Computed tomography in penetrating cranial injury by a wooden foreign body

We present a case in which the skull and brain were pierced by a piece of wood, the low attenuation value of which, in a CT scan, simulated an intracerebral pneumatocoele. The risk of misinterpreting the CT appearance of intracranial wood is discussed, and the importance of thorough exploration of a penetrating cranial injury is stressed.     

Necessity of monitoring after negative head CT in acute head injury

Objective

The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT).

Materials and methods

This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010–July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n = 2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72 h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication.

Results

The majority (n = 1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n = 27) of these patients returned to ED within 72 h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72 h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%.

Conclusion

In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.     

Sequential computerized tomography changes and related final outcome in severe head injury patients

Summary The authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan.92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%).Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes.Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.     

Proteolytic enzyme activity in patients with severe head injury and the effect of a proteinase inhibitor

Summary A study was performed to detect the inhibitory effect of intravenously administered aprotinin (Trasylol^®) on brain and CSF protease activity in 25 patients with severe head injury. The data presented include measurements of CSF protease activity, alpha-1-antitrypsin, alpha-2-macroglobulin, haptoglobulin, polyacrylamidgel-electrophoresis pattern, total protein and hemoglobin content. The results indicate that increased protease activity is present and that this induces autolytic processes which can be inhibited by aprotinin treatment. The survival rate was higher after aprotinin treatment. Total CSF protein content was significantly higher in nonsurvivors than in survivors.Dedicated to Professor Dr. F. Spath on occasion of his 80th birthday     

Clinical value of serial computed tomography with severe head injury

Serial computed tomography (CT) scanning was performed on 138 patients suffering from severe head injuries (i.e., with scores of 8 or less on Glasgow Coma Scale). Standard practice called for scans to be done upon admission (within hours of the injury) and after 1, 3, and 7 days and 1 month. Subsequent CT scans depended on the patient's condition. Clinical results at the time of discharge were graded according to the Glasgow Outcome Scale. During the serial CT scan, there were new findings (not visualized on the initial CT scan but appearing on subsequent scans) in 91 of the 138 patients. These new findings were classified into seven types: (1) decreased density collection in the subdural space; (2) ventricular dilatation; (3) intracerebral hematoma; (4) intraventricular hemorrhage; (5) extracerebral hematoma; (6) edema; and (7) infarction. We defined intracerebral hematoma, intraventricular hemorrhage, extracerebral hematoma, edema, and infarction as new lesions. Of the 60 patients with new lesions, 12 had a good outcome and 48 had a poor outcome. Of 78 patients who did not have any new lesions, 60 had a good outcome and 18 had a poor outcome. A significant correlation was found between good outcome and the absence of new lesions and between bad outcome and the development of new lesions (p < 0.001; x² = 44.038). We conclude that serial CT scanning can help predict the outcome of patients with severe head injuries and may be very important in their examination and care.     

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

IntroductionPatients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.MethodsFrom January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.ResultsIn our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p < 0.001), a Glasgow coma scale of 8 or less (p < 0.001), moderate or severe degrees of head injury severity scale (p < 0.001), positive physical examination findings (p < 0.001), and positive CT cranial abnormalities (p < 0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p < 0.001) and orbital fractures (p = 0.019).ConclusionsTBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.     

Implications of systemic hypotension for the neurological examination in patients with severe head injury

