Parenchymal Contusions Research Articles

Role of Computed Tomography in the Diagnosis, Treatment and Prognosis of Patients with Traumatic Head Injury

Background: Traumatic brain injury is defined as damage to the brain caused by external mechanical forces such as: A. Sudden acceleration or deceleration, pressure wave or projectile penetration, resulting in temporary or permanent impairment of brain function. B. In a rapidly developing country like Bangladesh, urbanization and industrialization have led to an increase in road traffic, which is the main cause of head injuries due to road accidents. Objectives: To evaluate the prognostic importance of CT on the outcome of head injury patients. Observation of the sequential anatomical course of pathological processes in the brain response to head injury and correlation with Glasgow Coma Scale. Methods: This is a hospital study carried out in patients of head injury referred to the BSM Medical University Hospital from July 2022 to August 2023. Total 120 patients were included; incidence of head injuries was more in males than females. The study included patients with head and craniofacial trauma who underwent CT scans. Patients were examined with a dual-slice CT, Siemens Somatom Emotion Duo. A P value of less than 0.05 was considered statistically significant. Results: Total 120 patients were included; incidence of head injuries was more in males than females. Headache was the commonest presentation. Contusions were the most common intraparenchymal injury found in 58, followed by EDH in 52 patients, followed by SDH and SAH which accounted for 52 and 32 respectively. Intraparenchymal hematoma was found in 24 of patients and DAI in 16, intraventricular hemorrhage in 10 patients. Conclusion: Parenchymal contusions, Subdural and extra dural hematoma were equally encountered findings in our study while subarachnoid haemorrhage was seen less frequently while intraventricula rhaemorrhage was rare.

Clinical and radiographic characteristics of traumatic brain injury patients undergoing endovascular rescue for posttraumatic vasospasm.

Cerebral vasospasm is a serious sequela of traumatic brain injury (TBI) which leads to further neurologic injury subsequent to the initial trauma. The natural history and associated risk factors are not well understood. The objective of this study is to evaluate the clinical and radiographic characteristics of patients with TBI. This is a descriptive case series of all patients with TBI who underwent cerebral angiogram for evaluation and rescue therapy for posttraumatic arterial vasospasm (PTV) between October 2017 and November 2019. The association of clinical and radiographic characteristics with cumulative severity of angiographic vasospasm was evaluated. The clinical characteristics comprised of age, sex, Glascow Coma Scale (GCS) and need for surgery. The radiographic characteristics were presence of subarachnoid hemorrhage (SAH), location of SAH, presence of contusion, presence of subdural hemorrhage (SDH), and presence of pseudoaneurysm. Twenty-two patients with PTV were identified requiring 69 cerebral angiograms (mean: 3.2; range: 1-9 angiograms per patient) during this period. The average age upon presentation was 40 years old, 81% of the patients were male sex, and the average GCS was 6.8. 67% of the patients underwent craniotomy or craniectomy. All patients had SAH, although only 60% had cisternal SAH. Parenchymal contusion was noted on 90% as well as SDH in 90%. The PTV was noted between 3 and 19 days after trauma. There was more vasospasm involving proximal arteries and higher severity of vasospasm in patients with cisternal SAH. Otherwise, there was no strong association between the clinical or radiographic characteristics and cumulative severity noted on the angiograms for each patient. Posttraumatic vasospasm can be detected as early as posttrauma day 3-19 in patients with TBI and SAH. The absence of cisternal SAH does not rule out the occurrence of the vasospasm during the course of treatment.

Appropriate incorporation of susceptibility-weighted magnetic resonance imaging into routine imaging protocols for accurate diagnosis of traumatic brain injuries: a systematic review.

