Dexamethasone in severe head injuries

Summary The results of a double-blind-study on the effects of placebo, a low dose and a high dose of dexamethasone on severe closed head injury are presented. 95 patients were selected and carefully analyzed according to mortality, neurological course and symptoms, midbrain lesions and final outcome. The results demonstrate that dexamethasone, particularly given in high doses, reduces mortality and improves the neurological course. The steroid treatment seems to improve chances as well as quality of survival. Apart from the dose, timing of administration is of great importance.

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Zusammenfassung Es werden die Ergebnisse einer Doppel-Blind-Studie über die Auswirkungen von Placebo, niedriger und hoher Dosierung von Dexamethason bei schweren gedeckten Schädel-Hirn-Verletzungen mitgeteilt. Die Daten von 95 Patienten wurden sorgfältig analysiert in bezug auf Mortalität, neurologischen Verlauf und neurologische Symptome, Mittelhirn-Läsionen und Endzustand. Die Ergebnisse zeigen, daß Dexamethason, besonders in hoher Dosis, die Mortalität senkt und den neurologischen Verlauf bessert. Die Steroid-Behandlung scheint sowohl die Überlebens-Chance wie auch -Qualität zu verbessern. Neben der Dosierung kommt dem Zeitpunkt der Verabreichung große Bedeutung zu.

     

Primary brain stem lesions caused by closed head injuries

Traumatic lesions of the brain stem are of two types: primary, which are considered to be caused at the moment of impact, and secondary, associated with supratentorial mass lesion. Of the 239 patients with a serious head injury who showed a severe disturbance of consciousness upon admisision and who had CT scan carried out immediately, 21 cases were considered to have a primary brain stem lesion with initial CT scan. A primary brain stem lesion was found in 21 of 239 (8.8%) of patients with serious head injury. Their injuries were caused primarily by traffic accidents. Sixteen of the 21 cases showed not only brain stem lesions but also other brain injuries such as cerebral contusion of the white and gray matter, callosal injury, intraventricular hemorrhage, and subarachnoid hemorrhage, which are considered to be caused by a diffuse shearing injury. Five cases who showed a single injury to the brain stem with no other brain lesions were considered to have a pure brain stem lesion. Primary brain stem lesions were observed on the dorsal side of the midbrain, where they can be differentiated from secondary brain stem lesions. These lesions are considered to result from the shearing mechanism in and around the brain stem very close to the tentorial edge, or to an injury of the lower brain stem by hyperextension of the cervical vertebrae. The prognosis of patients with a primary brain stem lesion was usually unfavorable, except in those with a single brain stem lesion.     

Cycling injuries and alcohol

BackgroundMost of the cycling accidents that occur in Finland do not end up in the official traffic accident statistics. Thus, there is minimal information on these accidents and their consequences, particularly in cases in which alcohol was involved. The focus of the present study is on cycling accidents and injuries involving alcohol in particular.MethodsData on patients visiting the emergency department at North Kymi Hospital because of a cycling accident was prospectively collected for two years, from June 1, 2004 to May 31, 2006. Blood alcohol concentration (BAC) was measured on admission with a breath analyser. The severity of the cycling injuries was classified according to the Abbreviated Injury Scale (AIS).ResultsA total of 217 cycling accidents occurred. One third of the injured cyclists were involved with alcohol at the time of visiting the hospital. Of these, 85% were males. A blood alcohol concentration of ≥ 1.2 g/L was measured in nearly 90% of all alcohol-related cases. A positive BAC result was more common among males than females (p < 0.001), and head injuries were more common among cyclists where alcohol was involved (AI) (60%) than among sober cyclists (29%) (p < 0.001). Two thirds (64%) of the cyclists with AI were not wearing a bicycle helmet. The figure for serious injuries (MAIS ≥ 3) was similar in both groups. Intoxication with an alcohol level of more than 1.5 g/L and the age of 15 to 24 years were found to be risk factors for head injuries. The mean cost of treatment was higher among sober cyclists than among cyclists with AI (€2143 vs. €1629), whereas in respect of the cost of work absence, the situation was the opposite (€1348 vs. €1770, respectively).ConclusionsCyclists involved with alcohol were, in most cases, heavily intoxicated and were not wearing a bicycle helmet. Head injuries were more common among these cyclists than among sober cyclists. As cycling continues to increase, it is important to monitor cycling accidents, improve the accident statistics and heighten awareness of the risks of head injuries when cycling under the influence of alcohol.     

