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Xiao F, Chiang IJ, Wong JM, Tsai YH, Huang KC, Liao CC. Automatic measurement of midline shift on deformed brains using multiresolution binary level set method and Hough transform. Comput Biol Med 2011; 41:756-62. [DOI: 10.1016/j.compbiomed.2011.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 04/22/2011] [Accepted: 06/14/2011] [Indexed: 10/17/2022]
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Plasma levels of oxidative stress biomarkers and hospital mortality in severe head injury: a multivariate analysis. J Crit Care 2011; 27:523.e11-9. [PMID: 21803537 DOI: 10.1016/j.jcrc.2011.06.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 06/01/2011] [Accepted: 06/12/2011] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The association between biomarkers of oxidative stress and the prognosis of patients with traumatic brain injury (TBI) remains inconclusive. OBJECTIVE The objective was to investigate the association between plasma levels of lipid peroxidation (thiobarbituric acid reactive species [TBARS]) and protein oxidation (carbonyl) biomarkers and the hospital mortality of patients with severe TBI. METHODS Plasma levels of TBARS and carbonyl were determined in 79 consecutive patients with severe TBI (Glasgow Coma Scale [GCS] ≤8) at a median of 12 hours (interquartile range [IQ] 25-75, 6.5-19.0), 30 hours (IQ 25-75, 24.7-37.0), and 70 (IQ 25-75, 55.0-78.5) hours after TBI and were compared with age- and sex-matched controls. The association between the TBARS and carbonyl levels and the hospital mortality was analyzed by multiple logistic regression analysis. RESULTS The mean age of patients was 34.8 years. Eighty-six percent were male. The TBARS and carbonyl levels were significantly higher in patients than in controls. There was a trend (P = .09) for higher plasma levels of TBARS and carbonyl proteins at 12 hours, but not at 30 or 70 hours, after trauma in nonsurvivors than in survivors. These findings were not confirmed after the adjustments by multiple logistic regression analysis. The final model showed a higher adjusted odds ratio for death for patients with admission GCS lower than 5 (odds ratio [OR] = 4.04; 95% confidence interval [CI], 1.33-12.13; P = .01) than those with higher GCS scores. Abnormal pupils were also associated with higher mortality (OR = 3.97; 95% CI, 1.22-12.13; P = .02). There was a nonsignificant trend for association between glucose greater than or equal to 150 mm/dL in the first 12 hours and death than levels between 70 and 149 mg/dL (OR = 2.92; 95% CI, 0.96-9.02; P = .06). CONCLUSIONS Plasma levels of TBARS and carbonyl increase significantly in the first 70 hours after severe TBI but are not independently associated with the hospital mortality.
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Gullo JDS, Bertotti MM, Silva CCP, Schwarzbold M, Diaz AP, Soares FMS, Freitas FC, Nunes J, Pinheiro JT, Morato EF, Prediger RD, Linhares MN, Walz R. Hospital mortality of patients with severe traumatic brain injury is associated with serum PTX3 levels. Neurocrit Care 2011; 14:194-9. [PMID: 20972645 DOI: 10.1007/s12028-010-9462-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a worldwide cause of morbidity and mortality. Pentraxin 3 (PTX3) is a humoral component of the innate immune system which has been studied as a marker of inflammatory, infections or cardiovascular pathologies. To investigate the association between serum levels of PTX3 and the hospital mortality of patients with severe TBI. METHODS The independent association between serum PTX3 levels after severe TBI (Glasgow Coma Scale, GCS ≤ 8) and hospital mortality was analyzed in a prospective study of 83 consecutive patients by a multiple logistic regression analysis. The leukocyte count in the same sample was analyzed as another marker of inflammatory response. RESULTS The mean age of patients was 35 years and 85% were male. Serum PTX3 levels were determined 18.0 (SD ± 17.0) h after TBI. Patients who died showed a mean serum PTX3 level of 9.95 μg/ml (SD ± 6.42) in comparison to 5.46 μg/ml (SD ± 4.87) of the survivor group (P = 0.007). Elevated serum PTX3 levels remain significantly associated with mortality (P = 0.04) in the subset of patients with isolated TBI (n = 34). There were no differences in the leukocytes count measured in the same blood sample used for PTX3 determination in survivors and non-survivors (P = 0.56). The final multiple logistic regression model including age, pupillary examination, GCS, associated trauma, and PTX3 levels shows that serum levels of PTX3 which were higher than 10 μg/ml were independently associated with the patients mortality (adjusted OR 3.06, CI 95% 1.03-9.15, P = 0.04). CONCLUSIONS Serum PTX3 levels after severe TBI are independently associated with higher hospital mortality and may be a useful marker of TBI and its prognosis.
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Affiliation(s)
- Jackson da Silva Gullo
- Centro de Neurociências Aplicadas (CeNAp), Hospital Universitário (HU), Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
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Bahloul M, Chelly H, Chaari A, Chabchoub I, Haddar S, Herguefi L, Dammak H, Hamida CB, Ksibi H, Kallel H, Rekik N, Bouaziz M. Isolated traumatic head injury in children: Analysis of 276 observations. J Emerg Trauma Shock 2011; 4:29-36. [PMID: 21633564 PMCID: PMC3097575 DOI: 10.4103/0974-2700.76831] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 09/22/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND To determine predictive factors of mortality among children after isolated traumatic brain injury. MATERIALS AND METHODS In this retrospective study, we included all consecutive children with isolated traumatic brain injury admitted to the 22-bed intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). Basic demographic, clinical, biochemical, and radiological data were recorded on admission and during ICU stay. RESULTS There were 276 patients with 196 boys (71%) and 80 girls, with a mean age of 6.7 ± 3.8 years. The main cause of trauma was road traffic accident (58.3%). Mean Glasgow Coma Scale score was 8 ± 2, Mean Injury Severity Score (ISS) was 23.3 ± 5.9, Mean Pediatric Trauma Score (PTS) was 4.8 ± 2.3, and Mean Pediatric Risk of Mortality (PRISM) was 10.8 ± 8. A total of 259 children required mechanical ventilation. Forty-eight children (17.4%) died. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 24 (OR: 10.98), neurovegetative disorder (OR: 7.1), meningeal hemorrhage (OR: 2.74), and lesion type VI according to Marshall tomographic grading (OR: 13.26). CONCLUSION In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic injuries. Short-term prognosis is influenced by demographic, clinical, radiological, and biochemical factors. The need to put preventive measures in place is underscored.
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Grote S, Böcker W, Mutschler W, Bouillon B, Lefering R. Diagnostic Value of the Glasgow Coma Scale for Traumatic Brain Injury in 18,002 Patients with Severe Multiple Injuries. J Neurotrauma 2011; 28:527-34. [DOI: 10.1089/neu.2010.1433] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stefan Grote
- Department of Trauma Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Wolfgang Böcker
- Department of Trauma Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Wolf Mutschler
- Department of Trauma Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Bertil Bouillon
- Department of Orthopaedic and Trauma Surgery, Cologne Medical Center, Cologne, Germany
| | - Rolf Lefering
- Institute of Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
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Automated assessment of midline shift in head injury patients. Clin Neurol Neurosurg 2010; 112:785-90. [DOI: 10.1016/j.clineuro.2010.06.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 06/08/2010] [Accepted: 06/27/2010] [Indexed: 12/15/2022]
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Stiell IG, Clement CM, Grimshaw JM, Brison RJ, Rowe BH, Lee JS, Shah A, Brehaut J, Holroyd BR, Schull MJ, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, Macphail I, Ross S, Perry JJ, Ip U, Lesiuk H, Bennett C, Wells GA. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ 2010; 182:1527-32. [PMID: 20732978 DOI: 10.1503/cmaj.091974] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments. METHODS We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head. RESULTS Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the "before" period (62.8%) to the "after" period (76.2%) (difference +13.3%, 95% CI 9.7%-17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%-10.8%). The change in mean imaging rates from the "before" period to the "after" period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes. INTERPRETATION Our knowledge-translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252).
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont.