Traumatic brain injury (TBI) results from physical or traumatic injuries to the brain's surrounding bony structures and associated tissues, which can lead to various sequelae, including simple concussion, acute epidural hematoma, parenchymal contusions, subarachnoid hemorrhage, diffuse axonal injury, and chronic traumatic encephalopathy. Susceptibility-weighted imaging (SWI) has enhanced the accuracy of neuroimaging for these injuries. SWI is based on 3D gradient echo magnetic resonance imaging (MRI) with long echo times and flow compensation. Owing to its sensitivity to deoxyhemoglobin, hemosiderin, iron, and calcium, SWI is extremely informative and superior to conventional MRI for the diagnosis and follow-up of patients with acute, subacute, and prolonged hemorrhage. This systematic review aimed to evaluate and summarize the published articles that report SWI results for the evaluation of TBI and to determine correlations between clinical status and SWI results. Consequently, our analysis also aimed to identify the appropriate MRI sequences to use in the assessment of patients with TBI. We searched the Medline and Embase online electronic databases for relevant papers published from 2012 onwards. We found that SWI had higher sensitivity than gradient echo MRI in detecting and characterizing microbleeds in TBIs and was able to differentiate diamagnetic calcifications from paramagnetic microhemorrhages. However, it is important that future research not only continues to evaluate the utility of SWI in TBIs but also attempts to overcome the limitations of the studies described in this review, which should help validate the conclusions and recommendations from our analysis.

Decompressive craniectomy at the National Hospital of Niamey: Prospective study of the epidemioclinical profile, indications, surgical techniques, and results in a context of limited resources.

Decompressive craniectomy (DC) is a neurosurgical technique that is gaining renewed interest due to the worldwide resurgence of head injuries. We aimed to analyze the quality of management and prognosis of patients who underwent this surgery in the context of limited resources. This was a prospective, longitudinal, descriptive, and analytical study following STROBE, lasting 36 months at the National Hospital of Niamey in patients who had undergone DC. P ≤ 0.05 was considered significant. During our study, we collected 74 cases of DC. The mean age was 32.04 years (10-75 years), with male predominance (91.89%). DC was mainly performed following head trauma (95.95%), the main cause of which was road traffic accidents (76%; 54/71). On admission, most patients presented with altered consciousness (95.95%) and pupillary abnormalities (62.16%). The average time between brain damage and brain scan was 31.28 h, with parenchymal contusion being the most frequent lesion (90.54%). The majority of patients (94.59%) underwent decompressive hemicraniectomy. Postoperative complications accounted for 71.62% of all cases, with 33.78% resulting in death. Among survivors, 55.10% had neurological sequelae at the last consultation (27/49). The main factors associated with the risk of death and morbidity were a Glasgow coma score ≤8, pupillary abnormality on admission, the presence of signs of brain engagement, and a long admission delay. Our study shows that the impact of limited resources on our care is moderate. Future research will concentrate on long-term monitoring, particularly focusing on the psychosocial reintegration of patients post-DC.

Post-Traumatic Pulmonary Pneumatoceles: A Case Report

Road accidents are the main cause of serious injuries worldwide, accounting for over 10% of trauma cases resulting in death or significant physical impairment. Thoracic injuries, on the other hand, are responsible for a quarter of all trauma-related deaths. In such cases, pneumothorax is the most common thoracic injury, affecting 30 to 40% of patients with thoracic trauma. This injury occurs twice as often in closed traumas as in penetrating traumas. However, post-traumatic pulmonary pneumatocele is a very rare condition that occurs mostly in children and young adults. It’s often a sequelae of acute pneumonia or barotrauma resulting from alveolar hyperpressure in the context of closed glottis trauma.
 Recognizing these injuries quickly can save lives, whether the patient is outside or in a modern intensive care unit.
 The reported case is an 8-year-old female child with no medical history, no delayed growth or development, who was involved in a public road accident with a thoracic impact. She presented with hemoptysis and chest pain, and a thoracic CT scan revealed bilateral pulmonary parenchymal contusions predominantly on the right, with post-traumatic pneumatoceles on the right side and a right pneumothorax blade, with good progress under surveillance, oxygen therapy, and prophylactic antibiotic treatment.

