Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation?

BACKGROUND

Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS).

METHODS

The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head.

RESULTS

From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13).

DISCUSSION

Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.

Murine Traumatic Brain Injury Model Comparison: Closed Head Injury Versus Controlled Cortical Impact

INTRODUCTION

Various murine models have been utilized to study TBI, including closed head injury (CHI) and controlled cortical impact (CCI), without direct comparison. The aim of our study was to evaluate these models to determine differences in neurological and behavioral outcomes postinjury.

METHODS

Male C57B/6 mice (9-10 wk) were separated into six groups including: untouched, sham craniotomy (4 mm), CCI 0.9 mm depth of impact, CCI 1.6 mm, CCI 2.2 mm, and CHI. CCI was performed using a 3 mm impact tip at a velocity of 5 m/s, dwell time of 250 ms, and depth as noted above. CHI was completed with a centered 400 g weight drop from 1 cm height. Mice were survived to 14-d (n = 5 per group) and 30-d (n = 5 per group) respectively for histological analysis of p-tau within the hippocampus. These mice underwent Morris Water Maze memory testing and Rotarod motor testing. Serum was collected from a separate cohort of mice (n = 5 per group) including untouched, isoflurane only, CCI 1.6 mm, CHI at 1, 4, 6, and 24 h for analysis of neuron specific enolase and glial fibrillary acidic protein (GFAP) via ELISA. Laser speckle contrast imaging was analyzed prior to and after impact in the CHI and CCI 1.6 mm groups.

RESULTS

There were no significant differences in Morris Water Maze or Rotarod testing times between groups at 14- or 30-d. P-tau was significantly elevated in all groups except CCI 1.6 mm contralateral and CCI 2.2 mm ipsilateral compared to untouched mice at 30-d. P-tau was also significantly elevated in the CHI group at 30 d compared to CCI 1.6 mm contralateral and CCI 2.2 mm on both sides. GFAP was significantly increased in mice undergoing CHI (9959 ± 91 pg/mL) compared to CCI (2299 ± 1288 pg/mL), isoflurane only (133 ± 75 pg/mL), and sham (86 ± 58 pg/mL) at 1-h post TBI (P < 0.0001). There were no differences in serum neuron specific enolase levels between groups. Laser doppler imaging demonstrated similar decreases in cerebral blood flow between CHI and CCI; however, CCI mice had a reduction in blood flow with craniotomy only that did not significantly decrease further with impact.

CONCLUSIONS

Based on our findings, CHI leads to increased serum GFAP levels and increased p-tau within the hippocampus at 30-d postinjury. While CCI allows the comparison of one cerebral hemisphere to the other, CHI may be a better model of TBI as it requires less technical expertise and has similar neurological outcomes in these murine models.

Photobiomodulation therapy alleviates repeated closed head injury-induced anxiety-like behaviors

Repeated closed head injury (rCHI) is one of the most common brain injuries. Although extensive studies have focused on how to treat rCHI-induced brain injury and reduce the possibility of developing memory deficits, the prevention of rCHI-induced anxiety has received little research attention. The current study was designed to assess the effects of photobiomodulation (PBM) therapy in preventing anxiety following rCHI. The rCHI disease model was constructed by administering three repeated closed-head injuries within an interval 5 days. 2-min daily PBM therapy using an 808 nm continuous wave laser at 350 mW/cm2 on the scalp was implemented for 20 days. We found that PBM significantly ameliorated rCHII-induced anxiety-like behaviors, neuronal apoptosis, neuronal injury, promotes astrocyte/microglial polarization to anti-inflammatory phenotype, preserves mitochondrial fusion-related protein MFN2, attenuates the elevated mitochondrial fission-related protein DRP1, and mitigates neuronal senescence. We concluded that PBM therapy possesses great potential in preventing anxiety following rCHI.

Management of Acute Injury and Illness in Pediatric Athletes by Athletic Trainers: Compliance With Emergency Medicine and Athletic Trainer Evidence-Based Guidelines

OBJECTIVE

This study aimed to determine athletic trainer compliance with emergency medicine and athletic training evidence-based guidelines for the on-the-field management of common pediatric sports-related injury and illness.

