Calvarial Fractures Research Articles

Bioactive impact of manuka honey and bone char incorporated into gelatin and chitosan cryogels in a rat calvarial fracture model.

Bone tissue engineered scaffolds are designed to mimic the natural environment for regeneration when typical healing is inhibited. Autografts are the current gold standard for treatment but are limited by available bone and supplementary surgical sites that broaden complications and comorbidities. Cryogels are an ideal scaffold in bone regeneration due to their mechanical integrity and marcoporous structure that elicits angiogenesis and subsequently new bone tissue formation. To aid in bioactivity and osteoinductivity, manuka honey (MH) and bone char (BC) were added to gelatin and chitosan cryogels (CG). Manuka honey has powerful antimicrobial properties to aid against graft infection, and bone char is composed of 90% hydroxyapatite, a well-studied bioactive material. These additives are natural, abundant, easy to use, and cost effective. CG cryogels incorporated with either BC or MH, and plain CG cryogels were implanted into rat calvarial fracture models for cortical bone regeneration analysis. We found indication of bioactivity with both bone char and manuka honey through the presence of woven bone structure in histology stains and micro computed tomography (microCT) data. Overall, plain CG cryogels supported greater bone regeneration capabilities than the BC or MH incorporated cryogels due to a lack of advanced organized tissue formation and collagen deposition after 8 weeks of implantation; however, future work should explore varying additive concentrations and delivery methods to further assess additive potential.

Epidemiological Trends of Traumatic Nervous System Injuries in a Tertiary Health Institution during the First Year of the Coronavirus Disease 2019 Pandemic in Turkey.

Traumatic nervous system injuries (TNSIs) remain one of the most debilitating injuries globally, including in Turkey. Despite its popularity, epidemiological studies revealing the true incidence of TNSIs in our country are scarce. This study aims to document the epidemiological trends of TNSIs in the first year of the coronavirus disease 2019 pandemic in Çorum, Turkey. This retrospective cohort study was conducted to analyze the incidence of TNSIs in patients admitted to the emergency department (ED) of a tertiary hospital in Çorum from March 1, 2020, to February 28, 2021. Of the 107,100 patients admitted to the ED, 492 (0.4%) were diagnosed with TNSIs. Traumatic head injuries (including scalp and calvarial injuries), traumatic brain injuries (TBIs, excluding scalp and calvarial injuries), traumatic spinal injuries (TSIs), and traumatic peripheral nerve injuries were detected in 262 (53.2%), 141 (28.6%), 268 (54.4%), and 9 (1.8%) patients, respectively. Overall, male predominance was 2/1 (male/female), with a mean age of 45 years. The main cause of trauma was falling (61%), followed by motor vehicle collisions (26%). This was mostly scalp injuries (59%) and calvarial fractures (42%), while subdural (12.8%) and subarachnoid (11.1%) hemorrhages were the predominant TBIs. The majority of TSIs were detected in the lumbar spine (66%). Conservatively treatment was administered to 432 (88%) patients, and 424 (86%) patients recovered completely, while 33 (7%) survived with some degree of motor, sensory, or sphincter deficits, and 35 (7%) died. This study reveals findings that will effectively guide the steps to increase public health awareness and preventive measures regarding TNSIs in our country.

Acute traumatic dural arteriovenous fistula of the superior sagittal sinus: illustrative case.

Dural arteriovenous fistulas (dAVFs) are aberrant vascular communications between meningeal arteries and venous sinuses or cortical veins. dAVF pathogenesis is incompletely understood; however, formation likely occurs as a result of angioneogensis. A 78-year-old man presented after trauma with basal and cortical subarachnoid hemorrhage (SAH). Computed tomography revealed a parietal bone fracture overlying the superior sagittal sinus (SSS). Catheter angiography performed within 24 hours of the injury demonstrated an SSS dAVF supplied by the middle meningeal artery, adjacent to the fracture. The authors present the case of an acute traumatic dAVF adjacent to a calvarial fracture. In this case, the authors proprose that the underlying pathogenesis is suggestive of direct vessel injury rather than the pathway commonly associated with this pathology.

