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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.

Objective Intracranial Arachnoid cysts (AC) are stable cerebral spinal fluid (CSF)-filled sacs that can rarely undergo progressive shrinkage or disappearance throughout life. In this manuscript, we present a case of post-traumatic complete resolution of an AC, review the possible triggers of this phenomenon, and discuss the pathophysiological mechanisms behind them. Methods After presenting our case, we performed a literature review using the PubMed Database of all the reported cases of AC reduction or resolution (last updated in February 2021). Spontaneous cases were excluded. An analysis of the remaining cases (1985–2021) according to their inciting event, demographical, and clinical characteristics was then presented. Results 58 patients were identified, 33 of which spontaneously resolved. The remaining 25 were included in the survey in addition to the case we presented. The mean age was 20.2 years, average time to resolution was 25.3 months, with only two third of the cases showing complete disappearance of the AC. A central nervous system infection was the inciting cause of resolution in one infant (4%), a history of head trauma in 16 (62%) patients and an intracranial procedure in 9 (35%) patients. Discussion AC disappearance is a rare phenomenon that can occur spontaneously or after an inciting event. The cyst wall rupture and CSF flow perturbation theories seem to be the most applicable pathophysiological mechanisms in triggered AC resolution.

Objective : Chronic subdural hematoma (CSDH) is one of the most common pathology in daily neurosurgical practice and incidence increases with age. The aim of this study was to evaluate the prognostic factors and surgical outcome of CSDH in patients aging over 90 years compared with a control group of patients aging under 90 years.Methods : This study reviewed 25 patients with CSDH aged over 90 years of age treated in our department. This group was compared with a younger group of 25 patients aged below their eighties. At admission past medical history was recorded concerning comorbidities (hypertension, dementia, ictus cerebri, diabetes, and heart failure or attack). History of alcohol abuse, anticoagulant and antiplatelet therapy, head trauma and seizures were analyzed. Standard neurological examination and Markwalder score at admission, 48 hours after surgery and 1–6 months follow-up, radiologic data including location and CSDH maximum thickness were also evaluated.Results : Their mean age was 92.8 years and the median was 92.4 years (range, 90–100 years). In older group, the Markwalder evaluation at one month documented the complete recovery of 24 patients out of 25 without statistical difference with the younger group. This data was confirmed at 6-month follow-up. One patient died from cardiovascular failure 20 days after surgery. The presence of comorbidities, risk factors (antiplatelet therapy, anticoagulant therapy, history of alcohol abuse, and head trauma), preoperative symptoms, mono or bilateral CSDH, maximum thickness of hematoma, surgical time and recurrence were similar and statistically not significant in both groups.Conclusion : In this study, we demonstrate that surgery for very old patients above 90 years of age affected by CSDH is safe and allows complete recovery. Comparing two groups of patients above and under 90 years old we found that complication rate and recovery were similar in both groups.

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+ (

Hospitals in low- and middle-income countries (LMICs) could benefit from decision support technologies to reduce time to triage, diagnosis, and surgery for patients with traumatic brain injury (TBI). Corticosteroid Randomization after Significant Head Injury (CRASH) and International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) are robust examples of TBI prognostic models, although they have yet to be validated in Sub-Saharan Africa (SSA). Moreover, machine learning and improved data quality in LMICs provide an opportunity to develop context-specific, and potentially more accurate, prognostic models. We aim to externally validate CRASH and IMPACT on our TBI registry and compare their performances to that of the locally derived model (from the Kilimanjaro Christian Medical Center [KCMC]). We developed a machine learning-based prognostic model from a TBI registry collected at a regional referral hospital in Moshi, Tanzania. We also used the core CRASH and IMPACT online risk calculators to generate risk scores for each patient. We compared the discrimination (area under the curve [AUC]) and calibration before and after Platt scaling (Brier, Hosmer-Lemeshow Test, and calibration plots) for CRASH, IMPACT, and the KCMC model. The outcome of interest was unfavorable in-hospital outcome defined as a Glasgow Outcome Scale score of 1-3. There were 2972 patients included in the TBI registry, of whom 11% had an unfavorable outcome. The AUCs for the KCMC model, CRASH, and IMPACT were 0.919, 0.876, and 0.821, respectively. Prior to Platt scaling, CRASH was the best calibrated model (χ

