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Kocik VI, April MD, Rizzo JA, Dengler BA, Schauer SG. A Review of Electrolyte, Mineral, and Vitamin Changes After Traumatic Brain Injury. Mil Med 2024; 189:e101-e109. [PMID: 37192042 DOI: 10.1093/milmed/usad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/27/2023] [Accepted: 03/24/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Despite the prevalence of traumatic brain injury (TBI) in both civilian and military populations, the management guidelines developed by the Joint Trauma System involve minimal recommendations for electrolyte physiology optimization during the acute phase of TBI recovery. This narrative review aims to assess the current state of the science for electrolyte and mineral derangements found after TBI. MATERIALS AND METHODS We used Google Scholar and PubMed to identify literature on electrolyte derangements caused by TBI and supplements that may mitigate secondary injuries after TBI between 1991 and 2022. RESULTS We screened 94 sources, of which 26 met all inclusion criteria. Most were retrospective studies (n = 9), followed by clinical trials (n = 7), observational studies (n = 7), and case reports (n = 2). Of those, 29% covered the use of some type of supplement to support recovery after TBI, 28% covered electrolyte or mineral derangements after TBI, 16% covered the mechanisms of secondary injury after TBI and how they are related to mineral and electrolyte derangements, 14% covered current management of TBI, and 13% covered the potential toxic effects of the supplements during TBI recovery. CONCLUSIONS Knowledge of mechanisms and subsequent derangements of electrolyte, mineral, and vitamin physiology after TBI remains incomplete. Sodium and potassium tended to be the most well-studied derangements after TBI. Overall, data involving human subjects were limited and mostly involved observational studies. The data on vitamin and mineral effects were limited, and targeted research is needed before further recommendations can be made. Data on electrolyte derangements were stronger, but interventional studies are needed to assess causation.
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Affiliation(s)
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- 40th Forward Resuscitative Surgical Detachment, Fort Carson, CO 80902, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Bradley A Dengler
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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Kocik VI, Dengler BA, Rizzo JA, Ma Moran M, Willis AM, April MD, Schauer SG. A Narrative Review of Existing and Developing Biomarkers in Acute Traumatic Brain Injury for Potential Military Deployed Use. Mil Med 2023:usad433. [PMID: 37995274 DOI: 10.1093/milmed/usad433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/31/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in both adult civilian and military populations. Currently, diagnostic and prognostic methods are limited to imaging and clinical findings. Biomarker measurements offer a potential method to assess head injuries and help predict outcomes, which has a potential benefit to the military, particularly in the deployed setting where imaging modalities are limited. We determine how biomarkers such as ubiquitin C-terminal hydrolase-L1 (UCH-L1), glial fibrillary acidic protein (GFAP), S100B, neurofilament light chain (NFL), and tau proteins can offer important information to guide the diagnosis, acute management, and prognosis of TBI, specifically in military personnel. MATERIALS AND METHODS We performed a narrative review of peer-reviewed literature using online databases of Google Scholar and PubMed. We included articles published between 1988 and 2022. RESULTS We screened a total of 73 sources finding a total of 39 original research studies that met inclusion for this review. We found five studies that focused on GFAP, four studies that focused on UCH-L1, eight studies that focused on tau proteins, six studies that focused on NFL, and eight studies that focused on S100B. The remainder of the studies included more than one of the biomarkers of interest. CONCLUSIONS TBI occurs frequently in the military and civilian settings with limited methods to diagnose and prognosticate outcomes. We highlighted several promising biomarkers for these purposes including S100B, UCH-L1, NFL, GFAP, and tau proteins. S100B and UCH-L1 appear to have the strongest data to date, but further research is necessary. The robust data that explain the optimal timing and, more importantly, trending of these biomarker measurements are necessary before widespread application.
