1
|
Dolmans RGF, Barber J, Foreman B, Temkin NR, Okwonko DO, Robertson CS, Manley GT, Rosenthal ES. Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-02054-7. [PMID: 39138718 DOI: 10.1007/s12028-024-02054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/21/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies. METHODS Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day. RESULTS A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation. CONCLUSIONS Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.
Collapse
Affiliation(s)
- Rianne G F Dolmans
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati and, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - David O Okwonko
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| |
Collapse
|
2
|
Guglielmi A, Graziano F, Bogossian EG, Turgeon AF, Taccone FS, Citerio G. Haemoglobin values, transfusion practices, and long-term outcomes in critically ill patients with traumatic brain injury: a secondary analysis of CENTER-TBI. Crit Care 2024; 28:199. [PMID: 38877571 PMCID: PMC11177426 DOI: 10.1186/s13054-024-04980-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024] Open
Abstract
Haemoglobin (Hb) thresholds and red blood cells (RBC) transfusion strategies in traumatic brain injury (TBI) are controversial. Our objective was to assess the association of Hb values with long-term outcomes in critically ill TBI patients. We conducted a secondary analysis of CENTER-TBI, a large multicentre, prospective, observational study of European TBI patients. All patients admitted to the Intensive Care Unit (ICU) with available haemoglobin data on admission and during the first week were included. During the first seven days, daily lowest haemoglobin values were considered either a continous variable or categorised as < 7.5 g/dL, between 7.5-9.5 and > 9.5 g/dL. Anaemia was defined as haemoglobin value < 9.5 g/dL. Transfusion practices were described as "restrictive" or "liberal" based on haemoglobin values before transfusion (e.g. < 7.5 g/dL or 7.5-9.5 g/dL). Our primary outcome was the Glasgow outcome scale extended (GOSE) at six months, defined as being unfavourable when < 5. Of 1590 included, 1231 had haemoglobin values available on admission. A mean Injury Severity Score (ISS) of 33 (SD 16), isolated TBI in 502 (40.7%) and a mean Hb value at ICU admission of 12.6 (SD 2.2) g/dL was observed. 121 (9.8%) patients had Hb < 9.5 g/dL, of whom 15 (1.2%) had Hb < 7.5 g/dL. 292 (18.4%) received at least one RBC transfusion with a median haemoglobin value before transfusion of 8.4 (IQR 7.7-8.5) g/dL. Considerable heterogeneity regarding threshold transfusion was observed among centres. In the multivariable logistic regression analysis, the increase of haemoglobin value was independently associated with the decrease in the occurrence of unfavourable neurological outcomes (OR 0.78; 95% CI 0.70-0.87). Congruous results were observed in patients with the lowest haemoglobin values within the first 7 days < 7.5 g/dL (OR 2.09; 95% CI 1.15-3.81) and those between 7.5 and 9.5 g/dL (OR 1.61; 95% CI 1.07-2.42) compared to haemoglobin values > 9.5 g/dL. Results were consistent when considering mortality at 6 months as an outcome. The increase of hemoglobin value was associated with the decrease of mortality (OR 0.88; 95% CI 0.76-1.00); haemoglobin values less than 7.5 g/dL was associated with an increase of mortality (OR 3.21; 95% CI 1.59-6.49). Anaemia was independently associated with long-term unfavourable neurological outcomes and mortality in critically ill TBI patients.Trial registration: CENTER-TBI is registered at ClinicalTrials.gov, NCT02210221, last update 2022-11-07.
Collapse
Affiliation(s)
- Angelo Guglielmi
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
- University of Pavia, PhD in Experimental Medicine, Pavia, Italy
- Intensive Care Department 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Graziano
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Québec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.
