Hours Of Head Injury Research Articles

Pediatric sport and nonsport concussions presenting to emergency departments: injury circumstances, characteristics, and clinical management.

The aim of this study was to compare injury circumstances, characteristics, and clinical management of emergency department (ED) presentations for sports-related concussion (SRC) and non-SRC. This multicenter prospective observational study identified patients 5-17 years old who presented to EDs within 24 hours of head injury, with one or more signs or symptoms of concussion. Participants had a Glasgow Coma Scale score of 13-15 and no abnormalities on CT (if performed). Data were stratified by age: young children (5-8 years), older children (9-12 years), and adolescents (13-17 years). Of 4709 patients meeting the concussion criteria, non-SRC accounted for 56.3% of overall concussions, including 80.9% of younger child, 51.1% of older child, and 37.0% of adolescent concussions. The most common mechanism of non-SRC was falls for all ages. The most common activity accounting for SRC was bike riding for younger children, and rugby for older children and adolescents. Concussions occurring in sports areas, home, and educational settings accounted for 26.2%, 21.8%, and 19.0% of overall concussions. Concussions occurring in a sports area increased with age, while occurrences in home and educational settings decreased with age. The presence of amnesia significantly differed for SRC and non-SRC for all age groups, while vomiting and disorientation differed for older children and adolescents. Adolescents with non-SRC were admitted to a ward and underwent CT at higher proportions than those with SRC. Non-SRC more commonly presented to EDs overall, with SRC more common with increasing age. These data provide important information to inform public health policies, guidelines, and prevention efforts.

Identification of Concussion Subtypes Based on Intrinsic Brain Activity

The identification of brain activity-based concussion subtypes at time of injury has the potential to advance the understanding of concussion pathophysiology and to optimize treatment planning and outcomes. To investigate the presence of intrinsic brain activity-based concussion subtypes, defined as distinct resting state quantitative electroencephalography (qEEG) profiles, at the time of injury. In this retrospective, multicenter (9 US universities and high schools and 4 US clinical sites) cohort study, participants aged 13 to 70 years with mild head injuries were included in longitudinal cohort studies from 2017 to 2022. Patients had a clinical diagnosis of concussion and were restrained from activity by site guidelines for more than 5 days, with an initial Glasgow Coma Scale score of 14 to 15. Participants were excluded for known neurological disease or history of traumatic brain injury within the last year. Patients were assessed with 2 minutes of artifact-free EEG acquired from frontal and frontotemporal regions within 120 hours of head injury. Data analysis was performed from July 2021 to June 2023. Quantitative features characterizing the EEG signal were extracted from a 1- to 2-minute artifact-free EEG data for each participant, within 120 hours of injury. Symptom inventories and days to return to activity were also acquired. From the 771 participants (mean [SD] age, 20.16 [5.75] years; 432 male [56.03%]), 600 were randomly selected for cluster analysis according to 471 qEEG features. Participants and features were simultaneously grouped into 5 disjoint subtypes by a bootstrapped coclustering algorithm with an overall agreement of 98.87% over 100 restarts. Subtypes were characterized by distinctive profiles of qEEG measure sets, including power, connectivity, and complexity, and were validated in the independent test set. Subtype membership showed a statistically significant association with time to return to activity. In this cohort study, distinct subtypes based on resting state qEEG activity were identified within the concussed population at the time of injury. The existence of such physiological subtypes supports different underlying pathophysiology and could aid in personalized prognosis and optimization of care path.

Predictive Value of CT Perfusion Parameters in Traumatic Brain Injury Patients: A Longitudinal Study