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Affiliation(s)
| | - Bradley A Dengler
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Julie A Rizzo
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | | | | | - Michael D April
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- 14th Field Hospital, Fort Stewart, GA 31314, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Departments of Anesthesiology and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Meister MR, Boulter JH, Yabes JM, Sercy E, Shaikh F, Yokoi H, Stewart L, Scanlon MM, Shields MM, Kim A, Tribble DR, Bartanusz V, Dengler BA. Epidemiology of cranial infections in battlefield-related penetrating and open cranial injuries. J Trauma Acute Care Surg 2023; 95:S72-S78. [PMID: 37246289 PMCID: PMC10389625 DOI: 10.1097/ta.0000000000004018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Penetrating brain injuries are a potentially lethal injury associated with substantial morbidity and mortality. We examined characteristics and outcomes among military personnel who sustained battlefield-related open and penetrating cranial injuries during military conflicts in Iraq and Afghanistan. METHODS Military personnel wounded during deployment (2009-2014) were included if they sustained an open or penetrating cranial injury and were admitted to participating hospitals in the United States. Injury characteristics, treatment course, neurosurgical interventions, antibiotic use, and infection profiles were examined. RESULTS The study population included 106 wounded personnel, of whom 12 (11.3%) had an intracranial infection. Posttrauma prophylactic antibiotics were prescribed in more than 98% of patients. Patients who developed central nervous system (CNS) infections were more likely to have undergone a ventriculostomy ( p = 0.003), had a ventriculostomy in place for a longer period (17 vs. 11 days; p = 0.007), had more neurosurgical procedures ( p < 0.001), and have lower presenting Glasgow Coma Scale ( p = 0.01) and higher Sequential Organ Failure Assessment scores ( p = 0.018). Time to diagnosis of CNS infection was a median of 12 days postinjury (interquartile range, 7-22 days) with differences in timing by injury severity (critical head injury had median of 6 days, while maximal [currently untreatable] head injury had a median of 13.5 days), presence of other injury profiles in addition to head/face/neck (median, 22 days), and the presence of other infections in addition to CNS infections (median, 13.5 days). The overall length of hospitalization was a median of 50 days, and two patients died. CONCLUSION Approximately 11% of wounded military personnel with open and penetrating cranial injuries developed CNS infections. These patients were more critically injured (e.g., lower Glasgow Coma Scale and higher Sequential Organ Failure Assessment scores) and required more invasive neurosurgical procedures. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Aderman MJ, Meister MR, Roach MH, Dengler BA, Ross JD, Malvasi SR, Cameron KL. Normative Values for Pupillary Light Reflex Metrics Among Healthy Service Academy Cadets. Mil Med 2023:usad271. [PMID: 37522744 DOI: 10.1093/milmed/usad271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/19/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION Assessments of the pupil's response to light have long been an integral part of neurologic examinations. More recently, the pupillary light reflex (PLR) has shown promise as a potential biomarker for the diagnosis of mild traumatic brain injury. However, to date, few large-scale normative data are available for comparison and reference, particularly, in military service members. The purpose of this study was to report normative values for eight PLR measurements among healthy service academy cadets based on sex, age, sleep, race, ethnicity, anisocoria, and concussion history. METHODS Freshmen entering a U.S. Service Academy completed a quantitative pupillometric assessment in conjunction with baseline concussion testing. PLR measurements were conducted using a Neuroptics PLR-3000 with a 121 µW light stimulus. The device measured maximum and minimum pupil diameter (mm), latency (time to maximum pupil constriction post-light stimulus [s]), peak and average constriction velocity (mm/s), average dilation velocity (mm/s), percentage pupil constriction, and T75 (time for pupil re-dilation from minimum pupil diameter to 75% maximum diameter [s]). During baseline testing, cadets also reported concussion history (yes and no) and hours slept the night before (<5.5 and ≥5.5). Normative values for each PLR measurement were calculated as mean ± SD, percentiles, and interquartile range. Mann-Whitney U tests were used to assess differences based on sex, concussion history, ethnicity, and hours slept for each PLR measurement. Kruskall-Wallis