Intraparenchymal Contusion Research Articles

Classification, risk factors, and outcomes of patients with progressive hemorrhagic injury after traumatic brain injury

BackgroundAccording to the pathoanatomic classification system, progressive hemorrhagic injury (PHI) can be categorized into progressive intraparenchymal contusion or hematoma (pIPCH), epidural hematoma (pEDH), subdural hematoma (pSDH), and traumatic subarachnoid hemorrhage (ptSAH). The clinical features of each type differ greatly. The objective of this study was to determine the predictors, clinical management, and outcomes of PHI according to this classification.MethodsMultivariate logistic regression analysis was used to identify independent risk factors for PHI and each subgroup. Patients with IPCH or EDH were selected for subgroup propensity score matching (PSM) to exclude confounding factors before evaluating the association of hematoma progression with the outcomes by classification.ResultsIn the present cohort of 419 patients, 123 (29.4%) demonstrated PHI by serial CT scan. Of them, progressive ICPH (58.5%) was the most common type, followed by pEDH (28.5%), pSDH (9.8%), and ptSAH (3.2%). Old age (≥ 60 years), lower motor Glasgow Coma Scale score, larger primary lesion volume, and higher level of D-dimer were independent risk factors related to PHI. These factors were also independent predictors for pIPCH, but not for pEDH. The time to first CT scan and presence of skull linear fracture were robust risk factors for pEDH. After PSM, the 6-month mortality and unfavorable survival rates were significantly higher in the pIPCH group than the non-pIPCH group (24.2% vs. 1.8% and 12.1% vs. 7.3%, respectively, p < 0.001), but not significantly different between the pEDH group and the non-pEDH group.ConclusionsUnderstanding the specific patterns of PHI according to its classification can help early recognition and suggest targeted prevention or treatment strategies to improve patients’ neurological outcomes.

Traumatic brain injury of childhood

Traumatic brain injury of childhood

Incidence of progressive hemorrhagic injury in patients presenting with traumatic brain injury at a large tertiary care hospital in Karachi, Pakistan. A Case Series.

Objectives: Our study aims to determine the frequency of progressive hemorrhagic injury as observed on the CT scan from the initial scan performed at the time of presentation to a subsequent one in the 12 hours after the initial scan. Study Design: The type of study is a prospective observational case series. Setting: At Tertiary Care Hospital in Karachi, Pakistan. Period: 3 months from June 2018 to August 2018. Materials &amp; Methods: All patients over 18 years of age who presented to the Accident and Emergency Department of the hospital with traumatic brain injury and had a CT scan performed within four hours of the injury were included in the study. A predesigned proforma was used to note down patient findings. CT scan findings were classified as subdural hematoma (SDH), intraparenchymal contusion (IPC) extradural hematoma (EDH) and subarachnoid hemorrhage (SAH). A repeat CT scan was performed twelve hours after the initial CT scan. Data were analyzed using IBM SPSS version 20.0, mean and frequencies were calculated for continuous variables while frequencies and percentages were calculated for categorical variables. Results: Of the n= 110 patients in our study 79 were males and 31 were female, the mean age of the patients was 34.25 years. The Glasgow Coma Scale scores at the time of arrival were between thirteen and fifteen for n= 33 (30%) of the patients, between nine and twelve for n= 54 (49.09%) of the patients, less than and equal to eight for n= 23 (20.90%) of the patients. Subarachnoid hemorrhage was present in n= 32 (29.09%) patients, intraparenchymal hematoma was present in n= 42 (38.18%) of the patients, while subdural hematoma and epidural hematoma was present in n= 14 (12.72%) and n= 22 (20%) of the patients respectively. Progressive hemorrhagic injury was found in n= 66 (60%) of the patients, while in n= 11 (10%) of the patients there was resolution of the lesion and n= 33 (33%) of the patients showed no observable changes in the repeat CT scan. Finally, our results indicate that of the 110 patients in our study PHI was seen in n= 17 (53.12%) patients with SAH, n= 18 (81.81%) patients of EDH, n= 5 (35.71%) patients of SDH and n= 26 (61.90%) patients of IPC respectively. Conclusion: According to the results of our study PHI is observed in 60% of the patients with a traumatic brain injury observed within the initial 12 hours after injury, and epidural hematoma and intraparenchymal contusions had the highest incidences of PHI among all the different types of traumatic brain injuries.

