[Main mechanisms of secondary ischemic brain damage formation in case of craniocerebral injury]. / Osnovnye mekhanizmy formirovaniya vtorichnykh ishemicheskikh povrezhdenii golovnogo mozga pri cherepno-mozgovoi travme.

OBJECTIVE: To systematize the mechanisms of formation and morphology of secondary ischemic brain damage, formed in the case of craniocerebral injury. MATERIAL AND METHODS: A literature review devoted to the study of formation mechanisms of secondary ischemic brain damage in craniocerebral injury was conducted. The secondary sequential and secondary long-term ischemic brain damage in the posttraumatic period, as well as intracranial and extracranial factors that contribute to their occurrence and progression, were considered. RESULTS AND CONCLUSION: Analysis of the literature has shown that primary lesions occurring at the time of head injury must be differentiated from sequential and long-term secondary ischemic changes in different brain structures.

Chronic traumatic encephalopathy (CTE)-features and forensic considerations.

Chronic traumatic encephalopathy (CTE) is a neurodegenerative condition, in which the only known cause is exposure to repeated episodes of blunt head trauma. It most often occurs in professional and amateur athletes who have had frequent and repetitive cranial impacts during contact sports, but may also be found in victims of domestic violence, military personnel exposed to explosive devices and in individuals with severe epilepsy. The pathognomonic pathological findings are of neurofibrillary tangles and pretangles in the depths of the cerebral sulci caused by perivascular accumulation of phosphorylated Tau (pTau). Cases may be high profile requiring an evaluation of whether the neuropathological findings of CTE can be related to injuries previously sustained on the sporting field. Failure to examine the brain or to adequately sample appropriate areas at autopsy may lead to cases being overlooked and to an underestimation of the incidence of this condition in the community. Performing immunohistochemical staining for pTau in three areas from the neocortex has been found to be a useful screening tool for CTE. Ascertaining whether there is a history of head trauma, including exposure to contact sports, as a standard part of forensic clinical history protocols will help identify at-risk individuals so that Coronial consideration of the need for brain examination can be appropriately informed. Repetitive head trauma, particularly from contact sport, is being increasingly recognized as a cause of significant preventable neurodegeneration.

[Clinical presentation and gross appearance of diffuse axonal injury in the early post-injury period]. / Klinicheskaya i makroskopicheskaya kharakteristika diffuznogo aksonal'nogo povrezhdeniya mozga v ostrom posttravmaticheskom periode.

The objective of the study was to investigate and characterize the clinical presentation, and establish macroscopic diagnostic signs of diffuse axonal injury (DAI) in the early (up to 3 days) post-injury period. In DAI, coma develops immediately after head injury and persists for 3 days post-injury until death. The coma is accompanied by dominant primary stem neurological symptoms, hemodynamic and respiratory disturbances and does not progress to a vegetative state. Lifetime computed tomography reveals cerebral hemorrhage in 40.5% of cases. We established the macroscopic signs of head injury in DAI. For the postmortem diagnosis of DAI, a detailed macroscopic appearance of pathognomonic cerebral hemorrhages is given, which are most frequently (67.5%) localized in the corpus callosum (CC), namely in the area from its genu to the middle of the trunk (97%). A rational, improved scheme of excision of CC trunk areas for the histological study is proposed.

Head/skull injury potential of empty 0.5-l beer glass bottles vs. 0.33-l Coke bottles.

The medical and biomechanical assessment of injuries from blows to the head is a common task in forensic medicine. In the context of a criminal justice process, the injury potential of different striking weapons is important. The article at hand compares the injury potential of assaults with a 0.5-l beer bottle and a 0.33-l Coke bottle, both made of glass. The research team hit 30 used empty 0.5-l beer bottles and 20 used empty 0.33-l Coke bottles manually on an aluminum dummy skull set on a force measuring plate, using acrylic and pork rind as a scalp surrogate. There was no significant difference in fracture threshold and energy transfer between the examined beer and Coke bottles. Both glass bottles are able to cause fractures to the facial bones while cranial bone fractures are primarily not to be expected. Blows with a 0.5-l beer bottle or with a 0.33-l Coke bottle to the head can transfer up to 1.255 N and thus are able to cause severe blunt as well as sharp trauma injuries.

Preventable fatal injury during rally race: a multidisciplinary approach.

