The Mount Sinai journal of medicine, New York
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In this article, the neuroradiological evaluation of traumatic brain injury is reviewed. Different imaging strategies in the assessment of traumatic brain injury are initially discussed, and this is followed by a review of the imaging characteristics of both primary and secondary brain injuries. Computed tomography remains the modality of choice for the initial assessment of acute head injury because it is fast, widely available, and highly accurate in the detection of skull fractures and acute intracranial hemorrhage. ⋯ Mild traumatic brain injury continues to be difficult to diagnose with current imaging technology. Advanced magnetic resonance techniques, such as diffusion-weighted imaging, magnetic resonance spectroscopy, and magnetization transfer imaging, can improve the identification of traumatic brain injury, especially in the case of mild traumatic brain injury. Further research is needed for other advanced imaging methods such as magnetic source imaging, single photon emission tomography, and positron emission tomography.
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Mild traumatic brain injury accounts for 1% to 2% of emergency department visits in the United States. Up to 15% of these patients will have an acute intracranial lesion identified on head computed tomography; less than 1% of mild traumatic brain injuries will require neurosurgical intervention. Clinical research over the past decade has focused on identifying the subgroup of patients with mild traumatic brain injury with acute traumatic lesions on computed tomography and specifically those at risk for harboring a potentially catastrophic lesion. ⋯ The utility of brain-specific biomarkers is rapidly evolving, and a growing body of evidence supports their potential role in determining the need for neuroimaging. Clinical predictors for identifying patients with abnormal computed tomography have been established and, if used, may have a significant positive impact on traumatic brain injury-related morbidity and healthcare utilization in the United States. Patients with negative computed tomography are at almost no risk of deteriorating; however, they should be counseled regarding postconcussive symptoms and should be given appropriate written instructions and referrals at discharge.
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Traumatic brain injury is a significant cause of morbidity and mortality. The prehospital care of the patient with a traumatic brain injury is critical to maximizing the chances for a good outcome. Prehospital management of the traumatic brain injury patient is directed toward preventing and limiting secondary brain injury while facilitating rapid transport to an appropriate facility capable of providing definitive neurocritical care. ⋯ Treatment strategies are directed toward maintaining adequate oxygenation and perfusion and treating herniation. Judicious use of temporary hyperventilation and hypertonic saline are considerations. This review provides the most recent evidence regarding the treatment of traumatic brain injury in the prehospital setting and introduces areas in need of future research.
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Severe traumatic brain injury is one of the leading causes of death and disability in the United States. The initial management of traumatic brain injury involves early resuscitation, computed tomography scanning, and surgical evacuation of mass lesions, when indicated. Recent research suggests that the prevention and treatment of secondary brain injury decrease mortality and improve outcomes. ⋯ To achieve the best outcomes, attention must be focused on optimizing blood pressure and brain tissue oxygenation, maintaining adequate cerebral perfusion pressures, and preventing seizures. In addition, maximizing good outcomes depends on proactively addressing the risk of common sequelae of brain injury, including infection, deep venous thrombosis, and inadequate nutrition. Guidelines developed for the management of severe traumatic brain injury have dramatically improved functional neurological outcomes.
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Traumatic brain injury is a major source of death and disability worldwide. Significant success has been achieved in improving short-term outcomes in severe traumatic brain injury victims; however, there are still great limitations in our ability to return severe traumatic brain injury victims to high levels of functioning. ⋯ These secondary injuries from traumatic brain injury lead to alterations in cell function and propagation of injury through processes such as depolarization, excitotoxicity, disruption of calcium homeostasis, free-radical generation, blood-brain barrier disruption, ischemic injury, edema formation, and intracranial hypertension. The best hope for improving outcome in traumatic brain injury patients is a better understanding of these processes and the development of therapies that can limit secondary brain injury.