Complications of depressed skull fracture

Obstetric factors and neonatal outcomes of depressed skull fractures in newborns

PURPOSE

To determine the obstetric factors affecting the development of depressed skull fracture in neonates.

MATERIALS AND METHODS

This was a retrospectively cohort study on neonates born between July 2016 and August 2021. Neonates diagnosed with depressed skull fractures within one week of birth through X-ray and/or brain ultrasonography were included, and their mothers' obstetric characteristics were reviewed.

RESULTS

There were 12 cases in 6791 live births. Five women were over 35 years old. All except two were nulliparous. Five cases were delivered from labor induction and others presented with spontaneous labor. Except for two cases, delivery occurred within an hour after full cervical dilatation. Two cases were assisted by vacuum. None displayed fetal distress signs such as low Apgar scores below 7, meconium staining, and umbilical cord pH under 7.2. All depressed fractures were found in the right parietal area. Three cases resulted in focal hyperechoic lesion in brain ultrasonography and two of them showed small hemorrhage-like lesion in magnetic resonance imaging. All depressed skull fractures improved within 6 months in followed X-rays or ultrasonography.

CONCLUSIONS

There was no definitely associated obstetric condition for depressed skull fracture of neonates although nulliparous women were majority of the affected cases.

Traumatic skull fractures in dogs and cats: A comparative analysis of neurological and computed tomographic features

BACKGROUND

Traumatic skull fractures (TSF) are relatively frequent in dogs and cats, but little information is available regarding their clinical and imaging features.

HYPOTHESIS/OBJECTIVES

To describe the neurological and computed tomographic (CT) features of a large cohort of dogs and cats with TSF.

ANIMALS

Ninety-one dogs and 95 cats with TSF identified on CT.

METHODS

Multicenter retrospective comparative study. Signalment, cause of trauma, fracture locations and characteristics, presence of neurological deficits, and 1-week survival were recorded. Fractures were classified according to the extent of fragmentation and displacement.

RESULTS

The cranial vault was affected more frequently in dogs (P = .003), whereas the face and base of the cranium more often was affected in cats (P < .001). Cats presented with multiple fractures more frequently (P < .001). All animals with TSF in the cranial vault were more likely to develop neurological signs (P = .02), especially when depressed fractures were present (95% confidence interval [CI], 1.7-8.2; P = .001). Animals with TSF located only in the facial region were less likely to have neurological signs (odds ratio with Mantel-Haenszel's method [ORMH ], 0.2; 95% CI, 0.1-0.6; P = .004). Most affected animals (84.9%) survived the first week post-trauma. Death was more likely with fractures of the cranial vault (P = .003), especially when fragmented (P = .007) and displaced (P = .004).

CONCLUSIONS AND CLINICAL IMPORTANCE

Traumatic skull fracture distribution and patterns are different between dogs and cats. Cranial vault fractures were associated with neurological deficits and worse survival. The presence of TSF alone should not be considered a negative prognostic factor because most affected animals survived the first week.

Treatment of Traumatic Depressed Compound Skull Fractures

BACKGROUND

A skull fracture widely occurs in patients with traumatic brain injury, leading to intracranial hematoma, brain contusion, and intracranial infection. It also influences the prognosis and death of patients. This study aimed to discuss cases of patients with comminuted skull fractures.

METHODS

From October 2015 to December 2018, 38 patients with comminuted skull fractures were admitted to the hospital. All patients underwent three-dimensional reconstruction of computed tomography scan images. Digital subtraction angiography or magnetic resonance venography was performed to find out the venous sinus. The clinical findings of the patients were significant regarding gender, age, injury mechanism, location, admission Glasgow Coma Scale (GCS), combined epidural, subdural, cerebral contusion, intracranial pneumatosis, maximum depth of depression, admission to surgery, dural tear, post-operative cerebrospinal fluid leakage, post-operative infection, and Glasgow Outcome Scale (GOS) 3 months after surgery.

