Influence of the Fukushima Daiichi Nuclear Power Plant Accident on the Use of Computed Tomography in Children With Mild Head Injuries.

BACKGROUND: Computed tomography (CT) is commonly used in children with mild head injuries. People in Japan are concerned about radiation exposure and radiation-induced cancer because of the Fukushima Daiichi Nuclear Power Plant accident on March 11, 2011. This study investigated whether the accident influenced the use of CT in children with mild head injuries. METHODS: Using the Japan Medical Data Center database, we identified patients aged ≤15 years visiting hospitals because of mild head injuries from January 1, 2008, to December 31, 2013. We excluded patients who were admitted to the hospital or received other medical examinations. Regression discontinuity analysis was used to compare proportions of patients undergoing head CT and having clinically important traumatic brain injury (ciTBI) overlooked before versus after the accident, adjusting for patient characteristics, secular trends, and hospital effect. RESULTS: Eligible patients (n = 40,440) were classified as visiting the hospital before (n = 11,659) or after (n = 28,781) the accident. The regression discontinuity analysis showed that the accident was associated with a reduction in the proportion of patients undergoing head CT (odds ratio [OR] 0.73; 95% confidence interval [CI], 0.63-0.86), whereas the accident was not associated with an increase in cases where ciTBI was overlooked (OR 0.72; 95% CI, 0.13-4.00). CONCLUSIONS: The use of CT in children with mild head injuries declined after the Fukushima Daiichi Nuclear Power Plant accident. Improving awareness of radiation exposure risks among patients and physicians could reduce unnecessary CT.

Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists.

Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.

Risk of mild head injury in preschool children: relationship to attention deficit hyperactivity disorder symptoms.

AIM: To investigate whether there is an association between mild head injury (MHI) and attention deficit hyperactivity disorder (ADHD) symptoms in preschool children. METHODS: The study included a patient group of 30 children aged 3-6 years with mild head trauma and a control group of 30 healthy and age- and sex-matched children. The symptoms of ADHD were evaluated using the Conners' Parent Rating Scale-Revised Long (CPRS-RL) form. RESULTS: The mean age was 4.73 ± 1.13 years in the patient group and 4.65 ± 0.99 years in the control group. No significant differences were determined between the groups in terms of age, gender, parents' age and education (p > 0.05). The total subscale points as reported by the parents of the children with MHI were significantly higher than those for the control group in terms of the following subscales: oppositional, cognitive problems/inattention, hyperactivity, social problems, ADHD index, Conners' Global Index (CGI)-Irritability-Impulsiveness, CGI-Emotional Lability, CGI-Total and DSM-IV ADHD symptoms (p < 0.05). A history of previous trauma treated in emergency services was determined in eight of the 30 patients (26.7%). CONCLUSIONS: The findings of this study suggest that preschool children with MHI have more pre-injury ADHD symptoms and oppositional and emotional-behavioural symptoms than healthy children without trauma. Clinicians should screen children with MHI for ADHD symptoms and refer them for treatment when necessary. Evaluation of children presenting with MHI by a child psychiatrist may prevent repetition of injuries.

Teleneurosurgery: Outcome of Mild Head Injury Patients Managed in Non-Neurosurgical Centre in the State of Johor.

BACKGROUND: With teleneurosurgery, more patients with head injury are managed in the primary hospital under the care of general surgical unit. Growing concerns regarding the safety and outcome of these patients are valid and need to be addressed. METHOD: This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months. RESULTS: Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368). CONCLUSION: In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.

The impact of the introduction of PECARN head CT rules on the utilisation of head CT scans in a private tertiary hospital in Sub-Saharan Africa.

BACKGROUND: The decision to order head CT scans to rule out clinically significant traumatic brain injury in mild head injury in children is made on the basis of clinical decision rules of which the Paediatric Emergency Care Applied Research Network (PECARN) CT head rules have been found to be most sensitive. PURPOSES: The purpose of this study is to determine the proportion of head CT scans done for children with mild head injury and to determine disposition of patients from casualty after the introduction of PECARN head CT rules compared to the period before. The research question is "will introduction of the PECARN CT head rules reduce the proportion of head CT scans requested for children under 18 years with mild head injury at the AKUHN?" METHODS: A before and after quasi experimental study with a study population including all children under 18 years presenting to the AKUHN with mild head injury and a Glasgow coma scale of 14 and above on presentation. Sample size was 85. RESULTS: A total of 42 patients files were analysed in the before study while 43 patients were selected for the after study. The median age was 5 years. The proportion of head CT scans reduced from 56% in the before group to 33% in the after group with no missed clinically significant traumatic brain injury. More patients were discharged home after evaluation in the after group (81%) than in the before group (58%). CONCLUSIONS: The number of head CT scans ordered reduced without missing any clinically significant traumatic brain injury.