Traumatic Subdural Hematoma and Intraparenchymal Contusion after a Firework Blast Injury

Traumatic Subdural Hematoma and Intraparenchymal Contusion after a Firework Blast Injury

S82. Paroxysmal sympathetic hyperactivity evident as cyclical pattern on quantitative EEG analysis

Introduction Episodic fluctuations in sympathetic activity following traumatic brain injury (TBI) have been described for decades, with paroxysmal sympathetic hyperactivity (PSH) being the currently accepted term for this entity. While early reports postulated an epileptic mechanism, our understanding of the pathophysiology of PSH has evolved. Current hypotheses center around deregulation of central descending inhibitory inputs from the insula and cingulate cortex, resulting in increased sympathetic output from the hypothalamus, diencephalon and brainstem. We present a case of PSH with evidence of disrupted sympathetic arousal networks. Methods A 41-year-old woman suffered a TBI with multifocal supratentorial hemorrhages and intraparenchymal contusions. Eight days post-MVA she developed episodes of tachycardia, hypertension, diaphoresis, back-arching and extensor posturing of the upper extremities upon stimulus. These events were assumed to be epileptic and treated with lorazepam (up to 16 mg/24 h) and phenobarbital (up to 345 mg/24 h) to no avail. Episodes improved with dexmedetomidine and clonidine. Continuous video-EEG was ordered for event characterization. Results EEG background was characterized by reactive generalized theta activity without interictal discharges. Multiple stimulus-induced stereotypical events were captured on the first EEG, prior to initiation of anti-epileptic drugs and dexmedetomidine. These were time-locked with static generalized rhythmic delta activity, often sharply contoured (GRDA + S). Quantitative EEG cycled between GRDA+S and polymorphic theta; transitions were often associated with stimulation or arousal. Thus, the events were shown to be stimulus/arousal-induced PSH time-locked with GRDA+S. The second EEG on lorazepam (2 mg q6h) and dexmedetomidine (26 mcg/kg/h) demonstrated less GRDA and no PSH. The third EEG on phenobarbital (130 mg qhs) and less dexmedetomidine (1.5 mcg/kg/h) demonstrated polymorphic delta slowing during episodes of PSH. Therefore, PSH was seen prior to initiation of dexmedetomidine and while on a low dose, but not while on a higher dose. Phenobarbital did not improve PSH. Conclusion Episodes of PSH were non-epileptic and concordant with cyclical stimulus or arousal-induced GRDA. This pattern is thought to represent cortical-subcortical dysfunction rather than hyperexcitability, as shown in a recent retrospective analysis of critical care continuous EEG in which no association was found between GRDA and seizures. The cyclical pattern on scalp and quantitative EEG reflected increased generalized rhythmicity with arousal and episodes of PSH; akin to stimulus/arousal-induced rhythmic or periodic or ictal discharges (SIRPIDs) seen in critically ill patients. The pattern seen on the cEEG reflects network disruption during PSH rather than a hyperirritable cortex; we believe that treatment of PSH should target sympathetic arousal networks rather than cortical hyperexcitability.

