Epidemiological Study of Frontal Sinus Fractures: Evaluation of 16 Years of Care at the Faculty of Dentistry of Ribeirão Preto/Brazil

Purpose

Aiming to evaluate and study the epidemiological profile of frontal sinus fractures treated in the region of Ribeirão Preto-Brazil.

Methods

Sixteen years of activity in the Oral and Maxillofacial service of the Faculty of Dentistry of Ribeirão Preto/SP (FORP/USP), totaling 9,736 consultations, 4,524 with facial fractures, those diagnosed with frontal sinus fracture (113) were evaluated and selected for the study.

Results

Frontal sinus fractures accounted for 2.5% of facial fractures, the majority occurring in men (89.4%), concentrated in the age group 21-30 years old, with 52.2% of cases being caused by road traffic accidents (RTA). Associations with other facial fractures are common and appeared in 75.2% of cases. Treatment was followed either surgically, by open reduction internal fixation (52.2%) or conservatively (35.4%). Analyzing only the 28 isolated frontal sinus fractures, the most common treatment was conservative (46.4%). surgical treatment dropped to 25%. The most common postoperative complications were temporal branch paralysis and supraorbital nerve paresthesia, both occurring in 30.5% of surgical cases.

Conclusion

The frequency of frontal sinus fractures may be decreasing, but the pattern of occurrence in young men due to road traffic accidents does not seem to change, fortunately the appearance of serious complications is not common and it is usually associated with more severe trauma.

high risk pediatric patients with skull fractures

BACKGROUND

To assess for occult fractures, physicians often opt to obtain skeletal surveys (SS) in young, acutely head-injured patients who present with skull fractures. Data informing optimal decision management are lacking.

OBJECTIVE

To determine the positive yields of radiologic SS in young patients with skull fractures presumed to be at low vs. high risk for abuse.

PARTICIPANTS AND SETTING

476 acutely head injured, skull-fractured patients <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021.

METHODS

We conducted a retrospective, secondary analysis of the combined, prospective Pediatric Brain Injury Research Network (PediBIRN) data set.

RESULTS

204 (43 %) of 476 patients had simple, linear, parietal skull fractures. 272 (57 %) had more complex skull fracture(s). Only 315 (66 %) of 476 patients underwent SS, including 102 (32 %) patients presumed to be at low risk for abuse (patients who presented with a consistent history of accidental trauma; intracranial injuries no deeper than the cortical brain; and no respiratory compromise, alteration or loss of consciousness, seizures, or skin injuries suspicious for abuse). Only one of 102 low risk patients revealed findings indicative of abuse. In two other low risk patients, SS helped to confirm metabolic bone disease.

CONCLUSIONS

Less than 1 % of low risk patients under three years of age who presented with simple or complex skull fracture(s) revealed other abusive fractures. Our results could inform efforts to reduce unnecessary skeletal surveys.

Automatically Diagnosing Skull Fractures Using an Object Detection Method and Deep Learning Algorithm in Plain Radiography Images

OBJECTIVE

Deep learning is a machine learning approach based on artificial neural network training, and object detection algorithm using deep learning is used as the most powerful tool in image analysis. We analyzed and evaluated the diagnostic performance of a deep learning algorithm to identify skull fractures in plain radiographic images and investigated its clinical applicability.

METHODS

A total of 2026 plain radiographic images of the skull (fracture, 991; normal, 1035) were obtained from 741 patients. The RetinaNet architecture was used as a deep learning model. Precision, recall, and average precision were measured to evaluate the deep learning algorithm's diagnostic performance.

RESULTS

In ResNet-152, the average precision for intersection over union (IOU) 0.1, 0.3, and 0.5, were 0.7240, 0.6698, and 0.3687, respectively. When the intersection over union (IOU) and confidence threshold were 0.1, the precision was 0.7292, and the recall was 0.7650. When the IOU threshold was 0.1, and the confidence threshold was 0.6, the true and false rates were 82.9% and 17.1%, respectively. There were significant differences in the true/false and false-positive/false-negative ratios between the anteriorposterior, towne, and both lateral views (p=0.032 and p=0.003). Objects detected in false positives had vascular grooves and suture lines. In false negatives, the detection performance of the diastatic fractures, fractures crossing the suture line, and fractures around the vascular grooves and orbit was poor.