RESULTS

The incidence of traffic accidents, fall from a height, railway accidents, fall of an object, and chop injury was 60.5%, 18.4%, 13.2%, 5.3%, and 2.6%, respectively. Intra-operative dural trar negatively correlated with epidural hematoma, cerebral contusion, and subdural hematoma. Also, post-operative infection negatively correlated with intracranial pneumatosis, depth of fracture depression, and pre-operative cerebrospinal fluid leakage. No correlation was found between contusion, subdural hematoma, intracranial pneumatosis, depth of fracture depression, and post-operative infection. The GOS score positively correlated with age, pre-operative cerebrospinal fluid leakage, and admission GCS score.

CONCLUSIONS

A perfect pre-operative examination is a key to successful surgery. Further studies should be conducted to find out more effective treatments for traumatic comminuted skull fractures.

Depressed Fractures of Skull: An Institutional Series of 453 Patients and Brief Review of Literature

Background:

There has been a substantial increase in the number of cases with head injuries in the past two decades which has simultaneously led to increase in the annual incidence of depressed fractures of skull. Most of these skull fractures are associated with considerable morbidity and mortality of patients and an unavoidable financial burden on the family members. However, many changes have been undertaken directed toward improved management of patients with head injuries and skull fractures in the past 20 years.

Objective:

To study and compare the patterns of occurrence of the depressed fractures of skull and examine the factors which may influence the surgical outcome of patients with reference to similar case series from the past literature.

Patients and Methods:

We reviewed patient records of 453 patients admitted with depressed skull fractures in Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India, during the period of March 2004 through July 2009.

Results:

The incidence of depressed skull fracture was highest (56%) in the age group of 16–45 years. There was a predominance of male cases over females with a ratio of 7:1. The most common mode of injury was noted to be alleged assault (36%) and the parietal region (34%) being the most common site. Most cases had mild injury (62%) with Glasgow Coma Scale score of 13–15. The percentage of pure depressed fractures was 57% and the rest 42% were associated with intracranial lesion, of which the most common was contusion (25%). Superficial wound infection was observed in 38% of the patients. Of all the 453 patients, 91% were operated and most of them were operated within 24 h with overall mortality rate of 17%.

Conclusions:

Our study revealed the increased incidence of mortality in the age group of 16–45 years, which can guide our focus of management on them with strategic planning at individual as well as community level. Primary surgical repair of depressed skull fractures is safe, feasible, and associated with good outcomes. There was no significant association between tear in dura and an increase in the complications and, also, no substantial data to support the use of prophylactic antibiotics in patients to reduce chances of infection with it.

Midline depressed skull fracture presenting with quadriplegia: A rare phenomenon

Background:

Midline depressed skull fractures (MDSFs) deserve a special mention among skull fractures and should always be treated with caution. Here, an extremely unusual clinical presentation of a case of MDSF is highlighted along with its successful surgical management.

Case Description:

A 26-year-old male presented with quadriplegia following assault on the head with sharp weapons. The patient had multiple lacerated wounds on the scalp with underlying cranial fractures. On evaluation, computerized tomography (CT) of the brain showed a midline depressed skull fracture compressing the superior sagittal sinus (SSS) causing bilateral frontoparietal venous infarction. CT venogram showed a filling defect of the SSS due to the penetrating bone fragment. He underwent elevation of the depressed fracture and repair of the sinus with pericranial graft. Patient improved neurologically, and follow-up magnetic resonance venogram showed a patent SS.

Conclusion:

MDSF can present with quadriparesis/quadriplegia due to middle one-third SSS obstruction/thrombosis leading to bilateral motor cortical venous infarction. Such MDSFs may require emergent surgical elevation of the depressed bone fragment for restoration of the patency of the sinus.

The Glasgow Coma Scale: History and current practice

The Glasgow Coma Scale (GCS) was devised to assess injury severity in a multi-centre study of outcome after severe brain damage. It uses unambiguous terms that are readily understood by a wide range of observers. Giving numbers to responses makes communication and display of responsiveness easy and the overall score allows classifi cation of overall severity of brain injury for triage and for epidemiological studies. The total score involves some loss of predictive information. Outcome correlates well with the early GCS both in head injuries and other intensive care patients. When early sedation and ventilation after head injury makes GCS assessment difficult, the motor score is often available and is a useful index of injury severity. The GCS also facilitates monitoring in the early stages after injury, allowing rapid detection of complications. Even among mild injuries (GCS 13- 15) the scale can discriminate between those more or less likely to have detectable brain damage and to be at risk of complications.

