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Traumatic head injuries remain a leading cause of death and disability worldwide. Although skull fractures are one of the most common head injuries, the fundamental mechanics of cranial bone and its impact tolerance are still uncertain. In the present study, a strain-rate-dependent material model for cranial bone has been proposed and implemented in subject-specific Finite Element (FE) head models in order to predict skull fractures in five real-world fall accidents. The subject-specific head models were developed following an established image-registration-based personalization pipeline. Head impact boundary conditions were derived from accident reconstructions using personalized human body models. The simulated fracture lines were compared to those visible in post-mortem CT scans of each subject. In result, the FE models did predict the actual occurrence and extent of skull fractures in all cases. In at least four out of five cases, predicted fracture patterns were comparable to ones from CT scans and autopsy reports. The tensile material model, which was tuned to represent rate-dependent tensile data of cortical skull bone from literature, was able to capture observed linear fractures in blunt indentation loading of a skullcap specimen. The FE model showed to be sensitive to modeling parameters, in particular to the constitutive parameters of the cortical tables. Nevertheless, this study provides a currently lacking strain-rate dependent material model of cranial bone that has the capacity to accurately predict linear fracture patterns. For the first time, a procedure to reconstruct occurrences of skull fractures using computational engineering techniques, capturing the all-in-all fracture initiation, propagation and final pattern, is presented., (© 2023. The Author(s).)

The aim of this study was to evaluate the morphological and biomechanical characteristics of a wound entrance on the parietal bone from the impact of projectiles presenting three different calibres. Three-dimensional finite element models of dry human skull and of three projectiles with calibres.380 Auto,.40 S&W and 9 × 19 mm Luger were obtained. These geometries were used to perform a simulation of projectile impact on the parietal bone by the finite element method. We calculated the morphological aspect of the wounds on the external bone surface, the equivalent von Mises stress and the kinetic energy loss. The wounds from the 9 × 19 mm and.380 calibres presented a circular aspect, while the wound from the.40 calibre presented an oval aspect. The 9 × 19 mm caused a major wound area compared with the other calibres. The maximum von Mises stress in the bone was higher from the.40 calibre penetration, and the.380 had the major kinetic energy loss. In conclusion, the 9 × 19 mm and.380 presented similarity in the shape of the entrance hole. The projectile with 9 × 19 mm calibre seems to have greater penetration power and the.40 S&W projectile greater power of destruction and dissipation of energy. [ABSTRACT FROM AUTHOR]

• A detailed analysis of the occurrence of pedestrian head injury types categorised separately into skull and brain injuries. • GIDAS accident data, Spearman's rank correlation coefficient and logistic regression model are employed. • Interrelationship between different head injury types was investigated. • Influences of impact speed, pedestrian age and car front shape on different kinds of pedestrian head injuries were studied. Head injury is one of the most common injury types in vehicle-to-pedestrian collisions, which leads to death and long-term disabilities. However, detailed analysis of pedestrian head injuries in real world collisions is scarce. Thus the current study used two samples of 120 cases and 184 cases extracted from 1060 pedestrian collision cases captured during 2000–2015 from the GIDAS (German In-Depth-Accident Study) database to investigate the detailed characteristics of AIS2+ pedestrian head injuries. Firstly, the interrelationship between different head injury types (skull fracture, focal brain injury, concussion and diffuse axonal injury (DAI)) was analysed using the sample of 120 cases which each had at least one AIS2+ head injury. Then the influences of impact speed, pedestrian age and car front shape parameters on the injury risk of skull fracture, focal brain injury and concussion were assessed using the logistic regression method, based on the sample of 184 AIS1+ cases where the primary head contact location was within the windscreen glass area. The results show that: skull fractures and focal brain injuries dominate for AIS3+ head injuries and are generally associated with each other; concussion is the most important injury type for AIS2 head injuries and usually occurs in isolation. Further, for head impacts to the windscreen glass area a higher bonnet leading edge helps to reduce concussion odds, and none of the selected car front shape parameters are significant for the odds of skull fracture and focal brain injury, and vehicle impact speed and pedestrian age are insignificant for concussion. These detailed characteristics of pedestrian head injuries provide a basis for future pedestrian head injury prevention strategies with skull fractures and focal brain injuries being the most important injuries to address. [ABSTRACT FROM AUTHOR]

This chapter employs the fracture assessment triad, a systematic analytical approach, as a vehicle to explore the components used to interpret gunshot trauma to the cranium. First, a list of pertinent observations associated with gunshot trauma to the cranium is presented with a brief description of each. These features include entrance and exit wound defect morphology, keyhole defect, gutter defect, radiating fractures, concentric fractures, bone plugs, and associated foreign material, debris and residue. Second, the intrinsic factors that govern the way bone responds to trauma can be surmised through a direct examination or knowledge of the skeletal case. Intrinsic factors rest primarily in bone being a viscoelastic material with anisotropic properties, but include other elements that affect fracture production, such as buttressing, bone architecture, sutures, and influences of age, sex and health. These influences may be discoverable and factored into the analysis. With direct observation of the defect/fracture pattern and an understanding of the intrinsic influences involved, the extrinsic factors can be deduced. Bullet velocity, mass, design and cavitation represent the major extrinsic factors involved in wound production. The interplay of each of these factors imparts varying amounts of kinetic energy to soft and hard tissues. The greater amount of kinetic energy conveyed, the larger the temporary cavity and the greater the potential for destruction. When interpreting gunshot trauma, precision is enhanced by the analyst's familiarity with firearms and ammunition, facilitating determination of firearm type (rifle/handgun or shotgun), bullet direction, range, sequence of fire, and potentially, speculations as to bullet velocity, mass and design. Neither caliber nor gauge can be determined from the entrance defect size, but elimination of certain calibers or gauges may be possible. [ABSTRACT FROM AUTHOR]