Fixation of femoral fractures in multiple-injury patients with combined chest and head injuries

Background: The purpose of the present paper was to study the effects of a femoral shaft fracture and its early stabilization on the morbidity, mortality, and outcome of multiple‐injury patients with combined blunt head and chest trauma. The clinical course of patients was analysed using a prospectively gathered data base. Methods: Out of 352 multitrauma patients, from September 1992 to June 2000, we identified 28 patients with combined blunt chest and head trauma (abbreviated injury scale ≥ 2) and a femoral fracture as the study group. A total of 120 patients with combined chest and head trauma but without femoral fracture formed the control group. Parameters examined included injury severity, injury pattern, haemodynamics at admission, mortality, duration of ventilation, length of stay in intensive care unit, and outcome. Results: There were no significant differences regarding the demographics and injury severity (injury severity score) between the two groups. No significant differences were found in terms of mortality, duration of ventilation\intensive care unit stay and outcome. Injury severity (P < 0.0001), age (P = 0.0153), and haemodynamics at admission (P = 0.0036) were shown to have a significant effect on mortality and outcome. Injury severity (P < 0.0001) and age (P = 0.017) had a significant effect on the duration of ventilation\intensive care unit stay. Conclusions: The present study suggests that a femoral shaft fracture and its early stabilization in a multitrauma patient with combined chest and head injury do not adversely affect mortality and outcome and supports aggressive surgical management for these patients.     

Combined orbito-frontal,sub- and infratemporal fossa approach to skull base neoplasms

Summary Neoplasms located along the antero-lateral skull base, with probable involvement of the orbit and with extension into the pterygoid and/or infratemporal fossa can usually not be sufficiently exposed using standard neurosurgical or otosurgical approaches, which is why combined approaches to these skull base targets have been developed in the recent past. In this report we describe our experience, using a combined orbito-frontal, sub- and infratemporal fossa approach which, starting with a pre-auricular incision and a standard pterional craniotomy, is extended to an extensive osteoplastic enbloc resection of the orbito-zygomatic area allowing for direct visualisation of the antero-temporo-lateral skull base from the orbital cavity to the depth of the infratemporal and pterygoid fossa. The surgical technique as well as the clinical experiences accumulated with this approach are described.     

Gunshot wounds to the head: gang- and non-gang-related injuries and outcomes

Primary objective: This study examined the differences between gang and non-gang-related incidents of penetrative missile injuries in terms of demographics, motivation, intra-cranial pathology, transit time, injury time and clinical outcome. Research design: Retrospective and prospective chart review. Methods and procedures: Between 1985-1992, 349 patients with penetrating missile injuries to the brain presenting to LAC-USC were studied. Experimental interventions: Inclusion criteria were implemented to keep the cohort as homogenous as possible. Patients excluded were those with multiple gunshot wounds, non-penetrating gunshot wounds to the head, systemic injuries and cases in which the motivation for the incident was unknown. Main outcomes and results: Gang-related shooting slightly out-numbered non-gang-related incidents. Demographic analysis showed both a male and Hispanic predominance for both gang- and non-gang-related victims and significant differences in gender, race and age. Occipital entrance sites were more common in the gang-related vs temporal entrance sites in the non-gang-related. Mean transit time to the emergency department for gang-related shootings was less than non-gang-related shootings (24.4 vs 27.8 minutes). Most shooting incidents took place between 6 pm and 3 am. No difference between survival and outcome was noted between gang and non-gang victims. Conclusions: Significant differences were found between gang- and non-gang-related shooting victims in terms of demographics, entrance site and transit time. No difference was found between injury time, survival and outcome between gang and non-gang populations.     

Barbiturates in severe head injuries?

Possible mechanisms for the therapeutic effects of barbituric acid derivatives in severe head injuries have been discussed for half a century. In the following, a survey of the literature, and a discussion of three controlled clinical studies available until now is presented. A proven effect in terms of a beneficial long-term outcome for all injured patients has not been established.On the other hand there might be a subgroup of patients with an intact CO₂ reactivity of the brain vessels who may profit from barbiturates administered after head trauma.Dedicated to Marianne and Gerhard Winkler     

Complications and side effects during thiopentone therapy in patients with severe head injuries