CONCLUSION

The object detection algorithm applied with deep learning is expected to be a valuable tool in diagnosing skull fractures.

Comparison of the predictive value of two international guidelines for safe discharge of patients with mild traumatic brain injuries and associated intracranial pathology

PURPOSE

To determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury.

METHODS

Retrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14-15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation.

RESULTS

Of the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%.

CONCLUSION

There was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline's original study. At present, neither guideline can be recommended for implementation in the current or similar settings.

Head Injury during Childbirth

Head injuries are the most common type of birth injuries. Among them, most of the injuries is limited to the scalp. and the prognosis is good enough to be unnoticed in some cases. Intracranial injuries caused by excessive forces during delivery are rare. However, since some of them can be fatal, it is necessary to suspect it at an early stage and evaluate thoroughly if there are abnormal findings in the patient.

[Skull and skull base injuries in children and adolescents : Results of a monocentric analysis]

BACKGROUND

The present study comprises a retrospective analysis of skull, skull base, and midface fractures in children, to provide clinical orientation for their management. To date, only few data are available on these injuries in this patient group.

METHODS

Data from inpatient cases diagnosed with a midface, skull, or skull base fracture in the Children's Hospital Auf der Bult from 2015 to 2020 were evaluated. Age, gender, fracture mechanism, diagnosis, treatment, and possible complications were analyzed. Data of 224 children were grouped into 107 cases with nose fractures, 104 cases with skull fractures, 9 patients with temporal bone fractures, 4 patients with rhinobasal fractures, and 2 cases with fractures of the orbital floor.

RESULTS

Among patients with nose fractures, the average age was 10.9 years (64% males), among patients with skull fractures 1.0 year (64% males), and in children with skull base fractures 6.0 years (85% males). Falls were the most frequent genesis (63%), followed by car accidents, collisions (25%), and violence (10%). Patients with skull fractures underwent sonography in 94% of cases; in 87% the fracture was verified. Patients with nose fractures underwent x‑ray in 92% of cases, or sonography only in 8%; 95% of patients with nose fractures underwent operative repositioning. Typical fracture signs (i.e., hemotympanum, ophthalmic symptoms) or signs of central nervous system involvement (i.e., nausea, amnesia) occurred in 12 of 13 children with skull base fractures, and CT was performed in all these cases (none of whom developed a cerebrospinal fluid leak).

CONCLUSION

The imaging modality should be selected based on the clinically suspected diagnosis and the course. Most fractures can be sufficiently treated without any permanent sequelae, except for nose fractures, which frequently require operative repositioning.

The effect of the presence or absence of skull fractures on intracranial lesion development in road traffic accidents

OBJECTIVE

The aim of this study was to investigate the effect of the presence or absence of skull fractures on the development of intracranial lesions in cases of head trauma associated with traffic accidents.

MATERIALS AND METHODS

A retrospective review was made of the medico-legal reports of 774 cases with injuries sustained in a traffic accident and which applied for expert examination as forensic cases at the Department of Forensic Medicine of our University between 1 January 2014 and 31 December 2019. A total of 162 cases (20.1%) were identified which were radiologically diagnosed with at least one skull fracture or intracranial lesion. These cases were evaluated in terms of age, gender, type of accident, and localization of skull fractures and/or intracranial lesions, and they were compared statistically to determine whether the presence or absence of skull fractures affected the development of intracranial lesions.

RESULTS

The 162 cases evaluated comprised 120 males and 42 females with a mean age of 25.1 ± 16.4 years. Intracranial lesions were accompanied by skull fractures in 77 cases, skull fracture alone was determined in 18 cases, and intracranial lesion alone in 67 cases. Skull fractures were mostly (64.5%) seen in the 1-20 years age group, and the intracranial lesions (90%) were mostly seen in the ≥41 years age group. Linear and diastatic fracture rates were highest in the temporal and frontal regions. The intracranial lesion/case ratio was 1.5/1 in cases without skull fracture, and 1.2/1 in cases with skull fracture.