METHODS

A questionnaire was distributed electronically to selected members of the National Athletic Trainer Association. The questionnaire included 10 clinical scenarios describing common sports-related injury/illness (closed head injury, cervical spine injury, blunt chest injury, blunt abdominal injury, ankle injury, knee injury with laceration, heat-related illness). On-the-field management decisions for each scenario were compared with selected emergency medicine and athletic training guidelines.

RESULTS

Analysis was performed on 564 completed questionnaires (9% response rate). Responders were compliant with practice guidelines for both emergency medicine and athletic training except for blunt chest trauma with tachycardia, closed head injury with loss of consciousness, closed head injury with repetitive speech, closed head injury with a fall higher than 5 feet, cervical spine injury with paresthesias, and heat-related illness with persistent symptoms. Discrepancies between emergency medicine and athletic training guidelines included closed head injury with repetitive speech, closed head injury and height of fall, closed head injury and unequal pupils, and cervical spine injury with neck pain and paresthesias.

CONCLUSIONS

Based on our sample, athletic trainers were compliant with many guidelines supported by both emergency medicine and athletic training. We identified several deficiencies in the availability of evidence-based guidelines and discrepancies between these guidelines and athletic trainer responses. To provide optimal care to pediatric athletes who sustain injury or illness, emergency medicine and athletic training organizations should collaborate to improve these discrepancies.

Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines

INTRODUCTION

This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines.

METHODS

We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10.

RESULTS

In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score.

CONCLUSION

A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.

Quantitative Analysis of Ball-Head Impact Exposure in Youth Soccer Players

Since the implementation of the US Soccer heading guidelines released in 2015, little to no research on ball-head impact exposure in the United States youth soccer population has been conducted. The purpose was to compare ball-head impact exposure across sex and age in youth soccer players over a weekend tournament. Ten male and female games for each age group (Under-12 [U12], U13, and U14) were video recorded at a weekend tournament for a total of 60 games. Ball-head impact exposure for each game was then coded following a review of each recording. Male players were 2.8 times more likely to have ball-head impacts than female players, (p < 0.001) particularly in the U14 age group when compared to the U12 age group (p = 0.012). Overall 92.4% of players experienced 0-1 ball-head impacts per game with the remaining players experiencing 2+ ball-head impacts per game. Ball-head impact exposure levels are low in the youth players. Most youth soccer players do not head the soccer ball during match play and those that did, only headed the ball on average once per game. Overall, the difference in ball-head impact exposure per player was less than 1 between all the groups, which may have no clinical meaning.

Traumatic brain injury detection performance of the infant scalp score in children younger than 2 years in the pediatric emergency department

BACKGROUND

Our study sought to externally validate the Infant Scalp Score (ISS) within an international pediatric emergency department (PED) setting. The ISS for pediatric Closed Head Injury (CHI), includes age, hematoma localization, and size, and has the potential to predict the presence of Traumatic Brain Injury (TBI) on computed tomography. We aimed to describe a potentially low risk cohort of children younger than 24 months with CHI and scalp hematomas, where clinicians may limit diagnostic radiation exposure to this vulnerable patient population.

METHODS

This single-center retrospective study was conducted in Gazi University. Faculty of Medicine, Pediatric Emergency Department, a tertiary trauma care hospital. We reviewed patients (< 24 months) with CHI and scalp hematoma who visited the PED of our institution between January 1, 2019, and June 30, 2021 for rates of TBI and clinically important TBI (ciTBI).

RESULTS

380 cases met inclusion criteria for this study. The median age was 11 months and 58.7% were male children. 121 (31.8%) patients underwent CT, and 57% (n:69) of these studies were normal. TBI on CT was found in 26 (21.5%) patients with ciTBI was detected in 5 (1.3%) patients. All children with TBI were noted to have ISS scores of ≥ 5. Hematoma location OR 18.9 (95% CI, 3.4-105.1) and hematoma size OR 3.0 (95% CI, 1.2-7.3) were positively associated with presence of TBI.

CONCLUSIONS

Children with ISS scores of ≥ 5 were noted to have increased rates of both TBI and ciTBI. CHI related scalp hematomas located in the temporal/parietal region or with a size greater than 3 cm were associated with increased rates of TBI. Within the context of this study, ISS scores of 4 or less represented a lower risk for TBI and ciTBI. Future research on this potentially low risk pediatric CHI cohort is needed.

