Temporal Contusion Research Articles

Automated Measurement of Cerebral Hemorrhagic Contusions and Outcomes After Traumatic Brain Injury in the TRACK-TBI Study

Because withdrawal of life-sustaining therapy based on perceived poor prognosis is the most common cause of death after moderate or severe traumatic brain injury (TBI), the accuracy of clinical prognoses is directly associated with mortality. Although the location of brain injury is known to be important for determining recovery potential after TBI, the best available prognostic models, such as the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) score, do not currently incorporate brain injury location. To test whether automated measurement of cerebral hemorrhagic contusion size and location is associated with improved prognostic performance of the IMPACT score. This prognostic cohort study was performed in 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018. Adult participants aged 17 years or older from the US-based Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study with moderate or severe TBI (Glasgow Coma Scale score 3-12) and contusions detected on brain computed tomography (CT) scans were included. The data analysis was performed between January 2023 and February 2024. Labeled contusions detected on CT scans using Brain Lesion Analysis and Segmentation Tool for Computed Tomography (BLAST-CT), a validated artificial intelligence algorithm. The primary outcome was a Glasgow Outcome Scale-Extended (GOSE) score of 4 or less at 6 months after injury. Whether frontal or temporal lobe contusion volumes improved the performance of the IMPACT score was tested using logistic regression and area under the receiver operating characteristic curve comparisons. Sparse canonical correlation analysis was used to generate a disability heat map to visualize the strongest brainwide associations with outcomes. The cohort included 291 patients with moderate or severe TBI and contusions (mean [SD] age, 42 [18] years; 221 [76%] male; median [IQR] emergency department arrival Glasgow Coma Scale score, 5 [3-10]). Only temporal contusion volumes improved the discrimination of the IMPACT score (area under the receiver operating characteristic curve, 0.86 vs 0.84; P = .03). The data-derived disability heat map of contusion locations showed that the strongest association with unfavorable outcomes was within the bilateral temporal and medial frontal lobes. These findings suggest that CT-based automated contusion measurement may be an immediately translatable strategy for improving TBI prognostic models.

Non Decompressive Single Stage Bilateral Craniotomy in Traumatic Brain Injury

Background and Aim: There is a substantial morbidity and mortality associated with traumatic brain injury (TBI). TBI still results in cerebral edema, which increases intracranial pressure (ICP) and reduces cerebral perfusion pressure (CPP) after traumatic brain injury (TBI). The purpose of this study was to evaluate the non-decompressive single stage bilateral craniotomy (SSBC) in traumatic brain injury. Patients and Methods: This prospective study was conducted on 44 TBI cases undergoing non decompressive single stage bilateral craniotomy (SSBC) in Neurosurgery Department of Prime Teaching Hospital, Peshawar from January 2022 to June 2022. All the patients underwent computed tomogram images and those fulfilling the inclusion criteria were enrolled. Demographic details, background parameters, measurement of intracranial pressure (ICP), and outcome were recorded. Results: Of the total 44 TBI patients, 32 (72.7%) were male and 12 (27.3%) were females. Age-wise distribution of patients were as follows: 3 (6.8%) in <20 years, 10 (22.7%) in 21-40 years, 16 (36.4%) in 41-60 years, 11 (25%) in 61-80 years, and 4 (9.1%) in >80 years. Glasgow comma scale at the time of admission and discharge were compared. Bilateral Csdh was the most prevalent diagnosis found in 16 (36.4%) patients followed by Bifrontal contusion 9 (20.5%), Bifrontal Edh with contralateral contusion 6 (13.6%), Bifrontal Edh 6 (13.6%), Bilateral temporal contusion 4 (9.1%), Unilateral Asdh with Contralateral Edh 2 (4.5%), and Bilateral Fronto-parietal Edh 1 (2.3%). Outcome of the non-decompressive SSBC in TBI were as follows: LAMA 5 (11.4%), discharged 28 (63.6%), Chest infection and tracheostomy 5 (11.4%), and expired 6 (13.6%) respectively. Conclusion: Our study concluded that male patients were more vulnerable to traumatic brain injury. Majority of the cases belonged to the age group 41-60 years. Non-decompressive single stage bilateral craniotomy is an effective, reliable, and economical procedure to manage traumatic brain injury patients. Single anesthesia along with single incision, shorter hospital stay, and postoperative management similar to unilateral procedure were the major advantages of non-decompressive SSBC. Keywords: Traumatic brain injury, Surgical treatment, Non-decompressive SSBC