Hormonal Deficiency in Patients with Acute Traumatic Brain Injury: A Prospective Study

Background :Traumatic brain injury (TBI) has become a major public health concern in developing and developed countries as it affects productivity and economy. The incidence, prevalence, and scope of survival and recovery from acute and chronic post-traumatic pituitary dysfunction (PTPD) have not been comprehensively assessed. Post-traumatic hypopituitarism accounts for 7.2% of all hypopituitarism cases. The identification of patients with acute brain injury who are at risk of hormonal deficiency and the provision of appropriate interventions can reduce morbidity associated with TBI. Study objectives • Assess the proportion of patients with severe head injury (Glasgow coma scale [GCS] score of < 9) who are at risk of reduced thyroidstimulating hormone (TSH), free T3 (FT3), free T4 (FT4), and serum cortisol levels within the first week after trauma. • Develop the Acute TBI Hormone Assessment Score (ATBIHAS), which is a 12-point scoring system comprising clinical and radiological parameters, and evaluate its correlation with hormone reduction during the acute phase of trauma, specifically on the fourth day. • Investigate whether the ATBIHAS can be used to quantify the percentage of hormonal reduction on the fourth day after trauma. • Evaluate the correlation between GCS score and hormonal reduction on the fourth day after trauma. Methods : This prospective observational study was conducted at the Neurosurgical Department of Rajiv Gandhi Government General Hospital, Chennai, India. In total, 30 patients with severe head injury who underwent brain computed tomography (CT) scan after the initial resuscitation and within the first 24 h after presentation were included in the analysis. Clinical Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany Manuscript submitted to Editorial Office of Central European Neurosurgery For Peer Review data were collected, and brain CT scan findings were recorded in the proforma. Moreover, information about sphenoidal hemosinus, frontal contusion, temporal contusion, edema, infarct, midline shift, and bony calvarial fracture was recorded. The ATBIHAS, a 12-point scoring system comprising clinical and radiological features and surgical procedures for the current scenario, was developed. This tool can assess pituitary stalk injury and hypothalamic pituitary axis disruption. All participants underwent the thyroid profile test, which comprised TSH, FT3, FT4, and serum cortisol levels. Samples were collected between 7:00 and 9:00 am on the day after the patient was successfully resuscitated. This time period was selected to prevent diurnal variations in hormone levels. The test was repeated between 7:00 and 9:00 am on the fourth day of admission. Data about all hormonal levels and their variations on the fourth day were assessed and compared with the ATBIHAS. This study was approved by the institutional ethics committee. Results: Among the participants, 27 were men and 3 women. Approximately 33.3% and 6.7% were aged 20–29 and 50–59 years, respectively. Hormonal reduction between the first and fourth days after trauma significantly differed (P < 0.001). The incidence rates of hormonal reduction after the fourth day of trauma were 90% for TSH, FT4, and serum cortisol and 93% for free T3. The ATBIHAS was found to be positively correlated with reduced TSH, FT3 and FT4, and serum cortisol levels. A higher score indicated a greater percentage of hormone reduction on the fourth day after trauma. However, there was no significant correlation between the GCS score as well as the ATBIHAS and TSH, FT3, FT4, and serum cortisol reduction (P > 0.05). Conclusion: Approximately > 90% of patients with severe head injury are at risk for TSH, FT3, FT4, and serum cortisol reduction within the first week after trauma. Moreover, there is a significant linear correlation between ATBIHAS and hormonal levels during the acute phase of trauma, specifically on the fourth day. Hence, the ATBIHAS ca

Evaluation of Patient-Specific Cranial Implant Design Using Finite Element Analysis

Various studies have investigated the load-bearing capacity of patient-specific cranial implants. However, little attention has been given to the evaluation of the design of ceramic-titanium (CeTi) implants. A biomechanical evaluation of 3 patient-specific cranial implants was performed using finite element analysis. The results of the analyses allowed the identification of the implant regions as well as the magnitudes of the maximum stresses on, and displacements along, these regions after traumatic impact. The analyses also showed that polyether ether ketone cranial implants offer inferior brain and neurocranial protection due to their high flexibility and local peak stresses at the bone-screw interface. In contrast, CeTi implants were able to evenly distribute the stresses along the interface and thus reduced the risk of neurocranial fracture. The scaffold structure at the border of these implants reduced stress shielding and enhanced bone ingrowth. Moreover, brain injuries were less likely to occur, as the CeTi implant exhibits limited deflection. From the finite element analyses, CeTi cranial implants appear less likely to induce calvarial fractures with a better potential to protect the brain under impact loads.

