Traumatic brain injury (TBI) encompasses heterogeneous insults and presentations resulting from blunt or penetrating mechanisms that disrupt normal cerebral function. While the primary injury may demand emergent intervention, secondary injury due to hypotension, hypoxia, edema, and ischemia can significantly worsen outcomes. Post-traumatic cerebral infarction (PTCI) remains an underrecognized but potentially preventable cause of deterioration. PTCI may arise through various systemic and brain-related factors, including those due to post-traumatic vasospasm. The clinical significance, mechanisms, and management of vasospasm after TBI are controversial and raise the question whether vasospasm is merely a marker of injury or a separate, modifiable contributor to ischemia. Thus, in this review, we examine the evidence regarding incidence, etiology, and consequence of PTCI with an emphasis on vasospasm. We highlight diagnostic challenges, therapeutic interventions, and opportunities for future clinical use directed toward improving outcomes after TBI.

Background:Intraventricular hemorrhage (IVH) is a common and severe complication of hemorrhagic brain injury. Current treatments offer limited improvement in long-term neurological outcomes. Inflammatory responses in the cerebrospinal fluid (CSF) after IVH are thought to drive secondary injury, but the cellular mechanisms underlying this inflammation remain poorly defined. Methods:We performed single-nucleus RNA sequencing of leukocytes isolated from CSF collected through external ventricular drains in subjects with intracerebral ( n = 6) or subarachnoid ( n = 1) hemorrhage. We characterized transcriptionally distinct subpopulations of neutrophils, monocytes, and lymphocytes by comparison to reference datasets. Cell-cell signaling networks were analyzed to infer cytokine-mediated communication, and a flow cytometry panel was developed to validate transcriptomic findings in independent CSF samples. Results:We obtained 11,191 high-quality nuclei comprising neutrophils (53.8%), monocytes (26.1%), lymphocytes (17.8%), and non-immune cells (2.4%). Neutrophils segregated into Nascent, Quiescent, and Interferon-Activated states. Monocytes exhibited classical phenotypes that include interferon-activated states (characterized by expression of VCAN or PROK2 ) and CXC-chemokine expressing states (characterized by expression of CXCL5 or CXCL8 ). Lymphocytes were mainly naïve and central memory CD4⁺ T cells. Cell-cell signaling analysis predicted strong CXC chemokine signaling from monocytes to neutrophil subsets and IL-1 family-driven inflammatory responses across multiple populations. Type I and III interferon signaling defined a neutrophil population not previously described in the central nervous system. Conclusion:This study delineates the diverse cellular immune landscape of CSF after IVH. Transcriptomic profiles reveal interferon, IL-1, and CXC chemokine signaling networks as potential therapeutic targets to mitigate secondary injury.

OBJECTIVE:Traumatic central cord syndrome (TCCS) is the most common incomplete spinal cord injury, yet the optimal management strategy remains controversial, particularly for older adults who often present with worse outcomes. The authors aimed to determine whether surgical intervention confers different benefits across age groups, focusing on 1-year functional and neurological recovery. METHODS:The authors retrospectively analyzed 890 patients with TCCS from the multi-institutional Spinal Cord Injury Model Systems (SCIMS) Database between 2006 and 2021. TCCS was defined as an American Spinal Injury Association (ASIA) Impairment Scale grade C or D cervical injury and at least a 5-point discrepancy favoring lower extremity motor score over upper extremity motor score. Missing admission ASIA data were addressed via validated random forest imputation. The authors compared surgical versus nonsurgical groups using full optimal matching to reduce confounding, achieving balanced cohorts (698 patients in the surgical group vs 179 in the nonsurgical group). The authors then applied a causal forest algorithm to detect heterogeneous treatment effects and used segmented regression to identify age-related inflection points. The primary outcome was the Physical Function Composite Score (PFCS) (range 0-300), which captures physical independence, mobility, and occupational function. Sensitivity analyses further evaluated neurological recovery on the basis of ASIA motor scores and stricter criteria for TCCS identification after the exclusion of imputed data. RESULTS:Across the matched cohort, surgery was associated with mean PFCS improvement of 6.6 points (95% CI -4.5 to 17.8), which did not reach statistical significance. However, subgroup analysis revealed that age was the strongest effect modifier of surgical benefit (relative importance 42.8%, p < 0.001). Segmented regression identified an inflection at approximately 64 years of age. Patients older than 64 years demonstrated a significant improvement of 34.7 points (95% CI 12.2-57.2), whereas younger individuals showed no statistically significant surgical benefit (-4.1 points, 95% CI -16.8 to 8.6). All sensitivity analyses were consistent with the results of our primary findings. CONCLUSIONS:The authors' findings suggest that the effectiveness of surgical intervention for TCCS may be influenced by age, with adults older than 64 years experiencing differentially greater functional and neurological benefit. These results may inform patient-specific treatment decisions and clinical guidelines. Prospective research is needed to validate these observations, elucidate underlying mechanisms, and guide evidence-based TCCS management.

