Incidence, Demographics, and Outcome of Traumatic Brain Injury in The Middle East: A Systematic Review

Asking questions that are "close to the bone": integrating thematic analysis and natural language processing to explore the experiences of people with traumatic brain injuries engaging with patient-reported outcome measures

Introduction

Patient-reported outcomes measures (PROMs) are valuable tools for assessing health-related quality of life and treatment effectiveness in individuals with traumatic brain injuries (TBIs). Understanding the experiences of individuals with TBIs in completing PROMs is crucial for improving their utility and relevance in clinical practice.

Methods

Sixteen semi-structured interviews were conducted with a sample of individuals with TBIs. The interviews were transcribed verbatim and analysed using Thematic Analysis (TA) and Natural Language Processing (NLP) techniques to identify themes and emotional connotations related to the experiences of completing PROMs.

Results

The TA of the data revealed six key themes regarding the experiences of individuals with TBIs in completing PROMs. Participants expressed varying levels of understanding and engagement with PROMs, with factors such as cognitive impairments and communication difficulties influencing their experiences. Additionally, insightful suggestions emerged on the barriers to the completion of PROMs, the factors facilitating it, and the suggestions for improving their contents and delivery methods. The sentiment analyses performed using NLP techniques allowed for the retrieval of the general sentimental and emotional "tones" in the participants' narratives of their experiences with PROMs, which were mainly characterised by low positive sentiment connotations. Although mostly neutral, participants' narratives also revealed the presence of emotions such as fear and, to a lesser extent, anger. The combination of a semantic and sentiment analysis of the experiences of people with TBIs rendered valuable information on the views and emotional responses to different aspects of the PROMs.

Discussion

The findings highlighted the complexities involved in administering PROMs to individuals with TBIs and underscored the need for tailored approaches to accommodate their unique challenges. Integrating TA-based and NLP techniques can offer valuable insights into the experiences of individuals with TBIs and enhance the interpretation of qualitative data in this population.

Pediatric Traumatic Brain Injury in the Middle East and North Africa Region: A Systematic Review and Meta-Analysis to Assess Characteristics, Mechanisms, and Risk Factors

Pediatric traumatic brain injury (pTBI) represents a major cause of child injuries in the Middle East and North Africa (MENA) region. This review aims to assess pTBIs in the MENA region and reports their clinical severity and outcomes. A search was conducted using major electronic databases, including Medline/Ovid, PubMed, EMBASE, Web of Science, and SCOPUS. Abstracts were screened independently and in duplicate to detect original research. The objective and study findings for each article were recorded, along with the mechanism of pTBI, patient age and sex, injury assessment tool(s) used, and outcome. A total of 1345 articles were retrieved, of which 152 met the criteria for full-text review, and 32 were included in this review. Males predominantly suffered from pTBIs (78%). Motor vehicle accidents, followed by child abuse, were the leading causes of pTBI. Overall, 0.39% of cases were mild, 0.58% moderate, 16.25% severe, and 82.27% unclassified. The mortality rate was 13.11%. Most studies used the computed tomography scan, Glasgow Coma Scale, Abbreviated Injury Scale, and Injury Severity Score as investigation methods. This review reports on the alarming rate of child-abuse-related pTBI and offers further understanding of pTBI-associated risk factors and insight into the development of strategies to reduce their occurrence, as well as policies to promote child well-being.

Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre

Background and Objective: About 14 million people will likely suffer a traumatic brain injury (TBI) per year by 2050 in sub-Saharan Africa. Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma centre in Cameroon. Materials and Methods: Data on demographics, causes, clinical aspects, and discharge status were collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality-of-Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes six months after TBI. Comparisons between two categorical variables were done using Pearson's chi-square test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years was most represented (78%). Males were more affected (90%). A low educational level was seen in 122 (76%) cases. Road traffic incidents (RTI) (85%), assaults (7.5%), and falls (2.5%) were the main causes of TBI, with professional bike riders being frequently involved (27%). Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% of cases, and intracranial traumatic abnormalities were identified in 64% of cases. Financial constraints (93%) was the main reason for not performing a CT scan. Forty-six (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) and high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only four patients received post-injury physical therapy services. Conclusions: TBI in Cameroon mainly results from RTIs and commonly affects young adult males. Lack of pre-hospital care, financial constraints limiting both CT scanning and medical care, and a lack of acute physiotherapy services likely influenced care and outcomes adversely.

