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Fatima N, Al Rumaihi G, Shuaib A, Saqqur M. The Role of Decompressive Craniectomy in Traumatic Brain Injury: A Systematic Review and Meta-analysis. Asian J Neurosurg 2019; 14:371-381. [PMID: 31143249 PMCID: PMC6515989 DOI: 10.4103/ajns.ajns_289_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The objective is to evaluate the efficacy of early decompressive craniectomy (DC) versus standard medical management ± late DC in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies, and prospective cohort studies on DC in moderate and severe TBI. Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and extended GCOS, and mortality. Data were extracted to Review Manager software. A total of 45 articles and abstracts that met the inclusion criteria were retrieved and analyzed. Ultimately, seven studies were included in our meta-analysis, which revealed that patients who had early DC had no statistically significant likelihood of having a favorable outcome at 6 months than those who had a standard medical care alone or with late DC (OR of favorable clinical outcome at 6 months: 1.00; 95% confidence interval (CI): 0.75–1.34; P = 0.99). The relative risk (RR) of mortality in early DC versus the standard medical care ± late DC at discharge or 6 months is 0.62; 95% CI: 0.40–0.94; P = 0.03. Subgroup analysis based on RR of mortality shows that the rate of mortality is reduced significantly in the early DC group as compared to the late DC. RR of Mortality is 0.43; 95% CI: 0.26–0.71; P = 0.0009. However, good clinical outcome is the same. Early DC saves lives in patients with TBI. However, further clinical trials are required to prove if early DC improve clinical outcome and to define the best early time frame in performing early DC in TBI population.
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Affiliation(s)
- Nida Fatima
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | | | - Ashfaq Shuaib
- Department of Neuroscience, Hamad General Hospital, Doha, Qatar.,Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Maher Saqqur
- Department of Neuroscience, Hamad General Hospital, Doha, Qatar.,Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
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Benefit on optimal cerebral perfusion pressure targeted treatment for traumatic brain injury patients. J Crit Care 2017; 41:49-55. [PMID: 28477510 DOI: 10.1016/j.jcrc.2017.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 04/02/2017] [Accepted: 04/20/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE The maintenance of patient-specific optimal cerebral perfusion pressure (CPPopt) is crucial for patients with traumatic brain injury (TBI). The goal of the study was to explore the influence of CPP declination from CPPopt value on the TBI patients' outcome. METHODS The CPP and cerebrovascular autoregulation (CA) monitoring of 52 TBI patients was performed. Patient-specific CPPopt has been identified and the associations between the patients' outcome and complex influence of time of CPP declination from CPPopt value, age, and the duration of CA impairment episodes has been analyzed. RESULTS The multiple correlation coefficient between the Glasgow outcome scale (GOS), duration of CA impairment events and percentage time, when 0<ΔCPPopt<10mmHg was r=-0.643 (P<0.001). The multiple correlation coefficients between GOS, age, and percentage time of ΔCPPopt when 0<ΔCPPopt<10mmHg was r=-0.587 (P<0.001). CONCLUSION The CPPopt-targeted patient-specific management might be useful for stabilizing CA in TBI patients as well as for improving their outcome. Better outcomes were obtained by maintaining CPP in light hyperperfusion condition (up to 10mmHg above CPPopt) when CPPopt is in the range of 60-80mmHg, and keeping CPP within the range of CPPopt +/-5mmHg when CPPopt is above 80mmHg.
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Gong JB, Wen L, Zhan RY, Zhou HJ, Wang F, Li G, Yang XF. Early decompressing craniectomy in patients with traumatic brain injury and cerebral edema. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0801.261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: Decompressing craniectomy (DC) is an important method for the management of severe traumatic brain injury (TBI).
Objective: To analyze the effect of prophylactic DC within 24 hours after head trauma TBI.
Methods: Seventy-two patients undergoing prophylactic DC for severe TBI were included in this retrospective study. Both of the early and late outcomes were studied and the prognostic factors were analyzed.
