Cardiac Dysfunction After Neurologic Injury: What Do We Know and Where Are We Going?

How to Define and Meet Blood Pressure Targets After Traumatic Brain Injury: A Narrative Review

BACKGROUND

Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings.

METHODS

We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions.

RESULTS

Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury.

DISCUSSION

Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI.

CONCLUSIONS

We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials.

Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

Diagnosis and management of subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.

Traumatic brain injury and risk of heart failure and coronary heart disease: A nationwide population-based cohort study

BACKGROUND

This study examined the long-term risks of heart failure (HF) and coronary heart disease (CHD) following traumatic brain injury (TBI), focusing on gender differences.

METHODS

Data from Taiwan's National Health Insurance Research Database included 29,570 TBI patients and 118,280 matched controls based on propensity scores.

RESULTS

The TBI cohort had higher incidences of CHD and HF (9.76 vs. 9.07 per 1000 person-years; 4.40 vs. 3.88 per 1000 person-years). Adjusted analyses showed a significantly higher risk of HF in the TBI group (adjusted hazard ratio = 1.08, 95% CI = 1.01-1.17, P = 0.031). The increased CHD risk in the TBI cohort became insignificant after adjustment. Subgroup analysis by gender revealed higher HF risk in men (aHR = 1.14, 95% CI = 1.03-1.25, P = 0.010) and higher CHD risk in women under 50 (aHR = 1.32, 95% CI = 1.15-1.52, P < 0.001). TBI patients without beta-blocker therapy may be at increased risk of HF.

CONCLUSION

Our results suggest that TBI increases the risk of HF and CHD in this nationwide cohort of Taiwanese citizens. Gender influences the risks differently, with men at higher HF risk and younger women at higher CHD risk. Beta-blockers have a neutral effect on HF and CHD risk.

Neurogenic pulmonary edema and Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage

PURPOSE

Neurogenic pulmonary edema (NPE) combined with Takotsubo cardiomyopathy (TCM) is a rare condition associated with aneurysmal subarachnoid hemorrhage (aSAH). Although several mechanisms have been proposed, the pathophysiology and management strategies are not yet fully established. We aimed to determine the radiological and clinical outcomes of patients with NPE and with TCM after aSAH to propose management strategies.

METHODS

We analyzed the data of 564 patients with aSAH recorded at a single medical center from February 2015 to July 2022. This study retrospectively investigated the incidence and demographics of SAH combined with both NPE and TCM and the clinical outcomes of the patients. Correlating factors, independently associated with NPE-TCM, were also investigated.

RESULTS

During the 7 years, 11 (2.0%) of 564 patients had NPE complicated with TCM after aSAH. Seven of 11 (63.6%) patients had poor-grade SAH (Hunt-Hess Grade 4 to 5). Three of 11 patients had a posterior circulation in the NPE-TCM group. The most prevalent treatment option was endovascular coil embolization, except for one case of clip. Long-term outcomes were favorable in 6 of 11 patients, and there was one case of mortality. Age, troponin I level, and alveolar-arterial oxygen gradient were correlating factors of NPE-TCM.

CONCLUSION

Although NPE-TCM represents a rare complication associated with aSAH, achieving active resolution of underlying neurological causes through early and appropriate treatment may contribute to a favorable prognosis. Considering the limited incidence of SAH complicated with NPE-TCM, a multi-center study may be needed.

Cardiovascular events in children with brain injury: A systematic review

BACKGROUND

Brain injury is a leading cause of morbidity and mortality in the pediatric population. Neurogenic stunned cardiomyopathy is a complication associated with several neurological conditions that can lead to worse outcomes. It presents as alterations in blood pressure, cardiac rhythm disturbances and the increase in cardiac injury biomarkers. This systematic review aims to assess the hemodynamic consequences of brain injury in the pediatric population to identify better management strategies and improve outcomes.

METHODS

An electronic literature search was performed in Pubmed, Scopus and WebOfScience, up until October 3rd, 2022. The selected articles underwent quality assessment using the National Heart, Lung and Blood Institute tools for cohort and case-control studies.

RESULTS

This systematic review includes thirteen articles on the effects of brain injury in arterial pressure, rhythm disturbances and biomarkers of myocardial injury. These studies showed the following key results: both hypotension and hypertension are associated with worse outcomes; brain injury could be related to longer QTc intervals; neurogenic stunned cardiomyopathy was a common found after brain injury.

CONCLUSION

This is the first systematic review to report cardiovascular abnormalities arising from brain injury in children. An early arterial pressure, electrocardiographic and echocardiographic evaluation, as well as the measure of serum biomarkers for myocardial injury, can be critical in identifying poor prognostic factors. Further research is required to understand the implications of our findings in clinical practice.

Cardiac Point-of-Care Ultrasound in Pediatric Neurocritical Care: A Case Series

BACKGROUND

Pediatric brain injury is accompanied by hemodynamic perturbations complicating the optimization of cerebral physiology. Point-of-care ultrasound (POCUS) uses dynamic real-time imaging to complement the physical examination and identify hemodynamic abnormalities in preload, contractility, and afterload conditions, but the contribution of cardiac POCUS in the context of pediatric brain injury is unclear.

METHODS

We reviewed cardiac POCUS images integrated in clinical care to examine those with neurological injury and hemodynamic abnormalities.

RESULTS

We discuss three children with acute brain injury and myocardial dysfunction identified using cardiac POCUS by bedside clinicians.

CONCLUSIONS

Cardiac POCUS may have an important role in caring for children with neurologic injury. These patients received personalized care informed by POCUS data in attempts to stabilize hemodynamics and optimize clinical outcomes.

The Heart Is at Risk: Understanding Stroke-Heart-Brain Interactions with Focus on Neurogenic Stress Cardiomyopathy-A Review

In recent years, it has been convincingly demonstrated that acute brain injury may cause severe cardiac complications-such as neurogenic stress cardiomyopathy (NSC), a specific form of takotsubo cardiomyopathy. The pathophysiology of these brain-heart interactions is complex and involves sympathetic hyperactivity, activation of the hypothalamic-pituitary-adrenal axis, as well as immune and inflammatory pathways. There have been great strides in our understanding of the axis from the brain to the heart in patients with isolated acute brain injury and more specifically in patients with stroke. On the other hand, in patients with NSC, research has mainly focused on hemodynamic dysfunction due to arrhythmias, regional wall motion abnormality, or left ventricular hypokinesia that leads to impaired cerebral perfusion pressure. Comparatively little is known about the underlying secondary and delayed cerebral complications. The aim of the present review is to describe the stroke-heart-brain axis and highlight the main pathophysiological mechanisms leading to secondary and delayed cerebral injury in patients with concurrent hemorrhagic or ischemic stroke and NSC as well as to identify further areas of research that could potentially improve outcomes in this specific patient population.

