Closed Head Injury Patients Research Articles

Management of Depressed Skull Fractures: Selective Conservative Management of Non Missile Injuries

Objective: To determine the outcomes of management of depressed skull fractures. Study Design: Descriptive Study Place and Duration of Study: Department of Neurosurgeries, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences Gambat and Chandka Medical College Hospital, Larkana from 1st March 2020 to 28th February 2021. Methodology: Eighty patients of both sexes were enrolled in this study. Patients were aged between 12-70 years of age. Patient’s detailed demographics age, sex and body mass index were recorded. Diagnosis of skull fractures from closed head injury patients were undergone for CT scan Depressed fracture of more than 5 mm, cosmetically disfiguring fractures and fracture over the sinuses were operated. All the patients were given prophylactic antibiotics and anticonvulsants. Patients were followed for 4-months. Outcomes were assessed by Glasgow Coma Scale (GCS). Results: Fifty five (68.8%) patients were males and thirty five (31.2%) were females with mean age was 18.21±7.32 years and mean body mass index was 20.04±3.14 kg/m2. Road traffic accident (56.25%) was the most common cause of the injury followed by fall from the height 25 (31.25%). The compound fractures have 48 (60%) and simple fractures were 32 (40%). Surgery was done among 70 (87.5%) cases and 10 (12.5%) patients were conservatively treated. Among these 50 (62.5%) patients were completely recovered. Cerebrospinal fluid leak was the most common complication and was found in 13 (16.25%) cases. Conclusion: The use of antibiotics and anticonvulsants had effective results during peri-operative periods to avoid infection and epilepsy. The initial stage of operation is particularly necessary when the fracture is larger than 5mm. Cerebrospinal fluid leaks occur after surgery as the most common complication. Keywords: Depressed skull fracture, Non-missile injuries, Cerebrospinal fluid

SECULAR TRENDS OF OPHTHALMIC MANIFESTATIONS IN CLOSED HEAD INJURY PATIENTS

Introduction – Ocular morbidities are frequently associated with closed head injury. These injuries are often ignored or treatment is delayed resulting in permanent visual loss. Aim- This study aimed to nd out the various Ophthalmic manifestation in patients of closed head injury and nd out an association between them. Method- A Prospective observational study was conducted with a total of 120 closed head injury patients in a tertiary care hospital for a period of 4 months. The initial ophthalmic examination was done within 12 hrs of admission and was reviewed daily. GCS was applied to grade the head injury and analysis was done to nd out the association. Results- Out of 120 enrolled patients, 88 cases were male and 32 were female patients in age group of 6 to70 years. Most common cause of sustaining head injury was road trafc accident followed by assault. Periorbital edema and ecchymosis was most common manifestation. RAPD was encountered as most common neuro-ophthalmic manifestation followed by disc edema and extraocular muscle restriction. Poor GCS is associated with frequent pupillary involvement. Conclusion – Young adult males are more vulnerable in sustaining ocular injury associated with head injury followed by road trafc accident. Poor GCS frequently involves pupil abnormality

Transcranial Doppler studies in severe closed head injury patients and their relevance to outcome

Transcranial Doppler studies in severe closed head injury patients and their relevance to outcome

Closed traumatic brain injury in children

Background Accidental injuries are the most common reason for death among children. Of all the types of traumatic injuries, brain injuries are the most cause of death or permanent disability. Aim The aim of this study is to evaluate posttraumatic hospital-admitted children to reach better management, outcome, and prognosis and to achieve the best possible care for closed-head injury patients. Patients and methods This prospective study (May 2018–May 2019), conducted at Luxor International Hospital and Al-Azhar University Hospital, includes all children aged 0–14 years with exclusion of children older than 14 years and penetrating head injuries. All the case records were reviewed and the pertinent data (clinical history, age, sex, mode of injury) were analyzed. We categorized them into mild, moderate, and severe head injuries based on the Glasgow coma scale (GCS) at the time of admission. Results Out of 30 children with traumatic brain injury (TBI), 17 (56.7%) were of mild, nine (30%) moderate, and four (13.3%) severe TBI. In the group of patients in the category of GCS less than or equal to 8, poor outcome was seen in 50%, followed by patients in group GCS 9–12 at 0%, succeeded by group of patients with GCS 13–15 at 0%, which was statistically significant. Conclusion This study has shown that the reason for TBI in children we managed was age dependent. Falls were widespread in toddlers, pedestrian accidents more common in preschool and school-age groups. This study has shown that the outcome of head injury in children we managed depended on the severity of the injury.