- Neurological Intensive Care Unit, Department Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| |
Collapse
|
3
|
Gakuba C, Le Barbey C, Sar A, Bonnet G, Cerasuolo D, Giabicani M, Moyer JD. Evaluation of ChatGPT in Predicting 6-Month Outcomes After Traumatic Brain Injury. Crit Care Med 2024; 52:942-950. [PMID: 38445975 DOI: 10.1097/ccm.0000000000006236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
OBJECTIVES To evaluate the capacity of ChatGPT, a widely accessible and uniquely popular artificial intelligence-based chatbot, in predicting the 6-month outcome following moderate-to-severe traumatic brain injury (TBI). DESIGN Single-center observational retrospective study. SETTING Data are from a neuro-ICU from a level 1 trauma center. PATIENTS All TBI patients admitted to ICU between September 2021 and October 2022 were included in a prospective database. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Based on anonymized clinical, imaging, and biological information available at the patients' hospital admission and extracted from the database, clinical vignettes were retrospectively submitted to ChatGPT for prediction of patients' outcomes. The predictions of two intensivists (one neurointensivist and one non-neurointensivist) both from another level 1 trauma center (Beaujon Hospital), were also collected as was the International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) scoring. Each intensivist, as well as ChatGPT, made their prognostic evaluations independently, without knowledge of the others' predictions and of the patients' actual management and outcome. Both the intensivists and ChatGPT were given access to the exact same set of information. The main outcome was a 6-month-functional status dichotomized into favorable (Glasgow Outcome Scale Extended [GOSE] ≥ 5) versus poor (GOSE < 5). Prediction of intracranial hypertension management, pulmonary infectious risk, and removal of life-sustaining therapies was also investigated as secondary outcomes. Eighty consecutive moderate-to-severe TBI patients were included. For the 6-month outcome prognosis, area under the receiver operating characteristic curve (AUC-ROC) for ChatGPT, the neurointensivist, the non-neurointensivist, and IMPACT were, respectively, 0.62 (0.50-0.74), 0.70 (0.59-0.82), 0.71 (0.59-0.82), and 0.81 (0.72-0.91). ChatGPT had the highest sensitivity (100%), but the lowest specificity (26%). For secondary outcomes, ChatGPT's prognoses were generally less accurate than clinicians' prognoses, with lower AUC values for most outcomes. CONCLUSIONS This study does not support the use of ChatGPT for prediction of outcomes after TBI.
Collapse
Affiliation(s)
- Clement Gakuba
- CHU de Caen Normandie, Department of Anesthesiology and Critical Care Medicine, Caen, France
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
| | - Charlene Le Barbey
- CHU de Caen Normandie, Department of Anesthesiology and Critical Care Medicine, Caen, France
| | - Alexandre Sar
- CHU de Caen Normandie, Department of Anesthesiology and Critical Care Medicine, Caen, France
| | - Gregory Bonnet
- Normandie Univ, UNICAEN, ENSICAEN, CNRS, Department of Groupe de Recherche en Informatique, Image, et Instrumentation de Caen (GREYC), Caen, France
| | - Damiano Cerasuolo
- CHU de Caen Normandie, Department of Public Health, Caen, France
- Normandie Univ, UNICAEN, INSERM U1086, ANTICIPE, Caen, France
| | - Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Jean-Denis Moyer
- CHU de Caen Normandie, Department of Anesthesiology and Critical Care Medicine, Caen, France
| |
Collapse
|
4
|
Bhattacharyay S, Beqiri E, Zuercher P, Wilson L, Steyerberg EW, Nelson DW, Maas AIR, Menon DK, Ercole A. Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units. J Neurotrauma 2024; 41:887-909. [PMID: 37795563 PMCID: PMC11005383 DOI: 10.1089/neu.2023.0377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.
