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Brolliar SM, Moore M, Thompson HJ, Whiteside LK, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Ng Boyle L, Mitchell PH, Rivara FP, Vavilala MS. A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines. J Neurotrauma 2016; 33:1554-60. [PMID: 26760283 PMCID: PMC5003009 DOI: 10.1089/neu.2015.4183] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.
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Affiliation(s)
- Sarah M Brolliar
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Megan Moore
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Hilaire J Thompson
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Lauren K Whiteside
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Richard B Mink
- 2 Harbor-University of California ; Los Angeles BioMedical Research Institute, Los Angeles, California
| | - Mark S Wainwright
- 3 Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois
| | | | | | - Christopher C Giza
- 6 Mattel Children's Hospital, University of California , Los Angeles, Los Angeles, California
| | - Douglas F Zatzick
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Richard G Ellenbogen
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Linda Ng Boyle
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Pamela H Mitchell
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Frederick P Rivara
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Monica S Vavilala
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
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Urdaneta AE, Fink KR, Krishnamoorthy V, Rowhani-Rahbar A, Vavilala MS. Radiographic and Clinical Predictors of Cardiac Dysfunction Following Isolated Traumatic Brain Injury. J Intensive Care Med 2016; 32:151-157. [DOI: 10.1177/0885066615616907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Although cardiac dysfunction after traumatic brain injury (TBI) has been described, there is little data regarding the association of radiographic severity and particular lesions of TBI with the development of cardiac dysfunction. We hypothesize that the Rotterdam or Marshall scores and particular TBI lesions are associated with the development of cardiac dysfunction after isolated TBI. Methods: We performed a retrospective cohort study. Adult patients with isolated TBI who underwent echocardiography between 2003 and 2010 were included. A board-certified neuroradiologist assessed the first computed tomography head, assigning the Rotterdam and Marshall scores and the type of TBI. Cardiac dysfunction was defined as either systolic or all cause based on the first echocardiogram after TBI. Demographic, radiological, and clinical variables were used in our analysis. Results: A total of 139 patients were identified, with 20 having isolated systolic dysfunction. The Marshall and Rotterdam scores were not associated with the development of cardiac dysfunction. Only head Abbreviated Injury Scale was found to be an independent predictor of systolic cardiac dysfunction (relative risk: 2.70, 95% confidence interval: 1.19-6.13; P = .02). Conclusions: No specific radiographic variable was found to be an independent predictor of cardiac dysfunction. Further study into clinical or radiological features that would warrant an echocardiogram is warranted, as it may direct patient management.
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Affiliation(s)
- Alfredo E. Urdaneta
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Kathleen R. Fink
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Monica S. Vavilala
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
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Needham E, McFadyen C, Newcombe V, Synnot AJ, Czosnyka M, Menon D. Cerebral Perfusion Pressure Targets Individualized to Pressure-Reactivity Index in Moderate to Severe Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2016; 34:963-970. [PMID: 27246184 DOI: 10.1089/neu.2016.4450] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Traumatic brain injury (TBI) frequently triggers a disruption of cerebral autoregulation. The cerebral perfusion pressure (CPP) at which autoregulation is optimal ("CPPopt") varies between individuals, and can be calculated based on fluctuations between arterial blood pressure and intracranial pressure. This review assesses the effect of individualizing CPP targets to pressure reactivity index (a measure of autoregulation) in patients with TBI. Cochrane Central Register of Controlled Trials, MEDLINE®, Embase, and Cumulative Index of Nursing and Allied Health Literature were searched in March 2015 for studies assessing the effect of targeting CPPopt in TBI. We included all studies that assessed the impact of targeting CPPopt on outcomes including mortality, neurological outcome, and physiological changes. Risk of bias was assessed using the RTI Item Bank and evidence quality was considered using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Eight cohort studies (based on six distinct data sets) assessing the association between CPPopt and mortality, Glasgow Outcome Scale and physiological measures in TBI were included. The quality of evidence was deemed very low based on the GRADE criteria. Although the data suggest an association between variation from CPPopt and poor clinical outcome at 6 months, the quality of evidence prevents firm conclusions, particularly regarding causality, from being drawn. Available data suggest that targeting CPPopt might represent a technique to improve outcomes following TBI, but currently there is insufficient high-quality data to support a recommendation for use in clinical practice. Further prospective, randomized controlled studies should be undertaken to clarify its role in the acute management of TBI.
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Affiliation(s)
- Edward Needham
- 1 Department of Neurology, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Charles McFadyen
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Virginia Newcombe
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Anneliese J Synnot
- 3 Australian & New Zealand Intensive Care Research Centre (ANZIC-RC) , School of Public Health and Preventive Medicine, Monash University, Melbourne Victoria, Australia; Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; National Trauma Research Institute, Melborne, Australia
| | - Marek Czosnyka
- 4 Brain Physics Lab, Division of Neurosurgery, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - David Menon
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
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Tanaka T, Litofsky NS. Anti-epileptic drugs in pediatric traumatic brain injury. Expert Rev Neurother 2016; 16:1229-34. [DOI: 10.1080/14737175.2016.1200974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Mazzeo AT, Filippini C, Rosato R, Fanelli V, Assenzio B, Piper I, Howells T, Mastromauro I, Berardino M, Ducati A, Mascia L. Multivariate projection method to investigate inflammation associated with secondary insults and outcome after human traumatic brain injury: a pilot study. J Neuroinflammation 2016; 13:157. [PMID: 27324502 PMCID: PMC4915034 DOI: 10.1186/s12974-016-0624-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Neuroinflammation has been proposed as a possible mechanism of brain damage after traumatic brain injury (TBI), but no consensus has been reached on the most relevant molecules. Furthermore, secondary insults occurring after TBI contribute to worsen neurological outcome in addition to the primary injury. We hypothesized that after TBI, a specific pattern of cytokines is related to secondary insults and outcome. METHODS A prospective observational clinical study was performed. Secondary insults by computerized multimodality monitoring system and systemic value of different cytokines were collected and analysed in the first week after intensive care unit admission. Neurological outcome was assessed at 6 months (GOSe). Multivariate projection technique was applied to analyse major sources of variation and collinearity within the cytokines dataset without a priori selecting potential relevant molecules. RESULTS Twenty-nine severe traumatic brain injury patients undergoing intracranial pressure monitoring were studied. In this pilot study, we demonstrated that after TBI, patients who suffered of prolonged and severe secondary brain damage are characterised by a specific pattern of cytokines. Patients evolving to brain death exhibited higher levels of inflammatory mediators compared to both patients with favorable and unfavorable neurological outcome at 6 months. Raised ICP and low cerebral perfusion pressure occurred in 21 % of good monitoring time. Furthermore, the principal components selected by multivariate projection technique were powerful predictors of neurological outcome. CONCLUSIONS The multivariate projection method represents a valuable methodology to study neuroinflammation pattern occurring after secondary brain damage in severe TBI patients, overcoming multiple putative interactions between mediators and avoiding any subjective selection of relevant molecules.
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Affiliation(s)
- Anna Teresa Mazzeo
- />Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Claudia Filippini
- />Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Rosalba Rosato
- />Department of Psychology, University of Torino, Torino, Italy
| | - Vito Fanelli
- />Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Barbara Assenzio
- />Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Ian Piper
- />Department of Clinical Physics, Southern General Hospital, Glasgow, UK
| | - Timothy Howells
- />Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Ilaria Mastromauro
- />Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Maurizio Berardino
- />Anesthesia and Intensive Care Unit, AOU Citta’ della Salute e della Scienza di Torino, Presidio CTO, Torino, Italy
| | - Alessandro Ducati
- />Neurosurgery Unit, Department of Neuroscience, University of Torino, Torino, Italy
| | - Luciana Mascia
- />Dipartimento di Scienze e Biotecnologie Medico Chirurgiche, Sapienza University of Rome, Rome, Italy
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van der Jagt M. Fluid management of the neurological patient: a concise review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:126. [PMID: 27240859 PMCID: PMC4886412 DOI: 10.1186/s13054-016-1309-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Maintenance fluids in critically ill brain-injured patients are part of routine critical care. Both the amounts of fluid volumes infused and the type and tonicity of maintenance fluids are relevant in understanding the impact of fluids on the pathophysiology of secondary brain injuries in these patients. In this narrative review, current evidence on routine fluid management of critically ill brain-injured patients and use of haemodynamic monitoring is summarized. Pertinent guidelines and consensus statements on fluid management for brain-injured patients are highlighted. In general, existing guidelines indicate that fluid management in these neurocritical care patients should be targeted at euvolemia using isotonic fluids. A critical appraisal is made of the available literature regarding the appropriate amount of fluids, haemodynamic monitoring and which types of fluids should be administered or avoided and a practical approach to fluid management is elaborated. Although hypovolemia is bound to contribute to secondary brain injury, some more recent data have emerged indicating the potential risks of fluid overload. However, it is acknowledged that many factors govern the relationship between fluid management and cerebral blood flow and oxygenation and more research seems warranted to optimise fluid management and improve outcomes.
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Affiliation(s)
- Mathieu van der Jagt
- Department of Intensive Care (Office H-611) and Erasmus MC Stroke Center, Erasmus Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Lund SB, Gjeilo KH, Moen KG, Schirmer-Mikalsen K, Skandsen T, Vik A. Moderate traumatic brain injury, acute phase course and deviations in physiological variables: an observational study. Scand J Trauma Resusc Emerg Med 2016; 24:77. [PMID: 27216804 PMCID: PMC4878035 DOI: 10.1186/s13049-016-0269-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 05/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with moderate traumatic brain injury (TBI) are a heterogeneous group with great variability in clinical course. Guidelines for monitoring and level of care in the acute phase are lacking. The main aim of this observational study was to describe injury severity and the acute phase course during the first three days post-injury in a cohort of patients with moderate TBI. Deviations from defined parameters in selected physiological variables were also studied, based on guidelines for severe TBI during the same period. METHODS During a 5-year period (2004-2009), 119 patients ≥16 years (median age 47 years, range 16-92) with moderate TBI according to the Head Injury Severity Scale were admitted to a Norwegian level 1 trauma centre. Injury-related and acute phase data were collected prospectively. Deviations in six physiological variables were collected retrospectively. RESULTS Eighty-six percent of the patients had intracranial pathology on CT scan and 61 % had extracranial injuries. Eighty-four percent of all patients were admitted to intensive care units (ICUs) the first day, and 51 % stayed in ICUs ≥3 days. Patients staying in ICUs ≥3 days had lower median Glasgow Coma Scale score; 12 (range 9-15) versus 13 (range 9-15, P = 0.003) and more often extracranial injuries (77 % versus 42 %, P = 0.001) than patients staying in ICU 0-2 days. Most patients staying in ICUs ≥3 days had at least one episode of hypotension (53 %), hypoxia (57 %), hyperthermia (59 %), anaemia (56 %) and hyperglycaemia (65 %), and the proportion of anaemia related to number of measurements was high (33 %). CONCLUSION Most of the moderate TBI patients stayed in an ICU the first day, and half of them stayed in ICUs ≥3 days due to not only intracranial, but also extracranial injuries. Deviations in physiological variables were often seen in this latter group of patients. Lack of guidelines for patients with moderate TBI may leave these deviations uncorrected. We propose that in future research of moderate TBI, patients might be differentiated with regard to their need for monitoring and level of care the first few days post-injury. This could contribute to improvement of acute phase management.