Machine Learning Approach for the Prediction of In-Hospital Mortality in Traumatic Brain Injury Using Bio-Clinical Markers at Presentation to the Emergency Department

BACKGROUND

Accurate prediction of in-hospital mortality is essential for better management of patients with traumatic brain injury (TBI). Machine learning (ML) algorithms have been shown to be effective in predicting clinical outcomes. This study aimed to identify predictors of in-hospital mortality in TBI patients using ML algorithms.

MATERIALS AND METHOD

A retrospective study was performed using data from both the trauma registry and electronic medical records among TBI patients admitted to the Hamad Trauma Center in Qatar between June 2016 and May 2021. Thirteen features were selected for four ML models including a Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), and Extreme Gradient Boosting (XgBoost), to predict the in-hospital mortality.

RESULTS

A dataset of 922 patients was analyzed, of which 78% survived and 22% died. The AUC scores for SVM, LR, XgBoost, and RF models were 0.86, 0.84, 0.85, and 0.86, respectively. XgBoost and RF had good AUC scores but exhibited significant differences in log loss between the training and testing sets (% difference in logloss of 79.5 and 41.8, respectively), indicating overfitting compared to the other models. The feature importance trend across all models indicates that aPTT, INR, ISS, prothrombin time, and lactic acid are the most important features in prediction. Magnesium also displayed significant importance in the prediction of mortality among serum electrolytes.

CONCLUSIONS

SVM was found to be the best-performing ML model in predicting the mortality of TBI patients. It had the highest AUC score and did not show overfitting, making it a more reliable model compared to LR, XgBoost, and RF.

High fat diet exacerbates long-term metabolic, neuropathological, and behavioral derangements in an experimental mouse model of traumatic brain injury

AIMS

Traumatic brain injury (TBI) constitutes a serious public health concern. Although TBI targets the brain, it can exert several systemic effects which can worsen the complications observed in TBI subjects. Currently, there is no FDA-approved therapy available for its treatment. Thus, there has been an increasing need to understand other factors that could modulate TBI outcomes. Among the factors involved are diet and lifestyle. High-fat diets (HFD), rich in saturated fat, have been associated with adverse effects on brain health.

MAIN METHODS

To study this phenomenon, an experimental mouse model of open head injury, induced by the controlled cortical impact was used along with high-fat feeding to evaluate the impact of HFD on brain injury outcomes. Mice were fed HFD for a period of two months where several neurological, behavioral, and molecular outcomes were assessed to investigate the impact on chronic consequences of the injury 30 days post-TBI.

KEY FINDINGS

Two months of HFD feeding, together with TBI, led to a notable metabolic, neurological, and behavioral impairment. HFD was associated with increased blood glucose and fat-to-lean ratio. Spatial learning and memory, as well as motor coordination, were all significantly impaired. Notably, HFD aggravated neuroinflammation, oxidative stress, and neurodegeneration. Also, cell proliferation post-TBI was repressed by HFD, which was accompanied by an increased lesion volume.

SIGNIFICANCE

Our research indicated that chronic HFD feeding can worsen functional outcomes, predispose to neurodegeneration, and decrease brain recovery post-TBI. This sheds light on the clinical impact of HFD on TBI pathophysiology and rehabilitation as well.

The evolving role of extracellular vesicles (exosomes) as biomarkers in traumatic brain injury: Clinical perspectives and therapeutic implications

