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Kim KA, Kim H, Ha EJ, Yoon BC, Kim DJ. Artificial Intelligence-Enhanced Neurocritical Care for Traumatic Brain Injury : Past, Present and Future. J Korean Neurosurg Soc 2024; 67:493-509. [PMID: 38186369 PMCID: PMC11375068 DOI: 10.3340/jkns.2023.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024] Open
Abstract
In neurointensive care units (NICUs), particularly in cases involving traumatic brain injury (TBI), swift and accurate decision-making is critical because of rapidly changing patient conditions and the risk of secondary brain injury. The use of artificial intelligence (AI) in NICU can enhance clinical decision support and provide valuable assistance in these complex scenarios. This article aims to provide a comprehensive review of the current status and future prospects of AI utilization in the NICU, along with the challenges that must be overcome to realize this. Presently, the primary application of AI in NICU is outcome prediction through the analysis of preadmission and high-resolution data during admission. Recent applications include augmented neuromonitoring via signal quality control and real-time event prediction. In addition, AI can integrate data gathered from various measures and support minimally invasive neuromonitoring to increase patient safety. However, despite the recent surge in AI adoption within the NICU, the majority of AI applications have been limited to simple classification tasks, thus leaving the true potential of AI largely untapped. Emerging AI technologies, such as generalist medical AI and digital twins, harbor immense potential for enhancing advanced neurocritical care through broader AI applications. If challenges such as acquiring high-quality data and ethical issues are overcome, these new AI technologies can be clinically utilized in the actual NICU environment. Emphasizing the need for continuous research and development to maximize the potential of AI in the NICU, we anticipate that this will further enhance the efficiency and accuracy of TBI treatment within the NICU.
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Affiliation(s)
- Kyung Ah Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea
| | - Hakseung Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Byung C Yoon
- Department of Radiology, Stanford University School of Medicine, VA Palo Alto Heath Care System, Palo Alto, CA, USA
| | - Dong-Joo Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
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Hirayama Y, Kida H, Inoue T, Sugimoto K, Oka F, Shirao S, Imoto H, Nomura S, Suzuki M. Focal brain cooling suppresses spreading depolarization and reduces endothelial nitric oxide synthase expression in rats. IBRO Neurosci Rep 2024; 16:609-621. [PMID: 38800086 PMCID: PMC11127172 DOI: 10.1016/j.ibneur.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/29/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
This study aimed to investigate the effects of focal brain cooling (FBC) on spreading depolarization (SD), which is associated with several neurological disorders. Although it has been studied from various aspects, no medication has been developed that can effectively control SD. As FBC can reduce neuronal damage and promote functional recovery in pathological conditions such as epilepsy, cerebral ischemia, and traumatic brain injury, it may also potentially suppress the onset and progression of SD. We created an experimental rat model of SD by administering 1 M potassium chloride (KCl) to the cortical surface. Changes in neuronal and vascular modalities were evaluated using multimodal recording, which simultaneously recorded brain temperature (BrT), wide range electrocorticogram, and two-dimensional cerebral blood flow. The rats were divided into two groups (cooling [CL] and non-cooling [NC]). Warm or cold saline was perfused on the surface of one hemisphere to maintain BrT at 37°C or 15°C in the NC and CL groups, respectively. Western blot analysis was performed to determine the effects of FBC on endothelial nitric oxide synthase (eNOS) expression. In the NC group, KCl administration triggered repetitive SDs (mean frequency = 11.57/h). In the CL group, FBC increased the duration of all KCl-induced events and gradually reduced their frequency. Additionally, eNOS expression decreased in the cooled brain regions compared to the non-cooled contralateral hemisphere. The results obtained by multimodal recording suggest that FBC suppresses SD and decreases eNOS expression. This study may contribute to developing new treatments for SD and related neurological disorders.
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Affiliation(s)
- Yuya Hirayama
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Hiroyuki Kida
- Department of Physiology, Graduate School of Medicine, Yamaguchi University, Japan
| | - Takao Inoue
- Organization of Research Initiatives, Yamaguchi University, Japan
| | - Kazutaka Sugimoto
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Fumiaki Oka
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Satoshi Shirao
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Hirochika Imoto
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Sadahiro Nomura
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2023:S2173-5808(23)00008-1. [PMID: 37031799 DOI: 10.1016/j.nrleng.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/04/2020] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- César E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA.