Inflammatory Response and Immune Regulation in Brain-Heart Interaction after Stroke

Cerebrocardiac syndrome (CCS) is one of the secondary myocardial injuries after stroke. Cerebrocardiac syndrome may result in a poor prognosis with high mortality. Understanding the mechanism of the brain-heart interaction may be crucial for clinical treatment of pathological changes in CCS. Accumulating evidence suggests that the inflammatory response is involved in the brain-heart interaction after stroke. Systemic inflammatory response syndrome (SIRS) evoked by stroke may injure myocardial cells directly, in which the interplay between inflammatory response, oxidative stress, cardiac sympathetic/parasympathetic dysfunction, and splenic immunoregulation may be also the key pathophysiology factor. This review article summarizes the current understanding of inflammatory response and immune regulation in brain-heart interaction after stroke.

Subarachnoidal hemorrhage related cardiomyopathy: an overview of Tako-Tsubo cardiomyopathy and related cardiac syndromes

INTRODUCTION

Subarachnoid hemorrhage (SAH) is caused by a ruptured intracranial aneurysm leading to acute extravasation of blood into the subarachnoid space. SAH has an incidence of 6.3 per 100,000 persons per year in Europe and accounts for 5% of all strokes. SAH occurs at a relatively young age and has poor clinical outcomes and high mortality rates. Cardiac syndromes are regularly seen in patients with acute neurologic disease including SAH. These cardiac complications of SAH are associated with increased morbidity and mortality and present in a large variety and severity.

AREAS COVERED

The main goal of this review is to describe the SAH-related cardiac syndromes. Secondly, we will provide an overview of the underlying pathophysiology regarding the development of cardiac syndromes. Thirdly, we will describe the impact of cardiac syndromes on patient outcome.

EXPERT OPINION

Of all neurology patients, SAH patients have the highest risk of developing takotsubo syndrome (TTS), occurring in about 0.8-30% of patients. Both TTS and neurogenic stunned myocardium have many similarities on echocardiographic evaluation. In European Cardiology consensus, SAH is recognized as a primary cause of TTS.

Risk Factors and Neurological Outcomes Associated With Circulatory Shock After Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study

BACKGROUND

Extracranial multisystem organ failure is a common sequela of severe traumatic brain injury (TBI). Risk factors for developing circulatory shock and long-term functional outcomes of this patient subset are poorly understood.

OBJECTIVE

To identify emergency department predictors of circulatory shock after moderate-severe TBI and examine long-term functional outcomes in patients with moderate-severe TBI who developed circulatory shock.

METHODS

We conducted a retrospective cohort study using the Transforming Clinical Research and Knowledge in TBI database for adult patients with moderate-severe TBI, defined as a Glasgow Coma Scale (GCS) score of <13 and stratified by the development of circulatory shock within 72 hours of hospital admission (Sequential Organ Failure Assessment score ≥2). Demographic and clinical data were assessed with descriptive statistics. A forward selection regression model examined risk factors for the development of circulatory shock. Functional outcomes were examined using multivariable regression models.

RESULTS

Of our moderate-severe TBI population (n = 407), 168 (41.2%) developed circulatory shock. Our predictive model suggested that race, computed tomography Rotterdam scores <3, GCS in the emergency department, and development of hypotension in the emergency department were associated with developing circulatory shock. Those who developed shock had less favorable 6-month functional outcomes measured by the 6-month GCS-Extended (odds ratio 0.36, P = .002) and 6-month Disability Rating Scale score (Diff. in means 3.86, P = .002) and a longer length of hospital stay (Diff. in means 11.0 days, P < .001).

CONCLUSION

We report potential risk factors for circulatory shock after moderate-severe TBI. Our study suggests that developing circulatory shock after moderate-severe TBI is associated with poor long-term functional outcomes.

Admission rate-pressure product as an early predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage

Early prediction of in-hospital mortality in aneurysmal subarachnoid hemorrhage (aSAH) is essential for the optimal management of these patients. Recently, a retrospective cohort observation has reported that the rate-pressure product (RPP, the product of systolic blood pressure and heart rate), an objective and easily calculated bedside index of cardiac hemodynamics, was predictively associated with in-hospital mortality following traumatic brain injury. We thus wondered whether this finding could also be generalized to aSAH patients. The current study aimed to examine the association of RPP at the time of emergency room (ER) admission with in-hospital mortality and its predictive performance among aSAH patients. We retrospectively included 515 aSAH patients who had been admitted to our ER between 2016 and 2020. Their baseline heart rate and systolic blood pressure at ER presentation were extracted for the calculation of the admission RPP. Meanwhile, we collected relevant clinical, laboratory, and neuroimaging data. Then, these data including the admission RPP were examined by univariate and multivariate analyses to identify independent predictors of hospital mortality. Eventually, continuous and ordinal variables were selected from those independent predictors, and the performance of these selected predictors was further evaluated and compared based on receiver operating characteristic (ROC) curve analyzes. We identified both low (< 10,000; adjusted odds ratio (OR) 3.49, 95% CI 1.93-6.29, p < 0.001) and high (> 15,000; adjusted OR 8.42, 95% CI 4.16-17.06, p < 0.001) RPP on ER admission to be independently associated with in-hospital mortality after aSAH. Furthermore, after centering the admission RPP by its median, the area under its ROC curve (0.761, 95% CI 0.722-0.798, p < 0.001) was found to be statistically superior to any of the other independent predictors included in the ROC analyzes (all p < 0.01). In light of the predictive superiority of the admission RPP, as well as its objectivity and easy accessibility, it is indeed a potentially more applicable predictor for in-hospital death in aSAH patients.

How to manage traumatic brain injury without invasive monitoring?

PURPOSE OF REVIEW

Severe traumatic brain injury (TBI) is an extremely serious health problem, especially in low-middle income countries (LMICs). The prevalence of severe TBI continues to increase in LMICs. Major limitations in the chain of care for TBI patients are common in LMICs including suboptimal or nonexistent prehospital care, overburdened emergency services, lack of trained human resources and limited availability of ICUs. Basic neuromonitoring, such as intracranial pressure, are unavailable or underutilized and advanced techniques are not available.

