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Conti F, McCue JJ, DiTuro P, Galpin AJ, Wood TR. Mitigating Traumatic Brain Injury: A Narrative Review of Supplementation and Dietary Protocols. Nutrients 2024; 16:2430. [PMID: 39125311 PMCID: PMC11314487 DOI: 10.3390/nu16152430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/18/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Traumatic brain injuries (TBIs) constitute a significant public health issue and a major source of disability and death in the United States and worldwide. TBIs are strongly associated with high morbidity and mortality rates, resulting in a host of negative health outcomes and long-term complications and placing a heavy financial burden on healthcare systems. One promising avenue for the prevention and treatment of brain injuries is the design of TBI-specific supplementation and dietary protocols centred around nutraceuticals and biochemical compounds whose mechanisms of action have been shown to interfere with, and potentially alleviate, some of the neurophysiological processes triggered by TBI. For example, evidence suggests that creatine monohydrate and omega-3 fatty acids (DHA and EPA) help decrease inflammation, reduce neural damage and maintain adequate energy supply to the brain following injury. Similarly, melatonin supplementation may improve some of the sleep disturbances often experienced post-TBI. The scope of this narrative review is to summarise the available literature on the neuroprotective effects of selected nutrients in the context of TBI-related outcomes and provide an evidence-based overview of supplementation and dietary protocols that may be considered in individuals affected by-or at high risk for-concussion and more severe head traumas. Prophylactic and/or therapeutic compounds under investigation include creatine monohydrate, omega-3 fatty acids, BCAAs, riboflavin, choline, magnesium, berry anthocyanins, Boswellia serrata, enzogenol, N-Acetylcysteine and melatonin. Results from this analysis are also placed in the context of assessing and addressing important health-related and physiological parameters in the peri-impact period such as premorbid nutrient and metabolic health status, blood glucose regulation and thermoregulation following injury, caffeine consumption and sleep behaviours. As clinical evidence in this research field is rapidly emerging, a comprehensive approach including appropriate nutritional interventions has the potential to mitigate some of the physical, neurological, and emotional damage inflicted by TBIs, promote timely and effective recovery, and inform policymakers in the development of prevention strategies.
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Affiliation(s)
- Federica Conti
- School of Physics, University of Sydney, Sydney, NSW 2050, Australia;
| | - Jackson J. McCue
- School of Medicine, University of Washington, Seattle, WA 98195, USA;
| | - Paul DiTuro
- Department of Exercise Science, University of South Carolina, Columbia, SC 29208, USA
| | - Andrew J. Galpin
- Center for Sport Performance, California State University, Fullerton, CA 92831, USA;
| | - Thomas R. Wood
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
- Institute for Human and Machine Cognition, Pensacola, FL 32502, USA
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Kaurani P, Moreira de Marchi Apolaro AV, Kunchala K, Maini S, Rges HAF, Isaac A, Lakkimsetti M, Raake M, Nazir Z. Advances in Neurorehabilitation: Strategies and Outcomes for Traumatic Brain Injury Recovery. Cureus 2024; 16:e62242. [PMID: 39006616 PMCID: PMC11244718 DOI: 10.7759/cureus.62242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 07/16/2024] Open
Abstract
Traumatic brain injury (TBI) consists of an external physical force that causes brain function impairment or pathology and globally affects 50 million people each year, with a cost of 400 billion US dollars. Clinical presentation of TBI can occur in many forms, and patients usually require prolonged hospital care and lifelong rehabilitation, which leads to an impact on the quality of life. For this narrative review, no particular method was used to extract data. With the aid of health descriptors and Medical Subject Heading (MeSH) terms, a search was thoroughly conducted in databases such as PubMed and Google Scholar. After the application of exclusion and inclusion criteria, a total of 146 articles were effectively used for this review. Results indicate that rehabilitation after TBI happens through neuroplasticity, which combines neural regeneration and functional reorganization. The role of technology, including artificial intelligence, virtual reality, robotics, computer interface, and neuromodulation, is to impact rehabilitation and life quality improvement significantly. Pharmacological intervention, however, did not result in any benefit when compared to standard care and still needs further research. It is possible to conclude that, given the high and diverse degree of disability associated with TBI, rehabilitation interventions should be precocious and tailored according to the individual's needs in order to achieve the best possible results. An interdisciplinary patient-centered care health team and well-oriented family members should be involved in every stage. Lastly, strategies must be adequate, well-planned, and communicated to patients and caregivers to attain higher functional outcomes.
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Affiliation(s)
- Purvi Kaurani
- Neurology, DY Patil University School of Medicine, Navi Mumbai , IND
| | | | - Keerthi Kunchala
- Internal Medicine, Sri Venkateswara Medical College, Tirupati, IND
| | - Shriya Maini
- Medicine and Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Huda A F Rges
- Mental Health, National Authority for Mental Health and Psychosocial Support, Benghazi, LBY
| | - Ashley Isaac
- General Medicine, Isra University Hospital, Hyderabad, PAK
| | | | | | - Zahra Nazir
- Internal Medicine, Combined Military Hospital, Quetta, PAK
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Yakhkind A, Niznick N, Bodien YG, Hammond FM, Katz D, Luaute J, McNett M, Naccache L, O'Brien K, Schnakers C, Sharshar T, Slomine BS, Giacino JT. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Behavioral Phenotyping. Neurocrit Care 2024; 40:909-917. [PMID: 37726548 DOI: 10.1007/s12028-023-01844-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND The recent publication of practice guidelines for management of patients with disorders of consciousness (DoC) in the United States and Europe was a major step forward in improving the accuracy and consistency of terminology, diagnostic criteria, and prognostication in this population. There remains a pressing need for a more precise brain injury classification system that combines clinical semiology with neuroimaging, electrophysiologic, and other biomarker data. To address this need, the National Institute of Neurological Disorders and Stroke launched the Common Data Elements (CDEs) initiative to facilitate systematic collection of high-quality research data in studies involving patients with neurological disease. The Neurocritical Care Society's Curing Coma Campaign expanded this effort in 2018 to develop CDEs for DoC. Herein, we present CDE recommendations for behavioral phenotyping of patients with DoC. METHODS The Behavioral Phenotyping Workgroup used a preestablished, five-step process to identify and select candidate CDEs that included review of existing National Institute of Neurological Disorders and Stroke CDEs, nomination and systematic vetting of new CDEs, CDE classification, iterative review, and approval of panel recommendations and development of corresponding case review forms. RESULTS We identified a slate of existing and newly proposed basic, supplemental, and exploratory CDEs that can be used for behavioral phenotyping of adult and pediatric patients with DoC. CONCLUSIONS The proposed behavioral phenotyping CDEs will assist with international harmonization of DoC studies and allow for more precise characterization of study cohorts, favorably impacting observational studies and clinical trials aimed at improving outcome in this population.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology, Tufts University School of Medicine, Boston, MA, USA
| | - Naomi Niznick
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, Canada
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas Katz
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, and Brain Injury Program, Encompass Health Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Jacques Luaute
- Department of Neuro-Rehabilitation, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Lionel Naccache
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau, ICM, INSERM, CNRS, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Katherine O'Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - Tarek Sharshar
- Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris, France
| | - Beth S Slomine
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA.
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.
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P A, Rengarajan S, Venkatachalam S, Pattabi S, Jones S, K P, Krishna V, Prasanth K. Neuroprotection by Cerebrolysin and Citicoline Through the Upregulation of Brain-Derived Neurotrophic Factor (BDNF) Expression in the Affected Neural Cells: A Preliminary Clue Obtained Through an In Vitro Study. Cureus 2024; 16:e54665. [PMID: 38524067 PMCID: PMC10960614 DOI: 10.7759/cureus.54665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVES Citicoline and cerebrolysin are two unique yet contentious medications because of inconsistencies in efficacy as well as the mystery surrounding their mode of action. The current study aimed to re-validate the neuroprotective benefits of these medications and investigate the possible molecular mechanism. METHODS Neuro-2A cells were exposed to tert-butyl hydroperoxide, a consistent in vitro model of neuronal damage caused by oxidative stress. The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, acridine orange/ethidium bromide (AO-EtBr) staining, and phase-view examinations were utilized to evaluate cell survival and cytotoxicity. Real-time reverse transcription-polymerase chain reaction (RT-PCR)-based gene expression studies were conducted. KEY FINDING Observations revealed that these two medications had modest but considerable neuroprotective effects. While the majority of the genes' expressions remained unchanged, cerebrolysin upregulated Neuregulin 1, and both upregulated brain-derived neurotrophic factor (BDNF) expression. CONCLUSION The findings of the current study may be the first to suggest that citicoline and cerebrolysin may increase host cells' defense mechanisms (secretion neurotrophic factors) rather than carrying nutrients for cell survival. Because of its simplicity, the current study can readily be repeated to learn more about these two disputed medications for treating ischemic stroke.
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Affiliation(s)
- Anandan P
- Department of General Medicine, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
| | - Santhanam Rengarajan
- Department of Neurosurgery, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
| | - Sankar Venkatachalam
- Department of Anatomy, Dr. A.L.M. PG Institute of Basic Medical Sciences, University of Madras, Chennai, IND
| | - Sasikumar Pattabi
- Department of Surgery, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
| | - Sumathi Jones
- Department of Pharmacology and Therapeutics, Sree Balaji Dental College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
| | - Prabhu K
- Department of Anatomy, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
| | - Vani Krishna
- Department of Anatomy, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
| | - Krishna Prasanth
- Department of Community Medicine, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, IND
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Gareri P, Cotroneo AM, Montella R, Gaglianone M, Putignano S. Citicoline: A Cholinergic Precursor with a Pivotal Role in Dementia and Alzheimer's Disease. J Alzheimers Dis 2024; 100:725-733. [PMID: 38905051 PMCID: PMC11307077 DOI: 10.3233/jad-240497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
Background Citicoline is a naturally occurring compound with pleiotropic effects on neuronal function and cognitive processes. Objective Based on previous studies, which shed light on the positive effects of citicoline 1 g when combined with acetylcholinesterase inhibitors (AChEIs) and/or memantine, we further investigated the benefits of citicoline in combination therapy in Alzheimer's disease and mixed dementia. Methods We integrated the datasets of CITIMEM and CITIDEMAGE, increasing the overall sample size to enhance statistical power. We analyzed data from these two investigator-initiated studies involving 295 patients. The primary outcome was the assessment over time of the effects of combined treatment versus memantine given alone or AChEI plus memantine on cognitive functions assessed by Mini-Mental State Examination (MMSE). The secondary outcomes were the influence of combined treatment on daily life functions, mood, and behavioral symptoms assessed by activities of daily life (ADL) and instrumental ADL, Geriatric Depression Scale, and Neuropsychiatric Inventory Scale. One-hundred-forty-three patients were treated with memantine and/or AChEI (control group), and 152 patients were treated with memantine and/or AChEI plus citicoline 1 g/day orally (Citicoline group). Results A significant difference in MMSE score was found in the average between the two groups of treatment at 6 and 12 months. Conclusions This study confirmed the effectiveness of combined citicoline treatment in patients with mixed dementia and Alzheimer's disease, with a significant effect on the increase of MMSE score over time. The treated group also showed a significant reduction in the Geriatric Depression Scale and a significant increase in the instrumental ADL scale.
