Severe cranioencephalic trauma: prehospital care, surgical management and multimodal monitoring

Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma

Symptomatic chiari malformation with syringomyelia after severe traumatic brain injury: case report

Chiari malformation Type I [CM-I] is a congenital disorder, which is basically a tonsillar herniation [>/=5 mm] below the foramen magnum with or without syringomyelia. The real cause behind this malformation is still nknown. Patients may remain asymptomatic until they engender a deteriorating situation, such as cervical trauma. The objective of this case report is to give a broad perspective on CM-I from the clinical findings obtained in a patient with asymptomatic non-communicating syringomyelia associated with a CM-I exacerbated within 2 years of a TBI, and to discuss issues related to that condition

Craniocerebral gunshot injuries; a review of the current literature

Craniocerebral gunshot injuries [CGI] are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately, more prevalent condition in developing countries, with major armed conflicts which is still persisting, since the main trigger is violence at the national or state level. Management goals of CGI should focus on aggressive resuscitation and correction of coagulopathy; those with stable vital signs should undergo CT scan head at the earliest possible opportunity. Neuroimaging is vital for planning of surgical management, especially to determine the type of surgery, routes of the approach to the surgical target area and extraction of the impacted foreign bodies, however, surgical management is not always indicated. Although subset of such cases may be managed even with non-surgical management. The treatment comprises of immediate life salvaging resuscitative measures including control of the persistent bleeding, care of associated injury, management of raised intracranial pressure, prevention of cerebrospinal fistula formation by primary watertight dural repair and prevention of infection, through extensive debridement of contaminated, macerated or ischemic tissues; preservation of nervous tissue and restoration of anatomic structures through the hermetic sealing of dural and scalp defect. Recently, only few studies of craniocerebral penetrating injuries are published that too involving smaller patients sample sizes; although classic studies in the military and civil situation noticed associated relatively very high mortality and morbidity and psychological as well as economic impact on the affected individual, the family and the health system in providing ongoing care to the sufferers and society at large. Currently various measures are advocated with aim to reduce the incidence of CGI especially in civilian populations. It is highly necessary and immensely urgent to promote research in a neurocritical care of CGI to provide positive impact on improvement of the quality of life and further providing better care and reduction of overall health care cost

Post-traumatic Balint's syndrome: a case report and review of the literature

Balint's syndrome is a rare neurological disorder associated with bilateral parieto-occipital damage which was described by Rezs? B?lint in 1909.The syndrome is manifested clinically by the presence of a hemispatial negligence. The lesion is usually inside parietooccipital region bilaterally in most cases but may also be compromised angular convolutions, the dorsolateral area of the occipital lobe as the superior parietal lobule. We herein report a 61-year-old man with traumatic brain injury who was diagnosed to have right parieto-occipital contusion in radiologic evaluation. Physical examination was consistent with Balint's syndrome. The patient was followed for 12 months post-injury and received 4-months of outpatient rehabilitation. Patient showed improvement of Balint's syndrome 8 months after the starts of symptoms

Odontogenic pain as the principal presentation of vertebral artery pseudoaneurysm; a case report

Dissection of the vertebral artery is an important but rare cause of cerebrovascular accidents. Here we report a 48-year-old man with toothache since 4 days before who presented to the emergency department with neck pain and final diagnosis of dissecting right vertebral artery pseudoaneurysm. To our knowledge, this maybe the first report of odontogenic pain as the first manifestation of vertebral artery pseudoaneurysm in the literatures

Management of Craniocerebral Gunshot Injuries: A Review / 대한신경손상학회지

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

Intravenous fluid therapy in traumatic brain injury and decompressive craniectomy

The patient with head trauma is a challenge for the emergency physician and for the neurosurgeon. Currently traumatic brain injury constitutes a public health problem. Knowledge of the various supportive therapeutic strategies in the pre-hospital and pre-operative stages is essential for optimal care. The immediate rapid infusion of large volumes of crystalloids to restore blood volume and blood pressure is now the standard treatment of patients with combined traumatic brain injury [TBI] and hemorrhagic shock [HS]. The fluid in patients with brain trauma and especially in patients with brain injury is a critical issue. In this context we present a review of the literature about the history, physiology of current fluid preparations, and a discussion regarding the use of fluid therapy in traumatic brain injury and decompressive craniectomy

Brain infarction: rare neurological presentation of African bee stings

Bee stings are commonly encountered worldwide. Various manifestations after bee sting have been described including local reactions which are common, systemic responses such as anaphylaxis, diffuse intravascular coagulation and hemolysis. We report a case of a 74-year-old man who developed neurologic deficit 5 hours after bee stings, which was confirmed to be left frontal infarction on brain CT-scan. The case does not follow the reported pattern of hypovolemic or anaphylactic shock, hemolysis and/or rhabdomyolysis, despite the potentially lethal amount of venom injected. Diverse mechanisms have been proposed to give an explanation to all the clinical manifestation of both toxic and allergic reactions secondary to bee stings. Currently, the most accepted one state that victims can develop severe syndrome characterized by the release of a large amount of cytokines

