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Health Technology Assessment... Sep 2015While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic intracerebral haemorrhage (TICH) is controversial. There is no evidence to support Early Surgery in this condition.
OBJECTIVES
There have been a number of trials investigating surgery for spontaneous intracerebral haemorrhage but none for TICH. This study aimed to establish whether or not a policy of Early Surgery for TICH improves outcome compared with a policy of Initial Conservative Treatment.
DESIGN
This was an international multicentre pragmatic parallel group trial. Patients were randomised via an independent telephone/web-based randomisation service.
SETTING
Neurosurgical units in 59 hospitals in 20 countries registered to take part in the study.
PARTICIPANTS
The study planned to recruit 840 adult patients. Patients had to be within 48 hours of head injury with no more than two intracerebral haematomas greater than 10 ml. They did not have a SDH or EDH that required evacuation or any severe comorbidity that would mean they could not achieve a favourable outcome if they made a complete recovery from their head injury.
INTERVENTIONS
Patients were randomised to Early Surgery within 12 hours or to Initial Conservative Treatment with delayed evacuation if it became clinically appropriate.
MAIN OUTCOME MEASURES
The Extended Glasgow Outcome Scale (GOSE) was measured at 6 months via a postal questionnaire. The primary outcome was the traditional dichotomised split into favourable outcome (good recovery or moderate disability) and unfavourable outcome (severe disability, vegetative, dead). Secondary outcomes included mortality and an ordinal assessment of Glasgow Outcome Scale and Rankin Scale.
RESULTS
Patient recruitment began in December 2009 but was halted by the funding body because of low UK recruitment in September 2012. In total, 170 patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes were obtained for 99% of 168 eligible patients (82 Early Surgery and 85 Initial Conservative Treatment patients). Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment [odds ratio 0.65; 95% confidence interval (CI) 0.35 to 1.21; p = 0.17]. Mortality was significantly higher in the Initial Conservative Treatment group (33% vs. 15%; absolute difference 18.3%; 95% CI 5.7% to 30.9%; p = 0.006). The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = 0.047 and p = 0.043 respectively).
CONCLUSIONS
This is the first ever trial of surgery for TICH and indicates that Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intraCerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intraCerebral Haemorrhage (STICH II). Further research is clearly warranted.
TRIAL REGISTRATION
Current Controlled Trials ISRCTN 19321911.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 70. See the NIHR Journals Library website for further project information.
Topics: Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Cerebral Hemorrhage, Traumatic; Female; Hematoma; Humans; Male; Middle Aged; Patient Selection; Sample Size; Time-to-Treatment; Treatment Outcome; Young Adult
PubMed: 26346805
DOI: 10.3310/hta19700 -
Laeknabladid Jun 2023A 50-year old male presented to our emergency department with sudden abdominal pain. Upon arrival he was diaphoretic, pale and tachycardic. A CT showed retroperitoneal...
A 50-year old male presented to our emergency department with sudden abdominal pain. Upon arrival he was diaphoretic, pale and tachycardic. A CT showed retroperitoneal hemorrhage with suspected tumor at the left adrenal gland. He was quickly stabilized with intravenous fluids and blood transfusion. Rebleed occurs roughly a week after discharge and a new CT showed a visceral pseudoaneurysm from the left middle adrenal artery. The pseudoaneurysm was embolized and the patient discharged in good condition. Follow-up MRI depicted reabsorption of the hematoma and no adrenal tumor. Thus, the etiology of the previous retroperitonal hemorrhage is considered spontaneous.
Topics: Male; Humans; Middle Aged; Aneurysm, False; Retroperitoneal Space; Hemorrhage; Hematoma; Adrenal Glands
PubMed: 37233620
DOI: 10.17992/lbl.2023.05.744 -
Clinical Radiology Nov 2022To quantitatively evaluate blood-brain barrier (BBB) permeability in the perihaematomal region of spontaneous intracerebral haemorrhage (ICH) and investigate the...
AIM
To quantitatively evaluate blood-brain barrier (BBB) permeability in the perihaematomal region of spontaneous intracerebral haemorrhage (ICH) and investigate the association between the alterations in cerebral blood flow and BBB permeability around the haematoma.
MATERIALS AND METHODS
Spontaneous ICH patients underwent unenhanced computed tomography (CT) and CT perfusion (CTP) simultaneously. Haematoma volume was measured on CT. The values of cerebral haemodynamic parameters including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP), and permeability-surface area product (PS) were measured in the perihaematomal region and the contralateral mirror region, and then relative values were calculated for statistical analysis. Linear regression was used to evaluate associations between BBB permeability and variables.
RESULTS
A total of 87 ICH patients were included in this study. The focally elevated BBB permeability was observed in the perihaematomal region in ICH patients. Linear regression showed that reduced rCBF (β = -0.379, p=0.001) and increased rCBV (β = 0.412, p=0.000) correlated independently with increased relative PS (rPS) value in deep ICH, while only increased rCBV (β = 0.423, p=0.071) correlated to increased rPS value in patients with lobar ICH.
