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Purpose Timely identification and treatment of intracranial hematomas in patients with brain injury is essential for successful treatment. This study evaluates Infra-scanner as a handy medical screening tool for diagnosing, on-site, cerebral hematomas in patients with head injury. Materials and methods Patients referred to the emergency department of university hospitals with mild to moderate brain trauma, up to 12 h from injury were included. NIR sensors of infra-scan device were placed on the right and left frontal, temporal, peritoneal and occipital parts of the head and light absorption was recorded. Positive or negative cerebral hemorrhage cases were compared with contrast-enhanced CT scan results as the gold standard. Diagnostic parameters of the device and cases related to bleeding were analyzed and reported. Results A total of 300 patients were studied. Sensitivity of the infrasound scanner in the Iranian study population was 94.8 (95% CI: 88% -100) and its specificity was 86.9 (95% CI: 79% -99% 99). Negative predictive value (NPV) was 90.3% and positive predictive value (PPV) was 92.9%. Sensitivity in men (95.7%) (95%CI, 90% -1) was more than women (95% CI, 81% -99%)90%. At the ages of less than 36 years, sensitivity (95.3%) and specificity (87.1%) were more than sensitivity (94.4%) and specificity (86.5%) over 36 years old. If the test had been performed in less than / equal to two hours from trauma, the sensitivity (94.9%) and the specificity (92%) were greater than the sensitivity (94.6%) and the specificity (75%) during when the scan had been performed in more than two hours from trauma. In general, in extra-axial bleeding including EDH, SAH, SDH, the sensitivity was 95.1% and the specificity was 84.5%, while in intra-axial bleeding, including ICH and IVH, the sensitivity was lower (93.9%) and the specificity was 91.7. The sensitivity of the device in detecting bleeding in the occipital lobe (95.8%) was higher than other brain lobes. Conclusion This study shows that Infra-scanner is useful in initial examination and screening of patients with head injury and can be used as an adjunct to a CT scan or when not available and may allow earlier treatment which reduce the secondary damage to the hematoma.

Video surveillance and detection of players with visible signs of concussion by experienced medical staff facilitates rapid on-field screening of suspected concussion in professional sports. This method, however has not been validated in community sports where video footage is unavailable. This study aimed to explore the utility of visible signs of concussion to identify players with decrements in performance on concussion screening measures. In this observational prospective cohort study, personnel with basic training observed live matches across a season (60 matches) of community male and female Australian football for signs of concussion outlined in the community-based Head Injury Assessment form (HIAf). Players identified to have positive signs of concussion (CoSign+) following an impact were compared with players without signs (CoSign-). Outcome measures, the Sport Concussion Assessment Tool (SCAT3) and Cogstate, were administered at baseline and post-match. CoSign+ (

This case–control study using baseline data from the population cohort Adolescent Brain Cognitive Development (ABCD) Study® compared lifetime history of concussion between children with and without...

Common methods for evaluating history of traumatic brain injury (TBI) include self-report, electronic medical record review (EMR), and structured interviews such as the Head Trauma Events Characteristics (HTEC). Each has strengths and weaknesses, but little is known regarding how TBI diagnostic rates or the associated symptom profile differ among them. This study examined 200 Veterans recruited within the VA Portland Health Care System, each evaluated for TBI using self-report, EMR, and HTEC. Participants also completed validated questionnaires assessing chronic symptom severity in broad health-related domains (pain, sleep, quality of life, post-concussive symptoms). The HTEC was more sensitive (80% of participants in our cohort) than either self-report or EMR alone (40%). As expected from the high sensitivity, participants screening positive for TBI through the HTEC included many people with mild or no post-concussive symptoms. Participants were grouped according to degree of concordance across these diagnostic methods: no TBI, n = 43; or TBI-positive in any one method (TBI-1dx, n = 53), positive in any two (TBI-2dx, n = 45), or positive in all three (TBI-3dx, n = 59). The symptom profile of the TBI-1dx group was indistinguishable from the no TBI group. The TBI-3dx group had the most severe symptom profile. Our results show that understanding the exact methods used to ascertain TBI is essential when interpreting results from other studies, given that results and conclusions may differ dramatically depending on the method. This issue will become even more critical when interpreting data merged from multiple sources within newer, centralized repositories (e.g., Federal Interagency Traumatic Brain Injury Research [FITBIR]).

Magnetic resonance imaging (MRI) is used rarely in the acute evaluation of traumatic brain injury (TBI) but may identify findings of clinical importance not detected by computed tomography (CT). We aimed to characterize the association of cytotoxic edema and hemorrhage, including traumatic microbleeds, on MRI obtained within hours of acute head trauma and investigated the relationship to clinical outcomes. Patients prospectively enrolled in the Traumatic Head Injury Neuroimaging Classification study (NCT01132937) with evidence of diffusion-related findings or hemorrhage on neuroimaging were included. Blinded interpretation of MRI for diffusion-weighted lesions and hemorrhage was conducted, with subsequent quantification of apparent diffusion coefficient (ADC) values. Of 161 who met criteria, 82 patients had conspicuous hyperintense lesions on diffusion-weighted imaging (DWI) with corresponding regions of hypointense ADC in proximity to hemorrhage. Median time from injury to MRI was 21 (10–30) h. Median ADC values per patient grouped by time from injury to MRI were lowest within 24 h after injury. The ADC values associated with hemorrhagic lesions are lowest early after injury, with an increase in diffusion during the subacute period, suggesting transformation from cytotoxic to vasogenic edema during the subacute post-injury period. Of 118 patients with outcome data, 60 had Glasgow Outcome Scale Extended scores ≤6 at 30/90 days post-injury. Cytotoxic edema on MRI (odds ratio [OR] 2.91 [1.32–6.37], p = 0.008) and TBI severity (OR 2.51 [1.32–4.74], p = 0.005) were independent predictors of outcome. These findings suggest that in patients with TBI who had findings of hemorrhage on CT, patients with DWI/ADC lesions on MRI are more likely to do worse.

