Global neurotrauma research challenges and opportunities. Nature. 2015;527:S193-S197. [PMID: 26580327 DOI: 10.1038/nature16035]

C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 pathway as a therapeutic target and regulatory mechanism for spinal cord injury

Spinal cord injury involves non-reversible damage to the central nervous system that is characterized by limited regenerative capacity and secondary inflammatory damage. The expression of the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis exhibits significant differences before and after injury. Recent studies have revealed that the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis is closely associated with secondary inflammatory responses and the recruitment of immune cells following spinal cord injury, suggesting that this axis is a novel target and regulatory control point for treatment. This review comprehensively examines the therapeutic strategies targeting the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis, along with the regenerative and repair mechanisms linking the axis to spinal cord injury. Additionally, we summarize the upstream and downstream inflammatory signaling pathways associated with spinal cord injury and the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis. This review primarily elaborates on therapeutic strategies that target the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis and the latest progress of research on antagonistic drugs, along with the approaches used to exploit new therapeutic targets within the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis and the development of targeted drugs. Nevertheless, there are presently no clinical studies relating to spinal cord injury that are focusing on the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis. This review aims to provide new ideas and therapeutic strategies for the future treatment of spinal cord injury.

Electroencephalogram biomarkers as predictors of mortality and functional recovery in patients with severe traumatic brain injury: Protocol study

Traumatic brain injury (TBI) is a global public health condition that causes cognitive and behavioral deficits. This protocol assesses the potential of quantitative electroencephalogram (EEG) biomarkers, associated with inflammatory indicators, to predict mortality and functional recovery in patients with severe TBI. Through continuous monitoring and analysis of abnormal brain activity patterns, the protocol aims to personalize therapeutic interventions and improve patient quality of life. This randomized clinical trial includes 84 adult participants with severe TBI, followed at different stages of recovery, using validated scales for functional and predictive analysis. Traumatic brain injury (TBI) is a globally impactful public health condition characterized by initial brain injuries caused by traumatic forces, leading to cognitive and behavioral deficits. The trauma triggers inflammatory and neurochemical changes that exacerbate neuronal damage, resulting in neuropsychiatric complications. The use of electroencephalogram (EEG), particularly in its quantitative form (QEEG), is crucial for patients with severe TBI, as it allows early detection of abnormal brain activity patterns, such as slow waves, which indicate a worse prognosis. This continuous monitoring, combined with inflammatory biomarkers, guides personalized therapeutic interventions and improves the prediction of clinical outcomes, contributing to patient quality of life.

Molecular Biomarkers Associated with Traumatic Brain Injury Outcome in Individuals of Black Racial Identity or African Ancestry: A Narrative Review

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and a major global health concern. In the United States, individuals of Black or African American racial identity experience disproportionately higher rates of TBI and suffer from worse postinjury outcomes. Contemporary research agendas have largely overlooked or excluded Black populations, resulting in the continued marginalization of Black patient populations in TBI studies, thereby limiting the generalizability of ongoing research to patients in the United States and around the world. This review aims to highlight what is currently known, and identify knowledge gaps, in research on molecular biomarkers associated with TBI in Black populations. A PubMed literature search was conducted to identify studies that investigate molecular biomarkers associated with TBI outcomes that include participants of Black racial identity and those of African ancestry. Studies identified for this review investigate biomarkers associated with TBI outcomes through a lens that specifically examines race, ethnicity, or ancestry. Most studies focused on blood- or cerebrospinal fluid-derived protein biomarkers. Studies identified statistical variation in S100ß, ubiquitin C-terminal hydrolase-L1, amyloid-ß, and tau across participant race, either at baseline or following TBI. Additionally, several studies identified genetic polymorphisms associated with TBI outcomes related to apolipoprotein E, ANKK1, and COMT polymorphism and TBI outcome and identified allele frequency variation across population ancestry. The role of race and ancestry on biomarkers associated with TBI outcome remains indeterminate and subsequent work is still required to understand the implications for patients with TBI.

Post-traumatic epilepsy: Insights from human cortical contused tissue

Traumatic brain injury is a significant risk factor for the development of post-traumatic epilepsy (PTE), posing a major clinical challenge. This review discusses the critical role of GABAergic interneurons and reactive astrogliosis in the pathophysiology of post-traumatic epilepsy, integrating findings from our research group within the traumatic brain injury context with recent literature to highlight the impact of excitation-inhibition imbalance. We analyzed alterations in interneuron populations, specifically subtypes expressing the calcium-binding proteins parvalbumin, calretinin, and calbindin, and their association with an increased risk of epileptogenesis after TBI. Furthermore, we detail the role of reactive astrogliosis, elucidating how dysregulated astrocytic functions, including impaired glutamate homeostasis and aberrant calcium signaling, contribute to an environment conducive to seizure activity. Increased expression of glial fibrillary acidic protein and crystallin alpha-B in reactive astrocytes identified in contused human tissue suggests their involvement in exacerbating epileptogenic circuits. Our findings emphasize the intricate interactions between GABAergic interneurons and astrocytes, underscoring the need for a comprehensive understanding of the mechanisms underlying post-traumatic epilepsy. By bridging our group's data with existing evidence, this review establishes a foundation for future studies aimed at validating systemic biomarkers and developing targeted therapies to prevent or mitigate epilepsy progression following TBI. These insights are essential for addressing the complexities of drug-resistant epilepsy in affected patients.

Advancements in diagnosing Post-concussion Syndrome: insights into epidemiology, pathophysiology, neuropathology, neuroimaging, and salivary biomarkers

Post-Concussion Syndrome (PCS) represents a complex constellation of symptoms that persist following a concussion or mild traumatic brain injury (mTBI), with significant implications for patient care and outcomes. Despite its prevalence, diagnosing PCS presents considerable challenges due to the subjective nature of symptoms, the absence of specific diagnostic tests, and the overlap with other neurological and psychiatric conditions. This review explores the multifaceted diagnostic challenges associated with PCS, including the heterogeneity of symptom presentation, the limitations of current neuroimaging techniques, and the overlap of PCS symptoms with other disorders. We also discuss the potential of emerging biomarkers and advanced imaging modalities to enhance diagnostic accuracy and provide a more objective basis for PCS identification. Additionally, the review highlights the importance of a multidisciplinary approach in the diagnosis and management of PCS, integrating clinical evaluation with innovative diagnostic tools to improve patient outcomes. Through a comprehensive analysis of current practices and future directions, this review aims to shed light on the complexities of PCS diagnosis and pave the way for improved strategies in the identification and treatment of this condition.

Serum C-Reactive Protein-to-Albumin Ratio as a Clinical Risk Factor for Traumatic Spinal Cord Injury

OBJECTIVE

To evaluate the effects of admission serum C-reactive protein-to-albumin ratio (CAR) in traumatic spinal cord injury (TSCI) severity evaluation and prognosis.

METHODS

We included 402 TSCI patients from 2 hospitals and collected relevant clinical and laboratory data. The effects of CAR on the prognosis of TSCI were explored using univariate and multivariate logistic regression analyses. The predictive values of different indicators were compared by evaluating the areas under the receiver operating characteristic curve.

RESULTS

We classified 224 (55.7%) patients as severe TSCI (American spinal injury association Impairment Scale [AIS] grades A-B) and 178 (44.3%) patients as nonsevere TSCI (AIS grades C-E) according to the American Spinal Cord Injury Society Impairment Scale (AIS). Further investigation into the correlation among C-reactive protein (CRP), CAR, and serum albumin with the AIS grade showed that the admission CRP and CAR decreased in an AIS grade-dependent manner, while serum albumin increased in an AIS grade-dependent manner. Of the total patients, 226 (56.2%) were categorized as having a good clinical outcome based on AIS grade at the 1-year follow-up. Serum CAR decreased as follow-up AIS grade decreased. Serum CAR was more strongly correlated with follow-up AIS grade than serum CRP and serum albumin alone. Multivariate logistic regression analyses showed that injury severity and CAR were independent risk factors for poor prognosis. The area under the curve (AUC) of serum CAR was 0.749 higher than that of serum CRP (AUC = 0.736) and serum albumin (AUC = 0.719).

CONCLUSIONS

Serum CAR is a readily available biomarker for assessing the severity of TSCI and predicting prognosis, which is clinically relevant for the functional recovery of patients with TSCI.

Analysis and comparison of the trends in burden of spinal cord injury in China and worldwide from 1990 to 2021: an analysis of the global burden of disease study 2021

Background

Spinal cord injury (SCI) is a globally prevalent neurological condition, often resulting in motor, sensory, and autonomic dysfunctions that lead to permanent disability. However, outdated epidemiological data hinder the development and implementation of effective public health policies. This study aimed to examine and compare trends in the burden of spinal cord injury-specifically incidence, prevalence, and years lived with disability (YLD)-in China and worldwide from 1990 to 2021, and to project these trends over the next 15 years.

