Measuring Blunt Force Head Impacts in Athletes.

INTRODUCTION: Although concussion continues to be a major source of acute and chronic injuries, concussion injury mechanisms and risk functions are ill-defined. This lack of definition has hindered efforts to develop standardized concussion monitoring, safety testing, and protective countermeasures. To overcome this knowledge gap, we have developed, tested, and deployed a head impact monitoring mouthguard (IMM) system. MATERIALS AND METHODS: The IMM system was first calibrated in 731 laboratory tests. Versus reference, Laboratory IMM data fit a linear model, with results close to the ideal linear model of form y = x + 0, R2 = 1. Next, during on-field play involving n = 54 amateur American athletes in football and boxing, there were tens of thousands of events collected by the IMM. A total of 890 true-positive head impacts were confirmed using a combination of signal processing and National Institute of Neurological Disorders and Stroke/National Institutes of Health Common Data Elements methods. RESULTS: The median and 99th percentile of peak scalar linear acceleration and peak angular acceleration were 20 and 50 g and 1,700 and 4,600 rad/s2, respectively. No athletes were diagnosed with concussion. CONCLUSIONS: While these data are useful for preliminary human tolerance limits, a larger population must be used to quantify real-world dose response as a function of impact magnitude, direction, location, and accumulation. This work is ongoing.

Reduction of Computed Tomography Use for Pediatric Closed Head Injury Evaluation at a Nonpediatric Community Emergency Department.

OBJECTIVE: The purpose of this study was to determine if implementation of a Pediatric Emergency Care Applied Research Network (PECARN)-based Closed Head Injury Assessment Tool could safely decrease computed tomography (CT) use for pediatric head injury evaluation at a nonpediatric community emergency department (ED). METHODS: A quality improvement project was initiated at a nonpediatric community ED to implement an institution-specific, PECARN-based Pediatric Closed Head Injury Assessment Tool. Baseline head CT use at the participating ED was determined for children with closed head injury through retrospective chart review from March 2014 through November 2015. Head injury patients were identified using International Classification of Disease (ICD)-9 codes for head injury, unspecified (959.01) and concussion with and without loss of consciousness (850-850.9) until October 2015, after which ICD-9 was no longer used. To identify eligible patients after October 2015, lists of all pediatric patients evaluated at the participating ED were reviewed, and patients were included in the analysis if they had a physician-assigned discharge diagnosis of head injury or concussion. Exclusion criteria were age ≥ 18 years, penetrating head trauma, history of brain tumor, ventriculoperitoneal shunt, bleeding disorder, or presentation > 24 hours postinjury. Medical history, injury mechanism, symptoms, head CT use, and disposition were recorded. Implementation of the Pediatric Closed Head Injury Assessment Tool was achieved through provider education sessions beginning in December 2015 and ending in August 2016. Head CT use was monitored for 12 months postimplementation, from September 2016 through August 2017. Patients were classified into low, intermediate, or high risk for clinically important traumatic brain injury (ciTBI) by chart review. ED length of stay (LOS), disposition, and ED returns within 72 hours were recorded. Categorical variables were compared using chi-square test or Fisher's exact test, and continuous variables, using Kruskal-Wallis test. RESULTS: A total of 252 children with closed head injury were evaluated preimplementation (March 2014 through November 2015), 132 children were evaluated during implementation (December 2015 through August 2016), and 172 children were evaluated postimplementation (September 2016 through August 2017). Overall CT use decreased from 37.7% (95% confidence interval [CI] = 31.7-43.7) preimplementation to 16.9% (95% CI = 11.3-22.5) postimplementation (p < 0.001). Only 1% (95% CI = 0%-2.9%) of low-risk patients received a head CT postimplementation compared to 22.6% (95% CI = 16.1%-29.1%) preimplementation (p < 0.001). CT use among patients ≥ 24 months decreased from 42.9% (95% CI = 36.5%-49.6%) to 19.6% (95% CI = 13.1%-26.1%; p < 0.001) and remained low and unchanged for patients < 24 months. Transfers to a pediatric trauma center and ED returns within 72 hours were unchanged, while median ED LOS improved from 1.5 to 1.3 hours (p = 0.03). There were no missed ciTBIs after implementation of the guideline. CONCLUSION: Implementation of the PECARN-based Pediatric Closed Head Injury Assessment Tool reduced head CT use in a nonpediatric ED. The greatest impact was seen among children aged ≥ 24 months at very low risk for ciTBI.