Large bone injuries, defects, and chronic wounds present a major problem for medicine. Several therapeutic strategies are used clinically to precipitate bone including a combination therapy delivering osteoinductive bone morphogenetic protein 2 (rhBMP‐2) via an osteoconductive scaffold (absorbable collagen sponge [ACS], i.e., INFUSE). Adverse side effects reportedly associated with rhBMP2 administration include rampant inflammation and clinical failures. Although acute inflammation is necessary for proper healing in bone, inflammatory cascade dysregulation can result in sustained tissue damage and poor healing. We hypothesized that a subclinical dose of rhBMP2 modeled in the murine calvarial defect would not precipitate alterations to inflammatory markers during acute phases of bone wound healing. We utilized the 5 mm critical size calvarial defect in C57BL6 wild‐type mice which were subsequently treated with ACS and a subclinical dose of rhBMP2 shown to be optimal for healing. Three and 7‐day postoperative time points were used to assess the role that rhBMP‐2 plays in modulating inflammation vs. ACS alone by cytokine array and histological interrogation. Data revealed that rhBMP‐2 delivery resulted in substantial modulation of several markers associated with inflammation, most of which decreased to levels similar to control by the 7‐day time point. Additionally, while rhBMP‐2 administration increased macrophage response, this peptide had a little noticeable effect on traditional markers of macrophage polarization (M1‐iNOS, M2‐Arg1). These results suggest that rhBMP‐2 delivered at a lower dose does not precipitate rampant inflammation. Thus, an assessment of dosing for rhBMP‐2 therapies may lead to better healing outcomes and less surgical failure. [ABSTRACT FROM AUTHOR]

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

Objective To investigate the application of neuroendoscopy and curative effect of lateral skull base surgery via transcranial approach. Methods Clinical data of 142 cases undergoing endoscopic lateral skull base surgeries via transcranial approach from July 2015 to July 2018 were retrospectively analyzed. There were 32 cases of primary hemifacial spasm, 56 cases of primary trigeminal neuralgia, 2 cases of primary glossopharyngeal neuralgia, 15 cases of epidermoid cyst, 14 cases of acoustic neuroma, 3 cases of trigeminal schwannoma, 18 cases of pontocerebellar trigone meningioma, and 2 cases of jugular foramen schwannoma. Among them, 90 cases (32 cases of primary hemifacial spasm, 56 cases of primary trigeminal neuralgia and 2 cases of primary glossopharyngeal neuralgia) underwent endoscopic microvascular decompression (MVD) via transcranial approach, and 52 cases (15 cases of epidermoid cyst, 14 cases of acoustic neuroma, 3 cases of trigeminal schwannoma, 18 cases of pontocerebellar trigone meningioma, and 2 cases of jugular foramen schwannoma) underwent endoscopic removal of lateral skull base tumors via transcranial approach. Results All the operations were performed under endoscopy, including 96 cases (67.61%) operated by single hand (the endoscope was held by a pneumatic arm) and the rest 46 cases (32.39%) operated by both hands. The cure rate of MVD was 87.78% (79/90) and the total removal rate of lateral skull base tumors was 90.38% (47/52). The mean follow - up period was (23.46 ± 8.93) months. There was no death or other serious complications. Conclusions The complex lateral skull base surgery via transcranial approach can be performed by neuroendoscope with pneumatic endoscopic fixed arm. It has the advantages of near and multi - angle observation, clear visual field, full exposure and high recognition of nerve and blood vessels. However, the requirements for endoscopic technology, instruments and assistive equipments are high, and it is necessary to receive relevant trainings and experiences in endoscopic surgery. [ABSTRACT FROM AUTHOR]

CSF leak in penetrating skull base injury is relatively rare compared to close head injury involving skull base fracture. We report a 5-year-old boy presented with epistaxis and impacted pencil into the left nostril. The child was hemodynamically stable without any neurological deficit. Intraoperatively, there was a nasal septal defect posteriorly with anterior skull base fracture associated with CSF leak. The pencil was removed from the left nostril and the CSF leak was repaired using harvested abdominal fat under the same setting. Computed Tomography (CT) of the brain showed right cribriform plate fracture with small pneumocranium. Postoperatively, a prophylactic antibiotic was given for seven days and he was discharged well. Subsequent clinic visits up to one-year postoperative period showed no recurrence of the CSF leak. History taking, physical examination and CT imaging give valuable diagnostic values in managing the penetrating skull base injury. Early intervention for removal of the foreign body and repair of the CSF leak is advocated to prevent catastrophic complication. [ABSTRACT FROM AUTHOR]

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Background: Craniomaxillofacial (CMF) injuries are very common in both civilian and military settings. Nearly half of all civilian trauma incidents include a scalp laceration and historical rates of CMF battle injuries increased from 16%-21% to 42.2%. The scalp is highly vascular tissue and uncontrolled bleeding can lead to hypotension, shock and death. Therefore, enabling on-scene providers, both military and civilian, to immediately manage scalp and face lacerations, in a manner that allows them to still function in a tactical way, offers operational advantages. This case series examines how effectively a wound-clamp (iTClamp) controlled bleeding from CMF injuries pre-hospital environment. Methods: The use of the iTClamp for CMF (scalp and face laceration) was extracted from iTrauma Care's post market surveillance database. Data was reviewed and a descriptive analysis was applied. Results: 216 civilian cases of iTClamp use were reported to iTrauma Care. Of the 216 cases, 37% (n=80) were for control of CMF hemorrhage (94% scalp and 6% face). Falls (n=24) and MVC (n=25) accounted for 61% of the mechanism of injury. Blunt accounted for 66% (n=53), penetrating 16% (n=13) and unknown 18% (n=14). Adequate hemorrhage control was reported in 87.5% (n=70) of cases, three respondents reported inadequate hemorrhage control and in seven cases hemorrhage control was not reported. Direct pressure and packing was abandoned in favor of the iTClamp in 27.5% (n=22) of cases. Conclusions: CMF injuries are common in both civilian and military settings. Current options like direct manual pressure (DMP) often do not work well, are formidable to maintain on long transports and Raney clips are a historical suggestion. The iTClamp offers a new option for control of external hemorrhage from open wounds within compressible zones. [ABSTRACT FROM AUTHOR]

