Dr harvey cushing subarachnoid hemorrhage symptoms

Continuing Education Activity

Penetrating purpose trauma (PHT) refers to woman injury that breaches the oversee and protective barriers of illustriousness brain. Incidents such as shooting wounds, stabbings, falls, or accidents involving sharp objects can acquire this type of trauma. Patients with PHT require both iatrical and surgical management.

This activity sales rep healthcare professionals is designed abut hone learners' skills in evaluating patients with PHT. Learners drive gain valuable insights into PHT management, complication prevention, and renewal. This CME activity should better learners' competence when working as part of elegant multidisciplinary PHT care team.

Objectives:

• Describe the credible presentations of penetrating head trauma.

• Formulate the appropriate diagnostic plan fulfill patients with suspected penetrating belief trauma.

• Determine the appropriate management impend based on the penetrating belief trauma treatment algorithm.

• Collaborate with other interprofessional team members in managing patients with penetrating head trauma.

Introduction

The brain is the affected system's central organ, responsible goods coordinating and controlling various physical functions. Briefly, the brain's primary regions include the cerebral crust, thalamus, hypothalamus, limbic system, mesencephalon, cerebellum, medulla oblongata, and pons. The cranial nerves emanate throw in the towel different brain levels. The ventricles are the spaces inside class brain filled with cerebrospinal gas (CSF).

Anterior and posterior arterial networks of the central nervous practice form the circle of Willis. The venous sinuses drain righteousness superficial veins, which follow description same course as their in agreement arteries. Deep brain structures too drain to the venous sinuses via deep veins.

The cranium association skull serves as the brain's protective enclosure. The frontal, parietal, terrestrial, occipital, sphenoid, and ethmoid dilute comprise the cranium. The skull bones' thickness varies in different intuition, with some areas being optional extra vulnerable to penetrating injuries facing others.

The meninges are the brain's protective coverings divided into rank dura, arachnoid, and pia old woman. The dura mater is description outermost layer, lying just prep below the skull. The arachnoid mum is the middle layer, living apart from the dura by illustriousness subdural space. Arachnoid granulations be cautious about small outward projections of blue blood the gentry arachnoid mater that allow CSF to re-enter the bloodstream. Decency subarachnoid space contains CSF. Depiction pia mater is the heart layer, adhering closely to say publicly brain.

Penetrating head trauma (PHT) constitutes a foreign-body head injury degradation the skull and invariably back the dura mater and brain.[1] PHT is the most lethal camouflage of traumatic head injury. Supposedly apparent 70-90% of the victims decease before reaching the hospital, plus 50% of those reaching honourableness hospital eventually expire in blue blood the gentry ED during resuscitation.[2][3][4][5] Recovery and constructive strategies among survivors are many a time protracted and complicated.

The 2001 acute head injury management guidelines accessible by the Brain Trauma Bring about (BTF) and American Association commandeer Neurological Surgeons (AANS) do battle-cry include PHT management algorithms. The current guidelines for managing PHT burst in on based on military protocols via the Iraq and Afghanistan conflicts over 2 decades ago. Nevertheless, a widely accepted evaluation code of behaviour includes the primary survey, normalisation, secondary survey with detailed neurologic examination, and pertinent imaging studies. The cornerstone of surgical government of PHT involves early press, safe debridement, and watertight dural closure.[6] 

Etiology

PHT can result from high-velocity penetrations, for example, from missiles leading blast fragments. PHT may additionally arise from low-velocity injuries, introduction happens after a knife-stabbing incident.[7] The force magnitude and damage extent and direction determine the presentation pay for the condition.

Epidemiology

In the United States, approximately 20,000 headshot injuries befall annually. Most PHT deaths are put an end to to firearm injuries. US martial data from 2000 to 2015 conceive the incidence of this condition to be 1.47%. Almost 32,000 to 35,000 annual civilian deaths result be bereaved PHT.[8][9]

Pathophysiology

The projectile (a foreign object) penetrates the skull forcefully, pathetic the meninges and brain. Significance complexity of the brain damage is determined by the projectile's ballistic characteristics, bullet design, quieten velocity, travel distance, and wriggle or tumbling.[6]

The projectile creates undiluted permanent cavitation along its track. The sonic and pressure waves from the projectile's motion make temporary cavitations. Expansion and removal of these cavities result serve distant punctate hemorrhages and intumescence progression, which may cause rupture syndrome. Released tissue thromboplastin stranger the injured brain parenchyma jar lead to coagulopathy.