[Guideline "Legal evaluation after closed brain injury in adulthood"]. / Leitlinie "Begutachtung nach gedecktem Schädel-Hirntrauma im Erwachsenenalter".

In 2005 and 2013, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Evaluation) together with other societies developed and consented guidelines fort the legal evaluation of patients with closed head injuries and published them trough the National Working Group of Scientific Medical Societies and in this journal. Five years later, a revision was necessary, this was developed on the higher S2 k level of consent through a Delphi conference.

Does Visual Performance Influence Head Impact Severity Among High School Football Athletes?

OBJECTIVE: To compare the odds of sustaining moderate and severe head impacts, rather than mild, between high school football players with high and low visual performance. DESIGN: Prospective quasi-experimental. SETTING: Clinical Research Center/On-field. PARTICIPANTS: Thirty-seven high school varsity football players. INTERVENTIONS: Athletes completed the Nike SPARQ Sensory Station visual assessment before the season. Head impact biomechanics were captured at all practices and games using the Head Impact Telemetry System. MAIN OUTCOME MEASURES: Each player was classified as either a high or low performer using a median split for each of the following visual performance measures: visual clarity, contrast sensitivity, depth perception, near-far quickness, target capture, perception span, eye-hand coordination, go/no go, and reaction time. We computed the odds of sustaining moderate and severe head impacts against the reference odds of sustaining mild head impacts across groups of high and low performers for each of the visual performance measures. RESULTS: Players with better near-far quickness had increased odds of sustaining moderate [odds ratios (ORs), 1.27; 95% confidence intervals (CIs), 1.04-1.56] and severe head impacts (OR, 1.45; 95% CI, 1.05-2.01) as measured by Head Impact Technology severity profile. High and low performers were at equal odds on all other measures. CONCLUSIONS: Better visual performance did not reduce the odds of sustaining higher magnitude head impacts. Visual performance may play less of a role than expected for protecting against higher magnitude head impacts among high school football players. Further research is needed to determine whether visual performance influences concussion risk. CLINICAL RELEVANCE: Based on our results, we do not recommend using visual training programs at the high school level for the purpose of reducing the odds of sustaining higher magnitude head impacts.

Grading system for retinal hemorrhages in abusive head trauma: clinical description and reliability study.

PURPOSE: There is currently no universally accepted grading system for describing retinal hemorrhages (RH) in abusive head trauma (AHT). The purpose of this study was to devise and evaluate a novel grading system and descriptive nomenclature for RH in AHT for clinical and research purposes. METHODS: A traumatic hemorrhagic retinopathy (THR) grading system was developed for assessing and quantitatively analyzing retinal findings in abusive head trauma. The criteria for the THR grade included the extent, spread, and morphology of RH. Extent was classified as region 1 (posterior pole) or region 2 (peripheral). Spread, based on number of retinal hemorrhages, was classified as mild (10 or fewer RH), moderate (more than 10 RH) and severe (more than half of involved regions covered by RH). Morphology was classified by its intraretinal or extraretinal involvement. Two independent graders calculated the THR grade from RetCam images of 38 eyes of 19 patients <3 years of age with retinal hemorrhages associated with head injury. Grading was performed on two separate occasions. Intra- and interobserver reliability was assessed with Spearman correlation coefficient (r) and intraclass correlation coefficient (ICC). RESULTS: There was a high level of intraobserver agreement across both assessments (97% agreement [Spearman r = 0.997; P < 0.0001] and 100% agreement [Spearman r = 1.0; P < 0.0000]). Intraclass correlation (ICC, 0.995; 95% CI, 0.991-0.997; P < 0.0001) confirmed a very high level of agreement overall. CONCLUSIONS: The traumatic hemorrhagic retinopathy grading system demonstrated excellent intraobserver and interobserver reliability. The nomenclature is easily understood and may be useful in medical records and medicolegal reports.

