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Thomas A Gennarelli

Publications and source records attributed to Thomas A Gennarelli.

At least 19 recordsLinked to original sources

Experimental model for civilian ballistic brain injury biomechanics quantification.

Biomechanical quantification of projectile penetration using experimental head models can enhance the understanding of civilian ballistic brain injury and advance treatment. Two of the most commonly used handgun projectiles (25-cal, 275 m/s and 9 mm, 395 m/s) were discharged to spherical head models with gelatin and Sylgard simulants. Four ballistic pressure transducers recorded temporal pressure distributions at 308kHz, and temporal cavity dynamics were captured at 20,000 frames/second (fps) using high-speed digital video images. Pressures ranged from 644.6 to -92.8 kPa. Entry pressures in gelatin models were higher than exit pressures, whereas in Sylgard models entry pressures were lower or equivalent to exit pressures. Gelatin responded with brittle-type failure, while Sylgard demonstrated a ductile pattern through formation of micro-bubbles along projectile path. Temporary cavities in Sylgard models were 1.5-2x larger than gelatin models. Pressures in Sylgard models were more sensitive to projectile velocity and diameter increase, indicating Sylgard was more rate sensitive than gelatin. Based on failure patterns and brain tissue rate-sensitive characteristics, Sylgard was found to be an appropriate simulant. Compared with spherical projectile data, full-metal jacket (FMJ) projectiles produced different temporary cavity and pressures, demonstrating shape effects. Models using Sylgard gel and FMJ projectiles are appropriate to enhance understanding and mechanisms of ballistic brain injury.

Biomechanical Phenomena↗

Biomechanical characterization of internal layer subfailure in blunt arterial injury.

Blunt carotid artery injuries occur in 0.3% of blunt injured patients and may lead to devastating neurological consequences. However, arterial mechanics leading to internal layer subfailure have not been quantified. Twenty-two human carotid artery segments and 18 porcine thoracic aorta segments were opened to expose the intimal side and longitudinally distracted to failure. Porcine aortas were a geometrically accurate model of human carotid arteries. Internal layer subfailures were identified using videography and correlated with mechanical data. Ninety-three percent (93%) of vessels demonstrated subfailure prior to catastrophic failure. All subfailures occurred on the intimal surface. Initial subfailure occurred at 79% of the stress and 85% of the strain to catastrophic failure in younger porcine specimens, compared to 44% and 60%, respectively, in older human specimens. In most cases, multiple subfailures occurred prior to catastrophic failure. Due to limitations in human specimen quality (age, prior storage), young and fresh porcine aorta specimens are likely a more accurate model of clinical blunt carotid artery injuries. Present results indicate that vessels are acutely capable of maintaining physiologic function following initial subfailure. Delayed symptomatology commonly associated with blunt arterial injuries is explained by this mechanics-based and experimentally quantified onset of subcatastrophic failure.

Animals↗

AIS 2005: a contemporary injury scale.

To determine and to quantify outcome from injury demands that multiple factors be universally applied so that there is uniform understanding that the same outcome is understood for the same injury. It is thus important to define the variables used in any outcome assessment. Critical to defining outcomes is the need for a universal language that defines individual injuries. The abbreviated injury scale (AIS) is the only dictionary specifically designed as a system to define the severity of injuries throughout the body. In addition to a universal injury language, it provides measures of injury severity that can be used to stratify and classify injury severity in all body regions. Its revision, AIS 2005 will be discussed here.

Abbreviated Injury Scale↗

Lateral impact injuries with side airbag deployments--a descriptive study.