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Chan CH. Clinical Predictors of Minor Head Injury Patients Presenting with Glasgow Coma Scale Score of 14 or 15 and Requiring Neurosurgical Intervention. HONG KONG J EMERG ME 2010. [DOI: 10.1177/102490791001700309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Minor head injury is the most common type of head injury assessed in accident and emergency departments. Emergency physicians have concerns in discharging patients with intracranial injuries which require neurosurgical interventions. The aim of this study is to find out the clinical signs and symptoms which can help to predict who need neurosurgical intervention following minor head injury. Methods This was a retrospective case-control study. Patients with head injury and GCS score of 14 or 15 and requiring neurosurgical intervention were recruited. Another group of patients with head injury and GCS score of 14 or 15 but not requiring neurosurgical intervention were enrolled as control. In all cases, clinical signs and symptoms were collected by chart review of the clinical records retrieved by the computerized Clinical Data Analysis & Reporting System (CDARS). The relationship between clinical features and need of neurosurgical intervention was analyzed by chi-square test with 95% confidence interval. Results A total of 22 cases were found and compared with 288 controls to study on the clinical variables for the prediction of the need of neurosurgical intervention. Six warning signs were found statistically significant by univariate analysis: severe headache (p=0.0206), vomiting more than once (p<0.0006), drop in GCS (p<0.0001), confusion/restlessness (p<0.0001), bleeding from ear (p<0.0001) and skull fracture in the X-ray (p<0.0001). Conclusion Patients with minor head injury presenting with GCS score of 14 or 15 to the accident and emergency department rarely require neurosurgical intervention. Some clinical risk factors can be used as a guide to identify those who need neurosurgical intervention following minor head injury.
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Automatic recognition of midline shift on brain CT images. Comput Biol Med 2010; 40:331-9. [DOI: 10.1016/j.compbiomed.2010.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 01/11/2010] [Accepted: 01/11/2010] [Indexed: 11/23/2022]
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Rickels E. Neurotraumatologie. NeuroRehabilitation 2010. [DOI: 10.1007/978-3-642-12915-5_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Traumatic brain injury (TBI) is still the major cause of death under 45 years of age and an important one for children under 15. Its incidence is 332/100,000 inhabitants. It results from an impact with the skull with/without lesion of the brain but at least a short-term neurological disorder. All other injuries to the skull should be called concussion. The duration of unconsciousness defines the severity of TBI. Patients with TBI should be admitted to a surgical ward. Those retaining consciousness and with GCS scores of 15 might be allowed to go home if under surveillance. With GCS of <15 or with risk factors, TBI requires a CT scan and in-hospital surveillance. Acutely life-threatening, i.e. space-occupying, bleeding must be operated on immediately. Epidural or subdural bleeding, especially in comatose patients, is still a vital risk and thus requires immediate surgery.
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Martins ET, Linhares MN, Sousa DS, Schroeder HK, Meinerz J, Rigo LA, Bertotti MM, Gullo J, Hohl A, Dal-Pizzol F, Walz R. Mortality in Severe Traumatic Brain Injury: A Multivariated Analysis of 748 Brazilian Patients From Florianópolis City. ACTA ACUST UNITED AC 2009; 67:85-90. [DOI: 10.1097/ta.0b013e318187acee] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med 2009; 39:377-83. [PMID: 19535215 DOI: 10.1016/j.jemermed.2009.04.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 12/30/2008] [Accepted: 04/11/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Blunt head trauma patients who have been alert but are deteriorating (talk and deteriorate [T&D]) due to a rapidly expanding epidural hematoma (EDH) usually have poor outcome if they must wait for hospital transfer for evacuation. We therefore have continued to teach skull trephination to emergency physicians (EPs). We are unaware of any literature on EP trephination for EDH in the age of computed tomography (CT) scanning. METHODS Patients with EDH from blunt trauma, either in our institution or known to our graduate network, who were T&D with anisocoria despite intubation plus medical therapy, and who had pre-transfer EP trephination, were compared to those who were transferred without trephination. RESULTS There were 5 patients with blunt trauma and CT-proven EDH who were T&D with anisocoria who underwent Emergency Department (ED) trephination at outlying hospitals before transfer. All 5 had improvement in condition and good outcomes. Three had complete recovery without disability and 2 others had mild disability with good cognitive function. None had complications. Two patients with T&D and anisocoria were transferred without trephination. Both had good neurologic outcomes. The mean time to pressure relief in the trephination group vs. transfer group was 55 vs. 207 min, respectively. CONCLUSION In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications. Time to relief of intracranial pressure was significantly shorter with trephination. Neurologic outcomes were not different.
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Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Bahloul M, Ben Hamida C, Chelly H, Chaari A, Kallel H, Dammak H, Rekik N, Bahloul K, Ben Mahfoudh K, Hachicha M, Bouaziz M. Severe head injury among children: prognostic factors and outcome. Injury 2009; 40:535-40. [PMID: 18703191 DOI: 10.1016/j.injury.2008.04.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Revised: 04/07/2008] [Accepted: 04/20/2008] [Indexed: 02/02/2023]
Abstract
AIM To determine predictive factors of mortality among children after traumatic brain injury. METHODS A retrospective study over 8 years of 222 children with severe head injury (Glasgow Coma Scale score < or = 8) admitted to a university hospital (Sfax, Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during intensive care unit stay. RESULTS The study included 163 boys (73.4%) and 59 girls, with mean age 7.54+/-3.8 years. The main cause of trauma was road traffic accident (75.7%). Mean Glasgow Coma Scale score was 6+/-1.5, mean Injury Severity Score (ISS) was 28.2+/-6.9, mean Paediatric Trauma Score (PTS) was 3.7+/-2.1 and mean Paediatric Risk of Mortality (PRISM) was 14.3+/-8.5; 54 children (24.3%) died. Univariate analysis showed that low PTS on admission, high ISS or PRISM, presence of shock or meningeal haemorrhage or bilateral mydriasis, and serum glucose > 10 mmol l(-1) were associated with mortality rate. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 20 and bilateral mydriasis on admission. CONCLUSIONS In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic accidents. Short-term prognosis is poor, with a high mortality rate (24.3%), and is influenced by demographic, clinical, radiological and biological factors.
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Affiliation(s)
- Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia.
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Zweckberger K, Plesnila N. Anatibant®, a selective non-peptide bradykinin B2 receptor antagonist, reduces intracranial hypertension and histopathological damage after experimental traumatic brain injury. Neurosci Lett 2009; 454:115-7. [DOI: 10.1016/j.neulet.2009.02.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 02/06/2009] [Accepted: 02/06/2009] [Indexed: 11/28/2022]
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The role of MR imaging in assessing prognosis after severe and moderate head injury. Acta Neurochir (Wien) 2009; 151:341-56. [PMID: 19224121 DOI: 10.1007/s00701-009-0194-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE The objective of this work is two-fold: to determine the role of MRI findings in establishing the prognosis of patients with moderate and severe traumatic brain injury (TBI) admitted to our centre, measured with different outcome scales; and to determine in which patients the information given by MR findings adds prognostic information to that from traditional prognostic factors. METHODS One hundred patients suffering moderate or severe head injury in whom MRI had been performed in the first 30 days after trauma were included. The MRI was evaluated by two neuroradiologists who were not aware of the initial CT results or the clinical situation of the patients. Outcome was determined 6 months after head injury by means of the extended version of the Glasgow Outcome Scale. The prognostic capacity of the different factors related to outcome was compared by the analysis of receiver operating characteristic (ROC) curves and the area under the curve (AUC) for each factor. RESULTS There exists a clear relation between the depth of the traumatic lesions shown on MRI, and their classification by the proposed scale, and the outcome of patients suffering traumatic brain injury determined by different scales 6 months after injury. CONCLUSIONS The anatomical substrate of TBI depicted by MRI could be a useful prognostic tool in patients suffering moderate and severe head injury. Patients with a score of 4 or less on the motor subscale of the GCS scale are those who could benefit most from the prognostic information provided by MRI.
