Traumatic alterations in consciousness: traumatic brain injury

Perceived Chronic Traumatic Encephalopathy and Suicidality in Former Professional Football Players

Importance

Participation in American-style football (ASF) has been linked to chronic traumatic encephalopathy neuropathological change (CTE-NC), a specific neuropathologic finding that can only be established at autopsy. Despite being a postmortem diagnosis, living former ASF players may perceive themselves to have CTE-NC. At present, the proportion and clinical correlates of living former professional ASF athletes with perceived CTE who report suicidality are unknown.

Objective

To determine the proportion, clinical correlates, and suicidality of living former professional ASF players with perceived CTE.

Design, Setting, and Participants

A cross-sectional study within the Football Players Health Study at Harvard University was conducted from 2017 to 2020. Using electronic and paper surveys, this population-based study included former ASF players who contracted with a professional league from 1960 to 2020 and volunteered to fill out a baseline survey. Data for this study were analyzed from June 2023 through March 2024.

Exposures

Data included demographics, football-related exposures (eg, position, career duration), and current health problems (anxiety, attention-deficit/hyperactivity disorder, depression, diabetes, emotional and behavioral dyscontrol symptoms, headache, hyperlipidemia, hypertension, low testosterone level, pain, sleep apnea, and subjective cognitive function).

Main Outcomes and Measures

The proportion of participants reporting perceived CTE. Univariable and multivariable models were used to determine clinical and suicidality correlates of perceived CTE.

Results

Among 4180 former professional ASF players who volunteered to fill out a baseline survey, 1980 (47.4%) provided follow-up data (mean [SD] age, 57.7 [13.9] years). A total of 681 participants (34.4%) reported perceived CTE. Subjective cognitive difficulties, low testosterone level, headache, concussion signs and symptoms accrued during playing years, depressive/emotional and behavioral dyscontrol symptoms, pain, and younger age were significantly associated with perceived CTE. Suicidality was reported by 171 of 681 participants with perceived CTE (25.4%) and 64 of 1299 without perceived CTE (5.0%). After adjusting for established suicidality predictors (eg, depression), men with perceived CTE remained twice as likely to report suicidality (odds ratio, 2.06; 95% CI, 1.36-3.12; P < .001).

Conclusions and Relevance

This study found that approximately one-third of living former professional ASF players reported perceived CTE. Men with perceived CTE had an increased prevalence of suicidality and were more likely to have health problems associated with cognitive impairment compared with men without perceived CTE. Perceived CTE represents a novel risk factor for suicidality and, if present, should motivate the diagnostic assessment and treatment of medical and behavioral conditions that may be misattributed to CTE-NC.

Effect of a seven-strain probiotic on dietary intake, inflammatory markers, and T-cells in severe traumatic brain injury patients: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Inflammatory processes are key factors in pathological events associated with severe traumatic brain injury (STBI). The aim of this trial was to determine the effect of probiotics on anthropometric measures, disease severity, inflammatory markers, and T cells in patients with STBI.

METHODS

Forty adult patients with STBI were enrolled in this parallel randomized, double-blind, placebo-controlled trial. Energy and protein status, Acute Physiology and Chronic Health Evaluation (APACHE II) score, Sequential Organ Failure Assessment (SOFA), interleukin 10 (IL-10), interleukin 1β (IL-1β), tumor necrosis factor-alpha (TNF-α), transforming growth factor beta (TGF-β), T-helper 17 (Th17), and T- Regulator (T-reg) cells were assessed at baseline (day 1), and week 2 (day 14) for each patient.

RESULTS

Probiotic supplementation led to a substantial reduction in the serum levels of TNF-α (from 10.15 ± 6.52 to 5.05 ± 3.27) (P = 0.034), IL-1β (from 11.84 ± 7.74 to 5.87 ± 3.77) (P < 0.001), and Th17 cells (from 5.19 ± 1.69 to 2.67 ± 1.89) (P < 0.001) and a substantial increase in the serum levels of IL-10 (from 3.35 ± 1.45 to 6.17 ± 2.04) (P = 0.038), TGF-β (from 30.5 ± 15.27 to 46.25 ± 21.05) (P < 0.001), and T-reg cells (from 2.83 ± 1.43 to 4.29 ± 1.89) (P < 0.001) compared with the placebo group. Furthermore, no notable changes were observed in energy and protein intake and also, terms of SOFA and APACHE II scores following probiotic treatment compared with the placebo.

CONCLUSIONS

Probiotics could reduce inflammation and improve cellular immunity and may be considered as an adjunctive therapy in STBI patients.

Concussion burden and later-life cardiovascular risk factors in former professional American-style football players

OBJECTIVE

Mid-life cardiovascular risk factors are associated with later cognitive decline. Whether repetitive head injury among professional athletes impacts cardiovascular risk is unknown. We investigated associations between concussion burden and postcareer hypertension, high cholesterol, and diabetes among former professional American-style football (ASF) players.

METHODS

In a cross-sectional study of 4080 professional ASF players conducted between January 2015 and March 2022, we used an mulitsymptom concussion symptom score (CSS) and the number of loss-of-consciousness (LOC) episodes as a single severe symptom to quantify football-related concussion exposure. Primary outcomes were hypertension, dyslipidemia, and diabetes, defined by current or recommended prescription medication use.

RESULTS

The prevalence of hypertension, high cholesterol, and diabetes among former players (52 ± 14 years of age) was 37%, 34%, and 9%. Concussion burden was significantly associated with hypertension (lowest vs. highest CSS quartile, odds ratio (OR) = 1.99; 95%CI: 1.33-2.98; p < 0.01) and high cholesterol (lowest vs. moderate CSS, OR = 1.46, 95%CI, 1.11-1.91; p < 0.01), but not diabetes. In fully adjusted models, the prevalence of multiple CVD was associated with CSS. These results were driven by younger former players (≤ 40 year of age) in which the odds of hypertension were over three times higher in those in the highest CSS quartile (OR = 3.29, 95%CI: 1.39-7.61; p = 0.01). Results were similar for LOC analyses.

INTERPRETATION

Prior concussion burden is associated with postcareer atherogenic cardiovascular risk profiles among former professional American football players.

Mechanisms of Injury Leading to Concussions in Collegiate Soccer Players: A CARE Consortium Study

BACKGROUND

Few previous studies have investigated how different injury mechanisms leading to sport-related concussion (SRC) in soccer may affect outcomes.

PURPOSE

To describe injury mechanisms and evaluate injury mechanisms as predictors of symptom severity, return to play (RTP) initiation, and unrestricted RTP (URTP) in a cohort of collegiate soccer players.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The Concussion Assessment, Research and Education (CARE) Consortium database was used. The mechanism of injury was categorized into head-to-ball, head-to-head, head-to-body, and head-to-ground/equipment. Baseline/acute injury characteristics-including Sports Concussion Assessment Tool-3 total symptom severity (TSS), loss of consciousness (LOC), and altered mental status (AMS); descriptive data; and recovery (RTP and URTP)-were compared. Multivariable regression and Weibull models were used to assess the predictive value of the mechanism of injury on TSS and RTP/URTP, respectively.

RESULTS

Among 391 soccer SRCs, 32.7% were attributed to a head-to-ball mechanism, 27.9% to a head-to-body mechanism, 21.7% to a head-to-head mechanism, and 17.6% to a head-to-ground/equipment mechanism. Event type was significantly associated with injury mechanism [χ2(3) = 63; P < .001), such that more head-to-ball concussions occurred in practice sessions (n = 92 [51.1%] vs n = 36 [17.1%]) and more head-to-head (n = 65 [30.8%] vs n = 20 [11.1]) and head-to-body (n = 76 [36%] vs n = 33 [18.3%]) concussions occurred in competition. The primary position was significantly associated with injury mechanism [χ2(3) = 24; P < .004], with goalkeepers having no SRCs from the head-to-head mechanism (n = 0 [0%]) and forward players having the least head-to-body mechanism (n = 15 [19.2%]). LOC was also associated with injury mechanism (P = .034), with LOC being most prevalent in head-to-ground/equipment. Finally, AMS was most prevalent in head-to-ball (n = 54 [34.2%]) and head-to-body (n = 48 [30.4%]) mechanisms [χ2(3) = 9; P = .029]. In our multivariable models, the mechanism was not a predictor of TSS or RTP; however, it was associated with URTP (P = .044), with head-to-equipment/ground injuries resulting in the shortest mean number of days (14 ± 9.1 days) to URTP and the head-to-ball mechanism the longest (18.6 ± 21.6 days).