Traumatic Brain Injury Patterns on Ct Scan: A Comparison of Motorcyclist Versus Passenger Vehicle Patients Involved in Road Traffic Accidents

Introduction: Traumatic brain injury following road traffic accidents is a common cause of morbidity and mortality in Malaysia. We aim to determine the differences of traumatic brain injury patterns based on CT findings among motorcyclist versus passenger vehicle patients involved in road traffic accidents. Materials and method: This retrospective study was conducted in Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang. A total of 100 CT scan brains of patients who were involved in road traffic accidents were retrieved and reviewed, 50 of them were motorcyclists and the other 50 were passenger vehicles. Results: Fifty percent of the motorcyclists had an abnormal CT brain finding while only 24% of the passenger vehicle showed abnormal finding. Among motorcyclist, skull fracture was the most common finding (30%) followed by subdural hemorrhage (28%). Among passenger vehicle, the most common finding was subdural hemorrhage (10%) followed by subarachnoid hemorrhage, intraparenchymal haemorrhage and skull fracture (8% each). The motorcyclist had significantly higher rate of subdural haemorrhage, extradural haemorrhage, intraparenchymal contusion and skull fracture compared to passenger vehicle patients with p value of 0.02, 0.03, 0.007 and 0.005 respectively. Conclusion: The occurrence of traumatic brain injury was significantly higher among the motorcyclist compared to passenger vehicle patients involved in road traffic accidents. The findings of this study highlighted the need for taking further measures to increase safety among the motorcyclists.

Early plasma transfusion is associated with improved survival after isolated traumatic brain injury in patients with multifocal intracranial hemorrhage

Plasma-based resuscitation improves outcomes in trauma patients with hemorrhagic shock, while large-animal and limited clinical data suggest that it also improves outcomes and is neuroprotective in the setting of combined hemorrhage and traumatic brain injury. However, the choice of initial resuscitation fluid, including the role of plasma, is unclear for patients after isolated traumatic brain injury. We reviewed adult trauma patients admitted from January 2011 to July 2015 with isolated traumatic brain injury. "Early plasma" was defined as transfusion of plasma within 4hours. Purposeful multiple logistic regression modeling was performed to analyze the relationship of early plasma and inhospital survival. After testing for interaction, subgroup analysis was performed based on the pattern of brain injury on initial head computed tomography: epidural hematoma, intraparenchymal contusion, subarachnoid hemorrhage, subdural hematoma, or multifocal intracranial hemorrhage. Of the 633 isolated traumatic brain injury patients included, 178 (28%) who received early plasma were injured more severely coagulopathic, hypoperfused, and hypotensive on admission. Survival was similar in the early plasma versus no early plasma groups (78% vs 84%, P=.08). After adjustment for covariates, early plasma was not associated with improved survival (odds ratio 1.18, 95% confidence interval 0.71-1.96). On subgroup analysis, multifocal intracranial hemorrhage was the largest subgroup with 242 patients. Of these, 61 (25%) received plasma within 4hours. Within-group logistic regression analysis with adjustment for covariates found that early plasma was associated with improved survival (odds ratio 3.34, 95% confidence interval 1.20-9.35). Although early plasma transfusion was not associated with improved in-hospital survival for all isolated traumatic brain injury patients, early plasma was associated with increased in-hospital survival in those with multifocal intracranial hemorrhage.

Predicting progressive hemorrhagic injury from isolated traumatic brain injury and coagulation

Progressive hemorrhagic injury (PHI) in traumatic brain injury (TBI) patients is associated with poor outcomes. Early prediction of PHI is difficult yet vital. We hypothesize that TBI subtype and coagulation would be predictors of PHI. This was a retrospective analysis of highest level activation adult trauma patients with evidence of TBI (head Abbreviated Injury Scale ≥3). Coagulopathy was determined using rapid thrombelastography (r-TEG), complete blood counts, and conventional coagulation tests obtained on arrival. Patients were dichotomized into PHI and stable groups based on head computerized CT. Subtypes of TBI included subdural hematoma, intraparenchymal contusions (IPC), subarachnoid hemorrhage, epidural hematoma, and combined. Data are reported as median values with interquartile range (IQR). Multivariate logistic regression was used to assess the effect of subtype and coagulation on PHI. We included 279 isolated TBI patients who met study criteria. There were 157 patients (56%) who experienced PHI; 122 (44%) were stable on repeat CT. Patients with PHI were older, had fewer hospital-free days, and higher mortality (all P<.001). No differences were noted in r-TEG parameters between groups; however, coagulopathy and age were independent predictors of progression in all subtypes (odds ratio [OR], 1.81; 95% CI, 1.09-3.01 [P=.021]; OR, 1.02, 95% CI, 1.01-1.04 [P=.006]). Controlling for age, Glasgow Coma Scale score, and coagulopathy, patients with IPC were more likely to experience PHI (OR, 4.49; 95% CI, 2.24-8.98; P<.0001). This study demonstrates that older patients with coagulation abnormalities and IPC on admission are more likely to experience PHI, identifying a target population for earlier therapies.

Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: A propensity score-matched analysis.

Although intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, the benefits remain controversial. We sought to determine the impact of ICP monitor placement on inpatient mortality within a regional trauma system after correcting for selection bias through propensity score matching. Data were collected on all severe TBI cases presenting to 14 trauma centers during the 2-year study period (2009-2010). Inclusion criteria were as follows: blunt injury, Glasgow Coma Scale (GCS) score of 8 or lower in the emergency department, and abnormal intracranial findings on head computed tomography (CT). Two separate multivariate logistic regression models were used to predict ICP monitor placement and inpatient mortality after controlling for demographics, severity of injury, comorbidities, and TBI-specific variables (GCS score, pupil reactivity, international normalized ratio, and nine specific head CT findings). To account for selection bias, we developed a propensity score-matched model to estimate the "true" effect of ICP monitoring on in-hospital mortality. A total of 844 patients met inclusion criteria; 22 died on arrival to the emergency department. Inpatient mortality was 38.8%; 46.0% of the patients underwent ICP monitor placement. Unadjusted mortality rates were significantly lower in the ICP monitoring group (30.7% vs. 45.7%, p < 0.001). ICP monitor placement was positively associated with CT findings of subdural hematoma, intraparenchymal contusion, and mass effect and negatively associated with age, alcoholism, and elevated international normalized ratio. After adjusting for selection bias via propensity score matching, ICP monitor placement was associated with an 8.3 percentage point reduction in the risk-adjusted mortality rate. ICP monitor placement occurred in only 46% of eligible patients but was associated with significantly decreased mortality after adjusting for baseline risk profile and the propensity to undergo monitoring. As the individual impact of ICP monitoring may vary, future efforts must determine who stands to benefit from invasive monitoring techniques. Therapeutic/care management study, level III.

Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?

More than 1.5 million Americans suffer a traumatic brain injury (TBI) each year. Seventy-five percent of these patients have a mild TBI, with Glasgow Coma Scale (GCS) Score 13-15. At the authors' institution, the usual practice has been to admit those patients with an associated intracranial hemorrhage (ICH) to an ICU and to obtain repeat head CT scans 12-24 hours after admission. The purpose of this study was to determine if there exists a subpopulation of mild TBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. This group of patients was further classified based on initial clinical factors and imaging characteristics. A retrospective review of all patients admitted to a Level I trauma center from January 2007 through December 2008 was performed using the hospital Trauma Registry Database, medical records, and imaging data. The inclusion criteria were as follows: 1) an admission GCS score ≥ 13; 2) an isolated head injury with no other injury requiring ICU admission; 3) an initial head CT scan positive for ICH; and 4) an initial management plan that was nonoperative. Collected data included age, etiology, initial GCS score, time of injury, duration of ICU stay, duration of hospital stay, and anticoagulation status. Primary outcomes measured were the occurrence of neurological or medical decline and the need for neurosurgical intervention. Imaging data were analyzed and classified based on the predominant blood distribution found on admission imaging. Data were further categorized based on the Marshall CT classification, Rotterdam score, and volume of intraparenchymal hemorrhage (IPH). Progression was defined as an increase in the Marshall classification, an increase in the Rotterdam score, or a 30% increase in IPH volume. Three hundred twenty-one of 1101 reviewed cases met inclusion criteria for the study. Only 4 patients (1%) suffered a neurological decline and 4 (1%) required nonemergent neurosurgical intervention. There was a medical decline in 18 of the patients (6%) as a result of a combination of events such as respiratory distress, myocardial infarction, and sepsis. Both patient age and the transfusion of blood products were significant predictors of medical decline. Overall patient mortality was 1%. Based on imaging data, the rate of injury progression was 6%. The only type of ICH found to have a significant rate of progression (53%) was a subfrontal/temporal intraparenchymal contusion. Other variables found to be significant predictors of progression on head CT scans were the use of anticoagulation, an age over 65 years, and a volume of ICH > 10 ml. Most patients with mild TBI have a good outcome without the necessity of neurosurgical intervention. Mild TBI patients with a convexity SAH, small convexity contusion, small IPH (≤ 10 ml), and/or small subdural hematoma do not require admission to an ICU or repeat imaging in the absence of a neurological decline.