Extracting the communication profile of a patient who underwent right Fronto-Temporo-Parietal decompressive craniotomy post Traumatic brain injury

Traumatic brain injury is one of the leading causes for cognitive-linguistic impairments in individuals. Considering cerebral lateralization, the type of communication impairments does depend on the hemisphere that is damaged. The current study reports about a 26-year-old female who has underwent right fronto-temporo-parietal (FTP) craniotomy and evacuation of acute subdural hematoma, followed by left FTP decompressive craniotomy and conservative evacuation of the left temporal contusion. A detailed assessment focussing on the linguistic, cognitive, and speech skills were done using formal and informal measures. Bangladesh Journal of Medical Science Vol. 21 No. 02 April’22 Page : 422-425

Predicting Neurological Deterioration after Moderate Traumatic Brain Injury: Development and Validation of a Prediction Model Based on Data Collected on Admission.

Moderate traumatic brain injury (mTBI) is a heterogeneous entity that is poorly defined in the literature. Patients with mTBI have a high rate of neurological deterioration (ND), which is usually accompanied by poor prognosis and no definitive methods to predict. The purpose of this study is to develop and validate a prediction model that estimates the ND risk in patients with mTBI using data collected on admission. Data for 479 patients with mTBI collected retrospectively in our department were analyzed by logistic regression models. Bivariable logistic regression identified variables with a p < 0.05. Multi-variable logistic regression modeling with backward stepwise elimination was used to determine reduced parameters and establish a prediction model. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated. The prediction model was validated using data for 176 patients collected from another hospital. Eight independent prognostic factors were identified: hypertension, Marshall scale (types III and IV), subdural hemorrhage (SDH), location of contusion (frontal and temporal contusions), Injury Severity Score >13, D-dimer level >11.4 mg/L, Glasgow Coma Scale score ≤10, and platelet count ≤152 × 109/L. A prediction model was established and was shown as a nomogram. Using bootstrapping, internal validation showed that the C-statistic of the prediction model was 0.881 (95% confidence interval [CI]: 0.849-0.909). The results of external validation showed that the nomogram could predict ND with an area under the curve of 0.827 (95% CI: 0.763-0.880). The present model, based on simple parameters collected on admission, can predict the risk of ND in patients with mTBI accurately. The high discriminative ability indicates the potential of this model for classifying patients with mTBI according to ND risk.

Hormonal Deficiency in Patients with Acute Traumatic Brain Injury: A Prospective Study