Introduction: Traumatic Brain Injury (TBI) is the most common cause of mortality and morbidity worldwide. Moreover, cerebral contusions, Subdural Haemorrhages (SDH), Extradural Haemorrhages (EDH), and Subarachnoid Haemorrhage (SAH), which are secondary injuries that occur due to alterations in cerebral haemodynamics, remain unevaluated and unchecked by plain non contrast scans. Timely delineation of the cerebral perfusion status of the patient can assist in modifying treatment plans and could lead to a better recovery of the patient. Aim: To assess the cerebral haemodynamics of patients with TBI at admission and evaluate the predictive value of Computed Tomography (CT) perfusion. Materials and Methods: The present prospective longitudinal study was conducted in the Department of Radiodiagnosis and Neurosurgery, Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India, from September 2019 to September 2020. A total of 40 participants were included in the study using a purposive sampling method. CT Perfusion (CTP) was performed within 72 hours of head injury, followed by Glasgow Outcome at Discharge Scale (GODS) assessments at discharge and one month later. Cerebral perfusion parameters such as Cerebral Blood Flow (CBF), Cerebral Blood Volume (CBV), Mean Transit Time (MTT), and Time To Peak (TTP) were measured, and correlations were established using Spearman’s rank correlation coefficients to determine the relationship of GODS with CTP parameters. Results: The mean age of study subjects was 35.8±13.4 years, with a median (25th-75th percentile) of 32 (25-42.75). Among a total of 40 patients, 22 (55%) were males and 18 (45%) were females. Significant positive correlations were observed between GODS at discharge and CBF (mL/100 gm/min) at presentation, CBV (mL/100 gm/min) at presentation, and the number of normal/hyperemic territories, with correlation coefficients of 0.398, 0.329, and 0.504, respectively. A significant negative correlation was found between GODS at discharge and TTP (seconds) at presentation, with a correlation coefficient of -0.392. Similarly, significant positive correlations were observed between GODS at one month with CBF (mL/100 gm/min) at presentation and the number of normal/ hyperemic territories, with correlation coefficients of 0.407 and 0.827, respectively. A significant negative correlation was seen between GODS at one month and MTT (seconds) at presentation, with a correlation coefficient of -0.344. CBV (mL/100 gm/min) at presentation exhibited a sensitivity of 100%, followed by MTT (seconds) at presentation (71.43%), and CBF (mL/100 gm/min) at presentation (57.14%). Conversely, CBF (mL/100 gm/min) at presentation showed a specificity of 92.31%, followed by TTP (seconds) at presentation (92.31%), and CBV (mL/100 gm/min) at presentation (53.85%). In predicting unfavourable outcomes, MTT (seconds) at presentation had the lowest specificity of 7.69%. Conclusion: Perfusion CT provides additional information compared to Non Contrast Computed Tomography (NCCT) with insights into the pericontusional areas. Therefore, it can be a potential tool in the evaluation of TBI. Perfusion parameters have prognostic value, and thus, this modality should be studied with a larger sample size for more precise results.

Profiles of Cognitive Functioning at 6 Months After Traumatic Brain Injury Among Patients in Level I Trauma Centers

Cognitive dysfunction is common after traumatic brain injury (TBI), with a well-established dose-response relationship between TBI severity and likelihood or magnitude of persistent cognitive impairment. However, patterns of cognitive dysfunction in the long-term (eg, 6-month) recovery period are less well known. To characterize the prevalence of cognitive dysfunction within and across cognitive domains (processing speed, memory, and executive functioning) 6 months after injury in patients with TBI seen at level I trauma centers. This prospective longitudinal cohort study used data from Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) and included patients aged 17 years or older presenting at 18 US level I trauma center emergency departments or inpatient units within 24 hours of head injury, control individuals with orthopedic injury recruited from the same centers, and uninjured friend and family controls. Participants were enrolled between March 2, 2014, and July 27, 2018. Data were analyzed from March 5, 2020, through October 3, 2023. Traumatic brain injury (Glasgow Coma Scale score of 3-15) or orthopedic injury. Performance on standard neuropsychological tests, including premorbid cognitive ability (National Institutes of Health Toolbox Picture Vocabulary Test), verbal memory (Rey Auditory Verbal Learning Test), processing speed (Wechsler Adult Intelligence Scale [4th edition] Processing Speed Index), and executive functioning (Trail Making Test). The sample included 1057 persons with TBI (mean [SD] age, 39.3 [16.4] years; 705 [67%] male) and 327 controls without TBI (mean [SD] age, 38.4 [15.1] years; 222 [68%] male). Most persons with TBI demonstrated performance within 1.5 SDs or better of the control group (49.3% [95% CI, 39.5%-59.2%] to 67.5% [95% CI, 63.7%-71.2%] showed no evidence of impairment). Similarly, 64.4% (95% CI, 54.5%-73.4%) to 78.8% (95% CI, 75.4%-81.9%) of participants demonstrated no evidence of cognitive decline (defined as performance within 1.5 SDs of estimated premorbid ability). For individuals with evidence of either cognitive impairment or decline, diverse profiles of impairment across memory, speed, and executive functioning domains were observed (ie, the prevalence was >0 in each of the 7 combinations of impairment across these 3 cognitive domains for most TBI subgroups). In this cohort study of patients seen at level I trauma centers 6 months after TBI, many patients with TBI demonstrated no cognitive impairment. Impairment was more prevalent in persons with more severe TBI and manifested in variable ways across individuals. The findings may guide future research and treatment recommendations.