DIFFERENCES OF RIB FRACTURES IN BLUNT TRAUMA PATIENTS ACCORDING TO AGE AND GENDER: A COMPUTED TOMOGRAPHY STUDY

Objective
 To investigate the difference between rib fractures
 according to age and sex in blunt trauma patients.
 Material and Method
 The patients were classified into 3 age groups:
 Group-1:18-44 years, Group-2:45-69 years, and
 Group-3:70 years or more. Rib fractures were
 classified into 3 groups based on their level on the
 coronal plane (upper (1st-4th ribs), medium (5th-
 8th ribs) and lower (9th-12th ribs)) and axial plane
 (anterior, lateral and posterior).
 Results
 Rib fractures were found to be more common in male
 (69%) to female (53%) (p=0.002). The incidence of
 fractures was seen to increase with age (p=0.001;
 r=615). Rib fractures were most commonly found in
 the middle ribs (5th-8th ribs) in all-age-groups. The
 incidence of fractures in the upper ribs was significantly
 lower in the advanced age than the other age groups
 (p=0.002). Fractures were least commonly found in the
 anterior part of the rib in all age groups. Rib fractures
 were observed at a higher rate in the lateral part in
 young adults unlike the other age groups (p=0.001).
 A significant difference was found between the age
 groups in favor of young adults (group 1) in terms of
 the presence of parenchymal contusion without rib
 fracture (p=0.014).
 Conclusion
 Rib fracture was seen at a higher rate in male than
 female in blunt thoracic trauma patients. Fractures
 possibility of in the upper rib structures is lower in the
 advanced age group. Unlike other groups, in young
 people, a higher rate of fractures was detected in
 the lateral part of the costa. One should be aware of
 the possibility of parenchymal contusion without a rib
 fracture in the young age group.

Injuries in Underbody Blast Fatalities: Identification of Five Distinct Mechanisms of Head Injury.

Previous research has shown that injuries to the head and neck were prevalent in 73% of all mounted fatalities of underbody blast. The mechanisms that cause such injuries to the central nervous system (CNS) are not yet known. The aim of this study was to identify the head and spinal injuries in fatalities due to underbody blast (UBB) and then develop hypotheses on the causative mechanisms. All U.K. military fatalities from UBB with an associated head injury that occurred during 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Computed tomography post-mortems (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology classification. Pearson's chi-square and Fisher's exact tests were used to show a relationship between variables and form a hypothesis for injury mechanisms. There were 50 fatalities from UBB with an associated head injury. Of these, 46 had complete CTPMs available for analysis. Chi-square and Fisher's exact tests showed a relationship between lateral ventricle blood and injuries to the abdomen and thorax. Five partially overlapping injury constellations were identified: 1.multiple-level spinal injury with skull fracture and brainstem injury, 2.peri-mesencephalic hemorrhage, 3.spinal and brainstem injury, 4.parenchymal contusions with injury to C0-C1, and 5.an "eggshell" pattern of fractures from direct impact. These injury constellations can now be used to propose injury mechanisms to develop mitigation strategies or clinical treatments.

The effect of cryoprecipitate on prevention of intra cerebral hemorrhage and brain contusion expansion in traumatic patients.

Traumatic brain injury (TBI) is a general and socioeconomic complication and is one of the important causes of mortality and disability among young people in the world. Falling and violence and sports injuries are the other cause. It causes for about ten million new patients, accounting for 9% of all deaths. This interventional study aims to investigate the effects of early administration of cryoprecipitate to prevent expansion of intracranial hemorrhage. This randomized clinical trial recruited 54 non-pregnant patients. 27 patients in the control group and 27patients in the interventional group. For all patients, common and accepted procedures in scientific centers, including anticonvulsant drugs, normal saline and the other routine management was done and only for patients in the intervention group, 4 units of cryoprecipitate were added to their routine treatments; computed tomography scan (CT) scan was performed 48 hours later in both groups and finally the contusion size was compared in both groups. It was observed in the intervention group that by adding 4 units of cryoprecipitate to their treatments; they had no increased size of the brain parenchymal contusion according to the criteria defined in the study compared to the control group (OR: 0.08, 95% CI: 0.0102_0.6303). According to a clinical trial, it seems that cryoprecipitate can prevent of cerebral parenchymal hemorrhage expansion in traumatic patients.

