Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation.

OBJECTIVEThere are limited data concerning the long-term functional outcomes of patients with penetrating brain injury. Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury. The purpose of this study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).METHODSThis study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.RESULTSA total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.CONCLUSIONSGood functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts.

[Successful treatment and rehabilitation of severe, penetrating brain injury].

Penetrating brain injuries due to gunshots are rare in Denmark. This is a case report of the successful treatment of a 31-year-old man who was shot in the right frontal region of the head. The bullet went through his brain without damaging the large intracranial vessels. On admission he had a GCS of 9. Haematoma removal and bifrontal craniectomy was performed to obtain lowering of the intracranial pressure. One year after the incidence the patient was able return to work. This case report illustrates the importance of early prehospital and neurointensive treatment with lowering of the intracranial pressure and highly specialised rehabilitation.

Penetrating brain injury: a case report.

BACKGROUND: Gunshot wounds as a result of attempted suicide, criminality or warfare comprise a significant group among penetrating injuries of the brain. A prognosis in such cases is based mainly on an initial score on the Glasgow Coma Scale (GCS). According to the literature, the mortality rate among patients with initial GCS ranging from 3 to 5 points is very high, up to 98.5%. Although there are also many other prognostic factors for high mortality, such as damage to the ventricular system or the involvement of two or more lobes, GCS score seems to be the most important determinant. The treatment in an ICU which is focused on decreasing the risk of secondary brain damage can significantly improve the prognosis and final outcome. CASE REPORT: The authors present the case of a 27-year-old man who suffered a gunshot wound to the right temporal region, self-inflicted from an air-gun. On admission to the intensive care unit he received a score of 3 points on the GCS. There were also other negative prognostic factors - the pellet penetrated two lobes and damaged the third ventricle. Despite the serious prognosis, the appropriate multiprofile treatment and rehabilitation resulted in unexpectedly good recovery. Two years after the trauma the patient was conscious, maintained logical verbal contact, and was able to walk using a walking-aid. CONCLUSION: Rapid transport to a major trauma center is essential for patients with penetrating brain injury. Among all interventions it seems essential to provide the prevention of posttraumatic nervous tissue damage and associated neurological dysfunction.

Reconstructive and rehabilitation challenges following a cranio-orbital gunshot wound.

We present a case of a 26-year-old man who sustained a close-range gunshot wound to the head. His injuries included significant left orbital injury resulting in a ruptured, blind eye and severely comminuted fractures of the left orbital roof, superior and inferior orbital rims, and orbital floor. Associated injuries included left frontal lobe injury, anterior and posterior table fractures of the left frontal sinus, and a comminuted left zygomaticomaxillary complex fracture. We employed an interdisciplinary surgical approach with collaboration among the Otolaryngology, Neurosurgery, and Oculoplastic Surgery services performed in two stages. Management of such extensive craniofacial injuries can be challenging and requires a coordinated, interdisciplinary approach.

Self-inflicted trans-oral intracranial stab wound.

BACKGROUND: Intracranial stab wounds are low-velocity, penetrating injuries to the brain and fatality and outcome significantly depend on route, depth and location of cranial penetration. Due to the effective barrier provided by the adult calvarium, most injuries occur through the orbitae or temporal regions where bony layers are thin. Self-inflicted intracranial stab wounds are an even rarer form of traumatic brain injury, with common entry points being the orbital space and the nose. Intracranial brainstem injuries mostly result in death, with reported penetration areas being the pons or midbrain. CASE: The following report reviews a first reported case of self-inflicted intracranial stabbing via a trans-oral route with lesions to the medulla oblongata and cerebellum. Unlike previous cases of low velocity penetrating injuries to the brainstem, the patient underwent full neurologic recovery after manual knife removal and intensive rehabilitation. CONCLUSION: Self-inflicted transcranial injuries have been mentioned only briefly and sporadically in the literature. This article highlights a rare case of self-inflicted intracranial stabbing with a not yet reported entry route and brainstem lesion. Unlike the other fatal outcomes associated with such injuries, the patient underwent full neurological and functional recovery through a comprehensive approach that included intensive rehabilitation.