Prevalence of and Risk Factors for Post-traumatic Headache in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study

ObjectiveTo ascertain the prevalence of and risk factors for post-traumatic headache (PTH) attributed to mild traumatic brain injury (mTBI). Patients and MethodsA prospective, longitudinal, multicenter cohort study of patients with mTBI and orthopedic trauma controls who were enrolled from February 26, 2014, to August 8, 2018. The baseline assessment was conducted as soon as possible following evaluation at the emergency department. Follow-ups were scheduled at 2 weeks, 3 months, 6 months, and 12 months postinjury. Eligible patients with mTBI included those 18 years of age or older who presented to the emergency department within 24 hours of head injury warranting evaluation by noncontrast head computed tomography scan. Acute PTH was considered present when a patient reported a headache score of greater than or equal to 2 on the Rivermead Post-concussion Questionnaire at 2 weeks postinjury (ie, headache is at least a mild problem compared with pre-injury). Persistent PTH was defined when a patient with acute PTH reported a Rivermead Post-concussion Questionnaire headache score of greater than or equal to 2 at the scheduled follow-up examinations. ResultsAcute PTH was reported by 963 (60.4%) of 1594 patients with mTBI at 2 weeks postinjury. Among those with acute PTH, 439 (52.4%) of 837 patients reported persistent PTH at 3 months postinjury. This figure decreased over time and 278 (37.5%) of 742 patients continued to report persistent PTH at 6 months, whereas 187 (28.9%) of 646 patients did so as well at 12 months postinjury. Risk factors for acute PTH included younger age, female sex, fewer years of formal education, computed tomography–positive scans, alteration of consciousness, psychiatric history, and history of migraine. Risk factors for persistent PTH included female sex, fewer years of formal education, and history of migraine. ConclusionPost-traumatic headache is a prevalent sequela of mTBI that persists for at least 12 months in a considerable proportion of affected individuals. The attributable burden necessitates better patient follow-up, disease characterization, improved awareness of PTH in clinical practice, and identification of effective therapies.

Factors Influencing the Surgical Outcomes of Extradural Haematoma

Background: Extradural Haematoma can occur in different reasons.
 Objective: The purpose of the present study was to see the factors influencing the surgical outcomes of extradural haematoma.
 Methodology: This cross-sectional study was conducted in the Department of Neurosurgery at Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2010 to June 2011 for a period of one year and six months. All patients presented with traumatic head injury having extradural haematoma in any age with both sexes who were underwent surgical or conservative management were selected as study population. The etiologies of head injuries were recorded.
 Result: Eighty (80) patients of traumatic head injury within and after 24 hours of head injury were enrolled in this study. In this study road traffic accident was the most common mode of injury which was 51(63.8%) cases followed by fall from height and assault which were 16(20.0%) cases and 13(16.2) cases respectively. Majority patients were recovered in good condition either surgery or conservative management which was 50(62.5%) cases. However, the moderate disability was reported in 17(21.2%) cases. Severe disability was found in 8(10.0%) cases. Persistent vegetative state was found in only 2 cases in conservative treatment. Death was found in 3(3.8%) cases.
 Conclusion: In conclusion road traffic accident is the most common mode of injury among the study population that causes extra dura haematoma which has the role as factors that influence the outcomes of the patients.
 Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 65-68

Clinical Features of Patients presented with Extra Dura Haematoma Attended at a Tertiary Care Hospital in Dhaka City