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Affiliation(s)
- Pietro Gareri
- Unit of Frailty, Center of Cognitive Impairment and Dementia, Catanzaro Lido, ASP Catanzaro, Catanzaro Lido, Italy
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Shavlovskaya OA. [Recognan (citicoline) in the correction of asthenic and anxiety-depressive disorders]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:43-47. [PMID: 39072565 DOI: 10.17116/jnevro202412406143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
The article reflects the results of a number of studies that demonstrate the therapeutic effectiveness of Recognan (citicoline) in anxiety-depressive and asthenic disorders against the background of somatic and neurological diseases, in the correction of post-stroke depression. Recent experimental animal studies prove the effect of citicoline on anxiety and depression. In the complex effect, Recognan potentiates the main pharmacological effect of antidepressants and anxiolytics. In some studies, a dose-dependent change in animal behavior has been observed in response to the analgesic and antidepressant effects of citicoline. The effectiveness of citicoline in combination with transcranial direct current stimulation in the treatment of depression has been shown. The analysis of these research materials allows us to recommend Recognan in the complex therapy of asthenic and anxiety-depressive disorders in response to such pathological conditions as anxiety, asthenia, depression.
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Affiliation(s)
- O A Shavlovskaya
- International University of Restorative Medicine, Moscow, Russia
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Wang CY, Wu JC, Kuo YH. Response to Folweiler KA et al., Unsupervised Machine Learning Reveals Novel Traumatic Brain Injury Patient Phenotypes With Distinct Acute Injury Profiles and Long-Term Outcomes (DOI: 10.1089/neu.2019.6705). J Neurotrauma 2024; 41:292-293. [PMID: 37756375 DOI: 10.1089/neu.2023.0396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Affiliation(s)
- Ching-Ying Wang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsuan Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Gusdon AM, Savarraj JPJ, Redell JB, Paz A, Hinds S, Burkett A, Torres G, Ren X, Badjatia N, Hergenroeder GW, Moore AN, Choi HA, Dash PK. Lysophospholipids Are Associated With Outcomes in Hospitalized Patients With Mild Traumatic Brain Injury. J Neurotrauma 2024; 41:59-72. [PMID: 37551969 PMCID: PMC11071087 DOI: 10.1089/neu.2023.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
Mild traumatic brain injury (mTBI) accounts for 70-90% of all TBI cases. Lipid metabolites have important roles in plasma membrane biogenesis, function, and cell signaling. As TBI can compromise plasma membrane integrity and alter brain cell function, we sought to identify circulating phospholipid alterations after mTBI, and determine if these changes were associated with clinical outcomes. Patients with mTBI (Glasgow Coma Score [GCS] ≥13 and loss of consciousness <30 min) were recruited. A total of 84 mTBI subjects were enrolled after admission to a level I trauma center, with the majority having evidence of traumatic intracranial hemorrhage on brain computed tomography (CT). Plasma samples were collected within 24 h of injury with 32 mTBI subjects returning at 3 months after injury for a second plasma sample to be collected. Thirty-five healthy volunteers were enrolled as controls and had a one-time blood draw. Lipid metabolomics was performed on plasma samples from each subject. Fold change of selected lipid metabolites was determined. Multivariable regression models were created to test associations between lipid metabolites and discharge and 6-month Glasgow Outcomes Scale-Extended (GOSE) outcomes (dichotomized between "good" [GOSE ≥7] and "bad" [GOSE ≤6] functional outcomes). Plasma levels of 31 lipid metabolites were significantly associated with discharge GOSE using univariate models; three of these metabolites were significantly increased, while 14 were significantly decreased in subjects with good outcomes compared with subjects with poor outcomes. In multivariable logistic regression models, higher circulating levels of the lysophospholipids (LPL) 1-linoleoyl-glycerophosphocholine (GPC) (18:2), 1-linoleoyl-GPE (18:2), and 1-linolenoyl-GPC (18:3) were associated with both good discharge GOSE (odds ratio [OR] 12.2 [95% CI 3.35, 58.3], p = 5.23 × 10-4; OR 9.43 [95% CI 2.87, 39.6], p = 7.26 × 10-4; and OR 5.26 [95% CI 1.99, 16.7], p = 2.04 × 10-3, respectively) and 6-month (OR 4.67 [95% CI 1.49, 17.7], p = 0.013; OR 2.93 [95% CI 1.11, 8.87], p = 0.039; and OR 2.57 [95% CI 1.08, 7.11], p = 0.046, respectively). Compared with healthy volunteers, circulating levels of these three LPLs were decreased early after injury and had normalized by 3 months after injury. Logistic regression models to predict functional outcomes were created by adding each of the described three LPLs to a baseline model that included age and sex. Including 1-linoleoyl-GPC (18:2) (8.20% improvement, p = 0.009), 1-linoleoyl-GPE (18:2) (8.85% improvement, p = 0.021), or 1-linolenoyl-GPC (18:3) (7.68% improvement, p = 0.012), significantly improved the area under the curve (AUC) for predicting discharge outcomes compared with the baseline model. Models including 1-linoleoyl-GPC (18:2) significantly improved AUC for predicting 6-month outcomes (9.35% improvement, p = 0.034). Models including principal components derived from 25 LPLs significantly improved AUC for prediction of 6-month outcomes (16.0% improvement, p = 0.020). Our results demonstrate that higher plasma levels of LPLs (1-linoleoyl-GPC, 1-linoleoyl-GPE, and 1-linolenoyl-GPC) after mTBI are associated with better functional outcomes at discharge and 6 months after injury. This class of phospholipids may represent a potential therapeutic target.
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Affiliation(s)
- Aaron M. Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Jude PJ Savarraj
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - John B. Redell
- Department of Neurobiology and Anatomy, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Atzhiry Paz
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Sarah Hinds
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Angela Burkett
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Glenda Torres
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Xuefang Ren
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Georgene W. Hergenroeder
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Anthony N. Moore
- Department of Neurobiology and Anatomy, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - H. Alex Choi
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Pramod K. Dash
- Department of Neurobiology and Anatomy, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas, USA
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Diaz-Arrastia R, Kochanek PM. Pharmacotherapy for Traumatic Brain Injury: The Next Generation of Clinical Trials. Neurotherapeutics 2023; 20:1428-1432. [PMID: 37698808 PMCID: PMC10684833 DOI: 10.1007/s13311-023-01438-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Affiliation(s)
- Ramon Diaz-Arrastia
- Traumatic Brain Injury Clinical Research Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA.
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Walter J, Mende J, Hutagalung S, Alhalabi OT, Grutza M, Zheng G, Skutella T, Unterberg A, Zweckberger K, Younsi A. The Single-Dose Application of Interleukin-4 Ameliorates Secondary Brain Damage in the Early Phase after Moderate Experimental Traumatic Brain Injury in Mice. Int J Mol Sci 2023; 24:12756. [PMID: 37628939 PMCID: PMC10454634 DOI: 10.3390/ijms241612756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Activation of the interleukin-4 (IL-4) pathway ameliorates secondary injury mechanisms after experimental traumatic brain injury (TBI); therefore, we assessed the effect of a therapeutic IL-4 administration on secondary brain damage after experimental TBI. We subjected 100 C57/Bl6 wildtype mice to controlled cortical impact (CCI) and administered IL-4 or a placebo control subcutaneously 15 min thereafter. Contusion volume (Nissl staining), neurological function (hole board, video open field, and CatWalkXT®), and the immune response (immunofluorescent staining) were analyzed up to 28 days post injury (dpi). Contusion volumes were significantly reduced after IL-4 treatment up to 14 dpi (e.g., 6.47 ± 0.41 mm3 vs. 3.80 ± 0.85 mm3, p = 0.011 3 dpi). Macrophage invasion and microglial response were significantly attenuated in the IL-4 group in the acute phase after CCI (e.g., 1.79 ± 0.15 Iba-1+/CD86+ cells/sROI vs. 1.06 ± 0.21 Iba-1/CD86+ cells/sROI, p = 0.030 in the penumbra 3 dpi), whereas we observed an increased neuroinflammation thereafter (e.g., mean GFAP intensity of 3296.04 ± 354.21 U vs. 6408.65 ± 999.54 U, p = 0.026 in the ipsilateral hippocampus 7 dpi). In terms of functional outcome, several gait parameters were improved in the acute phase following IL-4 treatment (e.g., a difference in max intensity of -7.58 ± 2.00 U vs. -2.71 ± 2.44 U, p = 0.041 3 dpi). In conclusion, the early single-dose administration of IL-4 significantly reduces secondary brain damage in the acute phase after experimental TBI in mice, which seems to be mediated by attenuation of macrophage and microglial invasion.
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Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Jannis Mende
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Samuel Hutagalung
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Obada T. Alhalabi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Martin Grutza
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Guoli Zheng
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Thomas Skutella
- Institute for Anatomy and Cell Biology, Heidelberg University, Im Neuenheimer Feld 307, 69120 Heidelberg, Germany;
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (J.M.); (S.H.); (O.T.A.); (M.G.); (G.Z.); (A.U.); (K.Z.)
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Mahmoodkhani M, Aminmansour B, Shafiei M, Hasas M, Tehrani DS. Citicoline on the Barthel Index: Severe and moderate brain injury. Indian J Pharmacol 2023; 55:223-228. [PMID: 37737074 PMCID: PMC10657618 DOI: 10.4103/ijp.ijp_570_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a paramount factor in mortality and morbidity. The clinical trials conducted to investigate the efficacy of neuroprotective agents, such as citicoline, as a therapeutic alternative for TBI have presented divergent findings. Therefore, this study aimed to evaluate and compare citicoline's effect on the Barthel Index in patients with severe and moderate brain injury. MATERIALS AND METHODS The study is a randomized clinical trial. Patients in the case group (35 patients) were treated with citicoline and the control group (34 patients) received a placebo. Data were analyzed using SPSS 16 software. RESULTS The results showed that changes in the Glasgow Coma Scale, changes in quadriceps muscle force score, Barthel Index score changes, achieving the status without intubation, and spontaneous breathing in patients treated with citicoline were not a statistically significant difference in the two groups (P > 0.05). CONCLUSION Findings revealed that citicoline did not impact the recovery process of severe and moderate TBI patients.
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Affiliation(s)
- Mehdi Mahmoodkhani
- Department of Neurosurgery, School of Medicine, Neurosciences Research Center, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Aminmansour
- Department of Neurosurgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Shafiei
- Department of Neurosurgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Hasas
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Sagaro GG, Amenta F. Choline-Containing Phospholipids in Stroke Treatment: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12082875. [PMID: 37109211 PMCID: PMC10143951 DOI: 10.3390/jcm12082875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/14/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Globally, stroke is the second leading cause of death and disability. In different studies conducted previously, the choline-containing phospholipids citicoline and choline alphoscerate have been proposed as adjuvants in the treatment of acute strokes. A systematic review was conducted to provide updated information on the effects of citicoline and choline alphoscerate in patients with acute and hemorrhagic strokes. METHODS PubMed/Medline, Scopus, and Web of Science were searched to identify relevant materials. Data were pooled, and odds ratios (OR) were reported for binary outcomes. Using mean differences (MD), we evaluated continuous outcomes. RESULTS A total of 1460 studies were reviewed; 15 studies with 8357 subjects met the eligibility criteria and were included in the analysis. In our study, citicoline treatment did not result in improved neurological function (NIHSS < 1, OR = 1.05; 95% confidence interval (CI): 0.87-1.27) or functional recovery (mRS < 1, OR = 1.36; 95% CI: 0.99-1.87) in patients with acute stroke. Choline alphoscerate improved neurological function and functional recovery in stroke patients based on the Mathew's scale and the Mini-Mental State Examination (MMSE). CONCLUSION Citicoline did not improve the neurological or functional outcomes in acute stroke patients. In contrast, choline alphoscerate improved neurological function and functional recovery and reduced dependency in stroke patients.
