Decompressive craniectomy surgery in a dog with intracranial extradural hematoma following blunt force trauma.

A young miniature poodle was presented following blunt force trauma to the head. The dog initially responded well to medical management before developing clinical signs associated with increased intracranial pressure 48 h post-injury that became refractory to hyperosmolar therapy. A computed tomography scan obtained 76 h post-injury showed a short, oblique, non-displaced, complete fissure in the right temporal bone and a second short, oblique, non-displaced, complete fissure in the ventral aspect of the temporal bone. A biconvex, moderately hyperattenuating, space-occupying temporoparietal lesion was visualized immediately adjacent to the area of the temporal fractures. These findings were consistent with a diagnosis of intracranial extradural hematoma. Decompressive craniectomy successfully evacuated the extradural hematoma to alleviate increased intracranial pressure. The dog's neurologic function recovered quickly postoperatively. At follow-up physical examinations at 14 and 437 d, excellent return to function was noted. Key clinical message: This report describes the diagnosis and surgical management of an intracranial extradural hematoma in a dog with increased intracranial pressure refractory to medical management. Furthermore, this report describes the diagnostic imaging findings used to diagnose this particular form of primary brain injury.

Chirurgie de craniectomie décompressive chez un chien présentant un hématome extradural intracrânien à la suite d'un traumatisme contondant. Un jeune caniche miniature a été présenté à la suite d'un traumatisme contondant à la tête. Le chien a initialement bien répondu à la prise en charge médicale avant de développer des signes cliniques associés à une augmentation de la pression intracrânienne 48 heures après la blessure, qui sont devenus réfractaires au traitement hyperosmolaire. Une tomodensitométrie obtenue 76 heures après la blessure a montré une fissure complète courte, oblique, non déplacée dans l'os temporal droit et une deuxième fissure complète courte, oblique, non déplacée dans la face ventrale de l'os temporal. Une lésion temporo-pariétale biconvexe, modérément hyperatténuée et occupant de l'espace a été visualisée immédiatement à côté de la zone des fractures temporales. Ces résultats concordaient avec un diagnostic d'hématome extradural intracrânien. La craniectomie décompressive a réussi à évacuer l'hématome extradural pour atténuer l'augmentation de la pression intracrânienne. La fonction neurologique du chien s'est rétablie rapidement après l'opération. Lors des examens physiques de suivi à 14 et 437 jours, un excellent retour au fonctionnement a été noté.Message clinique clé:Ce rapport décrit le diagnostic et la prise en charge chirurgicale d'un hématome extradural intracrânien chez un chien présentant une augmentation de la pression intracrânienne réfractaire à la prise en charge médicale. En outre, ce rapport décrit les résultats de l'imagerie diagnostique utilisée pour diagnostiquer cette forme particulière de lésion cérébrale primaire.(Traduit par Dr Serge Messier).

Closed head injury combined with orbital blowout fracture and displacement of the eyeball into the maxillary sinus in a 14-year-old boy: a case report.

BACKGROUND: Trauma-induced orbital blowout fracture (OBF) with eyeball displacement into the maxillary sinus is rare. CASE PRESENTATION: We present the case of a 14-year-old with a closed head injury, OBF, and displacement of the eyeball into the maxillary sinus following a car accident. A prompt transconjunctival access surgery was performed for eyeball repositioning and orbital reconstruction in a single session, mitigating anaesthesia-related risks associated with multiple surgeries. At the 12-month follow-up, his visual acuity was 20/200. Despite limited eye movement and optic nerve atrophy, overall satisfaction with the ocular appearance was achieved. CONCLUSIONS: This report offers novel insights into the mechanisms of OBF occurrence and the development of postoperative complications.

Risk factors for thromboembolic complications in isolated severe head injury.