| | - Nadxielli Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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Wolthers SA, Engelholm CP, Uslu B, Brandt CT. Noninvasive intracranial pressure monitoring in central nervous system infections. Minerva Anestesiol 2023; 89:206-216. [PMID: 36422116 DOI: 10.23736/s0375-9393.22.16863-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intracranial pressure (ICP) monitoring constitutes an important part of the management of traumatic brain injury. However, its application in other brain pathologies such as neuroinfections like acute bacterial meningitis is unclear. Despite focus on aggressive, prompt treatment, morbidity and mortality from acute bacterial meningitis remain high. Increased ICP is well-known to occur in severe neuroinfections. The increased ICP compromise cerebral perfusion pressure and may ultimately lead to brain stem herniation. Therefore, controlling the ICP could also be important in acute bacterial meningitis. However, risk factors for complications due to invasive monitoring among these patients may be significantly increased due to higher age and levels of comorbidity compared to the traumatic brain injury patient from which the ICP treatment algorithms are developed. This narrative review evaluates the different modalities of ICP monitoring with the aim to elucidate current status of non-invasive alternatives to invasive monitoring as a decision tool and eventually monitoring. Non-invasive screening using ultrasound of the optical nerve sheath, transcranial doppler, magnetic resonance imaging or preferably a combination of these modalities, provides measurements that can be used as a decision guidance for invasive ICP measurement. The available data do not support the replacement of invasive techniques for continuous ICP measurement in patients with increased ICP. Non-invasive modalities should be taken into consideration in patients with neuroinfections at low risk of increased ICP.
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Affiliation(s)
- Signe A Wolthers
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark -
| | - Cecilie P Engelholm
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Bülent Uslu
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Christian T Brandt
- Unit of Infectious Diseases, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
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Jeong TS, Choi DH, Kim WK. Comparison of Outcomes at Trauma Centers versus Non-Trauma Centers for Severe Traumatic Brain Injury. J Korean Neurosurg Soc 2023; 66:63-71. [PMID: 35996944 PMCID: PMC9837480 DOI: 10.3340/jkns.2022.0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/22/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Traumatic brain injury (TBI) is one of the most common injuries in patients with multiple trauma, and it associates with high post-traumatic mortality and morbidity. A trauma center was established to provide optimal treatment for patients with severe trauma. This study aimed to compare the treatment outcomes of patients with severe TBI between non-trauma and trauma centers based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS). METHODS From January 2018 to June 2021, 1122 patients were enrolled in the KNTDBS study. Among them, 253 patients from non-traumatic centers and 253 from trauma centers were matched using propensity score analysis. We evaluated baseline characteristics, the time required from injury to hospital arrival, surgery-related factors, neuromonitoring, and outcomes. RESULTS The time from injury to hospital arrival was shorter in the non-trauma centers (110.2 vs. 176.1 minutes, p=0.012). The operation time was shorter in the trauma centers (156.7 vs. 128.1 minutes, p0.003). Neuromonitoring was performed in nine patients (3.6%) in the non-trauma centers and 67 patients (26.5%) in the trauma centers (p<0.001). Mortality rates were lower in trauma centers than in non-trauma centers (58.5% vs. 47.0%, p=0.014). The average Glasgow coma scale (GCS) at discharge was higher in the trauma centers (4.3 vs. 5.7, p=0.011). For the Glasgow outcome scale-extended (GOSE) at discharge, the favorable outcome (GOSE 5-8) was 17.4% in the non-trauma centers and 27.3% in the trauma centers (p=0.014). CONCLUSION This study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI.