[Walcher's hat brim line rule--a literature review]. / Über die Walcher'sche Hutkrempenregel--eine Literaturstudie.

The first description in the forensic medical literature of a demarcation line for the localization of head injuries resulting from falling to the ground appears in Kratter (1919). Regarding a similar line, Walcher (1931) later introduced the relation to the hat brim (Hutkrempe), which gave the rule its name: the hat brim line rule (Hutkrempenregel). Thenceforth it was supposed to be called Kratter's and Walcher's hat brim line rule (Kratter-Walcher'sche Hutkrempenregel). Over the following decades, not only its content but also the area of application and the definition of the hat brim line rule were repeatedly, and in part significantly, altered. This could be one of the reasons for the confusing diversity of academic opinions about the rule's applicability. Generally, the hat brim line rule should be retained in its original sense: Fall-related injuries do not lie above the hat brim line if the fall occurred from a standing position to the ground, without intermediary blows to the head. If applied in this way, the rule can be a helpful point of orientation for experts. The demarcation line in the original anatomical definition according to Kratter (1919) should also be used henceforth: the line which connects "the frontal eminence, the parietal eminence and the tip of the occipital plate" and lies "somewhat.above the usual saw-line of the calvarium". This line corresponds roughly to the hat brim line as it is understood by hat makers. The hat brim line rule should not be applied with regard to small children, as they show a different falling behaviour due to their disproportionately large and heavy heads. The rule is also in no way applicable to the assessment of injuries from blows, falls from a height (including from stairs) or traffic accidents. There is an urgent need for research as to the applicability of the hat brim line rule in relation to falling backwards, particularly in cases of high alcohol consumption.

Computed tomographic scan in head trauma: what is the rational in children?

Traumatic brain injury (TBI) is the consequence of external forces that traumatically injure the brain. Closed head injury is common in children and is estimated to result in 650,000 to 1 million emergency department visits annually with approximately 7,400 deaths in the United States. Mild TBI is the most common form of closed head injury and constitutes 80 to 90% of all the TBI. Cranial computed tomography (cCT) is performed in usually more than 50% of the patients, thus, resulting in an extreme overuse with the inherent risk for inducing malignancies. The purpose of this article is to review current approaches, recommendations, and guidelines on pediatric head trauma with special emphasis on cCT. Therefore, after an overview on classification and TBI scores, diagnostic imaging, and management rules for clinical important TBI, as well as own experience including remarks on cCT technique will be discussed.

[About the Geserick sign--a literature study]. / Uber das Geserick-Zeichen--eine Literaturstudie.

Fractures of the medial and basal orbital wall as well as the petrous part of the temporal bone were described first in 1980 by a Berlin-based study group led by Geserick as new cranium findings resulting from a contrecoup mechanism. Experimental and comparative examinations revealed that indirect fractures of the orbital walls are caused by a coup action of the eyeballs, whereas the mechanogenesis of the petrous bone fractures continues to be unclear. The frequently combined occurrence with the orbital sign nonetheless permits an allocation to the contrecoup mechanism. Both signs are important criteria for forensic and clinical assessment of craniocerebral injuries.