testing was used to assess differences based on age, race, and anisocoria. Alpha was set at .05 and nonparametric effect sizes (r) were calculated for statistically significant results. Effect sizes were interpreted as no effect (r < .1), small (r ≥.1-<.3), medium (r ≥.3-<.5), or large (r ≥ .5). All procedures were reviewed and approved by the local institutional review board and the U.S. Army Human Research Protection Office before the study was conducted. Each subject provided informed consent to participate in the study before data collection. RESULTS Of the 1,197 participants baselined, 514 cadets (131 female; 18.91 ± 0.96 years) consented and completed a valid baseline pupillometric assessment. Eighty participants reported at least one previous concussion and participants reported an average of 5.88 ± 1.63 h slept the previous night. Mann-Whitney U results suggest females had larger initial (z = -3.240; P = .001; r = .10) and end pupil diameter (z = -3.080; P = .002; r = .10), slower average dilation velocity (z = 3.254; P = .001; r = .11) and faster T75 values (z = -3.342; P = .001; r = .11). Age, sleep, and race stratified by sex, also displayed a significant impact on specific PLR metrics with effect sizes ranging from small to medium, while ethnicity, anisocoria, and concussion history did not display an impact on PLR metrics. CONCLUSION This study provides the largest population-specific normative values for eight PLR measurements. Initial and end pupil diameter, dilation velocity, and the T75 metrics differed by sex; however, these differences may not be clinically significant as small effect size was detected for all metrics. Sex, age, sleep, and race may impact specific PLR metrics and are worth consideration when performing PLR assessments for mild traumatic brain injury management.
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Affiliation(s)
- Michael J Aderman
- John A. Feagin Jr. Sports Medicine Fellowship Department of Orthopaedic Surgery, Keller Army Community Hospital, West Point, NY 10996-1197, USA
| | - Melissa R Meister
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Megan H Roach
- DoD-VA Extremity Trauma & Amputation Center of Excellence, Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | - Bradley A Dengler
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Jeremy D Ross
- John A. Feagin Jr. Sports Medicine Fellowship Department of Orthopaedic Surgery, Keller Army Community Hospital, West Point, NY 10996-1197, USA
| | - Steven R Malvasi
- John A. Feagin Jr. Sports Medicine Fellowship Department of Orthopaedic Surgery, Keller Army Community Hospital, West Point, NY 10996-1197, USA
| | - Kenneth L Cameron
- John A. Feagin Jr. Sports Medicine Fellowship Department of Orthopaedic Surgery, Keller Army Community Hospital, West Point, NY 10996-1197, USA
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Gurney JM, Tadlock MD, Dengler BA, Gavitt BJ, Dirks MS, Holcomb JB, Kotwal RS, Benavides LC, Cannon JW, Edson T, Graybill JC, Sonka BJ, Marion DW, Eckert MJ, Schreiber MA, Polk TM, Jensen SD, Martin MJ, Joseph BA, Valadka A, Kerby JD. Committee on Surgical Combat Casualty Care Position Statement: Neurosurgical Capability for the Optimal Management of Traumatic Brain injury During Deployed Operations. Including Invited Commentaries. J Trauma Acute Care Surg 2023; Publish Ahead of Print:01586154-990000000-00391. [PMID: 37257063 PMCID: PMC10389628 DOI: 10.1097/ta.0000000000004058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Experiences over the last 3 decades of war have demonstrated a high incidence of Traumatic Brain Injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theatre of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a Position Statement to inform medical and non-medical military leaders about the risks of the lack of a specialized neurosurgical capability. METHODS The need for deployed neurosurgical capability Position Statement was identified during the spring 2021 CoSCCC meeting. A tri-service working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in Neurocritical Care, a trauma surgeon instrumental in developing the Brain Injury Guidelines (BIG), a practicing neurosurgeon with world-renowned expertise in TBI, and the Chair of the Committee on Trauma (COT). RESULTS After multiple revisions, Position Statement was finalized it was approved by the CoSCCC membership in February 2023. Challenges identified include: 1) military neurosurgeon attrition; 2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations; 3) the need for neurosurgical telemedicine capability and in-theatre CT scans to triage TBI casualties requiring neurosurgical care. CONCLUSION Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. These neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields. LEVEL OF EVIDENCE Brief Report, 3.
