[Management of severe traumatic brain injury]

Corticosteroid treatment for refractory intracranial hypertension: a rescue therapy in patients with severe traumatic brain injury with contusional lesions-a feedback

INTRODUCTION

Refractory intracranial hypertension (rICH) is a severe complication among patients with severe traumatic brain injury (sTBI). Medical treatment may be insufficient, and in some cases, the only viable treatment option is decompressive hemicraniectomy. The assessment of a corticosteroid therapy against vasogenic edema secondary to severe brain injuries seems interesting to prevent this surgery in sTBI patients with rICH caused by contusional areas.

METHODS

This is a monocentric retrospective observational study including all consecutive sTBI patients with contusion injuries and a rICH requiring cerebrospinal fluid drainage with external ventricular drainage between November 2013 and January 2018. Patient inclusion criterium was a therapeutic index load (TIL; an indirect measure of TBI severity) > 7. Intracranial pressure (ICP) and TIL were assessed before and 48 h after corticosteroid therapy (CTC). Then, we divided the population into two groups according to the evolution of the TIL: responders and non-responders to corticosteroid therapy.

RESULTS

During the study period, 512 patients were hospitalized for sTBI, and among them, 44 (8.6%) with rICH were included. They received 240 mg per day [120 mg, 240 mg] of Solu-Medrol for 2 days [1; 3], 3 days after the sTBI. The average ICP in patients with rICH before the CTC bolus was 21 mmHg [19; 23]. After the CTC bolus, the ICP fell significantly to less than 15 mmHg (p < 0.0001) for at least 7 days. The TIL decreased significantly the day after the CTC bolus and until day 2. Among these 44 patients, 68% were included in the responder group (n = 30).

DISCUSSION

Short and systemic corticosteroid therapy in patients with refractory intracranial hypertension secondary to severe traumatic brain injury seems to be a potentially useful and efficient treatment for lowering intracranial pressure and decreasing the need for more invasive surgeries.

Biphasic activation of nuclear factor-κB and expression of p65 and c-Rel following traumatic neuronal injury

The transcription factor nuclear factor-κB (NF-κB) has been shown to function as a key regulator of cell death or survival in neuronal cells. Previous studies indicate that the biphasic activation of NF-κB occurs following experimental neonatal hypoxia-ischemia and subarachnoid hemorrhage. However, the comprehensive understanding of NF-κB activity following traumatic brain injury (TBI) is incomplete. In the current study, an in vitro model of TBI was designed to investigate the NF-κB activity and expression of p65 and c-Rel subunits following traumatic neuronal injury. Primary cultured neurons were assigned to control and transected groups. NF-κB activity was detected by electrophoretic mobility shift assay. Western blotting and immunofluorescence were used to investigate the expression and distribution of p65 and c-Rel. Reverse transcription-quantitative polymerase chain reaction was performed to assess the downstream genes of NF-κB. Lactate dehydrogenase (LDH) quantification and trypan blue staining were used to estimate the neuronal injury. Double peaks of elevated NF-κB activity were observed at 1 and 24 h following transection. The expression levels of downstream genes exhibited similar changes. The protein levels of p65 also presented double peaks while c-Rel was elevated significantly in the late stage. The results of the trypan blue staining and LDH leakage assays indicated there was no sustained neuronal injury during the late peak of NF-κB activity. In conclusion, biphasic activation of NF-κB is induced following experimental traumatic neuronal injury. The elevation of p65 and c-Rel levels at different time periods suggests that within a single neuron, NF-κB may participate in different pathophysiological processes.

Defenestration in children younger than 6 years old: mortality predictors in severe head trauma

PURPOSE

This study aims to describe the characteristics of severe head injuries in children less than 6 years old, victims of falls from windows, and identify the main predictive factors of mortality in this population.

PATIENTS AND METHODS

A cross-sectional study was designed through data derived from medical records of less than 6-year-old children victims of falls from windows presenting with a severe head injury defined by an initial Glasgow coma scale (GCS) < or =8, hospitalized at a Pediatric Trauma center level III, between January 2000 and December 2005. Statistical analysis used univariate analysis and multiple logistic regressions.

RESULTS

We identified 58 severe head injuries in children victims of falls from windows. The mean age was 2.8 +/- 1.4 years, with a male prevalence (64%); 48% of patients had a GCS < or =5; 62.1% had a Pediatric Trauma Score (PTS) < or =3 at hospital admission. The mortality rate was 41% (24/58) and most of them (88%; 21/24) died within 48 h. An increased death rate was noted in children admitted with hypoxemia (p = 0.001), low systolic blood pressure (p = 0.002), hypothermia (p = 0.0001), GCS < or =5 (p = 10(-5)), PTS < or =3 (p = 0.008), hyperglycemia (p = 0.023), coagulation disorders (p = 0.02), and initial intracranial pressure > or =20 mmHg (p = 0.03). Initial hypothermia, hyperglycemia, and coagulation disorders were the only independent predictive factors of mortality.

CONCLUSION

Severe head injuries resulting from falls from windows carry a high risk of mortality in less than 6-year-old children. Hypothermia, hyperglycemia, and coagulation's disorders are independent predictive factors of mortality. Early deaths could be considered as direct consequences of uncontrollable brain lesions.