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Kim KH. Predictors for functional recovery and mortality of surgically treated traumatic acute subdural hematomas in 256 patients. J Korean Neurosurg Soc 2009; 45:143-50. [PMID: 19352475 DOI: 10.3340/jkns.2009.45.3.143] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 02/22/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the reliable factors influencing the surgical outcome of the patients with traumatic acute subdural hematoma (ASDH) and to improve the functional outcome of these patients. METHODS A total of 256 consecutive patients who underwent surgical intervention for traumatic ASDH between March 1998 and March 2008 were reviewed. We evaluated the influence of perioperative variables on functional recovery and mortality using multivariate logistic regression analysis. RESULTS Functional recovery was achieved in 42.2% of patients and the overall mortality was 39.8%. Age (OR=4.91, p=0.002), mechanism of injury (OR=3.66, p=0.003), pupillary abnormality (OR=3.73, p=0.003), GCS score on admission (OR=5.64, p=0.000), and intraoperative acute brain swelling (ABS) (OR=3.71, p=0.009) were independent predictors for functional recovery. And preoperative pupillary abnormality (OR=2.60, p=0.023), GCS score (OR=4.66, p=0.000), and intraoperative ABS (OR=4.16, p=0.001) were independent predictors for mortality. Midline shift, thickness and volume of hematoma, type of surgery, and time to surgery showed no independent association with functional recovery, although these variables were correlated with functional recovery in univariate analyses. CONCLUSION Functional recovery was more likely to be achieved in patients who were under 40 years of age, victims of motor vehicle collision and having preoperative reactive pupils, higher GCS score and the absence of ABS during surgery. These results would be helpful for neurosurgeon to improve outcomes from traumatic acute subdural hematomas.
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Affiliation(s)
- Kyu-Hong Kim
- Department of Neurosurgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine, Masan, Korea
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Tokutomi T, Miyagi T, Ogawa T, Ono JI, Kawamata T, Sakamoto T, Shigemori M, Nakamura N. Age-Associated Increases in Poor Outcomes after Traumatic Brain Injury: A Report from the Japan Neurotrauma Data Bank. J Neurotrauma 2008; 25:1407-14. [DOI: 10.1089/neu.2008.0577] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Takashi Tokutomi
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Japan
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
| | - Tomoya Miyagi
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Japan
| | - Takeki Ogawa
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
| | - Jun-ichi Ono
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
| | - Tatsuro Kawamata
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
| | - Tetsuya Sakamoto
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
| | - Minoru Shigemori
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Japan
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
| | - Norio Nakamura
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Japanese Council of Traffic Science, Tokyo, Japan
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Jagannathan J, Okonkwo DO, Yeoh HK, Dumont AS, Saulle D, Haizlip J, Barth JT, Jane JA, Jane JA. Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure. J Neurosurg Pediatr 2008; 2:240-9. [PMID: 18831656 DOI: 10.3171/ped.2008.2.10.240] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECT The management strategies and outcomes in pediatric patients with elevated intracranial pressure (ICP) following severe traumatic brain injury (TBI) are examined in this study. METHODS This study was a retrospective review of a prospectively acquired pediatric trauma database. More than 750 pediatric patients with brain injury were seen over a 10-year period. Records were retrospectively reviewed to determine interventions for correcting ICP, and surviving patients were contacted prospectively to determine functional status and quality of life. Only patients with 2 years of follow-up were included in the study. RESULTS Ninety-six pediatric patients (age range 3-18 years) were identified with a Glasgow Coma Scale score<8 and elevated ICP>20 mm Hg on presentation. The mean injury severity score was 65 (range 30-100). All patients were treated using a standardized head injury protocol. The mean time course until peak ICP was 69 hours postinjury (range 2-196 hours). Intracranial pressure control was achieved in 82 patients (85%). Methods employed to achieve ICP control included maximal medical therapy (sedation, hyperosmolar therapy, and paralysis) in 34 patients (35%), ventriculostomy in 23 patients (24%), and surgery in 39 patients (41%). Fourteen patients (15%) had refractory ICP despite all interventions, and all of these patients died. Seventy-two patients (75%) were discharged from the hospital, whereas 24 (25%) died during hospitalization. Univariate and multivariate analysis revealed that the presence of vascular injury, refractory ICP, and cisternal effacement at presentation had the highest correlation with subsequent death (p<0.05). Mean follow-up was 53 months (range 11-126 months). Three patients died during the follow-up period (2 due to infections and 1 committed suicide). The mean 2-year Glasgow Outcome Scale score was 4 (median 4, range 1-5). The mean patient competency rating at follow-up was 4.13 out of 5 (median 4.5, range 1-4.8). Univariate analysis revealed that the extent of intracranial and systemic injuries had the highest correlation with long-term quality of life (p<0.05). CONCLUSIONS Controlling elevated ICP is an important factor in patient survival following severe pediatric TBI. The modality used for ICP control appears to be less important. Long-term follow-up is essential to determine neurocognitive sequelae associated with TBI.
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Affiliation(s)
- Jay Jagannathan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Abstract
Traumatic and non-traumatic coma is a common problem in paediatric practice with high mortality and morbidity. Early recognition of the potential for catastrophic deterioration in a variety of settings is essential and several coma scales have been developed for recording depth of consciousness that are widely used in clinical practice in adults and children. Prediction of outcome is probably less important, as this may be able to be modified by appropriate emergency treatment, and other clinical and neurophysiological criteria allow a greater degree of precision. The scales should be reliable, i.e. with little variation between observers and in test-retest by one observer, since this promotes confidence in the assessments at different time points and by different examiners. This is particularly important when the patient is being assessed by personnel dealing with adults as well as children, discussed on the telephone, handed over at shift change, or transferred between units or hospitals. The British Paediatric Neurology Association has recommended one of the modified child's Glasgow coma scales (CGCS) for use in the UK. This review looks at the recent history of the development of coma scales and the rationale for recommending the CGCS.
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Affiliation(s)
- Fenella J Kirkham
- Neurosciences Unit, Institute of Child Health, University College London, London, UK.
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73
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Stein SC, Fabbri A, Servadei F, Glick HA. A critical comparison of clinical decision instruments for computed tomographic scanning in mild closed traumatic brain injury in adolescents and adults. Ann Emerg Med 2008; 53:180-8. [PMID: 18339447 DOI: 10.1016/j.annemergmed.2008.01.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 12/18/2007] [Accepted: 01/07/2008] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions. METHODS We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once. RESULTS The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P>.05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian). CONCLUSION NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19106, USA.
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74
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Goldschlager T, Rosenfeld JV, Winter CD. ‘Talk and Die’ patients presenting to a major trauma centre over a 10 year period: A critical review. J Clin Neurosci 2007; 14:618-23; discussion 624. [PMID: 17433688 DOI: 10.1016/j.jocn.2006.02.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2005] [Accepted: 02/05/2006] [Indexed: 10/23/2022]
Abstract
'Talk and die patients' describes a small number of patients who present with a mild head injury (Glasgow Coma Scale [GCS] 13-15) and then subsequently deteriorate and die from intracranial causes. We analysed the medical records of all those adult patients whose primary diagnosis as the cause of death was head injury, as determined by the coroner, who were admitted to a major Australian trauma centre between January 1994 and December 2003 (a 10-year period). The clinical profile of those patients who fulfilled the criteria of 'talk and die' were documented, including age, mode of injury, initial GCS, lucid interval, CT scan reports, operation performed, post mortem findings and intracranial cause of death. Factors considered potentially contributory to the patients' deterioration, such as delays in CT scanning or patient transfer, coagulopathy or hypoxic episodes were also noted. The incidence of 'talk and die' patients was 2.6% (15 out of 569) overall and the annual incidence did not significantly alter over the 10-year period of the study. The small number of patients precludes inferences regarding causal relationships, although potentially preventable factors, which could have been contributory to patient deterioration, were identified.
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Affiliation(s)
- Tony Goldschlager
- Departments of Neurosurgery and Surgery, Monash University, The Alfred Hospital, Commercial Rd, Prahran, 3181, Victoria, Australia.