Post-Trauma Combined Pulmonary Fat and Bone Embolism: Literature Review with Case Presentation

Following an accident in the workplace, a man received deep wounds in his left groin and left lower limb caused by plow blades. An external examination was carried out showing multiple, large, and deep slash injuries of the scrotal region, the left groin, and the left thigh. A complete autopsy was performed. The gross examination of the lungs showed edema and congestion, with some areas of parenchymal contusion and wide emphysema. The left femur showed complete, comminuted, displaced, and exposed fracture of its diaphyseal tract. Histopathological analysis was then carried out, showing unusual abnormalities in both lungs, with numerous endovascular drop-shaped fat globules with surrounding hematopoietic marrow that were mixed with small bone particles. The other organs did not show any signs that could explain the death. Given macroscopic and histopathological elements, the cause of death was ultimately identified as a traumatic shock with a high hemorrhagic component combined with pulmonary bone marrow and bone embolism. This paper aims to outline a rare case of post-trauma combined bone and bone marrow embolism. This occurrence is scantly described in the literature and should be considered in major trauma deaths. Therefore, in such cases, an accurate histopathological analysis should be mandatory to identify the correct cause of death and evaluate a possible medical liability.

Association of frontal and maxillary bone fractures and concomitant craniocerebral injuries in patients presenting with head trauma.

Maxillofacial fractures and craniocerebral injuries are common in patients with head trauma. These are injuries with high mortality and morbidity. Therefore, patients with head trauma should be evaluated early with a multidisciplinary approach. The association between frontal and maxillary bone fractures and concurrent craniocerebral injuries were investigated in patients presenting with head trauma in this study. The data of the patients were analyzed retrospectively. Age and gender distributions were evaluated in frontal and maxillary fractures. Concomitant craniocerebral injuries were investigated. Craniocerebral injuries were grouped as pneumocephalus, extra-axial, intra-axial injuries and brain edema. Craniocerebral injuries in frontal and maxillary fractures were compared statistically. Frontal bone and maxillary bone fractures were detected in 24% and 95% of the patients. Coexistence of pneumocephalus and intra-axial injuries in frontal bone fracture was statistically significant. The association of frontal posterior wall fractures with pneumocephalus and parenchymal contusion was found to be statistically significant. In addition, the association of craniocerebral injuries were evaluated and statistically significant ones were determined. The presence of maxillofacial fractures in patients presenting with head trauma increases mortality and morbidity. Craniocerebral injuries can be life-threatening and delay the treatment of facial fractures. Upper facial bone fractures are significantly more common in craniocerebral injuries.

WhatsApp as an Emergency Teleradiology Application for Cranial CT Assessment in Emergency Services

To evaluate the diagnostic agreement of transmitted images of cranial CT due to trauma, through WhatsApp software compared to workstation image-based diagnosis. Observational study. Department of Emergency Medicine, Adiyaman University Training and Research Hospital, from January 2017 to May 2018. A total of 94 cases that presented to the Emergency Department and underwent cranial CT were included in the study. CT images were video-recorded by the emergency physician using an Apple iPhone 7. The images were evaluated by two different radiologists using Samsung Galaxy Edge 7 and Samsung Note 8 mobile phones. Later, the radiological images were reviewed by two different radiologists at the PACS workstation. Then, the WhatsApp-mediated and final diagnoses were compared for various lesions to evaluate the interobserver agreement and diagnostic success of the use of WhatsApp software. In the assessment of the interobserver agreement, the kappa values were found to be 0.89 for normal findings, 0.84 for subdural hematoma, 0.73 for subarachnoid hemorrhage, 0.81 for epidural hematoma, 0.85 for fractures, 1 for parenchymal hematoma, and 0.68 for parenchymal contusion. Although WhatsApp can be used in the evaluation of emergency cranial CT images, it is essential to note that some findings, especially those indicating fractures, subdural hematoma, and parenchymal contusion, can be overlooked. Key Words: Teleradiology, PACS, Medical software, Computed tomography, WhatsApp, Instant Messenger.

