The risk of intracranial complications in pediatric head injury

Retrospective analysis of 12,072 pediatric head injury cases admitted to hospital revealed 159 patients with intracranial complications: 132 had intracranial hematoma and 27 had diffuse brain swelling. Multivariate analysis revealed two risk factors that could be recognized easily by primary-care physicians. They were found to be significant in predicting the development of incracranial complications. These risk factors were impairment of consciousness at the time of admission and clinical and/or radiological skull fracture. Analysis revealed that the combination of impaired consciousness and skull fracture carried the highest risk of complication (75%); however, the presence of impaired consciousness alone had an intermediate level of risk (19%). The presence of skull fracture alone carried a small overall risk (2%); however, this was higlly dependent on age. The absence of all the risk factors considered carried a negligible risk of intracranial complications, provided proper skull X-rays were taken and correctly interpreted.Presented at the 15th Annual Meeting of the International Society for Pediatric Neurosurgery, New York 1987     

Neuroimaging characterization of recovery of impaired consciousness in patients with disorders of consciousness

Elucidation of critical brain areas or structures that are responsible for recovery of impaired consciousness in patients with disorders of consciousness is important because it can provide information that is useful when developing therapeutic strategies for neurorehabilitation or neurointervention in patients with disorders of consciousness.In this review,studies that have demonstrated brain changes during recovery of impaired consciousness were reviewed.These studies used positron emission tomography,electroencephalography/transcranial magnetic stimulation,diffusion tensor tractography,and diffusion tensor tractography/electroencephalography.The majority of these studies reported on the importance of supratentorial areas or structures in the recovery of impaired consciousness.The important brain areas or structures that were identified were the prefrontal cortex,basal forebrain,anterior cingulate cortex,and parietal cortex.These results have a clinically important implication that these brain areas or structures can be target areas for neurorehabilitation or neurointervention in patients with disorders of consciousness.However,most of studies were case reports;therefore,further original studies involving larger numbers of patients with disorders of consciousness are warranted.In addition,more detailed information on the brain areas or structures that are relevant to the recovery of impaired consciousness is needed.     

Early and late outcome in head injury patients with radiological evidence of brain damage

This study examined the early and late outcome in head injury patients with focal or multifocal (unilateral or bilateral) brain contusions revealed by computerized tomography (CT) scanning. The outcome was also evaluated in patients hospitalized due to brain concussion. Three months after the injury (the early outcome) 43% of the 86 cases with multifocal contusions on the CT scan were dead. As evaluated by the Glasgow Outcome Scale, all the 57 patients with a focal brain contusion, as well as the 117 cases with brain concussion, made a good recovery or were moderately disabled. The late outcome (1 to 5 years after injury) was evaluated in 78 cases with brain contusion and in 85 cases with brain concussion, and revealed that complaints and impaired adaptive functioning were frequent in both the contusion and concussion group. The occurrence of headache, dizziness and sleep problems did not significantly differ among the various head injury groups. However, focal or multifocal brain contusions on the CT scan increased the frequency of impaired memory, impaired concentration, speech problems, weakness in arms or legs and seizures with loss of consciousness. Cognitive deficits and speech problems were particularly common in patients with a focal contusion in the temporal lobe. The late adaptive and social functioning were most markedly impaired in cases with multifocal bilateral contusions.     

Posttraumatic stress disorder after severe traumatic brain injury

OBJECTIVE: This study indexed the profile of posttraumatic stress disorder (PTSD) after severe traumatic injury to the brain. METHOD: Patients who sustained a severe traumatic brain injury (N=96) were assessed for PTSD 6 months after the injury with the PTSD Interview, a structured clinical interview based on DSM-III-R criteria. RESULTS: PTSD was diagnosed in 26 (27.1%) of the patients. While only 19.2% (N=5) of the patients with PTSD reported intrusive memories of the trauma, 96.2% (N=25) reported emotional reactivity. Intrusive memories, nightmares, and emotional reactivity had very strong positive predictive values for the presence of PTSD. CONCLUSIONS: These findings indicate that PTSD can develop after severe traumatic brain injury. The predominance of emotional reactivity and the relative absence of traumatic memories in patients with PTSD who suffered impaired consciousness during trauma suggest that traumatic experiences can mediate PTSD at an implicit level.     