Methods

This study analyzed the characteristics of the SCI burden in China and globally, examining changes in incidence, prevalence, and years lived with disability (YLD) using open data from the Global Burden of Disease database covering 1990 to 2021. Additionally, Joinpoint and age-period-cohort (APC) analyses were conducted to provide insights into the epidemiological characteristics of the SCI burden. The autoregressive integrated moving average (ARIMA) model was then applied to project SCI trends for the next 15 years.

Results

In 2021, the prevalence and incidence of SCI in China reached 2,766,277 and 99,363 cases, respectively, marking increases of 63.27 and 43.27% since 1990. From 1990 to 2021, the age-standardized prevalence rate (ASPR) of SCI decreased significantly, with an estimated annual percentage change (EAPC) of -0.34 (95% CI: -0.60 to-0.07). At the gender level, SCI prevalence and incidence were higher in men than in women. Joinpoint analysis revealed a significant decrease in the APC of the age-standardized incidence rate (ASIR) from 1990 to 2011 (APC = -0.98, p < 0.05), followed by a notable increase from 2011 to 2021 (APC = 2.05, p < 0.05). For ASPR, a significant decrease occurred from 2001 to 2005 (APC = -4.80, p < 0.05), while subsequent periods showed an increasing trend, particularly between 2010 and 2018 (APC = 1.43, p < 0.05) and 2018-2021 (APC = 2.84, p < 0.05). In terms of age-standardized YLD rates (ASYR), China experienced an overall downward trend from 1990 to 2010 (APC = -0.56 for 1990-2001; -5.97 for 2001-2005; -1.01 for 2005-2010, p < 0.05), followed by a slight upward trend post-2010, with fluctuations from 2010 and 2018 (APC = 0.88) and 2018-2021 (APC = 2.49, p < 0.05). Age-period-cohort analysis showed that the risk of SCI incidence increased with age in China, though both period and cohort effects demonstrated a significant downward trend. Projections indicate that by 2036, the ASIR and ASPR for SCI in China will reach 6 and 146 cases per 100,000 people, respectively.

Conclusion

The number and burden of SCI in China and globally have increased in the past. Among them, men and older people are more likely to develop SCI than women and younger people. Although the ASPR and ASIR for SCI are predicted to show a downward trend over the next 15 years, policy makers should continue to consider interventions to minimize the risk.

Global, regional, and national burden of spinal cord injury from 1990 to 2021 and projections for 2050: A systematic analysis for the Global Burden of Disease 2021 study

OBJECTIVES

Spinal cord injury (SCI) leads to significant functional impairments and mortality, yet outdated epidemiological data hinder effective public health policies. This study utilizes the latest data from the Global Burden of Disease Study 2021 (GBD 2021) to analyze SCI trends and inform prevention strategies.

METHODS

Using GBD 2021 data, we examined age-standardized incidence, prevalence, and years lived with disability (YLDs) of SCI, along with trends, driving factors, age-sex-time patterns, and projections up to 2050.

RESULTS

In 2021, the burden of SCI, including incidence, prevalence, and YLDs, increased with age. However, both prevalence and YLDs exhibited a slight decline after peaking at age 70, with similar trends observed in both males and females. From 1990-2021, the global burden of SCI showed a gradual decline across all populations, including males and females, and it is projected to decrease further by 2050. Nevertheless, significant disparities in disease burden exist between different countries and regions; high-SDI areas experienced a gradual decline after reaching a peak, while low-SDI areas saw a gradual increase from low levels. The primary drivers of this change include population growth and aging, although epidemiological shifts have somewhat alleviated the burden of SCI. The research also indicates that males and older adults, particularly those aged 70 and above, bear the most severe burden of SCI, with falls, road injuries, and interpersonal violence being the leading causes of this condition.

CONCLUSIONS

While the global burden of SCI is decreasing, the complex distribution across demographics and regions necessitates targeted prevention and treatment strategies to further reduce the burden and improve patient outcomes.

Neuroprotective effects of nutraceuticals and natural products in traumatic brain injury

Traumatic Brain Injury (TBI) is a global healthcare concern with considerable mortality and morbidity. Early diagnosis and timely treatment are critical for optimal clinical prognosis in TBI patients. Injury to the brain tissue following TBI is categorized into primary and secondary injury events, with the former being acute, while the latter evolves over a long period. Although surgical intervention is effective to treat primary injury, secondary injury events that could contribute to long term neurological deterioration, cognitive impairment and neurodegeneration do not have appropriate pharmacotherapy. To address this lacuna, studies based on modern medicine to explore novel drugs in TBI have met with limited success. This has led to focussed efforts to assess natural products capable of targeting multiple pathways in TBI. Complex natural mixtures and isolated phytochemicals capable of targeting redox mechanisms, neuroinflammation, mitochondrial dysfunction, cell death pathways and other specific targets etc. have been characterized. However, the field has met with certain limitations and challenges with inadequate clinical studies and trials being the most important concern. The current review provides an overview of the dietary factors, nutraceuticals, natural extracts, and phytochemicals that could be potentially applied in neuroprotection, TBI therapy and long-term management of cognitive symptoms and other neurological deficits.

Machine Learning Reveals Demographic Disparities in Palliative Care Timing Among Patients With Traumatic Brain Injury Receiving Neurosurgical Consultation

BACKGROUND

Timely palliative care (PC) consultations offer demonstrable benefits for patients with traumatic brain injury (TBI), yet their implementation remains inconsistent. This study employs machine learning methods to identify distinct patient phenotypes and elucidate the primary drivers of PC consultation timing variability in TBI management, aiming to uncover disparities and inform more equitable care strategies.

METHODS

Data on admission, hospital course, and outcomes were collected for a cohort of 232 patients with TBI who received both PC consultations and neurosurgical consultations during the same hospitalization. Patient phenotypes were uncovered using principal component analysis and K-means clustering; time-to-PC consultation for each phenotype was subsequently compared by Kaplan-Meier analysis. An extreme gradient boosting model with Shapley Additive Explanations identified key factors influencing PC consultation timing.

RESULTS

Three distinct patient clusters emerged: cluster A (n = 86), comprising older adult White women (median 87 years) with mild TBI, received the earliest PC consultations (median 2.5 days); cluster B (n = 108), older adult White men (median 81 years) with mild TBI, experienced delayed PC consultations (median 5.0 days); and cluster C (n = 38), middle-aged (median: 46.5 years), severely injured, non-White patients, had the latest PC consultations (median 9.0 days). The clusters did not differ by discharge disposition (p = 0.4) or inpatient mortality (p > 0.9); however, Kaplan-Meier analysis revealed a significant difference in time-to-PC consultation (p < 0.001), despite no differences in time-to-mortality (p = 0.18). Shapley Additive Explanations analysis of the extreme gradient boosting model identified age, sex, and race as the most influential drivers of PC consultation timing.

CONCLUSIONS

This study unveils crucial disparities in PC consultation timing for patients with TBI, primarily driven by demographic factors rather than clinical presentation or injury characteristics. The identification of distinct patient phenotypes and quantification of factors influencing PC consultation timing provide a foundation for developing for standardized protocols and decision support tools to ensure timely and equitable palliative care access for patients with TBI.

The influence of government-issued lockdowns during the COVID-19 pandemic on traumatic brain injuries in Tyrol, Austria

Introduction

In February 2020, COVID-19 infections started to spread in Austria. This was followed by governmental actions and constraints such as lockdowns, quarantine protocols, and a ban on outdoor sports. The goal of this study was to investigate the influence of these measures on the number of traumatic brain injuries (TBI) in the state of Tyrol.

Methods

The incidence of TBI during lockdowns and restrictions of outdoor activities in 2020 and 2021 were compared with corresponding periods in previous years. The data was retrospectively collected and analyzed.

Results

During the first lockdown in the winter of 2020/2021, there was a notably lower incidence of moderate and severe TBIs compared to the corresponding period in 2019/2020 (p = 0.016). Similarly, there was a reduction in TBIs from sports accidents during this period (p = 0.010). However, when comparing other lockdown periods to the previous years, no differences were observed.

Conclusion

The various governmental measures restricting mobility aimed to contain the COVID-19 pandemic but showed little influence on the number of TBI cases. Only a lockdown in the accident-prone winter months has influenced the incidence of TBIs.