Traumatic Dural Venous Sinus Injury

Objective

The importance of traumatic dural venous sinus injury lies in the probability of massive blood loss at the time of trauma or emergency operation resulting in a high mortality rate during the perioperative period. We considered the appropriate methods of treatment that are most essential in the overall management of traumatic dural venous sinus injuries.

Methods

We conducted a retrospective review of all cases involving patients with dural venous sinus injury who presented to our hospital between January 1999 and December 2014.

Results

Between January 1999 and December 2014, 20 patients with a dural venous sinus injury out of the 1,200 patients with severe head injuries who had been operated upon in our clinic were reviewed retrospectively. There were 17 male and 3 female patients. In 11 out of the 13 patients with a linear skull fracture crossing the dural venous sinus, massive blood loss from the injured sinus wall could be controlled by simple digital pressure using Gelfoam. All 5 patients with a linear skull fracture parallel to the sinus over the venous sinus developed massive sinus bleeding that could not be controlled by simple digital pressure.

Conclusion

When there is a linear skull fracture parallel to the sinus over the dural venous sinus or a depressed skull fracture penetrating the sinus, the surgeon should be prepared for the possibility of potentially fatal venous sinus injury, even in the absence of a hematoma.

Improvement in venous outflow following superior sagittal sinus decompression after a gunshot wound to the head: case report

The most commonly described indications for surgical management of closed depressed skull fractures are hematoma evacuation and repair of extensive cosmetic deformity. Venous sinus injury, which occurs in a subset of depressed skull fractures, is not typically listed as an indication for surgical treatment due to the potential for major venous hemorrhage associated with surgery near these structures. However, if patients exhibit signs and symptoms of intracranial hypertension and radiographic findings demonstrate sinus compromise, surgical elevation of the depressed skull fragments is indicated. The authors present the case of a 25-year-old woman with a depressed skull fracture secondary to a gunshot wound with symptomatic compromise in venous outflow of the posterior one-third of the superior sagittal sinus. The patient was treated with surgical decompression via bilateral craniectomy along with intracranial pressure-lowering medical therapy and had almost full resolution of her presenting symptoms with documented improvement in flow through the superior sagittal sinus. While the use of surgical treatment for these types of injuries is highly debated, the authors demonstrate here that safe, effective surgical management of these patients is possible and that surgical decompression should always be considered in the case of symptomatic venous sinus flow obstruction.

Sinovenous thrombosis associated with skull fracture in the setting of blunt head trauma

BACKGROUND

Emerging literature suggests that closed head injuries may be an important etiology of cerebral venous sinus thrombosis (CVST). Fractures over the dural sinuses, in particular, may predispose such patients to this secondary complication. The purpose of this study was to determine the incidence and characteristics of CVST resulting from skull fractures overlying cerebral venous sinuses at a single tertiary care center.

METHODS

A retrospective review of consecutive patients presenting to our institution with skull fractures from blunt head trauma between 1 January 2009 and 31 December 2011 who underwent either a computed tomography (CT) or magnetic resonance (MR) venogram. Patient demographics, associated intracranial injuries, admission Glasgow Coma Scale (GCS), presence of CVST, and post-hospital disposition were recorded.

RESULTS

Overall, 908 patients with skull fractures presented to the institution. Of those, 63 had fractures over a sinus and a venogram satisfying inclusion criteria. Twenty-two (34.9 %) patients demonstrated a thrombus in at least one sinus. There was no statistical difference in patient demographics, presenting GCS, length of stay (LOS), or outcome between patients with or without a thrombus. Pediatric patients had significantly shorter LOS (11 vs. 4 days, p < 0.01) compared to adults. Adults had a greater incidence of total sinus occlusions while children had more non-occlusive thrombus formations; both were statistically significant (p = 0.035 and p = 0.037, respectively).

CONCLUSIONS

This report suggests that over 10 % of skull fractures involve cerebral venous sinuses, thus emphasizing the need to rule out CVST in patients suffering blunt head trauma. We propose including a venogram as part of the initial trauma work-up for these patients. Moreover, our data suggest that pediatric patients may be predisposed to less severe injuries than their adult counterparts.