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Affiliation(s)
- Tae Seok Jeong
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dae Han Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea,Address for correspondence : Dae Han Choi Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel : +82-32-460-3304, Fax : +82-32-460-3899, E-mail :
| | - Woo Kyung Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - KNTDB Investigators
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Korea
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6
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Tas J, Czosnyka M, van der Horst ICC, Park S, van Heugten C, Sekhon M, Robba C, Menon DK, Zeiler FA, Aries MJH. Cerebral multimodality monitoring in adult neurocritical care patients with acute brain injury: A narrative review. Front Physiol 2022; 13:1071161. [PMID: 36531179 PMCID: PMC9751622 DOI: 10.3389/fphys.2022.1071161] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 11/07/2022] [Indexed: 07/27/2023] Open
Abstract
Cerebral multimodality monitoring (MMM) is, even with a general lack of Class I evidence, increasingly recognized as a tool to support clinical decision-making in the neuroscience intensive care unit (NICU). However, literature and guidelines have focused on unimodal signals in a specific form of acute brain injury. Integrating unimodal signals in multiple signal monitoring is the next step for clinical studies and patient care. As such, we aimed to investigate the recent application of MMM in studies of adult patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), acute ischemic stroke (AIS), and hypoxic ischemic brain injury following cardiac arrest (HIBI). We identified continuous or daily updated monitoring modalities and summarized the monitoring setting, study setting, and clinical characteristics. In addition, we discussed clinical outcome in intervention studies. We identified 112 MMM studies, including 11 modalities, over the last 7 years (2015-2022). Fifty-eight studies (52%) applied only two modalities. Most frequently combined were ICP monitoring (92 studies (82%)) together with PbtO2 (63 studies (56%). Most studies included patients with TBI (59 studies) or SAH (53 studies). The enrollment period of 34 studies (30%) took more than 5 years, whereas the median sample size was only 36 patients (q1- q3, 20-74). We classified studies as either observational (68 studies) or interventional (44 studies). The interventions were subclassified as systemic (24 studies), cerebral (10 studies), and interventions guided by MMM (11 studies). We identified 20 different systemic or cerebral interventions. Nine (9/11, 82%) of the MMM-guided studies included clinical outcome as an endpoint. In 78% (7/9) of these MMM-guided intervention studies, a significant improvement in outcome was demonstrated in favor of interventions guided by MMM. Clinical outcome may be improved with interventions guided by MMM. This strengthens the belief in this application, but further interdisciplinary collaborations are needed to overcome the heterogeneity, as illustrated in the present review. Future research should focus on increasing sample sizes, improved data collection, refining definitions of secondary injuries, and standardized interventions. Only then can we proceed with complex outcome studies with MMM-guided treatment.
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Affiliation(s)
- Jeanette Tas
- Maastricht University Medical Center +, Department of Intensive Care Medicine, Maastricht University, Maastricht, Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Iwan C. C. van der Horst
- Maastricht University Medical Center +, Department of Intensive Care Medicine, Maastricht University, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University, New York, NY, United States
| | - Caroline van Heugten
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico Santino IRCCS for Oncology and Neuroscience, Dipartimento di Scienze Chirurgiche Diagnostiche Integrate, University of Genova, Genova, Italy
| | - David K. Menon
- University Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- University Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Marcel J. H. Aries
- Maastricht University Medical Center +, Department of Intensive Care Medicine, Maastricht University, Maastricht, Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
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El-Swaify ST, Kamel M, Ali SH, Bahaa B, Refaat MA, Amir A, Abdelrazek A, Beshay PW, Basha AKMM. Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges. Surg Neurol Int 2022; 13:431. [DOI: 10.25259/sni_609_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).
Methods:
We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.
Results:
This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.
Conclusion:
Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.
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Affiliation(s)
- Seif Tarek El-Swaify
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Menna Kamel
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Ali
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassem Bahaa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman Amir
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Pavly Wagih Beshay
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Tracking Antioxidant Status in Spinal Cord Injured Rodents: A Voltammetric Method Suited for Clinical Translation. World Neurosurg 2022; 161:e183-e191. [PMID: 35093575 DOI: 10.1016/j.wneu.2022.01.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) triggers a signalling cascade that produces oxidative stress and damages the spinal cord. Voltammetry is a clinically accessible technique to detect, monitor, and guide correction of this potentially reversible secondary injury mechanism. Voltammetry is well suited for clinical translation because the method is inexpensive, simple, rapid, and portable. Voltammetry relies on the measurement of anodic current from a reagent-free, electrochemical reaction on the surface of a small electrode. METHODS The present study tested the use of new disposable carbon nanotube based screen printed electrodes (CNT-SPE) for the voltammetric measurement of antioxidant current (AC). Spinal cord, cerebrospinal fluid, and plasma were obtained from Sprague-Dawley rats after SCI. Locomotor function after SCI was assessed by using the Basso, Beattie, Bresnahan (BBB) score. RESULTS The more severe SCI caused a decline in spinal cord AC419 at 10 minutes (P < 0.05), 4 hours (P < 0.0001), and 1 day (P < 0.01) after injury compared with sham controls. It also caused a decline in plasma AC375 at 1 (P < 0.001) and 3 days (P < 0.05) after injury compared with their pre-injury baseline. Spinal cord AC419 correlated with plasma AC375 (r = 0.49, P < 0.01) and BBB score (r = 0.66, P < 0.0001) at 1 day after SCI. CONCLUSIONS AC measured by CNT-SPE demonstrated a time- and severity-dependent decline after SCI. Plasma AC could serve as a surrogate marker for spinal cord AC.