The article presents a discussion on the improvement of the repositioning and extension treatment in case of traumatic injuries to the head. Earlier treatment of such head injuries had a lot of difficulties and discomforts attached to them like immobility of the patients, slipping of the traction caps for certain head shapes and other discomforts in summer. The author puts up several cases where he demonstrates the possibility for combining craniofacial wire extension with plaster cranial cap fixation on the skull.

We report the case of a 38-year-old man with abducens palsy following a traumatic skull injury who failed multiple strabismus surgeries. A suture-armed 5 mm micro bone screw was placed on the anterior face of the lateral orbital rim and used to tether and abduct the globe. The patient remained orthotropic in primary position 12 months postoperatively. [ABSTRACT FROM AUTHOR]

Our institute of Legal Medicine was asked to examine a 27-year-old patient admitted to the neurosurgical department after a non-fatal accident (non-observed fall from height) at a construction site. Forensic advice was needed because of unexplainable injuries. By example of this case of a near-to-impalement, we would like to highlight an unusual, clinically frequently forgotten, and forensically thus far not discussed type of skull fracture with outward dislocation of bone fragment(s). These so-called compound elevated fractures of the skull are described occasionally in, mainly neurosurgical, case reports. Knowing its entity and its pathomechanism may be of forensic interest, particularly in order of reconstruction purpose. This article provides a brief review of the literature with special regard to the pathomechanism. In addition, it demonstrates the possible pitfall of computed tomography, or more specifically, the 3D reconstruction. To our knowledge, this is the first forensic report describing this kind of fracture. [ABSTRACT FROM AUTHOR]

Penetrating head injuries can be the result of numerous intentional or unintentional events, including missile wounds, stab wounds, and motor vehicle or occupational accidents (nails, screw-drivers). Penetrating head injuries in children constitute even a smaller part of the total number of traumatic head injuries seen in casualty. We report a case of neuro-trauma who was operated in our institution. A 6-year-old female presented in casualty with an iron rod penetrating into the skull. [ABSTRACT FROM AUTHOR]

Abstract The main purpose of regenerative biology is to improve human health by exploiting cellular and molecular mechanisms favoring tissue repair. In recent years, non-mammalian vertebrates have emerged as powerful model organisms to tackle the problem of tissue regeneration. Here, we analyze the process of bone repair in metamorphosing Xenopus tropicalis tadpoles subjected to traumatic skull injury. Five days after skull perforation, a dense and highly vascularized mesenchymal is apparent over the injury site. Using an in vivo bone staining procedure based on independent pulses of Alizarin red and Calcein green, we show that the deposition of new bone matrix completely closes the wound in 15 days. The absence of cartilage implies that bone repair follows an intramembranous ossification route. Collagen second harmonic imaging reveals that while a well-organized lamellar type of bone is deposited during development, a woven type of bone is produced during the early-phase of the regeneration process. Osteoblasts lying against the regenerating bone robustly express fibrillar collagen 1a1 , SPARC and Dlx5. These analyses establish Xenopus tropicalis as a new model system to improve traumatic skull injury recovery. Highlights • A novel traumatic skull injury assay was implemented in Xenopus tropicalis tadpoles and froglets. • A dense and highly irrigated mesenchymal plug forms over the wound in 5 days. • A woven type of bone closes the lesion in 15 days, and subsequently converts into lamellar bone. • Bone repair occurs in the absence of cartilage. • Osteoblasts involved in regeneration robustly express Collagen 1a1 , SPARC and Dlx5 transcripts. [ABSTRACT FROM AUTHOR]

A case of long-term continual self-inflicted penetrating craniocerebral injury to a 59-year-old man with a fatal outcome is reported. The man suffered from paranoid psychosis and alcohol dependence. Over five months, he continually scalped the skin and subcutaneous tissue of his head with a knife until he perforated the skull and dura mater and injured his brain. He eventually sought medical advice, but died after 10 days of hospitalization despite complex conservative treatment. The immediate cause of death was a combination of central nervous system failure and heart failure. The original case presented is sporadic in the forensic literature due to atypical long-term continual self-harm to the head and brain using a sharp object that resulted in perforation of the skull and a fatal outcome. This case also highlights the importance of autopsy to determine the mechanism of injury and cause of death. [ABSTRACT FROM AUTHOR]