Background :Traumatic brain injury (TBI) has become a major public health concern in developing and developed countries as it affects productivity and economy. The incidence, prevalence, and scope of survival and recovery from acute and chronic post-traumatic pituitary dysfunction (PTPD) have not been comprehensively assessed. Post-traumatic hypopituitarism accounts for 7.2% of all hypopituitarism cases. The identification of patients with acute brain injury who are at risk of hormonal deficiency and the provision of appropriate interventions can reduce morbidity associated with TBI. Study objectives • Assess the proportion of patients with severe head injury (Glasgow coma scale [GCS] score of &lt; 9) who are at risk of reduced thyroidstimulating hormone (TSH), free T3 (FT3), free T4 (FT4), and serum cortisol levels within the first week after trauma. • Develop the Acute TBI Hormone Assessment Score (ATBIHAS), which is a 12-point scoring system comprising clinical and radiological parameters, and evaluate its correlation with hormone reduction during the acute phase of trauma, specifically on the fourth day. • Investigate whether the ATBIHAS can be used to quantify the percentage of hormonal reduction on the fourth day after trauma. • Evaluate the correlation between GCS score and hormonal reduction on the fourth day after trauma. Methods : This prospective observational study was conducted at the Neurosurgical Department of Rajiv Gandhi Government General Hospital, Chennai, India. In total, 30 patients with severe head injury who underwent brain computed tomography (CT) scan after the initial resuscitation and within the first 24 h after presentation were included in the analysis. Clinical Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany Manuscript submitted to Editorial Office of Central European Neurosurgery For Peer Review data were collected, and brain CT scan findings were recorded in the proforma. Moreover, information about sphenoidal hemosinus, frontal contusion, temporal contusion, edema, infarct, midline shift, and bony calvarial fracture was recorded. The ATBIHAS, a 12-point scoring system comprising clinical and radiological features and surgical procedures for the current scenario, was developed. This tool can assess pituitary stalk injury and hypothalamic pituitary axis disruption. All participants underwent the thyroid profile test, which comprised TSH, FT3, FT4, and serum cortisol levels. Samples were collected between 7:00 and 9:00 am on the day after the patient was successfully resuscitated. This time period was selected to prevent diurnal variations in hormone levels. The test was repeated between 7:00 and 9:00 am on the fourth day of admission. Data about all hormonal levels and their variations on the fourth day were assessed and compared with the ATBIHAS. This study was approved by the institutional ethics committee. Results: Among the participants, 27 were men and 3 women. Approximately 33.3% and 6.7% were aged 20–29 and 50–59 years, respectively. Hormonal reduction between the first and fourth days after trauma significantly differed (P &lt; 0.001). The incidence rates of hormonal reduction after the fourth day of trauma were 90% for TSH, FT4, and serum cortisol and 93% for free T3. The ATBIHAS was found to be positively correlated with reduced TSH, FT3 and FT4, and serum cortisol levels. A higher score indicated a greater percentage of hormone reduction on the fourth day after trauma. However, there was no significant correlation between the GCS score as well as the ATBIHAS and TSH, FT3, FT4, and serum cortisol reduction (P &gt; 0.05). Conclusion: Approximately &gt; 90% of patients with severe head injury are at risk for TSH, FT3, FT4, and serum cortisol reduction within the first week after trauma. Moreover, there is a significant linear correlation between ATBIHAS and hormonal levels during the acute phase of trauma, specifically on the fourth day. Hence, the ATBIHAS ca

Diagnosing Status Epilepticus

Both diffusion-weighted MRI(DWI)modalities and continuous electroencephalography(cEEG)are useful for diagnosing status epilepticus. In case 1, DWI showed hyperintense regions in the right-sided parieto-occipital cortex during peri-ictal status. Intensity of the regions normalized after left hemiparesis improved. In status epilepticus , DWI usually depicts some hyperintense regions, such as the cerebral cortex, hippocampus, and thalamic pulvinar, where ictal brain activity and its propagation are likely occur the seizure. In case 2, cEEG led to an accurate diagnosis of non-convulsive status epilepticus due to right-sided temporal contusion. Intravenous application of levetiracetam and lacosamide alleviated the clinical symptoms and electrographic seizures. Abnormal cEEG findings during status epilepticus vary from rhythmic delta activity and epileptiform and generalized periodic discharges to ictal discharges. Accurate diagnosis of status epilepticus using MRI and cEEG can offer earlier intervention, such as prompt administration of benzodiazepines, midazolam, lorazepam, ultimately resulting in a good recovery.

Anterior Temporal Approach for Clipping Posterior-Projecting Supraclinoid Carotid Artery Aneurysms: A More Lateral Corridor to Better Visualize the Aneurysm Neck and Related Branches

Direct visualization of the aneurysm neck and its related branches during microsurgical clipping of supraclinoid internal carotid artery (SICA) aneurysms using a standard pterional approach may be difficult, especially when aneurysms are posteriorly projected. We evaluated the efficacy and safety of an anterior temporal approach for clipping posterior-projecting SICA aneurysms. Between December 2017 and March 2020, 26 patients with posterior-projecting SICA aneurysms who received microsurgical clipping via an anterior temporal approach were retrospectively reviewed. The percentage of complete aneurysm obliteration, intraoperative visualization, and preservation of related branches were evaluated. Aneurysm locations were the posterior communicating artery (PCoA) (internal carotid artery [ICA]-PCoA) in 22 patients (84.6%), the anterior choroidal artery (AChA) (ICA-AChA) in 3 patients (11.5%), and both locations in 1 patient (3.9%). Complete aneurysm obliteration was achieved in all patients. For ICA-PCoA aneurysms in which the PCoA was preoperatively identified, the artery was intraoperatively identified in all cases and preserved 100% after surgery. For ICA-AChA aneurysms, AChAs were intraoperatively identified and preserved in all cases after surgery. Procedural-related infarction was 8.7% for ICA-PCoA aneurysms and 7.7% for all SICA aneurysms. Transient oculomotor nerve palsy was found in 2 patients (7.7%). No postoperative temporal contusion was detected. A good outcome at 3 months after surgery was achieved in 90% of patients for good clinical-grade subarachnoid hemorrhage and unruptured cases. The anterior temporal approach is safe and effective for clipping SICA aneurysms with posterior projection, with a high preservation rate of the related branches.

