INTRODUCTIONHigh performing clinical decision rules (CDRs) have been derived to predict which head-injured child requires a computed tomography (CT) of the brain. We set out to evaluate the performance of these rules in the Singapore population.

MATERIALS AND METHODSThis is a prospective observational cohort study of children aged less than 16 who presented to the emergency department (ED) from April 2014 to June 2014 with a history of head injury. Predictor variables used in the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) and Pediatric Emergency Care Applied Research Network (PECARN) CDRs were collected. Decisions on CT imaging and disposition were made at the physician's discretion. The performance of the CDRs were assessed and compared to current practices.

RESULTSA total of 1179 children were included in this study. Twelve (1%) CT scans were ordered; 6 (0.5%) of them had positive findings. The application of the CDRs would have resulted in a significant increase in the number of children being subjected to CT (as follows): CATCH 237 (20.1%), CHALICE 282 (23.9%), PECARN high- and intermediate-risk 456 (38.7%), PECARN high-risk only 45 (3.8%). The CDRs demonstrated sensitivities of: CATCH 100% (54.1 to 100), CHALICE 83.3% (35.9 to 99.6), PECARN 100% (54.1 to 100), and specificities of: CATCH 80.3% (77.9 to 82.5), CHALICE 76.4% (73.8 to 78.8), PECARN high- and intermediate-risk 61.6% (58.8 to 64.4) and PECARN high-risk only 96.7% (95.5 to 97.6).

CONCLUSIONThe CDRs demonstrated high accuracy in detecting children with positive CT findings but direct application in areas with low rates of significant traumatic brain injury (TBI) is likely to increase unnecessary CT scans ordered. Clinical observation in most cases may be a better alternative.

Adolescent ; Algorithms ; Brain Contusion ; diagnostic imaging ; Brain Injuries, Traumatic ; diagnostic imaging ; Child ; Child, Preschool ; Craniocerebral Trauma ; diagnostic imaging ; Decision Support Systems, Clinical ; Emergency Service, Hospital ; Female ; Humans ; Infant ; Intracranial Hemorrhage, Traumatic ; diagnostic imaging ; Male ; Pediatric Emergency Medicine ; Pneumocephalus ; diagnostic imaging ; Prospective Studies ; Singapore ; Skull Fractures ; diagnostic imaging ; Tomography, X-Ray Computed

Cerebral concussion and mild traumatic brain injury (TBI) have been used interchangeably, although the two terms have different definitions. Traumatic axonal injury (TAI) is a more severe subtype of TBI than concussion or mild TBI. Regarding the evidence of TAI lesions in patients with concussion or mild TBI, since the 1960’s, several studies have reported on TAI in patients with concussion who showed no radiological evidence of brain injury by autopsy. However, conventional CT and MRI are not sensitive to detection of axonal injury in concussion or mild TBI, therefore, previously, diagnosis of TAI in live patients with concussion or mild TBI could not be demonstrated. With the development of diffusion tensor imaging (DTI) in the 1990’s, in 2002, Arfanakis et al. reported on TAI lesions in live patients with mild TBI using DTI for the first time. Subsequently, hundreds of studies have demonstrated the usefulness of DTI in detection of TAI and TAI lesions in patients with concussion or mild TBI. In Korea, the term “TAI” has rarely been used in the clinical field while diffuse axonal injury and concussion have been widely used. Rare use of TAI in Korea appeared to be related to slow development of DTI analysis techniques in Korea. Therefore, we think that use of DTI analysis techniques for diagnosis of TAI should be facilitated in Korea.
Autopsy ; Axons* ; Brain Concussion* ; Brain Injuries* ; Diagnosis ; Diffuse Axonal Injury ; Diffusion Tensor Imaging ; Humans ; Korea ; Magnetic Resonance Imaging

OBJECT: To investigate the changes in the expression_level of synaptophysin following diffuse brain injury (DBI) in rats and to correlate the changes of the synaptophysin expression_level with the post injury time interval. METHODS: Wister rats were used as a DBI model induced by Marmarou method. The changes of synaptophysin immunoreactivity on coronal sections of the rats sampled at different post-injury time intervals were used as a marker. The densitometry of the synaptophysin immunoreactivity was documented by imaging technique and analyzed by SPSS software. RESULTS: The expression level of synaptophysin in DBI rats showed dynamic changes following DBI as well as during the repairing period. CONCLUSION The changes of synaptophysin level may be used as a marker for estimation of the post injury time interval in DBI.
Animals ; Brain/pathology* ; Brain Injuries/pathology* ; Cerebral Cortex/pathology* ; Diffuse Axonal Injury/pathology* ; Disease Models, Animal ; Immunohistochemistry ; Intracranial Hemorrhage, Traumatic/pathology* ; Neurons/pathology* ; Rats ; Rats, Sprague-Dawley ; Staining and Labeling ; Synapses/pathology* ; Synaptophysin/metabolism* ; Time Factors