CONCLUSION

The mechanism of injury differed by event type and primary position, and LOC and AMS were different across mechanisms. Even though the mechanism of injury was not a significant predictor of acute symptom burden or time until RTP initiation, those with head-to-equipment/ground injuries spent the shortest time until URTP, and those with head-to-ball injuries had the longest time until URTP.

The neuroprotective potential of phytochemicals in traumatic brain injury: mechanistic insights and pharmacological implications

Traumatic brain injury (TBI) leads to brain damage, comprising both immediate primary damage and a subsequent cascade of secondary injury mechanisms. The primary injury results in localized brain damage, while the secondary damage initiates inflammatory responses, followed by the disruption of the blood-brain barrier, infiltration of peripheral blood cells, brain edema, and the release of various immune mediators, including chemotactic factors and interleukins. TBI disrupts molecular signaling, cell structures, and functions. In addition to physical tissue damage, such as axonal injuries, contusions, and haemorrhages, TBI interferes with brain functioning, impacting cognition, decision-making, memory, attention, and speech capabilities. Despite a deep understanding of the pathophysiology of TBI, an intensive effort to evaluate the underlying mechanisms with effective therapeutic interventions is imperative to manage the repercussions of TBI. Studies have commenced to explore the potential of employing natural compounds as therapeutic interventions for TBI. These compounds are characterized by their low toxicity and limited interactions with conventional drugs. Moreover, many natural compounds demonstrate the capacity to target various aspects of the secondary injury process. While our understanding of the pathophysiology of TBI, there is an urgent need for effective therapeutic interventions to mitigate its consequences. Here, we aimed to summarize the mechanism of action and the role of phytochemicals against TBI progression. This review discusses the therapeutic implications of various phytonutrients and addresses primary and secondary consequences of TBI. In addition, we highlighted the roles of emerging phytochemicals as promising candidates for therapeutic intervention of TBI. The review highlights the neuroprotective roles of phytochemicals against TBI and the mechanistic approach. Furthermore, our efforts focused on the underlying mechanisms, providing a better understanding of the therapeutic potential of phytochemicals in TBI therapeutics.

Traumatic brain injury derived pathological tau polymorphs induce the distinct propagation pattern and neuroinflammatory response in wild type mice

The misfolding and aggregation of the tau protein into neurofibrillary tangles constitutes a central feature of tauopathies. Traumatic brain injury (TBI) has emerged as a potential risk factor, triggering the onset and progression of tauopathies. Our previous research revealed distinct polymorphisms in soluble tau oligomers originating from single versus repetitive mild TBIs. However, the mechanisms orchestrating the dissemination of TBI brain-derived tau polymorphs (TBI-BDTPs) remain elusive. In this study, we explored whether TBI-BDTPs could initiate pathological tau formation, leading to distinct pathogenic trajectories. Wild-type mice were exposed to TBI-BDTPs from sham, single-blast (SB), or repeated-blast (RB) conditions, and their memory function was assessed through behavioral assays at 2- and 8-month post-injection. Our findings revealed that RB-BDTPs induced cognitive and motor deficits, concurrently fostering the emergence of toxic tau aggregates within the injected hippocampus. Strikingly, this tau pathology propagated to cortical layers, intensifying over time. Importantly, RB-BDTP-exposed animals displayed heightened glial cell activation, NLRP3 inflammasome formation, and increased TBI biomarkers, particularly triggering the aggregation of S100B, which is indicative of a neuroinflammatory response. Collectively, our results shed light on the intricate mechanisms underlying TBI-BDTP-induced tau pathology and its association with neuroinflammatory processes. This investigation enhances our understanding of tauopathies and their interplay with neurodegenerative and inflammatory pathways following traumatic brain injury.

DNA Methylation-Mediated Mfn2 Gene Regulation in the Brain: A Role in Brain Trauma-Induced Mitochondrial Dysfunction and Memory Deficits

Repeated mild traumatic brain injuries (rMTBI) affect mitochondrial homeostasis in the brain. However, mechanisms of long-lasting neurobehavioral effects of rMTBI are largely unknown. Mitofusin 2 (Mfn2) is a critical component of tethering complexes in mitochondria-associated membranes (MAMs) and thereby plays a pivotal role in mitochondrial functions. Herein, we investigated the implications of DNA methylation in the Mfn2 gene regulation, and its consequences on mitochondrial dysfunction in the hippocampus after rMTBI. rMTBI dramatically reduced the mitochondrial mass, which was concomitant with decrease in Mfn2 mRNA and protein levels. DNA hypermethylation at the Mfn2 gene promoter was observed post 30 days of rMTBI. The treatment of 5-Azacytidine, a pan DNA methyltransferase inhibitor, normalized DNA methylation levels at Mfn2 promoter, which further resulted into restoration of Mfn2 function. The normalization of Mfn2 function was well correlated with recovery in memory deficits in rMTBI-exposed rats. Since, glutamate excitotoxicity serves as a primary insult after TBI, we employed in vitro model of glutamate excitotoxicity in human neuronal cell line SH-SY5Y to investigate the causal epigenetic mechanisms of Mfn2 gene regulation. The glutamate excitotoxicity reduced Mfn2 levels via DNA hypermethylation at Mfn2 promoter. Loss of Mfn2 caused significant surge in cellular and mitochondrial ROS levels with lowered mitochondrial membrane potential in cultured SH-SY5Y cells. Like rMTBI, these consequences of glutamate excitotoxicity were also prevented by 5-AzaC pre-treatment. Therefore, DNA methylation serves as a vital epigenetic mechanism involved in Mfn2 expression in the brain; and this Mfn2 gene regulation may play a pivotal role in rMTBI-induced persistent cognitive deficits. Closed head weight drop injury method was employed to induce repeated mild traumatic brain (rMTBI) in jury in adult, male Wistar rats. rMTBI causes hyper DNA methylation at the Mfn2 promoter and lowers the Mfn2 expression triggering mitochondrial dysfunction. However, the treatment of 5-azacytidine normalizes DNA methylation at the Mfn2 promoter and restores mitochondrial function.

Opening the black box of traumatic brain injury: a holistic approach combining human 3D neural tissue and an in vitro traumatic brain injury induction device

Traumatic brain injury (TBI) is caused by a wide range of physical events and can induce an even larger spectrum of short- to long-term pathophysiologies. Neuroscientists have relied on animal models to understand the relationship between mechanical damages and functional alterations of neural cells. These in vivo and animal-based in vitro models represent important approaches to mimic traumas on whole brains or organized brain structures but are not fully representative of pathologies occurring after traumas on human brain parenchyma. To overcome these limitations and to establish a more accurate and comprehensive model of human TBI, we engineered an in vitro platform to induce injuries via the controlled projection of a small drop of liquid onto a 3D neural tissue engineered from human iPS cells. With this platform, biological mechanisms involved in neural cellular injury are recorded through electrophysiology measurements, quantification of biomarkers released, and two imaging methods [confocal laser scanning microscope (CLSM) and optical projection tomography (OPT)]. The results showed drastic changes in tissue electrophysiological activities and significant releases of glial and neuronal biomarkers. Tissue imaging allowed us to reconstruct the injured area spatially in 3D after staining it with specific nuclear dyes and to determine TBI resulting in cell death. In future experiments, we seek to monitor the effects of TBI-induced injuries over a prolonged time and at a higher temporal resolution to better understand the subtleties of the biomarker release kinetics and the cell recovery phases.

