Growing Skull Fracture and the Orbitocranial Variant: Nuances of Surgical Management.

AIMS: Growing skull fracture (GSF) is a rare complication resulting from diastatic enlargement of a pediatric skull fracture. Orbitocranial GSF is a distinct variant with more complex management issues due to the displacement of the globe. This study aims to discuss surgical considerations in the management of GSF, with particular reference to orbitocranial variants. METHODS: We conducted a retrospective analysis of 7 children operated for GSFs at our institute from 2008 to 2015. RESULTS: Four boys and 3 girls were operated during this period. The mean age at initial trauma was 2 years, and most of them sustained falls. The most frequent symptoms of GSF were progressive scalp swelling and proptosis. The most common location was the orbitofrontal region. Duraplasty with cranioplasty was performed in 5 patients, while duraplasty alone was only required in 2 patients. A postoperative complication was noted in 1 patient and managed successfully. Good cosmetic results were obtained in all of the cases. CONCLUSIONS: Duraplasty is essential in the repair of GSF and should be followed by cranioplasty to prevent recurrent leptomeningeal herniation. We recommend the use of autologous bone from the surgical site for cranioplasty. Orbital roof repair is advisable for good visual and cosmetic outcome in orbitocranial variants of GSF.

Predictive (subtle or overlooked) initial head CT findings in patients who develop delayed chronic subdural hematoma.

With the aging population, the incidence of chronic subdural hematoma (CSDH) is expected to rise. Once symptomatic the morbidity from CSDH is not insignificant. We studied patients who had a minor head injury and CT brain scan prior to developing CSDH to determine if there were any predictors on these scans for subsequent development of a CSDH. A retrospective review was performed on all patients operated for CSDH over a 3-year period and a review performed on those who had imaging studies at the time of a preceding minor head injury. Seven of 37 patients had CT scans prior to developing CSDH. All had evidence of small increases in CSF intensity on the side or sides of the subsequent CSDH. In conclusion, in those patients with a history of minor head injury prior to developing a CSDH, CT brain demonstrated small increases in cerebral spinal fluid (CSF) intensity on the side or sides of the subsequent CSDH. Recognizing this finding may be helpful in monitoring these patients or initiating medical therapy.

[SIMULTANEOUS MEASUREMENT OF INTRAVENTRICULAR AND PARENCHYMAL INTRACRANIAL PRESSURE IN PATIENTS WITH SEVERE TRAUMA BRAIN INJURY].

INTRODUCTION: "Standard" assessment of ICP by measuring liquor ventricular pressure recently questioned. THE OBJECTIVE OF THE STUDY: Compare the values of ventricular and parenchymal ICP against the closure of open liquor drainage and during active CSF drainage. MATERIALS AND METHODS: Examined 7 patients with TBI and intracranial hypertension syndrome, GCS 5.6 ± 1.2 points, 4.2 ± age 33 years. Compared parenchymal and ventricular ICP in three time periods: 1--during closure of ventricular drainage, 2--during of the open drains and drainage at the level of 14-15 mmHg, 3--during the period of active drainage. When comparing two methods of measurement used Bland-Altman method. RESULTS: 1. During time period of the closed drainage correlation coefficient was r = 0.83, p < 0.001. Bland-Altman method: the difference of the two measurements is equal to the minimum and 0.7 mm Hg, the standard deviation of 2.02 mm Hg 2. During time period of the open drainage was reduction of the correlation coefficient to r = 0.46, p < 0.01. Bland-Altman method: an increase in the difference of the two measurements to -0.84 mmHg, standard deviation 2.8 mm Hg 3. During time period of the active drainage of cerebrospinal fluid was marked difference between methods of measurement. Bland-Altman method: the difference was 8.64 mm Hg, and a standard deviation of 2.6 mm Hg. CONCLUSIONS: 1. During the closure of the ventricular drainage were good correlation between ventricular and parenchymal ICR 2. During open the liquor drainage correlation between the two methods of measuring the intracranial pressure is reduced. 3. During the active CSF drainage correlation between the two methods of measuring intracranial pressure can be completely lost. Under these conditions, CSF pressure is not correctly reflect the ICP 4. For an accurate and continuous measurement of intracranial pressure on the background of the active CSF drainage should be carried out simultaneous parenchymal ICP measurement.