Valoración del impacto del tratamiento cognitivo, dentro del programa de rehabilitación, en pacientes con traumatismo craneoencefálico / Evaluation of the impact of cognitive treatment within the rehabilitation program in patients with traumatic brain injury

Introducción. El objetivo es determinar el impacto del tratamiento de rehabilitación cognitiva, sobre el déficit cognitivo y la capacidad funcional, en pacientes con traumatismo craneoencefálico (TCE). Material y método. Diseño del estudio cuasiexperimental, con grupo control. Sujetos del estudio. 34 pacientes con TCE moderado o severo que cumplen los criterios de inclusión. Los pacientes fueron asignados a 1) grupo experimental: realizan tratamiento cognitivo, con programa de estimulación cognitiva SMARTBRAIN, y rehabilitación funcional, o a 2) grupo control: realizan programa de tratamiento de rehabilitación funcional. La duración del tratamiento fue de 4 meses. Instrumentos de medidas. La valoración cognitiva se hace por el test Minimental y la escala Neurobehavioral Functioning Inventory, y son clasificados según la escala de nivel de función cognitiva Rancho los Amigos. La valoración funcional se realiza con el Functional Independence Measure (FIM), en el momento de la inclusión en el estudio, y al finalizar el tratamiento. Resultados. Se observó recuperación del déficit cognitivo, en el grupo experimental, con valores superiores en el test Minimental (p < 0,001; IC 95%: 2-7) y en cada una de las áreas que este instrumento evalúa. También se observaron diferencias en los valores obtenidos en las 6 subescalas de la escala Neurobehavioral Functioning Inventory, principalmente en atención, memoria (p < 0,04; lC 95%: −21-−4), y comunicación (p < 0,001; IC 95%: −17-−3). El grupo experimental también presentó valores superiores en la subescala cognitiva del FIM (p < 0,008; IC 95%: 1-6), pero no en el nivel funcional, valorado por el FIM. Conclusiones. En pacientes con TCE, el tratamiento cognitivo mejora la recuperación del déficit cognitivo, no existiendo deferencias en los resultados funcionales de estos pacientes (AU)

Introduction. This study has aimed to determine the impact of Cognitive Rehabilitation treatment on cognitive deficits and functional capacity in patients with traumatic brain injury (TBI). Material and method. The study has a quasi-experimental design, with a control group. Study subjects. 34 patients with moderate or severe TBI who fulfilled the inclusion criteria. The patients were assigned to 1) an experimental group: cognitive therapy was performed using the SMARTBRAIN stimulation cognitive program, and functional rehabilitation, 2) control group: functional rehabilitation treatment program was performed. The treatment duration was 4 months. Measurement instruments. The cognitive assessment was performed using the Minimental test, Neurobehavioral Functioning Inventory Scale and classification was done according to the Rancho de los Amigos levels of cognitive functioning scale. Functional assessment was performed using the Functional Independence Measure (FIM) both during enrolment in the study and at the end of the treatment. Results. Recovery of cognitive deficit was observed in the experimental group, with high values in Minimental test (P < .001; 95% CI: 2-7) and in each of the areas evaluated by this instrument. Differences were also observed in the values obtained in the six subscales of Neurobehavioral Functioning Inventory scale. These were mainly in attention, memory (P < .04, 95 CI: −21-−4%) and communication (P < .001; 95% CI: −17-−3). The experimental group also had high values in the FIM cognitive subscale (P < 0,008; 95% CI: 1-6), but not at the functional level, valued by FIM. Conclusions. In TBI patients, cognitive treatment improves recovery of cognitive deficit. There are no differences in functional outcomes of these patients (AU)

Perfil psicopatológico de pacientes con traumatismo craneoencefálico evaluados mediante el Inventario Neuropsiquiátrico / Psychopatological evaluation of traumatic brain injury patients with the Neuropsychiatric Inventory

