A risk score based on admission characteristics to predict progressive hemorrhagic injury from traumatic brain injury in children.

Traumatic brain injury (TBI) is one of the leading causes of death and disability in children, and progressive hemorrhagic injury (PHI) post TBI is associated with poor outcomes. Therefore, the objective of this study was to develop and validate a prognostic model that uses the information available at admission to determine the likelihood of PHI occurrence after TBI in children. The identified demographic data, cause of injury, clinical predictors on admission, computed tomography scan characteristics, and routine laboratory parameters were collected and used to develop a PHI prognostic model with logistic regression analysis, and the prediction model was validated in 68 children. Eight independent prognostic factors were identified: lower Glasgow coma scale score (3 ~ 8) (6 points), intra-axial bleeding/brain contusion (4 points), midline shift ≥5 mm (9 points), platelets <100 × 109/L (11 points), prothrombin time >14 s (6 points), international normalized ratio >1.25 (7 points), D-dimer ≥5 mg/L (14 points), and glucose ≧10 mmol/L (11 points). We calculated risk scores for each child and defined three risk groups: low risk (0-16 points), intermediate risk (17-36 points), and high risk (37-68 points). In the development cohort, the PHI rates after TBI for the low-, intermediate-, and high-risk groups were 10.1, 47.9, and 84.2%, respectively. In the validation cohort, the corresponding PHI rates were 10.9, 47.5, and 85.4%, respectively. The C-statistic for the point system was 0.873 (p = 0.586 by the Hosmer-Lemeshow test) in the development cohort and 0.877 (p = 0.524 by the Hosmer-Lemeshow test) in the validation cohort. CONCLUSION: Using admission predictors, we developed a relatively simple risk score that accurately predicted the risk of PHI after TBI in children. What is Known: • TBI is one of the leading causes of death and disability in children, and PHI post TBI is associated with poor outcomes. •Prediction of patients at low risk of PHI could help reduce treatment costs, whereas identification of patients at high risk of PHI could direct early medical intervention to improve outcomes. What is New: • This study firstly developed a risk score system by assessing the admission information that could provide an earlier prediction of the occurrence of PHI after acute TBI in children.

Combined focal myoclonus and dystonia secondary to a cerebellar hemorrhage: a case report.

BACKGROUND: Myoclonus is a clinical sign characterized by sudden, brief jerky, shock-like involuntary movements of a muscle or group of muscles. Dystonia is defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures. Cases of myoclonus or dystonia secondary to a structural lesion in the cerebellum have been reported. However, there has never been a reported case of combined myoclonus and dystonia secondary to a cerebellar lesion. CASE PRESENTATION: Herein, we report a 22-year-old female patient with sudden-onset myoclonic jerks, dystonic posture and mild ataxia in the right upper extremity. At age 19, she experienced sudden headache with vomiting. The neurological examination showed ataxia, myoclonus and dystonia in the right upper extremity. Brain images demonstrated a hemorrhage in the right cerebellar hemisphere secondary to a cavernous malformation. After resection of the hemorrhagic mass, headache with vomiting disappeared and ataxia improved, but myoclonus and dystonia persisted. CONCLUSIONS: It is the first report of combined focal myoclonus and dystonia secondary to a cerebellar lesion.

Microbleeds may expand acutely after traumatic brain injury.

BACKGROUND AND PURPOSE: Susceptibility weighted imaging (SWI) is a very sensitive tool for the detection of microbleeds in traumatic brain injury (TBI). The number and extent of such traumatic microbleeds (TMBs) have been shown to correlate with the severity of the injury and the clinical outcome. However, the acute dynamics of TMBs have not been revealed so far. Since TBI is known to constitute dynamic pathological processes, we hypothesized that TMBs are not constant in their appearance, but may progress acutely after injury. MATERIALS AND METHODS: We present here five closed moderate/severe (Glasgow coma scale≤13) TBI patients who underwent SWI very early (average=23.4 h), and once again a week (average=185.8 h) after the injury. The TMBs were mapped at both time points by a conventional radiological approach and their numbers and volumes were measured with manual tracing tools by two observers. TMB counts and extents were compared between time points. RESULTS: TMBs were detected in four patients, three of them displaying an apparent TMB change. In these patients, TMB confluence and apparent growth were detected in the corpus callosum, coronal radiation or subcortical white matter, while unchanged TMBs were also present. These changes caused a decrease in the TMB count associated with an increase in the overall TMB volume over time. CONCLUSION: We have found a compelling evidence that diffuse axonal injury-related microbleed development is not limited strictly to the moment of injury: the TMBs might expand in the acute phase of TBI. The timing of SWI acquisition may be relevant for optimizing the prognostic utility of this imaging biomarker.