The present study was designed to provide descriptive data on side impact injuries in vehicles equipped with side airbags using the United States National Automotive Sampling System (NASS). The database was queried with the constraint that all vehicles must adhere to the Federal Motor Vehicle Safety Standards FMVSS 214, injured occupants be in the front outboard seats with no rollovers or ejections, and side impacts airbags be deployed in lateral crashes. Out of the 7812 crashes in the 1997-2004 weighted NASS files, AIS > or = 2 level injuries occurred to 5071 occupants. There were 3828 cases of torso-only airbags, 955 cases of torso-head bag combination, and 288 inflatable tubular structure/curtain systems. Side airbags were not attributed to be the cause of head or chest injury to any occupant at this level of severity. The predominance of torso-only airbags followed by torso-head airbag combination reflected vehicle model years and changing technology. Head and chest injuries were coupled for the vast majority of occupants with injuries to more than one body region. Comparing literature data for side impacts without side airbag deployments, the presence of a side airbag decreased AIS=2 head, chest, and extremity injuries when examining raw data incidence rates. Although this is the first study to adopt strict inclusion-exclusion criteria for side crashes with side airbag deployments, future studies are needed to assess side airbag efficacy using datasets such as matched-pair occupants in side impacts.

Abdominal Injuries↗

Biomechanics of side impact: injury criteria, aging occupants, and airbag technology.

This paper presents a survey of side impact trauma-related biomedical investigations with specific reference to certain aspects of epidemiology relating to the growing elderly population, improvements in technology such as side airbags geared toward occupant safety, and development of injury criteria. The first part is devoted to the involvement of the elderly by identifying variables contributing to injury including impact severity, human factors, and national and international field data. This is followed by a survey of various experimental models used in the development of injury criteria and tolerance limits. The effects of fragility of the elderly coupled with physiological changes (e.g., visual, musculoskeletal) that may lead to an abnormal seating position (termed out-of-position) especially for the driving population are discussed. Fundamental biomechanical parameters such as thoracic, abdominal and pelvic forces; upper and lower spinal and sacrum accelerations; and upper, middle and lower chest deflections under various initial impacting conditions are evaluated. Secondary variables such as the thoracic trauma index and pelvic acceleration (currently adopted in the United States Federal Motor Vehicle Safety Standards), peak chest deflection, and viscous criteria are also included in the survey. The importance of performing research studies with specific focus on out-of-position scenarios of the elderly and using the most commonly available torso side airbag as the initial contacting condition in lateral impacts for occupant injury assessment is emphasized.

Accidents, Traffic↗

Impact of a neurointensivist on outcomes in patients with head trauma treated in a neurosciences intensive care unit.

OBJECT: The aim of this study was to evaluate the impact of a newly appointed neurointensivist on outcomes in head-injured patients in the neurological/neurosurgical intensive care unit (NICU). METHODS: The mortality rate, length of stay (LOS), and discharge disposition of all patients with head trauma who had been admitted to a 10-bed tertiary care university hospital NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University HealthSystem Consortium (UHC) database. Samples of medical records were reviewed for Glasgow Coma Scale (GCS) score documentation. The authors analyzed data pertaining to 328 patients before and 264 after the neurointensivist's appointment. The unadjusted mean in-hospital mortality rate increased 1.1% in the after period, but this increase was significantly lower compared with the UHC-based expected increase of 8.1% in the mortality rate during the same period (p < 0.0001). The unadjusted mean mortality rate in the NICU decreased from 13.4 to 12.9% (relative mortality rate reduction 4%) and the mean NICU LOS increased from 3.1 to 3.6 days (relative NICU LOS increase 16%), both nonsignificantly. A 51% reduction in the NICU-associated mortality rate (p = 0.01), a 12% shorter hospital LOS (p = 0.026), and 57% greater odds of being discharged to home or to rehabilitation (p = 0.009) were found in the after period in multivariate models after controlling for baseline differences between the two time periods. Better documentation of the GCS score by the NICU team was also found in the after period (from 60.4 to 82%, p = 0.02). CONCLUSIONS: The institution of a neurointensivist-led team model had an independent, positive impact on patient outcomes, including a lower NICU-associated mortality rate and hospital LOS, improved disposition, and better chart documentation.