Introduction. A transorbital intracranial injury with a foreign body can be a very complex and controversial therapeutic problem. The orbit's content is susceptible to penetrating trauma, and neurovascular skull base structures are at high risk from injury. There are some traditional cranial surgical approaches, and more recently reported different endoscopic approaches for treating this kind of injury. Case report. We present a case of a 30-year-old male who had an accident at work when a piece of wood hit him in his head and entered through the medial aspect of his left orbit with skull base and cavernous sinus injury. Rapid and complete radiological and clinical assessments were performed, and the patient was treated in a minimally invasive manner. The foreign body was manually extracted with an endoscopic and endovascular team ready to treat adverse events. No postoperative complications were reported, and visual acuity increased at one month follow up. Conclusion. Penetrating wounds of the orbit represent a challenge that requires a multidisciplinary assessment and well-organized management. Combined endoscopic minimally invasive approaches should be considered during the treatment of this kind of injury.

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...

Introduction and objectives To compare clinical and psychoacoustic tinnitus characteristics in patients with the comorbidity of hyperacusis, hyperacusis and vertigo, and with Meniere's disease (MD). Materials and methods Three hundred and twenty-nine tinnitus patients underwent audiological and otoneurological evaluation. Records of 94 individuals younger than 65 years, 40 women and 54 men (mean age 41.8, range 24–64 years), who complained of tinnitus and hyperacusis, were analyzed. One hundred and thirty-one ears with tinnitus were identified: 67 in the group of patients with tinnitus and hyperacusis (group 1; 41 patients); 28 in the group fulfilling criteria of MD diagnosis (group 2; 28); and 36 in the group with tinnitus, hyperacusis and typical symptoms of vertigo (group 3; 25). Results and conclusions Mean value of interaural difference in canal paresis in group 1 was 6.3%; in group 2: 23.7%; and in group 3: 25.9%; p Mean tinnitus pitch was lower in the groups of patients with hyperacusis and peripheral labyrinthine lesion than in tinnitus sufferers with hyperacusis alone. Tinnitus sufferers with low tinnitus pitch should undergo vestibular system evaluation. Hyperacusis and vertigo are likely comorbidities in tinnitus patients after head trauma. Hyperacusis may coincide in tinnitus patients after head trauma.

INTRODUCTION Les décès de nourrissons par traumatisme crânien non accidentel s’inscrivent dans une procédure médico-judicaire pouvant compliquer les démarches de prélèvement multi-organes. L’objectif de cette étude est de décrire les pratiques du prélèvement d’organes chez ces nourrissons en état de mort encéphalique en France. METHODES Une enquête nationale rétrospective a été menée d’Avril à Décembre 2018 auprès des 33 coordinations de prélèvement d’organes pédiatriques et des 28 instituts médico-légaux. Le recueil de données a porté sur les cas recensés entre 2013 et 2017. RESULTATS Seize cas ont été recensés. La prise en charge des traumatismes crâniens non accidentels éligibles au prélèvement d’organes est très hétérogène selon les centres. Les coordinations considèrent que la judiciarisation des dossiers représente le principal obstacle au prélèvement. Seuls 6 des instituts médico-légaux approuvent systématiquement le prélèvement multi-organes dans ce contexte, 11 estimant qu’il pourrait empêcher la mise en évidence de lésions thoraco-abdominales, compromettre l’interprétation de certaines lésions ou encore la détermination des causes de la mort. CONCLUSION Une uniformisation des pratiques du prélèvement multi-organes incluant une collaboration étroite entre réanimateurs, coordinateurs, légistes et magistrats sont indispensables pour faciliter le prélèvement d’organes pédiatriques dans les situations médico-judiciaires le permettant, afin d’augmenter la disponibilité des greffons compatibles aux nourrissons en attente de greffe en France.