Volumetric MRI Findings in Mild Traumatic Brain Injury (mTBI) and Neuropsychological Outcome

Region of interest (ROI) volumetric assessment has become a standard technique in quantitative neuroimaging. ROI volume is thought to represent a coarse proxy for making inferences about the structural integrity of a brain region when compared to normative values representative of a healthy sample, adjusted for age and various demographic factors. This review focuses on structural volumetric analyses that have been performed in the study of neuropathological effects from mild traumatic brain injury (mTBI) in relation to neuropsychological outcome. From a ROI perspective, the probable candidate structures that are most likely affected in mTBI represent the target regions covered in this review. These include the corpus callosum, cingulate, thalamus, pituitary-hypothalamic area, basal ganglia, amygdala, and hippocampus and associated structures including the fornix and mammillary bodies, as well as whole brain and cerebral cortex along with the cerebellum. Ventricular volumetrics are also reviewed as an indirect assessment of parenchymal change in response to injury. This review demonstrates the potential role and limitations of examining structural changes in the ROIs mentioned above in relation to neuropsychological outcome. There is also discussion and review of the role that post-traumatic stress disorder (PTSD) may play in structural outcome in mTBI. As emphasized in the conclusions, structural volumetric findings in mTBI are likely just a single facet of what should be a multimodality approach to image analysis in mTBI, with an emphasis on how the injury damages or disrupts neural network integrity. The review provides an historical context to quantitative neuroimaging in neuropsychology along with commentary about future directions for volumetric neuroimaging research in mTBI.

Temporary or Permanent? A Clinical Challenge in the Evaluation of Traumatic Brain Injury Patients with Unconsciousness and Normal Initial Head CT

BACKGROUND

Traumatic brain injury (TBI) patients with unconsciousness and normal initial head computed tomography (CT) present a clinical dilemma for physicians and neurosurgeons in the emergency department (ED). We recorded how long it took for patients to regain consciousness and evaluated the patients' characteristics.

METHODS

From 2018 to 2020, TBI patients with unconsciousness and normal initial head CT [Glasgow coma scale (GCS) score < 13, negative CT scan and normal laboratory test results] were evaluated. Patients who regained consciousness were analyzed. Multivariate logistic regression (MLR) analyses were used to evaluate independent factors for regaining consciousness.

RESULTS

A total of 77 patients were included in this study. Fifty-eight (75.3%) patients regained consciousness, most within one day (43.1%). Nineteen (24.7%) patients never regained consciousness. MLR analysis showed that initial GCS score (odds 1.85, p = 0.017), early airway protection in ED (odds 25.02, p = 0.018) and 72-h GCS score improvement by two points (odds 0.02, p = 0.001) were independent factors for regaining consciousness. Overall, 94.1% of patients who received early airway protection and improved 2 points in 72-h GCS score regained consciousness. The association between days to M5 status and days to M6 status (consciousness) was highly significant. Fewer days to M5 status were highly associated with needing fewer days to regain consciousness.

CONCLUSIONS

For TBI patients with unconsciousness and normal initial head CT, a higher probability of regaining consciousness was observed in those who underwent early airway protection and who improved 2 points in 72-h GCS score. Regaining consciousness within a short period could be expected in patients with M5 status.

A consensus on optimization of care in patients with growth hormone deficiency and mild traumatic brain injury

OBJECTIVE/DESIGN

Approximately 2.9 million children and adults in the US experience traumatic brain injuries (TBIs) annually, most of which are considered mild. TBI can induce varying consequences on pituitary function, with growth hormone deficiency (GHD) among the more commonly reported conditions. Panels of pediatric and adult endocrinologists, neurologists, physical medicine and rehabilitation specialists, and neuropsychologists convened in February and October 2020 to discuss ongoing challenges and provide strategies for detection and optimal management of patients with mild TBI and GHD.

RESULTS

Difficulties include a low rate of seeking medical attention in the population, suboptimal screening tools, cost and complexity of GHD testing, and a lack of consensus regarding when to test or retest for GHD. Additionally, referrals to endocrinologists from other specialists are uncommon. Recommendations from the panels for managing such patients included multidisciplinary guidelines on the diagnosis and management of post-TBI GHD and additional education on long-term metabolic and probable cognitive benefits of GH replacement therapy.

CONCLUSION

As patients of all ages with mild TBI may develop GHD and/or other pituitary deficiencies, a multidisciplinary approach to provide education to endocrinologists, neurologists, neurosurgeons, traumatologists, and other providers and guidelines for the early identification and management of persistent mild TBI-related GHD are urgently needed.

Biomarkers of Neuroinflammation in Traumatic Brain Injury

Traumatic brain injury (TBI) is characterized by neuroinflammation and structural damage leading to symptoms and altered brain function. Biomarkers are useful in understanding neuroinflammation and correlations with TBI sequalae. The purpose of this paper is to identify and discuss biomarkers of neuroinflammation used to study TBI and its sequalae. A systematic review was conducted using PubMed, CINAHL, Embase, and Web of Science. A total of 350 articles met criteria; 70 used biomarkers. PRISMA criteria were used for Quality Assessment. Articles included reviews (n = 17), case-control (n = 25), cross-sectional (n = 25) studies, and randomized controlled trials (n = 3). Twenty-seven biomarkers were identified, including inflammasomes, cytokines, neuropeptides, complement complexes, miRNA and exosomes, and glial cell-specific proteins. Biomarkers aid in predicting morbidity and mortality and advance our understanding of neuroinflammation in TBI. This systematic review advances our understanding of the neuroinflammatory response to better enable nurses and clinicians to provide informed care of TBI patients.

"A" stands for airway - Which factors guide the need for on-scene airway management in facial fracture patients?

Background

Numerous guidelines highlight the need for early airway management in facial trauma patients since specific fracture patterns may induce airway obstruction. However, the incidence of these hallmark injuries, including flail mandibles and posterior displacement of the maxilla, is contentious. We aim to evaluate specific trauma-related variables in facial fracture patients, which affect the need for on-scene versus in-hospital airway management.

Methods

This retrospective cohort study included all patients with any type of facial fracture, who required early airway management on-scene or in-hospital. The primary outcome variable was the site of airway management (on-scene versus hospital) and the main predictor variable was the presence of a traumatic brain injury (TBI). The association of fracture type, mechanism, and method for early airway management are also reported. Altogether 171 patients fulfilled the inclusion criteria.

Results

Of the 171 patients included in the analysis, 100 (58.5) had combined midfacial fractures or combination fractures of facial thirds. Altogether 118 patients (69.0%) required airway management on-scene and for the remaining 53 patients (31.0%) airway was secured in-hospital. A total of 168 (98.2%) underwent endotracheal intubation, whereas three patients (1.8%) received surgical airway management. TBIs occurred in 138 patients (80.7%), but presence of TBI did not affect the site of airway management. Younger age, Glasgow Coma Scale-score of eight or less, and oro-naso-pharyngeal haemorrhage predicted airway management on-scene, whereas patients who had fallen at ground level and in patients with facial fractures but no associated injuries, the airway was significantly more often managed in-hospital.

Conclusions

Proper preparedness for airway management in facial fracture patients is crucial both on-scene and in-hospital. Facial fracture patients need proper evaluation of airway management even when TBI is not present.

Vestibular Rehabilitation Effectiveness for Adults With Mild Traumatic Brain Injury/Concussion: A Mini-Systematic Review

OBJECTIVE

Millions of people suffer from traumatic brain injuries every year with common sequelae, including dizziness, disequilibrium, compromised vision, and gait abnormalities. Individuals suffering a mild traumatic brain injury (mTBI) or concussion may be prescribed bed rest, but for some, symptoms may persist and require different treatment options. The aim of this mini-systematic review was to synthesize the best available evidence regarding the effectiveness of vestibular rehabilitation therapy (VRT) as a treatment option for adults with mTBIs.

METHOD

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search term concepts were VRT and mTBI. Records meeting the inclusion criteria were extracted from the following databases: PubMed and CINAHL. A manual search of reference lists identified additional studies. Inclusion criteria were (a) participants with mTBI/concussion characterized by dizziness, balance, and/or other vestibular symptoms; (b) VRT as the primary treatment; and (c) self-reported and/or performance-based outcome measures. Data were extracted using a standardized tool, and studies were critically appraised.

RESULTS

Five studies were included in the systematic review: one randomized controlled trial, two retrospective chart reviews, one pre-/post-intervention study, and one case series. Four of the five studies found VRT to be effective at reducing postconcussion symptoms after head injury. Self-reported measures were included in all studies; performance-based measures were included in four out of five studies. None of the studies reported adverse effects of intervention.

CONCLUSIONS

Results suggest VRT is an effective treatment option for patients with persistent/lingering symptoms after concussion/mTBI, as demonstrated by self-reported and performance-based outcome measures. Results of this study emphasize the need for audiologists to be thoroughly familiar with VRT as an effective treatment for patients with persistent symptoms following mTBI.

