Minor Brain Injury Research Articles

Prospective analysis of factors affecting the surgical outcomes of pediatric depressed skull fractures

Background: Around 42% of the pediatric patients present with skull fractures and the prognosis depends on several factors including type and location of fracture along with severity of associated brain trauma. The objective of this study was to find the factors affecting the outcome in childhood depressed skull fractures.Patients and methods: This prospective observational study included 68 patients with depressed fractures presenting in the neurosurgery emergency department of Children Hospital Lahore. After detailed history and routine investigations, patients underwent the standard surgical procedure and were closely observed during the hospital stay. All were followed up for one month after being discharged from the hospital.Results: The mean age of the children was 7.72±3.80 years. The male-to-female ratio was 1.42:1. Most of the patients had a history of fall (N=39, 57.4%). Twenty-nine (42.6%) had simple and 39 (57.4%) had complex fractures. Mostly presented with injuries at parietal (25%) and frontal (20.6%) region. Forty-seven (69.1%) were having GCS in between 13-15 (mild), 12 (17.6%) in between 9-12 (moderate) and 09 (13.2%) of the children were having GCS ≤8 (severe) at the time of presentation. Regarding outcome, good recovery was noticed in 49 (72.1%) children, moderate disability in 8 (11.8%), severe disability in 4 (5.9%), the vegetative state in 3 (4.4%), and death in 4 (5.9%) of the patients. A strong association was found between the GCS category and outcome of the surgery (p<0.001). No significant association was found between outcome and mode of injury (p=0.45), site (p=0.553), and type of fracture (p=0.66).Conclusion: Children with depressed fractures and a history of trauma normally present with minor brain injury and have a good post-surgical outcome.

Assessment of informative value of effective cerebral blood flow calculation technique according to 99mTc-HMPAO polyphase scintigraphy data

Background. According to single-photon emission computed tomography (SPECT) data, the most common technique to calculate volume cerebral blood flow (VCBF) is N.A. Lassen method. Following it, VCBF in different segments of the brain is assessed in comparison with blood flow in the cerebellum, where it is considered to be constant. However, this approach does not take into account that in some pathologies, in particular, injuries, occlusions of blood vessels, VCBF of the cerebellum also does change. Therefore, an original technique of calculating regional VCBF based on polyphase scintigraphy has been developed, which will make it possible to make a more accurate assessment of the effective perfusion of the brain.
 Purpose – to evaluate the clinical informative value of the developed technique for calculating effective cerebral blood flow according to 99mTc-HMPAO (hexamethylpropyleneaminoxime) polyphase brain scintigraphy data.
 Materials and methods. The study is focused on analyzing two groups of patients: Group A represented by patients with signs of chronic cerebral ischemia and Group B enrolling patients in the interim and long term of explosive minor brain injury (n=22). Group A patients were divided into two subgroups, depending on the presence of structural and hemodynamic changes in the vertebral arteries (VA) according to ultrasound (US) of the major vessels of the brain. I-A subgroup (n=13) was made up by those patients who had structural lesions of the vertebrobasilar basin; II-A (n=27) patients had no relevant signs.
 All patients underwent a comprehensive clinical examination including neuropsychological testing, ultrasound of major vessels, magnetic resonance imaging, single-photon emission computed tomography (SPECT). Effective volume cerebral blood flow (VCBF), according to the SPECT data, was calculated based on the original technique (VCBFSB). VCBFSB values were compared with the SPECT data using N.A. Lassen (VCBFLassen) method and the ultrasound data.
 Results and discussion. Analysing the data of the groups of patients with hemodynamic impairment in the vertebro-basilar basin shows that, according to the scintigraphy of VCBF, I-A group patients differ from II-A group on average 1.82± 0.06 times the amount for CBFSB and 0.95± 0.04 for CBFLassen. The total mean blood flow in the carotid and vertebral arteries of I-A group patients was 748.19±198.42 mL/min, II-A group patients – 1112.23±63.71 mL/min. Comparing the mean values of the hemodynamic parameters of the brain of Group B patients with the data of Group II-A
 patients, VCBFSB was 1.33±0.25-fold decreased, while CBFLassen showed 1.03±0.14-fold decrease of perfusion (in total average blood flow of vertebral and carotid arteries according to US of Group B – 1760±580 ml/min).
 Conclusions. Preliminary clinical studies, using the developed technique for calculating volume cerebral blood flow according to 99mTc-HMPAO scintigraphy data with the corresponding software, showed a rather high sensitivity in assessing VCBF in case of pathological changes in the brain, especially, in occlusion of the major vessels of the brain and contusions resulting from battle trauma, whereas N.A. Lassen method was insufficiently informative. The regression analysis of US data, SPECT data and neuropsychological testing shows clear linear correlation relationships, but they do also differ in sign depending on the diagnosis and the degree of pathological changes.

