Early management of severe traumatic brain injury

TMT-based proteomics analysis reveals the protective effects of Xuefu Zhuyu decoction in a rat model of traumatic brain injury

ETHNOPHARMACOLOGICAL RELEVANCE

Xuefu Zhuyu decoction (XFZYD) is a traditional Chinese herbal prescription. It is effective in treating traumatic brain injury (TBI). However, the underlying molecular mechanisms remain unclear.

AIM OF THE STUDY

This study aimed to reveal the possible mechanisms of XFZYD in treating acute TBI through proteomics clues.

MATERIALS AND METHODS

Controlled Cortical Impact (CCI) rats were given gavage administration of XFZYD (9 g/kg/d) or distilled water (equal volume) for three days. The Modified Neurological Severity Score (mNSS), brain water content, HE staining, Nissl staining and immunohistochemistry were performed to assess the effects of XFZYD for TBI treatment. Additionally, tandem mass tag-based (TMT) quantitative proteomics technology was applied to detect proteins of brain cortex. Bioinformatics analysis including Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways and Protein-protein interaction (PPI) networks were used to analyze differentially expressed proteins (DEPs). Bioinformatics Analysis Tool for Molecular mechanism of TCM (BATMAN-TCM) was conducted to anchor diseases and pathways. Besides, western blotting and immunofluorescence were exerted to verify related proteins.

RESULTS

XFZYD improved neurologic functions, reduced encephaledema and ameliorated cell morphology around the injured area in CCI rats. A total of 6099 proteins were identified with false discovery rate (FDR) < 1%. Overlapping DEPs (105 DEPs) were identified (295 DEPs and 804 DEPs in CCI/Sham or XFZYD/CCI group, respectively). Of these DEPs, 17 were regulated by XFZYD. Bioinformatics analysis showed that the 17 DEPs were predominantly related to platelet activation and PI3K-Akt signaling pathway. Next, PLG and CD34 were verified with molecular biotechnology.

CONCLUSIONS

XFZYD exerts therapeutic effects through multi-pathways regulation in the treatment of TBI. This work may provide proteomics clues for the continuation of research on TBI treatment with XFZYD.

Advance Directives in the Neurocritically Ill: A Systematic Review

OBJECTIVES

To determine the frequency of advance directives or directives disclosed by healthcare agents and their influence on decisions to withdraw/withhold life-sustaining care in neurocritically ill adults.

DATA SOURCES

PubMed, Embase, and Cochrane databases.

STUDY SELECTION

Screening was performed using predefined search terms to identify studies describing directives of neurocritically ill patients from 2000 to 2019. The review was registered prior to the screening process (International Prospective Register of Systematic Reviews identification number 149185).

DATA EXTRACTION

Data were collected using standardized forms. Primary outcomes were the frequency of directives and associated withholding/withdrawal of life-sustaining care.

DATA SYNTHESIS

Out of 721 articles, 25 studies were included representing 35,717 patients. The number of studies and cohort sizes increased over time. A median of 39% (interquartile range, 14-72%) of patients had directives and/or healthcare agents. The presence of directives was described in patients with stroke, status epilepticus, neurodegenerative disorders, neurotrauma, and neoplasms, with stroke patients representing the largest subgroup. Directives were more frequent among patients with neurodegenerative disorders compared with patients with other illnesses (p = 0.043). In reference to directives, care was adapted in 71% of European, 50% of Asian, and 42% of American studies, and was withheld or withdrawn more frequently over time with a median of 58% (interquartile range, 39-89%). Physicians withheld resuscitation in reference to directives in a median of 24% (interquartile range, 22-70%).

CONCLUSIONS

Studies regarding the use and translation of directives in neurocritically ill patients are increasing. In reference to directives, care was adapted in up to 71%, withheld or withdrawn in 58%, and resuscitation was withheld in every fourth patient, but the quality of evidence regarding their effects on critical care remains weak and the risk of bias high. The limited number of patients having directives is worrisome and studies aiming to increase the use and translation of directives are scarce. Efforts need to be made to increase the perception, use, and translation of directives of the neurocritically ill.

Intracranial Pressure during External Ventricular Drainage Weaning Is an Outcome Predictor of Traumatic Brain Injury

External ventricular drainage (EVD) is widely used in patients with a traumatic brain injury (TBI). However, the EVD weaning trial protocol varies and insufficient studies focus on the intracranial pressure (ICP) during the weaning trial. We aimed to establish the relationship between ICP during an EVD weaning trial and the outcomes of TBI. We enrolled 37 patients with a TBI with an EVD from July 2018 to September 2019. Among them, 26 were allocated to the favorable outcome group and 11 to the unfavorable outcome group (death, post-traumatic hydrocephalus, persistent vegetative state, and severe disability). Groups were well matched for sex, pupil reactivity, admission Glasgow Coma Scale score, Marshall computed tomography score, modified Fisher score, intraventricular hemorrhage, EVD days, cerebrospinal fluid output before the weaning trial, and the complications. Before and during the weaning trial, we recorded the ICP at 1-hour intervals to calculate the mean ICP, delta ICP, and ICP burden, which was defined as the area under the ICP curve. There were significant between-group differences in the age, surgery types, and intensive care unit days (p = 0.045, p = 0.028, and p = 0.004, respectively). During the weaning trial, 28 (75.7%) patients had an increased ICP. Although there was no significant difference in the mean ICP before and during the weaning trial, the delta ICP was higher in the unfavorable outcome group (p = 0.001). Moreover, patients who experienced death and hydrocephalus had a higher ICP burden, which was above 20 mmHg (p = 0.016). Receiver operating characteristic analyses demonstrated the predictive ability of these variables (area under the curve [AUC] = 0.818 [p = 0.002] for delta ICP and AUC = 0.758 [p = 0.038] for ICP burden > 20 mmHg). ICP elevation is common during EVD weaning trials in patients with TBI. ICP-related parameters, including delta ICP and ICP burden, are significant outcome predictors. There is a need for larger prospective studies to further explore the relationship between ICP during EVD weaning trials and TBI outcomes.

Cerebral Immunohistochemical Characterization of the H2S and the Oxytocin Systems in a Porcine Model of Acute Subdural Hematoma

The hydrogen sulfide (H₂S) and the oxytocin/oxytocin receptor (OT/OTR) systems interact in trauma and are implicated in vascular protection and regulation of fluid homeostasis. Acute brain injury is associated with pressure-induced edema formation, blood brain barrier disruption, and neuro-inflammation. The similarities in brain anatomy: size, gyrencephalic organization, skull structure, may render the pig a highly relevant model for translational medicine. Cerebral biomarkers for pigs for pathophysiological changes and neuro-inflammation are limited. The current study aims to characterize the localization of OT/OTR and the endogenous H₂S producing enzymes together with relevant neuro-inflammatory markers on available porcine brain tissue from an acute subdural hematoma (ASDH) model. In a recent pilot study, anesthetized pigs underwent ASDH by injection of 20 mL of autologous blood above the left parietal cortex and were resuscitated with neuro-intensive care measures. After 54 h of intensive care, the animals were sacrificed, the brain was removed and analyzed via immunohistochemistry. The endogenous H₂S producing enzymes cystathionine-ɤ-lyase (CSE) and cystathionine-β-synthase (CBS), the OTR, and OT were localized in neurons, vasculature and parenchyma at the base of sulci, where pressure-induced injury leads to maximal stress in the gyrencephalic brain. The pathophysiological changes in response to brain injury in humans and pigs, we show here, are comparable. We additionally identified modulators of brain injury to further characterize the pathophysiology of ASDH and which may indicate future therapeutic approaches.

The impact of a yoga-based physical therapy group for individuals with traumatic brain injury: results from a pilot study

OBJECTIVE

To compare the impacts of yoga-based physical therapy versus a seated rest within the context of standard rehabilitation practice on sleep, heart rate variability (HRV), anxiety, and fatigue during acute traumatic brain injury (TBI) rehabilitation.

METHODS

Eleven individuals participated in this crossover study involving the following interventions in a randomized order: group yoga-based physical therapy (YPT), conventional physical therapy (CPT), and group seated rest in a relaxing environment (SR). HRV and self-reported anxiety and fatigue were measured immediately before and after each group, and sleep after each condition and at baseline. Data was analyzed using generalized linear mixed models with repeated measures.