Early postinjury exercise reverses memory deficits and retards the progression of closed‐head injury in mice

Closed-head injury (CHI) usually involves both physical damage of neurons and neuroinflammation. Although exercise promotes neuronal repair and suppresses neuroinflammation, CHI patients currently often remain resting during the post-traumatic period. This study aimed to investigate whether and how postinjury exercise benefited the brain structure and function in mice after CHI. Closed-head injury immediately caused an elevated neurological severity score, with rapid loss of object recognition memory, followed by progressive location-dependent brain damage (neuronal loss and activation of microglia in the cortex and hippocampus). An early exercise protocol at moderate intensity (starting 2 days postimpact and lasting for 7 or 14 days) effectively restored the object recognition memory and prevented the progressive neuronal loss and activation of microglia. However, if the exercise started 9 days postimpact, it was unable to recover recognition memory deficits. In parallel, early exercise intervention drastically promoted neurite regeneration, while late exercise intervention was much less effective. We also tested the possible involvement of brain-derived neurotrophic factor (BDNF) and mitogen-activated protein kinase phosphatase-1 (MKP-1) in the exercise-induced beneficial effects. Exercise gradually restored the impact-abolished hippocampal expression of BDNF and MPK-1, while oral administration of triptolide (a synthesis inhibitor of MKP-1 and an antagonist of nuclear factor-B) before each bout of exercise blocked the restorative effects of exercise on MKP-1 and recognition memory, as well as the exercise-induced retardation of neuronal loss. Although triptolide treatment alone inhibited activation of microglia and maintained neuronal numbers, it did not recover the injury-hampered recognition memory. Overall, moderate exercise shortly after CHI reversed the deficits in recognition memory and prevented the progression of brain injury.

Sentence comprehension following moderate closed head injury in adults

The current study explores sentence comprehension impairments among adults following moderate closed head injury. It was hypothesized that if the factor of syntactic complexity significantly affects sentence comprehension in these patients, it would testify to the existence of syntactic processing deficit along with working-memory problems. Thirty-six adults (18 closed head injury patients and 18 healthy controls matched in age, gender, and IQ) participated in the study. A picture-sentence matching task together with various tests for memory, language, and reading abilities were used to explore whether sentence comprehension impairments exist as a result of a deficit in syntactic processing or of working-memory dysfunction. Results indicate significant impairment in sentence comprehension among adults with closed head injury compared with their non-head-injured peers. Results also reveal that closed head injury patients demonstrate considerable decline in working memory, short-term memory, and semantic knowledge. Analysis of the results shows that memory impairment and syntactic complexity contribute significantly to sentence comprehension difficulties in closed head injury patients. At the same time, the presentation mode (spoken or written language) was found to have no effect on comprehension among adults with closed head injury, and their reading abilities appear to be relatively intact.

The Effect of Anemia and Blood Transfusions on Mortality in Closed Head Injury Patients

The Effect of Anemia and Blood Transfusions on Mortality in Closed Head Injury Patients

Anticoagulation and the Elderly Head Trauma Patient

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.

The Effect of Anemia and Blood Transfusions on Mortality in Closed Head Injury Patients

The purpose of this study was to determine if anemia in isolated head trauma patients results in a higher mortality rate that would justify a more liberal use of blood transfusions. A retrospective review of isolated blunt head trauma patients was performed between January 2001 and December 2006. Comparisons were made between survivors and nonsurvivors regarding demographics, laboratory values, transfusions received, and lengths of stay. There were 788 patients with 735 survivors who were significantly younger (46.3 y +/- 21.5 survivors versus 68.9 y +/- 18.8 nonsurvivors, P < 0.0001) and less injured [(ISS: 14.7 +/- 5.2 survivors versus 23.2 +/- 4.7 nonsurvivors, P < 0.0001), (head abbreviated injury severity: 3.7 +/- 0.7 survivors versus 4.7 +/- 0.5 nonsurvivors, P < 0.0001)] than those who died (n = 53). The survivors also had shorter lengths of stay (days) [(ICU: 2.4 +/- 4.2 versus 5.6 +/- 11.7, P = 0.03), (hospital: 6.3 +/- 9.8 versus 7.8 +/- 14.8, P = 0.02)]. Multivariate logistic regression showed age (OR 1.063, CI 1.042-1.084), ISS (OR 1.376, CI 1.270-1.491), minimum hemoglobin (OR 0.855, CI 0.732-1.000), and total blood products transfused (OR 1.073, CI 1.008-1.142) to be independent predictors of mortality with an ROC of 0.942. Outcome was independent of the operative procedures, hematocrit and packed red blood cells transfused at 24, 48, and 72 h. Hemoglobin levels of <8 mg/dL were more predictive of death than >8 mg/dL (P = 0.01). This study supports the need to balance mild anemia with judicious blood product use in the head trauma patient. Given the risk with blood product use, each transfusion should be carefully considered and the patient re-evaluated regularly to determine the need for further intervention.