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Affiliation(s)
- Getu Gamo Sagaro
- Clinical Research, Telemedicine and Telepharmacy Center, School of Medicinal and Health Products Sciences, University of Camerino, 62032 Camerino, Italy
| | - Francesco Amenta
- Clinical Research, Telemedicine and Telepharmacy Center, School of Medicinal and Health Products Sciences, University of Camerino, 62032 Camerino, Italy
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Bodien YG, Barber J, Taylor SR, Boase K, Corrigan JD, Dikmen S, Gardner RC, Kramer JH, Levin H, Machamer J, McAllister T, Nelson LD, Ngwenya LB, Sherer M, Stein MB, Vassar M, Whyte J, Yue JK, Markowitz A, McCrea MA, Manley GT, Temkin N, Giacino JT. Feasibility and Utility of a Flexible Outcome Assessment Battery for Longitudinal Traumatic Brain Injury Research: A TRACK-TBI Study. J Neurotrauma 2023; 40:337-348. [PMID: 36097759 PMCID: PMC9902043 DOI: 10.1089/neu.2022.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The effects of traumatic brain injury (TBI) are difficult to measure in longitudinal cohort studies, because disparate pre-injury characteristics and injury mechanisms produce variable impairment profiles and recovery trajectories. In preparation for the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, which followed patients with injuries ranging from uncomplicated mild TBI to coma, we designed a multi-dimensional Flexible outcome Assessment Battery (FAB). The FAB relies on a decision-making algorithm that assigns participants to a Comprehensive (CAB) or Abbreviated Assessment Battery (AAB) and guides test selection across all phases of recovery. To assess feasibility of the FAB, we calculated the proportion of participants followed at 2 weeks (2w) and at 3, 6, and 12 months (3m, 6m, 12m) post-injury who completed the FAB and received valid scores. We evaluated utility of the FAB by examining differences in 6m and 12m Glasgow Outcome Scale-Extended (GOSE) scores between participant subgroups derived from the FAB-enabled versus traditional approach to outcome assessment applied at 2w. Among participants followed at 2w (n = 2094), 3m (n = 1871), 6m (n = 1736), and 12m (n = 1607) post-injury, 95-99% received valid completion scores on the FAB, in full or in part, either in person or by telephone. Level of function assessed by the FAB-enabled approach at 2w was associated with 6m and 12m GOSE scores (proportional odds p < 0.001). These findings suggest that the participant classification methodology afforded by the FAB may enable more effective data collection to improve detection of natural history changes and TBI treatment effects.
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Affiliation(s)
- Yelena G. Bodien
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Jason Barber
- University of Washington, Seattle, Washington, USA
| | - Sabrina R. Taylor
- University of California, San Francisco, San Francisco, California, USA
| | - Kim Boase
- University of Washington, Seattle, Washington, USA
| | | | | | - Raquel C. Gardner
- University of California, San Francisco, San Francisco, California, USA
| | - Joel H. Kramer
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Thomas McAllister
- University of Indiana School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Mark Sherer
- Baylor College of Medicine, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
| | - Murray B. Stein
- University of California San Diego, La Jolla, California, USA
| | - Mary Vassar
- University of California, San Francisco, San Francisco, California, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, USA
| | - John K. Yue
- University of California, San Francisco, San Francisco, California, USA
| | - Amy Markowitz
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Nancy Temkin
- University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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Citicoline for the Management of Patients with Traumatic Brain Injury in the Acute Phase: A Systematic Review and Meta-Analysis. Life (Basel) 2023; 13:life13020369. [PMID: 36836726 PMCID: PMC9958735 DOI: 10.3390/life13020369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/18/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Citicoline or CDP-choline is a neuroprotective/neurorestorative drug used in several countries for the treatment of traumatic brain injury (TBI). Since the publication of the controversial COBRIT, the use of citicoline has been questioned in this indication, so it was considered necessary to undertake a systematic review and meta-analysis to evaluate whether citicoline is effective in the treatment of patients with TBI. METHODS A systematic search was performed on OVID-Medline, EMBASE, Google Scholar, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Ferrer databases, from inception to January 2021, to identify all published, unconfounded, comparative clinical trials of citicoline in the acute phase of head-injured patients- that is, treatment started during the first 24 h. We selected studies on complicated mild, moderate, and severe head-injured patients according to the score of the Glasgow Coma Scale (GCS). The primary efficacy measure was independence at the end of the scheduled clinical trial follow-up. RESULTS In total, 11 clinical studies enrolling 2771 patients were identified by the end. Under the random-effects model, treatment with citicoline was associated with a significantly higher rate of independence (RR, 1.18; 95% CI = 1.05-1.33; I2, 42.6%). The dose of citicoline or the administration route had no effect on outcomes. Additionally, no significant effects on mortality were found, and no safety concerns were noticed. CONCLUSIONS This meta-analysis indicates some beneficial effects of citicoline's increasing the number of independent patients with TBI. The most important limitation of our meta-analysis was the presumed heterogeneity of the studies included. REGISTRATION PROSPERO CRD42021238998.
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Li M, Huo X, Wang Y, Li W, Xiao L, Jiang Z, Han Q, Su D, Chen T, Xia H. Effect of drug therapy on nerve repair of moderate-severe traumatic brain injury: A network meta-analysis. Front Pharmacol 2022; 13:1021653. [PMID: 36408253 PMCID: PMC9666493 DOI: 10.3389/fphar.2022.1021653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Objective: This network meta-analysis aimed to explore the effect of different drugs on mortality and neurological improvement in patients with traumatic brain injury (TBI), and to clarify which drug might be used as a more promising intervention for treating such patients by ranking. Methods: We conducted a comprehensive search from PubMed, Medline, Embase, and Cochrane Library databases from the establishment of the database to 31 January 2022. Data were extracted from the included studies, and the quality was assessed using the Cochrane risk-of-bias tool. The primary outcome measure was mortality in patients with TBI. The secondary outcome measures were the proportion of favorable outcomes and the occurrence of drug treatment–related side effects in patients with TBI in each drug treatment group. Statistical analyses were performed using Stata v16.0 and RevMan v5.3.0. Results: We included 30 randomized controlled trials that included 13 interventions (TXA, EPO, progesterone, progesterone + vitamin D, atorvastatin, beta-blocker therapy, Bradycor, Enoxaparin, Tracoprodi, dexanabinol, selenium, simvastatin, and placebo). The analysis revealed that these drugs significantly reduced mortality in patients with TBI and increased the proportion of patients with favorable outcomes after TBI compared with placebo. In terms of mortality after drug treatment, the order from the lowest to the highest was progesterone + vitamin D, beta-blocker therapy, EPO, simvastatin, Enoxaparin, Bradycor, Tracoprodi, selenium, atorvastatin, TXA, progesterone, dexanabinol, and placebo. In terms of the proportion of patients with favorable outcomes after drug treatment, the order from the highest to the lowest was as follows: Enoxaparin, progesterone + vitamin D, atorvastatin, simvastatin, Bradycor, EPO, beta-blocker therapy, progesterone, Tracoprodi, TXA, selenium, dexanabinol, and placebo. In addition, based on the classification of Glasgow Outcome Scale (GOS) scores after each drug treatment, this study also analyzed the three aspects of good recovery, moderate disability, and severe disability. It involved 10 interventions and revealed that compared with placebo treatment, a higher proportion of patients had a good recovery and moderate disability after treatment with progesterone + vitamin D, Bradycor, EPO, and progesterone. Meanwhile, the proportion of patients with a severe disability after treatment with progesterone + vitamin D and Bradycor was also low. Conclusion: The analysis of this study revealed that in patients with TBI, TXA, EPO, progesterone, progesterone + vitamin D, atorvastatin, beta-blocker therapy, Bradycor, Enoxaparin, Tracoprodi, dexanabinol, selenium, and simvastatin all reduced mortality and increased the proportion of patients with favorable outcomes in such patients compared with placebo. Among these, the progesterone + vitamin D had not only a higher proportion of patients with good recovery and moderate disability but also a lower proportion of patients with severe disability and mortality. However, whether this intervention can be used for clinical promotion still needs further exploration.
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Affiliation(s)
- Mei Li
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Stem Cell and Regenerative Medicine, General Hospital of Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Xianhao Huo
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Cerebrocranial Disease, Ningxia Medical University, Yinchuan, China
| | - Yangyang Wang
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Cerebrocranial Disease, Ningxia Medical University, Yinchuan, China
| | - Wenchao Li
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Cerebrocranial Disease, Ningxia Medical University, Yinchuan, China
| | - Lifei Xiao
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Cerebrocranial Disease, Ningxia Medical University, Yinchuan, China
| | - Zhanfeng Jiang
- Ningxia Key Laboratory of Stem Cell and Regenerative Medicine, General Hospital of Ningxia Medical University, Yinchuan, China
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Qian Han
- Ningxia Key Laboratory of Stem Cell and Regenerative Medicine, General Hospital of Ningxia Medical University, Yinchuan, China
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Dongpo Su
- Ningxia Key Laboratory of Stem Cell and Regenerative Medicine, General Hospital of Ningxia Medical University, Yinchuan, China
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Tong Chen
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
- *Correspondence: Tong Chen, ; Hechun Xia,
| | - Hechun Xia
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Stem Cell and Regenerative Medicine, General Hospital of Ningxia Medical University, Yinchuan, China
- *Correspondence: Tong Chen, ; Hechun Xia,
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Trimmel H, Herzer G, Derdak C, Kettenbach J, Grgac I. A novel pharmacological treatment concept for neuroprotection in severe traumatic brain injury-Two case reports. Clin Case Rep 2022; 10:e6626. [PMID: 36419580 PMCID: PMC9676123 DOI: 10.1002/ccr3.6626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022] Open
Abstract
Severe traumatic brain injury (sTBI) is a major cause of death and disability worldwide, resulting in a significant individual and socioeconomic burden. Current treatment guidelines do not include any recommendations for neuroprotective or neuoregenerative drugs. Here, we present a combined treatment with Cerebrolysin and Citicoline in two cases. Both drugs are experimentally better than clinically proven in their own effectiveness, but there is almost no clinical data on the combination of the two. Our case study hints at a promising approach that may improve neurological outcome after sTBI. The first patient was a 29 years male motorcyclist suffered polytrauma in a high-speed accident. He had severe bilateral chest trauma and fractures in both thighs and an sTBI. In addition to surgical and standard neurocritical care according to the evidence-based guidelines, he was given neuroprotective therapy with Cerebrolysin (50 ml/day) and Citicoline (3 g/day), by continuous intravenous infusion (IV), for 21 days. The second patient was a 30 years male ski mountaineer who had suffered a fall over 300 m in open terrain. In addition to the sTBI, he had fractures in the cervical spine, ribs, pelvis, and lower extremities, as well as lung contusions and massive soft tissue trauma. After initial treatment in a local hospital, he was transferred to our department and received the same neuroprotective drugs, like all of our patients with sTBI. Considering the severity of the injuries (Injury Severity Score [ISS]: 43/50, Revised Trauma Score [RTS: 5.0304, 2.7794]) and the unfavorable outcome probability (Hukkelhoven Score) of 93.1% and 82.6%, the outcomes of both patients are surprisingly encouraging 1 year after the accident. They achieved a Glasgow Outcome Score of 6 and 5 and grades 2 and 4 on the modified Rankin Scale, respectively. Currently, both are able to take care of themselves in activities of daily life to a large extent. Neuroprotective drugs may improve the regeneration of cell membranes, improve blood brain barrier integrity, and reduce neuroinflammation leading to secondary damage to the injured brain. Our clinical experience and data suggest that the combined administration of Citicoline and Cerebrolysin may contribute to better recovery, without relevant side effects. However, it would be important to validate these results by means of a controlled, prospective study.