Genetic deletion of the apoptosis associated speck like protein containing a card in LysM+ macrophages attenuates spinal cord injury by regulating M1/M2 polarization through ASC-dependent inflammasome signaling axis

Apoptosis associated speck like protein containing a card (ASC), the key adaptor protein of the assembly and activation of canonical inflammasomes, has been found to play a significant role in neuroinflammation after spinal cord injury (SCI). The previous studies indicated that widely block or knockout ASC can ameliorate SCI. However, ASC is ubiquitously expressed in infiltrated macrophages and local microglia, so further exploration is needed on which type of cell playing the key role. In this study, using the LysMcre;Ascflox/flox mice with macrophage-specifc ASC conditional knockout (CKO) and contusive SCI model, we focus on evaluating the specific role of ASC in lysozyme 2 (LysM)+ myeloid cells (mainly infiltrated macrophages) in this pathology. The results revealed that macrophage-specifc Asc CKO exhibited the follow effects: (1) A significant reduction in the numbers of infiltrated macrophages in the all phases of SCI, and activated microglia in the acute and subacute phases. (2) A significant reduction in ASC, caspase-1, interleukin (IL)-1β, and IL-18 compared to control mice. (3) In the acute and subacute phases of SCI, M1 subset differentiation was inhibited, and M2 differentiation was increased. (4) Histology and hindlimb motor recoveries were improved. In conclusion, this study elucidates that macrophage-specific ASC CKO can improve nerve function recovery after SCI by regulating M1/M2 polarization through inhibiting ASC-dependent inflammasome signaling axis. This indicates that ASC in peripheral infiltrated macrophages may play an important role in SCI pathology, at least in mice, could be a potential target for treatment.

Recent Strategies and Advances in Hydrogel-Based Delivery Platforms for Bone Regeneration

Bioactive molecules have shown great promise for effectively regulating various bone formation processes, rendering them attractive therapeutics for bone regeneration. However, the widespread application of bioactive molecules is limited by their low accumulation and short half-lives in vivo. Hydrogels have emerged as ideal carriers to address these challenges, offering the potential to prolong retention times at lesion sites, extend half-lives in vivo and mitigate side effects, avoid burst release, and promote adsorption under physiological conditions. This review systematically summarizes the recent advances in the development of bioactive molecule-loaded hydrogels for bone regeneration, encompassing applications in cranial defect repair, femoral defect repair, periodontal bone regeneration, and bone regeneration with underlying diseases. Additionally, this review discusses the current strategies aimed at improving the release profiles of bioactive molecules through stimuli-responsive delivery, carrier-assisted delivery, and sequential delivery. Finally, this review elucidates the existing challenges and future directions of hydrogel encapsulated bioactive molecules in the field of bone regeneration.

An integrated long-acting implant of clinical safe cells, drug and biomaterials effectively promotes spinal cord repair and restores motor functions

Spinal cord injury (SCI) is incurable and raises growing concerns. The main barrier to nerve repair is the complicated inhibitory microenvironment, where single-targeted strategies are largely frustrated. Despite the progress in combinatory therapeutic systems, the development and translation of effective therapies remain a challenge with extremely limited clinical materials. In this study, mesenchymal stem cells are transplanted in combination with sustained release of methylprednisolone through delivery in one composite matrix of a microsphere-enveloped adhesive hydrogel. All the materials used, including the stem cells, drug, and the matrix polymers gelatin and hyaluronan, are clinically approved. The therapeutic effects and safety issues are evaluated on rat and canine SCI models. The implantation significantly promotes functional restoration and nerve repair in a severe long-span rat spinal cord transection model. Distant spinal cord segments and the urinary system are effectively protected against pathologic damage. Moreover, the local sustained drug delivery mitigates the inflammatory microenvironment when overcoming the clinical issue of systemic side effects. The study presents an innovative strategy to achieve safe and efficient combinatory treatment of SCI.

Fluid biomarkers of chronic traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of long-term disability across the world. Evidence for the usefulness of imaging and fluid biomarkers to predict outcomes and screen for the need to monitor complications in the acute stage is steadily increasing. Still, many people experience symptoms such as fatigue and cognitive and motor dysfunction in the chronic phase of TBI, where objective assessments for brain injury are lacking. Consensus criteria for traumatic encephalopathy syndrome, a clinical syndrome possibly associated with the neurodegenerative disease chronic traumatic encephalopathy, which is commonly associated with sports concussion, have been defined only recently. However, these criteria do not fit all individuals living with chronic consequences of TBI. The pathophysiology of chronic TBI shares many similarities with other neurodegenerative and neuroinflammatory conditions, such as Alzheimer disease. As with Alzheimer disease, advancements in fluid biomarkers represent one of the most promising paths for unravelling the chain of pathophysiological events to enable discrimination between these conditions and, with time, provide prediction modelling and therapeutic end points. This Review summarizes fluid biomarker findings in the chronic phase of TBI (≥6 months after injury) that demonstrate the involvement of inflammation, glial biology and neurodegeneration in the long-term complications of TBI. We explore how the biomarkers associate with outcome and imaging findings and aim to establish mechanistic differences in biomarker patterns between types of chronic TBI and other neurodegenerative conditions. Finally, current limitations and areas of priority for future fluid biomarker research are highlighted.

Physical exercise as a cognitive rehabilitation treatment after traumatic brain injury: Intensity- and sex-dependent effects

We investigated the effects of forced physical exercise (PE) intensity on cognitive dysfunction and histological changes associated with traumatic brain injury (TBI), in both male and female rats. Controlled cortical impact (CCI) produced similar short- and long-term memory deficits in both sexes, and these deficits were associated with reduced volume and neuronal loss in the hippocampus, but not with changes in neurogenesis. We found sex differences in the effects of intensity of forced PE on cognitive recovery: all PE intensities tested improved short-term memory in both sexes, but to a greater extent in females, while long-term memory benefits were intensity- and sex-dependent. Males benefited most from low-intensity PE, while females showed optimal results at moderate intensity. These optimal PE intensities increased the neurogenesis in both sexes. A neuroprotective effect of low-intensity PE was evident in males, but no effect was observed in females. These findings suggest an intensity- and sex-specific effect of PE post-TBI, emphasizing the need for tailored PE protocols based on sex to enhance therapeutic outcomes.

Enhancing traumatic brain injury emergency care: the impact of grading and zoning nursing management

OBJECTIVE

This research aimed to evaluate the impact of grading and zoning nursing management on traumatic brain injury (TBI) patients' emergency treatment outcomes.

METHODS

This randomized controlled trial included 200 TBI patients. They were treated with a conventional care (control group, n = 100) and a novel grading and zoning approach (study group, n = 100), respectively. This innovative model organized care into levels based on urgency and complexity, facilitating targeted medical response and resource allocation. Key metrics compared included demographic profiles, consultation efficiency (time metrics and emergency treatment rates), physiological parameters (HR, RR, MAP, SpO2, RBS), and patient outcomes (hospital and ICU stays, complication rates, and emergency outcomes).

RESULTS

The study group demonstrated significantly improved consultation efficiency, with reduced times for physician visits, examinations, emergency stays, and specialist referrals (all p < 0.001), alongside a higher emergency treatment rate (93% vs. 79%, p = 0.004), notably better physiological stability, improved HR, RR, MAP, SpO2 and RBS (p < 0.001), shorter hospital and ICU stays, fewer complications, and superior emergency outcomes.

CONCLUSION

Grading and zoning nursing management substantially enhances TBI patients' emergency care efficiency and clinical outcomes, suggesting a viable model for improving emergency treatment protocols.

Downregulation of Circular RNA Gla Reduced Astrocyte Inflammatory Status by Regulating miR-488/MEKK1 Levels and Promoted Functional Recovery After Spinal Cord Injury

Background

Post-spinal cord injury (SCI) inflammation correlates with neurologic recovery. Through sequencing, we explored the roles of a differentially expressed circRNA in mice after SCI, circGla, on inflammation and recovery of SCI.

Methods

The T8-T10 SCI model was established in C57BL6 mice. HE staining and RT-qPCR verified circGla upregulation results after injury obtained through sequencing. RNase R digestion and primer amplification experiments confirmed the circular properties of circGla. Nucleus and cytoplasm isolation experiments and FISH confirmed circGla expression in the astrocyte cytoplasm. AAV was used to establish a circGla knockdown mouse model. Behavioral tests were conducted to assess the recovery of the neurological function. The key inflammatory molecules after SCI were evaluated through MRI, RT-qPCR, and ELISA. For in vitro experiments, circGla was upregulated or knocked down in mouse astrocytes to detect its effect. The binding between miR-488 and circGla was confirmed through RIP and the dual luciferase experiment. RT-qPCR and ELISA confirmed the content correlation of the two molecules and the in vitro inflammatory function of miR-488. The binding experiment in astrocytes confirmed the binding between miR-488 and MEKK1 mRNA. Western blotting of MAPK pathway-related proteins confirmed that MEKK1 is a downstream effector for circGla and miR-488 in astrocytes.

Results

Following SCI, the circular RNA circGla levels increased and it existed in the astrocyte cytoplasm. circGla knockdown reduced inflammation and improved neurological recovery in vivo. The correlation between circGla and proinflammatory factors was confirmed in vitro. circGla bound to miR-488, and the high miR-488 level was associated with the low astrocyte inflammatory state. miR-488 bound to MEKK1 mRNA, and upregulation or knockdown of circGla or miR-488 affected MAPK pathway-related protein expression.