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75
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Marmarou A, Lu J, Butcher I, McHugh GS, Murray GD, Steyerberg EW, Mushkudiani NA, Choi S, Maas AIR. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma 2007; 24:270-80. [PMID: 17375991 DOI: 10.1089/neu.2006.0029] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We studied the prognostic strength of the individual components of the Glasgow Coma Scale (GCS) and pupil reactivity to Glasgow Outcome Score (GOS) at 6 months post-injury. A total of 8721 moderate or severe traumatic brain injury (TBI) patient data from the IMPACT database on traumatic brain injury comprised the study cohort. The associations between motor score and pupil reactivity and 6-month GOS were analyzed by binary logistic regression and proportional odds methodology. The strength of prognostic effects were expressed as the unadjusted odds ratios presented for all individual studies as well as in meta-analysis. We found a consistent strong association between motor score and 6-month GOS across all studies (OR 1.74-7.48). The Eye and Verbal components were also strongly associated with GOS. In the pooled population, one or both un-reactive pupils and lower motor scores were significantly associated with unfavorable outcome (range 2.71-7.31). We also found a significant change in motor score from pre-hospital direct to study hospital enrollment ( p < 0.0001) and from the first in-hospital to study enrollment scores (p < 0.0001). Pupil reactivity was more robust between these time points. It is recommended that the study hospital enrollment GCS and pupil reactivity be used for prognostic analysis.
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Affiliation(s)
- Anthony Marmarou
- Department of Neurosurgery, Virginia Commonwealth University Medical Center, Richmond, Virginia 23219, USA.
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76
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Saboori M, Ahmadi J, Farajzadegan Z. Indications for brain CT scan in patients with minor head injury. Clin Neurol Neurosurg 2007; 109:399-405. [PMID: 17350162 DOI: 10.1016/j.clineuro.2007.01.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Revised: 01/26/2007] [Accepted: 01/26/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury. METHODS A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals. RESULTS Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan. CONCLUSION Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury.
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Affiliation(s)
- Masih Saboori
- Department of Neurosurgery, Medical School, Medical University of Isfahan, Isfahan, Iran.
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77
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Faleiro RM, Faleiro LCM, Oliveira MM, Silva T, Caetano EC, Gomide I, Pita CC, Lopes G, Gusmão S. [Decompressive craniectomy in children and adolescents with head injury: analysis of seven cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 64:839-44. [PMID: 17057894 DOI: 10.1590/s0004-282x2006000500024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 06/23/2006] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is a surgical technique used to treat patients with elevated intracranial pressure often found in head injury. Its indication remains a controversial issue in the pediatric population. OBJECTIVE To report seven cases managed with this technique. METHOD Retrospective study of seven patients, aged from 2 to 17 years, treated with unilateral DC due to increased intracranial pressure (ICP) as a consequence of head injury. All patients had ICP monitored post operatively and the DC classified as ultra-early (<6h), early (6-12h) or late (>24h) according to the time of its application. The minimum follow-up was six months. RESULTS Patients were evaluated with CT scans and clinical exams, and graded according the Glasgow Outcome Scale (GOS). Three patients deceased (GOS1), one was in vegetative state (GOS2), two recovered but still requiring nursing care (GOS3 and 4), and one had a full recovery (GOS5) at hospital discharge. After six months the GOS2 and a GOS3 patients achieved full recovery (GOS5). Subdural collection (2), hydrocephalus (1) and superficial infection (1) occurred as complication. Two patients had autologous cranioplasty and the other two heterologous cranioplasty. CONCLUSION Decompressive craniectomy remains a feasible treatment method to lower the ICP, but is not safe from complications. A multicentric study should be done for appropriate protocol treatment of pediatric patients.
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Affiliation(s)
- Rodrigo Moreira Faleiro
- Hospital Pronto Socorro João XXIII, Rua Timbiras 3642/801, 30140-062 Belo Horizonte MG, Brazil.
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78
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Sundstrøm T, Sollid S, Wentzel-Larsen T, Wester K. Head injury mortality in the Nordic countries. J Neurotrauma 2007; 24:147-53. [PMID: 17263678 DOI: 10.1089/neu.2006.0099] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality in Western countries. Effective management planning for these patients requires knowledge of TBI epidemiology. The purpose of this study was to describe and analyze the development of TBI mortality in the Nordic countries during the period 1987-2001. Data on TBI deaths were retrieved from the national official statistical agencies according to specified diagnostic codes. We also collected data on the number of operations for acute TBI in the year 2000 from all Nordic hospitals admitting trauma patients. Finland had about twice as high a TBI mortality rate as the other countries. Similarly, the Finnish incidence of acute TBI operations was nearly twice that of the other countries. The median TBI death rate for Finland was 21.2 per 100,000 per year, and for Denmark, Norway, and Sweden 11.5, 10.4, and 9.5, respectively. There were more male than female deaths in all countries. The mortality rate from extracranial injuries was relatively equal between the countries. We observed a sizeable reduction in TBI mortality rates for all countries, except in Finland. Younger age groups had the most pronounced decrease in TBI mortality rates. The oldest age group had the least favorable development of TBI mortality rates, and the mean age of TBI casualties increased substantially during the study period. This study demonstrates considerable differences in and between the Nordic countries regarding TBI mortality. Preventive measures and implementation of regional guidelines are needed to assure a positive development in the future.
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Affiliation(s)
- Terje Sundstrøm
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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79
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Ratanalert S, Kornsilp T, Chintragoolpradub N, Kongchoochouy S. The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand. Emerg Med J 2007; 24:25-30. [PMID: 17183038 PMCID: PMC2658147 DOI: 10.1136/emj.2006.039974] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the impact of implementing clinical practice guidelines (CPG) for head injury in a trauma referral system in Songkla province, Thailand. METHODS The CPG was developed by a local multidisciplinary team and implemented using multi-faceted methods. The outcome of patients with head injury from three community hospitals and a university hospital (Songklanagarind Hospital) was reported in terms of "talk and deteriorate" patients and a "poor" outcome for patients with severe head injury. Changes to clinical practice were observed where the guidelines were implemented. RESULTS 1000 patients with head injury were enrolled from 1st August 2005 to 15th January 2006. The incidence of "talk and deteriorate" patients was 10.5% and a poor outcome was noted in 35.5% of patients with severe head injury, similar to the results of a previous study in Songklanagarind Hospital (p>0.05). Following implementation of the guidelines, 19.8% of patients underwent CT scanning with similar outcomes for alert patients with and without basal skull fracture (p>0.05). The clinician-nurse relationship also improved and there was closer collaboration between hospitals. Short observation in community hospitals for repeat neurological examination may be an appropriate strategy for management of some patients with minor head injury. CONCLUSIONS Local ownership, an appropriate implementation strategy and working as a multidisciplinary team are key factors for success in implementing the CPG. Basal skull fracture may not be an absolute criterion for CT imaging of the head. Further initiatives will be developed in response to the incidence of "talk and deteriorate" patients.
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Affiliation(s)
- Sanguansin Ratanalert
- Neurosurgical Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla 90112, Thailand.
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80
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Davis DP, Kene M, Vilke GM, Sise MJ, Kennedy F, Eastman AB, Velky T, Hoyt DB. Head-Injured Patients Who “Talk and Die”: The San Diego Perspective. ACTA ACUST UNITED AC 2007; 62:277-81. [PMID: 17297312 DOI: 10.1097/ta.0b013e31802ef4a3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Head-injured patients who "talk and die" are potentially salvageable, making their early identification important. This study uses a large, comprehensive database to explore risk factors for head-injured patients who deteriorate after their initial presentation. METHODS Patients with a head Abbreviated Injury Score (AIS) score of 3+ and a preadmission verbal Glasgow Coma Scale (GCS) score of 3+ were identified from our county trauma registry during a 16-year period. Survivors and nonsurvivors were compared with regard to demographics, initial clinical presentation, and various risk factors. Logistic regression was used to explore the impact of multiple factors on outcome, including the significance of a change in GCS score from field to arrival. In addition, patients were stratified by injury severity and hospital day of death to further define the relationship between outcome and multiple clinical variables. RESULTS A total of 7,443 patients were identified with head AIS 3+ and verbal GCS score 3+. Overall mortality was 6.1%. About one-third of deaths occurred on the first hospital day, with more than one-third occurring after hospital day 5. Logistic regression revealed an association between mortality and older age, more violent mechanisms of injury (fall, gunshot wound, pedestrian versus automobile), greater injury severity (higher head AIS and Injury Severity Score), lower GCS score, and hypotension. In addition, mortality was associated with a decrease in GCS score from field to arrival, the use of anticoagulants, and a diagnosis of pulmonary embolus. Two important groups of "talk-and-die" patients were identified. Early deaths occurred in younger patients with more critical extracranial injuries. Anticoagulant use was also an independent risk factor in these early deaths. Later deaths occurred in older patients with less significant extracranial injuries. Pulmonary embolus also appeared to be an important contributor to late mortality. CONCLUSIONS More severe injuries and use of anticoagulants are independent risk factors for early death in potentially salvageable traumatic brain injury patients, whereas older age and pulmonary embolus are associated with later deaths.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California San Diego, CA 92103-8676, USA.
