Bifrontal Traumatic intracerebral hemorrhage

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Presence of bifrontal lobe injury, temporal lobe injury, dominant hemisphere injury, and contre-coup injury and severe parenchymal injury adversely influenced the final MMSE scores. They can be concluded to be poor prognostic factors in terms of cognitive function in TBI patients ¹⁾.

Severe bifrontal cerebral contusions in an awake traumatic brain injury (TBI) patient is a challenging clinical picture, as they are prone to late deterioration.

Better defined and progression after 6 hours

Bifrontal Traumatic intracerebral hemorrhage treatment.

Frontal intracerebral haemorrhage (ICH) is a common result of cranial trauma. Outcome differences between bilateral and unilateral frontal ICH are not well studied but would be valuable to predict prognosis in clinical practice. Two aims are proposed in this study: first to compare the risk of developing delayed ICH after bilateral or unilateral frontal ICH, and second to determine the variables helpful to predict outcome according to the Glasgow Outcome Scale (GOS). Between January 1993 and December 1997, 694 consecutive patients with traumatic ICH were admitted to the Chang Gung Medical Center within 24 h of the trauma. Patients with ICH in sites other than the frontal lobes were excluded. A total of 161 cases (mean age 46.3+/-20.3 years), including 57 bilateral (mean age 52.5+/-18.7 years) and 104 unilateral (mean age 42.9+/-20.5 years) traumatic frontal ICH were studied. Twenty-eight of 57 patients (49%) with bifrontal ICH versus 17 of 104 patients (16%) with unilateral frontal ICH had a further, delayed ICH. In 42 of 45 patients (93%) with delayed ICH, this occurred within 5 days of the initial trauma. Multivariate logistic regression was used to select significant predictors of outcome. We found that delayed ICH (p<0.001), age (p=0.004) and mechanism of injury (p=0.001) explained the worse outcome in patients with bifrontal ICH. The best-fitting logistic regression model included three variables: delayed ICH (p=0.011), initial GCS (p=0.023), and a sum score of clinical and radiological variables (p=0.003). Bifrontal ICH tended to occur in older patients after a fall and was associated with a higher risk of developing delayed ICH or brain stem compression compared to unilateral ICH damage. Using these three variables - delayed ICH, initial GCS, and the sum score - in a logistical regression model is useful to predict outcome in patients with traumatic frontal ICH and may aid patient management ²⁾.

A total of 63 patients (45 men and 18 women; mean age of 43 years with a range from 20 to 72 years) who suffered from traumatic bifrontal contusions between January 2007 and December 2012 were inspected. The clinical and imaging results were studied for all patients, and found that swelling of the mesencephalon and a downward shift of the bilateral red nucleus were significant signs of central herniation in the image of magnetic resonance imaging. All patients were given a simultaneous bilateral craniotomy for balanced decompressive surgery. The Glasgow Outcome Scale was used to monitor the patients during the follow-up period, which lasted from 6 to 52 months with a mean of 22 months. At the termination of the follow-up period, the following Glasgow Outcome Scale scores were obtained: 14 patients scored 5 points, 22 patients scored 4 points, 7 patients scored 3 points, 13 patients scored 2 points, and 7 patients scored 1 point. Therefore, the study suggested that an early magnetic resonance imaging scan could result in a more timely diagnosis of central brain herniation, and simultaneous bilateral craniotomy was found to be one of the best treatments for central brain herniation to improve patient outcomes ³⁾.

127 patients with bifrontal contusions were reviewed retrospectively. Among them, 63 patients accepted operations, 39 cases underwent intracranial pressure (ICP) monitoring, and 24 cases did not. They compared the Glasgow Outcome Scale (GOS) for prognosis, length of osmolar therapy, and length in intensive care unit (ICU) and hospital stay between ICP and non-ICP groups.

Compared with the non-ICP operation group, there was no significant difference in Glasgow Coma Scale score in the ICP group, both at admission (average 8.62 vs. 8.91, P = 0.711) and at discharge (average 11.32 vs. 10.45, P = 0.427). However, the length of stay in the ICU was much shorter in the ICP operation group than that of the non-ICP group (15.67 ± 8.72 days vs. 25.32 ± 18.78 days, P = 0.013). Hospital stay was also shortened significantly in the ICP operation group compared with the non-ICP operation group (18.94 ± 8.92 days vs. 34.29 ± 22.64 days, P = 0.001). The length of osmolar therapy with mannitol was also decreased in the ICP operation group compared with the non-ICP group (14.11 ± 6.65 days vs. 21.84 ± 12.02, P = 0.008). However, there was no difference in mortality between two groups (5/39 vs. 4/24). We followed up 29 ICP operation patients and nineteen non-ICP operation patients using GOS 6 months later. The average GOS was 4.21 and 3.32 for the ICP and non-ICP groups respectively (P = 0.025).

ICP is one of the most important intensive types of monitoring for patients with moderate-to-severe bifrontal contusions and may be beneficial in creating a better prognosis. Intensive care and proper management are necessary to reduce stays in ICU, hospitalization, and mannitol osmolar therapy, and to improve GOS ⁴⁾.

Peterson et al prospectively collected database of TBIs for patients with severe bifrontal contusions, defined as >30 cm. Only patients with Glasgow Coma Scale score of 10 or greater were included. Patients were divided into two groups: deterioration and nondeterioration. Clinical variables were compared between the two groups.

Thirteen patients met the above criteria. The mean Glasgow Coma Scale score was 13, and all were low mechanism injuries. All patients were managed with intensive care unit observation and hyperosmolar therapy to maintain serum osmolarity >300. Overall, 7 of 13 (54%) suffered an acute clinical deterioration a mean of 4.5 days postinjury. Of those managed with immediate surgical decompression, all had good outcomes and returned to work. There was no difference in contusion or edema volumes between the two groups.

Awake patients with bifrontal contusions represent a unique cohort of TBI patients who are prone to rapid deterioration late in their clinical course. They have extensive frontal edema and mass effect, yet we were unable to find a correlation between edema volumes and incidence of deterioration. Based on this series and our experience in other TBI patients, we no longer utilize prophylactic infusions of hypertonic saline in the setting of TBI. They recommend managing these patients with intensive care unit admission and early intracranial pressure monitoring. If they do deteriorate despite these measures, rapid bifrontal decompression can lead to good functional outcomes ⁵⁾.