Bihemispheric Injuries Research Articles

Physiological and radiological parameters predicting outcome from penetrating traumatic brain injury treated in the deployed military setting

IntroductionPenetrating traumatic brain injury (TBI) is the most common cause of death in current military conflicts, and results in significant morbidity in survivors. Identifying those physiological and radiological parameters associated...

Critical prognostic factors for poststroke dysphagia: a meta-analysis.

Poststroke dysphagia (PSD) is one of the most significant problems after stroke. The prognosis of dysphagia is closely related to the outcomes of stroke. This meta-analysis aimed at identifying and evaluating critical predictors of prognosis for PSD. Electronic databases were searched for relevant case-control and cohort studies in which the prognostic factors of PSD were reported. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale. Review Manager 5.3 was used to calculate odds ratios (OR) and their 95% confidence intervals (CI) of the included factors and to perform heterogeneity and sensitivity analyses. Stata 15.1 was used to evaluate publication bias. Eighteen of 3132 total studies were finally included in this meta-analysis. Ten predictors of PSD were identified, including 2 protective factors and 8 risk factors. Early intervention (OR=0.75, 95% CI=0.61-0.93) and an MRS (modified Rankin scale) score of 0 before onset (OR=0.58, 95% CI=0.47-0.71) were related to a better prognosis of PSD. The risk factors ranked by pooled OR values were aspiration (OR=7.64, 95% CI=5.94-9.82), brainstem injury (OR=4.82, 95% CI=3.01-7.72), severity of stroke (OR= 3.06, 95% CI=1.69-5.53), bihemispheric injury (OR=3.0, 95% CI=1.67-5.40), older age (OR=1.75, 95% CI=1.50-2.04), malnutrition (OR=1.36, 95% CI=1.22-1.53), severe dysphagia on admission (OR=1.16, 95% CI=1.03-1.29), and reduced level of consciousness (OR=1.03, 95% CI=1.00-1.07). Prognostic factors for a good outcome of PSD included early intervention and an MRS score of 0 before onset. Aspiration, brainstem injury, severe stroke and bihemispheric injury are the four most significant predictors of poor prognosis in PSD. Identifying these prognostic factors should help clinicians to better detect patients at risk and provide effective interventions for PSD.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review

Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population. A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231). Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients. This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization. Systematic Review, level IV.

Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: A decision-tree algorithm based on a single trauma center

Gunshot wounds (GSW) are one of the most lethal forms of head trauma. The lack of clear guidelines for civilian GSW complicates surgical management. We aimed to develop a decision-tree algorithm for mortality prediction and report long-term outcomes on survivors based on 15-year data from our level 1 trauma center. We retrospectively reviewed 96 consecutive patients who presented with cerebral GSWs between 2003 and 2018. Clinical information from our trauma database, EMR, and relevant imaging scans was reviewed. A decision-tree model was constructed based on variables showing significant differences between survivors and non-survivors. After excluding patients who died at arrival, 54 patients with radiologically confirmed intracranial injury were included. Compared to survivors (51.9%), non-survivors (48.1%) were significantly more likely to have perforating (entry and exit wound), as opposed to penetrating (entry wound only), injuries. Bi-hemispheric and posterior fossa involvement, cerebral herniation, and intraventricular hemorrhage were more commonly present in non-survivors. Based on the decision-tree, Glasgow Coma Scale (GCS) > 8 and penetrating, uni-hemispheric injury predicted survival. Among patients with GCS ≤ 8 and normal pupillary response, lack of 1) posterior fossa involvement, 2) cerebral herniation, 3) bi-hemispheric injury, and 4) intraventricular hemorrhage, were associated with survival. Favorable long-term outcomes (mean follow-up 34.4 months) were possible for survivors who required neurosurgery and stable patients who were conservatively managed. We applied clinical and radiological characteristics that predicted survival to construct a decision-tree to facilitate surgical decision-making for GSW. Further validation of the algorithm in a large patient setting is recommended.

