The early assessment and intensive care unit management of patients with severe traumatic brain and spinal cord injuries

Diabetes Insipidus after Traumatic Brain Injury

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in many age groups. Neuroendocrine dysfunction has been recognized as a consequence of TBI and consists of both anterior and posterior pituitary insufficiency; water and electrolyte abnormalities (diabetes insipidus (DI) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH)) are amongst the most challenging sequelae. The acute head trauma can lead (directly or indirectly) to dysfunction of the hypothalamic neurons secreting antidiuretic hormone (ADH) or of the posterior pituitary gland causing post-traumatic DI (PTDI). PTDI is usually diagnosed in the first days after the trauma presenting with hypotonic polyuria. Frequently, the poor general status of most patients prevents adequate fluid intake to compensate the losses and severe dehydration and hypernatremia occur. Management consists of careful monitoring of fluid balance and hormonal replacement. PTDI is associated with high mortality, particularly when presenting very early following the injury. In many surviving patients, the PTDI is transient, lasting a few days to a few weeks and in a minority of cases, it is permanent requiring management similar to that offered to patients with non-traumatic central DI.

Increased mean arterial pressure goals after spinal cord injury and functional outcome

Introduction:

Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies between patients. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome.

Materials and Methods:

All cervical and thoracic SCI patients treated at a level one trauma and regional SCI center over at 2.5-year period were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 h of hospitalization, allowing for quantification of mean MAP and the total number of episodic relative hypotensive events. These data were further compared to daily American spinal injury association motor score (AMS), which was used to determine the severity of SCI and improvement/decline during hospitalization. Patient's data were finally analyzed at theoretic MAP set points.

Results:

One hundred and five patients had complete data during the study period. At higher theoretic MAP set points (85 and 90), increased number of relative hypotensive episodes correlated with lower admission AMS (85 mmHg: <10 episodes, AMS 66.2; >50 episodes, 22.0; P < 0.001) and the need for vasopressors (P < 0.03) but showed no statistical change in AMS by hospital discharge. The need for vasopressors correlated with the number of hypotensive episodes and inversely related to admission AMS at all theoretic MAP goal set points but was not correlated with the change in AMS during the hospitalization.

Conclusions:

The frequency of relative hypotension and the need for vasopressors are progressively related to more severe SCI, as denoted by lower admission AMS. However, episodes of hypotension and the need for vasopressors did not affect the change in AMS during the acute hospitalization, regardless of theoretic MAP goal set-point. Arbitrarily elevated MAP goals may not be efficacious.

The mental health sequelae of traumatic head injury in South Vietnamese ex-political detainees who survived torture

Little is known about the relationship between traumatic head injury (THI) and psychiatric morbidity in torture survivors. We examine the relationship between THI and depression, PTSD, post-concussive syndrome (PCS), disability and poor health status in Vietnamese ex-political detainees who survived incarceration in Vietnamese re-education camps. A community sample of ex-political detainees (n=337) and a non-THI, non-ex-detainee comparison group (n=82) were surveyed. Seventy-eight percent of the ex-political detainees had experienced THI; 90.6% of the ex-political detainees and 3.6% of the comparison group had experienced 7 or more trauma events. Depression and PTSD were greater in ex-detainees than in the comparison group (40.9% vs 23.2% and 13.4% vs 0%). Dose-effect relationships for THI and trauma/torture in the ex-political detainee group were significant. Logistic regression in the pooled sample of ex-detainees and the comparison group confirmed the independent impact of THI from trauma/torture on psychiatric morbidity (OR for PTSD=22.4; 95% CI: 3.0-165.8). These results demonstrate important effects of THI on depression and PTSD in Vietnamese ex-detainees who have survived torture.