Results: In this series, cumulative death in the first 30 days after DC was 26%, and 28 (53%) of 53 survivors in the first month had a good outcomes. The factors including Glasgow Coma Score (GCS) score at admission, whether the patient had an abnormal pupil response and whether the midline shift was greater than 5 mm were most important prognostic factors for the prediction of death in the first 30 days and the final outcome at 6 months after DC.
Conclusion: Prophylactic DC plays an important role in the management of highly elevated ICP, especially when other methods of reduction of ICP are unavailable.
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Affiliation(s)
- Jiang-Biao Gong
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Liang Wen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Ren-Ya Zhan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Heng-Jun Zhou
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Fang Wang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Gu Li
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Xiao-Feng Yang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
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Han J, Yang S, Zhang C, Zhao M, Li A. Impact of Intracranial Pressure Monitoring on Prognosis of Patients With Severe Traumatic Brain Injury: A PRISMA Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e2827. [PMID: 26886639 PMCID: PMC4998639 DOI: 10.1097/md.0000000000002827] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
To evaluate the influences of using intracranial pressure (ICP) monitoring on the prognosis of patients with severe traumatic brain injury. Systematic search were conducted in PubMed, Embase, Cochrane Library, Wanfang, and CNKI. The eligible studies were identified for pooling analysis under fixed- or random effects model. Hospital mortality, functional outcomes, length of hospital stay, and the related complications in patients were extracted. Six randomized controlled trials with 880 cases and 12 cohort studies with 12,606 cases were included. Combined analysis found that ICP monitoring was effective for reducing the risk rate of electrolyte disturbances (RR = 0.47, 95% confidence interval (CI): 0.63-0.90), rate of renal failure (RR = 0.50, 95% CI: 0.30-0.83), and for improving favorable prognosis (RR = 1.15, 95% CI: 1.00-1.35). However, ICP monitoring was not significant for hospital mortality (RR = 0.91, 95% CI: 0.77-0.1.06), decreasing rate of pulmonary infection (RR = 0.93, 95% CI: 0.76-1.14), rate of mechanical ventilation (RR = 1.02, 95% CI: 0.86-1.09), and duration of hospital stays (weighted mean difference (WMD) = 0.06, 95% CI: -0.03, 0.16). ICP monitoring may not reduce the risk of hospital mortality, but plays a role in decreasing the rate of electrolyte disturbances, rate of renal failure, and increasing favorable functional outcome. However, effect of other outcomes need to be further confirmed in the future randomized controlled trials (RCTs) with larger sample size.
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Affiliation(s)
- Jinsong Han
- From the Department of Neurosurgery, First Affiliated Hospital of Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing (JH, SY, MZ, AL); Quanjian Tumor Hospital of Tianjin, Tianjin (SY); and Department of Medical Reform and Development, China-Japan Friendship Hospital, Beijing (CZ), China
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Yuan Q, Wu X, Sun Y, Yu J, Li Z, Du Z, Mao Y, Zhou L, Hu J. Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis. J Neurosurg 2014; 122:574-87. [PMID: 25479125 DOI: 10.3171/2014.10.jns1460] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECT Some studies have demonstrated that intracranial pressure (ICP) monitoring reduces the mortality of traumatic brain injury (TBI). But other studies have shown that ICP monitoring is associated with increased mortality. Thus, the authors performed a meta-analysis of studies comparing ICP monitoring with no ICP monitoring in patients who have suffered a TBI to determine if differences exist between these strategies with respect to mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. METHODS The authors systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (Central) from their inception to October 2013 for relevant studies. Randomized clinical trials and prospective cohort, retrospective observational cohort, and case-control studies that compared ICP monitoring with no ICP monitoring for the treatment of TBI were included in the analysis. Studies included had to report at least one point of mortality in an ICP monitoring group and a no-ICP monitoring group. Data were extracted for study characteristics, patient demographics, baseline characteristics, treatment details, and study outcomes. RESULTS A total of 14 studies including 24,792 patients were analyzed. The meta-analysis provides no evidence that ICP monitoring decreased the risk of death (pooled OR 0.93 [95% CI 0.77-1.11], p = 0.40). However, 