Establishment of differential model of recovery treatment for children with minor brain injury and mental disorder syndrome.

The paper established a differential equation model for 194 children with ADHD in outpatient clinics from September 2019 to August 2020 and compiled a children's clinical diagnostic interview scale based on the fourth edition of the American Diagnostic and Statistical Manual of Mental Disorders (DSM-Ⅳ). The CDIS standard divides it into three phenotypes: attention deficit predominant (ADHD-I), hyperactivity-impulsive predominance (ADHD-HI) and mixed (ADHD-C). The results of the study showed that the distribution of subtypes in the study cases: ADHD-I accounted for 45.9% (89 cases), ADHD-HI accounted for 7.7% (15 cases), ADHD-C accounted for 46.4% (90 cases); ADHD-C: ADHD-I is 1:1. CDIS scale total score: 194 cases of attention deficit symptoms were (7.2 ± 1.4) points, and hyperactivity-impulsive symptoms were (5.4 ± 2.2) points. The frequency of attention deficit symptoms in 194 cases was (79.5 ± 2.9) %, and the frequency of hyperactivity-impulsive symptoms was (59.8 ± 3.5) %. Therefore, it can be concluded that DSM-IV defines three phenotypes in this sample. The proportion of ADHD-HI is low, and the proportion of ADHD-I and ADHD-C is similar; age influences the phenotype distribution.

The Intertwined History of Malingering and Brain Injury: An Argument for Structural Competency in Traumatic Brain Injury.

Every year millions of people suffer minor brain injuries, many of which occur in collision sports. While there has been substantial commentary and debate about the nature of this public health crisis, it is clear that the scientific and clinical arguments reflect values preferences and judgments that are often invisible in documents which combine artful language with undue focus paid to sources of uncertainty at the cost of clarity and transparency. This essay gives a brief history of these patterns and proposes a remedy.

A review on four different paths to respiratory arrest from brain injury in children; implications for child abuse

Child abuse was suspected in a case of out-of-hospital arrest with minor brain injuries. Confronted with continued disputes on pathophysiologic correlates even after autopsy, to assist the differentiation of potential causes of sudden cardiopulmonary arrest in children, we tried to identify the mechanism of cardiopulmonary arrest in brain injuries from different causes.Systematic review was carried out in two stages. First, major external causes of cardiopulmonary arrest among children and infants were identified from Pubmed and Google Scholar search, and then the exact sequence of cardiopulmonary arrest, and their pathophysiologic features were identified based on articles of animal models of brain injury.From the review, we have identified four major groups of external circumstances for rather sudden cardiopulmonary arrest from brain damage in children, after excluding congenital and other unrelated diseases; 1) impact brain apnea, 2) anoxic insults, 3) drug or other substance induced central nervous system depression, and 4) traumatic brain damage. Each group has different features in the course of cardiac and respiratory arrests. Based on this review of pathophysiologic features of cardio-respiratory responses from external causes, we have presented a suspected, but unlikely, child abuse case of respiratory arrest from brain injury.The social consequences of both unknowingly missing, and falsely incriminating the abuse can be grave, and the identification of the mechanisms of cardiopulmonary arrest from brain injury can be important for the differentiation of various potential causes.