INTRODUCTION: The motor vehicle crash (MVC) constitutes an important challenge for forensic pathology in order to identify the manner and cause of death. Our study focuses on a fatal accident during a rally race corresponding to MVC sub-category. MATERIALS AND METHOD: Postmortem computed tomography (PMCT) was performed before the conventional autopsy. Autoptic and PMCT data were compared. Data collection allowed analyzing biomechanical dynamics of the incident and post-traumatic injuries through qualitative-statistics and solicitation quantitative indices. RESULTS: Photo and circumstantial evidence analysis showed a wrong installation of double shoulder belt system of head and neck support (HANS) collar. PMTC clearly highlighted multiple and bilateral fractures involving roof and base of skull; a displaced fracture of the right acetabulum was also encountered. Autopsy confirmed PMCT data and revealed a brainstem laceration. AIS (Abbreviated Injury Scale) achieved a maximum score in consideration of fatal injuries. DISCUSSION: The injuries analysis resulting from photographic surveys examination, conventional autopsy, and PMCT has led us to confirm a fatal front collision with a tree trunk. Head trauma represents a major injury in the present case. In this case, head injuries, related to whiplash trauma, are a consequence of a double shoulder belt system (HANS collar component) wrong installation. CONCLUSION: MVC and especially high-speed motor racing represent an important death cause. There was, for this reason, a marked development of cars and occupants' safety systems, such as HANS collar. PMCT improves the diagnostic performance of conventional autopsy and increases forensic medical knowledge related to traumatic injuries.

Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT).

Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological "triad", a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216-223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44-48% when all the spinal cord levels are analysed as opposed to just 0-18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.

Prevalence of cranial trauma in Eurasian Upper Paleolithic humans.

OBJECTIVES: This study characterizes patterns of cranial trauma prevalence in a large sample of Upper Paleolithic (UP) fossil specimens (40,000-10,000 BP). MATERIALS AND METHODS: Our sample comprised 234 individual crania (specimens), representing 1,285 cranial bones (skeletal elements), from 101 Eurasian UP sites. We used generalized linear mixed models (GLMMs) to assess trauma prevalence in relation to age-at-death, sex, anatomical distribution, and between pre- and post-Last Glacial Maximum (LGM) samples, while accounting for skeletal preservation. RESULTS: Models predicted a mean cranial trauma prevalence of 0.07 (95% CI 0.003-0.19) at the level of skeletal elements, and of 0.26 (95% CI 0.08-0.48) at the level of specimens, each when 76-100% complete. Trauma prevalence increased with skeletal preservation. Across specimen and skeletal element datasets, trauma prevalence tended to be higher for males, and was consistently higher in the old age group. We found no time-specific trauma prevalence patterns for the two sexes or age cohorts when comparing samples from before and after the LGM. Samples showed higher trauma prevalence in the vault than in the face, with vault remains being affected predominantly in males. DISCUSSION: Cranial trauma prevalence in UP humans falls within the variation described for Mesolithic and Neolithic samples. According to our current dataset, UP males and females were exposed to slightly different injury risks and trauma distributions, potentially due to different activities or behaviors, yet both sexes exhibit more trauma among the old. Environmental stressors associated with climatic changes of the LGM are not reflected in cranial trauma prevalence. To analyze trauma in incomplete skeletal remains we propose GLMMs as an informative alternative to crude frequency calculations.

Violence in the first millennium BCE Eurasian steppe: Cranial trauma in three Turpan Basin populations from Xinjiang, China.

OBJECTIVES: Violence affected daily life in prehistoric societies, especially at conflict zones where different peoples fought over resources and for other reasons. In this study, cranial trauma was analyzed to discuss the pattern of violence experienced by three Bronze to early Iron Age populations (1,000-100 BCE) that belonged to the Subeixi culture. These populations lived in the Turpan Basin, a conflict zone in the middle of the Eurasian Steppe. METHODS: The injuries on 129 complete crania unearthed from the Subeixi cemeteries were examined for crude prevalence rate (CPR), trauma type, time of occurrence, possible weapon, and direction of the blow. Thirty-three injuries identified from poorly preserved crania were also included in the analyses except for the CPR. Data was also compared between the samples and with four other populations that had violence-related backgrounds. RESULTS: Overall, 16.3% (21/129) of the individuals showed violence-induced traumatic lesions. Results also indicated that most of the injuries were perimortem (81.6%), and that women and children were more involved in conflict than the other comparative populations. Wounds from weapons accounted for 42.1% of the identified cranial injuries. Distribution analysis suggested no dominant handedness of the attackers, and that blows came from all directions including the top (17.1%). Wounds caused by arrowheads and a special type of battle-ax popular in middle and eastern Eurasian Steppe were also recognized. DISCUSSION: A comprehensive analysis of the skeletal evidence, historical records, and archeological background would suggest that the raiding to be the most possible conflict pattern reflected by the samples. The attackers were likely to have been nomadic invaders from the steppe (such as the Xiongnu from historical records), who attacked the residents in the basin more likely for their resources rather than territory or labor force.