Absence of calvarial fracture could predict the need for tracheostomy in traumatic brain injury.

AimTracheostomy is a common procedure for intubated patients with traumatic brain injury (TBI) in the intensive care unit (ICU) but optimal timing and the predictors of tracheostomy are still unclear. The aim of our study was to explore whether the traumatic variables of head injury predict the need for tracheostomy in intubated TBI patients.MethodsA single‐center, retrospective observational study including a series of TBI patients admitted to Fukui Prefectural Hospital from April 1, 2004 to March 31, 2020 was carried out. Our primary outcome was tracheostomy. Patients with TBI who were intubated and admitted into the ICU within 24 h after injury were enrolled. Exclusion criteria were age less than 18 years, pregnancy, mortality within 24 h, post‐cardiac arrest syndrome, and patients for whom life‐sustaining interventions were withheld. Radiologic images were also reviewed and the morphology of the head injury was categorized.ResultsSeventy‐six patients were included. Forty‐six patients (60.5%) underwent tracheostomy and 30 patients (39.5%) were successfully extubated. Calvarial fracture (odds ratio [OR] 0.34; 95% confidence interval [CI], 0.13–0.88; P = 0.03), Injury Severity Score (OR 1.07; 95% CI, 1.00–1.15; P = 0.04), and Glasgow Comas Scale score (OR 0.84; 95% CI, 0.73–0.96) were statistically significant in the univariable analysis. Multivariate logistic regression identified calvarial fracture as an independent predictor for tracheostomy. The model involving calvarial fracture, Injury Severity Score ≥16, and Glasgow Coma Scale score ≤8 showed the area under the receiver operating characteristic curve for the model was 0.737 (95% CI, 0.629–0.846).ConclusionsThe absence of calvarial fracture could predict the necessity for tracheostomy in intubated TBI patients when combined with other factors. Further prospective randomized trials are necessary to confirm the findings.

Multiple Bone Fractures in a Neonate with Osteogenesis Imperfecta: A Case Report

Osteogenesis Imperfecta (OI) is characterised by increased bone fractures. It is clinically and genetically a heterozygous disease of connective tissues. OI type 3 is the most severe, non lethal form which is caused by the mutation of caused by mutation of procollagen type1 A1 or A2(COL1A1 or COL1A2) genes. A one-day-old male baby with respiratory distress and multiple limb deformities was presented to the paediatric emergency department. The head appeared unduly large in comparison to the body and the anterior, posterior and lateral fontanelle were wide open. Sclera did not appear blue. Both upper limbs appeared short and stubby with diffuse swelling in the left arm. Both lower limbs appeared curved and were held in a frog-like position. Infantogram showed multiple calvarial fractures in the skull, multiple rib fractures, fracture of left humerus, bilateral ulna, left femur and there were multiple areas with callus formation suggestive of intrauterine fractures. There was no history of trauma during birth. Clinical diagnosis of OI was made and the neonate was managed medically. Genetic analysis could not be done owing to financial constraints. In conclusion, a high index of suspicion and careful clinical and radiological evaluation can identify very rare hereditary abnormalities like OI.