A percentage of the population suffers prolonged and persistent post-concussion symptoms (PCS) following average head injuries or develops severe neurological dysfunction following minor head trauma. Genetic variants that may contribute to individual response to head trauma have been investigated in some studies, but to date none have explored the use of machine learning (ML) methods with genomic data to specifically explore outcomes of head trauma. Whole exome sequencing (WES) was completed for three groups of individuals (N = 60): (a) 16 individuals with severe neurological responses to minor head trauma, (b) 26 individuals with persistent PCS and (c) 18 individuals with normal recovery from concussion or mTBI. Gradient boosted tree algorithms were applied to the data using XGBoost. By using variants with CADD scores above 15 in the training set (randomly sampled 70%), we identified signatures that accurately distinguish to accurately distinguish the test groups with an average area under the curve (AUC) of 0.8 (SE = 0.019). Metrics including positive and negative prediction values, as well as kappa were all within acceptable range to support the prediction accuracy. This study illustrates how ML methods in combination with WES data have the potential to predict severe or prolonged responses to head trauma from healthy recovery. KEY MESSAGES: Linear association analysis has been inconclusive in concussion genetics. Non-linear methods as boosted trees can offer better insights in small samples. Strong discrimination trends can be achieved from exome data of cases and controls.

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]).

Diffusion tensor imaging (DTI) of brain white matter (WM) may be useful for characterizing the nature and degree of brain injury after sport-related concussion (SRC) and assist in establishing obje...

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 Carotid cavernous fistula is a rare complication that is typically associated with head trauma and skull base fractures. The traumatic bilateral carotid cavernous fistula are significantly rarer. Case presentations We report a case of a 61-year-old man presenting with unilateral exophthalmos, swollen eyelids, conjunctival congestion, and edema etiologically associated with severe trauma. Thereafter, the patient demonstrated symptoms of contralateral oculomotor nerve injury caused by skull base fracture, such as ptosis of eyelid, dilated pupils, and eye movement disorder, and was diagnosed with bilateral carotid cavernous fistula. Conclusions The patient recovered after undergoing endovascular embolization of bilateral cavernous sinus fistulas. The patient demonstrated the classic symptoms of an extremely rare condition known as bilateral carotid cavernous fistula, in only one eye. Reporting and analyzing this case will help us elucidate the underlying mechanisms of this disease.

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.

INTRODUCTION Astereognosis is the tactile inability to recognize objects placed in the palms by touch with the eyes closed or blind-folded in the presence of intact primary sensory modalities. Stereognosis is usually considered a function of the contralateral sensory cerebral cortex. However, lesions of several anatomic areas and pathologic entities have been reported to be associated with astereognosis. Only two previous reports linked traumatic injury to isolated astereognosis: following surgical evacuation of traumatic parietal extradural hematoma and following bullet injury in the neck in 1992 and 1919, respectively. METHODS AND RESULTS All the pertinent literature was analyzed, focusing on the relevant definitions, clinical spectra, pathoanatomical processes, assessment, management, and outcomes of astereognosis. Also, an illustrative case was presented. The case highlights isolated post-traumatic left hand astereognosis in a 17-year-old boy following a blunt trauma to the head which resulted in a non-hemorrhagic contusion of the right post-central gyrus. CONCLUSIONS Post-traumatic isolated astereognosis is a rare and probably underreported sequel of traumatic brain injury. Neurosurgeons need to be more sensitive to the assessment and detection of subtle stereognostic deficits in general and in trauma patients in particular. Other anatomical areas, in addition to the contralateral post-central gyrus, may be considered in the pathogenesis of astereognosis with the involvement of the dorsal column medial lemniscus tract such as the brainstem, foramen magnum, and the cervical spinal cord. To the best of our knowledge, this rare case report is considered the second report on astereognosis following head trauma, and the third report on astereognosis following trauma in general.

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.

Background: Caregiver frustration with inconsolable crying is a commonly cited antecedent factor of Abusive head trauma (AHT) in infants. Objective: To assess the effectiveness of an educational intervention to improve patients’ knowledge of normal crying patterns in infants and the implications of AHT among women of Hispanic population. Methods: The Period of PURPLE Crying program was piloted as part of Centering Prenatal Care at an outpatient clinic site in the Harris County Health Department system, which cares for a primarily underserved and Spanish speaking population. Educational material and direct counseling were delivered by the clinician. Demographic data was collected and a pre- and post-test survey was administrated to assess participant’s knowledge and behavior. Results: Between April 2017 and April 2018, 63 Hispanic women were included in this study. Prior to implementation of the educational tool, most of the survey questions were answered incorrectly. After the intervention, knowledge regarding normal infant crying patterns was significantly improved in all questions. However, knowledge gaps persisted especially in relation to the adequacy of parents’ ability to soothe a crying infant and normalcy of excessive crying. Conclusions: The educational curriculum was an effective tool for improving knowledge about normal infant crying patterns in Hispanic mothers.