Critical Assessment of the Guidelines-Based Management of Severe Traumatic Brain Injury with the Appraisal of Guidelines for Research and Evaluation II

BACKGROUND

Severe traumatic brain injury constitutes a clinical entity with complex underlying pathophysiology. Management of patients with severe traumatic brain injury is guided by Clinical Practice Guidelines and Consensus Statements (CPG and CS). The published CPG and CS vary in quality, comprehensiveness, and clinical applicability. The value of critically assessing CPG and CS cannot be overemphasized. The aim of our study was to assess the quality of the published CPG and CS, based on the Appraisal of Guidelines for Research and Evaluation II instrument.

METHODS

A systematic search was performed in PubMed, Scopus, Embase, and Web of Science focusing on guidelines and consensi about severe traumatic brain injury . The search terms used were "traumatic brain injury," "TBI," "brain injury," "cerebral trauma," "head trauma," "closed head injury," "head injury," "guidelines," "recommendations," "consensus" in any possible combination. The search period extended from 1964 to 2021 and was limited to literature published in English. The eligible studies were scored by 4 raters, using the Appraisal of Guidelines for Research and Evaluation II instrument. The inter-rater agreement was assessed using the Cronbach's alpha.

RESULTS

Twelve CPG and CS were assessed. Overall, the study by Carney et al. was the most Appraisal of Guidelines for Research and Evaluation II compliant study. In general, the domains of clarity of presentation, and scope and purpose, achieved the highest scores. The lowest inter-rater agreement in our analysis was "fair."

CONCLUSIONS

The purpose of our study for assessing the quality of CPG and CS was served. We present the strong and weak points of CPG and CS. Our findings support the idea of periodically updating guidelines and improving their rigor of development.

Postmortem computed tomography plus forensic autopsy for determining the cause of death in child fatalities

BACKGROUND

Postmortem computed tomography (CT) and magnetic resonance imaging have been gradually introduced to forensic pathology centres over the past two decades, with varying results in comparison to autopsy.

OBJECTIVE

The purpose of this study was to determine the accuracy of postmortem CT in determining a cause of death in children who died of unnatural causes.

MATERIALS AND METHODS

This was a prospective recruitment of 30 children (< 18 years) who underwent postmortem CT and a forensic autopsy. A cause of death was independently assigned by two experienced paediatric radiologists and compared to that of the forensic autopsy.

RESULTS

A correct cause of death was assigned by reviewers 1 and 2 in 70% (n = 21/30) and 67% (n = 20/30) of cases, respectively. For gunshot injuries and blunt force head injuries, there was 91% (n = 10/11) and 100% (n = 6/6) agreement between forensic autopsy and both reviewers, respectively. No cause of death could be assigned by reviewers 1 and 2 in 27% (n = 8) and 30% (n = 9) of cases, respectively. An incorrect cause of death was assigned by both reviewers in one case (3%). The Cohen Kappa level of agreement between the forensic autopsy and reviewers 1 and 2 was k = 0.624 (95% confidence interval [CI]: 0.45-0.80, P = 0) and k = 0.582 (95% CI 0.41-0.76, P = 0), respectively. There was near perfect agreement between reviewers 1 and 2 (k = 0.905) (95% CI 0.78-1.00, P = 0).

CONCLUSION

Postmortem CT has good diagnostic accuracy for identifying a cause of death related to trauma, but it has poor accuracy for children dying from causes not associated with apparent physical injury.

Short-Term Neurologic Manifestations of Repetitive Head Impacts Among Athletes: A Scoping Review

OBJECTIVE

To summarize the evidence linking contact sports-related repetitive head impacts (RHIs) and short-term declines in neurologic function.

METHODS

A scoping review following the guidelines in the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and searching 3 databases (PubMed, EMBASE, and Web of Science) was performed. Peer-reviewed research articles were eligible for inclusion if they were full-length English language articles published between 1999 and 2019 examining athletes between the ages of 14 and 40 years exposed to RHIs, and reporting cognitive, vestibular, and/or oculomotor outcomes within 4 weeks of last head hit exposure.

