Penetrating Brain Injury Research Articles

Non-visible penetrating brain trauma: a case report

Objective: One of the most frequent causes of death and acquired disability in the pediatric population is the Traumatic Brain Injury (TBI). TBI is secondary to falls, road traffic and vehicle collisions, child abuse and assaults. Penetrating brain injury is a severe form of traumatic brain injury. Blunt head injury is more frequent than TBI in children, but the second one carries a poor prognosis and a worse outcomes. Case Presentation: We report a pediatric case of penetrating craniofacial trauma, caused by a pencil in to the eye, and the successful of multidisciplinary management. Conclusion: Traumatic head injuries in children are frequently seen in the emergency ward, but the penetrating head injuries are unusual in young children. This case shows the importance of the ‘first golden hour’ after head trauma. The collaboration between team members, added to a promptly and invasive strategy, allowed to reduce neurological sequelae.

Prognostic factors of intracranial purulent-septic complications of combat-related gunshot penetrating skull and brain wounds.

Purpose – to ana­lyze the structure of intracranial purulent-septic complications (IPSC), determine the factors influencing development of purulent-septic complications in patients with combat-related gunshot penetrating skull and brain wounds (CRPSBW), determine the effect of intracranial PSC on patients’ outcomes. A prospective analysis of results of exa­mination and treatment of 121 patients was performed. All patients had gunshot penetrating skull and brain wounds sustained in combat conditions during a local armed conflict in the Eastern Ukraine. Evaluation of treatment outcome included analysis of mortality in 1 month (survived/died) and dichotomous Glasgow Outcome Scale (GOS) score in 12 months (favorable/unfavorable outcome). 121 wounded men aged 18 to 56 (average, 34.1±9.1) were included in the study. Intracranial purulent-septic complications (IPSC) were diagnosed in 14 (11.6%) gunshot CRPSBW patients. The following prognostic factors had statistically significantly correlation with the risk of intracranial purulent-septic complications development: wound liquorrhea on admission (p = 0.043), intraventricular hemorrhage (p = 0.007), bone fragments left in the wound (p = 0.0152), and duration of inflow-outflow wound drainage for more than 3 days (p= 0.0123). Intracranial PSC patients had mortality rate of 50%, and only 14.3% of those patients had a favorable outcome according to GOS score in one year. Presence of intracranial PSC had statistically significant association with mortality rate (p=0.0091) and GOS score in one year (p=0.0001).

Commentary: Multicenter Validation of the Survival After Acute Civilian Penetrating Brain Injuries (SPIN)-Score.

Commentary: Multicenter Validation of the Survival After Acute Civilian Penetrating Brain Injuries (SPIN)-Score.

Multicenter Validation of the Survival After Acute Civilian Penetrating Brain Injuries (SPIN) Score.

Civilian penetrating traumatic brain injury (pTBI) is a serious public health problem in the United States, but predictors of outcome remain largely understudied. We previously developed the Survival After Acute Civilian Penetrating Brain Injuries (SPIN) score, a logistic, regression-based risk stratification scale for estimating in-hospital and 6-mo survival after civilian pTBI with excellent discrimination (area under the receiver operating curve [AUC-ROC=0.96]) and calibration, but it has not been validated. To validate the SPIN score in a multicenter cohort. We identified pTBI patients from 3 United States level-1 trauma centers. The SPIN score variables (motor Glasgow Coma Scale [mGCS], sex, admission pupillary reactivity, self-inflicted pTBI, transfer status, injury severity score, and admission international normalized ratio [INR]) were retrospectively collected from local trauma registries and chart review. Using the original SPIN score multivariable logistic regression model, AUC-ROC analysis and Hosmer-Lemeshow goodness of fit testing were performed to determine discrimination and calibration. Of 362 pTBI patients available for analysis, 105 patients were lacking INR, leaving 257 patients for the full SPIN model validation. Discrimination (AUC-ROC=0.88) and calibration (Hosmer-Lemeshow goodness of fit, P value=.58) were excellent. In a post hoc sensitivity analysis, we removed INR from the SPIN model to include all 362 patients (SPINNo-INR), still resulting in very good discrimination (AUC-ROC=0.82), but reduced calibration (Hosmer-Lemeshow goodness of fit, P value=.04). This multicenter pTBI study confirmed that the full SPIN score predicts survival after civilian pTBI with excellent discrimination and calibration. Admission INR significantly adds to the prediction model discrimination and should be routinely measured in pTBI patients.

