Patho-mechanical comparative morpho-characterization of contre-coup injuries of liver by cadaveric experimental simulation for medico-legal and forensic implications.

BACKGROUND: Liver is the most common organ to get injured in cases of blunt force trauma to the abdomen (BFTA). It is the 2nd commonest organ after brain to sustain injuries out of all the trauma related fatalities. However, the literature about contre-coup injuries to the liver due to BFTA is scarce in-spite of the high mortality rates seen out of injury to this particular organ. PURPOSE: The authors intended to systematize the characteristic morphogenesis of the contre-coup injuries of the liver on the basis of the patho-mechanics involved in various types of BFTA. METHODOLOGY: One hundred and sixty three cases of BFTA were identified, and interpretation was attempted for the contre-coup rupture of the liver seen in twenty out of all the trauma related fatalities that presented for post-mortem examination during the study period. However, the mechanics of the pattern of the rupture injuries to the liver were indiscernible. This motivated the authors to conduct the comparative characterization of injuries to the liver by experimental simulation of BFTA after necessary permission via inflicting pre-calculated forces on unclaimed cadavers. RESULTS: The patterns of contre-coup rupture/s of liver were established in all the twenty out of one sixty-three cases of BFTA. The rupture depicted patterns of injury in the situations of - 1) strong hits with a limited surface trauma, 2) very strong hits with a generalized surface trauma, 3) and collision with a solid surface resulting due to fall onto the side of the abdomen. The causative mechanism discerned was deformation of the liver, followed by its parenchymal rupture due to the shear and strain types of force/s consequent upon tissue compression. The minimum force and energy of impact required for the liver to rupture was estimated to be 2000 N and 141.5 J. CONCLUSION: This series of the simulation experiments revealed two variants of liver rupture in the contre-coup impact zone. The pattern of injury was maintained in cases, those studied at post-mortem examinations, but the relief ruptures were found to vary depending upon the overall mechanics of the traumatic forces involved in the simulation experiments performed on the cadavers. The anti-shock ruptures were formed during shock trauma, and shockproof ruptures were not seen in cases of underlying compressive forces. The morphogenetic characterization of the relief rupture surface of the liver was also delineated in relation to its surface orientation to the spine on the basis of the terms "large" and "very large" depicting the quantum of force/s delivered out of an impact or blow.

Posttraumatic Parinaud's syndrome as a contrecoup injury in a case of closed head trauma.

The purpose of the study was to present a rare case of post-traumatic Parinaud's syndrome with a history of closed head injury. The clinical characteristics, examination, and management are presented in a 12-year-old boy who was a victim of physical violence at the hands of a young boy who punched him in his chin with his fists, with associated paralysis of the upward gaze of the left eyeball, and convergence nystagmus with pupillary involvement. CT examination indicated posttraumatic lesions in the dorsal midbrain and in the cavity of third ventricle, suggestive of acute hemorrhages. Posttraumatic Parinaud's syndrome is a rare phenomenon that can occur in a case of closed head trauma as contrecoup injury.

Contrecoup injury of the prefronto-thalamic tract in a patient with mild traumatic brain injury: A case report.

RATIONALE: We report on a patient with mild traumatic brain injury (TBI) with contrecoup injury of the prefronto-thalamic tract (PTT), as demonstrated by diffusion tensor tractography (DTT). PATIENT CONCERNS: A 62-year-old female patient suffered a head trauma after falling backward. While working at a height of 85cm above the floor, she fell backward and struck the occipital area of her head on the ground. The patient experienced cognitive dysfunction and depressive mood after the head trauma. DIAGNOSES: The patient was diagnosed as mild TBI due to falling backward. INTERVENTIONS: Clinical evaluation of her brain was performed at 2 months after onset. OUTCOMES: DTT at 2 months after onset revealed narrowings in the right ventrolateral and both orbitofrontal PTTs, whereas both the dorsolateral and left ventrolateral PTTs were not reconstructed. LESSONS: Injuries of the PTTs associated with a contrecoup brain injury were demonstrated in a patient with mild TBI.

Contrecoup Injury-Induced Middle Meningeal Arteriovenous Fistula Detected by Time-of-Flight Magnetic Resonance Angiography and Magnetic Resonance Arterial Spin Labeling: Case Report and Review of the Literature.