RESULTS

The interaction between time and treatment was statistically significant (p = .0203). For the SR treatment, wake after sleep onset (WASO) rate was reduced from 14.99 to 10.60 (IRR = 0.71; p = .006). Time and treatment were not found to be statistically significantly associated with any of the secondary outcomes.

CONCLUSION

Yoga-based physical therapy is feasible and safe in the inpatient rehabilitation setting following TBI. Sleep quality improved following the addition of a one-hour seated rest in a relaxing environment to a standard rehabilitation daily schedule, suggesting that structured rest time may be beneficial to sleep hygiene during inpatient rehabilitation following TBI. ClinicalTrials.Gov Registration Number: NCT03701594.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study

BACKGROUND

The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI.

METHODS

We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation.

RESULTS

A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%).

CONCLUSION

In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

Integrated care pathways for Black persons with traumatic brain injury: a protocol for a critical transdisciplinary scoping review

BACKGROUND

Current understandings of the etiology of traumatic brain injury (TBI) and the trajectory of care significantly lack consideration for the inclusion of Black populations. The global prevalence of TBI is increasing, particularly in North America and Europe where approximately 65 million people are affected every year. Although community integration is an ultimate goal of rehabilitation post injury, persons with TBI, particularly Black populations continually face challenges with regards to unmet needs along the continuum of care including meaningful participation and vocation, resulting in occupational deprivation. While integrated care is seen as an appealing approach to service delivery, little is known about what this means for Black people with TBI. This protocol produces the first critical transdisciplinary (CTD) scoping review mapping the extent, range, and nature of integrated care pathways for Black people experiencing TBI.

METHODS

CTD provides an analytical tool with a health equity lens that will be applied as both a methodology and theory for undertaking this review. Under the methodological guidance of Arksey and O'Malley, CTD will be used to map the literature and better understand the elements of integrated care pathways for Black people experiencing TBI. To identify the published literature, several databases will be searched including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Sociological Abstracts.

DISCUSSION

The application of CTD compels health-care providers, administrators, clinician-scientists, rehabilitation specialists, and scholars in the field of TBI and integrated care to re-examine hidden assumptions about racism, racialization, and Blackness that are often embedded in current visions of health for all. The health equity lens of CTD asks about who is accounted for in the research and clinical literature and who is absented. It is anticipated that applying the health equity lens of CTD will provide a critical examination of the literature and illuminate significant implications for integrated care for Black persons experiencing TBI.

SYSTEMATIC REVIEW REGISTRATION

Not applicable.

Agathisflavone modulates astrocytic responses and increases the population of neurons in an in vitro model of traumatic brain injury

Traumatic brain injury (TBI) is a critical health problem worldwide, with a high incidence rate and potentially severe long-term consequences. Depending on the level of mechanical stress, astrocytes react with complex morphological and functional changes known as reactive astrogliosis. In cases of severe tissue injury, astrocytes proliferate in the area immediately adjacent to the lesion to form the glial scar, which is a major barrier to neuronal regeneration in the central nervous system. The flavonoid agathisflavone has been shown to have neuroprotective, neurogenic, and immunomodulatory effects and could have beneficial effects in situations of TBI. In this study, we investigated the effects of agathisflavone on modulating the responses of astrocytes and neurons to injury, using the in vitro scratch wound model of TBI in primary cultures of rat cerebral cortex. In control conditions, the scratch wound induced an astroglial injury response, characterized by upregulation of glial fibrillary acidic protein (GFAP) and hypertrophy, together with the reduction in proportion of neurons within the lesion site. Treatment with agathisflavone (1 μM) decreased astroglial GFAP expression and hypertrophy and induced an increase in the number of neurons and neurite outgrowth into the lesion site. Agathisflavone also induced increased expression of the neurotrophic factors NGF and GDNF, which are associated with the neuroprotective profile of glial cells. These results demonstrate that in an in vitro model of TBI, the flavonoid agathisflavone modulates the astrocytic injury response and glial scar formation, stimulating neural recomposition.

Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients

Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

Traumatic Brain Injury and Blood-Brain Barrier (BBB): Underlying Pathophysiological Mechanisms and the Influence of Cigarette Smoking as a Premorbid Condition

Traumatic brain injury (TBI) is among the most pressing global health issues and prevalent causes of cerebrovascular and neurological disorders all over the world. In addition to the brain injury, TBI may also alter the systemic immune response. Thus, TBI patients become vulnerable to infections, have worse neurological outcomes, and exhibit a higher rate of mortality and morbidity. It is well established that brain injury leads to impairments of the blood-brain barrier (BBB) integrity and function, contributing to the loss of neural tissue and affecting the response to neuroprotective drugs. Thus, stabilization/protection of the BBB after TBI could be a promising strategy to limit neuronal inflammation, secondary brain damage, and acute neurodegeneration. Herein, we present a review highlighting the significant post-traumatic effects of TBI on the cerebrovascular system. These include the loss of BBB integrity and selective permeability, impact on BBB transport mechanisms, post-traumatic cerebral edema formation, and significant pathophysiological factors that may further exacerbate post-traumatic BBB dysfunctions. Furthermore, we discuss the post-traumatic impacts of chronic smoking, which has been recently shown to act as a premorbid condition that impairs post-TBI recovery. Indeed, understanding the underlying molecular mechanisms associated with TBI damage is essential to better understand the pathogenesis and progression of post-traumatic secondary brain injury and the development of targeted treatments to improve outcomes and speed up the recovery process. Therapies aimed at restoring/protecting the BBB may reduce the post-traumatic burden of TBI by minimizing the impairment of brain homeostasis and help to restore an optimal microenvironment to support neuronal repair.

Extubation strategies in neuro-intensive care unit patients and associations with outcomes: the ENIO multicentre international observational study

Background

Prolonged invasive ventilation is common in patients with severe brain injury. Information on optimal management of extubation and on the use of tracheostomy in these patients is scarce. International guidelines regarding the ventilator liberation and tracheostomy are currently lacking.

Methods

The aim of ‘Extubation strategies in Neuro-Intensive care unit patients and associations with Outcomes’ (ENIO) study is to describe current management of weaning from invasive ventilation, focusing on decisions on timing of tracheal extubation and tracheostomy in intensive care unit (ICU) patients with brain injury. We conducted a prospective, international, multi-centre observational study enrolling patients with various types of brain injury, including trauma, stroke, and subarachnoid haemorrhage, with an initial Glasgow Coma Score equal or less than 12, and a duration of invasive ventilation longer than 24 hours from ICU admission. ENIO is expected to include at least 1,500 patients worldwide. The primary endpoint of the ENIO study is extubation success in the 48 hours following endotracheal tube removal. The primary objective is to validate a score predictive of extubation success. To accomplish this, the study population will be randomly divided to a development cohort (2/3 of the included patients) and a validation cohort (the remaining 1/3). Secondary objectives are: to determine the incidence of extubation success rate according to various time-frames (within 96 hours, >96 hours after extubation); to validate (existing) prediction scores for successful extubation according to various time-frames and definitions (i.e., tracheostomy as extubation failure); and to describe the current practices of extubation and tracheostomy, and their associations.

Discussion

ENIO will be the largest prospective observational study of ventilator liberation and tracheostomy practices in patients with severe brain injury undergoing invasive mechanical ventilation, providing a validated predictive score of successful extubation.

Trial registration

The ENIO study is registered in the Clinical Trials database: NCT 03400904.