Internal Carotid Artery Dissection with Traumatic Pseudoaneurysm Formation after Penetrating Head Injury

Internal Carotid Artery Dissection with Traumatic Pseudoaneurysm Formation after Penetrating Head Injury

Post-Traumatic Epilepsy and Seizure Susceptibility in Rat Models of Penetrating and Closed-Head Brain Injury.

Traumatic brain injury (TBI) carries a risk of developing post-traumatic epilepsy (PTE). Currently, animal models that replicate clinical PTE (delayed spontaneous and recurrent seizures) are limited, which hinders pre-clinical research. In this study, we used two rat models of penetrating ballistic-like brain injury (PBBI) and closed-head injury (CHI) to induce spontaneous seizures and also measure changes in seizure susceptibility. In the PBBI model, two trajectories (frontal and lateral) and two injury severities for each trajectory, were evaluated. In the CHI model, a single projectile impact to the dorsal/lateral region of the head was tested. Continuous video-electroencephalographic (EEG) recordings were collected for 10 days at 1 or 6 month(s) post-injury. After EEG recording, all rats were given a sub-convulsant dose of pentylenetetrazole (PTZ) to challenge the seizure susceptibility. The video-EEG recording did not detect PTE following the PBBI. Only one CHI rat demonstrated persistent and recurrent non-convulsive seizures detected at 6 months post-injury. However, after PTZ challenge, 50-100% of the animals across different TBI groups experienced seizures. Seizure susceptibility increased over time from 1 to 6 months post-injury across the majority of TBI groups. Injury severity effects were not apparent within the PBBI model, but were evident between PBBI and CHI models. These results demonstrated the difficulties in detecting delayed spontaneous post-traumatic seizures even in a high-risk model of penetrating brain injury. The PTZ-induced increase in seizure susceptibility indicated the existence of vulnerable risk of epileptogenesis following TBI, which may be considered as an alternative research tool for pre-clinical studies of PTE.

Deceased Donor Organ Transplantation Rates Following Blunt and Penetrating Head Trauma

Journal of the American College of Surgeons 229(4):p e223-e224, October 2019. | DOI: 10.1016/j.jamcollsurg.2019.08.1341

Development and Validation of a Nomogram for Predicting the Mortality after Penetrating Traumatic Brain Injury.

Objective:To determine the factors associated with mortality in penetrating brain injury (PTBI) and proposed the nomogram predicting the risk of death. Methods:A retrospective cohort study was conducted on all patients who had sustained PTBI between 2009 and 2018. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factors analysis was conducted using a forest plot. Therefore, the nomogram was developed and validated. For the propose of evaluation, the nomogram’s sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operating Characteristic (ROC) curve and the area under the receiver operating characteristic (AUC) were determined for validating the optimal cut-off point of the total scores. Results:During the study period, 62 individuals enrolled. In the univariate analysis, factors associated with the morality were normal pupils’ reactivity to light (OR 0.04, p < 0.001), hypotension (OR 9.91, p<0.001), hypoxia (OR 10.2, p=0.04), bihemispheric injuries (OR 19.0, p=0.001), multilobar injuries (OR 21.5, p< 0.001), subarachnoid hemorrhage (OR 6.9, p= 0.02), intraventricular hemorrhage (OR 26.6, p= 0.006), basal cistern effacement (OR 28.8, , p<0.001), midline shift >5 mm (OR 0.19, p<0.001) were significantly associated with death. In multivariable analysis, hypotension (OR 8.82, p=0.03), normal pupils’ reactivity to light (OR 0.07, p =0.01), midline shift >5 mm (OR 18.23, p<0.007) were significantly associated with death. The nomogram’s sensitivity, specificity, PPV, NPV, and AUC for predicting mortality (total score ≥ 100) were 80%, 92.6%, 72.7%, 95.0%, and, 0.86 respectively. Conclusions:PTBI is the fatal injury depend on both clinical and neuroimaging parameters. The nomogram is the alternative method providing prognostic parameters toward implication for clinical decision making.