Anesthetic considerations in acute spinal cord trauma

Patients with actual or potential spinal cord injury (SCI) are frequently seen at adult trauma centers, and a large number of these patients require operative intervention. All polytrauma patients should be assumed to have an SCI until proven otherwise. Pre-hospital providers should take adequate measures to immobilize the spine for all trauma patients at the site of the accident. Stabilization of the spine facilitates the treatment of other major injuries both in and outside the hospital. The presiding goal of perioperative management is to prevent iatrogenic deterioration of existing injury and limit the development of secondary injury whilst providing overall organ support, which may be adversely affected by the injury. This review article explores the anesthetic implications of the patient with acute SCI. A comprehensive literature search of Medline, Embase, Cochrane database of systematic reviews, conference proceedings and internet sites for relevant literature was performed. Reference lists of relevant published articles were also examined. Searches were carried out in October 2010 and there were no restrictions by study design or country of origin. Publication date of included studies was limited to 1990–2010.

Recent therapeutic strategies for spinal cord injury treatment: possible role of stem cells

Spinal cord injury (SCI) often results in significant dysfunction and disability. A series of treatments have been proposed to prevent and overcome the formation of the glial scar and inhibitory factors to axon regrowth. In the last decade, cell therapy has emerged as a new tool for several diseases of the nervous system. Stem cells act as minipumps providing trophic and immunomodulatory factors to enhance axonal growth, to modulate the environment, and to reduce neuroinflammation. This capability can be boosted by genetical manipulation to deliver trophic molecules. Different types of stem cells have been tested, according to their properties and the therapeutic aims. They differ from each other for origin, developmental stage, stage of differentiation, and fate lineage. Related to this, stem cells differentiating into neurons could be used for cell replacement, even though the feasibility that stem cells after transplantation in the adult lesioned spinal cord can differentiate into neurons, integrate within neural circuits, and emit axons reaching the muscle is quite remote. The timing of cell therapy has been variable, and may be summarized in the acute and chronic phases of disease, when stem cells interact with a completely different environment. Even though further experimental studies are needed to elucidate the mechanisms of action, the therapeutic, and the side effects of cell therapy, several clinical protocols have been tested or are under trial. Here, we report the state-of-the-art of cell therapy in SCI, in terms of feasibility, outcome, and side effects.

Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial

OBJECTIVE

Intracerebral hemorrhages, whether spontaneous or traumatic (tICH), often expand, and an association has been described between hemorrhage expansion and worse clinical outcomes. Recombinant factor VIIa (rFVIIa) is a hemostatic agent that has been shown to limit hemorrhage expansion and which, therefore, could potentially reduce morbidity and mortality in tICH. This first prospective, randomized, placebo-controlled, dose-escalation study evaluated the safety and preliminary effectiveness of rFVIIa to limit tICH progression.

METHODS

Patients were enrolled if they had tICH lesions of at least 2 ml on a baseline computed tomographic scan obtained within 6 hours of injury. rFVIIa or placebo was administered within 2.5 hours of the baseline computed tomographic scan but no later than 7 hours after injury. Computed tomographic scans were repeated at 24 and 72 hours. Five escalating dose tiers were evaluated (40, 80, 120, 160, and 200 microg/kg rFVIIa). Clinical evaluations and adverse events were recorded until Day 15.

RESULTS

No significant differences were detected in mortality rate or number and type of adverse events among treatment groups. Asymptomatic deep vein thrombosis, detected on routinely performed ultrasound at Day 3, was observed more frequently in the combined rFVIIa treatment group (placebo, 3%; rFVIIa, 8%; not significant). A nonsignificant trend for rFVIIa dose-response to limit tICH volume increase was observed (placebo, 21.0 ml; rFVIIa, 10.1 ml).

CONCLUSION

In this first prospective study of rFVIIa in tICH, there appeared to be less hematoma progression in rFVIIa-treated patients (80-200 microg/kg) compared with that seen in placebo treated patients. The potential significance of this biological effect on clinical outcomes and the significance of the somewhat higher incidence of ultrasound-detected deep vein thromboses in the rFVIIa-treated group need to be examined in a larger prospective randomized clinical trial.