Rapid Prediction of Brain Injury Pattern in mTBI by Combining FE Analysis With a Machine-Learning Based Approach

Mild traumatic brain injury (mTBI) is a significant issue worldwide. Public awareness of the dangers of mTBI has increased sharply in recent years, yet there is no easy-to-use tool available for early detection and post injury management. Computational models of the head impact, usually in the form of finite element analysis, are a method of choice for characterizing how mechanical impacts lead to brain damage by causing high strains in certain regions of the brain. However, those models require a prohibitively large amount of computational power as well as pre and post processing expertise, making them unrealistic to be used in clinical settings. In this study, we propose a framework that combines finite element analysis with a machine learning based approach where a large number of pre-computed FE results are used to train a statistical model. We analyzed a number of different head impact scenarios in which a football player would sustain a minor brain injury and computed brain internal strain patterns. These pre-computed strain patterns were then used to train a partial least squares regression model to be able to predict the general strain pattern and the location and magnitude of peak strains. Our models were able to predict the overall distribution pattern, including the location of the peak strain, with an average error of 3%. The peak strain magnitudes were also predicted accurately with the average error of 9% at almost real time speed (less than 10 seconds). This model may play an important role in developing a diagnostic tool for mTBI that can predict the severity of head impacts.

Galveston Orientation & Amnesia Test (GOAT) Score to Assess Degree of Severity in Mild Brain Injury

ABSTRACT
 Introduction. Most of the minor brain injuries will heal as usual, but around 10-15% even 58% experience a continuous or chronic disorder known as post-traumatic syndrome. Post traumatic syndrome has manifested in the first 7 days where the quality of life of patients has decreased significantly. This study aimed to assess post traumatic amnesia in minor traumatic brain injuries in Emergency, Inpatient, and Outpatient RSUP. Moh. Hoesin Palembang using GOAT to determine the classification of minor brain injuries based on post traumatic amnesia and determine the prognosis of mild traumatic brain injury according to the presence or absence of post-traumatic syndrome.
 Methods. This research is an analytic survey with cross sectional approach. The subjects of this study were patients who were admitted and treated at the Emergency Department, Inpatient Installation, and Outpatient Installation (Polyclinic) at the RSUP dr. Mohammad Hoesin Palembang with mild traumatic brain injury and met the inclusion criteria. Inclusion criteria were patients who present with mild brain injury (GCS EMV score 13-15), age ≥ 15 years, the time of the event lasts longer ≤ 24 hours, agreeing and signing informed consent
 Results. Amnesia assessment uses the GOAT (Galveston Orientation and Amnesia Test) which is divided into three categories, namely PTA free if results> 75, and still in amnesia period if results <66 and 66-75 are doubtful. Based on GOAT assessment the number of Amnesia respondents was 23 people (42.6%) with an average GOAT score or score of 67.6.
 Conclusion. There is a significant relationship between the incidence of amnesia and post-traumatic syndrome using the GOAT Score assessment.

Comparative characteristics of life quality in patients with distant consequences of combat brain injury

Objective: To define the main directions of diagnostic, therapeutic and rehabilitation actions in persons, who have had a combat brain injury based on assessment and comparison of indicators of life quality in various terms of postponed trauma.
 Material and methods: we have examined 180 males: 100 combatants in the Democratic republic of Afghanistan (1979–1989) and 80 combatants of the conflict in the East of Ukraine (from 2014 till present) with consequences of a combat brain injury of varying severity. We used clinical-neurological, instrumental (craniography of skull, magnetic resonance imaging, ultrasonic doppler sonography of the main vessels of the head and neck), biochemical, statistical methods of research, and questionnaire scale SF-36.
 Results: the study found that indicators of life quality in persons, who have had a combat brain injury depend on severity and term which has passed from the getting combat brain injury. In early terms after the combat brain injury and in persons who have had minor and moderate degree combat brain injury, the indicators connected with a psychological component are mainly broken. While the patients, who have had a combat brain injury, have violations of all aspects (physical, psychological and social), which in the absence of necessary rehabilitation and treatment, identically shown in the different terms of trauma.
 Conclusion: according to the results the level of life quality is in many respects caused by the degree of functional violations leading to activity restriction first in the social life, considerably affect adaptation potential of organism.

Reduced Upper Limb Recovery in Subcortical Stroke Patients With Small Prior Radiographic Stroke.