The effect of synthetic bone graft substitutes on bone formation in rabbit calvarial defects.

The aim of this study was to evaluate the influence of the intensity of the biomimetic hydroxyapatite (HA) coating of α-tricalcium phosphate (α-TCP) on biomaterial degradation and bone formation. Twenty-four female NZW rabbits of approximately 12 weeks of age were used. Critical size defects were randomly treated with 3%:97% HA:α-TCP (BBCP1), 12%:88% HA:α-TCP (BBCP2), and 23%:77% HA:α-TCP (BBCP3), respectively or sham. All defects were covered with a resorbable collagen membrane. Animals were euthanized after 3 and 12 weeks of healing and samples were investigated by micro-CT and histologic analysis. Ingrowth of newly formed woven bone from the original bone at 3-week healing period was observed in all samples. At the 12-week healing period, the new bone in the peripheral area was mainly lamellar and in the central region composed of both woven and lamellar bone. New bony tissue was found on the surface of all three types of granules and at the interior of the BBCP1 granules. Samples with 3% HA showed significantly less residual biomaterial in comparison to the other two groups. Furthermore, BBCP1 significantly promoted new bone area as compared to other three groups and more bone volume as compared to the control. Within its limitations, this study indicated the highest degradation rate in case of BBCP1 concomitant with the highest rate of bone formation. Hence, formation of new bone can be affected by the level of biomimetic HA coating of α-TCP.

Risk Factors for Intracranial Injury Caused by Falls at Home in Korea Using Data from the Emergency Department-based Injury In-depth Surveillance (2011-2018).

BACKGROUND: Most unintentional injuries that occur at home are preventable. However, it may be difficult to sufficiently reduce the number of falls occurring at home by only identifying risk factors focused on specific age groups. Therefore, this study aimed to identify the risk factors (especially age and places where injuries occurred at home) for intracranial injury (ICI) caused by unintentional falls at home. METHODS: Using the Emergency Department (ED)-Based Injury In-depth Surveillance, we analyzed the data of patients who visited the ED due to unintentional falls at home. Risk factors were identified using multivariable logistic regression according to age groups and interactions between place of injury occurrence and age groups, and sex and age groups were assessed. RESULTS: In total, 232,124 patients were included in the analysis; older adults had a higher adjusted odds ratio (aOR) 14.05 (95% confidence interval [CI], 12.74-15.49) of ICI than infants. The corridor was associated with ICI in the male pediatric group (aOR, 2.71; 95% CI, 1.08-6.84) and the balcony with the female pediatric group (aOR, 2.04; 95% CI, 1.03-4.04). In the adult group, aOR of kitchen was 1.38 (95% CI, 1.02-1.88) in females and 0.56 (95% CI, 0.48-0.66) in males. CONCLUSION: In this study, we identified the risk factors of ICI caused by falls at home using ED-based injury surveillance data. The risk of ICI was different among places of occurrence in the home depending on the age groups and sex.

Multiple myeloma complicated by skull plasmacytoma discovered after head injury.

Plasmacytoma is a malignant tumor originating from the plasma cells of the bone marrow. Those discovered after a head injury is rare. We report a case of a 48-year-old female who complained of scalp mass without other symptoms after head injury. Meningioma was considered preoperatively based on imaging findings, and surgical resection was performed. Postoperatively, multiple myeloma complicated by skull plasmacytoma was diagnosed by histopathology and systematic examinations in succession. When evaluating a head mass that appeared after a head injury, plasmacytoma should be considered at times. Osteolytic changes and biconvex form on imaging are beneficial to differentiation.

Beer stein blast to the head a rare case of combined blunt and sharp force trauma.