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Affiliation(s)
- Helmut Trimmel
- Department of Anesthesiology, Emergency and Critical Care MedicineGeneral Hospital Wiener NeustadtWiener NeustadtAustria
- Karl Landsteiner Institute of Emergency MedicineGeneral Hospital Wiener NeustadtWiener NeustadtAustria
- Danube Private UniversityKremsAustria
| | - Guenther Herzer
- Department of Anesthesiology, Emergency and Critical Care MedicineGeneral Hospital Wiener NeustadtWiener NeustadtAustria
| | - Christoph Derdak
- Department of Anesthesiology, Emergency and Critical Care MedicineGeneral Hospital Wiener NeustadtWiener NeustadtAustria
| | - Joachim Kettenbach
- Danube Private UniversityKremsAustria
- Institute of Diagnostic, Interventional Radiology and Nuclear MedicineLandesklinikum Wiener NeustadtWiener NeustadtAustria
| | - Ivan Grgac
- Department of Anesthesiology, Emergency and Critical Care MedicineGeneral Hospital Wiener NeustadtWiener NeustadtAustria
- Faculty of Medicine, Institute of AnatomyComenius UniversityBratislavaSlovakia
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Finnegan E, Daly E, Pearce AJ, Ryan L. Nutritional interventions to support acute mTBI recovery. Front Nutr 2022; 9:977728. [PMID: 36313085 PMCID: PMC9614271 DOI: 10.3389/fnut.2022.977728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/06/2022] [Indexed: 01/09/2023] Open
Abstract
When mild traumatic brain injury (mTBI) occurs following an impact on the head or body, the brain is disrupted leading to a series of metabolic events that may alter the brain's ability to function and repair itself. These changes may place increased nutritional demands on the body. Little is known on whether nutritional interventions are safe for patients to implement post mTBI and whether they may improve recovery outcomes. To address this knowledge gap, we conducted a systematic review to determine what nutritional interventions have been prescribed to humans diagnosed with mTBI during its acute period (<14 days) to support, facilitate, and result in measured recovery outcomes. Methods Databases CINAHL, PubMed, SPORTDiscus, Web of Science, and the Cochrane Library were searched from inception until January 6, 2021; 4,848 studies were identified. After removing duplicates and applying the inclusion and exclusion criteria, this systematic review included 11 full papers. Results Patients that consumed enough food to meet calorie and macronutrient (protein) needs specific to their injury severity and sex within 96 h post mTBI had a reduced length of stay in hospital. In addition, patients receiving nutrients and non-nutrient support within 24-96 h post mTBI had positive recovery outcomes. These interventions included omega-3 fatty acids (DHA and EPA), vitamin D, mineral magnesium oxide, amino acid derivative N-acetyl cysteine, hyperosmolar sodium lactate, and nootropic cerebrolysin demonstrated positive recovery outcomes, such as symptom resolution, improved cognitive function, and replenished nutrient deficiencies (vitamin D) for patients post mTBI. Conclusion Our findings suggest that nutrition plays a positive role during acute mTBI recovery. Following mTBI, patient needs are unique, and this review presents the potential for certain nutritional therapies to support the brain in recovery, specifically omega-3 fatty acids. However, due to the heterogenicity nature of the studies available at present, it is not possible to make definitive recommendations. Systematic review registration The systematic review conducted following the PRISMA guidelines protocol was registered (CRD42021226819), on Prospero.
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Affiliation(s)
- Emma Finnegan
- Department of Sport, Exercise and Nutrition, Atlantic Technological University (ATU), Galway, Ireland
| | - Ed Daly
- Department of Sport, Exercise and Nutrition, Atlantic Technological University (ATU), Galway, Ireland
| | - Alan J. Pearce
- College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, Australia
| | - Lisa Ryan
- Department of Sport, Exercise and Nutrition, Atlantic Technological University (ATU), Galway, Ireland
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Current and Potential Pharmacologic Therapies for Traumatic Brain Injury. Pharmaceuticals (Basel) 2022; 15:ph15070838. [PMID: 35890136 PMCID: PMC9323622 DOI: 10.3390/ph15070838] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
The present article reviewed the pharmacologic therapies of traumatic brain injury (TBI), including current and potential treatments. Pharmacologic therapies are an essential part of TBI care, and several agents have well-established effects in TBI care. In the acute phase, tranexamic acid, antiepileptics, hyperosmolar agents, and anesthetics are the mainstay of pharmacotherapy, which have proven efficacies. In the post-acute phase, SSRIs, SNRIs, antipsychotics, zolpidem and amantadine, as well as other drugs, have been used to manage neuropsychological problems, while muscle relaxants and botulinum toxin have been used to manage spasticity. In addition, increasing numbers of pre-clinical and clinical studies of pharmaceutical agents, including potential neuroprotective nutrients and natural therapies, are being carried out. In the present article, we classify the treatments into established and potential agents based on the level of clinical evidence and standard of practice. It is expected that many of the potential medicines under investigation will eventually be accepted as standard practice in the care of TBI patients.
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Hiskens MI. Targets of neuroprotection and review of pharmacological interventions in traumatic brain injury. J Pharmacol Exp Ther 2022; 382:149-166. [DOI: 10.1124/jpet.121.001023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 05/06/2022] [Indexed: 11/22/2022] Open
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Walter J, Kovalenko O, Younsi A, Grutza M, Unterberg AW, Zweckberger K. Interleukin-4 reduces lesion volume and improves neurological function in the acute phase after experimental traumatic brain injury in mice. J Neurotrauma 2022; 39:1262-1272. [PMID: 35505616 DOI: 10.1089/neu.2021.0497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Little is known about the impact of Interleukin-4 (IL-4) on secondary brain damage in the acute phase after experimental traumatic brain injury (TBI). Therefore, we evaluated the effect of IL-4-Knockout on structural damage as well as functional impairment in the acute phase after experimental TBI in mice. 28 C57Bl/6 wildtype and 20 C57BL/6-Il4tm1Nnt/J Interleukin-4-Knockout (IL-4-KO) mice were subjected to Controlled Cortical Impact (CCI). Contusion volumes, body weight and functional outcome (Video Open Field Test (VOF), Hole Board Test (HB), CatWalkXT®) were determined on postoperative days one (D1), three (D3) and seven (D7). Contusion volume (13.45 +/- 0.88 mm³ vs. 9.50 +/- 0.97 mm³, p=0.015) and weight loss (-2.92 +/- 0.52% vs. -0.85 +/- 0.67%, p=0.027) were significantly higher and exploration behavior significantly more impaired (e.g., 150.44 +/- 18.71 fields explored vs. 211.56 +/- 18.90 fields explored, p=0.028 in the VOF; 23.31 +/- 2.03 holes explored vs. 35.65 +/- 1.93 holes explored, p<0.001 in the HB) in IL-4-KO mice on D1. Gait impairment was significantly more pronounced in IL-4-KO mice throughout the first week after CCI (e.g., 0.07 +/- 0.01s vs. 0.00 +/- 0.01s, p=0.047 for right hindpaw Swing on D1; -1.76 +/- 1.34 U vs. 2.53 +/- 0.90 U, p=0.01 for right forepaw Mean Intensity on D3; -0.01 +/- 0.01cm² vs. 0.05 +/- 0.01cm², p=0.015 for left forepaw Mean Area on D7). In conclusion, IL-4 reduces structural damage and improves functional outcome in the acute phase after CCI. Neurobehavioral outcome assessment in IL-4-related studies should focus on motor function on the first three days after trauma induction.
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Affiliation(s)
- Johannes Walter
- University of Heidelberg, Department of Neurosurgery, Heidelberg, Germany;
| | - Olga Kovalenko
- University of Heidelberg, Department of Neurosurgery, Heidelberg, Germany;
| | - Alexander Younsi
- University of Heidelberg, Department of Neurosurgery, Heidelberg, Germany;
| | - Martin Grutza
- University of Heidelberg, Department of Neurosurgery, Heidelberg, Germany;
| | | | - Klaus Zweckberger
- University of Heidelberg, Department of Neurosurgery, Heidelberg, Germany;
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Sharif-Alhosein M, Khormali M, Mohammadi F, Amouzade M, Baigi V. Citicoline for traumatic brain injuries: A systematic review and implications for future research. ARCHIVES OF TRAUMA RESEARCH 2022. [DOI: 10.4103/atr.atr_51_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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22
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Citicoline and COVID-19-Related Cognitive and Other Neurologic Complications. Brain Sci 2021; 12:brainsci12010059. [PMID: 35053804 PMCID: PMC8782421 DOI: 10.3390/brainsci12010059] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023] Open
Abstract
With growing concerns about COVID-19’s hyperinflammatory condition and its potentially damaging impact on the neurovascular system, there is a need to consider potential treatment options for managing short- and long-term effects on neurological complications, especially cognitive function. While maintaining adequate structure and function of phospholipid in brain cells, citicoline, identical to the natural metabolite phospholipid phosphatidylcholine precursor, can contribute to a variety of neurological diseases and hypothetically toward post-COVID-19 cognitive effects. In this review, we comprehensively describe in detail the potential citicoline mechanisms as adjunctive therapy and prevention of COVID-19-related cognitive decline and other neurologic complications through citicoline properties of anti-inflammation, anti-viral, neuroprotection, neurorestorative, and acetylcholine neurotransmitter synthesis, and provide a recommendation for future clinical trials.
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Gareri P, Veronese N, Cotroneo AM. An Overview of Combination Treatment with Citicoline in Dementia. Rev Recent Clin Trials 2021; 17:4-8. [PMID: 34939548 DOI: 10.2174/1574887117666211221170344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The present article reports an overview of the studies about combination treatment with citicoline of Alzheimer's (AD) and mixed dementia (MD). METHODS A Medline search was carried out by using the keywords Alzheimer's dementia, mixed dementia, older people, treatment with citicoline, memantine, and acetylcholinesterase inhibitors (AchEIs). RESULTS Six studies were found to match the combination treatment of citicoline with AcheIs and/or memantine. The CITIRIVAD and CITICHOLINAGE studies were the first to report the potential benefits of adding citicoline to acetylcholinesterase inhibitors (AchEIs). Then, we added citicoline to memantine in the CITIMEM study, and finally, we demonstrated benefits in terms of delay in cognitive worsening with the triple therapy (citicoline + AchEIs + memantine). Other authors also reinforced our hypothesis through two further studies. CONCLUSIONS Open, prospective studies are advised to confirm the utility of combination therapy with citicoline for the treatment of AD and MD.
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Affiliation(s)
- Pietro Gareri
- Center for Cognitive Disorders and Dementia - Catanzaro Lido, ASP Catanzaro; Catanzaro. Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo. Italy
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Regenerative Effects of CDP-Choline: A Dose-Dependent Study in the Toxic Cuprizone Model of De- and Remyelination. Pharmaceuticals (Basel) 2021; 14:ph14111156. [PMID: 34832936 PMCID: PMC8623145 DOI: 10.3390/ph14111156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 12/20/2022] Open
Abstract
Inflammatory attacks and demyelination in the central nervous system (CNS) are the key factors responsible for the damage of neurons in multiple sclerosis (MS). Remyelination is the natural regenerating process after demyelination that also provides neuroprotection but is often incomplete or fails in MS. Currently available therapeutics are affecting the immune system, but there is no substance that might enhance remyelination. Cytidine-S-diphosphate choline (CDP-choline), a precursor of the biomembrane component phospholipid phosphatidylcholine was shown to improve remyelination in two animal models of demyelination. However, the doses used in previous animal studies were high (500 mg/kg), and it is not clear if lower doses, which could be applied in human trials, might exert the same beneficial effect on remyelination. The aim of this study was to confirm previous results and to determine the potential regenerative effects of lower doses of CDP-choline (100 and 50 mg/kg). The effects of CDP-choline were investigated in the toxic cuprizone-induced mouse model of de- and remyelination. We found that even low doses of CDP-choline effectively enhanced early remyelination. The beneficial effects on myelin regeneration were accompanied by higher numbers of oligodendrocytes. In conclusion, CDP-choline could become a promising regenerative substance for patients with multiple sclerosis and should be tested in a clinical trial.