BACKGROUND: Abdominal trauma, both blunt and penetrating abdominal trauma, is the third most common trauma, which is about 10% after head trauma (30%) and chest trauma (20%). Trauma has an influence on the balance of the immune system. The excessive inflammatory response can trigger systemic inflammatory response syndrome (SIRS). The ratio of neutrophils to lymphocytes acts as a marker of the inflammatory response in both surgical and non-surgical patients. AIM: The purpose of the study was to predict the incidence of SIRS using neutrophils-to-lymphocytes ratio (NLR) in patients with blunt abdominal trauma undergoing emergency laparotomy. METHODS: This study is an observational analytic study with a prospective design which was carried out at the emergency room, intensive care unit, Sanglah Hospital, Denpasar, Surgery for 1 year from January 2019 to December 2019, involving 59 research subjects with the consecutive sampling method who is met the inclusion and exclusion criteria. RESULTS: The area under the curve value obtained an NLR sensitivity of 87.1% with a cutoff point of 5.25. In the path analysis, it was found that NLR was the dominant factor and had a positive effect of 43.9% (p < 0.001) on SIRS. CONCLUSION: NLR is expected to be used as a reference to predict the incidence of SIRS in blunt abdominal trauma following laparotomy emergency.

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% (

Despite multiple prior pharmacological trials in traumatic brain injury (TBI), the search for an effective, safe, and practical treatment of these patients remains ongoing. Given the ease of delivery and rapid absorption into the systemic circulation, inhalational gases that have neuroprotective properties will be an invaluable resource in the clinical management of TBI patients. In this review, we perform a systematic review of both pre-clinical and clinical reports describing inhalational gas therapy in the setting of TBI. Hyperbaric oxygen, which has been investigated for many years, and some of the newest developments are reviewed. Also, promising new therapies such as hydrogen gas, hydrogen sulfide gas, and nitric oxide are discussed. Moreover, novel therapies such as xenon and argon gases and delivery methods using microbubbles are explored.

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.

Objectives Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear with a high rate of recurrence. Vascular disorders, migraine and autoimmune disorders have been considered facilitating factors for relapsing episodes. Our aim was to assess the role of vascular disorders, migraine and anti-thyroid antibodies in patients with recurrences. Methods We retrospectively analysed records of 3042 patients treated for BPPV without other lifetime vertigo. Clinical data included previous vascular disorders of the central nervous system, heart disorders, migraine and recent head trauma. The presence of anti-thyroid autoantibodies was assessed in all patients. Results Mean age of the first BPPV was 52.8 ± 14.5 years; there were 2339 females (76.9%), while 2048 (67.3%) of patients presented recurrences within two years of follow-up. Previous disorders of the central nervous system, presence of anti-thyroid antibodies, head trauma and migraine showed an association with recurrences. Above all, in subjects having the first BPPV while aged between 40 and 60 years, anti-thyroid antibodies were predictive for recurrences. Conclusions Our data are consistent with the hypothesis that anti-thyroid autoantibodies may play a role in recurrences in subjects with initial manifestations between 40 and 60 years.

A typical occurrence in emergency rooms is traumatic brain injury (TBI) resulting from head trauma which is normally responsible for far more than 1 million visits per year. The magnitude of TBIs varies from mild, intermittent symptoms to longer periods of altered states of consciousness. The precise mechanism of concussion is indefinite. In serious brain trauma, Axon tearing is expected, but there is no evidence for this concussion process. Most concussion patients improve rapidly and entirely. Concussion management is usually supportive and some cases may need hospital admissions and ICU care according to severity of injury and related symptoms.