A system of radiological criteria for grading and prognosticating temporal lobe contusions.

Temporal contusions are common in patients with head injuries and require close monitoring due to the propensity of these patients to deteriorate rapidly and fatally. This study attempts to introduce a radiological grading system for temporal lobe contusions and analyse its prognostic value so as to better identify patients at risk of deterioration. The study was conducted as a cross-sectional observational study from April 2011-March 2017 on 42 patients with temporal lobe contusion. Each patients was graded according to the proposed system from a minimum of four to a maximum of 13 and then further grouped in three grades - grade 1 (score = 4), grade 2 (score 5-7) and grade 3 (score > 7) - and their clinical course was closely observed. The minimum and maximum scores observed were four and 11 respectively. The proposed grading system has statistically significant correlation to the Glasgow Coma Scale (p-value < 0.05). All patients in grade 1 (17) could be managed conservatively, while all those in grade 3 (five) needed immediate surgical intervention. Of 20 patients in grade 2, 11 had a score of 5-6 and did not require surgery, whereas nine patients had a score of seven and of these eight required delayed surgical intervention. This correlation was statistically significant (p-value < 0.05). The proposed temporal lobe contusion grading system is a good radiological tool to predict the clinical course of patients and thereby identify patients at higher risk of delayed deterioration.

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.

Isolated Contralateral Mydriasis following Traumatic Intraparenchymal Hematoma: A Case Report

Pupillary dilation is a localizing sign for ipsilateral intracranial space occupying lesion with uncal herniation. However, this may not always be true and further evaluation may be needed before localizing a lesion in case of unilateral mydriasis. There is limited literature supporting the occurrence of isolated contralateral pupillary dilation in traumatic intraparenchymal hematoma. We report a case of pupillary dilation on the contralateral side in a patient with temporal hematoma following traumatic brain injury. The available literature is reviewed and possible mechanisms discussed. The patient presented after 5 hours of road traffic accident with temporal contusion. Emergency craniotomy was done and contusion evacuated. The patient recovered well, but mydriasis persisted. Unilateral fixed dilated pupil might act as a false localizing sign in patients with supratentorial intra-axial lesion. Physicians managing critically ill neurologic and neurosurgical patients must be aware of such an occurrence.

Endoscopic-assisted removal of traumatic brain hemorrhage: case report and technical note

The endoscopic technique has been described as a minimally invasive method for spontaneous hematoma evacuation, as a safe and effective treatment. Nevertheless, to our knowledge, there is no description of a technical report of traumatic intracerebral hematoma removal using the neuroendoscope. A 47-year-old man was admitted sustaining 13 points in Glasgow coma scale with brain computed tomography (CT) scan showing a temporal contusion. Guided by a 3D reconstructed CT, using the program OsiriX®, the posterior limit of the hematoma was identified. A burr hole was placed at the posterior temporal region, and we used the neuroendoscope to assist the hematoma evacuation. The postoperative tomography showed adequate hematoma removal. He was discharged from hospital 48 h after surgery. Two weeks later, he was conscious and oriented temporally. This endoscopic-assisted technique can provide safe removal of traumatic hematomas of the temporal lobe.