Developing effective disease-modifying therapies for neurodegenerative diseases (NDs) requires reliable diagnostic, disease activity, and progression indicators. While desirable, identifying biomarkers for NDs can be difficult because of the complex cytoarchitecture of the brain and the distinct cell subsets seen in different parts of the central nervous system (CNS). Extracellular vesicles (EVs) are heterogeneous, cell-derived, membrane-bound vesicles involved in the intercellular communication and transport of cell-specific cargos, such as proteins, Ribonucleic acid (RNA), and lipids. The types of EVs include exosomes, microvesicles, and apoptotic bodies based on their size and origin of biogenesis. A growing body of evidence suggests that intercellular communication mediated through EVs is responsible for disseminating important proteins implicated in the progression of traumatic brain injury (TBI) and other NDs. Some studies showed that TBI is a risk factor for different NDs. In terms of therapeutic potential, EVs outperform the alternative synthetic drug delivery methods because they can transverse the blood–brain barrier (BBB) without inducing immunogenicity, impacting neuroinflammation, immunological responses, and prolonged bio-distribution. Furthermore, EV production varies across different cell types and represents intracellular processes. Moreover, proteomic markers, which can represent a variety of pathological processes, such as cellular damage or neuroinflammation, have been frequently studied in neurotrauma research. However, proteomic blood-based biomarkers have short half-lives as they are easily susceptible to degradation. EV-based biomarkers for TBI may represent the complex genetic and neurometabolic abnormalities that occur post-TBI. These biomarkers are not caught by proteomics, less susceptible to degradation and hence more reflective of these modifications (cellular damage and neuroinflammation). In the current narrative and comprehensive review, we sought to discuss the contemporary knowledge and better understanding the EV-based research in TBI, and thus its applications in modern medicine. These applications include the utilization of circulating EVs as biomarkers for diagnosis, developments of EV-based therapies, and managing their associated challenges and opportunities.

Gender Discrepancy in Patients with Traumatic Brain Injury: A Retrospective Study from a Level 1 Trauma Center

Objectives. The objective of this study is to explore the gender discrepancy in patients with traumatic brain injury (TBI). Methods. A retrospective analysis of Qatar Trauma Registry (QTR) was conducted among patients (age ≥14y) who were hospitalized with TBI. Data were collected and analyzed based on the gender and age. Results. Over 5 years (2014-2019), 9, 309 trauma patients (90% males and 10% females) were admitted to the trauma center. Of these, 1, 620 (17.4%) patients were hospitalized with TBI (94% males and 6% females). Motor vehicle crash was the main mechanism of injury (MOI) in females, and fall from height was predominant among males. Subdural hematoma (SDH) was the more frequent type of TBI in both genders, but it was more prevalent in male patients ≥55 years. Injury severity score, Glasgow coma scale, and head abbreviated injury score were comparable between males and females. The length of stay in the ICU and hospital and mortality were similar in both genders. However, mortality was higher among males ≥55 years when compared to 14-54 years within the same gender (21% vs. 12%, $p=0.002$ ). The crude and adjusted odds ratio did not show that gender is a significant predictor of mortality among TBI patients. Conclusions. Although the incidence and MOI of TBI show significant differences between male and female patients, the severity and outcomes are comparable.

Mitoquinone Helps Combat the Neurological, Cognitive, and Molecular Consequences of Open Head Traumatic Brain Injury at Chronic Time Point

Traumatic brain injury (TBI) is a heterogeneous disease in its origin, neuropathology, and prognosis, with no FDA-approved treatments. The pathology of TBI is complicated and not sufficiently understood, which is the reason why more than 30 clinical trials in the past three decades turned out unsuccessful in phase III. The multifaceted pathophysiology of TBI involves a cascade of metabolic and molecular events including inflammation, oxidative stress, excitotoxicity, and mitochondrial dysfunction. In this study, an open head TBI mouse model, induced by controlled cortical impact (CCI), was used to investigate the chronic protective effects of mitoquinone (MitoQ) administration 30 days post-injury. Neurological functions were assessed with the Garcia neuroscore, pole climbing, grip strength, and adhesive removal tests, whereas cognitive and behavioral functions were assessed using the object recognition, Morris water maze, and forced swim tests. As for molecular effects, immunofluorescence staining was conducted to investigate microgliosis, astrocytosis, neuronal cell count, and axonal integrity. The results show that MitoQ enhanced neurological and cognitive functions 30 days post-injury. MitoQ also decreased the activation of astrocytes and microglia, which was accompanied by improved axonal integrity and neuronal cell count in the cortex. Therefore, we conclude that MitoQ has neuroprotective effects in a moderate open head CCI mouse model by decreasing oxidative stress, neuroinflammation, and axonal injury.