Conclusion

Following SCI, downregulation of circGla expression in astrocytes can reduce inflammatory manifestations and stimulate long-term functional recovery in mice through miR-488 and MEKK1.

Mesenchymal Stromal Cell Implants for Chronic Motor Deficits After Traumatic Brain Injury: Post Hoc Analysis of a Randomized Trial

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is frequently characterized by chronic motor deficits. Therefore, this clinical trial assessed whether intracranial implantation of allogeneic modified mesenchymal stromal (SB623) cells can improve chronic motor deficits after TBI.

METHODS

Post hoc analysis of the double-blind, randomized, prospective, surgical sham-controlled, phase 2, STEMTRA clinical trial (June 2016 and March 2019) with 48 weeks of follow-up was conducted. In this international, multicenter clinical trial, eligible participants had moderate-to-severe TBI, were ≥12 months postinjury, and had chronic motor deficits. Participants were randomized in a 1:1:1:1 ratio to stereotactic surgical intracranial implantation of SB623 cells (2.5 × 106, 5.0 × 106, 10 × 106) or surgical sham-controlled procedure. The prespecified primary efficacy end point was significantly greater change from baseline of the Fugl-Meyer Motor Scale (FMMS) score, a measure of motor status, for the SB623 pooled vs control arm at 24 weeks.

RESULTS

A total of 211 participants were screened, 148 were excluded, and 63 underwent randomization, of which 61 (97%; mean age, 34 [SD, 12] years; 43 men [70.5%]) completed the trial. Single participants in the SB623 2.5 × 106 and 5.0 × 106 cell dose groups discontinued before surgery. Safety and efficacy (modified intent-to-treat) were assessed in participants who underwent surgery (N = 61; SB623 = 46, controls = 15). The primary efficacy end point (FMMS) was achieved (least squares mean [SE] SB623: +8.3 [1.4]; 95% CI 5.5-11.2 vs control: +2.3 [2.5]; 95% CI -2.7 to 7.3; p = 0.04), with faster improvement of the FMMS score in SB623-treated groups than in controls at 24 weeks and sustained improvement at 48 weeks. At 48 weeks, improvement of function and activities of daily living (ADL) was greater, but not significantly different in SB623-treated groups vs controls. The incidence of adverse events was equivalent in SB623-treated groups and controls. There were no deaths or withdrawals due to adverse events.

DISCUSSION

Intraparenchymal implantation of SB623 cells was safe and significantly improved motor status at 24 weeks in participants with chronic motor deficits after TBI, with continued improvement of function and ADL at 48 weeks. Cell therapy can modify chronic neurologic deficits after TBI.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT02416492. Submitted to registry: April 15, 2015. First participant enrolled: July 6, 2016. Available at: classic.clinicaltrials.gov/ct2/show/NCT02416492.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that intracranial implantation of allogeneic stem (SB623) cells in adults with motor deficits from chronic TBI improves motor function at 24 weeks.

Characteristics of the Structural Connectivity in Patients with Brain Injury and Chronic Health Symptoms: A Pilot Study

Diffusion properties from diffusion tensor imaging (DTI) are exquisitely sensitive to white matter abnormalities incurred during traumatic brain injury (TBI), especially for those patients with chronic post-TBI symptoms such as headaches, dizziness, fatigue, etc. The evaluation of structural and functional connectivity using DTI has become a promising method for identifying subtle alterations in brain connectivity associated with TBI that are otherwise not visible with conventional imaging. This study assessed whether TBI patients with (n = 17) or without (n = 16) chronic symptoms (TBIcs/TBIncs) exhibit any changes in structural connectivity (SC) and mean fractional anisotropy (mFA) of intra- and inter-hemispheric connections when compared to a control group (CG) (n = 13). Reductions in SC and mFA were observed for TBIcs compared to CG, but not for TBIncs. More connections were found to have mFA reductions than SC reductions. On the whole, SC is dominated by ipsilateral connections for all the groups after the comparison of contralateral and ipsilateral connections. More contra-ipsi reductions of mFA were found for TBIcs than TBIncs compared to CG. These findings suggest that TBI patients with chronic symptoms not only demonstrate decreased global and regional mFA but also reduced structural network connectivity.

Beyond brain injury: Examining the neuropsychological and psychosocial sequelae of post-traumatic epilepsy

OBJECTIVE

This study investigates neuropsychological and psychosocial outcomes in patients with traumatic brain injury (TBI) and post-traumatic epilepsy (PTE) compared to a healthy control group.

METHOD

Utilizing a quasi-experimental cross-sectional design, the research involved patients with TBI and PTE referred from a Taiwanese medical center. An age- and education-matched control group of healthy adults without traumatic injuries was also recruited. The study involved analyzing retrospective medical records and applying a comprehensive suite of neuropsychological tests and psychosocial questionnaires.

RESULTS

Executive function measures revealed significantly reduced performance in both the TBI and PTE groups compared to controls. Specifically, the MoCA scores were lowest in the PTE group, followed by the TBI group, and highest in the controls. Measures of subjective symptomatology showed comparably elevated levels in both the TBI and PTE groups relative to controls.

CONCLUSION

The research suggests that PTE may intensify the difficulties faced by individuals with TBI, but its impact on overall recovery might not be significant, considering the trajectory of the brain injury itself. Notably, the MoCA results indicate that cognitive deficits are more pronounced in PTE patients compared to those with TBI, underscoring the necessity for targeted neuropsychological assessments. Further investigation is essential to explore PTE's broader neuropsychological and psychosocial impacts. These findings advocate for tailored care strategies that address both neuropsychological and psychosocial needs, ensuring comprehensive management of TBI and PTE.

Early predictors of long-term participation in patients with severe acquired traumatic injury discharged from Intensive Rehabilitation Unit

BACKGROUND

Participation represents the most relevant indicator of successful functioning after a severe traumatic brain injury (sTBI), since it correlates with a higher perceived quality of life by patients, their families, and healthcare professionals. Nevertheless, studies on Italian population are lacking.

AIM

The aim of this study was to evaluate the long-term participation and its early predictors in patients after a sTBI.

DESIGN

This paper is an observational retrospective single-site study with long-term follow-up.

SETTING

The Intensive Rehabilitation Units (IRU) of the IRCCS Don Gnocchi Foundation, Florence, Italy.

POPULATION

The population included adults who were admitted to the IRU after a sTBI from August 2012 to May 2020 and who underwent a longitudinal follow-up between September 2021 and April 2022.

METHODS

Patients were contacted by a phone interview including participation assessment using the Community Integration Questionnaire (CIQ). When the patients were unable to respond, the caregiver was interviewed. Early predictors of long-term participation at admission and discharge from the IRU were assessed by a univariate and a multivariate analysis.

RESULTS

Among one hundred and forty-nine eligible patients, 3 died during their IRU stay, 35 patients were lost at the follow-up, 5 refused to participate in the interview and 46 died between discharge and follow-up. Sixty patients (men: 48 [80%]; age: 53.8 [IQR: 34.1] years; time postonset [TPO]: 36.5 [IQR: 22] days; education level: 8 [IQR: 5] years; mean time event-follow-up: 5.8 [IQR: 3.5] years) were included. The total CIQ Score was 11 (0-28): Home integration score 4 (0-10), Social integration 6 (0-12) and Productive activity 0 (0-6). Among 33 patients who worked or studied before the event, 19 (57.6%) returned to their previous activities. Only a younger age was associated with a better long-term participation both at admission (B=-0.210, P<0.001, R2=0.307) and at discharge (B=-0.173, P<0.001, R2=0.398).

CONCLUSIONS

This study reveals that under the same umbrella label of sTBI there are patients whose trajectories of long-term participation recovery are extremely heterogeneous. Further studies on larger samples are needed to identify patients with better participation recovery profiles, to customize their rehabilitation pathway.

CLINICAL REHABILITATION IMPACT

The present study provides relevant information to help clinicians in giving accurate information to caregivers and drawing adequate rehabilitation pathways.

Clinical Capacity Building Through Partnerships: Boots on the Ground in Global Neurosurgery

Global neurosurgery seeks to provide quality neurosurgical health care worldwide and faces challenges because of historical, socioeconomic, and political factors. To address the shortfall of essential neurosurgical procedures worldwide, dyads between established neurosurgical and developing centers have been established. Concerns have been raised about their effectiveness and ability to sustain capacity development. Successful partnerships involve multiple stakeholders, extended timelines, and twinning programs. This article outlines current initiatives and challenges within the neurosurgical community. This narrative review aims to provide a practical tool for colleagues embarking on clinical partnerships, the Engagements and assets, Capacity, Operative autonomy, Sustainability, and scalability (ECOSystem) of care. To create the ECOSystem of care in global neurosurgery, the authors had multiple online discussions regarding important points in the practical tool. All developed tiers were expanded based on logistics, clinical, and educational aspects. An online search was performed from August to November 2023 to highlight global neurosurgery partnerships and link them to tiers of the ECOSystem. The ECOSystem of care involves 5 tiers: Tiers 0 (foundation), 1 (essential), 2 (complexity), 3 (autonomy), and 4 (final). A nonexhaustive list of 16 neurosurgical partnerships was created and serves as a reference for using the ECOSystem. Personal experiences from the authors through their partnerships were also captured. We propose a tiered approach for capacity building that provides structured guidance for establishing neurosurgical partnerships with the ECOSystem of care. Clinical partnerships in global neurosurgery aim to build autonomy, enabling independent provision of quality healthcare services.