Background: Traumatic intracranial aneurysms (TICAs) secondary to penetrating traumatic brain injuries (PTBIs) including gunshot wounds and shell fragments carry a significant risk of rupture, intracerebral hematoma, neurological injury, and death. Although these lesions were previously thought to arise in a delayed fashion, TICAs have been increasingly reported immediately after PTBI. Early detection and endovascular therapies have contributed to a significant evolution in their management. Here, we review and present reported TICAs in the literature spanning both civilian and military contexts. Lesions are analyzed by morphology, location, management strategies, and outcomes. Methods: Case series/reports published between 1940 and 2025 were considered. Injury mechanism, arterial location, diagnostic imaging modality, time to diagnosis, treatment, and outcome data were collected. Only full texts were considered in the final analysis. Results: A total of 250 traumatic intracranial pseudoaneurysms in 227 patients met inclusion criteria for this study. The most common vessel distribution was the middle cerebral artery (MCA, n = 98), followed by the anterior cerebral artery ( n = 68) and internal carotid artery (ICA n = 48, of which 13 were in the cavernous ICA). Historically, TICAs were detected in a delayed fashion using conventional angiography (104 patients, 113 TICAs). In recent years, early detection of TICAs has been facilitated by CT angiography (CTA; 52 patients and 64 TICAs) and digital subtraction angiography (DSA; 52 patients and 53 TICAs). Endovascular surgery and open approaches complement each other in the obliteration of TICAs, with a significant increase in the use of the former during the last three decades. Conclusion: TICAs are complex lesions secondary to PTBIs. Detection, management strategies, and outcomes have evolved over the last several decades. Early detection using CTA and DSA has significantly increased the incidence of these lesions in the acute phase. Vigilant monitoring and delayed follow-up imaging remain essential components of modern management given the risk of delayed aneurysm formation, growth, and recanalization.

Background.During emergency transport, clinical assessment and vital signs (VS) may lack the sensitivity to identify traumatic brain injury (TBI) and identify specific TBI subtypes which may have implications for triaging and timely delivery of life-saving interventions.Objective.To evaluate the ability of machine learning (ML) algorithms to identify the presence of TBI with or without specific important concomitant clinical phenotypes including shock, coagulopathy and polytrauma during air transport to a trauma center.Methods.We identified a cohort of consecutive trauma patients aged 18-65 transported from the scene of injury via helicopter to an urban academic trauma center and collected prehospital clinical data and continuous VSs. We used ElasticNet (regularized regression) and XGBoost (gradient boosting), comparing three variable sets: clinical variables only, continuous physiologic monitoring data only, and combined clinical and physiological data, to develop four predictive models: (1) presence/absence of TBI, (2) mild vs moderate-severe TBI, (3) presence/absence of polytrauma in moderate-severe TBI, (4) presence/absence of coagulopathy in TBI, and (5) presence/absence of shock in TBI.Results.1025 patients (median age 38, interquartile range (IQR): 27-53; 70% male; median Glasgow coma scale 15 (IQR: 13-15) were identified. Across all predictive models, ML algorithms exhibited good predictive discrimination, with area under the receiver operator curve of 0.79 (0.75-0.84), 0.79 (0.74-0.83), 0.89 (0.85-0.92), 0.77 (0.67-0.86), and 0.78 (0.72-0.84) for TBI, TBI severity, polytrauma, coagulopathy, and shock, respectively. Clinical data best predicted TBI severity and polytrauma, while physiologic data improved prediction of shock and coagulopathy.Conclusions.ML algorithms integrating clinical and continuous physiological monitoring can improve identification of TBI and concomitant clinical phenotypes during prehospital transport.