RESULTS

Fifty-two articles met criteria for review: 14 reported oculomotor outcomes, 23 reported vestibular outcomes, and 36 reported cognitive function. Short-term RHI-related declines in neurologic function were reported in 42.9% of oculomotor studies, in 20.8% of vestibular studies, and in 33.3% of cognitive studies. Most of the 52 studies involved American football, soccer, or ice hockey athletes at the collegiate ( n = 23) or high school ( n = 14) level. Twenty-four (46%) studies involved only male athletes. Wearable sensors were used to measure RHIs in 24 studies (46%), while RHIs were not measured in 26 studies (50%). In addition, many studies failed to control for attention-deficit/hyperactivity disorder/learning disability and/or concussion history.

CONCLUSION

The results of this scoping review suggest that the evidence linking RHIs to short-term declines in neurologic function is relatively sparse and lacking in methodological rigor. Although most studies failed to find a link, those that did were more likely to use objective measures of RHIs and to control for confounders. More careful trial design may be needed to definitively establish a causal link between RHIs and short-term neurologic dysfunction.

Cortical Spreading Depolarization, Blood Flow, and Cognitive Outcomes in a Closed Head Injury Mouse Model of Traumatic Brain Injury

BACKGROUND

Cortical spreading depolarizations (CSDs) are associated with worse outcomes in many forms of acute brain injury, including traumatic brain injury (TBI). Animal models could be helpful in developing new therapies or biomarkers to improve outcomes in survivors of TBI. Recently, investigators have observed CSDs in murine models of mild closed head injury (CHI). We designed the currently study to determine additional experimental conditions under which CSDs can be observed, from mild to relatively more severe TBI.

METHODS

Adult male C57Bl/6J mice (8-14 weeks old) were anesthetized with isoflurane and subjected to CHI with an 81-g weight drop from 152 or 183 cm. CSDs were detected with minimally invasive visible light optical intrinsic signal imaging. Cerebral blood flow index (CBFi) was measured in the 152-cm drop height cohort using diffuse correlation spectroscopy at baseline before and 4 min after CHI. Cognitive outcomes were assessed at 152- and 183-cm drop heights for the Morris water maze hidden platform, probe, and visible platform tests.

RESULTS

CSDs occurred in 43% (n = 12 of 28) of 152-cm and 58% (n = 15 of 26) of 183-cm drop height CHI mice (p = 0.28). A lower baseline preinjury CBFi was associated with development of CSDs in CHI mice (1.50 ± 0.07 × 10^-7 CHI without CSD [CSD-] vs. 1.17 ± 0.04 × 10^-7 CHI with CSD [CSD+], p = 0.0001). Furthermore, in CHI mice that developed CSDs, the ratio of post-CHI to pre-CHI CBFi was lower in the hemisphere ipsilateral to a CSD compared with non-CSD hemispheres (0.19 ± 0.07 less in the CSD hemisphere, p = 0.028). At a 152-cm drop height, there were no detectable differences between sham injured (n = 10), CHI CSD+ (n = 12), and CHI CSD- (n = 16) mice on Morris water maze testing at 4 weeks. At a 183-cm drop height, CHI CSD+ mice had worse performance on the hidden platform test at 1-2 weeks versus sham mice (n = 15 CHI CSD+, n = 9 sham, p = 0.045), but there was no appreciable differences compared with CHI CSD- mice (n = 11 CHI CSD-).

CONCLUSIONS

The data suggest that a lower baseline cerebral blood flow prior to injury may contribute to the occurrence of a CSD. Furthermore, a CSD at the time of injury can be associated with worse cognitive outcome under the appropriate experimental conditions in a mouse CHI model of TBI.

Sledding-Related Injuries Among Children and Adults Treated in US Emergency Departments From 2008 to 2017

OBJECTIVE

To describe the epidemiology of sledding-related injuries among children and adults treated in US emergency departments (EDs).

DESIGN

The researchers performed a retrospective analysis using data from the National Electronic Injury Surveillance System (NEISS).

SETTING

The NEISS collects data on consumer products-related and sports-related injuries treated in US EDs from approximately 100 hospitals that represent a probability sample of >5000 hospitals.

PATIENTS

Children (≤19 years of age) and adults who were treated for sledding-related injuries in EDs from 2008 to 2017.