Limitations of T2*-Gradient Recalled-Echo and Susceptibility-Weighted Imaging in Characterizing Chronic Subdural Hemorrhage in Infant Survivors of Abusive Head Trauma.

A possible misconception among radiologists is that chronic subdural hemorrhage should show some degree of blooming on T2*-gradient recalled-echo or susceptibility-weighted sequences such as SWI and susceptibility-weighted angiography, which is not necessarily true. We present 5 cases of chronic subdural hemorrhages in infants, demonstrating intensity near or greater than that of CSF with variable amounts of hemosiderin staining along the neomembranes. We review the physiology and MR imaging physics behind the appearance of a chronic subdural hemorrhage, highlighting that the absence of a BBB can allow hemosiderin to be completely removed from the subdural compartment. Finally, we stress the importance of reviewing all multiplanar sequences for the presence of neomembranes, which can be quite subtle in the absence of hemosiderin staining and are critical for making the diagnosis of chronic subdural hemorrhage.

Growing skull fractures: guidelines for early diagnosis and surgical management.

BACKGROUND: Growing skull fracture (GSF) is a rare complication of pediatric head trauma and causes delayed onset neurological deficits and cranial defect. GSF usually develops following linear fracture with underlying dural tear resulting in herniation of the brain. Early diagnosis and treatment are essential to avoid complications. However, there are no clear-cut guidelines for the early diagnosis of GSF. The present study was conducted to identify the criteria for the early diagnosis of GSF. MATERIAL AND METHODS: From 2010 to 2015, all pediatric patients of head trauma with linear fracture were evaluated. Patients of age <5 years with cephalhematoma, bone diastasis of 4 mm or more with underlying brain contusion were subjected to contrast brain MRI to find out the dural tear and herniation of the brain matter. Patients with contrast MRI showing dural tear and herniation of the brain matter were considered high risk for the development of GSF and treated surgically within 1 month of trauma. Patients with contrast brain MRI not showing dural tear and herniation of the brain matter were regularly followed for any signs of GSF. RESULTS: A total of 20 patients were evaluated, out of which 16 showed dural defects with herniation of the brain matter and were subjected to duraplasty. Four patients in which MRI did not show dural tear and herniation of the brain matter were regularly followed-up and have not shown any sign of GSF later on follow-up. CONCLUSION: Early diagnosis of GSF can be made based on the four criteria, i.e., (1) age <5 year with cephalhematoma, (2) bone diastasis 4 mm or more (3) underlying brain contusion (4) contrast MRI showing dural tear and herniation of the brain matter. Dural tear with herniation of the brain matter is the main etiopathogenic factor for the development of GSF. Early diagnosis and treatment of GSF can yield a good outcome.

Heridas por proyectil de arma de fuego en cráneo: revisión de la literatura / Firearm projectile wounds on skull: literature review

El trauma craneoencefálico es una de las principales causas de muerte en el mundo, y gran parte de estos se asocian a heridas por arma de fuego en cráneo. Conocer el manejo, las características y fisiopatología de la lesión nos permitirá saber abordar estos casos cuando se presenten a los diferentes centros asistenciales, al tiempo que nos permitirá tener en cuenta las posibles complicaciones, para evitar su aparición y así buscar mejorar la morbilidad por esta causa. Siempre acompañado de un manejo integral que permita abarcar todas las dimensiones afectadas.

Traumatic brain injury is a of the leading causes of death in the world, and many of these are associated with gunshot wounds in the skull. To know management the characteristics and pathophysiology of the lesion will tell as deal with these cases when presented to medical centers, while enabling us to take into account of possible complications, to prevent its occurrence and so try to improve morbidity from this cause. Always accompanied by an integrated management that can encompass all affected dimensions.