An Overview of Global Neurosurgery

Until recently, surgery had been passed over in the domain of global health, historically being described as "the neglected stepchild of global health." Knowledge of the existing global disparities in neurosurgical care has led to neurosurgery capacity-building efforts especially in low-income and middle-income countries. While many global collaborative projects are currently undertaken with philanthropic support, sustainability and scalability are not likely without governmental adoption of neurosurgery-inclusive national surgical plans. Momentum grows for the global neurosurgery community to develop a global neurosurgery action plan outlining goals, a guiding framework, an execution plan, and indicators for monitoring and evaluation.

Uncovering the protective potential of vanillic acid against traumatic brain injury-induced cognitive decline in male rats: Insights into underlying mechanisms

Traumatic brain injury (TBI) is a significant contributor to global mortality and disability, and there is still no specific drug available to treat cognitive deficits in survivors. Vanillic acid (VA), a bioactive phenolic compound, has shown protective effects in various models of neurodegeneration; however, its impact on TBI outcomes remains elusive. Therefore, this study aimed to elucidate the possible role of VA in ameliorating TBI-induced cognitive decline and to reveal the mechanisms involved. TBI was induced using the Marmarou impact acceleration model to deliver an impact force of 300 g, and treatment with VA (50 mg/kg; P.O.) was initiated 30 minutes post-TBI. The cognitive performance, hippocampal long-term potentiation (LTP), oxidative stress markers, neurological function, cerebral edema, and morphological changes were assessed at scheduled points in time. TBI resulted in cognitive decline in the passive avoidance task, impaired LTP in the perforant path-dentate gyrus (PP-DG) pathway, increased hippocampal oxidative stress, cerebral edema, neurological deficits, and neuronal loss in the rat hippocampus. In contrast, acute VA administration mitigated all the aforementioned TBI outcomes. The data suggest that reducing synaptic plasticity impairment, regulating oxidative and antioxidant defense, alleviating cerebral edema, and preventing neuronal loss by VA can be at least partially attributed to its protection against TBI-induced cognitive decline.

Nigella sativa extract abrogates traumatic brain injury-induced memory impairment in adult mice

Background

Traumatic brain injury (TBI) is an increasing widespread cause of disability and mortality, typically leading to dementia and memory impairment.

Objective

This study aims to investigate the neuroprotective potential of Nigella sativa extract against TBI induced memory impairment in adult albino mice.

Methods

Adult male mice were divided into four groups randomly: Control, Nigella sativa extract alone, TBI alone and TBI plus Nigella sativa extract. TBI induction was carried out in mice using a weight dropping method then Nigella sativa extract (10 mg/kg) was administered intraperitoneally for two weeks. Morris water maze and Y-maze tests were used to measure memory improvement ability and Western blot technique was used to analyse the neuroinflammatory and synaptic protein markers.

Results

Nigella sativa extract significantly decreased phosphorylated c-Jun N-terminal kinase (p-JNK), Tumor necrosis factor-alpha (TNF-α), and nuclear factor kappa B (NF-κB) proteins to reduce TBI-induced neuroinflammation accompanied by the restoration of both pre- and post-synaptic protein expression in adult mice model. Furthermore, Nigella sativa extract enhanced both short and long-term spatial memory against TBI in adult mice model.

Conclusion

Nigella sativa extract abrogated neuroinflammation mediated memory impairment in TBI mice model. Further research is needed to determine Nigella sativa extract ingredients detail completely and to understand its mechanisms of neuroprotection in reducing memory impairments associated with traumatic brain injury and other neurodegenerative diseases.

Prevalence of tinnitus following non-blast related traumatic brain injury: a systematic review of literature

OBJECTIVES

To establish the prevalence of tinnitus in adults who have sustained non-blast related traumatic brain injury (TBI), as well as the prevalence of tinnitus following TBI in the absence of hearing loss.

METHODS

A systematic search was carried out using MEDLINE, EMBASE, PsycINFO, CINAHL from January 1st 1990 to August 14th 2023. TBI, tinnitus and auditory findings were extracted from all eligible studies, and a descriptive synthesis performed. This systematic review was registered with PROSPERO (Registration number: CRD42022377637).

RESULTS

Based on the Oxford Centre of Evidence-Based Medicine (OCEBM) (2011) criteria, the highest quality evidence identified was at Level 2b, with the bulk of the included studies predominantly populating the lower evidence tiers. While there was a substantial variability in the methods used to establish and report the presence of tinnitus, its occurrence following TBI was evident in adults with and without hearing loss.

CONCLUSION

The need for prospective, longitudinal research into tinnitus following non-blast related TBI is evident. Such comprehensive studies hold the potential to inform and enhance the clinical diagnosis and management of this patient population.

Global traumatic brain injury intracranial pressure: from monitoring to surgical decision

Traumatic brain injury (TBI) is a significant global public health issue, heavily impacting human health, especially in low-and middle-income areas. Despite numerous guidelines and consensus statements, TBI fatality rates remain high. The pathogenesis of severe TBI is closely linked to rising intracranial pressure (ICP). Elevated intracranial pressure can lead to cerebral herniation, resulting in respiratory and circulatory collapse, and ultimately, death. Managing intracranial pressure (ICP) is crucial in neuro-intensive care. Timely diagnosis and precise treatment of elevated ICP are essential. ICP monitoring provides real-time insights into a patient's condition, offering invaluable guidance for comprehensive management. ICP monitoring and standardization can effectively reduce secondary nerve damage, lowering morbidity and mortality rates. Accurately assessing and using true ICP values to manage TBI patients still depends on doctors' clinical experience. This review discusses: (a) Epidemiological disparities of traumatic brain injuries across countries with different income levels worldwide; (b) The significance and function of ICP monitoring; (c) Current status and challenges of ICP monitoring; (d) The impact of decompressive craniectomy on reducing intracranial pressure; and (e) Management of TBI in diverse income countries. We suggest a thorough evaluation of ICP monitoring, head CT findings, and GCS scores before deciding on decompressive craniectomy. Personalized treatment should be emphasized to assess the need for surgical decompression in TBI patients, offering crucial insights for clinical decision-making.

Practical pearls for management of cranial injury in the developing world

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69 million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

Development of a Quality Indicator Set for the Optimal Acute Management of Moderate to Severe Traumatic Brain Injury in the Australian Context

BACKGROUND

The aim of this study was to develop a consensus-based set of indicators of high-quality acute moderate to severe traumatic brain injury (msTBI) clinical management that can be used to measure structure, process, and outcome factors that are likely to influence patient outcomes. This is the first stage of the PRECISION-TBI program, which is a prospective cohort study that aims to identify and promote optimal clinical management of msTBI in Australia.

METHODS

A preliminary set of 45 quality indicators was developed based on available evidence. An advisory committee of established experts in the field refined the initial indicator set in terms of content coverage, proportional representation, contamination, and supporting evidence. The refined indicator set was then distributed to a wider Delphi panel for assessment of each indicator in terms of validity, measurement feasibility, variability, and action feasibility. Inclusion in the final indicator set was contingent on prespecified inclusion scoring.

RESULTS

The indicator set was structured according to the care pathway of msTBI and included prehospital, emergency department, neurosurgical, intensive care, and rehabilitation indicators. Measurement domains included structure indicators, logistic indicators, and clinical management indicators. The Delphi panel consisted of 44 participants (84% physician, 12% nursing, and 4% primary research) with a median of 15 years of practice. Of the 47 indicators included in the second round of the Delphi, 32 indicators were approved by the Delphi group.

CONCLUSIONS

This study identified a set of 32 quality indicators that can be used to structure data collection to drive quality improvement in the clinical management of msTBI. They will also be used to guide feedback to PRECISION-TBI's participating sites.

Challenges in traumatic spinal cord injury care in developing countries - a scoping review

Objective

To evaluate the leading challenges in developing countries' traumatic spinal cord injury (TSCI) care.

Methods

We conducted a systematic search in electronic databases of PubMed, SCOPUS, Web of Science, EMBASE, and Cochrane Library on 16 April 2023. Studies that investigated challenges associated with the management of TSCI in developing countries were eligible for review. We extracted related outcomes and categorized them into four distinct parts: injury prevention, pre-hospital care, in-hospital care, and post-hospital care.