Background Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood. Methods An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases. Results A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed. Conclusion IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

Purpose We investigated clinical risk factors that predict poor 30-day headache outcomes among patients evaluated in the emergency department (ED) for post-traumatic headache (PTH). Methods This was an analysis of data from a randomized, placebo-controlled study of IV metoclopramide + diphenhydramine for acute PTH. Patients were enrolled during an ED visit and received telephone follow-up with a structured questionnaire 30 days later. The primary outcome was frequency of headaches 30 days after ED discharge. We used multivariable logistic regression models to determine which clinical variables were associated with frequent headaches at 30 days. Results In total, 160 patients were enrolled in the study. 134 (84%) patients completed the 30-day questionnaire and were included in the analysis, including 90 females and 44 males. 30 patients (22%, 95% CI = 0.16 to 0.30) reported frequent headaches at 30-day follow-up. In the multivariable analysis, female sex (OR = 4.03, 95% CI = 1.23±13.13), patients who blamed themselves for their injury (OR = 0.13, 95% CI = 0.04±0.45), and patients who were unsure if they sustained loss of consciousness during the traumatic incident (OR = 5.63, 95% CI = 1.89±16.78) were found to be associated with poor 30-day outcomes. Medication received in the ED and age were not associated. Conclusions More than 1 out of five patients treated in the ED for acute PTH experienced frequent headaches 30 days later. Women and patients who were uncertain as to whether they had experienced loss of consciousness were at increased risk of frequent PTH. Blaming oneself for the head trauma was associated with less frequent PTH.

Introduction: Traumatic injuries disproportionately affect populations in low and middle-income countries (LMIC) where head injuries predominate. The Rwandan Ministry of Health (MOH) has dramatically improved access to emergency services by rebuilding its health infrastructure. The MOH has strengthened the nation’s acute emergency response by renovating emergency departments (ED), developing the field of emergency medicine as a specialty, and establishing a prehospital care service: Service d’Aide Medicale Urgente (SAMU). Despite the prevalence of traumatic injury in LMIC and the evolving emergency service in Rwanda, data regarding head trauma epidemiology is lacking. Methods: We conducted this retrospective cohort study at the University Teaching Hospital of Kigali (UTH-K) and used a linked prehospital database to investigate the demographics, mechanism, and degree of acute medical interventions amongst prehospital patients with head injury. Results: Of the 2,426 patients transported by SAMU during the study period, 1,669 were found to have traumatic injuries. Data from 945 prehospital patients were accrued, with 534 (56.5%) of these patients diagnosed with a head injury. The median age was 30 years, with most patients being male (80.3%). Motor vehicle collisions accounted for almost 78% of all head injuries. One in six head injuries were due to a pedestrian struck by a vehicle. Emergency department interventions included intubations (6.7%), intravenous fluids (2.4%), and oxygen administration (4.9%). Alcohol use was not evaluated or could not be confirmed in 81.3% of head injury cases. The median length of stay (LOS) in the ED was two days (interquartile range: 1,3). A total of 184 patients were admitted, with 13% requiring craniotomies; their median in-hospital care duration was 13 days. Conclusion: In this cohort of Rwandan trauma patients, head injury was most prevalent amongst males and pedestrians. Alcohol use was not evaluated in the majority of patients. These traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of head injury, may be beneficial in the Rwandan setting.

To compare the efficacy of mannitol, the first choice of treatment in daily clinical practice for head trauma, and sugammadex, a frequently used neuroanesthesia in recent years. A total of 35 male rats were randomly selected and were divided into 5 groups, each comprising 7 rats. The groups were divided into Group I, sham (n = 7); Group II, control (head trauma, n = 7); Group III, treated with mannitol (head trauma, mannitol 20% 1 g/kg, n = 7); Group IV, treated with sugammadex (head trauma, sugammadex 100 mg/kg, n = 7); and Group V, treated with mannitol and sugammadex (head trauma, mannitol 20% 1 g/kg and sugammadex 100 mg/kg, n = 7). After the sacrification, histological examination and immunohistochemical staining were performed in the brain of all subjects. Mann-Whitney U test was used to evaluate the significance between neuronal density, neuronal nuclei, and activated caspase-3 immunohistochemistry results measured from the prefrontal cortex. Neuronal density showing neuronal viability was observed to significantly increase in Group III compared to Group IV. However, neuronal nuclei immunohistochemistry showing apoptotic neurons also significantly increased. The present study has shown that sugammadex, an agent reversing the effects of neuromuscular blocking agents, has neuroprotective effects and is as effective as mannitol.

The National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH-NINDS) Traumatic Brain Injury (TBI) Imaging Common Data Elements (CDEs) are standardized definitions for pathological intracranial lesions based on their appearance on neuroimaging studies. The NIH-NINDS TBI Imaging CDEs were designed to be as consistent as possible with the U.S. Food and Drug Administration (FDA) definition of biomarkers as "an indicator of normal biological processes, pathogenic processes, or biological responses to an exposure or intervention." However, the FDA qualification process for biomarkers requires proof of reliable biomarker test measurements. We determined the interrater reliability of TBI Imaging CDEs on subacute brain magnetic resonance imaging (MRI) performed on 517 mild TBI patients presenting to 11 U.S. level 1 trauma centers. Three U.S. board-certified neuroradiologists independently evaluated brain MRI performed 2 weeks post-injury for the following CDEs: traumatic axonal injury (TAI), diffuse axonal injury (DAI), and brain contusion. We found very high interrater agreement for brain contusion, with prevalence- and bias-adjusted kappa (PABAK) values for pairs of readers from 0.92 [95% confidence interval, 0.88-0.95] to 0.94 [0.90-0.96]. We found intermediate agreement for TAI and DAI, with PABAK values of 0.74-0.78 [0.70-0.82]. The near-perfect agreement for subacute brain contusion is likely attributable to the high conspicuity and distinctive appearance of these lesions on T1-weighted images. Interrater agreement for TAI and DAI was lower, because signal void in small vascular structures, and artifactual foci of signal void, can be difficult to distinguish from the punctate round or linear areas of slight hemorrhage that are a common hallmark of TAI/DAI on MRI.