Traumatic Brain Injury Screening and the Unmet Health Needs of Shelter-Seeking Women with Head Injuries Related to Intimate Partner Violence

Background: Unmet health needs of women with head injuries sustained by intimate partner violence (IPV) include risk of traumatic brain injury (TBI). The purpose of this evaluation was to explore the potential effectiveness of TBI screening as a health promotion strategy for shelter-seeking women with IPV head injuries. We wanted to learn if shelter-seeking women, willing to disclose IPV, would accept TBI screening if offered.

Methods: An extended version of the HELPS TBI screening tool and survey of daily symptoms and health needs were used to screen new residents of an urban shelter for women.

Results: The participants (N = 18) primarily were educated black women with one or more self-reported IPV-related head injury. Most participants (77.8%) had positive TBI screens for probable brain injury. The majority (88.8%) lived with one or more daily symptoms they did not have before sustaining a IPV head injury. The symptoms reported most frequently were depression (88.9%), anxiety (77.8%), and headache (66.7%). All participants had one or more unmet health need. Although most (77.8%) needed to see a primary care provider, mental health care was the most important health need identified.

Conclusions: TBI screening could be considered an effective health promotion strategy for IPV survivors if screening facilitates treatment for positive screens and other unmet health needs. Further research is needed to properly assess this.

Acute Kidney Injury Following Mannitol Administration in Traumatic Brain Injury: a Meta-analysis

BACKGROUND

Acute kidney injury (AKI) is one of the most frequent but anticipated potential complications. The objective of this meta-analysis was to evaluate the AKI incidence following mannitol administration in traumatic brain injury (TBI) patients worldwide.

OBJECTIVE

So in this study, authors will discuss the incidence of AKI related to the provision of mannitol in TBI cases so it is expected to provide a better prevention of complications.

METHODS

We were using meta-analysis. Studies were searched throughout Pubmed, Cochrane, JNS in December 2017. Studies that were included ranged from 2009-2018. Keywords were "renal" or "kidney" and "traumatic brain injury". Inclusion criteria were full-text observational study or randomized control trial, subjects in study were newly diagnosed AKI after TBI, GCS < 13, with age range 15-100 years old, survived and followed at least for 30 days after discharge, and given mannitol at least 1g/kg BW/day for at least 3 days. From 648 studies, total 4 studies were eligible for this study. Statistical analysis was done by using Review Manager 5.

RESULTS

From those 4 studies, it is shown than the pooled risk ratio AKI incidence following mannitol administration in traumatic brain injury (TBI) was 1.57. The pooled risk ratio had wide heterogeneity (I2 = 0.95 and 1, p< 0.05) so random effect model was used.

CONCLUSION

AKI appeared more frequent in patient with TBI with mannitol administration. It still needs more multicentre and long term period researches in the future to get better understanding AKI in TBI following mannitol administration.

Ultrasound measurement of the optic nerve sheath diameter in traumatic brain injury: a narrative review

Background : Raised intracranial pressure (ICP) needs to be investigated in various situations, especially in traumatic brain injury (TBI). Ultra-sonographic (US) measurement of the optic nerve sheath diameter (ONSD) is a promising noninvasive tool for assessing elevated ICP. Objectives : This narrative review aimed to explain the history of and indications forUS measurement of ONSD. We focused on the detection of elevated ICP after TBI and discussed the possible improvements in detection methods. Conclusions : US measurement of ONSD in TBI cases provides a qualitative but no quantitative assessment of ICP. Current studies usually calculate their own optimum cutoff value for detecting raised ICP based on the balance between sensitivity and specificity of the method when compared with invasive methods. There is no universally accepted threshold. We did not find any paper focusing on the prognosis of patients benefiting from it when compared with usual care. Another limitation is the lack of standardization. US measurement of ONSD cannot be used as the sole technique to detect elevated ICP and monitor its evolution, but it can be a useful tool in a multimodal protocol and it might help to determine the prognosis of patients in various situations.

Brainstem and Cortical Spreading Depolarization in a Closed Head Injury Rat Model

Traumatic brain injury (TBI) is the leading cause of death in young individuals, and is a major health concern that often leads to long-lasting complications. However, the electrophysiological events that occur immediately after traumatic brain injury, and may underlie impact outcomes, have not been fully elucidated. To investigate the electrophysiological events that immediately follow traumatic brain injury, a weight-drop model of traumatic brain injury was used in rats pre-implanted with epidural and intracerebral electrodes. Electrophysiological (near-direct current) recordings and simultaneous alternating current recordings of brain activity were started within seconds following impact. Cortical spreading depolarization (SD) and SD-induced spreading depression occurred in approximately 50% of mild and severe impacts. SD was recorded within three minutes after injury in either one or both brain hemispheres. Electrographic seizures were rare. While both TBI- and electrically induced SDs resulted in elevated oxidative stress, TBI-exposed brains showed a reduced antioxidant defense. In severe TBI, brainstem SD could be recorded in addition to cortical SD, but this did not lead to the death of the animals. Severe impact, however, led to immediate death in 24% of animals, and was electrocorticographically characterized by non-spreading depression (NSD) of activity followed by terminal SD in both cortex and brainstem.

Cellular Senescence in Traumatic Brain Injury: Evidence and Perspectives

Mild traumatic brain injury (mTBI) can lead to long-term neurological dysfunction and increase one's risk of neurodegenerative disease. Several repercussions of mTBI have been identified and well-studied, including neuroinflammation, gliosis, microgliosis, excitotoxicity, and proteinopathy – however the pathophysiological mechanisms activating these pathways after mTBI remains controversial and unclear. Emerging research suggests DNA damage-induced cellular senescence as a possible driver of mTBI-related sequalae. Cellular senescence is a state of chronic cell-cycle arrest and inflammation associated with physiological aging, mood disorders, dementia, and various neurodegenerative pathologies. This narrative review evaluates the existing studies which identify DNA damage or cellular senescence after TBI (including mild, moderate, and severe TBI) in both experimental animal models and human studies, and outlines how cellular senescence may functionally explain both the molecular and clinical manifestations of TBI. Studies on this subject clearly show accumulation of various forms of DNA damage (including oxidative damage, single-strand breaks, and double-strand breaks) and senescent cells after TBI, and indicate that cellular senescence may be an early event after TBI. Further studies are required to understand the role of sex, cell-type specific mechanisms, and temporal patterns, as senescence may be a pathway of interest to target for therapeutic purposes including prognosis and treatment.

Sports Related Brain Injury and Neurodegeneration in Athletes

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.

The burden of traumatic brain injury from low-energy falls among patients from 18 countries in the CENTER-TBI Registry: A comparative cohort study

BACKGROUND

Traumatic brain injury (TBI) is an important global public health burden, where those injured by high-energy transfer (e.g., road traffic collisions) are assumed to have more severe injury and are prioritised by emergency medical service trauma triage tools. However recent studies suggest an increasing TBI disease burden in older people injured through low-energy falls. We aimed to assess the prevalence of low-energy falls among patients presenting to hospital with TBI, and to compare their characteristics, care pathways, and outcomes to TBI caused by high-energy trauma.

METHODS AND FINDINGS

We conducted a comparative cohort study utilising the CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) Registry, which recorded patient demographics, injury, care pathway, and acute care outcome data in 56 acute trauma receiving hospitals across 18 countries (17 countries in Europe and Israel). Patients presenting with TBI and indications for computed tomography (CT) brain scan between 2014 to 2018 were purposively sampled. The main study outcomes were (i) the prevalence of low-energy falls causing TBI within the overall cohort and (ii) comparisons of TBI patients injured by low-energy falls to TBI patients injured by high-energy transfer-in terms of demographic and injury characteristics, care pathways, and hospital mortality. In total, 22,782 eligible patients were enrolled, and study outcomes were analysed for 21,681 TBI patients with known injury mechanism; 40% (95% CI 39% to 41%) (8,622/21,681) of patients with TBI were injured by low-energy falls. Compared to 13,059 patients injured by high-energy transfer (HE cohort), the those injured through low-energy falls (LE cohort) were older (LE cohort, median 74 [IQR 56 to 84] years, versus HE cohort, median 42 [IQR 25 to 60] years; p < 0.001), more often female (LE cohort, 50% [95% CI 48% to 51%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001), more frequently taking pre-injury anticoagulants or/and platelet aggregation inhibitors (LE cohort, 44% [95% CI 42% to 45%], versus HE cohort, 13% [95% CI 11% to 14%]; p < 0.001), and less often presenting with moderately or severely impaired conscious level (LE cohort, 7.8% [95% CI 5.6% to 9.8%], versus HE cohort, 10% [95% CI 8.7% to 12%]; p < 0.001), but had similar in-hospital mortality (LE cohort, 6.3% [95% CI 4.2% to 8.3%], versus HE cohort, 7.0% [95% CI 5.3% to 8.6%]; p = 0.83). The CT brain scan traumatic abnormality rate was 3% lower in the LE cohort (LE cohort, 29% [95% CI 27% to 31%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001); individuals in the LE cohort were 50% less likely to receive critical care (LE cohort, 12% [95% CI 9.5% to 13%], versus HE cohort, 24% [95% CI 23% to 26%]; p < 0.001) or emergency interventions (LE cohort, 7.5% [95% CI 5.4% to 9.5%], versus HE cohort, 13% [95% CI 12% to 15%]; p < 0.001) than patients injured by high-energy transfer. The purposive sampling strategy and censorship of patient outcomes beyond hospital discharge are the main study limitations.

