Effects of inpatient rehabilitation after acute care on functional and quality-of-life outcomes in children with severe traumatic brain injury

OBJECTIVE

Few studies have assessed the effectiveness of the rehabilitation process in children surviving severe traumatic brain injury (TBI). We evaluated whether receiving inpatient rehabilitation after acute hospitalization was associated with better functional outcomes compared to receiving only non-inpatient rehabilitation in children with severe TBI and explored an effect modification for Glasgow Coma Scale (GCS) score at hospital discharge.

METHODS

We included 254 children who received rehabilitation following severe TBI from a multinational observational study. The Pediatric Glasgow Outcome Scale - Extended (GOS-E Peds), parent/guardian-reported and child-reported Pediatric Quality of Life Inventory (PedsQL) at 12 months post-injury were assessed and described using summary statistics. Unadjusted and propensity score-weighted linear/ordinal logistic regression modeling were also performed.

RESULTS

180 children received inpatient rehabilitation and 74 children received only non-inpatient rehabilitation after acute hospitalization. Among children with a GCS<13 at discharge, those receiving inpatient rehabilitation had a more favorable GOS-E Peds score (OR = 0.12, p = 0.045). However, no such association was observed in children with a higher GCS. We found no differences in PedsQL scores between rehabilitation groups.

CONCLUSIONS

Future studies are warranted to confirm the benefits of inpatient rehabilitation for children with more severely impaired consciousness when medically stable.

Brain Tissue Damage Induced by Multimodal Neuromonitoring In Situ during MRI after Severe Traumatic Brain Injury: Incidence and Clinical Relevance

Both neuromonitoring and early magnetic resonance imaging (MRI) provide crucial information for treatment management and prognosis in patients with severe traumatic brain injury (sTBI). So far, neuromonitoring in situ impedes the routine implementation of MRI due to safety concerns. We aimed to evaluate the brain tissue damage induced by inserted neuromonitoring devices and its clinical relevance. Nineteen patients with sTBI and being exposed to at least one MRI with neuromonitoring in situ and one follow-up MRI after neuromonitoring removal were analyzed. All MRIs were reviewed for specific tissue damage. Three females and sixteen males (aged 20–74 years, mean 42.8 years) with an initial median GCS of 5 (range 3–8) were analyzed. No lesion was observed in six patients (31.6%), whereas another six patients (31.6%) demonstrated a detectable probe trajectory. Probe-related tissue damage was visible in seven patients (36.8%) with the size of the lesion prone to further enlarge with increasing cumulative duration of MRI examinations. Upon interdisciplinary evaluation, the lesions were not considered clinically relevant. Neuromonitoring probes in situ during MRI examinations may cause local brain tissue damage, yet without any clinical implications if placed correctly. Therefore, indications must be strictly based on joint decision from all involved disciplines.

Risk factors and risk nomogram model of reoperation for hemorrhages after severe traumatic brain injury craniotomy

Objective

This study aimed to explore the risk factors associated with reoperation for postoperative hemorrhages after severe traumatic brain injury (sTBI) craniotomy and establish a risk nomogram model.

Methods

A retrospective case-control study was performed. Overall, 367 patients who were diagnosed with sTBI and fulfilled the inclusion criteria were enrolled from the Department of Neurosurgery of the Affiliated Hospital of Zunyi Medical University between January 2015 and December 2020. They were divided into a reoperation group and a non-reoperation group according to whether they underwent reoperation for hemorrhages. Using univariate binary logistic regression analysis, the possible risk factors were screened. Subsequently, the independent risk factors of reoperation for postoperative hemorrhages were screened using the forward step method of multivariate binary logistic regression analysis, and a corresponding nomogram model was constructed. The receiver operative characteristic (ROC) curve was used to evaluate the reliability of the model. Finally, 30% of the data were randomly selected for internal verification of the model.

Results

The reoperation rate for hemorrhage after sTBI emergency craniotomy was 14.71% (54/367); multivariate logistic regression analysis showed that multiple hemorrhages (odds ratio [OR] = 4.38, 95% confidence interval [CI]: 1.815-10.587, p = 0.001), day or night surgery (OR = 0.26, 95% CI: 0.119-0.547, p < 0.001), operation duration (OR = 0.74, 95% CI: 0.119-0.547, p < 0.025), and abnormal intraoperative blood pressure fluctuation (OR = 4.15, 95% CI: 2.090-8.245, p < 0.001) were statistically significant. The sensitivity and specificity of the nomogram model were 0.815 and 0.661, respectively, and the area under ROC curve was 0.76 (95% CI: 0.705-0.833). Internal verification showed that the area under the ROC curve was 0.783 (95% CI: 0.683-0.883).