Adult↗

Interface parameters of impact-induced mild traumatic brain injury.

Commonly considered a continuum of injuries, diffuse brain injury (DBI) ranges from mild concussion to severe diffuse axonal injury. The lower end of the spectrum is generally referred to as mild traumatic brain injury (MTBI). More severe forms of DBI have garnered extensive experimentation while these milder cases are considerably less explored. Recently, a new device was designed to generate DBI in the rodent using impact-induced angular acceleration. This device is modifiable so the entire spectrum of DBI can be investigated. Severity of DBI is critically dependent on magnitude of angular acceleration. A small animal surrogate like a rodent has a relatively small brain mass. This constraint poses a unique problem because the angular acceleration necessary for DBI is inversely related to brain mass. Prior experimentation estimated an angular acceleration of approximately 350 krad/s2 is necessary for the induction of mild traumatic brain injury (MTBI) in the rodent. To induce these magnitudes of angular acceleration in a repeatable manner, the impacting interface must be critically analyzed. This investigation uses a mathematical model based on parameters of a previously developed experimental model to assess the impacting interface such that angular accelerations are sufficient to produce MTBI in the rodent.

Acceleration↗

Automating 3D meshing method for patient-specific modeling.

The purpose of this study was to develop an automating meshing method for patient-specific modeling. Three-dimensional geometries of two six-month-old infant heads were reconstructed from the CT data. Finite element meshes including cranial bone of skull, brain, and suture were generated. Both static and dynamic analyses were performed to verify the models. The study for blunt impact of infant head was performed by using these patient-specific models.

Acceleration↗

Role of translational and rotational accelerations on brain strain in lateral head impact.

Translational and rotational accelerations from blunt head impact can induce excessive brain strain and cause traumatic brain injuries. However, it is not clear which acceleration plays a major role in the mechanism. The current study used the SIMon human finite element head model (FEHM) and delineated the contributions of these accelerations using post mortem human subject (PMHS) lateral head impact experimental data. Results indicated that rotational acceleration contributes more than 90% of total strain, and translational acceleration produces minimal strain. Therefore, the rotational component is a more important biomechanical metric in this study.

Acceleration↗

Brain strains in vehicle impact tests.

The purpose of this research was to use vehicle impact test data and parametric finite element analysis to study the contribution of translational accelerations (TransAcc) and rotational accelerations (RotAcc) on strain-induced head injuries. Acceleration data were extracted from 33 non-contact vehicle crash tests conducted by the US Department of Transportation, National Highway Traffic Safety Administration. A human finite element head model was exercised using head accelerations from the nine accelerometer package placed inside the driver dummy in these tests. Three scenarios were parameterized: both TransAcc and RotAcc, only TransAcc, and only RotAcc to demonstrate the contribution of these accelerations on brain injury. Brain strains at multiple elements, cumulative strain damage, dilatation damage, and relative motion damage data were compared. Rotational accelerations contributed to more than 80% of the brain strain. Other injury metrics also supported this finding. These findings did not depend on the crash mode, peak amplitude of translational acceleration (29 to 120 g), peak amplitude of rotational acceleration (1.3 to 9.4 krad/s ( 2 ) ) or HIC (68-778). Rotational accelerations appeared to be the major cause of strain-induced brain injury.

Acceleration↗

Effect of image uncertainty on the dosimetry of trigeminal neuralgia irradiation.