Isolated lower extremity monoplegia due to a traumatic intraparenchymal contusion: Report of two cases

Background: Isolated lower extremity monoparesis/monoplegia (MP) due to epidural or subdural haematomas near the vertex have not been reported due to traumatic intraparenchymal contusions. Due to the limitations of conventional axial computed tomographic (CT) imaging, the evidence of a vertex contusion may be under-appreciated if an overlying skull fracture is absent.Case description: Two cases of isolated MP due to vertex contusions are described and the physical forces involved in the head trauma are described to explain the location of the contusions. Vertex intraparenchymal contusions are rare because of the way the brain deforms in response to the accelerational forces acting on it during head trauma. This study analyses patients’ injuries and addresses the importance of considering the forces acting on the brain when evaluating a victim of head trauma.Conclusion: Isolated lower extremity MP following head trauma is rare because haematomas in the fronto-parietal cortex near the midline that could produce such a deficit are rare. The limitations of typical axial CT imaging can be overcome with coronal reconstructions. Practitioners who evaluate patients with isolated MP after head injury should be aware of the possibility of an intraparenchymal lesion near the vertex as the cause of this deficit.

Rapid progression of traumatic bifrontal contusions to transtentorial herniation: A case report.

We report a case of mild to moderate traumatic brain injury in which ICP monitoring or quantitative cerebral perfusion data may have allowed earlier recognition of impending herniation, avoidance of a secondary insult, and ultimately resulted in a better outcome, even though the patient did not meet the standard guidelines of the Brain Trauma Foundation. A thirty-five year old male who presented with traumatic bifrontal contusions and GCS of fourteen and twelve hours later progressed rapidly to having dilated pupils and transtentorial/central herniation over the course of fifteen minutes. The patient was taken emergently for a bifrontal craniectomy. Post operatively he had an acute infarct in the posterolateral left temporal lobe with expected evolution of parenchymal contusions as well as infarcts in the splenium of the corpus callosum, left thalamus and medial right occipital lobe. This case signifies an exception from the guidelines submitted by the Brain Trauma Foundation for intracranial pressure monitoring in patients with severe brain injury.We also point out previous reports which state that in such a patient a more sensitive test for detection would perhaps be quantitative blood flow monitoring, and may have led to a better outcome. We recommend using intracranial pressure monitoring or blood flow measurements to trend patients with bifrontal intraparenchymal contusions and GCS greater than eight to prevent clinically undetected deterioration from transtentorial/central herniation.