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Affiliation(s)
- Stine B Lund
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway.
- Department of Nursing Science, Faculty of Health and Social Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Kari H Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kent G Moen
- Department of Medical Imaging, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
| | - Kari Schirmer-Mikalsen
- Department of Anaesthesia and Intensive care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Toril Skandsen
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
| | - Anne Vik
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
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Mansouri A, Aldakkan A, Badhiwala JH, Taslimi S, Kondziolka D. A Practical Methodological Approach Towards Identifying Core Competencies in Medical Education Based on Literature Trends: A Feasibility Study Based on Vestibular Schwannoma Science. Neurosurgery 2016; 77:594-602; discussion 602-3. [PMID: 26308645 DOI: 10.1227/neu.0000000000000837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Competency-based medical education (CBME) is gaining momentum in postgraduate residency and fellowship training. While randomized trials, consensus statements, and practice guidelines can help delineate some of the core competencies for CBME, they are not applicable to all clinical scenarios. OBJECTIVE To propose and assess the feasibility of a practical methodology for addressing this issue using radiosurgery for vestibular schwannoma (VS) science as an example. METHODS The Web of Science electronic database was searched using relevant terms. A 3-step review of titles and abstracts was used. Studies were classified independently and in duplicate as either efficacy or effectiveness analyses. Cohen's kappa score was used to assess inter-rater agreement. RESULTS Overall, 1818 surgical and 943 radiosurgical publications were identified. The number of effectiveness studies surpassed that of efficacy studies in the late 1980s for surgical studies, and in the early-to-mid 1990s among radiosurgical studies. The publication rate was higher for radiosurgery in the mid 1990s, but it paralleled that of surgical studies beyond the early 2000s. Variations in this overall trend corresponded to the emergence of studies that assessed the role of endoscopy and the utility of dose reduction in radiosurgery. CONCLUSION We have confirmed the feasibility and accuracy of this objective methodological approach. By understanding how the peer-reviewed literature reflects actual practice interests, educators can tailor curricula to ensure that trainees remain current. While further validation studies are needed, this methodology can serve as a supplemental strategy for identifying additional core competencies in CBME.
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Affiliation(s)
- Alireza Mansouri
- *Division of Neurosurgery, University of Toronto, Toronto, Ontario; ‡Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; §Division of Neurosurgery, King Saud University, Riyadh, Saudi Arabia; ¶Departments of Neurosurgery and ‖Radiation Oncology, NYU Langone Medical Center, New York University, New York
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Gradisek P, Dolenc S. Isoflurane rescue therapy for bronchospasm reduces intracranial pressure in a patient with traumatic brain injury. Brain Inj 2016; 30:1035-40. [PMID: 27120554 DOI: 10.3109/02699052.2016.1147598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To assess the unusual use of a volatile anaesthetic for treatment of life-threatening bronchospasm in a patient with traumatic brain injury (TBI). RESEARCH DESIGN Case report. METHODS AND PROCEDURES This study presents a previously healthy 30-year-old man with severe TBI and bronchospasm-induced acute hypercapnia. He was treated with inhaled isoflurane in combination with monitoring of intracranial pressure (ICP) and regional cerebral blood flow (rCBF). RESULTS Three-day-long isoflurane treatment resolved drug-refractory bronchospasm, decreased airway pressure and improved gas exchange, even at a low end-tidal concentration (0.3-0.5 vol%). Although rCBF was increased by 18 ml min(-1) 100 g(-1) during isoflurane treatment, there was a significant decrease in ICP (21 (SD = 3) mmHg, 9 (SD = 5) mmHg, 2 (SD = 3) mmHg; during pre-treatment, treatment and post-treatment, respectively; p < 0.001). Improved autoregulation due to lower partial pressure of carbon dioxide, restoration of carbon dioxide reactivity, isoflurane-induced regional differences in rCBF and improved microcirculation may have been responsible for the prompt and long-lasting normalization of ICP. The patient had no TBI-related disability at 6 months post-injury. CONCLUSIONS Isoflurane at a low dose can be an effective and safe treatment option for drug-refractory bronchospasm in a patient with traumatic intracranial hypertension, provided that multimodality neuromonitoring is used.
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Affiliation(s)
- Primoz Gradisek
- a Clinical Department of Anaesthesiology and Intensive Therapy , Centre for Intensive Therapy, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Simon Dolenc
- a Clinical Department of Anaesthesiology and Intensive Therapy , Centre for Intensive Therapy, University Medical Centre Ljubljana , Ljubljana , Slovenia
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The effect of continuous hypertonic saline infusion and hypernatremia on mortality in patients with severe traumatic brain injury: a retrospective cohort study. Can J Anaesth 2016; 63:664-73. [PMID: 27030131 DOI: 10.1007/s12630-016-0633-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/30/2015] [Accepted: 03/14/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Hypertonic saline (HTS) is used to control intracranial pressure (ICP) in patients with traumatic brain injury (TBI); however, in prior studies, the resultant hypernatremia has been associated with increased mortality. We aimed to study the effect of HTS on ICP and mortality in patients with severe TBI. METHODS We performed a retrospective cohort study of 231 patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to two neurotrauma units from 2006-2012. We recorded daily HTS, ICP, and serum sodium (Na) concentration. We used Cox proportional regression modelling for hospital mortality and incorporated the following time-dependent variables: use of HTS, hypernatremia, and desmopressin administration. RESULTS The mean [standard deviation (SD)] age of patients was 34 (17) and the median (interquartile range [IQR]) GCS was 6 [3-8]. Hypertonic saline was administered as a continuous infusion in 124 of 231 (54%) patients over 788 of 2,968 (27%) patient-days. Hypernatremia (Na > 145 mmol·L(-1)) developed in 151 of 231 (65%) patients over 717 of 2,968 (24%) patients-days. In patients who developed hypernatremia, the median [IQR] Na was 146 [142-147] mmol·L(-1). Overall hospital mortality was 26% (59 of 231 patients). After adjusting for baseline covariates, neither HTS (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.56 to 2.05; P = 0.84) nor hypernatremia (HR, 1.31; 95% CI, 0.68 to 2.55; P = 0.42) was associated with hospital mortality. There was no effect modification by either HTS or hypernatremia on each another. Patients who received HTS observed a significant decrease in ICP during their ICU stay compared with those who did not receive HTS (4 mmHg; 95% CI, 2 to 6; P < 0.001 vs 2 mmHg; 95% CI, -1 to 5; P = 0.14). CONCLUSIONS Hypertonic saline and hypernatremia are not associated with hospital mortality in patients with severe TBI.
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Roh D, Merkler AE, Al-Mufti F, Morris N, Agarwal S, Claassen J, Park S. Global cerebral edema from hypercapnic respiratory acidosis and response to hyperosmolar therapy. Neurology 2016; 86:1556-8. [PMID: 26992857 DOI: 10.1212/wnl.0000000000002584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/21/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Roh
- From Columbia University Medical Center, New York, NY.
| | | | | | | | | | - Jan Claassen
- From Columbia University Medical Center, New York, NY
| | - Soojin Park
- From Columbia University Medical Center, New York, NY
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Rodríguez-Rodríguez A, Egea-Guerrero JJ, Gordillo-Escobar E, Enamorado-Enamorado J, Hernández-García C, Ruiz de Azúa-López Z, Vilches-Arenas Á, Guerrero JM, Murillo-Cabezas F. S100B and Neuron-Specific Enolase as mortality predictors in patients with severe traumatic brain injury. Neurol Res 2016; 38:130-7. [PMID: 27078699 DOI: 10.1080/01616412.2016.1144410] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine temporal profile and prognostic ability of S100B protein and neuron-specific enolase (NSE) for prediction of short/long-term mortality in patients suffering from severe traumatic brain injury (sTBI). METHODS Ninety-nine patients with sTBI were included in the study. Blood samples were drawn on admission and on subsequent 24, 48, 72, and 96 h. RESULTS 15.2% of patients died in NeuroCritical Care Unit, and 19.2% died within 6 months of the accident. S100B concentrations were significantly higher in patients who died compared to survivors. NSE levels were different between groups just at 48 h. In the survival group, S100B levels decreased from 1st to 5th sample (p < 0.001); NSE just from 1st to 3rd (p < 0.001) and then stabilized. Values of S100B and NSE in non-survival patients did not significantly vary over the four days post sTBI. ROC-analysis showed that all S100B samples were useful tools for predicting mortality, the best the 72 h sample (AUC 0.848 for discharge mortality, 0.855 for six-month mortality). NSE ROC-analysis indicated that just the 48-h sample predicted mortality (AUC 0.733 for discharge mortality, 0.720 for six-month mortality). CONCLUSION S100B protein showed higher prognostic capacity than NSE to predict short/long-term mortality in sTBI patients.