Background: Research imaging costs limit lesion-based analyses in already expensive large stroke rehabilitation trials. Despite the belief that lesion characteristics influence recovery and treatment response, prior studies have not sufficiently addressed whether lesion features are an important consideration in motor rehabilitation trial design.Objective: Using clinically-obtained neuroimaging, evaluate how lesion characteristics relate to upper extremity (UE) recovery and response to therapy in a large UE rehabilitation trial.Methods: We reviewed lesions from 297 participants with mild-moderate motor impairment in the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) study and their association with motor recovery, measured by the UE Fugl-Meyer (UE-FM). Significant lesion features identified on correlational and bivariate analysis were further analyzed for associations with recovery and therapy response using longitudinal mixed models.Results: Prior radiographic stroke was associated with less recovery on UE-FM in participants with motor impairment from subsequent subcortical stroke (−5.8 points) and in the overall sample (−3.6 points), but not in participants with cortical or mixed lesions. Lesion volume was also associated with less recovery, particularly after subcortical stroke. Every decade increase in age was associated with 1 less point of recovery on UE-FM. Response to specific treatment regimens varied based on lesion characteristics. Subcortical stroke patients experienced slightly less recovery with higher doses of upper extremity task-oriented training. Participants with cortical or mixed lesions experienced more recovery with higher doses of usual and customary therapy. Other imaging features (leukoaraiosis, ischemic vs. hemorrhagic stroke) were not significant.Conclusions: ICARE clinical imaging revealed information useful for UE motor trial design: stratification of persons with and without prior radiographic stroke may be required in participants with subcortical stroke, the majority of motor rehabilitation trial participants. Most of the prior radiographic strokes were small and cortically-based, suggesting even minor prior brain injury remote to the acute stroke lesion may limit spontaneous and therapy-related recovery. Lesion location may be associated with response to different therapy regimens, but the effects are variable and of unclear significance.

Occurrence of Major and Minor Brain Injuries in Facial Bone Fractures

Background & objective: Road traffic accident (RTA), now a days, has become a common event worldwide. As face is the most exposed part of the body, is most at risk of sustaining trauma in RTA. However, there is paucity of information regarding the relationship between head injuries and facial trauma. A number of reviews have looked at brain injuries in patients with facial fractures. But these reviews failed to differentiate between major and minor brain injuries. Moreover, most studies were retrospective and based upon large trauma registries, which tend to preselect patients with multiple trauma and capture only major brain injuries. The incidence of minor brain injuries and concussion in this population is thus overlooked. This study was aimed to find the proportion of major and minor brain injuries in patients with facial bone fracture.
 Materials & Methods: This cross-sectional study was carried out in patients with facial bone fractures who attended at outpatient clinic, hospital ward of the Department of Oral and Maxillofacial Surgery, Dhaka Dental College Hospital, Dhaka, Neurosurgery Department, Emergency Department of Intensive Care Unit of Dhaka Medical College Hospital, Dhaka over a period of 2 years from January 2012 to December 2013. Only the patients of first encounters were included in the study. Patients referred from other centers with facial bone fracture were excluded. A total of 150 such patients were enrolled in the study. To assess and communicate the extent of an unconscious patient’s injury rapidly Glasgow Coma Scale (GCS) was used. The outcome variable was brain injury (major and minor).
 Result: Majority (80%) of the patients was male with mean age of the patients being 25 years (range: from 4 – 80 years). The most common mechanism of injury in the present study was road-traffic accident (60%), followed by assault (20%), fall from height (12%), crash (6%) and blast trauma (2%). Nearly half (46%) of the patients had multiple facial bone fractures. Over 10% of the patients received Zygomatico-maxillary complex fracture. Mandible fracture and frontal bone fracture each accounted for 7.3%. Nasal bone fracture was 6.7%, isolated maxilla fracture was 5.3%, Le Fort I fracture was 4.7% and orbital floor fracture was 4.0%. The Glasgow coma score 12 or below 12 was found in 52% cases and loss of consciousness and perievent amenesia were observed in 54% and 56% cases respectively. The major and minor brain injuries were found in 52% and 32% cases respectively together comprising an occurrence of 84% in facial bone fractures. Male patients, receiving trauma through RTA and multiple facial bones fractures were significantly associated with brain injury (p = 0.019, p < 0.001, p = 0.001 respectively). However, mandible and nasal bone fractures were less prone to be associated with brain injury in (p = 0.001 and p < 0.001 respectively).
 Conclusion: The study concluded that majority of the patients with facial bone fractures have had concomitant brain injuries. Male patients, receiving trauma through RTA and multiple fractures of the facial bones are more prone to be associated with brain injury than females, receiving injury through mechanisms other than RTA and isolated facial bone fractures.
 Ibrahim Card Med J 2016; 6 (1&2): 33-40

Coagulopathy in the Setting of Mild Traumatic Brain Injury: Truths and Consequences.