INDEPENDENT VARIABLES

The researchers analyzed characteristics that included sex, body part injured, injury diagnosis, disposition from the ED, injury locale, injury mechanism, and sled type.

MAIN OUTCOME MEASURES

All cases of sledding-related injuries were identified using NEISS product codes for sleds (1217), toboggans (1273), snow disks (1274), and snow tubes (1299).

RESULTS

An estimated 220 488 patients [95% confidence interval (CI): 169 839-271 137] were treated in EDs for sledding-related injuries. Overall, the injury rate decreased significantly for both children and adults. Children accounted for 69.7% of the injury cases. Fractures were the most common injury diagnosis for children (23.9%) and adults (27.4%). Compared to adults, children were more likely to sustain a head injury [relative risk (RR): 1.91 (95% CI: 1.73-2.13)] and be diagnosed with a concussion or closed-head injury (CHI) [RR: 1.58 (95% CI: 1.35-1.84)]. Most patients were injured by a collision (63.2%). Snow tube and disk riders were more likely to sustain a concussion or CHI compared to sled and toboggan riders [RR: 1.53 (95% CI: 1.18-1.99)]. Injuries predominantly occurred when patients collided with objects in the environment (47.2%).

CONCLUSIONS

Although sledding-related injuries decreased over the study period, more research and education to prevent these injuries is needed. The injury patterns and risk of injury type differed by age, with more head injuries sustained by children. Sledding should be performed in obstacle-free areas to reduce the risk of collision and while wearing helmets to mitigate head injuries.

Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury

OBJECTIVES

Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN).

METHODS

We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed.

RESULTS

Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals.

CONCLUSIONS

There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.

Mouse closed head traumatic brain injury replicates the histological tau pathology pattern of human disease: characterization of a novel model and systematic review of the literature

Traumatic brain injury (TBI) constitutes one of the strongest environmental risk factors for several progressive neurodegenerative disorders of cognitive impairment and dementia that are characterized by the pathological accumulation of hyperphosphorylated tau (p-Tau). It has been questioned whether mouse closed-head TBI models can replicate human TBI-associated tauopathy. We conducted longitudinal histopathological characterization of a mouse closed head TBI model, with a focus on pathological features reported in human TBI-associated tauopathy. Male C57BL/6 J mice were subjected to once daily TBI for 5 consecutive days using a weight drop paradigm. Histological analyses (AT8, TDP-43, pTDP-43, NeuN, GFAP, Iba-1, MBP, SMI-312, Prussian blue, IgG, βAPP, alpha-synuclein) were conducted at 1 week, 4 weeks, and 24 weeks after rTBI and compared to sham operated controls. We conducted a systematic review of the literature for mouse models of closed-head injury focusing on studies referencing tau protein assessment. At 1-week post rTBI, p-Tau accumulation was restricted to the corpus callosum and perivascular spaces adjacent to the superior longitudinal fissure. Progressive p-Tau accumulation was observed in the superficial layers of the cerebral cortex, as well as in mammillary bodies and cortical perivascular, subpial, and periventricular locations at 4 to 24 weeks after rTBI. Associated cortical histopathologies included microvascular injury, neuroaxonal rarefaction, astroglial and microglial activation, and cytoplasmatic localization of TDP-43 and pTDP-43. In our systematic review, less than 1% of mouse studies (25/3756) reported p-Tau using immunostaining, of which only 3 (0.08%) reported perivascular p-Tau, which is considered a defining feature of chronic traumatic encephalopathy. Commonly reported associated pathologies included neuronal loss (23%), axonal loss (43%), microglial activation and astrogliosis (50%, each), and beta amyloid deposition (29%). Our novel model, supported by systematic review of the literature, indicates progressive tau pathology after closed head murine TBI, highlighting the suitability of mouse models to replicate pertinent human histopathology.