Cranial falling bullet injuries, a series of 30 cases in Iraq

Purpose: The purpose of this study is to highlight the importance of cranial falling bullet injuries and raise awareness about them. We studied the clinical and radiological findings, and their relation to the treatment and outcome. There are limited studies in this field.Materials and methods: Thirty patients, (aged 8–55 years) with cranial falling bullet injury were included in this study. They were followed during their hospitalization and up to 6 months thereafter. Post-resuscitation clinical findings, unenhanced brain CT scan findings, treatment and outcome (Glasgow Outcome Scale) were studied.Results: Male to female ratio was (1.73:1). Median age of all patients was: 17.5 years. 20(66.7%) patients had a GCS of 13–15, 3(10%) had 9–12, 2(6.7%) had 6–8, and 5(16.6%) had 3–5 at presentation. 23(76.7%) patients had normal pupillary reaction and symmetry whereas 7(23.3%) had poor reaction and/or asymmetry. On CT scan, 13 had a unilobar injury, six had multilobar or bihemispheric injuries, 10 had a bullet through the deep midline structures of the brain, seven had transventricular with IVH, four had SAH, none had large intracranial hematomas. All patients received medical treatment. Local wound care and/or extraction of extracranial subgaleal bullets were performed in 24 patients (80%). More extensive surgery was performed in six patients (20%). There was significant correlation (using Correlation Coefficient) between GCS, pupillary reaction/symmetry and CT imaging findings with the patient outcome. Low GCS, poor pupillary reaction and/or asymmetry, CT findings of central area injury, transventricular, IVH, or multilobar injury were associated with poor outcome.Conclusions: Cranial falling bullet injuries are uncommon, but they can cause significant morbidity and mortality. More studies are needed to document the impact of these injuries and to raise awareness among the society to support the efforts aiming at controlling the irrational use of guns in different countries of the world.

Development and Validation of a Nomogram for Predicting the Mortality after Penetrating Traumatic Brain Injury.

Objective:To determine the factors associated with mortality in penetrating brain injury (PTBI) and proposed the nomogram predicting the risk of death. Methods:A retrospective cohort study was conducted on all patients who had sustained PTBI between 2009 and 2018. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factors analysis was conducted using a forest plot. Therefore, the nomogram was developed and validated. For the propose of evaluation, the nomogram’s sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operating Characteristic (ROC) curve and the area under the receiver operating characteristic (AUC) were determined for validating the optimal cut-off point of the total scores. Results:During the study period, 62 individuals enrolled. In the univariate analysis, factors associated with the morality were normal pupils’ reactivity to light (OR 0.04, p < 0.001), hypotension (OR 9.91, p<0.001), hypoxia (OR 10.2, p=0.04), bihemispheric injuries (OR 19.0, p=0.001), multilobar injuries (OR 21.5, p< 0.001), subarachnoid hemorrhage (OR 6.9, p= 0.02), intraventricular hemorrhage (OR 26.6, p= 0.006), basal cistern effacement (OR 28.8, , p<0.001), midline shift >5 mm (OR 0.19, p<0.001) were significantly associated with death. In multivariable analysis, hypotension (OR 8.82, p=0.03), normal pupils’ reactivity to light (OR 0.07, p =0.01), midline shift >5 mm (OR 18.23, p<0.007) were significantly associated with death. The nomogram’s sensitivity, specificity, PPV, NPV, and AUC for predicting mortality (total score ≥ 100) were 80%, 92.6%, 72.7%, 95.0%, and, 0.86 respectively. Conclusions:PTBI is the fatal injury depend on both clinical and neuroimaging parameters. The nomogram is the alternative method providing prognostic parameters toward implication for clinical decision making.

Penetrating Bihemispheric Traumatic Brain Injury: A Collective Review of Gunshot Wounds to the Head.

Head injuries that cross midline structures of the brain are bihemispheric. Other terms have been used to describe such injuries, but bihemispheric is the most accurate and should be standard nomenclature. Bihemispheric head injuries are associated with greater mortality and morbidity than other penetrating traumatic brain injuries (TBIs). Currently, there is a tendency to manage severe gunshot wounds (GSWs) to the head nonoperatively, despite reports of improved outcome in military patients treated aggressively. Thus, controversy exists in the management of civilian TBI. PubMed was searched for query terms, and PRISMA guidelines were used. Studies were selected by relevance and inclusion of data regarding etiology, diagnosis, and management of bihemispheric TBI. Case reports, studies not in English, and records lacking information on mechanism or bihemispheric injuries were excluded. Thirteen studies were included and most contained level IV evidence. The mean mortality rate of all head GSWs was 62% in adults and 32% in children. Bihemispheric GSWs had greater mortality rates of 82% in adults and 60% in children. There was a larger proportion of self-inflicted injury in studies with greater rates of bihemispheric injuries. Bihemispheric injuries have greater mortality rates than other penetrating TBI. Violation of midline brain structures such as the diencephalon and mesencephalon, increased rate of self-inflicted wounds, and lack of a standard management algorithm may increase the lethality of these injuries. Although bihemispheric injuries historically have been considered nonsalvageable, an aggressive surgical approach has been shown to improve outcomes, particularly in the military population.

Pediatric intracranial gunshot wounds: the Memphis experience.

OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

Bihemispheric gunshot wounds: survival and long-term neuropsychological follow-up of three siblings.