The lack of well-performing prognostic models for early prognostication of outcomes remains a major barrier to improving the clinical care of patients with mild traumatic brain injury (mTBI). We aimed to derive a prognostic model for predicting incomplete recovery at 1-month in emergency department (ED) patients with mTBI and a presenting Glasgow Coma Scale (GCS) score of 15 who were enrolled in the HeadSMART (Head Injury Serum Markers for Assessing Response to Trauma) study. The derivation cohort included 355 participants with complete baseline (day-of-injury) and follow-up data. The primary outcome measure was the Glasgow Outcome Scale Extended (GOSE) at 1-month and incomplete recovery was defined as a GOSE8. At 1-month post-injury, incomplete recovery was present in 58% (

To examine the effects of antithrombotics for head trauma, 393 consecutive patients were enrolled. The patients were divided into those that were (group A, n = 117) and were not (group B, n = 276) taking antithrombotics, and the groups’ outcomes were compared. To identify factors that affected functional independence in group A, clinical factors were compared between the patients that exhibited mRS of 0–2 and 3–6 at discharge. Furthermore, to assess the optimal time to restart antithrombotics, cases in which rebleeding occurred after antithrombotics were restarted or thromboembolic events occurred were extracted. The ratio of mRS 3–6 and death within 30 days were significantly higher in group A than in group B. Multivariate analysis of group A revealed that being aged ≥ 70, not receiving antiplatelet therapy, and intracranial hematoma enlargement were poor prognostic factors. Five patients in group A experienced ischemic strokes within 30 days. In 3 of these patients, the ischemic strokes occurred before antithrombotics were restarted. Rebleeding occurred in two cases after anticoagulants restarted within 48 hours. Patients taking antithrombotics are at high risk of poor prognosis after head trauma. To prevent thromboembolic events, the active resumption of antithrombotics after 48 hours is desirable if hemostasis has been achieved.

To identify a useful non-imaging tool to screen paediatric patients with traumatic brain injury for intracranial haemorrhage (ICH). We retrospectively analysed patients aged .

Understanding the effects of age on longitudinal traumatic brain injury (TBI) outcomes requires attention to both chronic and evolving TBI effects and age-related changes in health and function. The present study examines the independent and interactive effects of aging and chronicity on functional outcomes after TBI. We leveraged a well-defined cohort of individuals who sustained a moderate/severe TBI and received acute inpatient rehabilitation at specialized centers with high follow up rate as part of their involvement in the TBI Model Systems longitudinal study. We selected individuals at one of two levels of TBI chronicity (either 2 or 10 years post-injury) and used an exact matching procedure to obtain balanced chronicity groups based on age and other characteristics (N = 1993). We found that both older age and greater injury chronicity were related to greater disability, reduced functional independence, and less community participation. There was a significant age by chronicity interaction, indicating that the adverse effects of greater time post-injury were most pronounced among survivors who were age 75 or older. The inflection point at roughly 75 years of age was corroborated by post hoc analyses, dividing the sample by age at 75 years and examining the interaction between age group and chronicity. These findings point to a need for provision of rehabilitation services in the chronic injury period, particularly for those who are over 75 years old. Future work should investigate the underlying mechanisms of this interaction towards the goal of developing interventions and models of care to promote healthy aging with TBI.

Objective To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. Background Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. Methods This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. Results Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms. Conclusion The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.

Objectives Head trauma may cause dislodgement of otoconia and development of benign paroxysmal positional vertigo (BPPV). The risk of developing BPPV is expected to be highest shortly after the trauma, then decrease and approach the risk seen in the general population. The aim of this study was to estimate the risk-time curve of BPPV development after head trauma. Study design Prospective observational study. Methods Patients with minimal, mild, or moderate head trauma treated at the Department of Neurosurgery or the Department of Orthopedic Emergency at Oslo University Hospital, were interviewed and examined for BPPV using the Dix-Hallpike and supine roll maneuvers. BPPV was diagnosed according to the International diagnostic criteria of the Barany Society. Telephone interviews were conducted at 2, 6, and 12 weeks after the first examination. Results Out of 117 patients, 21% developed traumatic BPPV within 3 months after the trauma. The corresponding numbers were 12% with minimal trauma, 24% with mild, and 40% with moderate trauma. The difference in prevalence between the groups was significant (P = .018). During the first 4 weeks after the trauma, it was observed 20, 3, 0, and 1 BPPV onsets, respectively. No BPPV cases were seen for the remainder of the 3-month follow-up. Conclusion The risk of developing BPPV after minimal-to-moderate head trauma is considerable and related to trauma severity. Most cases occur within few days after the trauma, but any BPPV occurring within the first 2 weeks after head trauma are likely due to the traumatic event. Level of evidence 3 Laryngoscope, 2021.

Objective Head trauma causes a significant number of deaths as well as temporary and permanent disabilities every year. In this study, the prevalence of attention-deficit/hyperactivity disorder (ADHD) in primary school children who visited the emergency department (ED) for mild head trauma and the role of ADHD in mild head trauma of this age group were investigated. Methods It was performed with 134 children of primary school age (6-12 years) who were admitted to the ED with mild head trauma and 134 children (control group) who presented with complaints other than head trauma. Turgay DSM-IV-Based Child and Adolescent Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S) was used to evaluate the children for suspected ADHD. According to this scale, some children were referred to the child and adolescent psychiatry department (CAPD) for further evaluation. At the CAPD outpatient clinics, the children who were referred from the ED were examined in detail according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, for possible diagnosis of ADHD. After evaluation of their sociodemographic characteristics and the ADHD test scores that were recorded, the diagnosis of ADHD in these children was established or ruled out. Results It was observed that 41 of the 134 children (30.60%) who presented to the ED with mild head trauma and 12 of the 134 children (8.96%) in the control group were diagnosed with ADHD (P = 0.0001). When ADHD is corrected for sex, 29 of the 41 cases (70.7%) diagnosed with ADHD were boys and 12 (29.3%) were girls (P = 0.000). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, when the patients who had been diagnosed with ADHD were grouped according to the ages of the children, no statistically significant difference was found between the groups in terms of ADHD (P = 0.097). Conclusions The prevalence of ADHD has been found to be higher in children of primary school age who present to the ED with mild head trauma. Hence, it can be deduced that the diagnosis of childhood ADHD increases the risk of presenting to the ED with head trauma. We believe that it is very important to keep the possible diagnosis of ADHD in mind and to refer that cases to the CAPD in case of high clinical suspicion, especially in primary school boys who are admitted to the ED with mild head trauma. We believe that in this way, morbidity and mortality due to head trauma in this age group can be significantly reduced. © Wolters Kluwer Health, Inc. All rights reserved.

