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Background Dural venous sinus thrombosis (DVST) after blunt head trauma is not rare; however, its clinical manifestations are vague, which impedes early diagnosis that is vital for its management. Prior studies have demonstrated that the presence of gas in the dural venous sinus (DVS) after blunt head trauma increases the likelihood of DVST. On nonenhanced computed tomography (CT), hyperdensity in the DVS is considered a direct sign of thrombosis, which can enable early diagnosis of traumatic DVST with high specificity but low sensitivity. We describe a case of traumatic DVST, which was diagnosed early based on the findings of gas and increasing density in the DVS on regular nonenhanced CT. Case Description A 41-year-old man was admitted to our hospital after he landed on his head in a car accident. The initial CT (each slice 5.0 mm thick), taken 40 minutes after the injury, indicated right occipital skull fracture and gas in the right sigmoid sinus. Next, 16 hours after the injury, the patient underwent another head CT (each slice 1.25 mm thick). The image showed increasing density (>65 Hounsfield units) in the right sigmoid sinus and the area of intrasinus gas, which is an indication of traumatic DVST, and the bone window revealed right occipital skull fracture that extended to the right sigmoid sinus. Anticoagulant therapy was immediately started after subsequent computed tomographic venography confirmed nonocclusive venous thrombi in the right transverse sinus, the right sigmoid sinus, and the right internal jugular vein on the level of the second cervical vertebra. Three weeks after the injury, computed tomographic venography re-examination showed that the thrombi had resolved dramatically. Conclusions Traumatic DVST was diagnosed early through findings of gas and increasing density in DVS on different nonenhanced CTs. Finding this combination is a practical, sensitive method for early diagnosis of traumatic DVST, especially in patients with hidden skull fractures involving DVS and patients with hypocythemia.

Background Although traumatic dural arteriovenous fistula (AVF) is a rare condition, dural injury associated with skull fracture is one of the major factors for the formation of dural AVF at the skull fracture area. We report a case of de novo intraosseous AVF around the anterior condylar confluence after head injury associated with skull base fracture. Case Description A woman in her 70s presented with pulsatile tinnitus 3 months after cerebellar infarction and occipital bone fracture. The appearance of de novo intraosseous AVF was confirmed by magnetic resonance imaging and magnetic resonance angiography and treated with coil embolization, which led to symptomatic relief without recurrence on follow-up. Conclusions There is no previous report to our knowledge of intraosseous AVF around the anterior condylar confluence proven to appear after skull fracture. This case demonstrates that head injury associated with skull base fracture could be one etiology of dural AVF around the anterior condylar confluence.

Background Fetal trauma during pregnancy can have a significant impact on the developing brain. Fetal trauma can lead to several intracranial pathologies including hypoxic-ischemic injury, skull fractures, and intracranial hemorrhages. Blunt trauma to a fetus resulting in the need for neurosurgical intervention is a rare occurrence and seldom described in the literature. Case Description Here we present the case of a 28-year-old, 36-week pregnant woman who was brought to the hospital by ambulance following a high-speed motor vehicle collision as the restrained driver. On computed tomography of the abdomen, the fetus was found to have a left-sided skull fracture with intracranial hemorrhage. The fetus was emergently delivered by way of caesarean section for lack of fetal movement and indeterminate heart tracings. Postnatally, the neonate had a Glasgow Coma Scale of 7. A postnatal head computed tomography better defined the skull fractures and multiple areas of intracranial hemorrhage. The baby was taken to the operating room for evacuation of the hematomas. At 16 months of age, the baby was well with only mild developmental delay, although a ventriculoperitoneal shunt was needed in a delayed fashion at 3 months of age. Conclusions We present a rare situation where emergent caesarean section delivery followed by neonatal craniotomy was necessary. Our case illustrates that good outcomes can be achieved with rapid identification of fetal intracranial injury and intervention.