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Affiliation(s)
- Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, 3698 Chambers Pass, Joint Base San Antonio-Fort Sam Houston, TX 78234
| | - Matthew D Tadlock
- Department of Surgery, Navy Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814
| | - Brian J Gavitt
- US+UAE Trauma, Burn, and Rehabilitative Medicine Mission
| | - Michael S Dirks
- Department of Surgery, Department of Neurosurgery, Womack Army Medical Center 2817 Reilly Rd, Fort Bragg, NC 28310
| | | | | | - Linda C Benavides
- Department of Surgery, Madigan Army Medical Center, 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431
| | | | - Theodore Edson
- 1st Medical Battalion, 1st Marine Logistics Group, 22111 6 St Camp Pendleton, Oceanside, CA 92058
| | | | | | - Donald W Marion
- Division of Trauma, Brooke Army Medical Center, 3551 Roger Brook Dr., Joint Base San Antonio, San Antonio TX 78234
| | | | | | - Travis M Polk
- DoD Combat Casualty Care Research Program, US Army Medical Research and Development Command, Fort Detrick, MD
| | - Shane D Jensen
- Joint Trauma System, DoD Center of Excellence for Trauma, 3698 Chambers Pass, Joint Base San Antonio-Fort Sam Houston, TX 78234
| | | | - Bellal A Joseph
- Division of Surgery and Department of Neurosurgery, University of Arizona School of Medicine, 1501 N Campbell Ave, Tucson, Arizona 85724
| | - Alex Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Baidwan NK, Schauer SG, Dixon JM, Bhaumik S, April MD, April MD, Dengler BA, Mould-Millman NK. Tranexamic Acid Improves Survival in the Setting of Severe Head Injury in Combat Casualties. Med J (Ft Sam Houst Tex) 2023:34-40. [PMID: 36580522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Approximately 1.7 million people sustain traumatic brain injuries (TBI) annually in the US. To reduce morbidity and mortality, management strategies aim to control progressive intracranial bleeding. This study analyzes the association between Tranexamic Acid (TXA) administration and mortality among casualties within the Department of Defense Trauma Registry, specifically focusing on subsets of patients with varying degree of head injury severities. METHODS Besides descriptive statistics, we used inverse probability weighted (for age, military service category, mechanism of injury, total units of blood units administered), and injury severity (ISS) and Abbreviated Injury Scale (AIS) head score adjusted generalized linear models to analyze the association between TXA and mortality. Specific subgroups of interest were increasing severities of head injury and further stratifying these by Glasgow Coma Score of 3-8 and severe overall bodily injuries (ISS>=15). RESULTS 25,866 patients were included in the analysis. 2,352 (9.1%) received TXA and 23,514 (90.9%) did not receive TXA. Among those with ISS>=15 (n=6,420), 21.2% received TXA. Among those with any head injury (AIS head injury severity score>=1; n=9,153), 7.2% received TXA. The median ISS scores were greater in the TXA versus no-TXA group (17 versus 6). Weighted and adjusted models showed overall, there was 25% lower mortality risk between those who received TXA at any point and those who did not (OR:0.75, 95% CI: 0.59, 0.95). Further, as the AIS severity score increased from >=1 (1.08; 0.80, 1.47) to >=5 (0.56; 0.33, 0.97), the odds of mortality decreased. CONCLUSIONS TXA may potentially be beneficial in patients with severe head injuries, especially those with severe overall injury profiles. There is a need of definitive studies to confirm this association.
