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Kuzibaev Jamshid Muminovich, MD, Doctor of philosophy, Republican Research center of emergency medicine, Neurosurgery department Senior researcher
Email: [email protected] Makhkamov Kozim Ergashevich, MD, Doctor of medicine Republican Research center of emergency medicine, Neurosurgery department Chief of the department
Secondary intracerebral hemorrhage following traumatic brain injury
Abstract: 203 patients with traumatic brain injury who had CT scan more than twice were subject of this study. Secondary intracerebral hemorrhage was encountered in 41 (20.1%) patients, who have less favorable outcome in comparison with the patient without the hemorrhage. The present study demonstrated that high systolic blood pressure, the presence of coagulopathy and decompressive craniectomy were the risk factors for the development of secondary intracerebral hemorrhage.
Keywords: trauma, brain injury, secondary intracerebral hemorrhage, outcome, risk factors.
Introduction
Traumatic brain injury (TBI) is a common cause of death and disability, as well as one of the most important health and social problems in the majority of countries including Uzbekistan. Among various traumas, TBI has the highest mortality and the most serious consequences and is the most difficult to treat. It has been reported that patients who died of TBI account for 87% ofall trauma deaths. One of the most rated complications ofTBI is intracranial hemorrhage [2, 12].
Secondary intracerebral hemorrhage (SIH) which is delayed intracerebral hemorrhage after trauma should be distinguished from continuous intracerebral hemorrhage. Continuous intracerebral hemorrhage occurs at the moment of the trauma and increases in the size within first 24 hours postinjury [8]. In this study, the patients with TBI were retrospectively analyzed based on medical history and radiologic data to determine the rate of SIH and its influence to outcome.
Materials and methods
203 patients with TBI who had CT scan more than twice in our research center from 2011 to 2015 were subject of this study. SIH was defined as intracerebral hemorrhage on the second CT taken in 24 hours after the first CT which showed no initial intracerebral hemorrhage. Among 203 patients the incidence of SIH was 20.1% (41/203). The group of 41 with SIH and the group of 163 without SIH were compared. Based on the medical record and brain CT,
general medical condition, trauma, and factors associated with evaluation and outcome were investigated. General condition is specified into sex, age, past medical history. The trauma-related factors were the cause of trauma, the initial Glasgow Coma Scale (GCS) score, and the Glasgow Outcome Scale at discharge, the time from trauma to the first brain CT, and the time interval between the first and the second CT.
The management for TBI is divided into two groups; emergent surgery and conservative management. Emergent surgery was performed if intracranial hemorrhage was detected on brain CT and mass effect was present. If the condition of a patient and the amount of hemorrhage did not meet surgery based on clinical judgment, the patient's neurological status was observed closely with follow-up CT and conservatively managed.
Statistical analysis. Statistical analyses were performed using the MedCalc software package (Version 11.4.2.0). Normally distributed data are expressed as mean±SD and were compared using the unpaired t test. Other data are expressed as median and range and were compared with nonparametric tests. x2 was exact tests were used to determine associations between variables categorized. Avariate logistic analysis was used to determine the predictors of SIH. Predictors were defined as being significant if P value is lower than 0.05.
Illustration of case
Figure 1. Initial CT scans obtained 1 hour postinjury, demonstrating acute subdural hematoma on the right hemisphere of the brain with mass effect and subarachnoid hemorrhage
Secondary intracerebral hemorrhage following traumatic brain injury
39-year-old male who had an altered mentality when brought to the emergency room due to head injury 30 minutes ago. He was comatose with GCS score of 8. The initial CT scans obtained 1 hour postinjury showed acute subdural hematoma on the right hemisphere of the brain with mass effect and subarachnoid hemorrhage (Fig. 1). The patient underwent emergency craniectomy and
hematoma removal. The patient's neurological status was observed closely with follow-up CT scan, 36 hours after the first scan. On the postoperative CT, multiple intracerebral hemorrhage and ischemia of the brain were revealed (Fig. 2). However, his mental status did not improve due to secondary brain damage, and the outcome was lethal.
Figure 2. First postoperative CT scans revealing multiple intracerebral hemorrhage and ischemia of the brain Results
The mean age of total 203 patients was 42.5±13.2 years while the mean age of patients with SIH was 49.0±12.2, and the mean age of patients without SIH was 52.6±19.9. The mean age is lower in the group with SIH, but it was not statistically significant (P=0.27). SIH was found in 37 males and 4 females, revealing higher incidence in males. However, considering that intracranial hemorrhage occurred more in males (176 males, 27 females), the gender and the occurrence of PEH are not associated with p-value of 0.71 (Table 1). The mechanisms of trauma included 35 (17.2%) motor vehicle collisions, 12 (5.9%) falls, and 156 (7.7%) cases of assaults and other injuries. Mean time from injury to first CT scan was 2.7 hours and the time between first and second CT scans was 28.7 hours. Comparing to no history of diseases, the presence of past medical history such as diabetes showed no significance. The factors related to blood coagulation on blood laboratory at admission prove correlation with SIH with p-value of 0.03. When the hemodynamic parameters were taken into consideration, SIH happened more in patients with arterial hypertension (Table 1).
