Quality management in traumatic brain injury (TBI) lessons from the prospective study in 6.800 patients after acute TBI in respect of neurorehabilitation

Effects of dexmedetomidine vs sufentanil during percutaneous tracheostomy for traumatic brain injury patients: A prospective randomized controlled trial

BACKGROUND

Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients.

METHODS

The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), group D2 (n = 68, DEX infusion at 1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 μg·kg for 10 minutes, then adjusted to 0.2-0.4 μg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded.

RESULTS

Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ± 3.23 vs 12.42 ± 2.12 vs 13.88 ± 3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05).

CONCLUSIONS

During percutaneous tracheostomy, compared with sufentanil, DEX (1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.

The International Incidence of Traumatic Brain Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Understanding the epidemiology of traumatic brain injury (TBI) is essential to shape public health policy, implement prevention strategies, and justify allocation of resources toward research, education, and rehabilitation in TBI. There is not, to our knowledge, a systematic review of population-based studies addressing the epidemiology of TBI that includes all subtypes. We performed a comprehensive systematic review and meta-analysis of the worldwide incidence of TBI.

METHODS

A search was conducted on May 23, 2014, in Medline and EMBASE according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Abstracts were screened independently and in duplicate to identify original research. Study quality and ascertainment bias were assessed in duplicate using a previously published tool. Demographic data and incidence estimates from each study were recorded, along with stratification by age, gender, year of data collection, and severity.

RESULTS

The search strategy yielded 4944 citations. Two hundred and sixteen articles met criteria for full-text review; 144 were excluded. Hand searching resulted in ten additional articles. Eighty-two studies met all eligibility criteria. The pooled annual incidence proportion for all ages was 295 per 100,000 (95% confidence interval: 274-317). The pooled incidence rate for all ages was 349 (95% confidence interval: 96.2-1266) per 100,000 person-years. Incidence proportion and incidence rate were examined to see if associated with age, sex, country, or severity.

CONCLUSIONS

We conclude that most TBIs are mild and most TBIs occur in males among the adult population. The incidence of TBI varies widely by ages and between countries. Despite being an important medical, economic, and social problem, the global epidemiology of TBI is still not well-characterized in the current literature. Understanding the incidence of TBI, particularly mild TBI, remains challenging because of nonstandardized reporting among neuroepidemiological studies.

Head trauma in China

OBJECTIVE

The Chinese Head Trauma Data Bank (CHTDB) has been established, which includes 7,145 hospitalised cases with acute head trauma patients in 47 hospitals.

METHODS

We explored factors that might affect the outcome of acute traumatic brain injury.

RESULTS

There was no statistical difference in the mortality rate between male (7.5%) and female (7.2%) patients (P>0.05). The mortality rate in children (<18 years), adults (18-65 years) and elderly (>65 years) was 7.3%, 7.2% and 9.0%, respectively (P>0.05). The mortality rate of patients with mild (2.7%), moderate (5.0%) and severe (21.8%) head trauma was significantly different (P<0.001). The mortality rate of patients with unilateral tentorial herniation, bilateral tentorial herniation and tonsillar herniation was 24.2%, 60.2% and 78.8% respectively (P<0.001). The mortality rate of patients with intracranial pressure (ICP)<20 mm Hg, 20-40 mm Hg and >40 mm Hg was 6.3%, 21.4% and 93.1%, respectively (P<0.001). The mortality rate of patients with no cerebral contusion, single cerebral contusion and multiple cerebral contusions was 3.9%, 7.8% and 14.8%, respectively (P<0.001). The mortality rate of patients with and without traumatic subarachnoid haemorrhage (tSAH) was 9.5% and 5.4%, respectively (P<0.001). The mortality rate of patients with no intracranial haematomas, single intracranial haematoma and multiple intracranial haematomas was 5.8%, 8.4% and 20.6%, respectively (P<0.001).

CONCLUSION

The CHTDB, the first head trauma data bank in China, has one of the largest numbers of cases of any head trauma data bank in the world. Our major findings on mortality may be helpful to neurosurgeons for predicting the outcome of acute head trauma patients.

Computational neurotrauma--design, simulation, and analysis of controlled cortical impact model

The controlled cortical impact (CCI) model is widely used in many laboratories to study traumatic brain injury (TBI). Although external impact parameters during CCI tests could be clearly defined, little is known about the internal tissue-level mechanical responses of the rat brain. Furthermore, the external impact parameters tend to vary considerably among different labs making the comparison of research findings difficult if not impossible. In this study, a design of computer experiments was performed with typical external impact parameters commonly found in the literature. An anatomically detailed finite element (FE) rat brain model was used to simulate the CCI experiments to correlate external mechanical parameters (impact depth, impact velocity, impactor shape, impactor size, and craniotomy pattern) with rat brain internal responses, as predicted by the FE model. Systematic analysis of the results revealed that impact depth was the leading factor affecting the predicted brain internal responses. Interestingly, impactor shape ranked as the second most important factor, surpassing impactor diameter and velocity which were commonly reported in the literature as indicators of injury severity along with impact depth. The differences in whole brain response due to a unilateral or a bilateral craniotomy were small, but those of regional intracranial tissue stretches were large. The interaction effects of any two external parameters were not significant. This study demonstrates the potential of using numerical FE modeling to engineer better experimental TBI models in the future.