PURPOSE: Patients with traumatic brain injury (TBI) are at high risk for venous thromboembolism (VTE). The aim of the present study is to identify factors independently associated with VTE events. Specifically, we hypothesized that the mechanism of penetrating head trauma might be an independent factor associated with increased VTE events when compared with blunt head trauma. METHODS: The ACS-TQIP database (2013-2019) was queried for all patients with isolated severe head injuries (AIS 3-5) who received VTE prophylaxis with either unfractionated heparin or low-molecular-weight heparin. Transfers, patients who died within 72 h and those with a hospital length of stay < 48 h were excluded. Multivariable analysis was used as the primary analysis to identify independent risk factors for VTE in isolated severe TBI. RESULTS: A total of 75,570 patients were included in the study, 71,593 (94.7%) with blunt and 3977 (5.3%) with penetrating isolated TBI. Penetrating trauma mechanism (OR 1.49, CI 95% 1.26-1.77), increasing age (age 16-45: reference; age > 45-65: OR 1.65, CI 95% 1.48-1.85; age > 65-75: OR 1.71, CI 95% 1.45-2.02; age > 75: OR 1.73, CI 95% 1.44-2.07), male gender (OR 1.53, CI 95% 1.36-1.72), obesity (OR 1.35, CI 95% 1.22-1.51), tachycardia (OR 1.31, CI 95% 1.13-1.51), increasing head AIS (AIS 3: reference; AIS 4: OR 1.52, CI 95% 1.35-1.72; AIS 5: OR 1.76, CI 95% 1.54-2.01), associated moderate injuries (AIS = 2) of the abdomen (OR 1.31, CI 95% 1.04-1.66), spine (OR 1.35, CI 95% 1.19-1.53), upper extremity (OR 1.16, CI 95% 1.02-1.31), lower extremity (OR 1.46, CI 95% 1.26-1.68), craniectomy/craniotomy or ICP monitoring (OR 2.96, CI 95% 2.65-3.31) and pre-existing hypertension (OR 1.18, CI 95% 1.05-1.32) were identified as independent risk factors for VTE complications in isolated severe head injury. Increasing GCS (OR 0.93, CI 95% 0.92-0.94), early VTE prophylaxis (OR 0.48, CI 95% 0.39-0.60) and LMWH compared to heparin (OR 0.74, CI 95% 0.68-0.82) were identified as protective factors for VTE complications. CONCLUSION: The identified factors independently associated with VTE events in isolated severe TBI need to be considered in VTE prevention measures. In penetrating TBI, an even more aggressive VTE prophylaxis management may be justified as compared to that in blunt.

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.

Blunt Cerebrovascular Injury in the Elderly With Traumatic Cervical Spine Injuries: Results of a Retrospective Multi-Center Study of 1512 Cases in Japan.

This study is nationwide retrospective multi-center study to investigate the incidence and characteristics of blunt cerebrovascular injury (BCVI) in elderly Japanese patients with traumatic cervical spine injuries (CSI) including spinal cord injury (SCI) without major bone injury. The study enrolled 1512 patients (average age: 75.8 ± 6.9 years; 1007 males, 505 females) from 33 nationwide institutions, and 391 (26%) of the participants had digital subtraction angiography and/or computed tomography angiography. Fifty-three patients were diagnosed as having BCVI by angiography. We assessed neurological evaluation, comorbidities and classification of CSI in the elderly patients with/without BCVI and collected 6-month follow-up data on treatment, complications, and patient outcome. We also statistically analyzed the relative risk (RR) and relationship between BCVI and other factors. Significant differences were identified between BCVI (+) (n = 53) and (-) (n = 1459) patients with American Spinal Injury Association Impairment Scale (ASIA) A, C, D, cervical fracture, C3-7 injury level (AO type F and/or C), cervical dislocation, spinal surgery for CSI, tetraplegia type of SCI, and/or head injury. Fifty-three (3.5%) elderly patients had CSI complicated by BCVI including 10 (19%) cases of Denver grade I, four (7%) of grade II, 1 (2%) of grade III, 29 (55%) of grade IV, and nine (17%) of grade V. Sixteen cases were treated by interventional radiology. Rates of mortality and brain infarction from BCVI were 0.13% and 0.40%, respectively. RR of BCVI was significantly higher in the elderly cervical injury patients with head injury, severe neurological deficit, ASIA A (RR: 4.33), cervical fracture at the C3-7 level (RR: 7.39), and cervical dislocation at the C1-6 level (RR: 3.06-7.18). In conclusion, 53 (3.5%) elderly patients were complicated with BCVI. BCVI more frequently complicated head injury, severe neurological deficit (ASIA A or tetraplegia), AO type F, and/or C fractures and cervical dislocation in these patients. Six patients (11%) suffered brain infarction and two patients died from BCVI.