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Affiliation(s)
- Navneet K Baidwan
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Brooke Army Medical Center, JBSA Fort Sam Houston, TX; and Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Julia M Dixon
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO
| | - Smitha Bhaumik
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD; and 40th Forward Resuscitative Surgical Detachment, 627th Hospital Center, Fort Carson, CO
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD, and 40th Forward Resuscitation and Surgical Detachment, 627th Hospital Center, 1st Medical Brigade, Fort Carson, CO
| | - Bradley A Dengler
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, MD
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Baidwan NK, Schauer SG, Dixon JM, Bhaumik S, April MD, April MD, Dengler BA, Mould-Millman NK. Tranexamic Acid Improves Survival in the Setting of Severe Head Injury in Combat Casualties. Med J (Ft Sam Houst Tex) 2023:34-40. [PMID: 36607296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Approximately 1.7 million people sustain traumatic brain injuries (TBI) annually in the US. To reduce morbidity and mortality, management strategies aim to control progressive intracranial bleeding. This study analyzes the association between Tranexamic Acid (TXA) administration and mortality among casualties within the Department of Defense Trauma Registry, specifically focusing on subsets of patients with varying degree of head injury severities. METHODS Besides descriptive statistics, we used inverse probability weighted (for age, military service category, mechanism of injury, total units of blood units administered), and injury severity (ISS) and Abbreviated Injury Scale (AIS) head score adjusted generalized linear models to analyze the association between TXA and mortality. Specific subgroups of interest were increasing severities of head injury and further stratifying these by Glasgow Coma Score of 3-8 and severe overall bodily injuries (ISS>=15). RESULTS 25,866 patients were included in the analysis. 2,352 (9.1%) received TXA and 23,514 (90.9%) did not receive TXA. Among those with ISS>=15 (n=6,420), 21.2% received TXA. Among those with any head injury (AIS head injury severity score>=1; n=9,153), 7.2% received TXA. The median ISS scores were greater in the TXA versus no-TXA group (17 versus 6). Weighted and adjusted models showed overall, there was 25% lower mortality risk between those who received TXA at any point and those who did not (OR:0.75, 95% CI: 0.59, 0.95). Further, as the AIS severity score increased from >=1 (1.08; 0.80, 1.47) to >=5 (0.56; 0.33, 0.97), the odds of mortality decreased. CONCLUSIONS TXA may potentially be beneficial in patients with severe head injuries, especially those with severe overall injury profiles. There is a need of definitive studies to confirm this association.
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Affiliation(s)
- Navneet K Baidwan
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Brooke Army Medical Center, JBSA Fort Sam Houston, TX; and Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Julia M Dixon
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO
| | - Smitha Bhaumik
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD; and 40th Forward Resuscitative Surgical Detachment, 627th Hospital Center, Fort Carson, CO
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD, and 40th Forward Resuscitation and Surgical Detachment, 627th Hospital Center, 1st Medical Brigade, Fort Carson, CO
| | - Bradley A Dengler
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, MD
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Ravindra VM, Tadlock MD, Gurney JM, Kraus KL, Dengler BA, Gordon J, Cooke J, Porensky P, Belverud S, Milton JO, Cardoso M, Carroll CP, Tomlin J, Champagne R, Bell RS, Viers AG, Ikeda DS. Attitudes Toward Neurosurgery Education for the Nonneurosurgeon: A Survey Study and Critical Analysis of U.S. Military Training Techniques and Future Prospects. World Neurosurg 2022; 167:e1335-e1344. [PMID: 36103986 DOI: 10.1016/j.wneu.