Diversity in imaging findings of head injury patients: Our experience in a tertiary level hospital

Background
 Head injury is a major cause of mortality and morbidity worldwide. It can occur in isolation or in association with multisystem injuries. Proper and prompt imaging evaluation in head trauma can help in the triage and management of the patients.
 Material & methods
 A hospital-based study using a non-interventional study design was employed. A total of 219 patients with head trauma who underwent CT were evaluated for various possible injuries using different window settings and algorithms. Data was entered in a predesigned proforma, and analysis was done using IBM SPSS version 20.
 Results
 The most common age group involved in head trauma was 20 to 40 years of age. Male patients were more frequently involved than female patients. Most common finding associated with the head trauma was calvarial fracture followed by cerebral hematoma/ contusions. Diffuse axonal injury and intraventricular hemorrhage were the least common findings in patients with head trauma.
 Conclusions
 Road traffic accidents are the leading cause of head trauma in our part of the world. They commonly involve young males exposed to the vulnerable environment. Proper road safety measures, if undertaken cautiously, can help prevent significant mortality and morbidity associated with these kind of injuries.

Effects of Genetic Variants on Stroke Risk.

Effects of Genetic Variants on Stroke Risk.

Computed Tomographic Imaging Appraisal of Traumatic Brain Injury in a Tertiary Hospital in South-South Nigeria: A 6-Year Review.

Background:Computed tomography (CT) remains the gold standard in imaging evaluations of traumatic brain injury (TBI). TBI on its own has become a major concern in developing countries with its untoward effects.Objectives:The objective was to appraise the craniocerebral computed tomograms of patients who had TBIs.Materials and Methods:A retrospective study of patients who underwent craniocerebral CT on account of head injury in the University of Uyo Teaching Hospital, Uyo, Nigeria, from November 13, 2013 to May 31, 2019 was done. The duration was regardless of the disjointed periods of service interruption. Patients' demographic and CT features were evaluated with application of simple analysis of data.Results:Two hundred and thirty-two patients were evaluated with minimum and maximum ages of 6 months and 78 years, respectively. Males were predominant with a ratio of 2.74: 1. Most affected age ranges were 30–39 years (23.27%) and 20–29 (22.84%). Normal brain CT was seen in 44 patients (18.97%). The most frequent lesion in patients with abnormal CT was intracranial hemorrhages (n = 188, 81.03%). Here, extra-axial hemorrhages (n = 100, 53.19%) supersede intracerebral hemorrhages (n = 88, 46.81%). Half of the intracerebral hemorrhages were multiple. Calvarial fractures were seen in 34.48% (n = 80) of patients. The most common localization was the facial bones (n = 24, 30.00%), whereas the least site was the occipital bone (n = 4, 5.00%). Fifteen percent of the patients had multiple fractures which also included base of the skull.Conclusion:TBIs commonly occur among young active males. The most frequent lesion is intracranial hemorrhages with extra-axial bias.

Clinical significance of posttraumatic intracranial hemorrhage in clinically mild brain injury: a retrospective cohort study.

Much attention has been focused on management of severe traumatic brain injury (TBI); however, comparatively little is known about management of traumatic hemorrhage in clinically mild TBI. We aimed to clarify the role of clinical observation and repeat radiography for patients with mild TBI and abnormal findings on initial computed tomography (CT) of the head. We queried the neurotrauma database of the Ontario Trauma Registry and the Sunnybrook institutional database to identify patients with CT findings of a traumatic hemorrhage or calvarial fracture between November 2014 and December 2016. Exclusionary criteria were age less than 16 years, Glasgow Coma Scale (GCS) score less than 13, anticoagulant use, bleeding diathesis and midline shift greater than 5 mm. The primary outcome was the need for neurosurgical intervention. A total of 607 patients were included. Most (374 [61.6%]) had a GCS score of 15; 185 (30.5%) and 48 (7.9%) had a GCS score of 14 and 13, respectively. Five patients (0.8%) required surgical intervention, all within the first 72 hours, owing to clinical deterioration with subsequently demonstrated radiographic evidence of expanding hemorrhage. Most patients (506 [83.4%]) had routine repeat imaging, without documented change in their neurologic status. The majority of patients in our cohort had repeat imaging, which did not influence surgical management, at substantial cost to the health care system. The findings suggest the need to reevaluate repeat imaging protocols for this subset of patients with TBI.