Background/aims: Mouthguards (MGs) are devices that can reduce the risks of facial trauma. However, the large variety of MG types and thicknesses raises the question of which type is the most effective and beneficial for the athletes. The aim of this study was to evaluate stress distribution in the skull, teeth, and jaws as a consequence of a direct impact.Material and Methods: Using modeling software, a human skull was modeled and a human jaw was created with all teeth inserted into the respective alveolus. The models were divided according to the MG type (custom-made or stock) and thickness (1, 2, and 4 mm). Two models without MG were evaluated with and without teeth contact. The geometries were exported to analysis software and the materials were considered ideal. Fixation occurred at the base of the foramen magnum. The load (500 N) was applied on the canine tooth with a ball. Maximum principal (MPa) and Von-Mises results were obtained.Results: Without any protection, the generated tensile stress was of greater magnitude causing more damage in the absence of teeth contact. The presence of a MG significantly reduced the generated stress in all structures, and the customized/individualized type was more efficient than stock MGs.Conclusions: In extreme situations when it is impossible to use a MG, keeping the teeth in maximum intercuspal position is less harmful. Despite this, the use of any MG is beneficial and assists in dampening the generated stress. The thicker the device, the greater the capacity for decreasing the damage in all structures. The use of individual protectors for each patient is even more beneficial for preventing trauma during at-risk activities of impact. [ABSTRACT FROM AUTHOR]

Purpose: Mycobacterium abscessus, and rapidly growing mycobacteria in general, are rare but increasing causes of central nervous system (CNS) infections. The aim of this study is to highlight the importance of considering these microorganism in the differential diagnosis of CNS infections, obtaining a prompt diagnosis, and improving clinical outcomes.Methods: Case report and literature review.Results: We report a case of meningeal infection in a patient who underwent decompressive craniectomy after a craniofacial trauma. The diagnosis was made analyzing a sample obtained during a second operation of cranioplasty. A regimen of amikacin, clarithromycin, and imipenem/cilastatin was started. In the following days, the patient experienced a variety of side effects. So, first clarithromycin was replaced with linezolid, then amikacin was stopped and cefoxitin added to the therapy and at the end all the antibiotics were withdrawn. The patient was discharged in good conditions and a clinical interdisciplinary follow-up was started. After 12 months, the patient is still doing well. After a literature analysis, 15 cases of M. abscessus CNS infections were identified. Various modes of acquisition, underlying disease and therapeutic schemes were evident.Conclusions: Considering the results of the literature analysis and the increasing incidence of M. abscessus, all specialists involved in the management of CNS infection should be aware of the importance of atypical microorganisms in differential diagnosis. [ABSTRACT FROM AUTHOR]

Penetrating injuries of the cranium are relatively uncommon, only 0.4% of all head injuries. In patients with disturbed conscious level, an extensive examination should be performed in the emergency unit to rule out transorbital penetrating brain injury. A 25-year-old male was attacked with a dagger. He presented with ethylic intoxication and the physical examination demonstrated a small skin injury on the lateral canthus of the left eye with a large periocular hematoma which prevented eyelid opening. Cranial CT scan showed a metallic intraorbital foreign body consisting of a fragment of a dagger which perforated the eyeball, and penetrated through the superomedial wall of the orbit into the anterior cranial fossa. Reconstruction of the eyeball was performed and the fragment was removed. Orbital injuries with a knife in situ are very unusual. Early identification and removal of retained foreign bodies are essential. [ABSTRACT FROM AUTHOR]

Here we report on a skull of an adult male Noctilio leporinus caught in the Guiana Shield, South America. The animal was lacking the upper left molar-row and exhibited skeletal deformations in the rostral and palatal regions. This aberration could have been the result of a traumatic avulsion of the left C1. As a consequence of its position and depth of the root, the C1 avulsion could have broken much of the surrounding alveolar process during the initial injury, with subsequent loss of the remaining teeth via periodontal inflammation and tooth decay. [ABSTRACT FROM AUTHOR]

Parasomnia constitutes an important group among the situations that can lead to sleep-related violence scene. Parasomnia attacks are characterized by complex motor behaviors of various degrees, violent behaviors may result in life-threatening and rarely lethal conditions for patients and their relatives. Here is presented a patient with right temporoparietal bone fracture, pneumocephalus and hemotympanum in right ear due to head trauma during a parasomnia attack. The diagnosis could be made by a detailed history taking and polysomnography only after many other investigations. In this context, we aimed to emphasize that not only nocturnal epilepsies, especially frontal lobe epilepsies, but also parasomnia attacks should be kept in mind in differential diagnosis of sleep-related violence. [ABSTRACT FROM AUTHOR]

Military combat helmets protect the wearer from a variety of battlefield threats, including projectiles. Helmet back-face deformation (BFD) is the result of the helmet defeating a projectile and deforming inward. Back-face deformation can result in localized blunt impacts to the head. A method was developed to investigate skull injury due to BFD behind-armor blunt trauma. A representative impactor was designed from the BFD profiles of modern combat helmets subjected to ballistic impacts. Three post-mortem human subject head specimens were each impacted using the representative impactor at three anatomical regions (frontal bone, right/left temporo-parietal regions) using a pneumatic projectile launcher. Thirty-six impacts were conducted at energy levels between 5 J and 25 J. Fractures were detected in two specimens. Two of the specimens experienced temporo-parietal fractures while the third specimen experienced no fractures. Biomechanical metrics, including impactor acceleration, were obtained for all tests. The work presented herein describes initial research utilizing a test method enabling the collection of dynamic exposure and biomechanical response data for the skull at the BFD-head interface. [ABSTRACT FROM AUTHOR]

Abstract: A number of papers have provided insight into frequencies of violence‐related trauma, especially skull trauma, in Northern European skeletal assemblages dating to the Neolithic and Bronze Age. Although the cases are often well described, they lack further discussion about the consequences of skull trauma for the injured individual and the implications for the surrounding society, especially considering severe skull trauma leading to traumatic brain injuries. In this paper, we address questions of trauma and care for one individual associated with the Swedish–Norwegian Battle Axe Culture who suffered from 2 severe ante mortem skull traumas probably leading to brain injuries. These questions are addressed using the Web‐based application and analytic tool Index of Care. We found that daily care, both short term with basic needs such as nutrition and grooming and long term with cognitive impairments, was available in the Neolithic society. Considering the frequent number of ante mortem skull trauma in the Neolithic and Bronze Age skeletal assemblages, traumatic brain injury was probably a common phenomenon. We argue that the care provided was a necessity for survival and maintenance of a socially sustainable society. [ABSTRACT FROM AUTHOR]