Presentación sincrónica de tumor epidermoides intracraneal y absceso cerebral. Reporte de un caso

Introducción: Un paciente con tumor epidermoides intracraneal extradural con presentación sincrónica con absceso cerebral, sin antecedentes de trauma craneal penetrante, no ha sido reportado con anterioridad en la revisión del tema realizada por los autores. Se presenta un caso con estas características y se exponen consideraciones sobre el diagnóstico y el tratamiento. Caso clínico: Paciente femenina, de 48 años de edad, con antecedentes de cefalea crónica y tumor craneal palpable en región frontal izquierda. Los estudios humorales fueron normales. La RNM craneal mostró dos imágenes en anillo yuxtapuestas, extra e intraaxial de forma respectiva. En la cirugía se encontró tumor perlado extradural sin evidencia a la inspección de tumor intradural, se comprobó en el examen histopatológico tumor epidermoides. En los controles imagenológicos posoperatorios se descubrió la persistencia de la lesión intraaxial, en anillo, frontal izquierda. Una segunda cirugía evidenció un absceso cerebral de ubicación subcortical y se efectuó la resección radical. La evolución fue favorable, sin secuelas después de cuatro meses de seguimiento. Conclusiones: Se reportó un caso infrecuente, donde se presentó de forma sincrónica un tumor epidermoides extradural frontal izquierdo y absceso cerebral frontal ipsilateral, sin relación de continuidad ni comunicación fistulosa demostrada en las neuroimágenes ni en la exploración quirúrgica.

Trauma intracraneal penetrante trans-orbitario: Anatomía relevante, las dinámicas del trauma y los puntos clave para el tratamiento

Las lesiones intracraneales penetrantes trans-orbitarias representan pocos casos de todos los Traumas Craneo-encefálicos, sin embargo, representan del 25 al 50% de todos los traumas penetrantes craneales. Este tipo de traumas trans-orbitarios se han reportado por diferentes tipos de objetos, incluyendo objetos de metal y de madera. Muchos de estos traumas intracraneales pueden pasar desapercibidos en casos donde el material que ingresa no queda expuesto posterior al trauma y cuando no se presenta lesión neurológica que requiera examinación exhaustiva adicional con neuro-imágenes.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas: Erratum.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas: Erratum.

Ocular changes in traumatic brain injury: A review.

Traumatic brain injury is represented by a penetrating or non-penetrating head injury, which causes disruption in the normal functioning of the brain. Traumatic brain injury has been an ardently debated topic of discussion due to its prevalence in media centric persons such as military personnel and athletes. Current assessments for traumatic brain injury have looked at vestibulo-ocular and vascular parameters to aid in diagnosis. Innovations in non-invasive ophthalmic imaging have allowed for the visualization of specific tissue structure/function relationships in a variety of ophthalmic and neurodegenerative diseases. As the eye and brain share significant embryological and physiological pathways, ocular imaging modalities may provide a novel and impactful tool in advancing assessment of traumatic brain injury. Herein, we examined the available literature and data on visual fields, mean retinal nerve fiber layer thickness, retinal ganglion cell layer thickness, and cerebral blood flow following traumatic brain injury. This review of published individual and population-based studies was performed in order to explore the feasibility and importance of considering ocular imaging biomarkers following traumatic brain injury.