Antioxidant Therapies in Traumatic Brain Injury

Due to a multiplicity of causes provoking traumatic brain injury (TBI), TBI is a highly heterogeneous pathology, characterized by high mortality and disability rates. TBI is an acute neurodegenerative event, potentially and unpredictably evolving into sub-chronic and chronic neurodegenerative events, with transient or permanent neurologic, cognitive, and motor deficits, for which no valid standardized therapies are available. A vast body of literature demonstrates that TBI-induced oxidative/nitrosative stress is involved in the development of both acute and chronic neurodegenerative disorders. Cellular defenses against this phenomenon are largely dependent on low molecular weight antioxidants, most of which are consumed with diet or as nutraceutical supplements. A large number of studies have evaluated the efficacy of antioxidant administration to decrease TBI-associated damage in various animal TBI models and in a limited number of clinical trials. Points of weakness of preclinical studies are represented by the large variability in the TBI model adopted, in the antioxidant tested, in the timing, dosages, and routes of administration used, and in the variety of molecular and/or neurocognitive parameters evaluated. The analysis of the very few clinical studies does not allow strong conclusions to be drawn on the real effectiveness of antioxidant administration to TBI patients. Standardizing TBI models and different experimental conditions, as well as testing the efficacy of administration of a cocktail of antioxidants rather than only one, should be mandatory. According to some promising clinical results, it appears that sports-related concussion is probably the best type of TBI to test the benefits of antioxidant administration.

Vibration Does Not Affect Short Term Outcomes Following Traumatic Brain Injury in a Porcine Model

Introduction

Traumatic brain injury (TBI) has become increasingly prevalent among the injuries sustained in the military. Many wounded warriors require emergency medical evacuation via helicopter and subsequently fixed wing transport. During aeromedical evacuation, both pilots and patients experience whole body vibration due to engine, rotor, and propeller rotation. The impact of posttraumatic vibration and hypoxia exposure characteristic of the aeromedical evacuation environment on TBI is currently unknown.

Methods

A swine TBI model of controlled cortical impact was utilized. The pigs first underwent TBI or sham injury and were subsequently exposed to vibration or no vibration and hypoxia or normoxia for 2 hours. They were monitored for an additional 4 hours following vibration/hypoxia and blood was drawn at hourly intervals for cytokine and serum biomarker analysis. Continuous physiologic and neurologic monitoring were utilized. Prior to the conclusion of the experiment, the animals underwent brain magnetic resonance imaging. At the end of the study, the brain was extracted for histologic analysis.

Results

Physiologic parameters except for peripheral capillary oxygen saturation (SpO2) were similar between all groups. The hypoxia groups demonstrated the expected decrease in SpO2 and pO2 during the hypoxic period, and this was sustained throughout the study period. The pH, pCO2 and electrolytes were similar among all groups. Neuron specific enolase was increased over time in the TBI group, however it was similar to the sham TBI group at all time points. There were no differences in IL-1β, IL-6, IL-8, TNFα, GFAP, HIF1α, syndecan-1, or S100β serum levels between groups. The mean ICP during cortical impact in the TBI group was 279.8 ± 56.2 mmHg. However, the postinjury ICP was not different between groups at any subsequent time point. Brain tissue oxygenation and perfusion were similar between all groups.

Conclusion

In this novel study evaluating the effect of vibration on short-term outcomes following TBI, we demonstrate that the moderate vibration and hypoxia simulating aeromedical evacuation do not impact short term outcomes following TBI.

Early enteral nutrition in patients with severe traumatic brain injury: a propensity score-matched analysis using a nationwide inpatient database in Japan

BACKGROUND

Whether enteral nutrition (EN) should be administered early in severe traumatic brain injury (TBI) patients has not been fully addressed.

OBJECTIVE

The present study aimed to evaluate whether early EN can reduce mortality or nosocomial pneumonia among severe TBI patients.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2017 linked with the Survey for Medical Institutions, we identified patients admitted for intracranial injury with Japan Coma Scale scores ≥30 (corresponding to Glasgow Coma Scale scores ≤8) at admission. We designated patients who started EN within 2 d of admission as the early EN group, and those who started EN at 3-5 d after admission as the delayed EN group. The primary outcome was in-hospital mortality. The secondary outcome was nosocomial pneumonia. Propensity score-matched analyses were performed to compare the outcomes between the 2 groups.

RESULTS

We identified 3080 eligible patients during the 36-mo study period, comprising 1100 (36%) in the early EN group and 1980 (64%) in the delayed EN group. After propensity score matching, there was no significant difference in in-hospital mortality (difference: -0.3%; 95% CI: -3.7%, 3.1%) between the 2 groups. The proportion of nosocomial pneumonia was significantly lower in the early EN group than in the delayed EN group (difference: -3.2%; 95% CI: -5.9%, -0.4%).

CONCLUSIONS

Early EN may not reduce mortality, but may reduce nosocomial pneumonia in patients with severe TBI.

Genetic drivers of cerebral blood flow dysfunction in TBI: a speculative synthesis

Cerebral autoregulatory dysfunction after traumatic brain injury (TBI) is strongly linked to poor global outcome in patients at 6 months after injury. However, our understanding of the drivers of this dysfunction is limited. Genetic variation among individuals within a population gives rise to single-nucleotide polymorphisms (SNPs) that have the potential to influence a given patient's cerebrovascular response to an injury. Associations have been reported between a variety of genetic polymorphisms and global outcome in patients with TBI, but few studies have explored the association between genetic variants and cerebrovascular function after injury. In this Review, we explore polymorphisms that might play an important part in cerebral autoregulatory capacity after TBI. We outline a variety of SNPs, their biological substrates and their potential role in mediating cerebrovascular reactivity. A number of candidate polymorphisms exist in genes that are involved in myogenic, endothelial, metabolic and neurogenic vascular responses to injury. Furthermore, polymorphisms in genes involved in inflammation, the central autonomic response and cortical spreading depression might drive cerebrovascular reactivity. Identification of candidate genes involved in cerebral autoregulation after TBI provides a platform and rationale for further prospective investigation of the link between genetic polymorphisms and autoregulatory function.

Physician Prehospital Care in Mexico City: Retrospective Analysis of Endotracheal Intubation in Patients with Severe Head Trauma

INTRODUCTION

In Mexico, physicians have become part of public service prehospital care. Head injured patients are a sensitive group that can benefit from early advanced measures to protect the airway, with the objective to reduce hypoxia and maintain normocapnia.

PROBLEM

The occurrence of endotracheal intubation to patients with severe head injuries by prehospital physicians working at Mexico City's Service of Emergency Medical Care (SAMU) is unknown.

METHODS

A retrospective analysis of five-year data (2012-2016) from Mexico City's Medical Emergencies Regulation Center was performed. Only SAMU ambulance services were analyzed. Adult patients with a prehospital diagnosis of head injury based on mechanism of injury and physical examination with a Glasgow Coma Scale (GCS) <nine were included.

RESULTS

A total of 293 cases met the inclusion criteria; the mean GCS was five points. Of those, 150 (51.1%) patients were intubated. There was no difference in the occurrence of intubation among the different GCS scales, or if the patient was considered to have isolated head trauma versus polytrauma. Fifteen patients were intubated using sedation and neuromuscular blockage. Four patients were intubated with sedation alone and six patients with neuromuscular blockage alone. One patient was intubated using opioid analgesia, sedation, and neuromuscular blockage.

CONCLUSIONS

Patients with severe head injuries cared by prehospital physicians in Mexico City were intubated 51.1% of the time and were more likely to be intubated without the assistance of anesthetics.

The use of bioactive matrices in regenerative therapies for traumatic brain injury

Functional deficits due to neuronal loss are a common theme across multiple neuropathologies, including traumatic brain injury (TBI). Apart from mitigating cell death, another approach to treating brain injuries involves re-establishing the neural circuitry at the lesion site by utilizing exogeneous and/or endogenous stem cells to achieve functional recovery. While there has been limited success, the emergence of new bioactive matrices that promote neural repair introduces new perspectives on the development of regenerative therapies for TBI. This review briefly discusses current development on cell-based therapies and the use of bioactive matrices, hydrogels in particular, when incorporated in regenerative therapies. Desirable characteristics of bioactive matrices that have been shown to augment neural repair in TBI models were identified and further discussed. Understanding the relative outcomes of newly developed biomaterials implanted in vivo can better guide the development of biomaterials as a therapeutic strategy, for biomaterial-based cellular therapies are still in their nascent stages. Nonetheless, the value of bioactive matrices as a treatment for acute brain injuries should be appreciated and further developed. STATEMENT OF SIGNIFICANCE: Cell-based therapies have received attention as an alternative therapeutic strategy to improve clinical outcome post-traumatic brain injury but have achieved limited success. Whilst the incorporation of newly developed biomaterials in regenerative therapies has shown promise in augmenting neural repair, studies have revealed new hurdles which must be overcome to improve their therapeutic efficacy. This review discusses the recent development of cell-based therapies with a specific focus on the use of bioactive matrices in the form of hydrogels, to complement cell transplantation within the injured brain. Moreover, this review consolidates in vivo animal studies that demonstrate relative functional outcome upon the implantation of different biomaterials to highlight their desirable traits to guide their development for regenerative therapies in traumatic brain injury.