ACUTE TRAUMATIC INTRAPARENCHYMAL HEMORRHAGE

To characterize the natural course of traumatic intraparenchymal contusions and hematomas (IPHs) and to identify risk factors for IPH progression in the acute post-injury period. A retrospective analysis was performed on a prospective observational database containing 113 head trauma patients exhibiting 229 initially nonoperated acute IPHs. The main outcome variable was radiographic evidence of IPH progression on serially obtained head computed tomographic (CT) scans. Secondary outcomes included the actual amount of IPH growth and later surgical evacuation. Univariate and multivariate analyses (using a generalized estimate equation) were applied to both demographic and initial radiographic features to identify risk factors for IPH progression and surgery. Overall, 10 IPHs (4%) shrank, 133 (58%) remained unchanged, and 86 (38%) grew between the first and second head CT scan. IPH progression was independently associated with the presence of subarachnoid hemorrhage (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.3), presence of a subdural hematoma (OR, 1.94; 95% CI, 1.1-3.43), and initial size (OR, 1.11; 95% CI, 1.02-1.21, for each cm volume). Size of initial IPH proportionately correlated with the amount of subsequent growth (linear regression, P < 0.001). Worsened Glasgow Coma Score between initial and follow-up head CT scan (OR, 8.6; 95% CI, 1.5-50), IPH growth greater than 5 cm (OR, 7.3; 95% CI, 1.6-34), and effacement of basal cisterns on initial CT scan (OR, 9.0; 95% CI, 1.5-52) were strongly associated with late surgical evacuation. A large proportion of IPHs progress in the acute post-injury period. IPHs associated with subarachnoid hemorrhage, a subdural hematoma, or large initial size should be monitored carefully for progression with repeat head CT imaging. Effacement of cisterns on the initial head CT scan was strongly predictive of failure of nonoperative management, thereby leading to surgical evacuation. These findings should be important factors in the understanding and management of IPH.

Acute Traumatic Intraparenchymal Hemorrhage: Risk Factors for Progression in the Early Post-injury Period

To characterize the natural course of traumatic intraparenchymal contusions and hematomas (IPHs) and to identify risk factors for IPH progression in the acute post-injury period. A retrospective analysis was performed on a prospective observational database containing 113 head trauma patients exhibiting 229 initially nonoperated acute IPHs. The main outcome variable was radiographic evidence of IPH progression on serially obtained head computed tomographic (CT) scans. Secondary outcomes included the actual amount of IPH growth and later surgical evacuation. Univariate and multivariate analyses (using a generalized estimate equation) were applied to both demographic and initial radiographic features to identify risk factors for IPH progression and surgery. Overall, 10 IPHs (4%) shrank, 133 (58%) remained unchanged, and 86 (38%) grew between the first and second head CT scan. IPH progression was independently associated with the presence of subarachnoid hemorrhage (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.3), presence of a subdural hematoma (OR, 1.94; 95% CI, 1.1-3.43), and initial size (OR, 1.11; 95% CI, 1.02-1.21, for each cm volume). Size of initial IPH proportionately correlated with the amount of subsequent growth (linear regression, P < 0.001). Worsened Glasgow Coma Score between initial and follow-up head CT scan (OR, 8.6; 95% CI, 1.5-50), IPH growth greater than 5 cm (OR, 7.3; 95% CI, 1.6-34), and effacement of basal cisterns on initial CT scan (OR, 9.0; 95% CI, 1.5-52) were strongly associated with late surgical evacuation. A large proportion of IPHs progress in the acute post-injury period. IPHs associated with subarachnoid hemorrhage, a subdural hematoma, or large initial size should be monitored carefully for progression with repeat head CT imaging. Effacement of cisterns on the initial head CT scan was strongly predictive of failure of nonoperative management, thereby leading to surgical evacuation. These findings should be important factors in the understanding and management of IPH.