Background: The clinical presentation of head injury may vary. Objective: The purpose of the present study was to see the clinical features of patients presented with extra dural haematoma. Methodology: This cross-sectional study was conducted in the Department of Neurosurgery at Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2010 to June 2011 for a period of one year and six months. All patients who underwent surgery with traumatic head injury having extradural haematoma were included in the study. The clinical features of the patients were recorded. Result: Eighty (80) patients of traumatic head injury within and after 24 hours of head injury were enrolled in this study. In this study unconsciousness was in 32(40.0%) cases. However, convulsion was found in 12 (15.0%). Vomiting was the most common presenting features which was 71(88.7%) cases. Headache was reported in 48(60.0%) cases. The normal pupillary response was found in 42(52.5%) cases. The rest 38(47.5%) cases were dilated pupil. Conclusion: In conclusion vomiting is the most common clinical features of patients presented with extra dura haematemases vomiting followed by unconsciousness and headache. Bang. J Neurosurgery 2020; 9(2): 126-129

A study of prognostic value of CT scan brain within 48 hours of head injury

A study of prognostic value of CT scan brain within 48 hours of head injury

Surgical Outcome between Early and Delayed Surgery of Extradural Haematoma (EDH) in Closed Head Injury

Background: Surgical management of Extradural Haematoma (EDH) in Closed Head Injury is an essential issue.
 Objective: The purpose of the present study was to compare the surgical outcome between early and delayed surgery of extradural haematoma (EDH) in closed head injury.
 Methodology: This comparative cross-sectional study was carried out from January 2010 to June 2011 for a period of one year and six months in the Department of Neurosurgery, Dhaka medical College Hospital, Dhaka, Bangladesh. All patients presented with traumatic head injury having extradural haematoma in any age with both sexes who were underwent surgical management were selected as study population. The patients were categorized into groups designated as group A or early surgery group where operation was done within 24 hours of head injury and group B or delayed surgery group where operation was done after 24 hours to 3 days of head injury. Inclusion of patients in group B was not intentional but due to delayed referral from primary and secondary hospitals of` different parts of' the country. Glasgow coma scale (GCS) was used for initial assessment and Glasgow outcome scale (GOS) was applied to assess outcome in terms of neurological recovery in all patients. General and neurological examinations and findings were recorded. Surgical outcome was noted and recorded in the data collection sheet.
 Result: Eighty (80) patients of traumatic head injury with EDH operation (EDH operated within 24 hours and after 24 hours of head injury) were enrolled in this study. Mean (±SD) age of the patients of group A and group B was 32.66±16.65 and 33.23±13.38 respectively. In this study the patient's age ranged from 3 years to 64 years. In group A, 6 patients were admitted with GCS (14-15) and 01 patient in group B. With GCS (9~13), 19 patients in group A and 22 patients in group B. With GCS (3-8), 15 patients were admitted in group A and 17 patients in group B. Out of all patients’ good recovery occurred in 80.0% in group A and 45.0% in group B. Moderate disability and severe disability in both group A and group B was 12.5% vs 30% and 7.5% vs 12.5% respectively. Furthermore 5.0% persistent vegetative state and 7.5% death occurred only among the patients of group B (p<0.05). Out of all patients good recovery occurred in 82.6% in group A and 54.0% in group B. Moderate disability and severe disability in both group A and group B was 10.0% vs 27.5% and 7.5% vs 13.51% respectively. 5.41% persistent vegetative state occurred only in patients of group B (p<0.05).
 Conclusion: In conclusion morbidity and mortality rate can be reduced in patients with EDH by early surgical intervention in better GCS score.
 Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 24-28

Poor sleep is linked to impeded recovery from traumatic brain injury.