CONCLUSIONS

We observed that patients sustaining TBI from low-energy falls are an important component of the TBI disease burden and a distinct demographic cohort; further, our findings suggest that energy transfer may not predict intracranial injury or acute care mortality in patients with TBI presenting to hospital. This suggests that factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people. A specific focus to improve prevention and care for patients sustaining TBI from low-energy falls is required.

Available supports and resources for postsecondary students with traumatic brain injury: A systematic review of the literature

BACKGROUND: Postsecondary students with traumatic brain injuries (TBI) are a rapidly growing population, encompassing those who sustained injuries prior to attending postsecondary education and those who endure injuries during their postsecondary studies. Not only do these individuals face a broad range of symptoms, all of which can affect academic achievement, but they also do not achieve comparable academic outcomes to their peers without disabilities. OBJECTIVE: There is a need to develop and examine the effectiveness of available supports and resources to meet the needs of these students. METHODS: Twenty-three articles were systematically reviewed to illustrate what supports are currently described in the literature for postsecondary students with TBI and what research methods were used to assess the effectiveness of these supports. RESULTS: Three categories of supports emerged, including concussion management protocols, typical study/learning strategies and accommodations, and interventions developed specifically for this population. Findings also indicated a lack of rigorous research methods used to assess these interventions’ effects. CONCLUSIONS: Implications for future research include a need for additional study of all supports and resources described in this review, and assessment of whether or not education professionals, including postsecondary disability services professionals, are aware of and using the tools and strategies addressed in this review.

Mental Health Service Utilization among Adults with Head Injury with Loss of Consciousness: Implications for Social Work

The purpose of this study was to identify factors associated with mental health service utilization among adults with head injury with loss of consciousness (LOC) using Andersen's model of health. This secondary data analysis used the 2011-2014 National Health and Nutrition Examination Survey with data collected from 7,399 adults. Binary logistic regression was conducted to determine odds associated with predisposing, enabling, and needs factors on head injury with LOC and mental health service utilization. A total of  948 (12.8 percent) adults 40 years and older self-reported head injury with LOC. Head injury with LOC was higher among men and people with lower income, illicit drug use history, and moderate to severe depression. Mental health service utilization for people with head injury with LOC was lower among older-age adults and those with no health insurance. However, utilization was higher among adults with military service, history of drug use, and moderate to severe depression. Social workers in health care settings play critical roles serving adults with traumatic brain injury (TBI) through mental health and substance use disorder treatment and bridging gaps in service access. Social workers should recognize the complex needs of clients with TBI and factors affecting mental health service use.

Etiology of Burst Suppression EEG Patterns

Burst-suppression electroencephalography (EEG) patterns of electrical activity, characterized by intermittent high-power broad-spectrum oscillations alternating with isoelectricity, have long been observed in the human brain during general anesthesia, hypothermia, coma and early infantile encephalopathy. Recently, commonalities between conditions associated with burst-suppression patterns have led to new insights into the origin of burst-suppression EEG patterns, their effects on the brain, and their use as a therapeutic tool for protection against deleterious neural states. These insights have been further supported by advances in mechanistic modeling of burst suppression. In this Perspective, we review the origins of burst-suppression patterns and use recent insights to weigh evidence in the controversy regarding the extent to which burst-suppression patterns observed during profound anesthetic-induced brain inactivation are associated with adverse clinical outcomes. Whether the clinical intent is to avoid or maintain the brain in a state producing burst-suppression patterns, monitoring and controlling neural activity presents a technical challenge. We discuss recent advances that enable monitoring and control of burst suppression.

Craniofacial Fractures in Equine-Related Injuries: What Should a Maxillofacial Surgeon Expect?

ABSTRACT

Patients with equine-related injuries (ERI) have high rates of hospitalization and often require surgical treatment. This study aimed to clarify the injury profiles of patients sustaining ERI-related craniofacial fractures and their relationship with other severe head and neck injuries.This retrospective study included all patients with craniofacial fractures admitted to a tertiary trauma center during 2013 to 2018. Out of 3256 patients, a total of 39 patients were included in the study (1.2%). Demographic and clinically relevant variables were reported and statistically evaluated.Males represented only 7.7% of the study population. Isolated facial fractures were over-represented in this study population at 84.6% whereas only 7.7% of patients sustained isolated cranial fractures and 7.7% of patients sustained combined craniofacial fractures, respectively. Surgical intervention for craniofacial fractures was required in 48.7% of patients. In total, 17.9% of patients sustained severe head and neck injuries. Periods of unconsciousness and/or post-traumatic amnesia were seen in 41% of patients. Helmet use could only be confirmed in 17.9% of patients.As trauma mechanisms behind ERI are often multifactorial and patients are at a high risk of sustaining associated injuries, attentive examination, and exclusion of serious life-threatening injuries through a multi-disciplinary approach is imperative for this specific patient population.

Blue-Light Therapy Strengthens Resting-State Effective Connectivity within Default-Mode Network after Mild TBI

BACKGROUND

Emerging evidence suggests that post concussive symptoms, including mood changes, may be improved through morning blue-wavelength light therapy (BLT). However, the neurobiological mechanisms underlying these effects remain unknown. We hypothesize that BLT may influence the effective brain connectivity (EC) patterns within the default-mode network (DMN), particularly involving the medial prefrontal cortex (MPFC), which may contribute to improvements in mood.

METHODS

Resting-state functional MRI data were collected from 41 healthy-controls (HCs) and 28 individuals with mild traumatic brain injury (mTBI). Individuals with mTBI also underwent a diffusion-weighted imaging scan and were randomly assigned to complete either 6 weeks of daily morning BLT (N = 14) or amber light therapy (ALT; N = 14). Advanced spectral dynamic causal modeling (sDCM) and diffusion MRI connectometry were used to estimate EC patterns and structural connectivity strength within the DMN, respectively.

RESULTS

The sDCM analysis showed dominant connectivity pattern following mTBI (pre-treatment) within the hemisphere contralateral to the one observed for HCs. BLT, but not ALT, resulted in improved directional information flow (ie, EC) from the left lateral parietal cortex (LLPC) to MPFC within the DMN. The improvement in EC from LLPC to MPFC was accompanied by stronger structural connectivity between the 2 areas. For the BLT group, the observed improvements in function and structure were correlated (at a trend level) with changes in self-reported happiness.

CONCLUSIONS

The current preliminary findings provide empirical evidence that morning short-wavelength light therapy could be used as a novel alternative rehabilitation technique for mTBI.

TRIAL REGISTRY

The research protocols were registered in the ClinicalTrials.gov database (CT Identifiers NCT01747811 and NCT01721356).

One-Year Prospective Study of Plasma Biomarkers From CNS in Patients With Mild Traumatic Brain Injury

Objective: To investigate the longitudinal evolution of three blood biomarkers: neurofilament light (NFL), glial fibrillary acidic protein (GFAP) and tau, in out-patients and hospitalized patients with mild traumatic brain injury (mTBI) compared to controls, along with their associations—in patients—with clinical injury characteristics and demographic variables, and ability to discriminate patients with mTBI from controls.

Methods: A longitudinal observation study including 207 patients with mTBI, 84 age and sex-matched community controls (CCs) and 52 trauma controls (TCs). Blood samples were collected at 5 timepoints: acute (<24 h), 72 h (24–72 h post-injury), 2 weeks, 3 and 12 months. Injury-related, clinical and demographic variables were obtained at inclusion and brain MRI within 72 h.