Mild traumatic brain injury (mTBI) is a common, although poorly-defined clinical entity. Despite its initially mild presentation, patients with mTBI can rapidly deteriorate, often due to significant expansion of intracranial hemorrhage. TBI-associated coagulopathy is the topic of significant clinical and basic science research. Unlike trauma-induced coagulopathy (TIC), TBI-associated coagulopathy does not generally follow widespread injury or global hypoperfusion, suggesting a distinct pathogenesis. Although the fundamental mechanisms of TBI-associated coagulopathy are far from clearly elucidated, several candidate molecules (tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), tissue factor (TF), and brain-derived microparticles (BDMP)) have been proposed which might explain how even minor brain injury can induce local and systemic coagulopathy. Here, we review the incidence, proposed mechanisms, and common clinical tests relevant to mTBI-associated coagulopathy and briefly summarize our own institutional experience in addition to identifying areas for further research.

Injury mechanism of midfacial fractures in football causes in over 40% typical neurological symptoms of minor brain injuries.

The injury mechanisms of midfacial fractures may be typical causes of concussion, but hardly any scientific data on midfacial injuries sustained in football are available. Head and brain trauma represent frequent injuries in athletes of different sports that require appropriate treatment by sports and trauma physicians. This study investigated the management of midfacial fractures in football and the association of such fractures with concomitant brain injury. In a prospective cohort study lasting 24months (2012 to 2013), midfacial injuries of football players were analysed with regard to the injury mechanisms, first aid procedures on the field, treatment and return-to-play. To analyse concomitant and potentially overlooked minor brain injuries due to the trauma, we retrospectively investigated the neurological symptoms of the study population. The study included 132 football players (37 semi-professionals and 95 amateurs) with midfacial fractures. The main injury mechanisms were head-to-head and head-to-elbow trauma. The mean period of return-to-play after trauma was 33.5days, which was significantly shortened if a protective face mask was worn (mean 10.4days earlier, p = 0.0006). Semi-professional football players returned to play earlier (p = 0.009) and more often used protective face masks (p = 0.001). 55 players (41.6%) had neurological symptoms immediately after trauma as a possible sign of concomitant minor brain injury. 5 of 132 players with concussion had been hospitalised for 24h, but no persistent neurological symptoms were detected. In football, midfacial fractures represent moderate-to-severe injuries with time away from sports of more than 4weeks. Over 40% of athletes with a midfacial fracture showed concomitant neurological symptoms as a sign of minor brain injury. Therefore, sports physicians and other staff supervising athletes in daily practice should be aware of the presence of neurological symptoms. Level III.

The Impact of Age on Post-Concussive Symptoms: A Comparative Study of Symptoms Related and Not Related to the Default Mode Network

The Default Mode Network is a network of connected brain regions that are active when the brain is not focused on external tasks. Minor brain injuries, such as concussions, can affect this network and manifest symptoms. We measured the correlation between the symptoms people experienced after a concussion and their age at the time the concussion occurred. We hypothesized that some symptoms, including depression, anxiety, insomnia and other sleeping problems, have a higher correlation with age than other possible symptoms. Data were collected from 133 people who had experienced concussions, as well as data from 24 healthy controls. Investigation of healthy controls via regression analysis revealed no notable or significant patterns. In concussed individuals, the incidence of sleeping problems was not correlated with the maturity of the Default Mode Network; however, there was a higher percentage of people who had a concussion between the ages of 14–16 who experienced depression, anxiety, and insomnia, as compared to other age groups and symptoms. By comparing the regression analyses, we determined that the symptoms not related to the Default Mode Network were more linearly correlated with age than symptoms related to the Default Mode Network. This phenomenon is intriguing and deserving of further research.