Intraventricular hemorrhage (IVH) is a frequent and severe complication of hemorrhagic brain diseases. Treatment options for IVH are limited in their ability to improve long-term functional status. One promising target for treatment is the profound cellular inflammatory response that occurs after injury, but advances have been limited by our incomplete understanding of this phenomenon. We leveraged Recovery After Cerebral Hemorrhage, a prospective, observational study at the University of Maryland, to address this question. We sought to characterize the immune cell populations in the intraventricular cerebrospinal fluid (CSF) of human subjects after IVH. To do so, we generated a single-nucleus RNA sequencing (snRNA-seq) atlas of leukocytes in the CSF after acute brain injury. We performed 10x Genomics snRNA-seq of nuclei isolated from the CSF of 7 patients (ICH=6, SAH=1), yielding 11,191 high-quality transcriptomes. We identified four major cell populations, which we annotated as neutrophils (53.8%), monocytes (26.1%), lymphocytes (17.8%), and other cells (2.4%) based on the expression of canonical gene markers. Sub-clustering revealed distinct subtypes of neutrophils, monocytes, and lymphocytes that shared features with populations previously described in the systemic circulation. Neutrophils were categorized into nascent, quiescent, and interferon-activated states. The interferon-activated state has not been observed in the central nervous system previously. Monocytes were predominantly of a classical phenotype. Lymphocytes were predominantly T-cells, with the largest populations being naïve and central memory CD4+ T-cells. This snRNA-seq data informed the design of a flow cytometry panel that we used to validate the presence of cell subtypes identified by transcriptomics. This analysis demonstrates the feasibility of snRNA-seq approaches to identify previously unexplored pathways and immune cell types that may be relevant to disease. We anticipate that these tools will enable the discovery of new targets to mitigate inflammation-related secondary damage after IVH. ### Competing Interest Statement The authors have declared no competing interest.

OBJECTIVE:Traumatic spinal cord injury (tSCI) can cause lasting functional impairment. Concomitant traumatic brain injury (cTBI) is a common injury constellation, but the impact of tandem traumatic brain injury (TBI) and tSCI on long-term patient outcomes requires further study. The objective of this study was to compare outcomes among tSCI patients with and without TBI. METHODS:Patients with tSCI were identified from the Spinal Cord Injury Model System (SCIMS) database. Patients with cTBI and tSCI were 1:1 propensity score matched to those with tSCI only on demographic and injury characteristics. TBI severity was stratified in the SCIMS as mild (loss of consciousness [LOC] < 30 minutes), moderate (LOC 31 minutes to 24 hours), or severe (LOC > 24 hours). Multivariable linear and logistic regression models were specified to assess relationships between cTBI severity and 1-year follow-up outcome metrics including rehospitalization, functional recovery, and quality of life (QOL). RESULTS:Among the 1442 patients included (median age 36 [IQR 24-52] years), 44% (n = 636) presented with cTBI. After propensity score matching, 601 patients with cTBI were compared to 601 with tSCI only. Patients with cTBI had increased rehospitalization rates, reduced functional Craig Handicap Assessment and Reporting Technique mobility and occupational scores, and increased pain severity at 1-year follow-up (all p < 0.05). Additionally, patients with severe cTBI specifically exhibited significantly lower functional independence measure (FIM) scores, Satisfaction with Life Scale scores, and a higher incidence of new-onset depression (all p < 0.05) compared to those without cTBI. Multivariable analyses confirmed that moderate and severe cTBI were independently associated with worse outcomes across 8 of 10 assessed metrics, including increased rehospitalization, new-onset depression, lower FIM scores, and greater pain severity (all p < 0.05). CONCLUSIONS:Patients with tSCI and cTBI experience worse functional outcomes and have reduced QOL 1 year after injury. Targeted rehabilitation programs could benefit patients with cTBI in the setting of tSCI.

Traumatic brain injury (TBI) even in the mild form may result in long-lasting post-concussion symptoms. TBI is also a known risk to late-life neurodegeneration. Recent studies suggest that dysfunction in the glymphatic system, responsible for clearing protein waste from the brain, may play a pivotal role in the development of dementia following TBI. Given the diverse nature of TBI, longitudinal investigations are essential to comprehending the dynamic changes in the glymphatic system and its implications for recovery. In this prospective study, we evaluated two promising glymphatic imaging markers, namely the enlarged perivascular space (ePVS) burden and Diffusion Tensor Imaging-based ALPS index, in 44 patients with mTBI at two early post-injury time points: approximately 14 days (14Day) and 6-12 months (6-12Mon) post-injury, while also examining their associations with post-concussion symptoms. Additionally, 37 controls, comprising both orthopedic patients and healthy individuals, were included for comparative analysis. Our key findings include: 1) White matter ePVS burden (WM-ePVS) and ALPS index exhibit significant correlations with age. 2) Elevated WM-ePVS burden in acute mTBI (14Day) is significantly linked to a higher number of post-concussion symptoms, particularly memory problems. 3) The increase in the ALPS index from acute (14Day) to the chronic (6-12Mon) phases in mTBI patients correlates with improvement in sleep measures. Furthermore, incorporating WM-ePVS burden and the ALPS index from acute phase enhances the prediction of chronic memory problems beyond socio-demographic and basic clinical information, highlighting their distinct roles in assessing glymphatic structure and activity. Early evaluation of glymphatic function could be crucial for understanding TBI recovery and developing targeted interventions to improve patient outcomes.

