Novel Use of an Image-Guided Stereotactic Approach in Trauma for Localization of Transcranial Bullet.

Penetrating brain injuries from gunshot wounds can carry a poor prognosis and require an aggressive, multifaceted approach to obtain a good prognosis and outcome. An initial evaluation requires appropriate imaging studies followed by management and prophylaxis against increased intracranial pressure, infection, and seizures. Surgical management is then followed to ensure the watertight closure of any wounds, removal of any areas of hematoma, and removal of any potential areas of infection. In this paper, we report the case of a patient who presented with a self-inflicted gunshot wound to the head and then received aggressive medical and surgical management. This case presents that an image-guided stereotactic approach with suitable medical management should be used in patients with penetrating missile injuries to the head.

Use of Transcranial Doppler in Patients with Severe Traumatic Brain Injuries.

Severe traumatic brain injuries (TBI) are associated with a high rate of mortality and disability. Transcranial Doppler (TCD) sonography permits a noninvasive measurement of cerebral blood flow. The purpose of this study is to determine the usefulness of TCD in patients with severe TBI. TCD was performed, from April 2008 to April 2013, on 255 patients with severe TBI, defined as a Glasgow Coma Scale score of ≤8 on admission. TCD was performed on hospital days 1, 2, 3, and 7. Hypoperfusion was defined by having two out of three of the following: 1) mean velocity (Vm) of the middle cerebral artery <35 cm/sec, 2) diastolic velocity (Vd) of the middle cerebral artery <20 cm/sec, or 3) pulsatility index (PI) of >1.4. Vasospasm was defined by the following: Vm of the middle cerebral artery >120 cm/sec and/or a Lindegaard index (LI) >3. One hundred fourteen (45%) had normal measurements. Of these, 92 (80.7%) had a good outcome, 6 (5.3%) had moderate disability, and 16 (14%) died, 4 from brain death. Seventy-two patients (28%) had hypoperfusion and 71 (98.6%) died, 65 from brain death, and 1 patient survived with moderate disability. Sixty-nine patients (27%) had vasospasm, 31 (44.9%) had a good outcome, 16 (23.2%) had severe disability, and 22 (31.9%) died, 13 from brain death. The vasospasm was detected on hospital day 1 in 8 patients, on day 2 in 23 patients, on day 3 in 22 patients, and on day 7 in 16 patients. Patients with normal measurements can be expected to survive. Patients with hypoperfusion have a poor prognosis. Patients with vasospasm have a high incidence of mortality and severe disability. TCD is useful in determining early prognosis.

Streptococcus pneumoniae meningitis complicated by an intramedullary abscess: a case report and review of the literature.

BACKGROUND: Intramedullary abscess is a rare neurosurgical condition that usually arises in the setting of penetrating trauma to the spinal cord, infected congenital dural sinuses, or tuberculosis. CASE PRESENTATION: We describe a case of a 35-year-old African American male who presented with sepsis and a clinical picture of meningitis. The patient continued to have declining neurological status with decreasing sensation and worsening motor strength in all four extremities. He was found to have an intramedullary abscess in the cervical spinal cord that was treated with a decompressive posterior cervical laminectomy and drainage. The patient began to have a partial recovery of neurological function postoperatively. We also review the literature on intramedullary abscess that suggests the clinical presentation of our patient was a rare complication of acute meningitis. CONCLUSIONS: Intramedullary abscess formation is a rare entity, and a high index of suspicion for intramedullary abscess is the key for making the diagnosis and expediting treatment for these patients.

Isolated hemangioblastoma of the cervical spinal cord: A case report and literature review.

INTRODUCTION: Hemangioblastomas are benign, slow growing but highly vascularized tumors of the central nervous system, with the most common location of occurrence in the posterior fossa. Hemangioblastomas usually have an associated with patients that have Von-Hippel Lindau disease, resulting a germline mutation in the VHL tumor suppressor gene. Isolated or sporadic occurrences of hemangioblastomas are much more infrequent and typically respond well after surgery. PRESENTATION OF CASE: We present case of a 22year old female with worsening shoulder pain, decreased sensation in the hands and feet, and decreasing strength and was found to have a hemangioblastoma of the cervical spine. DISCUSSION: The patient was treated with surgery and responded well to treatment. We also present a review of the literature on isolated occurrences of hemangioblastomas of the spinal cord. CONCLUSION: Isolated hemangioblastoma are a rare tumor of the central nervous system and can be managed with surgery.

Can trauma surgeons manage mild traumatic brain injuries?

BACKGROUND: Current practices suggest that patients with mild traumatic brain injuries (MTBI) receive neurosurgical consultations, while less than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma surgeons alone may manage such patients with no impact on patient outcomes. METHODS: Data from a level I trauma registry were analyzed. Patients with MTBI resulting in an intracranial hemorrhage of 1 cm or less and a Glasgow Coma Score of 13 or greater were included. Patients with additional intracranial injuries were excluded. Multivariate regression was used to determine the relationship between neurosurgical management and good neurologic outcomes, while controlling for injury severity, demographics, and comorbidities. RESULTS: Implementation of the neurosurgical policy significantly reduced the number of such consults (94% before vs 65% after, P < .002). Multivariate analysis revealed that neurosurgical consultation was not associated with neurologic outcomes of patients. CONCLUSIONS: Implementation of a selective neurosurgical consultation policy for patients with MTBI reduced neurosurgical consultations without any impact on patient outcomes, suggesting that trauma surgeons can effectively manage these patients.

Management of embedded foreign body: penetrating stab wound to the head.

Penetrating craniocerebral trauma is an injury in which a projectile violates the skull but does not exit. The significance of penetrating injuries to the head depends largely on the circumstances of the injury, the velocity of impact, and attributes of the projectile. While most penetrating head injuries are caused by firearms, lower-velocity mechanisms of penetrating brain injury present unique challenges for the multidisciplinary team involved with the delivery of care. Appropriate management can lead to optimal outcomes and limit secondary brain injury.