7 of the studies including 12,944 patients were published after 2012 (January 2012 to October 2013), and they revealed that ICP monitoring was significantly associated with a greater decrease in mortality than no ICP monitoring (pooled OR 0.56 [95% CI 0.41-0.78], p = 0.0006). In addition, 7 of the studies conducted in North America showed no evidence that ICP monitoring decreased the risk of death, similar to the studies conducted in other regions. ICU LOSs were significantly longer for the group subjected to ICP monitoring (mean difference [MD] 0.29 [95% CI 0.21-0.37]; p < 0.00001). In the pooled data, the hospital LOS with ICP monitoring was also significantly longer than with no ICP monitoring (MD 0.21 [95% CI 0.04-0.37]; p = 0.01). CONCLUSIONS In this systematic review and meta-analysis of ICP monitoring studies, the authors found that the current clinical evidence does not indicate that ICP monitoring overall is significantly superior to no ICP monitoring in terms of the mortality of TBI patients. However, studies published after 2012 indicated a lower mortality in patients who underwent ICP monitoring.
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Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
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Intraoperative intracranial pressure and cerebral perfusion pressure for predicting surgical outcome in severe traumatic brain injury. Kaohsiung J Med Sci 2013; 29:540-6. [DOI: 10.1016/j.kjms.2013.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 09/26/2012] [Indexed: 11/21/2022] Open
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Abstract
In primary and secondary brain diseases, increasing volumes of the three compartments of brain tissue, cerebrospinal fluid, or blood lead to a critical increase in intracranial pressure (ICP). A rising ICP is associated with typical clinical symptoms; however, during analgosedation it can only be detected by invasive ICP monitoring. Other neuromonitoring procedures are not as effective as ICP monitoring; they reflect the ICP changes and their complications by other metabolic and oxygenation parameters. The most relevant parameter for brain perfusion is cerebral perfusion pressure (CPP), which is calculated as the difference between the middle arterial pressure (MAP) and the ICP. A mixed body of evidence exists for the different ICP-reducing treatment measures, such as hyperventilation, hyperosmolar substances, hypothermia, glucocorticosteroids, CSF drainage, and decompressive surgery.
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Dietrich W, Erbguth F. [Increased intracranial pressure and brain edema]. Med Klin Intensivmed Notfmed 2013; 108:157-69; quiz 170-1. [PMID: 23503630 DOI: 10.1007/s00063-013-0232-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Indexed: 01/12/2023]
Abstract
In primary and secondary brain diseases, increasing volumes of the three compartments of brain tissue, cerebrospinal fluid, or blood lead to a critical increase in intracranial pressure (ICP). A rising ICP is associated with typical clinical symptoms; however, during analgosedation it can only be detected by invasive ICP monitoring. Other neuromonitoring procedures are not as effective as ICP monitoring; they reflect the ICP changes and their complications by other metabolic and oxygenation parameters. The most relevant parameter for brain perfusion is cerebral perfusion pressure (CPP), which is calculated as the difference between the middle arterial pressure (MAP) and the ICP. A mixed body of evidence exists for the different ICP-reducing treatment measures, such as hyperventilation, hyperosmolar substances, hypothermia, glucocorticosteroids, CSF drainage, and decompressive surgery.
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Affiliation(s)
- W Dietrich
- Klinik für Neurologie, Klinikum Nürnberg
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Abstract
We conducted a systematic review to examine the relationship between intracranial pressure monitors (ICP) monitors and mortality in traumatic brain injury (TBI). We systematically searched for articles that met the following criteria: (1) adults patients, (2) TBI, (3) use of an ICP monitor, (4) point estimate for mortality with ICP monitoring (5) adjustment for potential confounders. Six observational studies were identified with 11,371 patients. There was marked between-study heterogeneity that precluded a pooled analysis. Patients with ICP monitors had different clinical characteristics and received more ICP targeted therapy in the ICU. Four studies found no significant relationship between ICP monitoring and survival, while the other two studies demonstrated conflicting results. Significant confounding by indication in observational studies limits the examination of isolated TBI interventions. More research should focus on interventions that affect TBI careplan systems. Further research is needed to identify which subset of severe TBI patients may benefit from ICP monitoring.