Penetrating gunshot wounds to the head (GSWH) have notoriously poor outcomes with extremely high mortality. Long-term follow-up data of affected children is scant in the medical literature. This report summarizes clinical presentation, management, and long-term outcomes from three children who survived "execution style" frontal, bihemispheric gunshot wounds with no or minimal surgical intervention. A retrospective chart review of available medical records and outcomes from standardized, validated psychological instruments was undertaken, summarized, and evaluated. Despite bihemispheric injuries in each patient, no patient required operative intervention. Each child survived without readily evident neurologic impairment; however, the extent of impaired executive function varied widely, and severe disinhibition remains profoundly disabling in one survivor. Bihemispheric penetrating gunshot injuries are not uniformly fatal and can occasionally be associated with long-term favorable survival; however, impaired executive function has significant potential to be profoundly disabling in these injuries.

Improving Survival Rates after Civilian Gunshot Wounds to the Brain

Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival rates of 10% to 15%. The aim of this study was to determine outcomes in patients with gunshot wounds to the brain, presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation in patients with gunshot wounds to the brain. We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma center over a 5-year period. Aggressive management was defined as resuscitation with blood products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The primary outcome was survival and the secondary outcome was organ donation. There were 132 patients with gunshot wounds to the brain, and the survival rates increased incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries. Aggressive management with blood products (p = 0.02) and hyperosmolar therapy (p = 0.01) was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale score ≥ 13 at hospital discharge. In patients who died (n = 92), 56% patients were eligible for organ donation, and they donated 60 organs. Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. The bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save patients with gunshot wound to the brain.

Penetrating craniocerebral injuries from the former Yugoslavia battlefields

In the period from September 10 th 1991 to December 31 st 1992, the total of 162 patients with penetrating craniocerebral war injuries from the former Yugoslavia battlefields were treated in the Military Medical Academy (MMA) in Belgrade. The severity of injury was graded according to the Glasgow Coma Score (GCS) as mild (13–15), moderate (9–12), and severe (3–8). The extensity of the cerebral lesion was classified as unilobar, multilobar, bihemispheric, transventricular, and haematoma with shift. Injuries were divided into those caused by bullets or shrapnel. According to the missile path, these were tangential, uncrossed, and crossed injuries. The patients were divided into the two groups according to the treatment that they received: Group A- 90 patients who were referred directly to the MMA without surgical treatment, and group B-72 patients who were treated surgically (minimal debridment or simple wound closure) in the local hospitals before the evacuation to the MMA. The outcome was assessed on the discharge from the MMA according to the Glasgow Outcome Scale (GOS). Severe penetrating injuries had poor outcome as compared to moderate and mild injuries (p=0.001). Multilobar and bihemispheric injuries as compared to unilobar, and crossing as compared to uncrossing or tangential injuries had a poor outcome (p=0.001). Bullet injuries had a poor outcome then shrapnel injuries (p=0.016). For the treatment of the complications or additional debridement 6.5% patients from the group A and 78% from the group B were reoperated. There was no statistically significant difference regarding the final outcome of the patients from the group A comparing to the group B (p = 0.169). Severity of the injury, extensity of the cerebral lesion, the missile path, and the type of missile significantly influenced the final outcome. Minimal debridement of penetrating gunshot injuries was not a sufficient solution because it required a high rate of reoperation in the later stage.

Craniocerebral gunshot injuries in children.

Despite the worldwide increase in the incidence of gunshot injuries, there are few large published series on craniocerebral gunshot injuries in children. The records of 30 consecutive children who were treated for craniocerebral gunshot injuries at the Red Cross War Memorial Children's Hospital from 1989 to 2002 were reviewed retrospectively. The circumstances of the injury, clinical status, CT findings, complications, and outcome were assessed. The median age was 7 years. Seventy-seven percent of the victims were boys. The majority of the children were injured in the crossfire of civilian violence. The initial management consisted of debridement under local anesthesia in 16 children and neurosurgical procedures under general anesthesia were performed in 14. Sixteen children sustained transhemispheric injuries, 5 bihemispheric injuries, 5 tangential injuries, and 4 transventricular injuries. All 3 children with a GCS <4 died within 72 h of admission. Three of the 7 children with GCS 4-7 died but there were no deaths in those children whose GCS was >7 post-resuscitation. Motor deficits, cranial nerve palsies, and visual field defects were very common. Early post-traumatic seizures were the commonest complication (18%). Children with higher post-resuscitation GCSs fared better than adults in terms of mortality but not necessarily morbidity. As in the case with adults, the GCS after resuscitation is a very good prognostic indicator of mortality.