Split Calvarial Graft Reconstruction for Growing Skull Fracture in Pediatrics

AbstractBackground: Growing skull fracture is a rare but well-known complication of skull fracture in infancy and early childhood. The definitive treatment is Duro-cranioplasty. The use of alloplastic material in cranial reconstruction has been well described in adult but in children it is hesitation about the safety of nonexpansible alloplastic material.Aim of Study: This is a retrospective study to evaluate autologous split thickness skull grafts and cranioplasty for treatment of growing skull fractures in pediatrics.Patients and Methods: This is a retrospective study of complicated calvarial fractures presented at Mansoura Uni-versity Hospital from 2015 to 2018 and included 10 patients with growing skull fractures. All patients underwent autologous cranioplasty of the skull defect secondary to growing skull fracture after duroplasty.Results: The age at injury ranged from 5M-6 years. The cause of these fractures included falls and vehicle accident. On average, progressive swelling was diagnosed 7 months after the initial injury. The size of the cranial defects was average 3 X 3cm after restoration of dural contour (duroplasty). Six patients (60%) needed blood transfusion. Follow-up for patients was an average of 6 months. All patients showed post-operative bone fusion without evidence of complications.Conclusion: The concern for growth restriction or implant instability in a growing pediatric skull also the cost, limit the use of alloplastic materials. Our data show that autologous bone grafting is the standard in pediatric population regarding the safety and cost with limited post-operative complications. Moreover, early recognition is crucial in the management of GSFs to avoid the progression of neurological consequences and skull deformities.

Surgical Elevation for Symptomatic Depressed Skull Fractures Over Dural Venous Sinus

AbstractBackground: Symptomatic depressed skull fractures over dural venous sinus occasionally lead to stenosis, obstruction, or thrombosis and resulting in intracranial hypertension and significant neurological deficit. Some neurosurgeons are treating these cases conservatively for fear of venous hemor-rhage. The surgical elevation of the depressed segment in these cases is a matter of controversy and these patients should be treated carefully.Aim of Study: The aim of this retrospective study was to evaluate outcome after surgical elevation of symptomatic depressed skull bone fracture over dural venous sinus.Patients and Methods: A retrospective study of sympto-matic depressed calvarial fractures presented at Mansoura University Hospital from 2015 to 2018 revealed 11 patients with depressed skull fractures over superior sagittal sinus (n=6) and transverse sinus (n=5). The age ranged from 11-31 years. The causes of these fractures were vehicle accidents and falling from height. Significant neurological deterioration ranged from blurring of vision and motor weakness. MR venography was done in stable and late symptomatic cases to assess sinus patency.Results: Surgical elevation was performed in 10 patients suffered from depressed skull fracture over large venous sinus and conservative treatment for one patient at the transverse sinus and the patient shows patent sinus on MRV and clinically well. Rapid resolution of symptoms and signs as well as sinus patency after elevation.Conclusion: Although the risk of sinus injury during surgical elevation of the depressed segment but it is recom-mended to perform surgery for these symptomatic patients with all precautions required like blood transfusion and preparing vascular graft form the pericranium for sinus repair and this leads to rapid resolution of symptoms and signs as well as sinus patency improvement after elevation.

Comparison of the Incidence and Severity of Traumatic Brain Injury Caused by Electrical Bicycle and Bicycle Accidents—A Retrospective Cohort Study From a Swiss Level I Trauma Center

Electrical bicycles (E-bikes) allow people of all ages to ride at high speeds but have an inherent risk of traumatic brain injury (TBI). Their sales have increased tremendously in recent years. We performed a retrospective cohort study to compare the incidence and severity of TBI in E-bikers and conventional bicyclists. We included patients at a Swiss level 1 trauma center admitted from 2010 to 2015. The primary outcome was the association between TBI and the bicycle type. The secondary outcome was the association between helmet use and TBI severity. Of 557 patients injured riding an E-bike (n= 73) or a bicycle (n= 484), 60% sustained a TBI, most of which were mild (Glasgow coma scale [GCS] score, 13-15; E-bike, 78%; bicycle, 88%). TBI was more often moderate (GCS score, 9-12) or severe (GCS score, 3-8) in E-bikers than in bicyclists (P= 0.04). Intracranial hemorrhage, traumatic subarachnoid hemorrhage, and subdural hematoma occurred significantly more often in E-bikers than in bicyclists (P < 0.05). Neurosurgical intervention was necessary for 5 E-bikers (7%) and 25 (5%) bicyclists (P= 0.15). Wearing a helmet correlated with a lower risk of neurosurgical intervention in bicyclists (odds ratio [OR], 0.21; 95% confidence interval [CI], 0.06-0.73; P= 0.01) and a lower risk of calvarial fractures in both bicyclists (OR, 0.16; 95% CI, 0.06-0.42; P < 0.01) and E-bikers (OR, 0.21; 95% CI, 0.05-0.84; P= 0.03). E-bikers had a significantly greater risk of moderate to severe TBI compared with bicyclists. Helmet use was associated with decreased odds of severe TBI in bicyclists and a tendency toward a more favorable outcome for E-bikers.