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Neuromonitoring in Severe Traumatic Brain Injury: A Bibliometric Analysis. Neurocrit Care 2022; 36:1044-1052. [PMID: 35075580 DOI: 10.1007/s12028-021-01428-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of mortality and disability among trauma-related injuries. Neuromonitoring plays an essential role in the management and prognosis of patients with severe TBI. Our bibliometric study aimed to identify the knowledge base, define the research front, and outline the social networks on neuromonitoring in severe TBI. We conducted an electronic search for articles related to neuromonitoring in severe TBI in Scopus. A descriptive analysis retrieved evidence on the most productive authors and countries, the most cited articles, the most frequently publishing journals, and the most common author's keywords. Through a three-step network extraction process, we performed a collaboration analysis among universities and countries, a cocitation analysis, and a word cooccurrence analysis. A total of 1884 records formed the basis of our bibliometric study. We recorded an increasing scientific interest in the use of neuromonitoring in severe TBI. Czosnyka, Hutchinson, Menon, Smielewski, and Stocchetti were the most productive authors. The most cited document was a review study by Maas et al. There was an extensive collaboration among universities. The most common keywords were "intracranial pressure," with an increasing interest in magnetic resonance imaging and cerebral perfusion pressure monitoring. Neuromonitoring constitutes an area of active research. The present findings indicate that intracranial pressure monitoring plays a pivotal role in the management of severe TBI. Scientific interest shifts to magnetic resonance imaging and individualized patient care on the basis of optimal cerebral perfusion pressure.
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Wang KK, Munoz Pareja JC, Mondello S, Diaz-Arrastia R, Wellington C, Kenney K, Puccio AM, Hutchison J, McKinnon N, Okonkwo DO, Yang Z, Kobeissy F, Tyndall JA, Büki A, Czeiter E, Pareja Zabala MC, Gandham N, Berman R. Blood-based traumatic brain injury biomarkers - Clinical utilities and regulatory pathways in the United States, Europe and Canada. Expert Rev Mol Diagn 2021; 21:1303-1321. [PMID: 34783274 DOI: 10.1080/14737159.2021.2005583] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major global health issue, resulting in debilitating consequences to families, communities, and health-care systems. Prior research has found that biomarkers aid in the pathophysiological characterization and diagnosis of TBI. Significantly, the FDA has recently cleared both a bench-top assay and a rapid point-of-care assays of tandem biomarker (UCH-L1/GFAP)-based blood test to aid in the diagnosis mTBI patients. With the global necessity of TBI biomarkers research, several major consortium multicenter observational studies with biosample collection and biomarker analysis have been created in the USA, Europe, and Canada. As each geographical region regulates its data and findings, the International Initiative for Traumatic Brain Injury Research (InTBIR) was formed to facilitate data integration and dissemination across these consortia. AREAS COVERED This paper covers heavily investigated TBI biomarkers and emerging non-protein markers. Finally, we analyze the regulatory pathways for converting promising TBI biomarkers into approved in-vitro diagnostic tests in the United States, European Union, and Canada. EXPERT OPINION TBI biomarker research has significantly advanced in the last decade. The recent approval of an iSTAT point of care test to detect mild TBI has paved the way for future biomarker clearance and appropriate clinical use across the globe.