OBJECTIVE: To investigate the relationship between the diffuse axonal injury (DAI) and cerebral contusion, primary brain stem injury and brain concussion. METHODS: One hundred and twelve cases with DAI were analyzed according to the characteristics of clinical signs and imaging features. RESULTS: Of 112 cases of DAI, 70.5% injured in traffic accident, 60.7% injured with blunt trauma more than one time and 71.4% injured with cerebral contusion. And 90 cases with brain with hemorrhage were found in CT or MRI imaging. CONCLUSION DAI may be associated with cortical contusion and primary brain stem injury. The CT or MRI is useful to investigate the cause of death and to evaluate the personal disability.
Accidents, Traffic ; Adolescent ; Adult ; Aged ; Brain Concussion/pathology* ; Brain Injuries/diagnosis* ; Brain Stem/pathology* ; Child ; Child, Preschool ; Diagnosis, Differential ; Diffuse Axonal Injury/pathology* ; Female ; Forensic Pathology ; Humans ; Intracranial Hemorrhages/etiology* ; Male ; Middle Aged ; Tomography, X-Ray Computed ; Young Adult

Mild traumatic brain injury (mTBI) is a common type of brain disorders among young adults. The dysfunction of the brain is often exacerbated due to diffuse axonal injury (DAI) which based on the injury of white matter fibers and axons. Since mild and moderate brain injury or DAI are diffuse and subtle, conventional CT and MRI are difficult to make a positive diagnosis. Recent clinical study indicated that functional magnetic resonance imaging has a high detection rate in the diagnosis of acute mild and moderate brain injury, especially the diffusion tensor imaging (DTI) and 1H-magnetic resonance spectroscopy (1H-MRS). This paper has reviewed the principles and characteristics of DTI and 1H-MRS, and recent research in the clinical and animal experiments on brain injury.
Animals ; Axons/pathology* ; Brain/pathology* ; Brain Concussion/pathology* ; Brain Injuries/pathology* ; Diagnosis, Differential ; Diffuse Axonal Injury/pathology* ; Diffusion Tensor Imaging ; Humans ; Magnetic Resonance Spectroscopy/methods* ; Nerve Fibers, Myelinated/pathology* ; Severity of Illness Index

PURPOSE: Post-traumatic seizures (PTS) are well-recognized complications from head injuries and children are particularly more vulnerable to them. The aim of this study was to investigate the clinical characteristics of PTS in children and the findings of several diagnostic tools and to determine the role of prophylactic anticonvulsants. METHODS: We retrospectively reviewed the medical records of patient under 18 years of age who presented with seizures after traumatic brain injuries. Data analyzed included patient's demographics, clinical presentations, radiological and electroencephalographic findings, management and outcomes. RESULTS: Thirty one patients with PTS were included in the study and consisted of 13 males and 18 females. A mean age of the accident was 3.2 years (4 months-6.8 years) and a mean duration of follow-up was 26.0 months (12 months-54 months). Twenty one patients (67.7%) developed seizures within 24 hours after injury. Focal radiological findings were observed in 83.8% and described as subdural or epidural hematoma (25.8%), intraparenchymal hemorrhage (19.3%) and intracerebral parenchymal lesions (51.6%). Electroecephalographic findings included background abnormalities in 32.2% and interictal epileptiform discharges in 45.1%. All patients were treated with anticonvulsants for a certain period of time and a mean duration of treatment was 12.5 weeks (4-40 weeks). Eight patients (25.8%) developed subsequent seizures during follow-up period and 2 patients (6.5%) were diagnosed afterward with post-traumatic epilepsy. CONCLUSION: PTS generally take a benign clinical course, but subsequent seizures including epileptic seizures can occur in minor proportion. In these cases, radiological and electroencephalographic findings are helpful in prediction of clinical course of PTS.
Anticonvulsants ; Brain Injuries ; Child ; Craniocerebral Trauma ; Demography ; Epilepsy ; Epilepsy, Post-Traumatic ; Female ; Follow-Up Studies ; Hematoma ; Hemorrhage ; Humans ; Male ; Medical Records ; Retrospective Studies ; Seizures

