ORBITAL-FRONTAL DELAYED HEMORRHAGIC CONTUSIONS - CLINICAL COURSE AND NEUROSURGICAL TREATMENT PROTOCOL

BACKGROUND Delayed posttraumatic hemorrhage into the underlying contus ion could cause significant elevation of intracranial pressure (ICP) a nd dramatic clinical and radiographic deterioration. The authors ident ified a subgroup of young patients with initial mild/moderate head inj ury, who presented with orbito-frontal and temporal tip minimal puncta te contusions, which within 24 hours, expanded into dramatically large r noncoalesced hemorrhagic contusions, METHODS Four consecutive patien ts within a 13-month period admitted to our institution with the above radiographic picture are presented and their clinical and treatment c ourses compared. RESULTS After observing the relentless downhill cours e of two earlier patients treated for the control of ICP, our treatmen t protocol changed to early prophylactic intubation and moderate hyper ventilation, insertion of an intraventricular catheter for ICP monitor ing, hyperosmolar therapy with mannitol, sedation, chemical paralytics , and eventually pentobarbital for control of increased ICP. These int erventions were mostly taken before the radiographic evidence of contu sion blossoming and dramatic clinical deterioration, These two subsequ ent patients had a prolonged course of intubation and ICP problems req uiring tracheostomy placement. The clinical outcome was excellent, how ever, with both patients decanulated from the tracheostomy within 6 we eks, and both returned to relatively normal premorbid functions. CONCL USION Although the series consists only of four consecutive patients w ith similar radiographic appearances, the authors advocate ultra-early aggressive medical treatment for this subgroup of patients with orbit o-frontal contusion, prior to dramatic clinical and radiographic deter ioration, as the outcome difference could be great. (C) 1997 by Elsevi er Science Inc.