Conclusions

Taken together, the results of our study reveal that multiple preoperative intracranial hemorrhages, day and night operation, operation duration, and abnormal fluctuation of intraoperative blood pressure were independent risk factors for postoperative bleeding and reoperation for sTBI. Through the analysis of the influencing factors, a prediction model for the risk of bleeding and reoperation after craniocerebral trauma was developed. Compared with other relevant studies, this prediction model has good prediction efficiency and can be used to predict the occurrence of bleeding and reoperation after sTBI in patients.

Cerebrospinal fluid purinomics as a biomarker approach to predict outcome after severe traumatic brain injury

Severe traumatic brain injury (TBI) is associated with high rates of mortality and long-term disability linked to neurochemical abnormalities. Although purine-derivatives play important roles in TBI pathogenesis in preclinical models, little is known about potential changes in purine levels and their implications in human TBI. We assessed cerebrospinal fluid (CSF) levels of purines in severe TBI patients as potential biomarkers that predict mortality and long-term dysfunction. This was a cross-sectional study performed in 17 severe TBI patients (Glasgow Coma Scale < 8) and 51 controls. Two to four hours after admission to ICU, patients were submitted to ventricular drainage and CSF collection for quantification of adenine and guanine purine-derivatives by HPLC. TBI patients survival was followed up to 3 days from admission. A neurofunctional assessment was performed through the modified Rankin Scale (mRS) two years after ICU admission. Purine levels were compared between control and TBI patients, and between surviving and non-surviving patients. Relative to controls, TBI patients presented increased CSF levels of GDP, guanosine, adenosine, inosine, hypoxanthine, and xanthine. Further, GTP, GDP, IMP, and xanthine levels were different between surviving and non-surviving patients. Among the purines, guanosine was associated with improved mRS (p=0.042; r= -0.506). Remarkably, GTP displayed predictive value (AUC=0.841, p=0.024) for discriminating survival vs. non-survival patients up to three days from admission. These results support TBI-specific purine signatures, suggesting GTP as a promising biomarker of mortality, and guanosine as an indicator of long-term functional disability.

OCTOGENARIAN' SURVIVAL AFTER NEUROSURGICAL PROCEDURES FOLLOWING SEVERE HEAD TRAUMA

BACKGROUND

Fall is a common phenomenon in advanced age and can result in severe traumatic brain injury (TBI). The purpose of the study is to find the survival benefit from aggressive operative intervention.

METHOD

Trauma quality improvement program (TQIP) database of 2013-2016 was accessed for the study. All patients 80 -89 years old and who sustained severe TBI with Glasgow Coma Scale (GCS) ≤8 and brain Abbreviated Injury Scale (AIS) score ≥3 and underwent operative intervention, craniotomy or craniectomy, were included in the study. Patients were divided into two groups, survivors and deceased, were compared on characteristics, injury severity score (ISS), types of intracranial hemorrhage and comorbidities. Multivariable logistic regression analysis was performed to find the factors associated with survival. A receiving operative characteristic (ROC) curve was created to test the model and area under the curve (AUC) was calculated.

RESULTS

Out of 1266 patients who qualified for the study, only 477 (37.68%) patients survived. Lower ISS, higher GCS and no history of coagulopathy had higher chances of survival. Operative intervention in epidural hematoma (EDH), brain contusion and Subdural hematoma (SDH) were associated with 3.5, 2.25 and 1.86 odds of survival respectively. Procedure type, craniectomy or craniotomy did not impact the outcome. The AUC was 0.723 [95% CI: 0.694-0.752] CONCLUSION: The octogenarians who underwent craniotomy or craniectomy for severe TBI following a fall had very high mortality. Lower ISS, higher GCS and no history of coagulopathy, and evacuation of SDH, EDH, brain contusion found to have higher probability of survival.

Outcomes associated with brain tissue oxygen monitoring in patients with severe traumatic brain injury undergoing intracranial pressure monitoring

OBJECTIVE

Brain tissue oxygen monitoring combined with intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (sTBI) may confer better outcomes than ICP monitoring alone. The authors sought to investigate this using a national database.

METHODS

The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with sTBI who had an external ventricular drain or intraparenchymal ICP monitor placed. Patients were stratified according to the placement of an intraparenchymal brain tissue oxygen tension (PbtO2) monitor, and a 2:1 propensity score matching pair was used to compare outcomes in patients with and those without PbtO2 monitoring. Sensitivity analyses were performed using the entire cohort, and each model was adjusted for age, sex, Glasgow Coma Scale score, Injury Severity Score, presence of hypotension, insurance, race, and hospital teaching status. The primary outcome of interest was in-hospital mortality, and secondary outcomes included ICU length of stay (LOS) and overall LOS.

