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Lee SY, Lee SJ, Kim SS, Jun HS, Oh C, Lin C, Phi JH. Post-traumatic Transient Neurological Dysfunction: A Proposal for Pathophysiology. J Neurotrauma 2024. [PMID: 38687331 DOI: 10.1089/neu.2021.0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Unexplained neurological deterioration is occasionally observed in patients with traumatic brain injuries (TBIs). We aimed to describe the clinical features of post-traumatic transient neurological dysfunction and provide new insight into its pathophysiology. We retrospectively collected data from patients with focal neurological deterioration of unknown origin during hospitalization for acute TBI for 48 consecutive months. Brain imaging, including computed tomography, diffusion-weighted imaging and perfusion-weighted imaging, and electroencephalography were conducted during the episodes. Fourteen (2.0%) patients experienced unexplained focal neurological deterioration among 713 patients who were admitted for traumatic intracranial hemorrhage during the study period. Aphasia was the predominant symptom in all patients, and hemiparesis or hemianopia was accompanied in three patients. These symptoms developed within 14 days after trauma. Structural imaging did not show any significant interval change, and electroencephalography showed persistent arrhythmic slowing in the corresponding hemisphere in most patients. Perfusion imaging revealed increased cerebral blood flow in the symptomatic hemisphere. Surgical intervention and anti-seizure medications were ineffective in abolishing the symptoms. The symptoms disappeared spontaneously after 4 h to 1 month. Transient neurological dysfunction (TND) can occur during the acute phase of TBI. Although TND may last longer than a typical transient ischemic attack or seizure, it eventually resolves regardless of treatment. Based on our observation, we postulate that this is a manifestation of spreading depolarization occurring in the injured brain, which is analogous to migraine aura.
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Affiliation(s)
- Seo-Young Lee
- Department of Neurology, Kangwon National University College of Medicine, Chuncheon, Korea
- Department of Neurology, Kangwon National University Hospital, Chuncheon, Korea
- Department of Critical Care Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Seung Jin Lee
- Department of Neurosurgery, Kangwon National University Hospital College of Medicine, Chuncheon, Korea
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Sam Soo Kim
- Department of Radiology, Kangwon National University Hospital College of Medicine, Chuncheon, Korea
| | - Hyo Sub Jun
- Department of Neurosurgery, Kangwon National University Hospital College of Medicine, Chuncheon, Korea
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Chungkun Oh
- Department of Neurology, Kangwon National University Hospital, Chuncheon, Korea
| | - Chen Lin
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan city, Taiwan
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Fu S, Liu H, Wang G, Hu X, Wang S. Incidence, risk factors, and clinical outcomes of acute brain swelling associated with traumatic acute subdural hematoma: a retrospective study utilizing novel diagnostic criteria. Ther Adv Neurol Disord 2024; 17:17562864241242944. [PMID: 38638672 PMCID: PMC11025420 DOI: 10.1177/17562864241242944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/11/2024] [Indexed: 04/20/2024] Open
Abstract
Background Post-traumatic acute brain swelling (ABS) is a major cause of elevated intracranial pressure and thus mortality. The current definition of post-traumatic ABS has certain limitations, and there is limited information available regarding ABS associated with traumatic acute subdural hematoma (ASDH). Objectives To investigate the incidence, risk factors, and clinical outcomes of ABS associated with traumatic ASDH. Design Retrospective study. Methods Data for 161 patients diagnosed with traumatic ASDH were retrospectively collected. Novel computed tomography-based criteria were proposed for diagnosing ABS in patients with ASDH and determining its incidence. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of post-traumatic ABS. The Glasgow Outcome Scale (GOS) score, mortality, and functional prognosis of all patients at discharge and the proportion of intraoperative malignant brain bulge in surgical patients were taken as clinical outcome measures. Results A total of 45 (28%) patients experienced post-traumatic ABS, exhibiting significantly lower Glasgow Coma Scale scores on admission (p < 0.001). The incidence of hemispheric and whole-brain swelling was 8.1% and 19.9%, respectively. Risk factors independently associated with post-traumatic ABS were: (1) age [odds ratio (OR) = 0.917, p < 0.001]; (2) platelet to white blood cell ratio (PWR) (OR = 0.887, p = 0.012); and (3) traumatic subarachnoid hemorrhage (SAH) (OR = 4.346, p = 0.005). The ABS cohort had a lower GOS score [2 (1-3) versus 4 (3-5); p < 0.001], higher mortality (46.7% versus 6.9%; p < 0.001), and higher proportion of unfavorable functional prognosis (75.6% versus 34.5%; p < 0.001) upon discharge compared to the no ABS cohort, along with higher proportion of intraoperative malignant brain bulge (43.8% versus 0%; p < 0.001). Conclusion The incidence of ABS associated with ASDH is significantly high overall. Patients with ASDH who have young age, low PWR, and traumatic SAH are at an increased risk of developing post-traumatic ABS, and therefore of poor clinical outcomes.