Introducción. El Inventario Neuropsiquiátrico (NPI) es una escala que valora la presencia de alteraciones psicopatológicas en pacientes con enfermedades neurológicas, principalmente demencias. A pesar de sus ventajas, existen pocos estudios publicado en pacientes con traumatismo craneoencefálico (TCE). Con la información derivada del NPI pretendemos describir las alteraciones psicopatológicas en un grupo de pacientes con TCE severo en fase crónica y determinar si se correlacionan con antecedentes psiquiátricos y medidas de resultado. Método. Se administró el NPI a los informantes de 53 pacientes con traumatismo craneoencefálico grave que se encontraban en fase crónica. Así mismo, se recogieron escalas de funcionalidad y de integración a la comunidad. Resultados. El 92,5% de la muestra estudiada presentaba alguna alteración psicopatológica según el NPI, siendo los síntomas más frecuentes la irritabilidad/labilidad, la apatía y la depresión/disforia. El antecedente de consumo habitual de tóxicos mostró una relación significativa con la presencia de psicopatología. Síntomas como la agitación, la apatía y la desinhibición se correlacionaron de forma significativa con el grado de discapacidad. Conclusiones. Las alteraciones psiquiátricas son frecuentes en pacientes con TCE. El nNPI es una herramienta que recoge de manera sistemática las alteraciones conductuales y emocionales más frecuentes en estos pacientes. Algunos de los síntomas influyen negativamente en el grado de discapacidad(AU)

Introduction. The Neuropsychiatric Inventory (NPI) is a scale that assesses psychiatric symptoms in patients with neurological disorders, principally dementia. Despite its advantages, there are few published studies in traumatic brain injury (TBI) patients. With the NPI information we are going to describe the psychopatologic disorders in a group of TBI chronic patients and look the possible association with psychiatric history and outcome measures. Method. The NPI was applied to caregivers of 53 patients with severe TBI in chronic phase. We also collected functional and community integration scales. Results. 92.5% of patients had some neuropsychiatric symptom, according to NPI. The most frequents were irritability/lability, apathy and depression/dysphoria. Those patients with drugs abuse history had more psychiatric symptoms. Presence of agitation/aggression, apathy and disinhibition were correlated with more disability. Conclusions. Psychiatric disorders are common between patients with TBI. The NPI is a scale that systematically assesses the behavioral and emotional disorders more common in these patients. Some of the symptoms negatively influence the degree of disability(AU)

[Optimization of medical-diagnostic process in patients with traumatic brain injury during early rehabilitation].

The problem of cardiovascular disease and cancer, the effects of traumatic brain injury is now one of the major health and social problems. Every year in Ukraine registered 200 thousand cases of the victims of traumatic brain injury. Of these, 30% of people then have persistent signs of disability that results in a disability, sometimes painful existence the patient and his relatives. Therefore, in order to bring man back into society after a traumatic brain injury, to the rehabilitation phase of treatment, immediately after the stabilization of the patient.

Fisiopatología de las tormentas eléctricas en el encéfalo del paciente con una lesión cerebral aguda. Resultados preliminares de un estudio piloto / Pathophysiology of electrical storms in the brain of patients with acute brain injury. Preliminary results of a pilot study

Los fenómenos de despolarización cortical propagada (CSD y CSD-like) son despolarizaciones celulares que se extienden en forma de onda y están implicados en la progresión de las lesiones en pacientes con ictus y traumatismo craneoencefálico (TCE). Son detectables en el registro de electrocorticografía (ECoG). Experimentalmente inducen hipoxia cerebral e incrementa la permeabilidad de la barrera hematoencefálica. Objetivos: Determinar la frecuencia y duración de estos episodios en pacientes con TCE o infarto maligno de la arteria cerebral media (IMACM) que requieran craniectomía. Material y métodos: 20 pacientes a los que se les colocó, en el córtex perilesional, una tira de seis electrodos. Análisis del número y la duración de los episodios de CSD registrados. Resultados: En cuatro, de los ocho registros de ECoG analizados, se identificaron episodios de CSD o CSD-like de duración y frecuencia variable. Conclusiones: Se detectan frecuentemente episodios de CSD y CSD-like en pacientes con IMACM y TCE (AU)