Results

We identified 82 articles that met the eligibility criteria including 13 studies on injury prevention, 25 on pre-hospital care, 32 on in-hospital care, and 61 on post-hospital care. Challenges related to post-hospital problems including the personal, financial, and social consequences of patients' disabilities and the deficiencies in empowering people with TSCI were foremost studied. Lack of trained human resources, insufficient public education and delays in care delivery were barriers in the acute and chronic management of TSCI. A well-defined pre-hospital network and standard guidelines for the management of acute neurotrauma are needed. Critical challenges in injury prevention include deficiencies in infrastructure and supportive legislation.

Conclusion

Studies focusing on injury prevention and pre-hospital care in TSCI management in developing countries warrant further investigation. It is imperative to develop systematic and evidence-based initiatives that are specifically tailored to the unique circumstances of each country to address these challenges effectively. By understanding the primary obstacles, policymakers and healthcare providers can establish goals for improving education, planning, legislation, and resource allocation.

Electromagnetic Cellularized Patch with Wirelessly Electrical Stimulation for Promoting Neuronal Differentiation and Spinal Cord Injury Repair

Although stem cell therapy holds promise for the treatment of spinal cord injury (SCI), its practical applications are limited by the low degree of neural differentiation. Electrical stimulation is one of the most effective ways to promote the differentiation of stem cells into neurons, but conventional wired electrical stimulation may cause secondary injuries, inflammation, pain, and infection. Here, based on the high conductivity of graphite and the electromagnetic induction effect, graphite nanosheets with neural stem cells (NSCs) are proposed as an electromagnetic cellularized patch to generate in situ wirelessly pulsed electric signals under a rotating magnetic field for regulating neuronal differentiation of NSCs to treat SCI. The strength and frequency of the induced voltage can be controlled by adjusting the rotation speed of the magnetic field. The generated pulsed electrical signals promote the differentiation of NSCs into functional mature neurons and increase the proportion of neurons from 12.5% to 33.7%. When implanted in the subarachnoid region of the injured spinal cord, the electromagnetic cellularized patch improves the behavioral performance of the hind limbs and the repair of spinal cord tissue in SCI mice. This work opens a new avenue for remote treatment of SCI and other nervous system diseases.

Clinical experiences, current approaches, opinions and awareness of healthcare professionals regarding the audio-vestibular consequences of individuals with traumatic brain injury: a cross-sectional online survey study

OBJECTIVE

To explore the experiences, current approaches, opinions and awareness of healthcare professionals (HCPs) caring for adults with traumatic brain injury (TBI) regarding the audio-vestibular consequences.

DESIGN/SETTING

Cross-sectional online survey study.

PARTICIPANTS

HCPs with experience of caring for adults with TBI, who were not ENT (ear nose throat) specialists or audiologists.

METHODS

The study was conducted from May 2022 to December 2022. The online survey consisted of 16 closed and open-text questions in English and Turkish about clinical experience, current approaches and awareness of audio-vestibular consequences following TBI. Frequencies of responses to closed questions and associations between variables were analysed using SPSS V.28. Open-text responses were summarised in Microsoft Excel.

RESULTS

Seventy HCPs participated from 17 professions and 14 countries, with the majority from the UK (42.9%). HCPs stated that 'some' to 'all' of their patients had auditory problems such as 'inability to understand speech-in-noise' (66%), 'tinnitus' (64%), 'hyperacusis' (57%) and balance problems such as 'dizziness' (79%) and 'vertigo' (67%). Usually, HCPs asked about the balance status of patients at appointments and when they observed dizziness and/or balance disorder they used screening tests, most commonly finger-to-nose (53%). For auditory impairments, HCPs preferred referring patients with TBI to audiology/ENT services. However, 6% of HCPs felt that audio-vestibular conditions could be ignored on referral because patients with TBI struggled with many impairments. Additionally, 44% would suggest hearing aids to patients with TBI with hearing loss 'if they would like to use' rather than 'definitely'.

CONCLUSIONS

Many audio-vestibular impairments are observed by HCPs caring for patients with TBI. The assessment and intervention opinions and awareness of HCPs for these impairments vary. However, non-expert HCPs may not be aware of negative consequences of untreated audio-vestibular impairments following TBI. Therefore, developing a simple framework for screening and indications of audio-vestibular impairments for referral may be helpful for non-audiological specialists regularly seeing these patients.

Hyperhomocysteinemia in a Patient With Subdural Hematoma and Subarachnoid Hemorrhage Secondary to a Traumatic Brain Injury

Traumatic brain injury (TBI) is a significant global health issue, contributing substantially to mortality and disability. Serum biomarkers, such as homocysteine (Hcy), play a critical role in the prognosis of brain injuries, with hyperhomocysteinemia (HHcy) potentially leading to neurological disorders. We present the case of a 64-year-old patient admitted to the emergency department following a road traffic accident (RTA). Magnetic resonance imaging (MRI) revealed parietal subdural hematoma (SDH), right frontal contusion, and left subarachnoid hemorrhage (SAH). The patient underwent a craniotomy to address SAH and SDH. Initial Hcy levels were markedly elevated compared to post-operative levels. Hcy represents a rapid, non-invasive, and cost-effective diagnostic tool for assessing brain injury severity and guiding medical intervention. Early detection of HHcy could potentially mitigate vascular and neurological complications, thereby improving patient outcomes.

Association Between Social Determinants of Health and Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Disparities exist in the populations that acquire TBIs, however, with a greater burden and poorer outcomes associated with communities of color and lower socioeconomic status. To combat health inequities such as these, institutions have begun to target social determinants of health (SDoH), which are environmental factors that affect health outcomes and risks. The SDoH may play a role in sustaining a TBI and provide modifiable targets for action to reduce the risk of TBI, especially in high-risk communities. In this study, we describe the existing literature regarding SDoH and their association with sustaining a TBI. We performed a scoping review with a comprehensive search of the Ovid MEDLINE/Embase databases. To summarize the literature, this review adapts the World Health Organization's Commission on SDoH's conceptual framework. Fifty-nine full-text articles, including five focusing on lower and middle-income countries, met our study criteria. Results of the scoping review indicate that several structural determinants of health were associated with TBI risk. Lower educational attainment and income levels were associated with higher odds of TBI. In addition, multiple studies highlight that minority populations were identified as having higher odds of TBI than their White counterparts. Literature highlighting intermediate determinants of health examined in this review describes associations between sustaining a TBI and rurality, work environment, medical conditions, medication/substance use, and adversity. Recommended exploration into lesser-researched SDoH is discussed, and the expansion of this review to other aspects of the TBI continuum is warranted.

Factors affecting severity and prognosis of traumatic brain injury among Bangladeshi patients: An institution based cross-sectional study

OBJECTIVE

Traumatic brain injury (TBI) proves to be an obstacle for Bangladeshi patients due to the lack of facilities and specialist doctors in regional sections of the country. This study aimed to record different attributes of Bangladeshi TBI patients over a year i.e., their injury characteristics, treatments received and understand their impacts on the severity of TBI.

METHOD

This cross-sectional study was carried out among 280 TBI patients treated in a tertiary care hospital in Dhaka. The physicians determined TBI's severity and prognosis as per the Glasgow Coma Scale (GCS) and Glasgow Outcome Score (GOS) respectively.

RESULTS

Most TBI patients were male (76.1%) and aged between 18 and 50 years (52.2%), as in previous studies in South Asian countries. However, the prevalence of TBI due to road traffic accidents (RTAs) was much higher (67.9%) than in the earlier studies in South Asia. Additionally, more patients suffered from severe TBI (29.3%) and moderate TBI (35.7%), and a higher percentage of patients went through surgery (56.8%) compared to previous studies. A significant association of demographic (residence) and clinical characteristics (consciousness after injury, CT scan findings and treatment type) with the severity of TBI was found in bivariate analysis. It also revealed the significant dependence of clinical characteristics (TBI etiology, post-injury consciousness, treatment type and TBI severity) on TBI prognosis. Multivariate analysis showed that patients who were unconscious after TBI and with evident brain injury observed in CT scans have a substantially higher risk of having moderate or severe TBI than mild TBI. Moreover, patients with TBI due to RTAs or falls, evident brain injury in CT scans, post-surgical seizure, and moderate or severe TBI have a significantly higher risk of getting a more unfavorable TBI prognosis than moderate disability.

CONCLUSIONS

In this study, RTAs were found to be the major cause of TBI. Additionally, some variables were identified as possible determinants of TBI severity and prognosis among Bangladeshi patients. The correlation of these variables with TBI should be further studied with the hopes that steps will be taken to reduce TBI incidents and improve its management to reduce the overall burden.