Non-missile penetrating brain injuries: cases registry in Sohag University Hospital

BackgroundNon-missile penetrating brain injuries are rarely seen in the surgical practice and few international literatures’ reported case reports or small case series, and it comprises a small percentage of head trauma cases. We reported a group of 18 cases of penetrating injuries with different tools and various mechanisms. We reported their epidemiological criteria, mechanism of trauma, complications, and their prognosis.AimThe purpose of this study is to report different patients’ criteria and the method of trauma and the prognosis.Patients and methodsA retrospective study was done in Trauma unit, Sohag University, between November 2012 and October 2014. Eighteen patients were reported with different mechanisms of trauma. All patients were clinically tested and subjected to CT brain. Cautious removal of the penetrating object with debridement of surrounding tissues was done. Patients were transferred to ICU for 48–72 h.ResultsPatients were subjected to operative intervention, and they were followed up for 3 years. Males were the predominant gender, 13 cases (72.2%), and the young age was higher than the elderly. The Glasgow outcome score was 15 in 13 patients and was 4 in five patients. Transient epileptic fits occurred in six patients and controlled on anti-epileptic drugs. Five patients had a neurological deficit in the form of hemiparesis or monoparesis.ConclusionPenetrating head injuries, although rare, are dangerous and should be cautiously managed and monitored in the ICU. The prognosis depends mainly on initial GCS and ventricular involvement, but in general, the prognosis is favorable.Trial registrationIRB#3747 Registered 27/08/2017

Reliability and stability of the metrical stress effect on segmental production accuracy in persons with apraxia of speech.

Acquired apraxia of speech (AOS) involves speech-production deficits on both the segmental and suprasegmental levels. Recent research has identified a non-linear interaction between the metrical structure of bisyllabic words and word-production accuracy in German speakers with AOS, with trochaic words (strong-weak stress) being resistant to errors compared with iambic words (weak-strong). To replicate previous findings in English speakers with AOS, to measure the test-retest reliability of the effect, and to examine the potential impact of different methods of word scoring. Speech samples were collected from 27 speakers with AOS and aphasia. Participants were at least 12 months post-stroke or penetrating brain injury, and represented a large range of AOS and aphasia severities. Productions were elicited via verbal model. Sampling was conducted on three separate occasions: the initial data-collection session and then repeated samplings at 1- and 4-week intervals. Bisyllabic words with a CVCVC segmental structure were selected. The list was divided into sublists representing differing lexical stress patterns: A list of 42 trochees, and one of 37 iambs. All speech samples were phonetically transcribed and then aligned with canonical transcriptions via an edit distance algorithm that followed transcription alignment principles. Phonetic-level errors (distortions) were penalized less severely than phonemic-level errors. Per cent consonants correct and whole-word accuracy were also examined. Trochee and iamb lists were analysed separately. Paired samples t-tests indicated that the modified edit distance was significantly lower for the trochee lists than for the iamb lists. There was a lack of a significant effect of time on the absolute difference between modified edit distance for both lists. Intraclass coefficients suggested the list and procedures used are appropriate as an outcome measure for group research. The results suggest that in English, as in German, the trochaic structure is more resistant to segmental errors in persons with AOS and aphasia, providing replication of the findings of Aichert etal. in 2016. Further, this effect is stable over repeated sampling occasions. Implications for clinical management of AOS include possible ways to scaffold item difficulty and potentially improve stimulus generalization.