RECENT FINDINGS

Attention to fundamental principles of TBI care in LMICs, including early categorization, prevention and treatment of secondary insults, use of low-cost technology for evaluation of intracranial bleeding and neuromonitoring, and emphasis on education of human resources and multidisciplinary work, are particularly important in LMICs. Institutional collaborations between high-income and LMICs have developed evidence focused on available resources. Accordingly, an expert group have proposed consensus recommendations for centers without availability of invasive brain monitoring.

SUMMARY

Severe TBI is very prevalent in LMIC and neuromonitoring is often not available in these environments. When intracranial pressure monitors are not available, careful attention to changes on clinical examination, serial imaging and noninvasive monitoring techniques can help recognize intracranial hypertension and effectively guide treatment decisions.

Left Ventricular Function in the Initial Period After Severe Traumatic Brain Injury in Swine

BACKGROUND

Cardiac dysfunction is common in the days after severe traumatic brain injury (TBI) and may contribute to hypotension episodes, leading to worse outcomes. Little is known about cardiac function in the minutes and hours immediately following TBI. By using fluid percussion TBI in a swine model, we aimed to characterize the immediate post injury cardiac function.

METHODS

Intubated, anesthetized immature (25.8 ± 1.5 kg) female swine were subjected to severe fluid percussion TBI (4.2 ± 0.2 atm). Beginning at 45 min, simulating hospital arrival, all animals were resuscitated with normal saline (NS), mannitol, and phenylephrine as needed to maintain a cerebral perfusion pressure more than 60 mm Hg and intracranial pressure (ICP) less than 20 mm Hg. Primary outcomes of cardiac function were cardiac output measured by thermodilution and transesophageal echo measurements of cardiac function recorded at prespecified time points and tested for trends over time using linear regression with spline at the time of resuscitation onset. Secondary outcomes included hemodynamic measurements, ICP, and cerebral perfusion pressure.

RESULTS

Eighteen animals were included. Post-TBI hemodynamic changes demonstrated an early decrease in mean arterial pressure and cerebral perfusion pressure with a corresponding increase in heart rate and ICP. Immediately after injury, there was a significant decrease in both left atrial area and tissue Doppler imaging e' of the LV lateral wall. In addition, there was a simultaneous increase in LV end diastolic diameter and increase in E/e' ratio of the lateral mitral annulus. All other transesophageal echo measurements demonstrated no significant changes throughout the duration of the experiment.

CONCLUSIONS

Traumatic brain injury is associated with cardiac dysfunction and increased mortality, however there is still a limited understanding of the hemodynamic and echocardiographic response associated with TBI. In this study we demonstrate the hemodynamic and echocardiographic changes in the early stages of TBI in swine. The authors hope that these results may help better understanding on the management of patients with severe head injury.

The Omnipresence of Autonomic Modulation in Health and Disease

The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.

Survival status and predictors of mortality among traumatic brain injury patients in an Ethiopian hospital: A retrospective cohort study

INTRODUCTION

Traumatic brain injury is a major global public health problem causing substantial mortality among the adult population. Hence, this study aimed to determine the predictors of mortality among adult traumatic brain injury patients in Felegehiwot Comprehensive Specialized Hospital in Northwest Ethiopia during 2020.

METHODS

A retrospective cohort study was conducted at Felegehiwot Comprehensive Specialized Hospital using anonymized patient data obtained from chart review. Descriptive statistics were used to summarise the patient characteristics. The Kaplan-Meier survival curve and log-rank test were used to test for differences in survival status among groups. The Cox proportional hazards regression model was used at the 5% level of significance to determine the net effect of each explanatory variable on time to death.

RESULTS

In total, 338 patients aged ≥15 years and diagnosed with traumatic brain injury were included in the analysis. Among these patients, 103 (30.45%) died, giving a crude death rate of 25.53 per 1000 (95% CI: 21.05-30.98) person-days of follow-up. The overall median survival time was 44 days. The independent predictors of mortality after diagnosis of traumatic brain injury were admission Glasgow coma scale score ≤ 8 (adjusted hazard ratio (AHR): 4.85; 95% confidence interval (CI): 1.73-13.62), bilateral non-reactive pupils at admission (AHR: 2.00 (95% CI: 1.10-3.71), elevated systolic blood pressure at admission (AHR: 0.31; 95% CI:0.11-0.86), elevated diastolic blood pressure at admission (AHR: 3.54; 95% CI: 1.33-9.43), and haematoma evacuation (AHR: 0.42; 95% CI: 0.16-0.90).

DISCUSSION

The Survival status of traumatic brain injury patients was relatively low in this study. Glasgow coma scale score, bilateral non-reactive pupils, and elevated blood pressure were significant predictors of mortality. Further prospective follow-up studies that include residence and occupation are recommended.

Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management

Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.

Takotsubo Syndrome: Uncovering Myths and Misconceptions

PURPOSE OF REVIEW

Takotsubo syndrome (TTS) was described in Japan 3 decades ago to affect predominately postmenopausal women after emotional stress. This history is the basis of commonly held beliefs which may contribute to the underdiagnosis and misperception of TTS.

RECENT FINDINGS

TTS affects not only women, but can be present in both sexes, and can appear in children as well as in the elderly. TTS is characterized by unique clinical characteristics with morphological variants, and incurs a substantial risk for recurrent events and adverse outcomes. Physical triggers are more common than emotional triggers and are major disease determinants. TTS seems not to be completely transient as patients report ongoing chest pain, dyspnea, or fatigue even after months of the acute event. Knowledge of the clinical features and outcomes of TTS patients has evolved substantially over the past decades. The heterogeneous appearance of TTS needs to be recognized in all medical disciplines to maximize therapy and improve outcomes.

Ten physiological commandments for severe head injury

Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.

Echocardiogram Utilization Patterns and Association With Mortality Following Severe Traumatic Brain Injury

BACKGROUND

Severe traumatic brain injury (TBI) can result in left ventricular dysfunction, which can lead to hypotension and secondary brain injuries. Although echocardiography is often used to examine cardiovascular function in multiple clinical settings, its use and association with outcomes following severe TBI are not known. To address this gap, we used the National Trauma Data Bank (NTDB) to describe utilization patterns of echocardiography and examine its association with mortality following severe TBI.

METHODS

A retrospective cohort study was conducted using a large administrative trauma registry maintained by the NTDB from 2007 to 2014. Patients >18 years with isolated severe TBI, and without concurrent severe polytrauma, were included in the study. We examined echocardiogram utilization patterns (including overall utilization, factors associated with utilization, and variation in utilization) and the association of echocardiography utilization with hospital mortality, using multivariable logistic regression models.