Table 1. - Clinical variables related to the development of SIH in the patients with head trauma
Clinical variables No. of patients with SIH P value
1 2 3 4
Gender 0.71
male 176 37 (20.9%)
female 27 4 (14.8%)
Age (years) 0.1
<30 52 5 (9.6%)
30-50 89 18 (20.2%)
>50 62 18 (29.0%)
Admission GCS scores 0.77
13-15 30 5 (16.6%)
9-12 105 20 (19.0%)
3-8 68 16 (23.5%)
Decompressive craniectomy 0.004**
Yes 107 32 (29.9%)
No 96 9 (0.9%)
Time from injury to 1st CT 0.04*
<2 hours 95 28 (29.4%)
2-6 hours 77 9 (11.6%)
>6 hours 31 4 (12.9%)
Coagulopathy 0.03*
Yes 33 13 (39.4%)
*X2 test P < 0.05 difference between groups. **X2 test P < 0-01 difference between groups.
A lethal outcome was seen in 21.1% ofpatients with SIH and in 51.2% of those without SIH, respectively (Table 2, x2 test, P = 0. 0006).
1 2 3 4
No 170 28 (16.4%)
Hypertension 0.001**
Yes 36 17 (47.2%)
No 167 24 (14.3%)
Table 2. - Association between SIH and Glasgow Outcome Scale scores
A lethal outcome No. of patients with SIH (%) P value
Yes 43 21 (39) 0.0006
No 160 23 (61)
Discussion
A policy of routine follow-up CT imaging for patients with head injury is commonly adopted at many trauma centers. It is well recognized that early repeated CT scanning is potentially crucial for detecting serious secondary injuries in patients with TBI. Furthermore, CT scanning has revealed that delayed/progressive hematomas after head trauma are more common than had been previously suspected. Several studies have reported that early progressive hemorrhage occurred in approximately 30-42.3% of head injured patients, and it occurs most frequently in intraparenchymal contusion or hematoma [1, 11].
SIH is also observed on serial CT scans in head trauma patients. It is currently defined on the basis of a radiologic criterion: intracerebral hematoma that is not present in the first CT scan after trauma, but that appears in sequential repeat CT scan during patient evolution. However, the amount of increasing hematoma and the timing of presence of hemorrhagic progression are ambiguous. In our study, SIH was defined as an appearance of new hematoma during hospitalization. The reported incidence of delayed intracerebral hematoma varies from 5.6% to 13.3% [8]. Similarly, we observed SIH in 20.1% of head-injured patients.
In the present study, SIH mainly developed early during the clinical course, and twenty-five patients developed SIH within the 2 days after injury. Later than 3 days after injury, SIH was rare.
We found that the average age of the patients with SIH was younger than the patients without SIH in this series, although there was no significant association between age differential and SIH by statistical analysis. Although the results showed no relation between the GCS score and SIH, this scale is useful to evaluate the status of patients with TBI. Ono et al. retrospectively analyzed 272 patients with severe head injury and suggested the GCS score was the only significant outcome prognostic factor [9].
The timing of the first CT scan is clearly an important factor to predict the occurrence of SIH. It is not doubt that the sooner after injury the first scan is performed, the greater likelihood of subsequent SIH development on later CT scans is. A similar finding was reported by Oertel et al. In their study of 107 patients in whom the initial CT scan was performed within the first 2 hours after-injury, 48.6% had progressive hemorrhagic injury, compared with 22.9% ofpatients who underwent their injury CT scan within 2-10 hours after- injury [8]. It is possible that head trauma patients undergo their first cranial CT scan, if the time interval from trauma to the initial CT scan is shorter, the intracerebral hematoma formation does not achieve its visible size. During this initial period, the intracranial injury may be rapidly evolving. Additionally, following repeat CT can reveal an increase in hematoma size compared with initial CT finding.
Another significant finding in the present study was that decompressive craniectomy seemed to be independently predictive
of SIH. Postoperative intracranial hematomas had been observed in previous reports with an incidence ranging from 7.8% to 61% [4]. In the present study, we found that almost 15.7% of patients who underwent decompressive craniectomy showed significant SIH. Decompressive craniectomy has been proved to be a useful means to decrease intracranial pressure, and usually performed as a last resort in patients with malignant edema because of intracranial hematomas. Whilst technically straightforward, the procedure is not without significant complications. However, a sudden decrease of cerebral vessels pressure after decompressive craniectomy may occasionally cause progressive hemorrhage [5].Thus, we proposed that routine postoperative CT scan should be performed immediately after cranial surgery for head trauma, particularly in those with subarachnoid hemorrhage. This would help in timely detection and treatment of such a complication.