Presence of Klùver-Bucy syndrome as a positive prognostic feature for the remission of traumatic prolonged disturbances of consciousness

After severe brain injury a prolonged disturbance of consciousness may occur, sometimes with transient apallic syndrome (awakening without awareness of self and surroundings). Klùver-Bucy is described in the literature as a typical post-traumatic remission phase, in which the patients show an increase of oral automatisms and/or of sexual drive. The study describes Klùver-Bucy syndrome as a sign associated with favourable prognosis in the outcome of traumatic disturbances of consciousness in survivors of head trauma. Seventy-seven patients who had suffered severe brain injury due to traffic accidents entered into the study. All had experienced a relatively benign clinical course since they recovered full awareness, that is were able to communicate with their relatives. The occurrence of prolonged coma, of apallic syndrome and of Klùver-Bucy syndrome are related to outcome date in regards to the patient's work and family function at a mean of 32 months later. In particular, the duration of the apallic syndrome (duration of unconsciousness) was significantly correlated with the global outcome of the patients (p < 0.001).     

Impaired spatial learning in a novel rat model of mild cerebral concussion injury

The aim of the present study was to develop a model of mild traumatic brain injury in the rat that mimics human concussive brain injury suitable to study pathophysiology and potential treatments. 34 male Wistar rats received a closed head trauma (TBI) and 30 animals served as controls (CON). Immediately following trauma, animals lost their muscle tone and righting reflex response, recovering from the latter within 11.4 +/- 8.2 min. Corneal reflex and whisker responses returned within 4.5 +/- 3.0 min and 6.1 +/- 2.9 min, respectively. The impact resulted in a short transient decrease of pO2 (P < 0.001), increase in mean arterial blood pressure (P = 0.026), and a reduction of heart rate (P < 0.01). Serial MRI did not show any abnormalities across the entire cerebrum on diffusion, T1, T2, and T2*-weighted images at all investigated time points. TBI animals needed significantly longer to locate the hidden platform in a Morris water maze and spent less time in the training quadrant than controls. TBI led to a significant neuronal loss in frontal cortex (P < 0.001), as well as hippocampal CA3 (P = 0.017) and CA1 (P = 0.002) at 9 days after the trauma; however, cytoskeletal architecture was preserved as indicated by normal betaAPP- and MAP-2 staining. We present a unique, noninvasive rat model of mild closed head trauma with characteristics of human concussion injury, including brief loss of consciousness, cognitive impairment, and minor brain injury.     

Diffuse axonal injury without direct head trauma and with delayed onset of coma

A 16-year-old female was involved in a jet ski (water craft) accident resulting in bilateral lower extremity fractures but no loss of consciousness or any other evidence of head trauma. Thirty hours later she became comatose. Magnetic resonance imaging was consistent with diffuse axonal injury. She recovered after several weeks without any clinical sequelae. This patient demonstrates an unusual example of diffuse axonal injury without direct head trauma and with delayed onset of symptoms. The authors recommend that patients involved in high-velocity accidents, even without immediate evidence of head injury, be observed for signs of diffuse axonal injury.     

Management and causes of pneumocephalus. Case report and review of the literature

Pneumocephalus is commonly seen after head and facial trauma, tumors of the skull base, after neurosurgery or otorhinolaryngology, and rarely spontaneously. Venous air embolism can result from right-to-left shunting or pneumocephalus. We report two cases of pneumocephalus, one after surgery of the paranasal sinus and the other after transabdominal prostatectomy. Clinical signs of the pneumocephalus were headache followed by epileptic seizures and, respectively, severely impaired consciousness after the operation. Treatment was either revision of the skull base with craniotomy or conservative therapy of the brain edema. Based on these case reports and the medical literature on pneumocephalus, we review the causes and treatment of this rare condition.     