Collapse
Affiliation(s)
- Shubhayu Bhattacharyay
- Division of Anaesthesia, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - David W. Nelson
- Department of Physiology and Pharmacology, Section for Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - David K. Menon
- Division of Anaesthesia, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Cambridge Center for Artificial Intelligence in Medicine, Cambridge, United Kingdom
| |
Collapse
|
5
|
Robba C, Graziano F, Picetti E, Åkerlund C, Addis A, Pastore G, Sivero M, Rebora P, Galimberti S, Stocchetti N, Maas A, Menon DK, Citerio G. Early systemic insults following traumatic brain injury: association with biomarker profiles, therapy for intracranial hypertension, and neurological outcomes-an analysis of CENTER-TBI data. Intensive Care Med 2024; 50:371-384. [PMID: 38376517 PMCID: PMC10955000 DOI: 10.1007/s00134-024-07324-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/13/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE We analysed the impact of early systemic insults (hypoxemia and hypotension, SIs) on brain injury biomarker profiles, acute care requirements during intensive care unit (ICU) stay, and 6-month outcomes in patients with traumatic brain injury (TBI). METHODS From patients recruited to the Collaborative European neurotrauma effectiveness research in TBI (CENTER-TBI) study, we documented the prevalence and risk factors for SIs and analysed their effect on the levels of brain injury biomarkers [S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neurofilament light (NfL), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and protein Tau], critical care needs, and 6-month outcomes [Glasgow Outcome Scale Extended (GOSE)]. RESULTS Among 1695 TBI patients, 24.5% had SIs: 16.1% had hypoxemia, 15.2% had hypotension, and 6.8% had both. Biomarkers differed by SI category, with higher S100B, Tau, UCH-L1, NSE and NfL values in patients with hypotension or both SIs. The ratio of neural to glial injury (quantified as UCH-L1/GFAP and Tau/GFAP ratios) was higher in patients with hypotension than in those with no SIs or hypoxia alone. At 6 months, 380 patients died (22%), and 759 (45%) had GOSE ≤ 4. Patients who experienced at least one SI had higher mortality than those who did not (31.8% vs. 19%, p < 0.001). CONCLUSION Though less frequent than previously described, SIs in TBI patients are associated with higher release of neuronal than glial injury biomarkers and with increased requirements for ICU therapies aimed at reducing intracranial hypertension. Hypotension or combined SIs are significantly associated with adverse 6-month outcomes. Current criteria for hypotension may lead to higher biomarker levels and more negative outcomes than those for hypoxemia suggesting a need to revisit pressure targets in the prehospital settings.
Collapse
Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Francesca Graziano
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Cecilia Åkerlund
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Alberto Addis
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giuseppe Pastore
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Mattia Sivero
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paola Rebora
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stefania Galimberti
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Nino Stocchetti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplant, Milan University, Milan, Italy
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
| | - David K Menon
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
| |
Collapse
|
6
|
Banco P, Taccone FS, Sourd D, Privitera C, Bosson JL, Teixeira TL, Adolle A, Payen JF, Bouzat P, Gauss T. Prediction of neurocritical care intensity through automated infrared pupillometry and transcranial doppler in blunt traumatic brain injury: the NOPE study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02435-1. [PMID: 38226989 DOI: 10.1007/s00068-023-02435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/28/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE This pilot study aimed to determine the capacity of automated infrared pupillometry (AIP) alone and in combination with transcranial doppler (TCD) on admission to rule out need for intense neuroAQ2 critical care (INCC) in severe traumatic brain injury (TBI). METHODS In this observational pilot study clinicians performed AIP and TCD measurements on admission in blunt TBI patients with a Glasgow Coma Score (GCS) < 9 and/or motor score < 6. A Neurological Pupil index (NPi) < 3, Pulsatility Index (PI) > 1,4 or diastolic blood flow velocity (dV) of < 20 cm/s were used to rule out the need for INCC (exceeding the tier 0 Seattle Consensus Conference). The primary outcome was the negative likelihood ratio (nLR) of NPi < 3 alone or in combination with TCD to detect need for INCC. RESULTS A total of 69 TBI patients were included from May 2019 to September 2020. Of those, 52/69 (75%) median age was 45 [28-67], median prehospital GCS of 7 [5-8], median Injury Severity Scale of 13.0 [6.5-25.5], median Marshall Score of 4 [3-5], the median Glasgow Outcome Scale at discharge was 3 [1-5]. NPi < 3 was an independent predictor of INCC. NPi demonstrated a nLR of 0,6 (95%CI 0.4-0.9; AUROC, 0.65, 95% CI 0.51-0.79), a combination of NPi and TCD showed a nLR of 0.6 (95% CI 0.4-1.0; AUROC 0.67 95% CI 0.52-0.83) to predict INCC. CONCLUSION This pilot study suggests a possible useful contribution of NPi to determine the need for INCC in severe blunt TBI patients on admission.
