Brain trauma in head injuries presenting with and without concurrent skull fractures

Subject-specific finite element head models for skull fracture evaluation-a new tool in forensic pathology

Post-mortem computed tomography (PMCT) enables the creation of subject-specific 3D head models suitable for quantitative analysis such as finite element analysis (FEA). FEA of proposed traumatic events is an objective and repeatable numerical method for assessing whether an event could cause a skull fracture such as seen at autopsy. FEA of blunt force skull fracture in adults with subject-specific 3D models in forensic pathology remains uninvestigated. This study aimed to assess the feasibility of FEA for skull fracture analysis in routine forensic pathology. Five cases with blunt force skull fracture and sufficient information on the kinematics of the traumatic event to enable numerical reconstruction were chosen. Subject-specific finite element (FE) head models were constructed by mesh morphing based on PMCT 3D models and A Detailed and Personalizable Head Model with Axons for Injury Prediction (ADAPT) FE model. Morphing was successful in maintaining subject-specific 3D geometry and quality of the FE mesh in all cases. In three cases, the simulated fracture patterns were comparable in location and pattern to the fractures seen at autopsy/PMCT. In one case, the simulated fracture was in the parietal bone whereas the fracture seen at autopsy/PMCT was in the occipital bone. In another case, the simulated fracture was a spider-web fracture in the frontal bone, whereas a much smaller fracture was seen at autopsy/PMCT; however, the fracture in the early time steps of the simulation was comparable to autopsy/PMCT. FEA might be feasible in forensic pathology in cases with a single blunt force impact and well-described event circumstances.

Risk factors and predictive model of cerebral edema after road traffic accidents-related traumatic brain injury

PURPOSE

Cerebral edema (CE) is the main secondary injury following traumatic brain injury (TBI) caused by road traffic accidents (RTAs). It is challenging to be predicted timely. In this study, we aimed to develop a prediction model for CE by identifying its risk factors and comparing the timing of edema occurrence in TBI patients with varying levels of injuries.

METHODS

This case-control study included 218 patients with TBI caused by RTAs. The cohort was divided into CE and non-CE groups, according to CT results within 7 days. Demographic data, imaging data, and clinical data were collected and analyzed. Quantitative variables that follow normal distribution were presented as mean ± standard deviation, those that do not follow normal distribution were presented as median (Q1, Q3). Categorical variables were expressed as percentages. The Chi-square test and logistic regression analysis were used to identify risk factors for CE. Logistic curve fitting was performed to predict the time to secondary CE in TBI patients with different levels of injuries. The efficacy of the model was evaluated using the receiver operator characteristic curve.

RESULTS

According to the study, almost half (47.3%) of the patients were found to have CE. The risk factors associated with CE were bilateral frontal lobe contusion, unilateral frontal lobe contusion, cerebral contusion, subarachnoid hemorrhage, and abbreviated injury scale (AIS). The odds ratio values for these factors were 7.27 (95% confidence interval (CI): 2.08 - 25.42, p = 0.002), 2.85 (95% CI: 1.11 - 7.31, p = 0.030), 2.62 (95% CI: 1.12 - 6.13, p = 0.027), 2.44 (95% CI: 1.25 - 4.76, p = 0.009), and 1.5 (95% CI: 1.10 - 2.04, p = 0.009), respectively. We also observed that patients with mild/moderate TBI (AIS ≤ 3) had a 50% probability of developing CE 19.7 h after injury (χ2 = 13.82, adjusted R2 = 0.51), while patients with severe TBI (AIS > 3) developed CE after 12.5 h (χ2 = 18.48, adjusted R2 = 0.54). Finally, we conducted a receiver operator characteristic curve analysis of CE time, which showed an area under the curve of 0.744 and 0.672 for severe and mild/moderate TBI, respectively.

CONCLUSION

Our study found that the onset of CE in individuals with TBI resulting from RTAs was correlated with the severity of the injury. Specifically, those with more severe injuries experienced an earlier onset of CE. These findings suggest that there is a critical time window for clinical intervention in cases of CE secondary to TBI.

Cellular and Molecular Pathophysiology of Traumatic Brain Injury: What Have We Learned So Far?