Epidemiological and Clinico-radiological Evaluation of Head Injury in Pediatric Population.

ABSTRACTBackground:Head injury in infancy and childhood has been documented as the single most common cause of death. In India, children aged <15 years constitute 35% of the total population and contribute to 20–30% of all head injuries. In this study, we attempted to analyze the epidemiological factors, management, and outcome of traumatic brain injury (TBI). The objective of this study were to find the causes of head injury in children and its pattern of distribution in this population and to analyze the efforts required to prevent the injury and management focusing on limiting the progression of primary brain injury and minimizing secondary brain insult.Results:A total of 2714 patients with head injury were admitted at our hospital during the study period and, out of them, 508 (18.17%) were pediatric patients with age less than 18 years. Of the 508 patients, only 497 patients were included in this study. In the present study, 357 (71.83%) were males and 140 (28.16%) were females. In total, 351 cases were managed conservatively whereas surgical intervention was conducted in 146 cases (P < 0.001). In this study, the most common mode of injury was a road traffic accident (RTA) (46.88%; n=233), followed by fall from height (34.8%; n=173) (P < 0.001). It was also seen that epidural hematoma and fracture hematoma were the most common computed tomography findings in pediatric patients with head injury followed by parenchymal contusion or contusion with or without fracture followed by diffuse axonal injury. A total of 344 cases out of 497 cases were discharged with Glasgow outcome score (GOS)-5 whereas nine cases remained in a persistent vegetative state (GOS-2).Conclusion:Early intervention aimed at the primary lesion in TBI in children generally carries a good outcome, and limits as much as possible the ongoing biomechanical, physiological, and pathological sequelae post-TBI. In teenagers, the importance of proper self-care along with adequate safety gears while doing any TBI-prone activity should be emphasized.

Computed tomography features of traumatic pulmonary pseudocysts

Objectives: To discuss the radiological characteristics of traumatic pulmonary pseudocyst (TPP) detected by thorax computed tomography. Methods: Retrospective screening was made of 107 patients applied with thorax computed tomography due to blunt thoracic trauma between 2014 and 2017 at our hospital. Results: TPP was detected in 6 (5.6%) patients. The patients comprised 5 males and 1 female with a mean age of 28 years (range, 15-49 years). Blunt thorax trauma was caused by traffic accidents in 4 patients and a fall from height in 2 patients. Eleven (64.7%) of the lesions were located in the lower lobes. The most common finding associated with TPP was ground glass opacities, which were present in all of the patients and represented the parenchymal contusion. Conclusion: Thorax computed tomography is an effective and reliable method for early and definitive diagnosis of the rare development of TPP after blunt thoracic trauma.

Temporal lobe contusions on computed tomography are associated with impaired 6-month functional recovery after mild traumatic brain injury: a TRACK-TBI study

