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.
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ABSTRACT: travmalar›nda diffüz akson zarar›, tan›da ß-APP'nin yeri. Adli T›p Bülteni 2008;13(1):30-39 Farkl› derecelerde kafa travmas› geçirmifl olan kiflilerde ölü-mün ya da uzam›fl nörolojik defisitlerin en önemli nedenlerin-den biri diffüz akson zarar›d›r (DAZ). Otopsi olgular›nda DAZ'›n tan›s› beynin uygun bölgelerinden al›nacak örneklerde Hematoksilen Eozin ile boyanm›fl kesitlerin mikroskopik ince-lenmesi ile mümkündür. Ancak, posttravmatik dönemde çok k›sa süre yaflam›fl olan olgularda zarar›n morfolojik bulgular› tam oluflmad›¤›ndan bu olgularda DAZ'›n tan›nmas› zordur. ß-APP bu tür olgularda DAZ'›n tan›nabilmesinde önemli rol oynamaktad›r. Canl› iken gerçekleflmifl olan zarar› yans›tmas›, sadece zarar görmüfl aksonlar› iflaretlemesi ve postmortem in-tervalden etkilenmemesi en önemli üstünlükleridir. Çal›flma-n›n amac›, DAZ'›n olufl mekanizmas› ile morfolojik bulgular›-n› gözden geçirmek, kafa travmas› geçirmifl olgular›n de¤erlen-dirilmesinde ß-APP'nin rolü ve önemini vurgulamakt›r. Anahtar kelimeler: Travma, beyin, diffüz akson zarar›, ß-APP SUMMARY One of the most significant reasons of death or extended ne-urological deficits in the persons suffering head trauma of dif-fering levels is the diffuse axonal damage (DAD). In autopsy ca-ses, DAD diagnosis could be possible on the samples to be ta-ken from suitable parts of the brain, by microscopic examina-tion of the sections stained with Hematoxyline Eosin. But, in the posttraumatic period, in the cases who lived for a very short time, since the morphological findings of the damage has not fully formed, it is difficult to diagnose DAD. ß-APP plays an important role in such cases for diagnosing DAD. Its most evident superiorities are its reflection of the loss which took place while alive, it marks only damaged axons and it is not inf-luenced by the postmortem interval. The aim of this study is to review the morphological findings associated with mecha-nism of development of DAD, to stress the importance and ro-le of ß-APP in the evaluation of the cases with a history of he-ad trauma. G‹R‹fi Adli travmatolojinin önemli bafll›klar›ndan biri kafa travmalar›d›r. Kafa travmalar› ister kazalara, ister vücut dokunulmazl›¤›na yönelik sald›r›lara ba¤l› olsun s›kl›kla ciddi yaralanma ve ölüme yol açan ve adli nitelik tafl›yan olgulard›r (1). Ço¤u olguda kafa travmalar› sonras›nda klini¤in bozulmas› özellikle de ani koma tablosunun ge-liflmesi diffüz ya da multifokal beyin zarar›n›n geliflti¤ini iflaret etmektedir (2,3). Olgular›n bir k›sm›nda ölüm ne-deni belirgin iken, baz› olgularda hikaye geçirilmifl kafa travmas›n› desteklemekte ancak, birlikte beynin makros-kopik görünümü normal bulunmaktad›r (4,5). Böyle bir durumda öncelikle düflünülmesi gereken patolojik 1 Adli T›p Kurumu, Morg ‹htisas Dairesi, ‹stanbul 2 Marmara Üniversitesi T›p Fakültesi, Patoloji Anabilim Dal›, ‹stanbul
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ABSTRACT: Brainstem haemorrhage is common in cases of head injury when it is associated with space-occupying lesion and increases in the intracranial pressure (duret haemorrhage), in cases of diffuse axonal injury (in dorso-lateral quadrant) and diffuses vascular injury (in the periventricular tissue). However focal traumatic brainstem injury is rare. We identified 12 cases of focal traumatic brainstem injury from review of 319 case of head injury. The head trauma had been caused by different mechanisms of complex fall from height and assault. 10/12 are associated with skull fracture, 11/12 with contre coup contusions in the frontal and temporal lobes, 5/12 direct contusions to cerebellum, 5/12 haemorrhage in corpus callosum and 2/11 have gliding contusions. None of the cases had pathological evidence of increase in the intracranial pressure. The bleeding in the pons was at the edge in 2/12 and cross the section in 10/12. The majority of patients were unconscious immediately after the incident (10/12) and 9/12 died within one day. Focal traumatic brainstem injury occurs most likely due to direct impact at the back of the head or stretching forces affecting the brainstem in cases of complex fall from height and after assault, particularly those associated with kicks. It is a serious and commonly fatal brain damage, which needed to be differentiated from other causes of brainstem haemorrhages.Journal of forensic and legal medicine 04/2012; 19(3):144-51.
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ABSTRACT: ABSTRACT Objective Motorcyclist collisions with fixed objects account for a substantial proportion of fatalities in many countries. Biomechanically valid crash test protocols are required to assess the injury potential of different fixed objects to motorcyclists and/or to develop safety devices that ameliorate this injury risk. The aim of the present paper is to provide field-observed injury data pertaining to motorcyclist head-leading collisions with fixed objects, to assist in the development of crash test protocols. Method The Australian National Coronial Information System was used to identify fatal motorcyclist head-leading collisions with fixed objects. Head and spine injuries were identified from the autopsy reports for these individuals. The head impact locations and injuries were used to infer impact orientations and corresponding injury mechanisms. Results A sample of 44 motorcyclists estimated to have impacted fixed objects in the head-leading orientation were identified. The analysis of autopsy reports indicated a predominance of basilar skull fractures, intracranial injuries to the frontal cerebrum and inferior aspects of the brain (brain stem and cerebellum), and upper cervical spine injuries. Analysis of head impact locations identified a predominance of impacts to the frontal and/or lateral aspects, and when considered in combination with the injury mechanisms, a typical impact orientation of sliding in the prone position with head extension was inferred. Conclusions The study results were used to suggest possible crash test protocols for motorcyclists sliding into fixed objects and/or safety devices designed to reduce the injury risk of fixed objects. The predominant orientation of lying prone with head extension led the authors to suggest a crash test using the motorcycle anthropomorphic test device (MATD) sliding prone. However, the occurrence of the supine orientation, albeit less frequently, indicates the utility of a crash test with an ATD sliding supine. The two options are discussed, particularly with regard to appropriate injury assessment reference values.Traffic injury prevention 05/2014;