Repeatedly Heading a Soccer Ball Does Not Increase Serum Levels of S-100B, a Biochemical Marker of Brain Tissue Damage: an Experimental Study

OBJECTIVES: The aim of the study was to analyse whether the controlled heading of soccer balls elicits increased serum concentrations of a biochemical marker of brain tissue damage S-100B. METHODS: Nineteen male soccer players were randomly divided into two groups, A and B. Group A headed a soccer ball falling from 18 m five times, while group B served as controls (no heading). Blood samples were taken before and 0.5 h, 2 h and 4 h after the heading for analysis of S-100B. RESULTS: No statistically significant (p > 0.05) increases in serum concentrations of S-100B were encountered in group A at 0.5 h (0.109 +/-0.024 mug/L), 2 h (0.098 +/- 0.026 mug/L), and 4 h (0.113 +/- 0.035 mug/L) when the blood samples obtained before and after the heading were compared (0.157 +/- 0.134 mug/L). No statistically significant difference was found when the serum concentrations of S-100B were compared between groups A and B either before or after heading. CONCLUSIONS: Heading a soccer ball dropped from a height of 18 m five times was not found to cause an increase in serum concentrations of S-100B, indicating that the impact was not sufficient to cause biochemically discernible damage of brain tissue.

Traumatic brain injuries in a well-defined population: epidemiological aspects and severity

The aim was to describe epidemiological and medical aspects of 449 cases of traumatic brain injury (TBI) from a well-defined geographical area with a population of 137,000 inhabitants. An episode of disturbed consciousness was a prerequisite for inclusion in the study. The incidence of TBI was 354/100,000 inhabitants. Median age was 23 years, range 0-91 years; 55% were men and 45% were women; 33% children 0-14 years, 50% adults 15-64 years, and 17% elderly persons 65-91 years old. Severity classification was based on Glasgow Coma Scale (GCS) on arrival; mild TBI 97% (GCS 13-15), moderate 1% (GCS 9-12), and severe 2% (GCS 3-8). The most common injury events were falls (55%) and vehicle-related events (30%). The percentage of falls was high among children and elderly persons but among adults vehicle-related injury events were also prominent. At least 17% of all patients were under the influence of alcohol, especially adult male bicyclists. CT was performed on 163 cases (36%) revealing 34 cases with intracranial hemorrhage (ICH) which is 21% of the examined or 8% of all the injured. The rate of ICH increased with increasing age (from 3% among children to 17% among the elderly persons) and also increased with decreasing GCS from 6% in the group of mild TBI to 60% among those with severe TBI. Attention should be directed to acute management of mild TBI in order to detect potentially dangerous ICH as well as to preventive actions against falls and vehicle related accidents.

Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results

Multislice-computed tomography (MSCT) and magnetic resonance imaging (MRI) are increasingly used for forensic purposes. Based on broad experience in clinical neuroimaging, post-mortem MSCT and MRI were performed in 57 forensic cases with the goal to evaluate the radiological methods concerning their usability for forensic head and brain examination. An experienced clinical radiologist evaluated the imaging data. The results were compared to the autopsy findings that served as the gold standard with regard to common forensic neurotrauma findings such as skull fractures, soft tissue lesions of the scalp, various forms of intracranial hemorrhage or signs of increased brain pressure. The sensitivity of the imaging methods ranged from 100% (e.g., heat-induced alterations, intracranial gas) to zero (e.g., mediobasal impression marks as a sign of increased brain pressure, plaques jaunes). The agreement between MRI and CT was 69%. The radiological methods prevalently failed in the detection of lesions smaller than 3mm of size, whereas they were generally satisfactory concerning the evaluation of intracranial hemorrhage. Due to its advanced 2D and 3D post-processing possibilities, CT in particular possessed certain advantages in comparison with autopsy with regard to forensic reconstruction. MRI showed forensically relevant findings not seen during autopsy in several cases. The partly limited sensitivity of imaging that was observed in this retrospective study was based on several factors: besides general technical limitations it became apparent that clinical radiologists require a sound basic forensic background in order to detect specific signs. Focused teaching sessions will be essential to improve the outcome in future examinations. On the other hand, the autopsy protocols should be further standardized to allow an exact comparison of imaging and autopsy data. In consideration of these facts, MRI and CT have the power to play an important role in future forensic neuropathological examination.