Low-level laser therapy for closed-head traumatic brain injury in mice: effect of different wavelengths.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) affects millions worldwide and is without effective treatment. One area that is attracting growing interest is the use of transcranial low-level laser therapy (LLLT) to treat TBI. The fact that near-infrared light can penetrate into the brain would allow non-invasive treatment to be carried out with a low likelihood of treatment-related adverse events. LLLT may treat TBI by increasing respiration in the mitochondria, causing activation of transcription factors, reducing inflammatory mediators and oxidative stress, and inhibiting apoptosis. STUDY DESIGN/MATERIALS AND METHODS: We tested LLLT in a mouse model of closed-head TBI produced by a controlled weight drop onto the skull. Mice received a single treatment with continuous-wave 665, 730, 810, or 980 nm lasers (36 J/cm(2) delivered at 150 mW/cm(2)) 4-hour post-TBI and were followed up by neurological performance testing for 4 weeks. RESULTS: Mice with moderate-to-severe TBI treated with 665 and 810 nm laser (but not with 730 or 980 nm) had a significant improvement in Neurological Severity Score that increased over the course of the follow-up compared to sham-treated controls. Morphometry of brain sections showed a reduction in small deficits in 665 and 810 nm laser treated mouse brains at 28 days. CONCLUSIONS: The effectiveness of 810 nm agrees with previous publications, and together with the effectiveness of 660 nm and non-effectiveness of 730 and 980 nm can be explained by the absorption spectrum of cytochrome oxidase, the candidate mitochondrial chromophore in transcranial LLLT.

Evidence-based community consultation for traumatic brain injury.

OBJECTIVES: The objective was to determine if geospatial techniques can be used to inform targeted community consultation (CC) and public disclosure (PD) for a clinical trial requiring emergency exception from informed consent (EFIC). METHODS: Data from January 2007 to December 2009 were extracted from a Level I trauma center's trauma database using the National Trauma Registry of the American College of Surgeon (NTRACS). Injury details, demographics, geographic codes, and clinical data necessary to match core elements of the clinical trial inclusion criteria (Glasgow Coma Scale [GCS] 3-12 and blunt head injury) were collected on all patients. Patients' home zip codes were geocoded to compare with population density and clustering analysis. RESULTS: Over a 2-year period, 179 patients presented with moderate to severe traumatic brain injury (TBI). Mapping the rate and frequency of TBI patients presenting to the trauma center delineated at-risk populations for moderate to severe head injury. Four zip codes had higher incidences of TBI than the rest, with one zip code having a very high rate of 80 per 100,000 population. CONCLUSIONS: Geospatial techniques and hospital data records can be used to characterize potential subjects and delineate a high-risk population to inform directed CC and public disclosure strategies.

Reality and risk of contact-type head injuries related to bicycle-mounted child seats.

OBJECTIVE: The authors have treated numerous children who have been injured by falling from bicycle-mounted child seats. Despite the greatly increased use of such seats, the understanding of their risk and the importance of helmet use remains alarmingly poor. The objective of this study was to confirm the risk of bicycle-mounted child seats and to evaluate the efficacy of helmets, seat belts, and back seat height in terms of preventing or mitigating contact-type head impacts that occur in falls from bicycle-mounted child seats. MATERIALS AND METHODS: Biometrical dummy tests were performed to examine contact-type head injuries in falls from stationary bicycles. A bicycle with an anthropometric test dummy placed in a bicycle-mounted child seat was tipped over. Each test was repeated three times and three-dimensional acceleration was measured using accelerometer. Head Injury Criteria (HIC) were calculated and the respective influences of a helmet, a seat belt, and increased height of the back of the seat on such impacts were evaluated. RESULTS: Only helmets unequivocally lowered maximal acceleration and/or HIC values with statistical significance. The seat belt lowered HIC values as long as it was used with the high-back seat. Only when the dummy wore a helmet sitting in a high-back seat did the HIC show less than the threshold of 570 for three-year-old children. The HIC showed the lowest score of 161.5 when the dummy wore both a helmet and a seat belt sitting in a high-back seat. CONCLUSIONS: Riders in bicycle-mounted child seats definitely have higher risks of contact-type head injuries. In transporting a child on a bicycle-mounted child seat, parents must use both a child-bicycle helmet and a high-back child seat at least; a seat belt is highly recommended as long as it is used with the other safety devices. IMPACT ON INDUSTRY: The bicycle-mounted child seat should have a high enough back and an appropriate seat belt to protect the head of the child from a contact-type injury.