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Affiliation(s)
- Ana Rodríguez-Rodríguez
- a NeuroCritical Care Unit , Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | - Juan José Egea-Guerrero
- a NeuroCritical Care Unit , Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | - Elena Gordillo-Escobar
- a NeuroCritical Care Unit , Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | - Judy Enamorado-Enamorado
- a NeuroCritical Care Unit , Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | - Conary Hernández-García
- b Department of Clinical Biochemistry , Virgen del Rocio University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | - Zaida Ruiz de Azúa-López
- a NeuroCritical Care Unit , Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | | | - Juan Miguel Guerrero
- b Department of Clinical Biochemistry , Virgen del Rocio University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
| | - Francisco Murillo-Cabezas
- a NeuroCritical Care Unit , Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville , Seville , Spain
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Tamm AS, McCourt R, Gould B, Kate M, Kosior JC, Jeerakathil T, Gioia LC, Dowlatshahi D, Hill MD, Coutts SB, Demchuk AM, Buck BH, Emery DJ, Shuaib A, Butcher KS. Cerebral Perfusion Pressure is Maintained in Acute Intracerebral Hemorrhage: A CT Perfusion Study. AJNR Am J Neuroradiol 2016; 37:244-51. [PMID: 26450534 PMCID: PMC7959964 DOI: 10.3174/ajnr.a4532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Although blood pressure reduction has been postulated to result in a fall in cerebral perfusion pressure in patients with intracerebral hemorrhage, the latter is rarely measured. We assessed regional cerebral perfusion pressure in patients with intracerebral hemorrhage by using CT perfusion source data. MATERIALS AND METHODS Patients with acute primary intracerebral hemorrhage were randomized to target systolic blood pressures of <150 mm Hg (n = 37) or <180 mm Hg (n = 36). Regional maps of cerebral blood flow, cerebral perfusion pressure, and cerebrovascular resistance were generated by using CT perfusion source data, obtained 2 hours after randomization. RESULTS Perihematoma cerebral blood flow (38.7 ± 11.9 mL/100 g/min) was reduced relative to contralateral regions (44.1 ± 11.1 mL/100 g/min, P = .001), but cerebral perfusion pressure was not (14.4 ± 4.6 minutes(-1) versus 14.3 ± 4.8 minutes(-1), P = .93). Perihematoma cerebrovascular resistance (0.34 ± 0.11 g/mL) was higher than that in the contralateral region (0.30 ± 0.10 g/mL, P < .001). Ipsilateral and contralateral cerebral perfusion pressure in the external (15.0 ± 4.6 versus 15.6 ± 5.3 minutes(-1), P = .15) and internal (15.0 ± 4.8 versus 15.0 ± 4.8 minutes(-1), P = .90) borderzone regions were all similar. Borderzone cerebral perfusion pressure was similar to mean global cerebral perfusion pressure (14.7 ± 4.7 minutes(-1), P ≥ .29). Perihematoma cerebral perfusion pressure did not differ between blood pressure treatment groups (13.9 ± 5.5 minutes(-1) versus 14.8 ± 3.4 minutes(-1), P = .38) or vary with mean arterial pressure (r = -0.08, [-0.10, 0.05]). CONCLUSIONS Perihematoma cerebral perfusion pressure is maintained despite increased cerebrovascular resistance and reduced cerebral blood flow. Aggressive antihypertensive therapy does not affect perihematoma or borderzone cerebral perfusion pressure. Maintenance of cerebral perfusion pressure provides physiologic support for the safety of blood pressure reduction in intracerebral hemorrhage.
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Affiliation(s)
- A S Tamm
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - R McCourt
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - B Gould
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - M Kate
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - J C Kosior
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - T Jeerakathil
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - L C Gioia
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D Dowlatshahi
- Division of Neurology (D.D.), University of Ottawa, Ottawa, Ontario, Canada
| | - M D Hill
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - S B Coutts
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - B H Buck
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D J Emery
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - A Shuaib
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - K S Butcher
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
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Lin H, Wang WH, Hu LS, Li J, Luo F, Lin JM, Huang W, Zhang MS, Zhang Y, Hu K, Zheng JX. Novel Clinical Scale for Evaluating Pre-Operative Risk of Cerebral Herniation from Traumatic Epidural Hematoma. J Neurotrauma 2016; 33:1023-33. [PMID: 25393339 DOI: 10.1089/neu.2014.3656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Secondary massive cerebral infarction (MCI) is the predominant prognostic factor for cerebral herniation from epidural hematoma (EDH) and determines the need for decompressive craniectomy. In this study, we tested the clinical feasibility and reliability of a novel pre-operative risk scoring system, the EDH-MCI scale, to guide surgical decision making. It is comprised of six risk factors, including hematoma location and volume, duration and extent of cerebral herniation, Glasgow Coma Scale score, and presence of preoperative shock, with a total score ranging from 0 to 18 points. Application of the EDH-MCI scale to guide surgical modalities for initial hematoma evacuation surgery for 65 patients (prospective cohort, 2012.02-2014.01) showed a significant improvement in the accuracy of the selected modality (95.38% vs. 77.95%; p = 0.002) relative to the results for an independent set of 126 patients (retrospective cohort, 2007.01-2012.01) for whom surgical modalities were decided empirically. Results suggested that simple hematoma evacuation craniotomy was sufficient for patients with low risk scores (≤9 points), whereas decompressive craniectomy in combination with duraplasty were necessary only for those with high risk scores (≥13 points). In patients with borderline risk scores (10-12 points), those having unstable vital signs, coexistence of severe secondary brainstem injury, and unresponsive dilated pupils after emergent burr hole hematoma drainage had a significantly increased incidence of post-traumatic MCI and necessity of radical surgical treatments. In conclusion, the novel pre-operative risk EDH-MCI evaluation scale has a satisfactory predictive and discriminative performance for patients who are at risk for the development of secondary MCI and therefore require decompressive craniectomy.
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Affiliation(s)
- Hong Lin
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Wen-Hao Wang
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Lian-Shui Hu
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Jun Li
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Fei Luo
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Jun-Ming Lin
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Wei Huang
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Ming-Sheng Zhang
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Yuan Zhang
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Kang Hu
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
| | - Jian-Xian Zheng
- Department of Neurosurgery, The 175th Hospital of PLA, Affiliated Southeast Hospital of Xiamen University , Center of Traumatic Neurosurgery in Nanjing Military Command, Zhangzhou, China
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Morbitzer KA, Jordan JD, Rhoney DH. Vancomycin pharmacokinetic parameters in patients with acute brain injury undergoing controlled normothermia, therapeutic hypothermia, or pentobarbital infusion. Neurocrit Care 2016; 22:258-64. [PMID: 25330755 DOI: 10.1007/s12028-014-0079-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Therapeutic strategies that cause an alteration in patient temperature, such as controlled normothermia (CN), therapeutic hypothermia (TH), and pentobarbital infusion (PI), are often used to manage complications caused by acute brain injury. The purpose of this study was to evaluate pharmacokinetic (PK) parameters of vancomycin in patients with acute brain injury undergoing temperature modulation. METHODS This was a retrospective cohort study of adult patients with acute brain injury admitted between May 2010 and March 2014 who underwent CN, TH, or PI and received vancomycin. Predicted PK parameters based on population data were compared with calculated PK parameters based on serum concentrations. RESULTS Seventeen CN patients and 10 TH/PI patients met inclusion criteria. Traumatic brain injury and aneurysmal subarachnoid hemorrhage accounted for the majority of admitting diagnoses. In the CN group, the median dose was 16.7 (15.5-18.4) mg/kg. The median calculated elimination rate constant [0.155 (0.108-0.17) vs. 0.103 (0.08-0.142) hr(-1); p = 0.04] was significantly higher than the predicted value. The median measured trough concentration [8.9 (7.7-11.1) vs. 17.1 (10.8-22.3) υg/mL; p = 0.004] was significantly lower than predicted. In the TH/PI group, the median dose was 15.4 (14.7-17.2) mg/kg. No significant differences were found between the median calculated and predicted elimination rate constant [0.107 (0.097-0.109) vs. 0.112 (0.102-0.127) hr(-1); p = 0.41] and median measured and predicted trough concentration [14.2 (12.7-17.1) vs. 13.1 (11-17.8) υg/mL; p = 0.71]. CONCLUSION Patients who underwent TH/PI did not exhibit PK alterations when compared to predicted PK parameters based on population data, while patients who underwent CN experienced PK alterations favoring an increased elimination of vancomycin.
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Affiliation(s)
- Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115 Beard Hall, Campus Box 7574, Chapel Hill, NC, 27599, USA
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Zhao HX, Liao Y, Xu D, Wang QP, Gan Q, You C, Yang CH. Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial. BMC Neurol 2016; 16:1. [PMID: 26727957 PMCID: PMC4700654 DOI: 10.1186/s12883-015-0524-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 12/29/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive craniectomy in severe traumatic brain injury patients with mass lesions. METHODS PRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive craniectomy group or a prophylactic decompressive craniectomy group. In the therapeutic decompressive craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5-8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage craniectomy in craniotomy patients at each investigation time point. DISCUSSION This study will provide evidence to optimize primary decompressive craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury. TRIAL REGISTRATION ISRCTN20139421.
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Affiliation(s)
- He-xiang Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Yi Liao
- Department of Neuro-intensive care unit, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Ding Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Qiang-ping Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Qi Gan
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Chao-hua Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
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67
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Rhodes JK, Chandrasekaran S, Andrews PJ. Early Changes in Brain Oxygen Tension May Predict Outcome Following Severe Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 122:9-16. [PMID: 27165868 DOI: 10.1007/978-3-319-22533-3_2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We report on the change in brain oxygen tension (PbtO2) over the first 24 h of monitoring in a series of 25 patients with severe traumatic brain injury (TBI) and relate this to outcome. The trend in PbtO2 for the whole group was to increase with time (mean PbtO2 17.4 [1.75] vs 24.7 [1.60] mmHg, first- vs last-hour data, respectively; p = 0.002). However, a significant increase in PbtO2 occurred in only 17 patients (68 %), all surviving to intensive care unit discharge (p = 0.006). Similarly, a consistent increase in PbtO2 with time occurred in only 13 patients, the correlation coefficient for PbtO2 versus time being ≥0.5 for all survivors. There were eight survivors and four non-survivors, with low correlation coefficients (<0.5). Significantly more patients with a correlation coefficient ≥0.5 for PbtO2 versus time survived in intensive care (p = 0.039). The cumulative length of time that PbtO2 was <20 mmHg was not significantly different among these three groups. In conclusion, although for the cohort as a whole PbtO2 increased over the first 24 h, the individual trends of PbtO2 were related to outcome. There was a significant association between improving PbtO2 and survival, despite these patients having cumulative durations of hypoxia similar to those of non-survivors.
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Affiliation(s)
- J K Rhodes
- Intensive Care Unit, Department of Anaesthesia, Critical Care and Pain Management, Western General Hospital, University of Edinburgh, Edinburgh, UK.
| | - S Chandrasekaran
- Intensive Care Unit, Department of Anaesthesia, Critical Care and Pain Management, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - P J Andrews
- Intensive Care Unit, Department of Anaesthesia, Critical Care and Pain Management, Western General Hospital, University of Edinburgh, Edinburgh, UK
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Zhu Y, Yin H, Zhang R, Ye X, Wei J. Therapeutic hypothermia versus normothermia in adult patients with traumatic brain injury: a meta-analysis. SPRINGERPLUS 2016; 5:801. [PMID: 27390642 PMCID: PMC4916079 DOI: 10.1186/s40064-016-2391-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Many single-center studies and meta-analyses demonstrate that therapeutic hypothermia (TH), in which the body temperature is maintained at 32-35°C, exerts significant neuroprotection and attenuates secondary intracranial hypertension after traumatic brain injury (TBI). In 2015, two well-designed multi-center, randomized controlled trials were published that did not show favorable outcomes with the use of TH in adult patients with TBI compared to normothermia treatment (NT). Therefore, we performed an updated meta-analysis to assess the effect of TH in adult patients with TBI. METHODS We reviewed the PubMed, EMbase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Databases. We included randomized controlled trials that compared TH and NT in adult patients with TBI. Two reviewers assessed the quality of each study and independently collected the data. We performed the meta-analysis using the Cochrane Collaboration's RevMan 5.3 software. RESULTS We included 18 trials involving 2177 patients with TBI. There was no significant heterogeneity among the studies. TH could not decrease mortality at 3 months post-TBI (RR 0.95; 95 % CI 0.59, 1.55; z = 0.19, P = 0.85) or 6 months post-TBI (RR 0.96; 95 % CI 0.76, 1.23; z = 0.29, P = 0.77). There were no significant differences in unfavorable clinical outcomes when TH was compared to NT at 3 months post-TBI (RR 0.79; 95 % CI 0.56, 1.12; z = 1.31, P = 0.19) or 6 months post-TBI (RR 0.80; 95 % CI 0.63, 1.00; z = 1.92, P = 0.05). TH was associated with a significant increase in pneumonia (RR 1.51; 95 % CI 1.12, 2.03; z = 2.72, P = 0.006) and cardiovascular complications (RR 1.75; 95% CI 1.14, 2.70; z = 2.54, P = 0.01). CONCLUSIONS Therapeutic hypothermia failed to demonstrate a decrease in mortality and unfavorable clinical outcomes at 3 or 6 months post-TBI. Additionally, TH might increase the risk of developing pneumonia and cardiovascular complications.