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81
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Vyas NA, Chicoine MR. Extended survival after evacuation of subdural hematoma in a 102-year-old patient: case report and review of the literature. ACTA ACUST UNITED AC 2006; 67:314-6; discussion 317. [PMID: 17320648 DOI: 10.1016/j.surneu.2006.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Accepted: 03/31/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Outcomes for elderly patients undergoing craniotomy for evacuation of subdural hematoma (SDH) have been reported to be poor with high mortality rates. CASE DESCRIPTION We present the case of a patient who underwent craniotomies at the age of 102 years, and again at the age of 103 years, for acute SDHs with good recovery to her premorbid neurologic condition. A 102-year-old woman presented after falling to the floor, and underwent a left-sided craniotomy for evacuation of a large, left hemispheric acute SDH. She recovered from that event and returned home. Six months later, she presented after falling again and was found to have a large, right hemispheric acute SDH. A right-sided craniotomy was performed and again she made good recovery with return to her neurologic baseline. CONCLUSION We report this unique case of good recovery after 2 separate craniotomies for acute SDH in a patient older than 100 years. Implications of acute SDH in the elderly are discussed, as relevant to this case, with a review of the literature. Although the morbidity and mortality of acute SDH are high, particularly in elderly patients, there is potential for good recovery and excellent outcome in appropriately selected patients.
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Affiliation(s)
- Nilesh A Vyas
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Salci K, Nilsson P, Goiny M, Contant C, Piper I, Enblad P. Low intracranial compliance increases the impact of intracranial volume insults to the traumatized brain: a microdialysis study in a traumatic brain injury rodent model. Neurosurgery 2006; 59:367-73; discussion 367-73. [PMID: 16883177 DOI: 10.1227/01.neu.0000222648.61065.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The vulnerability of the brain is considered to be increased after trauma. The present study was undertaken to determine whether intracranial volume insults in the posttraumatic period led to increased metabolic disturbances if intracranial compliance was decreased. METHODS A weight drop technique with a brain compression of 1.5 mm was used for injury. Intracranial compensatory volume was decreased 60 microl by placing rubber film between the dura mater and the bone. Intracranial volume insults were induced using the Bolus injection technique. Microdialysis was used to measure interstitial lactate, pyruvate, hypoxanthine, and glycerol. Fifty-two rats were allocated to trauma and sham groups with 0 to 3 layers of rubber film with and without intracranial volume insults. RESULTS In the groups with reduced intracranial volume exposed to intracranial volume insults, the time course of metabolic markers showed higher increases and slower recovery rates than for the other groups. Reduced intracranial volume or intracranial volume insults alone did not cause any changes compared with controls. CONCLUSION These results support the hypothesis that decreased intracranial compliance increases the vulnerability of the brain for secondary volume insults even with intracranial pressure at low levels between the insults. This finding has important clinical implications in that it stresses the need to identify patients with low intracranial compliance so that their treatment can be optimized.
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Affiliation(s)
- Konstantin Salci
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
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83
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Kawamata T, Katayama Y. Surgical management of early massive edema caused by cerebral contusion in head trauma patients. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 96:3-6. [PMID: 16671412 DOI: 10.1007/3-211-30714-1_1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Early massive edema caused by severe cerebral contusion results in elevation of intracranial pressure (ICP) and clinical deterioration within 24-72 hours post-trauma. Previous studies indicate that cells in the central area of the contusion undergo shrinkage, disintegration, and homogenization, whereas cellular swelling is predominant in the peripheral area, suggesting that early massive edema is attributable to high osmolality within necrotic brain tissue and may generate an osmotic potential across central and peripheral areas. We analyzed the effects of surgical excision of necrotic brain tissue in 182 patients with cerebral contusion registered with Japan Neurotrauma Data Bank; 121 patients (66%; Group I) were treated conservatively, and 61 (34%; Group II) were treated surgically. Most Group II cases (90%) underwent complete excision of necrotic brain tissue and evacuation of clots. Group I demonstrated higher mortality at 6 months post-trauma compared to Group II (48%) vs. 23%; p = 0.0001; n = 182). Striking differences were observed in patients scoring 9 or more on Glasgow Coma Scale at admission (56% vs. 17%); p = 0.017; n = 45) and demonstrated "talk-and-deteriorate" (64% vs. 22%: p = 0.026; n = 29), supporting our hypothesis that early massive edema is caused by cerebral contusion accompanied by necrotic brain tissue, indicating that surgical excision of necrotic brain tissue provides satisfactory control of progressive elevation in ICP and clinical deterioration in many cases.
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Affiliation(s)
- T Kawamata
- Japan Neurotrauma Databank, Japan Society of Neurotraumatology, and Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan.
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84
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Toczyłowska B, Chalimoniuk M, Wodowska M, Mayzner-Zawadzk E. Changes in concentration of cerebrospinal fluid components in patients with traumatic brain injury. Brain Res 2006; 1104:183-9. [PMID: 16793028 DOI: 10.1016/j.brainres.2006.05.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 05/17/2006] [Accepted: 05/19/2006] [Indexed: 11/25/2022]
Abstract
Brain injury, like other central nervous system pathologies, causes changes in the composition of the cerebrospinal fluid (CSF). In this study, changes in the concentration of small molecules of the CSF, which are in the minimal micromolar concentration, were observed and monitored using high-resolution proton (NMR) spectroscopy. Twenty-two patients with isolated traumatic brain injuries (TBI) and 15 patients making up the control group were recruited for the study. CSF samples were collected by lumbar puncture from the lumbar subarachnoid space in the patients just before commencement of therapy and on the first, third, seventh and fourteenth days of therapy at the ICU. Forty-four signals of the NMR spectra and NO concentration of the CSF samples were analyzed. The analysis shows that the amino acid and organic acid concentrations change during the therapy and mostly are higher than in the control group. Significant differences in concentration of the analyzed CSF components between the TBI patients and the control group have been noted. The rate of the lactate to pyruvate conversion increased because the L/P ratio showed no significant differences between the TBI group and the control group, while the concentrations of both components were significantly higher in the TBI patients than in the control group. Citrulline, arginine and nitric oxide concentrations were the focus of the analysis. Citrulline concentration changes overlapped NO changes from 0 until 3rd day of therapy, while for the remaining days of observation the NO concentration stabilized at the control level, whereas citrulline concentration significantly decreased.
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Affiliation(s)
- Beata Toczyłowska
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, 5A Pawinskiego Street, 02-109 Warsaw, Poland.
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85
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Furukawa M, Kinoshita K, Ebihara T, Sakurai A, Noda A, Kitahata Y, Utagawa A, Moriya T, Okuno K, Tanjoh K. Clinical characteristics of postoperative contralateral intracranial hematoma after traumatic brain injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 96:48-50. [PMID: 16671423 DOI: 10.1007/3-211-30714-1_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
OBJECTIVES To investigate the clinical characteristics of contralateral intracranial hematoma (ICH) after traumatic brain injury. METHODS The subjects included 149 patients with traumatic ICH treated by hematoma evacuation. The patients were retrospectively divided into a bilateral ICH (B-ICH) group and unilateral ICH (U-ICH) group after craniotomy using brain CT scans for comparison of the following parameters: complicated expanded brain bulk from the cranial window, hypotension during craniotomy, and outcome. RESULTS Post-craniotomy brain CT scans revealed U-ICH in 106 patients and B-ICH in 43 patients. Average Glasgow Coma Scale on arrival did not differ between the groups, but a higher proportion of patients in the B-ICH group deteriorated after admission (p = 0.02). The B-ICH patients also exhibited a significantly higher rate of expanded brain bulk from the cranial window (p < 0.05). No significant difference was observed between the groups with hypotension during craniotomy. The B-ICH group exhibited a lower rate of favorable outcome (p < 0.05) and higher mortality (p < 0.05). CONCLUSION The B-ICH patients had a worse outcome than the U-ICH patients. Contralateral ICH was difficult to forecast based on pre- and intraoperative clinical conditions. Subdural hematoma or contusional ICH was frequently observed as a contralateral ICH.