[Analysis on clinical classification and injury certification in 30 cases of acute closed head trauma].

OBJECTIVE: In order to improve accuracy of forensic expert conclusion and provide scientific and reasonable accordance for revising identifying criteria for the injury degree, correlation between clinical classification and injury certification of acute closed head trauma were explored. METHODS: A total of 30 cases about acute closed head trauma were selected. Comparison and analysis were made about their differences and the correlation between the clinical classification and the injury degree certification. RESULTS: Mild craniocerebral injury is equal to mild or moderate injury, moderate craniocerebral injury is equivalent to mild or severe injury, severe craniocerebral injury is mostly equivalent to severe injury. CONCLUSION: There are some correlation between the clinical classification and the injury certification in acute closed head trauma. It is necessary to refer to the criteria of clinical classification when revising identifying criteria for the injury degree so as to enhance scientific rigor and rationality.

Frequency, types and causes of intraventricular haemorrhage in lethal blunt head injuries.

Autopsy findings and neuropathological examination of formalin-fixed brains in 676 deaths due to blunt head injury, here with special attention to injuries of the inner (periventricular) cerebral structures and haemorrhages into the ventricles. Intraventricular haemorrhage of any degree was present in 17.6%, considering only distinct and massive haemorrhage in 10% of all cases. Considering the types of trauma, the frequency was lowest in ground level falls and highest in traffic accidents (pedestrians with head contact to the car) - indicating a relation between the severity of impacts and the likelihood of ventricular haemorrhage. They predominantly resulted from periventricular injuries (27%) or retrograde expansions of infratentorial lesion with subarachnoid bleeding (19%), from massive contrecoup lesions (14%) or deep intracerebral ruptures (13%). In cases with predominant lesions of the cerebral surface the rate was lower than in those with more diffuse or internal damages. Injuries of the internal cerebral regions (away from cortex and subcortical white matter) were classified into those directly affecting the periventricular structures (9.1-13.5%; half of them affecting corpus callosum and/or fornix) and lesions of deep white matter or basal ganglia not adjoining the ventricular walls (4.0-5.9%). Intraventricular haemorrhage as well as injuries of the inner cerebral structures mostly are one element of a complex and severe blunt head injury. Solitary lesions - without other intracranial findings clearly indicating a trauma and therefore cases producing difficulties in forensic classification (spontaneous? traumatic?) - are rarities according to literature as well as our experiences.

Shaken baby syndrome: a common variant of non-accidental head injury in infants.

BACKGROUND: Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality. METHODS: Selective literature review including an overview over national and international recommendations. RESULTS: Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations. CONCLUSIONS: The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation.