Collapse
Affiliation(s)
- Pierluigi Banco
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Dimitri Sourd
- Department of Public Health, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Claudio Privitera
- School of Optometry and Vision Science, University of California, Berkeley, Berkeley, CA, USA
| | - Jean-Luc Bosson
- Department of Public Health, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Thomas Luz Teixeira
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anais Adolle
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Jean-François Payen
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Pierre Bouzat
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France.
| |
Collapse
|
7
|
Åkerlund CAI, Holst A, Bhattacharyay S, Stocchetti N, Steyerberg E, Smielewski P, Menon DK, Ercole A, Nelson DW. Clinical descriptors of disease trajectories in patients with traumatic brain injury in the intensive care unit (CENTER-TBI): a multicentre observational cohort study. Lancet Neurol 2024; 23:71-80. [PMID: 37977157 DOI: 10.1016/s1474-4422(23)00358-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Patients with traumatic brain injury are a heterogeneous population, and the most severely injured individuals are often treated in an intensive care unit (ICU). The primary injury at impact, and the harmful secondary events that can occur during the first week of the ICU stay, will affect outcome in this vulnerable group of patients. We aimed to identify clinical variables that might distinguish disease trajectories among patients with traumatic brain injury admitted to the ICU. METHODS We used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study. We included patients aged 18 years or older with traumatic brain injury who were admitted to the ICU at one of the 65 CENTER-TBI participating centres, which range from large academic hospitals to small rural hospitals. For every patient, we obtained pre-injury data and injury features, clinical characteristics on admission, demographics, physiological parameters, laboratory features, brain biomarkers (ubiquitin carboxy-terminal hydrolase L1 [UCH-L1], S100 calcium-binding protein B [S100B], tau, neurofilament light [NFL], glial fibrillary acidic protein [GFAP], and neuron-specific enolase [NSE]), and information about intracranial pressure lowering treatments during the first 7 days of ICU stay. To identify clinical variables that might distinguish disease trajectories, we applied a novel clustering method to these data, which was based on a mixture of probabilistic graph models with a Markov chain extension. The relation of clusters to the extended Glasgow Outcome Scale (GOS-E) was investigated. FINDINGS Between Dec 19, 2014, and Dec 17, 2017, 4509 patients with traumatic brain injury were recruited into the CENTER-TBI core dataset, of whom 1728 were eligible for this analysis. Glucose variation (defined as the difference between daily maximum and minimum glucose concentrations) and brain biomarkers (S100B, NSE, NFL, tau, UCH-L1, and GFAP) were consistently found to be the main clinical descriptors of disease trajectories (ie, the leading variables contributing to the distinguishing clusters) in patients with traumatic brain injury in the ICU. The disease trajectory cluster to which a patient was assigned in a model was analysed as a predictor together with variables from the IMPACT model, and prediction of both mortality and unfavourable outcome (dichotomised GOS-E ≤4) was improved. INTERPRETATION First-day ICU admission data are not the only clinical descriptors of disease trajectories in patients with traumatic brain injury. By analysing temporal variables in our study, variation of glucose was identified as the most important clinical descriptor that might distinguish disease trajectories in the ICU, which should direct further research. Biomarkers of brain injury (S100B, NSE, NFL, tau, UCH-L1, and GFAP) were also top clinical descriptors over time, suggesting they might be important in future clinical practice. FUNDING European Union 7th Framework program, Hannelore Kohl Stiftung, OneMind, Integra LifeSciences Corporation, and NeuroTrauma Sciences.
