Danny McGeehan wrote:
>
> Colleagues
> Speaking as a clinician working in the front line of the speciality the NICE guidelines are unworkable in my opinion and subjected to a significant error.
>
> There is the well recognised condition of the delayed traumatic intracranial Haemotoma.  As opposed to a wait and see policy ie let the clinical condition dictate as to whether you need to scan the patient.  They have adapted the same technique as they have to door to needle times, 4 hour waits, trick and treat and so the list goes on.  Speed is of the essence at all costs, get them in and out as quick as possible as long as the exploding pie charts look good.
>
> If they advocate scanning within 2 hours a significant number of delayed traumatic bleeds (DTICH's)  will be discharged home as they will be missed.  I beleive the incidence is in the order of 10% but I could be corrected.  I'm sure there are a few people on the list who do nothing all day and they can get the reference for me,
>
> Danny McGeehan
>
>

Hi Danny,

Happy to oblige!!  First described in 1979.  Max rate of 12.2% reported,
though don't have the CT criteria (Zhang et al).  Tseng reports 1.4% of
all admitted or 5.9% of those with neurol deficit or abnormal CT.
Associated with anti-coag therapy.  One study suggests measuring
Thrombomodulin and vWf as possibel risk-stratifying method (Yokota et
al).  Grading system I-IV, Type III (24%) being no changes at subsequ
site of haematoma (Fukamachi et al).

Cheers
Anton


J Formos Med Assoc. 1992 Jun;91(6):585-9.
Delayed traumatic intracerebral hemorrhage: a study of prognostic
factors.
Tseng SH.
Department of Neurosurgery, Poh-Ai Hospital, Lo-Tung, National Taiwan
University Hospital, Taipei, Taiwan, R.O.C.

Experience in the management of 32 patients with delayed traumatic
intracerebral hemorrhage (DTICH) is presented with emphasis on the
incidence, clinical significance and factors affecting the outcome. The
incidence was 1.4% of all hospitalized head-injury patients, or 5.9% of
only those patients with neurologic signs or abnormal findings on
computed tomography (CT) identified on admission. After an injury, every
patient had an immediate CT scan to diagnose intracranial pathology.
Initially, nine patients underwent a craniotomy for intracranial
hematomas, and 23 patients had nonoperative treatment. CT follow-up was
carried out in 10 patients due to clinical deterioration and on 22
patients due to failure to recover neurologically. The delayed
hemorrhage was found after a time interval varying from seven hours to
10 days (average, three days and seven hours). Six patients underwent
operations for DTICH, and 26 were treated conservatively. Twenty-four
patients (75%) were functional (good or moderately disabled condition)
after one year of follow-up treatment, as measured on the Glasgow
Outcome Scale. The mortality was 16%. The patients were predicted to
have a poor prognosis if associated with an earlier occurrence, the
hematoma was large, the patient had a poor Glasgow Coma Scale score at
the time of CT follow-up, clinical deterioration was noted, or partial
or complete effacement of the suprachiasmatic cistern was noted on the
CT scan. The results indicate that the prognosis of DTICH is not as poor
as it was previously thought to be, and the factors affecting the
outcome in this study seem to justify a more vigilant approach.


J Neurotrauma. 2002 Sep;19(9):1007-15.
Cerebral endothelial injury in severe head injury: the significance of
measurements of serum thrombomodulin and the von Willebrand factor.
Yokota H, Naoe Y, Nakabayashi M, Unemoto K, Kushimoto S, Kurokawa A,
Node Y, Yamamoto Y.
Department of Emergency and Critical Care, Tama-Nagayama Hospital,
Nippon Medical School, Tokyo, Japan. [log in to unmask]