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Dhote VV, Raja MKMM, Samundre P, Sharma S, Anwikar S, Upaganlawar AB. Sports Related Brain Injury and Neurodegeneration in Athletes. Curr Mol Pharmacol 2021; 15:51-76. [PMID: 34515018 DOI: 10.2174/1874467214666210910114324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/03/2021] [Accepted: 06/03/2021] [Indexed: 11/22/2022]
Abstract
Sports deserve a special place in human life to impart healthy and refreshing wellbeing. However, sports activities, especially contact sports, renders athlete vulnerable to brain injuries. Athletes participating in a contact sport like boxing, rugby, American football, wrestling, and basketball are exposed to traumatic brain injuries (TBI) or concussions. The acute and chronic nature of these heterogeneous injuries provides a spectrum of dysfunctions that alters the neuronal, musculoskeletal, and behavioral responses of an athlete. Many sports-related brain injuries go unreported, but these head impacts trigger neurometabolic disruptions that contribute to long-term neuronal impairment. The pathophysiology of post-concussion and its underlying mechanisms are undergoing intense research. It also shed light on chronic disorders like Parkinson's disease, Alzheimer's disease, and dementia. In this review, we examined post-concussion neurobehavioral changes, tools for early detection of signs, and their impact on the athlete. Further, we discussed the role of nutritional supplements in ameliorating neuropsychiatric diseases in athletes.
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Affiliation(s)
- Vipin V Dhote
- Faculty of Pharmacy, VNS Group of Institutions, Bhopal, MP,462044. India
| | | | - Prem Samundre
- Faculty of Pharmacy, VNS Group of Institutions, Bhopal, MP,462044. India
| | - Supriya Sharma
- Faculty of Pharmacy, VNS Group of Institutions, Bhopal, MP,462044. India
| | - Shraddha Anwikar
- Faculty of Pharmacy, VNS Group of Institutions, Bhopal, MP,462044. India
| | - Aman B Upaganlawar
- Faculty of Pharmacy, VNS Group of Institutions, Bhopal, MP,462044. India
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Rosas LE, Doolittle LM, Joseph LM, El-Musa H, Novotny MV, Hickman-Davis JM, Hite RD, Davis IC. Postexposure Liponucleotide Prophylaxis and Treatment Attenuates Acute Respiratory Distress Syndrome in Influenza-infected Mice. Am J Respir Cell Mol Biol 2021; 64:677-686. [PMID: 33606602 DOI: 10.1165/rcmb.2020-0465oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There is an urgent need for new drugs for patients with acute respiratory distress syndrome (ARDS), including those with coronavirus disease (COVID-19). ARDS in influenza-infected mice is associated with reduced concentrations of liponucleotides (essential precursors for de novo phospholipid synthesis) in alveolar type II (ATII) epithelial cells. Because surfactant phospholipid synthesis is a primary function of ATII cells, we hypothesized that disrupting this process could contribute significantly to the pathogenesis of influenza-induced ARDS. The goal of this study was to determine whether parenteral liponucleotide supplementation can attenuate ARDS. C57BL/6 mice inoculated intranasally with 10,000 plaque-forming units/mouse of H1N1 influenza A/WSN/33 virus were treated with CDP (cytidine 5'-diphospho)-choline (100 μg/mouse i.p.) ± CDP -diacylglycerol 16:0/16:0 (10 μg/mouse i.p.) once daily from 1 to 5 days after inoculation (to model postexposure influenza prophylaxis) or as a single dose on Day 5 (to model treatment of patients with ongoing influenza-induced ARDS). Daily postexposure prophylaxis with CDP-choline attenuated influenza-induced hypoxemia, pulmonary edema, alterations in lung mechanics, impairment of alveolar fluid clearance, and pulmonary inflammation without altering viral replication. These effects were not recapitulated by the daily administration of CTP (cytidine triphosphate) and/or choline. Daily coadministration of CDP-diacylglycerol significantly enhanced the beneficial effects of CDP-choline and also modified the ATII cell lipidome, reversing the infection-induced decrease in phosphatidylcholine and increasing concentrations of most other lipid classes in ATII cells. Single-dose treatment with both liponucleotides at 5 days after inoculation also attenuated hypoxemia, altered lung mechanics, and inflammation. Overall, our data show that liponucleotides act rapidly to reduce disease severity in mice with severe influenza-induced ARDS.
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Affiliation(s)
| | | | | | | | - Michael V Novotny
- Department of Immunology and Inflammation, Cleveland Clinic, Cleveland, Ohio; and
| | - Judy M Hickman-Davis
- Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, Ohio
| | - R Duncan Hite
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
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Role of Citicoline in the Management of Traumatic Brain Injury. Pharmaceuticals (Basel) 2021; 14:ph14050410. [PMID: 33926011 PMCID: PMC8146347 DOI: 10.3390/ph14050410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/20/2021] [Accepted: 04/24/2021] [Indexed: 01/07/2023] Open
Abstract
Head injury is among the most devastating types of injury, specifically called Traumatic Brain Injury (TBI). There is a need to diminish the morbidity related with TBI and to improve the outcome of patients suffering TBI. Among the improvements in the treatment of TBI, neuroprotection is one of the upcoming improvements. Citicoline has been used in the management of brain ischemia related disorders, such as TBI. Citicoline has biochemical, pharmacological, and pharmacokinetic characteristics that make it a potentially useful neuroprotective drug for the management of TBI. A short review of these characteristics is included in this paper. Moreover, a narrative review of almost all the published or communicated studies performed with this drug in the management of patients with head injury is included. Based on the results obtained in these clinical studies, it is possible to conclude that citicoline is able to accelerate the recovery of consciousness and to improve the outcome of this kind of patient, with an excellent safety profile. Thus, citicoline could have a potential role in the management of TBI.
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Teng YD, Zafonte RD. Prelude to the special issue on novel neurocircuit, cellular and molecular targets for developing functional rehabilitation therapies of neurotrauma. Exp Neurol 2021; 341:113689. [PMID: 33745921 DOI: 10.1016/j.expneurol.2021.113689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 11/15/2022]
Abstract
The poor endogenous recovery capacity and other impediments to reinstating sensorimotor or autonomic function after adult neurotrauma have perplexed modern neuroscientists, bioengineers, and physicians for over a century. However, despite limited improvement in options to mitigate acute pathophysiological sequalae, the past 20 years have witnessed marked progresses in developing efficacious rehabilitation strategies for chronic spinal cord and brain injuries. The achievement is mainly attributable to research advancements in elucidating neuroplastic mechanisms for the potential to enhance clinical prognosis. Innovative cross-disciplinary studies have established novel therapeutic targets, theoretical frameworks, and regiments to attain treatment efficacy. This Special Issue contained eight papers that described experimental and human data along with literature reviews regarding the essential roles of the conventionally undervalued factors in neural repair: systemic inflammation, neural-respiratory inflammasome axis, modulation of glutamatergic and monoaminergic neurotransmission, neurogenesis, nerve transfer, recovery neurobiology components, and the spinal cord learning, respiration and central pattern generator neurocircuits. The focus of this work was on how to induce functional recovery from manipulating these underpinnings through their interactions with secondary injury events, peripheral and supraspinal inputs, neuromusculoskeletal network, and interventions (i.e., activity training, pharmacological adjuncts, electrical stimulation, and multimodal neuromechanical, brain-computer interface [BCI] and robotic assistance [RA] devices). The evidence suggested that if key neurocircuits are therapeutically reactivated, rebuilt, and/or modulated under proper sensory feedback, neurological function (e.g., cognition, respiration, limb movement, locomotion, etc.) will likely be reanimated after neurotrauma. The efficacy can be optimized by individualizing multimodal rehabilitation treatments via BCI/RA-integrated drug administration and neuromechanical protheses.
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Affiliation(s)
- Yang D Teng
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA.
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA.
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Wilson JE, Shinall MC, Leath TC, Wang L, Harrell FE, Wilson LD, Nordness MF, Rakhit S, de Riesthal MR, Duff MC, Pandharipande PP, Patel MB. Worse Than Death: Survey of Public Perceptions of Disability Outcomes After Hypothetical Traumatic Brain Injury. Ann Surg 2021; 273:500-506. [PMID: 31972638 PMCID: PMC8558681 DOI: 10.1097/sla.0000000000003389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the health utility states of the most commonly used traumatic brain injury (TBI) clinical trial endpoint, the Extended Glasgow Outcome Scale (GOSE). SUMMARY BACKGROUND DATA Health utilities represent the strength of one's preferences under conditions of uncertainty. There are insufficient data to indicate how an individual would value levels of disability after a TBI. METHODS This was a cross-sectional web-based online convenience sampling adaptive survey. Using a standard gamble approach, participants evaluated their preferences for GOSE health states 1 year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). Median (25th percentile, 75th percentile) health utility values for different GOSE states after TBI, ranging from -1 (worse than death) to 1 (full health), with 0 as reference (death). RESULTS Of 3508 eligible participants, 3235 (92.22%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated as worse than death, though the relationship was nonlinear and intervals were unequal between health states. Over 75% of participants rated a vegetative state (GOSE2, absence of awareness and bedridden) and about 50% rated lower severe disability (GOSE3, housebound needing all-day assistance) as conditions worse than death. CONCLUSIONS In the largest investigation of public perceptions about post-TBI disability, we demonstrate unequally rated health states, with some states perceived as worse than death. Although limited by selection bias, these results may guide future comparative-effectiveness research and shared medical decision-making after neurologic injury.
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Affiliation(s)
- Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of General Psychiatry, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Myrick C. Shinall
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of General Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Taylor C. Leath
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Laura D. Wilson
- Department of Communication Sciences and Disorders, Oxley College of Health Sciences, The University of Tulsa, Tulsa, OK
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Mina F. Nordness
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Shayan Rakhit
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Michael R. de Riesthal
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa C. Duff
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
- Nashville Veterans Affairs (VA) Medical Center, Geriatric Research Education and Clinical Centers; Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN
| | - Mayur B. Patel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
- Nashville Veterans Affairs (VA) Medical Center, Geriatric Research Education and Clinical Centers; Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN
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Biegon A. Considering Biological Sex in Traumatic Brain Injury. Front Neurol 2021; 12:576366. [PMID: 33643182 PMCID: PMC7902907 DOI: 10.3389/fneur.2021.576366] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/08/2021] [Indexed: 11/23/2022] Open
Abstract
Published epidemiological studies of traumatic brain injury (TBI) of all severities consistently report higher incidence in men. Recent increases in the participation of women in sports and active military service as well as increasing awareness of the very large number of women who sustain but do not report TBI as a result of intimate partner violence (IPV) suggest that the number of women with TBI is significantly larger than previously believed. Women are also grossly under-represented in clinical and natural history studies of TBI, most of which include relatively small numbers of women, ignore the role of sex- and age-related gonadal hormone levels, and report conflicting results. The emerging picture from recent studies powered to detect effects of biological sex as well as age (as a surrogate of hormonal status) suggest young (i.e., premenopausal) women are more likely to die from TBI relative to men of the same age group, but this is reversed in the 6th and 7th decades of life, coinciding with postmenopausal status in women. New data from concussion studies in young male and female athletes extend this finding to mild TBI, since female athletes who sustained mild TBI are significantly more likely to report more symptoms than males. Studies including information on gonadal hormone status at the time of injury are still too scarce and small to draw reliable conclusions, so there is an urgent need to include biological sex and gonadal hormone status in the design and analysis of future studies of TBI.