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury: an observational study

Background

The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts.

Methods

All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999–2015, Stockholm 2005–2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1–3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R²) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness.

Results

Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores’ AUCs and pseudo-R²s varied between 0.77–0.90 and 0.35–0.60 for mortality prediction and between 0.85–0.89 and 0.50–0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R² 0.71) and unfavorable outcome (AUC 0.89, pseudo-R² 0.53) prediction. None of the CT scores increased the base model’s AUC (p > 0.05) yet increased its pseudo-R² (0.09–0.15) for unfavorable outcome prediction.

Conclusion

Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04074-1) contains supplementary material, which is available to authorized users.

Characteristics of traumatic brain injury during Operation Enduring Freedom–Afghanistan: a retrospective case series

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality, especially among members of the armed services. Injuries sustained in the battlefield are subject to different mechanisms than those sustained in civilian life, particularly blast and high-velocity injury. Due to the unique nature of these injuries and the challenges associated with battlefield medicine, surgical interventions play a key role in acute management of TBI. However, the burden of chronic disease posed by TBI is poorly understood and difficult to investigate, especially in the military setting. The authors report the case logs of a United States Navy neurosurgeon, detailing the acute management and outcomes of 156 patients sustaining TBI between November 2010 and May 2011 during the war in Afghanistan. By demographics, more than half of the patients treated were local nationals. By mechanism of injury, blunt trauma (40.4%) and explosive injury (37.2%) were the most common contributors to TBI. Decompressive craniectomies (24.0%) and clot evacuations (14.7%) were the procedures most commonly performed. Nearly one-quarter of patients were transferred to receive further care, yet only 3 patients were referred for rehabilitative services. Furthermore, the data suggest that patients sustaining comorbid injuries in addition to TBI may be predisposed to worse outcomes. Improvements in documentation of military patients may improve knowledge of TBI and further identify potential variables or treatments that may affect prognosis. The increased survivability from TBI also highlights the need for additional research expenditure in the field of neurorehabilitation specifically.

Recent advances in traumatic brain injury

Traumatic brain injury (TBI) is the most common cause of death and disability in those aged under 40 years in the UK. Higher rates of morbidity and mortality are seen in low-income and middle-income countries making it a global health challenge. There has been a secular trend towards reduced incidence of severe TBI in the first world, driven by public health interventions such as seatbelt legislation, helmet use, and workplace health and safety regulations. This has paralleled improved outcomes following TBI delivered in a large part by the widespread establishment of specialised neurointensive care. This update will focus on three key areas of advances in TBI management and research in moderate and severe TBI: refining neurointensive care protocolized therapies, the recent evidence base for decompressive craniectomy and novel pharmacological therapies. In each section, we review the developing evidence base as well as exploring future trajectories of TBI research.

The Incidence and Management of Moderate to Severe Head Injury

BACKGROUND

The comprehensive expansion of the Trauma Register of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; TR-DGU) now enables, for the first time, studies on traumatic brain injury (TBI) with special attention to care processes, clinical course, and outcomes of treatment on discharge or transfer from the acute-care hospital.

METHODS

Retrospective analysis of patients documented in the TR-DGU in the period 2013-2017 who had moderate to severe head injury as defined by the Abbreviated Injury Scale (AIS).

RESULTS

In the period 2013-2017, 41 101 patients with moderate to severe TBI were treated in TR-DGU-associated hospitals in Germany (n = 605 hospitals), corresponding to 8220 cases per year and thus to a population-wide incidence of 10.1 cases per 100 000 persons per year. TBI was present as an isolated injury in 39.1% of cases. The mean age of the patients was 60 years (median; range 0-104 years), and the male-to-female ratio was 2:1. 97.5% of the patients had blunt trauma. Falls from a low height were the most common cause of TBI (38.7%). 43.6% of the patients were intubated before arriving at the hospital, and more than 95% underwent cranial tomographic imaging within 22 minutes of arrival (standard deviation [SD] = 17 minutes). 18.4% underwent an emergency neurosurgical procedure. The in-hospital mortality was 23.5%, corresponding to a population-wide mortality from TBI of 2.4 per 100 000 persons per year. More than half of the patients recovered well or with only mild disability; 14.9% had persistent severe disability or remained in a vegetative state.

CONCLUSION

Putting these figures in the appropriate international context requires the acquisition of comparable data in multiple countries and is the main task of international TBI consortia.

Low-value clinical practices in adult traumatic brain injury: an umbrella review protocol

INTRODUCTION

Traumatic brain injury (TBI) leads to 50 000 deaths, 85 000 disabilities and costs $60 billion each year in the USA. Despite numerous interventions and treatment options, the outcomes of TBI have improved little over the last three decades. In a previous scoping review and expert consultation survey, we identified 13 potentially low-value clinical practices in acute TBI. The objective of this umbrella review is to synthesise the evidence on potentially low-value clinical practices in the care of acute TBI.

METHODS AND ANALYSIS

Using umbrella review methodology, we will search Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, International Prospective Register of Systematic Reviews (PROSPERO) and PubMed to identify systematic reviews evaluating the effect of potential intrahospital low-value practices using tailored population, intervention, comparator, outcome and study design questions based on the results of a previous scoping review. We will present data on the methodological quality of these reviews (Assessing the Methodological Quality of Systematic Reviews-2), reported effect sizes and strength of evidence (Grading of Recommendations, Assessment, Development and Evaluation).

ETHICS AND DISSEMINATION

Ethics approval is not required as original data will not be collected. Knowledge users from five healthcare quality organisations and clinical associations are involved in the design and conduct of the study. Results will be disseminated in a peer-reviewed journal, at international scientific meetings and to clinical, healthcare quality and patient-partner associations. This work will support the development of metrics to measure the use of low-value practices, inform policy makers on potential targets for deimplementation and in the long term reduce the use of low-value clinical practices in acute TBI care.

PROSPERO REGISTRATION NUMBER

CRD42019132428.

Plasma and cerebrospinal fluid pharmacokinetics of hydroxysafflor yellow A in patients with traumatic brain injury after intravenous administration of Xuebijing using LC-MS/MS method

Hydroxysafflor yellow A (HSYA) is the most pharmaceutically relevant compound in Xuebijing (XBJ) for traumatic brain injury (TBI) treatment. We aimed to investigate biofluids pharmacokinetics of HSYA from XBJ to ensure the drug safety and to guide the clinical use.A sensitive, rapid and reliable liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was applied to investigate pharmacokinetics of HSYA in TBI patients after intravenous administration of XBJ. Non-compartmental methods using DAS 3.0 software were applied to analyse the pharmacokinetic parameters.A similar half-life (Plasma_t1/2: 14.55 ± 3.51 h vs. CSF_t1/2: 15.73 ± 3.63) was observed. HSYA reached the peak level rapidly, but exhibited a strongly slow absorption phase from blood to cerebrospinal fluid (CSF, Plasma_Tmax: 0.69 ± 0.26 h vs. CSF_Tmax: 4.0 ± 2.62 h). HSYA exhibited much higher C_max (Plasma_Cmax: 9342.76 ± 2489.23 μg/L vs. CSF_Cmax: 98.08 ± 14.51 μg/L) and AUC_0-t (Plasma_AUC0-t: 57490.5 ± 5560.3 μg h/L vs. CSF_AUC0-t: 1851.6 ± 269.1 μg h/L), yet a shorter CL (Plasma_CL: 0.02 ± 0.002 L/h/kg vs. CSF_CL: 0.55 ± 0.01 L/h/kg) in plasma than in CSF. The AUC_CSF/AUC_plasma of HSYA was almost 3.37%.In summary, the results demonstrate that part of HSYA come across blood-brain barrier after XBJ administration. This study provides evidence for better understanding the pharmacokinetics and potential for clinical guidance of XBJ for TBI treatment.