RESULTS

Among 47,808 patients, echocardiogram was utilized as part of clinical care in 2548 patients (5.3%). Clinical factors including vascular comorbidities and hemodynamic instability were associated with increased use of echocardiograms. Nearly half (46.0%, 95% confidence interval [CI], 40.3%-51.7%) of the variation in echocardiogram utilization was explained at the individual hospital level, above and beyond patient and injury factors. Exposure to an echocardiogram was associated with decreased odds of in-hospital mortality following severe TBI (adjusted odds ratio [OR] = 0.77; 95% CI, 0.69-0.87; P < .001).

CONCLUSIONS

Echocardiogram utilization following severe TBI is relatively low, with wide variation in use at the hospital level. The association with decreased in-hospital mortality suggests that the information derived from echocardiography may be relevant to improving patient outcomes but will require confirmation in further prospective studies.

Ten physiological commandments for severe head injury

Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.

Neurological complications of cardiomyopathies

There is a multifaceted relationship between the cardiomyopathies and a wide spectrum of neurological disorders. Severe acute neurological events, such as a status epilepticus and aneurysmal subarachnoid hemorrhage, may result in an acute cardiomyopathy the likes of Takotsubo cardiomyopathy. Conversely, the cardiomyopathies may result in a wide array of neurological disorders. Diagnosis of a cardiomyopathy may have already been established at the time of the index neurological event, or the neurological event may have prompted subsequent cardiac investigations, which ultimately lead to the diagnosis of a cardiomyopathy. The cardiomyopathies belong to one of the many phenotypes of complex genetic diseases or syndromes, which may also involve the central or peripheral nervous systems. A number of exogenous agents or risk factors such as diphtheria, alcohol, and several viruses may result in secondary cardiomyopathies accompanied by several neurological manifestations. A variety of neuromuscular disorders, such as myotonic dystrophy or amyloidosis, may demonstrate cardiac involvement during their clinical course. Furthermore, a number of genetic cardiomyopathies phenotypically incorporate during their clinical evolution, a gamut of neurological manifestations, usually neuromuscular in nature. Likewise, neurological complications may be the result of diagnostic procedures or medications for the cardiomyopathies and vice versa. Neurological manifestations of the cardiomyopathies are broad and include, among others, transient ischemic attacks, ischemic strokes, intracranial hemorrhages, syncope, muscle weakness and atrophy, myotonia, cramps, ataxia, seizures, intellectual developmental disorder, cognitive impairment, dementia, oculomotor palsies, deafness, retinal involvement, and headaches.

Multi-Organ Dysfunction in Cerebral Palsy

Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.

Effects of acute neurologic disease on the heart

Patients with acute neurologic disease often also have evidence of cardiac dysfunction. The cardiac dysfunction may result in a number of clinical signs including abnormal EKG changes, variations in blood pressure, development of cardiac arrhythmias, release of cardiac biomarkers, and reduced ventricular function. Although typically reversible, these cardiac complications are important to recognize as they are associated with increased morbidity and mortality. In this chapter, we discuss the suspected pathophysiology, clinical presentation, and management of the cardiac dysfunction that occur as a consequence of different types of acute neurologic illness.

Combined head and abdominal blunt trauma in the hemodynamically unstable patient: What takes priority?

BACKGROUND

The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness.

METHODS

National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures.

RESULTS

Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004).

CONCLUSION

The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Sedation for Rapid Sequence Induction and Intubation of Neurologically Injured Patients

There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.

Stress cardiomyopathy misinterpreted as ST-segment elevation myocardial infarction in a patient with aneurysmal subarachnoid hemorrhage: a case report

Cardiac abnormalities are frequently reported in acute subarachnoid hemorrhage (SAH) patients. However, frank ST-elevation and myocardial dysfunction mimicking acute coronary syndrome is a rare occurrence. Systemic and local catecholamine release mediate myocardial injury and may explain raised troponin levels, concordant regional wall motion abnormalities and systolic dysfunction. These findings can pose a significant problem in the acute setting where "time-is-muscle" paradigm can rush clinicians towards a "rule-in" diagnosis of acute myocardial infarction. We present the case of a 60-year-old male who arrived at a regional emergency department with loss of consciousness, chest pain and headache. His ECG showed ST-elevation in precordial leads with corresponding region wall motion abnormalities and dynamically elevated troponin levels which supported a diagnosis of acute myocardial infarction. Percutaneous coronary intervention was attempted but found no hemodynamically significant lesions and the patient was managed conservatively with antithrombotic treatment. Further work-up for his headache led to the diagnosis of aneurysmal SAH and subsequent endovascular coiling. The patient was discharged with a good clinical outcome. We discuss the potential catastrophic consequences of interpreting neurologic myocardial stunning as STEMI. Use of potent antithrombotic therapies, like bridging thrombolysis, in this setting can lead to dismal consequences. Clinical history should still be carefully obtained in the acute setting in this era of sensitive biomarkers.

Slow Heart Rate Within 72 Hours After Cardiac Arrest Is Associated with Good Neurologic Outcome in Out-of-Hospital Cardiac Arrest Survivors Who Undergo Targeted Temperature Management with 33°C

We aimed to verify whether slow heart rate (HR) is associated with neurologic outcome and the factors that can contribute to the development of bradycardia in out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management (TTM). We extracted the data of comatose adult OHCA survivors who underwent TTM between October 2015 and December 2018 from the prospective multicenter registry. Data on HR recorded every 6 hours within 72 hours after return of spontaneous circulation and calculated minimal, mean, and maximal HR and time to the lowest HR were obtained. HR <50 bpm was defined as bradycardia. The primary outcome was a 6-month neurologic outcome based on Pittsburgh-Glasgow Cerebral Performance Category Scale. Of the 814 included patients, 508 (62.4%) had poor neurologic outcome and 197 (24.2%) had bradycardia. Bradycardia (odds ratio [OR], 0.574; 95% confidence interval [CI], 0.362-0.192), minimal HR (OR, 1.023; 95% CI, 1.008-1.037), and mean HR (OR, 1.016; 95% CI, 1.002-1.030) were independently associated with poor neurologic outcome, but not maximal HR and time to the lowest HR. Preexisting arrhythmia (OR, 2.067; 95% CI, 1.037-4.118), renal disease (OR, 2.028; 95% CI, 1.153-3.567), cardiac etiology (OR, 1.526; 95% CI, 1.045-2.228), downtime (OR, 0.985; 95% CI, 0.974-0.996), and serum lactate levels (OR, 0.936; 95% CI, 0.900-0.974) were independently associated with bradycardia. Bradycardia and decreased mean and minimal HR were independently associated with good neurologic outcomes. Bradycardia was associated with preexisting arrhythmia, renal disease, cardiac etiology, shorter downtime, and lower serum lactate level.