Objective Among the pediatric population with minor head trauma, it is difficult to determine an indication for the usage of brain computerized tomography (CT). Our study aims to compare the efficiency of the most commonly used clinical decision rules: the Pediatric Emergency Care Applied Research Network (PECARN) and Canadian Assessment of Tomography for Childhood Head Injury 2 (CATCH2).Methods This retrospective study investigated whether the PECARN and CATCH2 rules were applicable to Korean children with minor head trauma for reducing the use of brain CT imaging, while detecting intracranial pathology.Results Overall, 251 patients (0–5 years old) admitted to emergency rooms within 24 hours of injury were included between August 2015 to August 2018. The performance results are as follows: the PECARN and CATCH2 rules had a sensitivity of 80.00% (51.91%–95.67%) and 100% (78.20%–100.00%) with a specificity of 28.39% (22.73%–34.60%) and 15.25% (10.92%–20.49%), respectively; the negative predictive values were 98.58% and 100%, respectively. Overall, the CATCH2 rule was more successful than the PECARN rule in detecting intracranial pathology; however, there was no significant difference between them. Furthermore, the PECARN and CATCH2 rules lowered the rate of head CT imaging in our study group.Conclusion Both the rules significantly lowered the rate of indicated brain CT. However, since the CATCH2 rule had higher sensitivity and negative predictive value than the PECARN rule, it is more appropriate to be used in emergency rooms for detecting intracranial pathology in children with minor head trauma.

Background: Persons with Huntington’s disease (HD) are at increased risk for subdural hematomas (SDH) because of underlying brain atrophy and increased frequency of falls and head trauma. SDH can cause serious disability, but there is little information about the association of SDH with HD in the medical literature. Objective: To review the occurrence and characteristics of SDH seen in clinics specializing in HD. Methods: A retrospective review identifying the occurrence and manifestations of SDH in HD patients attending three HDSA Centers of Excellence. Results: Twenty-five HD patients (16F/9M) were identified with SDH. Twelve (44%) SDH were bilateral, 16 (60%) required surgical intervention, and 2 resulted in death. Mean age at the time of SDH was 60 years, mean duration of HD symptoms prior to event was 8 years, mean CAG repeat expansion size was 43 and mean UHDRS motor score obtained closest to time of SDH was 51 (16 patients). Most SDH occurred in the context of ground level falls or using stairs although 5 patients had no history of head trauma. Additional brain injury may occur along with the SDH. The most common symptoms were altered mental status, hemiparesis and loss of consciousness. The over-representation of females in this study requires replication and further investigation. Conclusion: Patients with HD are at increased risk for SDH. An increased suspicion for SDH in HD patients should be considered, as this phenomenon may be initially unrecognized, may require extensive utilization of medical resources and is a potential cause of death.

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.

Objective We sought to identify and correlate the severity of traumatic brain injuries (TBIs) associated with olfactory dysfunction with cognitive and behavioral profiles. Participants and setting Patients with TBI undergoing treatment in a specialized neuro-rehabilitation hospital. Design Prospective study. Main measures Glasgow Coma Scale (GCS) at the time of injury and during posttraumatic amnesia. Motor functions were assessed with the Functional Instrument Measure and Disability Rating Scales. The Wechsler Adult Intelligence test was used for neuropsychologic assessment and the Neuropsychiatric Inventory was used to assess behavioral changes. The Barcelona Smell Test-24 was used to study subjective smell loss. Results A total of 111 patients with TBI were enrolled (33 females; mean age 32.86 years); 38.73% exhibited smell loss. Patients with no olfactory impairment (OI) had worse TBIs than those with OI (GCS scores 5.65 and 7.74, respectively); no significant differences in cognitive behaviors, such as attention memory, visuoperception, and visuoconstruction, were observed. However, patients with TBI and olfactory dysfunction showed statistically significant alterations in neuropsychiatric behavioral performances such as feeding when compared with patients with TBI without smell loss. Conclusion Olfactory dysfunction in patients with a TBI correlates with altered neuropsychiatric behavioral performances such as feeding, sleeping, and motor behavior.

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.

Cortical blindness is characterized by loss of vision due to dysfunction of the visual cortices, most commonly secondary to bilateral ischemic infarcts of the occipital lobe. Other causes include surgery such as aortic valve replacement, laryngeal surgery, craniotomy, cerebral angiography, head trauma, and partial seizures. Visual anosognosia is a distinct feature of cortical blindness, wherein patients claim they can see and confabulate visual perceptions, despite loss of sight. We herewith present a rare phenomenon known as Anton Syndrome, an eponym named after the Austrian neurologist and psychiatrist, Gabriel Anton (1858–1933). There are a limited number of cases of Anton’s Syndrome in the literature, with only 28 case reports published from 1965–2016. Although he was bestowed a neurologic eponym, Anton was an advocate of eugenics and racial hygiene. He publicly advocated for ‘superior breeding’ and ‘selection’ in order to ‘build a brave and noble race.’ We therefore propose replacing the eponym with Bilateral Occipital Lobe Infarct Neglect Deficit (BLIND) Syndrome, with intention of raising awareness of this unique presentation as well as of the widespread interest in eugenics in the early 1900s amongst physicians, notably Gabriel Anton.