181. Blood Transfusions do not Increase Mortality in Closed Head Injury Patients

181. Blood Transfusions do not Increase Mortality in Closed Head Injury Patients

Prevalence and types of sleep disturbances acutely after traumatic brain injury

Primary objective: To assess the prevalence of and risk factors for sleep disturbances in the acute post-traumatic brain injury (TBI) period.Research design: Longitudinal, observational study.Methods and procedures: Fifty-four first time closed-head injury patients were recruited and evaluated within 3 months after injury. Pre-injury and post-injury sleep disturbances were compared on the Medical Outcome Scale for Sleep. The subjects were also assessed on anxiety, depression, medical comorbidity and severity of TBI.Main outcomes and results: Subjects were worse on most sleep measures after TBI compared to before TBI. Anxiety disorder secondary to TBI was the most consistent significant risk factor to be associated with worsening sleep status.Conclusions: Anxiety is associated with sleep disturbances after TBI. Further studies need to be done to evaluate if this is a causal relationship.

Prevalence of Sleep Disturbance in Closed Head Injury Patients in a Rehabilitation Unit

Traumatic brain injury (TBI) is a leading cause of disability in young people in the United States. Disorders of arousal and attention are common in closed head injury (CHI). Daytime drowsiness impairs participation in rehabilitation, whereas nighttime wakefulness leads to falls and behavioral disturbances. Sleep disturbances in TBI reported in the literature have included excessive daytime somnolence, sleep phase cycle disturbance, narcolepsy, and sleep apnea. Although well known to the clinician treating these patients, the extent and prevalence of disrupted sleep in patients in an acute inpatient rehabilitation unit has not been described. Objective. To determine the prevalence of sleep wake cycle disturbance (SWCD) in patients with CHI in a TBI rehabilitation unit. Design. Prospective observational. Setting. Inpatient specialized brain injury rehabilitation unit. Patients. Thirty-one consecutive admissions to a brain injury rehabilitation unit with the diagnosis of CHI. Results. Twenty-one patients (68%) had aberrations of nighttime sleep. There was no significant difference in Glasgow Coma Score on admission to trauma nor was there any significant difference in age between the affected and unaffected groups. Patients with SWCD had longer stays in both the trauma center (P < .003) and the rehabilitation center (P < .03). Conclusions. There is a high prevalence of SWCD in CHI patients admitted to a brain injury rehabilitation unit. Patients with SWCD have longer stays in both acute and rehabilitation settings and may be a marker for more severe injury.

Mild head injury—a close relationship between motor function at 1 week post-injury and overall recovery at 3 and 6 months

Based on previous findings of impaired eye and arm motor control after mild closed head injury (CHI), this study examined whether early eye and arm motor function, and the level of post-injury cerebral dysfunction manifested in motor control, relates systematically to recovery at 3 and 6 months after mild CHI. At 1 week post-injury, we assessed oculomotor function, upper-limb visuomotor performance, and cognitive status in 37 mild CHI patients. Re-examination at 3 and 6 months determined outcome in terms of postconcussional symptoms and performance of everyday tasks, as assessed by the Rivermead Postconcussion Symptoms Questionnaire, the Rivermead Head Injury Follow-up Questionnaire and the SF-36 Health Survey. We then examined the association of early motor function, cognitive status and self-reported health condition with outcome using linear regression. Motor-based regression models explained a high proportion of the variance in outcome (70–89%), with motor function at 1 week being more closely related to outcome at 3 and 6 months than early psychometric assessment (13–32%) or self-reported health status (54–79%). These motor-based models incorporated subcortical/subconscious motor functions alongside motor functions that are subject to volitional control and are primarily mediated by frontal, parietal and temporal cortical brain regions. Early assessment of eye and arm motor function may help in improving accuracy of outcome prediction after mild CHI. Such assessment may assist in the better targeting of early health care intervention and help decrease head-trauma-related morbidity and rehabilitation costs.