The phenomena of cortical spreading depolarization (CSD and CSD-like phenomena) are cellular depolarization waves involved in the progression of lesions in patients with stroke and traumatic brain injury (TBI). Which are detected by an electrocorticographic (ECoG) recording. Experimentally, CSD induces cerebral hypoxia and increases the permeability of the blood-brain barrier. Objectives: To determine the frequency and duration of CSD episodes in patients with TBI and malignant middle cerebral artery infarction (MMCAI) requiring craniectomy. Material and methods: 20 patients were included. A strip of 6 electrodes was placed in the perilesional cortex. Analysis of the number and duration of CSD episodes in the ECoG recording was performed. Results: In four, of the eight ECoG recordings that was fully analyzed, CSD or CSD-like phenomena were identified with a variable frequency and duration. Conclusions: Episodes of CSD and CSD-like phenomena are frequently detected in patients with MMCAI and TBI (AU)

Predictores clínicos de marcha independiente en pacientes con traumatismo craneoencefálico severo / Clinical predictors of independent ambulation after severe traumatic brain injury

Objetivo. Identificar los predictores clínicos de marcha independiente en pacientes con traumatismo craneoencefálico (TCE) severo tras un programa de rehabilitación multidisciplinario y determinar la correlación entre los resultados de la rehabilitación y el estado neurológico del paciente al ingreso. Pacientes y métodos. Análisis retrospectivo de una muestra de 73 pacientes con TCE severo y sin capacidad de marcha al ingreso, seguidos longitudinalmente durante un período medio de 215,3±85,9 días. Todos ellos fueron clasificados en función de su estado neurológico al ingreso: estado vegetativo (EV, n=14), estado de mínima conciencia (EMC, n=16), amnesia postraumática (APT, n=30) y fuera de APT (n=13). Resultados. De forma general, el 41,1% de la muestra adquirió capacidad de marcha al finalizar el programa de rehabilitación multidisciplinario específico. En función del estado neurológico de los pacientes al ingreso, 3 pacientes (18,8%) del grupo de EMC, 17 pacientes (56,7%) del grupo de APT y 10 pacientes (76,9%) del grupo fuera de APT lograron realizar una marcha independiente. Ninguno de los pacientes clasificados inicialmente en EV fue capaz de andar de forma independiente. El modelo de regresión logística reveló que el estado neurológico general (p<0,001), la cronicidad (p=0,001) y la movilidad axial al ingreso evaluada con el Rivermead Mobility Index (p=0,02) fueron predictores independientes de marcha. Discusión. El estado neurológico general, el tiempo transcurrido desde la lesión y la movilidad general al ingreso pueden ayudar a predecir la recuperación de la capacidad de marcha independiente tras un programa de rehabilitación en esta población(AU)

Objective. To identify clinical predictors of independent ambulation in patients with severe traumatic brain injury (TBI) after a multidisciplinary rehabilitation program and to determine the correlation between rehabilitation outcomes and neurological status of the patient on admission. Patients and methods. A retrospective analysis of a sample of 73 patients with severe head injury and no ability to walk on admission, followed longitudinally for an average of 215.3±85.9days, was performed. All patients were classified into four groups based on their neurological status at admission: vegetative state (n=14), minimally conscious state (n=16), post-traumatic amnesia (PTA, n=30) and out-of-PTA (n=13). Results. Globally, 41.1% of the initial sample acquired gait abilities after specific multidisciplinary rehabilitation. Regarding neurological status at admission, three patients (18.8%) of the minimally conscious group, 17 patients (56.7%) of the PTA group, 10 patients (76.9%) of the out-of-PTA group, and none of the patients who were initially classified in the vegetative state group were able to walk independently after 6 months. The final multivariate logistic regression model revealed that global neurological status (p<0.001), chronicity (p=0.001), and Rivermead Mobility Index (p=0.02) were independent predictors of gait. Discussion. Global neurological status, time since injury, and global mobility at admission can help predict recovery of independent gait after six months of rehabilitation in this population(AU)

Aplicación de la clasificación internacional del funcionamiento, de la discapacidad y de la salud en la evaluación del paciente con secuelas de traumatismo craneoencefálico / Applicability of the International Classification of Functioning, Disability and health in the evaluation of patients with traumatic brain injury