Photobiomodulation therapy for repeated closed head injury in rats

Repeated traumatic brain injury, leads to cumulative neuronal injury and neurological impairments. There are currently no effective treatments to prevent these consequences. Growing interest is building in the use of transcranial photobiomodulation (PBM) therapy to treat traumatic brain injury. Here, we examined PBM in a repeated closed head injury (rCHI) rat model. Rats were administered a total of three closed head injuries, with each injury separated by 5 days. PBM treatment was initiated 2 hours after the first injury and administered daily for a total of 15 days. We found that PBM-treated rCHI rats had a significant reduction in motor ability, anxiety and cognitive deficits compared to CHI group. PBM group showed an increase of synaptic proteins and surviving neurons, along with a reduction in reactive gliosis and neuronal injury. These findings highlight the complexity of gliosis and neuronal injury following rCHI and suggest that PBM may be a viable treatment option to mitigate these effects and their detrimental consequences.

Youth Participation and Injury Risk in Martial Arts

The martial arts can provide children and adolescents with vigorous levels of physical exercise that can improve overall physical fitness. The various types of martial arts encompass noncontact basic forms and techniques that may have a lower relative risk of injury. Contact-based sparring with competitive training and bouts have a higher risk of injury. This clinical report describes important techniques and movement patterns in several types of martial arts and reviews frequently reported injuries encountered in each discipline, with focused discussions of higher risk activities. Some of these higher risk activities include blows to the head and choking or submission movements that may cause concussions or significant head injuries. The roles of rule changes, documented benefits of protective equipment, and changes in training recommendations in attempts to reduce injury are critically assessed. This information is intended to help pediatric health care providers counsel patients and families in encouraging safe participation in martial arts.

Numerical Simulation of Focused Shock Shear Waves in Soft Solids and a Two-Dimensional Nonlinear Homogeneous Model of the Brain

Shear waves that propagate in soft solids, such as the brain, are strongly nonlinear and can develop into shock waves in less than one wavelength. We hypothesize that these shear shock waves could be responsible for certain types of traumatic brain injuries (TBI) and that the spherical geometry of the skull bone could focus shear waves deep in the brain, generating diffuse axonal injuries. Theoretical models and numerical methods that describe nonlinear polarized shear waves in soft solids such as the brain are presented. They include the cubic nonlinearities that are characteristic of soft solids and the specific types of nonclassical attenuation and dispersion observed in soft tissues and the brain. The numerical methods are validated with analytical solutions, where possible, and with self-similar scaling laws where no known solutions exist. Initial conditions based on a human head X-ray microtomography (CT) were used to simulate focused shear shock waves in the brain. Three regimes are investigated with shock wave formation distances of 2.54 m, 0.018 m, and 0.0064 m. We demonstrate that under realistic loading scenarios, with nonlinear properties consistent with measurements in the brain, and when the shock wave propagation distance and focal distance coincide, nonlinear propagation can easily overcome attenuation to generate shear shocks deep inside the brain. Due to these effects, the accelerations in the focal are larger by a factor of 15 compared to acceleration at the skull surface. These results suggest that shock wave focusing could be responsible for diffuse axonal injuries.

Indications for Routine Repeat Head Computed Tomography (CT) Stratified by Severity of Traumatic Brain Injury

BACKGROUND

Controversy exists as to the role of a routine repeat head computed tomography (CT) for patients with traumatic brain injury and an initially abnormal head CT. The specific aim of this study is to identify patients with head injuries who would benefit from a routine repeat head CT.

METHODS

This was a 2-year (2003 and 2004) prospective study of all patients with blunt trauma admitted to an urban, Level I trauma center that presented with an abnormal head CT. Results of initial head CT and indications for repeat head CT (routine vs. neurologic change) were recorded. Interventions were both medical (diuresis, hyperventilation, barbiturates) and surgical (intracranial pressure monitor placement or craniotomy). Patients were categorized by Glasgow Coma Scale (GCS) score as having mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS < or = 8) head injury.

RESULTS

There were 354 patients admitted with an initially abnormal head CT. The 37 (10%) patients who went directly to craniotomy and the 43 (12%) patients who died within 24 hours of admission were excluded from analysis. The remaining 274 patients (44 years old, 70% male, mean injury severity score = 19, mean GCS = 10) are the focus of this analysis. After admission, 163 patients underwent a total of 241 repeat CT scans. Of the repeat scans obtained, 102 scans (43%) were unchanged, 54 scans (22%) were better, and 85 scans (35%) were worse. Neurologic deterioration prompted 45 repeat scans (19%), and 196 repeat scans (81%) were obtained routinely after admission without change in neurologic status. The 45 CT scans obtained for neurologic change led to medical or surgical intervention in 38% (n = 17) of cases, whereas scans obtained led to an intervention in only two patients (1%). Both patients who underwent an intervention after a routine scan had a GCS score < or =8 at admission and at the time of routine repeat head CT. One patient had an intracranial pressure monitor placed and the other was taken for craniotomy. No patient with a mild or moderate traumatic brain injury underwent an intervention after a routine repeat head CT.

