In depth studies of fatal vehicular accidents provide valuable data for implementing effective emergency services to reduce the trauma related mortality and strengthening legal measures in peak hours of fatal accidents. We aimed to study, pattern of injuries especially fatal traumatic brain injuries occurring in vehicular accidents. Postmortem reports and clinical records of victims of road traffic accident autopsied during the period of 2001–2005 at Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, were analyzed retrospectively. Out of total 7008 medico legal autopsies conducted during the study period, 2472 (35.27 %) were of vehicular accidents. The male/female ratio was 7.49:1. Commonest age group affected was between 21-40 years involving 1341 (54.24%) cases. Pre-hospital mortality was in 985 (39.84 %) cases. Fatal traumatic brain injuries were seen in 1699 (68.73%) cases. Skull fractures were found in 1183 (69.63%) cases of head injury; most common bone fractured was temporal bone (n=559, 47.25%). The commonest variety of intracranial hemorrhage was subdural hemorrhage (n=1514, 89.11%). The craniotomy was done in 297 (17.48%) cases; maximum mortality (41.07%) was seen within 4–ays. Most commonly injured abdominal organ was liver (n=532, 21.52%). No significant difference was evident in incidence of fatal vehicular accident on weekends and weekdays. However November month took maximum toll of deaths (n=273, 11.04%) of total vehicular accident fatalities in five year duration. 53.20% of fatal accident occurred between 6 PM and 6 AM. The results of study emphasize the need to improve the pre hospital care with provision of trauma services at site and to establish neurosurgical facilities with trauma registry.

Angiotensin-converting enzyme 2 (ACE2) is a key host protein by which severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) enters and multiplies within cells. The level of ACE2 expression in the lung is hypothesised to correlate with an increased risk of severe infection and complications in COrona VIrus Disease 2019 (COVID-19). To test this hypothesis, we compared the protein expression status of ACE2 by immunohistochemistry (IHC) in post-mortem lung samples of patients who died of severe COVID-19 and lung samples obtained from non-COVID-19 patients for other indications. IHC for CD61 and CD163 was performed for the assessment of platelet-rich microthrombi and macrophages, respectively. IHC for SARS-CoV-2 viral antigen was also performed. In a total of 55, 44 COVID-19 post-mortem lung samples were tested for ACE2, 36 for CD163, and 26 for CD61, compared to 15 non-covid 19 control lung sections. Quantification of immunostaining, random sampling, and correlation analysis were used to substantiate the morphologic findings. Our results show that ACE2 protein expression was significantly higher in COVID-19 post-mortem lung tissues than in controls, regardless of sample size. Histomorphology in COVID-19 lungs showed diffuse alveolar damage (DAD), acute bronchopneumonia, and acute lung injury with SARS-CoV-2 viral protein detected in a subset of cases. ACE2 expression levels were positively correlated with increased expression levels of CD61 and CD163. In conclusion, our results show significantly higher ACE2 protein expression in severe COVID-19 disease, correlating with increased macrophage infiltration and microthrombi, suggesting a pathobiological role in disease severity.

For decades, the petrous part of the temporal bone has haunted skull base neurosurgeons and continues to do so. The depth of lesions, difficulties of approaches, and challenging neurovascular structures, e.g., brainstem and cranial nerves, have frightened neurosurgeons for decades, causing this area to have a reputation of a "No Man's Land." 17,18,22 Operative approaches to this area include clivectomy after transcervical, transoral, extended transoral, subfrontal, transsellar-transcavernous, transsylvian, combined transsylvian and anterior subtemporal, and combined transsylvian and transpetrosal approaches. Approaches vary from pure extradural to intradural and combined ones. obJect The surgical corridor to the upper third of the clivus and ventral brainstem is hindered by critical neurovascular structures, such as the cavernous sinus, petrous apex, and tentorium. The traditional Kawase approach provides a 10 × 5-mm fenestration at the petrous apex of the temporal bone between the 5th cranial nerve and internal auditory canal. Due to interindividual variability, sometimes this area proves to be insufficient as a corridor to the posterior cranial fossa. The authors describe a modification to the technique of the extradural anterior petrosectomy consisting of additional transcavernous exploration and medial mobilization of the cisternal component of the trigeminal nerve. This approach is termed the modified Dolenc-Kawase (MDK) approach. methods The authors describe a volumetric analysis of temporal bones with 3D laser scanning of dry and drilled bones for respective triangles and rhomboid areas, and they compare the difference of exposure with traditional versus modified approaches on cadaver dissection. Twelve dry temporal bones were laser scanned, and mesh-based volumetric analysis was done followed by drilling of the Kawase triangle and MDK rhomboid. Five cadaveric heads were drilled on alternate sides with both approaches for evaluation of the area exposed, surgical freedom, and angle of approach. results The MDK approach provides an approximately 1.5 times larger area and 2.0 times greater volume of bone at the anterior petrous apex compared with the Kawase's approach. Cadaver dissection objectified the technical feasibility of the MDK approach, providing nearly 1.5-2 times larger fenestration with improved view and angulation to the posterior cranial fossa. Practical application in 6 patients with different lesions proves clinical applicability of the MDK approach. coNclusioNs The larger fenestration at the petrous apex achieved with the MDK approach provides greater surgical freedom at the Dorello canal, gasserian ganglion, and prepontine area and better anteroposterior angulation than the traditional Kawase approach. Additional anterior clinoidectomy and transcavernous exposure helps in dealing with basilar artery aneurysms.

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Quantitative comparative evaluation provides details of exposure and surgical ease with both techniques. We promote hybrid/EDAC technique for vascular pathologies because of better anatomic orientation. Extradural clinoidectomy is the preferred technique for midline cranial neoplasia. An awareness of different variations of clinoidectomy can prevent dependency on any particular approach and facilitate flexibility.