OBJECTIVE: Our objective was to quantify the uncertainty in localization of the trigeminal nerve (TGN) with magnetic resonance imaging (MRI) and computed tomography (CT) and to determine the effect of this uncertainty on gamma-knife dose delivery. METHODS: An MR/CT test phantom with 9, 0.6-mm diameter, copper rings was devised. The absolute ring positions in stereotactic space were determined by the angiographic module of the LGP software. The standard deviation, sigma, in the difference between the absolute and MR-measured or CT-measured coordinates of the rings was determined. The trigeminal nerve in 52 previously treated patients was contoured and expanded by 1sigma and 2sigma margins to model the uncertainty in the location of the nerve. For gamma-knife treatment, a single isocenter was used and was located at the distal cisternal portion of the trigeminal nerve root. Irradiation methods included a 4-mm collimator, 90 Gy to isocenter and a 4&8-mm collimator, 70 Gy to isocenter. A patient outcome survey that sampled pain relief and morbidity was done. RESULTS: The MR coordinate sigma was 0.7 mm left-right, 0.8 mm anterior-posterior, and 0.6 mm superior-inferior, and the CT coordinate sigma was 0.4 mm left-right, 0.2 mm anterior-posterior, and 0.2 mm superior-inferior. A 45% higher dose line covered the TGN with the 4&8-mm method. No significant increase in pain reduction or morbidity occurred. CONCLUSIONS: The uncertainty of target location by MRI is more than twice that found in CT imaging. The 4&8-mm collimator method covers the trigeminal root cross section with a higher isodose line than does the 4-mm method. This higher dose did not significantly reduce pain or increase morbidity.

Humans↗

Temporal cavity and pressure distribution in a brain simulant following ballistic penetration.

To study ballistic brain injury biomechanics, two common civilian full metal jacket handgun projectiles (25-caliber and 9-mm) were discharged into a transparent brain simulant (Sylgard gel). Five pressure transducers were placed at the entry (two), exit (two) and center (one) of the simulant. High-speed digital video photography (20,000 frames/second) was used to capture the temporal cavity pulsation. Pressure histories and high-speed video images were synchronized with a common trigger. Pressure data were sampled at 308 kHz. The 25-caliber projectile had an entry velocity of 238 m/s and exit velocity of 170 m/s. The 9-mm projectile had an entry velocity of 379 m/s and exit velocity of 259 m/s. Kinetic energies lost during penetration were 45.2 J for the 25-caliber projectile and 283.7 J for the 9-mm. Size of temporary cavities and pressures were dependent on projectile size and velocity. The 9-mm projectile created temporary cavities 1.5 times larger in size and lasted 1.5 times longer than the 25-caliber projectile. The 9-mm projectile had pressures three times higher than the 25-caliber projectile. Pressure differences between the center location and surrounding regions were approximately 1.4 times higher and lasted about 1.6 times longer in the 9- mm projectile than the 25-caliber projectile. Collapsing of the temporary cavity drew the brain simulant toward the center of the temporary cavity and created negative pressures of approximately -0.5 atmospheric pressure in the surrounding region. Pressures reached approximately +2 atmospheric pressure when temporary cavities collapsed. These quantified data may assist in understanding injury biomechanics and management of penetration brain trauma.

Biomechanical Phenomena↗

Intraventricular hemorrhage after aneurysmal subarachnoid hemorrhage: pilot study of treatment with intraventricular tissue plasminogen activator.

OBJECTIVE: Intraventricular (IVen) hemorrhage is considered a predictor of poor outcome after subarachnoid hemorrhage (SAH). This prospective study examines the feasibility and outcome of administration of IVen tissue plasminogen activator (tPA) after aneurysmal SAH. METHODS: Ten patients with SAH who received IVen tPA after the aneurysm had been secured were compared with 10 age-, sex-, and Glasgow Coma Scale score-matched control patients. The primary end point was third and fourth ventricle clot resolution. IVen blood was quantified by use of the Graeb and Le Roux scales on admission and at an additional time (equal or longer for the control group) after the injection was terminated. RESULTS: Six men and four women with a mean age of 52 years in each group were evaluated. On average, 3.5 mg tPA was injected 68 +/- 51 hours after admission without ensuing complications. Although the treated group had significantly more IVen blood on admission than control subjects (mean Le Roux scale +/- standard deviation, 11 +/- 3 versus 7.6 +/- 4.2, P = 0.055, and mean Graeb scale +/- standard deviation, 8.5 +/- 2.3 in tPA versus 5.3 +/- 3, P < 0.02), it also had a significant decrease in the amount of IVen blood (mean Le Roux and Graeb scale decrease +/- standard deviation, 6.7 +/- 3.3 and 4.8 +/- 2 in tPA patients versus 0.9 +/- 3.2 and 0.5 +/- 2.6 in control subjects, P = 0.002). The tPA group had a non-statistically significantly shorter length of stay, decreased mortality, and better Glasgow Outcome Scale and modified Rankin Scale scores at discharge. Treated survivors showed a decreased need for shunt placement (2 [22%] of 9 patients versus 5 [83%] of 6 control subjects, P = 0.04). CONCLUSION: This pilot study shows that IVen tPA administration is feasible without complications after SAH and may be associated with better outcomes. These results warrant a randomized clinical trial.