CONCLUSIONS

Patients with any head injury (mild, moderate, or severe) should undergo a repeat head CT after neurologic deterioration, because it leads to intervention in over one-third of patients. Routine repeat head CT is indicated for patients with a GCS score < or =8, as results might lead to intervention without neurologic change.

Hydrocephalus in intraspinal dermoids and dermal sinuses: the spectrum of an uncommon association in children

BACKGROUND

Hydrocephalus associated with intraspinal tumors constitutes a well-documented occurrence. The accepted mechanisms for this association seem to be well established. On the contrary, hydrocephalus in the context of intraspinal dermoids has been rarely recognized and its pathogenetic mechanism appears to be different.

PATIENTS AND METHODS

The authors report four pediatric cases of spinal dermoid tumors and dermal sinuses that developed hydrocephalus during the evolution of these congenital lesions of ectodermal origin.

DISCUSSION

In two children, the mechanism leading to the development of hydrocephalus consisted of leptomeningeal inflammation due to bacterial meningitis or to spillage of dermoid cyst contents in the cerebrospinal fluid spaces. We hypothesize that ventricular dilatation in the other two might be the result of chemical meningitis occurring during intrauterine life. Two cases developed ventriculomegaly prior to the diagnosis of their spinal cord disease.

CONCLUSIONS

The unusual evolution of these cases suggests that neuroimaging studies that include the spine should be performed in cases of childhood "unexplained hydrocephalus".

Large intradiploic growing skull fracture of the posterior fossa

Growing skull fractures (GSFs) are rare complications of head injury and mostly occur in infancy and early childhood. Location in the posterior fossa and intradiploic development of a GSF is very uncommon. We report a 7-year-old boy with a large, 9 x 7 x 4-cm, occipital intradiploic GSF. The lesion developed progressively over a period of 5 years following a documented occipital linear fracture. This case of a GSF developing from a known occipital linear fracture demonstrates that a GSF may reach a considerable size and, although uncommon, intradiploic development and occipital localization of a GSF is possible.

Propofol infusion syndrome--report of an adult fatality

This report describes a fatal case of the propofol infusion syndrome in an adult patient being sedated for a closed head injury using high doses of propofol. The features of circulatory collapse, metabolic acidosis, mild rhabdomyolysis and renal impairment are consistent with the syndrome and not readily attributable to alternative aetiologies. Potential mechanisms for the syndrome may relate to antagonism of beta-receptors, impaired myocardial oxygen utilization and a specific disruption to fatty-acid oxidation. This is the first published Australian case of the propofol infusion syndrome in an adult and should serve as an additional case report to the existing literature highlighting this potentially fatal syndrome in adults.

Rehabilitation outcome in a patient awakened from prolonged coma

BACKGROUND

This article describes the rehabilitation of a patient recovering from a prolonged coma (defined as lasting longer than 4 weeks). The case is noteworthy because it exemplifies the possibilities and difficulties entailed in treating these patients, who are often regarded as too severely impaired to justify intensive rehabilitation efforts.

CASE REPORT

The patient is a 28-year old Polish male, unmarried, who suffered serious closed head injuries in an automobile accident in April of 1999. He was in a comatose state for more than two months, with a GCS score of 5. When admitted for rehabilitation he was bedridden, with global aphasia, agraphia, limb apraxia, and executive dysfunction. The rehabilitation program developed for him is described in detail.

RESULTS

Over the course of rehabilitation, which began in December 1999 and continues to this writing, the patient has regained locomotion capabilities (though with impairments), and his speech has improved considerably. The apraxia has largely resolved, and he is able to write his name and copy words. He is now capable of performing many activities of daily living.

CONCLUSIONS

A comprehensive program of rehabilitation characterized by a strategic, heuristic approach is capable of achieving a good outcome even in very difficult cases, such as prolonged coma.