Fingolimod Attenuates Lung Injury and Cardiac Dysfunction after Traumatic Brain Injury

Acute lung injury (ALI) and cardiac dysfunction are common in traumatic brain injury (TBI) patients and always indicate poor outcomes. Inflammatory responses play important roles in TBI-induced cardiac and pulmonary damage. Fingolimod, an immunomodulatory agent, alleviates brain edema, restores the integrity of the blood-brain barrier (BBB), and improves functional deficits by inhibiting multiple inflammatory responses. Fingolimod (1 mg/kg) was injected intraperitoneally at 2 h after the controlled cortical impact (CCI) model was established in adult male mice. The concentration of inflammatory cytokines in the lung and heart after TBI was measured with a cytokine array. The lung wet/dry weight ratio and Evans blue dye leakage were used to quantify pulmonary edema and capillary leakage. Immunofluorescence, electron microscopy, and echocardiographic examination were used to assess the pathology and functional deficits in hearts. We found that TBI caused significant heart and lung damage. The administration of fingolimod significantly reduced the elevated inflammatory cytokine production, neutrophil infiltration, the leakage of protein in bronchoalveolar lavage fluid (BALF), and the wet/dry weight ratio in lung tissue at 3 days after TBI. In addition, fingolimod treatment also alleviated the inflammatory response in the heart; decreased cardiac apoptosis, fibrosis, and histological microstructural changes; and improved cardiac function from 3 days after TBI and maintained it for 30 days after TBI as measured by echocardiography. These results suggest that TBI resulted in significant cardiac and pulmonary damage accompanied by significant inflammatory responses in heart and lung tissue. Fingolimod treatment reduced the inflammatory response and alleviated TBI-induced lung and heart injury.

Cardiac-cerebral-renal associations in pediatric traumatic brain injury: Preliminary findings

OBJECTIVE

The clinical epidemiology of organ outcomes in pediatric traumatic brain injury (TBI) has not been examined. We describe associated markers of cerebral, cardiac and renal injury after pediatric TBI.

DESIGN

Prospective observational study.

PATIENTS

Children 0-18 years who were hospitalized with TBI.

MEASUREMENTS

Measures of myocardial (at least one elevated plasma troponin [cTnI] ≥ 0.4 ng/ml) and multiorgan (hemodynamic variables, cerebral perfusion, and renal) function were examined within the first ten days of hospital admission and within 24 h of each other.

MAIN RESULTS

Data from 28 children who were 11[IQR 10.3] years, male (64.3%), with isolated TBI (67.9%), injury severity score (ISS) 25[10], and admission Glasgow coma score (GCS) 11[9] were examined. Overall, 50% (14 children) had elevated cTnI, including those with isolated TBI (57.9%; 11/19), polytrauma (33.3%; 3/9), mild TBI (57.1% 8/14), and severe TBI (42.9%; 6/11). Elevated cTnI occurred within the first six days of admission and across all age groups, in both sexes, and regardless of TBI lesion type, GCS, and ISS. Age-adjusted admission tachycardia was associated with cTnI elevation (AUC 0.82; p < 0.001). Reduced urine output occurred more commonly in patients with isolated TBI (27.3% elevated cTnI vs. 0% normal cTnI).

CONCLUSIONS

Myocardial injury commonly occurs during the first six days after pediatric TBI irrespective of injury severity, age, sex, TBI lesion type, or polytrauma. Age-adjusted tachycardia may be a clinical indicator of myocardial injury, and elevated troponin may be associated with cardio-cerebro-renal dysfunction.

Speckle Tracking Analysis of Left Ventricular Systolic Function Following Traumatic Brain Injury: A Pilot Prospective Observational Cohort Study

BACKGROUND

Systolic dysfunction and reduction in left ventricular ejection fraction (LVEF) has been documented after traumatic brain injury (TBI). Speckle tracking is an emerging technology for myocardial strain assessment which has been utilized to identify subclinical myocardial dysfunction, and is most commonly reported as global longitudinal strain (GLS). We examined myocardial strain and regional strain patterns following moderate-severe TBI.

MATERIALS AND METHODS

We conducted a prospective cohort study of moderate-severe TBI patients (Glasgow Coma Scale≤12) and age/sex-matched controls. Transthoracic echocardiography was performed within the first day and 1 week following TBI. Myocardial function was assessed using both GLS and LVEF, and impaired systolic function was defined as GLS >-16% or LVEF ≤50%. Regional strain patterns and individual strain trajectories were examined.

RESULTS

Thirty subjects were included, 15 patients with TBI and 15 age/sex-matched controls. Among patients with adequate echocardiographic windows, systolic dysfunction was observed in 2 (17%) patients using LVEF and 5 (38%) patients using GLS within the first day after TBI. Mean GLS was impaired in patients with TBI compared with controls (-16.4±3.8% vs. -20.7±1.8%, P=0.001). Regional myocardial examination revealed impaired strain primarily in the basal and mid-ventricular segments. There was no improvement in GLS from day 1 to day 7 (P=0.81).

CONCLUSIONS

Myocardial strain abnormalities are common and persist for at least 1 week following moderate-severe TBI. Speckle tracking may be useful for the early diagnosis and monitoring of systolic dysfunction following TBI.

The Short-Term Effects of Isolated Traumatic Brain Injury on the Heart in Experimental Healthy Rats

BACKGROUND

To date, cardiac dysfunction after traumatic brain injury (TBI) has not been consistent. In this study, we hypothesized that TBI may play a role in the development of new-onset cardiac dysfunction in healthy experimental rats.

MATERIALS AND METHODS

Anesthetized healthy male Sprague-Dawley rats were divided into two groups: a sham-operated control group and a TBI group. The brain was injured with 2.4 atm percussion via a fluid percussion injury model. During the 120 min after TBI, we continuously measured brain parameters, including intracranial pressure (ICP) and cerebral perfusion pressure (CPP), and cardiac parameters, such as heart rate (HR), inter-ventricular septum dimension (IVSD), left ventricular internal dimension diastole (LVIDd), end-diastolic volume (EDV), ejection fraction (EF), fractional shortening (FS), and LV mass diastole (LVd mass) by cardiac echo. On days 1, 3, 7, and 14 after TBI, the brain damage volume was evaluated with triphenyltetrazolium chloride; the physiological parameters of the heart, including HR, IVSd, LVIDd, EDV, EF, FS, and LVd mass, were evaluated with cardiac echo; the morphology of cardiomyocytes was examined by hematoxylin and eosin (HE) and Masson trichrome staining; and the biomarkers of cardiac injury troponin I and B-type natriuretic peptide (BNP) were also examined.