Outcome prediction following penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 6 to 15

In an attempt to assess admission Glasgow Coma Scale (GCS) scores and other radiographic variables after penetrating craniocerebral injury in relationship to outcome, the author evaluated a series of 294 patients with penetrating injuries who presented with a GCS score of 6 to 15 over a 6-year period. Entrance criteria required a replicable neurological examination that was not altered by the presence of hypotension, drugs/toxins, or systemic injury. All patients underwent surgical intervention and aggressive perioperative management, including resuscitative protocols, in the neurosurgical intensive care unit. The author previously devised prospective models of outcome remained unchanged in this series. The variables most predictive of death include admission GCS score and subarachnoid hemorrhage in one model and admission GCS score and pupillary changes in a second when pupillary response was definitive at admission (p < or = 0.00005). Other important variables related to morbidity include admission GCS, bihemispheric injury when associated with intraventricular hemorrhage, and diffuse fragmentation (p < or = 0.001). In this study a significant relationship between operative intervention and survival (p < or = 0.01) was found in patients with an admission GCS scores of 6 to 8. No significant relationships between operative intervention and survival were found in patients with admission GCS scores of 9 to 12 and 13 to 15. A significant relationship between operative intervention and morbidity (p < or = 0.01) was also demonstrated in patients with an admission GCS score of 12 to 15. No significant relationships between operative intervention and morbidity were found in patients with an admission GCS score of 6 to 8 and 9 to 12.

Demographics of civilian cranial gunshot wounds: devastation related to escalating semiautomatic usage.

The demographics and outcome of patients with gunshot wounds to the head over the past 10 years at Chicago's Cook County Hospital was examined. The study group consisted of 476 consecutive patients admitted to this urban level I trauma center with a diagnosis of penetrating craniocerebral missile injury. All patients followed a protocol that included aggressive surgical management when indicated. The Glasgow Outcome Score was used to assess outcome. There is an alarming rise in firearm violence in general and craniocerebral injury in particular. Some patients with severe neurologic deficits and massive cerebral damage can benefit from aggressive treatment and make a good recovery. A large proportion of this violence is most likely attributable to gang activity. Factors correlating with poor outcome included hypotension, apnea, bihemispheric injuries, or ventricular penetration. Although aggressive surgical and medical management improves the outcome of these patients, much more stringent preventative measures are required to control this violent epidemic.

Penetrating craniocerebral injury resultant from gunshot wounds: gang-related injury in children and adolescents.

We prospectively and retrospectively reviewed a series of 780 patients who presented to the University of Southern California/Los Angeles County Medical Center with a diagnosis of gunshot wound to the brain during an 8-year period. Of these, 105 were children ranging in age from 6 months to 17 years. Injuries were gang related in 76 (72%) children and adolescents. Stepwise linear regression analysis was used to formulate a predictive model of outcome in this population. Patient age (F = 10.92), sex (F = 9.32), occipital entry site (F = 8.17), bihemispheric injury (F = 8.50), and admission Glasgow Coma Scale (F = 69.91) were all found to correlate with outcome (P < 0.05). Significant differences between pediatric and adult populations were noted in transit time, entrance site, and age-related outcome. Occipital or assassination-type wounds were most common in children. In addition, a younger age was associated with poor outcome (P < 0.0001). We describe both the economic and racial trends in our population of patients in addition to weapon type and toxicological evaluation. The Department of Neurological Surgery is becoming directly involved in providing information to children at the junior high school level regarding gang activity and brain and spinal cord injury. In conjunction with the Community Youth Gang Services Organization and Think First Organization, we are attempting to integrate prevention through education and community mobilization. This is a plan aimed at informing and recovering the youth affected by gangs.

The role of early surgical intervention in civilian gunshot wounds to the head.

Surgical management of gunshot wounds of the head has remained a controversial issue in the care of civilian patients. In an attempt to determine who might benefit from aggressive surgical intervention, we examined 89 patients over a 3-year period who had suffered cranial gunshot wounds and had at least one computed tomographic scan of the head after admission. Patients were divided into those receiving early (less than 24 hours) surgical intervention (ES, n = 27), late (greater than 24 hours) surgical intervention (LS, n = 6) or no surgical intervention (NS, n = 56). Overall mortality was 63%. Ten of 27 patients (37%) in the ES group died compared with 46 of 56 patients (82%) in the NS group (p less than 0.0001). Glasgow Coma Scale (GCS) scores in the ES group averaged 7.86 +/- 4.72 and in the NS group 5.59 +/- 4.42 (p less than 0.05). The GCS scores in the LS group (all of whom survived) were significantly higher than those of the other two groups, 12.17 +/- 4.10. The number of patients with GCS scores of 3 or 4 on admission was significantly less in the ES (41%) than in the NS group (66%, p = 0.035) and survival was better with surgery (36%) than without (3%, p = 0.007). Patients with mass lesions (clot, ventricular blood) were more often found in the ES group (17/27) than in the NS group (18/56) (p = 0.008). Patients with bihemispheric injuries fared better with surgery (7 of 14 survivors) than without (2 of 33 survivors, p = 0.0003). Only one infectious complication (brain abscess) was encountered in the LS group. No delayed intracranial complications in survivors in the NS group were seen.(ABSTRACT TRUNCATED AT 250 WORDS)