Background Penetrating injuries involving foreign objects that transgress the entirety of the human skull present challenges in the management of vascular injuries, infectious risk, cerebrospinal fluid leak, and cosmetic repair. Ultimately, effective management of these injuries requires a multidisciplinary team and judicious surgical planning. Case Description Here we present the treatment of a patient who experienced a penetrating injury from a railroad spike, with entry and exit points involving the left and right anterior aspects of the temporal fossa, respectively. Conclusions The rationale for management decisions is reviewed in the context of the published literature. [ABSTRACT FROM AUTHOR]

Background Pediatric nonmissile penetrating head injury (NMPHI) is usually accidental attributed mainly to the softer skulls of growing children. However, it is a rare entity, and therefore no consensus exists regarding treatment to effectively prevent immediate and long-term complications. Throughout the literature, these injuries are mostly discussed in case reviews and case series in the general population. No data originating from randomized studies are available because of ethical and practical limitations. Methods We retrospectively studied and present 5 cases of children with NMPHI treated in the last 6 years in the Neurosurgery Department of Children's Hospital “Aghia Sofia”. We performed a review of the literature in PubMed, using the key words “non-missile,” “penetrating head injury,” and “pediatric.” We included case reports and case series involving pediatric cases since 2008 and selected older reports as well as certain literature reviews focusing on analysis of complications and treatment suggestions. We compared reported practice in various institutions with suggestions from the literature. Results In the last year, 4 literature reviews were published suggesting treatment algorithms of NMPHIs. Surgery timing and method as well as anticonvulsant and antibiotic therapy still remain debatable. The only review concentrating on pediatric populations dates back to 1994, based on patient outcome studies from the 1980s. In our review, treatment steps were similar among various institutions and resembled recently suggested algorithms, with better treatment outcomes than originally reported 30 years ago. [ABSTRACT FROM AUTHOR]

Abstract: FV is primarily produced in the liver, and congenital FV deficiency is a disorder with an incidence of one in 1 million. Standard care is to treat severe bleeding phenotypes with FFP as there is no recombinant or plasma‐derived FV concentrate. We present a case of a neonate with known severe FV deficiency diagnosed after prolonged bleeding after circumcision who represented at age 2 months with a large left intraparenchymal hemorrhage. His bleed was treated with FFP, platelet transfusion, recombinant VIIa, and emergent evacuation. He was maintained on plasma infusions but was unable to space his infusions beyond 48 hours. Liver transplantation was considered as a definitive treatment for this condition. While awaiting a suitable liver, his FV trough levels occasionally dropped below 5%, and he suffered from a second acute intracranial bleed. He received an orthotopic liver transplant at age 5 months, resulting in correction of his FV levels. He has not required any plasma infusions post‐transplantation and has had no further bleeding episodes. Liver transplantation should be considered as definitive treatment early in the course for patients with severe FV deficiency and first time life‐threatening bleed. [ABSTRACT FROM AUTHOR]

Abstract: The care and the management of the healing of difficult wounds at the level of the skull‐facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial‐facial‐cervical region. We studied 16 patients with complex wounds of the cranial‐facial‐cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological‐reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1–5). Depression values were always between −75 and −125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum‐assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48–72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature. [ABSTRACT FROM AUTHOR]

Head injury is one of the most important regional injuries known to human beings since time immemorial. Head injury is a morbid state, resulting from gross or subtle structural changes in the scalp, skull and or the contents of the skull, produced by mechanical forces. Vehicular accident can be defined as, 'An event that occurs on a way or street open to public traffic; resulting in one or more persons being injured or killed, where at least one moving vehicle is involved. They involve high human suffering and socioeconomic costs in terms of premature deaths, injuries, loss of productivity, and so on. [ABSTRACT FROM AUTHOR]

Aim: In plastic surgery practice, restoration of the three-dimensional structure of calvarial skeleton also serves as a framework for soft tissue reconstruction. MatriDerm® is a three-dimensional matrix scaffold of collagen and elastin that mimics the most represented organic polymer of bone matrix. Epidermal Growth Factor (EGF) was shown to affect the osteogenic potential of rat calvaria and to stimulate bone resorption in cultured fetal rat long bone shafts. The aim of this study was to investigate the effect of MatriDerm® and EGF treatment on critical sized calvarial defect which can not be healed spontaneously. Method: Twenty-one rats were assigned to one of the following groups (n = 7 each group): sham-operated control, Matriderm, and Matriderm+EGF group. Atomic absorption spectrometry was used to determine the amount of calcium, the scanning electron microscopy was used to show the bone tissue and immunohistochemistry was used to assess trabecular bone formation, osteoblastic density, and osteopontin. Results / Discussion: Inflamation, new bone formation, resorption and osteocyte scores, osteoblastic density, osteopontin staining scores and the mean calcium accumulation did not indicate any statistical difference between the experimental and control groups histopathologically (p<0.05). EGF-like ligands, among other types of molecules are well-known potent mitogens osteoprogenitors, and they exert their activity through EGFR In transgenic (deletion of the EGFR genomic locus) and pharmacologic (inhibition of EGFR in wild-type phenotype) mouse models, Zhang et al. indicated an anabolic role of EGFR signaling in bone metabolism. Conclusion: It is thought that in critical sized calvarial defect application of EGF has a negative effect on bone healing, contrary to popular belief. [ABSTRACT FROM AUTHOR]

Suicide by power saws (bland, chain, circular or router saw) are an extreme exception. A few case reports are published in forensic literature regarding it. We report the case of a 30-year-old carpenter found dead lying on the floor next to a router saw in his carpenter workshop, with two gaping and deep wounds in his head. We summarize the findings of the death scene examination, the forensic autopsy, and the world literature concerning suicide committed with power saws.