We performed a clinical-radiographic association study investigating the hypothesis that paroxysmal sympathetic hyperactivity (PSH) occurs in traumatic brain injury (TBI) patients with structural damage to the central autonomic network (CAN). To this end, we identified critically ill acute TBI patients who underwent magnetic resonance imaging (MRI) of the brain between January 2016 and July 2018. All patients were scored retrospectively according to the PSH-Assessment Measure (PSH-AM), which provides a clinical feature score, a diagnosis likelihood score, and a total score. All MRIs were reviewed for lesions within a priori CAN regions of interest, including the brainstem, ventral diencephalon, thalamus, medial temporal lobes, insula, anterior cingulate/medial prefrontal cortex, corpus callosum, and bilateral hemispheric white matter, on diffusion-weighted imaging (DWI), fluid attenuated inversion recovery (FLAIR), and susceptibility-weighted imaging (SWI) sequences. PSH-AM scores were compared using non-parametric tests according to lesion presence in each region and sequence. Imaging features independently associated with PSH-AM scores were ascertained from multivariable linear regression models using backwards elimination feature selection. The strongest predictive models were adjusted for known PSH risk factors including age, sex, and Glasgow Coma Scale (GCS), to determine the independent contribution of imaging features to PSH-AM scores. We found that of 128 patients meeting inclusion criteria, 60 (47%) were clinically diagnosed with PSH. PSH-AM diagnosis likelihood and total scores and clinical diagnosis were strongly associated with CAN lesions. The strongest multivariable model, adjusted for age, sex, and GCS, identified SWI lesions in the corpus callosum and medial temporal lobes as independent imaging predictors of PSH diagnosis likelihood. This exploratory study supports the hypothesis that structural damage to CAN regions is associated with the clinical syndrome of PSH after TBI, and provides foundational evidence for future data-driven studies.

Introduction: Traumatic intracranial pseudoaneurysms (TICAs) and penetrating cerebrovascular injuries (PCVI) complicate gunshot wounds to the head (GSWH) and other forms of penetrating traumatic brain injury (pTBI). Recent developments in neuroimaging have allowed early detection of these lesions in the minutes and hours following the initial injury. CT angiography (CTA) and digitally subtracted angiography (DSA) have different sensitivity, periprocedural risks, and logistical limitations. Growing evidence is defining their role in clinical practice. Methods: A systematic review of the literature was performed for published articles treating the use of CTA and DSA to diagnose PCVI and TICAs after pTBI and GSWH. Four series, three retrospective and one prospective, were selected for this review. Results: In three retrospective and one prospective series (with a sensitivity of ~70% in the former studies vs 36% in the latter), DSA emerges as the modality of choice to study the intracranial vasculature of patients that suffered pTBI. Nonetheless, the use of CTA in the first hours after the injury can provide a wealth of information in emergent scenarios where TICAs and PCVIs can significantly affect surgical management and risk. Further, a significantly higher incidence of TICAs was reported in the first hours after civilian GSWH via CTA. Conclusions: DSA and CTA emerged as two complementary techniques in the study and management of PCVI and TICA related to pTBI and GSWH. Their integration can provide a safe approach to the emergent surgical management of vascular lesions via CTA, allowing for delayed DSA characterization after neurological and hemodynamical stabilization.