CONCLUSION

The results of this study showed that the rate of linear or diastatic fractures was higher in females, which was associated with skull thickness. Skull fractures were found to occur most between the ages of 1 and 20 years, and the presence of skull fractures was determined to reduce the incidence of intracranial lesions by decreasing intracranial pressure.

Multicentre study of hospitalised patients with sports- and recreational cycling-related traumatic brain injury in Hong Kong

INTRODUCTION

Cycling is associated with a greater risk of traumatic brain injury (TBI) than other recreational activities. This study aimed to investigate the epidemiology of sports-related TBI in Hong Kong and to examine predictors for recreational cycling-induced intracranial haemorrhage.

METHODS

This retrospective multicentre study included patients diagnosed with sports-related TBI in public hospitals in Hong Kong from 2015 to 2019. Computed tomography scans were reviewed by an independent assessor. The primary endpoint was traumatic intracranial haemorrhage. The secondary endpoint was an unfavourable Glasgow Outcome Scale (GOS) score at discharge from hospital.

RESULTS

In total, 720 patients were hospitalised with sports-related TBI. The most common sport was cycling (59.2%). The crude incidence of cycling-related TBI was 1.1 per 100 000 population. Cyclists were more likely to exhibit intracranial haemorrhage and an unfavourable GOS score, compared with patients who had TBI because of other sports. Although 47% of cyclists had intracranial haemorrhage, only 15% wore a helmet. In multivariate analysis, significant predictors for intracranial haemorrhage were age ≥60 years, antiplatelet medication, moderate or severe TBI, and skull fracture. Among 426 cyclists, 375 (88%) had mild TBI, and helmet wearing was protective against intracranial haemorrhage, regardless of age, antiplatelet medication intake, and mechanism of injury. Of 426 cyclists, 31 (7.3%) had unfavourable outcomes on discharge from hospital.

CONCLUSIONS

The incidence of sports-related TBI is low in Hong Kong. Although cycling-related head injuries carried greater risks of intracranial haemorrhage and unfavourable outcomes compared with other sports, most cyclists experienced good recovery. Helmet wearing among recreational cyclists with mild TBI was protective against intracranial haemorrhage and skull fracture.

Retrospective study about the postoperative stability of zygomaticomaxillary complex fracture

Background

The aim of this study is to evaluate the postoperative stability of zygomaticomaxillary complex (ZMC) fractures according to the number of fixation sites and to investigate the direction of postoperative displacement of the unfixed part of the fractured segment.

Methods

This study was retrospectively performed on 38 patients who were treated by open reduction and internal fixation of ZMC fractures and were taken postoperative computed tomography (CT) between February 2012 and July 2019. The patients were classified into 3 groups: 1-point fixation, 2-point fixation, 3-point fixation according to the number of fixations. The postoperative displacement of the fractured segment was evaluated by the superimposition between postoperative CT and follow-up CT, and the postoperative stability according to the fixation sites was investigated through the amount of postoperative displacement. In addition, it was investigated in which direction the location of the fractured segment was changed in the unfixed fractured segment according to the fixation sites.

Results

The amount of postoperative displacement of the fractured segment was 0.75 ± 1.18 mm on average.

In the postoperative displacement of the distal area according to the number of fixation of the fracture, there was no statistically significant difference in the amount of displacement of the fracture (p = 0.574).

As for the direction of the change in the location of the fractured segment, 12 patients among 38 patients with the change in the location of the fractured segment were investigated, and the displacement in the medial direction (n = 11, 91.67%) was the most common in all three fixation methods.

Conclusion

In patients with a ZMC fracture who were treated by open reduction and internal fixation, the number of fixations did not make the difference in the postoperative displacement of the fracture. In addition, the fractured segment mainly changes in the medial direction after surgery, and this fact can be used as a reference for the reduction direction during surgery for the stable prognosis.