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The U.S. military requires medical readiness to support forward-deployed combat operations. Because time and distance to neurosurgical capabilities vary within the deployed trauma system, nonneurosurgeons are required to perform emergent cranial procedures in select cases. It is unclear whether these surgeons have sufficient training in these procedures. METHODS This quality-improvement study involved a voluntary, anonymized specialty-specific survey of active-duty surgeons about their experience and attitudes toward U.S. military emergency neurosurgical training. RESULTS Survey responses were received from 104 general surgeons and 26 neurosurgeons. Among general surgeons, 81% have deployed and 53% received training in emergency neurosurgical procedures before deployment. Only 16% of general surgeons reported participating in craniotomy/craniectomy procedures in the last year. Nine general surgeons reported performing an emergency neurosurgical procedure while on deployment/humanitarian mission, and 87% of respondents expressed interest in further predeployment emergency neurosurgery training. Among neurosurgeons, 81% had participated in training nonneurosurgeons and 73% believe that more comprehensive training for nonneurosurgeons before deployment is needed. General surgeons proposed lower procedure minimums for competency for external ventricular drain placement and craniotomy/craniectomy than did neurosurgeons. Only 37% of general surgeons had used mixed/augmented reality in any capacity previously; for combat procedures, most (90%) would prefer using synchronous supervision via high-fidelity video teleconferencing over mixed reality. CONCLUSIONS These survey results show a gap in readiness for neurosurgical procedures for forward-deployed general surgeons. Capitalizing on capabilities such as mixed/augmented reality would be a force multiplier and a potential means of improving neurosurgical capabilities in the forward-deployed environments.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; Department of Neurosurgery, University of California San Diego, San Diego, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Matthew D Tadlock
- Department of Surgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, California, USA
| | - Jennifer M Gurney
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, Texas, USA
| | - Kristin L Kraus
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jennifer Gordon
- Department of Surgery, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Jonathon Cooke
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Paul Porensky
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Shawn Belverud
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Jason O Milton
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Mario Cardoso
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Christopher P Carroll
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Jeffrey Tomlin
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Roland Champagne
- Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Randy S Bell
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Angela G Viers
- Department of Surgery, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
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Cuenca CM, Borgman MA, Dengler BA, Schauer SG. Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq. Injury 2022; 53:3297-3300. [PMID: 35831207 DOI: 10.1016/j.injury.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population. METHODS This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission. RESULTS Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001). CONCLUSIONS Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | | | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda Maryland, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA; Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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10
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Boulter JH, Shields MM, Meister MR, Murtha G, Curry BP, Dengler BA. The Expanding Role of Quantitative Pupillometry in the Evaluation and Management of Traumatic Brain Injury. Front Neurol 2021; 12:685313. [PMID: 34322081 PMCID: PMC8310950 DOI: 10.3389/fneur.2021.685313] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/18/2021] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury is a rapidly increasing source of morbidity and mortality across the world. As such, the evaluation and management of traumatic brain injuries ranging from mild to severe are under active investigation. Over the last two decades, quantitative pupillometry has been increasingly found to be useful in both the immediate evaluation and ongoing management of traumatic brain injured patients. Given these findings and the portability and ease of use of modern pupillometers, further adoption and deployment of quantitative pupillometers into the preclinical and hospital settings of both resource rich and medically austere environments.