While disruptions in sleep are common after mild traumatic brain injury (TBI), the longitudinal relationships between sleep problems and global functioning after injury are poorly understood. Here, we prospectively investigate risk for functional impairment during the first 6 months of TBI recovery based on sleep onset insomnia symptoms and short sleep. Patients presenting to the Emergency Department (ED) at Johns Hopkins Hospital within 24 hours of head injury and evaluated for TBI were eligible for our study. Demographic and injury-related information were collected in the ED. Patients then completed in-person surveys and phone interviews to provide follow-up data on global functioning, sleep, and depressive symptoms at 1, 3, and 6 months post-injury. A total of 238 patients provided sufficient data for analysis, and hypotheses were tested using mixed effects modeling. Sleep quality and global functioning improved over the 6 months of TBI recovery, but patients were at increased risk for functional impairment when sleeping poorly (odds ratio [OR] = 7.69, p < .001). Sleep onset insomnia symptoms and short sleep both independently corresponded to poor global functioning. Functional impairment was highest among those with both insomnia and short sleep (43%-79%) compared to good sleepers (15%-25%) and those with short sleep (29%-33%) or insomnia alone (33%-64%). A bidirectional relationship between sleep quality and functioning was observed. Functionally impaired patients diagnosed predominantly with mild TBI exhibit high rates of insomnia and short sleep, which may impede TBI recovery. Monitoring sleep after head injury may identify patients with poor prognoses and allow for early intervention to improve functional outcomes.

CT Scan importance in the first eight hours of head injury

Traumatic brain injury following head injury is a major public health problem that can result in significant long-term morbidity and mortality among adults and children worldwide. Emergency brain imaging is necessary for individuals subjected to traumatic brain injury to early detect treatable conditions. Prompt neurosurgical management of treatable conditions can prevent further damage and secondary neurological deficits. This will subsequently improve the outcome and reduce long-term disability. Computed Tomography (CT) of the brain is the investigation of choice for assessment of patients with head injury due to its availability, advantages, and sensitivity for multiple lesions following head trauma. This article will review and discuss the importance of CT imaging in evaluating patients with traumatic brain injury, its advantages, limitations, and prognostic values.

Etiological Factors of Extradural Haematoma: Experience of 80 Cases in Bangladesh

Background: Extradural haematoma is due to different etiologies.Objectives: The purpose of the present study was to see the etiological factors of extradural haematoma.Methodology: This cross sectional study was conducted in the Department of Neurosurgery at Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2010 to June 2011 for a period of one year and half months. All patients who underwent surgery with traumatic head injury having extradural haematoma were included in the study. At admission, a detailed history of the illness was taken from the patients/patient’s attendants by face-to-face interview with the help of a preformed questionnaire. Questionnaire was prepared with key variables like age, sex and mode of injury.Result: Eighty (80) patients of traumatic head injury within and after 24 hours of head injury were enrolled in this study. 20(25.1%) patients were present in age group of 11 to 20 years. 19(23.8%) patients were in age group of 21-30 years. 20(25.1%) patients were present in age group of 31 to 40 years. Male was predominant than female which was 60(75.0%) cases and 20(25.0%) cases respectively. The most common mode of injury was road traffic accident which was 51(63.7%) cases followed by fall from height and assault which were 16(20.0%) cases and 13(16.3%) cases respectively.Conclusion: In conclusion RTA is the most common cause of extradural haematoma.Journal of Science Foundation, July 2016;14(2):44-48

A retrospective review of paediatric head injuries in Asia – a Pan Asian Trauma Outcomes Study (PATOS) collaboration

ObjectiveWe aim to examine the mechanisms of head-injured children presenting to participating centres in the Pan Asian Trauma Outcomes Study (PATOS) and to evaluate the association between mechanism of injury...

Metabolomic biomarkers of concussion

ObjectiveTo determine if1H NMR spectroscopy of urine and a quantitative metabolomics approach can aid diagnostic and prognostic outcomes in patients who have suffered acute sport concussion.DesignPre-concussion urine samples were collected from WinSport athletes at the beginning of the sport season. Any athlete who experienced a head injury reported to a brain injury clinic to be tested within 72 hours of head injury. This testing included collection of a post-concussion urine sample for metabolomic analysis.SettingBrain injury clinic and metabolomics laboratory.Participants167 athletes entered the study with a total of 39 concussions occurring. Inclusion criteria: at least 18 years old, diagnosis of concussion, and concussion sustained within 72 hours. Exclusion criteria: multiple injuries coinciding with concussion and a past history of neurological pathology.Outcome measuresMetabolite concentrations were calculated in pre- and post-concussion urine samples and compared using a paired t-test and partial least squares discriminant analysis (PLS-DA) to determine which metabolites led to significant variation between samples.Main resultsThe PLS-DA model showed significant variation between baseline and post-injury sample groups and passed all permutation and cross-validation testing. A paired t-test, with cross-validation, isolated five significant metabolites of interest in the concussion group (p&lt;0.05).ConclusionsUsing NMR spectroscopy we quantified urinary metabolites in patients before and after concussion. This revealed several metabolites that were shown to be significantly altered following injury, opening up future inquiry into both the pathways and processes involved in concussion and new avenues for personalized diagnosis and treatment.Competing interestsNone.