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Affiliation(s)
- Shilong Fu
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, The First Hospital of Putian City, Putian, China
| | - Haibing Liu
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzhou, China
| | - Guofeng Wang
- Department of Neurosurgery, The First Hospital of Putian City, Putian, China
| | - Xiaofang Hu
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzhou, China
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University Fuzhou, Fujian 350025, China
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzhou, China
- Fujian Provincial Clinical Medical Research Center for Minimally Invasive Diagnosis and Treatment of Neurovascular Diseases, Fuzhou, China
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Enam N, Deng H, Race NS, Majid DS, Okonkwo DO, Franzese KM. Continuum of care and longitudinal recovery in a 17-year-old athlete with second impact syndrome. Brain Inj 2023; 37:303-307. [PMID: 36519359 DOI: 10.1080/02699052.2022.2158227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Second impact syndrome (SIS) is an uncommon, but devastating sports-related structural brain injury that results from a second head injury before complete recovery from an initial concussion. The pathophysiology of second impact syndrome is poorly understood, but is hypothesized to involve loss of autoregulation, diffuse cerebral edema, with progression to rapid brain herniation syndromes. Here, we present a case of second impact syndrome in an adolescent high school football player who experienced acute brain herniation and coma. Following stabilization, the patient underwent comprehensive, multidisciplinary rehabilitation in order to achieve significant recovery. A narrative detailing the patient's recovery from one-year post-injury is reviewed.
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Affiliation(s)
- Nabela Enam
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicholas S Race
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dewan S Majid
- Department of Family Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin M Franzese
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Hsiao IH, Hsu SY, Lin MC, Shih PK. Associations between Zygoma Fracture and Post-Traumatic Headache: A Study among Taiwanese Population. J Clin Med 2021; 10:jcm10225377. [PMID: 34830666 PMCID: PMC8619399 DOI: 10.3390/jcm10225377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Few studies have discussed the development of post-traumatic headache (PTH) after zygoma fracture. This research aimed to examine the association between zygoma fracture and PTH and its other associated factors. A total of 3043 patients with zygoma fracture and 3043 patients with non-fracture were included in this analysis. They were matched to a non-fracture cohort from the National Health Insurance database according to age, sex, and index year. The incidence of PTH and its association with zygoma fracture were assessed. The zygoma fracture cohort had a significantly higher cumulative incidence of PTH than the non-fracture cohort in a 10-year follow-up. The confounding risk factors of PTH included zygoma fracture, female sex, and comorbidities, including obesity and depression. Female patients under 40 years old who had zygoma fractures had a higher incidence of PTH than the non-fracture group. Moreover, patients with zygoma fractures commonly developed PTH within three months after injury. Female patients under 40 years old with precedent zygoma fractures had a higher incidence rate of PTH than those without fractures. Moreover, patients with zygoma fractures commonly developed PTH within three months after injury. Nevertheless, before widely applying our results, a prospective study must be conducted to verify the risk factors found in this study.
