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Despite the significant clinical consequences and socioeconomic costs of gun-shot wounds to the head (GSWH), studies examining pre-hospital risk factors, geo-spatial patterns, and economic cost are lacking.A retrospective analysis was performed for GSWH patients (single or multiple injuries) presenting to the level one Ryder Trauma Center (hospital patients) as well as the Miami Dade County Medical Examiner (ME) Department, from October 2013 to October 2015. Additionally, ME data was queried from the previous decade (2008-2017) to analyze longitudinal trends.402 consecutive cases met inclusion criteria: 297 (74%) presented to the ME and 105 (26%) presented to the hospital. GSWH in our cohort had a case fatality rate of 89%, predominantly afflicting males, Caucasians, and victims of suicide, with a mean age of 41.9 ± 20.6 years. Hospital patients were more likely to be Black males from low socioeconomic (SES) regions involved in assault. Older, Caucasian males were overrepresented in patients attempting and completing suicide, thus comprised a higher percentage of ME cases. Geo-spatial analysis of hospital patient injury zip-codes illustrates GSWH are significantly clustered in low-income urban centers with greater poverty rates. In Miami-Dade County, the economic burden of GSWH, as measured by total healthcare costs and lifetime productivity losses, was estimated to be $11,867,415 and $246,179,498 respectively.In the first analysis of GSWH with the inclusion of both hospital and ME data in a representative urban setting, our findings demonstrate pre-hospital risk factors and the unequal distribution of the significant economic costs of GSWH.

Objective As the aged population is rapidly growing globally, geriatric traumatic brain injury (TBI) becomes an increasing problem. There are higher mortality and poorer functional outcome in the geriatric TBI population (≥65 years) compared with younger groups despite neurosurgical interventions. Therefore, current treatment priorities and cost-effectiveness should be critically examined. We evaluated the benefit of surgical management in the elderly (≥65 years) after TBI. Methods A total of 3194 patients with confirmed TBI were enrolled from 1998 to 2011, in the Japan Neurotrauma Data Bank. Retrospective analysis was conducted from the Japan Neurotrauma Data Bank on 888 (28%) patients (≥65 years) who did and did not undergo surgery. In particular, the effect of low Glasgow coma scale (GCS) (3–5) was compared with outcome with and without surgery. Results Of all the patients 65 years of age and over, 478 (54%) were given surgical management (craniectomy, craniotomy, or burr-hole evacuation). This group of patients had significantly more favorable outcome at 6 months (18% vs. 7%) and less mortality (62% vs. 81%). However, within this surgical group, patients with initial GCS scores of 3–5 had significantly more unfavorable outcome (96% vs. 79%) and more mortality (87% vs. 57%) compared with those with GCS scores of 6–15. Conclusions We confirmed that age is a major determinant of outcome after TBI. In addition, we found that neurosurgical management is associated with the improvement of the prognosis and a decrease in the rate of mortality in geriatric TBI. However, surgical management was not shown to be an effective treatment in elderly patients with GCS scores of 3–5.

Background Timely detection of intraorbital and skull base wooden foreign bodies is crucial. Wooden foreign bodies are difficult to detect on imaging. The radiologist may fail to identify wooden foreign bodies on two thirds of initial scans and can miss them in almost one third of total cases. Case Description A 66-year-old woman sustained a penetrating injury through the left upper eyelid with a small tree branch. The branch was immediately removed in the field, and she was provided with prompt medical care at a local hospital. Initial computed tomography (CT) scan diagnosis was “posttraumatic sinusitis,” and this was treated empirically with vancomycin and piperacillin/tazobactam. On the eighth day after injury, she developed progressive swelling and pain of her eyelid with left trigeminal/supraorbital numbness and complete left ophthalmoplegia. A new CT scan showed an open “track” from the region of the left upper orbit/superior rectus to the contralateral sphenoid sinus, which raised suspicion for a retained foreign body. Further imaging confirmed the suspicion. Endoscopic sinus surgery was performed with extraction of the wooden object and evacuation of the left orbital infection. Conclusions This case indicates that intraorbital and skull base wooden foreign bodies are elusive, demanding a high index of suspicion from both clinicians and radiologists to identify retained material in the setting of ocular or sinus trauma. For better identification of wooden foreign bodies, bone windows on CT should have a width of −1000 Hounsfield units with a soft tissue window level of −500 Hounsfield units.