Alterations of microRNAs expression profiles in small extracellular vesicle after traumatic brain injury in mice

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity worldwide. Tools available for diagnosis and therapy are limited. Small extracellular vesicle (sEV) microRNAs (miRNAs) play an important role in TBI disease progression. This study aimed to investigate the alterations in sEV miRNAs expression in the mouse brain extracellular space after TBI. Twenty-four C57BL/6J mice were randomly divided into two groups (12/group). The TBI group was subjected to all surgical procedures and fluid percussion injury (FPI). The sham group only underwent surgery. Brain specimens were collected 3 h after TBI/sham. The brain sEV were isolated. Differentially expressed miRNAs were identified. A total of 50 miRNAs were observed to be differentially expressed (fold change ≥1.5 and P<0.05) after TBI, including 5 upregulated and 45 downregulated. The major enriched Gene Ontology terms were metabolic processes, cell, intracellular, organelle, cytoplasm, axon, binding, protein kinase activity, protein binding, and protein dimerization activity. The KEGG pathway analysis predicted that the pathways affected by the variation of miRNAs in sEVs after TBI included the Wnt signaling pathway and NF-κB signaling pathway. The changes in five miRNAs were confirmed by qRT-PCR. In conclusion, this study demonstrated the differential expression of a series of miRNAs in brain sEV after TBI, which might be correlated with post-TBI physiological and pathological processes. The findings might also provide novel targets for further investigating the molecular mechanisms underlying TBI and potential therapeutic interventions.

Rotterdam and Marshall Scores for Prediction of in-hospital Mortality in Patients with Traumatic Brain Injury: An observational study

Background: We aimed to assess the prognostic value of Rotterdam and Marshall scoring systems to predict in-hospital mortality in patients with traumatic brain injury (TBI).Methods: A retrospective analysis was conducted for patients with TBI who underwent head computerized tomography (CT) scan at a Level I trauma center between 2011 and 2018. Receiver operating characteristic (ROC) curves were used to determine the cutoff values for predicting in-hospital mortality.Results: A total of 1035 patients with TBI were included with a mean age of 30 years. The mean Rotterdam and Marshall scores were higher among non-survivors (p = .001). Patients with higher Rotterdam (>3) or Marshall (>2) CT scores were older, had higher injury severity scores and in-hospital mortality and had lower GCS and blood ethanol levels than those with lower scores. The cutoff point of Rotterdam score was 3.5 (sensitivity, 61.2%; specificity, 85.6%) and Marshall score was 2.5 (74.3% sensitivity and 76.3% specificity). Multivariable logistic regression analyses showed that Marshall and Rotterdam scoring systems were independent predictors of mortality (odds ratio 8.4; 95% confidence interval 4.95-14.17 and odds ratio 4.4; 95% confidence interval 2.36-9.39, respectively).Conclusion: Rotterdam and Marshall CT scores have independent prognostic values in patients with TBI even in alcoholic patients.

Traumatic Brain Injury: A Perspective on the Silent Epidemic

Background: Epidemiological data regarding the causes, patterns, severity, and outcomes of traumatic brain injury (TBI) are essential to plan for preventive strategies addressing this public health epidemic. The main aim of this study is to explore the patterns and causes of traumatic brain injury at two trauma centers.

Methods: A retrospective cohort study was conducted using a pre-tested validated data collection sheet. Data were collected from the medical records and electronic database of patients who presented to the emergency department with head trauma. Variables including the mechanisms, patterns of the injury, accompanying injuries, level of consciousness, and hospitalization duration were investigated for any possible association.

Results: A total of 269 patients (78% males, 22% females) who satisfied our study criteria were included in the final analysis. Motor vehicle collisions were the most common reason for traumatic brain injury (57.6%) followed by falls (28.3%). There was a statistically significant association observed between type of hemorrhage and Glasgow coma scale at initial presentation (P < 0.05). 

Conclusion: The most common cause of traumatic brain injury is motor vehicle collisions, followed by falls. The public should be made aware of the importance of using safety and precautionary measures to minimize the impact of traumatic brain injuries. Educational programs for neurotrauma prevention can be developed and utilized as a blueprint for local hospitals and officials in the country.

