Pontomedullary tears and other gross brainstem injuries after vehicular accidents.
ABSTRACT In a series of 988 autopsied victims of road crashes, there were 36 (3.6%) cases of gross primary brainstem injury. These fell into three groups. The first comprised eight cases of pontomedullary tearing without other gross brain injury: in seven of these, there were associated atlanto-occipital dislocations and/or high cervical fracture-dislocations. The usual cause appeared to be facial impact inducing acute hyperextension. Second, there were 17 cases of pontomedullary tearing associated with other brainstem lacerations and/or major damage elsewhere in the brain: in all, there were fractures of the skull base, typically transverse middle fossa fractures. Most of these injuries appeared to be due to facial impacts transmitting force to the anterior skull base, although hyperextension was also a factor in some. There was a third heterogeneous group of 11 cases with brainstem lacerations in sites other than the pontomedullary junction: in some of these it appeared that the impacts had caused skull base fractures by inducing calvarial torsion. In this series, the proportion of motorcyclists (41.7%) was double the expected figure. The use of a helmet modifies the mechanisms of impact head injury; the overall benefits of helmet use are well established, but there is need for more research on helmet design.
- Srpski arhiv za celokupno lekarstvo 01/2013; 141(7-8):542-547. DOI:10.2298/SARH1308542Z · 0.17 Impact Factor
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ABSTRACT: L'objectif de cette recherche était d'actualiser et d'affiner les connaissances épidémiologiques sur les usagers de deux-roues motorisés accidentés qui représentent un enjeu majeur de sécurité routière et de santé publique. Les principales bases de données françaises ont été utilisées : les données nationales des forces de l'ordre, les données de l'enquête « Stupéfiants et Accidents Mortels » et celles du Registre des Victimes d'accident du Rhône. Nous avons d'abord dressé le bilan des connaissances épidémiologiques à partir des résultats de la littérature internationale sur les usagers de deux-roues motorisés et leurs accidents, et précisé les besoins en matière de recherches. En terme de sécurité primaire, nous avons étudié un certain nombre de facteurs de risque d'accidents de deux-roues motorisés, et particulièrement la dimension conduite sous l'influence de l'alcool et de stupéfiants. En terme de sécurité secondaire, nous avons présenté la typologie lésionnelle des usagers de deux-roues motorisés accidentés puis étudié les facteurs de gravité. Nous avons completécomplété nos recherches par une analyse spécifique sur l'évaluation de l'efficacité du casque et de ses éventuels effets lésionnels indésirables et terminé par l'étude des mécanismes lésionnels selon le type d'accident et le type de deux-roues motorisé. A la suite de nos travaux, nous avons proposé des recommandations pour prévenir les accidents de deux-roues motorisés et à défaut réduire leur gravité
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ABSTRACT: The sensitivity of plain radiographs for diagnosing traumatic atlanto-occipital dislocation and its association with craniocervical junction subarachnoid hemorrhage was examined in a retrospective review of seven patients. The purpose of this study was to demonstrate the frequency of nondiagnostic plain radiographs and the common association of craniocervical junction subarachnoid hemorrhage in the context of reported cases of atlanto-occipital dislocation to facilitate better recognition of this injury. The use of sagittal reconstructions of computed tomography or sagittal magnetic resonance imaging for diagnosis was evaluated. Although traumatic atlanto-occipital dislocation is a common cause of motor vehicle fatalities, survival has been more common in the last 16 years. However, the diagnosis was missed on lateral cervical radiographs in 38% of children and 59% of adults; fewer than half were diagnosed subsequently with plain radiography. Moreover, the diagnosis of traumatic atlanto-occipital dislocation often was not considered, because more than half of the survivors had no neurologic abnormality or unilateral deficit. Consequently, more than one third of initially undiagnosed patients experienced neurologic deterioration due to inadequate cervical immobilization. Additional radiographic studies allowing diagnosis were prompted by the neurologic worsening. The authors reviewed seven patients treated with traumatic atlanto-occipital dislocation during a 14-year period. Emergency department records were compared with reexamination of initial cervical radiographs to determine the success in diagnosis by means of published methods. The frequency of cranio-cervical junction subarachnoid hemorrhage on computed tomography was determined, and the use of sagittal imaging for subsequent diagnosis was evaluated. In the emergency department, only one patient's condition was diagnosed as atlanto-occipital dislocation. Review of the initial radiographs identified an additional four patients for whom atlanto-occipital dislocation could be diagnosed. Sagittal computed tomography reconstruction or sagittal magnetic resonance imaging identified the remaining two. All but one patient had craniocervical junction subarachnoid hemorrhage. A review of reported cases revealed a common association of craniocervical junction subarachnoid hemorrhage with traumatic atlanto-occipital dislocation but not with traumatic head injury. The diagnosis of traumatic atlanto-occipital dislocation is often missed in the emergency department, and current methods for evaluating the integrity of the atlanto-occipital joint on cervical radiographs fail to identify all patients with this injury. Although infratentorial subarachnoid hemorrhage is uncommon in traumatic head injury, craniocervical junction subarachnoid hemorrhage is often associated with atlanto-occipital dislocation and should raise the suspicion of severe craniocervical ligamentous injury. Sagittal computed tomography reconstructions or sagittal magnetic resonance imaging can allow for the diagnosis when plain radiography is inconclusive.Spine 09/1996; 21(15):1761-8. DOI:10.1097/00007632-199608010-00009 · 2.45 Impact Factor