RESULTS

A total of 3421 patients with sTBI who underwent ICP monitoring were identified. Of these, 155 (4.5%) patients had a PbtO2 monitor placed. Among the propensity score-matched patients, mortality occurred in 35.4% of patients without oxygen monitoring and 23.4% of patients with oxygen monitoring (OR 0.53, 95% CI 0.33-0.85; p = 0.007). The unfavorable discharge rates were 56.3% and 47.4%, respectively, in patients with and those without oxygen monitoring (OR 1.41, 95% CI 0.87-2.30; p = 0.168). There was no difference in overall LOS, but patients with PbtO2 monitoring had a significantly longer ICU LOS and duration of mechanical ventilation. In the sensitivity analysis, PbtO2 monitoring was associated with decreased odds of mortality (OR 0.56, 95% CI 0.37-0.84) but higher odds of unfavorable discharge (OR 1.59, 95% CI 1.06-2.40).

CONCLUSIONS

When combined with ICP monitoring, PbtO2 monitoring was associated with lower inpatient mortality for patients with sTBI. This supports the findings of the recent Brain Oxygen Optimization in Severe Traumatic Brain Injury phase 2 (BOOST 2) trial and highlights the importance of the ongoing BOOST3 trial.

Evaluation of the hyperbaric oxygen therapy on the flash visual evoked potential P2 in patients with severe traumatic brain injury

BACKGROUND

Studies have shown that hyperbaric oxygen therapy (HBOT) can improve the extraction rate and latency of cortical evoked potential N20 in patients with severe traumatic brain injury, but there are only a few studies on the effect of flash visual evoked potential.

OBJECTIVE

This study investigated the effect of hyperbaric oxygen therapy on the P2 wave of flash visual evoked potentials in patients with severe traumatic brain injury.

METHODS

In total, we examined 40 TBI patients who received HBOT, in combination with medication, and 38 TBI patients who received medication alone. The FVEPs apparatus was used to detect the P2 wave extraction rate and the latency of the elicited waveform before and after treatment in both the medicated-only controls and HBOT-treated cohorts.

RESULTS

Compared with the control group, the HBOT treatment group showed a higher P2 wave elicitation rate, and the P2 wave latency of the HBOT treatment group was significantly shortened (p <  0.05, all).

CONCLUSIONS

HBOT, in combination with drug therapy, can significantly increase the P2 wave extraction rate and shorten P2 latency in patients with TBI.

Characteristics Associated with the Use of an Inpatient Rehabilitation or Skilled Nursing Facility after Acute Care in Children with Severe Traumatic Brain Injury

To characterize inpatient rehabilitation services for children with severe traumatic brain injury (TBI), we included 254 children, whose parents/guardians reported receipt of rehabilitation within a 12-month follow-up period, from a multinational observational study. Children discharged to an inpatient rehabilitation or skilled nursing facility after acute care were classified into the "inpatient rehabilitation" group, and children discharged home after acute care were classified into the "non-inpatient rehabilitation" group. Multivariable regression analyses determined the associations of sociodemographic and clinical characteristics with rehabilitation groups. Children receiving inpatient rehabilitation had a shorter length of acute hospitalization. Children from the UK were less likely to receive inpatient rehabilitation compared to children from the US. Future studies are warranted to extend current findings by identifying the reasons behind differential access to inpatient rehabilitation among children with severe TBI.

Comparing the Outcomes of Early and Late Tracheostomy in Severe Traumatic Brain Injury Patient

Background

Patients with severe traumatic brain injury (TBI) were expected to have poor Glasgow Coma Scale (GCS) recovery and prolonged intubation. Therefore, an early tracheostomy procedure was indicated for all severe TBI. In view of growing concern regarding the safety and outcome of early tracheostomy on these patients, it was deemed valid and needed to be addressed.

Methods

This study was conducted to compare the outcomes of early and late tracheostomies in severe TBI. Only severe TBI patients who were admitted to the Neurosurgery High Dependency Unit (NHDU), Hospital Sultanah Aminah (HSA), Johor Bahru, Johor, Malaysia and who had underwent a tracheostomy were recruited. Three main outcomes noted: duration on ventilation, length of NHDU stay and rate of ventilator associated pneumonia (VAP).

Results

Out of 155 patients, 72 (46.5%) were in early tracheostomy group (ETG) and 83 (53.5%) were in late tracheostomy group (LTG). The majority of the participants, 95 (61.3%) were ethnic Malays. The mean duration on ventilator use was 2.65 days (1.57) for ETG and 5.63 days (2.35) for LTG. While, mean NHDU stay was 4.75 days (1.98) for ETG and 9.77 days (2.70) for LTG. Upon independent t-test, early duration of tracheostomies had shown significant outcome in reducing length of NHDU stay, (P < 0.001) and had shortening participants’ time on mechanical ventilator (P < 0.001). Then, based on forward multiple logistic regression test, there were significant association between comorbid (P = 0.003) and tracheostomy (P = 0.020) towards presence of VAP when adjusted for other variables.