Thrombomodulin (TM), which is located in the surface of the endothelium
in the arteries, veins, and capillaries of major organs such as the
brain, lungs, liver, kidneys, skeletal muscles, and gastrointestinal
tract, is one of several indicators of endothelial injury. Von
Willebrand factor (vWf), which is synthesized by endothelial cells, is
also an endothelial specific glycoprotein. The serum level of vWf
increases in response to various stimuli without endothelial injury. An
elevated serum level of vWf may suggest endothelial activation in severe
head injury. We hypothesize that the degree of cerebral endothelial
activation or injury depends on the type of head injury and that
measuring the TM and vWf is useful for predicting delayed traumatic
intracerebral hematoma (DTICH), produced by weakness of the vessel wall,
occuring either as a direct or indirect effect of head injury. The
values of vWf in focal brain injury (ranging from 332.5 +/- 52.8% to
361.7 +/- 86.2%) were significantly higher than those in diffuse axonal
injury from 2 h to 7 days after the injury occurred (ranging from 201.6
+/- 59.5% to 242.5 +/- 51.7%). The serum level of TM in focal brain
injury (ranging from 3.84 +/- 1.54 to 4.12 +/- 1.46 U/mL) was higher
than that in diffuse axonal injury (ranging from 2.96 +/- 0.63 to 3.67
+/- 1.70 U/mL), but these differences were not statistically
significant. In patients with DTICH, TM was significantly higher than in
patients without DTICH (p < 0.01). The results of our study demonstrate
that the degree of endothelial activation in focal brain injury was
significantly higher than in diffuse brain injury. In addition, the
serum level of TM in patients with DTICH was significantly higher than
in patients without DTICH. These findings suggest that cerebral tissue
injury is often accompanied by cerebral endothelial activation, and that
these two phenomena should be distinguished from each other. The levels
of serum TM and vWf appear to be good indicators of the cerebral
endothelial injury and of endothelial activation in severe head injury.


Zhonghua Wai Ke Za Zhi. 1995 Jul;33(7):430-2.
The delayed traumatic intracerebral haematomas
Zhang G, Wang D, Cheng D.
Gezhouba Centre Hospital, Yichang.

The results of CT observation of 378 inpatients with head injury were
reported. 46 delayed traumatic intracerebral haematomas (DTICH) patients
were found to have 71 haematomas. The incidence of DTICH was 12.2%.
80.7% of DTICH patients were noted 48 hours after injury. Most of them
were young and middle aged persons. The places of baematomas were at the
injured zones. The intracranial pressure continous monitor is useful to
judge the DTICH during the early stage. Surgical operation is proposed
for the patients with many haematomas and displaced central tissue. The
haematomas should be cleansed for the frequently occurring haematoma
patients. The death rate of the example was 17.4%, which was lower than
44%-71% reported elsewhere.


Acta Neurochir (Wien). 1985;74(1-2):35-9.
The incidence and developmental process of delayed traumatic
intracerebral haematomas.
Fukamachi A, Nagaseki Y, Kohno K, Wakao T.

Although delayed traumatic intracerebral haematomas (DTICH) have been
frequently reported especially after the advent of computerized
tomography (CT), the developmental processes of traumatic intracerebral
haematomas and the incidence of DTICH have not been described precisely.
Based on early sequential CT examinations of 84 intracerebral haematomas
for which initial CT scans were performed as early as within 6 hours of
injury, we could ascertain four types of the developmental processes:
Type I (39%) included the haematomas which were already evident in the
initial CT scans, Type II (11%) the haematomas which were small or
medium initially and increased their sizes afterwards, Type III (24%)
the haematomas of which admission CT scans could not demonstrate any
changes at the sites of development of the haematomas, and Type IV (26%)
the haematomas of which initial CT scans showed a salt and pepper or
flecked high-density appearance. Types III and IV denoted the DTICH and
accounted for 50% of all the haematomas. Therefore, DTICH are thought to
be not as uncommon as previously reported. Aetiologies and changes in
the concepts of the DTICH are discussed, and it is stressed that, in the
cases with eventual extra- and intra-cerebral combined haematomas, any
surgical treatment of an extracerebral haematoma plays an important role
in the development of DTICH.