Rehabilitation of endogenous task shift processes in closed head injury patients

This paper reports a study that was aimed to rehabilitate executive functions in CHI patients. When a subject is engaged in two speeded tasks, not simultaneously but with some form of alternation, the response is slower to an item of task A if it was preceded by an item of task B, than when it was preceded by an item of task A. This shift cost is small when subjects can prepare in advance for the new task (endogenous task shift), whereas the cost is much greater when preparation is not possible (exogenous task shift). The groups tested comprised 20 severe closed head injury (CHI) patients (10 who underwent treatment and 10 controls), 8 mild CHI patients, and 18 non-brain damaged (NBD) controls. In the present study, the shift cost was greater for severe CHI patients than for NBD controls. Treatment consisted of five sessions, in which an endogenous task shift paradigm was used. A significant reduction of the endogenous shift cost from assessment to retest was found. The reduction remained stable at the 4-month follow-up session. These results are not simply due to retesting, as the control patients did not show any improvement at retest. Interestingly, no reduction of exogenous task shift cost was found. The results showed also that the beneficial effect of the treatment generalises to other executive functions. Portions of these data were presented at the Nineteenth European Workshop on Cognitive Neuropsychology, Bressanone (Italy), 21–26 January 2001, and at the Second International Vipiteno/Sterzing Conference on Neuropsychological Rehabilitation after Brain Injury, Vipiteno (Italy), 9–12 June 2004.

Assessment of Visual-Spatial Deficits in Patients with Parkinson's Disease and Closed Head Injuries Using Virtual Environments

Cognitive spatial deficits have been reliably reported in patients with Closed Head Injury (CHI), though in patients with Parkinson's disease (PD) the phenomenon is disputed. CHI and non-demented PD patients were tested using a Judgement of Line Orientation Test, and two spatial tests using virtual environments (VEs). Performance on the Line Orientation and one VE test was worse in the CHI group than controls, but PD patients showed no apparent spatial deficits. However, performance on the second VE test (virtual tray of objects task) did reveal a deficit, both CHI and PD groups being significantly impaired. The data illustrate that particular spatial deficits can be differentiated using appropriate VE-based tasks, and that non-demented PD patients show a paradigm-specific visual-spatial impairment.

A neuropsychological assessment of dual-task costs in closed-head injury patients using Cohen’s effect size estimation method

A test of whether patients suffering from a severe closed-head injury (CHI) were affected by disproportionate dual-task costs compared to those of healthy control participants was carried out through a direct comparison of CHI effects on dual-task (psychological refractory period, or PRP) performance and on single-task performance. In the dual-task condition of the present experiment, independent choice-responses were required to two sequential stimuli presented at a variable stimulus onset asynchrony (SOA). A significant delay of the reaction time (RT) to the second stimulus was reported by both CHI patients and controls at short (SOA) compared to long SOA, i.e., a PRP effect. The PRP effect was more pronounced for CHI patients than controls. In the single-task condition, a single choice-response was required to a stimulus presented in isolation. The RT produced by CHI patients in the single-task paradigm was longer than the RT produced by controls. CHI effects on dual-task performance and on single-task performance were compared following (1) their transformation into Cohen's ds, and (2) the application of a correction algorithm taking into account the different reliability of single-task and dual-task measures. The analysis of Cohen's ds revealed that CHI effects on performance were, if anything, smaller in the dual-task condition than in the single-task condition. The results imply that CHI patient's slower responding in single- and dual-task performance reflects a single common cause--slowing of the central processing.

Reversal of Anticoagulation in Trauma: A North American Survey on Clinical Practices Among Trauma Surgeons

Recent studies addressing reversal of anticoagulation in trauma have reported conflicting results. We hypothesized that current clinical practice is variable throughout North America. We surveyed 100 trauma surgeons to obtain information regarding variability in current clinical practice. Seventy-five of 100 trauma surgeons surveyed responded, and the majority (98.7%) agreed that preinjury anticoagulation poses problems in trauma management that include bleeding, increased complications, and mortality. Nine participants (12.2%) had a protocol addressing reversal of anticoagulation in their institution. Most use fresh frozen plasma based on the type and location of injury, initial international normalized ratio (INR), and targeted INR value. Fresh frozen plasma was consistently used in patients with positive head computed tomographic scans, hemothorax, nonoperative solid organ injury management, pelvic and long bone fractures, and any operative intervention. Practice inconsistencies were found in patients with loss of consciousness and normal head computed tomographic scan, facial and rib fractures, and pulmonary contusion. Significant variability was found in the reversal INR target. One third of participants agreed that anticoagulation could be restarted 5 to 7 days after craniotomy; one sixth would do so within 72 hours and one third would wait 10 or more days. Most agreed that anticoagulation could be restarted 3 days after chest, abdominal, and orthopedic operations. Significant inconsistencies were also observed regarding when to restart anticoagulation in closed head injury patients treated nonoperatively. On the basis of the discrepancies observed in this survey, a clinical trial addressing specific injury location and patterns, INR thresholds, and type of strategy to achieve reversal is warranted, and most would agree to participate.