Conclusion

In this study it was found that early tracheostomy was significant in shortening the duration on ventilator, reducing the length of NHDU stay and reducing the rate of VAP.

When the Bone Flap Expands Like Bellows of Accordion: Feasibility Study Using Novel Technique of Expansile (Hinge) Craniotomy for Severe Traumatic Brain Injury

Background

Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty.

Objective

To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC.

Materials and Methods

A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year.

Results and Conclusions

Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.

Modulated Neuroprotection in Unresponsive Wakefulness Syndrome after Severe Traumatic Brain Injury

Background: We aimed to assess the effects of modulated neuroprotection with intermittent administration in patients with unresponsive wakefulness syndrome (UWS) after severe traumatic brain injury (TBI). Methods: Retrospective analysis of 60 patients divided into two groups, with and without neuroprotective treatment with Actovegin, Cerebrolysin, pyritinol, L-phosphothreonine, L-glutamine, hydroxocobalamin, alpha-lipoic acid, carotene, DL-α-tocopherol, ascorbic acid, thiamine, pyridoxine, cyanocobalamin, Q 10 coenzyme, and L-carnitine alongside standard treatment. Main outcome measures: Glasgow Coma Scale (GCS) after TBI, Extended Glasgow Coma Scale (GOS E), Disability Rankin Scale (DRS), Functional Independence Measurement (FIM), and Montreal Cognitive Assessment (MOCA), all assessed at 1, 3, 6, 12, and 24 months after TBI. Results: Patients receiving neuroprotective treatment recovered more rapidly from UWS than controls (p = 0.007) passing through a state of minimal consciousness and gradually progressing until the final evaluation (p = 0.000), towards a high cognitive level MOCA = 22 ± 6 points, upper moderate disability GOS-E = 6 ± 1, DRS = 6 ± 4, and an assisted gait, FIM =101 ± 25. The improvement in cognitive and physical functioning was strongly correlated with lower UWS duration (−0.8532) and higher GCS score (0.9803). Conclusion: Modulated long-term neuroprotection may be the therapeutic key for patients to overcome UWS after severe TBI.

Efficacy of a Novel Prophylactic Barbiturate Therapy for Severe Traumatic Brain Injuries: Step-down Infusion of a Barbiturate with Normothermia

This study aimed to examine the beneficial effects of a novel prophylactic barbiturate therapy, step-down infusion of barbiturates, using thiamylal with normothermia (NOR+sdB), on the poor outcome in the patients with severe traumatic brain injuries (sTBI), in comparison with mild hypothermia (MD-HYPO). From January 2000 to March 2019, 4133 patients with TBI were admitted to our hospital. The inclusion criteria were: a Glasgow coma scale (GCS) score of ≤8 on admission, age between 20 and 80 years, intracranial hematoma requiring surgical evacuation of the hematoma with craniotomy and/or external decompression, and patients who underwent management of body temperature and assessed their outcome at 6-12 months. Finally, 43 patients were included in the MD-HYPO (n = 29) and NOR+sdB (n = 14) groups. sdB was initiated intraoperatively or immediately after the surgical treatment. There were no significant differences in patient characteristics, including age, sex, past medical history, GCS on admission, type of intracranial hematoma, and length of hospitalization between the two groups. Although NOR+sdB could not improve the patient's poor outcome either at discharge from the intensive care unit (ICU) or at 6-12 months after admission, the treatment inhibited composite death at discharge from the ICU. The mean value of the maximum intracranial pressure (ICP) in the NOR+sdB group was <20 mmHg throughout the first 120 h. NOR+sdB prevented composite death in the ICU in patients with sTBI, and we may obtain novel insights into the beneficial role of prophylactic barbiturate therapy from suppression of the elevated ICP during the first 120 h.

Characteristics, treatments, and prognosis of a critical illness polyneuromyopathy patient with positive anti-GM1 after severe traumatic brain injury: A case report

To investigate the clinical features, treatment and prognosis of critical illness polyneuromyopathy (CIPNM) in patients with severe traumatic brain injury (sTBI) who had positive anti-ganglioside GM1 (anti-GM1) antibody IgG. A case of CIPNM with positive anti-GM1 antibody IgG was retrospectively analysed and followed-up for 30 months. After 1 week of treatment with large dose of short-term glucocorticoid and human immunoglobulin, the muscle strength of both lower extremities was restored to grade 1. Three months later, the muscle strength and muscle tension of the patient's limbs returned to normal except for grade 3 of bilateral dorsal extensor muscle strength. In addition, the patient can walk alone with a waddling gait. After 30 months, there was no recurrence. The application of large dose of short-term glucocorticoid and human immunoglobulin to CIPNM that are positive for anti-GM1 antibodies may be an effective treatment.

Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness

Objective: Severe traumatic brain injury (sTBI) often results in disorders of consciousness. Patients emerging from coma frequently exhibit aberrant behaviors such as agitation. These non-purposeful combative behaviors can interfere with medical care. Interestingly, agitation is associated with arousal and is often among the first signs of neurological recovery. A better understanding of these behaviors may shed light on the mechanisms driving the return of consciousness in sTBI patients. This study aims to investigate the association between posttraumatic agitation and the recovery of consciousness.

Methods: A retrospective chart review was conducted in 530 adult patients (29.1% female) admitted to Stony Brook University Hospital between January 2011 and December 2019 with a diagnosis of sTBI and Glasgow Coma Scale (GCS) ≤8. Agitation was defined as a Richmond Agitation Sedation Scale (RASS) > +1, or any documentation of equivalently combative and violent behaviors in daily clinical notes. The ability to follow verbal commands was used to define the recovery of consciousness and was assessed daily.

Results: Of 530 total sTBI patients, 308 (58.1%) survived. Agitation was present in 169 of all patients and 162 (52.6%) of surviving patients. A total of 273 patients followed commands, and 159 of them developed agitation. Forty patients developed agitation on hospital arrival whereas 119 developed agitation later during their hospital course. Presence of in-hospital agitation positively correlated with command-following (r = 0.315, p < 0.001). The time to develop agitation and time to follow commands showed positive correlation (r = 0.485, p < 0.001). These two events occurred within 3 days in 54 (44.6%) patients, within 7 days in 81 (67.8%) patients, and within 14 days in 96 (80.2%) patients. In 71 (59.7%) patients, agitation developed before command-following; in 36 (30.2%) patients, agitation developed after command-following; in 12 (10.1%) patients, agitation developed on the same day as command-following.

Conclusion: Posttraumatic agitation in comatose patients following sTBI is temporally associated with the recovery of consciousness. This behavior indicates the potential for recovery of higher neurological functioning. Further studies are required to identify neural correlates of posttraumatic agitation and recovery of consciousness after sTBI.

Memory functioning 7 years after severe childhood traumatic brain injury: Results of the Traumatisme Grave de l'Enfant study

OBJECTIVE

To explore memory functioning 7 years after severe paediatric traumatic brain injury (TBI), associated factors, and relationships with other outcomes.

METHOD

Children aged 0-15 years (n = 65), consecutively admitted over a 3-year period in a single trauma centre, who survived after severe non-inflicted TBI, were included in a prospective longitudinal study. Memory assessments were performed 7 years post-injury using the Children's Memory Scale or the Wechsler Memory Scale (WMS IV), according to age. The General Memory Score (GMS-7) was the primary outcome.

RESULTS

Thirty-seven patients were available for assessment at 7 years post-injury. Mean GMS-7 was in the low average range (M = 84.9, SD = 12.1). Lower GMS-7 was significantly associated with markers of higher injury severity, such as length of coma. One year post-injury functional and disability outcomes explained 74% of the variance of GMS-7. Concurrent intellectual ability and type of ongoing education correlated strongly with GMS-7. Age at injury and parental education were not associated with memory outcome.

CONCLUSIONS

Memory functioning is variable but often strongly impaired several years after severe paediatric TBI, and is mostly related to injury severity, functional outcomes measured 1 year post-injury, and concomitant cognitive and educational outcomes. GMS-7 was lower at 7 years than one year post-injury, supporting the importance of long term follow-up.

Elevated PCT at ICU discharge predicts poor prognosis in patients with severe traumatic brain injury: a retrospective cohort study

Purpose

Disease severity and inflammatory response status are closely related to a poor prognosis and must be assessed in patients with severe traumatic brain injury (STBI) before intensive care unit (ICU) discharge. Whether elevated serum procalcitonin (PCT) levels can predict a poor prognosis in STBI patients before ICU discharge is unclear.

Methods

This retrospective observational cohort study enrolled 199 STBI patients who were in the ICU for at least 48 hours and survived after discharge. Based on serum PCT levels at discharge, patients were divided into the high-PCT group (PCT ≥ 0.25 ng/mL) and the low-PCT group (PCT < 0.25 ng/mL). We assessed the relationship between serum PCT levels and a poor prognosis.

Results

The high-PCT group had a higher rate of adverse outcomes compared with the low-PCT group. Multivariate logistic regression analysis showed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, white blood cell (WBC) count, C-reactive protein (CRP) level, and PCT level at discharge were significantly associated with adverse outcomes.

Conclusions

Elevated PCT levels at ICU discharge were associated with a poor prognosis in STBI patients. The serum PCT level as a single indicator has limited value for clinical decision-making.

[Clinical efficacy of restrictive fluid management in patients with severe traumatic brain injury]

OBJECTIVE

To investigate the effects of restrictive fluid management in patients with severe traumatic brain injury (sTBI).