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Affiliation(s)
- I-Han Hsiao
- Department of Neurosurgery, China Medical University Hospital, Taichung 404, Taiwan;
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 404, Taiwan
| | - Shao-Yun Hsu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Mei-Chen Lin
- School of Medicine, China Medical University, Taichung 404, Taiwan;
- Management Office for Health Data, China Medical University and Hospital, Taichung 404, Taiwan
| | - Pin-Keng Shih
- School of Medicine, China Medical University, Taichung 404, Taiwan;
- Department of Surgery, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: ; Tel.: +88-692-165-8698
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Is there a common denominator for Brief Resolved Unexplained Events, Sudden Infant Death Syndrome, and alleged Shaken Baby Syndrome? Med Hypotheses 2020; 144:109939. [DOI: 10.1016/j.mehy.2020.109939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/17/2022]
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Lynøe N, Eriksson A. Is there an association between infantile colic and subdural hemorrhage? Med Hypotheses 2020; 144:110256. [PMID: 33254567 DOI: 10.1016/j.mehy.2020.110256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/01/2020] [Accepted: 09/05/2020] [Indexed: 11/15/2022]
Abstract
We present the hypothesis that subdural hemorrhages during childbirth might be associated with so-called three-month colic, whereby an infant cries intensively and repeatedly during its first three months. A traditional interpretation is that this infantile crying is associated with nutrition and is accordingly "a gut issue", but this is probably not the whole explanation. It has also been suggested that infantile crying can trigger a caregiver to shake the baby to make it stop crying, thereby inflicting a subdural hemorrhage. A mechanism-based argument supporting our hypothesis would be that the bilateral film-thin subdural hemorrhage associated with a high percentage of deliveries might cause meningeal irritation and in some cases also symptoms as inconsolable crying. An epidemiological argument is that infantile crying is more frequent among first-born, male and premature babies; these categories have also an increased incidence of subdural hemorrhage. Moreover, preventive programs for managing infantile crying have had no effect on the incidence of alleged shaken baby cases. As infantile crying is currently considered unexplained, it is reasonable to explore the proposed hypothesis and strategies which refute or corroborate it. We suggest that a cohort study of premature, first born and male babies with and without infantile crying are examined with brain MRI scan soon after delivery with clinically and MRI follow up during 3-6 months.
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Affiliation(s)
- Niels Lynøe
- Centre for Healthcare Ethics, Karolinska Institutet, 171 77 Stockholm, Sweden.
| | - Anders Eriksson
- Dept of Community Medicine and Rehabilitation/Forensic Medicine, Umeå University, Umeå, Sweden
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Second Impact Syndrome. Myth or reality? Neurochirurgie 2020; 67:265-275. [PMID: 32169407 DOI: 10.1016/j.neuchi.2019.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/21/2019] [Accepted: 12/27/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Second impact syndrome (SIS) is a devastating condition occurring in sport-induced mild brain injury. SIS is drastically defined by anamnestic, clinical and radiological criteria, which is unusual in the field of cranial traumatology. The purpose of this study was to provide a literature review of this syndrome. MATERIAL AND METHODS We conducted a literature review of all published studies on PubMed. The keywords were "second impact syndrome and catastrophic head injury", "second impact syndrome and sport", "repeat concussion and catastrophic brain injury", "catastrophic head injury and concussion", "catastrophic head injury", "concussion and second impact syndrome", "concussion and repetitive head injury". RESULTS Eighty-two full-text articles were assessed for eligibility. Finally, 41 studies were included in qualitative synthesis and 21 were included in quantitative synthesis. DISCUSSION The number of cases reported in the literature was extremely small compared to the population at risk, i.e., the number of athletes exposed to repeated concussions. SIS was similar to talk and die syndrome, with which it shares certain characteristics. If we consider SIS according to "talk and deteriorate tables", it opens up interesting perspectives because they are specific in children and adolescents. Taking into account the scarcity of this syndrome, one may question whether athlete-intrinsic features may be involved in at least some cases of SIS. On a pathophysiological level, many explanations remained unsatisfactory because they were unable to explain all the clinical phenomena and observed lesions. Triggering the trigeminocardiac reflex is a crucial element in explaining the sequence of clinical events. Its association with a state of neurogenic inflammation provides an almost complete explanation for this particular condition. Finally, on a practical level, a concussion occurring during the playing of a sport must be considered as any other injury before allowing a return to play.