Collapse
Affiliation(s)
- Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Anders Holst
- School of Electrical Engineering and Computer Science, KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Nino Stocchetti
- Department of Physiopathology and Transplant, Milan University, Milan, Italy; Fondazione IRCCS, Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | | | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden.
| |
Collapse
|
8
|
Barra ME, Zink EK, Bleck TP, Cáceres E, Farrokh S, Foreman B, Cediel EG, Hemphill JC, Nagayama M, Olson DM, Suarez JI. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Hospital Course, Confounders, and Medications. Neurocrit Care 2023; 39:586-592. [PMID: 37610641 DOI: 10.1007/s12028-023-01803-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
The convergence of an interdisciplinary team of neurocritical care specialists to organize the Curing Coma Campaign is the first effort of its kind to coordinate national and international research efforts aimed at a deeper understanding of disorders of consciousness (DoC). This process of understanding includes translational research from bench to bedside, descriptions of systems of care delivery, diagnosis, treatment, rehabilitation, and ethical frameworks. The description and measurement of varying confounding factors related to hospital care was thought to be critical in furthering meaningful research in patients with DoC. Interdisciplinary hospital care is inherently varied across geographical areas as well as community and academic medical centers. Access to monitoring technologies, specialist consultation (medical, nursing, pharmacy, respiratory, and rehabilitation), staffing resources, specialty intensive and acute care units, specialty medications and specific surgical, diagnostic and interventional procedures, and imaging is variable, and the impact on patient outcome in terms of DoC is largely unknown. The heterogeneity of causes in DoC is the source of some expected variability in care and treatment of patients, which necessitated the development of a common nomenclature and set of data elements for meaningful measurement across studies. Guideline adherence in hemorrhagic stroke and severe traumatic brain injury may also be variable due to moderate or low levels of evidence for many recommendations. This article outlines the process of the development of common data elements for hospital course, confounders, and medications to streamline definitions and variables to collect for clinical studies of DoC.
Collapse
Affiliation(s)
| | - Elizabeth K Zink
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Salia Farrokh
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Emilio Garzón Cediel
- Division of Neurosurgery, Clínica de Marly Jorge Cavelier Gaviria, Chía, Colombia
| | - J Claude Hemphill
- Department of Neurology, UCSF Weill Institute for Neurosciences, San Francisco, CA, USA
| | - Masao Nagayama
- Department of Neurology, International University of Health and Welfare Graduate School of Medicine, Narita, Japan
| | - DaiWai M Olson
- Department of Neurology and Neurosurgery, UT Southwestern, Dallas, TX, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA.
| |
Collapse
|
9
|
Brossard C, Grèze J, de Busschère JA, Attyé A, Richard M, Tornior FD, Acquitter C, Payen JF, Barbier EL, Bouzat P, Lemasson B. Prediction of therapeutic intensity level from automatic multiclass segmentation of traumatic brain injury lesions on CT-scans. Sci Rep 2023; 13:20155. [PMID: 37978266 PMCID: PMC10656472 DOI: 10.1038/s41598-023-46945-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023] Open
Abstract
The prediction of the therapeutic intensity level (TIL) for severe traumatic brain injury (TBI) patients at the early phase of intensive care unit (ICU) remains challenging. Computed tomography images are still manually quantified and then underexploited. In this study, we develop an artificial intelligence-based tool to segment brain lesions on admission CT-scan and predict TIL within the first week in the ICU. A cohort of 29 head injured patients (87 CT-scans; Dataset1) was used to localize (using a structural atlas), segment (manually or automatically with or without transfer learning) 4 or 7 types of lesions and use these metrics to train classifiers, evaluated with AUC on a nested cross-validation, to predict requirements for TIL sum of 11 points or more during the 8 first days in ICU. The validation of the performances of both segmentation and classification tasks was done with Dice and accuracy scores on a sub-dataset of Dataset1 (internal validation) and an external dataset of 12 TBI patients (12 CT-scans; Dataset2). Automatic 4-class segmentation (without transfer learning) was not able to correctly predict the apparition of a day of extreme TIL (AUC = 60 ± 23%). In contrast, manual quantification of volumes of 7 lesions and their spatial location provided a significantly better prediction power (AUC = 89 ± 17%). Transfer learning significantly improved the automatic 4-class segmentation (DICE scores 0.63 vs 0.34) and trained more efficiently a 7-class convolutional neural network (DICE = 0.64). Both validations showed that segmentations based on transfer learning were able to predict extreme TIL with better or equivalent accuracy (83%) as those made with manual segmentations. Our automatic characterization (volume, type and spatial location) of initial brain lesions observed on CT-scan, publicly available on a dedicated computing platform, could predict requirements for high TIL during the first 8 days after severe TBI. Transfer learning strategies may improve the accuracy of CNN-based segmentation models.Trial registrations Radiomic-TBI cohort; NCT04058379, first posted: 15 august 2019; Radioxy-TC cohort; Health Data Hub index F20220207212747, first posted: 7 February 2022.