Study Design: A retrospective database review.Objective: The aim of this study was to examine whether patient characteristics, distribution of care, and patient outcomes for spinal cord injury (SCI) in the United States have changed between 2001 and 2012.Summary Of Background Data: Although patient outcomes after cranial injury are better at high-volume centers with specialized, multidisciplinary teams, similar assessments have not been done for spinal injuries.Methods: We retrospectively reviewed the National and Nationwide Inpatient Samples for the years 2001, 2002, 2011, and 2012 to identify patients with spinal fracture with or without SCI. The demographic characteristics of the patient cohort, clinical course, hospital characteristics, interhospital transfer, and disposition were statistically analyzed relative to patient mortality, total hospital costs, and length of stay. How these data changed over this 11-year period was also evaluated.Results: A total of 159,875 cases were identified, with 141,737 fractures without SCI and 18,138 SCIs with or without fracture. There was a statistically significant decrease in the percentage of patients transferred with spine injury from 4.2% to 3.4% (P < 0.001) from the early years to the later years and in patient transfers for SCIs (8.1% vs. 6.5%, P < 0.001). Interestingly, the overall mortality rate (3.5% vs. 3.6%) remained unchanged (P = 0.679), but mortality from SCI increased (6.6-7.4%, P = 0.021).Conclusion: From 2002 to 2012, the rate of interhospital transfer of spinal injury patients declined, while the mortality rate for patients with SCI increased. Interestingly, there was an increase in transfers after spinal surgery at the index hospital. The decentralization of spine care may be responsible for the increase in mortality.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Introduction: Penetrating lesions by pencil in the temporal lobe in children and adolescents are uncommon. We present the case of a teenager with penetrating injury by strange object in the temporal lobe. Case: Twelve years old male patient, with history of trauma while he was playing with his friends, presents alteration of the consciousness state, weakness in right hemibody and dysphasia. Urgent surgery is practiced employing an incision in "C" form with improvement of the consciousness state during post-operative. Discussion: Penetrating lesions in the skull and brain are classified as missiles and non-missiles depending of their impact velocity. The wood is a porous organic material that provide a natural deposit of microbian agents, making it potentially lethal. Pre-operative radiological evaluation allows check the trajectory of the penetrating object and secondary lesions present guiding de neurosurgical approach. The prognostic depends on penetration site, timely handling and complications associated. Conclusion: Penetrating lesions by pencil are uncommon, an appropriate imaging evaluation is fundamental to determine the neurosurgical approach that allows prevent and/or decrease secondary damage. [ABSTRACT FROM AUTHOR]

Objective Functional endonasal sinus surgery (FESS) is widely practiced and is considered a generally safe procedure. Skull base injuries occur in <1% of procedures and are typically associated with cerebrospinal fluid leaks. Rarely, skull base injuries might result in cerebral lesions. Here we present a series of 4 patients with iatrogenic perforating injuries of the anterior skull base and cerebral lesions after routine FESS. Methods Four patients with iatrogenic perforating cerebral lesions after routine FESS, performed at other institutions, were referred to a tertiary neurosurgery department. Within a 10-year period these procedures were performed in 3 patients as endoscopic FESS and as a microscopic FESS in 1 patient. Results There were 3 men and 1 woman. Mean age at the time of surgery was 50 years. In 3 instances (in which an endoscope was used), the ear, nose, and throat physician had noted perforation of the skull base during surgery, but it went unnoticed in 1 patient operated with the microscope. Frontal lobe hematoma occurred in all patients, and in 3 of them cerebral infarction developed secondary to injury of branches of the anterior cerebral artery. Three patients developed acute hydrocephalus. Two had rapid global brain swelling and they succumbed within days. The other 2 patients survived without apparent neurological deficits. Conclusions Cerebral lesions during FESS still occur in contemporary surgery and they are possibly underreported. Even with prompt conservative and surgical measures, these lesions may result in catastrophic outcome. Associated vascular injuries have a worse prognosis. The only risk factor associated with lethal outcome in our series was younger age. [ABSTRACT FROM AUTHOR]

A human skull was discovered at the 16th-century drainage channel of market district ruins, one of the busiest streets in the capital of Joseon kingdom. By anthropological examination, we noticed the cut mark at the right occipital part of the cranium. Judging from the wound property, it might have been caused by a strong strike using a sharp-edged weapon. As no periosteal reaction or healing signs were observed at the cut mark, he might have died shortly after the skull wound was made. We speculated that this might have been of a civilian or soldier victim who died in a battle or the decapitated head of prisoner. This is the first report about the discovery of the skull damaged by sharp-edged weapon at the archaeological sites in the capital city of Joseon Kingdom. [ABSTRACT FROM AUTHOR]

