Vincent J. Miele

NEUROLOGICAL INJURY AND DEATH IN ALL-TERRAIN VEHICLE CRASHES IN WEST VIRGINIA: A 10-YEAR RETROSPECTIVE REVIEW

OBJECTIVEThe purpose of this study was to profile all-terrain vehicle crash victims with neurological injuries who were treated at a Level I trauma center. METHODSWe retrospectively reviewed trauma registry data for 238 patients who were admitted to the Jon Michael Moore Trauma Center at the West Virginia University School of Medicine after all-terrain vehicle crashes, between January 1991 and December 2000. Age, helmet status, alcohol and drug use, head injuries, length of stay, disposition, and hospital costs were studied. Death rates, head injuries, age, helmet use, and safety legislation in all 50 states were compared. RESULTSEighty percent of victims were male, with an average age of 27.3 years. Only 22% of all patients were wearing helmets. Alcohol and/or drugs were involved in almost one-half of all incidents. Fifty-five of 238 patients sustained spinal axis injuries; only 5 were wearing helmets. One-third of victims (75 of 238 victims) were in the pediatric population, and only 21% were wearing helmets. Only 15% of victims less than 16 years of age were wearing helmets. There were a total of eight deaths; only one patient was wearing a helmet. CONCLUSIONIn the United States, all-terrain vehicles caused an estimated 240 deaths/yr between 1990 and 1994, which increased to 357 deaths/yr between 1995 and 2000. Brain and spine injuries occurred in 80% of fatal crashes. West Virginia has a fatality rate approximately eight times the national rate. Helmets reduce the risk of head injury by 64%, but only 21 states have helmet laws. Juvenile passengers on adult-driven vehicles are infrequently helmeted (<20%) and frequently injured (>65%). We conclude that safety legislation would save lives.

Subaxial positional vertebral artery occlusion corrected by decompression and fusion.

Study Design. A rare case of subaxial vertebral artery (VA) positional occlusion is reviewed and treatment methods discussed. Objective. The decision process involved in treating subaxial VA positional occlusion is reviewed. Summary of Background Data. Bow Hunter stroke is a symptomatic vertebrobasilar insufficiency caused by stenosis or occlusion of the VA with physiologic head rotation. It most commonly occurs at the junction of C1 and C2 and less commonly as the VA enters the C6 transverse foramen. Rotational stenosis of the VA is quite rare during its passage through the foramen transversarium of C3–C6. Methods. A 48-year-old gentleman presented describing syncopal episodes when he turns his head to the left side. Imaging revealed a congenitally narrowed right foramen transversarium and high-grade stenosis of the left VA when the head was turned to the left. A routine anterior cervical discectomy and fusion was performed with the addition of decompression of the left transverse foramen. Results. Vascular imaging should be performed with the patient’s head in both the neutral position and in the symptomatic position. Surgical treatment may be chosen if conservative therapies fail and generally has 1 of 2 goals—decompression of the VA or elimination of rotational movement at the affected level. Decisions between anterior and posterior decompressions may be influenced by the surgeon’s comfort level with the approach and if the transverse foramen stenosis is caused mainly by an anterior (osteophytes at the uncinate process) or posterior (facet joint hypertrophy) process. The patient remains symptom-free after treatment. Conclusion. This report demonstrates the condition in the subaxial spine and describes successful treatment by fusion of the affected level combined with decompression of the foramen transversarium—a combination of previously described therapies.

Objectifying when to halt a boxing match: a video analysis of fatalities.