Cases of combined blunt and sharp force trauma to the head caused by one striking tool are rare. When beer steins are used as an assault weapon, they can cause blunt traumas upon initial contact phase. If the impact force exceeds the mechanical stability of the beer stein, it breaks into several sharp-edged pieces, which then can cause sharp force trauma injuries due to the interaction between the head and the stein fragments.We present a case of a 43-year old man, who suffered from blunt and sharp force head traumas due to one single blow with a 1-l beer stein. A forensic-biomechanical analysis of the event, together with witness testimony evaluation and experimental comparison helped to reconstruct the most probable chain of events. Based on these findings as well as on the medical diagnoses and treatment, the assault was assessed as a nonacute life-threatening, but potentially fatal offence. The case was indicted as grievous bodily harm.

Endemic violence in a pre-Hispanic Andean community: A bioarchaeological study of cranial trauma from the Majes Valley, Peru.

OBJECTIVES: This study examines violence-related cranial trauma frequencies and wound characteristics in the pre-Hispanic cemetery of Uraca in the lower Majes Valley, Arequipa, Peru, dating to the pre- and early-Wari periods (200-750 CE). Cranial wounds are compared between status and sex-based subgroups to understand how violence shaped, and was shaped by, these aspects of identity, and to reconstruct the social contexts of violence carried out by and against Uracans. MATERIALS AND METHODS: Presence, location, and characteristics (lethality, penetration, and post-traumatic sequelae) of antemortem and perimortem cranial fractures are documented for 145 crania and compared between subgroups. Cranial wounds are mapped in ArcGIS and the locational distribution of injuries is compared between male and female crania. RESULTS: Middle adult males were disproportionately interred at Uraca, particularly in the elite Sector I. The Uraca mortuary population presents the highest rate of cranial trauma reported for pre-Hispanic Peru: 67% of adults present trauma, and among those, 61.1% present more than one cranial injury. Males exhibit significantly more cranial trauma than females and present a higher mean number of injuries per person. Elite males show the highest mean number of injuries per person, more antemortem injuries, and are the only ones with perimortem cranial trauma, bladed injuries, penetrating injuries, and post-traumatic sequelae. Both sexes were most frequently injured on the anterior of the cranium, while the proportion of posterior injuries was higher for females. DISCUSSION: The rate, intensity, and locational patterns of cranial trauma suggests the community was engaged in raids and/or war with enemy groups, some of which may have increased physical violence between community members. Engaging in violence was likely a prerequisite for burial in the elite sector and was bound up with the generation and maintenance of social status differences linked to male social life.

Unplanned Complex Suicide by Self-Stabbing and Rail Suicide: A Case Report and Review of Literature.

Investigation of a complex suicide is a challenging task, particularly when the combination of modalities adopted is rare and unplanned. There is often a significant likelihood of labeling the case as a homicide. We present an interesting case of unplanned complex suicide with self-stabbing and head injury resulting from intentionally being struck by a train. There were also hesitation cuts evident over the neck and left wrist. This case highlights the importance of studying the nature and characterization of the wounds, examination of clothes, and examination of the scene to safely conclude the cause and the manner of death.

Comparison between postmortem computed tomography and autopsy in the detection of traumatic head injuries.

INTRODUCTION: The aim of this study was to assess the agreement between postmortem computed tomography (PMCT) and autopsy in detecting traumatic head injuries. MATERIALS AND METHODS: Consecutive cases of death that underwent both unenhanced PMCT and conventional autopsy were collected from our institution database during a period of 3 years and reviewed retrospectively. PMCT images were reviewed for the presence of fractures (cranial vault, skull base, facial bones and atlas/axis) and intracranial hemorrhage. Kappa values were calculated to determine the agreement between PMCT and autopsy reports. RESULTS: 73 cases were included, of which 44 (60%) had head trauma. Agreement between PMCT and autopsy was almost perfect (κ = 0.95) for fractures and substantial (κ = 0.75) for intracranial hemorrhage. PMCT was superior to autopsy in detecting facial bone and upper cervical spine fractures, and intraventricular hemorrhage. However, in some cases thin extra-axial blood collections were missed on PMCT. CONCLUSIONS: The agreement between PMCT and autopsy in detecting traumatic head injuries was good. Using a combination of both techniques increases the quality of postmortem evaluation because more lesions are detected.

[On the quality of the external post-mortem examination in cases of fatal head trauma : A comparison of death certificate and forensic autopsy]. / Zur Qualität der ärztlichen Leichenschau bei todesursächlichem Schädel­Hirn­Trauma : Ein Vergleich von Todesbescheinigung und gerichtlicher Obduktion.