Traumatismo craneal no accidental: a propósito de un caso / Abusive head trauma: Report of a case

El traumatismo craneal no accidental es una forma de maltrato infantil. Frecuentemente, se encuentran lesiones intracraneales, como el hematoma subdural y también las hemorragias retinianas, en general, sin otras lesiones externas. Por su complejidad, esta entidad requiere de un equipo médico multidisciplinario, donde el papel del especialista en imágenes es muy importante, ya que existen múltiples métodos diagnósticos que se complementan para arribar al correcto diagnóstico

The abusive head trauma is a form of child abuse. The most frequent injuries are intracranial lesions, such as subdural hematoma, as well as retinal hemorrhages, usually without other external injuries. Due to its complexity, this problem requires a multidisciplinary medical team, where the role of the radiologist is important, since there are multiple diagnostic methods that are complementary in order to arrive at the correct diagnosis

Chronic subdural hematoma - an up-to-date concept.

Chronic subdural hematoma (CSDH) is prevalent among elderly populations worldwide, and its mysterious pathogenesis has been discussed in the literature for decades. The issues remaining to be solved in regard to CSDH include the initiating events; the bleeding into the subdural space and the formation of the outer and inner membranes, its development; increase and liquefaction of hematoma, the optimal treatments, and the natural history. The pathophysiology is becoming more clear due to recent findings from computed tomography studies and human models of CSDH. In this work, we review previous studies on CSDH and present a new integrated concept about the development of this common condition after head injuries.

Mitigating effects of external ventricular drain usage in the management of severe head injury.

BACKGROUND: Cerebrospinal fluid (CSF) drainage has been variably employed to lower intracranial pressure (ICP) in patients with severe head injury. The efficacy of this manoeuvre remains under-explored (Brain Trauma Foundation Recommendation-optional treatment). This work seeks to report the results of CSF drainage via external ventricular drain (EVD) in severe head injury in comparison to other treatment options. METHODS: Retrospective observational comparative study of all consecutive patients admitted to a major trauma centre with severe traumatic brain injury over a period of 12 months. RESULTS: Out of a total 139 patients, 33 had delayed elevation of ICP despite conventional medical therapy, 16 patients were treated with EVD insertion (4 placed under AxiEM image guidance [Medtronic]) and 17 received either decompressive craniectomy or barbiturate coma. Subsequently, two patients with decompression had further ICP elevation and needed EVD. Two patients with EVD had raised ICP-one underwent decompression and the other was treated with barbiturate coma. One patient with EVD developed infection, which was successfully treated. Patients treated with EVD had a lower risk of needing definitive treatment for ICP control, i.e. decompressive craniectomy or barbiturate coma. CONCLUSIONS: EVD was a safe and less invasive procedure, and achieved sustained control of ICP in this patient group.

Mixtures of receiver operating characteristic curves.

RATIONALE AND OBJECTIVES: Receiver operating characteristic (ROC) curves are ubiquitous in the analysis of imaging metrics as markers of both diagnosis and prognosis. While empirical estimation of ROC curves remains the most popular method, there are several reasons to consider smooth estimates based on a parametric model. MATERIALS AND METHODS: A mixture model is considered for modeling the distribution of the marker in the diseased population motivated by the biological observation that there is more heterogeneity in the diseased population than there is in the normal one. It is shown that this model results in an analytically tractable ROC curve which is itself a mixture of ROC curves. RESULTS: The use of creatine kinase-BB isoenzyme in diagnosis of severe head trauma is used as an example. ROC curves are fit using the direct binormal method, ROCKIT software, and the Box-Cox transformation as well as the proposed mixture model. The mixture model generates an ROC curve that is much closer to the empirical one than the other methods considered. CONCLUSIONS: Mixtures of ROC curves can be helpful in fitting smooth ROC curves in datasets where the diseased population has higher variability than can be explained by a single distribution.

