Helsinki CT score

Helsinki CT score

Mass lesion type(s)

Mass lesion size

Hematoma volume > 25 cm3 2

Intraventricular hemorrhage

Suprasellar cisterns

Suprasellar cisterns

Normal 0

Compressed 1

Obliterated 5

Sum score -3 to 14 1).

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There are few specific prognostic models specifically developed for the pediatric traumatic brain injury (TBI) population. Mikkonen et al., tested the predictive performance of existing prognostic tools, originally developed for the adult TBI population, in pediatric TBI patients requiring stays in the ICU.

They used the Finnish Intensive Care Consortium database to identify pediatric patients (< 18 years of age) treated in 4 academic ICUs in Finlandbetween 2003 and 2013. They tested the predictive performance of 4 classification systems-the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) TBI model, the Helsinki CT score, the Rotterdam CT score, and the Marshall CT classification-by assessing the area under the receiver operating characteristic curve (AUC) and the explanatory variation (pseudo-R2 statistic). The primary outcome was 6-month functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 3-5).

Overall, 341 patients (median age 14 years) were included; of these, 291 patients had primary head CT scans available. The IMPACT core-based model showed an AUC of 0.85 (95% CI 0.78-0.91) and a pseudo-R2 value of 0.40. Of the CT scoring systems, the Helsinki CT score displayed the highest performance (AUC 0.84, 95% CI 0.78-0.90; pseudo-R2 0.39) followed by the Rotterdam CT score (AUC 0.80, 95% CI 0.73-0.86; pseudo-R2 0.34).

Prognostic tools originally developed for the adult TBI population seemed to perform well in pediatric TBI. Of the tested CT scoring systems, the Helsinki CT score yielded the highest predictive value 2).

References

1)

Raj R, Siironen J, Skrifvars MB, Hernesniemi J, Kivisaari R. Predicting outcome in traumatic brain injury: development of a novel computerized tomography classification system (Helsinki computerized tomography score). Neurosurgery. 2014 Dec;75(6):632-46; discussion 646-7. doi: 10.1227/NEU.0000000000000533. PubMed PMID: 25181434.
2)

Mikkonen ED, Skrifvars MB, Reinikainen M, Bendel S, Laitio R, Hoppu S, Ala-Kokko T, Karppinen A, Raj R. Validation of prognostic models in intensive care unit-treated pediatric traumatic brain injury patients. J Neurosurg Pediatr. 2019 Jun 7:1-8. doi: 10.3171/2019.4.PEDS1983. [Epub ahead of print] PubMed PMID: 31174193.

Cerebellar hemorrhage surgery

Cerebellar hemorrhage surgery

In 1906, Ballance first reported a surgical approach to treatment of cerebellar hemorrhage1) 2).

Since then, surgical treatment has become the general option for treatment 3).

Recommendations from Kobayashi et al in 1994 4)

1. patients with a Glasgow Coma Scale (GCS) score ≥14 and hematoma <4 cm diameter: treat conservatively

2. patients with GCS≤13 or with a hematoma ≥4 cm: surgical evacuation.

3. patients with absent brain stem reflexes and flaccid quadriplegia: intensive therapy is not indi- cated. Note: some authors contend that the loss of brain stem reflexes from direct compression may not be irreversible, 5) and that cerebellar hemorrhage represents a surgical emergency (and that the above criteria would thus deny potentially helpful surgery to some, see discussion of cerebellar infarction and decompression.

4. patients with hydrocephalus: ventricular catheter (if no coagulopathy). Caution: do not overdrain to avoid upward cerebellar herniation. Most cases with hydrocephalus also require evacuation of the clot

Criteria

Surgical treatment of cerebellar ICH can be life-saving but often leads to a poor functional outcome. New studies are needed on long-term functional outcome after a cerebellar ICH 6).

Since the 1970s, there has been a wide mutual consensus in the neurological and neurosurgical community that cerebellar ICHs should be operated on. However, the scientific proof is mainly based on small retrospective series with conflicting results 7).