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Affiliation(s)
- Youfeng Zhu
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 Guangdong China
| | - Haiyan Yin
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 Guangdong China
| | - Rui Zhang
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 Guangdong China
| | - Xiaoling Ye
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 Guangdong China
| | - Jianrui Wei
- Department of Cardiology, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 Guangdong China
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Abdominal insufflation for laparoscopy increases intracranial and intrathoracic pressure in human subjects. Surg Endosc 2015; 30:4029-32. [PMID: 26701703 DOI: 10.1007/s00464-015-4715-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Laparoscopy has emerged as an alternative to laparotomy in select trauma patients. In animal models, increasing abdominal pressure is associated with an increase in intrathoracic and intracranial pressures. We conducted a prospective trial of human subjects who underwent laparoscopic-assisted ventriculoperitoneal shunt placement (lap VPS) with intraoperative measurement of intrathoracic, intracranial and cerebral perfusion pressures. METHODS Ten patients undergoing lap VPS were recruited. Abdominal insufflation was performed using CO2 to 0, 8, 10, 12 and 15 mmHg. ICP was measured through the ventricular catheter simultaneously with insufflation and with desufflation using a manometer. Peak inspiratory pressures (PIP) were measured through the endotracheal tube. Blood pressure was measured using a noninvasive blood pressure cuff. End-tidal CO2 (ETCO2) was measured for each set of abdominal pressure level. Pressure measurements from all points of insufflation were compared using a two-way ANOVA with a post hoc Bonferroni test. Mean changes in pressures were compared using t test. RESULTS ICP and PIP increased significantly with increasing abdominal pressure (both p < 0.01), whereas cerebral perfusion pressure (CPP) and mean arterial pressure did not significantly change with increasing abdominal pressure over the range tested. Higher abdominal pressure values were associated with decreased ETCO2 values. CONCLUSION Increased ICP and PIP appear to be a direct result of increasing abdominal pressure, since ETCO2 did not increase. Though CPP did not change over the range tested, the ICP in some patients with 15 mmHg abdominal insufflation reached values as high as 32 cmH2O, which is considered above tolerance, regardless of the CPP. Laparoscopy should be used cautiously, in patients who present with baseline elevated ICP or head trauma as abdominal insufflation affects intracranial pressure.
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Cardim D, Robba C, Donnelly J, Bohdanowicz M, Schmidt B, Damian M, Varsos GV, Liu X, Cabeleira M, Frigieri G, Cabella B, Smielewski P, Mascarenhas S, Czosnyka M. Prospective Study on Noninvasive Assessment of Intracranial Pressure in Traumatic Brain-Injured Patients: Comparison of Four Methods. J Neurotrauma 2015; 33:792-802. [PMID: 26414916 DOI: 10.1089/neu.2015.4134] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Elevation of intracranial pressure (ICP) may occur in many diseases, and therefore the ability to measure it noninvasively would be useful. Flow velocity signals from transcranial Doppler (TCD) have been used to estimate ICP; however, the relative accuracy of these methods is unclear. This study aimed to compare four previously described TCD-based methods with directly measured ICP in a prospective cohort of traumatic brain-injured patients. Noninvasive ICP (nICP) was obtained using the following methods: 1) a mathematical "black-box" model based on interaction between TCD and arterial blood pressure (nICP_BB); 2) based on diastolic flow velocity (nICP_FVd); 3) based on critical closing pressure (nICP_CrCP); and 4) based on TCD-derived pulsatility index (nICP_PI). In time domain, for recordings including spontaneous changes in ICP greater than 7 mm Hg, nICP_PI showed the best correlation with measured ICP (R = 0.61). Considering every TCD recording as an independent event, nICP_BB generally showed to be the best estimator of measured ICP (R = 0.39; p < 0.05; 95% confidence interval [CI] = 9.94 mm Hg; area under the curve [AUC] = 0.66; p < 0.05). For nICP_FVd, although it presented similar correlation coefficient to nICP_BB and marginally better AUC (0.70; p < 0.05), it demonstrated a greater 95% CI for prediction of ICP (14.62 mm Hg). nICP_CrCP presented a moderate correlation coefficient (R = 0.35; p < 0.05) and similar 95% CI to nICP_BB (9.19 mm Hg), but failed to distinguish between normal and raised ICP (AUC = 0.64; p > 0.05). nICP_PI was not related to measured ICP using any of the above statistical indicators. We also introduced a new estimator (nICP_Av) based on the average of three methods (nICP_BB, nICP_FVd, and nICP_CrCP), which overall presented improved statistical indicators (R = 0.47; p < 0.05; 95% CI = 9.17 mm Hg; AUC = 0.73; p < 0.05). nICP_PI appeared to reflect changes in ICP in time most accurately. nICP_BB was the best estimator for ICP "as a number." nICP_Av demonstrated to improve the accuracy of measured ICP estimation.
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Affiliation(s)
- Danilo Cardim
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Chiara Robba
- 2 Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
| | - Joseph Donnelly
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Michal Bohdanowicz
- 3 Institute of Electronic Systems, Warsaw University of Technology , Warsaw, Poland
| | - Bernhard Schmidt
- 4 Department of Neurology, University Hospital Chemnitz , Chemnitz, Germany
| | - Maxwell Damian
- 5 Department of Neurology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Georgios V Varsos
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Xiuyun Liu
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Manuel Cabeleira
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Gustavo Frigieri
- 6 University of Sao Paulo , Physics Institute of Sao Carlos, Sao Carlos, Sao Paulo, Brazil
| | - Brenno Cabella
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Peter Smielewski
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Sergio Mascarenhas
- 6 University of Sao Paulo , Physics Institute of Sao Carlos, Sao Carlos, Sao Paulo, Brazil
| | - Marek Czosnyka
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom .,3 Institute of Electronic Systems, Warsaw University of Technology , Warsaw, Poland
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Kochanek PM, Bramlett HM, Dixon CE, Shear DA, Dietrich WD, Schmid KE, Mondello S, Wang KKW, Hayes RL, Povlishock JT, Tortella FC. Approach to Modeling, Therapy Evaluation, Drug Selection, and Biomarker Assessments for a Multicenter Pre-Clinical Drug Screening Consortium for Acute Therapies in Severe Traumatic Brain Injury: Operation Brain Trauma Therapy. J Neurotrauma 2015; 33:513-22. [PMID: 26439468 DOI: 10.1089/neu.2015.4113] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Traumatic brain injury (TBI) was the signature injury in both the Iraq and Afghan wars and the magnitude of its importance in the civilian setting is finally being recognized. Given the scope of the problem, new therapies are needed across the continuum of care. Few therapies have been shown to be successful. In severe TBI, current guidelines-based acute therapies are focused on the reduction of intracranial hypertension and optimization of cerebral perfusion. One factor considered important to the failure of drug development and translation in TBI relates to the recognition that TBI is extremely heterogeneous and presents with multiple phenotypes even within the category of severe injury. To address this possibility and attempt to bring the most promising therapies to clinical trials, we developed Operation Brain Trauma Therapy (OBTT), a multicenter, pre-clinical drug screening consortium for acute therapies in severe TBI. OBTT was developed to include a spectrum of established TBI models at experienced centers and assess the effect of promising therapies on both conventional outcomes and serum biomarker levels. In this review, we outline the approach to TBI modeling, evaluation of therapies, drug selection, and biomarker assessments for OBTT, and provide a framework for reports in this issue on the first five therapies evaluated by the consortium.
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Affiliation(s)
- Patrick M Kochanek
- 1 Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Helen M Bramlett
- 2 Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami , and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida
| | - C Edward Dixon
- 3 Department of Neurological Surgery, Brain Trauma Research Center, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Deborah A Shear
- 4 In Vivo Neuroprotection Labs, Brain Trauma Neuroprotection & Neurorestoration Branch, Center of Excellence for Psychiatry & Neuroscience, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - W Dalton Dietrich
- 5 Miami Project to Cure Paralysis, Departments of Neurological Surgery, Neurology and Cell Biology, Miller School of Medicine, University of Miami , Miami, Florida
| | - Kara E Schmid
- 6 Brain Trauma Neuroprotection and Neurorestoration Department, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - Stefania Mondello
- 7 Department of Neurosciences, University of Messina , Messina, Italy
| | - Kevin K W Wang
- 8 Center of Neuroproteomics and Biomarkers Research, Department of Psychiatry and Neuroscience, University of Florida , Gainesville, Florida
| | - Ronald L Hayes
- 9 Center for Innovative Research, Center for Neuroproteomics and Biomarkers Research, Banyan Biomarkers, Inc. , Alachua, Florida
| | - John T Povlishock
- 10 Department of Anatomy and Neurobiology, Virginia Commonwealth University , Richmond, Virginia
| | - Frank C Tortella
- 11 Department of Applied Neurobiology and Combat Casualty Care Research Program for Brain Trauma & Neuroprotection Research, Walter Reed Army Institute of Research , Silver Spring, Maryland
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Anemia and Blood Transfusion in Patients with Isolated Traumatic Brain Injury. Crit Care Res Pract 2015; 2015:672639. [PMID: 26605080 PMCID: PMC4641180 DOI: 10.1155/2015/672639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/02/2015] [Accepted: 10/11/2015] [Indexed: 11/23/2022] Open
Abstract
Rationale. By reducing cerebral oxygen delivery, anemia may aggravate traumatic brain injury (TBI) secondary insult. This study evaluated the impact of anemia and blood transfusion on TBI outcomes. Methods. This was a retrospective cohort study of adult patients with isolated TBI at a tertiary-care intensive care unit from 1/1/2000 to 31/12/2011. Daily hemoglobin level and packed red blood cell (PRBC) transfusion were recorded. Patients with hemoglobin < 10 g/dL during ICU stay (anemic group) were compared with other patients. Results. Anemia was present on admission in two (2%) patients and developed in 48% during the first week with hemoglobin < 7 g/dL occurring in 3.0%. Anemic patients had higher admission Injury Severity Score and underwent more craniotomy (50% versus 13%, p < 0.001). Forty percent of them received PRBC transfusion (2.8 ± 1.5 units per patient, median pretransfusion hemoglobin = 8.8 g/dL). Higher hospital mortality was associated with anemia (25% versus 6% for nonanemic patients, p = 0.01) and PRBC transfusion (38% versus 9% for nontransfused patients, p = 0.003). On multivariate analysis, only PRBC transfusion independently predicted hospital mortality (odds ratio: 6.8; 95% confidence interval: 1.1–42.3). Conclusions. Anemia occurred frequently after isolated TBI, but only PRBC transfusion independently predicted mortality.