Cranioplasty in the deployed environment: experience for host-country nationals.

OBJECTIVE: Decompressive craniectomy (DC) is the definitive neurosurgical treatment for managing refractory malignant cerebral edema and intracranial hypertension due to combat-related severe traumatic brain injury (TBI). To date, the long-term outcomes and sequelae of this procedure on host-country national (HCN) populations during Operation Iraqi Freedom (Iraq, 2003-2011), Operation Enduring Freedom (Afghanistan, 2001-2014), and Operation Freedom's Sentinel (Afghanistan, 2015-2021) have not been described, specifically the process and results of delayed custom synthetic cranioplasty. The Joint Trauma System's Clinical Practice Guidelines (JTS-CPG) for severe head injury counsels surgeons to discard the cranial osseous explant when treating coalition service members. Ongoing political and healthcare system instabilities often preclude opportunities for delayed cranioplasty by host-country assets. Various surgical options (such as hinge craniectomy) are inadequate in the setting of complicated cranial comminution from blast or missile injuries, severe cerebral edema, grossly contaminated wounds, complex polytrauma, and tissue devitalization. Delayed cranioplasty with a custom synthetic implant is a viable but logistically challenging alternative. In this retrospective review, the authors present the first patient series describing delayed custom synthetic cranioplasty in an HCN population performed during active military conflict. METHODS: Patients were identified through the Joint Trauma System/Theater Medical Data Store, and subgroup analyses were performed to include mechanisms of injury, surgical complications, and clinical outcomes. RESULTS: Twenty-five patients underwent DC between 2012 and 2020 to treat penetrating, blast, and high-energy closed head injuries per JTS-CPG criteria. The average time from injury to surgery was 1.4 days, although 6 patients received delayed care (3-6 days) due to protracted evacuation from local hospitals. Delayed care correlated with an increased rate of intracranial abscess and empyema. The average time to cranioplasty was 134 days due to a lack of robust mechanisms for patient follow-up, tracking, and access to NATO hospitals. HCN patients who recovered from DC demonstrated overall benefit from custom synthetic cranioplasty, although formal statistical analysis was impeded by a lack of long-term follow-up. CONCLUSIONS: This review demonstrates that cranioplasty with a custom synthetic implant is a safe and feasible treatment for vulnerable HCN patients who survive their index DC surgery. This unique paradigm of care highlights the capabilities of deployed neurosurgical healthcare teams working in partnership with the prosthetics laboratory at Walter Reed National Military Medical Center.

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.

Prophylactic treatment with CN-105 improves functional outcomes in a murine model of closed head injury.