OBJECTIVE Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

Objective : COVID-19 has spread worldwide since the first case was reported in Wuhan, China, in December 2019. Our institution is a regional trauma and emergency center in the northern Gyeonggi Province. The changing trend of patient care in the emergency room of this hospital likely reflects the overall trend of patients in the area. In the present study, whether changes in the surrounding social environment following the outbreak of COVID-19 changed the incidence of neurosurgical emergency patients and whether differences in practice existed were investigated.Methods : The overall trend was analyzed from January 2020 which is before the outbreak of COVID-19 to September 2020. To remove bias due to seasonal variation, the previous 2 year's records during the same period were reviewed and compared. Confirmed COVID-19 patients in the northern Gyeonggi Province were identified using data released by the government. And patients who came to the emergency department with head trauma and stroke were identified.Results : Based on the present study results, the total number of neurosurgery emergency patients decreased over the study period. In the trauma patient group, the number of patients not involved in traffic accidents significantly decreased compared with patients involved in traffic accidents. Among the stroke cases, the rate of ischemic stroke was lower than hemorrhagic stroke, although a statistically significant difference was not observed. Meanwhile, an increase in the risk of mortality associated with trauma or stroke cases was not observed during the COVID-19 outbreak compared with the same time period in the previous year.Conclusion : Due to the occurrence of COVID-19, non-essential activities have decreased and trauma cases not associated with traffic accidents appeared to decrease. Due to the decrease in overall activity, the number of stroke patients has also decreased. This trend is expected to continue even in the post-COVID-19 era, and accordingly, the results from the present study are relevant especially if the current situation continues.

Purpose Low-velocity penetrating brain injury (LVPBI) caused by foreign bodies can pose life-threatening emergencies. Their complexity and lack of validated classification data have prevented standardization of clinical management. We aimed to compare the trans-base and trans-vault phenotypes of LVPBI to help provide guidance for clinical decision-making of such injury type. Methods A retrospective study on LVPBI patients managed at our institution from November 2013 to March 2020 was conducted. We included LVPBI patients admitted for the first time for surgery, and excluded those with multiple injuries, gunshot wounds, pregnancy, severe blunt head trauma, etc. Patients were categorized into trans-base and trans-vault LVPBI groups based on the penetration pathway. Discharged patients were followed up by outpatient visit or telephone. The data were entered into the Electronic Medical Record system by clinicians, and subsequently derived by researchers. The demography and injury characteristics, treatment protocols, complications, and outcomes were analyzed and compared between the two groups. A t-test was used for analysis of normally distributed data, and a Mann-Whitney U test for non-parametric data. A generalized linear model was further established to determine whether the factors length of stay and performance scale score were influenced by each factor. Results A total of 27 LVPBI patients were included in this analysis, comprised of 13 (48.1%) trans-base cases and 14 (51.9%) trans-vault cases. Statistical analyses suggested that trans-base LVPBI was correlated with deeper wounds; while the trans-vault phenotype was correlated with injury by metal foreign bodies. There was no difference in Glasgow Coma Scale score and the risk of intracranial hemorrhage between the two groups. Surgical approaches in the trans-base LVPBI group included subfrontal (n = 5, 38.5%), subtemporal (n = 5, 38.5%), lateral fissure (n = 2, 15.4%), and distal lateral (n = 1, 7.7%). All patients in the trans-vault group underwent a brain convex approach using the foreign body as reference (n = 14, 100%). Moreover, the two groups differed in application prerequisites for intracranial pressure monitoring and vessel-related treatment. Trans-base LVPBI was associated with higher rates of cranial nerve and major vessel injuries; in contrast, trans-vault LVPBI was associated with lower functional outcome scores. Conclusion Our findings suggest that trans-base and trans-vault LVPBIs differ in terms of characteristics, treatment, and outcomes. Further understanding of these differences may help guide clinical decisions and contribute to a better management of LVPBIs.