Collapse
Affiliation(s)
- Clément Brossard
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Jules Grèze
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Jules-Arnaud de Busschère
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Arnaud Attyé
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Marion Richard
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Florian Dhaussy Tornior
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Clément Acquitter
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Jean-François Payen
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Emmanuel L Barbier
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Pierre Bouzat
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France
| | - Benjamin Lemasson
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), U1216, Eq. "Neuroimagerie Fonctionnelle et Perfusion Cérébrale", 38700, Grenoble, France.
| |
Collapse
|
10
|
Payen JF, Launey Y, Chabanne R, Gay S, Francony G, Gergele L, Vega E, Montcriol A, Couret D, Cottenceau V, Pili-Floury S, Gakuba C, Hammad E, Audibert G, Pottecher J, Dahyot-Fizelier C, Abdennour L, Gauss T, Richard M, Vilotitch A, Bosson JL, Bouzat P. Intracranial pressure monitoring with and without brain tissue oxygen pressure monitoring for severe traumatic brain injury in France (OXY-TC): an open-label, randomised controlled superiority trial. Lancet Neurol 2023; 22:1005-1014. [PMID: 37863590 DOI: 10.1016/s1474-4422(23)00290-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Optimisation of brain oxygenation might improve neurological outcome after traumatic brain injury. The OXY-TC trial explored the superiority of a strategy combining intracranial pressure and brain tissue oxygen pressure (PbtO2) monitoring over a strategy of intracranial pressure monitoring only to reduce the proportion of patients with poor neurological outcome at 6 months. METHODS We did an open-label, randomised controlled superiority trial at 25 French tertiary referral centres. Within 16 h of brain injury, patients with severe traumatic brain injury (aged 18-75 years) were randomly assigned via a website to be managed during the first 5 days of admission to the intensive care unit either by intracranial pressure monitoring only or by both intracranial pressure and PbtO2 monitoring. Randomisation was stratified by age and centre. The study was open label due to the visibility of the intervention, but the statisticians and outcome assessors were masked to group allocation. The therapeutic objectives were to maintain intracranial pressure of 20 mm Hg or lower, and to keep PbtO2 (for those in the dual-monitoring group) above 20 mm Hg, at all times. The primary outcome was the proportion of patients with an extended Glasgow Outcome Scale (GOSE) score of 1-4 (death to upper severe disability) at 6 months after injury. The primary analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew consent or had protocol violations. This trial is registered with ClinicalTrials.gov, NCT02754063, and is completed. FINDINGS Between June 15, 2016, and April 17, 2021, 318 patients were randomly assigned to receive either intracranial pressure monitoring only (n=160) or both intracranial pressure and PbtO2 monitoring (n=158). 27 individuals with protocol violations were not included in the modified intention-to-treat analysis. Thus, the primary outcome was analysed for 144 patients in the intracranial pressure only group and 147 patients in the intracranial pressure and PbtO2 group. Compared with intracranial pressure monitoring only, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with GOSE score 1-4 (51% [95% CI 43-60] in the intracranial pressure monitoring only group vs 52% [43-60] in the intracranial pressure and PbtO2 monitoring group; odds ratio 1·0 [95% CI 0·6-1·7]; p=0·95). Two (1%) of 144 participants in the intracranial pressure only group and 12 (8%) of 147 participants in the intracranial pressure and PbtO2 group had catheter dysfunction (p=0.011). Six patients (4%) in the intracranial pressure and PbtO2 group had an intracrebral haematoma related to the catheter, compared with none in the intracranial pressure only group (p=0.030). No significant difference in deaths was found between the two groups at 12 months after injury. At 12 months, 33 deaths had occurred in the intracranial pressure group: 25 (76%) were attributable to the brain trauma, six (18%) were end-of-life decisions, and two (6%) due to sepsis. 