OBJECTIVEAlthough numerous prestigious medical organizations have called for its abolishment, participation in the sport of boxing has reached an all-time high among both men and women, and its elimination is unlikely in the near future. Physicians should strive to increase boxing safety by improving the rules of competition, which have evolved minimally over the past two centuries. Currently, subjective criteria are used to determine whether or not a contest should be halted. Developing a standardized, objective method of determining when a contest should be halted would be a significant paradigm shift and could increase the safety of the sports participants. This study analyzed the number and types of punches landed in a typical professional match, in bouts considered to be competitive and in those that ended in fatalities, to determine whether or not this would be a practical method of differentiating between these groups. METHODSThree groups of professional boxing matches were defined at the beginning of the study: 1) a “fatal” group, consisting of bouts that resulted in the death of a participant; 2) a “classic” group that represented competitive matches; and 3) a “control” group of 4000 professional boxing matches representing the average bout. A computer program known as Punchstat (Compubox, Inc., Manorville, NY) was used in the objective analysis of these matches via videotape playback. RESULTSSeveral statistically significant differences were discovered between matches that resulted in fatalities and the control group. These include the number of punches landed per round, the number of power punches landed per round, and the number of power punches thrown per round by losing boxers. However, when the fatal bouts were compared with the most competitive bouts, these differences were no longer evident. CONCLUSIONBased on the data analyzed between the control and fatal-bout groups, a computerized method of counting landed blows at ringside could provide sufficient data to stop matches that might result in fatalities. However, such a process would become less effective as matches become more competitive, and implementing such a change would significantly decrease the competitive nature of the sport. Therefore, other methods of quantifying acceleration–deceleration brain injuries are necessary to improve the safety of boxing.

Globus hystericus: a brief review.

Globus hystericus, a form of conversion disorder, is characterized by an uncomfortable sensation of a mass in the esophagus or airway. Evaluation proves no mass exists. Anxiety or psychological conflict is judged to be significantly related to the onset and progression of the sensation. The sensation may lead to difficulty swallowing or breathing and may become severe or life threatening. The disorder is poorly studied and understood. The differential diagnosis is vast. Management of the disorder is similar to that suggested for other conversion disorders. This article reviews the current literature about diagnosis, etiology, treatment, and prognosis of globus hystericus.

Ventriculoperitoneal shunt dysfunction in adults secondary to conditions causing a transient increase in intra-abdominal pressure: report of three cases.

OBJECTIVE AND IMPORTANCE:Ventriculoperitoneal (VP) shunts function because of the pressure differential between the intracranial space and the peritoneal cavity. The pressure in the peritoneal cavity is the lower of the two in a properly functioning shunt; thus, cerebrospinal fluid flows distally. Although not reported in the literature, adult constipation, ileus, or small bowel obstruction can alter this pressure balance and cause dysfunction. If not recognized as a transient, easily treated phenomenon, patients may be subjected to unnecessary shunt revisions. This study analyzed the occurrence of shunt malfunction in three adults secondary to transient increases in intra-abdominal pressure. CLINICAL PRESENTATION:Three patients with clinical symptoms and radiographic evidence of VP shunt malfunction at presentation were found to have transient conditions causing a significant increase in intra-abdominal pressure. These patients’ records were evaluated with an emphasis on risk factors, treatments, and outcomes. INTERVENTION:After resolution of the patients’ abdominal issues, clinical signs and symptoms of VP shunt dysfunction resolved within 24 hours. Radiographic evidence of the resolution of shunt failure also was observed. CONCLUSION:Shunt malfunction or dysfunction consumes many person-hours and healthcare dollars. This study provides anecdotal evidence that transient and easily reversible increases in the intra-abdominal pressure of adults with VP shunts can result in dysfunction. Although it may not be practical to delay shunt revision while attempting to correct constipation, ileus, or small bowel obstruction, clinicians treating patients with these abdominal conditions should be aware that they could cause transient VP shunt failure. It would seem prudent that patients with VP shunts be started on a prophylactic bowel regimen before surgical procedures to decrease the risk of this somewhat preventable result.

Unruptured aneurysm of the middle cerebral artery presenting with psychomotor seizures: case study and review of the literature.