Mild head injury and attention deficit hyperactivity disorder in children.

PURPOSE: Post-concussion syndrome is a well-described complication following moderate and severe head trauma but whether it occurs after mild head injury in children remains unclear. The aim of this study was to evaluate whether exposure to mild head injury with potential additional risk factors (non-surgical lesion on computed tomographic, high kinetic trauma, or Glasgow Coma Scale <15) is associated with attention deficit hyperactivity disorder (ADHD) after the head trauma. METHODS: This study was performed in an emergency department on children admitted between 2009 and 2013. It compared victims of mild head injury aged 6-16 years with matched children presenting isolated non-surgical forearm fracture (ratio1/2). ADHD was assessed using Conners' Global Index-Parent short version 3-40 months after the trauma. The patients were compared using chi-square test or Fisher's exact test, t test or u-test as appropriate with a p value set at 0.05. RESULTS: During the study period, 676 patients were admitted for mild head injury. Among them, 34 (5 %) fulfilled the inclusion criteria and were compared with 64 matched patients admitted for a forearm fracture. The groups were comparable. ADHD was observed in both groups (18 % in the mild head injury group, 11 % in the control group) with no significant differences between groups. The prevalence was high when compared to an expected frequency of 3.5-5.6 % in children aged 6-12 years in the general population. CONCLUSIONS: These results suggest that pre-existing ADHD may have contributed to injury proneness in both groups and does not argue for a specific risk of ADHD induced by mild head injury. The diagnosis of ADHD should be evoked at admission of children aged 6-16 years presenting with a trauma.

Cognitive reserve and persistent post-concussion symptoms--A prospective mild traumatic brain injury (mTBI) cohort study.

PRIMARY OBJECTIVE: Having three or more persisting (i.e. > 3 months) post-concussion symptoms (PCS) affects a significant number of patients after a mild traumatic brain injury (mTBI). A common complaint is cognitive deficits. However, several meta-analyses have found no evidence of long-term cognitive impairment in mTBI patients. The study sought to answer two questions: first, is there a difference in cognitive performance between PCS and recovered mTBI patients? Second, is lower cognitive reserve a risk factor for developing PCS? RESEARCH DESIGN: Prospective inception cohort study. METHODS AND PROCEDURE: One hundred and twenty-two adult patients were recruited from emergency departments within 24 hours of an mTBI. Three months post-injury, participants completed the Rivermead Post Concussion Symptoms Questionnaire and a neuropsychological assessment. A healthy control group (n = 35) were recruited. The estimate of cognitive reserve was based upon sub-test Information from Wechsler Adult Intelligence Scale and international classifications of educational level and occupational skill level. MAIN OUTCOME AND RESULTS: mTBI patients showed reduced memory performance. Patients with lower cognitive reserve were 4.14-times more likely to suffer from PCS. CONCLUSIONS: mTBI may be linked to subtle executive memory deficits. Lower cognitive reserve appears to be a risk factor for PCS and indicates individual vulnerabilities.

Infrascanner in the diagnosis of intracranial lesions in children with traumatic brain injuries.

BACKGROUND: The number of traumatic injuries among children is increasing. However, so-called mild TBI might result in unfavourable outcomes. Early diagnosis of intracranial haematomas prior to development of serious complications may be a decisive factor for a favourable outcome. InfraScan company developed and brought to the market the Infrascanner model 1000, which is a portable detector of blood collections that operates in the near infrared (NIR) band. OBJECTIVE: To estimate the efficiency of the Infrascanner model 1000 for detection of intracranial haematomas among children with mild TBI. MATERIALS AND METHODS: Ninety-five patients with mild TBI were examined. An indication for cerebral CT after mild TBI was the presence of risk factors of intracranial lesions. The Infrascanner was used by a neurosurgeon during primary examination. CT was performed in 43 patients (45%), while 52 patients (55%) with a low risk of intracranial lesions were under observation. RESULTS: The results of examination of patients using CT and infrared scanning coincided in 39 cases and intracranial haematomas were detected in eight patients. False-positive results were obtained in three cases. The sensitivity of the procedure used in this group of patients with a medium and high risk of development of intracranial haemorrhages was 1.00 (0.66; 1.00). The specificity was 0.91 (0.81; 1.00)--the proportions and a 95% CI. The false-positive risk is 0.27 (0.00; 0.58). During infrared scanning in patients with low risk of intracranial lesions, false-positive results were obtained in four cases and false-negative results were absent. CONCLUSION: Infra-scanning might be viewed as a screening technique for intracranial haemorrhages in ambulances and outpatient trauma centres in order to decide on hospitalization, CT scanning and referral to a neurosurgeon. Infra-scanning combined with evaluation of risk factors of intracranial damage might reduce the number of unnecessary radiological examinations.