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Affiliation(s)
- Kevin K Wang
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.,Brain Rehabilitation Research Center (BRRC), Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Jennifer C Munoz Pareja
- Department of Pediatric Critical Care, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Canada
| | - Kimbra Kenney
- Department of Neurology, Uniformed Service University, Bethesda, Maryland, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jamie Hutchison
- The Hospital for Sick Children, Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole McKinnon
- The Hospital for Sick Children, Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.,Brain Rehabilitation Research Center (BRRC), Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Firas Kobeissy
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.,Brain Rehabilitation Research Center (BRRC), Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - J Adrian Tyndall
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Endre Czeiter
- Department of Neurosurgery, Pecs University, Pecs, Hungary
| | | | - Nithya Gandham
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rebecca Berman
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
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Merz T, McCook O, Denoix N, Radermacher P, Waller C, Kapapa T. Biological Connection of Psychological Stress and Polytrauma under Intensive Care: The Role of Oxytocin and Hydrogen Sulfide. Int J Mol Sci 2021; 22:9192. [PMID: 34502097 PMCID: PMC8430789 DOI: 10.3390/ijms22179192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022] Open
Abstract
This paper explored the potential mediating role of hydrogen sulfide (H2S) and the oxytocin (OT) systems in hemorrhagic shock (HS) and/or traumatic brain injury (TBI). Morbidity and mortality after trauma mainly depend on the presence of HS and/or TBI. Rapid "repayment of the O2 debt" and prevention of brain tissue hypoxia are cornerstones of the management of both HS and TBI. Restoring tissue perfusion, however, generates an ischemia/reperfusion (I/R) injury due to the formation of reactive oxygen (ROS) and nitrogen (RNS) species. Moreover, pre-existing-medical-conditions (PEMC's) can aggravate the occurrence and severity of complications after trauma. In addition to the "classic" chronic diseases (of cardiovascular or metabolic origin), there is growing awareness of psychological PEMC's, e.g., early life stress (ELS) increases the predisposition to develop post-traumatic-stress-disorder (PTSD) and trauma patients with TBI show a significantly higher incidence of PTSD than patients without TBI. In fact, ELS is known to contribute to the developmental origins of cardiovascular disease. The neurotransmitter H2S is not only essential for the neuroendocrine stress response, but is also a promising therapeutic target in the prevention of chronic diseases induced by ELS. The neuroendocrine hormone OT has fundamental importance for brain development and social behavior, and, thus, is implicated in resilience or vulnerability to traumatic events. OT and H2S have been shown to interact in physical and psychological trauma and could, thus, be therapeutic targets to mitigate the acute post-traumatic effects of chronic PEMC's. OT and H2S both share anti-inflammatory, anti-oxidant, and vasoactive properties; through the reperfusion injury salvage kinase (RISK) pathway, where their signaling mechanisms converge, they act via the regulation of nitric oxide (NO).
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Affiliation(s)
- Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
- Clinic for Psychosomatic Medicine and Psychotherapy, Medical Center, Ulm University, 89081 Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Nuremberg General Hospital, Paracelsus Medical University, 90471 Nuremberg, Germany;
| | - Thomas Kapapa
- Clinic for Neurosurgery, Medical Center, Ulm University, 89081 Ulm, Germany;
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Niño MC, Cohen D, Mejía JA, Gutiérrez JA, González M. Letter: Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. Neurosurgery 2021; 88:E370-E371. [PMID: 33442723 DOI: 10.1093/neuros/nyaa574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Maria Claudia Niño
- Department of Anesthesiology Hospital Universitario Fundación Santa Fe de Bogotá Bogotá, Colombia
| | - Darwin Cohen
- Department of Anesthesiology Hospital Universitario Fundación Santa Fe de Bogotá Bogotá, Colombia
| | - Juan Armando Mejía
- Department of Neurosurgery Hospital Universitario Fundación Santa Fe de Bogotá Bogotá, Colombia
| | - Javier Andrés Gutiérrez
- Department of Anesthesiology Hospital Universitario Fundación Santa Fe de Bogotá Bogotá, Colombia
| | - Mariana González
- Department of Anesthesiology Hospital Universitario Fundación Santa Fe de Bogotá Bogotá, Colombia
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2020; 38:S0213-4853(20)30274-7. [PMID: 33069447 DOI: 10.1016/j.nrl.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Increased intracranial pressure has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury. Traditionally, intracranial pressure-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe traumatic brain injury in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- C E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, EE. UU..
| | - N Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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14
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Yang MT. Multimodal neurocritical monitoring. Biomed J 2020; 43:226-230. [PMID: 32651135 PMCID: PMC7424082 DOI: 10.1016/j.bj.2020.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/01/2020] [Accepted: 05/03/2020] [Indexed: 01/11/2023] Open
Abstract
Neurocritical monitoring is important in caring for patients in the neurological intensive care unit. Although clinical neurologic examination is standard for neurocritical monitoring, changes found during the examination are often late signs and insufficient to detect and prevent secondary brain injury. Therefore, various neuromonitoring tools have been developed to monitor different physiologic parameters, such as cerebral oxygenation, cerebral blood flow, cerebral pressure, cerebral autoregulation, cerebral electric activity, and cerebral metabolism. In this review, we have discussed current commonly used neurocritical monitoring tools. No single monitor is sufficient and perfect for neurocritical monitoring. Multimodal neurocritical monitoring is the current trend. However, the lack of common formatting standards and uncertainty of improvement in patients' outcomes warrant further studies of multimodal neurocritical monitoring. Nevertheless, multimodal neurocritical monitoring considers individual pathophysiological variations in patients or their injuries and allows clinicians to tailor individualized management decisions.
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Affiliation(s)
- Ming-Tao Yang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan, Taiwan.