A Study on Head Wounds in Kitāb al-'Umda fī Ṣinā'a al-Jirāḥa by Ibn al-Quff

The aim of this study is to investigate the knowledge on head wounds contained in the Kitāb al-'Umda fī Ṣinā'a al-Jirāḥa, written by Ibn al-Quff in the thirteenth century. This study was based on a copy of the Kitāb al-'Umda fī Ṣinā'a al-Jirāḥa, printed in 2 volumes in Dā'ira al-Mā'ārif al-Uthmāniyya in Hyderabad in 1356/1937-38 and reprinted by the Institute for the History of Arabic-Islamic Science at the Johann Wolfgang Goethe University. This printed copy was compared with the manuscript of İstanbul University Rare Works Library, Arabic Manuscripts, A 4749. Relevant chapters were translated from Arabic to English, after which they were thoroughly examined. Obtained knowledge is presented in the Results section and is compared in the Discussion section with other reports of this subject. The first chapter classified head wounds into 6 types: the first 3 types are conservatively treated and the remaining 3 types are surgically treated. This chapter also presents information on how to proceed when there is a head wound-related hemorrhage, which medications should be used, and which are the adequate treatment protocols. The second chapter discusses the symptoms and signs that follow head blow and fall injuries. The characteristics and noteworthy circumstances of skull fractures as well as the surgical treatment methods are included in the fifteenth chapter, which is concluded with surgery-related complications. The present study shows that Ibn al-Quff benefited from his predecessors' knowledge and made some considerable contributions to this subject.

Occipital condyle fracture-A rare but severe injury in cranial fracture patients

We clarified occurrence, severity, and associated injuries of occipital condyle fractures (OCFs) in a cranial fracture population. Retrospective data of cranial fracture patients were analyzed. The outcome variable was presence of OCF in cranial fracture patients. Predictor variables were type of associated injury, Glasgow Coma Scale (GCS) value under 6, and death during hospital care. In addition, occurrence of OCF was assessed according to cranial fracture subtypes. Explanatory variables were age, sex, injury mechanism, involvement of alcohol, and high-energy injury. Treatment and outcome of OCFs were analyzed. Of 637 cranial fracture patients, 19 (3.0%) sustained an OCF, eight of whom had no other cranial fractures. In the multivariate adjusted model, increased risk for OCF was detected in patients with cervical injuries (OR 18.66, 95% CI 5.52, 63.12; p < 0.001) and facial fractures (OR 5.99, 95% CI 1.01, 35.45; p = 0.049). Patients with fractures not extending to the skull base were less likely to have OCF (OR 0.01, 95% CI 0.001, 0.25; p = 0.004), and fractures localized solely to the base of the skull offered a protective effect for OCF (OR 0.19, 95% CI 0.06, 0.58; p = 0.003). All OCFs were treated non-operatively with a cervical collar without complications. OCF patients typically sustain other severe injuries, particularly cervical injuries and facial fractures. Careful screening for associated injuries is therefore crucial when examining a patient with OCF. The classification scheme of Mueller et al. seems to be useful in guiding the treatment of OCFs, at least type 1 and 2 fractures.

Growing Skull Fracture in the Primary Motor Cortex in a 50-day-old Child: A Case Report

Growing skull fracture (GSF) is a rare complication of skull fracture in children. We report a case of GSF, also known as leptomeningeal cyst with significant damage in the motor cortex in a 50-day-old child, but the motor function was preserved. A 50-day-old male baby visited our hospital after trauma in the left side of the head. His level of consciousness and motor function were normal. Brain computed tomography (CT) scan revealed gapped skull fracture of the left parietal lobe with underlying contusion and subdural hemorrhage. During hospitalization, bulging in the left parietal scalp had progressed, and follow-up magnetic resonance imaging revealed increased skull defect with enlarged leptomeningeal cyst at the left motor cortex. Cranioplasty and duroplasty were performed. Intraoperatively, a dura tear, brain tissue herniation and fluid collection around the motor cortex were observed. One-year follow-up CT revealed cystic encephalomalacia in the left motor cortex. During the 30-month follow-up, nearly normal gross motor function was observed except for few fine motor impairments. We report a case of GSF with significant damage on the motor cortex in an early infant, but with the preserved motor function during the postoperative developmental process.