Do self-reported concussions have cumulative or enduring effects on drivers' anticipation of traffic hazards?

AIM: To investigate the cumulative effect of multiple self-reported concussions and the enduring effect of concussion on drivers' hazard perception ability. It was hypothesized: (1) that individuals reporting multiple previous concussions would be slower to anticipate traffic hazards than individuals reporting either one previous concussion or none; and (2) that individuals reporting a concussion within the past 3 months would be slower to anticipate traffic hazards than individuals reporting either an earlier concussion or no prior concussion. METHOD: Two hundred and eighty-two predominantly young drivers (nconcussed = 68, Mage = 21.57 years, SDage = 6.99 years, 66% female) completed a validated hazard perception test (HPT) and measures of emotional, cognitive, health and driving status. RESULTS: A one-way analysis of variance showed that there was no significant effect of concussion number on HPT response times. Similarly, pairwise comparisons showed no significant differences between the HPT response times of individuals reporting a concussion within the previous 3 months, individuals reporting an earlier concussion and the never concussed group. CONCLUSION: The findings suggest that previous concussions do not adversely affect young drivers' ability to anticipate traffic hazards; however, due to reliance on self-reports of concussion history, further prospective longitudinal research is needed.

A systematic review of age and gender factors in prolonged post-concussion symptoms after mild head injury.

BACKGROUND: Older age and female gender are known factors in the development of persisting post-concussion symptoms (PCS) after mild head injury (MHI), i.e. at 3+ months. Very few studies have examined longer-term symptoms. A recent review, however, established the importance of these variables in permanent PCS (18+ months). The current study repeats the review for prolonged symptoms (12-18 months). METHODS: Systematic electronic database searches were conducted to identify all studies with data on (i) correlations between age/gender and prolonged outcome and (ii) mean ages/gender mixes of (a) prolonged samples selected for poor symptomatic outcome, (b) prolonged samples not selected for poor outcome and (c) epidemiological studies of MHI patients presenting to hospital. RESULTS: Correlation studies showed poorer outcome to be associated with both older age (2/5 studies) and female gender (5/6 studies). Those with poor prolonged outcome had a significantly higher mean age (35.9) than MHI patients in general (29.9). The proportion of men in these samples (48.6%) was significantly lower than MHI patients in general (66.7%). CONCLUSIONS: Older age and female gender are vulnerability factors in the development of prolonged PCS. The main clinical implications are for how early intervention and reassurance are best provided.

Consideration of Brain CT Imaging Standard for Mild Head Injuries.

It has been reported that various clinical criteria indicate computed tomography (CT) examination for mild head injury (MHI). However, the decision to perform CT for MHI largely depends on the physician. Data on severe head injuries is available in sources such as the Japan Neurotrauma Data Bank, but only a few data has been collected on MHI. A total of 1688 patients with MHI (Glasgow Coma Scale 14 and 15) treated at our hospital from June 2017 to May 2019 were reviewed. CT was performed in 1237 patients (73.28%), and intracranial hemorrhage was detected in 50 patients. Three patients deteriorated, and all were surgically treated. Statistical analysis of the presence or absence of acute intracranial hemorrhage and "risk factors for complications of intracranial lesions in MHI" showed significant differences in unclear or ambiguous accident history (p = 0.022), continued post-traumatic amnesia (p < 0.01), trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) (p = 0.012), age <60 years (p < 0.01), coagulation disorders (p < 0.01), and alcohol or drug intoxication (p < 0.01). The 453 patients who did not satisfy these risk factors included only one patient with intracranial hemorrhage, so the negative predictive value was 99.78%. This study shows that the "risk factors for complications of intracranial lesions in MHI" are effective criteria for excluding acute intracranial hemorrhage and CT should be actively considered for patients with the above factors that showed significant differences.