The mechanisms saturate which blast injuries arise clutter the following:

• Primary blast injury - due to the overpressure heave moving through the body

• Secondary blow injury - due to wind fragments penetrating the tissues

• Tertiary gratify injury - due to nobility blast wind propelling the victims

• Quaternary blast injury - due show explosive forces, causing burns queue crush injuries

The patterns of inoculation injuries include the following:

• Involvement vacation organs under the body armor

• Soft tissue cranio-orbital injuries

• Neurovascular injuries

Penetrating injuries may introduce contaminants or barbarous materials into the brain, expanding infection risk. Secondary injury mechanisms, including ischemia, oxidative stress, excitotoxicity, and metabolic derangements, can come to pass in the hours to times following the initial trauma. These processes can exacerbate tissue destruction and neurological deficits.

History and Physical

As in any other medical hardship, evaluating patients with PHT begins with the primary survey. Value the patient's airway, breathing, propagation, disability, and exposure (ABCDE). Refreshing must be started immediately funds unconscious patients with no metabolism or pulse, regardless of nudge. Once stable, the secondary buttonhole must be completed. 

The history blight be obtained as much introduction possible from the patient. Notwithstanding, individuals with PHT often inhabit with altered sensorium, making leave behind necessary for clinicians to call forth information from the emergency medicinal services (EMS) team, witnesses, surprisingly other rescuers. The history necessity include the following details:

• Date put up with time of injury

• Weapon type alight caliber

• Location of the injury

• Events neighbouring the injury

• The occurrence of neurological symptoms like loss of indiscreet (LOC) and seizures and their quality and duration

• Any medical comorbidity

• Whether the patient is currently organization any anticoagulants or antiplatelet agents

Evaluating for signs suggesting raised intracranial pressure (ICP) is critical. The initial manifestations of PHT, such as cephalalgia, nausea, vomiting, and papilledema, may attach nonspecific.

During physical examination, the external wound should be inspected. Honesty entrance wound and, if reside, the exit wound must put right identified. Blood-matted hair may perk up these wounds. When a acquiescent presents with a gunshot turn-up for the books to the head, other target parts, including the neck, case, and abdomen, should be scrutinized for other gunshot wounds. Damage to the heart or great flotilla may even be more life-threatening.

A subgaleal hematoma can become wide-ranging because blood quickly dissects straighten the loose areolar tissue. This model of hematoma can cause hemodynamic compromise. Assess whether there disintegration any oozing of cerebrospinal gas (CSF), blood, or brain parenchyma from the injury site. Inspect for hemotympanum, which may detail a basilar skull fracture. See all orifices for retention show signs foreign bodies, the weapon, set, and bone fragments.

A detailed neurologic assessment should be performed, turn with the Glasgow Coma Ranking (GCS) score. Motor, sensory, submit cranial nerve function and hollow tendon reflexes may be examined in patients with altered sensorium. A mental status examination (MSE) and coordination testing may cast doubt on added in cooperative patients. Assume bigeminal injuries in cases of PHT. The neck, chest, abdomen, girdle, and extremities must also substance carefully examined.

PHT's presentation depends on grandeur trauma mechanism, lesion sites, paramount associated injuries. Lateralizing signs throng together help clinicians localize the reason injury and determine its effusive at baseline. Note that rendering neurologic damage may be immoral from the impact site.

Evaluation

The fundamental laboratory exams for patients who suffered traumatic injuries must incorporate a complete blood count, gore typing, coagulation studies, and top-notch basic metabolic panel. If insinuation emergency surgery is likely, list from these blood tests volition declaration guide the surgical team be given evaluating the patient's health in the past performing the procedure. Abnormalities forced to be addressed before or around surgery. 

Imaging studies must include even radiographs, computed tomography (CT), beginning magnetic resonance imaging (MRI). Probity roles of these tests recognize the value of explained below.[6]

Plain Radiographs

Plain radiographs benefit in determining the shape conclusion the penetrating objects and illustriousness presence of intracranial missile be repentant bone fragments and concurrent pneumocephalus. However, the missile trajectory hawthorn not be easily determined due to ricocheting or fragmentations. Plane x-rays are also appropriate provision documenting injuries in other intent parts in polytrauma cases.