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Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, Herscovitch P, Hinds SR, Manley GT, Pacifico A, Razumovsky A, Riley J, Salzer W, Shih R, Smirniotopoulos JG, Stocker D. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. J Neurotrauma 2015; 32:1693-721. [PMID: 26176603 PMCID: PMC4651019 DOI: 10.1089/neu.2013.3306] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The incidence of traumatic brain injury (TBI) in the United States was 3.5 million cases in 2009, according to the Centers for Disease Control and Prevention. It is a contributing factor in 30.5% of injury-related deaths among civilians. Additionally, since 2000, more than 260,000 service members were diagnosed with TBI, with the vast majority classified as mild or concussive (76%). The objective assessment of TBI via imaging is a critical research gap, both in the military and civilian communities. In 2011, the Department of Defense (DoD) prepared a congressional report summarizing the effectiveness of seven neuroimaging modalities (computed tomography [CT], magnetic resonance imaging [MRI], transcranial Doppler [TCD], positron emission tomography, single photon emission computed tomography, electrophysiologic techniques [magnetoencephalography and electroencephalography], and functional near-infrared spectroscopy) to assess the spectrum of TBI from concussion to coma. For this report, neuroimaging experts identified the most relevant peer-reviewed publications and assessed the quality of the literature for each of these imaging technique in the clinical and research settings. Although CT, MRI, and TCD were determined to be the most useful modalities in the clinical setting, no single imaging modality proved sufficient for all patients due to the heterogeneity of TBI. All imaging modalities reviewed demonstrated the potential to emerge as part of future clinical care. This paper describes and updates the results of the DoD report and also expands on the use of angiography in patients with TBI.
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Affiliation(s)
- Franck Amyot
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David B. Arciniegas
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Baylor College of Medicine, Houston, Texas
- Brain Injury Research, TIRR Memorial Hermann, Houston, Texas
| | | | - Kenneth C. Curley
- Combat Casualty Care Directorate (RAD2), U.S. Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Ramon Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Amir Gandjbakhche
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Peter Herscovitch
- Positron Emission Tomography Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Sidney R. Hinds
- Defense and Veterans Brain Injury Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Silver Spring, Maryland
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Anthony Pacifico
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | | | - Jason Riley
- Queens University, Kingston, Ontario, Canada
- ArcheOptix Inc., Picton, Ontario, Canada
| | - Wanda Salzer
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | - Robert Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - James G. Smirniotopoulos
- Department of Radiology, Neurology, and Biomedical Informatics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Derek Stocker
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Lorente L, Martín MM, Argueso M, Ramos L, Solé-Violán J, Riaño-Ruiz M, Jiménez A, Borreguero-León JM. Serum caspase-3 levels and mortality are associated in patients with severe traumatic brain injury. BMC Neurol 2015; 15:228. [PMID: 26545730 PMCID: PMC4636758 DOI: 10.1186/s12883-015-0485-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/29/2015] [Indexed: 01/10/2023] Open
Abstract
Background Different apoptosis pathways activate caspase-3. In a study involving 27 patients with traumatic brain injury (TBI), higher caspase-3 levels were found in contusion brain tissue resected from non-survivors than from survivors. The objective of this study was to determine whether there is an association in TBI patients between serum caspase-3 levels (thus using an easier, quicker, less expensive and less invasive procedure) and mortality, in a larger series of patients. Methods We carried out a prospective, observational and multicenter study in six Spanish Hospital Intensive Care Units including 112 patients with severe TBI. All had Glasgow Coma Scale (GCS) scores lower than 9. Patients with an Injury Severity Score (ISS) in non-cranial aspects higher than 9 were excluded. Blood samples were collected on day 1 of TBI to measure serum caspas-3 levels. The endpoint was 30-day mortality. Results We found that non-surviving patients (n = 31) showed higher (p = 0.003) serum caspase-3 levels compared to survivors (n = 81). Kaplan-Meier survival analysis showed a higher risk of death in TBI patients with serum caspase-3 levels >0.20 ng/mL than in patients with lower concentrations (Hazard Ratio = 3.15; 95 % CI = 1.40 to 7.08; P < 0.001). Multiple logistic regression analysis showed that serum caspase-3 levels > 0.20 ng/mL were associated with mortality at 30 days in TBI patients controlling for Marshall CT classification, age and GCS (Odds ratio = 7.99; 95 % CI = 2.116 to 36.744; P = 0.001). Conclusions The association between serum caspase-3 levels and mortality in TBI patients was the major novel finding of our study.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, Santa Cruz de Tenerife, 38010, Spain.
| | - Mónica Argueso
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibáñez n°17-19, Valencia, 46004, Spain.
| | - Luis Ramos
- Intensive Care Unit, Hospital General de La Palma, Buenavista de Arriba s/n, Breña Alta, La Palma, 38713, Spain.
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, CIBERES, Barranco de la Ballena s/n, Las Palmas de Gran Canaria, 35010, Spain.
| | - Marta Riaño-Ruiz
- Servicio de Bioquímica Clínica, Complejo Hospitalario Universitario Insular Materno-Infantil, Plaza Dr. Pasteur s/n, Las Palmas de Gran Canaria, 35016, Spain.
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - Juan M Borreguero-León
- Laboratory Deparment, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
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Rønning P, Gunstad PO, Skaga NO, Langmoen IA, Stavem K, Helseth E. The impact of blood ethanol concentration on the classification of head injury severity in traumatic brain injury. Brain Inj 2015; 29:1648-53. [PMID: 26480239 DOI: 10.3109/02699052.2015.1075154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is classified into mild, moderate and severe, based on the Glasgow Coma Score (GCS). However, TBI patients are often influenced by ethanol, which in itself can attenuate the level of consciousness. This study investigated the effect of ethanol on the GCS group classification in TBI patients. METHODS The Oslo University Hospital trauma database was searched for all patients admitted with a head injury where the blood ethanol concentration (BEC) had been measured (n = 1004). The effect of BEC on GCS groups was analysed using multivariate ordinal logistic regression. RESULTS This study identified 546, 142 and 316 patients in the mild, moderate and severe groups, respectively. Increasing BEC by 1 g kg(-1) and pre-hospital intubation had OR = 1.34 and 16.34 for being in a more severe GCS group, respectively. Increasing head abbreviated injury scale (head-AIS) was significantly associated with being in a more severe GCS group. The modelled probability of detecting a head-AIS of 4 or 5 in a patient with BEC of 2.0 g kg(-1) was 20%, 38% and 65% in the mild, moderate and severe groups, respectively. CONCLUSIONS Increasing BEC was associated with increasing odds of being in a more severe GCS group. However, because the modelled probability of significant brain injury was high in patients with high levels of BEC, a reduced level of consciousness in intoxicated patients mandates further radiological investigations.
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Affiliation(s)
- Pål Rønning
- a Department of Neurosurgery , Oslo University Hospital , Norway
| | | | | | - Iver Arne Langmoen
- a Department of Neurosurgery , Oslo University Hospital , Norway .,b The Faculty of Medicine, University of Oslo , Norway
| | - Knut Stavem
- b The Faculty of Medicine, University of Oslo , Norway .,d Department of Pulmonary Medicine , Akershus University Hospital , Norway , and.,e HØKH, Research Centre, Akershus University Hospital , Norway
| | - Eirik Helseth
- a Department of Neurosurgery , Oslo University Hospital , Norway .,b The Faculty of Medicine, University of Oslo , Norway
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Patet C, Quintard H, Suys T, Bloch J, Daniel RT, Pellerin L, Magistretti PJ, Oddo M. Neuroenergetic Response to Prolonged Cerebral Glucose Depletion after Severe Brain Injury and the Role of Lactate. J Neurotrauma 2015; 32:1560-6. [DOI: 10.1089/neu.2014.3781] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Camille Patet
- Department of Intensive Care Medicine, University of Lausanne, Switzerland
| | - Hervé Quintard
- Department of Intensive Care Medicine, University of Lausanne, Switzerland
| | - Tamarah Suys
- Department of Intensive Care Medicine, University of Lausanne, Switzerland
| | - Jocelyne Bloch
- Department of Clinical Neurosciences, University of Lausanne, Switzerland
| | - Roy T. Daniel
- Department of Clinical Neurosciences, University of Lausanne, Switzerland
| | - Luc Pellerin
- Departement of Physiology, University of Lausanne, Switzerland
| | - Pierre J. Magistretti
- Division of Biological and Environmental Sciences and Engineering, King Abdullah University of Science and Technology, Thuwal, Kingdom of Saudi Arabia
- Department of Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Laboratory of Neuroenergetics and Cellular Dynamics, Brain Mind Institute, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, University of Lausanne, Switzerland
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Fulkerson DH, White IK, Rees JM, Baumanis MM, Smith JL, Ackerman LL, Boaz JC, Luerssen TG. Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr 2015; 16:410-9. [PMID: 26140392 DOI: 10.3171/2015.3.peds14679] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a "normal" outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.