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Johnson U, Nilsson P, Ronne-Engström E, Howells T, Enblad P. Favorable Outcome in Traumatic Brain Injury Patients With Impaired Cerebral Pressure Autoregulation When Treated at Low Cerebral Perfusion Pressure Levels. Neurosurgery 2011; 68:714-21; discussion 721-2. [DOI: 10.1227/neu.0b013e3182077313] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral pressure autoregulation (CPA) is defined as the ability of the brain vasculature to maintain a constant blood flow over a range of different systemic blood pressures by means of contraction and dilatation.
OBJECTIVE:
To study CPA in relation to physiological parameters, treatment, and outcome in a series of traumatic brain injury patients.
METHODS:
In this prospective observational study, 44 male and 14 female patients (age, 15–72 years; mean, 38.7 years; Glasgow Coma Scale score, 4-13; median, 7) were analyzed. Patients were divided into groups on the basis of status of CPA (more pressure active vs more pressure passive) and level of cerebral perfusion pressure (CPP; low vs high CPP). The proportions of favorable outcome in the groups were assessed. Differences in physiological variables in the different groups were analyzed.
RESULTS:
Patients with more impaired CPA treated at CPP levels below median had a significantly higher proportion of favorable outcome compared with patients with more impaired CPA treated at CPP levels above median. No significant difference in outcome was seen between patients with more intact CPA when divided by level of CPP. In patients with more impaired CPA, CPP < 50 mm Hg and CPP < 60 mm Hg were associated with favorable outcome, whereas CPP > 70 mm Hg and CPP > 80 mm Hg were associated with unfavorable outcome. In patients with more intact CPA, no difference in physiological variables was seen between patients with favorable and unfavorable outcomes.
CONCLUSION:
Our results support that in traumatic brain injury patients with impaired CPA, CPP should not be elevated.
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Affiliation(s)
- Ulf Johnson
- Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
| | - Tim Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
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Kourbeti IS, Papadakis JA, Neophytou C, Filippou M, Ioannou A, Karabetsos DA, Bertsias G, Anastasaki M, Vakis AF. Infections in patients with traumatic brain injury who undergo neurosurgery. Br J Neurosurg 2010; 25:9-15. [DOI: 10.3109/02688697.2010.500411] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Lingsma HF, Roozenbeek B, Steyerberg EW, Murray GD, Maas AIR. Early prognosis in traumatic brain injury: from prophecies to predictions. Lancet Neurol 2010; 9:543-54. [PMID: 20398861 DOI: 10.1016/s1474-4422(10)70065-x] [Citation(s) in RCA: 287] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Traumatic brain injury (TBI) is a heterogeneous condition that encompasses a broad spectrum of disorders. Outcome can be highly variable, particularly in more severely injured patients. Despite the association of many variables with outcome, prognostic predictions are notoriously difficult to make. Multivariable analysis has identified age, clinical severity, CT abnormalities, systemic insults (hypoxia and hypotension), and laboratory variables as relevant factors to include in models to predict outcome in individual patients. Advances in statistical modelling and the availability of large datasets have facilitated the development of prognostic models that have greater performance and generalisability. Two prediction models are currently available, both of which have been developed on large datasets with state-of-the-art methods, and offer new opportunities. We see great potential for their use in clinical practice, research, and policy making, as well as for assessment of the quality of health-care delivery. Continued development, refinement, and validation is advocated, together with assessment of the clinical impact of prediction models, including treatment response.