METHODS

Between January, 2019 and June, 2020, we randomly assigned 51 postoperative patients (stay in the ICU of no less than 7 days) with sTBI into treatment group (n=25) with restrictive fluid management and the control group (n=26) with conventional fluid management. The data of optic nerve sheath diameter (ONSD), middle cerebral artery pulsatility index (MAC- PI), neuron-specific enolase (NSE) level, inferior vena cava (IVC) diameter, Glascow Coma Scale (GCS) score, mean arterial blood pressure, heart rate, and fluid balance of the patients were collected at ICU admission and at 1, 3 and 7 days after ICU admission, and the duration of mechanical ventilation, ICU stay, and 28-day mortality were recorded.

RESULTS

The cumulative fluid balance of the two groups were positive on day 1 and negative on days 3 and 7 after ICU admission; at the same time points, the patients in the treatment group had significantly greater negative fluid balance than those in the control group (P < 0.05). In both of the groups, the ONSD and MCA-PI values were significantly higher on day 1 than the baseline (P < 0.05), reached the peak levels on day 3, and decreased on day 7; at the same time point, these values were significantly lower in the treatment group than in the control group (P < 0.05). No significant difference was found in NSE level on day 1 between the two groups (P>0.05); on day 3, NSE level reached the peak level and was significantly higher in the control group (P < 0.05); on day 7, NSE level was lowered the level of day 1 in the treatment group but remained higher than day 1 level in the control group. The 28-day mortality rate did not differ significantly between the two groups (16.00% vs 23.08%, P>0.05); the duration of mechanical ventilation, length of ICU stay, and the number of tracheotomy were all significantly shorter or lower in the treatment group than in the control group (P < 0.05).

CONCLUSIONS

Restrictive fluid management can reduce cerebral edema and improve the prognosis but does not affect the 28-day mortality of patients with sTBI.

The Association of Early Electrocardiographic Abnormalities With Brain Injury Severity and Outcome in Severe Traumatic Brain Injury

The aim of this study was to evaluate the frequency of electrocardiographic (ECG) abnormalities in the acute phase of severe traumatic brain injury (TBI) and the association with brain injury severity and outcome. In contrast to neurovascular diseases, sparse information is available on this issue. Data of adult patients with severe TBI admitted to the Intensive Care Unit (ICU) for intracranial pressure monitoring of a level-1 trauma center from 2002 till 2018 were analyzed. Patients with a cardiac history were excluded. An ECG recording was obtained within 24 h after ICU admission. Admission brain computerized tomography (CT)-scans were categorized by Marshall-criteria (diffuse vs. mass lesions) and for location of traumatic lesions. CT-characteristics and maximum Therapy Intensity Level (TILmax) were used as indicators for brain injury severity. We analyzed data of 198 patients, mean (SD) age of 40 ± 19 years, median GCS score 3 [interquartile range (IQR) 3–6], and 105 patients (53%) had thoracic injury. In-hospital mortality was 30%, with sudden death by cardiac arrest in four patients. The incidence of ECG abnormalities was 88% comprising ventricular repolarization disorders (57%) mostly with ST-segment abnormalities, conduction disorders (45%) mostly with QTc-prolongation, and arrhythmias (38%) mostly of supraventricular origin. More cardiac arrhythmias were observed with increased grading of diffuse brain injury (p = 0.042) or in patients treated with hyperosmolar therapy (TILmax) (65%, p = 0.022). No association was found between ECG abnormalities and location of brain lesions nor with thoracic injury. Multivariate analysis with baseline outcome predictors showed that cardiac arrhythmias were not independently associated with in-hospital mortality (p = 0.097). Only hypotension (p = 0.029) and diffuse brain injury (p = 0.017) were associated with in-hospital mortality. In conclusion, a high incidence of ECG abnormalities was observed in patients with severe TBI in the acute phase after injury. No association between ECG abnormalities and location of brain lesions or presence of thoracic injury was present. Cardiac arrhythmias were indicative for brain injury severity but not independently associated with in-hospital mortality. Therefore, our findings likely suggest that ECG abnormalities should be considered as cardiac mimicry representing the secondary effect of traumatic brain injury allowing for a more rationale use of neuroprotective measures.

Low-Protein, Hypocaloric Nutrition with Glutamine versus Full-Feeding in the Acute Phase in ICU Patients with Severe Traumatic Brain Injury

OBJECTIVE

To investigate the 28-day mortality, the length of ICU stay, days in the hospital, days of ventilator use, adverse events, and nosocomial infection events of low-protein, hypocaloric nutrition with glutamine in the first 7 days of the intensive care unit (ICU) patients with severe traumatic brain injury (STBI).