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Affiliation(s)
- Daniel H Fulkerson
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Ian K White
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jacqueline M Rees
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Maraya M Baumanis
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jodi L Smith
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Laurie L Ackerman
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Joel C Boaz
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Thomas G Luerssen
- Department of Neurological Surgery, Baylor College of Medicine, Texas Children's Hospital, Pediatric Neurosurgery, Houston, Texas
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Lorente L, Martín MM, Abreu-González P, Ramos L, Argueso M, Cáceres JJ, Solé-Violán J, Lorenzo JM, Molina I, Jiménez A. Association between serum malondialdehyde levels and mortality in patients with severe brain trauma injury. J Neurotrauma 2015; 32:1-6. [PMID: 25054973 DOI: 10.1089/neu.2014.3456] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
There is a hyperoxidative state in patients with trauma brain injury (TBI). Malondialdehyde (MDA) is an end-product formed during oxidative stress, concretely lipid peroxidation. In small studies (highest sample size 50 patients), higher levels of MDA have been found in nonsurviving than surviving patients with TBI. An association between serum MDA levels and mortality in patients with TBI, however, has not been reported. Thus, the objective of this prospective, observational, multicenter study, performed in six Spanish intensive care units, was to determine whether MDA serum levels are associated with early mortality in a large series of patients with severe TBI. Serum MDA levels were measured in 100 patients with severe TBI on day 1 and in 75 healthy controls. The end-point of the study was 30-day mortality. We found higher serum MDA levels in patients with severe TBI than in healthy controls (p < 0.001). Nonsurviving patients with TBI (n = 27) showed higher serum MDA levels (p < 0.001) than survivors (n = 73). Logistic regression analysis showed that serum MDA levels were associated with 30-day mortality (odds ratio [OR] = 4.662; 95% confidence interval [CI] = 1.466-14.824; p = 0.01), controlling for Glasgow Coma Score, age, and computed tomography findings. Survival analysis showed that patients with serum MDA levels higher than 1.96 nmol/mL presented increased 30-day mortality than patients with lower levels (hazard ratio = 3.5; 95% CI = 1.43-8.47; p < 0.001). Thus, the most relevant new finding of our study, the largest to date on serum MDA levels in patients with severe TBI, was an association between serum MDA levels and early mortality.
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Affiliation(s)
- Leonardo Lorente
- 1 Intensive Care Unit, Hospital Universitario de Canarias , Santa Cruz de Tenerife, Spain
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Sood S, Marupudi N, Haridas A, Ham SD. Intracranial pressure and sagittal craniosynostosis. J Neurosurg Pediatr 2015; 16:351-2. [PMID: 26067334 DOI: 10.3171/2015.1.peds14705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Flynn LM, Rhodes J, Andrews PJ. Therapeutic Hypothermia Reduces Intracranial Pressure and Partial Brain Oxygen Tension in Patients with Severe Traumatic Brain Injury: Preliminary Data from the Eurotherm3235 Trial. Ther Hypothermia Temp Manag 2015; 5:143-51. [PMID: 26060880 PMCID: PMC4575517 DOI: 10.1089/ther.2015.0002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of disability and death and a huge economic burden throughout the world. Much of the morbidity associated with TBI is attributed to secondary brain injuries resulting in hypoxia and ischemia after the initial trauma. Intracranial hypertension and decreased partial brain oxygen tension (PbtO2) are targeted as potentially avoidable causes of morbidity. Therapeutic hypothermia (TH) may be an effective intervention to reduce intracranial pressure (ICP), but could also affect cerebral blood flow (CBF). This is a retrospective analysis of prospectively collected data from 17 patients admitted to the Western General Hospital, Edinburgh. Patients with an ICP >20 mmHg refractory to initial therapy were randomized to standard care or standard care and TH (intervention group) titrated between 32°C and 35°C to reduce ICP. ICP and PbtO2 were measured using the Licox system and core temperature was recorded through rectal thermometer. Data were analyzed at the hour before cooling, the first hour at target temperature, 2 consecutive hours at target temperature, and after 6 hours of hypothermia. There was a mean decrease in ICP of 4.3±1.6 mmHg (p<0.04) from 15.7 to 11.4 mmHg, from precooling to the first epoch of hypothermia in the intervention group (n=9) that was not seen in the control group (n=8). A decrease in ICP was maintained throughout all time periods. There was a mean decrease in PbtO2 of 7.8±3.1 mmHg (p<0.05) from 30.2 to 22.4 mmHg, from precooling to stable hypothermia, which was not seen in the control group. This research supports others in demonstrating a decrease in ICP with temperature, which could facilitate a reduction in the use of hyperosmolar agents or other stage II interventions. The decrease in PbtO2 is not below the suggested treatment threshold of 20 mmHg, but might indicate a decrease in CBF.
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Affiliation(s)
- Liam M.C. Flynn
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
| | - Jonathan Rhodes
- Department of Anesthesia and Critical Care, University of Edinburgh and NHS Lothian, Western General Hospital, Edinburgh, United Kingdom
| | - Peter J.D. Andrews
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
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Herrera-Melero MC, Egea-Guerrero JJ, Vilches-Arenas A, Rincón-Ferrari MD, Flores-Cordero JM, León-Carrión J, Murillo-Cabezas F. Acute predictors for mortality after severe TBI in Spain: Gender differences and clinical data. Brain Inj 2015; 29:1439-44. [DOI: 10.3109/02699052.2015.1071428] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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82
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Stein SC, Attiah MA. Clinical Prediction and Decision Rules in Neurosurgery. Neurosurgery 2015; 77:149-55; discussion 156. [DOI: 10.1227/neu.0000000000000818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kummer TT, Magnoni S, MacDonald CL, Dikranian K, Milner E, Sorrell J, Conte V, Benetatos JJ, Zipfel GJ, Brody DL. Experimental subarachnoid haemorrhage results in multifocal axonal injury. Brain 2015; 138:2608-18. [PMID: 26115676 DOI: 10.1093/brain/awv180] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 04/29/2015] [Indexed: 11/12/2022] Open
Abstract
The great majority of acute brain injury results from trauma or from disorders of the cerebrovasculature, i.e. ischaemic stroke or haemorrhage. These injuries are characterized by an initial insult that triggers a cascade of injurious cellular processes. The nature of these processes in spontaneous intracranial haemorrhage is poorly understood. Subarachnoid haemorrhage, a particularly deadly form of intracranial haemorrhage, shares key pathophysiological features with traumatic brain injury including exposure to a sudden pressure pulse. Here we provide evidence that axonal injury, a signature characteristic of traumatic brain injury, is also a prominent feature of experimental subarachnoid haemorrhage. Using histological markers of membrane disruption and cytoskeletal injury validated in analyses of traumatic brain injury, we show that axonal injury also occurs following subarachnoid haemorrhage in an animal model. Consistent with the higher prevalence of global as opposed to focal deficits after subarachnoid haemorrhage and traumatic brain injury in humans, axonal injury in this model is observed in a multifocal pattern not limited to the immediate vicinity of the ruptured artery. Ultrastructural analysis further reveals characteristic axonal membrane and cytoskeletal changes similar to those associated with traumatic axonal injury. Diffusion tensor imaging, a translational imaging technique previously validated in traumatic axonal injury, from these same specimens demonstrates decrements in anisotropy that correlate with histological axonal injury and functional outcomes. These radiological indicators identify a fibre orientation-dependent gradient of axonal injury consistent with a barotraumatic mechanism. Although traumatic and haemorrhagic acute brain injury are generally considered separately, these data suggest that a signature pathology of traumatic brain injury-axonal injury-is also a functionally significant feature of subarachnoid haemorrhage, raising the prospect of common diagnostic, prognostic, and therapeutic approaches to these conditions.
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Affiliation(s)
- Terrance T Kummer
- 1 Department of Neurology, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - Sandra Magnoni
- 2 Department of Anaesthesiology and Intensive Care, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza, 33, 20122, Milan, Italy
| | - Christine L MacDonald
- 1 Department of Neurology, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - Krikor Dikranian
- 3 Department of Anatomy and Neurobiology, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - Eric Milner
- 4 Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - James Sorrell
- 1 Department of Neurology, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - Valeria Conte
- 2 Department of Anaesthesiology and Intensive Care, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza, 33, 20122, Milan, Italy
| | - Joey J Benetatos
- 1 Department of Neurology, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - Gregory J Zipfel
- 4 Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - David L Brody
- 1 Department of Neurology, Washington University School of Medicine, 660 S Euclid Ave, Saint Louis, Missouri, 63110, USA
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Lee KJ, Park C, Oh J, Lee B. Non-invasive detection of intracranial hypertension using a simplified intracranial hemo- and hydro-dynamics model. Biomed Eng Online 2015; 14:51. [PMID: 26024843 PMCID: PMC4449568 DOI: 10.1186/s12938-015-0051-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/18/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Monitoring of intracranial pressure (ICP) is highly important for detecting abnormal brain conditions such as intracranial hemorrhage, cerebral edema, or brain tumor. Until now, the monitoring of ICP requires an invasive method which has many disadvantages including the risk of infections, hemorrhage, or brain herniation. Therefore, many non-invasive methods have been proposed for estimating ICP. However, these methods are still insufficient to estimate sudden increases in ICP. METHODS We proposed a simplified intracranial hemo- and hydro-dynamics model that consisted of two simple resistance circuits. From this proposed model, we designed an ICP estimation algorithm to trace ICP changes. First, we performed a simulation based on the original Ursino model with the real arterial blood pressure to investigate our proposed approach. We subsequently applied it to experimental data that were measured during the Valsalva maneuver (VM) and resting state, respectively. RESULTS Simulation result revealed a small root mean square error (RMSE) between the estimated ICP by our approach and the reference ICP derived from the original Ursino model. Compared to the pulsatility index (PI) based approach and Kashif's model, our proposed method showed more statistically significant difference between VM and resting state. CONCLUSION Our proposed method successfully tracked sudden ICP increases. Therefore, our method may serve as a suitable tool for non-invasive ICP monitoring.
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Affiliation(s)
- Kwang Jin Lee
- Department of Medical System Engineering (DMSE), Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea.
| | - Chanki Park
- School of Mechatronics, Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea.
| | - Jooyoung Oh
- Department of Medical System Engineering (DMSE), Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea.
| | - Boreom Lee
- Department of Medical System Engineering (DMSE), Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea. .,School of Mechatronics, Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea.
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85
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Friess SH, Lapidus JB, Brody DL. Decompressive craniectomy reduces white matter injury after controlled cortical impact in mice. J Neurotrauma 2015; 32:791-800. [PMID: 25557588 DOI: 10.1089/neu.2014.3564] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Reduction and avoidance of increases in intracranial pressure (ICP) after severe traumatic brain injury (TBI) continue to be the mainstays of treatment. Traumatic axonal injury is a major contributor to morbidity after TBI, but it remains unclear whether elevations in ICP influence axonal injury. Here we tested the hypothesis that reduction in elevations in ICP after experimental TBI would result in decreased axonal injury and white matter atrophy in mice. Six-week-old male mice (C57BL/6J) underwent either moderate controlled cortical impact (CCI) (n=48) or Sham surgery (Sham, n=12). Immediately after CCI, injured animals were randomized to a loose fitting plastic cap (Open) or replacement of the previously removed bone flap (Closed). Elevated ICP was observed in Closed animals compared with Open and Sham at 15 min (21.4±4.2 vs. 12.3±2.9 and 8.8±1.8 mm Hg, p<0.0001) and 1 day (17.8±3.7 vs. 10.6±2.0 and 8.9±1.9 mm Hg, p<0.0001) after injury. Beta amyloid precursor protein staining in the corpus callosum and ipsilateral external capsule revealed reduced axonal swellings and bulbs in Open compared with Closed animals (32% decrease, p<0.01 and 40% decrease, p<0.001 at 1 and 7 days post-injury, respectively). Open animals were also found to have decreased neurofilament-200 stained axonal swellings at 7 days post-injury compared with Open animals (32% decrease, p<0.001). At 4 weeks post-injury, Open animals had an 18% reduction in white matter volume compared with 34% in Closed animals (p<0.01). Thus, our results indicate that CCI with decompressive craniectomy was associated with reductions in ICP and reduced pericontusional axonal injury and white matter atrophy. If similar in humans, therapeutic interventions that ameliorate intracranial hypertension may positively influence white matter injury severity.