Concomitant Injury of Vagus and Hypoglossal Nerves Caused by Fracture of Skull Base: A Case Report and Literature Review

Injury of lower cranial nerves (CNs) by skull base fracture after head trauma can occur sometimes. However, selectively different CN damage on either side is extremely rare. A 53-year-old man had difficulty of swallowing, phonation, and articulation after falling off his bicycle. In physical examination, a deviated tongue to the right side was shown. Brain computed tomography showed a skull base fracture involving bilateral jugular foramina and right hypoglossal canal. Left vocal cord palsy was confirmed by laryngoscopy. Electromyography confirmed injury of left superior laryngeal nerve, recurrent laryngeal nerve, and right hypoglossal nerve. Video fluoroscopic swallowing study revealed large amounts of remnant in vallecula and pyriform sinus without opening of upper esophageal sphincter due to dysfunction of cricopharyngeus muscle. After constant rehabilitation for dysphagia, he was allowed to eat a general diet with compensatory techniques at discharge and further recovery after 3 months. Injury of lower CNs after fracture of the skull base can cause severe morbidity. However, the prognosis of such injuries can be favorable with early rehabilitation treatment by identifying the injured CN. A careful and accurate examination of lower CN injury in skull base fracture is essential for planning a treatment strategy.

Ceiling Fan-Related Head Injuries in Children: A Queensland Neurosurgical Experience

INTRODUCTION

Ceiling fans are a widespread energy-efficient appliance required for managing the sweltering weather extremes encountered in northern Australian states including Queensland. Ceiling fans are also a rare cause of serious head injury in children requiring neurosurgical intervention. There is limited available evidence on the presentation, mechanism, and management of these injuries.

METHODS

A retrospective analysis of children who suffered ceiling fan injuries admitted to the Queensland Children's Hospital, a level-1 paediatric trauma hospital in Brisbane, Queensland, under the neurosurgery unit from November 2014 to July 2018 was performed.

RESULTS

Seventeen children (64.7% male) with a mean age of 4.24 years (range 0.66-7.25) sustained ceiling fan injuries requiring neurosurgical management during this period. Children were injured following being accidentally lifted or thrown into the ceiling fan path; jumping, playing, climbing, or being pushed from a bunk bed; or climbing on other furniture. All patients suffered skull fractures (88.2% depressed), and 65% suffered extra-axial or intracerebral haemorrhage. Operative management was required in 76.5% of the patients. No patients suffered adverse outcomes, and no complications, including infections, were recorded.

CONCLUSIONS

Despite their rarity, paediatric ceiling fan injuries requiring neurosurgical management are a cause of significant morbidity. Surgical management targeted elevation of depressed fractures and washout of open fractures rather than evacuation of intracranial collections. Almost all included patients required transfer with associated social and economic implications. Such injuries are largely preventable with improved supervision and safety awareness. Hazard modification may be extended to regulatory changes or improved ceiling fan design.

Restoration of the Fronto-Orbital Buttress with Primary Bone Fragments

Objective

Forehead deformities are often caused by lack of treatment or incorrect restoration of the frontal buttress, so the underlying frontal buttress should be restored to its previous position to ensure that the previous forehead contour is restored in cases of complex depressed skull fractures. However, since brain injuries from skull fractures could have fatal consequences, the clinical concern in primary surgery has been to save the patient's life, and cosmetic concerns have always been secondary. We retrospectively reviewed fronto-orbital fracture patients who underwent primary restoration with primary bone fragments or an alloplastic implant and compared the surgical outcomes of autologous bone (group 1) and artificial materials (group 2).

Methods

A retrospective review was conducted of 47 patients with fronto-orbital fractures between March 2012 and January 2018. The patients underwent primary reconstruction with primary bone fragments or an alloplastic implant. The surgical results were evaluated by the incidence of infection and cosmetic satisfaction of patients.

Results

Infections occurred in one patient (5%) in group 1 and in two patients (15.3%) in group 2, which was not a statistically significant difference. In contrast, at 6 months after surgery, patient satisfaction showed a statistically significant between-group difference (group 1: 4.32 points, group 2: 3.54 points, p=0.001).

Conclusion

Primary reconstruction using fractured bone fragments is an effective and preferable method that could result in better surgical outcomes than restoration using an alloplastic implant.