OBJECTIVE: External ventricular drain (EVD) placement is a common neurosurgical procedure that can be performed at bedside. A frequent complication following EVD placement is catheter-associated hemorrhage (CAH). The hemorrhage itself is rarely clinically significant but may be complicated in patients taking anticoagulant or antiplatelet (AC/AP) medications. METHODS: A total of 757 patients were who underwent EVD placement at bedside were included as part of a retrospective study at a large academic medical center. Demographic factors, use of AC/AP therapies, and several other clinical variables were recorded and assessed in nivariate and multivariate regression analysis for association with CAH and mortality. RESULTS: One hundred (13.2%) patients experienced CAH within 24 hours of the procedure. After univariate analysis, in 2 tandem -run multivariate regression analyses after stepwise variable selection, use of 2 or more AC/AP agents (odds ratio [OR] = 2.362, P = 0.020) and dual antiplatelet therapy with aspirin and clopidogrel (OR = 3.72, P = 0.009) were significantly associated with CAH. Use of noncoated catheters was a protective factor against CAH compared to use of antibiotic-coated catheters (OR = 0.55, P = 0.019). Multivariate analysis showed age, multiagent therapy, and thrombocytopenia were significantly associated with increased mortality. CONCLUSIONS: There was increased risk of CAH after EVD placement in patients taking more than one AC/AP agent regardless of presenting pathology. In particular, use of aspirin and clopidogrel combined was associated with significantly higher odds of CAH, although it was not associated with higher mortality. In addition, there appears to be an association between use of antibiotic-coated catheters and CAH across univariate and multivariate analysis.

In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (cGSWH) was ∼3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission computed tomographic angiography (aCTA) in cGSWH. Over the period from 2017 to 2022, 341 patients were admitted to R. Adams Cowley Shock Trauma Center with cGSWH; 136 subjects had aCTA ∼3 (standard deviation [SD] 3.5) h post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, and outcomes were analyzed. Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission Glasgow Coma Scale (GCS) score was 6 (SD 3.9). Entry site was frontal in 41, temporal in 55, parietal in 18, occipital in 6, suboccipital in 9, temporo-parietal in 1, and frontobasal-temporal in 6. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subject: 24 were located along the middle cerebral artery (MCA), 6 in the anterior cerebral artery (ACA), 3 in the internal carotid artery (ICA), 1 in the posterior cerebral artery (PCA), and 1 in the middle meningeal artery (MMA). Eleven TICAs resolved spontaneously in nine patients. Eight aneurysms were treated by endovascular means, two via combined endovascular/open approaches. Forty-nine patients died, 10 of whom had 15 TICAs. Eighty patients developed intracerebral hematoma s (ICHs). Regression models showed that the presence of an ICH was the main predictor of TICA in cGSWH. Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with cGSWH suggest hidden TICAs. Nearly 30% of patients had spontaneous resolution within 1 week. When CTA was performed acutely, TICAs were 10 times more frequent in cGSWH than in previous literature, and those patients were more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of cGSWH.

Management of chronic subdural hematoma (cSDH) poses unique challenges and can be fraught with complications. Understanding the spatial relationships of cSDH to adjacent brain tissue and skull topography is critical for successful surgical treatment. The aim of this report is to highlight the feasibility and efficacy of a novel augmented reality (AR) overlay tool for surgical planning with technical description of two surgical cases using AR for surgical management of cSDH. This report describes a fiducial-less AR system for surgical planning of surgical evacuation of cSDH. The AR system was used to superimpose 3D anatomy onto the patients head to provide image guidance during two cases of evacuation. Imaging demonstrated convexity cSDH. A 3D model of the patient's anatomy was created and registered onto the patients' heads using a novel AR system. Surgical evacuation of the cSDH was completed in each case with surgical planning assisted by AR overlay.

BACKGROUND: Decompression of the injured spinal cord confers neuroprotection. Compared with timing of surgery, verification of surgical decompression is understudied. OBJECTIVE: To compare the judgment of cervical spinal cord decompression using real-time intraoperative ultrasound (IOUS) following laminectomy with postoperative MRI and CT myelography. METHODS: Fifty-one patients were retrospectively reviewed. Completeness of decompression was evaluated by real-time IOUS and compared with postoperative MRI (47 cases) and CT myelography (4 cases). RESULTS: Five cases (9.8%) underwent additional laminectomy after initial IOUS evaluation to yield a final judgment of adequate decompression using IOUS in all 51 cases (100%). Postoperative MRI/CT myelography showed adequate decompression in 43 cases (84.31%). Six cases had insufficient bony decompression, of which 3 (50%) had cerebrospinal fluid effacement at >1 level. Two cases had severe circumferential intradural swelling despite adequate bony decompression. Between groups with and without adequate decompression on postoperative MRI/CT myelography, there were significant differences for American Spinal Injury Association motor score, American Spinal Injury Association Impairment Scale grade, AO Spine injury morphology, and intramedullary lesion length (IMLL). Multivariate analysis using stepwise variable selection and logistic regression showed that preoperative IMLL was the most significant predictor of inadequate decompression on postoperative imaging (P = .024). CONCLUSION: Patients with severe clinical injury and large IMLL were more likely to have inadequate decompression on postoperative MRI/CT myelography. IOUS can serve as a supplement to postoperative MRI/CT myelography for the assessment of spinal cord decompression. However, further investigation, additional surgeon experience, and anticipation of prolonged swelling after surgery are required.