Factors affecting the outcome in surgically treated civilian penetrating head injury: Case series

Penetrating brain injury (PBI) is any injury that causes penetration of the scalp, skull, meninges, and brain. It is a traumatic brain injury caused by either low-velocity sharp objects (e.g. a knife), high-velocity projectiles (shell fragment or bullets) or blast injury is the consequence of the detonation of complex explosives with or without PBI and closed head injury. To evaluate the factors (pre-operative and operative) that affect the surgical outcome of civilian PBI. This study was done from February 2017 to October 2018 prospectively &amp; retrospectively. The study involved only the civilian patients that got a penetrating head injury and surgically treated in Neurosurgical Teaching Hospital/Baghdad/Iraq. The data include thirty-nine (39) operated patients with PBI. Data information includes the Glasgow Coma Scale (GCS), radiological investigations (computerized tomov graphy (CT-scan) and plain X-ray) the outcome determined by Glasgow Outcome Score (GOS). The patients were followed up during the time of hospitalization. The surgical outcome of the penetrating head injury in this study was assessed by GOS and was as follow, good recovery 10 patients (25.6%), moderately disabled 11 patients (28.2%), severely disabled 5 patients (12.8%), vegetative 6 patients (15.4%), Dead 7 patients (18.0%). Good outcome 21 patients 53.8% while poor outcome 18 patients 46.2%. GCS is significant factor (p-value = 0.002), time not affecting, CT-finding is significant factor (p-value = 0.000), blood pressure &gt;= 90 mm Hg is a good predictor factor (p-value =0.001), speech difficulty is poor predictor factor (p-value = 0.004), outcome of inlet alone better than inlet and outlet. There are many factors affecting the surgical outcome in civilian penetrating head injury, and the significant factor is pre-operative GCS, CT-scan which is the best radiological investigation for pre-operative and post-operative assessment and show the details of the injury, blood pressure &gt; = 90 mm Hg which is a good prognostic factor.

Fencing unmasked: A case of penetrating cranio-orbital injury

Introduction: Transorbital low-velocity penetrating head injuries are uncommon but important. Minor skin wounds may herald intracranial injury with high morbidity and mortality. Case presentation: A fencing coach was pierced by a sabre between his nose and right eye resulting in orbital roof fracture and frontal lobe laceration. With prompt recognition of these injuries under multidisciplinary management, he attained uncomplicated recovery. Conclusion: The emergency physician should maintain a high index of suspicion for intracranial injury in patients presenting with history of penetrating head injury. Understanding orbital anatomy, injury mechanisms and patterns can facilitate timely management to prevent potentially sight-threatening and life-threatening complications.

Spatiotemporal dynamics of PDGFRβ expression in pericytes and glial scar formation in penetrating brain injuries in adults.

AimsUnderstanding the spatiotemporal dynamics of reactive cell types following brain injury is important for future therapeutic interventions. We have previously used penetrating cortical injuries following intracranial recordings as a brain repair model to study scar‐forming nestin‐expressing cells. We now explore the relationship between nestin‐expressing cells, PDGFRβ+ pericytes and Olig2+ glia, including their proliferation and functional maturation.MethodsIn 32 cases, ranging from 3 to 461 days post injury (dpi), immunohistochemistry for PDGFRβ, nestin, GFAP, Olig2, MCM2, Aquaporin 4 (Aq4), Glutamine Synthetase (GS) and Connexin 43 (Cx43) was quantified for cell densities, labelling index (LI) and cellular co‐expression at the injury site compared to control regions.Results PDGFRβ labelling highlighted both pericytes and multipolar parenchymal cells. PDGFRβ LI and PDGFRβ+/MCM2+ cells significantly increased in injury Zones at 10–13 dpi with migration of pericytes away from vessels with increased co‐localization of PDGRFβ with nestin compared to control regions (P < 0.005). Olig2+/MCM2+ cell populations peaked at 13 dpi with significantly higher cell densities at injury sites than in control regions (P < 0.01) and decreasing with dpi (P < 0.05). Cx43 LI was reduced in acute injuries but increased with dpi (P < 0.05) showing significant cellular co‐localization with nestin and GFAP (P < 0.005 and P < 0.0001) but not PDGFRβ.ConclusionsThese findings indicate that PDGFRβ+ and Olig2+ cells contribute to the proliferative fraction following penetrating brain injuries, with evidence of pericyte migration. Dynamic changes in Cx43 in glial cell types with dpi suggest functional alterations during temporal stages of brain repair.