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A Look Ahead. Concussion 2020. [DOI: 10.1016/b978-0-323-65384-8.00015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2023] Open
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Orman G, Kralik SF, Meoded A, Desai N, Risen S, Huisman TAGM. MRI Findings in Pediatric Abusive Head Trauma: A Review. J Neuroimaging 2019; 30:15-27. [PMID: 31696594 DOI: 10.1111/jon.12670] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 12/20/2022] Open
Abstract
Trauma is the most common cause of death and significant morbidity in childhood; abusive head trauma (AHT) is a prominent cause of significant morbidity and mortality in children younger than 2 years old. Correctly diagnosing AHT is challenging both clinically and radiologically. The primary diagnostic challenges are that the abused children are usually too young to provide an adequate history, perpetrators are unlikely to provide truthful account of trauma, and clinicians may be biased in their assessment of potentially abused children. The main radiological challenge is that there is no single imaging finding that is independently specific for or diagnostic of AHT. The radiological evaluation should be based on the multiplicity and severity of findings and an inconsistency with the provided mechanism of trauma. While the most common neuroimaging finding in AHT is subdural hemorrhage, other less well-known magnetic resonance imaging (MRI) findings such as the "lollipop sign" or "tadpole sign," parenchymal or cortical lacerations, subpial hemorrhage, cranio-cervical junction injuries including retroclival hematomas, as well as diffuse hypoxic brain injury have been identified and described in the recent literature. While AHT is ultimately a clinical diagnosis combining history, exam, and neuroimaging, familiarity with the typical as well as the less-well known MRI findings will improve recognition of AHT by radiologists.
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Affiliation(s)
- Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Nilesh Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Sarah Risen
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, TX
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Demartini C, Greco R, Zanaboni AM, Sances G, De Icco R, Borsook D, Tassorelli C. Nitroglycerin as a comparative experimental model of migraine pain: From animal to human and back. Prog Neurobiol 2019; 177:15-32. [DOI: 10.1016/j.pneurobio.2019.02.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 01/19/2019] [Accepted: 02/10/2019] [Indexed: 12/13/2022]
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Teixeira SR, Gonçalves FG, Servin CA, Mankad K, Zuccoli G. Ocular and Intracranial MR Imaging Findings in Abusive Head Trauma. Top Magn Reson Imaging 2018; 27:503-514. [PMID: 30516697 DOI: 10.1097/rmr.0000000000000169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.
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Affiliation(s)
- Sara Reis Teixeira
- Division of Radiology, Clinical Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto
| | | | - Carolina A Servin
- Centro Medico La Costa - Centro de Diagnóstico, Av General José Gervasio Artigas, Asunción, Paraguay
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Giulio Zuccoli
- Professor of Radiology, University of Pittsburgh School of Medicine, Director of Pediatric Neuroradiology, Children Hospital of Pittsburgh, Pittsburgh, PA
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12
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Costine-Bartell BA, McGuone D, Price G, Crawford E, Keeley KL, Munoz-Pareja J, Dodge CP, Staley K, Duhaime AC. Development of a Model of Hemispheric Hypodensity ("Big Black Brain"). J Neurotrauma 2018; 36:815-833. [PMID: 30039743 PMCID: PMC6387571 DOI: 10.1089/neu.2018.5736] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Subdural hematoma (SDH) is the most common finding after abusive head trauma (AHT). Hemispheric hypodensity (HH) is a radiological indicator of severe brain damage that encompasses multiple vascular territories, and may develop in the hemisphere(s) underlying the SDH. In some instances where the SDH is predominantly unilateral, the widespread damage is unilateral underlying the SDH. To date, no animal model has successfully replicated this pattern of injury. We combined escalating severities of the injuries and insults commonly associated with HH including SDH, impact, mass effect, seizures, apnea, and hypoventilation to create an experimental model of HH in piglets aged 1 week (comparable to human infants) to 1 month (comparable to human toddlers). Unilateral HH evolved over 24 h when kainic acid was applied ipsilateral to the SDH to induce seizures. Pathological examination revealed a hypoxic-ischemic injury-type pattern with vasogenic edema through much of the cortical ribbon with relative sparing of deep gray matter. The percentage of the hemisphere that was damaged was greater on the ipsilateral versus contralateral side and was positively correlated with SDH area and estimated seizure duration. Further studies are needed to parse out the pathophysiology of this injury and to determine if multiple injuries and insults act synergistically to induce a metabolic mismatch or if the mechanism of trauma induces severe seizures that drive this distinctive pattern of injury.