Detection of cerebral spinal fluid-associated chemokines in birth traumatized premature babies by chip-based immunoaffinity CE.

A major concern in treating premature infants with birth-associated head trauma is the rapid determination of reliable biomarkers of neuroinflammation. To this end a chip-based immunoaffinity CE device has been applied to determine the concentrations of inflammation-associated chemokines in samples of cerebral spinal fluid collected from such subjects. The chip utilizes replaceable immunoaffinity disks, to which reactive antibody fragments (FAb) of six antichemokine-specific antibodies were immobilized. Following injection of a sample into the device, the analytes were captured by the immobilized FAbs, labeled in situ with a red laser dye, chemically released and separated by CE. Each resolved peak was measured on-line by LIF detection and the results compared to standard curves produced by running known chemokine standards through the immunoaffinity system. The complete processing of a sample took 10 min with separation of all six analytes being achieved in less than 2 min. The system compared well to commercial ELISA, analysis of the results by linear regression demonstrating r(2) values in the range of 0.903-0.978, and intra and interassay CV of the migration times and the measured peak areas being less than 2.3 and 5%, respectively. Application of the system to analysis of cerebrospinal fluid from head traumatized babies clearly indicated the group with mild trauma versus those with severe injury. Additionally, CE analysis demonstrated that the severe trauma group could be divided into individuals with good and poor prognosis, which correlated with the clinical finding for each patient.

CSF-biomarkers in Olympic boxing: diagnosis and effects of repetitive head trauma.

BACKGROUND: Sports-related head trauma is common but still there is no established laboratory test used in the diagnostics of minimal or mild traumatic brain injuries. Further the effects of recurrent head trauma on brain injury markers are unknown. The purpose of this study was to investigate the relationship between Olympic (amateur) boxing and cerebrospinal fluid (CSF) brain injury biomarkers. METHODS: The study was designed as a prospective cohort study. Thirty Olympic boxers with a minimum of 45 bouts and 25 non-boxing matched controls were included in the study. CSF samples were collected by lumbar puncture 1-6 days after a bout and after a rest period for at least 14 days. The controls were tested once. Biomarkers for acute and chronic brain injury were analysed. RESULTS: NFL (mean ± SD, 532±553 vs 135±51 ng/L p = 0.001), GFAP (496±238 vs 247±147 ng/L p<0.001), T-tau (58±26 vs 49±21 ng/L p<0.025) and S-100B (0.76±0.29 vs 0.60±0.23 ng/L p = 0.03) concentrations were significantly increased after boxing compared to controls. NFL (402±434 ng/L p = 0.004) and GFAP (369±113 ng/L p = 0.001) concentrations remained elevated after the rest period. CONCLUSION: Increased CSF levels of T-tau, NFL, GFAP, and S-100B in >80% of the boxers demonstrate that both the acute and the cumulative effect of head trauma in Olympic boxing may induce CSF biomarker changes that suggest minor central nervous injuries. The lack of normalization of NFL and GFAP after the rest period in a subgroup of boxers may indicate ongoing degeneration. The recurrent head trauma in boxing may be associated with increased risk of chronic traumatic brain injury.

Decompressive craniectomy and early cranioplasty for the management of severe head injury: a prospective multicenter study on 147 patients.