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15
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Lovett ME, O'Brien NF, Leonard JR. Children With Severe Traumatic Brain Injury, Intracranial Pressure, Cerebral Perfusion Pressure, What Does it Mean? A Review of the Literature. Pediatr Neurol 2019; 94:3-20. [PMID: 30765136 DOI: 10.1016/j.pediatrneurol.2018.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 11/18/2022]
Abstract
Severe traumatic brain injury is a leading cause of morbidity and mortality in children. In 2003 the Brain Trauma Foundation released guidelines that have since been updated (2010) and have helped standardize and improve care. One area of care that remains controversial is whether the placement of an intracranial pressure monitor is advantageous in the management of traumatic brain injury. Another aspect of care that is widely debated is whether management after traumatic brain injury should be based on intracranial pressure-directed therapy, cerebral perfusion pressure-directed therapy, or a combination of the two. The aim of this article was to provide an overview and review the current evidence regarding these questions.
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Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio.
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Jeffrey R Leonard
- Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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Abstract
Neuromonitoring is important for patients with acute brain injury. The bedside neurologic examination is standard for neurologic monitoring; however, a clinical examination may not reliably detect subtle changes in intracranial physiology. Changes found during neurologic examinations are often late signs. The assessment of multiple physiological variables in real time can provide new clinical insights into treatment decisions. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism, such as in multimodal monitoring, allows an innovative approach to individualized patient care.
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Affiliation(s)
- Sarah H Peacock
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Amanda D Tomlinson
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
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17
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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Abstract
Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
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20
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Management and outcome of moderate head trauma: our experience. ROMANIAN NEUROSURGERY 2018. [DOI: 10.2478/romneu-2018-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractObjective: The aim of this study is to follow up patients with moderate head trauma who were admitted to Mansoura University Hospital in the period from 1 Dec. 2015 to 30 Jul. 2016 until discharge and determine the outcome of head trauma.Material and Methods:This prospective study were conducted on all patients with moderate head trauma admitted to Mansoura Emergency Hospital during the period from 1 Dec. 2015 to 30 Jul. 2016 with exclude Polytrauma, bleeding disorders, severe liver and kidney disease patients.Results: In this study, we correlated different risk factors with management and with outcome. Management may be surgical or conservative and outcome may be alive or dead. We have 60 patients with 17 cases (28.3%) were treated surgically and 43 cases (71.6%) were treated conservatively. According to outcome 36 cases (60%) were alive and 24 cases (40%) died, all cases managed in ICU. According to sex, 10 cases (17%) were female and 50 cases were male (83%) with statistically nonsignificant effect on outcome (P = 0.7) and management (P =0.7). road traffic accidents is most common cause of injury with 33 cases (55%), and Cause of injury had statistically significant effect on management (P = 0.02) and statistically non-significant effect on outcome (p = 0.4). GCS on admission had no statistically significant effect on management (P=0.8) and outcome (P=0.1) with mean of 10.1±1.2 and GCS on discharge had no statistically significant effect on management (P=0.6).Conclusion: There were significant effect of age of patients, systemic diseases (such as DM, HTN, chronic kidney diseases, and chronic liver diseases), type of lesions (especially SDH, SAH), and serum electrolytes (especially serum Sodium) on outcome which determined by GCS at discharge, length of hospital stay, and the state of the patient at discharge.
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22
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Godoy DA, Videtta W, Di Napoli M. Practical Approach to Posttraumatic Intracranial Hypertension According to Pathophysiologic Reasoning. Neurol Clin 2017; 35:613-640. [DOI: 10.1016/j.ncl.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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23
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Marklund N. The Neurological Wake-up Test-A Role in Neurocritical Care Monitoring of Traumatic Brain Injury Patients? Front Neurol 2017; 8:540. [PMID: 29089921 PMCID: PMC5650971 DOI: 10.3389/fneur.2017.00540] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/26/2017] [Indexed: 12/12/2022] Open
Abstract
The most fundamental clinical monitoring tool in traumatic brain injury (TBI) patients is the repeated clinical examination. In the severe TBI patient treated by continuous sedation in a neurocritical care (NCC) unit, sedation interruption is required to enable a clinical evaluation (named the neurological wake-up test; NWT) assessing the level of consciousness, pupillary diameter and reactivity to light, and presence of focal neurological deficits. There is a basic conflict regarding the NWT in the NCC setting; can the clinical information obtained by the NWT justify the risk of inducing a stress response in a severe TBI patient? Furthermore, in the presence of advanced multimodal monitoring and neuroimaging, is the NWT necessary to identify important clinical alterations? In studies of severe TBI patients, the NWT was consistently shown to induce a stress reaction including brief increases in intracranial pressure (ICP) and changes in cerebral perfusion pressure (CPP). However, it has not been established whether these short-lived ICP and CPP changes are detrimental to the injured brain. Daily interruption of sedation is associated with a reduced ventilator time, shorter hospital stay and reduced mortality in many studies of general intensive care unit patients, although such clinical benefits have not been firmly established in TBI. To date, there is no consensus on the use of the NWT among NCC units and systematic studies are scarce. Thus, additional studies evaluating the role of the NWT in clinical decision-making are needed. Multimodal NCC monitoring may be an adjunct in assessing in which TBI patients the NWT can be safely performed. At present, the NWT remains the golden standard for clinical monitoring and detection of neurological changes in NCC and could be considered in TBI patients with stable baseline ICP and CPP readings. The focus of the present review is an overview of the existing literature on the role of the NWT as a clinical monitoring tool for severe TBI patients.