Characterization of Traumatic Brain Injury Research in the Middle East and North Africa Region: A Systematic Review

OBJECTIVES

Traumatic brain injury (TBI) represents a major health concern worldwide with a large impact in the Middle East and North Africa (MENA) region as a consequence of protracted wars and conflicts that adversely affect the general population. Currently, systematic TBI studies in the MENA region are lacking, nonetheless they are immensely needed to enhance trauma management and increase survival rates among TBI patients. This systematic review aims to characterize TBI in the MENA region to guide future policy choices and research efforts and inform tailored guidelines capable of improving TBI management and patient treatment and outcome. Furthermore, it will serve as a road map to evaluate and assess knowledge of trauma impact on regional health systems that can be adopted by health-care providers to raise awareness and improve trauma care.

METHODS

We conducted a comprehensive search strategy of several databases including MEDLINE/Ovid, PubMed, Embase, Scopus, CINAHL, Google Scholar, and the grey literature in accordance with the PROSPERO systematic review protocol CRD42017058952. Abstracts were screened, and selected eligible studies were reviewed independently by 2 reviewers. We collected demographics information along with TBI characteristics, mortality rates, and regional distribution. Data were extracted using REDCap and checked for accuracy.

RESULTS

The search strategy yielded 23,385 citations; 147 studies met the eligibility criteria and were included in this review. Motor vehicle accident (MVA) was the leading cause of TBI (41%) in the MENA region, followed by the military- (15.6%) and fall- (8.8%) related TBI. Males predominantly suffer from TBI-related injuries (85%), with a high prevalence of MVA- and military-related TBI injuries. The TBI mortality rate was 12.9%. The leading causes of mortality were MVA (68%), military (20.5%), and assault (2.9%). The vast majority of reported TBI severity was mild (63.1%) compared to moderate (10.7%) and severe TBI (20.2%). Patients mainly underwent a Glasgow Coma Scale assessment (22.1%), followed by computed tomography scan (8.9%) and surgery (4.1%).

CONCLUSIONS

Despite its clinical, social, and economic burden, the evidence of TBI research in the MENA region is scarce. Further research and high-quality epidemiological studies are urgently needed to gain a deep understanding of the TBI burden in the region, facilitate the allocation of adequate resources, implement effective preventive and intervention strategies and advise on the TBI patient management as reflective on the TBI patterns and modes.

Traumatic Brain Injury: Oxidative Stress and Novel Anti-Oxidants Such as Mitoquinone and Edaravone

Traumatic brain injury (TBI) is a major health concern worldwide and is classified based on severity into mild, moderate, and severe. The mechanical injury in TBI leads to a metabolic and ionic imbalance, which eventually leads to excessive production of reactive oxygen species (ROS) and a state of oxidative stress. To date, no drug has been approved by the food and drug administration (FDA) for the treatment of TBI. Nevertheless, it is thought that targeting the pathology mechanisms would alleviate the consequences of TBI. For that purpose, antioxidants have been considered as treatment options in TBI and were shown to have a neuroprotective effect. In this review, we will discuss oxidative stress in TBI, the history of antioxidant utilization in the treatment of TBI, and we will focus on two novel antioxidants, mitoquinone (MitoQ) and edaravone. MitoQ can cross the blood brain barrier and cellular membranes to accumulate in the mitochondria and is thought to activate the Nrf2/ARE pathway leading to an increase in the expression of antioxidant enzymes. Edaravone is a free radical scavenger that leads to the mitigation of damage resulting from oxidative stress with a possible association to the activation of the Nrf2/ARE pathway as well.

Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study

BACKGROUND

Managing children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation's impact on CT rates and clinical outcomes.

METHODS

Retrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups.

RESULTS

We included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs.

CONCLUSIONS

PECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.

Prediction of quality of life by Helsinki computed tomography scoring system in patients with traumatic brain injury

PURPOSE

The aim of this study is to assess the association between the Computed Tomography (CT) findings on admission, according to the Helsinki computed tomography CT score, and patient's Quality of Life (QoL) following traumatic brain injury (TBI) in Lebanon.