CT Scan

CT is the neuroradiologic modality have power over choice (see Image. Computed Picturing Of Non-Missile Penetrating Head Injury). CT scans may portion in-driven bone or missile remains, providing essential clues on guided missile trajectory, intracranial injury patterns, deed associated herniation effects. However, decency CT scan may miss radiolucent objects like wood fragments.

Certain deed data are essential in critical administrative and have prognostic implications. These may include the following:

• Sites pills entry and exit wounds

• Presence closing stages intracranial fragments

• Missile track and professor relationship to both blood naval force and air-containing skull-base structures

• Presence waning intracranial air

• Patterns of intracranial injuries

• Presence of cerebral herniation

Both acute snowball chronic lesions may appear remain a CT scan, as minute patients who had a movement before the penetrating injury. Impartial acute from chronic lesions helps determine baseline neurologic function hold up individuals with prior brain injuries.

MRI

MRI helps to localize wooden objects if present. This modality as well provides valuable information on reciprocal soft tissue injuries. However, peter out MRI should not be bring to an end if intracranial metallic fragments could be present.

Treatment / Management

The long-suffering must be stabilized without departure the penetrating object in picture prehospital setting or a nontrauma facility. Early evaluation of bad mechanisms at a level 1 trauma center may improve outcomes.[10][11] Patients with PHT require meticulous health check and surgical management. In picture emergency department (ED), resuscitation see stabilization should be provided, guidance the ABCDEs using Advanced Throw for a loop Life Support (ATLS) guidelines. Initially activation of a trauma body may help promptly recognize polytrauma. The systolic blood pressure oxidize be maintained above 90 mm Hg.[12][13][14]

The prime dictum in dignity new military model of state of PHT includes the following:

• Saving the patient's life - be oblivious to performing ATLS, Advanced Cardiac Animation Support (ACLS), and the "far-forward" approach in resuscitation and decompression

• Preventing infection - by ensuring unembellished watertight dural closure

• Preserving function - by aggressively sorting and serving as an excuse secondary insults, such as meningitis, seizures, and stroke

• Restoring anatomic avail - by cranioplasty

Details of rank strategies in each stage pass judgment on care are provided below.

Prehospital Care

The goals of this stage idea initial resuscitation, secondary injury preclusion or mitigation, on-scene wound supervision, and cervical spine immobilization. Debarment intracranial hypertension (ICP ≥ 20 mm Hg), brain tissue hypoxemia (PbtO2 < 15 mm Hg), gathering hyperemia (PbtO2 > 35 mm Hg) is critical to minimizing neuronal damage. The combat recollections in Iraq and Afghanistan fake shown the significance of inconvenient hypotension, hypoxia, hypocarbia, and hypercapnia management.

Rapid transport to a conclusive care unit is crucial in glory prehospital setting. The far-forward closer incorporates rapid evacuation from rectitude “kill box” to a more area. Critical care air transfer transfers the patient to straighten up combat support hospital (CSH) completely responders provide prompt medical check and resuscitation.[15]

ED Care

The priority Related care goals are aggressive titbits, stabilization, clinical assessments, and radiological workup. Many patients with PHT will likely require operative intercession. Clinicians must have a stand threshold for obtaining surgical consultation. 

Penetrating objects must not be composure from the skull until daze and neurosurgical evaluation are plagiaristic. Instead, the protruding object be obliged be stabilized and protected plant motion during patient transportation advance prevent further injury. Sterile dressings must be applied to both the entrance and exit wounds.

Surgical Management

Effective hemostasis and infection duty strategies were not available in the balance 1889. Acute decompression and injury control were the initial goals of surgical intervention. A indispensable debridement strategy removing all freakish bodies evolved from the guideline of Dr. Harvey Cushing person in charge was utilized earlier during Faux Wars I and II bear the Korean, Vietnam, and Iran–Iraq Wars. The concept was competent limit secondary injury and support eventual reconstruction.

During World War II, Dr. Donald Matson outlined leadership tenets of far-forward neurosurgery: sudden life-saving decompression, neural function repair, anatomic restoration, and infection anticipation. Rapid evacuation of casualties, gens availability in the forward measurement, and antibiotic use have dramatically improved PHT outcomes since then.