Adult↗

Risk of pediatric head injury after motor vehicle accidents.

OBJECT: Injury to the brain as a result of motor vehicle accidents (MVAs) represents a frequent cause of pediatric disability. The authors analyze the correlation between the relative risk of pediatric brain injury and the use of child safety seats (CSSs). METHODS: A national database of MVAs was examined to provide data for the analysis of four age categories (infant, toddler, young child, and adolescent) and four restraint categories (unrestrained, properly restrained, improperly restrained, and other). The Abbreviated Injury Scale (AIS) was used to assess the severity of head injury; children with no injuries and children with moderate-to-maximum head injuries were evaluated. The data confirm that proper use of a CSS substantially increases the likelihood of not sustaining head injury in an MVA. The data are most dramatic for infants (the likelihood of sustaining no head injury was 15.2% for unrestrained infants compared with 92.8% for properly restrained infants) but the protective effect is seen in all age categories, with the least difference observed in the adolescent category. For children who sustain a moderate-to-maximum head injury, proper use of a CSS reduces the incidence of injury, again most dramatically for the infant category (unrestrained infants had a 7% risk of moderate-to-maximum head injury compared with only 0.5% for properly restrained infants). CONCLUSIONS: Improvements in CSSs have reduced the risk of moderate-to-maximum head injuries in children of all age categories. Overall, a CSS is most protective for the infant and toddler categories. The improperly restrained child still has substantial protection, although the properly restrained child has more. Detailed parental education regarding appropriate restraint system installation and use should be required.

Accidents, Traffic↗

Localized cervical facet joint kinematics under physiological and whiplash loading.

OBJECT: Although facet joints have been implicated in the whiplash injury mechanism, no investigators have determined the degree to which joint motions in whiplash are nonphysiological. The purpose of this investigation was to quantify the correlation between facet joint and segmental motions under physiological and whiplash loading. METHODS: Human cadaveric cervical spine specimens were exercise tested under physiological extension loading, and intact human head-neck complexes were exercise tested under whiplash loading to correlate the localized component motions of the C4-5 facet joint with segmental extension. Facet joint shear and distraction kinematics demonstrated a linear correlation with segmental extension under both loading modes. Facet joints responded differently to whiplash and physiological loading, with significantly increased kinematics for the same-segmental angulation. The limitations of this study include removal of superficial musculature and the limited sample size for physiological testing. CONCLUSIONS: The presence of increased facet joint motions indicated that synovial joint soft-tissue components (that is, synovial membrane and capsular ligament) sustain increased distortion that may subject these tissues to a greater likelihood of injury. This finding is supported by clinical investigations in which lower cervical facet joint injury resulted in similar pain patterns due to the most commonly reported whiplash symptoms.

Biomechanical Phenomena↗

New mechanism for inducing closed head injury in the rat.