Protein and Nitrogen Metabolism Changes Following Closed Head Injury or Cardiothoracic Surgery in Pediatric Patients

We compared markers of protein metabolism between children who had a controlled injury and an acute traumatic event. Significant protein catabolism occurs after acute severe injury. During surgery the injury is controlled and the degree of subsequent catabolism may be blunted. This was a prospective, unblinded observational study in 10 children 2 to 12 years old with a closed head injury (CHI) and an admission Physiologic Stability Index of ≥ 10 and in 10 children who underwent elective cardiothoracic surgery (CTS). Nutrient intake, nitrogen balance, serum albumin and prealbumin, urinary 3-methylhistidine excretion, and 3-methylhistidine to creatinine ratios were evaluated on days 1, 2, 3, 4, and 10 after injury. Nutrient intake was similar in both groups on study days 1-4 and did not meet estimated needs. By day 10, 7 patients in the CTS group and 2 patients in the CHI group had been discharged home. The 3 CTS patients were still in the ICU while the 8 hospitalized CHI patients had been transferred to the floor. Compared to the CTS group, nitrogen balance in the CHI group was lower on day 1. On day 10, nitrogen balance and prealbumin were greater in the CHI group than in the CTS group, consistent with recovery and increased nutrient intake. Markers of protein metabolism follow similar patterns after CTS or CHI in children. However, markers of protein metabolism indicate more severe catabolism soon after injury in CHI.

Attention to Affective Pictures in Closed Head Injury: Event-Related Brain Potentials and Cardiac Responses

We examined whether closed head injury patients show altered patterns of selective attention to stimulus categories that naturally evoke differential responses in healthy people. Self-reported rating and electrophysiological (event-related potentials [ERPs], heart rate [HR]) responses to affective pictures were studied in patients with mild head injury (n = 20; CT/MRI negative), in patients with predominantly frontal brain lesions (n = 12; CT/MRI confirmed), and in healthy controls (n = 20). Affective valence similarly modulated HR and ERP responses in all groups, but group differences occurred that were independent of picture valence. The attenuation of P3-slow wave amplitudes in the mild head injury group indicates a reduction in the engagement of attentional resources to the task. In contrast, the general enhancement of ERP amplitudes at occipital sites in the group with primarily frontal brain injury may reflect disinhibition of input at sensory receptive areas, possibly due to a deficit in top-down modulation performed by anterior control systems. Support for this research was provided to A.-K. Solbakk by the Research Council of Norway, grant no. 109500/320. The authors are grateful to Søren Jakob Bakke for evaluating the CT and MRI scans of the brain injured participants. We thank Magnus Lindgren for valuable help and advice in the preparation of this article. We also thank Kaisa Hartikainen, Robert T. Knight, and Semir Zeki for helpful comments on this manuscript. We thank two anonymous reviewers for their helpful suggestion on a previous draft of this article.

Differences between CT and MR imaging in acute closed head injuries

The authors sought to compare the early MRI and CT findings in patients suffering closed head injury and to investigate the impact of imaging discrepancies on treatment management. A group of 62 patients with closed head injury and discrepancy between the apparently normal or with minor findings CT scan, and their neurological statuses were prospectively studied with MRI. Both CT and MRI were performed within the first 6 days after injury. According to the Glasgow Coma Scale (GCS), 46 patients suffered severe head injury (GCS≤8) and 16 patients moderate head injury (GCS 9–12). Four MRI sequences in various planes were applied using a 1T MR scanner. CT findings were present in 19 out of 62 patients and MRI findings in 61. Extra-axial lesions were found in 52 patients with MRI and in 16 with CT. Subarachnoid hemorrhage (SAH) was observed in 40 patients with MRI and in 12 with CT. Intraventricular hemorrhage was observed in 15 patients with MRI and in 6 with CT. Intraaxial lesions were demonstrated in 54 patients with MRI and in 17 patients with CT. MRI demonstrated diffuse axonal injuries (DAI) type I in 27 patients, type II in 32 and type III in 9 as opposed to 2, 1 and 0 patients with CT respectively. Subcortical gray matter injuries were shown in 12 patients with MRI and 4 with CT. Primary brainstem injuries were shown in 6 patients with MRI and 1 with CT. The FLAIR sequence alone, revealed 89% of the findings demonstrated by all 4 MRI sequences. No statistically significant difference on GCS versus the hemorrhagic and non-hemorrhagic nature of the lesions was found ( p>0.05). In conclusion, in closed head injury patients with minor or absent CT findings and severe or moderate injury, MRI findings are almost always present and include particularly DAI lesions and SAH. These differences in favor of MRI do not alter the treatment management.