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: It is a well-documented fact that pontomedullary lacerations (PML) occur as a result of severe craniocervical injury, but their underlying mechanism has yet to be fully clarified. The aim of this prospective study has been to give greater insight into the underlying mechanism of PML through determining the site of blunt head-impact, as well as the presence of concomitant head and neck injuries in cases of brainstem PML. A total of 56 cases with partial PML have been analysed for this study. The case group was composed of 40 men and 16 women, averaging in age 44.2 ± 19.2 years and consisting of 7 motorcyclists, 4 bicyclists, 18 car occupants, 16 pedestrians, and 10 victims of falls from a height, as well as 1 victim of a fall from standing height. The presented study has shown that there are several possible mechanisms of PML. Impact to the chin, with or without a skull base fracture, most often leads to this fatal injury, due to the impact force transmission either through the jawbone or vertebral column; most likely in combination with a fronto-posterior hyperextension of the head. Additionally, lateral head-impacts with subsequent hinge fractures and PML may also be a possible mechanism. The jawbone and other facial bones are able to act as shock absorbers, and their fracture may diminish the energy transfer towards the skull and protect the brain and brainstem from injury. The upper cervical spine can act as damper and energy absorber as well, and may prevent any occurrence of fracture to the base of the skull.Forensic Science Medicine and Pathology 12/2011; 8(3):237-42. · 2.44 Impact Factor