OBJECTIVE: In emergency care of patients with severe blunt head injury, uncontrollable high intracranial pressure is one of major causes of morbidity and mortality. The purpose of this study was to evaluate the efficacy of aggressive surgical treatment in managing uncontrollable elevated intracranial pressure coupled with early skull reconstruction. METHODS: This was a prospective study on a series of 147 consecutive patients, managed according to the same protocol by five different neurosurgical units, for severe head injuries (Glasgow coma scale score ≤8/15 and high intracranial pressure >25 mm Hg) during a five-year period. All patients received a wide decompressive craniectomy and duroplasty in the acute phase, and a cranioplasty was also performed within 12 weeks (median 6 weeks, range 4-12 weeks). RESULTS: The emergency decompressive surgery was performed within 28 hours (median 16 hours, range 6-28 hours) after sustaining the head injury. The median preoperative Glasgow coma scale score was 6/15 (range 3-8/15). At a mean follow-up of 26 months (range 14-74 months) 14 patients were lost to long-term follow-up, leaving only 133 patients available for the study. The outcome was favorable in 89 (67%, Glasgow outcome score 4 or 5), it was not favorable in 25 (19%, Glasgow outcome score 2 and 3), and 19 patients (14%) died. A younger age (<50 years) and earlier operation (within 9 hours from trauma) had a significant effect on positive outcomes (P < 0.0001 and P < 0.03, respectively). CONCLUSIONS: A prompt aggressive surgery, including a wide decompressive craniectomy coupled with early cranioplasty, could be an effective treatment method to improve the outcome after a severe closed head injury reducing, perhaps, many of the complications related to decompressive craniectomy.

Imaging of skull-base cephalocoeles and cerebrospinal fluid leaks.

Skull-base cephalocoeles and cerebrospinal fluid (CSF) leaks may be congenital, spontaneous, or secondary. A classification of congenital lesions is formulated and the imaging features are illustrated. The concept of spontaneous skull-base CSF leaks and the significance of aberrant arachnoid granulations in imaging these patients are explored. The majority of secondary lesions relate to trauma; however, other potential causes of secondary skull-base cephalocoeles and CSF leaks are discussed. Imaging evaluation in these clinical scenarios may be complex and the role of each imaging method is reviewed.

[Intracranial pressure-volume relationship. Physiology and pathophysiology]. / Intrakranielle Druck-Volumen-Beziehung. Physiologie und Pathophysiologie.

Posttraumatic increase of intracranial pressure (ICP) is a strong prognostic factor for the outcome of patients after traumatic brain injury. After exhausting all compensatory mechanisms ICP increases exponentially, where ICP(norm)=(CSF production*CSF flow resistance)+venous pressure((sinus sagittalis))=10-15 mmHg. The ICP curve is influenced by the compliance (DeltaV/DeltaP) and elasticity (DeltaP/DeltaV) of the brain. Marmarou could demonstrate that the non-linear cranio-spinal pressure-volume relationship describes a logarithmic, mono-exponential, strongly linear relationship between pressure and volume and named this the pressure volume index (PVI=log ICP/DeltaV). The pressure volume index describes the volume necessary to increase ICP by a factor of 10. Additionally to PVI the measurement of volume-pressure response (VPR) was introduced. The continuous intracranial compliance could be determined on the principle of pulsatile volume increases as an equivalent of very small intra-cranial volume increases. However, to ascertain functional status of the injured brain a combination of measurements of different parameters, such as tissue oxygen partial pressure (p(ti)O2), cerebral blood flow (CBF), microdialysis and electrocorticography (ECoG) is recommended.

NGF, DCX, and NSE upregulation correlates with severity and outcome of head trauma in children.

BACKGROUND: Secondary brain damage after traumatic brain injury (TBI) involves neuroinflammatory mechanisms, mainly dependent on the intracerebral production of specific biomarkers, such as cytokines, neurotrophic factors, and neuron-specific enolase (NSE). NSE is associated with neuronal damage, while neurotrophic factors play a neuroprotective role due to their ability to modulate neuronal precursor biosynthesis, such as doublecortin (DCX). However, the relationships between the expression of these factors and the severity and outcome of TBI are not understood. METHODS: To determine whether the concentrations of neurotrophic factors (nerve growth factor [NGF], brain-derived neurotrophic factor [BDNF], glial-derived neurotrophic factor [GDNF]), DCX, and NSE in the CSF of children with TBI correlate with the severity of brain damage and neurologic outcome, we prospectively collected CSF samples from 32 children at 2 and 48 hours after admission for severe TBI and from 32 matched controls. Severity of TBI was evaluated by Glasgow Coma Scale and neurologic outcome by Glasgow Outcome Score. RESULTS: Early NGF, DCX, and NSE concentrations correlated significantly with the severity of head injury, whereas no correlation was found for BDNF and GDNF. Furthermore, NGF and DCX upregulation and lower NSE expression were associated with better neurologic outcomes. No significant association was found between BDNF and GDNF expression and outcome. CONCLUSIONS: Nerve growth factor (NGF), doublecortin (DCX), and neuron-specific enolase concentrations in the CSF are useful markers of brain damage following severe traumatic brain injury (TBI). NGF and DCX upregulation correlates also with better neurologic outcome and could be useful to obtain clinical and prognostic information in children with severe TBI.