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Affiliation(s)
- Anat Biegon
- Department of Radiology and Neurology, Stony Brook University School of Medicine, Stony Brook, NY, United States
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31
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An S, Jia Y, Tian Y, Sun J, Wei Y, Yue S, Lin L, Wei Y, Li Y, Lei P, Zhang J, Jiang R. Mouse nerve growth factor promotes neurological recovery in patients with acute intracerebral hemorrhage: A proof-of-concept study. J Neurol Sci 2020; 418:117069. [PMID: 32798840 DOI: 10.1016/j.jns.2020.117069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND ew drugs were confirmed to be effective in the treatments of neurological dysfunction caused by acute intracerebral hemorrhage (ICH). The present prospective clinical trial aims to evaluate the effect of mouse nerve growth factor (mNGF) on neurological function in patients with acute ICH. METHODS 60 patients with acute spontaneous ICH were randomized to receive mNGF (mNGF group) and citicoline (control group) for 4 weeks within 24-72 h after onset, respectively. The primary outcome was difference in the neurological functional outcome at 3 months by the modified Rankin Scale score (mRS). The secondary outcomes were the changes in hematoma volume at 4 weeks and 3 months. RESULTS There were 55 patients receiving treatment (29 patients in the mNGF group, 26 patients in the control group). Among the patients, 46 patients finished the trial at 3 months; the odds of a shift towards death or dependence (mRS > 3) at 3 months in the mNGF group were lower than that in the control group with adjustment for age, sex, NIHSS at admission, and hematoma volume at admission (adjusted OR, 0.185; 95%CI, 0.059-0.582; P = 0.0039). The hematoma was gradually reduced in all 46 patients and absorbed after non-surgical treatment at 3 months. There was no significant difference in hematoma volume between the two groups. No serious adverse event was found. CONCLUSIONS The administration of mNGF and citicoline was well-tolerated in patients with acute ICH. mNGF was associated with improved neurological function and less disability in patients with ICH. Therefore, the quality of life of patients with ICH may be improved by mNGF. TRIAL REGISTRATION The trial is registered with the Chinese Clinical Trial Registry, number ChiCTR1800020258.
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Affiliation(s)
- Shuo An
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ying Jia
- Department of Rehabilitation Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Ye Tian
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jian Sun
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yingsheng Wei
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuyuan Yue
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Lijuan Lin
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yongyue Wei
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ying Li
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ping Lei
- Laboratory of Neuro-Trauma and Neurodegenerative Disorders, Tianjin Geriatrics Institute, Tianjin Medical University General Hospital, Tianjin, China; Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Jianning Zhang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
| | - Rongcai Jiang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
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Zou LF, Pierce B, Nielson JL. A Multi-Modal Assessment of Clinical Predictors for Traumatic Brain Injury End-Points. J Neurotrauma 2020; 38:261-271. [PMID: 33023400 PMCID: PMC8020558 DOI: 10.1089/neu.2020.7222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) is a complex injury that has a multi-faceted recovery process. The current "gold standard" for classifying severity of TBI symptoms is the Glasgow Outcome Scale (GOSE), a crude measure of overall dysfunction after TBI. Exploratory factor analysis performed on TRACK-TBI Pilot (N = 297) identified candidate multi-variate outcome measures of neuropsychological impairment and cognitive speed and flexibility at 6 months post-TBI that were confirmed in data from the COBRIT study (N = 645) using confirmatory factor analysis. These new outcome measures were used as the dependent variables in an ordinal logistic regression model, using common data elements (CDE) collected in the emergency department as independent variables, including basic demographics, socioeconomic status, medical history, and measures of blood alcohol and blood pressure. We directly compared these prediction models with the GOSE as the 6-month outcome variable and found that in both the TRACK-TBI pilot and COBRIT studies, both neuropsychiatric complications (approx. 36.0% and 22.3% variance explained) and cognitive speed and flexibility (approx. 33.9% and 24.5% variance explained) were better explained by the prediction model, compared with GOSE (approx. 19.9% and 14.4% variance explained), respectively. While differences in overall distributions of impairment between TRACK-TBI pilot and COBRIT exist and should be explored further for applications of these prediction models, we think these multi-variate end-points more accurately characterize patients' functioning at six-months post-TBI. A multi-variate assessment of end-points seems especially important for characterizing TBI outcomes in cases where gross impairment, such as those measured by the GOSE, may be less evident.
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Affiliation(s)
- Lin F Zou
- School of Statistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Benjamin Pierce
- Department of Psychiatry and Behavioral Science, and University of Minnesota, Minneapolis, Minnesota, USA
| | - Jessica L Nielson
- Department of Psychiatry and Behavioral Science, and University of Minnesota, Minneapolis, Minnesota, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
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Jasielski P, Piędel F, Piwek M, Rocka A, Petit V, Rejdak K. Application of Citicoline in Neurological Disorders: A Systematic Review. Nutrients 2020; 12:E3113. [PMID: 33053828 PMCID: PMC7601330 DOI: 10.3390/nu12103113] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/19/2022] Open
Abstract
Citicoline is a chemical compound involved in the synthesis of cell membranes. It also has other, not yet explained functions. Research on the use of citicoline is conducted in neurology, ophthalmology, and psychiatry. Citicoline is widely available as a dietary supplement. It is often used to enhance cognitive functions. In our article, accessible databases were searched for articles regarding citicoline use in neurological diseases. This article has a systemic review form. After rejecting non-eligible reports, 47 remaining articles were reviewed. The review found that citicoline has been proven to be a useful compound in preventing dementia progression. It also enhances cognitive functions among healthy individuals and improves prognosis after stroke. In an animal model of nerve damage and neuropathy, citicoline stimulated regeneration and lessened pain. Among patients who underwent brain trauma, citicoline has an unclear clinical effect. Citicoline has a wide range of effects and could be an essential substance in the treatment of many neurological diseases. Its positive impact on learning and cognitive functions among the healthy population is also worth noting.
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Affiliation(s)
- Patryk Jasielski
- Department of Neurology, Medical University of Lublin, 20-059 Lublin, Poland; (F.P.); (M.P.); (A.R.); (V.P.); (K.R.)
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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Walter J, Kovalenko O, Younsi A, Grutza M, Unterberg A, Zweckberger K. The CatWalk XT® is a valid tool for objective assessment of motor function in the acute phase after controlled cortical impact in mice. Behav Brain Res 2020; 392:112680. [DOI: 10.1016/j.bbr.2020.112680] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 01/01/2023]
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Yue JK, Satris GG, Dalle Ore CL, Huie JR, Deng H, Winkler EA, Lee YM, Vassar MJ, Taylor SR, Schnyer DM, Lingsma HF, Puccio AM, Yuh EL, Mukherjee P, Valadka AB, Ferguson AR, Markowitz AJ, Okonkwo DO, Manley GT. Polytrauma Is Associated with Increased Three- and Six-Month Disability after Traumatic Brain Injury: A TRACK-TBI Pilot Study. Neurotrauma Rep 2020; 1:32-41. [PMID: 34223528 PMCID: PMC8240880 DOI: 10.1089/neur.2020.0004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Polytrauma and traumatic brain injury (TBI) frequently co-occur and outcomes are routinely measured by the Glasgow Outcome Scale-Extended (GOSE). Polytrauma may confound GOSE measurement of TBI-specific outcomes. Adult patients with TBI from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study had presented to a Level 1 trauma center after injury, received head computed tomography (CT) within 24 h, and completed the GOSE at 3 months and 6 months post-injury. Polytrauma was defined as an Abbreviated Injury Score (AIS) ≥3 in any extracranial region. Univariate regressions were performed using known GOSE clinical cutoffs. Multi-variable regressions were performed for the 3- and 6-month GOSE, controlling for known demographic and injury predictors. Of 361 subjects (age 44.9 ± 18.9 years, 69.8% male), 69 (19.1%) suffered polytrauma. By Glasgow Coma Scale (GCS) assessment, 80.1% had mild, 5.8% moderate, and 14.1% severe TBI. On univariate logistic regression, polytrauma was associated with increased odds of moderate disability or worse (GOSE ≤6; 3 month odds ratio [OR] = 2.57 [95% confidence interval (CI): 1.50-4.41; 6 month OR = 1.70 [95% CI: 1.01-2.88]) and death/severe disability (GOSE ≤4; 3 month OR = 3.80 [95% CI: 2.03-7.11]; 6 month OR = 3.33 [95% CI: 1.71-6.46]). Compared with patients with isolated TBI, more polytrauma patients experienced a decline in GOSE from 3 to 6 months (37.7 vs. 24.7%), and fewer improved (11.6 vs. 22.6%). Polytrauma was associated with greater univariate ordinal odds for poorer GOSE (3 month OR = 2.79 [95% CI: 1.73-4.49]; 6 month OR = 1.73 [95% CI: 1.07-2.79]), which was conserved on multi-variable ordinal regression (3 month OR = 3.05 [95% CI: 1.76-5.26]; 6 month OR = 2.04 [95% CI: 1.18-3.42]). Patients with TBI with polytrauma are at greater risk for 3- and 6-month disability compared with those with isolated TBI. Methodological improvements in assessing TBI-specific disability, versus disability attributable to all systemic injuries, will generate better TBI outcomes assessment tools.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Gabriela G Satris
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - J Russell Huie
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Young M Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Mary J Vassar
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sabrina R Taylor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - David M Schnyer
- Department of Psychology, University of Texas, Austin, Texas, USA
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.,Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.,Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Alex B Valadka
- Department of Neurological Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Pattankar S, Misra BK. Protocol-Based Early Decompressive Craniectomy in a Resource-Constrained Environment: A Tertiary Care Hospital Experience. Asian J Neurosurg 2020; 15:634-639. [PMID: 33145218 PMCID: PMC7591208 DOI: 10.4103/ajns.ajns_41_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/05/2020] [Accepted: 05/05/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Decompressive craniectomy (DC) is an emergency life-saving procedure used to treat refractory intracranial hypertension (RICH). The authors aim to analyze their experience with protocol-based early DC (<24 h) in RICH cases diagnosed based on clinical and radiological evidence, without preoperative intracranial pressure monitoring done over 10 years. MATERIALS AND METHODS This is a retrospective, observational study which includes 58 consecutive patients who underwent protocol-based early DC by the senior author at a single institution between 2007 and 2017. Background variables and outcome in the form of Glasgow Outcome Score-Extended (GOS-E) at 6 months and 1 year were analyzed. RESULTS Fourteen patients had traumatic brain injury (TBI), 17 had intracranial hemorrhage (ICH), 14 had malignant cerebral infarcts (MCI), and the reminder 13 patients had other causes. At 6 months, the mortality rate was 22.4%. Good recovery, moderate disability, and severe disability were seen in 13.8%, 17.2%, and 43.1% of patients, respectively. Two patients were in vegetative state. The cutoff for favorable/unfavorable outcome was defined as GOS-E 4-8/1-3. By this application, 63.8% of patients had favorable outcome at 6 months. The favorable outcome in patients of TBI, ICH, and MCI was 57.1%, 58.8%, and 85.7%, respectively. CONCLUSIONS DC helps in obtaining a favorable outcome in selected patients with a defined pathology. The diagnosis of RICH based on clinical and radiological parameters, and protocol-based early DC, is reasonably justified as the way forward for resource-constrained environments. The risk of vegetative state is small.
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Affiliation(s)
- Sanjeev Pattankar
- Department of Neurosurgery, P. D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
| | - Basant Kumar Misra
- Department of Neurosurgery, P. D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
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Folweiler KA, Sandsmark DK, Diaz-Arrastia R, Cohen AS, Masino AJ. Unsupervised Machine Learning Reveals Novel Traumatic Brain Injury Patient Phenotypes with Distinct Acute Injury Profiles and Long-Term Outcomes. J Neurotrauma 2020; 37:1431-1444. [PMID: 32008422 PMCID: PMC7249479 DOI: 10.1089/neu.2019.6705] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The heterogeneity of traumatic brain injury (TBI) remains a core challenge for the success of interventional clinical trials. Data-driven approaches for patient stratification may help to identify TBI patient phenotypes during the acute injury period as well as facilitate targeted trial patient enrollment and analysis of treatment efficacy. In this study, we implemented an unsupervised machine learning approach to identify TBI subpopulations at injury baseline using data from 1213 TBI patients who participated in the Citicoline Brain Injury Treatment Trial (COBRIT) Trial. A wrapper framework utilizing generalized low-rank models automatically selected relevant clinical features that were subsequently used to cluster patients using a partitioning around medoids clustering algorithm. Using this approach, we identified three patient phenotypes with unique clinical injury profiles based on a subset of acute injury features. Phenotype-specific differences in long-term functional outcome trajectories were respectively observed at 3 and 6 months after injury. In comparison, when patients were grouped by baseline Glasgow Coma Scale (GCS), no differences in baseline clinical feature profiles or long-term outcomes were observed. To test phenotype reproducibility in an external validation data set, we used a K-nearest neighbors algorithm to classify subjects in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot data set into corresponding phenotypes, then measured the Gower's dissimilarities between TRACK-TBI and COBRIT subjects in each phenotype. No significant differences were found between trial subjects within two phenotypes, suggesting that these phenotypes may be generalizable within a broad range of TBI severity. Further, Extended Glasgow Outcome Scale (GOS-E) outcomes in the TRACK-TBI data set similarly demonstrated phenotype-specific differences in long-term outcomes. Our results suggest that unsupervised machine learning is a promising and effective approach for discovery of novel injury subpopulations over the conventional GCS-based method, and may improve patient selection in future TBI clinical trials.