Due to the frequency of closed head injuries and cost of treatment, there is great interest in the mechanical parameters involved in provoking the injury. A new device has been developed to produce closed head injury due to impact-induced angular acceleration in the rat. A 488-gram mass was propelled down a 2-meter drop tube by springs at a velocity of 21 mph (9.5 m/s), depending on strength and displacement of the springs. The projectile then impacts a lever arm protruding laterally from an aluminum helmet fixed at the anterior face with a ball-bearing pivot allowing only lateral rotation, which has been shown to cause severe brain injury. A sodium silicate elastomeric material with a thickness of 1 cm was placed at the impact interface to increase the contact time between the projectile and the lever arm. Biomechanical results from a lumped parameter mathematical model and testing indicated an angular acceleration of 300,000 +/- 20,000 rad/s2, angular velocity of 300 +/- 50 rad/s, and impact duration of 2.0 +/- 0.3 ms. When scaled to the human, the results indicated an angular acceleration of 4,100 rad/s2, angular velocity of 32 rad/s, and impact duration of 20 ms, consistent with values associated with classical concussion. Magnitudes and durations at these levels have not been produced in the rat by rotational loading caused by impact, and due to the flexibility of the design, these parameters can be further increased.

Animals↗

Field data on head injuries in side airbag vehicles in lateral impact.

Field data on side airbag deployments in lateral crashes and head injuries have largely remained anecdotal. Consequently, the purpose of this research was to report head injuries in lateral motor vehicle impacts. Data from the National Automotive Sampling System files were extracted from side impacts associated with side airbag deployments. Matched pairs with similar vehicle characteristics but without side airbags were also extracted. All data were limited to the United States Federal Motor vehicle Safety Standards FMVSS 214 compliant vehicles so that the information may be more effectively used in the future. In this study, some fundamental analyses are presented regarding occupant- and vehicle-related parameters.

Accidents, Traffic↗

The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit.

OBJECTIVE: To evaluate the impact of a newly appointed neurointensivist on neurosciences intensive care unit (NICU) patient outcomes and quality of care variables. DESIGN: Observational cohort with historical controls. SETTING: Ten-bed neurointensive care unit in tertiary university hospital. PATIENTS: Mortality, length of stay (LOS), and discharge disposition of all patients admitted to the NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University Hospitals Consortium database. Individual patient medical records were reviewed for major complications and important prognostic variable documentation. INTERVENTIONS: Appointment of a neurointensivist. MEASUREMENTS AND MAIN RESULTS: We analyzed 1,087 patients before and 1,279 after the neurointensivist's appointment. The unadjusted in-hospital mortality decreased from 10.1% in the before to 9.1% in the after period (95% confidence interval, -1.3 to 3%, relative mortality reduction of 9.9%), but this decrease was significantly different than the expected increase of 1.4% in University Hospitals Consortium mortality during the same period (p = .048). The unadjusted mortality in the NICU decreased from 8% to 6.3% (95% confidence interval, -0.5 to 4, relative mortality reduction 21%) and mean NICU LOS from 3.5 to 2.9 days (95% confidence interval, 0.2 to 0.9, relative NICU LOS reduction 17%). A significant 42% reduction of the risk of death during the first 3 days of NICU admission (p = .003) and a 12% greater risk for NICU discharge (p = .02) were found in the after period in multivariate proportional hazard models. Discharge home increased from 51.7% in the before to 59.7% in the after period (95% confidence interval, 4 to 12, relative increase of 15%) and discharge to a nursing home decreased from 8.1% to 6.8% (95% confidence interval, -1 to 4, relative decrease of 16%). Although a higher total number of complications occurred in the after period, fewer of them occurred in the NICU (odds ratio, 0.2; 95% confidence interval, 0.08 to 0.54, p = .001); this may possibly be due to the better documentation by the NICU team in the after period. CONCLUSIONS: The institution of a neurointensivist-led team model was associated with an independent positive impact on patient outcomes, including a lower intensive care unit mortality, LOS, and discharge to a skilled nursing facility and a higher discharge home.

Adult↗