BACKGROUND: In Germany it is required by law that basically every type of physician needs to be capable of executing a correct external post-mortem examination of a corpse. In recent years, numerous investigations on external post-mortem examinations repeatedly reported systematic mistakes and erroneous procedures in various clinical and medicolegal case groups. Accordingly, the completion of death certificates is frequently performed incorrectly. As one of the typical unnatural death cases, decedents dying from fatal head trauma (FHT) represent a special autopsy case group, which is expected to be correctly recognized during the primary external post-mortem examination because the external injuries are mostly obvious. OBJECTIVE: The present study aimed at investigating the quality of the external post-mortem examination in medicolegal FHT cases by means of comparison of death certificates and autopsy reports from a 10-year period. MATERIAL AND METHODS: In a retrospective study design all autopsy cases from the Institute of Legal Medicine of the University Hospital Münster in the years 2006-2015 (n = 3611) were analyzed as to the presence of FHT. A total of 328 cases with FHT and the concomitant presence of a death certificate filled out before the autopsy were identified. Subsequently, the cause of death according to the death certificate was compared with the cause of death according to the autopsy. The degree of agreement was classified into six different categories from I to VI. While category I represented a complete lack of agreement, category VI was assigned to cases with full agreement. RESULTS: In 58.5% of the cases (category VI) FHT was identified correctly during the external post-mortem examination. In 1.5% of the cases, a completely different cause of death was determined during the external post-mortem examination (category I). In 19.2% of the cases, no cause of death or the statement "unclear" was given as the cause of death in the death certificate (categories II and III). Cross-analyses and intuitive heatmap visualization were generated to identify case constellations with an increased risk for discrepancies. These analyses revealed that among all discrepant cases (categories I-V), falls were found significantly more often than in the nondiscrepant cases (p < 0.01), especially falls of women older than 57 years (median age of women) or falls considered as accidents by the examiner. In addition, traffic-associated FHT of men older than 44.5 years (median age of men) was identified more frequently in the external post-mortem examination. CONCLUSION: Despite the fact that FHT should be a cause of death that is comparably easy to identify during external post-mortem examination, more than one third of the cases were not sufficiently recognized. Therefore, special attention must still be paid to certain case constellations during the external post-mortem examination. Typical examples of such cases are burned bodies, cases of advanced putrefaction and falls.

Mechanism of brain swelling in cases of brain evisceration due to catastrophic craniocerebral injury - an autopsy study.

Some previously reported cases of brain evisceration in catastrophic craniocerebral injuries showed the presence of brain swelling. The aim of this study was to observe the occurrence of focal or diffuse brain swelling in such cases in order to explain the underlying mechanism. An observational autopsy study included 23 adults, 18 males and 5 females, whose average age was 48 ± 22 years (range: 19-89 years) and who died as the result of catastrophic craniocerebral injury with brain evisceration. In all the examined cases, either focal (12 cases) or diffuse (11 cases) brain swelling was present. Grossly visible brain contusions (either cortical or deep) were rarely present - only in 6 out of 23 cases, while microscopic brain contusions were observed in 22 out of 23 cases, with 1 remaining case of microscopic subarachnoid bleeding. Blood aspiration in the lungs, as a vital reaction, was noted in 20 out of 23 cases. Microscopic examination showed absence of edema in 20 cases and mild edema in only 3 cases, while microscopic signs of moderate or severe edema were absent. Brain swelling in cases of brain evisceration likely represents a biomechanical reaction (i.e. decompression) due to a sudden decrease in intracranial pressure. The rapidity of death, together with marked absence of microscopic signs of edema, suggests that this is not a form of biological response to injury, but rather a pure physical phenomenon, strictly in a living person. In such cases, the occurrence of brain swelling and parenchymal microbleeding should be considered vital reactions.

Altered brain microstructure in association with repetitive subconcussive head impacts and the potential protective effect of jugular vein compression: a longitudinal study of female soccer athletes.