Subgaleal hematoma, accumulation of blood in the loose areolar tissue of the subgaleal space of the skull, is considered the most catastrophic complication of instrumental delivery. It is a rare finding in older ages, usually associated with coagulation disorders, severe head trauma leading to skull base fractures and accidental or abusive hair pulling. Complications include periorbital necrotising fasciitis, permanent blindness, infections and, in extreme rare cases, airway obstruction. Most cases of subgaleal hematoma resolve spontaneously, without the need of aspiration or drainage. We present here the case of a 62-year-old male on anticoagulant therapy with apixaban for chronic atrial fibrillation, who came to the emergency department after a car accident suffering from mild head trauma. The patient was complaining of a diffuse headache and physical examination showed a large ecchymosis and edema on the frontal area of the head. His neurological examination was unremarkable. Full-body computed tomography (CT) revealed a fracture of the third right rib. Twelve hours after admission, due to an excessive decrease of hematocrit, a second CT was performed. Although the images didn’t show intracranial hemorrhage or skull base fractures, a large and diffuse hematoma of the subaponeurotic space was observed and the diagnosis of subgaleal hematoma was confirmed. Massive subgaleal hematoma after mild head trauma is rather infrequent. Early diagnosis improves outcomes and can avert serious complications. Therapeutic strategy should be based on the severity of each case. In our case, conservative treatment appeared to be a valid alternative to surgery, as hematoma resolved spontaneously within 10 days. It is noteworthy that the use of anticoagulation is the only evident factor that could have been the precipitating factor for the development of the hematoma in our patient.

Early treatment of moderate/severe traumatic brain injury (TBI) with progesterone does not improve clinical outcomes. This is in contrast with findings from pre-clinical studies of progesterone in TBI. To understand the reasons for the negative clinical trial, we investigated whether progesterone treatment has the desired biological effect of decreasing brain cell death. We quantified brain cell death using serum levels of biomarkers of glial and neuronal cell death (glial fibrillary acidic protein [GFAP], ubiquitin carboxy-terminal hydrolase-L1 [UCH-L1], S100 calcium-binding protein B [S100B], and Alpha II Spectrin Breakdown Product 150 [SBDP]) in the Biomarkers of Injury and Outcome–Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (BIO-ProTECT) study. Serum levels of GFAP, UCHL1, S100B, and SBDP were measured at baseline (≤4 h post-injury and before administration of study drug) and at 24 and 48 h post-injury. Serum progesterone levels were measured at 24 and 48 h post-injury. The primary outcome of ProTECT was based on the Glasgow Outcome Scale-Extended assessed at 6 months post-randomization. We found that at baseline, there were no differences in biomarker levels between subjects randomized to progesterone treatment and those randomized to placebo (p > 0.10). Similarly, at 24 and 48 h post-injury, there were no differences in biomarker levels in the progesterone versus placebo groups (p > 0.15). There was no statistically significant correlation between serum progesterone concentrations and biomarker values obtained at 24 and 48 h. When examined as a continuous variable, baseline biomarker levels did not modify the association between progesterone treatment and neurological outcome (p of interaction term >0.39 for all biomarkers). We conclude that progesterone treatment does not decrease levels of biomarkers of glial and neuronal cell death during the first 48 h post-injury.

Introduction Forearm shaft fracture is common in young adult patients and associated with soft tissue and organ injuries. In open fractures in polytrauma patients, damage control orthopaedics (DCO) is well indicated. The aim of this study is to describe intramedullary Steinmann pin fixation of the ulna as a DCO procedure for the forearm and present a case series. Description of the technique A 3.0 mm Steinmann pin is inserted retrograde in the ulna proximal fragment through the fracture site using the open wound as the approach. With direct visualization of the reduction, the pin is advanced into the distal fragment. The reduction of the longitudinal axis and shortening is thus achieved. Patients and methods This method was used for all open fractures of forearm both-bone fractures in polytrauma patients undergoing DCO from 2014 to 2019. The alignment and length of the ulna were evaluated radiographically after pin fixation and before and after definitive fixation. Differences in the need for secondary procedures and infection rate between DCO and definitive fixation were also evaluated. Results There were 30 males (85.7%) with an average age of 32.9 ± 12.0 years and a mean ISS (Injury Severity Score) of 29.4 (range, 18.0-41.0). The most common associated injuries were thoracic trauma (62.8%) and head trauma (45.7%). In the radius and ulna, 51.4% and 60.0% of fractures, respectively, were multifragmentary (types B and C). Gustilo type IIIA represented 77.1% of the injuries. Pin fixation achieved good alignment and length in all cases. The mean time between DCO and definitive fixation was 12.0 days, and no secondary procedure was needed, nor any case developed either superficial or deep infection. The conversion from DCO to definitive fixation was considered easy in all cases. Conclusion Intramedullary Steinmann pin fixation of the ulna is a viable option for DCO for forearm both-bone fractures in open fractures in polytrauma patients.

Background: Sensorineural hearing loss can be cured by cochlear implantation (CI), but complications can occur. Based on when the complications develop, they are categorized as intraoperative complications, early postoperative complications, or delayed postoperative complications (>3 months after the surgery).Aims/objectives: We aimed to investigate the occurrence of delayed complications after CI surgery, and identify appropriate management methods.Material and methods: We analyzed 624 sensorineural hearing loss patients who had been consecutively treated with CI using the conventional surgical technique in our institution and had been followed-up until September 2017.Results: A total of 43 (6.86%) patients out of the 624 CIs (627 ears) reported complications, and 9 (1.44%) were major complications and 34 (5.42%) were minor complications. Wound infection and device failure were the most common major complications, and hematoma was the most common minor complication.Conclusions and significance: CI surgery is a relatively mature technology; the incidence of complications is low, and with early diagnosis and treatment most complications have a good prognosis. Head trauma was the main reason for children's complications, and patients and guardians should be given good education preoperatively about how to manage the CI postoperatively.