Susceptibility Weighted Imaging and Mapping of Micro-Hemorrhages and Major Deep Veins after Traumatic Brain Injury.

Micro-hemorrhages are a common result of traumatic brain injury (TBI), which can be quantified with susceptibility weighted imaging and mapping (SWIM), a quantitative susceptibility mapping approach. A total of 23 TBI patients (five women, 18 men; median age, 41.25 years old; range, 21.69-67.75 years) with an average Glasgow Coma Scale score of 7 (range, 3-15) at admission were recruited at mean 149 d (range, 57-366) after injury. Susceptibility-weighted imaging data were collected and post-processed to create SWIM images. The susceptibility value of small hemorrhages (diameter ≤10 mm) and major deep veins (right septal, left septal, central septal, right thalamostriate, left thalamostriate, internal cerebral, right basal vein of Rosenthal, left basal vein of Rosenthal, and pial veins) were evaluated. Different susceptibility thresholds were tested to determine SWIM's sensitivity and specificity for differentiating hemorrhages from the veins. A total of 253 deep veins and 173 small hemorrhages were identified and evaluated. The mean susceptibility of hemorrhages was 435±206 parts per billion (ppb) and the mean susceptibility of deep veins was 108±56 ppb. Hemorrhages showed a significantly higher susceptibility than all deep veins (p<0.001). With different thresholds (250, 227 and 200 ppb), the specificity was 97%, 95%, and 92%, and the sensitivity was 84%, 90%, and 92%, respectively. These results show that SWIM could be used to differentiate hemorrhages from veins in TBI patients in a semi-automated manner with reasonable sensitivity and specificity. A larger cohort will be needed to validate these findings.

[Cerebrovascular resistance in patients with severe combined traumatic brain injury].

UNLABELLED: Cerebrovascular resistance is an important parameter of the microcirculation. The main objective of cerebrovascular resistance is to maintain the constancy of cerebral blood flow and protect downstream vessels when changing perfusion pressure. The purpose of the study was to assess cerebrovascular resistance (CVR) in patients with severe combined traumatic brain injury (CTBI) with and without intracranial hematomas (IHs). MATERIAL AND METHODS: We analyzed treatment outcomes in 70 patients with severe CTBI (42 males and 28 females). The mean age was 35.5 ± 14.8 years (min 15 years; max 73 years). All patients were divided into 2 groups, depending on the presence of intracranial hemorrhage. The first group included 34 patients without IH, and the second group included 36 patients with epidural (6), subdural (26), and multiple (4) hematomas. The GCS score was 10.4 ± 2.6 in the first group and 10.6 ± 2.8 in the second group. The ISS severity injury score was 32 ± 8 in the first group and 31 ± 11 in the second group. All patients were operated on within the first 3 days, with 30 (83.3%) patients being operated on during the first day. Perfusion computed tomography (PCT) of the brain was performed within 1-14 days after TBI in the first group and within 2-8 days after surgical evacuation of hematoma in the second group. After PCT, the mean arterial pressure was measured, and the blood flow rate in the middle cerebral artery was determined using transcranial dopplerography. Cerebrovascular resistance was calculated using the formula modificated by P. Scheinberg. Comparisons between the groups were performed using the Student t-test and χ² criterion. RESULTS: The mean CVR values in each group (both with and without hematomas) were statistically significantly higher than the mean normal value of this parameter. Intergroup comparison of CVR values demonstrated a statistically significant increase in the CVR level in group 2 on the side of removed hematoma compared to group 1 (p=0.037). CVR in the perifocal zone of removed hematoma remained significantly higher compared to the symmetrical zone of the contralateral hemisphere (p=0.0009). CONCLUSION: Cerebrovascular resistance in patients with combined traumatic brain injury is significantly increased compared to the normal value. Cerebrovascular resistance in the perifocal zone after evacuation of hematoma in patients with multiple injury remains significantly increased compared to the symmetrical zone in the contralateral hemisphere.