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Affiliation(s)
- Stuart H Friess
- 1Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jodi B Lapidus
- 1Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - David L Brody
- 2Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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86
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Hansen G, Joffe AR, Bowman SM, Richer L. Nonconvulsive seizures and status epilepticus in pediatric head trauma: A national survey. SAGE Open Med 2015; 3:2050312115573817. [PMID: 26770768 PMCID: PMC4679225 DOI: 10.1177/2050312115573817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 01/22/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES It remains uncertain whether nonconvulsive seizures and nonconvulsive status epilepticus in pediatric traumatic brain injury are deleterious to the brain and/or impact the recovery from injury. Consequently, optimal electroencephalographic surveillance and management is unknown. We aimed to determine specialists' opinion regarding the detection and treatment of nonconvulsive seizures or nonconvulsive status epilepticus in pediatric traumatic brain injury, regardless of their practice. METHODS In 2012, 183 surveys were sent to all 93 neurologists, 27 neurosurgeons, and 63 intensivists in the14 tertiary pediatric hospitals across Canada. The survey included an initial scenario of pediatric TBI that evolved into three further scenarios. Each scenario had required responses and an embedded branching logic algorithm ascertaining clinical management. The survey instrument assimilated data about the importance of nonconvulsive status epilepticus and nonconvulsive seizures detection and treatment, and whether they are a cause of brain injury that adversely affects neurologic outcomes. RESULTS Of the 79 specialists who replied (43% response rate), 68%-78% elected to order an electroencephalographic across all four scenarios, and one-third (31%-36%; scenario dependent) would request an urgent electroencephalographic (within the hour) in the comatose pediatric traumatic brain injury patient. In the absence of pharmacologic paralysis or intracranial pressure spikes, half-hour electroencephalographic (41%-55%) was preferred over ⩾24-h continuous electroencephalographic monitoring (29%-40%). Finally, nonconvulsive status epilepticus (81%-87%) and nonconvulsive seizures (61%-73%) were considered to be a cause of poor neurologic outcomes warranting aggressive pharmacologic management. CONCLUSION The Canadian specialists' opinion is that nonconvulsive seizures and nonconvulsive status epilepticus are biomarkers of brain injury and contribute to worsened outcomes. This suggests the urgency of future outcome-oriented research in the identification and management of nonconvulsive seizures or nonconvulsive status epilepticus.
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Affiliation(s)
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Stephen M Bowman
- Johns Hopkins University, Baltimore, MD, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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87
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Sriram N, Yarrow S. Intensive care management of head injury. Br J Hosp Med (Lond) 2015; 75:C183-7. [PMID: 25488460 DOI: 10.12968/hmed.2014.75.sup12.c183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- N Sriram
- Senior House Officer in the Department of Anaesthesia, Northwick Park Hospital, London
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88
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Radomski M, Zettervall S, Schroeder ME, Messing J, Dunne J, Sarani B. Critical Care for the Patient With Multiple Trauma. J Intensive Care Med 2015; 31:307-18. [PMID: 25673631 DOI: 10.1177/0885066615571895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023]
Abstract
Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.
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Affiliation(s)
- Michal Radomski
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Sara Zettervall
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Mary Elizabeth Schroeder
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Jonathan Messing
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - James Dunne
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
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89
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Raj R, Skrifvars MB, Kivisaari R, Hernesniemi J, Lappalainen J, Siironen J. Acute alcohol intoxication and long-term outcome in patients with traumatic brain injury. J Neurotrauma 2015; 32:95-100. [PMID: 25010885 PMCID: PMC4291208 DOI: 10.1089/neu.2014.3488] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effect of blood alcohol concentration (BAC) on outcome after traumatic brain injury (TBI) is controversial. We sought to assess the independent effect of positive BAC on long-term outcome in patients with TBI treated in the intensive care unit (ICU). We performed a retrospective analysis of 405 patients with TBI, admitted to the ICU of a large urban Level 1 trauma center between January 2009 and December 2012. Outcome was six-month mortality and unfavorable neurological outcome (defined as a Glasgow Outcome Scale score of 1 [death], 2, [vegetative state], or 3 [severe disability]). Patients were categorized by admission BAC into: no BAC (0.0‰; n=99), low BAC (<2.3‰; n=140) and high BAC (≥2.3‰; n=166). Logistic regression analysis, adjusting for baseline risk and severity of illness, was used to assess the independent effect of BAC on outcome (using the no BAC group as the reference). Overall six-month mortality was 25% and unfavorable outcome was 46%. Multivariate analysis showed low BAC to independently reduce risk of six-month mortality compared with no BAC (low BAC adjusted odds ratio [AOR] 0.41, 95% confidence interval [CI] 0.19-0.88, p=0.021) and high BAC (AOR 0.58, 95% CI 0.29-1.15, p=0.120). Furthermore, a trend towards reduced risk of six-month unfavorable neurological outcome for patients with positive BAC, compared to patients with negative BAC, was noted, although this did not reach statistical significance (low BAC AOR 0.65, 95% CI 0.34-1.22, p=0.178, and high BAC AOR 0.59, 95% CI 0.32-1.09, p=0.089). In conclusion, low admission BAC (<2.3‰) was found to independently reduce risk of six-month mortality for patients with TBI, and a trend towards improved long-term neurological outcome was found for BAC-positive patients. The role of alcohol as a neuroprotective agent warrants further studies.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Markus B. Skrifvars
- Department of Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Jaakko Lappalainen
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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90
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Berlin T, Murray-Krezan C, Yonas H. Comparison of parenchymal and ventricular intracranial pressure readings utilizing a novel multi-parameter intracranial access system. SPRINGERPLUS 2015; 4:10. [PMID: 25674495 PMCID: PMC4320187 DOI: 10.1186/2193-1801-4-10] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 12/17/2014] [Indexed: 11/16/2022]
Abstract
Introduction Both ventricular and parenchymal devices are available for measurement of intracranial pressure (ICP). The Hummingbird® Synergy Ventricular System is a novel device allowing multi-parametric neurological monitoring, including both ventricular and parenchymal ICP. The purpose of this study is to compare the congruence of the device’s ventricular and parenchymal ICP readings. Methods This single-center, quantitative, interventional study compared parenchymal and ventricular ICP readings from 35 patients with the Hummingbird® System. If a difference of > ± 3 mmHg existed between an individual patient’s parenchymal and ventricular values, progressive intervention strategies were applied to correct identified issues. Results From a total of 2,259 observations, statistical analysis revealed congruence (within ±0-3 mmHg) of 93% of readings comparing parenchymal and ventricular ICP. Of the observations requiring intervention, 58% involved the parenchymal component, 30% involved the ventricular component, and 12% involved both components. Following prescribed interventions, 98% of readings became congruent (within ±0-3 mmHg). The adjusted mean difference between the two methods was -0.95 (95% CI: -0.97,-0.93) mmHg and all mean ICP readings fell between -2 and 2 mmHg. Conclusion The Hummingbird® Synergy Ventricular System demonstrates congruence between ventricular and parenchymal ICP measurements within accepted parameters. Interventions required to realign parenchymal and ventricular readings serve as reminders to clinicians to be vigilant with catheter/cable connections and to maintain appropriate positioning of the ventricular drainage system. The results of this study support the recommendation to use the parenchymal ICP component for routine ICP monitoring, allowing dedication of the ventricular catheter to drainage of cerebrospinal fluid (CSF).
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Affiliation(s)
- Tracey Berlin
- Department of Neurosurgery, University of New Mexico Hospital, MSC10 5615, 1 University of New Mexico, Albuquerque, NM 87131-0001 USA
| | - Cristina Murray-Krezan
- Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, MSC10 5550, 1 University of New Mexico, Albuquerque, NM 87131-0001 USA
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 University of New Mexico, Albuquerque, NM 87131-0001 USA
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91
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Mangat HS, Chiu YL, Gerber LM, Alimi M, Ghajar J, Härtl R. Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg 2015; 122:202-10. [DOI: 10.3171/2014.10.jns132545] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECT
Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI.
METHODS
The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples.
RESULTS
A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56).
CONCLUSIONS
HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.
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Affiliation(s)
- Halinder S. Mangat
- Departments of 1Neurology and
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | | | - Linda M. Gerber
- Departments of 3Public Health and
- 4Medicine, Weill Cornell Medical College
| | - Marjan Alimi
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | - Jamshid Ghajar
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 6The Brain Trauma Foundation, New York, New York
| | - Roger Härtl
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
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92
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Skolnick BE, Maas AI, Narayan RK, van der Hoop RG, MacAllister T, Ward JD, Nelson NR, Stocchetti N. A clinical trial of progesterone for severe traumatic brain injury. N Engl J Med 2014; 371:2467-76. [PMID: 25493978 DOI: 10.1056/nejmoa1411090] [Citation(s) in RCA: 324] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Progesterone has been associated with robust positive effects in animal models of traumatic brain injury (TBI) and with clinical benefits in two phase 2 randomized, controlled trials. We investigated the efficacy and safety of progesterone in a large, prospective, phase 3 randomized clinical trial. METHODS We conducted a multinational placebo-controlled trial, in which 1195 patients, 16 to 70 years of age, with severe TBI (Glasgow Coma Scale score, ≤8 [on a scale of 3 to 15, with lower scores indicating a reduced level of consciousness] and at least one reactive pupil) were randomly assigned to receive progesterone or placebo. Dosing began within 8 hours after injury and continued for 120 hours. The primary efficacy end point was the Glasgow Outcome Scale score at 6 months after the injury. RESULTS Proportional-odds analysis with covariate adjustment showed no treatment effect of progesterone as compared with placebo (odds ratio, 0.96; confidence interval, 0.77 to 1.18). The proportion of patients with a favorable outcome on the Glasgow Outcome Scale (good recovery or moderate disability) was 50.4% with progesterone, as compared with 50.5% with placebo. Mortality was similar in the two groups. No relevant safety differences were noted between progesterone and placebo. CONCLUSIONS Primary and secondary efficacy analyses showed no clinical benefit of progesterone in patients with severe TBI. These data stand in contrast to the robust preclinical data and results of early single-center trials that provided the impetus to initiate phase 3 trials. (Funded by BHR Pharma; SYNAPSE ClinicalTrials.gov number, NCT01143064.).