Anticoagulants prevent thrombosis and death in patients with atrial fibrillation and venous thromboembolism (VTE) but also increase bleeding risk. The benefit/risk ratio favors anticoagulation in most of these patients. However, some will have a bleeding complication, such as the common trip-and-fall brain injury in elderly patients that results in traumatic intracranial hemorrhage. Clinicians must then make the difficult decision about when to restart the anticoagulant. Restarting too early risks making the bleeding worse. Restarting too late risks thrombotic events such as ischemic stroke and VTE, the indications for anticoagulation in the first place. There are more data on restarting patients with spontaneous intracranial hemorrhage, which is very different than traumatic intracranial hemorrhage. Spontaneous intracranial hemorrhage increases the risk of rebleeding because intrinsic vascular changes are widespread and irreversible. In contrast, traumatic cases are caused by a blow to the head, usually an isolated event portending less future risk. Clinicians generally agree that anticoagulation should be restarted but disagree about when. This uncertainty leads to long restart delays causing a large, potentially preventable burden of strokes and VTE, which has been unaddressed because of the absence of high quality evidence. Restart Traumatic Intracranial Hemorrhage (the “r” distinguished intracranial from intracerebral) (TICrH) is a prospective randomized open label blinded end-point response-adaptive clinical trial that will evaluate the impact of delays to restarting direct oral anticoagulation (1, 2, or 4 weeks) on the composite of thrombotic events and bleeding in patients presenting after traumatic intracranial hemorrhage.

OBJECTIVES Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. METHODS We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of

Background Protocols for expediting critical trauma patients directly from the helipad to the operating room tend to vary by center, rely heavily on physician gestalt, and lack supporting evidence. We evaluated a population of severely injured trauma patients with the aim of determining objective factors associated with the need for immediate surgical intervention. Methods All highest-activation trauma patients transported by air ambulance between 1/1/16 and 12/31/17 were enrolled retrospectively. Transfer, pediatric, isolated burn, and isolated head trauma patients were excluded. Patients who underwent emergency general surgery within 30 min of arrival without the aid of cross-sectional imaging were compared to the remainder of the cohort. Results Of the 863 patients who were enrolled, 85 (10%) spent less than 30 min in the emergency department (ED) before undergoing an emergency operation. The remaining 778 patients (90%) formed the comparison group. The ED ≤ 30 min group had a higher percentage of penetrating injuries, lower blood pressure, and was more likely to have a positive FAST exam. The “Direct to Operating Room” (DTOR) score is a predictive scoring system devised to identify patients most likely to benefit from bypassing the ED. The odds ratio of emergency operation within 30 min of hospital arrival increased by 2.71 (95% confidence interval 2.23-3.29; P Conclusions Trauma patients with profound hypotension or acidosis and positive FAST were more likely to require surgery within 30 min of hospital presentation. Use of a scoring system may allow early identification of these patients in the prehospital setting by nonphysician providers.

A growing body of evidence links abusive head trauma (AHT) to patterns of direct and indirect spinal injuries, such as spinal subdural hemorrhage (SDH). Identification of evidence of spinal injury such as spinal SDH plays a crucial role in the diagnosis and subsequent management of the index child with AHT and his or her siblings. In a value-based practice of medicine, it can be argued that adding spine imaging to identify spinal SDH in the workup of AHT adds value to both the short- and long-term management of the patient. This pictorial review describes the normal appearance of spinal SDH and challenges of identifying spinal SDH, and it explores the mechanism of spinal SDH development in AHT.

Transcranial ultrasound has been described as a tool to identify intracranial pathology, however, it is seldom used in the adult patient population due to poor imaging windows and rapid availability of more advanced imaging such as CT and MRI. We report a unique population in which transcranial ultrasound may be beneficial: those with a history of hemicraniectomy. We present a case of a 65-year-old male with a history of hemicraniectomy who suffered head trauma after a fall from his wheelchair. An initial non-contrast head CT scan identified an intracranial hemorrhage. Point-of-care bedside transcranial ultrasound was able to identify the progression of intracranial hemorrhage, which was confirmed by interval head CT. This prompted repeat CT imaging followed by neurosurgical intervention with the placement of an external ventricular drain in the right lateral ventricle. While ultrasound is unlikely to replace the need for more advanced imaging in these patients, point-of-care transcranial ultrasound may be a useful tool that can be employed rapidly at the bedside for interval screening in patients with hemicraniectomy and concern for new or worsening intracranial hemorrhage. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40477-021-00588-6.

Progression of intracranial hemorrhage (PICH) is a significant cause of secondary brain injury in patients with traumatic brain injury (TBI). Previous studies have implicated a variety of mediators that contribute to PICH. We hypothesized that patients with PICH would display either a hypocoagulable state, hyperfibrinolysis, or both. We conducted a prospective study of adult trauma patients with isolated TBI. Blood was obtained for routine coagulation assays, platelet count, fibrinogen, thrombelastography, markers of thrombin generation, and markers of fibrinolysis at admission and 6, 12, 24, and 48 h. Univariate analyses were performed to compare baseline characteristics between groups. Linear regression models were created, adjusting for baseline differences, to determine the relationship between individual assays and PICH. One hundred forty-one patients met entry criteria, of whom 71 had hemorrhage progression. Patients with PICH had a higher Injury Severity Score and Abbreviated Injury Scale score (head), a lower Glasgow Coma Scale score, and lower plasma sodium on admission. Patients with PICH had higher D-dimers on admission. After adjusting for baseline differences, elevated D-dimers remained significantly associated with PICH compared to patients without PICH at admission. Hypocoagulation was not significantly associated with PICH in these patients. The association between PICH and elevated D-dimers early after injury suggests that fibrinolytic activation may contribute to PICH in patients with TBI.