The Skin Findings Associated with Neurotrauma

Head trauma is a common condition, but often, serious pathological conditions associated with it are hidden. Skin findings in child abuse cases, such as skull base fracture, battle signs, raccoon eye, open head injury, penetrating wounds, traumatic aneurysm of the superficial temporal artery, traumatic carotid cavernous sinus fistula, and fat embolism have been presented in this paper. It is necessary to observe and record skin findings at the time of consultation and to listen to the detailed medical history that resulted in such an injury. It is important to comprehensively diagnose skin findings through medical history, and image inspection.

Brain tissue saving effects by single-dose intralesional administration of Neuroprotectin D1 on experimental focal penetrating brain injury in rats

Traumatic brain injury (TBI) is followed by a secondary inflammation in the brain. Neuroprotectin D1 (NPD1) is synthesized from docosahexaenoic acid (DHA) and has anti-inflammatory and antiapoptotic effects in experimental models of neurodegenerative disease and brain ischemia-reperfusion. It is not known whether intralesional administration of NPD1 ameliorates inflammation and cell death after severe TBI. We therefore investigated the effects of NPD1 following a severe form of focal penetrating TBI. A total of 30 male Sprague-Dawley rats weighing between 350 and 450 g were exposed to focal penetrating TBI or sham surgery. The rats were randomized to NPD1 treatment (50 ng intralesionally, immediately following TBI) or no treatment. The rats were sacrificed at 24 or 72 h. All subgroups consisted of 5 rats. Brains were removed, fresh frozen, cut in 14-µm coronal sections and subjected to Fluoro-Jade, TUNEL, MnSOD, 3-NT, COX-2, Ox-42 and NF-κB immuno-staining and lesion size analyses. NPD1 decreased the lesion area at 72 h compared to no treatment with a mean change 42% (NPD1 14.1 mm2; no treatment 24.5 mm2) (p < 0.01). No difference was detected in markers for neuronal degeneration, apoptosis, anti-inflammatory or antioxidative enzymes, or immune cells. In conclusion, single-dose intralesional administration of NPD1 had brain tissue sparing effects after focal penetrating TBI, which may be beneficial in preventing brain tissue damage, making NPD1 a potential candidate for further clinical applications. Exact mechanisms of action could not be determined and it is possible that continuous or multiple administration regimens may increase efficacy in sequential preclinical studies.

The identification of key factors predictive of traumatic brain injury in paediatric patients with a minor blunt head injury

Introduction: Traumatic brain injury (TBI) is a major public health concern, and contributes significantly to mortality and morbidity in paediatric patients. Objective: The study is aimed to identify the factors predictive of TBI in paediatric patients with a minor blunt head injury. Methods: This was a retrospective cohort study conducted on 274 paediatric patients with a minor head injury and registered to Hospital Universiti Sains Malaysia (USM) from the year 2009 to 2013. Patients with a minor blunt head injury aged less than 18 years who underwent computed tomography (CT) of the brain were included, while the patients with penetrating head injuries were excluded from the study. Simple and multiple logistic regression analysis were performed. Results: TBI occurred in 49% of the patients. Headache (adjusted odd ratio (AOR): 2.24; 95% confidence interval (CI): 1.24, 4.05, p = 0.008), dizziness (AOR: 3.08, 95% CI: 1.27, 7.51, p = 0.013) and the presence of scalp haematoma (AOR: 2.93, 95% CI: 1.60, 5.34, p &lt; 0.001) were the most important clinical variables for predicting TBI following a minor blunt head injury in paediatric populations. Conclusion: Headache, dizziness and scalp haematoma were identified as important clinical variables that can be used to predict TBI on a CT scan of paediatric minor head injury. The presence of these factors should alert emergency physicians to the need to monitor such children closely.