Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies.

The purpose of this systematic review was to analyze evidence based on existing studies on the ability of initial CT imaging to predict mortality in severe traumatic brain injuries (TBIs) in pediatric patients. An experienced librarian searched for all existing studies based on the inclusion and exclusion criteria. The studies were screened by two blinded reviewers. Of the 3277 studies included in the search, data on prevalence of imaging findings and mortality rate could only be extracted from 22 studies. A few of those studies had patient-specific data relating specific imaging findings to outcome, allowing the data analysis, calculation of the area under the curve (AUC) and receiver operating characteristic (ROC), and generation of a forest plot for each finding. The data were extracted to calculate the sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predicted value (NPV), AUC, and ROC for extradural hematoma (EDH), subdural hematoma (SDH), traumatic subarachnoid hemorrhage (tSAH), skull fractures, and edema. There were a total of 2219 patients, 747 females and 1461 males. Of the total, 564 patients died and 1651 survived; 293 patients had SDH, 76 had EDH, 347 had tSAH, 244 had skull fractures, and 416 had edema. The studies included had high bias and lower grade of evidence. Out of the different CT scan findings, brain edema had the highest SN, PPV, NPV, and AUC. EDH had the highest SP to predict in-hospital mortality.

Sixty-nine million people have a traumatic brain injury (TBI) each year, and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and increased morbidity and mortality. A limited number of studies, however, evaluate recent trends in the diagnosis and management of SAH in the context of trauma. The objective of this scoping review was to understand the extent and type of evidence concerning the diagnostic criteria and management of TSAH. This scoping review was conducted following the Joanna Briggs Institute methodology for scoping reviews. The review included adults with SAH secondary to trauma, where isolated TSAH (iTSAH) refers to the presence of SAH in the absence of any other traumatic radiographic intracranial pathology, and TSAH refers to the presence of SAH with the possibility or presence of additional traumatic radiographic intracranial pathology. Data extracted from each study included study aim, country, methodology, population characteristics, outcome measures, a summary of findings, and future directives. Thirty studies met inclusion criteria. Studies were grouped into five categories by topic: TSAH associated with mild TBI (mTBI), n = 13), and severe TBI (n = 3); clinical management and diagnosis (n = 9); imaging (n = 3); and aneurysmal TSAH (n = 1). Of the 30 studies, two came from a low- and middle-income country (LMIC), excluding China, nearly a high-income country. Patients with TSAH associated with mTBI have a very low risk of clinical deterioration and surgical intervention and should be treated conservatively when considering intensive care unit admission. The Helsinki and Stockholm computed tomography scoring systems, in addition to the American Injury Scale, creatinine level, age decision tree, may be valuable tools to use when predicting outcome and death.

Traumatic subarachnoid hemorrhage (SAH) is a common finding following traumatic brain injury. In some cases, it can be associated with hydrocephalus. This type of hemorrhage is mostly caused by the rupture of small vessels in the brain and is usually managed conservatively.
We present a case of a 60-year-old woman who presented with traumatic luxation of the eye following a fall. This resulted in diffuse SAH (Fisher grade IV) with associated hydrocephalus. We also report on 3 previous similar cases found in the literature. Avulsion of the ophthalmic artery was found to be the cause of the traumatic SAH. Apart from cerebrospinal fluid diversion using an external ventricular drain, the case was managed conservatively. There was no evidence of delayed clinical or radiologic vasospasm.
Traumatic avulsion of the ophthalmic artery may result in diffuse SAH, mimicking that of aneurysmal rupture. This case shows that management of early complications, such as hydrocephalus and seizures, should be the main aim. Surgical or endovascular treatment of the injured artery, however, would be unnecessary.

BACKGROUND: Intracranial pseudoaneurysm is a rare entity, with few cases described in the literature, and is mostly associated with a history of traumatic brain injury. Traumatic aneurysms comprise <1% of all intracranial aneurysms. In particular, middle meningeal artery (MMA) aneurysms are uncommon and usually caused by a skull fracture in the temporal region. About 40 traumatic MMA aneurysms are reported in the literature, and only 28 nontraumatic aneurysms are reported, usually related to high-flow conditions. The behavior of these aneurysms is largely unknown: both spontaneous resolution and aneurysm growth, leading to subsequent rupture, have been reported. Surgical and endovascular management are feasible for MMA aneurysms; however, the criterion standard treatment is not defined.
METHODS: We report the case of a traumatic pseudoaneurysm of the right MMA treated with an endovascular approach and provide a review of the literature.
CONCLUSIONS: Aneurysms of the MMA are a rare entity that must be taken into account in the setting of a traumatic brain injury or predisposing factors. The diagnosis and aggressive treatment are mandatory, preventing the devastating consequences of their rupture. Endovascular and surgical techniques are well defined and available, even though there is not a demonstrated superiority in any of them.