METHODS

A retrospective study was performed on 49 males suffering from war induced TBI. Participants were stratified into two groups based on the date of injury. Helsinki CT score was calculated for CT scans of participants. Outcomes were assessed using QoL scales including the Project for the Epidemiological Analysis of Critical Care Patients scale (PAEEC).

RESULTS

Correlation analysis showed that QoL, up to 4 years post-TBI, was significantly associated with Helsinki CT classification. Group 1 of subjects living with TBI for 1-2 years revealed a correlation coefficient r = 0.536, p-value = 0.027, whereas, group 2 including subjects who are injured since 3-4 years, had a correlation coefficient r = 0.565, p-value = 0.001.

CONCLUSION

The present study showed that patients with traumatic brain injury experienced significant quality of life deterioration up to 4 years post-TBI. Our findings propose the important role of Helsinki score in predicting the quality of life among patients with TBI.

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury

BACKGROUND

Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI.

METHODS

A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared.

RESULTS

Multivariate logistic regression analysis revealed that cranioplasty performed later than 2 months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047).

CONCLUSIONS

Our results show that early cranioplasty within 2 months after DC was associated with a lower rate of PTH development after TBI.

Effect of Human Umbilical Cord Perivascular Cell-Conditioned Media in an Adult Zebrafish Model of Traumatic Brain Injury

The pathophysiological events of secondary brain injury contribute to poor outcome after traumatic brain injury (TBI). The neuroprotective effects of mesenchymal cells have been extensively studied and evidence suggests that their effects are mostly mediated through paracrine effects. Human umbilical cord perivascular cells (HUCPVCs) are mesenchymal stem cells with potential therapeutic value in TBI. In this study, we assessed the effect of HUCPVC-conditioned media (CM) in an established adult zebrafish model of TBI induced by pulsed high-intensity focused ultrasound (pHIFU). This model demonstrates similarities to mammalian outcome after TBI. Administration of HUCPVC-CM 1 h postinjury (hpi) resulted in improved outcome after pHIFU-induced TBI. Western blot and immunohistochemistry results demonstrated that the HUCPVC-CM reduced (p < 0.05) reactive astrogliosis at 24 hpi. Moreover, at 24 hpi, the HUCPVC-CM treatment resulted in reduced apoptosis in HUCPVC-CM-treated zebrafish. Behavioral analysis demonstrated improvement in locomotor activity (p < 0.05) and anxiety (p < 0.05) at 6 and 24 hpi following HUCPVC-CM treatment. Overall, HUCPVC-CM treatment improved acute outcome measures in pHIFU-injured zebrafish. Collectively, the data demonstrate a cell-free treatment approach for traumatic brain injuries.

A comparison of publication to TBI burden ratio of low- and middle-income countries versus high-income countries: how can we improve worldwide care of TBI?

OBJECTIVE

Traumatic brain injury (TBI) is a global public health problem and more than 70% of trauma-related deaths are estimated to occur in low- and middle-income countries (LMICs). Nevertheless, there is a consistent lack of data from these countries. The aim of this work is to estimate the capacity of different and heterogeneous areas of the world to report and publish data on TBI. In addition, we wanted to estimate the countries with the highest and lowest number of publications when taking into account the relative TBI burden.

METHODS

First, a bibliometric analysis of all the publications about TBI available in the PubMed database from January 1, 2008, to December 31, 2018, was performed. These data were tabulated by country and grouped according to each geographical region as indicated by the WHO: African Region (AFR), Region of the Americas (PAH), South-East Asia Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), and Western Pacific Region (WPR). In this analysis, PAH was further subdivided into Latin America (AMR-L) and North America (AMR-US/Can). Then a “publication to TBI volume ratio” was derived to estimate the research interest in TBI with respect to the frequency of this pathology.