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

Comparing the outcomes of isolated, serious traumatic brain injury in older adults managed at major trauma centres and neurosurgical services: A registry-based cohort study

BACKGROUND

The incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS).

METHOD

Older adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury.

RESULTS

From 2007-2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21).

CONCLUSION

For older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults.

Early cardiovascular function and associated hemodynamics in adults with isolated moderate-severe traumatic brain injury: A pilot study

BACKGROUND

While cardiac dysfunction has been described following traumatic brain injury (TBI), its association with systemic and cerebral hemodynamics is not known. We examined the contemporaneous relationship between early cardiac function with systemic and cerebral hemodynamic parameters after moderate-severe TBI.

METHODS

Bedside transthoracic echocardiography (TTE) and transcranial Doppler (TCD) ultrasonography were performed within 24 h in patients > 18 years with isolated moderate-severe TBI. Systemic hemodynamic parameters were quantified using routine monitoring [heart rate and mean arterial pressures (MAP)] and calculation from echocardiographic data [stroke volume index (SVI), cardiac index (CI), and systemic vascular resistance index (SVRI)]. Systolic dysfunction was defined using TTE as global longitudinal strain (GLS) > -16%. Mean middle cerebral artery velocity (FVm) was the measure of cerebral hemodynamics and quantified using TCD.

RESULTS

Among 15 patients [mean age 43 ± 13 years, GCS 5 ± 3, 73% male], 15 TTE and 15 TCD exams were performed simultaneously. Five (33%) patients had systolic dysfunction, with significantly worse GLS (median [IQR] -12.1% [-14.1, -12] vs. -19.1% [-19.9, -17.7], p = 0.004). Median (IQR) MAP was 97 (89, 107) mmHg, SVI (29.0 [20.5, 31.0] mL m^-2), and CI (2.83 [2.05, 3.10] L/min m^-2) were low to normal, while SVRI (2704 dyne sec/cm⁵ m^-2 [2210, 4084]) was normal to high. None of the patients had abnormal TCDs. Higher GLS (reduced systolic function) was associated with lower SVI (r² = 0.274, p = 0.03) but not other parameters.

CONCLUSION

Systemic hemodynamic parameters were consistent with an early catecholamine-excess state. While reduced systolic function was associated with lower SVI, there was no relationship with reduced cerebral perfusion, possibly due to normal MAP.

Head of the Bed Down: Paradoxical Management for Paradoxical Herniation

Emergency physicians are well versed in cerebral herniation, pathology that typically results from increased intracranial pressure; however, paradoxical herniation is less common and requires opposing treatments. We describe a case of paradoxical herniation following lumbar puncture in a patient with previous hemicraniectomy. The symptomatology was similar to cerebral herniation from intracranial hypertension and included lethargy, bradycardia, headache, and compression of brain structures on non-contrast head computed tomography. However, contrary to treatment modalities for intracranial hypertension, our management strategy aimed to reverse intracerebral hypotension. Treatment for paradoxical herniation involved increasing intracranial pressure using fluid resuscitation and Trendelenburg positioning. In the intensive care unit our patient received an epidural blood patch and hydration with resolution of his symptoms.

Infections after a traumatic brain injury: The complex interplay between the immune and neurological systems

Traumatic brain injury (TBI) is a serious global health issue, being the leading cause of death and disability for individuals under the age of 45, and one of the largest causes of global neurological disability. In addition to the brain injury itself, it is increasingly appreciated that a TBI may also alter the systemic immune response in a way that renders TBI patients more vulnerable to infections in the acute post-injury period. Such infections pose an additional challenge to the patient, increasing rates of mortality and morbidity, and worsening neurological outcomes. Hospitalization, surgical interventions, and a state of immunosuppression induced by injury to the central nervous system (CNS), may all contribute to the high rate of infections seen in the population with TBI. Ongoing research to better understand the immunomodulators that underlie TBI-induced immunosuppression may aid in the development of effective therapeutic strategies to improve the recovery trajectory for patients. This review first describes the clinical scenario, posing the question of whether TBI patients are more susceptible to infections such as pneumonia, and if so, why? We then consider how cross-talk between the injured brain and the systemic immune system occurs, and further, how the additional immune challenge of an acquired infection can contribute to ongoing neuroinflammation and neurodegeneration after a TBI. Experimental models combining TBI with infection are discussed, as well as current treatment options available for this double-barreled insult. The aims of this review are to summarize current understanding of the bidirectional relationship between the CNS and the immune system when faced with a mechanical trauma combined with a concomitant infection, and to highlight key outstanding questions that remain in the field.

Improving Understanding and Outcomes of Traumatic Brain Injury Using Bidirectional Translational Research

Recent clinical trials in traumatic brain injury (TBI) have failed to demonstrate therapeutic effects even when there appears to be good evidence for efficacy in one or more appropriate pre-clinical models. While existing animal models mimic the injury, difficulties in translating promising therapeutics are exacerbated by the lack of alignment of discrete measures of the underlying injury pathology between the animal models and human subjects. To address this mismatch, we have incorporated reverse translation of bedside experience to inform pre-clinical studies in a large animal (pig) model of TBI that mirror practical clinical assessments. Cerebral autoregulation is impaired after TBI, contributing to poor outcome. Cerebral perfusion pressure (CPP) is often normalized by use of vasoactive agents to increase mean arterial pressure (MAP) and thereby limit impairment of cerebral autoregulation and neurological deficits. Vasoactive agents clinically used to elevate MAP to increase CPP after TBI, such as phenylephrine (Phe), dopamine (DA), norepinephrine (NE), and epinephrine (EPI), however, have not been compared sufficiently regarding effect on CPP, autoregulation, and survival after TBI, and clinically, current vasoactive agent use is variable. The cerebral effects of these clinically commonly used vasoactive agents are not known. This review will emphasize pediatric work and will describe bidirectional translational studies using a more human-like animal model of TBI to identify better therapeutic strategies to improve outcome post-injury. These studies in addition investigated the mechanism(s) involved in improvement of outcome in the setting of TBI.

Demographics, presentation, and clinical outcomes after traumatic bifrontal contusions: a systematic review

Traumatic bifrontal contusions (TBC) form a recognised clinical entity among patients with traumatic brain injury (TBI). This study aims to systematically review current literature on demographics, management, and predictors of outcomes of patients with TBC. A multi-database literature search (PubMed, Cochrane, OVID Medline/Embase) was performed using PRISMA as a search strategy. Studies were selected by predefined selection criteria (PROSPERO: CRD42018055390), and risk of bias was assessed using an adapted form of ROBINS-I tool. Of the 275 studies yielded by the literature search, seven articles met the criteria for inclusion, all of which were level III evidence. Total cohort consisted of 468 patients; predominantly male (n = 5; 303/417 patients) with average age 44.3 years (range, 7–81). Falls (44.9%) and road traffic accidents (46.6%) were the commonest mechanisms of injury with an average presentation GCS of 9.2 (n = 3, 119 patients). GCS on admission of ≤ 13.1 and contusion volume at day 2 post-injury of ≥ 62.9cm³ were associated with increased risk of deterioration needing surgical interventions (n = 1, 7 patients). The majority of patients underwent surgery; the average GOS was 4, at an average follow-up duration of 11.7 months (n = 6, 356 patients). The currently available evidence on the management of TBC is scarce. Larger multicentre well-designed studies are needed to further delineate the factors behind acute deterioration, the effectiveness of management options. Once in place, this can be used to develop and test an algorithmic approach to management of TBC resulting in consistently improved outcomes.

The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources

OBJECTIVE

The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources.

METHODS

The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma.

RESULTS

Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources.

CONCLUSION

Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.

A concomitant bone fracture delays cognitive recovery from traumatic brain injury

BACKGROUND

Brain injury progression after severe traumatic brain injury (TBI) is associated with worsening cerebral inflammation but it is unknown how a concomitant bone fracture (BF) affects this progression. Enoxaparin (ENX) decreases penumbral leukocyte mobilization after TBI and improves neurologic recovery. We hypothesized that a concomitant BF worsens learning/memory recovery weeks after TBI and that ENX improves this recovery.