Hypothalamic injury as a cause of refractory hypotension after sellar region tumor surgery

INTRODUCTION

Fluid-resistant arterial hypotension can result in hypoperfusion of the brain and other organs. Well-known causes of arterial hypotension in neurosurgical practice include cardiac failure, septic shock, adrenal insufficiency, brainstem, and cervical spinal cord damage. Fluid-resistant arterial hypotension can occur in patients with brain edema without damage to brainstem when hypothalamic nuclei suffer. This phenomenon is not a well-documented cause of hypotension.

METHODS

We prospectively investigated 15 cases with clinical syndrome of arterial hypotension in patients following surgery for sellar region tumors. These cases were taken from 1005 patients operated between May 2003 and December 2005. Pulmonary artery catheter was used to investigate hemodynamic profile.

RESULTS

The mechanism of arterial hypotension consisted of decrease of vascular tone (SVRI was 1503 +/- 624 dyn x s x cm(5) x m(2)) and relative hypovolemia (CVP: 4.5 +/- 2.6 torr, PAWP: 7.4 +/- 3.5 torr). In all cases arterial hypotension was corrected with phenylephrine after failure to respond to fluid resuscitation alone. Fluid balance was positive over the next 72 h. Twenty-seven percent of patients had transitory thyroid insufficiency. In these situations dopamine was administrated as symptomatic therapy and dose of thyroid hormone was increased. Mortality was 53%.

CONCLUSION

Hypothalamic damage can result in life-threatening vasodilatory arterial hypotension after sellar region tumor surgery. beta-Sympatomimetics are indicated in cases with thyroid insufficiency.

Hemodynamic parameters and timing of surgical decompression in acute cervical spinal cord injury

BACKGROUND/OBJECTIVES

To evaluate the relationship between the severity of cervical spinal cord injury (SCI) (American Spinal Injury Association [ASIA] grade), presence of neurogenic shock, and timing of surgical intervention. This is a post-hoc analysis from the Sygen multicenter randomized controlled trial.

METHODS

Blood pressure (BP) and heart rate (HR) data were collected when patients were first assessed in the emergency room (Time A) and at the time of randomization (Time B). Individuals were subdivided by ASIA grade and by the level of the systolic BP (SBP).

RESULTS

Only individuals with cervical SCI from the Sygen trial (n = 577) were evaluated. Severe complete SCI (ASIA grade = A) was established in 57% of these patients. A total of 74 (13%) patients with neurogenic shock (SBP < 90 mmHg) at Time A were identified. The SBP increased significantly from Time A to Time B (P < 0.0001). The median time from SCI to surgical intervention, for ASIA A, was 80.9 hours for patients with initial SBP < 90 mmHg and 58 hours for patients with initial SBP > or = 90 mmHg (P = 0.025). Multivariable analysis after adjusting for confounders revealed a statistically significant difference in the time to surgical intervention based on SBP for ASIA A (P = 0.026), yet not for ASIA B or C/D.

CONCLUSIONS

The presence of neurogenic shock was associated with a delay in the timing of surgical intervention in patients with cervical SCI. Detailed evaluation of autonomic dysfunctions following SCI including cardiovascular instability could improve our understanding of the complexities of clinical presentations and possible neurological outcomes.

Management of spinal injury

Spinal injury often affects young adults and results in debilitating neurological status, which in turn places a significant burden on society. This review article describes the current practice and controversies surrounding the management of spinal injury. General principles of pre-hospital management, resuscitation, medical treatment, surgical intervention and future advancement are reviewed.

Strategies of medical intervention in the management of acute spinal cord injury

STUDY DESIGN

: Literature review.

OBJECTIVE

: The purpose of this paper is to review clinical treatment strategies and future developments in the treatment of acute spinal cord injury.

SUMMARY OF BACKGROUND DATA

: The treatment of acute spinal cord injury continues to be supportive. The search for specialized pharmacologic agents to prevent secondary injury and promote repair or regeneration remains heated.

METHODS

: Medline search from 1996 to present limited to clinical research and basic science review articles in the English Language.