RESULTS

Compared to sham-operated controls, the TBI groups had higher ICP, lower CPP, and higher brain neuronal apoptosis and infarction contusion volume. The impact of TBI on heart function showed hyperdynamic response trends in IVSd, LVIDd, EDV, EF, FS, and LVd mass within 30 min after TBI; however, EF and FS exhibited eventual decreasing trends. Simultaneously, the values of the biomarkers troponin I and BNP were within normal limits, and HE and Mass trichrome staining revealed no significant differences between the sham-operated control group and the TBI group.

CONCLUSIONS

Our results suggest that TBI due to 2.4 atm fluid percussion injury in healthy experimental rats may cause significant damage to the brain and affect the heart function as investigated by cardiac echo but not as investigated by HE and Masson trichrome stainings or troponin I and BNP evaluation.

Inhibition of Hypothalamic Inhibitor κB Kinase β/Nuclear Transcription Factor κB Pathway Attenuates Metabolism and Cardiac Dysfunction in Type 2 Diabetic Rats

BACKGROUND

Inflammation and oxidative stress play important roles in energy imbalance and its complications. Recent research indicates that hypothalamic inflammation may contribute to the pathogenesis of metabolic syndrome and cardiac dysfunction, but the mechanisms remain unclear. We hypothesized that suppression of the proinflammatory IKKβ/NF-κB pathway in the hypothalamus can improve energy balance and cardiac function in type 2 diabetic (T2D) rats.

METHODS

Normal and T2D rats received bilateral hypothalamic arcuate nucleus (ARC) infusions of the IKKβ inhibitor SC-514 or vehicle via osmotic minipump. Metabolic phenotyping, immunohistochemical analyses, and biochemical analyses were used to investigate the outcomes of inhibition of the hypothalamic IKKβ. Echocardiography and glucometer were used for measuring cardiac function and blood glucose, respectively. Blood samples were collected for the evaluation of circulating proinflammatory cytokines. Heart was harvested for cardiac morphology evaluations. The ARC was harvested and analyzed for IKKβ, NF-κB, proinflammatory cytokines, reactive oxygen species (ROS), and NAD(P)H (gp91phox, p47phox) oxidase activity levels and neuropeptides.

RESULTS

Compared with normal rats, T2D rats were characterized by hyperglycemia, hyperinsulinemia, glucose intolerance, cardiac dysfunction, as well as higher ARC levels of IKKβ, NF-κB, proinflammatory cytokines, ROS, gp91phox, and p47phox. ARC infusion of the IKKβ inhibitor SC-514 attenuated all these changes in T2D rats, but not in normal rats.

CONCLUSIONS

Our results indicate that the hypothalamic IKKβ/NF-κB pathway plays a key role in modulating energy imbalance and cardiac dysfunction, suggesting its potential therapeutic role during type 2 diabetes mellitus.

A Randomized Trial of Intravenous Thyroxine for Brain-Dead Organ Donors With Impaired Cardiac Function

RATIONALE

Brain death (BD) precipitates cardiac dysfunction impairing the ability to transplant hearts from eligible organ donors. Retrospective studies have suggested that thyroid hormone may enhance myocardial recovery and increase hearts transplanted. We performed a randomized trial evaluating whether intravenous thyroxine (T4) improves cardiac function in BD donors with impaired ejection fraction (EF).

METHODS

All heart-eligible donors managed at a single-organ procurement organization (OPO) underwent protocolized fluid resuscitation. Those weaned off vasopressors underwent transthoracic echocardiography (TTE) within 12 hours of BD and, if EF was below 60%, were randomized to T4 infusion or no T4 for 8 hours, after which TTE was repeated.

RESULTS

Of 77 heart-eligible donors, 36 were weaned off vasopressors. Ejection fraction was depressed in 30, of whom 28 were randomized to T4 (n = 17) vs control (n = 11). Baseline EF was comparable (45%, interquartile range [IQR] 42.5-47.5 vs 40%, 40-50, P = .32). Ejection fraction did not improve more with T4 (10%, IQR 5-15 vs 5%, 0-12.5, P = .24), although there was a trend to more hearts transplanted (59% vs 27%, P = .14). This difference appeared to be accounted for by more donors with a history of drug use in the T4 group, who exhibited greater improvements in EF (15% vs 0% without drug use, P = .01) and more often had hearts transplanted (12 of 19 vs 1 of 9, P = .01).

CONCLUSIONS

In this small randomized study of BD donors with impaired cardiac function, T4 infusion did not result in greater cardiac recovery. A larger randomized trial comparing T4 to placebo appears warranted but would require collaboration across multiple OPOs.

Cerebral Perfusion Pressure Directed-Therapy Modulates Cardiac Dysfunction After Traumatic Brain Injury to Influence Cerebral Autoregulation in Pigs

BACKGROUND

Traumatic brain injury (TBI) is an important contributor to morbidity and mortality. Low cerebral perfusion pressure (CPP, mean arterial pressure [MAP] minus intracranial pressure) after TBI is associated with cerebral ischemia, impaired cerebral autoregulation, and poor outcomes. Normalization of CPP and limitation of cerebral autoregulation impairment is a key therapeutic goal. However, some vasoactive agents used to elevate MAP such as phenylephrine (Phe) improve outcome in females but not male piglets after TBI while dopamine (DA) does so in both sexes. Clinical evidence has implicated neurological injuries as a cause of cardiac dysfunction, and we recently described cardiac dysfunction after TBI. Cardiac dysfunction may, in turn, influence brain health. One mechanism of myocyte injury may involve catecholamine excess. We therefore tested the hypothesis that TBI caused cardiac dysfunction and catecholamine excess which may reciprocally be modulated by vasoactive agent choice to normalize CPP and prevent impairment of cerebral autoregulation after injury.

METHODS

TBI was produced in anesthetized pigs equipped with a closed cranial window, and Phe or DA administered to normalize CPP.

RESULTS

Plasma cardiac enzymes troponin and creatine kinase and catecholamines epinephrine and norepinephrine were elevated by TBI, such release potentiated by Phe in males but blocked in female piglets and blocked in both sexes after DA. Cerebral autoregulation was impaired after TBI, worsened by Phe in males but protected in females and males treated with DA. Papaverine-induced dilation was unchanged by fluid percussion brain injury, DA, and Phe.