METHODS

CD1 male mice underwent controlled cortical impact or sham craniotomy with or without tibial fracture, receiving either daily ENX (0.8 mg/kg) or saline for 14 days after injury. Randomization defined four groups (Sham, TBI only, TBI + Fx, TBI + Fx + ENX, n = 5/each). Body weight loss and neurologic recovery (Garcia Neurologic Test, max score = 18) were assessed each day. Mouse learning (swimming time [s] and total distance [m] to reach the submerged platform Days 14 to 17 after TBI) and memory (swimming time [s] in platform quadrant after platform removed [probe]) was assessed by the Morris water maze. Ly-6G (cerebral neutrophil sequestration) and glial fibrillary acidic protein were evaluated by immunohistochemistry in brain tissue post mortem. Analysis of variance with Tukey's post hoc test determined significance (p < 0.05).

RESULTS

A concurrent BF worsened Garcia Neurologic Test scores post-TBI Days 2 to 4 (p < 0.01) as compared with TBI only, and ENX reversed this worsening on Day 4 (p < 0.01). Learning was significantly slower (greater swimming time and distance) in TBI + Fx versus TBI only on Day 17 (p < 0.01). This was despite similar swimming velocities in both groups, indicating intact extremity motor function. Memory was similar in isolated TBI and Sham which was significantly better than in TBI + Fx animals (p < 0.05). Glial fibrillary acidic protein-positive cells in penumbral cortex were most prevalent in TBI + Fx animals, significantly greater than in Sham (p < 0.05).

CONCLUSION

A long BF accompanying TBI worsens early neurologic recovery and subsequent learning/memory. Enoxaparin may partially counter this and improve neurologic recovery.

Testosterone Administration after Traumatic Brain Injury Reduces Mitochondrial Dysfunction and Neurodegeneration

Traumatic brain injury (TBI) increases Ca²⁺ influx into neurons and desynchronizes mitochondrial function leading to energy depletion and apoptosis. This process may be influenced by brain testosterone (TS) levels, which are known to decrease after TBI. We hypothesized that a TS-based therapy could preserve mitochondrial neuroenergetics after TBI, thereby reducing neurodegeneration. C57BL/6J mice were submitted to sham treatment or severe parasagittal controlled cortical impact (CCI) and were subcutaneously injected with either vehicle (VEH-SHAM and VEH-CCI) or testosterone cypionate (15 mg/kg, TS-CCI) for 10 days. Cortical tissue homogenates ipsilateral to injury were used for neurochemical analysis. The VEH-CCI group displayed an increased Ca²⁺-induced mitochondrial swelling after the addition of metabolic substrates (pyruvate, malate, glutamate, succinate, and adenosine diphosphate [PMGSA]). The addition of Na⁺ stimulated mitochondrial Ca²⁺ extrusion through Na⁺/Ca²⁺/Li⁺ exchanger (NCLX) in VEH-SHAM and TS-CCI, but not in the VEH-CCI group. Reduction in Ca²⁺ efflux post-injury was associated with impaired mitochondrial membrane potential formation/dissipation, and decreased mitochondrial adenosine triphosphate (ATP)-synthase coupling efficiency. Corroborating evidence of mitochondrial uncoupling was observed with an increase in H₂O₂ production post-injury, but not in superoxide dismutase (SOD2) protein levels. TS administration significantly reduced these neuroenergetic alterations. At molecular level, TS prevented the increase in pTau^Ser396 and alpha-Spectrin fragmentation by the Ca²⁺dependent calpain-2 activation, and decreased both caspase-3 activation and Bax/BCL-2 ratio, which suggests a downregulation of mitochondrial apoptotic signals. Search Tool for the Retrieval of Interacting Genes/Proteins database provided two distinct gene/protein clusters, "upregulated and downregulated," interconnected through SOD2. Therefore, TS administration after a severe CCI improves the mitochondrial Ca²⁺extrusion through NCLX exchanger and ATP synthesis efficiency, ultimately downregulating the overexpression of molecular drivers of neurodegeneration.

Trends in demographics and outcome of patients presenting with traumatic brain injury

Objective

To analyze the trends in demographics and outcomes of patients presenting with traumatic brain injury by performing a retrospective database review of the Illinois Department of Public Health (IDPH) Trauma Registry.

Methods

We utilized the IDPH Trauma Registry to retrieve data on patients treated for traumatic brain injuries at our large, tertiary care hospital from 2004 to 2012, inclusive. From this data, logistic regression models were used to analyze and compare basic demographics such as age, sex, and clinical outcome.

Results

Three thousand and thirty-nine patients were analyzed with a mean age of 43 (standard deviation, 24) and a median age of 41 (interquartile range, 23 to 60). Over the study period, patients’ age increased steadily from 32 to 49 years. The percentage of female patients increased, from 16.4% to 27.5% over the last 4 years. Overall mortality was greater for males than females (22.1% vs. 17.3%; odds ratio [OR], 1.36; 95% confidence interval [CI], 1.10 to 1.68). Mortality decreased over the period (OR, 0.88; 95% CI, 0.85 to 0.91), with a greater decrease in females (OR, 0.84; 95% CI, 0.78 to 0.90) than in males (OR, 0.90; 95% CI, 0.86 to 0.94).

Conclusion

Although the age of patients presenting with traumatic brain injury is increasing substantially, the data suggests that overall mortality appears to be decreasing, and this decrease appears to be greater in females than in males. These changes in trends found in the IDPH Trauma Registry supports the importance for further analysis of other reliable public datasets to identify areas of future study.

Dutch Prospective Observational Study on Prehospital Treatment of Severe Traumatic Brain Injury: The BRAIN-PROTECT Study Protocol

Background: Severe traumatic brain injury (TBI) is associated with a high mortality rate and those that survive commonly have permanent disability. While there is a broad consensus that appropriate prehospital treatment is crucial for a favorable neurological outcome, evidence to support currently applied treatment strategies is scarce. In particular, the relationship between prehospital treatments and patient outcomes is unclear. The BRAIN-PROTECT study therefore aims to identify prehospital treatment strategies associated with beneficial or detrimental outcomes. Here, we present the study protocol. Study Protocol: BRAIN-PROTECT is the acronym for BRAin INjury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma. It is a prospective observational study on the prehospital treatment of patients with suspected severe TBI in the Netherlands. Prehospital epidemiology, interventions, medication strategies, and nonmedical factors that may affect outcome are studied. Multivariable regression based modeling will be used to identify confounder-adjusted relationships between these factors and patient outcomes, including mortality at 30 days (primary outcome) or mortality and functional neurological outcome at 1 year (secondary outcomes). Patients in whom severe TBI is suspected during prehospital treatment (Glasgow Coma Scale score ≤ 8 in combination with a trauma mechanism or clinical findings suggestive of head injury) are identified by all four helicopter emergency medical services (HEMS) in the Netherlands. Patients are prospectively followed up in 9 participating trauma centers for up to one year. The manuscript reports in detail the objectives, setting, study design, patient inclusion, and data collection process. Ethical and juridical aspects, statistical considerations, as well as limitations of the study design are discussed. Discussion: Current prehospital treatment of patients with suspected severe TBI is based on marginal evidence, and optimal treatment is basically unknown. The BRAIN-PROTECT study provides an opportunity to evaluate and compare different treatment strategies with respect to patient outcomes. To our knowledge, this study project is the first large-scale prospective prehospital registry of patients with severe TBI that also collects long-term follow-up data and may provide the best available evidence at this time to give useful insights on how prehospital care can be improved.

Development of a quality indicator set to measure and improve quality of ICU care for patients with traumatic brain injury

Background

We aimed to develop a set of quality indicators for patients with traumatic brain injury (TBI) in intensive care units (ICUs) across Europe and to explore barriers and facilitators for implementation of these quality indicators.

Methods

A preliminary list of 66 quality indicators was developed, based on current guidelines, existing practice variation, and clinical expertise in TBI management at the ICU. Eight TBI experts of the Advisory Committee preselected the quality indicators during a first Delphi round. A larger Europe-wide expert panel was recruited for the next two Delphi rounds. Quality indicator definitions were evaluated on four criteria: validity (better performance on the indicator reflects better processes of care and leads to better patient outcome), feasibility (data are available or easy to obtain), discriminability (variability in clinical practice), and actionability (professionals can act based on the indicator). Experts scored indicators on a 5-point Likert scale delivered by an electronic survey tool.