Utility of Serum Biomarkers in the Diagnosis and Stratification of Mild Traumatic Brain Injury.

The objective was to compare test characteristics of a single serum concentration of glial fibrillary acidic protein (GFAP), S-100β, and ubiquitin carboxyl terminal hydrolase L1 (UCH-L1), obtained within 6 hours of head injury, to diagnose mild traumatic brain injury (mTBI) in head-injured subjects. Adults aged 18 to 80 years who presented to one of seven EDs with a blunt closed head injury underwent head CT within 4 hours of injury and had blood drawn for biomarker analysis within 6 hours of injury were eligible. Subjects were considered to have mTBI if they had an initial Glasgow Coma Scale (GCS)>13 and met one or more of the following criteria: loss of consciousness (LOC), posttraumatic amnesia, or confusion. Subjects with mTBI and an abnormal head computed tomography (CT) scan were categorized as complicated mTBI; those with a normal head CT were categorized as uncomplicated mTBI; and subjects with a GCS=15, no LOC, no posttraumatic amnesia, and no confusion were considered to not have a mTBI. Biomarker concentration measurements for GFAP and UCH-L1 were performed using an enzyme-linked immunosorbent assay. S-100β concentration was determined using an electrochemiluminescence immunoassay. Median biomarker concentration for each group was compared using the Kruskal-Wallis test. Logistic regression was used to determine area under the receiver operating curve (AUC) for each of the three biomarkers. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and negative and positive likelihood ratios (LRs) for the three biomarkers to differentiate between complicated mTBI, uncomplicated mTBI, and no mTBI were calculated. A total of 247 subjects were enrolled and had adequate clinical and biomarker information for analysis. A total of 188 met criteria for mTBI, with 34 (18.1%) having an acute abnormality on CT (complicated mTBI). The mean (±SD) age of the study population was 45.8 (±17.3) years, and 59.9% were male. Median serum concentrations for all biomarkers were significantly different between groups, lowest in the no mTBI group, and progressively increasing in the uncomplicated and complicated mTBI groups (p<0.0001). All three biomarkers were significant classifiers of mTBI versus no mTBI, with the following AUCs: GFAP, 0.70; S-100β, 0.69; and UCH-L1, 0.65 (p=0.17). Sensitivity for mTBI was highest for S-100β (96.5%). NPVs ranged from 31% for UCH-L1 to 35% for GFAP. PPVs ranged from 75.5% for S-100β to 96.5% for GFAP. Negative LR ranged from 0.59 for GFAP to 0.71 for UCH-L1, with positive LR ranging from 1.0 for both UCH-L1 and S-100β to 8.7 for GFAP. A single serum concentration of GFAP, UCH-L1, or S-100β within 6 hours of head injury may be useful in identifying and stratifying the severity of brain injury in emergency department patients with head trauma, but cannot reliably exclude a diagnosis of concussion. A positive GFAP was associated with the presence of concussion.

Early Hyperglycemia in Pediatric Traumatic Brain Injury Predicts for Mortality, Prolonged Duration of Mechanical Ventilation, and Intensive Care Stay.

We aim to study the association between hyperglycemia and in-hospital outcomes among children with moderate and severe traumatic brain injury (TBI). This retrospective cohort study was conducted in a tertiary pediatric hospital between 2003 and 2013. All patients < 16 years old who presented to the Emergency Department within 24 hours of head injury with a Glasgow Coma Scale (GCS) ≤ 13 were included. Our outcomes of interest were death, 14 ventilation-free, 14 pediatric intensive care unit- (PICU-) free, and 28 hospital-free days. Hyperglycemia was defined as glucose > 200 mg/dL (11.1 mmol/L). Among the 44 patients analyzed, the median age was 8.6 years (interquartile range (IQR) 5.0–11.0). Median GCS and pediatric trauma scores were 7 (IQR 4–10) and 4 (IQR 3–6), respectively. Initial hyperglycemia was associated with death (37% in the hyperglycemia group versus 8% in the normoglycemia group, p = 0.019), reduced median PICU-free days (6 days versus 11 days, p = 0.006), and reduced median ventilation-free days (8 days versus 12 days, p = 0.008). This association was however not significant in the stratified analysis of patients with GCS ≤ 8. Conclusion. Our findings demonstrate that early hyperglycemia is associated with increased mortality, prolonged duration of mechanical ventilation, and PICU stay in children with TBI.