Role of computed tomography scan in assessment of skull fracture patterns among motorcycle road traffic accident patients in South Western Nigeria

Background: Commercial motorcycling is a common means of transportation in Nigeria, and motorcycle road traffic accidents (MCRTAs) are commonly associated with multiple skull fractures. Cranial computed tomography (CT) scan is the standard imaging modality of patients with head injury. Aim: The aim of this study is to describe the pattern of skull fractures on cranial CT scan in patients with head injury following MCRTA. Patients and Methods: This was a descriptive cross-sectional study conducted at the University College Hospital, Ibadan, between June and October 2016. Noncontrast cranial CT scan was performed on 190 patients who presented with head injury following MCRTAs. Results: Over half (n = 59.8%) of the patients were within the ages of 20–39 years with a mean age of 33 ± 14.37 years. A total of 183 patients did not use crash helmet at the time of accident, out of which 168 (n = 88.4%) sustained skull fractures. Six different skull fracture patterns were identified on cranial CT scan of these patients. The most common fracture pattern seen was the combined calvarial, facial, and base of skull fractures representing 22.1% while the least fracture pattern was the base of skull fracture (n = 4.7%). Most of the patients with calvarial fractures were without helmet at the time of injury (n = 98.3%) compared to 1.7% of patients who wore helmet at the time of injury. This was statistically significant (P = 0.040). Conclusion: This study further underscores the usefulness of cranial CT scan in identifying and evaluating patients with skull fractures following MCRTA in our environment, thus guiding proper medical and surgical management of such patients in a low-resource setting.

Deep learning algorithms for detection of critical findings in head CT scans: a retrospective study

Non-contrast head CT scan is the current standard for initial imaging of patients with head trauma or stroke symptoms. We aimed to develop and validate a set of deep learning algorithms for automated detection of the following key findings from these scans: intracranial haemorrhage and its types (ie, intraparenchymal, intraventricular, subdural, extradural, and subarachnoid); calvarial fractures; midline shift; and mass effect. We retrospectively collected a dataset containing 313 318 head CT scans together with their clinical reports from around 20 centres in India between Jan 1, 2011, and June 1, 2017. A randomly selected part of this dataset (Qure25k dataset) was used for validation and the rest was used to develop algorithms. An additional validation dataset (CQ500 dataset) was collected in two batches from centres that were different from those used for the development and Qure25k datasets. We excluded postoperative scans and scans of patients younger than 7 years. The original clinical radiology report and consensus of three independent radiologists were considered as gold standard for the Qure25k and CQ500 datasets, respectively. Areas under the receiver operating characteristic curves (AUCs) were primarily used to assess the algorithms. The Qure25k dataset contained 21 095 scans (mean age 43 years; 9030 [43%] female patients), and the CQ500 dataset consisted of 214 scans in the first batch (mean age 43 years; 94 [44%] female patients) and 277 scans in the second batch (mean age 52 years; 84 [30%] female patients). On the Qure25k dataset, the algorithms achieved an AUC of 0·92 (95% CI 0·91-0·93) for detecting intracranial haemorrhage (0·90 [0·89-0·91] for intraparenchymal, 0·96 [0·94-0·97] for intraventricular, 0·92 [0·90-0·93] for subdural, 0·93 [0·91-0·95] for extradural, and 0·90 [0·89-0·92] for subarachnoid). On the CQ500 dataset, AUC was 0·94 (0·92-0·97) for intracranial haemorrhage (0·95 [0·93-0·98], 0·93 [0·87-1·00], 0·95 [0·91-0·99], 0·97 [0·91-1·00], and 0·96 [0·92-0·99], respectively). AUCs on the Qure25k dataset were 0·92 (0·91-0·94) for calvarial fractures, 0·93 (0·91-0·94) for midline shift, and 0·86 (0·85-0·87) for mass effect, while AUCs on the CQ500 dataset were 0·96 (0·92-1·00), 0·97 (0·94-1·00), and 0·92 (0·89-0·95), respectively. Our results show that deep learning algorithms can accurately identify head CT scan abnormalities requiring urgent attention, opening up the possibility to use these algorithms to automate the triage process. Qure.ai.

