Delayed Traumatic Intracranial Hemorrhage DTICH

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					Delayed Traumatic Intracranial
    Hemorrhage (DTICH)
           Ri 林鴻錡
History
   Böllinger1 described in 1891:four patients
    died from ICH occurred 2 weeks after they
    suffered head injury ("Traumatische Spät-
    Apoplexie").
Traumatische Spät-Apoplexie
 A definite history of the minor head trauma
  and young age
 An asymptomatic interval longer than 24 h
 An apoplectic event
 Absence of vascular disease
Present Criteria
   evolved since the advent of CT
   Lipper et al : initial CT shows no lesions or if any
    lesion measures less than 1 cm and subsequent
    scans show high-density parenchymatous lesions
   Fukamachi et al: established that the initial CT
    scan must be performed within 6 hours after injury
    to allow DPTH to be distinguished from ICH of
    other causes
 Delayed Posttraumatic
     Hemorrhage
   "Spät-Apoplexie"
  José Álvarez-Sabín, MD; Antoni
Turon; Manuel Lozano-Sánchez; José
 Vázquez, MD; Agustí Codina, MD

       Stroke 1995 Sep Vol:26(9) P1531-1535
Method
 Ten cases of CT-proven DPTH from a
  series of 216 patients (age range, 15 to 50
  years) with ICH
 Previous CT in the first 6 hours after head
  injury were normal in all patients
 Cerebral angiography showed no evidence
  of vascular disorders in any patient.
Result(1)
 Incidence: 4.5% (10patients of 216 ICH)
 PTICH: the fourth ICH cause after arterial
  hypertension, vascular malformations, and
  alcoholism
 Gender: M/F 7/3
 Age:15-50
 Cause: T/A:3 Fall:2 F-E:2 Bump:2 Work:2
Result(2)
 Underline: Alcoholics:2 Smoker2 HTN:1
  DM:1
 Initial symptoms:concussion(6),
  confusion(1), headache(1), confusion and
  headache(1)
 Interval:1-15 days, average:5.23 days
Result(3)
 Hematoma location:capsule-basal
  ganglia(6), the frontal lobe(3), and pons(1).
 The hematoma volume:ranged from 0.3 to
  19.6 mL, with an average of 9.9±7.0 mL
 Severe neurological deficit (Oxford
  Handicap Scale score of 3) persists in one
  patient and one epilepsy
Discussion
 Symptom-free interval: depending on the
  series, varies between 24 hours and several
  weeks, or even months
 Age:Baratham and Dennyson series, from 5
  to 83 years, with the majority in their sixties,
  which is when the incidence of amyloid
  angiopathy as a cause of ICH should be
  considered.
 HTN induced ICH: basal ganglia location is
  normally attributed to a possible
  hypertensive etiology
 Mortality: Nil. 1.patients' relative youth,
  2.the absence of other concurrent
  intracranial bleeding or skull fracture
Hypotheses
 Initial injury would cause areas of necrosis
  in the cerebral parenchyma and walls of the
  small arteries due to vasospasm caused by
  the trauma
 release of free radicals, accumulation of
  lipid peroxidase
 Kaufman et al: Trauma=> the release of
  thrombogenic substances=> intravascular
  coagulation =>subsequent fibrinolysis
 Evans and Scheinker and Gudeman et al :
  dysautoregulation=>perivascular
  hemorrhage
Conclusion
 DPTH is one of the causes of ICH in adult
  patients under 50 years of age.
 Most head injuries causing DPTH are of
  low intensity, and initial clinical signs are
  mild.
 Most DPTH are located deep in the
  hemispheres and are of small or medium
  size.
 Prognosis in the short and long term is good.