Results

The expert panel consisted of 50 experts from 18 countries across Europe, mostly intensivists (N = 24, 48%) and neurosurgeons (N = 7, 14%). Experts agreed on a final set of 42 indicators to assess quality of ICU care: 17 structure indicators, 16 process indicators, and 9 outcome indicators. Experts are motivated to implement this finally proposed set (N = 49, 98%) and indicated routine measurement in registries (N = 41, 82%), benchmarking (N = 42, 84%), and quality improvement programs (N = 41, 82%) as future steps. Administrative burden was indicated as the most important barrier for implementation of the indicator set (N = 48, 98%).

Conclusions

This Delphi consensus study gives insight in which quality indicators have the potential to improve quality of TBI care at European ICUs. The proposed quality indicator set is recommended to be used across Europe for registry purposes to gain insight in current ICU practices and outcomes of patients with TBI. This indicator set may become an important tool to support benchmarking and quality improvement programs for patients with TBI in the future.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2377-x) contains supplementary material, which is available to authorized users.

Use of Hematocrit for Short-Term Prognosis of Patients with Traumatic Brain Injury After Decompressive Craniectomy

OBJECTIVE

To discuss the effects of the hematocrit (Hct) in patients with traumatic brain injury after decompressive craniectomy (DC).

METHODS

Demographic data, inspection and treatment procedures, and 30-day prognosis were obtained for 158 patients with head injury who underwent unilateral DC in our hospital between January 2013 and June 2018. Uni- and multivariate logistic regression was applied to analyze independent risk factors for 30-day outcome. The quantitative analysis of postoperative Hct, ΔHct (postoperative Hct minus initial Hct), and their combination for the prognosis of patients with TBI was displayed graphically using receiver operating characteristic (ROC) curves. Multiple linear regression was used to explore factors influencing postoperative Hct and ΔHct.

RESULTS

Short-term mortality was 29.7%. Uni- and multivariate logistic regression analysis showed that age (odds ratio [OR], 1.064; P = 0.024), Glasgow Coma Scale score (OR, 0.711; P = 0.027), Injury Severity Score (ISS) (OR, 1.156; P = 0.047), midline shift in millimeters (OR, 1.809; P <0.001), postoperative Hct (OR, 0.743; P = 0.001), and ΔHct (OR, 1.242; P =0.048) were independent risk factors for short-term death. In ROC curves, a combination of postoperative Hct and ΔHct showed the highest sensitivity (77.5%) and highest specificity (89.4%). When using this combination to predict prognosis, we could achieve an accuracy of 94.5%. ISS (β = -0.172, P = 0.022), initial Hct (β = 0.243, P = 0.001), principal hematoma location (β = -2.628, P < 0.001), hours of operation (β = -0.884, P = 0.048), and colloid quantity (β = -0.002, P = 0.001) were independent contributing factors for ΔHct, which was similar to postoperative Hct.

CONCLUSIONS

A combination of postoperative Hct and ΔHct could better predict short-term survival of patients with TBI. Developing an appropriate treatment strategy to increase postoperative Hct and reduce the ΔHct may be good for the short-term prognosis of patients with TBI after DC.

A Detailed Overview of Long-Term Outcomes in Severe Traumatic Brain Injury Eight Years Post-injury

Background and aims: Severe traumatic brain injury is a leading cause of acquired persistent disabilities, and represents an important health and economic burden. However, the determinants of long-term outcome have rarely been systematically studied in a prospective longitudinal study of a homogeneous group of patients suffering exclusively from severe TBI

Methods: Prospective observational study of an inception cohort of adult patients with severe traumatic brain injury in the Parisian area (PariS-TBI). Outcome was assessed with face-to-face interview 8 years after Traumatic Brain Injury, focusing on impairments, activity limitations, and participation restriction.

Results: Five hundred and four patients were included between 2005 and 2007. At 8-year follow-up, 261 patients were deceased, 128 were lost to follow-up, 22 refused to participate, and 86 were finally evaluated. Age, gender, initial injury severity did not significantly differ between evaluated patients and lost to follow-up, but the latter were more frequently students or unemployed. Mean age was 41.9 (SD 13.6), 79% were male, median initial Glasgow Coma Scale Score was 6. The most frequent somatic complaints concerned balance (47.5%), motricity (31%), and headaches (36%), but these were less frequent than cognitive complaints (Memory 71%, Slowness 68%, Concentration 67%). According to the Hospital Anxiety and Depression Scale (HADS), 25 % had a score >8 for anxiety and 23.7% for depression. According to the Extended Glasgow Outcome Scale, 19.8% remained severely disabled, 46.5% moderately disabled, 33.7% had a good recovery. Older age, longer education duration, lower functional status upon intensive care discharge, and more severe 8-year dysexecutive problems were significantly associated with a lower Extended Glasgow Outcome Scale score in multivariable analysis. At 8 years, 48.7% of patients were employed in a productive job. Of those, 38% declared a salary loss since traumatic brain injury. Unemployment was significantly associated with lower 1-year GOSE score and more severe 8-year dysexecutive problems.

Conclusions: These results from an inception cohort study highlight the fact that long-term outcome after severe TBI is determined by a complex combination of injury-related, demographic and neuropsychological factors. Long after the injury, persisting impairments still interfere with social integration, and participation.

Traumatic brain injury in China

China has more patients with traumatic brain injury (TBI) than most other countries in the world, making this condition a major public health concern. Population-based mortality of TBI in China is estimated to be approximately 13 cases per 100 000 people, which is similar to the rates reported in other countries. The implementation of various measures, such as safety legislation for road traffic, establishment of specialised neurosurgical intensive care units, and the development of evidence-based guidelines, have contributed to advancing prevention and care of patients with TBI in China. However, many challenges remain, which are augmented further by regional differences in TBI care. High-level care, such as intracranial pressure monitoring, is not universally available yet. In the past 30 years, the quality of TBI research in China has substantially improved, as evidenced by an increasing number of clinical trials done. The large number of patients with TBI and specialised trauma centres offer unique opportunities for TBI research in China. Furthermore, the formation and development of research collaborations between China and international groups are considered essential to advancing the quality of TBI care and research in China, and to improve quality of life in patients with this condition.

Post-traumatic stress disorder and self-reported outcomes after traumatic brain injury in victims of assault

Introduction

Assault is the third most common cause of traumatic brain injury (TBI), after falls and road traffic collisions. TBI can lead to multiple long-term physical, cognitive and emotional sequelae, including post-traumatic stress disorder (PTSD). Intentional violence may further compound the psychological trauma of the event, in a way that conventional outcome measures, like the Glasgow Outcome Scale (GOS), fail to capture. This study aims to examine the influence of assault on self-reported outcomes, including quality of life and symptoms of PTSD.

Methods

Questionnaire were completed by 256 patients attending a TBI clinic, including Quality of Life after Brain Injury (QOLIBRI) and PTSD checklist (PCL-C). Medical records provided demographics, clinical data and aetiology of injury. Subjective outcomes were compared between assault and other causes.

Results

Of 202 patients analysed, 21% sustained TBI from assault. There was no difference in severity of injuries between assault and non-assault groups. No relationship was found between self-reported outcomes and TBI severity or GOS. The assault group scored worse in all self-reported questionnaires, with statistically significant differences for measures of PTSD and post-concussion symptoms. However, using threshold scores, the prevalence of PTSD in assaulted patients was not higher than non-assault. After adjusting for age, ethnicity and the presence of extra-cranial trauma, assault did not have a significant effect on questionnaire scores. Exploratory analysis showed that assault and road traffic accidents were associated with significantly worse outcomes compared to falls.

Conclusion

Quality of life is significantly related to functional and psychological outcomes after TBI. Assaulted patients suffer from worse self-reported outcomes than other patients, but these differences were insignificant when adjusted for demographic factors. Intentionality behind the traumatic event is likely more important than cause alone. Differences in quality of life and other self-reported outcomes are not reflected by the Glasgow Outcome Scale. This information is useful in arranging earlier and targeted review and support.