Heme Regulation in Traumatic Brain Injury: Relevance to the Adult and Developing Brain

Intracranial bleeding is one of the most prominent aspects in the clinical diagnosis and prognosis of traumatic brain injury (TBI). Substantial amounts of blood products, such as heme, are released because of traumatic subarachnoid hemorrhages, intraparenchymal contusions, and hematomas. Despite this, surprisingly few studies have directly addressed the role of blood products, in particular heme, in the setting of TBI. Heme is degraded by heme oxygenase (HO) into three highly bioactive products: iron, bilirubin, and carbon monoxide. The HO isozymes, in particular HO-1 and HO-2, exhibit significantly different expression patterns and appear to have specific roles after injury. Developmentally, differences between the adult and immature brain have implications for endogenous protection from oxidative stress. The aim of this paper is to review recent advances in the understanding of heme regulation and metabolism after brain injury and its specific relevance to the developing brain. These findings suggest novel clinical therapeutic options for further translational study.

Pediatric Closed Head Injuries Treated in an Observation Unit

Closed head injury (CHI) is common in childhood and frequently results in hospital admission for observation and treatment. Observation units (OUs) have shown significant benefits for patients and physicians. At our institution, a level 1 pediatric trauma center, patients with CHI are often admitted to an OU for up to 24 hours of observation and treatment. To describe characteristics of patients with a CHI admitted to a pediatric OU and to identify demographic, historical, clinical, and radiographic factors associated with the need for unplanned inpatient admission (UIA) after OU management. Retrospective cohort review of all OU admissions for CHI at Primary Children's Medical Center (PCMC) from August 1999 through July 2001. Data collected included age, gender, mechanism of injury, presenting symptoms, physical examination findings, head computed tomography (CT) results, diagnosis, length of stay, outcome of the injury, and need for UIA. During the study period, 827 patients were seen in the ED for CHI. Two hundred eighty-five patients (34%) were admitted to the OU, 273 (33%) were admitted to an inpatient service, and 269 (33%) were discharged home. OU patients had a median age of 5.2 years, ranging from 2 weeks to 17 years. Sixty-one percent were male. The median admission length of stay was 13 hours. Common mechanisms of injury included: falls (60%), motor vehicle accidents (12%), bicycle accidents (10%), impacts from objects (9%), auto-pedestrian accidents (4.6%), and snow-related accidents (4.6%). Presenting symptoms in the ED included vomiting (39%), loss of consciousness (26%), amnesia to event (19%), persistent amnesia (5%), and seizures (4%). Physical examination findings noted in the ED included altered mental status (45%), facial abnormalities (43%), scalp abnormalities (38%), and neurologic deficits (9%). Two hundred eighty patients (98%) admitted to the OU had a head CT performed. Skull fractures were present in 109 patients (39%) and intracranial pathology (ie, epidural hematoma, subdural hematoma, or intraparenchymal contusion) was present in 38 patients (13%). Only 13 patients (5%) required admission to an inpatient service from the OU for the following reasons: continued need for intravenous (IV) fluids (n = 5), venous thrombosis (n = 2), persistent CSF leakage (n = 3), decreased level of consciousness (n = 1), pain management (n = 1), and clearing of the patient's cervical spine (n = 1). No patient deteriorated or required neurosurgery. Patients with basilar skull fractures, a head laceration (scalp or facial), and patients that needed IV fluids in the ED were more likely to need inpatient admission after a 24-hour observation stay. Logistic regression analysis identified basilar skull fractures (OR 11.61), face/scalp lacerations (OR 7.52), and the need for ED IV fluid administration (OR 4.26) to be associated with UIA. Most children with these findings were successfully discharged within 24 hours, however. Age, sex, loss of consciousness, seizure, vomiting, amnesia, altered mental status, neurologic deficits, intracranial pathology, and skull fractures (aside from basilar skull fractures) were not related to UIA. The vast majority (96%) of pediatric OU patients with CHI such as small intracranial hematomas, skull fractures, and concussions were discharged safely within 24 hours without serious complications. The presence of a basilar skull fracture, head laceration, and the need for ED IV fluids were associated with increased risk of UIA. OU admission is an efficient and effective management setting for children with stable intracranial pathology, skull fractures, and concussions.