In addition to the natural turnover during life, the bones in the skeleton possess the ability to self-repair in response to injury or disease-related bone loss. Based on studies of bone defect models, both processes are largely supported by resident stem cells. In the long bones, the source of skeletal stem cells has been widely investigated over the years, where the major stem cell population is thought to reside in the perivascular niche of the bone marrow. In contrast, we have very limited knowledge about the stem cells contributing to the repair of calvarial bones. In fact, until recently, the presence of specific stem cells in adult craniofacial bones was uncertain. These flat bones are mainly formed via intramembranous rather than endochondral ossification and thus contain minimal bone marrow space. It has been previously proposed that the overlying periosteum and underlying dura mater provide osteoprogenitors for calvarial bone repair. Nonetheless, recent studies have identified a major stem cell population within the suture mesenchyme with multiple differentiation abilities and intrinsic reparative potential. Here we provide an updated review of calvarial stem cells and potential mechanisms of regulation in the context of skull injury repair. [ABSTRACT FROM AUTHOR]

Suicides committed by intraorally placed firecrackers are rare events. Given to the use of more powerful components such as flash powder recently, some firecrackers may cause massive life-threatening injuries in case of such misuse. Innocuous black powder firecrackers are subject to national explosives legislation and only have the potential to cause harmless injuries restricted to the soft tissue. We here report two cases of suicide committed by an intraoral placement of firecrackers, resulting in similar patterns of skull injury. As it was first unknown whether black powder firecrackers can potentially cause serious skull injury, we compared the potential of destruction using black powder and flash powder firecrackers in a standardized skull simulant model (Synbone, Malans, Switzerland). This was the first experiment to date simulating the impacts resulting from an intraoral burst in a skull simulant model. The intraoral burst of a 'D-Böller' (an example of one of the most powerful black powder firecrackers in Germany) did not lead to any injuries of the osseous skull. In contrast, the 'La Bomba' (an example of the weakest known flash powder firecrackers) caused complex fractures of both the viscero- and neurocranium. The results obtained from this experimental study indicate that black powder firecrackers are less likely to cause severe injuries as a consequence of intraoral explosions, whereas flash powder-based crackers may lead to massive life-threatening craniofacial destructions and potentially death. [ABSTRACT FROM AUTHOR]

Objectives This study aims to identify the patterns and prevalence of violence-related skull trauma (including the cranium and mandible) among a large sample of skeletons from medieval London (1050-1550 AD). Materials and Methods In total, data from 399 skulls, representing six different sites from across medieval London, were analyzed for evidence of trauma and assessed for the likelihood that it was caused by violence. The sites include the three parish cemeteries of St Nicholas Shambles (GPO75), St Lawrence Jewry (GYE92), and St Benet Sherehog (ONE94); the two monastic houses of London Blackfriars (PIC87) and St Mary Graces (MIN86); and the early inmate cemetery from the medieval hospital of St Mary Spital (NRT85). Results The overall findings suggest that violence affected all aspects of medieval London society, but how that violence was characterized largely depended on sex and burial location. Specifically, males from the lay cemeteries appear to have been the demographic most affected by violence-related skull injuries, particularly blunt force trauma to the cranial vault. Discussion Using both archaeological and historical evidence, the results suggest that violence in medieval London may have been more prevalent than in other parts of medieval England, particularly rural environments, but similar to other parts of medieval Europe. However, more studies focusing on medieval trauma, and violence specifically, need to be carried out to further strengthen these results. In particular, males from the lay cemeteries were disproportionately affected by violence-related trauma, especially blunt force trauma. It perhaps indicates a means of informal conflict resolution as those of lower status did not always have the newly established medieval legal system available to them. [ABSTRACT FROM AUTHOR]

The presence of regional variation in the osteogenic abilities of cranial bones underscores the fact that the mechanobiology of the mammalian skull is more complex than previously recognized. However, the relationship between patterns of cranial bone formation and biomineralization remains incompletely understood. In four strains of mice, micro-computed tomography was used to measure tissue mineral density during perinatal development in three skull regions (calvarium, basicranium, mandible) noted for variation in loading environment, embryological origin, and ossification mode. Biomineralization levels increased during perinatal ontogeny in the mandible and calvarium, but did not increase in the basicranium. Tissue mineral density levels also varied intracranially, with density in the mandible being highest, in the basicranium intermediate, and in the calvarium lowest. Perinatal increases in, and elevated levels of, mandibular biomineralization appear related to the impending postweaning need to resist elevated masticatory stresses. Similarly, perinatal increases in calvarial biomineralization may be linked to ongoing brain expansion, which is known to stimulate sutural bone formation in this region. The lack of perinatal increase in basicranial biomineralization could be a result of earlier developmental maturity in the cranial base relative to other skull regions due to its role in supporting the brain’s mass throughout ontogeny. These results suggest that biomineralization levels and age-related trajectories throughout the skull are influenced by the functional environment and ontogenetic processes affecting each region, e.g., onset of masticatory loads in the mandible, whereas variation in embryology and ossification mode may only have secondary effects on patterns of biomineralization. Knowledge of perinatal variation in tissue mineral density, and of normal cranial bone formation early in development, may benefit clinical therapies aiming to correct developmental defects and traumatic injuries in the skull, and more generally characterize loading environments and skeletal adaptations in mammals by highlighting the need for multi-level analyses for evaluating functional performance of cranial bone. [ABSTRACT FROM AUTHOR]