Subdural hygroma following decompressive craniectomy or non-decompressive craniectomy in patients with traumatic brain injury: Clinical features and risk factors

Objective: Subdural hygroma (SDG) is a common complication that can occur after head trauma or secondary to decompressive craniectomy (DC). SDGs can be located not only ipsilateral or contralateral to the side of the DC, but also bilateral or unilateral in patients without DC. This study investigated the incidence and risk factors for different types of SDG in a large cohort of patients with traumatic brain injury (TBI).Methods: A retrospective study was conducted involving 379 adult patients with TBI who were admitted to Huashan Hospital, Fudan University between January 2009 and December 2013. As the outcome was dichotomous (SDG vs no SDG or hydrocephalus vs no hydrocephalus), multivariate logistic regression analyses were used to identify independent risk factors for the development of SDGs in patients without DC, ipsilateral SDG after unilateral DC, contralateral SDG after unilateral DC or SDG after bilateral DC. Risk factors for the development of hydrocephalus were also evaluated in patients with and without DC.Results: Among the 207 (54.6%) patients without DC, 30 (14.5%) had unilateral SDGs and 34 (16.4%) had bilateral SDGs. Of the 172 patients (45.4%) with DC, 134 (77.9%) underwent unilateral DC and 38 (22.1%) underwent bilateral DC. Of the 134 patients who underwent unilateral DC, 49 developed SDG, including 22 (16.4%) ipsilateral SDG, 19 (14.2%) contralateral SDG and eight (6.0%) both ipsilateral and contralateral SDGs. For patients undergoing bilateral DC, 13 (34.2%) developed a SDG. No significant difference in the incidence of SDG was observed between the patients with and without DC (36.0% vs 30.9%, p = 0.291), but the characteristics of SDGs were different between the two groups. Logistic regression analysis showed that factors independently associated with the development of SDG were male sex (odds ratio [OR] = 3.861; 95% CI = 1.642–9.091; p = 0.002), older age (OR = 1.046; 95% CI = 1.021–1.070; p < 0.001), basal cistern haemorrhage (OR = 4.608; 95% CI = 1.510–14.064; p = 0.007), diffuse injury and swelling (OR = 3.158; 95% CI = 1.341–7.435; p = 0.008) or diffuse injury and shift (OR = 3.826; 95% CI = 1.141–12.830; p = 0.030) in patients without DC. Temporal haematoma or contusion in the non-DC side (OR = 2.623; 95% CI = 1.070–6.428; p = 0.035) and traumatic SAH (OR = 3.751; 95% CI = 1.047–13.438; p = 0.042) were independently associated with the development of ipsilateral SDG in patients who underwent unilateral DC. However, factors independently associated with the development of contralateral SDG were frontal haematoma or contusion on the non-DC side (OR = 3.145; 95% CI = 1.272–7.774; p = 0.013) and SDH on the non-DC side (OR = 7.024; 95% CI = 1.477–33.390; p = 0.014). Only craniectomy area (OR = 1.030; 95% CI = 1.008–1.052; p = 0.008) was independently associated with the development of SDG in patients with bilateral DC. In the multivariate analysis, SDG in patients without DC was not associated with the development of hydrocephalus. However, SDG was significantly associated with the development of hydrocephalus for patients who underwent DC (OR = 2.173; 95% CI = 1.362–3.467; p = 0.001).Conclusions: This study suggested that the incidence of SDG in patients who have and have not undergone DC was identical; however, the patients’ characteristics and risk factors differed. Therefore, the management and prediction of SDG should be performed according to SDG type.

Bilateral temporal contusions causing third ventricular compression and acute hydrocephalus

Post-traumatic hydrocephalus (PTH) is rare but potentially treatable sequel of head injury. We report an uncommon cause of PTH in a 54-year patient who had bilateral temporal contusions causing compression of the third ventricle. We discuss the underlying pathology of the hydrocephalus; discuss the imaging finding and management of the patient.