CONCLUSIONS

These data indicate that pressor choice in elevation of CPP is important in limiting cardiac dysfunction and suggest that DA protects cerebral autoregulation in both sexes via reduction of cardiac biomarkers of injury and catecholamines released after TBI.

Neurogenic Stunned Myocardium in Two Children with Neurological Injury

Neurogenic stunned myocardium is described as sudden and reversible cardiac dysfunction induced by an acute neurological event. This phenomenon has not been thoroughly investigated in infants, and is probably underdiagnosed. Here, we report the cases of two infants with neurogenic stunned myocardium in whom the clinical suspicion was relevant, with a brief discussion of this condition.

Elevated Cardiac Troponin in Clinical Scenarios Beyond Obstructive Coronary Artery Disease

In this systematic review article, we aim to summarize the most up-to-date evidence regarding elevations of cardiac troponin, especially in clinical scenarios other than obstructive coronary artery disease. The accurate interpretation of raised cardiac troponin is challenging because it relies on unconfirmed postulations and dogmatic knowledge (e.g., the exclusive provenience of cardiac troponin from cardiac myocytes), based on which every troponin elevation is assumed to definitely indicate myocardial damage. Indeed, the investigation of the pathophysiologic mechanism leading to the release in the bloodstream of cardiac biomarkers should be the first step of the diagnostic process to fully understand the clinical significance of the elevated serum levels and identify the best management. A prominent effort should be put in place to identify the contribution of potential confounding factors, both cardiac and non-cardiac in etiology, with the ability to affect synthesis and clearance of cardiac biomarkers. Regardless of the underlying cause, it is well established that cardiovascular biomarkers are increasingly useful to further risk stratification and prognosticate patients. Accordingly, we sought to clarify the meaning and impact of elevated cardiac troponin in those frequently encountered real-world scenarios presenting clinicians with a diagnostic dilemma, with the final goal of facilitating the diagnosis and help optimize individually tailored treatment strategies.

Propranolol protects cerebral autoregulation and reduces hippocampal neuronal cell death through inhibition of interleukin-6 upregulation after traumatic brain injury in pigs

BACKGROUND

Traumatic brain injury (TBI) is associated with reduced cerebral blood flow and impaired autoregulation after TBI, which may lead to poor outcome. Clinical evidence has implicated neurological injuries and associated neuroinflammation as causes of cardiac dysfunction. Studies on newborn pigs show an association of elevated catecholamines with a sex-dependent impairment of cerebral autoregulation after TBI. One strategy to decrease sympathetic hyperactivity is pharmacological intervention with beta blockade. We tested the hypothesis that propranolol would prevent the impairment of cerebral autoregulation and tissue changes after TBI via inhibition of interleukin-6 (IL-6) upregulation.

METHODS

Using newborn pigs of both sexes equipped with a closed cranial window, TBI was induced via lateral fluid percussion injury. Propranolol was administered at 1 h post-TBI. Analyses included cerebral autoregulation (pial artery reactivity) before and 4 h post-TBI, CSF IL-6 analysed (enzyme-linked immunosorbent assay), and histopathology at 4 h post-TBI.

RESULTS

Propranolol administration prevented impairment of hypotensive dilation in both male and female newborn pigs after fluid percussion injury, which was paralleled by reduced upregulation of IL-6 in the CSF. Moreover, propranolol prevented neuronal cell death in cornu amonis (CA)1 and CA3 hippocampus equivalently in male and female pigs after TBI. Papaverine-induced dilation was unchanged by TBI and propranolol.

CONCLUSIONS

These data indicate that sympathetic hyperactivity noted after TBI can be limited by propranolol administration to result in improved brain outcome post-injury via block of IL-6 upregulation, and this effect is irrespective of sex.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Resuscitation Strategies for Traumatic Brain Injury

PURPOSE OF REVIEW

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality; however, little definitive evidence exists about most clinical management strategies. Here, we highlight important differences between two major guidelines, the 2016 Brain Trauma Foundation guidelines and the Lund Concept, along with recent pre-clinical and clinical data.

RECENT FINDINGS

While intracranial pressure (ICP) monitoring has been questioned, the majority of literature demonstrates benefit in severe TBI. The optimal cerebral perfusion pressure (CPP) and ICP are yet unknown, but likely as important is the concept of ICP burden. The evidence for anti-hypertensive therapy is strengthening. Decompressive craniectomy improves mortality, but at the cost of increased morbidity. Plasma-based resuscitation has demonstrated benefit in multiple pre-clinical TBI studies.

SUMMARY

The management of hemodynamics and intravascular volume are crucial in TBI. Based on recent evidence, ICP monitoring, anti-hypertensive therapy, minimal use of vasopressors/inotropes, and plasma resuscitation may improve outcomes.

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

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

Prognostic Value of Echocardiography for Left Ventricular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

Cardiac dysfunction may worsen outcomes after aneurysmal subarachnoid hemorrhage (SAH). This study quantitatively assessed the prognostic value of left ventricular dysfunction with respect to functional outcomes and mortality in patients with aneurysmal SAH.

METHODS

We searched MEDLINE and EMBASE databases to retrieve relevant studies evaluating echocardiographic left ventricular dysfunction following aneurysmal SAH. Fourteen relevant observational studies evaluating 2234 patients were finally included in this study.

RESULTS

Echocardiographic regional wall motion abnormalities (RWMA) and neurogenic cardiomyopathy (NCM) of the left ventricle occurring after SAH were significantly related to an increase of in-hospital mortality (in 8 studies for RWMA, odds ratio [OR] 2.37; 95% confidence interval [CI] 1.74-3.25 and in 5 studies for NCM, OR 2.82; 95% CI 1.2-6.6). Decreased ejection fraction on echocardiography was not associated with the increase of in-hospital mortality (in 4 studies, OR 1.76; 95% CI 0.86-3.61). The heterogeneities of decreased ejection fraction and NCM were significantly resolved by analyzing only the studies based on echocardiogram measurements obtained within 72 hours after admission.

CONCLUSIONS

The present meta-analysis suggests that the identification of echocardiographic left ventricular dysfunction identified by RWMA and NCM after SAH could provide better prognostic information for in-hospital mortality.

Traumatic brain injury may worsen clinical outcomes after prolonged partial resuscitative endovascular balloon occlusion of the aorta in severe hemorrhagic shock model

BACKGROUND

The use of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) in combined hemorrhagic shock (HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that the use of pREBOA in the setting of TBI would be associated with worse clinical outcomes.