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Affiliation(s)
- Jason H Boulter
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Margaret M Shields
- School of Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Melissa R Meister
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Gregory Murtha
- School of Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Brian P Curry
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Bradley A Dengler
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
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11
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Whiting MD, Dengler BA, Rodriguez CL, Blodgett D, Cohen AB, Januszkiewicz AJ, Rasmussen TE, Brody DL. Prehospital Detection of Life-Threatening Intracranial Pathology: An Unmet Need for Severe TBI in Austere, Rural, and Remote Areas. Front Neurol 2020; 11:599268. [PMID: 33193067 PMCID: PMC7662094 DOI: 10.3389/fneur.2020.599268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Severe traumatic brain injury (TBI) is a leading cause of death and disability worldwide, especially in low- and middle-income countries, and in austere, rural, and remote settings. The purpose of this Perspective is to challenge the notion that accurate and actionable diagnosis of the most severe brain injuries should be limited to physicians and other highly-trained specialists located at hospitals. Further, we aim to demonstrate that the great opportunity to improve severe TBI care is in the prehospital setting. Here, we discuss potential applications of prehospital diagnostics, including ultrasound and near-infrared spectroscopy (NIRS) for detection of life-threatening subdural and epidural hemorrhage, as well as monitoring of cerebral hemodynamics following severe TBI. Ultrasound-based methods for assessment of cerebrovascular hemodynamics, vasospasm, and intracranial pressure have substantial promise, but have been mainly used in hospital settings; substantial development will be required for prehospital optimization. Compared to ultrasound, NIRS is better suited to assess certain aspects of intracranial pathology and has a smaller form factor. Thus, NIRS is potentially closer to becoming a reliable method for non-invasive intracranial assessment and cerebral monitoring in the prehospital setting. While one current continuous wave NIRS-based device has been FDA-approved for detection of subdural and epidural hemorrhage, NIRS methods using frequency domain technology have greater potential to improve diagnosis and monitoring in the prehospital setting. In addition to better technology, advances in large animal models, provider training, and implementation science represent opportunities to accelerate progress in prehospital care for severe TBI in austere, rural, and remote areas.
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Affiliation(s)
- Mark D Whiting
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Stephens Family Clinical Research Institute, Carle Foundation Hospital, Urbana, IL, United States
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Carissa L Rodriguez
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - David Blodgett
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - Adam B Cohen
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States.,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Todd E Rasmussen
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David L Brody
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Laboratory of Functional and Molecular Imaging, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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12
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Dengler BA, Plaza-Wüthrich S, Chick RC, Muir MT, Bartanusz V. Secondary Overtriage in Patients with Complicated Mild Traumatic Brain Injury: An Observational Study and Socioeconomic Analysis of 1447 Hospitalizations. Neurosurgery 2020; 86:374-382. [PMID: 30953054 DOI: 10.1093/neuros/nyz092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 02/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Secondary overtriage is a problematic phenomenon because it creates unnecessary expense and potentially results in the mismanagement of healthcare resources. The rates of secondary overtriage among patients with complicated mild traumatic brain injury (cmTBI) are unknown. OBJECTIVE To determine the rate of secondary overtriage among patients with cmTBI using the institutional trauma registry. METHODS An observational study using retrospective analysis of 1447 hospitalizations including all consecutive patients with cmTBI between 2004 and 2013. Data on age, sex, race/ethnicity, insurance status, GCS, Injury Severity Score (ISS), Trauma Injury Severity Score, transfer mode, overall length of stay (LOS), LOS within intensive care unit, and total charges were collected and analyzed. RESULTS Overall, the rate of secondary overtriage among patients with cmTBI was 17.2%. These patients tended to be younger (median: 41 vs 60.5 yr; P < .001), have a lower ISS (9 vs 16; P < .001), and were more likely to be discharged home or leave against medical advice. CONCLUSION Our findings provide evidence to the growing body of literature suggesting that not all patients with cmTBI need to be transferred to a tertiary care center. In our study, these transfers ultimately incurred a total cost of $13 294 ($1337 transfer cost) per patient.