Gender may be related with the outcome of patients with acute traumatic brain injury. We explored the effect of gender on the outcome of 7145 patients with acute traumatic brain injury. There was no statistical difference between male and female in the causes of trauma, age, GCS score, CT findings, and surgical management. The mortality of patients with 7145 acute head trauma in male and female was 7.48% and 7.22% respectively with the corresponding unfavorable outcomes of 16.05% and 17.23% respectively (P>0.05 in both cases). The mortality of 1626 patients with severe traumatic brain injury in male and female was 19.68% and 20.72% respectively with the corresponding unfavorable outcomes of 46.96% and 48.85% respectively (P>0.05 in both cases). Our data suggest that gender does not play a role in the outcome of patients with acute traumatic brain injury.

Objective: Seizure is the most common neurological disorders in children, where 4-10% of the cases experience at least one seizure before the age of 16. The most frequent causes of seizures in children are fever, epilepsy, infection and brain damage. The aim of this study was to investigate the frequency of organic lesions in MRI of children with seizures unrelated to fever. Materials and Methods: This cross-sectional study included children presented with fever-unrelated seizures. The MRI was examined by a radiologist to identify abnormal findings in each patient. A researcher-made questionnaire including general information, history of head trauma, obstructed labor and the history of seizure was completed for the patients. Results: Of 287 children with fever-related seizure, 127 (45.7%) were male and 151 (54.3%) were female. History of seizure, history of obstructed labor, abnormal MRI, complete delay, use of antiepileptic drug and history of trauma were 22(9.9%), 1 (0.4%), 11(4%), 5(1.8%), 259(93.2%) and 12 (4.3%), respectively. Of 11 patients with abnormal MRI, 4 had MTS lesions, 2 had tumor lesions, 2 had scarring trauma, 1 had an epidural abscess and 1 had meningitis. The frequency of organic lesions had no significant differences based on gender, use of antiepileptic drug and traumatic history, but it had a significant relation with obstructed labor andthehistory of seizure. Conclusion: The results showed that organic brain lesions in children with fever-unrelated seizure had a significant relationship with the history of seizure and obstructed maternal labor.

BackgroundMild internal jugular vein (IJV) compression, aimed at increasing intracranial fluid volume to prevent motion of the brain relative to the skull, has reduced brain injury markers in athletes suffering repeated traumatic brain injuries. However, an increase in intracranial volume with IJV compression has not been well demonstrated. This study used transorbital ultrasound to identify changes in optic nerve sheath diameter (ONSD) as a direct marker of accompanying changes in intracranial volume.MethodsNineteen young, healthy adult volunteers (13 males and 6 females) underwent IJV compression of 20 cm H2O low in the neck, while in upright posture. IJV cross-sectional area at the level of the cricoid cartilage, and the change in right ONSD 3 mm behind the papillary segment of the optic nerve, were measured by ultrasound. Statistical analysis was performed using a paired t-test with Bonferroni correction.ResultsMean (SD) cross-sectional area for the right IJV before and after IJV compression was 0.10 (0.05) cm2 and 0.57 (0.37) cm2, respectively (p=0.001). ONSD before and after IJV compression was 4.6 (0.5) mm and 4.9 (0.5) mm, respectively (p=0.001).ConclusionsThese data verify increased cerebral volume following IJV compression, supporting the potential for reduced brain ‘slosh’ as a mechanism connecting IJV compression to possibly reducing traumatic brain injury following head trauma.

Diffuse axonal injury (DAI) is a microscopic damage of axons in the brain. Its occurrence results from head trauma with acceleration or deceleration. This article presents current knowledge about DAI and two cases of patients who experienced DAI as a consequence of a traffic accident. A26 years old man was brought to hospital after traffic accident during which his vehicle had overturned. Computed tomography (CT) showed features of brain edema and disseminated small petechiae. Psychiatric consultation on ninth day of hospitalization showed memory deficits presenting as retrograde and anterograde amnesia, attention deficits and lack of criticism in regard to his condition. A 38 years old woman who was hit by a car while cycling was admitted to hospital. CT scan showed features of brain edema, subarachnoid hemorrhage and multiple fractures. On the tenth day of hospitalization the patient was confused, did not remember new information, her psychomotor drive was increased and she presented lack of criticism in regard to her condition. While suspecting DAI we should be vigilant, particularly in cases of patients hospitalized due to traffic accidents with behavioral problems, features of amnestic syndrome and without significant focal neurological symptoms.

OBJECTIVE: To determine whether clinically normal older adults with remote, mild traumatic brain injury (mTBI) show evidence of higher cortical Aβ burden. PARTICIPANTS AND MEASUREMENTS: We studied 134 clinically normal older adults (age 74.1±6.8 years, 59.7% female, 85.8% white) who underwent Aβ positron emission tomography (Aβ-PET) and who completed the Ohio State University Traumatic Brain Injury Identification questionnaire. We limited participants to those reporting injuries classified as mTBI. A subset (N=30) underwent a second Aβ-PET scan (mean 2.7 years later). We examined the effect of remote mTBI on Aβ-PET burden, interactions between remote mTBI and age, sex, and APOE status, longitudinal Aβ accumulation, and the interaction between remote mTBI and Aβ burden on memory and executive functioning. RESULTS: Of 134 participants, 48 (36%) reported remote mTBI (0, N=86; 1, N=31, 2+, N=17; mean 37±23 years since last mTBI). Effect size estimates were small to negligible for the association of remote mTBI with Aβ burden (p=.94, η(2)

Parosmia, defined as the distorted perception of an odor stimulus, has been reported to be associated with head trauma, upper respiratory tract infections, sinonasal diseases, and toxin/drug consumption. To date, little is known about parosmia in right-lateralized semantic variant primary progressive aphasia. A 60-year-old right-handed man presented with a 2-year history of parosmia and prosopagnosia. Brain magnetic resonance imaging demonstrated severe atrophy of the right anterior and mesial temporal lobe, particularly in the fusiform cortex and the regions known as the primary olfactory cortex. 18F-fluorodeoxyglucose position emission tomography showed asymmetric hypometabolism of the bilateral temporal lobes (right > left). We clinically diagnosed him with right-lateralized semantic variant primary progressive aphasia. As the right hemisphere is known to be more involved in the processing of pleasant odors than the left hemisphere, we speculate that the unique manifestation of parosmia observed in this patient might be associated with the lateralization of the olfactory system.