Bilateral pupillary dilatation with normal intracranial pressure

Sir, The standard management of non-operable severe head injury is ventilation with intracranial pressure (ICP) monitoring (brain trauma foundation).[1] Since the patient is often sedated for ventilation, neurological monitoring is restricted to examination of the pupils. We report the case of a patient who almost forced a fundamental change in our management protocol. A 50-year-old diabetic female patient was admitted 2 h following a road traffic accident with a Glasgow coma scales core of 8/15, minimally asymmetric, but briskly reacting pupils and no lateralizing deficit. A computerized tomography (CT) scan of the brain showed bilateral frontal and a small right temporal contusion with preserved basal cisterns [Figure 1]. She was managed conservatively with ventilation and ICP monitoring. The ICP remained below 15 mmHg for the 1st 3 days and then showed a minimal increase up to a maximum of 18 mmHg. It was therefore decided to repeat a CT scan before weaning from the ventilator. The CT scan was performed 76 h after the trauma showed resolving contusions with increased edema around them [Figure 2]. Hence, mannitol was started and later vasopressors were added to maintain an adequate cerebral perfusion pressure. Figure 1 Axial computerized tomography scan 3 h following trauma showing bilateral frontal contusions adjacent to the falx with some surrounding edema. cerebrospinal fluid cisterns are seen Figure 2 Computerized tomography scan 3 days later showing a decrease in the volume of hemorrhage and an increase in the edema. CSF cisterns are better visualized than in the earlier scan At 16 h after the second scan, her pupils became large and non-reacting, though ICP remained below 20 mmHg. Assuming the ICP values were wrong, patient was taken up for a bifrontal decompressive craniectomy. After craniectomy, dura and brain were lax, excluding raised ICP. After craniectomy, blood pressure dropped further and had severe metabolic acidosis with a pH of 6.91 and a chloride of 123 mmol/L. Despite vigorous treatment of acidosis, blood pressure never recovered and she died 4 h later. This report highlights the importance of hemodynamic changes and escalating needs of vasoactive drugs while managing a severe head injury with ICP monitoring. The hypotension was assumed to be due to the effects of acidosis on the heart and vasculature.[2] Though hyperchloremic acidosis is not fatal, Kellum et al. have reported that saline resuscitation significantly shortened survival. The survival time inversely correlated with the decrease in pH and the rise in serum chloride.[3] Ritter et al. demonstrated reduced blood flow in the midbrain in patients with pupillary dilatation, independent of the ICP and brainstem lesions on CT scan and concluded that brainstem ischemia was an important causal factor in pupillary dilatation.[4] It is possible that the severe acidosis could have caused local vascular changes in the region of brainstem in our patient resulting in pupillary dilatation since there were no clinical or surgical features of raised ICP or herniation. In conclusion, we wish to reiterate that pupillary changes in head injury need not always be caused by herniation. This case also shows that excessive importance given to one parameter (in our case, ICP) can result in decreased attention to other equally important clinical and laboratory findings and less than optimal care.

Vômitos em traumatismo cranioencefálico leve na infância

Resumo Objetivo: O presente trabalho visa identificar o significado do vômito em crianças com traumatismo cranioencefálico (TCE) leve. Métodos: O presente trabalho foi prospectivo e descritivo em 88 pacientes com idade abaixo de 16 anos, atendidos no setor de urgência do HUSE (Aracaju-Sergipe). Foram analisados idade, gênero, causas do trauma, quadro neurológico, exames complementares e conduta. Resultados: Foram analisados 88 pacientes. O gênero M 74/F 14 casos. A média das idades foi de 5,5 anos. As causas do TCE foram: queda acidental (62 casos), seguida de acidente de trânsito (10 casos), queda de bicicleta (9 casos), maus-tratos (2 casos) e desconhecido (5 casos). A média de episódios de vômitos foi de dois. Outras queixas foram cefaleia e sonolência. Raios x simples de crânio realizados em 84 casos demonstraram fratura linear em dois e afundamento craniano em um. TC realizada em 88 pacientes revelou hematoma extradural (1), hematoma subdural (1), hemorragia subaracnóidea (1) e contusão temporal (1). Tratamento cirúrgico foi instituído em dois casos. Não houve relação entre o número de episódios de vômitos e achados de imagem. Achados anormais do exame de raios x simples associados com vômitos e sonolência foram preditores de lesão cerebral. Não houve óbito. Conclusão: O conhecimento do significado de vômito em TCE leve na infância é imprescindível para evitar a realização desnecessária de exames de imagem que acarretam riscos biológicos e custos adicionais. Não encontramos relação entre vômitos e lesão cerebral em crianças com TCE leve. Ausência de vômitos em crianças com TCE leve não exclui ausência de lesão cerebral.