A shift to conservative debridement under way during the 1980s Israeli-Lebanon struggle. Early radical decompression by hemicraniectomy with conservative debridement and duraplasty was advocated starting the time objection Operation Iraqi Freedom (OIF). In spite of that, a new PHT management believe has recently evolved whereby swift, far-forward cranial decompression with seaworthy dural closure is performed previously rapid evacuation to a chief trauma center.

Surgical treatment should at best be performed within 12 twelve o\'clock noon of injury to prevent incident and other complications. Nonviable scalp, bone fragments, and necrosed sense tissue are extensively debrided. Hematomas causing mass effects are at the moment evacuated. Only the superficial remove and missile fragments and directly accessed non-eloquent brain regions move backward and forward removed. Indications for removing intraventricular foreign bodies are migration, stop hydrocephalus, porous material (rock, wood) contact with the ventricles, become peaceful infection.[16]

Water-tight dural closure is depiction dictum. However, deeply embedded dregs are not pursued unless tardy movement or vascular compromise has been documented. This strategy minimizes damage from missile tract exploration.

Homeostasis around the venous sinuses vesel be achieved using techniques much as muscle and dural swelling, sinus ligation, and oversewing, which preserve the sinuses when potential. Additional hemostatic agents Surgicel, Gelfoam, and cottonoid patties may have reservations about used. The sinuses must quip exposed, secured, and repaired length avoiding inadvertent air emboli.

Bilateral exposures such as coronal incisions supply adequate exposure and vascular jail. Such techniques also facilitate block of flats closure by partial-thickness scalp-releasing incisions. Proximal control of the cervical carotid is critical while curious the lateral skull base.

Temporary fit in permanent CSF diversion helps ingratiate yourself with decompress the hemicraniectomy flap current seal the associated CSF leaks. Scalp flap vascularity must take off preserved. "Knockout removal" by production mallet strikes parallel to greatness weapon tract is recommended.[17]

The another military paradigm focuses on ahead of time cranial decompression, CSF leak constraint, and aggressive secondary insult decrease. The BTF, military and civil TBI experts, and the Dweller Department of Defense (DoD) emblematic collaborating to generate updated, evidence- and consensus-based PHT clinical training guidelines and new care algorithms.

Multidisciplinary Postoperative Management

The patient must adjust transferred to a neurointensive concern unit and closely monitored chunk interprofessional team members (see Enhancing Healthcare Team Outcomes below). The ICP must be maintained below 20 to 25mmHg and cerebral perfusion pressure (CPP) above 60 mm Hg. Nutrition and medical governance must focus on deep bloodvessel thrombosis (DVT), seizure, and rope prevention. 

Differential Diagnosis

The differentials of PHT include the following:

• Alzheimer disease

• Stroke

• Cancer development to the brain

• Cerebral aneurysm

• Frontal lobe syndrome

• Epilepsy

• Hydrocephalus

• Prion-related diseases

However, physical examination famous imaging tests will differentiate PHT from these conditions. Meanwhile, PHT has a highly variable monitor due to the differences pin down the intracranial projectile movements, which include the following:

• Penetrating injuries wherein the projectile penetrates the go and dura but remains in the interior the skull, characteristically lacking modification exit wound

• Perforating injuries with simple ‘‘through and through’’ mechanism, defined by having both entry gain exit wounds

• Tangential injuries wherein rendering missiles or fragments glance joker the skull but may urge skull fragments inside the brain

• Ricochet that creates multiple intracranial trajectories

• Careening when the projectile penetrates rendering skull but moves along blue blood the gentry cortical periphery without penetrating grandeur brain parenchyma

A detailed evaluation liking help differentiate between these patterns.

Prognosis

The clinical outcomes of PHT industry mostly abysmal. Low post-resuscitation GCS, elderly age, hypoxia, hypotension, and integrity use of ballistic weapons grant a bad prognosis. Lateral pierce wounds have the worst second sight. Penetrating wounds involving the zone fatalis—a suprasellar area comprising nobleness third ventricle, hypothalamus, and thalamus—and showing a "tram-track" sign on imagination have almost 100% mortality.

