Severe open craniofacial trauma with exposed brain parenchyma is generally associated with devastating neurological injury, raised intracranial pressure, and poor outcomes. However, rare exceptions may occur in which extensive calvarial disruption paradoxically provides a decompressive effect, thereby limiting secondary brain injury. We report an unusual case illustrating this phenomenon
Abstract Traumatic brain injury (TBI) remains a major cause of death and disability. Comparative outcome data for surgically and conservatively managed moderate and severe TBI remain limited in low- and middle-income settings. The aim of the study is to compare 18-month functional outcomes among hospital survivors of moderate and severe TBI managed surgically or conservatively. This retrospective cohort included 527 adults with isolated moderate (Glasgow Coma Scale [GCS] 9–12) or severe TBI (GCS 3–8) admitted from July 2022 to June 2023. The Glasgow Outcome Scale–Extended (GOS-E) was assessed at 6, 12, and 18 months; GOS-E 7–8 was considered favorable and death was assigned a GOS-E score of 1. Inverse probability of treatment weighting (IPTW) was used to address measured confounding, and repeated outcomes were analyzed using generalized estimating equations. The cohort included 340 patients with moderate and 187 with severe TBI patients; 239 (45.4%) underwent surgery. At 18 months, a favorable outcome occurred in 103/135 (76.3%) surgical versus 149/205 (72.7%) conservative patients with moderate TBI, and in 45/104 (43.3%) versus 16/83 (19.3%) patients with severe TBI, respectively. After IPTW, surgery was not significantly associated with favorable outcome in moderate TBI (OR 1.29, 95% CI 0.79–2.09; p = 0.304) but remained associated with favorable outcomes in severe TBI (OR 2.37, 95% CI 1.20–4.66; p = 0.013). The treatment-by-severity interaction was not significant (p = 0.151). Among hospital survivors, recovery continued through 18 months. Surgery remained associated with favorable outcome in severe, but not moderate, TBI after adjustment. Because treatment was clinically selected and in-hospital deaths were excluded, these findings should not be interpreted as causal.
Abstract Generative AI models are large language models capable of interacting with humans in a man–machine interface. Endowed with extensive training on an expansive corpus of textual data, these GPTs excel across diverse domains, notably in the realms of medicine and healthcare. Generative AIs like ChatGPT, if incorporated into routine practice, can prove beneficial in patient diagnosis, management, and timely referral. This study aims to evaluate and compare the currently available GPT models with the expertise of neurosurgeons. We explored the most widely used LLMs that are free to use to test and compare them with neurosurgeon's expertise viz, ChatGPT with GPT 4o, Claude Sonnet 4, Gemini 2.5 Flash, DeepSeek v3, Perplexity (AI search engine based on multiple LLMs), Microsoft Copilot, and Grok 3. Data were collected from 32 patients with head injury coming to the OPD or emergency department of a tertiary care center in India. Neurosurgeon's opinion on whether to operate or provide conservative management versus the opinions of the different GPT models were compared using McNemar's exact test, and raw agreement was calculated. Out of 32 patients, the neurosurgeon advised conservative management in 29 patients (90.6%) versus surgery in three patients (9.4%). Raw agreement between the neurosurgeon and each AI model ranged from 50.0 to 81.2%. DeepSeek V3 (conservative 71.9% vs. surgery 28.1%; 81.2%) and Perplexity (conservative 71.9% vs. surgery 28.1%; 81.2%) achieved the highest agreement with the neurosurgeon's preferred method of treatment, followed by ChatGPT-4o (conservative 59.4% vs. surgery 40.6%; 68.8%) and Gemini 2.5 (conservative 59.4% vs. surgery 40.6%; 68.8%), Claude Sonnet 4 (conservative 16 patients vs. surgery 16 patients; 59.4%) Copilot (conservative 16 patients vs. surgery 16 patients; p-value 59.4%), and Grok 3, which had raw agreement of only 50%. On McNemar's exact test, five of seven models – ChatGPT-4o, Gemini 2.5 Flash, Claude Sonnet 4, Copilot, and Grok 3–showed statistically significant asymmetric disagreement with the neurosurgeon after Bonferroni correction; DeepSeek V3 and Perplexity did not reach significance (p = 0.031 for each, above the adjusted threshold of 0.0071). In this small, single-center retrospective comparative study – freely available generative AI tools showed a tendency to recommend surgery more often than neurosurgeons. The disagreement occurred in a single direction only across all models. We are still at the initial stages of AI development. However, as the technology advances, these AI tools can prove to be beneficial adjuncts for the care of patients, and neurosurgeons should learn and incorporate these tools in their practice.