Traumatic brain injury (TBI) is one of the leading causes of long-lasting morbidity and mortality worldwide, being a devastating condition related to the impairment of the nervous system after an external traumatic event resulting in transitory or permanent functional disability, with a significant burden to the healthcare system. Harmful events underlying TBI can be classified into two sequential stages, primary and secondary, which are both associated with breakdown of the tissue homeostasis due to impairment of the blood-brain barrier, osmotic imbalance, inflammatory processes, oxidative stress, excitotoxicity, and apoptotic cell death, ultimately resulting in a loss of tissue functionality. The present study provides an updated review concerning the roles of brain edema, inflammation, excitotoxicity, and oxidative stress on brain changes resulting from a TBI. The proper characterization of the phenomena resulting from TBI can contribute to the improvement of care, rehabilitation and quality of life of the affected people.

Cranial Bone Changes Induced by Mild Traumatic Brain Injuries: A Neglected Player in Concussion Outcomes?

Mild traumatic brain injuries (TBIs), particularly when repetitive in nature, are increasingly recognized to have a range of significant negative implications for brain health. Much of the ongoing research in the field is focused on the neurological consequences of these injuries and the relationship between TBIs and long-term neurodegenerative conditions such as chronic traumatic encephalopathy and Alzheimer's disease. However, our understanding of the complex relationship between applied mechanical force at impact, brain pathophysiology, and neurological function remains incomplete. Past research has shown that mild TBIs, even below the threshold that results in cranial fracture, induce changes in cranial bone structure and morphology. These structural and physiological changes likely have implications for the transmission of mechanical force into the underlying brain parenchyma. Here, we review this evidence in the context of the current understanding of bone mechanosensitivity and the consequences of TBIs or concussions. We postulate that heterogeneity of the calvarium, including differing bone thickness attributable to past impacts, age, or individual variability, may be a modulator of outcomes after subsequent TBIs. We advocate for greater consideration of cranial responses to TBI in both experimental and computer modeling of impact biomechanics, and raise the hypothesis that calvarial bone thickness represents a novel biomarker of brain injury vulnerability post-TBI.

Causative effects of cranial depression fractures: A case study of structural violence and social vulnerability within the Mississippi state asylum

Cranial depression fractures (CDFs) are often associated with violence in a forensic and bioarchaeological context. Interpretations of CDFs, using a structural vulnerability framework, allow for examination of possible socioeconomic and sociocultural factors that influence an individual's life history. Placement of CDFs in relation to traumatic brain injuries (TBIs) and their potential connections to structural violence become essential for analysis. This case study presented Burial 49 from the Mississippi State Lunatic Asylum (MSA). Burial 49 was an adult individual (probable male) who exhibited antemortem trauma to the left parietal bone with an associated CDF. The injury location had the potential to cause a variety of neurological and developmental issues, including difficulty understanding spoken/written language. This case study demonstrates how CDFs, structural violence, and social vulnerabilities might have contributed to an increased risk of MSA admittance and provide context for why this individual was marginalized.

A Case of Penetrating Head Wound Due to Helicopter Rotor Blade Injury in a 34-Year-Old Naval Helicopter Pilot Who Returned to Active Service 5 Years Later

BACKGROUND Head trauma, defined as damage to the brain, skull, or scalp when the head is hit by an external force, is a major cause of mortality in military personnel. Therefore, we report a novel case involving a naval helicopter pilot who sustained a helicopter propeller rotor blade injury. CASE REPORT We describe a case involving a pilot struck on the head by a helicopter rotor blade. He received care from medical staff shortly after the injury and was en route to the nearest trauma center. Cranial computed tomography (CT) scans revealed a comminuted fracture of the right occipital bone, with bone fragment retention in the right cerebral hemispheres. We performed an emergency right occipital craniotomy. The visual field patterns demonstrated right homonymous hemianopia when the patient was discharged. The patient underwent delayed titanium mesh cranioplasty about 3 months after the right occipital craniotomy. From discharge to 5 years, the patient had performed rehabilitation exercise for at least 3 days every week. The patient's continued recovery was confirmed at the 5-year follow-up in 2019. The bilateral visual acuity was 20/20, and the right homonymous hemianopia problem also disappeared. In the same year, after a physical and psychological assessment by an aviation doctor, he was able to resume flying. CONCLUSIONS This report has shown that despite safety regulations for military and civilian helicopter personnel, which include the wearing of helmets, helicopter rotor blade injuries still occur and can have long-term consequences due to the severity of head injury.