Thirty-six patients admitted with severe head injury and various degrees of systemic hypotension were studied to determine the effect of hypotension on the validity of the neurological examination in reflecting mechanical brain compression. All patients had clinical signs of transtentorial herniation or upper brainstem compression and underwent immediate bilateral placement of exploratory burr holes for the diagnosis and removal of intracranial hematomas. All patients were initially hypotensive: 10 were in cardiac arrest, 7 had a systolic blood pressure (SBP) < 60 torr, and 19 had SBP of 60–90 torr. The median score on the Glascow coma scale was 3 (range 3–8). Although 4 of the 10 cardiac arrest patients had anisocoria, only one (10%) had an intracranial hematoma. Among the seven patients with severe hypotension, only two had anisocoria and neither had an intracranial hematoma; one patient in this group (14%) had a hematoma that was diagnosed at autopsy. In contrast, intracranial hematomas were discovered by burr-hole placement and evacuated in 13 (68%) of 19 patients with initially moderate hypotension, including seven (78%) of nine patients with anisocoria. Anisocoria was associated with mechanical brain compression from an intracranial hematoma significantly more often in patients with an initial SBP of 60–90 torr than in those with initial cardiac arrest or SBP < 60 torr (chi-square p < 0.05). Intracranial hematomas were significantly more frequent among patients with SBP of 60–90 torr than among those with a lower SBP or initial cardiac arrest (p < 0.01). Thirty-three of 36 patients died; each of the three survivors had an initial SBP of 60–90 torr, and hematomas were removed in two. In head-injured patients with SBP > 60 torr, clinical signs of tentorial herniation or upper brainstem dysfunction remain valid indicators of possible mechanical compression; the high percentage of patients with acute intracranial hematomas in this group warrants immediate diagnostic burr-hole exploration. In patients with severe initial hypotension (SBP < 60 torr) or cardiac arrest, clinical findings of brainstem dysfunction cannot be relied upon to indicate mechanical compression, and computed tomography scanning should be done immediately after resuscitation to determine the need for surgical exploration.     

Computerized tomography (CT) in patients with head injuries

Summary In a retrospective series of 144 patients with cranial trauma admitted to the Department of Neurosurgery, 96 were initially examined by CT. The initial clinical assessment, operative findings, if any, and the clinical course were compared to the results of the primary CT scan. In patients presenting lateralizing deficits, 49% had lesions on the expected side, and 23% on the opposite side. Thirty-one per cent of brain stem affected patients had a supratentorial mass lesion requiring craniotomy. Three decerebrate patients who died had an initially normal CT scan. Thirty craniotomies were performed on the basis of the CT scans, and six cases deviated from the expected, but no case showed a false positive indication for surgery. The final diagnosis was in accordance with the initial clinical diagnosis, and with the initial CT scan in 44% and 84%, respectively, of all cases.Parts of the material have been presented at the Congress of Scandinavian Neurosurgical Society at Oulu, 1979.     

Moderate hypothermia therapy for patients with severe head injury

ＳＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ ,ＣｈｅｎｇｄｕＧｅｎｅｒａｌＨｏｓｐｉｔａｌｏｆＣｈｅｎｇｄｕＭｉｌｉｔａｒｙＣｏｍｍａｎｄ ,Ｃｈｅｎｇｄｕ 6 10 0 83,Ｃｈｉｎａ (ＣｈｅｎＬＧ ,ＰｉａｏＹＸ ,ＺｅｎｇＦＪ ,ＬｕＭ ,ＫｕａｎｇＹＱａｎｄＬｉＸ)ｉｎｃｅ 1990ｓ ,ｉｔｈａｓｂｅｅｎｐｒｏｖｅｄｂｙｃｌｉｎｉｃａｌｓｔｕｄｉｅｓａｔｈｏｍｅａｎｄａｂｒｏａｄｔｈａｔＭＨＴｉｓａｎｅｆｆｅｃｔｉｖｅａｎｄｓａｆｅｍｅｔｈｏｄ .1 3Ｔｏｂｅｔｔｅｒｕｎｄｅｒｓｔａｎｄｉｔｓｅｆｆｅｃｔａｎ…     

Transcranial doppler waveform differences in hyperemic and nonhyperemic patients after severe head injury

Although increased cerebral blood flow velocity is readily measured by transcranial doppler ultrasonography (TCD), the causes of the velocity elevation may differ. After severe head injury, increased blood flow velocity can develop both in patients with global hyperemia (suggestive of vasodilation) and in those without hyperemia (suggestive of vasospasm). The present study attempts to determine whether TCD can differentiate these two mechanisms of velocity increase.

Fourteen severely brain-injured patients who developed increased middle cerebral artery blood flow velocity (time-averaged mean velocity > 100 cm/s) were studied. Eight cases were nonhyperemic and six were hyperemic as defined by arterial-jugular venous oxygen content differences of more than 4 mL/dL and less than 4 mL/dL, respectively. The TCD waveform of all eight nonhyperemic cases showed a diastolic notch, which was absent in all six hyperemic patients (p = 0.00066). TCD waveform profile appears to provide a noninvasive means of differentiating at the bedside the two causes of increased flow velocity. If associated with raised intracranial pressure, these require different treatment.     