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Affiliation(s)
- Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sonia Plaza-Wüthrich
- Division of Spine Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, San Antonio, Texas
| | - Mark T Muir
- Department of Surgery, University of Texas Health San Antonio, Texas
| | - Viktor Bartanusz
- Department of Neurosurgery, University of Texas Health San Antonio, Texas
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13
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Dengler BA, Hawksworth SA, Berardo L, McDougall I, Papanastassiou AM. Bilateral amygdala stimulation reduces avoidance behavior in a predator scent posttraumatic stress disorder model. Neurosurg Focus 2019; 45:E16. [PMID: 30064318 DOI: 10.3171/2018.5.focus18166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The predator scent model of posttraumatic stress disorder (PTSD) produces prolonged abnormal anxiety and avoidance-like behaviors. Increased basolateral amygdala activity has been shown to correlate with severity of PTSD symptoms in human studies. Modulation of this increased amygdala activity by deep brain stimulation led to improved symptoms in prior studies that used a foot shock model of inducing PTSD. The predator scent model is a different technique that induces long-lasting avoidance behavioral responses by exposing the animal to an inescapable scent of one of its predators. The authors hypothesize that high-frequency stimulation of the bilateral basolateral amygdala will decrease avoidance and anxiety-like behaviors in a predator scent rodent model of PTSD. METHODS Rodents underwent cat urine exposure in a place preference protocol. Avoidance in the place preference paradigm and anxiety-like behavior in the elevated plus maze were measured before and after high-frequency stimulation. RESULTS Predator scent exposure resulted in long-term significant avoidance behavior in rodents. Bilateral stimulation significantly decreased avoidance behavior in rodents compared to no stimulation following predator scent exposure. There were no significant differences in anxiety behaviors on the elevated plus maze between stimulated and unstimulated cohorts. CONCLUSIONS Bilateral stimulation of the basolateral amygdala leads to decreased avoidance behavior compared to controls in a predator scent model of PTSD.
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Affiliation(s)
- Bradley A Dengler
- 1Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland; and
| | - Shane A Hawksworth
- 2Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - Laura Berardo
- 2Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - Ian McDougall
- 2Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
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14
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Affiliation(s)
- Bradley A Dengler
- University of Texas Health Science Center at San Antonio, Departments of Neurosurgery and Neurology, 7703 Floyd Curl Drive, MC# 7843, San Antonio, TX 78229, United States
| | - Deanna Kitchen
- University of Texas Health Science Center at San Antonio, School of Medicine, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
| | - Ali Seifi
- University of Texas Health Science Center at San Antonio, Departments of Neurosurgery and Neurology, 7703 Floyd Curl Drive, MC# 7843, San Antonio, TX 78229, United States.
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15
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Dengler BA, Mendez-Gomez P, Chavez A, Avila L, Michalek J, Hernandez B, Grandhi R, Seifi A. Safety of Chemical DVT Prophylaxis in Severe Traumatic Brain Injury with Invasive Monitoring Devices. Neurocrit Care 2016; 25:215-23. [DOI: 10.1007/s12028-016-0280-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Dengler BA, Jimenez DF, Bartanusz V. Reabsorption of a calcified herniated nucleus pulposus in a 14-year-old boy. J Pediatr 2014; 164:424.e1-2. [PMID: 24183210 DOI: 10.1016/j.jpeds.2013.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 09/18/2013] [Indexed: 01/30/2023]
Affiliation(s)
- Bradley A Dengler
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas
| | - David F Jimenez
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas
| | - Viktor Bartanusz
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas
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Dengler BA, Bartanusz V. Bilateral abducens nerve palsy following ligamentous C1-C2 distraction. Eur Spine J 2013; 23 Suppl 2:248-52. [PMID: 24311020 DOI: 10.1007/s00586-013-3121-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/24/2013] [Accepted: 11/24/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Posttraumatic abducens nerve palsy is well documented following head injury, but only few case reports exist on sixth nerve palsy after cervical spine trauma. Bilateral abducens palsy following vertical C1-C2 ligamentous distraction has not been described yet. METHODS We report two patients who sustained motor vehicle accident-related C1-C2 distraction injury and were diagnosed with posttraumatic bilateral abducens nerve palsy. RESULTS Patients underwent surgical stabilization of the upper cervical spine and demonstrated a remarkable recovery of the sixth nerve deficit up to 1 year after injury. CONCLUSION We hypothesize that ligamentous C1-C2 distraction leads to caudal displacement of the brainstem in relation to the cranial base causing traction injury to the abducens nerve at its entry into Dorello's canal in the cavernous sinus.
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Affiliation(s)
- Bradley A Dengler
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
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