The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention

Head injury is often associated with other serious trauma. Clinical decision rules such as the Canadian CT Head Rule can guide clinicians in the judicious use of neuroimaging, which can then guide the appropriate course of treatment. Rapid assessment of patients requiring neurosurgical intervention is critical, as is appropriate management of blood pressure and hypoxia. This chapter considers a case study of blunt head injury with loss of consciousness of a skier in the backcountry, The author addresses patient history, physical exam, differential diagnoses, clinical course, and key management steps. The patient’s condition relative to the Canadian CT Head Rule is specifically discussed.

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Immunolocalization of Heat Shock Protein after Fluid Percussive Brain Injury and Relationship to Breakdown of the Blood-Brain Barrier

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.1993.14 ◽

1993 ◽

Vol 13 (1) ◽

pp. 116-124 ◽

Cited By ~ 68

Author(s):

Hirokazu Tanno ◽

Russ P. Nockels ◽

Lawrence H. Pitts ◽

Linda J. Noble

Keyword(s):

Brain Injury ◽

Head Injury ◽

Blood Vessels ◽

Blood Brain Barrier ◽

Time Course ◽

Cortical Layer ◽

Brain Barrier ◽

Impact Site ◽

Blood Brain ◽

The Impact

We have previously developed a model of mild, lateral fluid percussive head injury in the rat and demonstrated that although this injury produced minimal hemorrhage, breakdown of the blood–brain barrier was a prominent feature. The relationship between posttraumatic blood–brain barrier disruption and cellular injury is unclear. In the present study we examined the distribution and time course of expression of the stress protein HSP72 after brain injury and compared these findings with the known pattern of breakdown of the blood–brain barrier after a similar injury. Rats were subjected to a lateral fluid percussive brain injury (4.8–5.2 atm, 20 ms) and killed at 1, 3, and 6 h and 1,3, and 7 days after injury. HSP72-like immunoreactivity was evaluated in sections of brain at the light-microscopic level. The earliest expression of HSP72 occurred at 3 h postinjury and was restricted to neurons and glia in the cortex surrounding a necrotic area at the impact site. By 6 h, light immunostaining was also noted in the pia-arachnoid adjacent to the impact site and in certain blood vessels that coursed through the area of necrosis. Maximal immunostaining was observed by 24 h postinjury, and was primarily associated with the cortex immediately adjacent to the region of necrosis at the impact site. This region consisted of darkly immunostained neurons, glia, and blood vessels. Immunostaining within the region of necrosis was restricted to blood vessels. HSP72-like immunoreactivity was also noted in a limited number of neurons and glia in other brain regions, including the parasagittal cortex, deep cortical layer VI, and CA3 in the posterior hippocampus. Immunoreactive cells in these areas were not apparent until 24 h postinjury. By 7 days postinjury, HSP72-like immunoreactivity was minimal or absent in these injured brains and notable cell loss was apparent only in the impact site. This study demonstrates an early and pronounced expression of HSP72 at the impact site and a more delayed and less prominent expression of this protein in other regions of the brain. These findings parallel the temporal and regional pattern of breakdown of the blood–brain barrier after a similar head injury.

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Presenting characteristics of children who required neurosurgical intervention for head injury

Child s Nervous System ◽

10.1007/s00381-016-3030-5 ◽

2016 ◽

Vol 32 (5) ◽

pp. 827-831

Author(s):

Oren Tavor ◽

Sirisha Boddu ◽

Abhaya V. Kulkarni

Keyword(s):

Head Injury ◽

Neurosurgical Intervention

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Delayed lethal pulmonary air embolism after a gunshot head injury

BMJ Case Reports ◽

10.1136/bcr-2017-223545 ◽

2018 ◽

pp. bcr-2017-223545

Author(s):

Jakob Emanuel Brune ◽

Denis Laurent Kaech ◽

Daniel Wyler ◽

Raphael Jeker

Keyword(s):

Head Injury ◽

Negative Pressure ◽

Superior Sagittal Sinus ◽

Young Male ◽

Air Embolism ◽

Dural Sinus ◽

Severe Head Trauma ◽

Sagittal Sinus ◽

Watertight Closure ◽

Neurosurgical Intervention

We present a case of a young male patient with a fatal pulmonary air embolism following a penetrating gunshot head injury. He suffered from severe head trauma including a laceration of the superior sagittal sinus. Operative neurosurgical intervention did not establish a watertight closure of the wounds. Eight days after the trauma, the patient suddenly collapsed and died after an attempt to mobilise him to the vertical. Forensic autopsy indicated pulmonary air embolism as the cause of death. Retrospectively, we postulate an entry of air to the venous system via the incompletely occluded wounds and the lacerated superior sagittal sinus while mobilisation to the vertical created a negative pressure in the dural sinus.