Objective Epidural hematoma (EDH), most often caused by rupture of the middle meningeal artery secondary to head trauma with fracture of the temporal bone, is a potentially fatal condition that can lead to elevated intracranial pressure, herniation, and death within hours following the inciting traumatic incident, unless surgical evacuation is accomplished. Several markers have been found to be associated with hematoma expansion in intracerebral hemorrhage (ICH) patients, including: the CT Blend Sign, Swirl Sign, and Black Hole Sign. This study aims to examine these markers, along with intradural air close to or in the region of an EDH and/or close to a significant fracture, fractures involving the skull base, and complicated (i.e., comminuted or displaced) fractures for possible associations to EDH growth in the pediatric population. Predicting hematoma growth is a crucial part of patient management, as surgery can be a life-saving intervention. Methods Scans from all pediatric patients with EDH from 2012 to 2019 across two separate health systems were examined and measurements were taken to determine whether these additional factors are of predictive value. Specifications such as length, transverse, and height measurements were taken from CT images. Statistical Analysis The average percent change in the hematoma measurements was used to determine which predictive factors were associated with a “noteworthy increase,” namely, an increase of greater than 25%. Additionally, the average percent change in hematoma size was evaluated for patients whose original imaging showed either all three CT signs or intradural air in all three specified locations. Results Most of the proposed markers were associated with EDH growth in this cohort. The established CT signs were also supported. This is notable, as most of the research on these signs has been in adult populations rather than pediatric. Conclusions Adding these novel imaging signs could aid in the decision to operate on versus observe PEDH patients, thereby preventing unnecessary procedures or preserving brain function quickly when surgery is indicated. This study serves as a starting point for several other investigations into the validity of the proposed markers as well as a reevaluation of the current signs in the pediatric population.

Since its creation in the 1980s, transcranial Doppler (TCD) has provided a method of non-invasively monitoring cerebral physiology and has become an invaluable tool in neurocritical care. In this narrative review, we examine the role TCD has in the management of the moderate and severe traumatic brain injury (TBI) patient. We examine the principles of TCD and the ways in which it has been applied to gain insight into cerebral physiology following TBI, as well as explore the clinical evidence supporting these applications. Its usefulness as a tool to non-invasively determine intracranial pressure, detect post-traumatic vasospasm, predict patient outcome, and assess the state of cerebral autoregulation are all explored.

INTRODUCTION The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

Objective This study aimed to assess the long-term recurrence rate and correlations between recurrence and potential risk factors in patients with benign paroxysmal positional vertigo (BPPV). Design A total of 548 consecutive patients who demonstrated typical posterior or horizontal BPPV between January 2010 and December 2012 were included in this prospective study. All patients were contacted by phone every 6 months for 5 years and were asked to revisit the clinic when they experienced positional vertigo to be reexamined for recurrence. Recurrence of BPPV was defined as having positional vertigo and nystagmus confirmed following a symptom-free period of at least 7 days after complete resolution. We assessed the 5-year recurrence rate of BPPV, and the time point of recurrence in all patients as well as the risk factors of BPPV recurrence, including the clinical characteristics, therapeutic results of BPPV, and various comorbidities. Results Among the 548 patients, 121 (22.1 %) had at least one recurrence. Of these, 78 patients (54.5%) had only one recurrence within 5 years, while 43 (45.5%) patients experienced two or more recurrences. A recurrence occurred within 1 year in 82 patients (67.8%). The Cox proportional hazard ratio analysis found that head trauma (p = 0.015), Meniere's disease (p = 0.016), the number of canalith repositioning procedures performed (p = 0.037), and the number of previous vertigo attacks (p = 0.038) were significant risk factors of BPPV recurrence as opposed to hypertension or hyperlipidemia. Conclusions The recurrence rate of BPPV was 22.1% at 5 years after the initial treatment. About 70% of recurred patients had a recurrence within 1 year. Head trauma, ipsilateral Meniere's disease, the number of canalith repositioning procedures performed, and the number of previous vertigo attacks were significant risk factors of BPPV recurrence.