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Affiliation(s)
- M Furukawa
- Department of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan.
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Chambers IR, Barnes J, Piper I, Citerio G, Enblad P, Howells T, Kiening K, Matterns J, Nilsson P, Ragauskas A, Sahuquillo J, Yau YH. BrainIT: a trans-national head injury monitoring research network. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 96:7-10. [PMID: 16671413 DOI: 10.1007/3-211-30714-1_2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Studies of therapeutic interventions and management strategies on head injured patients are difficult to undertake. BrainIT provides validated data for analysis available to centers that contribute data to allow post-hoc analysis and hypothesis testing. METHODS Both physiological and intensive care management data are collected. Patient identification is eliminated prior to transfer of data to a central database in Glasgow. Requests for missing/ ambiguous data are sent back to the local center. Country coordinating centers provide advice, training, and assistance to centers and manage the data validation process. RESULTS Currently 30 centers participate in the group. Data collection started in January 2004 and 242 patients have been recruited. Data validation tools were developed to ensure data accuracy and all analysis must be undertaken on validated data. CONCLUSION BrainIT is an open, collaborative network that has been established with primary objectives of i) creating a core data set of information, ii) standardizing the collection methodology, iii) providing data collection tools, iv) creating and populating a data base for future analysis, and v) establishing data validation methodologies. Improved standards for multi-center data collection should permit the more accurate analysis of monitoring and management studies in head injured patients.
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Affiliation(s)
- I R Chambers
- Critical Care Physics, Regional Medical Physics Department, Newcastle General Hospital, Newcastle Upon Tyne, UK.
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87
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Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 2006; 104:469-79. [PMID: 16619648 DOI: 10.3171/jns.2006.104.4.469] [Citation(s) in RCA: 390] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to assess outcome following decompressive craniectomy for malignant brain swelling due to closed traumatic brain injury (TBI).
Methods
During a 48-month period (March 2000–March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow Outcome Scale (GOS) score.
Decompressive craniectomy lowered ICP to less than 20 mm Hg in 85% of patients. In the 40 patients who had undergone ICP monitoring before decompression, ICP decreased from a mean of 23.9 to 14.4 mm Hg (p < 0.001). Fourteen of 50 patients died, and 16 either remained in a vegetative state (seven patients) or were severely disabled (nine patients). Twenty patients had a good outcome (GOS Score 4–5). Among 30-day survivors, good outcome occurred in 17, 67, and 67% of patients with postresuscitation Glasgow Coma Scale scores of 3 to 5, 6 to 8, and 9 to 15, respectively (p < 0.05). Outcome was unaffected by abnormal pupillary response to light, timing of decompressive craniectomy, brain shift as demonstrated on computerized tomography scanning, and patient age, possibly because of the small number of patients in each of the subsets. Complications included hydrocephalus (five patients), hemorrhagic swelling ipsilateral to the craniectomy site (eight patients), and subdural hygroma (25 patients).
Conclusions
Decompressive craniectomy was associated with a better-than-expected functional outcome in patients with medically uncontrollable ICP and/or brain herniation, compared with outcomes in other control cohorts reported on in the literature.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery and R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Salci K, Nilsson P, Howells T, Ronne-Engström E, Piper I, Contant CF, Enblad P. Intracerebral microdialysis and intracranial compliance monitoring of patients with traumatic brain injury. J Clin Monit Comput 2006; 20:25-31. [PMID: 16532279 DOI: 10.1007/s10877-006-2864-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2004] [Revised: 08/22/2005] [Accepted: 08/25/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aims of this study were to get an impression of the relationships between intracranial compliance (IC) and Lactate/Pyruvate (L/P) ratio and temperature and L/P ratio, and to determine if patients with low IC had an increased vulnerability for the secondary insult hyperthermia (as reflected in the L/P ratio). The effects of coma treatment on the results were also studied. METHODS Ten TBI patients were monitored for IC, in vivo microdialysis (MD) and bladder temperature. Mean Glasgow Coma Scale (GCS) score was 7 (range 4-10). Three patients underwent induced coma treatment. Three statistical models were used to look at the relationships between IC, temperature and L/P ratio in patients with and without coma. RESULTS We found that with high temperature L/P ratios increased as IC decreased (P < 0.0001). The patients with coma treatment had significantly higher average L/P ratios (P < 0.02). The effect of IC on the L/P ratio differed by coma treatment (P < 0.02). The temperature effect was not dependent on coma treatment (P < 0.49). CONCLUSIONS These findings suggest the importance of avoiding hyperthermia in TBI patients, especially in patients with low or decreased IC (monitored or anticipated). The present technical solution seems promising for analysis of complex clinical data.
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Affiliation(s)
- Kontsantin Salci
- Department of Neurosurgery, Uppsala University Hospital, S-751 85 Uppsala, Sweden
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89
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de Andrade AF, de Almeida AN, Bor-Seng-Shu E, Lourenço L, Mandel M, Marino R. The value of cranial computed tomography in high-risk, mildly head-injured patients. ACTA ACUST UNITED AC 2006; 65 Suppl 1:S1:10-1:13. [PMID: 16427436 DOI: 10.1016/j.surneu.2005.11.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 11/03/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this article was to assess if high-risk, mildly head-injured patients with normal CT scan present an outcome similar to the group with "low-risk MHI." METHODS A total of 379 hospital charts of inpatients with Glasgow Coma Scale scores of 13, 14, and 15 were reviewed. Information regarding age, fGCS, trauma mechanism, cranial CT scan findings, hospital course, and follow-up using the GOS were obtained from all patients. RESULTS Patients were separated in 3 groups: fGCS 13 (46 patients), fGCS 14 (138 patients), and fGCS 15 (195 patients). The groups with different scores on fGCS did not differ regarding CT scan abnormalities, surgical treatment, or outcome. Patients were also separated in 2 groups based on CT scan findings: 266 patients had CT interpreted as abnormal and 113 had CT interpreted as normal. The 2 groups differed statistically regarding surgical treatment and scores on GOS (P < .05). There was no statistically significant difference between the 2 groups regarding sex, trauma mechanism, fGCS, or age. CONCLUSIONS Our findings support the idea that a normal cranial CT scan in patients with fGCS scores of 13 or higher ascertain a low-risk MHI outcome and, therefore, such patients must be included in this category of traumatic brain injury. On the other hand, patients with cranial CT scan abnormalities should be included in the group with moderate head injury.
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Affiliation(s)
- Almir Ferreira de Andrade
- Department of Neurology of Hospital das Clínicas of São Paulo University, Medical School, Rue Eneas Carvalho de Aguiar 255, Caixa Postal 8091, São Paulo (SP), Brazil.