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Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury

CJEM ◽

10.1017/cem.2020.378 ◽

2020 ◽

Vol 22 (6) ◽

pp. 793-801

Author(s):

Jessica A. Harper ◽

Terry P. Klassen ◽

Robert Balshaw ◽

Justin Dyck ◽

Martin H. Osmond ◽

...

Keyword(s):

Risk Factors ◽

Head Injury ◽

High Risk ◽

Skull Fracture ◽

Minor Head Injury ◽

Intracranial Injury ◽

Altered Level ◽

High Risk Factors ◽

Recurrent Vomiting ◽

Neurosurgical Intervention

ABSTRACTObjectivesVomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury.MethodsThis secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0–16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models.ResultsA total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7–3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5–7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9–3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors.ConclusionsRecurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.

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Beware of the 3776.24 m peak

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907920982758 ◽

2020 ◽

pp. 102490792098275

Author(s):

Stephanie Dorothy Pui Ming Yu ◽

James Siu Ki Lau ◽

Puisy Yau Ng Chan ◽

Pui Gay Kan

Keyword(s):

Emergency Department ◽

Head Injury ◽

Early Diagnosis ◽

Middle Aged ◽

Radiological Findings ◽

Threatening Condition ◽

Life Threatening ◽

Neurosurgical Intervention

A middle-aged man presented to the emergency department after a seemingly trivial head injury. Recognition of pathognomonic radiological findings allowed early diagnosis of a potentially life-threatening condition. The patient recovered uneventfully after prompt neurosurgical intervention.

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Role of repeat CT in mild to moderate head injury: an institutional study

Neurosurgical FOCUS ◽

10.3171/2019.8.focus19527 ◽

2019 ◽

Vol 47 (5) ◽

pp. E2 ◽

Cited By ~ 3

Author(s):

Madhusudhan Nagesh ◽

Kautilya Rajendrakumar Patel ◽

Ajit Mishra ◽

Ujwal Yeole ◽

Andiperumal R. Prabhuraj ◽

...

Keyword(s):

Head Injury ◽

Ct Scan ◽

Neurological Deterioration ◽

Ct Scans ◽

Midline Shift ◽

Head Ct ◽

Gcs Score ◽

Neurosurgical Intervention ◽

Basal Cisterns

OBJECTIVEPatients with traumatic brain injury (TBI) often undergo repeat head CT scans to identify the possible progression of injury. The objective of this study is to evaluate the need for routine repeat head CT scans in patients with mild to moderate head injury and an initial positive abnormal CT scan.METHODSThis is a retrospective study of patients presenting to the emergency department from January 2016 to December 2017 with Glasgow Coma Scale (GCS) scores > 8 and an initial abnormal CT scan, who underwent repeat CT during their in-hospital medical management. Patients who underwent surgery after the first CT scan, had a GCS score < 9, or had a normal initial CT scan were excluded. Demographic, medical history, and physical examination details were collected, and CT scans were reviewed. Radiological deterioration, neurological deterioration, and/or the need for neurosurgical intervention were the primary outcome variables.RESULTSA total of 1033 patients were included in this study. These patients underwent at least two CT scans on an inpatient basis. Of these 1033 patients, 54.1% had mild head injury and 45.9% had moderate head injury based on GCS score at admission. The most common diagnosis was contusion (43.8%), followed by extradural hematoma (28.8%) and subdural hematoma (26.6%). A total of 2636 CT scans were performed for 1033 patients, with a mean of 2.55 per patient. Of these, 25 (2.4%) had neurological deterioration, 90 (8.7%) had a progression of an existing lesion or appearance of a new lesion on repeat CT, and 101 (9.8%) required neurosurgical intervention. Seventy-five patients underwent surgery due to worsening of repeat CT without neurological deterioration, so the average number of repeat CT scans required to identify one such patient was 21.3. On multiple logistic regression, GCS score at admission (p = 0.024), abnormal international normalized ratio (INR; p < 0.001), midline shift (p = 0.005), effaced basal cisterns (p < 0.001), and multiple hemorrhagic lesions (p = 0.010) were associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention.CONCLUSIONSThe role of routine repeat head CT in medically managed patients with head injury is controversial. The authors have tried to study the various factors that are associated with neurological deterioration, radiological deterioration, and/or need for neurosurgical intervention. In this study the authors found lower GCS score at admission, abnormal INR, presence of midline shift, effaced basal cisterns, and multiple lesions on initial CT to be significantly associated with the above outcomes.

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