To relieve brainstem compression and hydrocephalus, surgeons tend to favor occipital craniectomy or occipital craniotomy with hematoma evacuation in patients with a declining level of consciousness 8). Some regard this counterintuitive as long-term outcomes after surgical treatment of cerebellar ICH are generally pessimistic 9).


Since the report by Little et al., 10) the hematoma diameter has been considered a significant factor in the decision-making process for optimal treatment.

The criteria for surgery remain controversial, and many researchers have determined that a hematoma larger than 3 cm, obstruction of the quadrigeminal cistern, and compression of the fourth ventricle are surgical criteria 11) 12) 13).

Cohen et al. 14) used a maximal hematoma diameter greater than 3 cm as the surgical criterion, however, some patients with a hematoma larger than 3 cm who underwent conservative treatment had a good prognosis as well. In addition, a hematoma volume greater than 15 mL, being equivalent with a hematoma with a maximal diameter greater than 3 cm, has also been used as a criterion in some cases 15).


The criteria of Kobayashi et al., are as follows:

1) patients with Glasgow Coma Scale scores of 14 or 15 and with a hematoma of less than 40 mm in maximum diameter are treated conservatively

2) for the patients with Glasgow Coma Scale scores of 13 or less at admission or with a hematoma measuring 40 mm or more, hematoma evacuation with decompressive suboccipital craniectomy should be a treatment of choice

3) for the patient whose brain stem reflexes are entirely lost with flaccid tetraplegia or whose general condition is poor, intensive therapy is not indicated. The validity of these criteria was tested and confirmed in 49 cases 16).

Technique

Position

Lateral oblique position with the involved side up.

If rapidity is crucial a suboccipital midline skin incision is preferred because it can be taken down quickly with little fear of encountering a vertebral artery.

Suboccipital craniectomy is preferred over suboccipital craniotomy to accomodate postoperative swelling.

A prophylactically ventriculostomy at Frazier’s point is recommended to allow rapid treatment of postoperative hydrocephalus or intracranial pressure monitoring.

In cases where there has been rupture into the ventricular system, the surgical microscope should be used to follow the clot to the fourth ventriclewhich is then cleared of clot.

External ventricular drainage (EVD) combined with intraventricular thrombolysis (IVF) is rarely used in severe spontaneous cerebellar hemorrhage(SCH) with intraventricular hemorrhage (IVH).

It is a treatment option for elderly patients with severe SCH + IVH 17).

Video

References

1) , 15)

Cho SM, Hu C, Pyen JS, Whang K, Kim HJ, Han YP, et al. Predictors of outcome of spontaneous cerebellar hemorrhage. J Korean Neurosurg Soc. 1997 Oct;26(10):1395–1400.
2) , 3)

Dahdaleh NS, Dlouhy BJ, Viljoen SV, Capuano AW, Kung DK, Torner JC, Hasan DM, Howard MA 3rd. Clinical and radiographic predictors of neurological outcome following posterior fossa decompression for spontaneous cerebellar hemorrhage. J Clin Neurosci. 2012 Sep;19(9):1236-41. doi: 10.1016/j.jocn.2011.11.025. Epub 2012 Jun 20. PubMed PMID: 22721890.
4)

Kobayashi S, Sato A, Kageyama Y, et al. Treatment of Hypertensive Cerebellar Hemorrhage – Surgical or Conservative Management. Neurosurgery. 1994; 34:246–251
5)

Heros RC. Surgical Treatment of Cerebellar Infarc- tion. Stroke. 1992; 23:937–938
6)

Satopää J, Meretoja A, Koivunen RJ, Mustanoja S, Putaala J, Kaste M, Strbian D, Tatlisumak T, Niemelä MR. Treatment of intracerebellar haemorrhage: Poor outcome and high long-term mortality. Surg Neurol Int. 2017 Nov 9;8:272. doi: 10.4103/sni.sni_168_17. eCollection 2017. PubMed PMID: 29204307; PubMed Central PMCID: PMC5691556.
7)