轻型颅脑损伤致脑梗死临床分析

目的探讨轻型颅脑损伤后发生脑梗死的特点、治疗及预后。方法统计2000年至2007年内25例此类患者,对其发生原因、发病特点,治疗及预后进行研究,并结合文献进行临床分析。结果青少年、老年人,全身多发损伤病人及不适当的治疗后轻型颅脑损伤患者易出现脑梗死;治疗应采用综合疗法;预后大多良好。结论对轻型颅脑损伤后脑梗死讨论对预防其发生在临床上有重要意义。     

Changes in localization of synaptophysin following fluid percussion injury in the rat brain

Traumatic brain injuries damage neurons and cause progressing dysfunctions of the brain. Synaptophysin (SYP), a major integral transmembrane protein of synaptic vesicles, provides a molecular marker for the synapse and serves as a functional marker of the brain. This study examined magnitude-dependent changes of SYP in the rat brain 2 days following low, moderate or high fluid percussion injuries and investigated time-dependent changes of SYP in the rat brain with moderate fluid percussion injury 2, 15 and 30 days after trauma using immunohistochemistry and Western blotting. SYP immunoreactivity increased in the lateral cortex and in the subcortical white matter, with increasing magnitude of injury and time after trauma. Increased SYP immunoreactivity was accompanied with degeneration of neuronal cell bodies, their processes and terminals as well as glial cell proliferations. Amounts of SYP measured by Western blotting remained unchanged in brains with moderate fluid percussion within 30 days after trauma. These findings indicate that trauma accumulates SYP at injured sites of neurons without changing SYP contents and that increased SYP immunoreactivity in the cerebral cortex following traumatic injury reflects an inhibition of synaptic vesicle transportation and dysfunction of synapses, thus providing a histological substrate for brain dysfunctions.     

灯盏花素对大鼠颅脑损伤脑组织线粒体ATP酶活性的影响

目的 探讨灯盏花素对创伤性颅脑损伤后脑组织线粒体ATP酶活性水平的影响。方法 建立自由落体脑挫裂伤模型,伤后立即腹腔注射灯盏花素注射液,采用生化检测的方法分别测定伤后4h、24h和48h及各自的对照组大鼠脑组织线粒体ATP酶活性水平。结果 颅脑损伤后大鼠脑组织线粒体Na~ -K~ ATP酶,Ca~(2 )-ATP酶及Mg~(2 )-ATP酶活性均明显下降(P<0.05),灯盏花素治疗后24h和48h脑组织线粒体ATP酶活性均高于各自时间点对照组(P<0.05)。结论 灯盏花素可以通过影响线粒体功能而减轻创伤性颅脑损伤后的继发性脑损害,从而改善预后。     

Non-convulsive status epilepticus; the rate of occurrence in a general hospital

BackgroundNon-convulsive status epilepticus (NCSE) has been increasingly recognized as a cause of impaired level of consciousness in the ICU and emergency rooms. The diagnosis can be easily missed without an electroencephalogram (EEG) given the paucity of overt clinical signs in this condition. Recently few published data estimated the prevalence to be between 3% and 8%.ObjectiveTo assess the rate of occurrence of NCSE among patients with various degrees of impaired consciousness referred to the Neurophysiology Laboratory at Vancouver General Hospital.MethodWe conducted a retrospective analysis of 451 adult patients (>16 years of age) with a question of NCSE or with an unknown cause of impaired level of consciousness between the years 2002 and 2004. NCSE was defined according to the Young's criteria of electrographic status epilepticus. NCSE was categorized into focal and generalized epileptic activity based on the continuous EEG monitoring (CEEG). Further analysis of age, gender and etiology was performed.ResultsOf 451 patients, EEG demonstrated electrographic status epilepticus with no overt clinical signs in 42 patients (9.3%). Median age was 61.8 years (range 21–94). According to etiology, 38.1% of patients with NCSE had hypoxic–anoxic injury, 19% had intracerebral hemorrhage (including trauma), 11.9% had the diagnosis of idiopathic or cryptogenic epilepsy, 7.1% had ischemic stroke, 4.8% were secondary to tumors and 4.8% to viral encephalitis.ConclusionThe rate of occurrence of NCSE in patients with decreased level of consciousness was 9.3%. The cohort represented a group of patients who were comatose and required assisted ventilation or had altered level of consciousness. Hypoxic brain injury was the most responsible etiology of NCSE in the cohort studied.     

Short-term outcomes of skull fracture: a population-based study of survival and neurologic complications

All Olmsted County, Minnesota, residents who experienced brain injury from 1935 through 1979 were identified and their medical records reviewed for survival and neurologic outcome. Minimum inclusion criteria included loss of consciousness or post-traumatic amnesia or neurologic evidence of brain injury or skull fracture. Of 4,660 cases identified, skull fractures were observed in 28%. Over half of brain-injured patients who died did so within 24 hours of trauma; among 1-day survivors, subsequent survival was moderately impaired, especially in older individuals. Mortality was lowest in subjects without a skull fracture and increased with fracture severity. Associated neurologic injuries, complications, and deficits were generally more common in patients with skull fracture than those without and were much more frequent with more severe skull fractures. The types of neurologic deficits differed little between those with and without fractures, except that subjects with complicated skull fractures had higher proportions of special sensory deficits and multiple deficits.     