Long-term neurologic outcomes after traumatic brain injury

OBJECTIVE

To determine the relations between traumatic brain injury (TBI) and several neurologic outcomes 6 months or more after TBI.

PARTICIPANTS

Not applicable.

DESIGN

Systematic review of the published, peer-reviewed literature.

PRIMARY MEASURES

Not applicable.

RESULTS

We identified 75 studies that examined the relations between TBI and neurologic outcomes. Unprovoked seizures are causally related to penetrating TBI as well as to moderate and severe TBI. There was only limited evidence of an association between seizures and mild TBI. Dementia of the Alzheimer's type (DAT) was associated with moderate and severe TBI, but not with mild TBI unless there was loss of consciousness (LOC); the evidence for the latter was limited. Parkinsonism was associated with moderate and severe TBI, but there was only modest evidence of a link with mild TBI without LOC. Dementia pugilistica was associated with professional boxing. There was insufficient evidence to support an association between TBI and both multiple sclerosis and amyotrophic lateral sclerosis. TBI appeared to produce a host of postconcussive symptoms (eg, memory problems, dizziness, and irritability). Moderate and severe TBI were associated with endocrine problems such as hypopituitarism and growth hormone deficiency and possibly with diabetes insipidus. There was only limited evidence of an association between mild TBI and the development of ocular/visual motor deterioration.

CONCLUSION

TBI is strongly associated with several neurologic disorders 6 months or more after injury. Clinicians caring for TBI patients should monitor them closely for the development of these disorders. While some of these disorders can be treated after they arise (eg, seizures), a greater public health benefit would be achieved by preventing them before they develop. Research efforts to develop therapies aimed at secondary prevention are currently underway.

Simple depressed skull fracture causing sagittal sinus stenosis and increased intracranial pressure: case report and review of the literature

The surgical management of depressed skull fractures is determined in part by whether a fracture is open or closed. Open fractures are usually elevated surgically, but closed fractures are most often treated nonoperatively, and the only 2 indications commonly described for operative treatment of closed fractures are hematoma evacuation and correction of cosmetic deformity. There is another indication, however, that is occasionally encountered when a depressed skull fracture injures a venous sinus. This injury can result in venous sinus stenosis, leading to venous hypertension and elevated intracranial pressure (ICP). A case is presented of closed depressed fracture of the midline skull, causing compressive stenosis of the superior sagittal sinus (SSS), venous hypertension, and encephalopathy. The fracture was surgically elevated to relieve the compression of the SSS and the encephalopathy resolved. The clinical identification, the imaging, and the risks and benefits of operative repair of this condition are reviewed. Increased ICP secondary to venous sinus injury is not commonly described in association with closed depressed skull fractures, but should always be considered in patients with the appropriate clinical findings when a fracture overlies a venous sinus, even in the absence of a hematoma.

Resolution of Intracranial Hypertension after Elevation of Depressed Cranial Fracture over the Superior Sagittal Sinus:Case Report

OBJECTIVE AND IMPORTANCE:

It is common neurosurgical wisdom that depressed cranial fractures (DCFs) over the superior sagittal sinus (SSS) should not be elevated because of the risk of fatal venous hemorrhage.

CLINICAL PRESENTATION:

A 34-year-old man presented with severe headache and diplopia after a motor vehicle accident. Clinical examination demonstrated severe papilledema and bilateral abducens palsy. Imaging findings demonstrated a DCF over the posterior third of the SSS and absent flow distal to the fracture with dilated cortical venous drainage.

INTERVENTION:

Conservative treatment with acetazolamide only partially alleviated the patient's headache and diplopia. Definitive surgical treatment via elevation of the DCF was discussed and decided upon. Twelve days after injury, the patient underwent midline parieto-occipital craniotomy with successful elevation of the DCF off the posterior third of the SSS. Postoperative magnetic resonance venograms revealed restoration of patency in the SSS with reduced tortuosity of cortical veins. The patient's headache resolved, and his papilledema and diplopia resolved gradually.

CONCLUSION:

Elevation of DCF over the SSS can be attempted in cases in which favorable bone anatomy and the patient's clinical condition warrant. This may result in rapid and dramatic resolution of signs and symptoms of secondary intracranial hypertension.