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Affiliation(s)
- Beth A Costine-Bartell
- 1 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts.,2 Department of Neurosurgery, Harvard Medical School , Boston, Massachusetts
| | - Declan McGuone
- 3 Department of Pathology, Yale School of Medicine , New Haven, Connecticut
| | - George Price
- 1 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Eleanor Crawford
- 1 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Kristen L Keeley
- 1 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Jennifer Munoz-Pareja
- 4 Department of Pediatrics, University of Florida Health Shands Children's Hospital, University of Florida College of Medicine , Gainesville, Florida
| | - Carter P Dodge
- 5 Department of Anesthesiology, Children's Hospital at Dartmouth , Dartmouth Medical School, Lebanon , New Hampshire
| | - Kevin Staley
- 6 Departments of Neurology, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Ann-Christine Duhaime
- 1 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts.,2 Department of Neurosurgery, Harvard Medical School , Boston, Massachusetts
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Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children. Oral Maxillofac Surg Clin North Am 2018; 30:11-24. [PMID: 29153234 DOI: 10.1016/j.coms.2017.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
After a thorough review of the history and presentation of a child's facial pain, a targeted head and neck examination is critical to the appropriate diagnosis of facial pain and temporomandibular joint disorders. It is critical to distinguish between the structural (trauma, degenerative disease, and tumor) and nonstructural (neurogenic, myogenic, and psychological) causes of pain, which will allow for incorporation of appropriate strategies of medical, psychological, dental, and surgical therapies.
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Luyet FM, Feldman KW, Knox BL. The Big Black Brain: Subdural Hemorrhage with Hemispheric Swelling and Low Attenuation. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2018; 11:241-247. [PMID: 32318153 PMCID: PMC7163906 DOI: 10.1007/s40653-017-0132-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The term "Big Black Brain" was first coined in 1993 to describe cases of abusive head trauma associated with subdural hematoma(s), brain swelling, and uni- or bilateral hypo-density involving the entire supratentorial compartment on CT scan imaging. This constellation of findings was invariably followed by extensive cerebral parenchymal destruction and a dismal neurological outcome or death. We describe two such cases and review the pathophysiology and differential diagnosis of this entity.
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Affiliation(s)
- Francois M. Luyet
- Department of Pediatrics, University of Wisconsin American Family Children’s Hospital, 600 Highland Ave, H4/428 Clinical Science Center, Madison, WI 53792-4108 USA
| | - Kenneth W. Feldman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
| | - Barbara L. Knox
- Department of Pediatrics, University of Wisconsin American Family Children’s Hospital, 600 Highland Ave, H4/428 Clinical Science Center, Madison, WI 53792-4108 USA
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Hansen JB, Frazier T, Moffatt M, Zinkus T, Anderst JD. Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces. J Neurosurg Pediatr 2018; 21:31-37. [PMID: 29099352 DOI: 10.3171/2017.7.peds17317] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs. METHODS The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs. RESULTS Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08-0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03-0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5-7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05-0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms. CONCLUSIONS The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.
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Affiliation(s)
| | | | | | - Timothy Zinkus
- 2Radiology, Children's Mercy Hospital, Kansas City, Missouri
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Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI-an update. Childs Nerv Syst 2017; 33:1677-1681. [PMID: 29149393 DOI: 10.1007/s00381-017-3535-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pediatric head trauma is one of the commonest presentations to emergency departments. Over 90% of such head injuries are considered mild, but still present risk acute clinical deterioration and longer term morbidity. Identifying which children are at risk of clinically important brain injuries remains challenging and much of the data on minor head injuries is based on the adult population. CHALLENGES IN PEDIATRICS Children, however, are different, both anatomically and in terms of mechanism of injury, to adults and, even within the pediatric group, there are differences with age and stage of development. IMAGING CT scans have added to the repertoire of clinicians in the assessment of pediatric head injury population, but judicious use is required given radiation exposure, malignancy risk, and resource constraints. Guidelines and head injury rules have been developed, for adults and children, to support decision-making in the emergency department though whether their use is applicable to all population groups is debatable. Further challenges in mild pediatric head trauma also include appropriate recommendations for school attendance and physical activity after discharge. FURTHER DEVELOPMENTS Concern remains for second-impact syndrome and, in the longer term, for post-concussive syndrome and further research in both is still needed. Furthermore, the development of clinical decision rules raises further questions on the purpose of admitting children with minor head injuries and answering this question may aid the evolution of clinical decision guidelines. CONCLUSIONS The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.
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Affiliation(s)
- Navneet Singh
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada
| | - Ash Singhal
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada.