Minor,moderate and severe head injury

Summary The future role of the neurosurgeon in the management of head injury is reviewed in terms of the care of patients with minor, moderate and severe head injuries. In minor head injury it is predicted that there will be increasing pressure on the neurosurgeon to undertake the management and follow-up of all patients who have sustained head injury, and this will place a considerable additional load on each neurosurgical unit. This is based on a survey of 1919 head injuries admitted in one calendar year (1981), consisting of 93 severe injuries (GCS < 8), 210 moderate injuries (GCS 8–12), and 1616 minor injuries (GCS 13/14). In moderate injuries CT will assume a major role in detecting hematoma early and identifying contusions. There may yet be a role for steroids in these cases and there should be a greater use of neurorehabilitation, instead of the current overemphasis on the severely injured. In severe injury future efforts will be to prevent early secondary insults and to find better methods of controlling raised intracranial pressure.     

重型脑伤病人脑氧和脑温监护及其临床意义

目的研究急性重型脑伤患者亚低温期间,脑组织氧分压(PbtO2)及脑温(Tb)变化规律的临床意义及手术对脑温的影响。方法选择重脑伤患者116例随机分为两组:亚低温组和常温对照组各58例。进行亚低温治疗同时,用Licox-II型PbtO2、Tb监测仪,监测PbtO2、Tb1～7天,平均86小时,同时监测肛温、颅内压(ICP)、脑灌注压(CPP)、动脉氧分压(PaO2)、动脉二氧化碳分压(PaCO2)。随访6个月,以GOS评估法判断预后。结果116例严重脑伤病人24小时PbtO2均值13.7±4.94,比正常值偏低,亚低温组比常温对照组PbtO2恢复到平均低值时间缩短10±4.15小时(P<0.05)。降温组成活率60.43%,高于对照组46.55%。复温后PbtO2随脑温升高而增加。肛温(Tr)与Tb的变化:手术组低于正常差距,占66.7%;非手术组高于正常差距,占52.9%,两组有显著性差异。结论PbtO2、Tb直接监测技术安全可靠,对严重脑伤病人判定病情和指导治疗有重要意义。     

孕妇创伤性颅脑损伤临床特点与治疗

为提高孕妇颅脑损伤的救治水平,作者对22例孕妇颅脑损伤的临床资料进行分析,并观察东莨菪碱治疗作用。结果表明,脑挫裂伤合并脑内灶性出血多见(14/22),颅内血肿发生率低(8/22)。东莨菪碱对高颅压患者具有一定的降颅压作用。本组9例开颅手术,13例保守治疗。随访:2例轻残,20例治愈;婴、幼儿发育正常。结论:孕妇颅脑损伤及时正确处理,不影响正常妊娠。东莨菪碱尤其适用于妊娠高血压合并脑外伤患者。     

Prospective survey on neurosurgical intensive care for patients with severe head injury

ＴＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ ,ＧｅｎｅｒａｌＨｏｓｐｉｔａｌｏｆＴｉａｎｊｉｎＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ ,Ｔｉａｎｊｉｎ 30 0 0 5 2 ,Ｃｈｉｎａ (ＹａｎｇＸＪ ,ＹａｎｇＳＹ ,ＷａｎｇＭＬａｎｄＧａｏＹＺ)ｈｅｍａｒｋｅｄｉｍｐｒｏｖｅｍｅｎｔｏｆｃｕｒａｔｉｖｅｏｕｔｃｏｍｅｆｏｒｓｅｖｅｒｅｈｅａｄｉｎｊｕｒｙｉｓａｓｃｒｉｂｅｄｔｏｕｎｄｅｒｓｔａｎｄｉｎｇｏｆｉｔｓｐａｔｈｏｐｈｙｓｉｏｌｏｇｙａｎｄａｄｏｐｔｉｎｇａｎｉｎｔｅｎｓｉｖｅａｐｐｒｏａｃｈｆｏｒｐ…     

An outcome study of severe traumatic head injury using the "Lund therapy" with low-dose prostacyclin

Background: There are two independent head injury outcome studies using the “Lund concept”, and both showed a mortality rate of about 10%, and a favourable outcome (Glasgow outcome scale, GOS 4 and 5) of about 70%. The Lund concept aims at controlling intracranial pressure, and improving microcirculation around contusions. Intracranial pressure is controlled by maintaining a normal colloid osmotic pressure and reducing the hydrostatic capillary pressure. Microcirculation is improved by ensuring strict normovolaemia and reducing sympathetic discharge. The endogenous substance prostacyclin with its antiaggregatory/antiadhesive effects may further improve microcirculation, which finds support from a microdialysis‐based clinical study and an experimental brain trauma study. The present clinical outcome study aims at evaluating whether the previously obtained good outcome with the Lund therapy can be reproduced, and whether the addition of prostacyclin has any adverse side‐effects. Methods: All 31 consecutive patients with severe head injury, Glasgow coma scale (GCS) ≤8, admitted to the University Hospital of Umeå during 1998 were included. The Lund therapy including prostacyclin infusion for the first three days at a dose of 0.5 ng kg^?1 min^?1. Outcome was evaluated according to the GOS >10 months after the injury. Results: One patient died, another suffered vegetative state and 7 severe disability. Of the 22 patients with favourable outcome, 19 showed good recovery and 3 moderate disability. No adverse side‐effects of prostacyclin were observed. Conclusion: The outcome results from previous studies using the Lund therapy were reproduced, and no adverse side‐effects of low‐dose prostacyclin were observed.     

Early ischaemia after severe head injury preliminary results in patients with diffuse brain injuries

Summary Ischaemic brain lesions still have a high prevalence in fatally head injured patients and are the single most important cause of secondary brain damage. The present study was undertaken to explore the acute phase of severely head injured patients in order to detect early ischaemia using Robertson's approach of estimating cerebral blood flow (CBF) from calculated arterio-jugular differences of oxygen (AVDO₂), lactates (AVDL), and the lactate-oxygen index (LOI).Twenty-eight cases with severe head injury were included (Glasgow Coma Scale Score below or equal to 8). All patients but one had a non-missile head injury. All the patients had a diffuse brain injury according to the admission CT scan. ICP measured at the time of admission was below 20 mmHg in 17 cases (61%). All patients were evaluated with the ischaemia score (IS) devised in our center to evaluate risk factors for developing ischaemia. Mean time from injury to the first AVDO₂/AVDL study was 23.9±9.9 hours.According to Robertson's criteria, 13 patients (46%) had a calculated LOI (-AVDL/AVDO₂) value above or equal to 0.08 and therefore an ischaemia/infarction pattern in the first 24 hours after the accident. Of the 15 patients without the ischaemia/infarction pattern, in three cases the CBF was below the metabolic demands and therefore in a situation of compensated hypoperfusion. No patient in our series had hyperaemia. Comparing different variables in ischaemic and non-ischaemic patients, only arterial haemoglobin and ischaemia score (IS) was significantly different in both groups. The ischaemia score had mean of 4.3±1.7 in the ischaemic group and 2.7±1.4 in non-ischaemic patients (p=0.01). It is concluded that ischaemia is highly prevalent in the early period after severe head injury. Factors potentially responsible of early ischaemia are discussed.     

Cerebral lactate production in relation to intracranial pressure,cranial computed tomography findings,and outcome in patients with severe head injury

Summary Severe head injury is frequently associated with focal or global disturbances of cerebral blood flow and metabolism. Routine monitoring of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in these patients does not provide information about critically reduced local or global cerebral blood flow. Measurements of cerebral lactate difference, Lactate-Oxygen-Index (LOI) and cerebral oxygen extraction were evaluated for advanced monitoring by comparing these parameters with ICP, cranial computed tomography (CCT) findings, and outcome in a group of severely head-injured patients.In 21 patients with severe brain trauma (GCS 8), arterial as well as jugular venous lactate levels and oxygen saturation were measured in vitro every 6 h after admission of patients to the intensive care unit (ICU) throughout the acute course of treatment. Arterial blood pressure, blood gases, and ICP were assessed by standard monitoring measurements. CCT was performed initially after admission of the patients to the hospital, during the acute period in the ICU, if indicated, and 10 to 14 days after trauma. Outcome was classified according to the Glasgow outcome scale (GOS) at six months after injury. Data were averaged in each patient for every day after trauma and over the entire monitoring period. Resulting values were tested for correlation by regression analysis. Additionally, the data of the group of patients with normal to minimally elevated mean ICP (ICP<20 mmHg, n=12) were compared to those of the patients with increased mean ICP (ICP>20 mmHg, n=9).The cerebral lactate difference in all patients on the day of trauma was significantly increased as compared to the later period (0.20 vs. 0.11-0.07 mmol/L, p<0.05), but was not different with high or normal to minimally elevated ICP. In patients with intracranial hypertension, the cerebral lactate difference remained significantly increased from the first to the fifth day after injury, whereas it normalized in this period in the group with normal to minimally elevated ICP. Averaged over the acute course, patients with increased ICP had significantly higher mean lactate differences (0.18±0.16 vs. 0.067±0.025 mmol/L, p=0.001) and higher mean LOIs (0.072±0.071 vs. 0.028±0.013, p=0.011). There was a significant correlation of increased mean cerebral lactate difference to poor outcome (r=0.46, p=0.035). Cerebral oxygen extraction in all patients tended to increase on the day of trauma (36.7% vs. 29.2% to 31.5% during the subsequent course), but this difference was not significant. The initial degree of brain swelling, classified by CCT according to Marshallet al. (1991), showed no correlation with cerebral lactate differences, ICP, O₂-extraction, or outcome. Neither was there a correlation of cerebral oxygen extraction to ICP nor to outcome.In conclusion, the severity of brain trauma and outcome of patients was reflected by increased cerebral lactate production. Unchanged values of global cerebral oxygen extraction suggest that the regulatory mechanisms of brain oxygen supply were not impaired by trauma. Measurements of cerebral lactate differences and brain oxygen extraction may contribute to advanced monitoring in severe head injury.     

Compliance with evidence-based guidelines for computed tomography of children with head and abdominal trauma

Introduction

Recently, two large prospective clinical trials developed and validated prediction rules for children at very low risk for clinically important traumatic brain injuries (ciTBI) or abdominal injury for whom CT is unnecessary. Specific criteria/guidelines were identified which if met would obviate the need for CT scanning. The purpose of this study was to assess compliance at a level one pediatric center with these guidelines as a tool for quality improvement.

Clinical outcome and cognitive impairment in patients with severe head injuries treated with barbiturate coma

Summary This study reports on clinical outcome in 38 patients with severe head injuries (posttraumatic coma for 6 hours or more) treated with barbiturate coma because of intracranial hypertension. Eighteen patients died, 4 patients remained in a severely disabled or a chronic vegetative state, and 16 patients reached the levels good recovery/ moderate disability. Six of these patients returned to work or school full time, 4 for half time and 3 were in a rehabilitation program. Fourteen patients were subjected to a comprehensive neuropsychological assessment. All patients except one exhibited varying degrees of cognitive dysfunction and 6 patients had signs of personality change. The quality of life for the majority of surviving patients was relatively good but the positive effects of barbiturate coma therapy in the age groups over 40 years appeared to be limited.     

Cautious observation or blanket scanning? An investigation into paediatric attendances to an emergency department after head injury

In September 2007, the National Institute for Health and Clinical Excellence (NICE) in the UK issued a newly updated guideline (CG56) on the early care of adults and children with head injuries.⁸ The guideline gives some new recommendations, in particular with regards to imaging of children with head injury.We undertook a study to investigate the management of children presenting with head injury to our emergency department and to assess their outcomes and the CT scanning rate. We then retrospectively applied the new NICE guidelines, using information documented in the case notes, to establish whether adherence to the guidelines would significantly affect CT scanning rates.237 paediatric head injury cases were seen over the 2-month period that was studied. The actual CT scanning rate observed was 2.1%, rising to 18.1% after strictly applying NICE criteria. This increased scanning rate raises some important issues with regards to patient safety and service provision.