Admission levels of serum biomarkers have additive and cumulative prognostic value in traumatic brain injury

Elevated levels of CNS-derived serum proteins are associated with poor outcome in traumatic brain injury (TBI), but the value of adding acute serum biomarker levels to common clinical outcome predictors lacks evaluation. We analyzed admission serum samples for Total-Tau (T-Tau), Neurofilament light chain (Nfl), Glial fibrillary acidic protein (GFAP), and Ubiquitin C-terminal hydrolase L1 (UCHL1) in a cohort of 396 trauma patients including 240 patients with TBI. We assessed the independent association of biomarkers with 1-year mortality and 6-12 months Glasgow Outcome Scale Extended (GOSE) score, as well as the additive and cumulative value of biomarkers on Glasgow Coma Scale (GCS) and Marshall Score for outcome prediction. Nfl and T-Tau levels were independently associated with outcome (OR: Nfl = 1.65, p = 0.01; T-Tau = 1.99, p < 0.01). Nfl or T-Tau improved outcome prediction by GCS (Wald Chi, Nfl = 6.8-8.8, p < 0.01; T-Tau 7.2-11.3, p < 0.01) and the Marshall score (Wald Chi, Nfl = 16.2-17.5, p < 0.01; T-Tau 8.7-12.4, p < 0.01). Adding T-Tau atop Nfl further improved outcome prediction in majority of tested models (Wald Chi range 3.8-9.4, p ≤ 0.05). Our data suggest that acute levels of serum biomarkers are independently associated with outcome after TBI and add outcome predictive value to commonly used clinical scores.

Extended tests for evaluating post-traumatic brain injury deficits in resource-limited settings: methods and pilot study data

Introduction

Traumatic brain injury (TBI) is one of the leading causes of all injury-related deaths and disabilities in the world, especially in low to middle-income countries (LMICs) which also suffer from lower levels of funding for all levels of the health care system for patients suffering from TBI. These patients do not generally get comprehensive diagnostic workup, monitoring, or treatment, and return to work too quickly, often with undiagnosed post-traumatic deficits which in turn can lead to subsequent incidents of physical harm.

Methods

Here, we share methods and results from our research project to establish innovative, simple, and scientifically based practices that dramatically leverage technology and validated testing strategies to identify post-TBI deficits quickly and accurately, to circumvent economic realities on the ground in LMICs. We utilized paper tests such as the Montreal cognitive assessment (MoCA), line-bisection, and Bell's test. Furthermore, we combined modifications of neuroscience computer tasks to aid in assessing peripheral vision, memory, and analytical accuracies. Data from seventy-one subjects (51 patients and 20 controls, 15 females and 56 males) from 4 hospitals in Ethiopia are presented. The traumatic brain injury group consists of 17 mild, 28 moderate, and 8 severe patients (based on the initial Glasgow Comma Score). Controls are age and education-matched subjects (no known history of TBI, brain lesions, or spatial neglect symptoms).

Results

We found these neurophysiological methods can: 1) be implemented in LMICs and 2) test impairments caused by TBI, which generally affect brain processing speed, memory, and both executive and cognitive controls.

Discussion

The main findings indicate that these examinations can identify several deficits, especially the MoCA test. These tests show great promise to assist in the evaluation of TBI patients and support the establishment of dedicated rehabilitation centers. Our next steps will be expansion of the cohort size and application of the tests to other settings.

ZL006 mitigates anxiety-like behaviors induced by closed head injury through modulation of the neural circuit from the medial prefrontal cortex to amygdala

Closed head injury is a prevalent form of traumatic brain injury with poorly understood effects on cortical neural circuits. Given the emotional and behavioral impairments linked to closed head injury, it is vital to uncover brain functional deficits and their driving mechanisms. In this study, we employed a robust viral tracing technique to identify the alteration of the neural pathway connecting the medial prefrontal cortex to the basolateral amygdala, and we observed the disruptions in neuronal projections between the medial prefrontal cortex and the basolateral amygdala following closed head injury. Remarkably, our results highlight that ZL006, an inhibitor targeting PSD-95/nNOS interaction, stands out for its ability to selectively reverse these aberrations. Specifically, ZL006 effectively mitigates the disruptions in neuronal projections from the medial prefrontal cortex to basolateral amygdala induced by closed head injury. Furthermore, using chemogenetic approaches, we elucidate that activating the medial prefrontal cortex projections to the basolateral amygdala circuit produces anxiolytic effects, aligning with the therapeutic potential of ZL006. Additionally, ZL006 administration effectively mitigates astrocyte activation, leading to the restoration of medial prefrontal cortex glutamatergic neuron activity. Moreover, in the context of attenuating anxiety-like behaviors through ZL006 treatment, we observe a reduction in closed head injury-induced astrocyte engulfment, which may correlate with the observed decrease in dendritic spine density of medial prefrontal cortex glutamatergic neurons.

Moving from the clinic to telehealth during the COVID-19 pandemic - a pilot clinical trial comparing in-clinic rehabilitation versus telerehabilitation for persisting symptoms following a mild Traumatic brain injury

PURPOSE

The objective of this study was to compare the effects of an in-clinic cervicovestibular rehabilitation program (education, home exercises, manual techniques, sub-symptom threshold aerobic exercise [STAE] program) to a similar program (education, home-exercises, STAE program), but without manual techniques, provided in a telerehabilitation format in adults with persisting post-concussion symptoms (PCS).

MATERIALS AND METHODS DESIGN

In this parallel-group non-randomized clinical trial, 41 adults with persisting PCS were allocated to the in-clinic (n = 30) or telerehabilitation (n = 11) program. The outcome measures, which included the Post-Concussion Symptom Scale (PCSS; primary outcome), Numerical Pain Rating Scale (NPRS) for neck pain and headache and three disability questionnaires, were collected at baseline, weeks 6, 12, and 26. Non-parametric analysis for longitudinal data (NparLD) was used.

RESULTS

For the PCSS, there was a group-by-time interaction (p = 0.05) with significant between-group differences at week 6, 12, and 26 (p < 0.05) for the in-clinic group. There were also group-by-time interactions for NPRS neck pain and headache (p < 0.05) for the in-clinic group.

CONCLUSION

The study suggests that a telehealth format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement. These results must be interpreted with caution given the limited number of participants. ClinicalTrials.gov Identifier: NCT03677661.IMPLICATION FOR REHABILITATIONThe telerehabilitation format for adults with persisting post-concussion symptoms was widely implemented in the COVID-19 pandemic without any evidence of efficacy over the more traditional in-clinic rehabilitation format.The study suggests that a telerehabilitation format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement.Clinicians should try to incorporate some in-clinic appointments when a telerehabilitation format is required such as for patients in underserved area.

Effect of l-oxiracetam and oxiracetam on memory and cognitive impairment in mild-to-moderate traumatic brain injury patients: Study protocol for a randomized controlled trial

Objectives

Patients with traumatic brain injury (TBI) often suffer memory and cognitive impairments, and oxiracetam-like drugs are considered to have a positive impact on these symptoms potentially. However, the efficacy and safety of l-oxiracetam and oxiracetam in TBI patients have not been sufficiently investigated.

Methods

The study adopts a multicenter, randomized, double-blind, parallel-group, phase 3 clinical trial design in 74 centers across 51 hospitals in China. A total of 590 TBI patients meeting criteria will be randomly allocated into three groups in a 2:2:1 ratio: l-oxiracetam group, oxiracetam group, and placebo group. The treatment period is 14 days, with a follow-up period of 90 days. The primary outcome measure is the change in the Loewenstein Occupational Therapy Cognitive Assessment score at 90 days after treatment. Secondary outcomes include changes in other cognitive assessments, neurological function, activities of daily living, and safety assessments.

Discussion

There is no robust evidence to suggest that l-oxiracetam and oxiracetam can enhance memory and cognitive function in patients with mild to moderate TBI. This study has the potential to answer this crucial clinical question.

Trial registration

chinadrugtrials.org.cn, identifier CTR20192539; ClinicalTrials.gov, identifier NCT04205565.

Development of a Multimodal Machine Learning-Based Prognostication Model for Traumatic Brain Injury Using Clinical Data and Computed Tomography Scans: A CENTER-TBI and CINTER-TBI Study

Computed tomography (CT) is an important imaging modality for guiding prognostication in patients with traumatic brain injury (TBI). However, because of the specialized expertise necessary, timely and dependable TBI prognostication based on CT imaging remains challenging. This study aimed to enhance the efficiency and reliability of TBI prognostication by employing machine learning (ML) techniques on CT images. A retrospective analysis was conducted on the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) data set (n = 1016). An ML-driven binary classifier was developed to predict favorable or unfavorable outcomes at 6 months post-injury. The prognostic performance was assessed using the area under the curve (AUC) over fivefold cross-validation and compared with conventional models that depend on clinical variables and CT scoring systems. An external validation was performed using the Comparative Indian Neurotrauma Effectiveness Research in Traumatic Brain Injury (CINTER-TBI) data set (n = 348). The developed model achieved superior performance without the necessity for manual CT assessments (AUC = 0.846 [95% CI: 0.843-0.849]) compared with the model based on the clinical and laboratory variables (AUC = 0.817 [95% CI: 0.814-0.820]) and established CT scoring systems requiring manual interpretations (AUC = 0.829 [95% CI: 0.826-0.832] for Marshall and 0.838 [95% CI: 0.835-0.841] for International Mission for Prognosis and Analysis of Clinical Trials in TBI [IMPACT]). The external validation demonstrated the prognostic capacity of the developed model to be significantly better (AUC = 0.859 [95% CI: 0.857-0.862]) than the model using clinical variables (AUC = 0.809 [95% CI: 0.798-0.820]). This study established an ML-based model that provides efficient and reliable TBI prognosis based on CT scans, with potential implications for earlier intervention and improved patient outcomes.