Trans-cranial Doppler in severe head injury: Evaluation of pattern of changes in cerebral blood flow velocity and its impact on outcome

Background Trans-cranial Doppler (TCD) studies after head injury have been done in the first 24 hours after injury and do not specify the exact interval between injury and time of recordings. We have studied cerebral blood flow changes in patients with severe head injury using serial TCD starting within 6 hours after trauma, and present our findings and its correlation with clinical outcome. Methods Thirty-two patients with closed severe brain injuries formed the study group. Six-hourly serial TCD studies were done starting within 6 hours after trauma until 48 hours after trauma or death of the patient, whichever was earlier. Flow velocities of the extracranial internal carotid ( V EC-ICA) and middle cerebral artery ( V MCA) were recorded to identify vasospasm, hyperemia, or oligemia. Serial changes in flow velocities were correlated with the clinical outcome of the patients at 12 months' follow-up after injury. Result Oligemia (n = 30) and vasospasm (n = 2) were the earliest changes observed within 6 hours of trauma. In the oligemia group, persistent oligemia (n = 14), hyperemia (n = 6), normal flow velocity (n = 5), and vasospasm developing within 24 hours (n = 5) were observed. Eight patients developed vasospasm after 24 hours. All patients with persistent oligemia and vasospasm developing within 24 hours had poor outcome. Conclusion Oligemia is the most common change within 6 hours of head injury. Persistence of oligemia beyond 24 hours is associated with poor outcome. Early (within 24 hours posttrauma) onset of vasospasm is associated with poor outcome; however, delayed (>24 hours after trauma) vasospasm is not associated with poor outcome.

Incidence and mechanisms of cerebral ischemia in early clinical head injury.

Antemortem demonstration of ischemia has proved elusive in head injury because regional CBF reductions may represent hypoperfusion appropriately coupled to hypometabolism. Fifteen patients underwent positron emission tomography within 24 hours of head injury to map cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2), and oxygen extraction fraction (OEF). We estimated the volume of ischemic brain (IBV) and used the standard deviation of the OEF distribution to estimate the efficiency of coupling between CBF and CMRO2. The IBV in patients was significantly higher than controls (67 +/- 69 vs. 2 +/- 3 mL; P < 0.01). The coexistence of relative ischemia and hyperemia in some patients implies mismatching of perfusion to oxygen use. Whereas the saturation of jugular bulb blood (SjO2) correlated with the IBV (r = 0.8, P < 0.01), SjO2 values of 50% were only achieved at an IBV of 170 +/- 63 mL (mean +/- 95% CI), which equates to 13 +/- 5% of the brain. Increases in IBV correlated with a poor Glasgow Outcome Score 6 months after injury (rho = -0.6, P < 0.05). These results suggest significant ischemia within the first day after head injury. The ischemic burden represented by this "traumatic penumbra" is poorly detected by bedside clinical monitors and has significant associations with outcome.

Risk factors for mortality within first 24 hours of head injury.

Immediate or instantaneous death following cranial trauma occurs due to unpreventable primary brain insults. However, death occurring within 24 hours of head injury can be averted by timely institution of the therapeutic measures that could prevent secondary brain insults. From the management point of view, this is the most important subset of all head injured patients. Therefore, it is important to study risk factors associated with such deaths. In a retrospective study undertaken at Trauma Center, Safdarjang Hospital, New Delhi, the demographic characteristics, neurological and radiological findings were studied for 100 head injured children admitted in the pediatric surgical ward, who later died after surviving the initial neurosurgical resuscitation. Death occurring within first 24 hours of head injury was defined as "early" death; and "late death", if it occurred thereafter. Bivariate analysis revealed the severity of head injury GCS<=8 (OR: 3.09; 95% CI: 1.22-7.8), a finding of diffuse brain edema, (OR: 3.73; 95% CI: 0.95-14.74), midline shift (OR: 4.8; 95% CI: 1.03-22.37) on cranial CT scans were found to be statistically associated with early deaths. Child's age or gender, the mode of injury and the presence of extracerebral injuries were not found to be significantly associated. When these variables were simultaneously considered in a multivariate logistic regression model, the diffuse brain edema on head CT scan was found to be both clinically and statistically significant of early death (Adj. OR: 527; 95% CI: 1.23-22.6). However, absence of hemorrhagic contusion was clinically important predictor of an early death (Adj. OR: 6.45; 95% CI: 0.68.-62.5) though not statistically significant