Introducción. El traumatismo craneoencefálico (TCE) es la causa más común de discapacidad en las primeras décadas de la vida y sus secuelas comprenden cambios motores, conductuales y cognitivos. Medir estos cambios es un aspecto esencial en la rehabilitación para identificar objetivos, cuantificar secuelas y crear planes de intervención. El objetivo de este estudio es evaluar la funcionalidad tras un programa de rehabilitación empleando la Clasificación Internacional de la Funcionalidad (CIF) como marco conceptual. Material y método. Se revisaron retrospectivamente los resultados funcionales de 77 pacientes con TCE grave según la escala FIM FAM expresados en la nomenclatura de la CIF siguiendo la metodología de las linking rules. Resultados. Sólo un 3,8% del total de la CIF se evalúa mediante la FIM FAM. Se pudo traducir la mayoría de los conceptos a la nomenclatura de la CIF, pero es notoria la ausencia de factores medioambientales. A nivel cognitivo, el deterioro fue máximo en las categorías de solución de problemas (81,8%), empleabilidad (77,9%) y juicio (77,9%). Subir escaleras (85,7%) y movilidad comunitaria (81,8%) fueron las más afectadas a nivel motor. Conclusiones. El uso de la CIF como marco conceptual permite describir el estado de salud de individuos como TCE y conceptualmente es capaz de detectar limitaciones como la ausencia de factores medioambientales(AU)

Introduction. Traumatic Brain Injury (TBI) is the leading cause of disability in the first decades of life. Motor, cognitive and behavioral changes are examples of its sequelae. The measurement of these changes are essential aspects of rehabilitation in order to identify objectives, quantify problems and plan interventions. The objective of this study is to evaluate functioning after a rehabilitation programme using the International Classification of Functioning (ICF) as a conceptual framework. Material and method. The outcome of 77 patients with severe TBI were retrospectively analyzed using the FIM FAM scale expressed in terms of ICF coding following the methodology of the «linking rules.» Results. Only 3.8% of the ICF are evaluated by the FIM FAM. Most of the concepts could translated into the ICF language. However, the lack of environmental factors stands out. The most affected cognitive areas were problem solving (81.8%), employability (77.9%) and judgment with a 77.9% of patients showing problem (4). Climbing stairs (85.7%) and Community mobility (81.8%) were the mostly affected motor functions. Conclusions. The use of ICF as a conceptual framework allows to describe the health status of a TBI patient and it is conceptually capable of detecting limitations such as a lack in evaluating environmental factors(AU)

Reinserción sociofamiliar del traumatismo craneoencefálico grave / Social-familiar reintegration in severe traumatic brain injury subject

Introducción. El traumatismo craneoencefálico (TCE) es causa importante de discapacidad en población con edad laboral y condiciona una situación de minusvalía que dificulta la reinserción sociolaboral. En España la incidencia con discapacidad grave en 2002 fue de 2/100.000 habitantes/año. Objetivo. Analizar la reincorporación laboral y la situación sociofamiliar de los TCE graves después de un año de evolución. Pacientes y métodos. Se realiza un estudio de pacientes con TCE grave (Glasgow inicial ≤ 8) y que realizaron tratamiento de rehabilitación, ingresados durante el período del 1 de enerode 2002 al 31 de diciembre de 2006. Se excluyen los fallecidos y los trasladados a otro hospital. Se valora la situación sociofamiliar por la Escala de Gijón y la reinserción laboral por entrevista telefónica, con un seguimiento mínimo de un año. Resultados. De los 215 TCE graves ingresados en la unidad de cuidados intensivos (UCI), se estudian 69 con una media de 42,6 (14-90) años de edad, predominio masculino (72 %) y Glasgow inicial de 5,46 (3-8). El accidente de tráfico es la causa más frecuente (63,7 %). Las lesiones asociadas más frecuentes son los politraumatismos (57,2 %). Tras el tratamiento la medida de independencia funcional (FIM) mejora 41 puntos (0-94). Se reincorpora al mundo laboral el 36,6 % y tiene un estado sociofamiliar normal el 50 %. Conclusión. La reinserción laboral se produce aproximadamente en un tercio de los pacientes, en cambio la integración sociofamiliar es buena en la mitad de ellos. Los pacientes experimentan una mejoría media de 41 puntos de FIM en la capacidad funcional durante el período de tratamiento (AU)