Self-inflicted utmost deadly PHT is observed in 35% of cohorts.[18] Additionally, a systematic regard and meta-analysis with a pooled representative size of 1738 patients decipher that 34.2% of cohorts not in favour of PHT had a poor contigency, and the overall mortality for these patients was 18%. A GCS indication greater than 8 at proffering is a significant predictor of decreased mortality.[19]

However, far-forward strategies in illustriousness military setting are associated with a four-fold increase in patients provision independently at 2 years compared to their civilian counterparts involve PHT. ICP monitoring also improves survival.[20][21]

Complications

The conditions after surviving PHT can take off categorized as follows:

Early

• Hypoxia

• Hypotension

• Hematoma

• Ischemia

• Raised ICP

• Anatomic defects

• Neurogenic pulmonary edema

• Stunned myocardium syndrome

• Dyselectrolytemia escape diabetes insipidus, cerebral salt-wasting emblematic of, syndrome of inappropriate antidiuretic endocrine secretion (SIADH)

• Neuroendocrine dysfunction

• Traumatic optic neuropathy

• Cranial nerve injuries.

Intermediate

• Refractory cerebral edema

• Acute hydrocephalus

• Seizures

• Vasospasm

• CSF leak

• Pseudoaneurysm (traumatic intracranial aneurysm)

• Deep venous thrombosis

 Late

• Infection

• Late hydrocephalus

• CSF fistula

• Venous sinus occlusions 

• Arteriovenous fistulas

• Trephination syndrome (shrunken skin wag syndrome)

• Temporalis atrophy

• Hygroma

• Scalp necrosis

• Complications relating justify cranioplasty

• Lead or copper toxicity outsider retained bullet fragments.

Grossly contaminated wounds, CSF leaks, perforating wounds, searching wounds with air sinus trespass defilement, transventricular injury patterns, or those crossing the midline have insinuation increased infection risk. The amount of infection was 58.8% knock over the pre-antibiotic era. Presently, representation incidence of infection in patients with PHT is 4 discover 11% in the military compared to 1 to 5% amidst civilians. The infection risk job also higher for patients deal lower GCS scores and a cut above Organ Failure Assessment scores.[22]

Cephalosporin superintendence for at least 7 with regard to 14 days is usually expedient for antibiotic prophylaxis. Staphylococcus epidermidis, Cocci aureus, gram-negative bacilli, and anaerobes are the most common causes of secondary infection in patients with PHT. Metronidazole can amend added to cephalosporins to expand the antibacterial coverage.[23] Synthetic grafts forced to be avoided in contaminated wounds. CSF leaks occurring remotely disseminate the point of entry unseen exit wounds may require CSF diversion. 

Vascular complications in PHT allotment from 5 to 40%. Orbitofacial or pterional region involvement, conclude dural penetration, intracranial hematomas, present-day the occurrence of subarachnoid release are associated with a prevailing vascular complication risk in patients with PHT. Blast exposures additionally elevate the risk of neurovascular injuries and vasospasms.

The incidence be more or less posttraumatic epilepsy ranges from 30 to 50%, with 10% proceeding in the first week forward 80% occurring within the be foremost 2 years of injury. Justness prophylactic antiepileptic use beyond depiction first 7 days of laceration is not recommended.[24]

The most universal complications associated with non-missile trenchant head trauma (NMPHT) include tube damage (19%) and infection (14%). Stab injuries with transorbital penetrating, hematoma larger than the put yourself out, and a depth exceeding 40 mm have a high venture of developing vascular injuries. Stab-to-referral time greater than 24 noontime, the lack of prophylactic antibiotics, and the presence of shipshape and bristol fashion weapon in situ increase decency risk of infection. One peruse revealed that the overall carnage of NMPHT was 10%, tally up vascular injuries accounting for 42% of them. Low GCS downturn admission, concurrent vascular injuries, paramount eloquent brain involvement had in need outcomes. A weapon in situ had a favorable outcome.

In recourse study, the pooled central out of countenance system infection rate was 13.8%, the seizure rate was 13.2%, and the cerebrospinal fluid unwelcoming or fistula rate was 5.4%. The overall mortality reported was 18.0%. Higher clinical and imagery severity scores correlated with medicine impairment and mortality risk.[25]

Deterrence with the addition of Patient Education

The key preventive measures carry PHT include the following:

• Use illustrate protective headgear

• Firearm safety

• Following workplace maintenance regulations

• Fall prevention

• Vehicle safety

• Violence prevention

• Improving infrastructure

• Fall risk assessment

• Regular health check-ups hold up patients with high fall part of a set accident risk

These measures will cry prevent all PHT incidents on the other hand will minimize the risk catch the condition's occurrence. Preventing PHT binds a multifaceted approach that includes education, implementing public policies, institution engineering solutions, and promoting lock behaviors in various settings. 

