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CT images performed initially after the head injury (a), after neurological deterioration (b), and after surgical haematoma evacuation (c).
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Treatment with anticoagulants and antiplatelet agents are well-known risk factors for an unfavourable outcome after traumatic brain injury (TBI). Guidelines for decision making in patients who sustained mild head injury do not apply to anticoagulated patients and therefore, in these cases diagnostic and therapeutic procedures have to be tailored pa...
Citations
... The small risk of DICH is a difficult dilemma from safety and resource allocation perspectives. In terms of safety, severe disability and death are real consequences of DICH, and very late presentations of DICH contribute to worse outcomes [1,13,14]. In terms of resource allocation, this is a rare complication of a common problem: the cost of routine hospitalizations for 24-hour observation and for repeat CT scans is difficult to justify with an estimated number needed to treat of up to 61 persons [15]. ...
Current literature estimates the risk of delayed intracranial hemorrhage as between 0.6 and 6% after mild head injury for patients on warfarin. Due to resource allocation issues, the need to actually diagnose delayed intracranial haemorrhage has been questioned, especially if it does not require surgery. The purpose of our case report is to consider the functional implications during the six months following a mild traumatic brain injury complicated by delayed intracranial hemorrhage in a patient undergoing warfarin therapy. To the best of our knowledge, the rehabilitative and functional considerations of delayed intracranial haemorrhage in head injury have not been previously described in the literature.
A previously independent 74-year-old Lebanese man living in Australia sustained mild traumatic brain injury following an unwitnessed fall from the height of two meters while on warfarin therapy, with an international normalized ratio of 4.2. He was found to have amnesia of the event and extensive facial bruising. His Glasgow Coma Scale score was 14 to 15 throughout observation. Following a non-diagnostic initial computerised tomography scan, a repeat scan at 24 hours from the injury identified large intracerebral, subdural and subarachnoid hemorrhages. A detailed examination demonstrated visuospatial and cognitive impairments. He required inpatient rehabilitation for three weeks, and outpatient rehabilitation for two months. By six months, he had returned to his pre-injury level of functioning, but was unable to resume driving.
We describe rehabilitation outcomes of delayed intracranial haemorrhage and mild traumatic brain injury, with diminishing disability over six months. In our case report, the complication of the delayed intracranial haemorrhage resulted in significant activity limitations and participation restrictions, which affected the clinical management, including the need for multidisciplinary rehabilitation. The risk of delayed intracranial haemorrhage in mild head injury remains a significant problem requiring further research.
Introduction: Delayed Intracranial Hemorrhage (D-ICH), defined as finding of ICH on subsequent imaging after a normal computed tomography of the brain (CTB), is a feared complication after head trauma. The aim of this study was to determine the incidence and severity of D-ICH.
Methods: This retrospective cohort study included patients that presented directly from the scene of injury to an adult major trauma center from Jan 2013 to Dec 2018.
Results: There were 6536 patients who had an initial normal CTB and 23 (0.3%; 95%CI: 0.20–0.47) had D-ICH. There were 653 patients who had a repeat CTB (incidence of D-ICH 3.5%; 95%CI: 2.2–5.2). There was no significant association of D-ICH with age>65 years (OR 1.33; 95%CI: 0.54–3.29), presenting GCS <15 (OR 1.21; 95% CI: 0.52–2.80) and anti-platelet medications (OR 0.68; 95%CI: 0.26–1.74). Exposure to anti-coagulant medications was associated with lower odds of D-ICH (OR 0.23; 95%CI: 0.05–0.99). All cases of D-ICH were diffuse injury type II lesions on the Marshall classification. There were no cases that underwent neurosurgical intervention and no deaths were attributed to D-ICH.
Conclusions: These results question observation of patients with head injury in hospital after a normal CTB for the sole purpose of excluding D-ICH.
A 7-year-old boy was admitted to the emergency department after closed head injury. Physical examination revealed no neurologic disturbances or scalp laceration. Computed tomography revealed depressed skull fracture on the right occipital bone with multiple fracture lines over the right transverse sinus. Magnetic resonance imaging revealed right transverse sinus thrombosis, and magnetic resonance venography identified total occlusion of the right transverse sinus due to bone compression. Despite the presence of venous sinus injury secondary to a depressed skull fracture, surgery was not indicated for this patient. Despite persistence of a right occipital depression fracture identified during a three-dimensional cranial tomography performed in the third month following the trauma, the patient’s magnetic resonance venography showed spontaneous recanalization of the right transverse sinus. It was demonstrated that venous sinus occlusion secondary to a depressed fracture could heal spontaneously and independently of bone pathology. With such characteristics, this report represents an extremely rare case.