This study reports all complications and side effects occurring in 38 patients with severe traumatic brain lesions treated with barbiturate coma because of a dangerous increase in intracranial pressure. The treatment was induced by intravenous infusion of thiopentone (5-11 mg.kg-1) followed by a continuous infusion of 4-8 mg.kg-1.h-1. The subsequent rate of thiopentone infusion was governed by the level of the intracranial pressure with the intention of keeping ICP below 20 mmHg (2.7 kPa). The duration of treatment was 1-15 days. Arterial hypotension occurred in 58%, hypokalemia in 82%, respiratory complications in 76%, infections in 55%, hepatic dysfunction in 87% and renal dysfunction in 47% of the patients. Twenty patients survived. Mortality in 17 patients was caused by an untreatable increase in intracranial pressure. In one patient complications due to barbiturate treatment may have contributed to the fatal outcome. In none of the other cases were the noted complications and side effects associated with any permanent symptoms or dysfunctions.     

The future role of neurosurgery in the care of head injuries

Summary Head injuries are major cause of death and disability under the age of 45 years even in developing countries. Mortality and morbidity are frequently due to avoidable secondary brain damage in patients whose initial injury was not very severe. Optimal care depends on neurosurgeons defining clear management policies for injuries of all severities so that other surgeons know which patients need neurosurgical care and know how to deal with the others. More patients need to go to neurosurgeons; only specialized centers dealing with many cases can develop advanced clinical skills and have the capability to carry out major clinical research. In the competitive world of high technology medicine neurosurgery needs to deliver good care for head injuries in the community as a whole if it is to attract substantial support.     

Snowboarding injuries: Comparison of injuries in snowboarders and skiers

To clarify the characteristics of injuries occurring in snowboarding accidents, we compared, injuries in 138 snowboarders and 128 skiers (aged 15–35 years), injured at the “H” Ski Resort. In the snowboarder group, injuries to the upper extremities, particularly the wrist joint, were more frequent, whereas injuries to the lower extremities, particularly the knee joint, were less frequent. As for the type of injury, fractures were more frequent in snowboarders, while sprains and ligament injuries were less frequent. Fractures, sprains of the wrist joint, and contusions of the shoulder were more frequent in snowboarders, with sprains of the knee joint and the thumb were being less frequent. The duration of sporting activity was significantly longer in snowboarders. Injuries to snowboarders occurred more often while they were traveling at “reckless speed” on moderate slopes. There were no significant differences in skill levels between the two groups. Differences between the snow boarders' and skiers' boots and differences in sliding on boards and on skis are believed to have contributed to the differences in their injuries. Our analysis indicates that it is necessary to create slopes that are safe and enjoyable for board riders as well as skiers. Lessons are also recommended so that snowboarders learn the proper technique, and understand the general principles of slope safety; the potential for injury would thus be reduced.     

Combined tracheoesophageal injuries

From 1974 through 1984, 23 patients with combined tracheoesophageal injuries from penetrating wounds were treated. Physical examination, endoscopy, a barium swallow, or a combination of these techniques confirmed the diagnosis preoperatively in 19 patients. A variety of operative techniques were used, with 20 of 23 repairs involving some type of primary repair of the trachea and esophagus, such as side repair or end-to-end anastomosis, with or without a tracheostomy. Major complications occurred in 74 percent of the patients and included eight cases of pneumonia, eight esophageal leaks, six tracheoesophageal fistulas, five mediastinal abscesses, four wound infections, and two carotid artery blowouts. To decrease the number of complications, several refinements in operative technique have been suggested.     

Hyperaemia prior to acute cerebral swelling in severe head injuries: The role of transcranial doppler monitoring

Summary Acute cerebrovascular congestion after a closed head injury is significantly related to intracranial hypertension. As an indirect method of cerebral blood flow measurement, transcranial doppler sonography (TCD) provides a rapid and noninvasive assessment of cerebral haemodynamics, including hyperaemic conditions.TCD examinations was serially performed in 35 patients with severe head injury with intact cerebral circulation; i.e. the mean flow velocity (MFV) patterns of the middle cerebral artery (MCA) did not show signs of cerebral circulatory arrest such as systolic spike, to and fro, or no flow. The results showed that the MFV of the MCAs and ipsilateral extracranial internal carotid arteries (ICAs) in 9 of these patients increased sharply and pulsatility index (PI) decreased during 48–96 hours after the injury. This was soon followed by patterns of high intracranial resistance, consistent with elevated intracranial pressure (ICP) in monitored patients and acute brain swelling on repeated computed tomographic (CT) scans. The correlation between increased MFVs, decreased PIs, and cerebral haemodynamic changes leading to acute brain swelling is discussed.The number of patients who ended with severe disability, vegetative state, or death was 66% in this group of 9 patients, compared to only 34% for the 35 patients overall with severe head injury. Though the morbidity and mortality rates largely depend on the primary injury, the presence of acute cerebral swelling aggravate the grave course in these patients. And the ability of TCD to monitor the hyperaemic state prior to oedema should lead us to adjust the therapy in order to minimize the secondary insult related to intracranial hypertension.     