Undetected traumatic diastasis of cranial sutures: a case of child abuse

Traumatic diastasis of cranial sutures is a type of bone fracture more common in children than in adults, but little attention has been paid to this skull damage. Differentiation between inflicted and accidental traumatic head injury is still a challenge in forensic pathology, particularly in pediatric population. In fact, diastasis of cranial sutures may occur with or without other skull fractures and may be the only evidence of an abusive head trauma (AHT). This is a case study dealing with undetected traumatic diastasis of cranial sutures in child abuse. The skeletonized juvenile remains were found inside a suitcase. A diastasis of the coronal and sagittal sutures was the only finding recorded at the autopsy with no other relevant bone defects. The diastasis was originally attributed by the medical examiner to a physiological unfused stage of the calvarial bones. Therefore, the cause of death was undetermined. Twelve years later an anthropological revision of the cold case showed that diastasis of the coronal and sagittal sutures was assessed as the evidence of an AHT. Analysis of skull fractures in child abuse can be challenging as normal skull suture variants mimicking intentional injury are reported. Diastasis of the cranial sutures can be also a post-mortem effect of burning or freezing. Therefore, a differential diagnosis between natural, accidental or inflicted skull defects is mandatory in death investigation. A multidisciplinary approach in such circumstances is strongly recommended in order to reduce the risk of misdiagnosis.

Reduction of Closed Frontal Sinus Fractures through Suprabrow Approach

Background

The traditional approach for reduction of frontal sinus fractures is coronal incision. Inherent complications of the coronal approach include long scar, hair loss, and long operation time. We describe a simple approach for the reduction of frontal sinus anterior wall fractures using a suprabrow incision that is commonly used for brow lift.

Methods

From March 2007 to October 2016, the authors identified patients with anterior wall frontal sinus fractures treated by open reduction through a suprabrow incision. Only cases with photographic/radiographic documentation and a minimum follow-up of 6 months were included. The incision line was designed to be at the upper margin of the eyebrow. Medical records and radiographic data were retrospectively reviewed. Surgical outcomes, cosmetic results, and complication were assessed. The patient scale of the patient and observer scar assessment scale was used to assess patient satisfaction for incisional scar at the 6-month follow-up.

Results

Thirty-one patients underwent fracture reduction through a suprabrow approach during the study period, with a mean follow-up of 41 months. No patients showed any recurrent displacement, eyebrow asymmetry, or infection during follow-up. Thirteen patients reported their forehead paresthesia postoperatively, and 12 of them had preoperative symptom. One patient complained of incisional scar and underwent scar revision. All patients were satisfied with their eyebrow and forehead contour.

Conclusion

The suprabrow approach allowed for an accurate reduction of the fractures in the anterior wall frontal sinus by providing direct visualization of the fracture. This transcutaneous approach can effectively restore forehead contour with acceptable postoperative complications and patient satisfaction.

Clinical Features and Outcomes of Bilateral Decompression Surgery for Immediate Contralateral Hematoma after Craniectomy Following Acute Subdural Hematoma

Objective

Immediate contralateral epidural hematoma (EDH) and traumatic intracerebral hematoma (T-ICH) after craniectomy for traumatic subdural hematoma (SDH) are rare but devastating post-operative complications. Their clinical features and outcomes are not well studied. In this report, we present the clinical features and outcomes of immediate contralateral acute hematoma cases requiring a second operation.

Methods

This study includes 10 cases of immediate contralateral EDH and T-ICH following bilateral craniectomy for the evacuation of traumatic SDH and contralateral hematoma between 2004 and 2015. Their medical records and radiographic findings were reviewed and analyzed retrospectively.

Results

Ten of the 528 patients (1.89%) who underwent craniectomy for the evacuation of traumatic SDH developed post-operative EDH (n=5), T-ICH (n=5). The trauma was caused by a fall in 5 patients and by a traffic accident in 5 patients. The patients who suffered trauma due to pedestrian accidents died. Seven patients had a low admission Glasgow Coma Scale (GCS; GCS≤8) score in the preoperative state (average admission GCS, 7.7; average discharge GCS, 3.4; and average discharge Glasgow Outcome Scale, 2.0). Severe intra-operative brain swelling was noted in all patients, while skull fracture was observed in 8. Multiple associated injuries and medication for heart disease were characteristic of patients who died.