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Affiliation(s)
- Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden.,Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
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Zeiler FA, Donnelly J, Calviello L, Smielewski P, Menon DK, Czosnyka M. Pressure Autoregulation Measurement Techniques in Adult Traumatic Brain Injury, Part II: A Scoping Review of Continuous Methods. J Neurotrauma 2017; 34:3224-3237. [PMID: 28699412 DOI: 10.1089/neu.2017.5086] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A scoping review of the literature was performed systematically on commonly described continuous autoregulation measurement techniques in adult traumatic brain injury (TBI) to provide an overview of methodology and comprehensive reference library of the available literature for each technique. Five separate small systematic reviews were conducted for each of the continuous techniques: pressure reactivity index (PRx), laser Doppler flowmetry (LDF), near infrared spectroscopy (NIRS) techniques, brain tissue oxygen tension (PbtO2), and thermal diffusion (TD) techniques. Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to December 2016), and reference lists of relevant articles were searched. A two-tier filter of references was conducted. The literature base identified from the individual searches was limited, except for PRx. The total number of articles using each of the five searched techniques for continuous autoregulation in adult TBI were: PRx (28), LDF (4), NIRS (9), PbtO2 (10), and TD (8). All continuous techniques described in adult TBI are based on moving correlation coefficients. The premise behind the calculation of these moving correlation coefficients focuses on the impact of slow fluctuations in either mean arterial pressure (MAP) or cerebral perfusion pressure (CPP) on some indirect measure of cerebral blood flow (CBF), such as: intracranial pressure (ICP), LDF, NIRS signals, PbtO2, or TD CBF. The thought is the correlation between a hemodynamic driving factor, such as MAP or CPP, and a surrogate for CBF or cerebral perfusion sheds insight on the state of cerebral autoregulation. Both PRx and NIRS indices were validated experimentally against the "gold standard" static autoregulatory curve (Lassen curve) at least around the lower threshold of autoregulation. The PRx has the largest literature base supporting the association with patient outcome. Various methods of continuous autoregulation assessment are described within the adult TBI literature. Many studies exist on these various indices, suggesting an association between their values and patient morbidity/death.
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Affiliation(s)
- Frederick A Zeiler
- 1 Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom .,2 Section of Neurosurgery, Department of Surgery, University of Manitoba , Winnipeg, Manitoba, Canada .,3 Clinician Investigator Program, University of Manitoba , Winnipeg, Manitoba, Canada
| | - Joseph Donnelly
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Leanne Calviello
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Peter Smielewski
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - David K Menon
- 1 Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Marek Czosnyka
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
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25
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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Affiliation(s)
- Mohamed H Abou El Fadl
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA
| | - Kristine H O'Phelan
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA.