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Affiliation(s)
- Kaitlin A Folweiler
- Department of Anesthesiology and Critical Care Medicine, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Danielle K Sandsmark
- Department of Neurology and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Akiva S Cohen
- Department of Anesthesiology and Critical Care Medicine, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Aaron J Masino
- Department of Anesthesiology and Critical Care Medicine, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Blumenthal JA, Smith PJ, Sherwood A, Mabe S, Snyder L, Frankel C, McKee DC, Hamilton N, Keefe FJ, Shearer S, Schwartz J, Palmer S. Remote Therapy to Improve Outcomes in Lung Transplant Recipients: Design of the INSPIRE-III Randomized Clinical Trial. Transplant Direct 2020; 6:e535. [PMID: 32195326 PMCID: PMC7056276 DOI: 10.1097/txd.0000000000000979] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/21/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Impaired functional capacity and emotional distress are associated with lower quality of life (QoL) and worse clinical outcomes in post lung transplant patients. Strategies to increase physical activity and reduce distress are needed. METHODS The Investigational Study of Psychological Interventions in Recipients of Lung Transplant-III study is a single site, parallel group randomized clinical trial in which 150 lung transplant recipients will be randomly assigned to 3 months of telephone-delivered coping skills training combined with aerobic exercise (CSTEX) or to a Standard of Care plus Education control group. The primary endpoints are a global measure of distress and distance walked on the 6-Minute Walk Test. Secondary outcomes include measures of transplant-specific QoL, frailty, health behaviors, and chronic lung allograft dysfunction-free survival. RESULTS Participants will be evaluated at baseline, at the conclusion of 3 months of weekly treatment, at 1-year follow-up, and followed annually thereafter for clinical events for up to 4 years (median = 2 y). We also will determine whether functional capacity, distress, and health behaviors (eg, physical activity, medication adherence, and volume of air forcefully exhaled in 1 second (FEV1), mediate the effects of the CSTEX intervention on clinical outcomes. CONCLUSIONS Should the CSTEX intervention result in better outcomes compared with the standard of care plus post-transplant education, the remotely delivered CSTEX intervention can be made available to all lung transplant recipients as a way of enhancing their QoL and improving clinical outcomes.
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Affiliation(s)
- James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Laurie Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Courtney Frankel
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Daphne C. McKee
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Natalie Hamilton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Francis J. Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Sheila Shearer
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Jeanne Schwartz
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Scott Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC
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Carnevale C, Manni G, Roberti G, Micera A, Bruno L, Cacciamani A, Altafini R, Quaranta L, Agnifili L, Tanga L, Riva I, Oddone F. Human vitreous concentrations of citicoline following topical application of citicoline 2% ophthalmic solution. PLoS One 2019; 14:e0224982. [PMID: 31725734 PMCID: PMC6855484 DOI: 10.1371/journal.pone.0224982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/26/2019] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To evaluate the presence and concentration of citicoline and its metabolites (choline, cytidine and uridine) in the vitreous body in human eyes after topical application of an ophthalmic solution of citicoline 2%, in vivo. METHODS Twenty-one subjects affected by epiretinal membrane with surgical indication for pars-plana vitrectomy underwent treatment with 1 drop 3 times/day of a solution of citicoline 2%, 0.2% high molecular weight hyaluronic acid and 0.01% benzalkonium chloride (OMK1, Omikron Italia s.r.l., Rome, Italy) 14 days before surgery and 2 hours prior to surgery. Five additional patients served as controls and received an OMK1 vehicle solution without citicoline. The vitreous samples were taken at the beginning of the pars-plana vitrectomy and analyzed for qualitative/quantitative determination of vitreous concentration of citicoline and its metabolites by means of high performance liquid chromatography. RESULTS The overall mean concentration of citicoline in patients treated with citicoline 2% solution was 406.72 ± 52.99 μg/mL, while the mean concentration of choline, cytidine and uridine was 180.88 ± 41.49 μg/mL, 44.45 ± 10.19 μg/mL and 330.41 ± 75.8 μg/mL, respectively. The concentration of citicoline in phakic eyes (n = 13, 366.61 ± 129.61 μg/mL) was lower compared to that found in pseudophakic eyes (n = 8, 435.89 ± 131.42 μg/mL) and the difference was not statistically significant. The concentration of citicoline in the control eyes was 45.66 ± 26.36 μg/mL, while the concentration of choline, cytidine and uridine were 17.21 ± 9.93 μg/mL, 6.24 ± 3.6 μg/mL and 172.80 ± 99.76 μg/mL, respectively. CONCLUSION Citicoline can reach the human vitreous in high concentration when administered in ophthalmic solution. This evidence contributes to the build-up of the pyramid of the evidences required for determining the role of citicoline administered in ophthalmic formulation in retinal and optic nerve neurodegenerative diseases.
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Affiliation(s)
| | - Gianluca Manni
- IRCCS-Fondazione Bietti, Rome, Italy
- DSCMT, University of Rome Tor Vergata, Rome, Italy
| | | | | | | | | | | | - Luciano Quaranta
- Department of Surgical & Clinical, Diagnostic and Pediatric Sciences, Section of Ophthalmology, University of Pavia-IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Luca Agnifili
- Ophthalmology Clinic, Department of Medicine and Aging Science, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
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Khellaf A, Khan DZ, Helmy A. Recent advances in traumatic brain injury. J Neurol 2019; 266:2878-2889. [PMID: 31563989 PMCID: PMC6803592 DOI: 10.1007/s00415-019-09541-4] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Abdelhakim Khellaf
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Box 167, Hills Road, Cambridge, CB2 0QQ UK
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Danyal Zaman Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Box 167, Hills Road, Cambridge, CB2 0QQ UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Box 167, Hills Road, Cambridge, CB2 0QQ UK
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Bodien YG, McCrea M, Dikmen S, Temkin N, Boase K, Joan M, Taylor SR, Sherer M, Levin H, Kramer JH, Corrigan JD, McAllister TW, Whyte J, Manley GT, Giacino JT. Optimizing Outcome Assessment in Multicenter TBI Trials: Perspectives From TRACK-TBI and the TBI Endpoints Development Initiative. J Head Trauma Rehabil 2019; 33:147-157. [PMID: 29385010 PMCID: PMC5940527 DOI: 10.1097/htr.0000000000000367] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Traumatic brain injury (TBI) is a global public health problem that affects the long-term cognitive, physical, and psychological health of patients, while also having a major impact on family and caregivers. In stark contrast to the effective trials that have been conducted in other neurological diseases, nearly 30 studies of interventions employed during acute hospital care for TBI have failed to identify treatments that improve outcome. Many factors may confound the ability to detect true and meaningful treatment effects. One promising area for improving the precision of intervention studies is to optimize the validity of the outcome assessment battery by using well-designed tools and data collection strategies to reduce variability in the outcome data. The Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, conducted at 18 sites across the United States, implemented a multidimensional outcome assessment battery with 22 measures aimed at characterizing TBI outcome up to 1 year postinjury. In parallel, through the TBI Endpoints Development (TED) Initiative, federal agencies and investigators have partnered to identify the most valid, reliable, and sensitive outcome assessments for TBI. Here, we present lessons learned from the TRACK-TBI and TED initiatives aimed at optimizing the validity of outcome assessment in TBI.
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Affiliation(s)
- Yelena G. Bodien
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
| | - Michael McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA Departments of
| | - Nancy Temkin
- Neurological Surgery and Biostatistics, University of Washington, Seattle, WA
| | - Kim Boase
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA Departments of
| | - Machamer Joan
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA Departments of
| | - Sabrina R. Taylor
- Department of Neurological Surgery, Brain and Spinal Injury Center, University of California, San Francisco, CA
| | - Mark Sherer
- TIRR Memorial Hermann, Houston, TX
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX
| | - Harvey Levin
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX
| | - Joel H. Kramer
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, CA
| | - John D. Corrigan
- Department of Physical Medicine & Rehabilitation, The Ohio State University
| | - Thomas W. McAllister
- Department of Psychiatry, University of Indiana School of Medicine, Indianapolis, IN
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, Brain and Spinal Injury Center, University of California, San Francisco, CA
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio A, Diaz-Arrastia R, Okonkwo DO. Long-term outcome in traumatic brain injury patients with midline shift: a secondary analysis of the Phase 3 COBRIT clinical trial. J Neurosurg 2019; 131:596-603. [PMID: 30074459 DOI: 10.3171/2018.2.jns173138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Following traumatic brain injury (TBI), midline shift of the brain at the level of the septum pellucidum is often caused by unilateral space-occupying lesions and is associated with increased intracranial pressure and worsened morbidity and mortality. While outcome has been studied in this population, the recovery trajectory has not been reported in a large cohort of patients with TBI. The authors sought to utilize the Citicoline Brain Injury Treatment (COBRIT) trial to analyze patient recovery over time depending on degree of midline shift at presentation. METHODS Patient data from the COBRIT trial were stratified into 4 groups of midline shift, and outcome measures were analyzed at 30, 90, and 180 days postinjury. A recovery trajectory analysis was performed identifying patients with outcome measures at all 3 time points to analyze the degree of recovery based on midline shift at presentation. RESULTS There were 892, 1169, and 895 patients with adequate outcome data at 30, 90, and 180 days, respectively. Rates of favorable outcome (Glasgow Outcome Scale-Extended [GOS-E] scores 4-8) at 6 months postinjury were 87% for patients with no midline shift, 79% for patients with 1-5 mm of shift, 64% for patients with 6-10 mm of shift, and 47% for patients with > 10 mm of shift. The mean improvement from unfavorable outcome (GOS-E scores 2 and 3) to favorable outcome (GOS-E scores 4-8) from 1 month to 6 months in all groups was 20% (range 4%-29%). The mean GOS-E score for patients in the 6- to 10-mm group crossed from unfavorable outcome (GOS-E scores 2 and 3) into favorable outcome (GOS-E scores 4-8) at 90 days, and the mean GOS-E of patients in the > 10-mm group nearly reached the threshold of favorable outcome by 180 days postinjury. CONCLUSIONS In this secondary analysis of the Phase 3 COBRIT trial, TBI patients with less than 10 mm of midline shift on admission head CT had significantly improved functional outcomes through 180 days after injury compared with those with greater than 10 mm of midline shift. Of note, nearly 50% of patients with > 10 mm of midline shift achieved a favorable outcome (GOS-E score 4-8) by 6 months postinjury.