n the cold gray light before dawn, my wife and I were 120 nautical miles south of Madagascar in the Southern Ocean. IWe had spent a sleepless and frightening night fighting a south-westerly gale with 45-knot winds, but the constant roaring grayness and windblown spume seemed to be receding with the morning light.suddenly we were engulfed by a huge rumbling noise like a jetliner passing right overhead.and in a few seconds, our home-built, 12-ton steel sailboat was hoisted 40 feet upward, rolled over, and dropped onto the cabin top in a sickening 360degree rollover. We were flung around inside the small cabin like rag dolls in a washing machine, along with a lot of sea water and our possessions. When I opened the hatch to look around, walls of gray water towered up 50 feet or more above the boat, topped by terrifying foaming, tumbling, white breaking wave tops. The boat was miraculously intact, but we’d lost all electronics and the storm trysail. We turned and ran downwind, hand steering, careening down the giant waves for 12 hours without a break, surfing the crests to avoid another knock down. The Southern Ocean is an unforgiving place, for novices. Maybe parallels can be drawn to that first intraoperative aneurysm rupture, after residency.instant action is needed, and life is in the balance. Since that memorable “maiden voyage,” we have been enormously privileged to sail more than 17,000 blue water miles in 3 oceans, from the beautiful, subarctic Outer Hebrides in Northern Scotland, across the Atlantic to the Caribbean, the Bahamas (Figures 1 and 2), and the peaceful anchorages of the Chesapeake Bay. Thanks to wonderful neurosurgical colleagues, it has been possible to integrate these blue water experiences with a full and demanding neurosurgical life. Our children were conceived at sea, and textbooks were edited in the mid Atlantic.

Objective Many efforts have been made to create new diagnostic technologies for use in the diagnosis of central nervous system injury. However, there is still no consensus for the use of biomarkers in clinical acute spinal cord injury (SCI). The aims of this review are (1) to evaluate the current status of neurochemical biomarkers and (2) to discuss their potential acute diagnostic role in SCI by reviewing the literature. Methods PubMed (http://www.ncbi.nlm.nih.gov/pubmed) was searched up to 2012 to identify publications concerning diagnostic biomarkers in SCI. To support more knowledge, we also checked secondary references in the primarily retrieved literature. Results Neurofilaments, cleaved-Tau, microtubule-associated protein 2, myelin basic protein, neuron-specific enolase, S100β, and glial fibrillary acidic protein were identified as structural protein biomarkers in SCI by this review process. We could not find reports relating ubiquitin C-terminal hydrolase-L1 and α-II spectrin breakdown products, which are widely researched in other central nervous system injuries. Therefore, we present our preliminary data relating to these two biomarkers. Some of biomarkers showed promising results for SCI diagnosis and outcome prediction; however, there were unresolved issues relating to accuracy and their accessibility. Conclusion Currently, there still are not many reports focused on diagnostic biomarkers in SCI. This fact warranted the need for greater efforts to innovate sensitive and reliable biomarkers for SCI.

Objective Severe traumatic brain injury (TBI) is a dynamic neuropathologic process in which a substantial proportion of patients die within the first 48-hours. The assessment of injury severity and prognosis are of primary concern in the initial management of severe TBI. Supplemental testing that aids in the stratification of patients at high risk for deterioration may significantly improve posttraumatic management in the acute setting. Methods This retrospective study assessed the utility of both single-marker and multimarker models as predictive indicators of acute clinical status after severe TBI. Forty-four patients who sustained severe TBI (admission Glasgow Coma Scale [GCS] score ≤8) were divided into two cohorts according to a dichotomized clinical outcome at 72 hours after admission: Poor status (death or GCS score ≤8) and improved status (GCS score improved to >8). Threshold values for clinical status prediction were calculated for serum S-100B, matrix metalloproteinase-9, and plasma D-dimer, upon admission and at 24 hours after TBI by the use of receiver operating characteristic analysis. Performance characteristics of these single-marker predictors were compared with those derived from a multimarker logistic regression analysis. Results Biomarkers with the greatest predictive value for poor status at 72 hours included serum S-100B on admission, as well as plasma D-dimer and serum S-100B at 24 hours, for which, associations were strongly significant. Multimarker analysis indicated no substantial improvement in prediction accuracy over the best single predictors during this time frame. Conclusion In conjunction with other clinical, physical, and radiologic evidence, blood-derived biochemical markers may serve to enhance prediction of early clinical trends after severe TBI.

Objective Survival after a gunshot wound (GSW) to the head is becoming more common, with an accompanying increase in spontaneous migration of these intracranial bullet fragments. This phenomenon is well described in current literature and is a potentially life-threatening delayed complication of GSW to the head. Methods We present the case of a 17-year-old boy who survived a penetrating GSW to the cranium and cerebellum after an accident involving an AK (Automatic Kalashnikov)–47 (7.62 mm). Results Following initial attempts to remove the bullet and associated hematoma from the cerebellar hemisphere, intraoperative fluoroscopy revealed that the bullet had migrated to lie within the right middle cerebellar peduncle with the development of intraoperative cardiac arrhythmia. The bullet could not be retrieved without risk of damage to the superior and inferior cerebellar arteries. The patient then developed bacterial meningitis, and further imaging revealed the bullet had again migrated under the cerebellar cortex to an accessible location. The infection was treated with aggressive antibiotic therapy and the bullet was removed from the posterior fossa, thus preventing recurrence of infection and further migration. The patient regained full motor, speech, and proprioceptive function within months after injury. Conclusion The potential for spontaneous migration exists with any penetrating brain injury involving a retained foreign body. When a retained intracranial foreign body is unable to be safely extracted during initial debridement, close clinical evaluation is essential and plain-film or computed tomographic imaging should be considered in order to enhance the early detection of delayed-onset life-threatening deterioration, such as meningitis and occlusion of cerebrospinal fluid drainage, because of spontaneous migration.