Background: The research was done to evaluate the value of the visual evoked potentials test in the assessment of visual pathways function in cases with head trauma and minimal findings on routine testing. Materials and Methods: A prospective case series evaluating use of visual evoked potentials testing in patients with a history of head trauma and suffering from visual symptoms with no significant clinical and neuroimaging findings, referred for further work up. Results: Thirty-four patients with a history of head trauma and subsequent visual complaints were included. 27 cases (79.4%) were male and 7 cases (20.6%) were female. The mean elapsed time after the trauma was 47.6 weeks (range: 3.5 to 320 weeks). Twenty-five cases had unilateral and 9 cases had bilateral visual complaints. History of coma with mean duration of 12 days was present in 4 cases. The best-corrected visual acuity was less than 1 Log MAR (legally blind) in 21 eyes. In 4 eyes (12%) the relative afferent papillary defect test was positive. Mild to moderate optic disc pallor was present bilaterally in 4 cases and unilaterally in 3 cases. Hemorrhagic patches were reported on MRI in 2 cases; no other cases had pathologic MRI findings. In unilateral cases, there was a statistically significant difference between the involved eye-sided lobe and the sound eye-sided lobe implicit time and amplitude. In patients with bilateral complaints, by testing each eye, the VEP amplitudes of both eyes showed significant differences with the International Society for Clinical Electrophysiology of Vision standards, whereas the implicit times showed not-statistically significant differences. Conclusion: The visual evoked potentials test shows not only additional diagnostic value, not seen on routine clinical and neuroimaging testing, but also rather a high validity in tracing visual disability in traumatic brain injury.

Aim and Background: Traumatic epidural hematoma (EDH) is a rare but possibly fatal complication of head trauma in infants. In this study, infants who were younger than 1 year and followed up and treated for TEDH in our clinic were evaluated. Our series is the largest series consisting only infantile cases in the literature. Material and Methods: There were 50 patients younger than 1 year followed up and treated in our hospital between January 2011 and December 2019. Their age, gender, hospital admission signs and symptoms, trauma type, localization and thickness of the hematoma, and accompanying skull fracture were noted from their hospital files. Decisions for conservative or surgical treatment were made according to neurological status, Children Coma Scale (CCS) score, and EDH thickness, degree of the midline shift on cranial computerized tomography (CT), and presence of additional intracranial pathology. Results: Patients’ age ranged from 0 day to 12 months (7 months as median), and their male/female ratio was 30/20. Falling from a height (Conclusions: Because the symptoms and signs in infants are nonspecific, it is difficult to diagnose EDH clinically. Cranial CT should be performed in cases with irritability, swelling of the scalp, pallor, deterioration of consciousness, and anisocoria after head trauma. Traumatic EDHs with normal neurological examination, high CCS score, hematoma thickness below 20 mm, no apparent shift, and without associated brain pathology can be treated conservatively. None of those patients treated conservatively required operation after that.

OBJECTIVEThere is disagreement about the occurrence of severe traumatic brain injury, especially subdural hematoma, caused by short falls in very young children. To verify intracranial injury due to these falls and examine its characteristics, the authors compared infants and toddlers with head trauma witnessed by a nonrelative with those whose injuries were not witnessed by a nonrelative.METHODSThe authors retrospectively reviewed clinical records of children younger than 2 years with head trauma due to a short fall who visited the emergency department of the National Center for Child Health and Development in Japan between April 2015 and March 2018. Patients were classified into two groups: falls that were witnessed by a nonrelative and falls not witnessed by a nonrelative. The authors compared the age in months, sex, mechanism of injury, fall height, prevalence rate of intracranial injury, skull fracture, type of traumatic brain injury, retinal hemorrhage, rib or long-bone fracture, and outcomes between patients whose fall was witnessed by a nonrelative and those whose fall was not witnessed by a nonrelative.RESULTSAmong 1494 patients included in the present analysis, 392 patients were classified into the group of falls witnessed by a nonrelative, and 1102 patients were classified into the group of falls that were not witnessed by a nonrelative. The prevalence rates of intracranial injury, skull fracture, epidural hematoma, and subarachnoid hemorrhage were equal between the groups. The prevalence rate of subdural hematoma in the group whose falls were witnessed by a nonrelative was significantly lower than that of the other group (p = 0.027). There were no patients with subdural hematoma, retinal hemorrhage, or neurological sequelae in the group whose fall was witnessed by a nonrelative.CONCLUSIONSSubdural hematoma, retinal hemorrhage, and neurological sequelae due to short falls were not seen after witnessed falls in the present study.

PURPOSE: Abusive head trauma (AHT) can have debilitating sequelae for children who survive. A retrospective medical record review was used to describe short-term developmental outcomes of children with AHT and identify predictors of poorer outcomes. METHOD: Children with AHT who received follow up by the hospital’s rehabilitation department for 12 to 24 months post-injury were included in this review. Data for 85 children were collected on hearing, vision, gross motor, fine motor, speech and language, cognition, play, adaptive functioning, behaviour and personal-social skills. RESULTS: Global assessment found 42% of children had a good recovery, 34% had a moderate disability and 24% had a severe disability. For whom there was data, more than half had abnormal cognition, behaviour and personal-social skills, whilst more than a third had abnormal speech and language, neurological signs on last assessment, vision, play skills, and gross and fine motor skills. Factors that predicted poorer prognosis across all developmental domains included paediatric intensive care unit admission, longer length of hospital stay, breathing difficulty and lower Glasgow Coma Scale on presentation. CONCLUSION: This study highlights the substantial number of children who have abnormal development in the short-term post-AHT and assists in identifying those who require extensive long-term follow up.