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Affiliation(s)
- Ross C Puffer
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - John K Yue
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | | | | | | | | | - Ava Puccio
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | - Ramon Diaz-Arrastia
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Alali AS, Temkin N, Barber J, Pridgeon J, Chaddock K, Dikmen S, Hendrickson P, Videtta W, Lujan S, Petroni G, Guadagnoli N, Urbina Z, Chesnut RM. A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury. J Neurosurg 2019; 131:612-619. [PMID: 30265194 PMCID: PMC6586526 DOI: 10.3171/2018.4.jns173166] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension. METHODS Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT). RESULTS The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%-98.3%), a specificity of 42.3% (95% CI 31.7%-53.6%), a positive predictive value of 55.5% (95% CI 50.7%-60.2%), and a negative predictive value of 90% (95% CI 77.1%-96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort. CONCLUSIONS A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).
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Affiliation(s)
- Aziz S. Alali
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Jim Pridgeon
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Kelley Chaddock
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Sureyya Dikmen
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Peter Hendrickson
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Walter Videtta
- Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Silvia Lujan
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Gustavo Petroni
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Nahuel Guadagnoli
- Hospital Emergencia, Hospital Privado de Rosario, Rosario, Argentina
| | | | - Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
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Gardner RC, Cheng J, Ferguson AR, Boylan R, Boscardin J, Zafonte RD, Manley GT. Divergent Six Month Functional Recovery Trajectories and Predictors after Traumatic Brain Injury: Novel Insights from the Citicoline Brain Injury Treatment Trial Study. J Neurotrauma 2019; 36:2521-2532. [PMID: 30909795 DOI: 10.1089/neu.2018.6167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cross-sectional approaches to outcome assessment may not adequately capture heterogeneity in recovery after traumatic brain injury (TBI). Using latent class mixed models (LCMM), a data-driven analytic that identifies groups of patients with similar trajectories, we identified distinct 6 month functional recovery trajectories in a large cohort (n = 1046) of adults 18-70 years of age with complicated mild to severe TBI who participated in the Citicoline Brain Injury Treatment Trial (COBRIT). We used multinomial logistic fixed effect models and backward elimination, forward selection, and forward stepwise selection with several stopping rules to explore baseline predictors of functional recovery trajectory. Based on statistical and clinical considerations, the seven-class model was deemed superior. Visualization of these seven functional recovery trajectories revealed that each trajectory class started at one of three recovery levels at 1 month, which, for ease of reference we labeled groups A-C: Group A, good recovery (two classes; A1 and A2); Group B, moderate disability (two classes; B1 and B2); and Group C, severe disability (three classes; C1, C2, and C3). By 6 months, these three groups experienced dramatically divergent trajectories. Group A experienced stable good recovery (A1, n = 115) or dramatic decline (A2, n = 4); Group B experienced rapid complete recovery (B1, n = 71) or gradual recovery (B2, n = 742); Group C experienced dramatic rapid recovery (C1, n = 12), no recovery (C2, n = 91), or death (C3, n = 11). Trajectory class membership was not predicted by citicoline treatment (p = 0.57). The models identified demographic, pre-injury, and injury-related predictors of functional recovery trajectory, including: age, race, education, pre-injury employment, pre-injury diabetes, pre-injury psychiatric disorder, site, Glasgow Coma Scale (GCS) score, post-traumatic amnesia, TBI mechanism, major extracranial injury, hemoglobin, and acute computed tomographic (CT) findings. GCS was the most consistently selected predictor across all models. All models also selected at least one demographic or pre-injury medical predictor. LCMM successfully identified dramatically divergent, clinically meaningful 6 month recovery trajectories with utility to inform clinical trial design.
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Affiliation(s)
- Raquel C Gardner
- Department of Neurology, Memory and Aging Center, and Weill Institute for Neurosciences, University of California, San Franscisco, San Francisco, California.,Department of Neurology and Center for Population Brain Health, San Francisco Veterans Affairs Mecical Center, San Francisco, California
| | - Jing Cheng
- Deparment of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Adam R Ferguson
- Department of Neurological Surgery and Weil Institute for Neurosciences, University of California San Francisco, San Francisco, California.,Brain and Spinal Injury Center, Zuckerberg san Francisco General Hospital, San Francisco, California.,Department of Research and Development, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Ross Boylan
- Deparment of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - John Boscardin
- Deparment of Epidemiology and Biostatistics, University of California, San Francisco, California.,Department of Research and Development, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Department of Medicine, University of California, san Francisco, California
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Geoffrey T Manley
- Department of Neurological Surgery and Weil Institute for Neurosciences, University of California San Francisco, San Francisco, California.,Brain and Spinal Injury Center, Zuckerberg san Francisco General Hospital, San Francisco, California
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D'Souza A, Mollayeva S, Pacheco N, Javed F, Colantonio A, Mollayeva T. Measuring Change Over Time: A Systematic Review of Evaluative Measures of Cognitive Functioning in Traumatic Brain Injury. Front Neurol 2019; 10:353. [PMID: 31133955 PMCID: PMC6517520 DOI: 10.3389/fneur.2019.00353] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/22/2019] [Indexed: 12/19/2022] Open
Abstract
Objectives: The purpose of evaluative instruments is to measure the magnitude of change in a construct of interest over time. The measurement properties of these instruments, as they relate to the instrument's ability to fulfill its purpose, determine the degree of certainty with which the results yielded can be viewed. This work systematically reviews all instruments that have been used to evaluate cognitive functioning in persons with traumatic brain injury (TBI), and critically assesses their evaluative measurement properties: construct validity, test-retest reliability, and responsiveness. Data Sources: MEDLINE, Central, EMBASE, Scopus, PsycINFO were searched from inception to December 2016 to identify longitudinal studies focused on cognitive evaluation of persons with TBI, from which instruments used for measuring cognitive functioning were abstracted. MEDLINE, instrument manuals, and citations of articles identified in the primary search were then screened for studies on measurement properties of instruments utilized at least twice within the longitudinal studies. Study Selection: All English-language, peer-reviewed studies of longitudinal design that measured cognition in adults with a TBI diagnosis over any period of time, identified in the primary search, were used to identify instruments. A secondary search was carried out to identify all studies that assessed the evaluative measurement properties of the instruments abstracted in the primary search. Data Extraction: Data on psychometric properties, cognitive domains covered and clinical utility were extracted for all instruments. Results: In total, 38 longitudinal studies from the primary search, utilizing 15 instruments, met inclusion and quality criteria. Following review of studies identified in the secondary search, it was determined that none of the instruments utilized had been assessed for all the relevant measurement properties in the TBI population. The most frequently assessed property was construct validity. Conclusions: There is insufficient evidence for the validity and reliability of instruments measuring cognitive functioning, longitudinally, in persons with TBI. Several instruments with well-defined construct validity in TBI samples warrant further assessment for test-retest reliability and responsiveness. Registration Number: www.crd.york.ac.uk/PROSPERO/, identifier CRD42017055309.
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Affiliation(s)
- Andrea D'Souza
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, University of Toronto, Toronto, ON, Canada
| | - Shirin Mollayeva
- Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, University of Toronto, Toronto, ON, Canada
| | - Nicole Pacheco
- Faculty of Life Sciences, McMaster University, Hamilton, ON, Canada
| | - Fiza Javed
- Department of Biology, University of Toronto Mississauga, Mississauga, ON, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, University of Toronto, Toronto, ON, Canada
| | - Tatyana Mollayeva
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, University of Toronto, Toronto, ON, Canada
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Primary External Ventricular Drainage Catheter Versus Intraparenchymal ICP Monitoring: Outcome Analysis. Neurocrit Care 2019; 31:11-21. [DOI: 10.1007/s12028-019-00712-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Lazaridis C. Intracranial Pressure Monitoring in Traumatic Brain Injury: Start Ventricular or Parenchymal? Neurocrit Care 2019; 31:22-23. [DOI: 10.1007/s12028-019-00719-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Killen MJ, Giorgi-Coll S, Helmy A, Hutchinson PJ, Carpenter KL. Metabolism and inflammation: implications for traumatic brain injury therapeutics. Expert Rev Neurother 2019; 19:227-242. [PMID: 30848963 DOI: 10.1080/14737175.2019.1582332] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Traumatic Brain Injury (TBI) is a leading cause of death and disability in young people, affecting 69 million people annually, worldwide. The initial trauma disrupts brain homeostasis resulting in metabolic dysfunction and an inflammatory cascade, which can then promote further neurodegenerative effects for months or years, as a 'secondary' injury. Effective targeting of the cerebral inflammatory system is challenging due to its complex, pleiotropic nature. Cell metabolism plays a key role in many diseases, and increased disturbance in the TBI metabolic state is associated with poorer patient outcomes. Investigating critical metabolic pathways, and their links to inflammation, can potentially identify supplements which alter the brain's long-term response to TBI and improve recovery. Areas covered: The authors provide an overview of literature on metabolism and inflammation following TBI, and from relevant pre-clinical and clinical studies, propose therapeutic strategies. Expert opinion: There is still no specific active drug treatment for TBI. Changes in metabolic and inflammatory states have been reported after TBI and appear linked. Understanding more about abnormal cerebral metabolism following TBI, and its relationship with cerebral inflammation, will provide essential information for designing therapies, with implications for neurocritical care and for alleviating long-term disability and neurodegeneration in post-TBI patients.
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Affiliation(s)
- Monica J Killen
- a Division of Neurosurgery, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK
| | - Susan Giorgi-Coll
- a Division of Neurosurgery, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK
| | - Adel Helmy
- a Division of Neurosurgery, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK
| | - Peter Ja Hutchinson
- a Division of Neurosurgery, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK.,b Wolfson Brain Imaging Centre, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK
| | - Keri Lh Carpenter
- a Division of Neurosurgery, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK.,b Wolfson Brain Imaging Centre, Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio AM, Diaz-Arrastia R, Okonkwo DO. Recovery Trajectories and Long-Term Outcomes in Traumatic Brain Injury: A Secondary Analysis of the Phase 3 Citicoline Brain Injury Treatment Clinical Trial. World Neurosurg 2019; 125:e909-e915. [PMID: 30763755 DOI: 10.1016/j.wneu.2019.01.207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospects for recovery after traumatic brain injury (TBI) are often underestimated, potentially leading to withdrawal of care in the comatose TBI patient who may ultimately have a favorable outcome with aggressive care. Outcomes and trajectories of recovery in a large series of patients with TBI were evaluated at 30, 90, and 180 days postinjury. METHODS A secondary analysis of the phase 3 Citicoline Brain Injury Treatment (COBRIT) trial was performed analyzing recovery trajectories and long-term outcomes at 30, 90, and 180 days postinjury. A Glasgow Outcome Scale-Extended (GOS-E) score of 5 or higher was considered favorable. Pearson χ2 analysis was used, and a P value of 0.05 was considered significant. A locally weighted, polynomial regression model was used to model recovery trajectories in a nonlinear fashion. RESULTS Subjects with TBI in the COBRIT trial had high rates of favorable outcome (57% of severe TBI, 86% of moderate TBI, and 93% of complicated mild TBI) at 6-month follow-up. These favorable outcomes often converted from high rates of unfavorable outcome at initial 1-month follow-up (85% of severe TBI, 57% of moderate TBI, and 21% of complicated mild TBI). Recovery trajectories had not plateaued at 6 months, suggesting that further improvement occurs beyond 6 months postinjury. CONCLUSIONS In this secondary analysis of the COBRIT trial, most patients had favorable outcomes by the GOS-E at 6 months postinjury in all complicated mild and moderate TBI groups, with over half of patients with severe TBI achieving a favorable outcome as well. Of subjects in a vegetative state (GOS-E score 2) at 1 month postinjury, 18% improved to a favorable outcome by 6 months postinjury. There was substantial improvement in all groups from 1 to 6 months, and this improvement may continue beyond 6 months. Clinical trials in TBI should consider recovery curves with repeated measures to assess outcomes because arbitrary single-moment outcome determination likely underestimates treatment effect in TBI care.
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Affiliation(s)
- Ross C Puffer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John K Yue
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Matthew Mesley
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Jane Sharpless
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Anita L Fetzick
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ava M Puccio
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA.
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