OBJECT: A Glasgow Coma Scale (GCS) score of 3 on presentation in patients with severe traumatic brain injury due to blunt trauma has been recognized as a bad prognostic factor. The reported mortality rate in these patients is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. Consequently, there is often a tendency to treat these patients less aggressively because of the low expectations for a good recovery. In this paper, the authors' purpose is to report their experience in the management of this patient population, analyzing the mortality rate, prognostic factors, and functional outcome of survivors. METHODS: The authors performed a retrospective review of patients who presented between 1997 and 2007 with blunt head trauma and a GCS score of 3. Demographics, mechanism of injury, examination, blood alcohol level, associated injury, intracranial pressure (ICP), surgical procedures, and outcome were all recorded. RESULTS: A total of 189 patients met the inclusion criteria and were included in this study. The overall mortality rate was 49.2%. At the 6-month follow-up, 13.2% of the entire series achieved a good functional outcome (Glasgow Outcome Scale [GOS] score of 1 or 2). The patient population was then divided into 2 groups: Group 1 (patients who survived [96]) and Group 2 (patients who died [93]). Patients in Group 1 were younger (mean 33.3 +/- 12.8 vs 40.3 +/- 16.97 years; p = 0.002) and had lower ICP on admission (mean 16.3 +/- 11.1 vs 25.7 +/- 12.7 mm Hg; p < 0.001) than those in Group 2. The difference between the 2 groups regarding sex, mechanism of injury, hypotension on admission, alcohol, surgery, and associated injuries was not statistically significant. The presence of bilateral fixed, dilated pupils was found to be associated with the highest mortality rate (79.7%). Although not statistically significant because of the sample size, pupil status was also a good predictor of the functional outcome at the 6-month follow-up; a good functional outcome (GOS Score 1 or 2) was achieved in 25.5% of patients presenting with bilateral reactive pupils, and 27.6% of patients presenting with a unilateral fixed, dilated pupil, compared with 7.5% for those presenting with bilateral fixed, nondilated pupils, and 1.4% for patients with bilateral fixed, dilated pupils. CONCLUSIONS: Overall, 50.8% of patients survived their injury and 13.2% achieved a good functional outcome after at 6 months of follow-up (GOS Score 1 or 2). Age, ICP on admission, and pupil status were found to be significant predictive factors of outcome. In particular, pupil size and reactivity appeared to be the most important prognostic factor since the mortality rate was 23.5% in the presence of bilateral reactive pupils and 79.7% in the case of bilateral fixed, dilated pupils. The authors believe that patients having suffered traumatic brain injury and present with a GCS score of 3 should still be treated aggressively initially since a good functional outcome can be obtained in some cases.

Guardian availability in children evaluated in the emergency department for blunt head trauma.

BACKGROUND: Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. OBJECTIVES: The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. METHODS: This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10-month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient's guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. RESULTS: The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. CONCLUSIONS: Nearly one-half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias.

Diffusion tensor MR imaging in pediatric head trauma.

PURPOSE: We propose to investigate the fractional anisotropy (FA) values in pediatric patients with closed head trauma and correlate them with the initial Glasgow Coma Scale (GCS). MATERIALS AND METHODS: A retrospective evaluation of 24 pediatric patients (15 men, 9 women; mean age, 13 years; range, 2-18 years) who underwent both unenhanced head computed tomography and cerebral magnetic resonance imaging (MRI), including the tensor diffusion sequence, within 30 days of the incident. Twenty-two atraumatic control patients (9 men, 13 women; mean age, 9 years; range, 4-17 years) were randomly selected from the records of the radiology department within the same period. Fractional anisotropy measurements were taken from each of 6 major white matter volumes. Data extracted from the record of each subject included GCS, initial head computed tomographic results, and length of hospital stay. Kruskal-Wallis and t tests were used for statistical evaluation. RESULTS: The mean acute score on the GCS was 9.7 +/- 5. Mean duration of hospitalization days was 8.7 +/- 10. Statistically significant differences in mean FA values between trauma and control subjects were noted in corpus callosum. Trauma patients with positive findings on MRI and with GCS less than 10 also had lower FA values than patients with GCS greater than 10 and patients who had normal MRI findings. There was a negative correlation between time to discharge and FA values. CONCLUSIONS: In pediatric head trauma, MRI diffusion FA measurements can show abnormalities despite normal-appearing brain MRI findings. Larger investigations are required to verify the stability of correlations.

Posttraumatic balance disorders.

Head trauma is being more frequently recognized as a causative agent in balance disorders. Most of the published literature examining traumatic brain injury (TBI) after head trauma has focused on short-term prognostic indicators and neurocognitive disorders. Few data are available to guide those individuals who see patients with balance disorders secondary to TBI. Our group has previously examined balance disorders after mild head trauma. In this study, we study all classes of head trauma. We provide a classification system that is useful in the diagnosis and management of balance disorders after head trauma and we examine treatment outcomes. As dizziness is one of the most common outcomes of TBI, it is essential that those who study and treat dizziness be familiar with this subject.