We present a case of angiographically confirmed transection of the cisternal segment of the anterior choroidal artery (AChA) associated with a severe head trauma in a 15-year old boy. The initial brain computed tomography scan revealed a diffuse subarachnoid hemorrhage (SAH) and pneumocephalus with multiple skull fractures. Subsequent cerebral angiography clearly demonstrated a complete transection of the AChA at its origin with a massive extravasation of contrast medium as a jet trajectory creating a plume. We speculate that severe blunt traumatic force stretched and tore the left AChA between the internal carotid artery and the optic tract. In a simulation of the patient's brain using a fresh-frozen male cadaver, the AChA is shown to be vulnerable to stretching injury as the ipsilateral optic tract is retracted. We conclude that the arterial injury like an AChA rupture should be considered in the differential diagnosis of severe traumatic SAH.
Angiography ; Arteries* ; Brain ; Cadaver ; Carotid Artery, Internal ; Cerebral Angiography ; Choroid* ; Craniocerebral Trauma ; Diagnosis, Differential ; Humans ; Male ; Pneumocephalus ; Rupture ; Skull Fractures ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic* ; Visual Pathways

Traumatic brain injury (TBI) could give rise to variable clinical manifestations based on the involved structures of our bodies. Although there are no structural abnormalities proven, the patients with mild TBI suffer from chronic dizziness and imbalance. Herein, I will discuss the visuo-vestibular interaction and neurotological finding in TBI, which could demonstrate the clue to the diagnosis and management in dizzy patients with TBI.
Brain Concussion ; Brain Injuries ; Diagnosis ; Dizziness ; Humans ; Vestibular Diseases

OBJECTIVES: To determine the prevalence, risk factors, etiology, location, and outcome of non-traumatic intracerebral hemorrhage (ICH) in young Filipino patients. To identify factors associated with poor outcome and mortality
METHODOLOGY: Review of charts of patients age /- 45 years admitted for acute non-traumatic intracerebral hemorrhage with neuroimaging evidence of symptomatic ICH was done. Data regarding risk factors, location, etiology and outcome were analyzed using SPSS 9.01 for Windows and Epi 6 for univariate and multiple regression analysis
RESULTS: Seventy subjects were included. 66 percent were males and 34 percent were females. The mean age of the subjects was 37 years old. Prevalence of non-traumatic ICH among stroke in young adults is 17 percent. The most frequent risk factors were hypertension, smoking, alcohol use, and family history of CVD. The common locations in order were basal ganglia/internal capsule (44 percent), thalamus (22 percent), lobar, and brainstem. The common causes of ICH were hypertension (46 percent), vascular malformations (16 percent) and hematologic/coagulation disorders (13 percent). Arteriography was done in 33 percent of cases. Overall in-hospital mortality rate was 8.5 percent in the acute stage of ICH. Factors independently associated with poor outcome and mortality on multivariate regression analysis were posterior circulation (p=0.005), presence of intraventricular extension (p=0.002), ICH volume 30 cc (p= 0.011), and smoking history (p=0.021)
CONCLUSION: Non-traumatic intracerebral hemorrhage in young Filipino adults has a heterogenous etiology. Non-traumatic ICH occurred in 17 percent of young stroke patients. Posterior circulation involvement, presence of intraventricular extension, ICH volume of 30cc and smoking history were significant factors associated with poor outcome.

Human ; Male ; Female ; Adult ; Adolescent ; Smoking ; Cerebral Hemorrhage ; Stroke ; Cerebral Hemorrhage, Traumatic ; Hypertension ; Brain Stem ; Vascular Malformations

We review current topics in sport-related head injuries including acute subdural hematoma (ASDH), traumatic cerebrovascular disease, cerebral concussion, and chronic traumatic encephalopathy (CTE). Sports-related ASDH is a leading cause of death and severe morbidity in popular contact sports like American football and Japanese judo. Rotational acceleration can cause either cerebral concussion or ASDH due to rupture of a parasagittal bridging vein. Although rare, approximately 80% of patients with cerebral infarction due to sport participation are diagnosed with ischemia or infarction due to arterial dissection. Computed tomography angiography, magnetic resonance angiography, and ultrasound are useful for diagnosing arterial dissection; ultrasound is particularly useful for detecting dissection of the common and internal carotid arteries. Repeated sports head injuries increase the risks of future concussion, cerebral swelling, ASDH, and CTE. To avoid fatal consequences of CTE, it is essential to understand the criteria for safe post-concussion sports participation. Once diagnosed with a concussion, an athlete should not be allowed to return to play on the same day and should not resume sports before the concussion symptoms have completely resolved. Information about the risks and management of head injuries in different sports should be widely disseminated in educational institutions and by sport organization public relations campaigns.
Acceleration ; Angiography ; Asian Continental Ancestry Group ; Athletes ; Brain Concussion ; Brain Injuries ; Brain Injury, Chronic ; Carotid Artery, Internal ; Cause of Death ; Cerebral Infarction ; Cerebrovascular Disorders ; Craniocerebral Trauma* ; Football ; Head* ; Hematoma, Subdural, Acute ; Humans ; Infarction ; Ischemia ; Magnetic Resonance Angiography ; Martial Arts ; Public Relations ; Rupture ; Sports ; Ultrasonography ; Veins