黄芪对大鼠脑外伤后脑组织线粒体酶活性影响的研究

目的　探讨黄芪对大鼠创伤性脑损伤后脑组织线粒体酶活性水平的影响。方法　建立大鼠自由落体脑挫裂伤模型 ,伤后立即腹腔注射黄芪注射液 ,采用生化检测的方法分别测定治疗后 4小时、2 4小时和 4 8小时及各自的对照组大鼠脑组织线粒体ATP酶和超氧化物歧化酶 (SOD)活性以及丙二醛 (MDA)水平。结果　黄芪治疗后 2 4小时和 4 8小时大鼠脑组织线粒体ATP酶和SOD活性均高于各自时间点对照组 (P <0 .0 5 ,P <0 .0 1) ,而MDA水平则明显低于各自对照组 (P <0 .0 1)。结论　黄芪可以通过影响线粒体功能而减轻大鼠创伤性脑损伤后的继发性脑损害 ,从而改善预后     

Simple clinical predictors of brain lesions in patients with impaired consciousness: a cross sectional study from a rural, tertiary hospital in central India

OBJECTIVE: To evaluate the diagnostic accuracy of vital signs for detecting brain lesions in patients with impaired consciousness in a rural setting. METHODS: We enrolled patients older than 12 years who presented with impaired consciousness of non-traumatic origin to the intensive care unit of a rural teaching hospital. The design was a cross sectional analysis of a hospital-based case series, independently comparing vital signs on admission (temperature, pulse, systolic and diastolic blood pressure) against a reference standard (final diagnosis). Diagnostic accuracy was measured by computing multi-level likelihood ratios, and area under the receiver operating characteristic (ROC) curve. RESULTS: We studied 386 patients of whom 242 (62.7%) were men. A total of 178 patients (46%) had a brain lesion. None of the clinical predictors could accurately distinguish between those with and without a brain lesion. The area under the ROC curve for pulse was 0.61 (S.E. 0.02); that for the systolic and diastolic blood pressure 0.70 (S.E. 0.02) each. Systolic BP provided informative test results in 29.7%, diastolic BP in 37.2% and pulse rate in 19.9% patients. CONCLUSION: Our findings suggest that the vital signs lack accuracy for ruling in or ruling out brain lesion in patients with impaired consciousness.     

重型颅脑损伤救治中早期康复治疗及临床意义

目的 探讨重型颅脑损伤患者早期康复治疗的效果。方法 124例颅脑损伤患者，其中38例原发性脑干损伤．51例脑挫伤，35例急性颅内血肿，在接受治疗的三周之内进行康复指导和治疗。结果 56例(45．2％)重新获得参与社会工作的能力，59例(47．6％)病人达到生活自理或部分自理，9例(7．2％)病人长期卧床和植物生存。结论 早期康复治疗在促进重型颅脑损伤患者的康复工作中起着重要作用，对于提高患者的生活质量、预防并发症有着明显的作用。     

Relevance of emergency head CT scan for fall in the elderly person

ObjectivesFall of the elderly person is a public health problem. The objectives of our study were to evaluate the relevance of systematically performing in emergency a computed tomography (CT) scan for fall in the elderly person, to identify specific criteria predicting the appearance of lesions.Material and methodsWe performed a retrospective analysis of 500 consecutive patients aged 65 and over, who underwent an emergency head CT scan for fall from their height. Outcome at the end of the acute care, clinico-biological data and delays between trauma an d CT were collected, and crossed with a detection of head lesion on the CT scan.ResultsOf 500 patients, 38 (7.6%) had traumatic lesions depicted on the CT scan and 267 (53.4%) were hospitalized after the CT scan. Three (0.6%) had been operated for urgent head surgery. Nine of the 38 (23.6%) patients with traumatic lesion returned home. Presence of a lesion depicted on the CT scan was not correlated with the orientation of the patient (P < 0.0001). Post-traumatic injury was significantly associated with male sex (RR = 2.19, P = 0.0217), consciousness impairment (RR = 1.56, P < 0.0001), focal neurological deficit (RR = 6.36, P = 0.0362) and past history of post-traumatic brain injury (RR = 7.17, P = 0.0027). Anticoagulant therapy was not associated with increased risk of traumatic lesions (P = 0.3315). ROC analysis determined that a 5-hours time-interval between head trauma and CT allowed optimal detection of lesions.ConclusionThe systematic indication of an emergency head CT scan for fall in elderly patients presents a low diagnostic and therapeutic yield and is not relevant. Male sex, consciousness impairment, focal neurological deficit, past history of post-traumatic brain injury and time-interval between head trauma and CT are statistically related to the presence of lesions and should therefore be taken into account.     