PURPOSE: To (1) quantify white matter (WM) alterations in female high school athletes during a soccer season and characterise the potential for normalisation during the off-season rest period, (2) determine the association between WM alterations and exposure to repetitive subconcussive head impacts, and (3) evaluate the efficacy of a jugular vein compression collar to prevent WM alterations associated with head impact exposure. METHODS: Diffusion tensor imaging (DTI) data were prospectively collected from high school female soccer participants (14-18 years) at up to three time points over 9 months. Head impacts were monitored using accelerometers during all practices and games. Participants were assigned to a collar (n=24) or non-collar group (n=22). The Tract-Based Spatial Statistics approach was used in the analysis of within-group longitudinal change and between-group comparisons. RESULTS: DTI analyses revealed significant pre-season to post-season WM changes in the non-collar group in mean diffusivity (2.83%±2.46%), axial diffusivity (2.58%±2.34%) and radial diffusivity (3.52%±2.60%), but there was no significant change in the collar group despite similar head impact exposure. Significant correlation was found between head impact exposure and pre-season to post-season DTI changes in the non-collar group. WM changes in the non-collar group partially resolved at 3 months off-season follow-up. DISCUSSION: Microstructural changes in WM occurred during a season of female high school soccer among athletes who did not wear the collar device. In comparison, there were no changes in players who wore the collar, suggesting a potential prophylactic effect of the collar device in preventing changes associated with repetitive head impacts. In those without collar use, the microstructural changes showed a reversal towards normal over time in the off-season follow-up period.

Relative Head Impact Exposure and Brain White Matter Alterations After a Single Season of Competitive Football: A Pilot Comparison of Youth Versus High School Football.

OBJECTIVE: Youth athletes are believed to be more susceptible to white matter (WM) degradation resulting from head impact exposure relative to high school (HS) athletes; this hypothesis has not been objectively tested. The purpose of this study was to determine preseason to postseason changes in WM integrity from repetitive head impacts for youth football (YFB) players compared with HS football players during a competitive football season. DESIGN: Prospective cohort. SETTING: One season of YFB (grades 7 and 8) and varsity HS football (grades 10-12). PATIENTS OR OTHER PARTICIPANTS: Twelve YFB (13.08 ± 0.64 years) and 21 HS (17.5 ± 0.78 years) athletes. INTERVENTIONS: Participants completed 2 magnetic resonance imaging sessions: preseason and postseason. Head impact exposure was recorded during practice and games using a helmet-mounted accelerometer. MAIN OUTCOME MEASURES: Tract-based spatial statistics were used to evaluate group differences in preseason to postseason changes in diffusion tensor imaging, including fractional anisotropy and mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD). RESULTS: The HS group exhibited significant preseason to postseason reductions in MD, AD, and RD (P < 0.05, corrected) in widespread WM areas. Significant WM reductions for the YFB group were only observed for AD (P < 0.05, corrected), but was more limited in extent compared with HS. CONCLUSIONS: Significant preseason to postseason AD reduction was found in both YFB and HS groups after one season of competitive play. Our results did not confirm recent speculation that younger children are more susceptible to the deleterious effects of repetitive head impacts compared with their older counterparts.

The Impact of Head of Bed Elevation on Optic Nerve Sheath Diameter in Cervical Collar Applied Healthy Volunteers.

BACKGROUND: Guidelines recommend placing a cervical collar (c-collar) until spinal injury is excluded. Previous studies have shown that c-collar placement increases intracranial pressure (ICP), which can worsen outcomes for trauma patients who are at risk of increased ICP. Head of bed elevation (HBE) has been found to decrease ICP. However, there is no consensus in the literature for the optimal degree of HBE to decrease ICP. OBJECTIVE: We aimed to find an optimal HBE degree to decrease ICP to its baseline values in healthy volunteers with increased ICP caused by c-collar. METHODS: This is a randomized controlled and blinded study performed in healthy volunteers. Two sonographers measured the optic nerve sheath diameter (ONSD) of each subject's eyes separately for different time points. Then, we calculated a mean ONSD value for five time points: before c-collar placement (T0), 5 and 20 min in supine position after c-collar placement (T5 and T20), and 5 and 20 min after HBE (T25 and T40). We randomized the subjects into three groups of HBE: 15, 30, and 45°, and compared the mean ONSD values among groups. RESULTS: All groups were similar with regard to baseline demographics and ONSD measurements before HBE. We found significant increases in mean ONSD values at T5 and at T20 caused by the c-collar. Thirty and forty-five degrees of HBE for 20 min decreased ONSD to its baseline values. The inter-rater reliability of the sonographers was > 0.9. CONCLUSIONS: Our results show that c-collar increases ONSD in healthy volunteers. Elevating the head of the bed 30 and 45° for 20 min decreased ONSD to baseline values.