Active and passive executive function disorder subsequent to closed-head injury

BACKGROUND

Executive dysfunction is one of the most destructive sequelae of closed head injuries (CHI), often impeding or even preventing the patient's return to normal functioning. On the basis of extensive clinical testing of patients with neurobehavioral disturbances resulting from CHI, the authors propose a new typology of executive dysfunction based on the primary behavioral distinction between active ('acting without thinking') and passive ('thinking without acting') forms of executive function disorder.

MATERIAL/METHODS

Two patients were selected for detailed presentation. Both present with mild to moderate motor and cognitive symptoms resulting from closed head injury. The medical histories of the two patients are similar (educated professionals, mid-40s, married with children, injuries suffered in a traffic accident, 2 months in coma) except for the location of focal injuries.

RESULTS

Despite considerable progress in rehabilitation, the extent of functional disorder is disproportionately large in comparison to the degree of objective disability measured by standard instruments. It is suggested that the reason for this disparity lies in executive dysfunction. In particular, a model for executive functioning will be presented to explain why and how selective destruction of particular anatomical/functional components leads to the behavioral consequences known as 'executive dysfunction'.

CONCLUSIONS

Executive dysfunction is a distinct clinical syndrome which occurs in at least two distinguishable varieties, active and passive.

Traumatic brain injury in children and adolescents

Traumatic brain injury is an insult to the brain caused by an external force that results in an impairment (transient or permanent) of cognitive, behavioral, emotional, or physical function. Traumatic brain injury encompasses shearing injury, which might be seen in a shaken infant, as well as penetrating injury from a foreign body, such as a bullet. This article addresses the recovery phase and functional sequelae following traumatic brain injury. Research and clinical experience over the past decade have led to a better understanding of the pathophysiology of head injury and, in turn, improved management.

Predictors of psychological health in caregivers of patients with closed head injury

The purpose of the current study was to investigate the contribution of coping strategies, subjective burden, and social support to psychological health in caregivers. The sample included 69 primary caregivers of patients with severe closed head injuries. There were three groups of caregivers: acute (0-6 months post-injury); intermediate (6 months-1.5 years); and long-term (> 1.5 years). All had participated in rehabilitation. Caregivers completed an interview and series of questionnaires, including the Ways of Coping Questionnaire, Social Support Questionnaire, Subjective Burden Measure, and General Health Questionnaire. The Disability Rating Scale was completed by staff to assess patients' level of functioning at the time of caregivers' assessment. ANOVA revealed no between-group differences in coping style or social support. Multiple regression revealed that greater use of emotion-focused coping was associated with greater emotional distress. Coping style contributed to a greater proportion of the variance in caregivers' psychological health that did patients' level of functioning. Increased satisfaction with social support was associated with less emotional distress. The full model, including group, caregiver gender, emotion-focused coping, social support, patient level of recovery, burden, and the burden x coping interaction accounted for over half of the variance in psychological health. Results support a multidimensional model for explaining caregivers' adjustment.

Influence of major depression on 1-year outcome in patients with traumatic brain injury

The authors examine those factors that contributed to deterioration in social functioning, activities of daily living, or intellectual functioning during a 1-year period after traumatic brain injury (TBI). Fifty-two patients suffering an acute TBI were evaluated for existence and severity of mood disorders and impairment during their hospital stays and at 3-, 6-, and 12-month follow-up examinations. Patients whose scores on intellectual function, social function, or daily activities deteriorated during the 1-year period after trauma were considered to have a poor outcome. Eleven of 52 patients had a poor outcome in social function, which was associated with race, right-hemisphere lesions, intellectual impairment, and prolonged major depression. Seven of 52 patients had a poor outcome in daily activities, which was associated with a major depression of more than 6 months' duration and severity of Hamilton Depression Rating Scale scores. Eleven of these patients had a poor outcome in cognitive function, which was associated with cognitive impairment immediately after TBI. A major depression lasting more than 6 months was associated with deterioration of social functioning and activities of daily living during the 1-year period after TBI.

BILATERAL INTERNAL CAROTID ARTERY OCCLUSION SECONDARY TO CLOSED HEAD INJURIES

Images