METHODS

Female Yorkshire swine were randomized to the following groups: HS-TBI, HS-TBI-pREBOA, and HS-pREBOA (n = 5/cohort). Animals in the HS-TBI group were left in shock for a total of 2 hours, whereas animals assigned to pREBOA groups were treated with supraceliac pREBOA deployment (60 minutes) 1 hour into the shock period. All animals were then resuscitated, and physiologic parameters were monitored for 6 hours. Further fluid resuscitation and vasopressors were administered as needed. At the end of the observation period, brain hemispheric swelling (%) and lesion size (mm) were assessed.

RESULTS

Mortality was highest in the HS-TBI-pREBOA group (40% [2/5] vs. 0% [0/5] in the other groups, p = 0.1). Severity of shock was greatest in the HS-TBI-pREBOA group, as defined by peak lactate levels and pH nadir (p < 0.05). Fluid resuscitation and norepinephrine requirements were significantly higher in the HS-TBI-pREBOA group (p < 0.05). No significant differences were noted in brain hemispheric swelling and lesion size between the groups.

CONCLUSION

Prolonged application of pREBOA in the setting of TBI does not contribute to early worsening of brain lesion size and edema. However, the addition of TBI to HS-pREBOA may worsen the severity of shock. Providers should be aware of the potential physiologic sequelae induced by TBI.

Speckle tracking-vs conventional echocardiography for the detection of myocardial injury-A study on patients with subarachnoid haemorrhage

BACKGROUND

Myocardial injury with regional wall motion abnormalities (RWMA) is common in subarachnoid haemorrhage (SAH). We hypothesized that the diagnostic performance of left ventricular (LV) global and regional longitudinal strain (GLS and RLS, respectively), assessed with speckle tracking echocardiography is superior to standard echocardiography for the detection of myocardial injury in SAH.

METHODS

Seventy-one unselected patients with verified SAH were included. Echocardiography was performed within 48 hours after admission. hsTnT was followed daily up to 3 days post-admission. RWMA, LV ejection fraction (LVEF), GLS and RLS were analysed by two experienced echocardiographists, blinded to the information on plasma hsTnT. A reduced GLS was defined as >-15%. Two cut-off levels were used for the definition of RLS, ie when segmental strain was >-15% (liberal) or >-11% (conservative) in ≥2 adjacent segments. Myocardial injury was defined as a peak hsTnT ≥90 ng/L.

RESULTS

The incidence of myocardial injury was 25%. The hsTnT (median, 25% and 75% percentile) in patients with (a) reduced LV ejection fraction (LVEF <50%, n = 10) was 502 (175-718), (b) RWMA (n = 12) was 648 (337-750), (c) reduced GLS (n = 12) was 502 (132-750) and (d) reduced RLS (n = 42) was 40 (10-216), respectively. The specificity/sensitivity for LVEF, RWMA, GLS and RLS to detect myocardial injury 98%/50%, 100%/67%, 96%/56% and 54%/94%, respectively. The intra- and inter-observer variability for assessment of RLS was high.

CONCLUSION

The diagnostic performance of GLS by strain imaging is not superior to standard echocardiography for the detection of myocardial injury in SAH. RLS could not reliably detect regional myocardial injury.

Traumatic Brain Injury Increases the Risk of Major Adverse Cardiovascular and Cerebrovascular Events: A 13-Year, Population-Based Study

BACKGROUND

Previous studies have indicated traumatic brain injury (TBI) as a risk factor for stroke and myocardial injury. Whether TBI increases new onset of major adverse cardiovascular and cerebrovascular events (MACCE) is not well established.

METHODS

Patients with a diagnosis of TBI from 2000 to 2012 were 1:2 age-, sex-, and age-adjusted comorbidities matched with normal population cohorts. The MACCE, which included coronary artery disease, heart failure and arrhythmia, ischemic and hemorrhagic stroke, and death, was defined as one inpatient admission with MACCE diagnosis. The maximum follow-up duration to MACCE after the initial TBI diagnosis was 5 years. The baseline comorbidities before TBI, including hypertension, diabetes mellitus, renal disease, and liver disease, also were considered to estimate the risk of MACCE.

RESULTS

In total, 16,211 patients with TBI and 32,422 people from the control group were enrolled in the current study. Our results showed that patients with TBI had a 2.77-fold risk of MACCE, 1.72-fold risk of cardiovascular disease, 2.10-fold risk of ischemic stroke, 6.02-fold risk of hemorrhagic stroke, and 3.13-fold risk of mortality compared with the control group (all P < 0.0001) after adjusting the confounding factors. In addition, the trend of cumulated incidence risk among MACCE, cardiovascular disease, ischemic and hemorrhagic stroke, and mortality presented the greatest incidence within the first year after diagnosis and persisted during the 5 years of follow-up.

CONCLUSIONS

Our results showed that patients with TBI have a significantly greater risk of MACCE than the control group. We hope this information will remind critical-care physicians and neurosurgeons to keep in mind the long-term effects of TBI on MACCE.

Probability of New-Onset Cancer Between Patients with Traumatic Brain Injury and a Comparison General Population Cohort

BACKGROUND

Traumatic brain injury (TBI) has been reported as a risk factor for the development of brain tumors. However, whether TBI affects systemic cancer remains to be determined. We investigated the incidence and factors associated with cancer development in patients with TBI.

METHODS

A propensity score (age, gender, and comorbidity)-matched longitudinal cohort study of 34,556 patients with pre-existing TBI and 69,112 patients without TBI from January 2000 to December 2015 was presented using the Taiwan's National Health Insurance Research Database. The Cox proportional hazard regression model was used to estimate the hazard ratio of developing cancer adjusted by the potential confounding factors. The stratified analysis of age, gender, and comorbidities for each cancer type was evaluated using forest plot analysis.

RESULTS

The cancer incidence rate in the patients with TBI (4.38%) was greater than that in patients without TBI (3.88%). The interval to cancer development in those with TBI (5.65 ± 3.58 years) was shorter than that in those without TBI (6.02 ± 3.65 years). The cancer risk in those with TBI was increased 1.27-fold compared with that in the general population. Of the patients with TBI, age <55 years and male gender indicated a greater incidence of cancer than that of the general population. The patients with TBI had greater cancer frequencies in the head and neck structures compared with those in the general population.

CONCLUSIONS

TBI is a risk factor for cancer development, especially in males and those aged <55 years. We hope this information will remind physicians to consider the long-term effects of TBI on cancer development.