创伤性脑血管损伤

颅脑创伤是现代人类社会的一大公害。在我国,随着交通运输、建筑及制造业的飞速发展,颅脑创伤已成为社会劳动力损失最重要的原因之一。以往的临床治疗和应用基础研究工作,要么缺少对原发脑血管损伤的独立研究,要么与创伤造成的神经组织损害相比,对颅脑创伤缺乏足够的关注,这就势必造成对继发性脑损伤的认识不足而影响治疗结果。近期,临床科研者已经开展了有关创伤后脑血管损伤许多工作,并取得了一定成果,相信这些不断的努力必将促进颅脑创伤救治理论的快速发展。     

Traumatic brain axonal injury produces sustained decline in intracellular free magnesium concentration

Decline in brain intracellular free magnesium concentration following experimental traumatic brain injury has been widely reported in a number of studies. However, to date, these studies have been confined to focal models of brain injury and temporally limited to the immediate 8-h period post-trauma. Recently, a new model of impact-acceleration brain injury has been developed which produces nonfocal diffuse axonal injury more typical of severe clinical trauma. The present study has used phosphorus magnetic resonance spectroscopy and the rotarod motor test to characterise magnesium homeostasis and neurologic outcome over a period of 8 days after induction of severe impact-acceleration injury in rats. Severe impact-acceleration induced injury resulted in a highly significant and sustained decline in intracellular free magnesium concentration that was apparent for 4 days post-trauma with recovery to preinjury levels by day six. There were no significant changes in pH or ATP concentration at any time point post-injury. All animals demonstrated a significant neurologic deficit over the assessment period. The extended period of magnesium decline after severe diffuse brain trauma suggests that repeated administration may be required for pharmacotherapies targeted at restoring magnesium homeostasis.     

促红细胞生成素抑制大鼠创伤性脑水肿形成

目的探讨促红细胞生成素(erythropoietin,EPO)对大鼠创伤性脑水肿的影响及其的潜在分子机制。方法取SD大鼠90只,随机分为假手术组,创伤组和EPO组。创伤组:制作改进式Feeney's脑创伤模型;EPO组:伤后给大鼠腹腔注射重组人促红细胞生成素(5000 IU/kg)。伤后24 h,72 h和120 h,使用平衡木法评定各组大鼠行为学评分。伤后72 h时,检测各组大鼠脑含水量,脑组织胞外调节蛋白激酶(extracellular regulated protein kinases,ERK)的磷酸化水平、水通道蛋白4(aquaporin 4,AQP4)mRNA和蛋白表达水平。结果在伤后各时间点,EPO组大鼠神经功能障碍的行为学评分也较创伤组有明显降低(均P<0.05)。伤后脑组织含水量由假手术组的78.76%±0.65%上升至创伤组的81.26%±0.40%(P<0.01),EPO组脑含水量则降低至79.71%±0.59%(与创伤组比较P<0.01)。与假手术组比较,创伤组ERK磷酸化的水平在伤后72 h明显上升(P<0.01),EPO组伤后ERK磷酸化水平则明显低于创伤组(0.369±0.046 vs.0.815±0.127,P<0.01);AQP4 mRNA和蛋白在伤后的表达水平均较假手术组明显增高(均P<0.01),EPO组AQP4 mRNA和蛋白的表达水平较创伤组均显著下降(均P<0.01)。结论EPO可抑制大鼠脑创伤后ERK信号通路的过度激活及下游AQP4的过表达,减轻大鼠的创伤性脑水肿。