ABSTRACTIntroduction: Mild traumatic brain injury (MTBI) can cause persistent functional deficits and healthcare burden. Understanding the association between intracranial contusions and outcome may aid in MTBI treatment and prognosis.Methods: MTBI patients with Glasgow Coma Scale 13–15 and 6-month outcomes [Glasgow Outcome Scale-Extended (GOSE)], without polytrauma from the prospective TRACK-TBI Pilot study were analyzed. Intracranial contusions on computed tomography (CT) were coded by location. Multivariable regression evaluated associations between intracranial injury type (temporal contusion [TC], frontal contusion, extraaxial [epidural/subdural/subarachnoid], other-intraaxial [intracerebral/intraventricular hemorrhage, axonal injury]) and GOSE. Odds ratios (OR) are reported.Results: Overall, 260 MTBI subjects were aged 44.4 ± 18.1-years; 67.7% were male. Ninety-seven subjects were CT-positive and 46 had contusions (41.3%–frontal, 30.4%–temporal, 21.7%–frontal + temporal, 2.2% each-parietal/occipital/brainstem); 95.7% had concurrent extraaxial hemorrhage. Mortality was 0% at discharge and 2.3% by 6-months.GOSE distribution was 2.3%–death, 1.5%–severe disability, 27.7%–moderate disability, 68.5%–good recovery. Forty-six percent of TC-positive subjects suffered moderate disability or worse (GOSE ≤6) and 41.7% were unable to return to baseline work capacity (RTBWC), compared to 29.1%/20.4% for CT-negative and 26.1%/20.9% for CT-positive subjects without TC. On multivariable regression, TC associated with OR = 3.33 (95% CI [1.16–9.60], p = 0.026) for GOSE ≤6, and OR = 4.48 ([1.49–13.51], p = 0.008) for inability to RTBWC.Conclusions: Parenchymal contusions in MTBI are often accompanied by extraaxial hemorrhage. TCs may be associated with 6-month functional impairment. Their presence on imaging should alert the clinician to the need for heightened surveillance of sequelae complicating RTBWC, with low threshold for referral to services.

Mini-Pterional Craniotomy for Resection of Parasellar Meningiomas

Surgical resection of parasellar meningiomas is a challenging operation that traditionally has been performed with a large pterional or orbitozygomatic craniotomy. In this study, we report patient outcomes and detail our surgical approach when resecting these tumors with a smaller, less invasive "mini-pterional" craniotomy. We performed a retrospective review on all patients undergoing a mini-pterional craniotomy for resection of parasellar meningiomas from 2012 to 2016. We describe the technical aspects of the mini-pterional craniotomy and provide the outcomes of patients who received an operation with this approach. Twenty-four patients were treated with a mini-pterional craniotomy for resection of parasellar meningiomas. Median tumor volume was 6.2 cm3. Twenty-two of 24 (92%) patients had a World Health Organization grade I meningioma, and 2 of 24 (8%) patients had a World Health Organization grade II meningioma. Tumors were located at the medial sphenoid wing (60%), anterior clinoid (24%) and spheno-cavernous junction (12%). Nineteen of 24 (79%) patients had a Simpson Grade I resection and 5 of 24 (21%) a Simpson Grade IV resection. Median length of the operations was 242 minutes. Neurosurgical complications occurred in 2 patients who had a surgical-site infection and cerebrospinal fluid leak; one of these patients also developed postoperative hydrocephalus. In this series, no deaths, parenchymal contusions, or repeat operations occurred. The mini-pterional craniotomy can be used to resect parasellar meningiomas with good results and a low complication profile. This approach provides an efficacious method of resecting these tumors without sacrificing Simpson grade or patient safety.