Effects of glycemic level on outcome of patients with traumatic brain injury: a retrospective cohort study

Objective: To determine the effects of glycemic level on outcome patients with traumatic brain injury

Methods: From September 2010 to December 2012, all medical records of adult patients with TBI admitted to the Emergency Room of Laura Daniela Clinic in Valledupar City, Colombia, South America were enrolled. Both genders between 18 and 85 years who referred during the first 48 hours after trauma, and their glucose level was determined in the first 24 hours of admission were included. Adults older than 85 years, with absence of Glasgow Coma Scale [GCS] score and a brain Computerized Tomography [CT] scans were excluded. The cut-off value was considered 200 mg/dL to define hyperglycemia. Final GCS, hospital admission duration and complications were compared between normoglycemic and hyperglycemic patients

Results: Totally 217 patients were identified with TBI. Considering exclusion criteria, 89 patients remained for analysis. The mean age was 43.0 +/- 19.6 years, the mean time of remission was 5.9 +/- 9.4 hours, the mean GCS on admission was 10.5 +/- 3.6 and the mean blood glucose level in the first 24 hours was 138.1 +/- 59.4 mg/dL. Hyperglycemia was present in 13.5% of patients. The most common lesions presented by patients with TBI were fractures [22.5%], hematoma [18.3%], cerebral edema [18.3%] and cerebral contusion [16.2%]. Most of patients without a high glucose level at admission were managed only medically, whereas surgical treatment was more frequent in patients with hyperglycemia [p=0.042]. Hyperglycemia was associated with higher complication [p=0.019] and mortality rate [p=0.039]. GCS was negatively associated with on admission glucose level [r=0.11; p=0.46]

Conclusion: Hyperglycemia in the first 24-hours of TBI is associated with higher rate of surgical intervention, higher complication and mortality rates. So hyperglycemia handling is critical to the outcome of patients with traumatic brain injury

Fatal massive cerebral infarction in a child after mild brain trauma: a case report and literature review

Traumatic brain injury is a common entity. However cerebral infarction in infants is a rare entity while the diagnosis of this pathology in the pediatric population is usually difficult. The mild head trauma is rarely accompanied by intracranial injury and even less, with cerebral infarction. We herein report the first case of cerebral infarction after a mild brain trauma in a 2-year-old Latin-American male patient, in which brain computed tomography [CT] scan was performed on the first day of the accident, showed right hemispheric cerebral ischemia compromising the fronto-parieto-occipital region. Conservative management was established. The patient died at day 5. So Brain CT scan may be beneficial to reveal any hemispheric infarction due to a probable mass effect

Bilateral traumatic basal ganglia hemorrhage associated with epidural hematoma: case report and literature review

Traumatic basal ganglia hematoma is a rare condition defined as presence of hemorrhagic lesions in basal ganglia or adjacent structures suchas internal capsule, putamen and thalamus. Bilateral basal ganglia hematoma are among the devastating and rare condition. We herein report a 28-year old man, a victim of car-car accident who was brought to our surgical emergency room by immediate loss of consciousness and was diagnosed to have hyperdense lesion in the basal ganglia bilaterally, with the presence of right parietal epidural hematoma. Craniotomy and epidural hematoma drainage were considered, associated to conservative management of gangliobasal traumatic contusions. On day 7 the patient had sudden neurologic deterioration, cardiac arrest unresponsive to resuscitation. Management of these lesions is similar to any other injury in moderate to severe traumatic injury. The use of intracranial pressure monitoring must be guaranteed

Emergent decompressive craniectomy in patients with fixed dilated pupils; a single center experience

This is a case series which report the clinical results of decompressive craniectomy in 4 patients with dilated fjpupils secondary to traumatic brain injury and postoperative edema. Between 2011 and 2012, four patients, 3 males and 1 female, aged between 35 and 64 with mean age of 50.1 +/- 8.9 years, underwent decompressive jjcraniectomy due to brain traumatic edema. The follow up period ranged between 1 to 6 months. All patients jhad Glasgow coma score [GCS] of 3-4 at admission, and the duration of pupils being mydriatic was less than 20 minutes before the operation. All patients had moderate disability with GCS of 4 after the operation. Decompressive craniectomy can be a life-saving procedure which provides a better outcome in patients with Bilated pupils secondary to brain trauma injury and postoperative edema with timing of less than 20 minutes. However, the small number of the patients in this study is the main limitation to the accuracy of the results, and more studies with larger number of patients are warranted to evaluate the efficiency of decompressive craniectomy in patients with dilated pupils