Treatment of calvarial defects by resorbable and non-resorbable sonic activated polymer pins and mouldable titanium mesh in two dogs: a case report

BackgroundTo date, calvarial defects in dogs have traditionally been addressed with different types of implants including bone allograft, polymethylmethacrylate and titanium mesh secured with conventional metallic fixation methods. This report describes the use of an absorbable and non absorbable novel polymer fixation method, Bonewelding® technology, in combination with titanium mesh for the repair of calvarial defects in two dogs. The clinical outcomes and comparative complication using resorbable and non-resorbable thermoplastic pins were compared.Case presentationThis report of two cases documents the repair of a traumatic calvarial fracture in an adult male Greyhound and a cranioplasty following frontal bone tumor resection in an adult female Cavalier King Charles Spaniel with the use of a commercially available titanium mesh secured with an innovative thermoplastic polymer screw system (Bonewelding®). The treatment combination aimed to restore cranial structure, sinus integrity and cosmetic appearance. A mouldable titanium mesh was cut to fit the bone defect of the frontal bone and secured with either resorbable or non-resorbable polymer pins using Bonewelding® technology. Gentamycin-impregnated collagen sponge was used intraoperatively to assist with sealing of the frontal sinuses. Calvarial fracture and post-operative implant positioning were advised using computed tomography. A satisfactory restoration of skull integrity and cosmetic result was achieved, and long term clinical outcome was deemed clinically adequate with good patient quality of life. Postoperative complications including rostral mesh uplift with minor associated clinical signs were encountered when resorbable pins were used. No postoperative complications were experienced in non-resorbable pins at 7 months follow-up, by contrast mesh uplift was noted 3 weeks post-procedure in the case treated using absorbable pins.ConclusionsThe report demonstrates the innovative use of sonic-activated polymer pins (Bonewelding® technology) alongside titanium mesh is a suitable alternative technique for skull defect repair in dogs. The use of Bonewelding® may offer advantages in reduction of surgical time. Further, ultrasonic pin application may be less invasive than alternative metallic fixation and potentially reduces bone trauma. Polymer systems may offer enhanced mesh-bone integration when compared to traditional metallic implants. The use of polymer pins demonstrates initial potential as a fixation method in cranioplasty. Initial findings in a single case comparison indicate a possible advantage in the use of non-absorbable over the absorbable systems to circumvent complications associated with variable polymer degradation, further long term studies with higher patient numbers are required before reliable conclusions can be made.

Number of Fractured Calvarial Bones Predicts Outcome in Traumatic Brain Injury Patients After Early Craniotomy