RESULTS

Between 2008 and 2018 a total of 8144 articles were published and indexed in the PubMed database about TBI. Leading WHO regions in terms of contributions were AMR-US/Can with 4183 articles (51.36%), followed by EUR with 2003 articles (24.60%), WPR with 1507 (18.50%), AMR-L with 141 articles (1.73%), EMR with 135 (1.66%), AFR with 91 articles (1.12%), and SEAR with 84 articles (1.03%). The highest publication to TBI volume ratios were found for AMR-US/Can (90.93) and EUR (21.54), followed by WPR (8.71) and AMR-L (2.43). Almost 90 times lower than the ratio of AMR-US/Can were the ratios for AFR (1.15) and SEAR (0.46).

CONCLUSIONS

An important disparity currently exists between countries with a high burden of TBI and those in which most of the research is conducted. A call for improvement of data collection and research outputs along with an increase in international collaboration could quantitatively and qualitatively improve the ability of LMICs to ameliorate TBI care and develop clinical practice guidelines.

Comparison between traumatic brain injury with and without concomitant injuries: an analysis based on a national trauma registry 2008-2016

Objective: To compare demographic, injury and hospitalization characteristics and mortality between Isolated and Non-Isolated traumatic brain injury.Methods: A retrospective study based on the Israeli National Trauma Registry of patients hospitalized for traumatic brain injury (TBI) between 2008 and 2016. Isolated TBI was defined as no other anatomic region was having concomitant injury with AIS ≥2. X² test and multivariate logistic regression analysis were used for data analysis.Results: Of the 23566-study population, 40.4% were admitted for isolated TBI. Isolated TBI was significantly more frequent in elderly aged ≥65 years, female, Jews, and injuries sustained at home or in residential institution. The Non-isolated TBI was greater in road traffic injuries, particularly among pedestrians and motor cyclists, and in violence injuries. The Non-isolated TBI group had greater injury severity and hospital resource utilization. In-hospital mortality was higher in the patients with Non-isolated TBI [OR: 1.56(95% CI: 1.33-1.83)], particularly in patients with GCS 13-15; elderly aged 65+ years; and patients with concomitant injuries to abdomen, spine or external body regions.Conclusion: In a patient with TBI, concomitant injuries with AIS ≥2 matter, and awareness of the identified factors has relevance for guiding injury prevention efforts and indeed for potentially improving care and outcome.

Prognostic utility of circulating nucleic acids in acute brain injuries

INTRODUCTION

Acute brain injuries represent major causes of morbidity and mortality worldwide. Nevertheless, therapeutic options are centered mainly on supportive care, and accurate prognosis prediction following traumatic brain injury (TBI) or stroke remains a challenge in clinical settings. Areas covered: Circulating DNA and RNA have shown potential as predictive molecules in acute brain injuries. In particular, plasma cell-free DNA (cfDNA) levels have been correlated to severity, mortality, and outcome after TBI and stroke. The real-time quantitative polymerase chain reaction (qPCR) is the most widely used technique for determination of cfDNA in brain injuries; however, to consider the use of cfDNA in emergency settings, a quicker and easier methodology for detection should be established. A recent study proposed detection of cfDNA applying a rapid fluorescent test that showed compatible results with qPCR. Expert commentary: As a promising perspective, detection of cfDNA levels using simple, rapid, and cheap methodology has potential to translate to clinic as a point-of-care marker, supporting the clinical decision-making in emergency care settings. Conversely, miRNA profiles may be used as signatures to determine the type and severity of injuries. Additionally, in the future, some miRNAs may constitute innovative neurorestorative therapies without the common hurdles associated with cell therapy.

Predictors and Time-Based Hospital Mortality in Patients with Isolated and Polytrauma Brain Injuries

BACKGROUND

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. We studied the predictors and time-based mortality in patients with isolated and polytrauma brain injuries in a rapidly developing country. We hypothesized that TBI-related 30-day mortality is decreasing over time.

METHODS

A retrospective analysis was conducted for all patients with moderate-to-severe TBI who were admitted directly to a level 1 trauma center between 2010 and 2014. Patient's data were analyzed and compared according to survival (survived vs. not survived), time (early death [2 days], intermediate [3-7 days] versus late [>7 days]) post-injury, and type (polytrauma vs. isolated TBI). Cox proportional hazards models were performed for the predictors of mortality.