Introduction. Traumatic brain injury (TBI) is an important reason of disability in the working-age population and determines a situation of handicap that hinders social work reintegration. In Spain, the incidence of severe disabilityin 2002 was 2/100,000 inhabitants per year. Objective. To analyze the return to work and the social family situation of the severe TBI subject after a one-year evolution. Patients and methods. We carried out a study of patients admitted during the period from January 1, 2002, to December 31, 2006, with severe TBI (initial Glasgow ≤ 8) and with rehabilitation treatment. Patients with exitus and those transferred to another hospital were excluded. The social and family situation was assessed using the Gijón Scale and returnto work by telephone interview, with a minimum follow-up of one year. Results. A total of 69 severe TBI out of the 215 admitted to the intensive care unit (ICU), age 42.6 (14-90) years, malepredominance (72 %) and initial Glasgow 5.46 (3-8) werestudied. Traffic accident was the most frequent cause (63.7 %). The polytrauma was the most frequent injury associated (57.2 %). After treatment, the functional independence measure (FIM) improved 41 points (0-94), 36.6 % returning to the work world and 50 % obtaining a normal social-family status. Conclusion. Re-entry into the work word occurs in approximately one third of the patients while social-integrationis good in half of them. The patients experienced a mean improvementof 41 points on the FIM in functional capacity during the treatment period (AU)

Prevalencia de lesiones asociadas a lesionados medulares simultáneas al evento traumático / Prevalence of associated lesions in patients with acute traumatic spinal cord injury

Introducción. Los traumatismos suelen ocasionar otras lesiones más allá de la lesión medular (LM) que pueden pasar desapercibidas en los primeros momentos, acarreando riesgo vital, retrasos en la recuperación funcional o aumento de la discapacidad. Los objetivos de este trabajo son determinar la prevalencia de las lesiones asociadas entre los pacientes que sufrieron una lesión traumática aguda, conocer su tipo y la relación con las variables epidemiológicas y con las complicaciones concurrentes durante el ingreso. Material y método. Se realizó un estudio transversal en los pacientes ingresados en el Hospital Nacional de Parapléjicos, que presentasen LM traumática aguda, edad igual o superior a 18 años, haber sufrido al menos una lesión asociada simultánea a la LM y que no fueran dados de alta en la semana del estudio. De los 196 pacientes ingresados, se seleccionaron por lesión traumática 90, de los que 62 tenían lesiones asociadas agudas. Se evaluaron edad, género, etiología, prevalencia de lesiones óseas y viscerales, traumatismo craneoencefálico, hemotórax, neumotórax, lesiones de plexo y factores psicosociales. Resultados. La prevalencia de lesiones asociadas fue 68,9 %. La edad media de estos pacientes fue significativamente menor. El género no se asoció a mayor vulnerabilidad para lesiones asociadas. Etiologicamente los tráficos doblaron a las caídas.Aquellos que sufrieron fractura o LM dorsal presentaron un número mayor de lesiones asociadas con significación estadística. Conclusión. Las lesiones agudas asociadas deben ser siempre tenidas en cuenta en la valoración inicial por su prevalencia alta, especialmente si hay fractura o LM dorsal (AU)

Introduction. Traumatic patients afflicted with spinal cord injury (SCI) could have lesions in other anatomical regions.These lesions frequently receive delayed diagnosis and may increase the mortality risk, modify the course of recovery and produce worse functional outcomes.The aims of the present work is to determine the prevalence, etiology, epidemiology and complications of associated lesions in patients with acute traumatic SCI. Material and methods. We perfomed a cross-sectional study of associated lesions in acute traumatic SCI patients admitted to the National Paraplegic Hospital of Toledo.The selection criteria were to suffer an acute traumatic SCI, to be older than eighteen years, to have at least one associated lesion concomitant with the SCI and not to be discharged during the time of acquisition data (one week). 90 out of 196 admitted patients had an acute traumatic SCI, 62 of them showing associated lesions.We obtained data regarding age, gender, etiology, prevalence of simultaneous visceral or bone lesions, traumatic brain injury, pneumothorax, hemothorax, braquial plexus injury and psychosocial profile. Results. The prevalence of associated lesions in acute traumatic SCI patients was 68.9 % with a mean age lower than the reported in other series and without gender differences. Traffic accidents doubled in frequency to falls as cause of the SCI. Statistical test showed that the frequency of associated lesions was significantly in patients with thoracic SCI or thoracic vertebrae fractures, compared to patients with injuries at other spinal or vertebrae levels. Conclusions. Taking into consideration the high prevalence of associated lesions in patients with acute traumatic SCI, it is of major importance to suspect them in the initial clinical assessment, particularly in patients with thoracic SCI or vertebral trauma (AU)