Management of Minor Closed Head Injury in Children

To the Editor. I would like to question a recommendation in “The Management of Minor Closed Head Injury in Children” practice parameter by the AAP's Committee on Quality Improvement.1 In what is otherwise a very helpful compilation of the literature, the Committee recommends in the algorithm that fundoscopic examination be part of the neurologic examination of the child evaluated within 24 hours of head injury. I don't think that this recommendation is substantiated in any literature I could find published in English since 1970. My practice and teaching is that the performance of fundoscopy in acute head trauma is not warranted. An exception would be in the evaluation for “shaken baby syndrome.”The study by Steffen et al2 prospectively examined the discs of 37 patients with monitored elevated intracranial pressures. Only 9 of these were traumatically induced, the rest produced by intracerebral bleeding. Only 1 of the patients developed papilledema and 3 others had fundus changes “considered to be a secondary sign of papilledema.” The only papilledema occurred in a woman who died of a subarachnoid hemorrhage after failed clipping of an aneurysm. The time of occurrence is not stated. The other 3 developed fundoscopic changes on the fifth or sixth day.The definitive study by Selhorst et al3 evaluated 426 patients after head injury. They found papilledema in 1 patient (with a GCS of 6 out of 15) on the day of injury. In another patient papilledema was discovered on the day of admission, but he had had his most recent injury 3 days previously and at operation had a chronic subdural. Another had changes on the second day and 12 others between days 3 and 199. They reference a 1929 study by Blakeslee showing “papillitis” in 18 of 610 patients with skull fracture that I do not have ready access to. In addition, papilledema was shown at autopsy by Lindenburg in a patient who died within 1 hour from head trauma.I do not think that there is sufficient evidence that fundoscopy should be a recommendation in any algorithm for the immediate evaluation of head trauma. Its lack should not be construed as an inadequate neurologic examination by peers or particularly in a court of law.In Reply. Dr Smally raises concern that there is not sufficient evidence, as to value added, that fundoscopy should be recommended in the immediate evaluation of head trauma. In the guideline “The Management of Minor Closed-Head Injuries in Children,” the AAP Committee on Quality Improvement states (in the algorithm notes), “This parameter addresses the management of previously neurologically healthy children with minor closed-head injury who have normal mental status on presentation, no abnormal or focal findings on neurologic (including fundoscopic) examinations, and no physical evidence of skull fracture, etc.” This statement should not lead the reader to infer that all children presenting with minor head injury should undergo fundoscopic examination. But rather, when done as part of the physical evaluation of the minor head-injured child, the findings should be used as part of the process of evaluation and management.Fundoscopic examination performed during the initial evaluation of a child with a recent minor head injury is a test with low sensitivity and limited predictive power when findings are negative. If fundoscopic examination is performed and papilledema or other signs of increased intracranial pressure are found, these findings should direct the practitioner toward increased diagnostic evaluations and appropriate management. As pointed out by Smally, the literature indicates that papilledema or eye signs of increased intracranial pressure are highly unusual in the first 24 hours after a head injury.Given the minimal costs and limited time required to perform fundoscopy, common sense suggests that a fundoscopic examination should certainly not be discouraged as part of the physical examination. If a positive finding for increased intracranial pressure is observed, the result will be beneficial to the management of the child. If negative, as pointed out by Dr Smally, this finding alone should not completely reassure the examiner that a more serious problem is not present.As written, the guideline does not recommend that fundoscopic examinations be performed on all children undergoing evaluation for minor head injury.