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Affiliation(s)
- Brett E Skolnick
- From the Department of Neurosurgery, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (B.E.S., R.K.N.); the Department of Neurosurgery, University Hospital Antwerp and University of Antwerp, Edegem, Belgium (A.I.M.); BHR Pharma, Herndon (R.G.H., T.M., N.R.N.), and the Department of Neurosurgery, Virginia Commonwealth University, Richmond (J.D.W.) - both in Virginia; and the Department of Physiopathology and Transplantation, Milan University and Neuro Intensive Care Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Cà Granda Ospedale Maggiore Policlinico, Milan (N.S.)
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93
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The physiologic effects of indomethacin test on CPP and ICP in severe traumatic brain injury (sTBI). Neurocrit Care 2014; 20:230-9. [PMID: 24233815 DOI: 10.1007/s12028-013-9924-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Refractory intracranial hypertension (RICH) is associated with high mortality in severe traumatic brain injury (sTBI). Indomethacin (INDO) can decrease intracranial cerebral pressure (ICP) improving cerebral pressure perfusion (CPP). Our aim was to determine modifications in ICP and CPP following INDO in RICH secondary to sTBI. METHODS INDO was administered in a loading dose (0.8 mg/kg/15 min), followed by continuous 2-h infusion period (0.5 mg/kg/h). Clinical outcome was assessed at 30 days according to Glasgow Outcome Scale (GOS). Differences in ICP and CPP values were assessed using repeated-measures ANOVA. Receiver operating characteristic curve (AUC) was used for discrimination in predicting 30-day survival and good functional outcome (GOS 4 or 5). Analysis of INDO safety profile was also conducted. RESULTS Thirty-two patients were included. Median GCS score was 6 (interquartile range: 4-7). The most frequent CT finding was the evacuated mass lesion (EML) according to Marshall classification (28.1 %). Mortality rate was 34.4 %. Within 15 min of INDO infusion, ICP decreased (Δ%: -54.6 %; P < 0.0001), CPP increased (Δ%: +44.0 %; P < 0.0001), and the remaining was stable during the entire infusion period. Patients with good outcome (n = 12) showed a greater increase of CPP during INDO test (P = 0.028). CPP response to INDO test discriminated moderately well surviving patients (AUC = 0.751; P = 0.0098) and those with good functional recovery (AUC = 0.763; P = 0.0035) from those who died and from those with worse functional outcome, respectively. No adverse events were observed. CONCLUSIONS INDO appears effective in reducing ICP and improving CPP in RICH. INDO test could be a useful tool in identifying RICH patients with favorable outcome. Future studies are needed.
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Bader MK. Clinical Q & A: Translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2014; 4:201-7. [PMID: 25423606 DOI: 10.1089/ther.2014.1516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
PURPOSE OF REVIEW The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified. RECENT FINDINGS When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data. SUMMARY Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.
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96
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Friedman A, Bar-Klein G, Serlin Y, Parmet Y, Heinemann U, Kaufer D. Should losartan be administered following brain injury? Expert Rev Neurother 2014; 14:1365-75. [PMID: 25346269 DOI: 10.1586/14737175.2014.972945] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Brain injury is a major health concern and associated with delayed neurological complications, including post-injury epilepsy, cognitive and emotional disabilities. Currently, there is no strategy to prevent post-injury delayed complications. We recently showed that dysfunction of the blood-brain barrier, often reported in brain injuries, can lead to epilepsy and neurodegeneration via activation of inflammatory TGF-β signaling in astrocytes. We further showed that the FDA approved angiotensin II type 1 receptor antagonist, losartan, blocks brain TGF-β signaling and prevents epilepsy in the albumin or blood-brain barrier breakdown models of epileptogenesis. Here we discuss the potential of losartan as an anti-epileptogenic and a neuroprotective drug, the rationale of its use following brain injury and the challenges of designing clinical trials. We highlight the urgent need to develop reliable biomarkers for epileptogenesis (and other complications) after brain injury as a pre-requisite to challenge neuroprotective therapies.
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Affiliation(s)
- Alon Friedman
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, PO Box 15000, 5850 College Street, Halifax Nova Scotia B3H 4R2, Canada
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97
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Raj R, Siironen J, Kivisaari R, Hernesniemi J, Skrifvars MB. Predicting outcome after traumatic brain injury: development of prognostic scores based on the IMPACT and the APACHE II. J Neurotrauma 2014; 31:1721-32. [PMID: 24836936 PMCID: PMC4179932 DOI: 10.1089/neu.2014.3361] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Prediction models are important tools for heterogeneity adjustment in clinical trials and for the evaluation of quality of delivered care to patients with traumatic brain injury (TBI). We sought to improve the predictive performance of the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials) prognostic model by combining it with the APACHE II (Acute Physiology and Chronic Health Evaluation II) for 6-month outcome prediction in patients with TBI treated in the intensive care unit. A total of 890 patients with TBI admitted to a large urban level 1 trauma center in 2009-2012 comprised the study population. The IMPACT and the APACHE II scores were combined using binary logistic regression. A randomized, split-sample technique with secondary bootstrapping was used for model development and internal validation. Model performance was assessed by discrimination (by area under the curve [AUC]), calibration, precision, and net reclassification improvement (NRI). Overall 6-month mortality was 22% and unfavorable neurological outcome 47%. The predictive power of the new combined IMPACT-APACHE II models was significantly superior, compared to the original IMPACT models (AUC, 0.81-0.82 vs. 0.84-0.85; p<0.05) for 6-month mortality prediction, but not for unfavorable outcome prediction (AUC, 0.81-0.82 vs. 0.83; p>0.05). However, NRI showed a significant improvement in risk stratification of patients with unfavorable outcome by the IMPACT-APACHE II models, compared to the original models (NRI, 5.4-23.2%; p<0.05). Internal validation using split-sample and resample bootstrap techniques yielded equivalent results, indicating low grade of overestimation. Our findings show that by combining the APACHE II with the IMPACT, improved 6-month outcome predictive performance is achieved. This may be applicable for heterogeneity adjustment in forthcoming TBI studies.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Markus B. Skrifvars
- Department of Intensive Care, Helsinki University Hospital, Helsinki, Finland
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Colton K, Yang S, Hu PF, Chen HH, Bonds B, Stansbury LG, Scalea TM, Stein DM. Pharmacologic Treatment Reduces Pressure Times Time Dose and Relative Duration of Intracranial Hypertension. J Intensive Care Med 2014; 31:263-9. [PMID: 25320157 DOI: 10.1177/0885066614555692] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/18/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Past work has shown the importance of the "pressure times time dose" (PTD) of intracranial hypertension (intracranial pressure [ICP] > 19 mm Hg) in predicting outcome after severe traumatic brain injury. We used automated data collection to measure the effect of common medications on the duration and dose of intracranial hypertension. METHODS Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a single, large urban tertiary care facility, were retrospectively enrolled. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. The ICP data were collected automatically at 6-second intervals and averaged over 5 minutes. The percentage of time of intracranial hypertension (PTI) and PTD (mm Hg h) were calculated. RESULTS A total of 98 patients with 664 treatment instances were identified. Baseline PTD ranged from 27 (before administration of propofol and fentanyl) to 150 mm Hg h (before mannitol). A "small" dose of hypertonic saline (HTS; ≤250 mL 3%) reduced PTD by 38% in the first hour and 37% in the second hour and reduced the time with ICP >19 by 38% and 39% after 1 and 2 hours, respectively. A "large" dose of HTS reduced PTD by 40% in the first hour and 63% in the second (PTI reduction of 36% and 50%, respectively). An increased dose of propofol or fentanyl infusion failed to decrease PTD but reduced PTI between 14% (propofol alone) and 30% (combined increase in propofol and fentanyl, after 2 hours). Barbiturates failed to decrease PTD but decreased PTI by 30% up to 2 hours after administration. All reductions reported are significantly changed from baseline, P < .05. CONCLUSION Baseline PTD values before drug administration reflects varied patient criticality, with much higher values seen before the use of mannitol or barbiturates. Treatment with HTS reduced PTD and PTI burden significantly more than escalation of sedation or pain management, and this effect remained significant at 2 hours after administration.
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Affiliation(s)
- Katharine Colton
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Duke University School of Medicine, Durham, NC, USA
| | - S Yang
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - P F Hu
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - H H Chen
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - B Bonds
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - L G Stansbury
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - T M Scalea
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - D M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Stover JF, Belli A, Boret H, Bulters D, Sahuquillo J, Schmutzhard E, Zavala E, Ungerstedt U, Schinzel R, Tegtmeier F. Nitric oxide synthase inhibition with the antipterin VAS203 improves outcome in moderate and severe traumatic brain injury: a placebo-controlled randomized Phase IIa trial (NOSTRA). J Neurotrauma 2014; 31:1599-606. [PMID: 24831445 DOI: 10.1089/neu.2014.3344] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Traumatic brain injury (TBI) is an important cause of death and disability. Safety and pharmacodynamics of 4-amino-tetrahydrobiopterin (VAS203), a nitric oxide (NO)-synthase inhibitor, were assessed in TBI in an exploratory Phase IIa study (NOSynthase Inhibition in TRAumatic brain injury=NOSTRA). The study included 32 patients with TBI in six European centers. In a first open Cohort, eight patients received three 12-h intravenous infusions of VAS203 followed by a 12-h infusion-free interval over 3 days (total dose 15 mg/kg). Patients in Cohorts 2 and 3 (24) were randomized 2:1 to receive either VAS203 or placebo as an infusion for 48 or 72 h, respectively (total dose 20 and 30 mg/kg). Effects of VAS203 on intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain metabolism using microdialysis, and the therapy intensity level (TIL) were end points. In addition, exploratory analysis of the extended Glasgow Outcome Score (eGOS) after 6 months was performed. Metabolites of VAS203 were detected in cerebral microdialysates. No significant differences between treatment and placebo groups were observed for ICP, CPP, and brain metabolism. TIL on day 6 was significantly decreased (p<0.04) in the VAS203 treated patients. The eGOS after 6 months was significantly higher in treated patients compared with placebo (p<0.01). VAS203 was not associated with hepatic, hematologic, or cardiac toxic effects. At the highest dose administered, four of eight patients receiving VAS203 showed transitory acute kidney injury (stage 2-3). In conclusion, the significant improvement in clinical outcome indicates VAS203-mediated neuroprotection after TBI. At the highest dose, VAS203 is associated with a risk of acute kidney injury.
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Affiliation(s)
- John F Stover
- 1 University Hospital Zuerich , Zuerich, Switzerland
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