Uso de biomateriales con fines neurorregenerativos. Aplicación en modelo experimental de traumatismo craneoencefálico / Use of biomaterials in neural regeneration. Application in an experimental model of head injury

Objetivos: Evaluar el rendimiento de los biomateriales poliméricos basados en ácido hialurónico y su utilidad en el Sistema Nervioso Central, sirviendo como soporte, para la supervivencia y diferenciación celular. Material y Metodos: Con el fin de evaluar la viabilidad de los soportes poliméricos y acanalados, se realizaron experimetos in vitro e in vivo mediante el implante en corteza cerebral de ratas Wistar. Mediante técnicas inmunocitoquímicas e histológicas se procedió al análisis de la viabilidad de los soportes. Resultados: Tras el cultivo pudimos constatar la viabilidad celular sobre los biomateriales, asi como su potencial utilidad para la regeneración in vivo de estructuras vasculares y neurales. Conclusiones: La posibilidad de regenerar estructuras vasculares y neurales a través del implante de biomateriales basados en ácido hialurónico, constituye un avance en la utilización de biomateriales en el Sistema Nervioso Central (AU)

Objetives: To evaluate the performance of polymeric biomaterials based on hyaluronic acid and their usefulness in the central nervous system as support for cell differentiation and survival. Material and methods: With the purpose of assessing the viability of polymeric cannulated scaffolds, in vitro and in vivo experiments were made involving implantation in the Wistar rate brain cortex. Immunocytochemical and histological techniques were used to analyze scaffold viability. Results: Following culture, cell viability on the biomaterials was confirmed, together with the potential usefulness of the latter for the in vivo regeneration of vascular and neural structures. Conclusions: The possibility of regenerating vascular and neural structures through the implantation of biomaterials based on hyaluronic acid constitutes an advance in the use of biomaterials in the central nervous system (AU)

Comparing functional status and community integration in severe penetrating and motor vehicle-related brain injuries.

OBJECTIVE: To examine the functional status of persons surviving a severe penetrating traumatic brain injury (TBI) resulting from a gunshot wound who require inpatient rehabilitation. DESIGN: Data were collected prospectively at 4 different time periods: rehabilitation admission and discharge and year 1 and year 2 postinjury. SETTING: Rehabilitation hospital within a Traumatic Brain Injury Model System. PARTICIPANTS: Forty-five persons with severe penetrating brain injury and 45 persons involved in a motor vehicle crash (MVC). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS), FIM instrument, and Community Integration Questionnaire (CIQ). RESULTS: Results indicated functional improvements for both the penetrating and motor vehicle severe TBI groups on the DRS and the FIM from rehabilitation admission to discharge. Follow-up data at 1 and 2 years postinjury revealed continued improvements on the DRS and FIM measures for both groups, with the greatest improvement in recovery during the first year. In addition, improved community reintegration emerged between 1 and 2 years postinjury for both groups, as measured by the CIQ. There was a small significant difference on the outcome measures between the 2 groups in the course of their recovery. CONCLUSIONS: Persons who survive severe penetrating brain injuries and who require inpatient rehabilitation may show continuing improvement in functioning over time. For persons receiving inpatient rehabilitation services, initial improvement is most likely to occur during the hospital stay and continue postinjury, with the largest improvement in the first year after injury. Community reintegration can also be expected over time. One can expect similar outcomes for individuals who sustain a severe penetrating brain injury and a severe brain injury ensuing from an MVC.

Military TBI during the Iraq and Afghanistan wars.

Traumatic brain injury (TBI) is an important source of morbidity in the Iraq and Afghanistan wars. Although penetrating brain injuries are more readily identified, closed brain injuries occur more commonly. Explosion or blast injury is the most common cause of war injuries. The contribution of the primary blast wave (primary blast injury) in brain injury is an area of active research. Lessons learned from the sports concussion and civilian mild TBI literature are useful. Individuals with TBI and posttraumatic stress disorder require treatment of both conditions. Families and communities need to be cognizant of the needs of these returning veterans.