Results: Plasma GFAP and tau were most elevated acutely and NFL at 2 weeks and 3 months. The group of patients with mTBI and concurrent other somatic injuries (mTBI+) had the highest elevation in all biomarkers across time points, and were more likely to be victims of traffic accidents and violence. All biomarkers were positively associated with traumatic intracranial findings on MRI obtained within 72 h. Glial fibrillary acidic protein and NFL levels were associated with Glasgow Coma Scale (GCS) score and presence of other somatic injuries. Acute GFAP concentrations showed the highest discriminability between patients and controls with an Area Under the Curve (AUC) of 0.92. Acute tau and 2-week NFL concentrations showed moderate discriminability (AUC = 0.70 and AUC = 0.75, respectively). Tau showed high discriminability between mTBI+ and TCs (AUC = 0.80).

Conclusions: The association of plasma NFL with traumatic intracranial MRI findings, together with its later peak, could reflect ongoing secondary injury or repair mechanisms, allowing for a protracted diagnostic time window. Patients experiencing both mTBI and other injuries appear to be a subgroup with greater neural injury, differing from both the mTBI without other injuries and from both control groups. Acute GFAP concentrations showed the highest discriminability between patients and controls, were highly associated with intracranial traumatic injury, and showed the largest elevations compared to controls at the acute timepoint, suggesting it to be the most clinically useful plasma biomarker of primary CNS injury in mTBI.

Concussion and Risk of Chronic Medical and Behavioral Health Comorbidities

While chronic neurological effects from concussion have been studied widely, little is known about possible links between concussion and long-term medical and behavioral comorbidities. We performed a retrospective cohort study of 9205 adult patients with concussion, matched to non-concussion controls from a hospital-based electronic medical registry. Patients with comorbidities before the index visit were excluded. Behavioral and medical comorbidities were defined by International Classification of Diseases, Ninth and Tenth Revision codes. Groups were followed for up to 10 years to identify comorbidity incidence after a concussion. Cox proportional hazards models were used to calculate associations between concussion and comorbidities after multi-variable adjustment. Patients with concussion were 57% male (median age: 31; interquartile range [IQR] = 23-48 years) at enrollment with a median follow-up time of 6.1 years (IQR = 4.2-9.1) and well-matched to healthy controls. Most (83%) concussions were evaluated in outpatient settings (5% inpatient). During follow-up, we found significantly higher risks of cardiovascular risks developing including hypertension (hazard ratio [HR] = 1.7, 95% confidence interval [CI]: 1.5-1.9), obesity (HR = 1.7, 95% CI: 1.3-2.0), and diabetes mellitus (HR = 1.8, 95% CI: 1.4-2.3) in the concussion group compared with controls. Similarly, psychiatric and neurological disorders such as depression (HR = 3.0, 95% CI: 2.6-3.5), psychosis (HR = 6.0, 95% CI: 4.2-8.6), stroke (HR = 2.1 95% CI: 1.5-2.9), and epilepsy (HR = 4.4, 95% CI: 3.2-5.9) were higher in the concussion group. Most comorbidities developed less than five years post-concussion. The risks for post-concussion comorbidities were also higher in patients under 40 years old compared with controls. Patients with concussion demonstrated an increased risk of development of medical and behavioral health comorbidities. Prospective studies are warranted to better describe the burden of long-term comorbidities in patients with concussion.

Randomized Study of Metoclopramide Plus Diphenhydramine for Acute Posttraumatic Headache

OBJECTIVE

To determine whether IV metoclopramide 20 mg + diphenhydramine 25 mg (M + D) was more efficacious than IV placebo for acute moderate or severe posttraumatic headache in the emergency room.

METHODS

We conducted this randomized, double-blind, placebo-controlled, parallel-group study in 2 urban emergency departments (EDs). Participants who experienced head trauma and presented to our EDs within 10 days with a headache fulfilling criteria for acute posttraumatic headache were included. We randomized participants in a 1:1 ratio to M + D or placebo. Participants, caregivers, and outcome assessors were blinded to assignment. The primary outcome was improvement in pain on a scale of 0 to 10 between baseline and 1 hour after treatment.

RESULTS

This study was completed between August 2017 and March 2020. We screened 414 patients for participation and randomized 160: 81 to M + D and 79 to placebo. Baseline characteristics were comparable between the groups. All enrolled participants provided primary outcome data. Patients receiving placebo reported mean improvement of 3.8 (SD 2.6), while those receiving M + D improved by 5.2 (SD 2.3), for a difference favoring metoclopramide of 1.4 (95% confidence interval [CI] 0.7-2.2, p < 0.01). Adverse events were reported by 35 of 81 (43%) patients who received metoclopramide and 22 of 79 (28%) of patients who received placebo (95% CI 1-30 for difference of 15%, p = 0.04).

CONCLUSION

M + D was more efficacious than placebo with regard to relief of posttraumatic headache in the ED.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT03220958.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that for patients with acute moderate or severe posttraumatic headache, IV M + D significantly improved pain compared to placebo.

Cortical Volume and Thickness in Youth Several Years After Concussion

OBJECTIVE

The long-term effects of pediatric concussion on brain morphometry remain poorly delineated. This study used magnetic resonance imaging (MRI) to investigate cortical volume and thickness in youth several years after concussion.

METHODS

Participants aged 8-19 years old with a history of concussion (n = 37) or orthopedic injury (n = 20) underwent MRI, rated their postconcussion symptoms, and completed cognitive testing on average 2.6 years (SD = 1.6) after injury. FreeSurfer was used to obtain cortical volume and thickness measurements as well as determine any significant correlations between brain morphometry, postconcussion symptoms (parent and self-report), and cognitive functioning.

RESULTS

No significant group differences were found for either cortical volume or thickness. Youth with a history of concussion had higher postconcussion symptom scores (both parent and self-report Postconcussion Symptom Inventory) than the orthopedic injury group, but symptom ratings did not significantly correlate with cortical volume or thickness. Across both groups, faster reaction time on a computerized neurocognitive test battery (CNS Vital Signs) was associated with a thinner cortex in the left pars triangularis of the inferior frontal gyrus and the left caudal anterior cingulate. Better verbal memory was associated with a thinner cortex in the left rostral middle frontal gyrus.

CONCLUSION

Findings do not support differences in cortical volume or thickness approximately 2.5 years postconcussion in youth, suggesting either long-term cortical recovery or no cortical differences as a result of injury. Further research using a longitudinal study design and larger samples is needed.

Effects of an acute care brain injury medicine continuity consultation service on health care utilization and rehabilitation outcomes

INTRODUCTION

Although general physiatry acute-care consultation services are commonplace and improve length of stay (LOS), the benefits of a subspecialty physiatric continuity consultation service targeting patients with severe brain injury have not been reported.

OBJECTIVES

Our primary objective was to characterize patient care recommendations from a Brain Injury Medicine (BIM) Continuity Consult Service, and to investigate the effects on acute-care LOS relative to brain injury patients receiving General Physical Medicine & Rehabilitation (PM&R) Consult Services. Our secondary objectives were to examine inpatient rehabilitation (IPR) health care utilization metrics and costs between groups and evaluate clinical improvements during IPR and discharge disposition.

DESIGN

Retrospective cohort comparison study.

SETTING

Academic medical center with level 1 trauma center.

PARTICIPANTS

Adults with severe brain injury admitted to a single-site acute-care facility and subsequently admitted to a single inpatient brain injury rehabilitation unit over the same time period.

PHYSIATRIC CARE MODELS

BIM Continuity Consult Service versus General PM&R Consult Service.

MAIN OUTCOME MEASURES

Acute-care LOS; unplanned discharges to acute-care.

RESULTS

Despite no major demographic or clinical group differences, the BIM Consult Service had more patient comorbidities than General PM&R Consult Service (17.5±5.3 versus 16±5.1;P = .04). BIM Consult Service patients spent fewer days in acute care (30±11.8 versus 36±22.8; P = .008), and early BIM consult (≤7 days after admission) was associated with shorter acute-care LOS (P < .002). IPR LOS was similar between groups when considering unplanned transfers. Unplanned transfers among General PM&R Consult Service patients occurred twice as frequently as in BIM Consult Service patients; average readmission costs were $2778 per patient on the BIM Consult Service and $6702 per patient on the General PM&R Consult Service. More BIM Consult Service (85.7%) than General PM&R Consult Service (27.3%) patients emerged from disorders of consciousness during IPR (P = .02).