Minimizing Collateral Brain Injury Using a Protective Layer of Fibrin Glue: Technical Note

Neurosurgical procedures expose the brain surface to a constant risk of collateral injury. We describe a technique where the brain surface is covered with a protective layer of fibrin glue and discuss its advantages. A thin layer of fibrin glue was applied on the brain surface after its exposure in 34 patients who underwent different craniotomies for tumoral and vascular lesions. Data of 35 more patients who underwent standard microsurgical technique were collected as a control group. Cortical and pial injuries were evaluated using an intraoperative visual scale. Eventual abnormal signals at the early postoperative T2-weighted fluid-attenuated inversion recovery (T2FLAIR) magnetic resonance imaging (MRI) sequences were evaluated in oncological patients. Total pial injury was noted in 63% of cases where fibrin glue was not used. In cases where fibrin glue was applied, a significantly lower percentage of 26% (P < 0.01) had pial injuries. Only 9% had injuries in areas covered with fibrin glue (P < 0.0001). Early postoperative T2FLAIR MRI confirmed the differences of altered signal around the surgical field in the two populations. We propose beside an appropriate and careful microsurgical technique the possible use of fibrin glue as alternative, safe, and helpful protection during complex microsurgical dissections. Its intrinsic features allow the neurosurgeon to minimize the cortical manipulation preventing minor collateral brain injury.

An investigation on correlation of severity of brain injury with the expression of activin A and C-reactive protein

To determine the dynamic change in serum levels of activin A (ACTA) and C-reaction protein (CRP) in patients with brain injury, and to investigate its significance. A prospective study was conducted. A total of 57 adult patients with brain injury occurring within 24 hours admitted to intensive care unit (ICU) of the First Affiliated Hospital of Zhengzhou University from August 2012 to June 2013 were enrolled. The patients were allocated into three groups according to their Glasgow coma scale (GCS) as follows: minor brain injury (GCS 13-15, n=17), moderate brain injury (GCS 9-12, n=18), heavy brain injury (GCS 3-8, n=22). The clinical and related laboratory data (reflecting the function of liver, kidney, lung, blood coagulability etc.) were recorded after ICU admission. At the same time, venous samples were collected on the day 1, 2, 3, 5, 7 after ICU admission for determination of ACTA with enzyme linked immunosorbent assay (ELISA) and CRP with fluorescence immunoassay technology. The correlation between ACTA and CRP was analyzed by linear correlation. The receiver operating characteristic (ROC) curve was plotted to analyze the accuracy of ACTA and CRP as a prognostic indicator in brain injury. Fifteen healthy persons were enrolled as the control group. The serum levels of ACTA and CRP in patients with minor, moderate and heavy brain injury were significantly higher than those in healthy control group [ACTA (μg/L): 23.96±3.55, 42.06±5.67, 52.32±4.46 vs. 13.66±2.45, all P<0.01; CRP (mg/L): 14.12±2.45, 23.05±2.85, 30.93±2.35 vs. 3.42±2.25, all P<0.01]. As the patients' condition worsening, levels of ACTA and CRP tended to elevate (all P<0.01). Levels of ACTA and CRP in minor, moderate and heavy brain injury groups were increased after ICU admission. On day 3, levels of serum ACTA and CRP reached the peak values [ACTA (μg/L):30.62±2.54, 51.35±2.55, 60.52±2.55; CRP (mg/L): 18.62±2.64, 30.35±2.25, 37.52±2.55], and then they lowered gradually. In minor and moderate brain injury groups, the levels of ACTA and CRP were slowly descending, and on day 7, they maintained at a lower level [ACTA (μg/L): 13.68±2.54, 37.74±2.55; CRP (mg/L): 6.68±2.44, 19.74±2.55]. On the contrary, the levels of ACTA and CRP in heavy brain injury group persistently maintained at a high level on day 7 [ACTA: (42.32±2.54) μg/L, CRP: (33.32±2.56) mg/L]. There were significant differences in ACTA and CRP among different degrees of brain injury groups (all P<0.01). There was a positive correlation between ACTA and CRP (r=0.958, P=0.007). ROC curve analysis showed that the sensitivity for brain injury prediction was 93.3% for ACTA with specificity 95.0%, area under ROC curve(AUC) 0.843, and the sensitivity for CRP was 89.1% with specificity 68.2%, AUC 0.723. Serum levels of ACTA and CRP in patients with brain injury are strongly correlated with the severity of the injury. Furthermore, ACTA is more sensitive than CRP in detecting early brain injury. Therefore, ACTA is a specific factor for detecting brain injury.

Cognitive decline in Dravet syndrome: Is there a cerebellar role?