RESULTS

A total of 810 patients were admitted with moderate-to-severe TBI with a median age of 27 years. Traffic-related injury was the main mechanism of TBI (65%). Isolated TBIs represented 22.6% of cases and 56% had head AIS >3. The overall mortality rate was 27%, and most of deaths occurred in the intermediate (40%) and early period (38%). The incidence of TBI was greater in patients aged 21-30 years but the mortality was proportionately higher among elderly. The average annual incidence was 8.43 per 100,000 population with an overall mortality of 2.28 per 100,000 population. Kaplan-Meier curves showed that polytrauma had greater mortality than isolated TBI. However, Cox survival analysis showed that age [Hazard ratio (HR) 1.02], scene GCS (HR 0.86),subarachnoid hemorrhage (HR 1.7), and blood transfusion amount (HR 1.03) were the predictors of mortality regardless of being polytrauma or isolated TBI after controlling for 14 relevant covariates.

CONCLUSIONS

The 30-day survival in patients with TBI is improving over the years in Qatar; however, the mortality remains high in the elderly males. The majority of deaths occurred within a week after the injury. Further studies are needed to assess the long-term survival in patients with moderate-to-severe TBI.

Prognostic role of D-dimer level upon admission in patients with traumatic brain injury

BACKGROUND

The aim of this study was to evaluate the prognostic role of D-dimer level upon admission in patients with traumatic brain injury (TBI) through performing a meta-analysis.

METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE were searched for potential eligible literature. The study characteristics and relevant data were extracted. Poor functional outcome was defined according to the Glasgow Outcome Scale (GOS ≤3). Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the predictive value of D-dimer for progressive hemorrhagic injury (PHI) and poor functional outcome at 3 months (3M GOS ≤3) in patients with TBI.

RESULTS

Eleven studies with 2761 patients were included. Eight studies examined the predictive role of higher D-dimer level for the risk of PHI, and the pooled OR was 1.72 (95% CI, 1.23-2.42). Three studies examined the predictive role of higher D-dimer level for the risk of 3M GOS ≤3, and the pooled OR was 2.00 (95% CI, 0.87-4.59). Significant between-study heterogeneities were observed, and sensitivity analyses and subgroup analyses were performed. No significant publication bias was found.

CONCLUSIONS

In conclusion, in patients with TBI, higher D-dimer level upon admission was associated with higher risk of PHI, yet no significant relationship was found between D-dimer level and the risk of 3M GOS ≤3. In the future, this readily available marker could help identify patients at risk and tailor management of these patients, thus reducing PHI and improving outcome.

Clinicopathological Characteristics of Traumatic Head Injury in Juvenile, Middle-Aged and Elderly Individuals

BACKGROUND Traumatic head injury is a leading cause of death and disability worldwide. How clinicopathological features differ by age remains unclear. This epidemiological study analyzed the clinicopathological features of patients with head injury belonging to 3 age groups. MATERIAL AND METHODS Data of patients with traumatic head injury were obtained from the Department of Cerebral Surgery of the Affiliated Hospital of Guizhou Medical University and the Guizhou Provincial People's Hospital in 2011-2015. Their clinicopathological parameters were assessed. The patients were divided into 3 age groups: elderly (≥65 years), middle-aged (18-64 years), and juvenile (≤17 years) individuals. RESULTS Among 3356 hospitalizations for traumatic head injury (2573 males and 783 females, 654 died (19.49%), the highest and lowest mortality rates were in the elderly and juvenile groups, respectively. Fall was the most common cause in juvenile and elderly individuals (32.79% and 43.95%, respectively), while traffic injury was most common in the elderly group (35.08%). The manners of injury differed considerably among the 3 age groups. Scalp injury, skull fracture, intracranial hematoma, and cerebral injury were the most common mechanisms in juvenile (67.32%), middle-aged (63.50%), elderly (69.56%) and middle-aged (90.44%) individuals, respectively. Scalp injury and skull fracture types differed among the groups. Epidural, subdural, and intracerebral hematomas were most common in juvenile, middle-aged, and elderly individuals, respectively. Cerebral contusion showed the highest frequency in the 3 groups, and concussion the lowest. CONCLUSIONS Patients with traumatic HI show remarkable differences in clinicopathological features among juvenile, middle-aged, and elderly individuals.