The treatment of traumatic brain injury (TBI) in military populations is hindered by underreporting and underdiagnosis. Clinical symptoms and outcomes may be mitigated with an effective pre-injury prophylaxis. This study evaluates whether CN-105, a 5-amino acid apolipoprotein E (ApoE) mimetic peptide previously shown to modify the post-traumatic neuroinflammatory response, would maintain its neuroprotective effects if administered prior to closed-head injury in a clinically relevant murine model. CN-105 was synthesized by Polypeptide Inc. (San Diego, CA) and administered to C57-BL/6 mice intravenously (IV) and/or by intraperitoneal (IP) injection at various time points prior to injury while vehicle treated animals received IV and/or IP normal saline. Animals were randomized following injury and behavioral observations were conducted by investigators blinded to treatment. Vestibulomotor function was assessed using an automated Rotarod (Ugo Basile, Comerio, Italy), and hippocampal microglial activation was assessed using F4/80 immunohistochemical staining in treated and untreated mice 7 days post-TBI. Separate, in vivo assessments of the pharmacokinetics was performed in healthy CD-1. IV CN-105 administered prior to head injury improved vestibulomotor function compared to vehicle control-treated animals. CN-105 co-administered by IP and IV dosing 6 h prior to injury also improved vestibulomotor function up to 28 days following injury. Microglia counted in CN-105 treated specimens were significantly fewer (P = 0.03) than in vehicle specimens. CN-105 improves functional outcomes and reduces hippocampal microglial activation when administered prior to injury and could be adapted as a pre-injury prophylaxis for soldiers at high risk for TBI.

Resultados del manejo no operatorio en trauma hepático de los pacientes que se presentaron al servicio de urgencias del Hospital San Vicente Fundación, Medellín / Outcomes of non-operative management of liver trauma in patients who presented to the Emergency Department of Hospital San Vicente Fundación, Medellín

Introducción. El hígado continúa siendo uno de los órganos más afectados en los pacientes con trauma. Su evaluación y manejo han cambiado sustancialmente con los avances tecnológicos en cuanto a diagnóstico y las técnicas de manejo menos invasivas. El objetivo de este estudio fue realizar un análisis de los resultados del manejo no operatorio del trauma hepático en cuanto a incidencia, eficacia, morbimortalidad, necesidad de intervención quirúrgica, tasa y factores relacionados con el fallo del manejo no operatorio. Métodos. Se realizó un estudio descriptivo observacional retrospectivo, analizando pacientes con trauma hepático confirmado con tomografía o cirugía, durante un periodo de 72 meses, en el Hospital Universitario San Vicente Fundación, un centro de IV nivel de atención, en Medellín, Colombia. Resultados. Se incluyeron 341 pacientes con trauma hepático, 224 por trauma penetrante y 117 por trauma cerrado. En trauma penetrante, 208 pacientes fueron llevados a cirugía inmediatamente, el resto fueron manejados de manera no operatoria, con una falla en el manejo en 20 pacientes. En trauma cerrado, 22 fueron llevados a cirugía inmediata y 95 sometidos a manejo no operatorio, con una falla en 9 pacientes. La mortalidad global fue de 9,7 % y la mortalidad relacionada al trauma hepático fue de 4,4 %. El grado del trauma, el índice de severidad del trauma y las lesiones abdominales no hepáticas no se consideraron factores de riesgo para la falla del manejo no operatorio. Conclusiones. El manejo no operatorio continúa siendo una alternativa segura y efectiva para pacientes con trauma hepático, sobretodo en trauma cerrado. En trauma penetrante se debe realizar una adecuada selección de los pacientes.

Introduction. The liver continues to be one of the most affected organs in trauma patients. Its evaluation and management have changed substantially with technological advances in diagnosis and less invasive techniques. The objective of this study was to perform an analysis of the results of non-operative management of liver trauma in terms of incidence, efficacy, morbidity and mortality, need for surgical intervention, rate and factors related to the failure of non-operative management.Methods. A retrospective observational descriptive study was performed, analyzing patients with hepatic trauma confirmed by tomography or surgery, during a period of 72 months at the Hospital Universitario San Vicente Fundación level 4 medical center, in Medellín, Colombia.Results. 341 patients with liver trauma were analyzed, 224 with penetrating trauma and 117 with blunt trauma. In the penetrating trauma group, 208 patients were taken to surgery immediately, the rest were managed nonoperatively with a failure in 20 patients. In the blunt trauma group, 22 were taken to immediate surgery and 95 underwent nonoperative management, with failure in nine patients. Overall mortality was 9.7% and mortality related to liver trauma was 4.4%. Trauma grade, trauma severity index, and non-hepatic abdominal injuries were not considered risk factors for failure of nonoperative managementConclusions. Nonoperative management continues to be a safe and effective alternative for patients with liver trauma, especially in blunt trauma. In penetrating trauma, an adequate selection of patients must be made.