Background Traumatic brain injury (TBI) is major contributor to the global burden of disease, especially in low- and middle- income countries, where most TBIs are traffic-related. Evidence shows that helmets protect against severe TBI. Cambodia continues to have the greatest motorcycle fatality rate in Southeast Asia. We investigated whether the National Motorcycle Helmet Law introduced in January 2016 had an impact on the epidemiology of motorcycle-related TBI in a neurosurgical referral center in Phnom Penh. Methods This is a cross-sectional study of all patients admitted to the Department of Neurosurgery at Preah Kossamak Hospital with TBI following motorcycle accidents between January 2014 and December 2017. Results TBI admissions increased (from 234 in 2014 to 768 in 2017). The median age was 26 years, and most patients were male. The percentage of helmeted patients was 9% in 2014 and 13% in 2015; this increased to 18% in 2016, but dropped to 9% in 2017. Most TBIs occurred during the evening rush hour. Since 2016, more patients wore helmets in the daytime (up to 23%) than at night (5% between 1:00 and 5:00 am ). Skull fracture, the most common pathology pre-law, decreased by 25% post-law (P Conclusions With growing urbanization and motorization, TBI is a significant cause of morbidity and mortality in Cambodia. Two years after helmets became compulsory, most patients with TBI are still unhelmeted. Likely contributing factors are low penalty for noncompliance and inconsistent law enforcement. TBI is a major public health problem warranting further efforts to understand how to improve prevention strategies and advocate for change.

Background Traumatic intracranial hemorrhage (TICH) is one of the commonest indications for neurosurgical consultation after trauma. Worsening neurologic examination results, size of initial TICH, presence of displaced skull fracture, and concomitant anticoagulant use at the time of injury drive the recommendations for repeat computed tomography of head (RCTH), to assess for stability of intracranial hemorrhage. Chronic alcohol use is not generally considered an indication for repeat head computed tomography (CT). Methods A retrospective study of 423 patients with TICH with normal admission platelet (PLT) counts was reviewed for this study, taken as a subset of 1330 patients with TICH admitted to Lahey Hospital and Medical Center over a 3-year period. Of these 423 patients, 330 were classified as nonalcoholics and 93 were classified as alcoholics, based on whether alcohol use disorder was documented in the patient’s medical record, present before injury. The normal PLT level was defined as ≥100,000 μ/L. Patients were excluded from review if they had comorbid conditions that could cause PLT dysfunction or coagulopathy. Continuous and categorical variables were compared using independent t test and χ2, respectively. Binary logistic regression was used to predict outcome: stable versus worsening of TICH on RCTH. Statistical analysis was conducted using SPSS version 25. Results The mean age of the nonalcoholic and alcoholic cohorts were 71.9 years and 54.8 years, respectively. A significantly higher percentage of alcoholics were male. There was a statistically significant difference (χ2 = 8.14; P Conclusions Chronic alcohol use was an independent predictor of radiologic progression of TICH in the setting of normal PLT level. Modification of this risk of progression with transfusion of fresh PLTs in chronic alcoholic patients with TICH needs to be investigated in a prospective trial.

Background Traumatic posterior fossa subdural hemorrhage (SDH) is a rare subtype of subdural hemorrhage in head injuries. Existing data on its pathophysiology and outcome are currently limited; therefore, the condition is not yet fully understood. The present study aimed to determine the incidence, outcome, and prognostic factors for traumatic posterior fossa SDH. Methods We performed a retrospective cohort study using the nationwide trauma registry Japan Trauma Data Bank. We identified adult patients (i.e., aged ≥18 years) who had posterior fossa SDH after blunt head trauma from 2004 to 2015. The primary endpoint was in-hospital mortality. We compared patients with and without posterior fossa SDH and adjusted for confounders using a multivariate logistic regression model. Results A total of 75,838 patients had blunt head injuries. Of these, 266 (0.35%) had posterior fossa SDH, and 177 (median age, 69 years; interquartile range, 55–76) were eligible for analysis. The distribution of the Glasgow Coma Scale (GCS) score was bimodal, and the median score was 14 (interquartile range, 9–15). The mortality rate was 16.9% (95% confidence interval [CI], 11.7%–23.3%). A large posterior fossa SDH (>30 cm3; >1 cm thick), low GCS score on arrival, and the presence of a skull fracture were significantly associated with mortality, with an adjusted odds ratio of 4.51 (95% CI, 1.46–13.9), 0.82 (95% CI, 0.73–0.92), and 4.59 (95% CI, 1.52–13.9), respectively. Conclusions Traumatic posterior fossa SDH was extremely rare in our data set. Mortality correlated with the size of the SDH, GCS score on admission, and the presence of a skull fracture.