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90
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91
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Karabiyikoglu M, Keep R, Hua Y, Xi G. Acute Subdural Hematoma: New Model Delineation and Effects of Coagulation Inhibitors. Neurosurgery 2005; 57:565-72; discussion 565-72. [PMID: 16145537 DOI: 10.1227/01.neu.0000170435.47739.ae] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To develop a highly reproducible rat model and behavioral tests for acute subdural hematoma (ASDH) and to investigate the role of intravascular coagulation and thrombin in the pathogenesis of brain injury in this model. METHODS A new method was implemented to inject 200 microl of autologous blood subdurally in rats. Immunohistochemistry was used to investigate intravascular fibrin deposition and thrombin levels in the cortex underlying the ASDH. Effectiveness of systemic heparin, argatroban, or ginkgolide B treatment was determined by histological lesion volume, number of occluded microvessels, and neurological deficits. Neurological deficits were monitored for 7 days after ASDH by use of forelimb placing, forelimb use asymmetry, and corner turn tests. RESULTS Consistent brain damage and sensorimotor deficits were observed in all animals with ASDH. Histological analysis demonstrated occluded microvessels and enlarged perivascular spaces in the underlying cortex starting 1 hour after hematoma induction. Fibrin and thrombin immunoreactivity were increased in the lesioned cortical parenchyma at 4 and 24 hours. However, no intravascular fibrin deposition was detected. Heparin induced hemorrhagic transformation in the cortical lesion and did not attenuate microvessel occlusion. Argatroban and ginkgolide B did not induce hemorrhage but failed to improve microvessel occlusion, lesion volume, and neurological deficits. CONCLUSION Intravascular coagulation and thrombin are not the major mediators of brain damage after ASDH. The model and behavioral tests presented in this study can be used to investigate other putative mechanisms of injury and to test future therapeutic interventions in ASDH.
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Affiliation(s)
- Murat Karabiyikoglu
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-0532, USA.
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92
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Giannetti AV, Prandini MN, Araujo ABS, Herval LMDA. [Post-traumatic temporal lobe lesions: surgical decision making based on CT scan findings]. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:437-42. [PMID: 16059595 DOI: 10.1590/s0004-282x2005000300014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The indication for surgical treatment of post-traumatic parenchymal lesions in the temporal lobe remains controversial. OBJECTIVE We reviewed the tomographic parameters that might be useful in making surgical decisions. METHOD The tomographic findings of 69 patients were analyzed in a retrospective manner considering: 1) the effects of the lesion (classified into 4 variables: midline shift, status of the cisterns, status of the ventricles, and status of the peripheral sulci); and 2) the characteristics of the lesion: anterior, posterior or anteroposterior location (as defined by a coronal plane tangent to the cerebral peduncles) and its mediolateral diameter. RESULTS When none or only one of the aforementioned variables was found to be altered, conservative treatment was instituted (22 out of 38 lesions). In two cases, all four variables were altered, and surgery was performed in both. Anterior, anteroposterior and posterior lesions measuring 21, 23 and 28 mm in diameter, respectively, had a 50% chance of surgical removal. CONCLUSION Amongst the patients who underwent surgical intervention, the more anterior the location of the temporal lobe lesion, the smaller the diameter.
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93
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Jaffres P, Brun J, Declety P, Bosson JL, Fauvage B, Schleiermacher A, Kaddour A, Anglade D, Jacquot C, Payen JF. Transcranial Doppler to detect on admission patients at risk for neurological deterioration following mild and moderate brain trauma. Intensive Care Med 2005; 31:785-90. [PMID: 15834704 DOI: 10.1007/s00134-005-2630-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Accepted: 03/22/2005] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate the contribution of transcranial Doppler measurements obtained in the emergency room for detecting patients with secondary neurological deterioration after mild or moderate brain trauma. DESIGN AND SETTING Prospective cohort study in the emergency room in a university teaching hospital. PATIENTS Seventy-eight adult patients admitted to the emergency room after a traumatic brain injury (TBI), including 42 patients with Glasgow Coma Score 14-15 and 36 with 9-13. MEASUREMENTS AND RESULTS All patients had transcranial Doppler measurements on both middle cerebral arteries and computed tomography on admission. Neurological outcome was assessed 7 days after trauma. Of the patients included 7 and 10 had secondary neurological deterioration after mild and moderate TBI, respectively. On admission these groups of patients had significantly more injuries on computed tomography using the Trauma Coma Data Bank classification and higher pulsatility index using transcranial Doppler than the patients having no subsequent neurological worsening. CONCLUSIONS Increased pulsatility index after mild or moderate TBI is a reason for concern about the possibility of further neurological deterioration. Computed tomography and Doppler measurements could be combined to detect on admission patients at risk for secondary neurological deterioration in order to improve their initial disposition.
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Affiliation(s)
- Paul Jaffres
- Department of Anaesthesiology and Critical Care Medicine, Albert Michallon Hospital, 38043 Grenoble, France
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Hlatky R, Valadka AB, Goodman JC, Robertson CS. Evolution of Brain Tissue Injury after Evacuation of Acute Traumatic Subdural Hematomas. Neurosurgery 2004; 55:1318-23; discussion 1324. [PMID: 15574213 DOI: 10.1227/01.neu.0000143029.42638.2c] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2003] [Accepted: 08/02/2004] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE:
Acute traumatic subdural hematoma complicated by brain parenchymal injury is associated with a 60 to 90% mortality rate. Early surgical evacuation of the mass lesion is essential for a favorable outcome, but the severity of the underlying brain injury determines the outcome, even when surgery has been prompt. The purpose of this study was to analyze tissue biochemical patterns in the brain underlying an evacuated acute subdural hematoma to identify a characteristic pattern of changes that might indicate evolving brain injury.
METHODS:
Prospectively collected data from 33 patients after surgical evacuation of acute subdural hematoma were analyzed. Both a brain tissue oxygen tension probe and an intracerebral microdialysis probe were placed in brain tissue exposed at surgery. On the basis of the postoperative clinical course, the patients were divided into three groups: patients with early intractable intracranial hypertension, patients with evolution of delayed traumatic injury (DTI), and patients with an uncomplicated course (the no-DTI group).
RESULTS:
The overall mortality rate was 46%, with 100% mortality in the intracranial hypertension group (five patients). Mortality in the DTI group was 53% compared with only 9% in the no-DTI group (P = 0.002). There were no significant differences in the initial computed tomographic scan characteristics, such as thickness of the subdural hematoma or amount of midline shift, among the three groups. Physiological variables, as well as the microdialysate measures of brain biochemistry, were markedly different in the intracranial hypertension group compared with the other groups. Differences between the other two groups were more subtle but were significant. Significantly lower values of brain tissue oxygen tension (14 ± 8 mm Hg versus 27 ± 14 mm Hg) and higher dialysate values of lactate and pyruvate were documented in patients who developed a delayed injury compared with patients with uncomplicated courses (4.1 ± 2.3 mmol/L versus 1.7 ± 0.7 mmol/L for lactate, and 104 ± 47 μmol/L versus 73 ± 54 μmol/L for pyruvate at 24 h after injury).
CONCLUSION:
Evolution of DTI in the area of brain underlying an evacuated subdural hematoma is associated with a significant increase in mortality. Postoperatively decreasing brain tissue oxygen tension and increasing dialysate concentrations of lactate and pyruvate in this area may warn of evolving brain injury and evoke further diagnostic and therapeutic activity.
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Affiliation(s)
- Roman Hlatky
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA
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95
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Bahloul M, Chelly H, Ben Hmida M, Ben Hamida C, Ksibi H, Kallel H, Chaari A, Kassis M, Rekik N, Bouaziz M. Prognosis of Traumatic Head Injury in South Tunisia: A Multivariate Analysis of 437 Cases. ACTA ACUST UNITED AC 2004; 57:255-61. [PMID: 15345970 DOI: 10.1097/01.ta.0000083004.35231.1e] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to determine predictive factors of mortality after posttraumatic brain injury. METHODS A retrospective study conducted over a 3-year period (1997-1999) involved 437 adult patients with head injury admitted to the intensive care unit of a university hospital in Sfax, Tunisia. Basic demographic, clinical, biologic, and radiologic data were recorded at admission and during the intensive care unit stay. RESULTS This study included 393 men (90%) and 44 women with a mean age of 36 +/- 17 years. Traffic accidents were the main cause of trauma (85.6%). In 58% of the cases, the injury was serious (Glasgow Coma Score, <8). The mean simplified acute physiology score was 39 +/- 15, and the mean Injury Severity Score was 34.5 +/- 17. Of the 437 patients, 127 (29.1%) died. According to multivariate analysis, the factors that correlated with a poor prognosis were age older than 40 years (p < 0.01), simplified acute physiology score exceeding 40 (p < 0.001), Glasgow Coma Score lower than 7 (p = 0.03), intracranial mass lesion (p = 0.02), a cerebral herniation (p < 0.001), diabetes insipidus (p < 0.001), and blood sugar level higher than 10 mmol/L (p < 0. 001). CONCLUSIONS In Tunisia, head injury is a frequent cause of hospitalization, comprising 14.4% of all adult admissions. It is observed most often among young patients involved in traffic accidents. The short-term prognosis is poor, with a high (29%) mortality rate, and determined by demographic, clinical, radiologic, and biologic factors. Prevention is highly advised.