BACKGROUND: Middle meningeal arteriovenous fistula (MM-AVF) is rare; however, it will sometimes be followed by intracranial hemorrhage or progressive symptoms caused by abnormal shunt flow. Radiological examination and endovascular treatment of this condition have recently advanced; thus, we have described the pathogenesis, clinical features, and appropriate diagnostic and therapeutic management of MM-AVF. We also reviewed the reported data of the past 35 years, including 30 cases of MM-AVF. CASE DESCRIPTION: We report the case of 24-year-old man who had presented with right tinnitus who had experienced previous head trauma on the opposite side to the tinnitus ear. Time-of-flight magnetic resonance angiography and magnetic resonance arterial spin labeling findings were suggestive of MM-AVF, and catheter angiography confirmed MM-AVF with shunt flow draining into the cavernous sinus. Endovascular transarterial embolization was performed, and the MM-AVF was embolized successfully using detachable coils and n-butyl-2-cyanoacrylate. The tinnitus disappeared completely immediately after the treatment. CONCLUSIONS: MM-AVF is caused, not only by coup injury, but also by contrecoup injury. Time-of-flight magnetic resonance angiography and magnetic resonance arterial spin labeling are useful for detecting MM-AVF. Endovascular transarterial embolization is an effective and safe treatment.

Acute contrecoup epidural hematoma that developed without skull fracture in two adults: two case reports.

BACKGROUND: The incidence of acute epidural hematoma not accompanied by fracture is low, and it mostly occurs right below the impact point in children. Acute epidural hematoma on the contralateral side of the impact point without fracture is very rare. CASE PRESENTATION: Case 1: a 52-year-old Japanese woman fell and was bruised in the left occipital region, and acute epidural hematoma developed in the right frontal region. No fracture line was observed in the right frontal region on head computed tomography or during surgery, and the source of bleeding was the middle meningeal artery. Case 2: a 56-year-old Japanese man fell down the stairs and was bruised in the right occipital region, and acute epidural hematoma developed in the right occipital supra- and infratentorial regions and left frontal region. Separation of the lambdoid suture was noted in the right occipital region, but no fracture line was present in the left frontal region on either head computed tomography or during surgery, and the source of bleeding was the middle meningeal artery. CONCLUSIONS: Two rare cases of frontal contrecoup acute epidural hematoma without facture near the hematoma were reported. It is possible that the dura mater detaches from the inner surface of the skull due to cavitation theory-related negative pressure and blood vessels in the dura mater are damaged, causing contrecoup acute epidural hematoma even though no fracture occurs, for which careful course observation is necessary.

Serial Mini-Mental Status Examination to Evaluate Cognitive Outcome in Patients with Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: This study was aimed at finding out the changes in cognitive dysfunction in patients with traumatic brain injury (TBI) and investigating the factors limiting their cognitive improvement. METHODS: Between January 2010 and March 2014, 33 patients with TBI participated in serial mini-mental status examination (MMSE). Their cognitive functions were statistically analyzed to clarify their relationship with different TBI status. Patients who developed hydrocephalus were separately analyzed in regards to their cognitive function depending on the placement of ventriculoperitoneal shunt (VPS). RESULTS: Bi-frontal lobe injury (beta=-10.441, p<0.001), contre-coup injury (beta=-6.592, p=0.007), severe parenchymal injury (beta=-7.210, p=0.012), temporal lobe injury (beta=-5.524, p=0.027), and dominant hemisphere injury (beta=-5.388, p=0.037) significantly lowered the final MMSE scores. The risk of down-grade in the prognosis was higher in severe parenchymal injury [odds ratio (OR)=13.41, 95% confidence interval (CI)=1.31-136.78], temporal lobe injury (OR=12.3, 95% CI=2.07-73.08), dominant hemisphere injury (OR=8.19, 95% CI=1.43-46.78), and bi-frontal lobe injury (OR=7.52, 95% CI=1.31-43.11). In the 11 post-traumatic hydrocephalus patients who underwent VPS, the final MMSE scores (17.7+/-6.8) substantially increased from the initial MMSE scores (11.2+/-8.6). CONCLUSION: Presence of bi-frontal lobe injury, temporal lobe injury, dominant hemisphere injury, and contre-coup injury and severe parenchymal injury adversely influenced the final MMSE scores. They can be concluded to be poor prognostic factors in terms of cognitive function in TBI patients. Development of hydrocephalus aggravates cognitive impairment with unpredictable time of onset. Thus, close observation and routine image follow-up are mandatory for early detection and surgical intervention for hydrocephalus.

Investigation of cavitation as a possible damage mechanism in blast-induced traumatic brain injury.