A Prospective Study on Hyponatremia in Traumatic Brain Injury

<b>Background</b> Hyponatremia is the commonest electrolyte imbalance in traumatic brain injury (TBI) with a reported incidence of 15 to 20%. <b>Methodology</b> A prospective observational analytical study was conducted from January 2015 to December 2015. Mild and moderate TBI patients aged between 13 and 65 years, with no comorbid conditions were included in the study. Patients were monitored for hyponatremia, and etiology was found out using standard investigation protocol. <b>Results</b> A total of 153 patients were included in the study. Incidence of hyponatremia was 21.6% (33/153). Cerebral salt wasting syndrome was more common than syndrome of inappropriate secretion of antidiuretic hormone. Incidence was higher in patients with low Glasgow coma scale score (<i>p</i> = 0.001) and in patients with parenchymal contusions (<i>p</i> = 0.008). Incidence correlated well with Marshal computed tomography (CT) score (<i>p</i> = 0.013). No significant difference of incidence was noted in relation to age or gender. Patients with hyponatremia had significantly prolonged intensive care unit (<i>p</i> < 0.001) and hospital stay (<i>p</i> < 0.001). Outcome at discharge was worse in patients with hyponatremia (<i>p</i> = 0.002), whereas both groups had similar outcome at 3-month follow-up (<i>p</i> = 0.087). <b>Conclusions</b> Hyponatremia is a very common electrolyte imbalance in patients of TBI. Marshal CT grading and initial Glasgow coma scale score correlate well with the incidence of hyponatremia. More aggressive sodium monitoring may be required in parenchymal contusions in view of increased chance of development of hyponatremia. Hyponatremia adversely affect the immediate outcome in TBI, while long term outcome is usually unaffected.

Predictors of Hypopituitarism in Patients with Traumatic Brain Injury.

Hypopituitarism may often occur in association with traumatic brain injury (TBI). Identification of reliable predictors of pituitary dysfunction is of importance in order to establish a rational testing approach. We searched the records of patients with TBI, who underwent neuroendocrine evaluation in our institution between 2007 and 2013. One hundred sixty-six adults (70% men) with TBI (median age: 41.6 years; range: 18-76) were evaluated at a median interval of 40.4 months (0.2-430.4).Of these, 31% had ≥1 pituitary deficiency, including 29% of patients with mild TBI and 35% with moderate/severe TBI. Growth hormone deficiency was the most common deficiency (21%); when body mass index (BMI)-dependent cutpoints were used, this was reduced to 15%. Central hypoadrenalism occurred in10%, who were more likely to have suffered a motor vehicle accident (MVA, p = 0.04), experienced post-traumatic seizures (p = 0.04), demonstrated any intracranial hemorrhage (p = 0.05), petechial brain hemorrhages (p = 0.017), or focal cortical parenchymal contusions (p = 0.02). Central hypothyroidism occurred in 8% and central hypogonadism in 12%; the latter subgroup had higher BMI (p = 0.03), were less likely to be working after TBI (p = 0.002), and had lower Global Assessment of Functioning (GAF) scores (p = 0.03). Central diabetes insipidus (DI) occurred in 6%, who were more likely to have experienced MVA (p < 0.001) or sustained moderate/severe TBI (p < 0.001). Patients with MVA and those with post-traumatic seizures, intracranial hemorrhage, petechial brain hemorrhages, and/or focal cortical contusions are at particular risk for serious pituitary dysfunction, including adrenal insufficiency and DI, and should be referred for neuroendocrine testing. However, a substantial proportion of patients without these risk factors also developed hypopituitarism.

Conséquences fatales de l’ouverture d’un « airbag » chez un nourrisson. Un danger méconnu ?

We report the case of an 8-month-old baby killed by the deployment of an airbag. He was correctly positioned, in a safety seat designed for his age class, on the passenger side, and rear-facing. The accident occurred at low speed, on the left front of the car, without provoking any harm to the mother who was driving the vehicle, but the impact led to airbag deployment. A CT scan showed an occipital fracture, hemorrhagic parenchymal contusions, subarachnoid hemorrhage and edema, which quickly led to fatal intracranial hypertension. Severe retinal hemorrhages were also noted. Brain death was declared 24h later. Both direct impact and violent projection of the head are involved in the severity of brain lesions. Retinal hemorrhages are similar to what is observed in shaken-baby syndrome. To our knowledge, this is the first French publication on this topic in childhood. In France, children are allowed to be positioned on the passenger side seat, but the airbag, if present, is supposed to be deactivated, which is not always possible. In recent cars, depowering the airbag is easy, with on/off switches, but these systems are not uniform between models. Moreover, it is very likely that this possibility is ignored by numerous parents. A widespread communication on this topic should be initiated in France to prevent such events. Banning infants from front passenger seats completely does not seem possible. Nevertheless, greater attention on the part of police departments and better information to drivers appear necessary.