Background The neurosurgical literature rarely describes managing open head injuries caused by machetes, although this is a common head injury in developing countries. We present our experience managing cranial machete injuries in Nicaragua over a 5-year period. Methods A retrospective chart review identified patients admitted to a neurosurgery service for cranial machete injury. Results Among 51 patients studied, the majority (n = 42, 82%) presented with mild neurologic deficits (Glasgow Coma Scale score ≥14). Nondepressed skull fracture (25/37, 68%) was the most common injury identified on skull radiography, and pneumocephalus (15/29, 52%) was the most common injury identified with computed tomography. Overall, 38 patients (75%) underwent surgical intervention for 1 or more conditions, including laceration length ≥10 cm (n = 20), open intracranial wound (n = 8), pneumocephalus (n = 7), cerebral contusion (n = 6), intracranial hemorrhage (n = 5), and depressed fracture (n = 5). All patients received aggressive antibiotic therapy. Patients without intracranial injury received a 7-day course of intravenous ceftriaxone, followed by a 10-day course of oral ciprofloxacin. Patients with violation of the dura received a 7- to 14-day course of intravenous metronidazole, ceftriaxone, and vancomycin, followed by a 10-day course of oral ciprofloxacin. Postoperative complications included a visible skull defect (n = 6), infection (n = 3), and unspecified neurologic (n = 2) and mixed (n = 1) complications. At discharge, most patients had only minimal disabilities (47/51, 92%). In-hospital mortality rate was zero. Conclusions An aggressive approach to managing open head injury caused by machete yields good outcomes, with the majority of patients experiencing minimal disability at hospital discharge and a low rate of infection.

Compound depressed skull fracture (DSF) is a neurosurgical emergency. Preoperative knowledge of dural status is indispensable for treatment decision making. This study aimed to determine predictors of dural tear from clinical and imaging characteristics in patients with compound DSF.This prospective, multicenter correlational study in neurosurgical hospitals in Addis Ababa, Ethiopia, included 128 patients operated on from January 1, 2016, to October 31, 2016. Clinical, imaging, and intraoperative findings were evaluated. Univariate and multivariate analyses were used to establish predictors of dural tear. A logistic regression model was developed to predict probability of dural tear. Model validation was done using the receiver operating characteristic curve.Dural tear was seen in 55.5% of 128 patients. Demographics, injury mechanism, clinical presentation, and site of DSF had no significant correlation with dural tear. In univariate and multivariate analyses, depth of fracture depression (odds ratio 1.3, P0.001), pneumocephalus (odds ratio 2.8, P = 0.005), and brain contusions/intracerebral hematoma (odds ratio 5.5, P0.001) were significantly correlated with dural tear. We developed a logistic regression model (diagnostic test) to calculate probability of dural tear. Using the receiver operating characteristic curve, we determined the cutoff value for a positive test giving the highest accuracy to be 30% with a corresponding sensitivity of 93.0% and specificity of 43.9%.Dural tear in compound DSF can be predicted with 93.0% sensitivity using preoperative findings and may guide treatment decision making in resource-limited settings where risk of extensive cranial surgery outweighs the benefit.