The aim of the study was to perform a detailed assessment of cognitive abilities and behaviour in a series of epileptic patients with Dravet syndrome (DS) in order to establish a possible cerebellar-like pattern. Nine children with DS without major behavioural disturbances and with cognitive abilities compatible with the assessment of specific cognitive skills (IQ>45) were enrolled in the study, in parallel with another group of nine epileptic patients (cryptogenic or symptomatic with minor brain injuries) consecutively admitted into the hospital matched for chronological age and IQ. All cases underwent neurological examination, long term EEG monitoring, neuroimaging and genetic analysis as well as a neuropsychological assessment including specific cognitive skills. On neurological examination 8 of the 9 DS patients had cerebellar signs, which were mild in six and more severe in the other two cases. DS patients had a constant discrepancy between verbal and performance items scales (verbal better than visual-spatial) that was not found in the control group. As to specific cognitive competence, the DS patients differ from the control group in the pattern of cognitive defects involving four main areas of cognitive abilities (a) expressive language with relatively spared comprehension, (b) visual-spatial organization, (c) executive function defects, (d) behavioural disorders. The pattern of cognitive difficulties found in DS patients is consistent with what is reported in literature as cerebellar cognitive syndrome and may account for a possible cerebellar origin (at least as co-factor) of the cognitive decline observed in DS patients, as suggested by other clinical and experimental studies.

Neuroinflammation in white matter tracts of Cnp1 mutant mice amplified by a minor brain injury

Oligodendrocytes make myelin for rapid impulse propagation and contribute to the long-term survival of myelinated axons. The mechanisms by which oligodendroglial dysfunction(s) contribute to slowly progressive neurodegeneration are not well understood. Here, we demonstrate in Cnp1 mutant mice that secondary axonal degeneration in the subcortical white matter is associated with an age-dependent activation of both, innate and adaptive immune responses, including an expansion of infiltrating CD8+ T cells. While the detrimental role of lymphocytes in inherited myelin diseases is known, the role of activated microglia for the hypothetical cycle of inflammation/degeneration is unclear. We used a mild standardized cryolesion of the right parietal cortex to activate microglia at the vulnerable age of mouse puberty (postnatal day (P) 28). When applied to Cnp1 mutant mice, analyzed more than 3 months later, minor brain injury had acted as a "second hit" and significantly enhanced astrogliosis, microgliosis and axon degeneration, but not T cell infiltration. Interestingly, exacerbated neuropathological changes were also reflected by specific deterioration of working memory on top of an essentially normal basic behavior. We propose a model in which oligodendroglial dysfunctions can trigger a vicious cycle of neurodegeneration and low-grade inflammation that is amplified by nonspecific activators of the innate immune system. This interaction of genetic and environmental factors may be relevant for neuropsychiatric diseases associated with secondary neuroinflammation.

A ‘knock on the noggin’