Implementing Interventions for Women and Youth with Traumatic Brain Injury at Transition from Custodial Settings: A Call to Action

Traumatic brain injury (TBI) is a serious public health concern and overrepresented among justice-involved populations. An emerging area of research focuses on the complex, interrelated and unmet health and social needs of justice-involved women and youth with TBI. Evidence of these needs continues to grow, yet the health and justice systems continue to underperform in supporting the health and social care of justice-involved women and youth. This commentary is a call to action to begin to redress these gaps. We first provide an overview of the needs of women and youth with TBI that affect their transition from custody to community, including those related to victimization, trauma, mental health, substance use, and homelessness. We then highlight the current gaps in knowledge and practice with respect to interventions for women and youth with TBI at transition from custody. The available evidence for the impact of interventions on people with head injury who are justice-involved is sparse, especially studies of interventions focused on women and youth. We conclude with a call for implementation science studies to support translation from research to practice, emphasizing that researchers, practitioners, policy makers, and women and youth at transition should collaborate to develop, implement, and evaluate accommodations and interventions for TBI. To have meaningful, positive impacts on the systems that serve these women and youth, interdisciplinary service delivery approaches should aim to prevent, raise awareness, identify, and provide timely support and services for the varied needs of women and youth with TBI in transition.

Risk factors and predictive model of cerebral edema after road traffic accidents-related traumatic brain injury

PURPOSE

Cerebral edema (CE) is the main secondary injury following traumatic brain injury (TBI) caused by road traffic accidents (RTAs). It is challenging to be predicted timely. In this study, we aimed to develop a prediction model for CE by identifying its risk factors and comparing the timing of edema occurrence in TBI patients with varying levels of injuries.

METHODS

This case-control study included 218 patients with TBI caused by RTAs. The cohort was divided into CE and non-CE groups, according to CT results within 7 days. Demographic data, imaging data, and clinical data were collected and analyzed. Quantitative variables that follow normal distribution were presented as mean ± standard deviation, those that do not follow normal distribution were presented as median (Q1, Q3). Categorical variables were expressed as percentages. The Chi-square test and logistic regression analysis were used to identify risk factors for CE. Logistic curve fitting was performed to predict the time to secondary CE in TBI patients with different levels of injuries. The efficacy of the model was evaluated using the receiver operator characteristic curve.

RESULTS

According to the study, almost half (47.3%) of the patients were found to have CE. The risk factors associated with CE were bilateral frontal lobe contusion, unilateral frontal lobe contusion, cerebral contusion, subarachnoid hemorrhage, and abbreviated injury scale (AIS). The odds ratio values for these factors were 7.27 (95% confidence interval (CI): 2.08 - 25.42, p = 0.002), 2.85 (95% CI: 1.11 - 7.31, p = 0.030), 2.62 (95% CI: 1.12 - 6.13, p = 0.027), 2.44 (95% CI: 1.25 - 4.76, p = 0.009), and 1.5 (95% CI: 1.10 - 2.04, p = 0.009), respectively. We also observed that patients with mild/moderate TBI (AIS ≤ 3) had a 50% probability of developing CE 19.7 h after injury (χ2 = 13.82, adjusted R2 = 0.51), while patients with severe TBI (AIS > 3) developed CE after 12.5 h (χ2 = 18.48, adjusted R2 = 0.54). Finally, we conducted a receiver operator characteristic curve analysis of CE time, which showed an area under the curve of 0.744 and 0.672 for severe and mild/moderate TBI, respectively.

CONCLUSION

Our study found that the onset of CE in individuals with TBI resulting from RTAs was correlated with the severity of the injury. Specifically, those with more severe injuries experienced an earlier onset of CE. These findings suggest that there is a critical time window for clinical intervention in cases of CE secondary to TBI.

Epidemiological Burden of Neurotrauma in Nigeria: A Systematic Review and Pooled Analysis of 45,763 Patients

OBJECTIVE

Neurotrauma is a significant cause of morbidity and mortality in Nigeria. We conducted this systematic review to generate nationally generalizable reference data for the country.

METHODS

Four research databases and gray literature sources were electronically searched. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions and Cochrane's risk of bias tools. Descriptive analysis, narrative synthesis, and statistical analysis (via paired t-tests and χ2 independence tests) were performed on relevant article metrics (α = 0.05).

RESULTS

We identified a cohort of 45,763 patients from 254 articles. The overall risk of bias was moderate to high. Most articles employed retrospective cohort study designs (37.4%) and were published during the last 2 decades (81.89%). The cohort's average age was 32.5 years (standard deviation, 20.2) with a gender split of ∼3 males per female. Almost 90% of subjects were diagnosed with traumatic brain injury, with road traffic accidents (68.6%) being the greatest cause. Altered consciousness (48.4%) was the most commonly reported clinical feature. Computed tomography (53.5%) was the most commonly used imaging modality, with skull (25.7%) and vertebral fracture (14.1%) being the most common radiological findings for traumatic brain injury and traumatic spinal injury, respectively. Two-thirds of patients were treated nonoperatively. Outcomes were favorable in 63.7% of traumatic brain injury patients, but in only 20.9% of traumatic spinal injury patients. Pressure sores, infection, and motor deficits were the most commonly reported complications in the latter.

CONCLUSIONS

This systematic review and pooled analysis demonstrate the significant burden of neurotrauma across Nigeria.

Incidence and associated in-hospital mortality of myocardial injury characterised by elevated cardiac troponin in adult patients with traumatic brain injury: protocol for a systematic review and meta-analysis

INTRODUCTION

Myocardial injury is a relatively common complication of traumatic brain injury (TBI). However, the incidence and clinical impact of myocardial injury characterised by elevated cardiac troponin (cTn) levels after TBI are still poorly known. The objective of our study is to assess the global incidence of myocardial injury characterised by elevated cTn in adult patients with TBI and its association with in-hospital mortality.

METHODS AND ANALYSIS

The protocol of our systematic review and meta-analysis is performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will search the Medline, Embase, Cochrane Library, Scopus and Web of Science databases from inception to 1 January 2024, for observational studies in any language that reported the incidence of elevated cTn and/or in-hospital mortality associated with elevated cTn among adult patients with TBI. Two reviewers will independently assess study eligibility, extract the data and assess the risk of bias. ORs and 95% CIs will be used with a random-effects or fixed-effects model according to the estimated heterogeneity among studies assessed by the I2 index. We will perform a quantitative synthesis for the incidence of elevated cTn and in-hospital mortality data. If sufficient data are available, we will perform subgroup analysis and meta-regression to address the heterogeneity. In addition, we will perform a narrative analysis if quantitative synthesis is not appropriate.

ETHICS AND DISSEMINATION

Ethics approval was not required for this study. We intend to publish our findings in a high-quality, peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023454686.

Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury

BACKGROUND

Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands.

METHODS

This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis.

RESULTS

In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data.

CONCLUSIONS

The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population.

EDITOR’S PERSPECTIVE

Human Adipose Tissue Lysate-Based Hydrogel for Lasting Immunomodulation to Effectively Improve Spinal Cord Injury Repair

The long-term inflammatory microenvironment is one of the main obstacles to inhibit acute spinal cord injury (SCI) repair. The natural adipose tissue-derived extracellular matrix hydrogel shows effective anti-inflammatory regulation because of its unique protein components. However, the rapid degradation rate and removal of functional proteins during the decellularization process impair the lasting anti-inflammation function of the adipose tissue-derived hydrogel. To address this problem, adipose tissue lysate provides an effective way for SCI repair due to its abundance of anti-inflammatory and nerve regeneration-related proteins. Thereby, human adipose tissue lysate-based hydrogel (HATLH) with an appropriate degradation rate is developed, which aims to in situ long-term recruit and induce anti-inflammatory M2 macrophages through sustainedly released proteins. HATLH can recruit and polarize M2 macrophages while inhibiting pro-inflammatory M1 macrophages regardless of human or mouse-originated. The axonal growth of neuronal cells also can be effectively improved by HATLH and HATLH-induced M2 macrophages. In vivo experiments reveal that HATLH promotes endogenous M2 macrophages infiltration in large numbers (3.5 × 105/100 µL hydrogel) and maintains a long duration for over a month. In a mouse SCI model, HATLH significantly inhibits local inflammatory response, improves neuron and oligodendrocyte differentiation, enhances axonal growth and remyelination, as well as accelerates neurological function restoration.