Diagnosis and treatment of an obsessive–compulsive disorder following traumatic brain injury: A single case and review of the literature

A 27-year-old patient with traumatic brain injury and neuropsychiatric symptoms fitting the obsessive–compulsive disorder was investigated. Brain CT-scan revealed left temporal and bilateral fronto-basal parenchymal contusions. Main Outcome Measure was the Yale–Brown Obsessive Compulsive Scale at pre- and post-treatment and at 6 months follow-up. The combination of pharmacotherapy and psychotherapy resulted in lower intensity and frequency of symptoms. Our case illustrates the importance of a detailed diagnostic procedure in order to provide appropriate therapeutic interventions. Further studies are needed to guide the clinician in determining which patients are likely to benefit from a psychotherapeutic intervention in combination with pharmacotherapy.

Cognitive retraining in traumatic brain injury

Traumatic brain injury (TBI) is often associated with cognitive impairments. The psychological sequelae of cognitive deficits and emotional problems contribute significantly to the disability in the patient and to the distress of the family. The study aimed to develop a cognitive retraining programme to enhance cognitive functioning in TBI. 25 years old male presenting with history of left temporal hemorrhagic contusion with cerebral edema underwent 2 months of a cognitive retaining programme, addressing executive functions impairment. A single case experimental design with pre- and postassessment was adopted to evaluate changes in the patient in response to the intervention. Improvements were found in cognitive functioning, and in symptom reduction and behaviour. The 2 months hospital based cognitive retraining programme was found to be efficacious in ameliorating symptoms and improving cognitive, social and occupational functioning post traumatic brain injury.

Low-grade infection complicating silastic dural substitute 32 years post-operatively

Background: A complication of a silastic dural substitute is described, which appeared after 32 years—by far the longest latency period reported in the literature.Methods: Case report and literature review.Results: In 1971, a 20-year old woman suffered from an acute subdural haematoma and a temporal cerebral contusion due to a motorbike accident. She underwent an operation with evacuation of these and the dura was mended with a silastic duraplasty. Thirty-two years later she deteriorated with increased memory problems and dysphasia. CT revealed an expanding haemorrhagic mass around the previous duraplasty, which demanded surgery with removal of the silastic dural implant and evacuation of the haemorrhagic mass. Although the haemorrhagic mass enveloped the silastic implant, a contribution of the acrylate flap cannot be ruled out. Bacteriological cultures revealed Acinetobacter spp. in the CSF. Adequate post-operative antibiotic treatment was administered. The patient slowly improved, but the complication represented a major setback in her long-term cognitive and communicative functions.Conclusions: This case widens the previously reported time-frame of late complications by 60%, from 20 to 32 years, and will hopefully serve to increase the awareness of late infections and haemorrhages induced by silastic dural implants, thereby improving diagnosis and treatment in future cases.

A P1 Aneurysm and Diabetes Insipidus Caused by Traumatic Brain Injury

We describe a patient with a P1 aneurysm of the posterior cerebral artery (PCA) with diabetes insipidus (DI) caused by traumatic brain injury. A 21-year-old woman presented with epidural hematoma, left temporal contusion and subarachnoid hemorrhage caused by head trauma. DI occurred with normal anterior hypophyseal function on the second day after admission and cerebral angiography demonstrated an aneurysm at the right P1 portion after one month. DI was treated with administration of desmopressin and the aneurysm and P1 portion of the right PCA were occluded completely. After three months, her DI recovered and decompressin was discontinued. The six month follow-up angiogram confirmed cure of the P1 aneurysm. P1 aneurysm and DI can be caused by traumatic brain injury. Cranial DI caused by head injury with perturbations in water balance may be transitory and resolve.

Acute interdural hematoma mimicking epidural hematoma: a case report

Intracranial hematoma rarely presents between two dural layers of pachimeninges. Here, we present a case of an interdural hematoma with similar appearance to an epidural hematoma. A 51-year-old man presented with a left temporal contusion following a motor vehicle accident. After craniotomy and contusion removal, the post-operative CT scan showed a parietal intracranial hematoma located posterior and superior to the bone flap. The CT scan appearance of the new hematoma was similar to the CT scan appearance of an epidural hematoma. Upon operation, we determined that the hematoma was located between two layers of dura mater, i.e., an interdural hematoma. We removed the hematoma and sutured the two layers of dura to each other at multiple sites. Interdural hematoma is a rare entity. Its appearance in a CT scan can be mistaken for an extradural hematoma.