Pseudobulbar Affect in an Elderly Female With Small Vessel Ischemic Disease and Alcohol Abuse Disorder: A Case Report.

Pseudobulbar affect (PBA) is a neurological condition characterized by recurrent, inappropriate, and involuntary outbursts of emotion, primarily crying and laughter, which are dissociated from the individual's emotional experience. The precise underlying cause of PBA remains unknown; however, existing evidence suggests the involvement of dopaminergic, serotonergic, and glutamatergic neurotransmission within the corticopontine-cerebellar pathways responsible for regulating the motor expression of emotions. Additionally, PBA has been observed to co-occur with other neurocognitive and psychiatric disorders. Therefore, it is crucial to consider the possibility of a PBA diagnosis in patients with underlying neurological damage and disorders.

Awareness and use of the Canadian computed tomography head rule for mild head injury patients among Chinese emergency physicians.

OBJECTIVE: Computed tomography (CT) scan has been an increasingly essential diagnostic tool for emergency physicians (EPs) to triage emergency patients. Canadian computed tomography Head Rule (CCHR) had been established and widely used to spare patients with mild head injury from unnecessary radiation. However, the awareness of CCHR and its actual utilization among Chinese EPs were unknown. This survey was to investigate the awareness and use of CCHR and their associated characteristics among Chinese EPs. METHODS: Questionnaire was randomly sent to EPs from different Chinese hospitals. Surveyed EPs were asked how well they know about the CCHR and how often they use the CCHR to guide head CT use. Association between the awareness and utilization of CCHR and the physicians' characteristics were analyzed using repeated-measures logistic regression. RESULTS: About 41.7% of the total 247 responders noted they "very familiar" or "somewhat familiar" with CCHR while the utilization rate was 24.7%. With respect to the most important underlying barriers for the use of CCHR, approximate half (48.5%) cited "fear of malpractice" as the leading cause. "Received specific training regarding radiation dose of CT" was the significant predicting factor both for the awareness (OR 5.87; 95% CI, 3.08-11.21) and the use (OR 6.10, 95% CI, 2.91-12.80) of CCHR. CONCLUSIONS: Fear of malpractice and lack of radiation risk knowledge were two main barriers to apply CCHR in the request of CT for patients with mild head injury. Furthermore, EPs with specific training about radiation risk of CT were more likely to know and use of CCHR.

Correlation of clinical features with neuroimaging in children with mild head injury.

Objectives: Mild head injury is defined as a pediatric Glasgow Coma Scale (GCS) score of 13-15 at admission following head trauma. There are no clear indications for neuroimaging in such children. The aim of our study was to analyze the correlation of symptoms commonly encountered following mild head injury with any abnormality on the computed tomography (CT) scan. Materials and Methods: This is a retrospective and observational study done in a tertiary care hospital. Records of all the children fulfilling the inclusion criteria were retrieved. Demographic details such as age, gender, and type of injury (hit by a blunt object, fall from height, and road traffic accident), symptoms such as presence and number of episodes of vomiting, presence and duration of loss of consciousness (LOC), presence of drowsiness, headache, giddiness, seizures, focal deficits and the GCS score, and CT scan findings were noted in a predesigned proforma. A CT scan with any of the following abnormalities such as skull fracture, cerebral edema, intracranial bleed (epidural hematoma, subdural hematoma, intracerebral hematoma, and subarachnoid hemorrhage), and cerebral contusion was considered as abnormal. Any neurosurgical intervention done was also noted. Results: A total of 134 children in the age group of 1 month to 18 years with mild head injury were included in this study. The median (interquartile range) age of the children was 5 (2, 8) years, with majority being males. Road traffic accidents (34.3%) were the most common cause of injury, followed by fall from lesser than 3 feet height (31.3%). The most common symptoms were vomiting (43.6%), scalp/facial abrasions (37.2%), and LOC (31.9%). CT scan was abnormal in 53.7% of the cases, with skull fracture (35.1%) being the most common finding, followed by cerebral edema (13.4%). Among all the symptoms, ear/nosebleed or cerebrospinal fluid (CSF) otorrhea/rhinorrhea had a statistically significant association with a positive CT scan with P = 0.05 and an odds ratio of 1.4 (95% confidence interval, 1-1.9). Conclusion: Children with mild head injury presenting with clinical features such as bleeding from the ear or nose and CSF otorrhea/rhinorrhea are more likely to have an abnormal CT scan. Hence, such children require close neurological observation and prompt intervention if necessary. However, abnormality on CT scan cannot be reliably ruled out based on the symptoms alone.