Our data suggested that hemocoagulative disorder after injury was an independent risk factor for suffering SIH. Studies by Stein et al. and Engstrom et al. also showed that a decrease in platelets was predictive for PHI [3, 10]. However, other studies indicate that progressive hemorrhage after head injury is associated with diffuse intravascular coagulation as defined by increased concentration of fibrin degradation products and low fibrinogen concentration [6].
Our analysis showed such a direct correlation of SIH with arterial blood hypertension. We speculated that resuscitation efforts in the emergency room could lead to significant variations of blood pressure, which might increase the risk of rebleeding. Hence, the effects of hypertension on the development of SIH remain questionable and should be clearly defined further.
Our study has several limitations. Foremost is the patient-selection bias intrinsic to all retrospective studies. Specifically, the decisions to obtain repeated CT scans in this study were made by the neurosurgeons involved in the care of the individual patients. Almost all such scans were obtained, not through a prospective plan to routinely perform follow- up scans. Furthermore, more detailed outcome measures could not be effectively collected in our study because of the retrospective design and difficulties with follow up in our patient population.
Conclusions
We performed serial CT scans on 203 in hospital patients with head trauma. Secondary intracerebral hemorrhage was encountered in 41 (20.1%), which can be developed within the first three days after head trauma. Early identification and successful management of this complication require a high index of clinical suspicion. Patients with SIH have less favorable outcome in comparison with the patient without SIH (lethality rate, 21.1% versus 51.2%). The present study demonstrated that high systolic blood pressure, the presence of coagulopathy and decompressive craniectomy were the risk factors for the development of SIH.
Status of the cervix in the forecast of labor in post-term pregnancy
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Karimova Feruza Dzhavdatovna, Professor, Department of Obstetrics and Gynecology of the Tashkent Institute of Postgraduate Institute Mamadazimova Dilorom Fayzymamatovna, Senior Research Scientist of the Department of Obstetrics and Gynecology of the Tashkent Institute of Postgraduate Institute E-mail: [email protected]
Status of the cervix in the forecast of labor in post-term pregnancy
Abstract: Depending on the length of the cervix at transvaginal sonography [10-20 mm, 21-30 mm, 31-40 mm, 40 mm] for pregnant women identified the forecast delivery.
Keywords: post-term pregnancy, cervical bimanual technique, transvaginal ultrasonic research.
The incidence of pregnancy is from 3.5 to 16% and has a downward trend [1, 3-4] Adverse perinatal outcomes when post-term pregnancy increase with increasing gestational age. This perinatal mortality rate 6 times higher than that at term, due to the low resistance of the brain to mature fetal hypoxia [2, 1-3; 4, 1-2].
Perinatal central nervous system [CNS] post-term children have determined the high frequency of neurological disorders. In connection with above, it becomes important selection of the optimal time and method of delivery of patients with post-term pregnancy that is determined by the degree of readiness of the cervix for childbirth and fetus. Widely used bimanual method of assessing the state ofthe cervix with vaginal research, being subjective, does not allow to fully appreciate the cervical length and the state of the internal os [5, 1-2]. Therefore now it attaches great importance to the echographic assessment of the cervix during transvaginal ultrasonography study.
Objective: The objective was to determine the characteristics of the state of the cervix in pregnant women with gestational age more than 41 weeks at transvaginal sonography.
Materials and Methods: We have conducted a comprehensive survey of119 prospective pregnant with gestational age more than 41 weeks (287 days).
We were excluded from the study patients with a scar on the uterus, Multiple pregnancy, wrong position fetus, pelvic presentation who came in as a result of assisted reproductive technologies.
Results and discussion: gestational age was calculated from the first day of the last menstrual period (formula Negele) based on the data of ultrasound scanning, performed in the period from 7 to 20 weeks of pregnancy. When determining the degree of maturity of the cervix using score scale necessity E. Bishop.
With transvaginal ultrasound cervical length was measured, the state of the internal os and cervical canal. Patients with the opening of the internal os was evaluated in the same form recesses (V, Y, U — shaped) and the degree of opening. When proposed cervical preparation used for childbirth, prostaglandin E2, or a combination thereof. The remaining patients developed own labors.
Depending on the length of the cervix transvaginal sonography (10-20 mm, 21-30 mm, 31-40 mm and over 40 mm) surveyed pregnant were divided into 4 groups.
With a length of 10-20 mm of the cervix, all patients have given birth vaginally. Spontaneous activities onset of labor was observed in 4 [3.4%] of pregnant women, amniotomy was performed in two, the introduction of prostaglandin gel — eight patients.