Background Paroxysmal sympathetic hyperactivity (PSH) occurs in a subset of patients with traumatic brain injury (TBI) and is associated with worse outcomes. Sepsis is also associated with worse outcomes after TBI and shares several physiologic features with PSH, potentially creating diagnostic confusion and suboptimal management of each. This is the first study to directly investigate the interaction between PSH and infection using robust diagnostic criteria. Methods We performed a retrospective cohort study of patients with TBI admitted to a level I trauma center intensive care unit with hospital length of stay of at least 2 weeks. From January 2016 to July 2018, 77 patients diagnosed with PSH were 1:1 matched by age and Glasgow Coma Scale to 77 patients without PSH. Trauma infectious diseases subspecialists prospectively documented assessments corroborating diagnoses of infection. Extracted data including incidence, timing, classification, and anatomical source of infections were compared according to PSH diagnosis. We also evaluated daily PSH clinical feature severity scores and systemic inflammatory response syndrome (SIRS) criteria and compared values for patients with and without confirmed infection, stratified by PSH diagnosis. Results During the first 2 weeks of hospitalization, there were no differences in rates of suspected (62%) nor confirmed (48%) infection between patients with PSH and controls. Specific treatments for PSH were initiated on median hospital day 7 and for confirmed infections on median hospital day 8. SIRS criteria could identify infection only in patients who were not diagnosed with PSH. Conclusions In the presence of brain injury-induced autonomic nervous system dysregulation, the initiation and continuation of antimicrobial therapy is a challenging clinical decision, as standard physiologic markers of sepsis do not distinguish infected from noninfected patients with PSH, and these entities often present around the same time. Clinicians should be aware that PSH is a potential driver of SIRS, and familiarity with its diagnostic criteria as proposed by the PSH assessment measure is important. Management by a multidisciplinary team attentive to these issues may reduce rates of inappropriate antibiotic usage and misdiagnoses.

Expansion duraplasty to reopen effaced subarachnoid space and improve spinal cord perfusion, autoregulation, and spinal pressure reactivity index (sPRX) has been advocated in patients with traumatic cervical spinal cord injury (tCSCI). We designed this study to identify candidates for expansion duraplasty, based on the absence of cerebrospinal fluid (CSF) interface around the spinal cord on magnetic resonance imaging (MRI), in the setting of otherwise adequate bony decompression. Over a 61-month period, 104 consecutive American Spinal Injury Association Impairment Scale (AIS) grades A-C patients with tCSCI had post-operative MRI to assess the adequacy of surgical decompression. Their mean age was 53.4 years, and 89% were male. Sixty-one patients had falls, 31 motor vehicle collisions, 11 sport injuries, and one an assault. The AIS grade was A in 56, B in 18, and C in 30 patients. Fifty-four patients had fracture dislocations; there was no evidence of skeletal injury in 50 patients. Mean intramedullary lesion length (IMLL) was 46.9 (standard deviation = 19.4) mm. Median time from injury to decompression was 17 h (interquartile range 15.2 h). After surgery, 94 patients had adequate decompression as judged by the presence of CSF anterior and posterior to the spinal cord, whereas 10 patients had effacement of the subarachnoid space at the injury epicenter. In two patients whose decompression was not definitive and post-operative MRI indicated inadequate decompression, expansion duraplasty was performed. Candidates for expansion duraplasty (i.e., those with inadequate decompression) were significantly younger (p < 0.0001), were AIS grade A (p < 0.0016), had either sport injuries (six patients) or motor vehicle collisions (three patients) (p < 0.0001), had fracture dislocation (p = 0.00016), and had longer IMLL (p = 0.0097). In regression models, patients with sport injuries and inadequate decompression were suitable candidates for expansion duraplasty (p = 0.03). Further, 9.6% of patients failed bony decompression alone and either did (2) or would have (8) benefited from expansion duraplasty.