Child head injury criteria investigation through numerical simulation of real world trauma.

Finite element modelling has been used for decades in the study of adult head injury biomechanics and determination of injury criteria. Interest is recently growing in investigation on pediatric head injury which requires elaboration of biofidelic models that take into account child's head particularities in terms of size, geometry, and mechanical properties. In this study, a finite element model of a 3-year-old child head is proposed. The model is reconstructed from real CT scan images and mechanical properties are extracted from available data in the literature. A large number of real accidents (25 falls) are reconstructed with proposed model using different brain constitutive relationships in order to investigate their influence on model response. Mechanical output parameters (HIC, pressure, shearing stress) are calculated from these simulations. Statistical analysis was performed in order to evaluate predictive capability of the parameters. Von Mises stress appears to be clearly the most predictive parameters, allowing clear distinction between injured and non-injured cases. To the authors' knowledge, this study proposes for the first time a statistically based neurological injury criterion for a pediatric population using finite element modelling.

S100B protein and its clinical effect on craniocerebral injury.

OBJECTIVE: To explore the role of S100B protein in the early diagnosis, treatment, and prognosis judgement of craniocerebral injury. METHODS: In this study, we reviewed the domestic and foreign research reports about the relationship between S100B protein and craniocerebral injury. RESULTS: The concentration of S100B protein had a different increase based on the degree of injury in early stage after craniocerebral injury, and the increasing degree of S100B protein showed a positive correlation with the grading of pathogenetic condition and prognosis of craniocerebral injury. CONCLUSIONS: S100B protein may be taken as a specific index of early diagnosis, grading of pathogenetic condition, and prognosis judgement after craniocerebral injury. To grasp and regulate the mechanism of neurotoxicity and to elucidate the therapeutic effect of S100B protein will be a research direction in clinical treatment of craniocerebral injury.

[Differential diagnosis of subdural liquor accumulation in recurrent craniocerebral injury].

Criteria are proposed for the diagnosis of the origin and time- lapse of subdural accumulations of liquor in patients with repeated craniocerebral injury. The set of this criteria includes specific features of association and relative position of subdural liquor accumulations, their volume, and intracranial manifestations of primary and repeated craniocerebral injuries. Algorithms and nomograms have been developed in the course of the study allowing for accurate differentiation between subdural liquor accumulations as consequences of primary and repeated craniocerebral injuries. The results of the study have implications for practical forensic medical evaluation of repeated craniocerebral injuries with subdural liquor accumulation.

[Oxidative stress in victims with heavy combined cranium-facial trauma].

For acute posttraumatic period of heavy combined cranium-facial trauma (CFT) considerable activation of peroxide lipids oxidation in the liquor is typical beginning from the 1st day of posttraumatic period on the background of speedy and drastic depletion of fermentative and low-molecular antioxidant liquor system (in spite of introduction of antioxidants particularly a-tocopherol acetate). Non-adequate functioning of the system of antioxidant defense on the background of free radical activity splash can be considered as breakdown of the process of adaptive reaction forming. It leads to weighting the course of posttraumatic period of heavy combined cranium-facial trauma and its outcome as a whole.