Traumatic brain injuries: the influence of the direction of impact.

Head impact direction has been identified as an influential risk factor in the risk of traumatic brain injury (TBI) from animal and anatomic research; however, to date, there has been little investigation into this relationship in human subjects. If a susceptibility to certain types of TBI based on impact direction was found to exist in humans, it would aid in clinical diagnoses as well as prevention methods for these types of injuries. To examine the influence of impact direction on the presence of TBI lesions, specifically, subdural hematomas, subarachnoid hemorrhage, and parenchymal contusions. Twenty reconstructions of falls that resulted in a TBI were conducted in a laboratory based on eyewitness, interview, and medical reports. The reconstructions involved impacts to a Hybrid III anthropometric dummy and finite element modeling of the human head to evaluate the brain stresses and strains for each TBI event. The results showed that it is likely that increased risk of incurring a subdural hematoma exists from impacts to the frontal or occipital regions, and parenchymal contusions from impacts to the side of the head. There was no definitive link between impact direction and subarachnoid hemorrhage. In addition, the results indicate that there is a continuum of stresses and strain magnitudes between lesion types when impact location is isolated, with subdural hematoma occurring at lower magnitudes for frontal and occipital region impacts, and contusions lower for impacts to the side. This hospital data set suggests that there is an effect that impact direction has on TBI depending on the anatomy involved for each particular lesion.

Pediatric MRI of the Brain: A Primer

1. Kamakshya P. Patra, MD* 2. Jeffrey D. Lancaster, MD* 3. Jeffery Hogg, MD† 4. Jeffrey S. Carpenter, MD† 1. *Department of Pediatrics, Section of Hospital Pediatrics, West Virginia University Children’s Hospital, Morgantown, WV. 2. †Department of Neuroradiology, West Virginia University Health Sciences Center, Morgantown, WV. * Abbreviations: ADHD: : attention-deficit/hyperactivity disorder CSF: : cerebrospinal fluid CT: : computed tomography DWI: : diffusion-weighted magnetic resonance imaging FLAIR: : fluid-attenuated inversion recovery fMRI: : functional magnetic resonance imaging MRI: : magnetic resonance imaging MRV: : magnetic resonance venography NAA: : N -acetylaspartate SDH: : subdural hematoma Because of recent advances in magnetic resonance imaging (MRI) techniques, pediatricians should be aware of the different modalities and their unique advantages and appropriateness in different clinical situations. After completing this article, readers should be able to: 1. Understand the pros and cons of MRI and computed tomography of the brain. 2. Know the basic principles of MRI and its different image modalities. 3. Be aware of the appropriateness of different modalities in specific clinical situations. Magnetic resonance imaging (MRI) is based on the absorption and emission of radiofrequency energy by hydrogen protons whose spin is influenced by changing magnetic fields (0.3 to 1.5 T). Unlike computed tomography (CT), there is no radiation exposure. T1-weighted images cause fat (eg, myelin in white matter) to appear bright and water (eg, cerebrospinal fluid [CSF] or edema) to appear dark on this sequence. The gray-white interfaces of the brain are well depicted on these sequences, especially if with the images are thinly sliced. T2-weighted images cause water (eg, CSF and edema) to appear bright and fat to appear dark. The MRI-based intravenous contrast agents (eg, gadolinium) are frequently used in T1-weighted images (Fig 1A and B) to make serum appear bright. The blood-brain barrier typically serves to limit the passage of many molecules out of the blood vessels. If disease processes break down this barrier (such as infection, tumors, or inflammation), intravenous contrast agents can cross into the brain, causing areas of contrast entry to appear very bright. Figure 1. T1-weighted image at the level of midbrain. A. The cerebrospinal fluid (CSF) appears dark. B. The CSF appears bright. Note the gray and white matter differentiation …