CONCLUSIONS

BIM Continuity Consultation Services were associated with shorter acute-care LOS, fewer unplanned acute-care transfers, and an increased likelihood of emerging from a minimally conscious state during IPR.

Mural cell dysfunction leads to altered cerebrovascular tau uptake following repetitive head trauma

A pathological characteristic of repetitive traumatic brain injury (TBI) is the deposition of hyperphosphorylated and aggregated tau species in the brain and increased levels of extracellular monomeric tau are believed to play a role in the pathogenesis of neurodegenerative tauopathies. The pathways by which extracellular tau is eliminated from the brain, however, remains elusive. The purpose of this study was to examine tau uptake by cerebrovascular cells and the effect of TBI on these processes. We found monomeric tau interacts with brain vascular mural cells (pericytes and smooth muscle cells) to a greater extent than other cerebrovascular cells, indicating mural cells may contribute to the elimination of extracellular tau, as previously described for other solutes such as beta-amyloid. Consistent with other neurodegenerative disorders, we observed a progressive decline in cerebrovascular mural cell markers up to 12 months post-injury in a mouse model of repetitive mild TBI (r-mTBI) and human TBI brain specimens, when compared to control. These changes appear to reflect mural cell degeneration and not cellular loss as no difference in the mural cell population was observed between r-mTBI and r-sham animals as determined through flow cytometry. Moreover, freshly isolated r-mTBI cerebrovessels showed reduced tau uptake at 6 and 12 months post-injury compared to r-sham animals, which may be the result of diminished cerebrovascular endocytosis, as caveolin-1 levels were significantly decreased in mouse r-mTBI and human TBI cerebrovessels compared to their respective controls. Further emphasizing the interaction between mural cells and tau, similar reductions in mural cell markers, tau uptake, and caveolin-1 were observed in cerebrovessels from transgenic mural cell-depleted animals. In conclusion, our studies indicate repeated injuries to the brain causes chronic mural cell degeneration, reducing the caveolar-mediated uptake of tau by these cells. Alterations in tau uptake by vascular mural cells may contribute to tau deposition in the brain following head trauma and could represent a novel therapeutic target for TBI or other neurodegenerative disorders.

Subcallosal haemorrhage as a sign of diffuse axonal injury in patients with traumatic brain injury

AIM

To identify the relationship between subcallosal haemorrhage and diffuse axonal injury (DAI) grading.

MATERIALS AND METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) images of all patients with traumatic brain injury over the past 5 years were reviewed. Subcallosal haemorrhage was defined as the presence of haemorrhage on admission CT underneath the corpus callosum. Grading of DAI was performed using MRI or CT exclusive of subcallosal haemorrhage status. The association of demographic factors, mechanism of injury, Glasgow Coma Scale (GCS) on admission, and positive subcallosal haemorrhage status with the presence of moderate-severe DAI was assessed. Receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of subcallosal haemorrhage status in predicting DAI severity. Median modified Rankin Scale (mRS) scores were compared between subcallosal haemorrhage positive and negative cases.

RESULTS

The images of 1,150 patients were reviewed with 301 patients showing DAI. Of those, 64 patients (21.2%) and 237 patients (78.7%) were positive and negative for subcallosal haemorrhage, respectively. Isolated subcallosal haemorrhage was noted in 15 patients (23.4%). A subcallosal haemorrhage positive status (OR=5.16, p < 0.001) was statistically significantly associated with moderate-severe DAI. The ROC curve for predicting moderate-severe DAI with subcallosal haemorrhage status showed an area under the curve of 0.625 (95% confidence interval [CI]: 0.561-0.688, p < 0.001). The median mRS score was significantly higher (p < 0.001) in the subcallosal haemorrhage positive group (median 4.5, interquartile range [IQR] 2-6) versus the negative group (median 2, IQR 2-3). Isolated subcallosal haemorrhage group showed moderate-severe DAI in 80% (12/15) of cases.

CONCLUSION

Subcallosal haemorrhage is a highly specific radiographic predictor of moderate-severe DAI (grade 2-3).

Correlation between bispectral index value and modified Glasgow Coma Scale score in dogs with altered level of consciousness

OBJECTIVE

This study aims to identify the correlation between bispectral index (BIS) value and modified Glasgow Coma Scale (MGCS) score in dogs with altered level of consciousness (ALOC).

DESIGN

This prospective, observational, clinical study was conducted from February 2016 to March 2017, and follow-up was conducted until the death of dogs or their discharge from the hospital.

SETTING

This study was performed at the Small Animal Teaching Hospital.

ANIMALS

A total of 31 client-owned dogs (males, 20; females, 11) with ALOC and MGCS score <18 with no restrictions for age, breed, sex, and body weight were included. Dogs that received neuromuscular blocking agents before MGCS score evaluation were excluded.

INTERVENTIONS

BIS values were measured using the Covidien BIS Loc 2 Channel OEM module and a pediatric 4 sensor with a bifrontal application pattern.

MEASUREMENTS AND MAIN RESULTS

Minimal databases of initial neurological assessment, blood profiles, and chest and skull radiographs were developed. In addition, MGCS scores and BIS values were recorded. The mean BIS values for mild, moderate, and severe brain injuries were 89.14 ± 6.52, 77.21 ± 9.82, and 50.58 ± 27.04, respectively. Correlation analysis revealed a significantly positive relationship between BIS values and MGCS scores (r = 0.75; P < 0.001).

CONCLUSIONS

The significant correlation observed between MGCS scores and BIS values in dogs with ALOC demonstrated the usefulness of BIS as an alternative to MGCS for monitoring consciousness in patients with ALOC caused by traumatic brain injury, encephalitis, etc.

Bypassing TBI: Metabolic Surgery and the Link between Obesity and Traumatic Brain Injury-a Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be a most effective therapy for TBI.

In vivo estimates of axonal stretch and 3D brain deformation during mild head impact

The rapid deformation of brain tissue in response to head impact can lead to traumatic brain injury. In vivo measurements of brain deformation during non-injurious head impacts are necessary to understand the underlying mechanisms of traumatic brain injury and compare to computational models of brain biomechanics. Using tagged magnetic resonance imaging (MRI), we obtained measurements of three-dimensional strain tensors that resulted from a mild head impact after neck rotation or neck extension. Measurements of maximum principal strain (MPS) peaked shortly after impact, with maximal values of 0.019-0.053 that correlated strongly with peak angular velocity. Subject-specific patterns of MPS were spatially heterogeneous and consistent across subjects for the same motion, though regions of high deformation differed between motions. The largest MPS values were seen in the cortical gray matter and cerebral white matter for neck rotation and the brainstem and cerebellum for neck extension. Axonal fiber strain (Ef) was estimated by combining the strain tensor with diffusion tensor imaging data. As with MPS, patterns of Ef varied spatially within subjects, were similar across subjects within each motion, and showed group differences between motions. Values were highest and most strongly correlated with peak angular velocity in the corpus callosum for neck rotation and in the brainstem for neck extension. The different patterns of brain deformation between head motions highlight potential areas of greater risk of injury between motions at higher loading conditions. Additionally, these experimental measurements can be directly compared to predictions of generic or subject-specific computational models of traumatic brain injury.

Dynamic neural and glial responses of a head-specific model for traumatic brain injury in Drosophila

Traumatic brain injury (TBI) is the strongest environmental risk factor for the accelerated development of neurodegenerative diseases. There are currently no therapeutics to address this due to lack of insight into mechanisms of injury progression, which are challenging to study in mammalian models. Here, we have developed and extensively characterized a head-specific approach to TBI in Drosophila, a powerful genetic system that shares many conserved genes and pathways with humans. The Drosophila TBI (dTBI) device inflicts mild, moderate, or severe brain trauma by precise compression of the head using a piezoelectric actuator. Head-injured animals display features characteristic of mammalian TBI, including severity-dependent ataxia, life span reduction, and brain degeneration. Severe dTBI is associated with cognitive decline and transient glial dysfunction, and stimulates antioxidant, proteasome, and chaperone activity. Moreover, genetic or environmental augmentation of the stress response protects from severe dTBI-induced brain degeneration and life span deficits. Together, these findings present a tunable, head-specific approach for TBI in Drosophila that recapitulates mammalian injury phenotypes and underscores the ability of the stress response to mitigate TBI-induced brain degeneration.