Fatal subarachnoid hemorrhage (SAH) caused by anterior communicating artery (ACoA) rupture is a rare event in medicolegal practice. Anatomical variations of the ACoA tend to make its anatomical structure, and as a result, blood flow through it, more complicated, which may increase hemodynamic stress and cause weak spots in the affected blood vessels. Variant ACoAs are prone to rupture in the event of a blunt-force trauma. Here, we report a fatal case of SAH caused by the rupture of a variant ACoA when the victim\'s head was struck from behind, causing the head to rotate and the victim to fall forward onto the ground. A medicolegal autopsy revealed diffuse basal SAH and ACoA duplication. The smaller of the two variant ACoA branches had ruptured near its junction with the right anterior cerebral artery. No basal aneurysms or other fatal diseases or injuries were found. This case highlights the significance of anatomical variation in forensic pathology.

Penetrating head injuries due to the use of screwdrivers as wounding agents in acts of interpersonal violence seldom occur. The aim of this article is to update and summarize the relevant literature on penetrating craniocerebral screwdriver stab wounds and to report a new case of screwdriver assault. A number of studies were reviewed to investigate the incidence, distribution, common findings, mechanism of injury, differential diagnostic criteria, complications, treatment, and prognosis of craniocerebral screwdriver stab injuries. It was observed that the degree of traumatic severity depends on the cross-sectional area of the screwdriver and the anatomical region of injury. Craniocerebral screwdriver injuries are mainly cases of interpersonal violence and the mortality rate is approximately 47.6%. In 23.8% of the incidents, the trauma is overlooked on admission because of the small entry wound and, thus, the severity of the injury is not initially appreciated.

Penetrating injury to the head, with the exception of missile injuries is rare owing to thick calvarium. Orbital and temporal areas are comparatively vulnerable to penetrating injuries, due to their relative thinness. A case is presented in which a man killed his wife by forcefully thrusting a screw driver into her cranial cavity. The deceased presented to the hospital with the screw driver embedded in her head. She was declared as \'brought dead on arrival\' at the emergency of the hospital. Pre-autopsy plain radiography and Computed Tomography (CT) of the head were done to assess the extent of brain damage. The peculiarity of this case lies in the fact that screw driver as a stabbing weapon in the head is very rarely used. In such cases, there is a need to perform radiography and CT with the weapon in-situ for better interpretation on injuries. In this paper role of radiography and CT in intra cranial penetration is discussed with review of literature.

With an incidence of less than 1-3 per million, pediatric aneurysms are rare clinical entities. A traumatic etiology is implicated in a large proportion of these cases, leading to the formation of both \'false\' and \'true\' aneurysms. These occur most often in the distal circulation, but have also been described in the supraclinoid distal internal carotid artery (ICA). Blood blister aneurysms are also found in this location; however, they have not been described in the pediatric population. We report the case of a 15-year-old male who presented following cranial trauma with diffuse basal subarachnoid hemorrhage and limited additional intracranial pathology. Computed tomography angiography demonstrated a small, 2-mm blister-like aneurysm arising from the dorsal surface of the left supraclinoid ICA at a non-branching site. Despite early endovascular treatment with Guglielmi detachable coils, the lesion continued to grow over subsequent studies, necessitating open surgical clipping. At the time of surgery, gross pathology of the native ICA was observed, raising the possibility of a preexisting blood-blister aneurysm. We review the epidemiology, pathophysiology and diagnostic considerations of these lesions. The endovascular and surgical management of these complex non-branching supraclinoid ICA aneurysms is also discussed.

Odontoid fractures have been classified by Anderson and D\'Alonzo into three main categories. The most unstable injuries, type II fractures involve the base of the odontoid peg at the junction with the C2 body. Due to the proximity of vital neural structures, fracture of the odontoid process may result in instability and fatal neurological damage. Treatment aims to re-establish stability of the atlanto-axial complex by restoring the odontoid process. This may be achieved by conservative or surgical treatment. Anterior screw fixation of the odontoid peg is an interresting alternative surgical option but this technique has a significant complication rate. However, vascular injury is very rare with three case reported in the literature: one case of an intracranial vertebral artery (VA) injury, one case of a cervical internal carotid artery (ICA) injury and one case of anterior pseudoaneurysm of the spinal artery branch. We report a new case of long term vascular injury after screw fixation revealed by a subarachnoid hemorrhage. We discuss the incidence, the mechanisms of injury and the conditions necessary for the occurrence of this complication.