An intracranial aneurysm would be low on the differential diagnosis of a patient presenting with behavioral or emotional changes. Nonetheless, complex partial seizures (CPS) may cause such symptoms and result from an unruptured intracranial aneurysm. Failure to diagnose and treat this condition in a timely manner increases the patients risk of catastrophic aneurysmal rupture. This report describes a 55-year-old woman who presented following two CPS which began with the perception of a strange smell and culminated in a brief loss of consciousness. She had no history of seizure disorder or recent trauma. Magnetic resonance imaging (MRI) revealed a space-occupying lesion over the right temporal lobe near the amygdala. Magnetic resonance angiography (MRA) confirmed a 1.5-cm right middle cerebral artery aneurysm, with a dome projecting toward the amygdalohippocampal region. Following surgical ablation, the patients CPS were well controlled. A review of the literature is performed on this unusual etiology and management strategies are discussed.

Editorial: Leather football helmets

At the request of the editor we are providing this editorial to Rowson et al.’s “Biomechanical performance of leather and modern football helmets. Technical note.”5 In their paper, Rowson et al. have attempted to provide additional data and insight to clarify certain conclusions reported in an earlier American football helmet study by Bartsch et al.1 In the real world, American football collisions always involve combinations of linear and rotational motion that may pose risk to the participant’s short-term and longterm brain health. When Rowson et al.’s rigid drop tests are contrasted with Bartsch et al.’s common “on-field” laboratory impacts, it is of utmost importance to consider the testing methodologies and head motions induced. Rowson et al. drop-tested helmets against a rigid surface with infinite mass and stiffness under standard conditions.4 These standard drop tests allowed mainly linear head motion and benchmarked skull fracture risk. Their data showed that modern helmets, which are designed to perform under these standardized testing conditions, performed significantly better than leather helmets. A realworld analogy to these results is that one’s skull would be significantly better protected when running headfirst into a brick wall while wearing a modern American football helmet versus a vintage leather helmet. In contrast, Bartsch et al. tested a helmeted head form striking a second helmeted head form that was mounted on a flexible neck, permitting linear and rotational head motion. These laboratory tests represented an approximation of two players colliding headfirst while wearing modern and vintage helmets under common on-field conditions that could induce skull, brain, and neck loading. Bartsch et al.’s data demonstrated that in these common on-field impact scenarios, modern and vintage leather helmets frequently protected the skull and brain comparably. The two studies used disparate methodologies, examined different injury risk metrics, and hence produced divergent results. Therefore, Rowson et al.’s additional data do not clarify the limitations of, but rather stand in contrast to, the data presented in Bartsch et al.’s study. Rowson et al. are correct in recharacterizing the conclusions of Bartsch et al.’s experiments by stating “leather helmets performed similarly to modern helmets when struck by a Riddell VSR4 helmet....” However, even with this recharacterization, the resulting differences between the studies reported by Rowson et al. and by Bartsch et al. provide ample motivation to reassess the rigid drop test standard. These differences also suggest the need to continue physics-based helmet performance investigations under on-field conditions that induce linear and rotational head motion. Furthermore, Rowson et al. as well as others have recently published on-field impact data2,3,6 validating the fact that Bartsch et al.’s “on-field” laboratory impact conditions generated linear and rotational head motions similar to those commonly occurring in the real world. It is emphasized that these common linear and rotational real-world head motions have now been conclusively proven to be markedly different from Rowson et al.’s drop test head motions. We now have two studies—by Rowson et al. and by Bartsch et al.—that provide dissimilar results in spite of apparent similarities in head forms, helmets, impact energy, and impact momenta. The difference in results can be conclusively explained by the two very different testing methodologies used and the head motions induced. We also can conclude that not all impact tests are created equal. Therefore, we must continue examining experimental protocols to achieve better quantification of helmet performance under conditions in which on-field physics testing methodologies and relevant injury risk metrics are considered. (http://thejns.org/doi/abs/10.3171/2012.12.JNS122174)