Brief communication: neurotraumatological aspects of head injuries resulting from sharp and blunt force in the early medieval period of southwestern Germany

Approximately 10% (33 of 304) of the predominantly male skulls from the 6th through 8th centuries in southwestern Germany exhibit cranial fractures derived from blunt or sharp force trauma. No evidence of fracture healing characterizes 24% (n = 8) of these individuals. All nonhealed fractures were caused by sharp force, and four of these wounds cross the sagittal sinus. The lengths of these straight-edged wounds, produced exclusively by sword blows, measure around 8.0 cm for fatal, and about 5.0 cm for nonfatal wounds. Seventy-six percent (n = 25) of these skulls exhibit some healing, which indicates that these injuries did not lead to immediate death. In this group are all depressed fractures resulting from blunt force blows. Two thirds of the 45 cranial injuries noted on these 33 skulls are located on the left side of these individuals, with a concentration in the frontoparietal region. Bony indications of wound infection occur in four cases (12%). Three crania exhibit circular trepanations in association with fractures. These phenomena are discussed in the context of modern neurotraumatological knowledge.

Golf related head injuries in children: the little tigers

Head injury is a major cause of morbidity in Western society and sport related incidents account for approximately 11% of all head injured patients attending Accident and Emergency Departments. Golf was shown to be one of the sports most commonly associated with head injury requiring referral to a regional neurosurgical centre. Previous studies have demonstrated that it is predominantly children who sustain golf related head injuries which present either to an accident and emergency department or a regional neurosurgical centre. This study examines the number and pattern of golf related head injuries in children presenting to an accident and emergency department or requiring admission to the regional neurosurgical centre, over a three month period.

Depressed skull fracture overlying the superior sagittal sinus as a cause of benign intracranial hypertension. Case report

The use of surgical treatment for depressed skull fractures that are located over major venous sinuses is a matter of controversy. However, if clinical and radiological findings of sinus obliteration and related intracranial hypertension are present, surgical decompression is indicated. The authors present the case of a 38-year-old man who had a depressed skull fracture overlying the posterior one-third portion of the superior sagittal sinus. The lesion was initially treated conservatively and the patient was readmitted 1 month later with signs and symptoms of intracranial hypertension. The role of radiological investigation in the detection of venous sinus flow and indications for surgical treatment are discussed. If venous sinus flow obstruction is revealed in the presence of signs and symptoms of intracranial hypertension, surgery is indicated as the first line of treatment.

Pediatric depressed skull fractures: analysis of 530 cases

Depressed skull fractures (DSFs) account for 7-10% of children admitted to hospital with a head injury and 15-25% of children with skull fractures. We reviewed the records of 530 patients operated on for DSF from January 1, 1973, to December 31, 1993. This group was made up of 357 boys (67%) and 173 girls (33%) whose ages ranged from 1 day to 16 years (mean age 6.1 years). Fall was the most common cause of injury. Of the 530 patients with DSF, 66% had compound fractures. The incidence of compound fractures increased with age. Compound fractures caused more brain lacerations (29%) than simple fractures (15.5%) did. We also classified DSFs radiologically as true, flat, or ping-pong ball fractures. Associated intracranial lesions were found to be a bad prognostic factor. There were 13 deaths (2.5%) in this series. Satisfactory results were achieved in over 95% of the patients. Compound fractures are associated with a worse outcome and a higher incidence of intracranial lesions and cortical laceration. Unilateral pupillary dilatation and an admission GCS score of 8 or less are ominous signs in regard to mortality. We also found that the deeper the depressed bone, the higher the risk of both dural tear and cortical laceration and the worse the prognosis. A conservative approach should be followed in cases of simple DSF without associated intracranial hematoma and in cases in which the bone depression is not deeper than 1 cm.