We report the case of a 2-month-old infant who was found moribund in her crib. Postmortem computed tomography (PMCT) was performed before autopsy. As the baby had a severe subdural hematoma, retinal hemorrhage, and encephalopathy on PMCT, abusive head trauma (AHT) was tentatively diagnosed. At autopsy, no scalp hemorrhages or skull fractures were found; however, the classic triad of AHT was present, mainly on the right side. Additionally, there was dark red discoloration around the heart, and the liver, spleen, and pancreas were enlarged. Peripheral blood was macroscopically cloudy with marked leukocytosis. After careful histological examination, B-cell precursor acute lymphoblastic leukemia (ALL) was diagnosed. All the macroscopic lesions could be attributed to ALL. The manner of death was natural. To the best of our knowledge, this is the first report of infantile ALL mimicking AHT on PMCT images. This case demonstrates the importance of a comprehensive systematic approach to considering differential diagnosis when PMCT shows multiple intracranial hemorrhages suggestive of AHT in an infant.

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.

Aim: Road traffic accidents (RTAs) are the most common cause of polytrauma. This study aims to evaluate the various ocular manifestations in cases of RTAs. Materials and Methods: A retrospective review of patients who were treated for RTAs in a tertiary hospital in 6 months from December 2018 to May 2019. A total of 126 patients were reviewed. Age ranged from 2 to 85 years. The mean age was 32 years. Results: Ophthalmological examination was undertaken in all patients involved in RTA. Out of 126 patients, 112 were males and 14 were females. Young adult males (21-30 years) were most vulnerable to RTAs. Soft tissue injuries were the most common manifestations (57.93%) followed by neuro-ophthalmic manifestations (26.98%) and orbital fractures (15.07%). The presence of CT abnormalities especially intra cranial haemorrhage was associated with neuro-ophthalmic deficits. Conclusions: Soft tissue injuries were the most common ocular manifestations. It was found that head trauma causes many neuro-ophthalmic manifestations. Relative afferent pupillary defect (RAPD) was the most common neuro-ophthalmic manifestation. The most common cranial nerve involved was found to be oculomotor nerve. Retrobulbar neuritis was a rare finding. Keywords: Road traffic accidents, Head injury, Soft tissue injuries, Orbital fractures, Neuro Ophthalmic, manifestations.

Head trauma (HT) is emerging as an event anticipating onset of neurodegenerative disorders. However, the potential contribution of HT in young-onset cases (YOPD, age at onset

Based on a patient encounter in which genetically confirmed Marfan's syndrome (MFS) underlay a spontaneously resolving subdural hygroma (SDHy) diagnosed in infancy, we review the literature of MFS clinically manifest in early life (early-onset MFS [EOMFS]) and of differential diagnoses of SDHy and subdural hemorrhage (SDHe) at this age. We found that rare instances of SDHy in the infant are associated with EOMFS. The most likely triggers are minimal trauma in daily life or spontaneous intracranial hypotension. The differential diagnosis of etiologies of SDHy include abusive and nonabusive head trauma, followed by perinatal events and infections. Incidental SDHy and benign enlargement of the subarachnoid spaces must further be kept in mind. SDHy exceptionally also may accompany orphan diseases. Thus, in the infant, EOMFS should be considered as a cause of SDHe and/or SDHy. Even in the absence of congestive heart failure, the combination of respiratory distress syndrome, muscular hypotonia, and joint hyperflexibility signals EOMFS. If EOMFS is suspected, monitoring is indicated for development of SDHe and SDHy with or without macrocephaly. Close follow-up is mandatory.

The meninges are membranous tissues that are pivotal in maintaining homeostasis of the central nervous system. Despite the importance of the cranial meninges in nervous system physiology and in head injury mechanics, our knowledge of the tissues' mechanical behavior and structural composition is limited. This systematic review analyzes the existing literature on the mechanical properties of the meningeal tissues. Publications were identified from a search of Scopus, Academic Search Complete, and Web of Science and screened for eligibility according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review details the wide range of testing techniques employed to date and the significant variability in the observed experimental findings. Our findings identify many gaps in the current literature that can serve as a guide for future work for meningeal mechanics investigators. The review identifies no peer-reviewed mechanical data on the falx and tentorium tissues, both of which have been identified as key structures in influencing brain injury mechanics. A dearth of mechanical data for the pia-arachnoid complex also was identified (no experimental mechanics studies on the human pia-arachnoid complex were identified), which is desirable for biofidelic modeling of human head injuries. Finally, this review provides recommendations on how experiments can be conducted to allow for standardization of test methodologies, enabling simplified comparisons and conclusions on meningeal mechanics. QC 20210621

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.