Enduring Neuroprotective Effect of Subacute Neural Stem Cell Transplantation After Penetrating TBI

Traumatic brain injury (TBI) is the largest cause of death and disability of persons under 45 years old, worldwide. Independent of the distribution, outcomes such as disability are associated with huge societal costs. The heterogeneity of TBI and its complicated biological response have helped clarify the limitations of current pharmacological approaches to TBI management. Five decades of effort have made some strides in reducing TBI mortality but little progress has been made to mitigate TBI-induced disability. Lessons learned from the failure of numerous randomized clinical trials and the inability to scale up results from single center clinical trials with neuroprotective agents led to the formation of organizations such as the Neurological Emergencies Treatment Trials (NETT) Network, and international collaborative comparative effectiveness research (CER) to re-orient TBI clinical research. With initiatives such as TRACK-TBI, generating rich and comprehensive human datasets with demographic, clinical, genomic, proteomic, imaging, and detailed outcome data across multiple time points has become the focus of the field in the United States (US). In addition, government institutions such as the US Department of Defense are investing in groups such as Operation Brain Trauma Therapy (OBTT), a multicenter, pre-clinical drug-screening consortium to address the barriers in translation. The consensus from such efforts including “The Lancet Neurology Commission” and current literature is that unmitigated cell death processes, incomplete debris clearance, aberrant neurotoxic immune, and glia cell response induce progressive tissue loss and spatiotemporal magnification of primary TBI. Our analysis suggests that the focus of neuroprotection research needs to shift from protecting dying and injured neurons at acute time points to modulating the aberrant glial response in sub-acute and chronic time points. One unexpected agent with neuroprotective properties that shows promise is transplantation of neural stem cells. In this review we present (i) a short survey of TBI epidemiology and summary of current care, (ii) findings of past neuroprotective clinical trials and possible reasons for failure based upon insights from human and preclinical TBI pathophysiology studies, including our group's inflammation-centered approach, (iii) the unmet need of TBI and unproven treatments and lastly, (iv) present evidence to support the rationale for sub-acute neural stem cell therapy to mediate enduring neuroprotection.

Pioglitazone Therapy and Fractures: Systematic Review and Meta- Analysis

INTRODUCTION

Thiazolidinediones are a group of synthetic medications used in type 2 diabetes treatment. Among available thiazolidinediones, pioglitazone is gaining increased attention due to its lower cardiovascular risk in type 2 diabetes mellitus sufferers and seems a promising future therapy. Accumulating evidence suggests that diabetic patients may exert bone fractures due to such treatments. Simultaneously, the female population is thought to be at greater risk. Still, the safety outcomes of pioglitazone treatment especially in terms of fractures are questionable and need to be clarified.

METHODS

We searched MEDLINE, Scopus, PsyInfo, eLIBRARY.ru electronic databases and clinical trial registries for studies reporting an association between pioglitazone and bone fractures in type 2 diabetes mellitus patients published before Feb 15, 2016. Among 1536 sources that were initially identified, six studies including 3172 patients proved relevant for further analysis.

RESULT

Pooled analysis of the included studies demonstrated that after treatment with pioglitazone patients with type 2 diabetes mellitus had no significant increase in fracture risk [odds ratio (OR): 1.18, 95% confidence interval (CI): 0.82 to 1.71, p=0.38] compared to other antidiabetic drugs or placebo. Additionally, no association was found between the risk of fractures and pioglitazone therapy duration. The gender of the patients involved was not relevant to the risk of fractures, too.

CONCLUSION

Pioglitazone treatment in diabetic patients does not increase the incidence of bone fractures. Moreover, there is no significant association between patients' fractures, their gender and the period of exposure to pioglitazone. Additional longitudinal studies need to be undertaken to obtain more detailed information on bone fragility and pioglitazone therapy.

The Role of Transcranial Doppler in Traumatic Brain Injury: A Systemic Review and Meta-Analysis

To evaluate whether transcranial Doppler (TCD) monitoring plays a role as a prognostic indicator, by being both a diagnostic as well as a monitoring tool for increased intracranial pressure and cerebral vasospasm (VSP), in traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to the present. Randomized control trials, case–control studies, and prospective cohort studies on TCD in TBI (>18 years old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and Extended GCOS and mortality. Data were extracted to Review Manager Software. Twenty-five articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI with abnormal TCD (mean flow velocity [MFV] >120 cm/sec or MFV <35 cm/sec and Pulsatility Index >1.2) have a >3-fold higher likelihood of having poor clinical outcome in comparison to patients with TBI and normal TCD monitoring (odds ratio [OR]: 3.87; 95% confidence interval [CI]: 2.97–5.04; P < 0.00001). Subgroup analysis revealed that abnormal TCD has a 9-fold higher likelihood of mortality (OR: 9.96; 95% CI: 4.41–22.47; P < 0.00001). Further, subgroup analysis based on TCD findings revealed that the presence of hypoperfusion on TCD (middle cerebral artery [MCA] <35 cm/s) is associated with a three-fold higher likelihood of having poor functional outcome (OR: 3.72; 95% CI: 1.97–7.0; P < 0.0001). The presence of VSP (MCA >120 cm/s) is associated with three-fold higher likelihood of poor functional outcome (OR: 3.64; 95% CI: 1.55–8.52; P = 0.003). TCD is an evolving diagnostic tool that might play a role in determining the prognosis of patients with TBI. Further prospective study is needed to prove the role of TCD in TBI.

Xyloketal derivative C53N protects against mild traumatic brain injury in mice

Purpose

Mild traumatic brain injury (mTBI), the most common type of TBI, can result in prolonged cognitive impairment, mood disorders, and behavioral problems. Reducing oxidative stress and inflammation can rescue the neurons from mTBI-induced cell death. Xyloketal B, a natural product from mangrove fungus, has shown good antioxidative and neuroprotective effects in several disease models. Here, we investigated the potential protection afforded by a xyloketal derivative, C53N, in a closed-skull mTBI model.

Materials and methods

Skulls of mice were thinned to 20–30 µm thickness, following which they were subjected to a slight compression injury to induce mTBI. One hour after TBI, mice were intraperitoneally injected with C53N, which was solubilized in 0.5% dimethyl sulfoxide in saline. In vivo two-photon laser scanning microscopy was used to image cell death in injured parenchyma in each mouse over a 12-hour period (at 1, 3, 6, and 12 hours). Water content and oxidation index, together with pathological analysis of glial reactivity, were assessed at 24 hours to determine the effect of C53N on mTBI.

Results

Cell death, oxidative stress, and glial reactivity increased in mTBI mice compared with sham-injured mice. Treatment with 40 or 100 mg/kg C53N 1 hour after mTBI significantly attenuated oxidative stress and glial reactivity and reduced parenchymal cell death at the acute phase after mTBI.

Conclusion

The present study highlights the therapeutic potential of the xyloketal derivative C53N for pharmacological intervention in mTBI.

Exploring Pharmacological Mechanisms of Xuefu Zhuyu Decoction in the Treatment of Traumatic Brain Injury via a Network Pharmacology Approach

Objectives

Xuefu Zhuyu decoction (XFZYD), a traditional Chinese medicine (TCM) formula, has been demonstrated to be effective for the treatment of traumatic brain injury (TBI). However, the underlying pharmacological mechanisms remain unclear. This study aims to explore the potential action mechanisms of XFZYD in the treatment of TBI and to elucidate the combination principle of this herbal formula.

Methods

A network pharmacology approach including ADME (absorption, distribution, metabolism, and excretion) evaluation, target prediction, known therapeutic targets collection, network construction, and molecule docking was used in this study.

Results

A total of 119 bioactive ingredients from XFZYD were predicted to act on 47 TBI associated specific proteins which intervened in several crucial pathological processes including apoptosis, inflammation, antioxidant, and axon genesis. Almost each of the bioactive ingredients targeted more than one protein. The molecular docking simulation showed that 91 pairs of chemical components and candidate targets had strong binding efficiencies. The “Jun”, “Chen”, and “Zuo-Shi” herbs from XFZYD triggered their specific targets regulation, respectively.

Conclusion

Our work successfully illuminates the “multicompounds, multitargets” therapeutic action of XFZYD in the treatment of TBI by network pharmacology with molecule docking method. The present work may provide valuable evidence for further clinical application of XFZYD as therapeutic strategy for TBI treatment.