Cavitation was investigated as a possible damage mechanism for war-related traumatic brain injury (TBI) due to an improvised explosive device (IED) blast. When a frontal blast wave encounters the head, a shock wave is transmitted through the skull, cerebrospinal fluid (CSF), and tissue, causing negative pressure at the contrecoup that may result in cavitation. Numerical simulations and shock tube experiments were conducted to determine the possibility of cranial cavitation from realistic IED non-impact blast loading. Simplified surrogate models of the head consisted of a transparent polycarbonate ellipsoid. The first series of tests in the 18-inch-diameter shock tube were conducted on an ellipsoid filled with degassed water to simulate CSF and tissue. In the second series, Sylgard gel, surrounded by a layer of degassed water, was used to represent the tissue and CSF, respectively. Simulated blast overpressure in the shock tube tests ranged from a nominal 10-25 pounds per square inch gauge (psig; 69-170 kPa). Pressure in the simulated CSF was determined by Kulite thin line pressure sensors at the coup, center, and contrecoup positions. Using video taken at 10,000 frames/sec, we verified the presence of cavitation bubbles at the contrecoup in both ellipsoid models. In all tests, cavitation at the contrecoup was observed to coincide temporally with periods of negative pressure. Collapse of the cavitation bubbles caused by the surrounding pressure and elastic rebound of the skull resulted in significant pressure spikes in the simulated CSF. Numerical simulations using the DYSMAS hydrocode to predict onset of cavitation and pressure spikes during cavity collapse were in good agreement with the tests. The numerical simulations and experiments indicate that skull deformation is a significant factor causing cavitation. These results suggest that cavitation may be a damage mechanism contributing to TBI that requires future study.

Noncontrast and perfusion CT provides accurate assessment of head deceleration injury.

AIM: To investigate the feasibility of noncontrast computed tomography (NcCT) and perfusion CT (PCT) in the assessment of head deceleration injury (HDI). MATERIAL AND METHODS: A small animal HDI device was developed. A total of 20 healthy adult rabbits with frontal impacts resulting from a 3.5 m drop were included in this study. All subjects underwent NcCT and PCT scans 12 hours before injury and three to four hours after head injury. Brain injuries were evaluated by traditional macroscopic and microscopic examination after CT scans. RESULTS: Microscopic examination revealed hemorrhagic cerebral contusions in 14 subjects and cerebral parenchyma hyperemia in 6 subjects. Contrecoup injuries were more severe than the coup injuries in this study. As verified by pathoanatomical observations, NcCT effectively revealed all of the calvarial fractures and basal skull fractures in 12 subjects. Furthermore, most rabbits suffered acute scalp contusions, subarachnoid hemorrhages and cerebral contusions. PCT analysis revealed much larger and more severe contusions when compared to those observed via NcCT. CONCLUSION: The combination of NcCT and PCT could be an effective approach for detection of acute cerebral contusions, which can provide sufficient experimental evidence for accurate clinical diagnosis and prognosis of HDI.

Contrecoup injury in patients with traumatic temporal bone fracture.

OBJECTIVE: To study the prevalence and patterns of contrecoup injury in traumatic temporal bone fracture cases. METHOD: A prospective, cohort study was undertaken of all patients with traumatic head injury admitted to a tertiary referral hospital in Malaysia within an 18-month period. High resolution computed tomography scans of the brain and skull base were performed in indicated cases, based on clinical findings and Glasgow coma score. Patients with a one-sided temporal bone fracture were selected and subsequent magnetic resonance imaging performed in all cases. Contrecoup injury incidence, type, severity and outcome were recorded. RESULTS: Of 1579 head injury cases, 81 (5.1 per cent) met the inclusion criteria and were enrolled in the study. Temporal bone fractures were significantly associated with intracranial injuries (p < 0.001). The incidence of a contrecoup injury in cases with temporal bone fracture was 13.6 per cent. Contrecoup injury was significantly associated with petrous temporal bone fracture (p < 0.01). The commonest contrecoup injury was cerebral contusion, followed by extradural haematoma and subdural haematoma. CONCLUSION: Contrecoup injury is not uncommon in cases of temporal bone fracture, and is significantly associated with petrous temporal bone fracture.

The facial-bone fractures among fatally injured car occupants in frontal collisions.

The retrospective study was performed of all deceased car-occupants in frontal car collisions in order to identify persons with facial-bone fractures. The sample consisted of 482 cases: 378 males and 104 females, average age of 39.59+/-16.01 years. There were 239 car-drivers, 194 front-seat passengers, and 49 rear-seat passengers. In 46 of 482 cases, single fracture of upper facial bones was established: nasal fractures were the most common, followed by zygomatic. In 118 of 482 cases, fracture of upper facial bones was established, as well as 70 cases of jawbone. The fractured facial bones either of the upper or lower face could not be a factor that predicts the position of the deceased in the motor vehicle at the moment of injury (lambda=0.989, p>0.05). The multi-fractured facial-bones were very often associated with the multi-fractured cranial bones - 85 cases (chi(2) =138.75, df=8, p<0.001), as well as jawbone fracture - 35 cases (chi(2) =20.52, df=4, p<0.001). Brain injuries were more present and more severe (coup and contrecoup-contusion and brain laceration) if more facial-bone fractures were involved (chi(2) =147.99, df=8, p<0.001). Cases with only contrecoup brain contusions, associated with multi-fractured facial-bones, were rare - 6 of 118. These fractures are very often associated with cranial fractures, as well as with brain injuries and were caused by intensive contact of the deceased's head with the car's pillar.