Susceptibility-weighted MRI in mild traumatic brain injury.

OBJECTIVE: To compare the frequency of microbleeds identified by susceptibility-weighted MRI (SWMRI) in patients with mild traumatic brain injury (mTBI) and normal controls, and correlate these findings with neuropsychological tests. METHODS: Research ethics committee approval and patient written informed consents were obtained. One hundred eleven patients with mTBI without parenchymal hemorrhage on CT and conventional MRI received SWMRI as well as a digit span and continuous performance test. One hundred eleven healthy volunteers without history of traumatic brain injury were enrolled as the control group and received conventional MRI with additional SWMRI study. We analyzed the number and location of microbleeds in both groups. RESULTS: Twenty-six patients with mTBI and 12 control subjects presented microbleeds on SWMRI (p = 0.0197). Sixty microbleeds were found in 26 patients with mTBI and 15 microbleeds in 12 control subjects. The mTBI group showed notably more microbleeds in the cortex/subcortical region (52 microbleeds, 86.7%, vs 3 microbleeds, 20%; p < 0.0001). Conversely, the control group showed more microbleeds in the central brain (9 microbleeds, 60%, vs 3 microbleeds, 5%; p < 0.0001). There was no statistical difference in number of microbleeds in the cerebellum and brainstem (p = 0.2598 and p = 0.4932, respectively). Patients with mTBI who had detected microbleeds had lower digit span scores than the patients with negative SWMRI findings (p = 0.017). CONCLUSION: Presence of mTBI-related microbleeds showed a neuropsychological defect on short-term memory function, indicating that the presence of microbleeds could be a possible severity biomarker for mTBI. Addition of the SWMRI technique to the MRI protocol for patients with mTBI is recommended.

[Substantiation of the choice of treatment strategy in isolated traumatic injury of the frontal lobes of the brain].

An analysis of the results of the treatment of 132 patients with isolated traumatic parenchymatous injury of the frontal lobes of the brain was made. The treatment strategy was determined in consideration of the traumatic substratum volume and a combination of neurologic status and instrumental data. There were unfavorable risk factors to the course of traumatic parenchymatous injury of the frontal lobes of the brain such as low initial GCS score, the progression of neurologic deficiency in the presence of contusion hemorrhagic foci in the frontal lobe with the volume more than 25 cm3, shifting of midline structures on 5 mm and more or signs of deformation of basilar region cisterns and the presence of mass-effect according to the tomographic data. The developed algorithm allowed improving the results of treatment and the quality of life for patients with traumatic parenchymatous injury of the frontal lobes of the brain.

Effectiveness of a nonpenetrating captive bolt for euthanasia of 3 kg to 9 kg pigs.