Background Brain parenchyma herniation through a disrupted inner table into an enlarged diploic cavity with an intact outer table is described as intradiploic encephalocele. Intradiploic encephaloceles share common morphologic characteristics with expanding skull fractures and intradiploic arachnoid cysts. Herein, we describe a case of traumatic occipital intradiploic encephalocele. Case Description Cranial computed tomography of an 11-year-old boy revealed erosion of the inner table of the left side of occipital bone and expansion of the cranial diploe by a soft-tissue density with a gyral pattern. His medical history was positive for head trauma at the age of 3 years to the same region. Magnetic resonance imaging showed herniation of left occipital parenchyma with cystic encephalomalacic changes into the diploe. Conclusions Intradiploic encephaloceles have different features compared with the classic encephalocele and can be considered as a variant of expanding skull fracture and intradiploic arachnoid cyst.

Prognostic markers are important for neurosurgeons to evaluate the indications for aggressive surgical management. The purpose of this study was to investigate whether the number of fractured calvarial bones could predict the outcome in patients with traumatic brain injury (TBI) after early craniotomy.TBI patients who underwent early craniotomy were reviewed. The number of fractured calvarial bones was recorded by referring to preoperative computed tomographic (CT) images. Accordingly, patients were assigned to no calvarial fracture group, single calvarial fracture group, and multiple calvarial fractures group. Good outcome was defined as Glasgow Outcome Scale scores of 4 and 5 at discharge. Logistic regression analyses were used to assess the effect of calvarial fracture on outcome. A receiver operating characteristic curve was generated for the final model.In all, a total of 141 patients were enrolled. Patients with no calvarial fracture had a significantly lower rate of good outcome (12.5%) than did those with a single calvarial fracture (62.2%, P0.001) and those with multiple calvarial fractures (48.6%, P = 0.005). Binary logistic regression showed that the number of fractured calvarial bones was an independent imaging marker for predicting outcome (P = 0.003) after adjustment for age, Glasgow Coma Scale score on admission, and decompressive craniectomy. The area under the curve of the final model was 0.863.The number of fractured calvarial bones is an independent predictor of outcome in TBI patients after early craniotomy. No calvarial facture is associated with poor outcome in these patients.

A 53-year-old man was admitted to our hospital following a traffic accident. He had been riding a bicycle and was knocked down by a motorcycle, injuring the right side of his forehead. Upon arrival at our department, he was conscious and we found no cerebrospinal fluid rhinorrhea or otorrhea. His Glasgow Coma Scale score was 15. Neurologic examination was normal, except for reduced vision in his right eye. Head computed tomography showed extensive pneumocephalus involving the cisterna ambiens, prepontine and suprasellar cisterns, and temporal, frontal, parietal, and occipital lobes. A right frontal skull fracture was evident. The patient was treated conservatively, with bed rest with the head of the bed elevated at 30 degrees. The patient was instructed to avoid any movements that might increase intracranial pressure, and he was placed on conventional concentration oxygen therapy of about 40%. Repeat computed tomography 9 hours later showed partial absorption of the pneumocephalus, which was almost completely absorbed 4 days later. He recovered well and was discharged after 7 days. At the 1-month follow-up, the patient was well, although the reduced vision in his right eye persisted.

Background Diastatic skull fractures (DSFs) in children are difficult to detect in skull radiographs before they develop into growing skull fractures; therefore, little information is available on this topic. However, recent advances in 3-dimensional (3D) computed tomography (CT) imaging technology have enabled more accurate diagnoses of almost all forms of skull fracture. The present study was undertaken to document the clinical characteristics of DSFs in children and to determine whether 3D CT enhances diagnostic accuracy. Methods Two hundred and ninety-two children younger than 12 years with skull fractures underwent simple skull radiography, 2-dimensional (2D) CT, and 3DCT. Results were compared with respect to fracture type, location, associated lesions, and accuracy of diagnosis. Results DSFs were diagnosed in 44 (15.7%) of children with skull fractures. Twenty-two patients had DSFs only, and the other 22 had DSFs combined with compound or mixed skull fractures. The most common fracture locations were the occipitomastoid (25%) and lambdoid (15.9%). Accompanying lesions consisted of subgaleal hemorrhages (42/44), epidural hemorrhages (32/44), pneumocephalus (17/44), and subdural hemorrhages (3/44). A total of 17 surgical procedures were performed on 15 of the 44 patients. Fourteen and 19 patients were confirmed to have DSFs by skull radiography and 2D CT, respectively, but 3D CT detected DSFs in 43 of the 44 children ( P Conclusion 3D CT was found to be markedly superior to skull radiography or 2D CT for detecting DSFs. This finding indicates that 3D CT should be used routinely rather than 2D CT for the assessment of pediatric head trauma.