A Clinical Observation on Head Injuries in Infants and Children

A clinical analysis was carried out with 400 cases of head injuries under 15 years of age admitted at the Department of Neurosurgery, Inha University Hospital during 4 years from 1987 to 1990. The material was classified into three groups according to main lesions, i.e. 1) simple cerebral contusion without skull fractures, 2) various types of skull fractures, 3) intracranial hemorrhagic lesions, representing such lesions as follows;a) epidural hematoma, b) subdural hematoma, c) intracerebral hematoma, intraventricular and subarachnoid hemorrhage. The results were as follows; 1) The age incidence was greatest in 7 years of age, and 188 cases(47%) were included in the age group between seven and ten. The accident occurred mostly from March to May, especially in April. 2) The head injuries were caused by traffic accident(203 cases:51%), fall down(152 cases:38%), etc. In clinical pictures, neck sprain(52.8%), nausea and vomiting(47.5%), and early epilepsy)9%) were developed. 3) The linear skull fracture was higher than other type fractures(74.6%) and the locations of skull fractures were parietal, occipital, temporal and frontal bone in order of frequency. 4) Among the intracranial hemorrhagic lesions, EDH was most common lesion, 73 cases(79%) of the patients with intracranial hemorrhagic lesions were accompanied by skull fractures but of the patients with skull fracture, 51.4% were accompanied by hemorrhagic lesions. Lucid interval was observed in 15 of the cases with intracranial hemorrhagic lesions and contre-coup injury was developed in 19(12%). 5) In the GOS, the high scored cases on the GCS were better than the low scored cases. 4 cases of 23 people scored under 8 on the GCS died. 14 cases of them were included in the age between 6 and 10(61%). 6) Associated injuries were found in about 16% of the total patient, the most common injury was clavicle fracture and most frequent sequala was post traumatic syndrome. The late epilepsy was occurred in about 13% of the early epilepsy cases except the cases had pre-traumatic epilepsy history.

A Clinical Observation on Head Injuries in Infants and Children

A clinical analysis was carried out with 108 cases of head injuries under 15 years of age, admitted at the Department of Neurosurgery, In Ha University Hospital in 11/2 years between Jan., 1987 and June., 1988. The material was classified into three groups according to main lesions, i.e. 1) simple cerebral contusion without skull fractures. 2) various types of skull fractures. 3) intracranial hemorrhagic lesions, representing such lesions as follows:a) epidural hematoma b) subdural hematoma. c) intracerebral hematoma, intraventricular and subarachnoid hemorrhage. The results were as follows: 1) The age incidence was greatest in 7 years of age, and 51 cases(47.2% of total) were included in the age group between seven and ten. 2) The accident occurred mostly between March and May. 3) Males outnumbered females by almost 2:1. 4) The head injuries were caused by traffic accident(52 cases:48%), fall down(47 cases:43%), hit(9 cases:9%). 5) In clinical picture, vomiting(57 cases:53.7%) and convulsion(8 cases:7.4%) and neck sprain(55 cases:50.9%) were developed and at accident, forty seven cases(43.5%) had the history of loss of consciousness. 6) Of the patients between GCS 5 and 14, 57 cases(92%) were included in the simple cerebral contusion. Of the patients below GCS 13, 45 cases(98%) were included in the skull fracture or intracranial hemorrhagic lesions but eighteen cases of the patients below GCS 13 were taken operation. 7) In skull fracture patients, the location in the order of frequency was parietal, occipital, temporal and frontal bone. The vault skull fracture was about twelfth fold as frequent as basal skull fracture and the incidence of linear skull fracture was higher than that of depressed skull fracture, the ratio being about 7:1. 8) Among the intracranial hemorrhagic lesions, the epidural hematoma was most common lesion. Twenty one cases(81%) of the patients with intracranial hemorrhagic lesions were accompanied by skull fracture but of the patients with skull fracture, 21 cases(47%) were accompanied by intracranial hemorrhagic lesions. Seventeen cases(46%) with the linear skull fracture involved in the intracranial hemorrhagic lesions. 9) Contre coup injury was developed in 6 cases(12%) and Lucid interval was observed in 4 cases(5%) of the cases with intracranial hemorrhagic lesions. 10) Associated injuries were found in about 27% of the total patients. The frequent ones were clavicle fracture, femur fracture, tibia/fibular fracture, pelvic fracture and so on order. 11) Sequelae were noticed in about 20% of the total patients. The most frequent one was post traumatic syndrome. 12) The period of hospitalization was about 2 weeks on an average in non-surgical cases(83%) and 4-6 weeks on an average in surgical cases(70%).