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Asehnoune K, Balogh Z, Citerio G, Cap A, Billiar T, Stocchetti N, Cohen MJ, Pelosi P, Curry N, Gaarder C, Gruen R, Holcomb J, Hunt BJ, Juffermans NP, Maegele M, Midwinter M, Moore FA, O'Dwyer M, Pittet JF, Schöchl H, Schreiber M, Spinella PC, Stanworth S, Winfield R, Brohi K. The research agenda for trauma critical care. Intensive Care Med 2017; 43:1340-1351. [PMID: 28756471 DOI: 10.1007/s00134-017-4895-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/20/2017] [Indexed: 01/18/2023]
Abstract
In this research agenda on the acute and critical care management of trauma patients, we concentrate on the major factors leading to death, namely haemorrhage and traumatic brain injury (TBI). In haemostasis biology, the results of randomised controlled trials have led to the therapeutic focus moving away from the augmentation of coagulation factors (such as recombinant factor VIIa) and towards fibrinogen supplementation and administration of antifibrinolytics such as tranexamic acid. Novel diagnostic techniques need to be evaluated to determine whether an individualised precision approach is superior to current empirical practice. The timing and efficacy of platelet transfusions remain in question, while new blood products need to be developed and evaluated, including whole blood variants, lyophilised products and novel red cell storage modalities. The current cornerstones of TBI management are intracranial pressure control, maintenance of cerebral perfusion pressure and avoidance of secondary insults (such as hypotension, hypoxaemia, hyperglycaemia and pyrexia). Therapeutic hypothermia and decompressive craniectomy are controversial therapies. Further research into these strategies should focus on identifying which subgroups of patients may benefit from these interventions. Prediction of the long-term outcome early after TBI remains challenging. Early magnetic resonance imaging has recently been evaluated for predicting the long-term outcome in mild and severe TBI. Novel biomarkers may also help in outcome prediction and may predict chronic neurological symptoms. For trauma in general, rehabilitation is complex and multidimensional, and the optimal timing for commencement of rehabilitation needs investigation. We propose priority areas for clinical trials in the next 10 years.
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Affiliation(s)
- Karim Asehnoune
- Department of Anesthesiology and Critical Care Medicine, Hôtel Dieu, Centre hospitalier universitaire (CHU) de Nantes, 44000, Nantes, France.
- Laboratory EA 3826, University of Nantes, Nantes, France.
| | - Zsolt Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, Australia
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Neurointensive Care Unit, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Andre Cap
- US Army Institute of Surgical Research, San Antonio, TX, USA
| | - Timothy Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mitchell J Cohen
- University of Colorado School of Medicine, Denver Health Medical Center, Aurora, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Nicola Curry
- Oxford University Hospital NHS Trust, John Radcliffe Hospital, Oxford, UK
| | | | - Russell Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University, Nanyang, Singapore
| | - John Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX, USA
| | - Beverley J Hunt
- Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - Mark Midwinter
- Rural Clinical School (Bundaberg), University of Queensland, Bundaberg, QLD, Australia
| | | | - Michael O'Dwyer
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Jean-François Pittet
- Critical Care Division, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Martin Schreiber
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University in St Louis School of Medicine, Washington, USA
| | - Simon Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | | | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
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28
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Reis C, Akyol O, Araujo C, Huang L, Enkhjargal B, Malaguit J, Gospodarev V, Zhang JH. Pathophysiology and the Monitoring Methods for Cardiac Arrest Associated Brain Injury. Int J Mol Sci 2017; 18:ijms18010129. [PMID: 28085069 PMCID: PMC5297763 DOI: 10.3390/ijms18010129] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/31/2016] [Accepted: 01/04/2017] [Indexed: 12/23/2022] Open
Abstract
Cardiac arrest (CA) is a well-known cause of global brain ischemia. After CA and subsequent loss of consciousness, oxygen tension starts to decline and leads to a series of cellular changes that will lead to cellular death, if not reversed immediately, with brain edema as a result. The electroencephalographic activity starts to change as well. Although increased intracranial pressure (ICP) is not a direct result of cardiac arrest, it can still occur due to hypoxic-ischemic encephalopathy induced changes in brain tissue, and is a measure of brain edema after CA and ischemic brain injury. In this review, we will discuss the pathophysiology of brain edema after CA, some available techniques, and methods to monitor brain oxygen, electroencephalography (EEG), ICP (intracranial pressure), and microdialysis on its measurement of cerebral metabolism and its usefulness both in clinical practice and possible basic science research in development. With this review, we hope to gain knowledge of the more personalized information about patient status and specifics of their brain injury, and thus facilitating the physicians’ decision making in terms of which treatments to pursue.
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Affiliation(s)
- Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Camila Araujo
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Lei Huang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Budbazar Enkhjargal
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Jay Malaguit
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Vadim Gospodarev
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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Adams H, Kolias AG, Hutchinson PJ. The Role of Surgical Intervention in Traumatic Brain Injury. Neurosurg Clin N Am 2016; 27:519-28. [DOI: 10.1016/j.nec.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Badenes R, García-Pérez ML, Bilotta F. Intraoperative monitoring of cerebral oximetry and depth of anaesthesia during neuroanesthesia procedures. Curr Opin Anaesthesiol 2016; 29:576-81. [DOI: 10.1097/aco.0000000000000371] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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