PATIENTS AND METHODS

A total of 53 patients diagnosed with STBI enrolled from the third affiliated hospital of Nanchang University (Nanchang, China), from January 2019 to July 2020, were divided into two groups. We performed a randomized prospective controlled trial. The intervention group (n=27) was nutritional supported (intestinal or parenteral) with a caloric capacity of 20-40% of European Conference on Clinical Nutrition and Metabolism (ESPEN) recommendations; specifically, low-protein intake was 0.5-0.7g/kg per day (containing the amount of alanyl-glutamine), glutamine was 0.3 g/kg per day, and the intervention treatment lasted for 7 days. The control group (n=26) was nutritionally supported with a caloric capacity of 70-100% of ESPEN recommendations, and the protein intake was 1.2-1.7 g/kg per day. The primary endpoint was 28-day mortality. Secondary endpoints were the length of ICU stay, days in the hospital, days of ventilator use, adverse events and nosocomial infection events.

RESULTS

There were no differences in baseline characteristics between groups. Survival curve analysis using the Kaplan-Meier method revealed no significant difference in 28-day mortality between the two groups (P=0.31) while adverse events (χ ²= 5.853, P=0.016), nosocomial infection rate (χ ² = 4.316, P=0.038), the length of ICU stay (t=-2.617, P=0.012), hospitalization time (t=-2.169, P=0.036), and days of ventilator use (t=-2.144,P=0.037) of patients in the intervention group were significantly lower than those in the control group.

CONCLUSION

Low-protein, hypocaloric nutrition with glutamine did not show different outcomes in 28-day mortality compared to full-feeding nutritional support in the ICU patients with STBI. However, low-protein, hypocaloric nutrition with glutamine could provide a lower need for ICU time, hospitalization time, and ventilator time in the ICU patients with STBI.

Low Molecular Weight Dextran Sulfate (ILB®) Administration Restores Brain Energy Metabolism Following Severe Traumatic Brain Injury in the Rat

Traumatic brain injury (TBI) is the leading cause of death and disability in people less than 40 years of age in Western countries. Currently, there are no satisfying pharmacological treatments for TBI patients. In this study, we subjected rats to severe TBI (sTBI), testing the effects of a single subcutaneous administration, 30 min post-impact, of a new low molecular weight dextran sulfate, named ILB^®, at three different dose levels (1, 5, and 15 mg/kg body weight). A group of control sham-operated animals and one of untreated sTBI rats were used for comparison (each group n = 12). On day 2 or 7 post-sTBI animals were sacrificed and the simultaneous HPLC analysis of energy metabolites, N-acetylaspartate (NAA), oxidized and reduced nicotinic coenzymes, water-soluble antioxidants, and biomarkers of oxidative/nitrosative stress was carried out on deproteinized cerebral homogenates. Compared to untreated sTBI rats, ILB^® improved energy metabolism by increasing ATP, ATP/ adenosine diphosphate ratio (ATP/ADP ratio), and triphosphate nucleosides, dose-dependently increased NAA concentrations, protected nicotinic coenzyme levels and their oxidized over reduced ratios, prevented depletion of ascorbate and reduced glutathione (GSH), and decreased oxidative (malondialdehyde formation) and nitrosative stress (nitrite + nitrate production). Although needing further experiments, these data provide the first evidence that a single post-injury injection of a new low molecular weight dextran sulfate (ILB^®) has beneficial effects on sTBI metabolic damages. Due to the absence of adverse effects in humans, ILB^® represents a promising therapeutic agent for the treatment of sTBI patients.

Effect of acupuncture method of removing-stasisand resuscitating on the consciousness of patients with severe traumatic brain injury: A randomized clinical trial

INTRODUCTION

With the development of social economy, transportation and various infrastructures have also developed, but it has objectively increased the number of patients with head injury. Although the current craniocerebral medicine technology continues to advance, long-term bed rest and other complications have led to an insignificant decrease in the mortality rate of coma patients. It is not uncommon for patients with disturbance of consciousness caused by head injury in major hospitals.

METHODS/DESIGN

This will be a retrospective, single-blind clinical observational study. We will select 50 cases that meet the subject's selection criteria. According to whether they received acupuncture treatment or not, they will be randomly divided into 2 groups, namely treatment group and control group. The control group will be given conventional Western medicine treatment, and the treatment group will be given acupuncture method of removing-stasis and resuscitating treatment on the basis of the control group.

DISCUSSION

Our purpose is to observe the role of acupuncture method of removing-stasis and resuscitating in promoting the recovery of patients with severe head injury. We aim to provide more evidence-based medical evidence for acupuncture treatment of this disease.

TRIAL REGISTRATION

ClinicalTrials.gov, ChiCTR2000034732, Registered on 19 July 2020.