Biomechanical factors in patient selection for radiography after head injury

In order to assess the predictive value of certain biomechanical parameters for skull fracture after head injury, a prospective analysis was undertaken of a series of 5416 head-injured patients. In each case an assessment was made at presentation as to the velocity of impact and the physical properties of the impacting agent. The incidence of skull vault fracture was then calculated for injuries sustained at different velocities and for different types of contact. The incidence of fracture was also calculated with respect to the presence of post-traumatic amnesia (PTA). The incidences (95 per cent confidence intervals) of skull fracture at low, medium and high speeds were 0.17 (0.0427-0.433), 1.99 (1.47-2.63) and 10.2 (7.41-12.6) per cent respectively. Fractures tended to occur with greater frequency after impacts against broad hard surfaces or small objects rather than against broad soft objects. The percentage incidence of fracture in adults suffering more than 5 min of PTA was 17.93 (12.4-23.5) compared with 0.674 (0.372-1.1) in those without amnesia. Patient selection for skull radiography after an apparently minor head injury can be guided by an assessment of post-traumatic amnesia and the biomechanics of the injury.

Extradural haematoma in a child after an apparently mild head injury

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Progress in the management of head injury

Three 1-year surveys of head injury management spanning a 9-year period in a single regional centre are presented. There was a reduction in total numbers of head injury admissions after guidelines for admission and referral were implemented. More liberal use of computed tomography resulted in detection of a greater number of intracranial haematomas with the majority detected in non-comatose patients. The early mortality rate in severe head injury fell from 45 per cent to 34 per cent despite referral of large numbers of patients with multiple injuries and a substantial proportion (12 per cent) of patients aged more than 70 years in whom outcome did not improve. Total occupied bednights and bednights occupied per surviving patient with severe head injury fell over the period of study. Care for patients with significant head injury should be based on regional neurosurgical units associated with trauma services.

Accidental golf club injuries

Over a 2 month period, 33 patients with injuries caused by golf clubs were identified among attenders at the accident and emergency department at Glasgow Royal Infirmary. The vast majority of these were to the face and head, including three compound skull fractures. Attention is drawn to the average age of those injured (8.1 years) and to the fact that only one of the injuries occurred on a golf course. The dangers of unsupervised experimentation with golf clubs by young children are emphasized.

Evaluation of minor head trauma in children younger than two years

The recent medical literature emphasizes the limitations of skull films in the evaluation of minor head trauma. However, the emergency medicine literature places little emphasis on the particular risks in children younger than 2 years old with blunt head injury. These children have immature bone and unfused sutures that may increase risk of cranial injury and delayed complications. A case is presented to illustrate this point. Unlike severe head trauma, where evaluation is directed toward computed tomography, the literature continues to be controversial regarding the indications for skull radiographs and computed tomography in minor head trauma. The authors recommend a low threshold for radiographic imaging in blunt heat injuries in children younger than 2 years.

Management of depressed skull fractures. Selective conservative management of nonmissile injuries

The management of 319 cases with nonmissible depressed skull fractures is discussed. The majority of these injuries (75%) resulted from assaults and more than 90% were compound fractures. Of these, 35 cases were excluded from the series; these were patients who died before investigation or treatment could be instituted, or whose major injury was an intracranial hematoma or extensive traumatic hemorrhagic necrosis rather than a depressed fracture with underlying localized contusion. In the remaining 284 cases a comparison is made between the outcome in 124 (44%) patients treated by a conventional surgical method and 160 (56%) selected patients whose wound was only inspected, cleaned, and sutured in the emergency room. The nonsurgical group included 21 (9%) patients with simple depressed fractures and also patients without severe wound contamination, established infection, severe comminution of the fracture, or brain or cerebrospinal fluid in the wound. The results of management were assessed in relation to septic complications, the outcome of focal neurological abnormalities, and fatal complications. The group treated conservatively compared favorably with the surgical cases and also with previously reported series. The obvious bias in favor of the conservative group is admitted; however, it is clear that the majority of simple fractures and some compound depressed skull fractures can be managed safely without major surgical intervention. Socioeconomic implications are discussed.

Gas gangrene occurring soon after compound depressed skull fracture

Two cases of Clostridium perfringens infection occurring less than 24 hours after compound depressed skull fracture are reported. The infection was principally intracranial in the first and extracranial in the second; both required surgical debridement and antibiotic treatment. Attention is drawn to the rapidity with which a potentially life-threatening infection can develop in civilian head injury and to the implications for acute management of patients with compound depressed fractures.