CONCLUSIONS
BBB permeability is focally elevated in the region around the haematoma. Cerebral haemodynamic alterations are associated with increased BBB permeability. Cerebral hypoperfusion may aggravate BBB compromise, and a compensatory increase in CBV may lead to reperfusion injury on BBB.
Topics: Humans; Blood-Brain Barrier; Cerebral Hemorrhage; Cerebrovascular Circulation; Hematoma
PubMed: 35786315
DOI: 10.1016/j.crad.2022.05.028 -
Journal of Thrombosis and Haemostasis :... Sep 2010
Topics: Hematology; Hemorrhage; Hemorrhagic Disorders; Humans; Reproducibility of Results; Severity of Illness Index; Surveys and Questionnaires; von Willebrand Diseases
PubMed: 20626619
DOI: 10.1111/j.1538-7836.2010.03975.x -
Transfusion Aug 2022Transfusion of defective platelets could contribute to the inefficiency of platelet transfusion in preventing or stopping bleeding.
BACKGROUND
Transfusion of defective platelets could contribute to the inefficiency of platelet transfusion in preventing or stopping bleeding.
STUDY DESIGN AND METHODS
This single-center prospective study aimed to determine the prevalence of functional platelet abnormalities in a population of blood donors with a clinical history of bleeding diathesis or with history of hematoma (>4 cm) during blood donation. Donors with positive bleeding screening questionnaire were referred to the reference center for rare platelet diseases at La Timone University Hospital (Marseille) to confirm the bleeding tendency using a more extensive bleeding questionnaire (MCMDMscore) and to assess hemostasis, including a comprehensive platelet analysis.
RESULTS
One hundred and ninety-five donors identified based on a history of hematoma and 2434 blood donors were included in the study. Eighty-eight donors (3.6%) had a bleeding score indicating a potential bleeding disorder. Five donors with a history of hematoma (2.5%) and 15 (17%) donors with a confirmed bleeding score underwent hemostatic analysis, including two men and 18 women with average age of 33.9 years. Minor hemostatic abnormalities were observed in three donors. Two donors exhibited accelerated fibrinolysis with reduced euglobulin lysis time and increased D-dimer levels in serum. Two donors had a platelet granule defect, without identification of genetic abnormality.
CONCLUSION
The bleeding questionnaire proved to be a valuable tool to screen blood donors for potential platelet defects. Platelet dysfunction was rare in the blood donor population assessed. Additional studies are necessary to understand the clinical impact that the transfusion of platelets with qualitative defects has on recipients.
Topics: Adult; Blood Coagulation Disorders; Blood Donors; Blood Platelet Disorders; Blood Platelets; Female; Hematoma; Hemorrhage; Hemorrhagic Disorders; Hemostasis; Hemostatics; Humans; Male; Prospective Studies
PubMed: 35748562
DOI: 10.1111/trf.16990 -
Revista Espanola de Enfermedades... Apr 202459-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee...
59-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee grounds" vomiting. On examination he presented abdominal distension and pain on palpation in the epigastrium, without peritonism. He had a BP of 235/100 mmHg and in the blood-tests, leukocytosis with neutrophilia and normal hemoglobin. An urgent abdominal CT scan was performed, identifying a 5x6 cm nodular lesion of homogeneous density attached to the wall of the second and third duodenal portions that compressed the lumen, with two vessels with active bleeding within it. Therefore, percutaneous embolization of the gastroduodenal artery was performed. Subsequently, the patient suffered an episode of severe acute pancreatitis that required ICU admission. Finally, he presented a good clinical evolution with ceasing of pain, complete reabsorption of the hematoma and resolution of the obstructive symptoms.
Topics: Male; Humans; Acute Disease; Pancreatitis; Hematoma; Duodenal Diseases; Gastrointestinal Hemorrhage; Abdominal Pain; Hematemesis
PubMed: 37706445
DOI: 10.17235/reed.2023.9793/2023 -
Diagnostic and Interventional Imaging 2015Spontaneous muscle hematomas are a common and serious complication of anticoagulant treatment. The incidence of this event has increased along with the rise in the... (Review)
Review
Spontaneous muscle hematomas are a common and serious complication of anticoagulant treatment. The incidence of this event has increased along with the rise in the number of patients receiving anticoagulants. Radiological management is both diagnostic and interventional. Computed tomography angiography (CTA) is the main tool for the detection of hemorrhage to obtain a positive, topographic diagnosis and determine the severity. Detection of an active leak of contrast material during the arterial or venous phase is an indication for the use of arterial embolization. In addition, the interventional radiological procedure can be planned with CTA. Arterial embolization of the pedicles that are the source of the bleeding is an effective technique. The rate of technical and clinical success is 90% and 86%, respectively.