Interleukin 10 and Heart Fatty Acid-Binding Protein as Early Outcome Predictors in Patients With Traumatic Brain Injury

Background: Patients with traumatic brain injury (TBI) exhibit a variable and unpredictable outcome. The proteins interleukin 10 (IL-10) and heart fatty acid-binding protein (H-FABP) have shown predictive values for the presence of intracranial lesions. Aim: To evaluate the individual and combined outcome prediction ability of IL-10 and H-FABP, and to compare them to the more studied proteins S100β, glial fibrillary acidic protein (GFAP), and neurofilament light (NF-L), both with and without clinical predictors. Methods: Blood samples from patients with acute TBI (all severities) were collected <24 h post trauma. The outcome was measured >6 months post injury using the Glasgow Outcome Scale Extended (GOSE) score, dichotomizing patients into: (i) those with favorable (GOSE≥5)/unfavorable outcome (GOSE ≤ 4) and complete (GOSE = 8)/incomplete (GOSE ≤ 7) recovery, and (ii) patients with mild TBI (mTBI) and patients with TBIs of all severities. Results: When sensitivity was set at 95-100%, the proteins' individual specificities remained low. H-FABP showed the best specificity (%) and sensitivity (100%) in predicting complete recovery in patients with mTBI. IL-10 had the best specificity (50%) and sensitivity (96%) in identifying patients with favorable outcome in patients with TBIs of all severities. When individual proteins were combined with clinical parameters, a model including H-FABP, NF-L, and ISS yielded a specificity of 56% and a sensitivity of 96% in predicting complete recovery in patients with mTBI. In predicting favorable outcome, a model consisting IL-10, age, and TBI severity reached a specificity of 80% and a sensitivity of 96% in patients with TBIs of all severities. Conclusion: Combining novel TBI biomarkers H-FABP and IL-10 with GFAP, NF-L and S100β and clinical parameters improves outcome prediction models in TBI.

Analysis of skull bone thickness during growth: an anatomical guide for safe pin placement in halo fixation

PURPOSE

To assess skull bone thickness from birth to skeletal maturity at different sites to provide a reference for the correct selection of pin type and pin placement according to age.

METHODS

270 children and adolescents (age: 0-17 years) with a normal CT scan obtained at Emergency Department for other medical reasons were included. Skull thickness was measured on the axial plane CT scans at eight different sites of the vault: midline anterior (A) and posterior (P), right and left lateral (L), antero-lateral (AL), postero-lateral (PL).

RESULTS

From birth to skeletal maturity, L thickness was increased significantly less (+ 58%) compared with AL (+ 205%), P (+ 233%), PL (+ 247%), and A (+ 269%) thickness (P < 0.01). At the end of growth, the thickest and thinnest points of the vault (absolute value) were found at the P and L measurement sites, respectively (P < 0.01). Children aged < 4 years exhibited the highest variability in AL and PL skull bone thickness, with thickness < 3 mm observed in 85% (64/75 patients) and 92% (69/75 patients) of cases, respectively.

CONCLUSION

We recommend that the tip of the pin should not exceed 2-3 mm in children aged < 4, and 4 mm in children aged 4-6 years, to decrease the risk of inner table perforation. After the age of 7 years and 13 years, standard-sized pin tips (5 and 6 mm, respectively) may be safely used. Children aged < 4 years show significant variability in skull thickness, and therefore a CT scan may be required for this particular age group.

The Relation Between Loss of Consciousness, Severity of Traumatic Brain Injury, and Injury of Ascending Reticular Activating System in Patients With Traumatic Brain Injury

OBJECTIVE

Loss of consciousness is an indicator of the severity of traumatic brain injury and the ascending reticular activating system has been considered as a main structure for consciousness. However, no study on the relation between loss of consciousness and ascending reticular activating system injury in traumatic brain injury has been reported. We investigated the relation between loss of consciousness, severity of traumatic brain injury, and ascending reticular activating system injury using diffusion tensor tractography.

DESIGN

One hundred twenty patients were recruited. Three components of ascending reticular activating system, fractional anisotropy, and tract volume were measured.

RESULTS

In lower dorsal and ventral ascending reticular activating system, fractional anisotropy and tract volume value in mild group were higher than those of moderate and severe groups, and there was no difference between moderate and severe groups. In upper ascending reticular activating system, fractional anisotropy value in mild group was higher than in moderate group, and it was higher than in moderate group than in severe group. Tract volume value in mild group was higher than in severe group. Loss of consciousness showed moderate negative correlations with tract volume value of lower dorsal ascending reticular activating system (r = -0.348), fractional anisotropy value of lower ventral ascending reticular activating system (r = -0.343), and fractional anisotropy value of upper ascending reticular activating system (r = -0.416).

CONCLUSIONS

Injury severity was different among the three traumatic brain injury groups in upper ascending reticular activating system but did not differ between moderate and severe groups in lower dorsal and ventral ascending reticular activating system.

Transplantation of mesenchymal stem cells overexpressing interleukin-10 induces autophagy response and promotes neuroprotection in a rat model of TBI

Autophagy, including mitophagy, is critical for neuroprotection in traumatic brain injury (TBI). Transplantation of mesenchymal stem cells (MSCs) provides neuroprotection and induces autophagy by increasing anti-inflammatory cytokines, such as interleukin-10 (IL-10). To evaluate these effects of IL10 that are released by MSCs, we genetically engineered MSCs to overexpress IL10 and compared their effects to unaltered MSCs following transplantation near the site of induced TBIs in rats. Adult, male Sprague-Dawley rats were divided into four groups: Sham + vehicle, TBI + vehicle, TBI + MSCs-IL-10 and TBI + MSCs-GFP. Thirty-six hours post-TBI, the first two groups received vehicle (Hanks balance salt solution), whereas last two groups were transplanted with MSCs-IL-10 or MSCs-GFP. Three weeks after transplantation, biomarkers for neurodegenerative changes, autophagy, mitophagy, cell death and survival markers were measured. We observed a significant increase in the number of dead cells in the cortex and hippocampus in TBI rats, whereas transplantation of MSCs-IL-10 significantly reduced their numbers in comparison to MSCs alone. MSCs-IL-10 rats had increased autophagy, mitophagy and cell survival markers, along with decreased markers for cell death and neuroinflammation. These results suggest that transplantation of MSCs-IL-10 may be an effective strategy to protect against TBI-induced neuronal damage.

The Impact of Physical Activity and Sleep on Physiology Following a mTBI

A mild traumatic brain injury (mTBI) is a common injury that happens to people across a range of lifestyles. Rest has been regarded as the most effective remedy to restore impaired physiological functions in those who have experienced this kind of injury. However, recent data suggests that a gradual increase in physical activity post-injury can lead to quicker recovery from negative symptoms. The impact of physical activity on physiologic recovery is not completely understood and the purpose of this study was to better understand how physical activity and sleep influence physiological outcomes following a mTBI. The data collected in this study came from two groups of young adults: a healthy control (n=5) and those that had a mTBI (n = 5). The daily activity was measured using an activity monitor for a week immediately after injury. Physiological measurements of excitability and inhibition within the motor cortex and neurotransmitter concentrations were collected within 72 hours of injury and again at two months to determine if physical activity or sleep within one week after injury had an influence on physiologic recovery. Control participants had higher levels of total (d = 1.2), light (d = 1.3) and moderate physical activity (d = 0.7), and lower total sleep time (d = -1.9), compared with the mTBI group. Across the two months, relative to the control group the mTBI group showed similar changes in excitability (d = 0.13), but greater changes in inhibition (d = -0.66). Changes in the excitatory (d = 0.06) and inhibitory (d = -0.16) neurotransmitters were similar between groups. Neither physical activity, nor sleep quality were significantly associated with the change in motor cortex excitability (R ² ≤ 0.18, p ≥ 0.22), inhibition (R ² ≤ 0.3, p ≥ 0.08) or neurotransmitter concentrations (R ² ≤ 0.15, p ≥ 0.20) between 72 hours and two months post-injury. These preliminary results suggest there is no direct effect of physical activity on physiological outcomes.