Prevalence of Computed Tomography Overuse for Mild Head Injury in Adults.

INTRODUCTION: The Canadian CT Head Rule (CCHR) is one of many established guidelines for assessing the need for computed tomography (CT) imaging in patients with minor head injuries. Adhering to such criteria would promote the appropriate use of CT imaging, lower healthcare expenses, and prevent harmful radiation exposure. There is no current literature assessing the overuse of CT imaging for minor head injuries in the Kingdom of Bahrain. This study aims to evaluate CT overuse in adult patients with minor head trauma.  Methods: The study was conducted at the Bahrain Defense Force Hospital over 12 months from January to December 2021. All adult patients (>14 years) who sustained a minor head injury and were referred to the emergency department for CT brain imaging were included in the study. Patients presenting for other reasons or suffering from moderate to severe head injuries were excluded. CT reports were retrieved for analysis. The CCHR was used as a reference.  Results: A total of 486 CT scans were performed. Loss of consciousness was the most common symptom on presentation (n = 74 cases). Only 12.1% of CT scans reported positive findings. The prevalence of CT overuse was highest in patients aged 21-30 years. Patients presenting with loss of consciousness showed a high overuse of CT imaging, accounting for 20.3% of all cases. Only 77.4% of cases met the CCHR criteria and 22.6% were defined as overuse, with 95% confidence interval (0.189, 0.266).  Conclusion: When referring to the CCHR, CT imaging for a minor head injury in adults was overused in 22.6% of cases. Further research will be required to reveal the underlying reasons for these findings along with interventions to reduce future overuse.

Post-Traumatic Stress as a Psychological Effect of Mild Head Injuries in Children.

BACKGROUND: Head trauma is one of the most common pediatric emergencies. While the psychological effects of severe head injuries are well studied, the psychological consequences of mild head injuries often go overlooked. Head injuries with a Glasgow Coma Scale score of 13-15, with symptoms such as headache, vomiting, brief loss of consciousness, transient amnesia, and absence of focal neurological signs, are defined as mild. The aim of this study is to evaluate the stress of children with mild head injuries and their parents' relevant perception during the early post-traumatic period. METHODS: This is a prospective cross-sectional study on a cohort of children with mild head injuries and their parents. Two questionnaires were implemented, the Child Trauma Screening Questionnaire (CTSQ) which was compiled by the children, and the Children's Revised Impact of Event Scale (CRIES-13), compiled by their parents. Both questionnaires are widely used and reliable. The first presents an excellent predictive ability in children with a risk of post-traumatic stress disorder, while the second is a weighted self-completed detecting instrument for the measurement of post-traumatic stress in children and adolescents, with a detailed evaluation of their reactions to the traumatic incident. The participants responded one week and one month after the traumatic event. RESULTS: A total of 175 children aged 6-14 years and 174 parents participated in the study. Stress was diagnosed in 33.7% of children after one week, and in 9.9% after one month. Parental responses suggesting stress presence in their children were 19.0% and 3.9%, respectively. These outcomes showed that mild head injuries are not so innocent. They are often underestimated by their parents and may generate a psychological burden to the children during the early post-traumatic period. CONCLUSIONS: Mild head injuries may affect the emotional welfare of children. Healthcare providers should understand the importance of the psychological effect of this overlooked type of injury. They should be trained in the psychological effect of trauma and be aware of this probability, promptly notify the parents accordingly, and provide psychological assistance beyond medical treatment. Follow-up and support are needed to avoid the possibility of future post-traumatic stress disorder. More extensive research is needed as the outcomes of this study regarded a limited population in numbers, age, and survey period. Furthermore, many children with mild head injuries do not ever visit the emergency department and stay at home unrecorded. Community-based research on the topic should therefore be considered.

Mild paediatric head injury: the diagnostic value of physical examinations compared with computed tomographic scans.

The study objective was to determine the diagnostic value of physical examinations for positive computer tomography (CT) scans in children with mild head injuries. Retrospective data of patients evaluated for mild head injuries with loss of consciousness (LOC) or amnesia were reviewed. Estimations of prevalence, sensitivity, specificity and predictive values were calculated. Agreement between the physical examinations and CT brain scans was calculated using the Kappa test. 225 patients were included in the study. Of this group, 19.56% of patients had positive CT scans and 7.56% had normal physical examinations. 15 underwent neurosurgical intervention. For positive CT scans, sensitivity and specificity were 61.36% and 60.22%, respectively. Agreement between physical examinations and CT scans was Kappa = 0.147 (P < 0.05), 95% CI (0.035, 0.259). The present study demonstrated that physical examinations were significantly associated with positive CT scans (P = 0.01). However, the calculated Kappa value showed only slight agreement between these 2 variables and the low sensitivity and specificity of the physical examinations suggest that intracranial pathology in children with mild head injuries and LOC or amnesia cannot be excluded based on physical examinations alone.