The cognitive impairments due to the occipito-parietal brain injury after gunshot. A successful neurorehabiliation case study.

OBJECTIVE: The presented case study describes the beneficial results of the neuropsychological rehabilitation of a gunshot victim, even with late initialization of the therapy--over 1 year after head trauma. DESIGN: A case study of DE, a victim with bilateral damage of the parietal-occipital regions of the brain due to a gunshot. METHODS: Neuropsychological rehabilitation, first preceded by an initial neuropsychological examination (standard psychological tests: WAIS-R, RAVLT, Rey's CFT, BVRT and clinical experiments tailored to DE's condition), was initiated 1 year after trauma. The rehabilitation programme consisted of computer-based tasks, paper-and-pencil exercises, and occupational therapy. The patient's progress was assessed as improvement in performance in standardized tests and computer-based tasks. RESULTS: DE was diagnosed with complex cognitive deficits syndrome, including visual associative agnosia, apraxia, visuospatial and constructive disorders and linguistic defects. After 1 year of rehabilitation the patient's functioning significantly improved as measured by psychological tests and computer-based tasks (p<0.05) as well as the evaluation of the patient's quality of life. CONCLUSIONS: The case study demonstrates beneficial effects of neurorehabilitation even initialized at the so-called 'late stage' after a brain injury.

Anterior hypopituitarism with unusual delayed onset of diabetes insipidus after penetrating head injury.

Neuroendocrine dysfunctions are among the various complications that occur after traumatic brain injury. We report a case of onset of diabetes insipidus during acute rehabilitation of a 20-yr-old patient with a traumatic brain injury caused by a gunshot wound. Our case is the latest onset of diabetes insipidus after traumatic brain injury that has been reported in the literature.

Quantitative imaging in late TBI. Part II: cognition and work after closed and penetrating head injury: a report of the Vietnam head injury study.

CONTEXT: Functional outcome in relation to CT findings in traumatic brain injured (TBI) patients is not well established in relation to cognitive and vocational outcome. OBJECTIVE: To investigate the possible correlation between relatively simple quantitative radiological measurements and cognitive and vocational outcome. DESIGN: Retrospective analysis of quantitative assessment of CT studies in relation to post-injury cognitive changes and vocational outcome. SETTING: US Army Medical Centre. PATIENTS: 74 penetrating head injured (PHI) and 37 closed head injured (CHI) Vietnam war veterans. OUTCOME MEASURES: The Armed Forces Qualification Test (AFQT); Disability score; Return to work. RESULTS: Total brain volume loss, third ventricle width (3VW), ventricular score (VS), and septum-caudate distance (SCD) were significantly related to cognitive change and return to work in PHI patients. Volume loss and 3VW were the most valuable radiologic predictors of outcome in multivariate linear and logistic regression models for both CHI and PHI. CONCLUSION: 3VW on late CT scans following traumatic brain injury is a powerful predictor of overall long-term cognitive outcomes and potential for return to work.

Penetrating head injury: a prospective study of outcomes.

The purpose of our study was to describe the outcomes of persons with penetrating brain injury resulting from a gunshot wound to the head. It is a prospective study of 442 patients admitted with gunshot wounds to the head over a 7 year period to our University Trauma Center Emergency Department, an urban trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Measures and factors described include initial Glasgow Coma Scale score, Revised Trauma Score, the Disability Rating Scale, Functional Independence Measure, levels of cognitive functioning, patient demographics, length of stay, hospital charges, and discharge disposition. Initially 36% of patients expired in or were dead upon arrival to the Emergency Department; 64% of patients survived to be admitted for inpatient care. Of those admitted, 41% expired within the first 48 h of admission. Fifty-two percent of those admitted had severe injuries, 7% moderate injuries, and 42% had mild head injuries. Sixty-two percent of the survivors were discharged from acute care to private residences. The remaining 38% were discharged to programs providing varying levels of care depending upon their level of functioning and care needs. Patients sustaining severe injuries following gunshot wound(s) to the head have high early mortality. Survivors able to participate in an inpatient rehabilitation program have good potential for functional improvement.