Isolated penetrating head injury in children is rare and is usually accidental. Each case is unique since the penetrating object and the trajectory through the brain parenchyma vary greatly among patients. We present a three-year-old girl who presented with a kitchen utility knife penetrating her left midface, skull, and brain abutting the anterior cerebral vasculature. Though the patient initially presented to a local trauma center, there were no pediatric nor vascular neurosurgeons on staff. Thus, she was transferred to our tertiary facility for definitive surgical management. A pediatric and vascular neurosurgeon worked together to remove the knife safely and the underlying vasculature remained intact. Postoperatively, the patient did well and was neurologically intact. Though penetrating cranial injury is rare in the pediatric population, such complex cases of brain injury can be properly managed with good outcome by an interdisciplinary team of specialists in tertiary care centers and can result in an excellent surgical and functional outcome for the patient. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyze the variability in the shape and number of supraorbital transcranial passages, supraorbital notch or foramen (SON/F) in southeast Serbian population using three-dimensional computer tomography (3D-CT) with the volume rendering and to evaluate these variations in relation to gender and side. One hundred and fifteen CT scans of adult subjects (59 men and 56 women) without any skull trauma or malformation, aged 21 to 83 years, were analyzed in our study. Of 230 supraorbital regions, a smooth supraorbital rim with absent SON/F was observed in 37.39%. The most common type of the supraorbital passage was single SON (53.48%). Single SOF was found in 5.22% and incomplete SOF in 0.44%. The frequency of double SON was 1.30%, double SOF 0.87% and SON with SOF on the same side was 1.30%. There was no statistically significant difference between genders and sides (p>0.05). Fourteen various combinations of different types were observed in our material. The most common combination was bilateral SON (33.91%) and bilateral absence of SON/F (20.87%). A very frequent combination was SON on one side and the absence of SON/F on the contralateral side (32.17%). Other combinations of types were rare. The knowledge of the frequency of the types of supraorbital transcranial passages and their bilateral distribution may be helpful for clinicians in anticipating the exit point of the supraorbital neurovascular bundle during surgical procedures and planning of local anesthesia. [ABSTRACT FROM AUTHOR]

This paper reviews and discusses cases of skull trepanation in ancient Italy on the basis of information provided by the literature. A total of 54 individuals from 43 different Italian archaeological sites were found to have evidence of trepanation. The analysis of evidences of trepanation in Italy has demonstrated that no differences can generally be perceived between the trepanned individual and the social context of the burial, leading to exclude a special role of the former within the group. Trepanation in Italy covers a time span of approximately 7000 years, the most ancient cases dating back to the fifth millennium bc and the most recent to the 18th-19th centuries ad. The geographic distribution appears quite homogeneous, with a prevalence of cases in Central Italy and abundant evidence from prehistoric Sardinia. The majority of individuals show a single trepanation, whereas others present skulls with multiple holes. Trepanation in Italy was reserved to adult individuals, except for some rare cases, and shows a relevant preponderance for the male sex. The most diffused technique is scraping; cutting and drilling are less attested, especially as unique techniques for trepanation, but they were used more frequently in combination with scraping. Trepanation could in some cases be hypothesised as therapeutic intervention for the treatment of a traumatic wound or of other pathologies, whereas in other cases, a number of evidences are attested of trepanation performed as probable ritual intervention or as experimental surgery; in the remaining cases, the reasons for trepanation are unclear or not determinable. A high percentage of long-term healing associated with trepanation has been evidenced. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: To present an overview of varied clinical presentations, investigations and treatment options for Osteolytic skull lesions. Study Design: It is a prospective study. Materials and Methods: We conducted this study from January 2013 to December 2015 in the Department of Neurosurgery, Nil Ratan Sircar Medical College and Hospital, Kolkata. During this period, 14 patients presented with osteolytic skull lesions through the outpatient department. All patients were thoroughly investigated with appropriate hematological and radiological investigations and treated following admission, and surgery was performed in the Neurosurgery Department. All were followed regularly in OPD. Results: Total 14 patients were included in the study. Amongst these 7 were male and 7 female. Age group of patients ranged from 5 to 72 years. Of 14 cases, three cases had dermoid cyst, four cases had metastasis, and one each case had epidermoid cyst, intradiploic meningioma, benign cystic lesion, tuberculosis, histiocytosis X, hemangioma, and osteomyelitis. All underwent diagnostic/therapeutic procedures and referred for Radio or chemotherapy where indicated. Conclusion: All scalp/skull lesions need careful clinical correlation, appropriate radiological investigations to establish diagnosis and subject them to suitable treatment. [ABSTRACT FROM AUTHOR]

Head injury in childhood is the single most common cause of death or permanent disability from injury. However, despite its frequency and significance, there is little understanding of the response of a child's head to injurious loading. This is a significant limitation when making early diagnoses, informing clinical and/or forensic management or injury prevention strategies. With respect to impact vulnerability, current understanding is predominantly based on a few post-mortem-human-surrogate (PMHS) experiments. Researchers, out of experimental necessity, typically derive acceleration data, currently an established measure for head impact vulnerability, by calculation. Impact force is divided by the head mass, to produce a "global approximation", a single-generalised head response acceleration value. A need exists for a new experimental methodology, which can provide specific regional or localised response data. A surrogate infant head, was created from high resolution computer tomography scans with properties closely matched to tissue response data and validated against PMHS head impact acceleration data. The skull was 3D-printed from co-polymer materials. The brain, represented as a lumped mass, comprised of an injected gelatin/water mix. High-Speed Digital-Image-Correlation optically measured linear and angular velocities and accelerations, strains and strain rates. The "global approximation" was challenged by comparison with regional and local acceleration data. During impacts, perpendicular (at 90°) to a surface, regional and local accelerations were up to three times greater than the concomitant "global" accelerations. Differential acceleration patterns were very sensitive to impact location. Suture and fontanelle regions demonstrated ten times more strain (103%/s) than bone, resulting in skull deformations similar in magnitude to those observed during child birth, but at much higher rates. Surprisingly, perpendicular impacts produced significantly greater rotational velocities and accelerations, which are closer to current published injury thresholds than expected, seemingly as a result of deformational changes to the complex skull geometry. The methodology has proven a significant new step in characterising and understanding infant head injury mechanics. [ABSTRACT FROM AUTHOR]