The objective of this study was to determine the effectiveness of a nonpenetrating captive bolt, Zephyr-E, for euthanasia of suckling and weaned pigs from 3 to 9 kg (5-49 d of age) using signs of insensibility and death as well as postmortem assessment of traumatic brain injury (TBI). The Zephyr-E was used by 15 stock people to euthanize 150 compromised pigs from 4 farrowing and nursery units from commercial farms and 2 research stations. Brainstem reflexes, convulsions, and heartbeat were used to assess insensibility, time of brain death, and cardiac arrest following Zephyr-E application. Skull fracture displacement (FD) was quantified from computed tomography (CT) scans (n = 24), macroscopic scoring was used to assess brain hemorrhage and skull fracture severity (n = 150), and microscopic scoring was used to assess subdural hemorrhage (SDH) and parenchymal hemorrhage within specific brain regions that are responsible for consciousness and vital function (n = 32). The Zephyr-E caused immediate, sustained insensibility until death in 98.6% of pigs. On average, clonic convulsions (CC) ceased in 82.2 s (± 3.4 SE), brain death was achieved in 144.9 s (± 5.4 SE), and cardiac arrest occurred in 226.5 s (± 8.7 SE). Time of brain death and cardiac arrest differed significantly among stock people (P = 0.0225 and P = 0.0369). Age was positively related to the duration of CC (P = 0.0092), time of brain death (P = 0.0025), and cardiac arrest (P = 0.0068) with shorter durations seen in younger pigs. Average FD was 8.3 mm (± 1.0 SE). Macroscopic scores were significantly different among weight classes for subcutaneous (P = 0.0402) and subdural-ventral (P = 0.0037) hemorrhage with the lowest severity hemorrhage found in the 9-kg weight category. Microscopic scores differed among brain sections (P = 0.0070) for SDH with lower scores found in the brainstem compared to the cerebral cortex and midbrain. Parenchymal hemorrhage differed among brain sections (P = 0.0052) and weight categories (P = 0.0128) with the lowest scores in the midbrain and brainstem and the 7- and 9-kg weight categories. The Zephyr-E was highly effective for the euthanasia of pigs up to 9 kg (49 d) based on immediate insensibility sustained until death. Postmortem results confirmed that severe skull fracture and widespread brain hemorrhage were caused by the Zephyr-E nonpenetrating captive bolt.

[Factors indicative of differentiated approach to the treatment of severe focal lesions of the brain].

The article is devoted the study of complex research 126 patients with a heavy craniocerebral trauma, accompanied vnutrimozgovoy traumatic haematoma and hearth crushing of cerebrum, passing treatment in the clinic of neuro-surgery. The use of modern diagnostic methods of research considerably changed the informative providing of diagnostic and medical process at the different hearth defeats of cerebrum, including traumatic hearth injuries of cerebrum. The long-term looking after intracraneal haematomas allowed to mark that haematomas suffer successive changes which are expressly traced on computer tomography researches in course of time.

Long-term sequelae after acquired pediatric hemorrhagic cerebellar lesions.

PURPOSE: The aim of the present study was to assess cognitive, affective, and motor long-term sequelae after acquired focal pediatric cerebellar lesions. METHODS: Eight patients with a history of isolated acquired hemorrhagic cerebellar lesions before the age of 13 participated in this study. All participants underwent a neurologic examination, including the Zurich Neuromotor Assessment (ZNA) and the International Cooperative Ataxia Rating Scale (ICARS). Cognitive functions have been evaluated with a general cognitive assessment and an extensive neuropsychological battery. Furthermore, patients and parents filled in questionnaires about quality of life and possible behavioral or emotional problems. RESULTS: The results revealed that all patients exhibited motor problems (ZNA). Most participants had further restricted oculomotor movements (ICARS). Age at injury and the full scale IQ were significantly positively correlated (Pearson correlation 0.779; p = 0.023). Conversely, no overall neuropsychological profile could be identified except for marginally reduced reaction times and susceptibility to interference. In addition, borderline results in semantic and phonemic word fluency tasks were apparent. A dysexecutive syndrome was diagnosed in one patient. However, verbal performance and reading abilities were non-pathologic in all participants. The patients reported having a good quality of life without major physical restrictions. CONCLUSIONS: Emotional disturbances and the presence of a mild cerebellar cognitive affective syndrome (as frequently described in adult patients) could only be confirmed in adolescents with vermis lesions. Nevertheless, in laboratory conditions, neuropsychological impairments were present in all patients. Heterogeneity of age at injury and exact lesion site may have led to interpersonal differences in neuropsychological outcome.

The role of advanced MR imaging findings as biomarkers of traumatic brain injury.