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Stovitz SD, Weseman JD, Hooks MC, Schmidt RJ, Koffel JB, Patricios JS. What Definition Is Used to Describe Second Impact Syndrome in Sports? A Systematic and Critical Review. Curr Sports Med Rep 2017; 16:50-55. [PMID: 28067742 DOI: 10.1249/jsr.0000000000000326] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Concern about what has been termed, "second impact syndrome" (SIS) is a major factor determining return-to-play decisions after concussion. However, definitions of SIS vary. We used Scopus to conduct a systematic review and categorize the definitions used to describe SIS. Of the 91 sources identified, 79 (87%) clearly specified that SIS involved either cerebral edema or death after a concussion when a prior concussion had not resolved. Twelve articles (13%) could be interpreted as merely the events of two consecutive concussions. Among the articles that listed mortality rates, nearly all (33/35, 94%) said the rate of death was "high" (e.g., 50% to 100%). Our review found that most articles define SIS as a syndrome requiring catastrophic brain injury after consecutive concussive episodes. Given that it is unclear how common it is to have a second concussion while not fully recovered from a first concussion, the actual mortality rate of SIS is unknown.
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Affiliation(s)
- Steven D Stovitz
- 1Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN; 3Bio-Medical Library, University of Minnesota, Minneapolis, MN; 4Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; and 5Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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18
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Squier W, Mack J, Jansen AC. Infants dying suddenly and unexpectedly share demographic features with infants who die with retinal and dural bleeding: a review of neural mechanisms. Dev Med Child Neurol 2016; 58:1223-1234. [PMID: 27435495 DOI: 10.1111/dmcn.13202] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 01/01/2023]
Abstract
The cause of death in infants who die suddenly and unexpectedly (sudden unexpected death in infancy [SUDI]) remains a diagnostic challenge. Some infants have identified diseases (explained SUDI); those without explanation are called sudden infant death syndrome (SIDS). Demographic data indicate subgroups among SUDI and SIDS cases, such as unsafe sleeping and apparent life-threatening events. Infants dying suddenly with retinal and dural bleeding are often classified as abused, but in many there is no evidence of trauma. Demographic features suggest that they may represent a further subgroup of SUDI. This review examines the neuropathological hypotheses to explain SIDS and highlights the interaction of infant oxygen-conserving reflexes with the brainstem networks considered responsible for SIDS. We consider sex- and age-specific vulnerabilities related to dural bleeding and how sensitization of the dural innervation by bleeding may influence these reflexes, potentially leading to collapse or even death after otherwise trivial insults.
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Affiliation(s)
- Waney Squier
- Formerly Department of Neuropathology, Oxford University John Radcliffe Hospital, Oxford, UK
| | - Julie Mack
- Department of Radiology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Anna C Jansen
- Paediatric Neurology Unit, Department of Paediatrics, UZ Brussel, Brussels, Belgium.,Neurogenetics Research Unit, Vrije Universiteit Brussel, Brussels, Belgium
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19
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McLendon LA, Kralik SF, Grayson PA, Golomb MR. The Controversial Second Impact Syndrome: A Review of the Literature. Pediatr Neurol 2016; 62:9-17. [PMID: 27421756 DOI: 10.1016/j.pediatrneurol.2016.03.009] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 03/11/2016] [Accepted: 03/18/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Second impact syndrome is a devastating injury that primarily affects athletic children and young adults. It occurs when a second concussion occurs before symptoms from the first concussion have resolved. Diffuse and often catastrophic cerebral edema results. Reports of second impact syndrome are few, and some argue that second impact syndrome is simply diffuse cerebral swelling unrelated to the first concussion. METHODS Ovid and PubMed were searched from years 1946 to 2015 using the terms "second impact syndrome," "repeat concussion," and "catastrophic brain injury." In addition, review articles were found using a combination of the terms, "concussion," "second impact syndrome," and "repetitive head trauma." RESULTS Seventeen patients in seven publications met the criteria of having two witnessed hits and persistent symptoms from the first to the second concussion. Ten of the 17 (59%) included individuals were football players. All were male. Ages ranged from 13 to 23 years. All children with poor outcomes (death or permanent disability) were younger than 20 years, while four of the five players with good outcomes were older than 19 years. The lag time from first to second concussion ranged from one hour to four weeks, and in many cases, at least one of the two hits appeared minor. CONCLUSIONS American football, male gender, and young age appear to be associated with second impact syndrome. Controversies surrounding this syndrome are discussed. There is a need for prospective studies to clarify risk factors and outcomes of second impact syndrome to guide return-to-play recommendations for young athletes.