Neurological deteriorations in mild brain injuries: the strategy of evaluation and management.

PURPOSE: Most mild traumatic brain injuries (TBIs) can be treated conservatively. However, some patients deteriorate during observation. Therefore, we tried to evaluate the characteristics of deterioration and requirement for further management in mild TBI patients. METHODS: From 1/1/2017 to 12/31/2017, patients with mild TBI and positive results on CT scans of the brain were retrospectively studied. Patients with and without neurological deteriorations were compared. The characteristics of mild TBI patients with further neurological deterioration or the requirement for interventions were delineated. RESULTS: One hundred ninety-two patients were enrolled. Twenty-three (12.0%) had neurological deteriorations. The proportions of deterioration occurring within 24 h, 48 h and 72 h were 23.5, 41.2 and 58%, respectively. Deteriorated patients were significantly older than those without neurological deteriorations (69.7 vs. 60.2; p = 0.020). More associated extracranial injuries were observed in deteriorated patients [injury severity score (ISS): 20.2 vs. 15.9; p = 0.005). Significantly higher proportions of intraventricular hemorrhage (8.7 vs. 1.2%; p = 0.018) and multiple lesions (78.3 vs. 53.8%; p = 0.027) were observed on the CT scans of patients with neurological deteriorations. Subset analysis showed that deteriorated patients who required neurosurgical interventions (N = 7) had significantly more initial GCS defects (13 or 14) (71.4 vs. 12.5%; p = 0.005) and more initial decreased muscle power of extremities (85.7 vs. 18.8%; p = 0.002). CONCLUSION: More attention should be given to mild TBI patients with older age, GCS defects, decreased muscle power of the extremities, multiple lesions on CT scans and other systemic injuries (high ISS). Most deteriorations occur within 72 h after trauma.

Advocacy for Change: An Osteopathic Review of Traumatic Brain Injury Among Combat Veterans.

As a "signature injury" of the Iraq and Afghanistan wars, traumatic brain injury (TBI) remains a major health concern among military service members. Traumatic brain injury is associated with a wide range of symptoms which may be cognitive, emotional, psychological, biochemical, and social in nature. Mild TBI (mTBI) ranks as the most common traumatic brain injury among veterans. Due to the absence of specific symptoms, mTBI diagnosis may be challenging in acute settings. Repetitive traumatic brain injury during combat deployments can lead to devastating chronic neurodegenerative diseases and other major life disruptions. Many cases of TBI remain undetected in veterans and may lead to long-term adverse comorbidities such as post-traumatic stress disorder (PTSD), suicide, alcohol disorders, psychiatric diagnoses, and service-related somatic dysfunctions. Veterans with TBI are almost twice as likely to die from suicide in comparison to veterans without a history of TBI. Veterans diagnosed with TBI experience significant comorbid conditions and thus advocacy for improved care is justified and necessary. Given the complexity and variation in the symptomatology of TBI, a personalized, multimodal approach is warranted in the evaluation and treatment of veterans with TBI and other associated conditions. As such, this review provides a broad overview of treatment options, with an emphasis on advocacy and osteopathic integration in the standard of care for veterans.

Extradural Anesthesia in a Case of Mild Head Injury.

We experienced a case posted for bilateral lower limb surgery in a patient having mild traumatic brain injury (TBI), where administration of graded epidural anesthesia led to agitation, probably resulting from the transient elevation of intracranial pressure (ICP). Due to the wide range of benefits provided by regional anesthesia, an anesthetist should be aware of the possible options for perioperative management to best handle such polytrauma cases. In this case, agitation was managed with a bolus of benzodiazepine and maintenance infusion of dexmedetomidine while the six-hour-long surgery continued with epidural anesthesia. This patient was a smoker who had bronchospasm and underlying pneumonia precluding a high risk for postoperative ventilatory support if only general anesthesia was administered. Post-surgery the patient was conscious, oriented, and pain-free leading to early mobilization and discharge from the hospital. The patient did not report any neurological deterioration in a follow-up period of one month.