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Affiliation(s)
- Hester F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Are head injury guidelines changing the outcome of head injured children? A regional investigation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2009. [PMID: 19388293 DOI: 10.1007/978-3-211-85578-2_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
BACKGROUND Secondary pathophysiological CPP insult is related to outcome after head injury, and improved management would be expected to reduce secondary brain insult. Paediatric head injury management guidelines have been published in recent years, by SIGN (2000), RCPCH (2001), NICE (June 2003), and jointly by Critical/Intensive Care Societies (C/ICS July 2003). We investigated whether outcome of children's head injury (and total burden of secondary CPP insult) has changed (1) annually; (2) before and after the introduction of any HI guidelines, and (3) following other service changes. METHODS Seventy-six children (aged 1-14 years with severe HI) were admitted to the Edinburgh Regional Head Injury Service between 1989 and 2006, and dichotomised at various time points and compared in terms of: demographic factors, intracranial pressure (ICP), cerebral perfusion pressure (CPP) insults [e.g. age-banded pressure-time index (PTI)], and Glasgow Outcome Scale (GOS) score (assessed at 6 months post injury). FINDINGS When dichotomised around the SIGN guidelines, there were no statistically significant differences between the two group's demography or in primary brain injury, but the outcomes were different (p = 0.03), with 6 vs 4 GOS1 (died), 2 vs 4 GOS3 (severely disabled), 5 vs 16 GOS4 (moderately disabled) and 23 vs 14 GOS5 (good recovery), when comparing before and after year 2000. GOS4 was significantly different (chi-square = 7.99, p < 0.007). There was a (non-significant) trend for the later years to have longer insult durations of ICP, hypertension, CPP, hypoxia, pyrexia, tachycardia and bradycardia, greater PTI for both CPP and ICP, and more CPP insults (p = 0.003). There was, however, significantly less CPP insult (p = 0.030) after the introduction of the more management-oriented C/ICS guidelines. CONCLUSIONS The most recent paediatric HI guidelines appear to have reduced the burden of secondary insult, but more time is required to determine if this will be reflected in improved outcomes.
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Tau proteins in serum predict outcome after severe traumatic brain injury. J Surg Res 2009; 160:302-7. [PMID: 19345376 DOI: 10.1016/j.jss.2008.12.022] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 12/02/2008] [Accepted: 12/15/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND The identification of reliable outcome predictors after traumatic brain injury (TBI) is crucial. The objective of our study was to investigate the role of tau protein as a serum marker of TBI. METHODS Thirty-four patients with severe TBI (Glasgow Coma Scale [GCS] score at admission <or= 8) were considered. The tau protein level in the blood samples obtained at the time of admission was measured. The outcome was assessed by using the Glasgow Outcome Scale (GOS) at 6 mo post-injury. Demographic, clinical, and laboratory variables were analyzed to study their effect on the outcome. RESULTS tau Protein levels were higher in the poor outcome group (436.2 +/- 473.6 pg/mL) than in the good outcome group (51.6 +/- 81.5 pg/mL) (P < 0.0001). Univariate analyses demonstrated that poor outcome was significantly associated with a poor GCS score (P = 0.001), higher serum tau protein levels (P < 0.001), abnormal pupil light reflex (P = 0.013), and basal cistern compression on computed tomogram (CT) (P = 0.026). Multivariate analyses revealed that a poor GCS score (P = 0.049) and higher serum tau protein levels (P = 0.043) were independent prognostic factors for poor outcome. The receiver-operating characteristic (ROC) curve demonstrated that a tau protein level >or= 114.5 pg/mL yielded 88% sensitivity and 94% specificity for predicting a poor outcome. CONCLUSIONS These results suggest that in addition to GCS; serum tau protein levels may serve as indicators for the prediction of outcome following severe TBI. However; it should be viewed with caution because of the small sample size and wide standard deviations.
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Kim GT. Management of Head Injury in the Emergency Department. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2007. [DOI: 10.5124/jkma.2007.50.8.692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Gab-Teug Kim
- Department of Emergency Medicine, Dankook University College of Medicine, Korea.
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