Controlling nutritional status score and prognostic nutrition index predict the outcome after severe traumatic brain injury

OBJECTIVES

Immune-nutritional status is correlated with a clinical outcome in critical illness. Recently, controlling nutritional status (CONUT) score and prognostic nutrition index (PNI) has been reported to predict prognosis following cancer and other diseases. The aim of this study was to explore the relationship between the CONUT score and PNI and 6-month outcome in patients with severe traumatic brain injury (STBI).

METHODS

We retrospectively analyzed the clinical data of 78 patients with STBI, including the CONUT score and PNI. Patients were divided into high CONUT group and low CONUT group. Patients were also divided into high PNI and low PNI group respectively. The 6-month outcome was evaluated by the modified Rankin scale (mRS). The unfavorable outcome was defined as mRS score ≥3.

RESULTS

The unfavorable outcome group had lower Glasgow coma scale (GCS) scores, serum albumin, total cholesterol, PNI, and higher CONUT scores (P < 0.05). Both CONUT scores and PNI were strongly correlated with mRS (r = 0.429, P < 0.05; r = -0.590, P < 0.05, respectively). After adjustment for confounding factors, the odds ratios of CONUT scores and PNI for predicting unfavorable outcome were 10.478 (95% CI: 2.793-39.301) and -0.039 (95% CI: 0.008-0.204), respectively. The area under the curve (AUC) of CONUT scores for predicting unfavorable outcome was 0.777 (95% CI: 0.674-0.880, P < 0.01), which was similar to PNI (0.764, 95% CI: 0.657-0.87, P < 0.01).

CONCLUSION

Both CONUT scores and PNI might be novel independent predictors of the poor outcome in STBI.

Significance of ICP-related parameters for the treatment and outcome of severe traumatic brain injury

Objective

To analyze the significance of intracranial pressure (ICP)-related parameters on outcome in patients with severe traumatic brain injury. The ICP-related parameters included ICP, ICP dose (DICP), regression of the correlation coefficient between amplitude and pressure (RAP), pressure reactivity index (PRx), and cerebral perfusion pressure (CPP).

Methods

A retrospective analysis was performed using clinical information from 29 patients with severe traumatic brain injury who were admitted to the Department of Neurosurgery from January 2018 to January 2019. All patients underwent ICP probe implantation after admission. Patients were followed up for 6 months after discharge, and were categorized into either the favorable or unfavorable outcome group based on their Glasgow Outcome Scale score. The differences in ICP, DICP, RAP, PRx, and CPP between the two groups were analyzed for their effects on outcome.

Results

The average ICP, DICP, PRx, and RAP values in patients with favorable outcomes were significantly lower than in patients with unfavorable outcomes, while CPP values were significantly higher in the favorable outcome group.

Conclusion

Average ICP, DICP, PRx, RAP, and CPP values may indicate disease status and relate to patient outcomes. It is important to use multiple parameters to predict patients’ disease severity and prognosis.

Safety of Early MRI Examinations in Severe TBI: A Test Battery for Proper Patient Selection

Introduction: Early magnetic resonance imaging (MRI) provides important information for management and prognosis in patients with severe traumatic brain injury (sTBI). Yet, optimal timing of MRI remains unknown. The aim of our study was to evaluate the safety of early MRI and to identify a method for appropriate patient selection to minimize adverse events related to the intrahospital transport (IHT) and the MRI examination.

Methods: Twenty-six patients with sTBI [mean Glasgow Coma Scale (GCS) 6, range 3–8] admitted to our neurosurgical ICU from 03/2015 to 12/2017 and receiving at least one MRI within the first 14 days after initial traumatic event were prospectively included in the study. The following requirements were fulfilled for at least 4 h prior to anticipated MRI: MAP > 70 mmHg, aPCO₂ 30–40 mmHg, stable ICP < 25 mmHg. All relevant cardiopulmonary and cerebral parameters and medication were recorded. The following MRI sequences were performed: DWI, FLAIR, 3D T2-space, 3D T1 MPRAGE, 3D SWI, 3D TOF, pASL, and ¹H/³¹P-MRS.

Results: Four females and 22 males (aged 23–78 years, mean 46.4 years) with a median GCS on admission of 5 (range 3–8) were analyzed. In total, 40 IHTs were performed within the first 14 days (mean 6 days, range 1–14 days). Mean pre-MRI ICP was 14.1 mmHg (range 3–32 mmHg). The mean post-MRI ICP was 14.3 mmHg (range 3–29 mmHg), decreasing to a mean ICP of 13.2 mmHg after 1 h (range 3–29 mmHg). There were no significant differences in ICP measurements before and after MRI (p = 0.30). MAP remained stable with no significant changes during the entire IHT and MRI. No other adverse events were observed as well.

Conclusion: Early MRI in acute severe TBI is feasible and safe. Yet, careful patient selection with prior adequate testing of cardiopulmonary and cerebral parameters is crucial to minimize transport- or examination-related morbidity.