Witsch J, Neugebauer H, Zweckberger K, Jüttler E. Primary cerebellar haemorrhage: complications, treatment and outcome. Clin Neurol Neurosurg. 2013 Jul;115(7):863-9. doi: 10.1016/j.clineuro.2013.04.009. Epub 2013 May 6. Review. PubMed PMID: 23659765.
8)

Wijdicks EF, St Louis EK, Atkinson JD, Li H. Clinician’s biases toward surgery in cerebellar hematomas: an analysis of decision-making in 94 patients. Cerebrovasc Dis. 2000 Mar-Apr;10(2):93-6. PubMed PMID: 10686446.
9)

Luney MS, English SW, Longworth A, Simpson J, Gudibande S, Matta B, Burnstein RM, Veenith T. Acute Posterior Cranial Fossa Hemorrhage-Is Surgical Decompression Better than Expectant Medical Management? Neurocrit Care. 2016 Dec;25(3):365-370. PubMed PMID: 27071924; PubMed Central PMCID: PMC5138260.
10)

Little JR, Tubman DE, Ethier R. Cerebellar hemorrhage in adults. Diagnosis by computerized tomography. J Neurosurg. 1978 Apr;48(4):575-9. PubMed PMID: 632882.
11) , 14)

Cohen ZR, Ram Z, Knoller N, Peles E, Hadani M. Management and outcome of non-traumatic cerebellar haemorrhage. Cerebrovasc Dis. 2002;14(3-4):207-13. PubMed PMID: 12403953.
12)

Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery. 2001 Dec;49(6):1378-86; discussion 1386-7. PubMed PMID: 11846937.
13)

Salvati M, Cervoni L, Raco A, Delfini R. Spontaneous cerebellar hemorrhage: clinical remarks on 50 cases. Surg Neurol. 2001 Mar;55(3):156-61; discussion 161. PubMed PMID: 11311913.
16)

Kobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of hypertensive cerebellar hemorrhage–surgical or conservative management? Neurosurgery. 1994 Feb;34(2):246-50; discussion 250-1. PubMed PMID: 8177384.
17)

Zhang J, Wang L, Xiong Z, Han Q, Du Q, Sun S, Wang Y, You C, Chen J. A treatment option for severe cerebellar hemorrhage with ventricular extension in elderly patients: intraventricular fibrinolysis. J Neurol. 2014 Feb;261(2):324-9. doi: 10.1007/s00415-013-7198-2. Epub 2013 Dec 3. PubMed PMID: 24297364.

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

The Scandinavian Neurotrauma Committee (SNC) published practical, evidence based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI).

1).


A prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 to November 2016. All consecutive adult patients with HI presenting to the ED within 24 hours from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients and the result was available at the ED. Head CTs were performed according to the on-call physician’s evaluation. Only the samples collected within 6 hours after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age=67.0 years, range=18-100; women=48.8%) were enrolled. Of those, 196 (66.4%) were scanned. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% CI=0.77-0.99) and specificity 0.19 (95% CI=0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI=0.12-0.25) and 0.94 (95% CI=0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED and 2 patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions following HI and have the potential to reduce unnecessary CT scanning 2).


In a large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, they compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.

The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.

The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI 3).

References

1)

Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760-6. PubMed PMID: 10780615.
2)

Minkkinen M, Iverson GL, Kotilainen AK, Pauniaho SL, Mattila V, Lehtimäki T, Berghem K, Posti JP, Luoto TM. Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults. J Neurotrauma. 2019 May 21. doi: 10.1089/neu.2018.6351. [Epub ahead of print] PubMed PMID: 31111795.
3)

Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med. 2018 Oct 12;16(1):176. doi: 10.1186/s12916-018-1166-8. PubMed PMID: 30309392; PubMed Central PMCID: PMC6182797.
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