Highlights • Telemedicine is an emerging field with diverse applications. • Mild TBI patients may be candidates for screening before inter-facility transfer. • Avoiding unnecessary hospital transfers can better optimize resource utilization., We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38). In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Background Although posttraumatic olfactory disturbances are frequent, they have a poor prognosis. Our study aimed to investigate the impact of clinical factors on the progress of these olfactory disturbances. Methods Among patients admitted with evidence of head trauma, only suspected cases of posttraumatic olfactory disturbances were included. Patients were examined by the Sniffin’Sticks test, early posttraumatic and then later after recovery. Such factors as age, sex, olfactory bulb status, and observation period were enrolled in logistic regression analysis, because they are considered to have a possible influence on olfactory function improvements. Amelioration of olfaction was expressed as an alteration in olfactory function to a better level. Results A total of 70 patients were involved, with a mean age of 38 years. The mean duration of follow-up was 6 months. Twelve patients (17.1%) had olfactory function improvements. In univariate and multivariate analyses, no clinical factors had an impact on olfactory recovery (all P > 0.05) except olfactory bulb integrity, which appears to influence improvement in olfactory function (P = 0.0327 and 0.0293). Conclusions Olfactory bulb integrity, probably the sole prognostic factor for posttraumatic olfactory recovery, where frank damage to such a structure carries a prognosis of poor posttraumatic olfactory function.

Purpose To estimate the incidence of patients presenting to emergency departments (EDs) as a result of facial trauma sustained from skateboarding. Patients and Methods The National Electronic Injury Surveillance System (NEISS) database was queried for skateboard-related head and face fractures, contusions, abrasions, and lacerations from 2009 through 2018. We identified 2,519 reported injuries, extrapolating to a national incidence of 100,201 injuries. Fractures accounted for 14.1% of these visits. There were 355 ED visits for fractures, extrapolating to an estimated 11,893 visits nationally. Entries were tabulated for demographic information, fracture type, mechanism of injury, and disposition. Results Patients sustaining injury to the head and face were aged 16 years, on average, and predominantly male patients (85.9%). Most patients sustaining fractures were male patients (87.9%), with a mean age of 18 years. The most common fracture types included unspecified skull fractures (31%), nasal fractures (29%), and mandibular fractures (18%). The most common mechanism of injury was falling off the skateboard while riding (76.9%). Collisions with motor vehicles also accounted for a substantial proportion of the injuries (7.3%). Conclusions A substantial number of ED visits were a result of skateboarding-related facial trauma. Given the neurologic outcomes of head trauma and functional consequences of facial fractures, especially among adolescents, our findings suggest that injury prevention programs and more aggressive helmet use may be necessary to reduce morbidity and hospitalization.

Background Spinal subdural hematomas (SDHs) have been reported secondary to direct trauma or iatrogenic causes associated with coagulopathies. Spinal SDHs found after the development of acute intracranial SDHs, without any evidence of trauma to the spine, are extremely rare. In addition to this rare presentation, there is a lack of consensus regarding whether surgical decompression is the ideal treatment strategy. Depending on the extent of SDH within the spinal canal, surgical decompression may be difficult where diffuse hematoma within the intradural space requires multilevel decompression for treatment. Case Description A 46-year-old man initially presented with an acute cranial SDH following isolated head trauma. After a period of full recovery, he developed delayed lower extremity paraparesis secondary to the formation of a thoracolumbar SDH. This hematoma coincided with resolution of the cranial SDH and likely was due to redistribution of blood from the cranial subdural space into the spinal canal. Given the diffuse multilevel nature of the spread of hematoma and lack of a focal area of compression, he was managed conservatively. He demonstrated small signs of neurologic improvement over several days and regained considerable strength over the following several weeks. Conclusions This report demonstrates a very rare occurrence of a traumatic intracranial SDH migrating into the thoracic and lumbar spine. This case also highlights that despite acute neurologic deficits, conservative management may be a feasible strategy that can result in recovery of neurologic function.

Millions suffer a traumatic brain injury (TBI) each year wherein the outcomes associated with injury can vary greatly between individuals. This study postulates that variations in each biomechanical parameter of a head trauma lead to differences in histological and behavioral outcome measures that should be considered collectively in assessing injury. While trauma severity typically scales with the magnitude of injury, much less is known about the effects of rate and duration of the mechanical insult. In this study, a newly developed voice-coil fluid percussion injury system was used to investigate the effects of injury rate and fluid percussion impulse on a collection of post-injury outcomes in male rats. Collectively the data suggest a potential shift in the specificity and progression of neuronal injury and function rather than a general scaling of injury severity. While a faster, shorter fluid percussion first presents as a mild TBI, neuronal loss and some behavioral tasks were similar among the slower and faster fluid percussion injuries. This study concludes that the sequelae of neuronal degeneration and behavioral outcomes are related to the complete temporal profile of the fluid percussion and do not scale only with peak pressure.

Background Head trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia. Objectives To investigate whether the PECARN rules can be safely applied to Japanese children. Methods We conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017. The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%. Results We included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86–100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%. Conclusions The PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.

AimTo report disability and visual outcomes following suspected abusive head trauma (AHT) in children under 2 years.MethodsWe present a retrospective case series (1995–2017) of children with suspected AHT aged ≤24 months. King’s Outcome Score of Childhood Head Injury (KOSCHI) was used to assess disability outcomes at hospital discharge and at follow-up. The study used a retinal haemorrhage score (RHS) to record findings at presentation and a visual outcome score at follow-up.ResultsWe included 44 children (median age 16 weeks). At presentation, 98% had a subdural haemorrhage and 93% had a retinal haemorrhage. At discharge, 61% had moderate-to-severe disability, and 34% a good recovery. A higher RHS was observed in those with more disability (r=−0.54, p=0.0002). At follow-up, 14% had a worse KOSCHI score (p=0.055). 35% children had visual impairment, including 9% with no functional vision. Those with poorer visual function had a higher RHS (r=0.53, p=0.003). 28% attended mainstream school without support; 50% were in foster care or had been adopted, 32% lived with birth mother and 18% with extended family.ConclusionIt is known that injuries from suspected AHT result in high levels of morbidity; our cohort showed significant rates of disability and visual impairment. Those with higher disability at discharge and poorer visual function showed more significant retinal changes. The extent of disability was not always apparent at hospital discharge, impacting on provision of prognostic information and targeted follow-up.