The utility of post-traumatic skull X-rays

During two 12-month periods, 12,395 accident and emergency department attenders with head injury were collected. Those characteristics which were significantly more common in head-injured patients who had skull fractures on X-ray were identified. These characteristics were: recent alcohol consumption in adults, initial unconsciousness, amnesia of any duration, vomiting, neurological signs, injuries sustained by pedestrians, motorcyclists and cyclists. Such characteristics were then further examined and their power as diagnostic tests for the presence of skull fracture on X-ray was detailed. In individual patients and especially in children, these characteristics were generally of little value in identifying patients with fractures. It was considered that, in the majority of individual patients with head injuries, accurate clinical diagnosis of radiologically apparent fractures was not possible. In view of this and in the light of the known risks in patients with fractures, it was concluded that skull X-rays should continue to be used relatively freely in the management of these patients.

Assessment of closed head injury in trauma-related spinal cord injury

The complete medical records of 122 patients who sustained traumatic spinal cord injuries were reviewed to determine the frequency and results of emergency room assessments for loss of consciousness (LOC) and post-traumatic amnesia (PTA). Eighty-eight percent of the patients were assessed for LOC and 19% were assessed for PTA. Fifty patients (41% of the total population) admitted to LOC, PTA or both. Fourteen of these 50 patients underwent subsequent radiographic examinations of the skull, all of which were negative. Because of the association of intracranial complications and long-term cognitive sequelae with even brief LOC or PTA, early recognition of craniocerebral trauma is an important component of the acute management of spinal cord injured patients.

Minor, moderate and severe head injury

The future role of the neurosurgeon in the management of head injury is reviewed in terms of the care of patients with minor, moderate and severe head injuries. In minor head injury it is predicted that there will be increasing pressure on the neurosurgeon to undertake the management and follow-up of all patients who have sustained head injury, and this will place a considerable additional load on each neurosurgical unit. This is based on a survey of 1919 head injuries admitted in one calendar year (1981), consisting of 93 severe injuries (GCS less than 8), 210 moderate injuries (GCS 8-12), and 1616 minor injuries (GCS 13/14). In moderate injuries CT will assume a major role in detecting hematoma early and identifying contusions. There may yet be a role for steroids in these cases and there should be a greater use of neurorehabilitation, instead of the current overemphasis on the severely injured. In severe injury future efforts will be to prevent early secondary insults and to find better methods of controlling raised intracranial pressure.

The work of a regional head injury service

A survey was done of the workload involved in conducting a programme in which all degrees of severity of head injury are managed in one unit staffed by neurosurgeons. Of 1919 patients admitted to the unit in 1981, 93 were classed as severe (in coma), 210 as moderate, and 1616 as minor (fully conscious or confused only) on admission. Although the proportion of intracranial haematomas, multiple injuries, life-threatening complications, and deaths was highest in severe cases, the work of looking after the very large numbers of moderate and minor cases was as great as that of looking after severe cases as defined by number of investigations, operations, and complications, morbidity, and duration of hospital stay. In 1982 the admission policy was changed so that temporary loss of consciousness was no longer an indication for admission. This change resulted in a 24% reduction in number of admissions. Seat-belt legislation, enacted early in 1983, was followed by a further 21% reduction in the admission rate and this was maintained in 1984. Not all of this latter reduction can, however, be attributed to the wearing of seat belts.

Posttraumatic seizures: an assessment of the epidemiologic literature

Confusion about the risk of seizures following head trauma might in part reflect methodologic limitations of reported studies. This epidemiologic review emphasizes four methodologic issues: selection of cases, selection of controls, definition and ascertain of seizures, and definition, of seizures, and definition, classification, and ascertainment of trauma. Although the focus of this review is a set of reports of civilian injuries, the relevance of war studies to civilian injuries is also discussed.

Serious head injury in sport

Of 1900 head injuries serious enough to be admitted to the neurosurgical unit in Glasgow over a five year period, 52 (2.7%) were due to "sport." Golf, horse-riding, and Association football were the sports most commonly linked with serious head injury. Golfing injuries were all compound depressed fractures, and all these patients made a good recovery; horse-riding produced more severe injuries, three of the eight patients being left with residual disability. Much attention has been directed to preventing repeated minor head injury in boxing, but this study emphasises the need for preventing both the primary head injury and secondary complications associated with other sports.