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Affiliation(s)
- Loren A McLendon
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Stephen F Kralik
- Division of Pediatric Neuroradiology, Department of Radiology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Patricia A Grayson
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Meredith R Golomb
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
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Momose H, Sorimachi T, Aoki R, Atsumi H, Matsumae M. Cerebral Infarction following Acute Subdural Hematoma in Infants and Young Children: Predictors and Significance of FLAIR Vessel Hyperintensity. Neurol Med Chir (Tokyo) 2015; 55:510-8. [PMID: 26041626 PMCID: PMC4628204 DOI: 10.2176/nmc.oa.2014-0334] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A phenomenon of cerebral infarction following acute subdural hematoma (ASDH) in infants and young children, termed cerebral infarction following ASDH (CIASDH), has been well recognized, though both its mechanisms and risk factors have been poorly understood. The purpose of the present study was to investigate the predictors for CIASDH in a population of ASDH, and to evaluate the imaging studies to presume the mechanisms of CIASDH. We retrospectively examined consecutive children 6 years of age or younger, who were diagnosed with ASDH and were admitted to our hospital between 2000 and 2014. In 57 consecutive children with ASDH, 12 (21.1%) developed CIASDH. The multivariate analysis revealed five predictors for CIASDH: presence of seizure, consciousness disturbance at admission, absence of skull fracture, hematoma thickness ≥ 5 mm on computed tomography (CT), and midline shift ≥ 3 mm on CT (p < 0.05). In three of six patients (50%) undergoing magnetic resonance (MR) imaging/fluid-attenuated inversion recovery (FLAIR) within 5 days of admission, serpentine hyperintensities in the subarachnoid space (FLAIR vessel hyperintensities) were demonstrated. MR angiography showed neither occlusion nor stenosis of the cerebral arteries. Single photon emission CT performed at admission in one patient showed a cerebral blood flow reduction in the ASDH side. All the children with CIASDH showed unfavorable outcomes at discharge. Children showing multiple predictors at admission should be carefully observed for development of CIASDH. Evaluation of the imaging studies suggested that a blood flow disturbance in the level of peripheral arteries to microcirculation was one candidate for possible mechanisms to induce the CIASDH.
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Goriely A, Geers MGD, Holzapfel GA, Jayamohan J, Jérusalem A, Sivaloganathan S, Squier W, van Dommelen JAW, Waters S, Kuhl E. Mechanics of the brain: perspectives, challenges, and opportunities. Biomech Model Mechanobiol 2015; 14:931-65. [PMID: 25716305 PMCID: PMC4562999 DOI: 10.1007/s10237-015-0662-4] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 02/14/2015] [Indexed: 12/24/2022]
Abstract
The human brain is the continuous subject of extensive investigation aimed at understanding its behavior and function. Despite a clear evidence that mechanical factors play an important role in regulating brain activity, current research efforts focus mainly on the biochemical or electrophysiological activity of the brain. Here, we show that classical mechanical concepts including deformations, stretch, strain, strain rate, pressure, and stress play a crucial role in modulating both brain form and brain function. This opinion piece synthesizes expertise in applied mathematics, solid and fluid mechanics, biomechanics, experimentation, material sciences, neuropathology, and neurosurgery to address today’s open questions at the forefront of neuromechanics. We critically review the current literature and discuss challenges related to neurodevelopment, cerebral edema, lissencephaly, polymicrogyria, hydrocephaly, craniectomy, spinal cord injury, tumor growth, traumatic brain injury, and shaken baby syndrome. The multi-disciplinary analysis of these various phenomena and pathologies presents new opportunities and suggests that mechanical modeling is a central tool to bridge the scales by synthesizing information from the molecular via the cellular and tissue all the way to the organ level.