Abstract Stroke-like cerebral injury following mild traumatic brain injury (TBI) in infants is exceedingly rare. We report a 10-month-old male infant who sustained mild TBI in a road traffic accident, presenting with a pediatric Glasgow Coma Scale of E4V4M6 and a brain computed tomography (CT) scan showing only a thin left frontotemporal subdural hygroma. Despite intravenous levetiracetam, he developed recurrent focal seizures over 2 days followed by progressive left hemiparesis. Repeat CT on day 3 revealed extensive hypodensity in the right internal carotid artery territory and patchy hypodensities in the contralateral left middle cerebral artery (MCA) territory—a distribution atypical for single-vessel occlusion—necessitating emergency right-sided decompressive craniectomy. Both CT angiography and digital subtraction angiography were negative for vascular pathology. Magnetic resonance imaging at day 15 demonstrated right hemispheric cortical laminar necrosis with focal hemorrhages, without established structural injury in the left MCA territory. At 2-month follow-up, the infant was alert and active with normal power (5/5) in all four limbs. The negative vascular imaging, combined with recurrent pre-infarction seizures and a multi-territorial infarct distribution, raises the possibility of seizure-mediated cerebral injury as a contributing mechanism. This case underscores the diagnostic uncertainty inherent in angiographically negative stroke-like injury following mild pediatric TBI and the role of early decompressive surgery.
Abstract Posttraumatic hypopituitarism (PTHP) is an increasingly recognized complication of traumatic brain injury (TBI) and may contribute to delayed neurological recovery, persistent fatigue, cognitive dysfunction, and poor rehabilitation outcomes. Although global literature reports a variable prevalence, data from Indian trauma populations remain limited and routine endocrine screening after TBI is not uniformly practiced. To determine the prevalence, temporal evolution, and predictors of hypopituitarism following TBI in adults treated at a tertiary care center. This prospective observational study included adult patients with mild, moderate, and severe TBI. Hormonal evaluation of the hypothalamic– pituitary axis was performed during the acute phase and at 3, 6, and 12 months of follow-up to predict the prevalence of hypopituitarism. Clinical parameters including the Glasgow Coma Scale, pupillary abnormalities, ventilatory requirement, and radiological parameters, such as type of intracranial injury, presence of skull base fractures, diffuse axonal injury (DAI), and Marshall computed tomography classification, were recorded and statistically analyzed to find their correlation with hypopituitarism, so as to predict its outcome. Statistical analysis was performed using the Chi-square test or Fisher's exact test, with p-value <0.05 considered significant. Of 61 patients enrolled, 55 completed follow-up. Hypopituitarism was detected in 18 patients (32.7%) during the acute phase, declining to 9 (16.4%) at 3 months and persisting in 7 patients (12.7%) at both 6 and 12 months. Hypocortisolism was the most common acute abnormality, while hyperprolactinemia predominated during follow-up. Skull base fracture demonstrated a consistent and statistically significant association with hypopituitarism at 3 months (p = 0.039), 6 months (p = 0.001), and 12 months (p = 0.001). DAI and epidural hematoma were significantly associated at 6 months (p = 0.004). No significant association was observed with any other head injury–related parameter. PTHP is common following TBI, with persistent endocrine dysfunction in a significant subset of patients up to 1 year. Skull fracture is a reliable predictor of long-term pituitary dysfunction. Focused endocrine screening in high-risk TBI patients may facilitate early detection and improve long-term outcomes.