Cerebral Venous Sinus Thrombosis in Closed Head Injury: Systematic Review and Meta-analysis.

BACKGROUND: Cerebral venous sinus thrombosis (CSVT) is a rare condition, causing 0.5% of all strokes only, several mechanisms might be involved in forming the thrombosis, including closed head injury. METHODS: Systematic review was done by using the following databases: PubMed, Google Scholar, Microsoft Academic, Clinical Trials, Cochrane Library, and Web of Science. RESULTS: 25 articles met our criteria out of 152 articles, average and standard deviation of the age was 38.2 ± 16.8 years with an age range of 18-82. The majority of cases presented with loss of consciousness or decreased GCS (41%), followed by headache (26%), scalp abrasions/lacerations (21%), paralysis (18%), visual disturbance (18%), nystagmus (15%), and agitation (15%). The most commonly used diagnostic method was angiography. Thrombosis was the most frequently reported radiological finding among all the cases (26/34, 76%). Comparisons of outcomes between patients who underwent surgical intervention and those who did not undergo surgery revealed a significant difference in outcome favoring non-surgical treatment (p < 0.005, odds ratio (OR) 0.04, (95% CI) 0.003 - 0.30). CONCLUSION: Non-surgical outcomes were better than the surgical outcomes. However, no significant difference was seen comparing anti-coagulation versus conservative management (supportive without anticoagulation), single versus multi-sinuses (≥2 sinuses) involvement, and between any of the sinuses involved.

Comparison of CATCH, PECARN, and CHALICE clinical decision rules in pediatric patients with mild head trauma.

PURPOSE: The present study compares the most frequently used the CATCH, PECARN, and CHALICE clinical decision protocols with an aim to evaluate their effectiveness from the population perspective. METHODS: This study included all patients under 18 years of age presenting with blunt head trauma and a Glasgow Coma Scale score of 13 and higher for whom the attending physician decided to order head computed tomography scans, and the legal representative provided an informed consent for inclusion in the study. The PECARN, CATCH, and CHALICE clinical decision rules were applied to the participating patients, and the data for each of the three international clinical decision rules were recorded. These data were then compared to head CT results. RESULTS: Based on the head CT positivity, the sensitivity and specificity values for the PECARN were 82.76 and 45.03%; the sensitivity and specificity values for CATCH were 89.29 and 47.44%, showing statistical significance in predicting CT positivity; the CHALICE did not show statistical significance in detecting a pathological CT result. In terms of evaluating the need for hospitalization, the PECARN had a sensitivity of 83.87% and a specificity of 45.12%; the CATCH had a sensitivity of 90% and a specificity of 47.54%, showing statistical significance while the CHALICE did not significantly detect the need for hospitalization. CONCLUSIONS: The present study found that the PECARN and CATCH rules in children with minor head injury were significantly sensitive in detecting CT positivity and the need for hospitalization.

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS.

PURPOSE: Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population. METHODS: Blunt trauma patients presenting to our Level I trauma center (11/2015-10/2019) with first ED GCS 9-12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1-6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS). RESULTS: After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3-4] vs. 3[3-3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5-5.3] vs. 5.2[3.6-7.5]h, p < 0.001 and 5.5[3.3-8.9] vs. 8.1[5.2-11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1-4] vs. 2[1-3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122). CONCLUSIONS: Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma.

Repeat CT after blunt head trauma and Glasgow Coma Scale score 13-15 without neurological deterioration is very low yield for intervention.