Prognostic markers are important for neurosurgeons to evaluate the indications for aggressive surgical management. The purpose of this study was to investigate whether the number of fractured calvarial bones could predict the outcome in patients with traumatic brain injury (TBI) after early craniotomy. TBI patients who underwent early craniotomy were reviewed. The number of fractured calvarial bones was recorded by referring to preoperative computed tomographic (CT) images. Accordingly, patients were assigned to no calvarial fracture group, single calvarial fracture group, and multiple calvarial fractures group. Good outcome was defined as Glasgow Outcome Scale scores of 4 and 5 at discharge. Logistic regression analyses were used to assess the effect of calvarial fracture on outcome. A receiver operating characteristic curve was generated for the final model. In all, a total of 141 patients were enrolled. Patients with no calvarial fracture had a significantly lower rate of good outcome (12.5%) than did those with a single calvarial fracture (62.2%, P < 0.001) and those with multiple calvarial fractures (48.6%, P= 0.005). Binary logistic regression showed that the number of fractured calvarial bones was an independent imaging marker for predicting outcome (P= 0.003) after adjustment for age, Glasgow Coma Scale score on admission, and decompressive craniectomy. The area under the curve of the final model was 0.863. The number of fractured calvarial bones is an independent predictor of outcome in TBI patients after early craniotomy. No calvarial facture is associated with poor outcome in these patients.

Cranial Vault Fractures in Civilian Head Injury: Clinical and Radiologic Predictors of Seizures and the Fracture Seizure Index: A Prospective Single-Center Observational Cohort Study

Abstract Study Objectives To determine the risk factors of posttraumatic seizures (PTS) among patients with civilian head injury and skull vault fractures. Methods A 5-year prospective cohort study of patients with skull fractures presenting to our center from March 2013 to February 2017. Results Of 637 patients with traumatic brain injury (TBI), 135 (21.2%) patients sustained calvarial fractures, 91 (72%) were from road traffic accidents (RTAs), and most were young adult males (M:F = 11.6, mean age = 29.1 ± 2.3 years, 95% CL). Linear fractures in 69 patients and depressed fractures in 50 (39.7%) were the common fracture types. Seventy-seven (61.1%) patients had cerebral contusions, 31 (24.6%) had extradural hematoma (EDH), and 21 (16.7%) patients had Glasgow coma scale (GCS) ≤ 8. Twenty-five (18.5%) patients suffered early PTS, and five had late PTS. Among nonfracture patients (n = 361), 31 (8.6%) had seizures. Seizures occurred more in the fracture subgroup (χ2 = 10.1, p &lt; 0.05, df = 1) and earlier (χ2 = 5.9, p = 0.027, df = 1). Fractures and seizures followed a similar trend in occurrence. Among patients with vault fractures, severe head injury, contusions, and intracranial hematoma, the relative risk and odds for early seizures followed a trend predicted by a statistical index—the fracture seizure index (FSI). Late PTS did not show a statistical relationship with early PTS (χ2 = 2.98, df = 1, p &gt; 0.05). Conclusion GCS score ≤8, depressed fracture and multifocal cerebral contusions are predictors of early PTS. Seizure risk associated with fractures and other lesions can be predicted by the FSI.

Venous Sinus Thrombosis in Blunt Trauma: Incidence and Risk Factors.

The aim of our study was to determine the incidence and risk factors of dural venous sinus thrombosis and epidural hemorrhage in the setting of a blunt trauma causing a calvarial fracture crossing a dural venous sinus. A retrospective review of 472 blunt trauma patients with calvarial fracture crossing a dural venous sinus was performed. Two hundred ten patients who underwent computed tomography venography were identified and evaluated for the presence of dural venous sinus thrombosis and/or epidural hemorrhage. Site and displacement of fractures, as well as age, sex, Glasgow Coma Scale (GCS) score, and mechanism of injury, were considered for potential predictive value of thrombosis and/or epidural hemorrhage. We found a 23% incidence of dural venous sinus thrombosis in patients with a fracture traversing a dural venous sinus. Significant predictors of thrombosis included temporal fracture (38% incidence) and skull base fracture (31% incidence). Occipital fracture not involving the skull base was associated with a significantly decreased risk of thrombosis, with an incidence of 9%. Decreased GCS score and fall from height greater than 10 feet additionally predicted dural venous sinus thrombosis. Significant predictors of epidural hemorrhage included parietal fractures and displaced fractures, although a large percentage of nondisplaced fractures in other bones demonstrated epidural hemorrhage as well. Dural venous sinus thrombosis in the setting of blunt trauma with a calvarial fracture crossing a dural venous sinus has an incidence of 23%. Increased suspicion for thrombosis is warranted in patients with temporal or skull base fractures, low GCS score, and recent fall from great height.