Treatment of traumatic brain injury (TBI) requires proper classification of the pathophysiology. Clinical classifiers and conventional neuroimaging are limited in TBI detection, outcome prediction, and treatment guidance. Advanced magnetic resonance imaging (MRI) techniques such as susceptibility weighted imaging, diffusion tensor imaging, and magnetic resonance spectroscopic imaging are sensitive to microhemorrhages, white matter injury, and abnormal metabolic activities, respectively, in brain injury. In this article, we reviewed these 3 advanced MRI methods and their applications in TBI and report some new findings from our research. These MRI techniques have already demonstrated their potential to improve TBI detection and outcome prediction. As such, they have demonstrated the capacity of serving as a set of biomarkers to reveal the heterogeneous and complex nature of brain injury in a regional and temporal manner. Further longitudinal studies using advanced MRI in a synergistic approach are expected to provide insight in understanding TBI and imaging implications for treatment.

The impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with hemorrhagic brain injury.

BACKGROUND: More elderly trauma patients are identified with preinjury use of clopidogrel, aspirin, or warfarin (CAW). The purpose of this study was to determine whether preinjury CAW use was an important predictor of mortality in patients aged >or=50 years with blunt, hemorrhagic brain injury (HBI). METHODS: A retrospective review of patients with blunt, HBI aged >or=50 years with subgroup analysis for older (>70 years) and younger (50-70 years) patients was performed. CAW use was analyzed for differences in age, gender, hospital length of stay (LOS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), mechanism of injury (MOI), platelet transfusion therapy (PLT), disposition at discharge, and in-hospital mortality. RESULTS: From January 2003 to October 2005, 416 patients were identified. The mean age was 69+/-1 years. No differences were found for ISS (24 +/- 0.5), GCS (12 +/- 0.2), or LOS (8 +/- 0.4 days). CAW use was present in 40% of patients and significantly higher in older patients. Mortality was not different between older and younger CAW(+) patients, but it significantly increased for older CAW(-) patients. Significant predictors of death included age, ISS, and GCS (P<.02). CONCLUSIONS: Preinjury CAW use in older blunt, HBI patients is not associated with increased mortality. Age was a significant predictor of mortality independent of CAW use.

Haematoma of the tentorium cerebelli - new pathology or new prognostic factor in neurotraumatology? A preliminary report.

BACKGROUND AND PURPOSE: The aim of the study was to establish the frequency of haematoma of the tentorium cerebelli, to elucidate the possible pathomechanism related to its formation, and to assess its clinical significance. MATERIAL AND METHODS: 84 patients with haematoma of the tentorium cerebelli were selected out of the 1159 patients treated in our Department from 2003 to 2005 due to craniocerebral trauma. All patients had computed tomography (CT) performed on admission. In selected cases, magnetic resonance imaging (MRI) was performed. Additionally, 4 autopsies were performed using a special technique for better recognition of blood location within the region of the tentorium. RESULTS: The study group comprised 61 men (73%) and 23 women (age range: 18-84 years). Fall on the occiput was the main cause of trauma. The clinical status of patients was rather serious (53% of patients scored below 8 pts on the Glasgow Coma Scale on admission), as was the clinical course (39% of patients eventually died). The following co-existing pathologies were found in CT: traumatic subarachnoid haemorrhage and cerebral contusion (60% of patients), subdural haematoma (45%), intracerebral haematoma (31%), pathology in posterior fossa (12%), and epidural haematoma (8%). MRI revealed subdural collection of blood above or below the tentorium or the subarachnoid haemorrhage beneath the occipital lobes and/or over the cerebellar hemisphere. CONCLUSIONS: The progress in neuroimaging, especially in CT scanning, enables haematoma of the tentorium cerebelli to be discerned as a distinct clinical entity.

[Uncontrollable bleeding in a patient with head trauma treated with blood component therapy guided by thromboelastography]. / Ukontrollabel blødning hos en patient med hovedtraume behandlet med blodkomponentterapi vejledt af tromboelastografi.

This is a case report concerning a patient with traumatic uncontrolled bleeding. The patient was admitted with a severe head injury and facial fractures. During neurosurgery, the bleeding became life-threatening and there was a request for recombinant factor VIIa therapy (NovoSeven). Before the treatment, thromboelastography was performed. This showed platelet insufficiency, and after infusion of platelets, the bleeding was under control and there was no longer a need for recombinant factor VIIa therapy. We therefore recommend thromboelastography to evaluate coagulation status before treatment with recombinant factor VIIa.