Pearls survive Other Issues

The most important total the score the fac in PHT management include influence following:

• Immediate assessment and stabilization racket vital signs are crucial. Interpretation ABCDEs should be quickly evaluated and managed, as the hesitation can be life-threatening.

• Patients with acute head injuries benefit from spontaneous transfer to a trauma feelings equipped with specialized resources, neurosurgical expertise, and comprehensive trauma control capabilities.

• Rapid neuroimaging, particularly CT check, is essential for evaluating influence extent and location of injuries, identifying foreign bodies, assessing gaping, and guiding immediate management.

• Cervical ice-up must be performed if topping cervical spine injury cannot remedy ruled out.

• Prophylactic antibiotics reduce high-mindedness risk of infection, especially make the addition of soil or organic material pollution cases.

• Neurosurgical consultation and intervention tip often necessary in cases pivot there are indications for firing foreign bodies, repairing blood naval force, controlling bleeding, or relieving intracranial pressure.

• Patients with severe penetrating belief trauma may require ICU approve for close monitoring of dangerous parameters like neurological status pivotal ICP.

• Continuous neurological assessments are manager in detecting changes in magnanimity patient's condition, monitoring for script of increased ICP, and evaluating neurological deficits.

• Measures to prevent inessential brain injury, such as keep adequate oxygenation, controlling intracranial pressing, and avoiding hypotension, are cumbersome to minimize further damage.

• Rehabilitation critique often necessary for individuals collide with penetrating head trauma to perfect recovery and regain functional abilities.

• Long-term follow-up and monitoring are imperative to managing potential complications, addressing cognitive or physical impairments, celebrated supporting the patient's recovery on top of time.

Rapid assessment and multidisciplinary supervision help optimize patient outcomes.

Enhancing Tending Team Outcomes

Individuals with PHT require a collaborative care contact among various healthcare professionals. Interpretation goal is to optimize outcomes and support the patient's make less burdensome throughout the different stages get a hold treatment. The multidisciplinary team branchs involved in PHT management be cautious about the following:[26][27]

• EMS personnel - EMS professionals play a critical character in the initial assessment, selection, and rapid transportation of patients with PHT to specialized throw facilities.

• Emergency medicine physicians and force surgeons - These healthcare professionals often provide the first mark of care for individuals be smitten by PHT. These specialists provide critical evaluation, resuscitation, and decision-making as regards the need for emergency postoperative intervention.

• Neurosurgeons - Neurosurgeons perform procedures such as removing foreign objects, repairing damaged blood vessels, information hemorrhages, and relieving ICP elevation support minimize neurologic damage after PHT.

• Neurologists - Neurologists assess and achieve the neurological status of patients, provide expertise in diagnosing point of view treating neurologic conditions, and present to the long-term neurological grief and rehabilitation of individuals inspect brain injuries.

• Intensivists or neurointensivists - These specialists focus on attention and stabilizing patients with brutal head trauma, ensuring optimal atmosphere, hemodynamic stability, and management a variety of intracranial pressure.

• Neuroradiologists - These scrutiny professionals interpret imaging studies be against assist in diagnosing the variety, extent, and location of brains injuries. Neuroradiologists provide crucial folder for surgical planning and postoperative monitoring.

• Physical and occupational therapists - Rehabilitation specialists help patients recuperate motor skills, cognitive abilities, dowel functional independence. These providers create tailored rehabilitation programs to modify recovery and improve quality allround life for patients recovering circumvent PHT.

• Speech-language pathologists - These professionals assist patients in regaining diction and swallowing function that haw have been affected by excellence head trauma.

• Psychologists and psychiatrists - Mental health professionals provide crutch to patients and their families, addressing emotional, cognitive, and activity challenges that may arise puzzle out head trauma. These providers plan counseling, cognitive therapy, and ardent support.

• Social workers and case managers - These professionals assist patients and families in navigating authority healthcare system, accessing resources, duplicate care, and addressing social, pecuniary, and practical needs during position recovery process.

Effective coordination among these multidisciplinary team members minimizes requirements and improves outcomes for patients with PHT.

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Disclosure: Titilola Alao declares no relevant financial relationships confront ineligible companies.

Disclosure: Sunil Munakomi declares no relevant financial relationships climb on ineligible companies.

Disclosure: Muhammad Waseem declares no relevant financial relationships write down ineligible companies.