Topics: Abdominal Muscles; Aged; Angiography; Anticoagulants; Embolization, Therapeutic; Extravasation of Diagnostic and Therapeutic Materials; Female; Hematoma; Humans; Male; Muscular Diseases; Psoas Muscles; Risk Factors; Tomography, X-Ray Computed
PubMed: 26066549
DOI: 10.1016/j.diii.2015.03.014 -
Wound Management & Prevention Jul 2022Pretibial injury is common. Although the mechanism of injury may be minor, in a specific patient population, misdiagnosis and delay in appropriate treatment can lead to... (Review)
Review
BACKGROUND
Pretibial injury is common. Although the mechanism of injury may be minor, in a specific patient population, misdiagnosis and delay in appropriate treatment can lead to dire consequences. The ability to identify and properly treat these patients early has the potential to reduce the need for surgical intervention, hospitalization, and prolonged care.
METHODS
A literature review was performed to develop the Lower Extremity Hematoma Algorithm (LEHA) to aid in identifying and managing these injuries in the patient population at greatest risk.
RESULTS
A case example is provided to demonstrate how implementation of the LEHA may have led to early diagnosis and treatment, avoiding expensive advanced and prolonged care.
CONCLUSION
Implementation of the LEHA may expedite the identification of patients at risk for deep dissecting hematomas, enabling faster implementation of appropriate treatment and thereby helping to contain health care costs through avoiding surgical intervention.
Topics: Algorithms; Hematoma; Hospitalization; Humans; Lower Extremity
PubMed: 35895292
DOI: No ID Found -
Stroke Oct 2023Spreading depolarizations (SDs) occur in all types of brain injury and may be associated with detrimental effects in ischemic stroke and subarachnoid hemorrhage. While...
BACKGROUND
Spreading depolarizations (SDs) occur in all types of brain injury and may be associated with detrimental effects in ischemic stroke and subarachnoid hemorrhage. While rapid hematoma growth during intracerebral hemorrhage triggers SDs, their role in intracerebral hemorrhage is unknown.
METHODS
We used intrinsic optical signal and laser speckle imaging, combined with electrocorticography, to investigate the effects of SD on hematoma growth during the hyperacute phase (0-4 hours) after intracortical collagenase injection in mice. Hematoma expansion, SDs, and cerebral blood flow were simultaneously monitored under normotensive and hypertensive conditions.
RESULTS
Spontaneous SDs erupted from the vicinity of the hematoma during rapid hematoma growth. We found that hematoma growth slowed down by >60% immediately after an SD. This effect was even stronger in hypertensive animals with faster hematoma growth. To establish causation, we exogenously induced SDs (every 30 minutes) at a remote site by topical potassium chloride application and found reduced hematoma growth rate and final hemorrhage volume (18.2±5.8 versus 10.7±4.1 mm). Analysis of cerebral blood flow using laser speckle flowmetry revealed that suppression of hematoma growth by spontaneous or induced SDs coincided and correlated with the characteristic oligemia in the wake of SD, implicating the vasoconstrictive effect of SD as one potential mechanism of action.
CONCLUSIONS
Our findings reveal that SDs limit hematoma growth during the early hours of intracerebral hemorrhage and decrease final hematoma volume.
Topics: Mice; Animals; Cortical Spreading Depression; Subarachnoid Hemorrhage; Electrocorticography; Cerebral Hemorrhage; Hematoma
PubMed: 37610105
DOI: 10.1161/STROKEAHA.123.042632 -
Journal of Cellular and Molecular... Feb 2018The products of erythrocyte lyses, haemoglobin (Hb) and haem, are recognized as neurotoxins and the main contributors to delayed cerebral oedema and tissue damage after... (Review)
Review
The products of erythrocyte lyses, haemoglobin (Hb) and haem, are recognized as neurotoxins and the main contributors to delayed cerebral oedema and tissue damage after intracerebral haemorrhage (ICH). Finding a means to efficiently promote absorption of the haemolytic products (Hb and haem) around the bleeding area in the brain through stimulating the function of the body's own garbage cleaning system is a novel clinical challenge and critical for functional recovery after ICH. In this review, available information of the brain injury mechanisms underlying ICH and endogenous haematoma scavenging system is provided. Meanwhile, potential intervention strategies are discussed. Intracerebral blood itself has 'toxic' effects beyond its volume effect after ICH. Haptoglobin-Hb-CD163 as well as haemopexin-haem-LRP1 is believed to be the most important endogenous scavenging pathway which participates in blood components resolution following ICH. PPARγ-Nrf2 activates the aforementioned clearance pathway and then accelerates haematoma clearance. Meanwhile, the scavenger receptors as novel targets for therapeutic interventions to treat ICH are also highlighted.
Topics: Animals; Brain Injuries; Cerebral Hemorrhage; Hematoma; Humans; Models, Biological; Phagocytosis; Receptors, Scavenger
PubMed: 29278306
DOI: 10.1111/jcmm.13441