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Affiliation(s)
- Alain Goriely
- Mathematical Institute, University of Oxford, Oxford, OX2 6GG, UK,
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22
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Pryazhnikov E, Kislin M, Tibeykina M, Toptunov D, Ptukha A, Shatillo A, Gröhn O, Giniatullin R, Khiroug L. Opposite reactivity of meningeal versus cortical microvessels to the nitric oxide donor glyceryl trinitrate evaluated in vivo with two-photon imaging. PLoS One 2014; 9:e89699. [PMID: 24586970 PMCID: PMC3938546 DOI: 10.1371/journal.pone.0089699] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 01/23/2014] [Indexed: 11/18/2022] Open
Abstract
Vascular changes underlying headache in migraine patients induced by Glyceryl trinitrate (GTN) were previously studied with various imaging techniques. Despite the long history of medical and experimental use of GTN, its effects on the brain vasculature are still poorly understood presumably due to low spatial resolution of the imaging modalities used so far. We took advantage of the micrometer-scale vertical resolution of two-photon microscopy to differentiate between the vasodynamic effects of GTN on meningeal versus cortical vessels imaged simultaneously in anesthetized rats through either thinned skull or glass-sealed cranial window. Intermediate and small calibre vessels were visualized in vivo by imaging intravascular fluorescent dextran, and detection of blood flow direction allowed identification of individual arterioles and venules. We found that i.p.-injected GTN induced a transient constriction of meningeal arterioles, while their cortical counterparts were, in contrast, dilated. These opposing effects of GTN were restricted to arterioles, whereas the effects on venules were insignificant. Interestingly, the NO synthase inhibitor L-NAME did not affect the diameter of meningeal vessels but induced a constriction of cortical vessels. The different cellular environment in cortex versus meninges as well as distinct vessel wall anatomical features probably play crucial role in the observed phenomena. These findings highlight differential region- and vessel-type-specific effects of GTN on cranial vessels, and may implicate new vascular mechanisms of NO-mediated primary headaches.
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Affiliation(s)
- Evgeny Pryazhnikov
- Neuroscience Center, University of Helsinki, Helsinki, Finland
- Neurotar LTD, Helsinki, Finland
| | - Mikhail Kislin
- Neuroscience Center, University of Helsinki, Helsinki, Finland
| | | | | | - Anna Ptukha
- Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Artem Shatillo
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli Gröhn
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Rashid Giniatullin
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Leonard Khiroug
- Neuroscience Center, University of Helsinki, Helsinki, Finland
- Neurotar LTD, Helsinki, Finland
- * E-mail:
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Varatharaj A, Squier W, Mack J. Mast cells in the human dura: effects of age and dural bleeding--authors' reply. Childs Nerv Syst 2013; 29:1969-70. [PMID: 24013266 DOI: 10.1007/s00381-013-2278-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 08/26/2013] [Indexed: 11/29/2022]
Affiliation(s)
- A Varatharaj
- Department of Neuropathology, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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Scheimberg I, Cohen MC, Zapata Vazquez RE, Dilly S, Adnani MA, Turner K, Sethuraman C. Nontraumatic intradural and subdural hemorrhage and hypoxic ischemic encephalopathy in fetuses, infants, and children up to three years of age: analysis of two audits of 636 cases from two referral centers in the United Kingdom. Pediatr Dev Pathol 2013; 16:149-59. [PMID: 23113698 DOI: 10.2350/12-08-1232-oa.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We analyzed the presence or absence of intradural hemorrhage (IDH) and subdural hemorrhage (SDH) and the degree of hypoxic-ischemic encephalopathy (HIE) in the brain of all nonmacerated fetuses of >24 weeks, neonates, and children up to 3 years of age who died of natural causes over a defined period. We looked into the cause of death and the performance of cardiopulmonary resuscitation in our cohort. The IDH was classified as macroscopic or negative/microscopic only; the HIE was classified as absent, indeterminate, or definite. In fetuses, SDH with IDH was present in 22%; IDH alone was present in 31%, and there was no or minimal hemorrhage in 47% of cases. In infants and children SDH with IDH was present in 19%; IDH alone was present in the 32%, and there was no or minimal hemorrhage in 49% of cases. There was a statistically significant correlation between SDH and HIE, especially in infants and children (P < 0.001). When cases were grouped per age, a significant association between age and hemorrhage (P < 0.0001) was demonstrated, SDH being more common in infants ≤1 month corrected age. Intradural hemorrhage can be the source of thin-film SDH in fetuses, infants, and young children. The presence of SDH is associated with hypoxia. Intradural and subdural hemorrhages are more common in autopsies of infants under 1 month corrected age. Although more rare, they can also be found in children between 1 month and 3 years of age in the absence of trauma.
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