PURPOSE: Due to the increase in accessibility of computed tomography (CT), repeat head CT scans are routinely ordered for patients with minor head injuries. The aim of this study is to evaluate the necessity and outcomes of routine repeat head CT in patients with GCS score of 13-15 who presented to the emergency department (ED) of Antalya University Hospital in Turkey with blunt head trauma. METHODS: We retrospectively reviewed the charts of patients with minor head trauma that received initial and repeat head CT results from July 1, 2013 to June 30, 2015. Clinical characteristics of patients were compared for two groups of patients: those with neurological deterioration, and those who had routine head CT not required by change in neurological status. Repeat head CT results were analyzed for radiological worsening and the necessity of a surgical or medical intervention such as craniotomy, ICP monitoring, VP shunt and mannitol or hypertonic saline administration. RESULTS: Of 3578 patients with blunt head trauma, 656 (18.3%) patients had repeat head CT; 449 of these (68.4%) had a GCS score of 13-15. We analyzed 441 patients for CT and clinical changes. Eight patients were excluded because of poor image quality and/or penetrating injury. Neurological deterioration was the reason for repeat head CT in 73 (16.5%) patients Rates of medical (mannitol treatment) or surgical (craniotomy) intervention in this group were 26% (95% Confidence Interval [95% CI], 15.7-36.3%) in contrast to 0.8% (95% CI 0.1-1.7%) in the group of patients with routinely ordered head CT but without clinical deterioration. The following factors were statistically associated with need for intervention: use of anticoagulant or antithrombotic medication, fracture in middle meningeal artery territory, even a single point decrease in GCS score, increased headache, recurrent vomiting, neurological deficit, and finally, changes in repeat head CT. CONCLUSIONS: In patients with minor head injuries, those without neurological deterioration have a very low risk of need for medical or surgical intervention. Routinely ordering repeat head CT scans in this group may not be routinely indicated.

Timing of venous thromboembolic pharmacological prophylaxis in traumatic combined subdural and subarachnoid hemorrhage.

BACKGROUND: The combination of subdural and subarachnoid hemorrhage is the most common intracranial bleeding. The present study evaluated the timing and type of venous thromboembolic chemoprophylaxis (VTEp) for efficacy and safety in patients with blunt head trauma with combined acute subdural and subarachnoid hemorrhage. METHODS: Patients with isolated combined acute subdural and subarachnoid hemorrhage were extracted from the ACS-TQIP database (2013-2017). After 1:1 cohort matching of patients receiving early prophylaxis (EP, ≤48 h) versus late prophylaxis (LP, >48 h) outcomes were compared with univariable and multivariable regression analysis. RESULTS: Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.468, CI 0.293-0.748) but not mortality (p = 0.485). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.283). The type of VTEp was not associated with VTE complications (p = 0.301), mortality (p = 0.391) or delayed craniectomy (p = 0.126). CONCLUSIONS: Early VTEp (≤48 h) was associated with fewer VTE complications in patients and did not increase the risk for craniectomies in patients with combined acute subdural and subarachnoid hemorrhage.

Surgical approach for traumatic chiasmal syndrome and complete third nerve palsy following severe head trauma.

Traumatic chiasmal syndrome and traumatic third nerve palsies are rare entities usually caused by severe, high-speed, closed-head road accidents that require a thorough diagnostic work-up and complex medical and surgical management. This report presents the case of a young adult who was involved in a motorcycle accident and sustained blunt frontal head trauma, resulting in optical chiasmal syndrome and complete unilateral third nerve palsy. Ophthalmological examination demonstrated a right complete ptosis, a downward and outward position of the right eye with a fixed and dilated pupil, and bitemporal hemianopsia. In addition, funduscopy revealed bilateral optical nerve atrophy. After stabilisation and during follow-up, strabismus surgery was performed with improvement of ocular alignment in the primary position. Subsequently, eyelid surgery was carried out with good amplification of the visual field, particularly on the left side. Although challenging, surgical intervention in these cases should be considered for both functional and cosmetic reasons.

A Prediction Model for Selective Use of Facial Computed Tomography in Blunt Head Trauma Patients.