Combined high cervical spine and brain stem injuries: a complex and devastating injury in children

Background

In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions.

Methods

Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale <8).

Results

Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 ± 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery.

Conclusions

Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory.     

Neuropsychological function 23 years after mild traumatic brain injury: a comparison of outcome after paediatric and adult head injuries

Primary objective: To the authors' knowledge no study comparing very long-term neuropsychological outcome after mild paediatric and adult traumatic brain injury (TBI) has been published. The primary objective of this study was to compare neuropsychological outcome 23 years after mainly mild paediatric and adult TBI.

Research design: The study was a neuropsychological follow-up 23 years after a prospective head injury study conducted at a Norwegian public hospital.

Methods and procedures: One hundred and nineteen patients were assessed with a comprehensive neuropsychological test battery. Of these, 45 were paediatric TBI and 74 were adult TBI.

Main outcomes and results: Both the paediatric and adult groups obtained scores in the normal range. In the paediatric group significant relationships were found between head injury severity and current neuropsychological function. The most important predictors of poor outcome were length of post-traumatic amnesia (PTA) and a combination of PTA and EEG pathology within 24 hours of injury. No influence of pre- and post-injury risk factors on current neuropsychological function was evident.

Conclusions: The findings indicate that children sustaining complicated mild TBI may be more vulnerable to development of chronic mild neuropsychological dysfunction than adults sustaining similar head injuries.     

关节镜手术治疗前交叉韧带并半月板损伤

目的 探讨关节镜手术治疗前交叉韧带(ACL)合并半月板损伤的方法及疗效.方法 关节镜下对135例ACL合并半月板损伤患者行ACL重建,同时行半月板修复或半月板修整.结果 患者均获随访,时间3～12个月,术后未出现关节粘连、血管神经损伤等并发症,半月板修整患者均无交锁且回旋挤压试验阴性.半月板修复患者3个月时随访,回旋挤压试验阳性1例;12个月时随访,回旋挤压试验阳性3例,交锁1例,两者都有1例.Lysholm评分:手术前为(46.3±6.2)分,术后6个月为(73.4±7.6)分,术后12个月为(87.8±8.2)分,术前与术后比较差异有统计学意义(P<0.01).结论 ACL与半月板常同时损伤,手术前应作好ACL重建及半月板修复或修整准备,关节镜同期治疗ACL并半月板损伤可取得较好疗效.     

The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries

BACKGROUND: The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies. METHODS: Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay. RESULTS: Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs. CONCLUSIONS: Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.     

Use of a Simulation Model to Investigate the Mechanisms of Sports-related Head Injuries

A simulation model was developed to better understand the mechanisms of brain injuries in sports. A three-dimensional model comprising approximately 1.22 million elements was constructed from cranial computed tomography images of adult male volunteers by the voxel method. To simulate contact sports that permit actions such as tackling, a sinusoidal wave with duration of 10 ms and maximum acceleration of 2000 m/s² was applied to the lowest point of the model to apply rotational acceleration to the head from different directions. The von Mises stress was then observed at five points in the coronal plane of the brain: cingulate gyrus (CG), corpus callosum (CC), brain stem (BS), lateral temporal lobe (LT), and medial temporal lobe (MT). LS-DYNA universal finite element analysis software with explicit time integration was used for the analysis. Concentrations of stress started to appear in the CC and BS at 10 ms post-impact, after which they also became evident in the CG and MT. The maximum changes in stress at each location occurred 10–15 ms post-impact. The von Mises stress was 9–14 kPa in the CG, 8–24 kPa in the CC, 12–24 kPa in the BS, 7–12 kPa in the LT, and 12–18 kPa in the MT. The highest stress in every part of the brain occurred after lateral impact, followed by oblique impact and sagittal impact. Such simulations may help elucidate the mechanisms of brain injuries in sports and help develop measures to prevent chronic traumatic encephalopathy.