Conclusion

The prognosis of delayed contralateral hematoma was very poor. Multiple associated injuries, past medical history and traffic accidents, especially pedestrians were seemed to be associated with higher mortality rates. Finally, contralateral skull fractures can indicate high risk of delayed contralateral acute intracranial hematoma.

Death due to fracture of thin calvarial bones after a fall: A forensic approach

A 45-year-old male was autopsied. He had fallen backwards from a two-stairs height to the ground and passed away. A skull fracture was detected in the left occipital area, extending up to the left side of the skull base. The patient's death occurred due to the very low thickness of the calvarial bones, which led to the aforementioned fracture, and in turn resulted in subarachnoid hemorrhage and death. The cortical thickness was measured and compared with average values at standardized points. Uniform bone thinning was confirmed rather than localized. Calvarial thinning may result from various conditions. In the present case study, however, the exact mechanism which led to the low thickness of the calvarial bones of the patient is undetermined. Death due to the susceptible structure and fracture of calvarial bones has rarely been reported throughout relevant literature.

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.

Bi-Coronal Separated Skull Fracture: A Unique and Fatal Type of Traumatic Head Injury in Infancy: A Case Report

The infantile skull is malleable, and its sutures are tightly adhering to the underlying dura and venous sinus. These characteristics, in association with the small amount of total blood volume, can result in a specific fatal type of skull fracture, which is unique to infancy. The authors report a case of this injury, and stress the need to pay attention to the possibility of massive bleeding during operation in infants. A 23-month-old female baby presented with semicomatose mentality after sustaining injuries by falling from a second-floor. Plain skull films showed bi-frontal skull fracture crossing the midline. Computed tomography revealed an acute subdural hematoma along the right convexity with severe brain edema. In the emergency operation, the scalp incision exposed massive bleeding from the fracture site. The bleeding was identified as arising from the lacerated and widely separated sagittal sinus beneath the fracture. The patient entered hypovolemic shock immediately after the scalp incision, and died from severe brain edema two days after the trauma and surgery. This case implies that special care should be paid during the operation of patients that have skull fracture overlying the venous sinus, especially when the fracture line is separated.

Cochlear implantation after bilateral transverse temporal bone fractures

Patients deafened by a severe head injury are rarely encountered. We report a case of a 65-yr-old man with bilateral transverse temporal bone fractures due to head injury. He underwent cochlear implant and achieved a satisfactory auditory rehabilitation. Imaging studies of temporal bone before performing a cochlear implantation provide important information on a patient with bilateral temporal bone fractures. Cochlear implantations with careful planning in such a patient may be a very effective method for aural rehabilitation.

An evaluation of the effect that the implementation of the NICE rules may have on a diagnostic imaging department for the early management of head injuries

INTRODUCTION

Guidelines by the National Institute of Clinical Excellence (NICE) for the early management of minor head injuries initiate the use of computed tomography (CT) for patients who may be at risk of developing intracranial haematoma. This retrospective study was designed to evaluate the effect the implementation of the NICE guidelines would have on the diagnostic imaging department of a local district general hospital. The main objective was to establish if there would be an increase in the number of CT head referrals for patients with minor head injuries. Secondly to assess how the implementation of these guidelines would affect the workload to the diagnostic imaging department in terms of cost and time, and to discuss the issue of radiation dose to patients.

METHOD

A sample of 100 patients who were referred from the Accident and Emergency department (A&E) for plain skull radiographs, over a 4-month period were selected. The clinical information on each of these patients' was then extracted and a data collection sheet was to assess each patient according to the NICE criteria.

RESULTS AND CONCLUSION

The study found an 18% (n=100) increase in the referral rate for CT heads for patients presenting with minor head injuries. It was also found that the use of these guidelines would mean a decrease in cost to the diagnostic imaging department of £324. Furthermore a saving of 10h of radiographers' time was established, although the effective radiation dose to patients would be increased by 29mSv. The NICE guidelines have proved efficient in identifying patients with intracranial damage although this coincides with an 18% (n=100) increase in referral rates for CT and increased radiation dose to patients. However, the use of these guidelines would reduce workload to the diagnostic imaging department in terms of cost and time.