Influence of Skull Fracture on Traumatic Brain Injury Risk Induced by Blunt Impact

This study is aimed at investigating the influence of skull fractures on traumatic brain injury induced by blunt impact via numerous studies of head-ground impacts. First, finite element (FE) damage modeling was implemented in the skull of the Total HUman Model for Safety (THUMS), and the skull fracture prediction performance was validated against a head-ground impact experiment. Then, the original head model of the THUMS was assigned as the control model without skull element damage modeling. Eighteen (18) head-ground impact models were established using these two FE head models, with three head impact locations (frontal, parietal, and occipital regions) and three impact velocities (25, 35, and 45 km/h). The predicted maximum principal strain and cumulative strain damage measure of the brain tissue were employed to evaluate the effect of skull fracture on the cerebral contusion and diffuse brain injury risks, respectively. Simulation results showed that the skull fracture could reduce the risk of diffuse brain injury risk under medium and high velocities significantly, while it could increase the risk of brain contusion under high-impact velocity.

Traumatic skull fractures in children and adolescents: A retrospective observational study

OBJECTIVE

To investigate the epidemiological features of child and adolescent (≤18 years old) patients managed for traumatic skull fractures (TSKFs) and associated traumatic brain injury (TBI).

DESIGN

393 Patients who were children and adolescent who had TSKFs admitted to our university affiliated hospitals between January 2003 and December 2010. The incidence and patterns were summarized with respect to different age group, admission time and etiology.

SETTING

Two university-affiliated hospitals from January 2003 to May 2010.

RESULTS

The most common etiologies were motor vehicle collisions (MVCs) (166, 42.2%) and high fall (101, 25.7%). The most common skull fracture sites were parietal fractures (n=111, 28.2%) and basilar skull fracture (n=111, 28.2%). A total of 300 (76.3%) patients suffered TBI and 23 (5.9%) patients suffered OCI. The most common intracranial hemorrhage was epidural hemorrhage (n=94, 23.9%). The frequencies of emergency admission, medical insurance and associated injuries were 56.2% (n=221), 22.4% (n=88) and 37.2% (n=146). The frequencies of TBI and associated injuries were significantly increased from 53.45% to 76.3% and from 6.9% to 41.6% with age, respectively.

CONCLUSIONS

MVCs were the most common etiologies. Parietal and basilar skull fractures, epidural hemorrhages were the most common fracture sites and intracranial hemorrhage.

Effects of neurofeedback on the short-term memory and continuous attention of patients with moderate traumatic brain injury: A preliminary randomized controlled clinical trial

PURPOSE

There are some studies which showed neurofeedback therapy (NFT) can be effective in clients with traumatic brain injury (TBI) history. However, randomized controlled clinical trials are still needed for evaluation of this treatment as a standard option. This preliminary study was aimed to evaluate the effect of NFT on continuous attention (CA) and short-term memory (STM) of clients with moderate TBI using a randomized controlled clinical trial (RCT).

METHODS

In this preliminary RCT, seventeen eligible patients with moderate TBI were randomly allocated in two intervention and control groups. All the patients were evaluated for CA and STM using the visual continuous attention test and Wechsler memory scale-4th edition (WMS-IV) test, respectively, both at the time of inclusion to the project and four weeks later. The intervention group participated in 20 sessions of NFT through the first four weeks. Conversely, the control group participated in the same NF sessions from the fifth week to eighth week of the project.

RESULTS

Eight subjects in the intervention group and five subjects in the control group completed the study. The mean and standard deviation of participants' age were (26.75 ± 15.16) years and (27.60 ± 8.17) years in experiment and control groups, respectively. All of the subjects were male. No significant improvement was observed in any variables of the visual continuous attention test and WMS-IV test between two groups (p ≥ 0.05).

CONCLUSION

Based on our literature review, it seems that our study is the only study performed on the effect of NFT on TBI patients with control group. NFT has no effect on CA and STM in patients with moderate TBI. More RCTs with large sample sizes, more sessions of treatment, longer time of follow-up and different protocols are recommended.