BACKGROUND: Head trauma patients may have concomitant facial fractures, which are usually underdetected by head computed tomography alone. This study aimed to identify the clinical indicators of facial fractures and to develop a risk-prediction model to guide the discriminative use of additional facial computed tomography in head trauma. METHODS: The authors retrospectively reviewed head trauma patients undergoing simultaneous head and facial computed tomography at a Level II trauma center from 2015 to 2018. Multivariate logistic regression analysis was used to evaluate independent risk factors for concomitant facial fractures in head trauma patients using data collected from 2015 to 2017, and a risk-prediction model was created accordingly. Model performance was validated with data from 2018. RESULTS: In total, 5045 blunt head trauma patients (development cohort, 3534 patients, 2015 to 2017; validation cohort, 1511 patients, 2018) were enrolled. Concomitant facial fractures occurred in 723 head trauma patients (14.3 percent). Ten clinical and head computed tomographic variables were identified as predictors, including age, male sex, falls from elevation, motorcycle collisions, Glasgow Coma Scale scores less than 14, epistaxis, tooth rupture, facial lesions, intracranial hemorrhage, and skull fracture. In the development cohort, the model showed good discrimination (area under the receiver operating characteristic curve = 0.891), calibration (Hosmer-Lemeshow C test, p = 0.691), and precision (Brier score = 0.066). In the validation cohort, the model demonstrated excellent discrimination (area under the receiver operating characteristic curve = 0.907), good calibration (Hosmer-Lemeshow C test, p = 0.652), and good precision (Brier score = 0.083). With this model, 77.1 percent of unnecessary facial computed tomography could be avoided. CONCLUSION: This model could guide the discriminative use of additional facial computed tomography to detect concomitant facial fractures in blunt head trauma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience.

BACKGROUND: Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years. METHODS: All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort. RESULTS: Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications. CONCLUSIONS: This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Antithrombotic choice in blunt cerebrovascular injuries: Experience at a tertiary trauma center, systematic review, and meta-analysis.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) may occur following trauma and lead to ischemic stroke if untreated. Antithrombotic therapy decreases this risk; however, the optimal agent has yet to be determined in this population. The aim of this study was to compare the risk-benefit profile of antiplatelet (AP) versus anticoagulant (AC) therapy in rates of ischemic stroke and hemorrhagic complications in BCVI patients. METHODS: We performed a retrospective review of BCVI patients at our tertiary care Trauma hospital from 2010 to 2015, and a systematic review and meta-analysis of the literature. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to September 16, 2019. References of included publications were searched manually for other relevant articles. The search was limited to articles in humans, in patients 18 years or older, and in English. Studies that reported treatment-stratified clinical outcomes following AP or AC treatment in BCVI patients were included. Exclusion criteria included case reports, case series with n < 5, review articles, conference abstracts, animal studies, and non-peer-reviewed publications. Data were extracted from each study independently by two reviewers, including study design, country of origin, sex and age of patients, Injury Severity Score, Biffl grade, type of treatment, ischemic stroke rate, and hemorrhage rate. Pooled estimates using odds ratio (OR) were combined using a random-effects model using a Mantel-Hanzel weighting. The main outcome of interest was rate of ischemic stroke due to BCVI, and the secondary outcome was hemorrhage rate based on AC or AP treatment. RESULTS: In total, there were 2044 BCVI patients, as reported in the 22 studies in combination with our institutional data. The stroke rate was not significantly different between the two treatment groups (OR, 1.27; 95% confidence interval, 0.40-3.99); however, the hemorrhage rate was decreased in AP versus AC treated groups (OR, 0.38; 95% confidence interval, 0.15-1.00). CONCLUSION: Based on this meta-analysis, both AC and AP seem similarly effective in preventing ischemic stroke, but AP is better tolerated in the trauma population. This suggests that AP therapy may be preferred, but this should be further assessed with prospective randomized trials. LEVEL OF EVIDENCE: Review article, level II.

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry.

BACKGROUND: Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS: Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS: Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION: Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE: Epidemiological III; Therapeutic IV.