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Affiliation(s)
- Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia.
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Salci K, Enblad P, Piper I, Contant C, Nilsson P. A model for studies of intracranial volume pressure dynamics in traumatic brain injury. J Neurotrauma 2004; 21:317-27. [PMID: 15115606 DOI: 10.1089/089771504322972103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The present study was undertaken to establish an experimental trauma model where it was possible to alter intracranial pressure (ICP) dynamics without raising intracranial pressure to abnormal levels and monitor metabolic disturbances with microdialysis. Thirty rats were intubated and mechanically ventilated before and after trauma. ICP was measured in the left ventricle. A weight-drop technique (21 g from 35 cm) with a brain compression of 1.5 mm was used to produce the injury. Intracranial compensatory volume was decreased 20 or 60 microL by placement of rubber film between the dura mater and bone. A bolus injection technique was used for the pressure volume response. ICP remained within normal limits for 2 h after trauma irrespective of the reduction in compensatory intracranial volume. Pressure-volume index decreased from 0.0825 +/- 0.009 to 0.0779 +/- 0.011 mL in the sham trauma and from 0.0871 +/- 0.018 to 0.0748 +/- 0.017 mL in the trauma groups (p < 0.015) when the intracranial volume was reduced by 60 microL. Intracranial compliance was not affected significantly. The present study shows that it is possible to vary ICP dynamics in a traumatic brain injury model without causing pathological increases in baseline ICP. This model may be used to study the effects of secondary insults (i.e., hypotension, hypoxia, hypercarbia, and hyperthermia) on the injured brain when ICP is normal but intracranial compensatory volume is impaired.
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Affiliation(s)
- K Salci
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
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Fabbri A, Servadei F, Marchesini G, Dente M, Iervese T, Spada M, Vandelli A. Which type of observation for patients with high-risk mild head injury and negative computed tomography? Eur J Emerg Med 2004; 11:65-9. [PMID: 15028893 DOI: 10.1097/00063110-200404000-00002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Current guidelines suggest hospital admission followed by home monitoring for high-risk patients with mild head injury and negative computed tomography scan. We tested early home monitoring under the care of a competent observer. METHODS A total of 1480 patients with mild head injury and negative computed tomography scan were prospectively studied. Based on clinical status and available home caretakers, patients were managed by in-hospital observation (n = 646) or early home monitoring (n = 834). Outcome measures were: (1) the detection of previously undiagnosed post-traumatic intracranial injury; (2) neurosurgical intervention; and (3) unfavourable outcome (death, permanent vegetative state or severe disability). RESULTS In the in-hospital arm, nine cases (1.4%) developed intracranial injuries (in three after discharge). In the early home-monitoring arm, six patients (0.7%) had a previously undiagnosed lesion after re-admission (P = 0.773 versus in-hospital arm). No patients with previously undiagnosed intracranial injuries had a neurosurgical intervention. After 6 months, five patients had died in the home monitoring arm (0.8%) versus eight (1.0%) in the in-hospital arm (P=0.785). No permanent disability or vegetative state was observed. CONCLUSION Early home monitoring may be safely proposed to selected "high-risk" patients, with an early negative computed tomography scan, normal clinical examination and feasible home monitoring.
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Affiliation(s)
- Andrea Fabbri
- Dipartimento Emergenza-Urgenza Accettazione, Ospedale G.B. Morgagni, Azienda Unità Sanitaria Locale di Forlì, Forli, Italy.
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Abstract
The management of pediatric head injuries has evolved over the past decade,and a number of significant advances have been made. Evidence-based guide-lines and algorithms for the management of severe pediatric head injuries have recently been published, and all pediatricians who care for children with severe head injuries should be familiar with these guidelines. It is hoped the guidelines will streamline the clinical management of these children and stimulate future research into the many areas that require further investigation.
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Affiliation(s)
- Mark S Dias
- Department of Pediatric Neurosurgery, Penn State University College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.
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Fabbri A, Servadei F, Marchesini G, Morselli-Labate AM, Dente M, Iervese T, Spada M, Vandelli A. Prospective validation of a proposal for diagnosis and management of patients attending the emergency department for mild head injury. J Neurol Neurosurg Psychiatry 2004; 75:410-6. [PMID: 14966157 PMCID: PMC1738984 DOI: 10.1136/jnnp.2003.016113] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In mild head injury, predictors to select patients for computed tomography (CT) and/or to plan proper management are needed. The strength of evidence of published recommendations is insufficient for current use. We assessed the diagnostic accuracy and the clinical validity of the proposal of the Neurotraumatology Committee of the World Federation of Neurosurgical Societies on mild head injury from an emergency department perspective. METHODS In a three year period, 5578 adolescent and adult subjects were prospectively recruited and managed according to the proposed protocol. Outcome measures were: (a) any post-traumatic lesion; (b) need for neurosurgical intervention; (c) unfavourable outcome (death, permanent vegetative state or severe disability) after six months. The predictive value of a model based on five variables (Glasgow coma score, clinical findings, risk factors, neurological deficits, and skull fracture) was tested by logistic regression analysis. FINDINGS At first CT evaluation 327 patients (5.9%) had intracranial post-traumatic lesions. In 16 cases (0.3%) previously undiagnosed lesions were detected after re-evaluation within seven days. Neurosurgical intervention was needed in 71 patients (1.3%) and an unfavourable outcome occurred in 39 cases (0.7%). The area under the ROC curve of the variables in predicting post-traumatic lesions was 0.906 (0.009) (sensitivity 70.0%, specificity 94.1% at best cut off), neurosurgical intervention was 0.926 (0.016) (sensitivity 81.7%, specificity 94.1%), and unfavourable outcome was 0.953 (0.014) (sensitivity 88.1%, specificity 95.1%). INTERPRETATION The variables prove highly accurate in the prediction of clinically meaningful outcomes, when applied to a consecutive set of patients with mild head injury in the clinical setting of a 1st level emergency department.
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Affiliation(s)
- A Fabbri
- Dipartimento Emergenza-Urgenza Accettazione, Ospedale GB Morgagni, Azienda Unità Sanitaria Locale di Forlì, Italy.
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Kinoshita K, Kushi H, Hayashi N. Characteristics of parietal-parasagittal hemorrhage after mild or moderate traumatic brain injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2004; 86:343-6. [PMID: 14753465 DOI: 10.1007/978-3-7091-0651-8_73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
UNLABELLED The aim of this study is to clarify the clinical characteristics of parietal-parasagittal traumatic intracranial hemorrhage (TICH) after mild or moderate traumatic brain injury (TBI). METHODS; Subjects were 105 patients with mild or moderate TBI. The patients with parietal-parasagittal TICH were clinically analyzed based on the initial brain CT findings, hematoma sites and the clinical course as compared to those with TICH at other sites. RESULTS Hematoma was located in the frontal or temporal lobes in 89.5% of the subjects and the parietal-parasagittal in 10.5%. Ten of the 11 patients suffering parietal-parasagittal TICH had skull fractures (7 depressed and 3 linear) but no depressed fracture observed in patients with frontal or temporal lobe hemorrhage. Neurological deterioration leading to a comatose state more frequently occurred in 63.6% of patients with parietal-parasagittal TICH than in those with frontal or temporal lobe hemorrhage (19.1%, p < 0.01). The incidence of hematoma growth was significantly higher in patients with parietal-parasagittal TICH (63.6%) than in those with frontal or temporal lobe hemorrhage (31.9%, p < 0.05). DISCUSSION The incidence of parietal-parasagittal TICH is low, but the risk of neurological deterioration due to hematoma enlargement is significantly high. Parietal-parasagittal TICH may differ clinically from frontal-temporal TICH.
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Affiliation(s)
- K Kinoshita
- Department of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan.
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