RESULTS

: Steroids continue to be administered in the clinical setting of acute spinal cord injury primarily out of peer pressure and fear of litigation. Basic science experiments suggest that modulation of post-traumatic inflammation may provide the best opportunity to arrest the secondary injury cascade. Protein kinase and metalloproteinase inhibition are promising treatment strategies. Regeneration techniques are concentrating on cell transplantation and manipulating glial receptors and protein production. Clinical investigations are limited to Phase III trials on a very select few of these drugs.

CONCLUSIONS

: While many advances in the basic science of spinal cord injury provide optimism for future treatments, clinical science lags. At present, there are no pharmacologic strategies of proven benefit. Although steroids continue to be given to patients with spinal cord injury in many institutions, evidence of deleterious effects continues to accumulate. Current standard of care management includes support of arterial oxygenation and spinal cord perfusion pressure.

The clinical problems in cardiovascular control following spinal cord injury: an overview

On a daily basis, individuals with cervical and upper thoracic spinal cord injury face the challenge of managing their unstable blood pressure, which frequently results in persistent hypotension and/or episodes of uncontrolled hypertension. This chapter will focus on the clinical issues related to abnormal cardiovascular control in individuals with spinal cord injury, which include neurogenic shock, autonomic dysreflexia and orthostatic hypotension. Blood pressure control depends upon tonic activation of sympathetic preganglionic neurons by descending input from the supraspinal structures (Calaresu and Yardley, 1988). Following spinal cord injury, these pathways are disrupted, and thus spinal circuits are solely responsible for the generation of sympathetic activity (Osborn et al., 1989; Maiorov et al., 1997). This results in a variety of cardiovascular abnormalities that have been well documented in human studies, as well as in animal models (Osborn et al., 1990; Mathias and Frankel, 1992a, b; Krassioukov and Weaver, 1995; Maiorov et al., 1997, 1998; Teasell et al., 2000). However, the recognition and management of these cardiovascular dysfunctions following spinal cord injury represent challenging clinical issues. Moreover, cardiovascular disorders in the acute and chronic stages of spinal cord injury are among the most common causes of death in individuals with spinal cord injury (DeVivo et al., 1999).

Diabetes Insipidus in the Head-Injured Patient

Diabetes insipidus (DI) is an uncommon but important complication in the head-injured population. A retrospective review of all trauma patients admitted to the intensive care unit (ICU) during a 4-year period who developed DI was undertaken. The incidence of DI was 1.3 per cent in ICU trauma admissions and 2.9 per cent in traumatic head injuries admitted to the ICU. The overall mortality was 69 per cent (18/26). The mean onset time of DI in nonsurvivors (1.5 ± 0.7 days) was shorter compared to survivors (8.9 ± 10.2 days) ( P < 0.001). All patients who died developed DI within the first 3 days of hospitalization. Patients who develop DI early in their course have a higher mortality than those who develop DI later in their hospital course. The development of diabetes insipidus after head injury carries a 69 per cent mortality rate, and if the onset is within the first 3 days after injury, mortality rate rises to 86 per cent.

Blood pressure management after acute spinal cord injury

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Hypotension (systolic blood pressure <90 mmHg) should be avoided if possible or corrected as soon as possible after acute spinal cord injury. Maintenance of mean arterial blood pressure at 85 to 90 mmHg for the first 7 days after acute spinal cord injury to improve spinal cord perfusion is recommended.

Systemic complications of neurologic diseases

The systemic complications associated with neurologic disease constitute an extensive topic, because the central nervous system controls many of the functions of the other organ systems in the body and because the brain cannot live in isolation of these systems. The precise mechanisms of many of these systemic alterations are poorly understood, but they appear to depend on the location and the severity of the initial central nervous system pathologic lesion.

Acute management of the patient with spinal cord injury

Spinal cord injuries are not as common as many other types of injuries. The victims are often young, the injury debilitating, and the effects devastating and incalculable. The acute management of patients with spinal cord injury can significantly affect the patient's eventual neurologic and functional outcome and ultimately their quality of life. Early interventions are aimed at reestablishing physiologic homeostasis, lessening the amount of secondary injury, and preserving neurologic function.