in the chronic stage. The possibility of symptomatic cerebral infarctions due to traumatic VAD following cervical fracture should be considered.
Aged ; Angiography ; Aspirin ; Brain ; Cerebral Infarction* ; Cervical Vertebrae ; Corpus Callosum ; Diffusion ; Female ; Frontal Lobe ; Humans ; Intensive Care Units ; Magnetic Resonance Imaging ; Mesencephalon ; Neck ; Paresis ; Parietal Lobe ; Pons ; Rabeprazole ; Spinal Fractures ; Spine ; Stroke ; Stupor ; Subarachnoid Hemorrhage, Traumatic ; Thalamus ; Tomography, X-Ray Computed ; Vertebral Artery ; Vertebral Artery Dissection*

Progressive hemorrhagic injury (PHI) can be divided into coagulopathy-related PHI and normal coagu- lation PHI. Coagulation disorders after traumatic brain injuries can be included in trauma-induced coagulopathy (TIC). Some studies showed that TIC is associated with PHI and increases the rates of disability and mortality. In this review, we discussed some mechanisms in TIC, which is of great importance in the development of PHI, including tissue factor (TF) hypothesis, protein C pathway and thrombocytopenia. The main mechanism in the relation of TIC to PHI is hypocoagulability. We also reviewed some coagulopathy parameters and proposed some possible risk factors, predictors and therapies.
Blood Coagulation Disorders ; epidemiology ; etiology ; Brain Injuries, Traumatic ; complications ; Cerebral Hemorrhage ; epidemiology ; etiology ; therapy ; Fibrin Fibrinogen Degradation Products ; analysis ; Humans ; Incidence ; Protein C ; physiology ; Risk Factors ; Thromboplastin ; physiology

An intracranial saccular aneurysm is uncommonly diagnosed in a patient with closed head trauma. We herein present a patient with delayed rebleeding of a cerebral aneurysm misdiagnosed as traumatic subarachnoid hemorrhage (SAH). A 26-year-old female visited our emergency department because of headache after a motorcycle accident. Brain computed tomography (CT) showed a right-side dominant SAH in Sylvian fissure. Although traumatic SAH was strongly suggested because of the history of head trauma, we performed a CT angiogram to exclude any vascular abnormalities. The CT angiogram showed no vascular abnormality. She was discharged after conservative treatment. One day after discharge, she returned to the emergency department because of mental deterioration. Brain CT showed diffuse SAH, which was dominant in the right Sylvian fissure. The CT angiogram revealed a right middle cerebral artery bifurcation aneurysm. During operation, a non-traumatic true saccular aneurysm was found. The patient recovered fully after successful clipping of the aneurysm and was discharged without neurologic deficit. Normal findings on a CT angiogram do not always exclude aneurysmal SAH. Follow-up vascular study should be considered in trauma patients who are highly suspicious of aneurysmal rupture.
Adult ; Aneurysm ; Brain ; Craniocerebral Trauma ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Head Injuries, Closed ; Headache ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery ; Motorcycles ; Neurologic Manifestations ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic*