Prognostic factors in the occurrence of posttraumatic epilepsy after penetrating head injury suffered during military service

Neurological Surgery Manpower Training and Density in Islamic Republic of Iran: A Population Study

BACKGROUND AND OBJECTIVES

Significant disparities in worldwide neurosurgical training and workforce distribution are prominent primarily in low-income and middle-income countries. Although Iran is considered a lower middle-income country, neurosurgical density and distribution in Iran has surpassed the recommended ratio of 1 neurosurgeon for every 100 000 population. The objective was to determine neurological surgery density and distribution in Iran and the factors significant in the relative success in training and allocation of neurosurgeons in Iran.

METHODS

Review of PubMed and administration of site surveys of multiple data sources including Neurosurgical Society of Iran, Iranian Board of Neurological Surgery, Medical Council of Islamic Republic of Iran, Universities of Medical Sciences in Iran, and Ministry of Health and Higher Education of Iran.

RESULTS

Over the 72-year period from 1952 to 2024, 1200 neurosurgeons have been trained and distributed in 31 provinces in Iran, attaining a ratio of 1.4/100 000 population. All but 40 neurosurgeons were trained after 1981, which coincided with the Iran-Iraq War. Decentralization of medical and neurosurgical residency training programs, resolving the immediate need for neurosurgeons managing penetrating traumatic brain and spinal cord injuries during the 1980 to 1988 Iran-Iraq War, and active participation of legislative and executive branches of government in solving health care disparities were major factors in meeting the needs of the country. At the present time, more than 555 neurosurgeons are practicing in Tehran Province, a proportion of 3.8 neurosurgeons for every 100 000 population, which indicates an element of disparity in density distribution across Iranian land.

CONCLUSION

Legislative initiatives and government support of public health care delivery and decentralization of medical and residency training programs after the Iran-Iraq War and introduction of the Ministry of Health and Medical Education are considered the main reasons for the relative success in meeting the neurosurgical demand and manpower density. Still, further adjustment of distribution of manpower is needed.

The Approach to Cranioorbital Gunshot Wounds

Gunshot wounds to the head result in significant morbidity with a low rate of survival. Current treatment recommendations for penetrating traumatic brain injury (pTBI), established in 2001, are based off techniques used in recent Middle Eastern conflicts. However, many advancements in care have been made and updates in official pTBI treatment guidelines are being formulated. While some penetrating brain injury patients are managed nonoperatively due to poor prognosis, many undergo emergent interventions and delayed reconstruction by various surgical subspecialists. This article explores the management of pTBI and the collaborative roles of neurosurgeons, ophthalmologists, and plastic surgeons.

Hospital-acquired infections as a risk factor for post-traumatic epilepsy: A registry-based cohort study

OBJECTIVE

Hospital-acquired infections are a common complication for patients with moderate or severe traumatic brain injury (TBI), contributing to morbidity and mortality. As infection-mediated immune responses can predispose towards epilepsy, we hypothesized that post-injury hospital-acquired infections increase the risk of post-traumatic epilepsy (PTE).

METHODS

A retrospective cohort study of adults with moderate to severe TBI was conducted using data from the Victorian State Trauma Registry in Australia. Infections were identified from the International Statistical Classification of Diseases and Related Health Problems 10th Revision-Australian Modification (ICD-10-AM) codes, and diagnosis of PTE was determined by the Glasgow Outcome Scale - Extended questionnaire regarding epileptic fits at 24 months follow-up.

RESULTS

Of all TBI patients (n = 15 152), 24% had evidence of having had any type of infection, with the most common being pneumonia, urinary tract, and respiratory infections. Of those who responded to the PTE question at 24 months (n = 1361), 11% had developed PTE. Univariable analysis found that the incidence of PTE was higher in patients who had any type of infection compared to patients without an infection (p < 0.001). After adjustment for covariates associated with both development of PTE and risk of infection, multivariable analysis found a solid association between infection and PTE (adjusted RR = 1.59; 95% CI: 1.11-2.28; p = 0.011). Having any type of complicating infection acquired during admission was also associated with poor GOSE outcomes at subsequent follow-ups (adjusted OR = 0.20; 95% CI: 0.11-0.35, p < 0.001).

SIGNIFICANCE

These findings suggest that hospital-acquired infections contribute to PTE development after TBI. Future investigation into infections as a modifiable target to reduce poor outcomes after TBI is warranted.

PLAIN LANGUAGE SUMMARY

Hospital-acquired infections are common in patients with traumatic brain injuries. A database study of adults with moderate or severe brain injuries in Australia examined whether these infections are associated with the development of epilepsy after a brain injury. 24% of patients had infections, with pneumonia and urinary tract infections being the most common. Of those surveyed 2 years after the injury, 11% developed post-traumatic epilepsy. Patients with infections had a significantly higher risk of epilepsy, even when accounting for other known risk factors, and infections were also linked to poor outcomes more broadly. The study suggests that preventing hospital-acquired infections could be a crucial target for improving outcomes after traumatic brain injuries.

Low-velocity penetrating brain injury: a review of the literature and illustrative case

INTRODUCTION

Low-velocity penetrating brain injury (LVPBI) is a class of brain injury where a foreign object violates the skull and damages the brain. Such injuries are rare and consequently understudied.

CASE

As such, we report an illustrative case of a 29-year-old female with a dense, plastic spike penetrating her right orbit and into her midbrain. After assessment with a CT scan and angiography, the object was removed with careful attention to possible vascular injury. The patient had an uncomplicated post-operative course and received antibiotic and antiepileptic prophylaxis. She was discharged on post-operative day 5, experiencing only mild left-sided weakness.

DISCUSSION

Common concerns regarding LVPBI include infection, post-traumatic epilepsy, and vascular injury. A review of published LVPBI cases over the past 20 years demonstrated that most cases (55.2%) are due to accidents. Of patients undergoing surgery, 43.4% underwent a craniotomy, and 22.8% underwent a craniectomy. Despite the grave nature of LVPBI, only 13.5% of the patients died. Additionally, 6.5% of patients developed an infection over their clinical course.

CONCLUSION

In all, more reported cases further paint a picture of the current state of management and outcomes regarding LVPBI, paving the way for more cohesive guidelines to ensure the best possible patient outcomes.

Transorbital penetrating intracranial injury involving bilateral frontal lobes with evisceration of right eye: A case report

Key Clinical Message

Timely diagnosis, multidisciplinary surgical intervention, and appropriate imaging are crucial in managing transorbital-penetrating intracranial injuries (TOPIs), minimizing morbidity, and optimizing patient outcomes.

Abstract

Transorbital-penetrating intracranial injuries (TOPIs) are rare occurrences with potential for severe neurological complications and high mortality rates. Prompt diagnosis and management are essential to mitigate adverse outcomes. Understanding injury patterns and employing appropriate imaging modalities are crucial for effective surgical planning and patient care. We present a case of a 22-year-old male mechanic who sustained a TOPI involving bilateral frontal lobes with evisceration of the right eye following a workplace accident with a metal cutter. Upon arrival at the emergency department, the patient exhibited vision loss in the right eye, proptosis, and a dilated pupil. Imaging studies revealed the trajectory of a metal arrow through the right orbital roof, necessitating surgical intervention. A multidisciplinary team performed bifrontal craniectomy with duroplasty to remove the foreign body and address associated injuries. Postoperatively, the patient received broad-spectrum antibiotics and anticonvulsants, leading to full recovery and discharge on postoperative day 10. TOPIs present unique challenges due to their rarity and potential for devastating consequences. Our case highlights the importance of timely diagnosis, meticulous surgical planning, and multidisciplinary collaboration in achieving favorable outcomes. Radiological imaging plays a crucial role in guiding treatment decisions and optimizing patient care. This report underscores the significance of early surgical intervention, antimicrobial therapy, and prophylactic measures in reducing morbidity and mortality associated with TOPIs.

Insights into epileptogenesis from post-traumatic epilepsy

Post-traumatic epilepsy (PTE) accounts for 5% of all epilepsies. The incidence of PTE after traumatic brain injury (TBI) depends on the severity of injury, approaching one in three in groups with the most severe injuries. The repeated seizures that characterize PTE impair neurological recovery and increase the risk of poor outcomes after TBI. Given this high risk of recurrent seizures and the relatively short latency period for their development after injury, PTE serves as a model disease to understand human epileptogenesis and trial novel anti-epileptogenic therapies. Epileptogenesis is the process whereby previously normal brain tissue becomes prone to recurrent abnormal electrical activity, ultimately resulting in seizures. In this Review, we describe the clinical course of PTE and highlight promising research into epileptogenesis and treatment using animal models of PTE. Clinical, imaging, EEG and fluid biomarkers are being developed to aid the identification of patients at high risk of PTE who might benefit from anti-epileptogenic therapies. Studies in preclinical models of PTE have identified tractable pathways and novel therapeutic strategies that can potentially prevent epilepsy, which remain to be validated in humans. In addition to improving outcomes after TBI, advances in PTE research are likely to provide therapeutic insights that are relevant to all epilepsies.

Right-to-Left Displacement of an Airgun Lead Bullet after Transorbital Entry into the Skull Complicated by Posttraumatic Epilepsy : A Case Report

Penetrating head injury is a serious open cranial injury. In civilians, it is often caused by non-missile, low velocity flying objects that penetrate the skull through a weak cranial structure, forming intracranial foreign bodies. The intracranial foreign body can be displaced due to its special quality, shape, and location. In this paper, we report a rare case of right-to-left displacement of an airgun lead bullet after transorbital entry into the skull complicated by posttraumatic epilepsy, as a reminder to colleagues that intracranial metal foreign bodies maybe displaced intraoperatively. In addition, we have found that the presence of intracranial metallic foreign bodies may be a factor for the posttraumatic epilepsy, and their timely removal appears to be beneficial for epilepsy control.

Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq

OBJECTIVES

Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population.

METHODS

This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission.

RESULTS

Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001).

CONCLUSIONS

Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.

Outcomes Following Penetrating Brain Injuries in Military Settings: A Systematic Review and Meta-Analysis

OBJECTIVE

While neurosurgeons are experienced in treating penetrating brain injuries (PBIs) in civilian settings, much less is known about management and outcomes of PBIs in military settings.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data extracted included surgical management, age, gender, location/type of injury, initial Glasgow Coma Scale (GCS) score, and outcomes. The primary outcomes were last reported Glasgow Outcome Score (GOS) and mortality. The secondary outcomes included central nervous system infections, seizures, and cerebrospinal fluid leak/fistula. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used for outcome analysis.

RESULTS

Twelve studies with 1738 patients treated for PBIs in military settings were included. The weighted mean age was 27.8 years, 86.7% were male, and 64.3% underwent neurosurgical intervention. Most patients (64.3%) presented with a GCS score >8, while 31.0% presented in a coma (GCS score <8). Over a median last follow-up time of 9 months, 68.6% achieved a favorable (GOS = 4-5) outcome and 34.2% achieved a poor (GCS score = 1-3) outcome. The overall mortality was 18.0%. A meta-analysis was performed using 5 of 12 studies to evaluate the effect of the presenting GCS score on primary outcomes. Patients with an initial GCS score <8 had statistically significant lower odds of a favorable (GOS = 4-5) outcome (OR: 0.03; 95% CI: 0.00-0.19; P: 0.000) and higher odds of mortality (OR: 28.46; 95% CI: 8.62-94; P: 0.000) than patients with an initial GCS score >8. The pooled rates of central nervous system infection, seizures, and cerebrospinal fluid leak/fistula were 13.8%, 13.2%, and 5.4%, respectively.

CONCLUSIONS

In this first systematic review and meta-analysis of outcomes following combat-related PBIs, a GCS score >8 at presentation was found to be an important predictor of a favorable GOS and decreased mortality.

Hypoxia-inducible factor 1 alpha (HIF-1α) stimulated and P2X7 receptor activated by COVID-19, as a potential therapeutic target and risk factor for epilepsy

Based on available evidence, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a neuroinvasive virus. According to the centers for disease control and prevention (CDC), coronavirus disease 2019 (COVID-19) may cause epilepsy. In this line, COVID-19 can stimulate hypoxia-inducible factor-1 alpha (HIF-1α) and activate P2X7 receptor. Both HIF-1α and P2X7 receptors are linked to epileptogenesis and seizures. Therefore, in the current study, we suggested that COVID-19 may have a role in epileptogenesis and seizure through HIF-1α stimulation and P2X7 receptor activation. Consequently, pharmacological targeting of these factors could be a promising therapeutic approach for such patients.

Pediatric traumatic brain injury and a subsequent transient immune challenge independently influenced chronic outcomes in male mice

Traumatic brain injury (TBI) is a major contributor to death and disability worldwide. Children are at particularly high risk of both sustaining a TBI and experiencing serious long-term consequences, such as cognitive deficits, mental health problems and post-traumatic epilepsy. Severe TBI patients are highly susceptible to nosocomial infections, which are mostly acquired within the first week of hospitalization post-TBI. Yet the potential chronic impact of such acute infections following pediatric TBI remains unclear. In this study, we hypothesized that a peripheral immune challenge, such as lipopolysaccharide (LPS)-mimicking a hospital-acquired infection-would worsen inflammatory, neurobehavioral, and seizure outcomes after experimental pediatric TBI. To test this, three-week old male C57Bl/6J mice received a moderate controlled cortical impact or sham surgery, followed by 1 mg/kg i.p. LPS (or 0.9% saline vehicle) at 4 days TBI. Mice were randomized to four groups; sham-saline, sham-LPS, TBI-saline or TBI-LPS (n = 15/group). Reduced general activity and increased anxiety-like behavior were observed within 24 h in LPS-treated mice, indicating a transient sickness response. LPS-treated mice also exhibited a reduction in body weights, which persisted chronically. From 2 months post-injury, mice underwent a battery of tests for sensorimotor, cognitive, and psychosocial behaviors. TBI resulted in hyperactivity and spatial memory deficits, independent of LPS; whereas LPS resulted in subtle deficits in spatial memory retention. At 5 months post-injury, video-electroencephalographic recordings were obtained to evaluate both spontaneous seizure activity as well as the evoked seizure response to pentylenetetrazol (PTZ). TBI increased susceptibility to PTZ-evoked seizures; whereas LPS appeared to increase the incidence of spontaneous seizures. Post-mortem analyses found that TBI, but not LPS, resulted in robust glial reactivity and loss of cortical volume. A TBI × LPS interaction in hippocampal volume suggested that TBI-LPS mice had a subtle increase in ipsilateral hippocampus tissue loss; however, this was not reflected in neuronal cell counts. Both TBI and LPS independently had modest effects on chronic hippocampal gene expression. Together, contrary to our hypothesis, we observed minimal synergy between TBI and LPS. Instead, pediatric TBI and a subsequent transient immune challenge independently influenced chronic outcomes. These findings have implications for future preclinical modeling as well as acute post-injury patient management.

Rupture of the Superior Sagittal Sinus in Penetrating Head Injury-Management of a Rare Trauma Mechanism

Civilian penetrating head injury caused by foreign objects is rare in Germany (Europe), but can result in complex neurovascular damage. We report on a patient who in suicidal intent inflicted on himself a penetrating brain injury near the vertex with a captive bolt gun. A laceration at the junction of the middle to the posterior third of the superior sinus occurred by bolt and bone fragments leading to critical stenosis and subsequent thrombosis. Upon surgery, the proximal and distal sinus openings were completely thrombosed. The sinus laceration was closed by suture and the intraparenchymal bone fragments were retrieved. Postoperative angiography disclosed persistent occlusion of the superior sagittal sinus. The patient did not develop any symptoms due to venous congestion (edema, hemorrhage), suggesting sufficient collateral venous outflow. The patient completely recovered despite the complexity of the lesion.

Visual Disturbance Caused by a Nail Gun-Induced Penetrating Brain Injury

<p>Penetrating brain injury caused by a nail gun is an uncommon clinical scenario reported in the literature. A 36-year-old male presented with a nail that had penetrated through the occipital bone. He was alert and neurologically intact except for visual disturbance. Computed tomography (CT) of the brain showed the nail lodged at the occipital lobe and the parietal lobe, with minimal intracerebral hemorrhage. The nail was placed in the occipital lobe close to the superior sagittal sinus. We removed the nail with craniotomy since the entrance of the nail was close to the superior sagittal sinus. There were no newly developed neurological deficits postoperatively. Immediate postoperative CT showed no newly developed lesions. The patient recovered well without any significant complications. Two weeks postoperatively, magnetic resonance imaging showed no remarkable lesions. The visual disturbance was followed up at the outpatient department. To summarize, we report a rare case of penetrating head injury by a nail gun and discuss relevant aspects of the clinical management.</p>

Nonmissile penetrating head injury with a wooden table leg: An illustrative case

Penetrating head injuries are relatively uncommon and require a unique approach. This report highlights a previously unreported mechanism of injury with a table leg and the steps required to evaluate and promptly treat the patient.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Transorbital-penetrating intracranial injury due to a homemade metal arrow: A case report

A transorbital-penetrating intracranial injury (TOPI) is an unusual traumatic brain injury. This rare injury has the potential to result in serious and fatal brain damage with a high mortality rate and requires prompt multidisciplinary surgical intervention. Here, we describe an interesting case in which a patient who presented with accidental penetrating injuries of the brain was found to have a transorbital-penetrating intracranial injury (TOPI). We chose an anterior approach to the foreign body above the entrance wound for removal in a retrograde manner with fluoroscopic guidance. The patient remained well with no complications and was discharged on postoperative day 10. Reasonable diagnostic imaging, surgical planning, and careful post-surgery management can increase patients successful outcomes.

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A transorbital-penetrating intracranial injury (TOPI) is an uncommon traumatic brain injury.

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TOPIs have the potential to result in serious brain damage with a high mortality rate.

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An interesting case of accidental TOPI that was treated successfully with fluoroscopic guidance is presented.

Infections after a traumatic brain injury: The complex interplay between the immune and neurological systems

Traumatic brain injury (TBI) is a serious global health issue, being the leading cause of death and disability for individuals under the age of 45, and one of the largest causes of global neurological disability. In addition to the brain injury itself, it is increasingly appreciated that a TBI may also alter the systemic immune response in a way that renders TBI patients more vulnerable to infections in the acute post-injury period. Such infections pose an additional challenge to the patient, increasing rates of mortality and morbidity, and worsening neurological outcomes. Hospitalization, surgical interventions, and a state of immunosuppression induced by injury to the central nervous system (CNS), may all contribute to the high rate of infections seen in the population with TBI. Ongoing research to better understand the immunomodulators that underlie TBI-induced immunosuppression may aid in the development of effective therapeutic strategies to improve the recovery trajectory for patients. This review first describes the clinical scenario, posing the question of whether TBI patients are more susceptible to infections such as pneumonia, and if so, why? We then consider how cross-talk between the injured brain and the systemic immune system occurs, and further, how the additional immune challenge of an acquired infection can contribute to ongoing neuroinflammation and neurodegeneration after a TBI. Experimental models combining TBI with infection are discussed, as well as current treatment options available for this double-barreled insult. The aims of this review are to summarize current understanding of the bidirectional relationship between the CNS and the immune system when faced with a mechanical trauma combined with a concomitant infection, and to highlight key outstanding questions that remain in the field.

Penetrating head trauma: 03 rare cases and literature review

Penetrating head trauma (PHT) include all open head injuries with foreign object in the brain. Although less common than closed head trauma, penetrating head trauma carry a worse prognosis. We received three unusual cases of penetrating head injuries whose prognosis was different according to clinical presentation and initial management of the patient. Treatment of penetrating head trauma aims at controlling bleeding, controlling intracranial pressure and preventing infections. Despite the efforts made by national authorities as well as the adequate management in hospitals, penetrating head injuries are still frequent with significant mortality and morbidity.

Genetic biomarkers of posttraumatic epilepsy: A systematic review

INTRODUCTION

Posttraumatic epilepsy (PTE) is caused by traumatic brain injury (TBI) and is an important contributor to the overall social and economic burden of epilepsy. Epidemiological studies suggest that there is a genetic contribution to the development of PTE. Identification of clinically useful genetic biomarkers is important for advancements in diagnosis and treatment of PTE.

METHODS

A systematic review was performed on the existing literature of genetic biomarkers of posttraumatic epilepsy (PTE). A multi-database search yielded 4 articles deemed suitable for review. Potential genetic biomarkers were identified and critically evaluated.

RESULTS & DISCUSSION

Biomarkers identified included single nucleotide polymorphism (SNP) rs1143634 of the interkeukin-1β (IL-1β) gene, SNPs rs3828275, rs3791878, and rs769391 of the glutamic acid decarboxylase 1 (GAD1) gene, SNPs rs3766553 and rs10920573 of the adenosine A1 receptor (A1AR) gene, and the functional variant C677T of the methylenetetrahydrofolate reductase (MTHFR) enzyme. The most promising biomarkers identified were IL-1β rs1143634 and A1AR rs10920573. Both had heterogenous at risk genotypes (CT). Those with IL-1β rs1143634 CT genotype developed PTE in 47.7% of cases (p=0.008) and those with A1AR rs10920573 CT genotype developed PTE in 19.2% of cases (p=0.022).

CONCLUSION

The majority of articles were preliminary with a need for validation of results. There is a need for continued high calibre research in order to validate the currently identified genetic biomarkers as well as to discover new genetic biomarkers in PTE.

Antiepileptic prophylaxis following severe traumatic brain injury within a military cohort

INTRODUCTION

Traumatic brain injury increases the risk of both early and late seizures. Antiepileptic prophylaxis reduces early seizures, but their use beyond 1 week does not prevent the development of post-traumatic epilepsy. Furthermore, prolonged prophylaxis exposes patients to side effects of the drugs and has occupational implications. The American Academy of Neurology recommends that antiepileptic prophylaxis should be started for patients with severe traumatic brain injury and discontinued after 1 week. An audit is presented here that investigates the use of prophylaxis in a cohort of military patients admitted to the UK Defence Medical Rehabilitation Centre (DMRC).

METHODS

Data were collected and analysed retrospectively from electronic and paper records between February 2009 and August 2012. The timing and duration of antiepileptic drug use and the incidence of seizures were recorded.

RESULTS

During the study period, 52 patients with severe traumatic brain injury were admitted to the rehabilitation centre: 25 patients (48%) were commenced on prophylaxis during the first week following injury while 27 (52%) did not receive prophylaxis. Only one patient (2%) received prophylaxis for the recommended period of 1 week, 22 patients (42%) received prophylaxis for longer than 1 week with a mean duration of 6.2 months. Two patients (4%) had post-traumatic epilepsy and started on treatment at DMRC.

CONCLUSIONS

The use of antiepileptic prophylaxis varies widely and is generally inconsistent with evidence-based guidance. This exposes some patients to a higher risk of early seizures and others to unnecessary use of antiepileptics. Better implementation of prophylaxis is required.

Surgical management of civilian gunshot wounds to the head

Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.

Penetrating brain injury after suicide attempt with speargun: case study and review of literature

Penetrating cranial injury by mechanisms other than gunshots are exceedingly rare, and so strategies and guidelines for the management of PBI are largely informed by data from higher-velocity penetrating injuries. Here, we present a case of penetrating brain injury by the low-velocity mechanism of a harpoon from an underwater fishing speargun in an attempted suicide by a 56-year-old Caucasian male. The case raised a number of interesting points in management of low-velocity penetrating brain injury (LVPBI), including benefit in delaying foreign body removal to allow for tamponade; the importance of history-taking in establishing the social/legal significance of the events surrounding the injury; the use of cerebral angiogram in all cases of PBI; advantages of using dual-energy CT to reduce artifact when available; and antibiotic prophylaxis in the context of idiosyncratic histories of usage of penetrating objects before coming in contact with the intracranial environment. We present here the management of the case in full along with an extended discussion and review of existing literature regarding key points in management of LVPBI vs. higher-velocity forms of intracranial injury.

Craniocerebral injury by penetration of a T-shaped metallic spanner: A rare presentation

BACKGROUND

Craniocerebral injuries caused by penetration of metallic foreign bodies present a significant challenge to neurosurgeons as an extensive surgery may be required, leading to high morbidity and mortality.

CASE DESCRIPTION

We describe a unique case of penetrating brain injury (PBI) caused by a T-shaped metallic spanner in an assault victim. The patient presented with profuse bleeding from the scalp and necrotic brain tissue evident at the point of entry of the retained short arm of the spanner. Skull X-ray and head computerized tomography (CT) revealed the short arm of spanner penetrating the left parieto-occipital lobe of the brain, extending up to the contralateral occipital lobe. Safe removal of the retained spanner was achieved with a craniectomy and durotomy. Postoperative CT revealed no residual metallic foreign body, and patient had a good functional and neurological outcome at six months' follow up.

CONCLUSION

To the best of our knowledge, the successful surgical treatment of a PBI caused by a similar metallic object has not been reported in scientific literature previously. The case is also unique considering the fact that it was managed within the medical and diagnostic constraints of an East African country.

Mapping connectivity damage in the case of Phineas Gage

White matter (WM) mapping of the human brain using neuroimaging techniques has gained considerable interest in the neuroscience community. Using diffusion weighted (DWI) and magnetic resonance imaging (MRI), WM fiber pathways between brain regions may be systematically assessed to make inferences concerning their role in normal brain function, influence on behavior, as well as concerning the consequences of network-level brain damage. In this paper, we investigate the detailed connectomics in a noted example of severe traumatic brain injury (TBI) which has proved important to and controversial in the history of neuroscience. We model the WM damage in the notable case of Phineas P. Gage, in whom a "tamping iron" was accidentally shot through his skull and brain, resulting in profound behavioral changes. The specific effects of this injury on Mr. Gage's WM connectivity have not previously been considered in detail. Using computed tomography (CT) image data of the Gage skull in conjunction with modern anatomical MRI and diffusion imaging data obtained in contemporary right handed male subjects (aged 25-36), we computationally simulate the passage of the iron through the skull on the basis of reported and observed skull fiducial landmarks and assess the extent of cortical gray matter (GM) and WM damage. Specifically, we find that while considerable damage was, indeed, localized to the left frontal cortex, the impact on measures of network connectedness between directly affected and other brain areas was profound, widespread, and a probable contributor to both the reported acute as well as long-term behavioral changes. Yet, while significantly affecting several likely network hubs, damage to Mr. Gage's WM network may not have been more severe than expected from that of a similarly sized "average" brain lesion. These results provide new insight into the remarkable brain injury experienced by this noteworthy patient.

Perforating brain injury from a speargun. A case report

A case of a perforating brain injury caused by a speargun in a suicide attempt is described. Although this kind of injuries has been previously reported, the present case is specially interesting because the patient showed no neurological deficit after surgery. Some advices about the medical and surgical management are proposed based on this case and our literature review. The use of antibiotics and antiepileptic drugs and the anterograde extraction of the harpoon aided by the performance of a craniotomy surrounding the exit point are recommended.

Management of penetrating brain injury

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.

Traumatic brain injury: a disease process, not an event

Traumatic brain injury (TBI) is seen by the insurance industry and many health care providers as an "event." Once treated and provided with a brief period of rehabilitation, the perception exists that patients with a TBI require little further treatment and face no lasting effects on the central nervous system or other organ systems. In fact, TBI is a chronic disease process, one that fits the World Health Organization definition as having one or more of the following characteristics: it is permanent, caused by non-reversible pathological alterations, requires special training of the patient for rehabilitation, and/or may require a long period of observation, supervision, or care. TBI increases long-term mortality and reduces life expectancy. It is associated with increased incidences of seizures, sleep disorders, neurodegenerative diseases, neuroendocrine dysregulation, and psychiatric diseases, as well as non-neurological disorders such as sexual dysfunction, bladder and bowel incontinence, and systemic metabolic dysregulation that may arise and/or persist for months to years post-injury. The purpose of this article is to encourage the classification of TBI as the beginning of an ongoing, perhaps lifelong process, that impacts multiple organ systems and may be disease causative and accelerative. Our intent is not to discourage patients with TBI or their families and caregivers, but rather to emphasize that TBI should be managed as a chronic disease and defined as such by health care and insurance providers. Furthermore, if the chronic nature of TBI is recognized by government and private funding agencies, research can be directed at discovering therapies that may interrupt the disease processes months or even years after the initiating event.

Impact of injury location and severity on posttraumatic epilepsy in the rat: role of frontal neocortex

Human posttraumatic epilepsy (PTE) is highly heterogeneous, ranging from mild remitting to progressive disabling forms. PTE results in simple partial, complex partial, and secondarily generalized seizures with a wide spectrum of durations and semiologies. PTE variability is thought to depend on the heterogeneity of head injury and patient's age, gender, and genetic background. To better understand the role of these factors, we investigated the seizures resulting from calibrated fluid percussion injury (FPI) to adolescent male Sprague-Dawley rats with video electrocorticography. We show that PTE incidence and the frequency and severity of chronic seizures depend on the location and severity of FPI. The frontal neocortex was more prone to epileptogenesis than the parietal and occipital, generating earlier, longer, and more frequent partial seizures. A prominent limbic focus developed in most animals, regardless of parameters of injury. Remarkably, even with carefully controlled injury parameters, including type, severity, and location, the duration of posttraumatic apnea and the age and gender of outbred rats, there was great subject-to-subject variability in frequency, duration, and rate of progression of seizures, indicating that other factors, likely the subjects' genetic background and physiological states, have critical roles in determining the characteristics of PTE.

Association of the severity of cortical damage with the occurrence of spontaneous seizures and hyperexcitability in an animal model of posttraumatic epilepsy

Posttraumatic epilepsy is a common consequence of traumatic brain injury in humans. Major predictors for the development of posttraumatic epilepsy include the severity of injury and occurrence of cortical contusions. The effect of the size or location of the cortical lesion on the risk of epileptogenesis, however, is poorly understood. Here, we investigated the extent and location of cortical damage and its association with a lowered seizure threshold and the occurrence of spontaneous seizures in rats (n=77) that had experienced moderate or severe lateral fluid-percussion brain injury (FPBI) 12 months earlier. Spontaneous seizures were detected with video-electroencephalography monitoring and a lowered seizure threshold was determined based on a pentylenetetrazol (PTZ) test. Cortical atrophy was evaluated from thionin-stained sections using the Cavalieri estimation in four different experiments in which rats developed either spontaneous recurrent seizures (i.e., epilepsy) or a lowered seizure threshold. Our data show that damage to the cortex ipsilateral to the injury was more severe and extended more caudally in epileptic animals than in those without epilepsy (p<0.05 and p<0.001 for 2 independent experiments). Further, the extent of the cortical damage correlated positively with chronically increased hyperexcitability (number of spikes in PTZ test) in animals with traumatic brain injury (r=-0.54, p<0.05; r=-0.72, p<0.01 for 2 independent experiments). Specifically, cortical lesions located at the level of the perirhinal, entorhinal, and postrhinal cortices were associated with a lowered seizure threshold and seizures. The severity of the cortical injury did not correlate with the severity of hippocampal damage. These findings indicate that, like in humans, the severity of cortical injury correlates with epileptogenesis and epilepsy in an experimental model of posttraumatic epilepsy.

Correlates of posttraumatic epilepsy 35 years following combat brain injury

BACKGROUND

The Vietnam Head Injury Study (VHIS) is a prospective, longitudinal follow-up of 1,221 Vietnam War veterans with mostly penetrating head injuries (PHIs). The high prevalence (45%-53%) of posttraumatic epilepsy (PTE) in this unique cohort makes it valuable for study.

METHODS

A standardized multidisciplinary neurologic, cognitive, behavioral, and brain imaging evaluation was conducted on 199 VHIS veterans plus uninjured controls, some 30 to 35 years after injury, as part of phase 3 of this study.

RESULTS

The prevalence of seizures (87 patients, 43.7%) was similar to that found during phase 2 evaluations 20 years earlier, but 11 of 87 (12.6%) reported very late onset of PTE after phase 2 (more than 14 years after injury). Those patients were not different from patients with earlier-onset PTE in any of the measures studied. Within the phase 3 cohort, the most common seizure type last experienced was complex partial seizures (31.0%), with increasing frequency after injury. Of subjects with PTE, 88% were receiving anticonvulsants. Left parietal lobe lesions and retained ferric metal fragments were associated with PTE in a logistic regression model. Total brain volume loss predicted seizure frequency.

CONCLUSIONS

Patients with PHI carry a high risk of PTE decades after their injury, and so require long-term medical follow-up. Lesion location, lesion size, and lesion type were predictors of PTE.

Unusual penetrating head injury in children: personal experience and review of the literature

INTRODUCTION

A penetrating head injury belongs to the most severe traumatic brain injuries, in which communication can arise between the intracranial cavity and surrounding environment.

DISCUSSION

The authors present a literature review and typical case reports of a penetrating head injury in children. The list of patients treated at the neurosurgical department in the last 5 years for penetrating TBI is briefly referred. Rapid transfer to the specialized center with subsequent urgent surgical treatment is the important point in the treatment algorithm. It is essential to clean the wound very properly with all the foreign material during the surgery and to close the dura with a water-tight suture. Wide-spectrum antibiotics are of great use. In case of large-extent brain damage, the use of anticonvulsants is recommended.

CONCLUSION

The prognosis of such severe trauma could be influenced very positively by a good medical care organization; obviously, the extent of brain tissue laceration is the limiting factor.

Prognostic factors in the persistence of posttraumatic epilepsy after penetrating head injuries sustained in war

Object

The goal of this paper was to investigate the long-term outcome and the possible prognostic factors that might have influenced the persistence of posttraumatic epilepsy after penetrating head injuries sustained during the Iraq–Iran war (1980–1988).

Methods

In this retrospective study, the authors evaluated 189 patients who sustained penetrating head injury and suffered posttraumatic epilepsy during the Iraq–Iran war (mean 18.6 ± 4.7 years after injury). The probabilities of persistent seizures (seizure occurrence in the past 2 years) in different periods after injury were estimated using the Kaplan-Meier method. The possible prognostic factors (patients and injury characteristics, clinical findings, and seizure characteristics) were studied using log-rank and Cox regression analysis.

Results

The probability of persistent seizures was 86.4% after 16 years and 74.7% after 21 years. In patients with < 3 pieces of shrapnel or no sphincter disturbances during seizure attacks, the probability of being seizure free after these 16 and 21 years was significantly higher.

Conclusions

Early seizures, prophylactic antiepileptics drugs, and surgical intervention did not significantly affect long-term outcome in regard to persistence of seizures.

[Penetrating head injury from harpoon. Case report]

The harpoon presence as aggressor weapon is unusual in the neurosurgical practice. Most cases are associated with diving or sport activities as result of imprudence. A 31 year old patient who sustained a penetrating craniocerebral injury with a fishing harpoon is presented and complementary exams, neurosurgical procedure and postoperative evolution are detailed. We discuss the management of this unusual injury and review the current literature on craniocerebral injuries caused by similar objects.