Objective The most common birth-associated head injuries during vaginal delivery are cephalhematomas and subgaleal hematomas. Cranial injuries are rarely encountered. The neonate cranium is soft and pliable, and greenstick skull fractures (GSFs) are expected to be more frequent than linear or depressed fractures, but they are extremely difficult to detect with simple skull radiography. As a result, no reports have been issued on this topic to date. Recent reports suggest that technological advances in 3-dimensional (3D) computed tomography (CT) have successfully enhanced the diagnostic accuracy for cranial fractures. The authors researched the types and characteristics of GSFs and the diagnostic accuracy of 3D CT for cranial fractures in neonates. Methods The simple skull radiographs and 3D CT images of 101 neonates were retrospectively evaluated and compared with respect to diagnosis of cranial fractures, and skull GSFs were classified on the basis of 3D CT findings into 5 types depending on multiplicity and location. Results 3D CT detected 88 cases of cranial fractures, that is, 89 GSFs, 4 combined GSFs and linear fractures, and 3 combined GSFs and depressed fractures. The diagnostic rate of 3DCT was 91% and this was significantly higher than the 13% rate of simple skull radiographs (P Conclusions GSFs rather than linear fractures were found to account for most cranial injuries among neonates. The diagnostic accuracy of 3D CT was considerably superior than simple skull radiography, but the high radiation exposure levels of 3D CT warrant the need for development of a modality with lower radiation exposure.

Objective Only eight cases of cerebral myiasis in humans have been reported worldwide and only one in the United States. Presented here is a case of cerebral myiasis in the setting of head trauma in suburban Los Angeles. Methods The article includes chart review and description of a clinical case presentation. Results A 42-year-old HIV-positive man was found in a ditch after 2 weeks, the victim of apparent assault. He had multiple facial fractures along with open depressed bifrontal sinus fractures with necrotic bone, eroded dura, exposed cortex, and extensive maggot infestation of the left frontal lobe. The patient was taken urgently to the operating room, where the maggots where evacuated by irrigation and suction. Debridement of necrotic bone, dura, and brain was performed, the frontal sinuses were exenterated, and skull defects plated with titanium mesh. Intraoperative cultures revealed a polymicrobial meningitis/encephalitis, which was treated postoperatively with antibiotics. The patient's neurologic exam stabilized and the patient was transferred to a rehabilitation facility for further care, ultimately achieving functionality and holding a job. Conclusion This is the first published case of cerebral myiasis secondary to trauma, and to our knowledge, the first documented long-term survivor of extensive cerebral myiasis. Wide debridement to normal brain followed by 6 weeks of broad-spectrum antibiotic treatment is effective in managing this condition. A well-functioning outcome can be expected with prompt recognition and treatment of the disease. Larval infestation may have a protective effect against bacterial infection and may allow for greater tolerance of treatment delay.

Objective Skull bone fractures are common in trauma. They are usually linear undisplaced or depressed; however, a distinct possibility of elevated fracture remains. We describe an entity of everted fracture skull in which the fracture segment is totally everted. The nature of trauma, management, and complications of this unique case are discussed. Case Report A 21-year-old woman involved in a railway accident presented to us with a primary dressing on her wound. Investigations revealed an everted fracture skull. She underwent surgery with good results. Conclusion We would like to add everted fracture skull to the nomenclature describing skull fractures in addition to elevated compound fracture skull as a new entity.