A 14-year-old mountain biker is brought by his parents to a local emergency care centre with a 5 cm facial laceration and a headache. He had been biking on one of the local trails alone and is a bit vague about the nature of the injury; “I must have fallen and cut myself on a rock”. He called his father on his cell phone at the time and arranged to meet him at the trailhead. He was wearing a helmet that was inspected by his father, which sustained no apparent impact. His Glasgow Coma Scale score is 15, and other than occasional yawning and apparent reduced attention, he seems fine. He is a bit tender over his right shoulder, and his jersey is dirty on this side. After cleaning and suturing the wound, he is discharged home. Learning points A high index of suspicion for concussion is always warranted. Not all head injuries involve brain injury (1), but enough do that it is always wise to consider this possibility. Concussion, a functional injury, accounts for most minor brain injuries. Only a few acutely injured children have structural abnormalities on imaging (2), and a subset may require neurosurgical intervention (2). Concussion may be quite subtle in presentation, particularly within the first 24 h (3). During the initial assessment, if there remains any doubt about the patient’s clinical status, choose to remove the patient from activity. ‘If in doubt, sit them out’. Over the next two days, he complained about a persistent headache, which felt worse when he climbed the stairs, and was not relieved with ibuprofen. He has been very irritable with his two younger siblings, finding them too loud. He called from school, complaining that his headache was markedly worse during math class, and he asked to come home, where he promptly fell asleep. His mother had him complete the symptom score of the Sport Concussion Assessment Tool 2 (SCAT2) (4), which she had downloaded from the Internet. He endorses 12/22 symptoms for a total score of 34/132. She is concerned and brings him to the evening clinic. He says he does not feel right. His general physical examination is normal, as is most of his formal neurological examination. Of note, he walks slowly, appears unsteady at times and has difficulty with tandem gait backwards with eyes open. Learning points The evaluation of concussion symptoms with the Sport Concussion Assessment Tool 2 (4) is recommended. A diagnosis of concussion is made with the appearance of symptoms (physical, emotional/behavioural, cognitive and sleep) following brain trauma (either direct or transmitted) (5) after alternative diagnoses have been considered. The current cornerstone of concussion management is physical and cognitive rest, until symptoms resolve (6). However, implementation is challenging, because rest is not easy for adolescents and even more problematic for younger children. The patient returns two weeks later, stating he has been headache-free for five days. He is attending school full-time as an honour-level student. His physical examination appears to be normal. Learning points Most adolescents’ concussions will resolve within several days (6),and 95% within three weeks (7). Because of the difficulty determining when concussions are ‘over’(8) and concern about children and adolescents’ vulnerability to brain injury, many agree on an asymptomatic period of several days before initiating return to play (6). Once medically cleared, a stepwise return to play exertional protocol should be followed with at least one day per step (5). In February 2012, a CPSP one-time survey showed that Canadian paediatricians frequently encounter patients with concussions. They use heterogeneous criteria to determine when patients become asymptomatic and variable return to play duration. More research and education are needed to ensure optimal management of concussions in the paediatric population.

Incidence of Major and Minor Brain Injuries in Facial Fractures

Facial fractures can be associated with brain and cervical spine injuries because impact forces are transmitted through the head and neck. Although major brain injury is commonly recognized in these patients, incidence of minor brain injury is not well-known, despite potential morbidity and mortality. This prospective study aimed to determine the incidence of both major and minor brain injuries in 100 patients presenting to a craniofacial surgery service with facial fractures and to identify characteristics associated with brain injury. Data were collected for a 9-month period by a craniofacial surgeon at a level I trauma center. A questionnaire and checklist were designed to capture information about major and minor brain injury in patients with facial fractures. Assessments were completed in the outpatient clinic, emergency department, hospital ward, or intensive care unit during the first patient encounters. The average age of patients was 34 years; 79% were male. Time between injury and assessment ranged from less than a few hours to 4 months. Incidence of brain injury was 67% overall: 29% with major brain injury and 38% with minor injury. Major brain injury was commonly diagnosed early in the emergency department or intensive care unit. Conversely, minor brain injury tended to be diagnosed late in the clinic. Patient age, mechanism of injury, and type of facial fracture predicted brain injuries overall, but mechanism of injury was the sole predictor of minor brain injury. Facial fractures are often associated with brain injury. A high level of suspicion is warranted for minor traumatic brain injuries.

Reasons for ordering computed tomography scans of the head in patients with minor brain injury

BackgroundMinor brain injury is a frequent condition. Validated clinical decision rules can help in deciding whether a computed tomogram (CT) of the head is required. We hypothesized that institutional guidelines are not frequently used, and that psychological factors are a common reason for ordering an unnecessary CT. MethodsPhysicians at the emergency department of a tertiary care hospital completed an anonymous questionnaire before ordering a CT of the head for a patient presenting with a GCS of 13–15 after a head trauma. ResultsOver a period of 10 months, 1018 CTs of the head were performed in patients presenting with a GCS of 13–15 after a head trauma; 168 (16.5%) questionnaires were completed. The most four common reasons for ordering a CT were “to confirm/rule out traumatic intracranial lesion” (in 94% of all questionnaires), “to expedite diagnosis” (63%) “guidelines” (58%) and “fear of missing a traumatic intracranial lesion” (50%). A positive answer for “fear of being sued” was declared in 21%, and “pressure from the patient or his relatives” in 8% of all questionnaires. Of 71 questionnaires without “guidelines” as a positive answer, there were 40 (56%) positive answers of “fear of missing a traumatic cerebral lesion”. ConclusionBesides guidelines, fear of missing a traumatic intracranial lesion played a role in ordering head CTs. Although the physicians had been instructed in the use of guidelines, including validated clinical decision rules, this did not prevent them from ordering unnecessary CTs.