34 deaths had occured in the intracranial pressure and PbtO2 group at 12 months: 25 (74%) were attributable to the brain trauma, six (18%) were end-of-life decisions, one (3%) due to pulmonary embolism, one (3%) due to haemorrhagic shock, and one (3%) due to cardiac arrest. INTERPRETATION After severe non-penetrating traumatic brain injury, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with poor neurological outcome at 6 months. Technical failures related to intracerebral catheter and intracerebral haematoma were more frequent in the intracranial pressure and PbtO2 group. Further research is needed to assess whether a targeted approach to multimodal brain monitoring could be useful in subgroups of patients with severe traumatic brain injury-eg, those with high intracranial pressure on admission. FUNDING The French National Program for Clinical Research, La Fondation des Gueules Cassées, and Integra Lifesciences.
Collapse
Affiliation(s)
- Jean-François Payen
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France.
| | - Yoann Launey
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Russell Chabanne
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Samuel Gay
- Department of Intensive Care, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Gilles Francony
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Laurent Gergele
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Saint-Etienne, Saint-Etienne, France
| | - Emmanuel Vega
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Lille, Lille, France
| | - Ambroise Montcriol
- Department of Intensive Care, Hopital Instruction des Armées Saint-Anne, Toulon, France
| | - David Couret
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Sud, Reunion, France
| | - Vincent Cottenceau
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Sebastien Pili-Floury
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Clement Gakuba
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Caen Normandie, Caen, France
| | - Emmanuelle Hammad
- Department of Anaesthesia and Intensive Care, Hôpital Nord, Assistance Publique des Hopitaux de Marseille, Marseille, France
| | - Gerard Audibert
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Nancy, Nancy, France
| | - Julien Pottecher
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Strasbourg, Strasbourg, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Poitiers, Poitiers, France
| | - Lamine Abdennour
- Department of Anaesthesia and Intensive Care, Hôpital Pitie-Salpetriere, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Marion Richard
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Antoine Vilotitch
- Department of Public Health, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
| | - Jean-Luc Bosson
- Department of Public Health, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
| | - Pierre Bouzat
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| |
Collapse
|
11
|
Oddo M, Taccone FS, Petrosino M, Badenes R, Blandino-Ortiz A, Bouzat P, Caricato A, Chesnut RM, Feyling AC, Ben-Hamouda N, Hemphill JC, Koehn J, Rasulo F, Suarez JI, Elli F, Vargiolu A, Rebora P, Galimberti S, Citerio G. The Neurological Pupil index for outcome prognostication in people with acute brain injury (ORANGE): a prospective, observational, multicentre cohort study. Lancet Neurol 2023; 22:925-933. [PMID: 37652068 DOI: 10.1016/s1474-4422(23)00271-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/17/2023] [Accepted: 07/11/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Improving the prognostication of acute brain injury is a key element of critical care. Standard assessment includes pupillary light reactivity testing with a hand-held light source, but findings are interpreted subjectively; automated pupillometry might be more precise and reproducible. We aimed to assess the association of the Neurological Pupil index (NPi)-a quantitative measure of pupillary reactivity computed by automated pupillometry-with outcomes of patients with severe non-anoxic acute brain injury. METHODS ORANGE is a multicentre, prospective, observational cohort study at 13 hospitals in eight countries in Europe and North America. Patients admitted to the intensive care unit after traumatic brain injury, aneurysmal subarachnoid haemorrhage, or intracerebral haemorrhage were eligible for the study. Patients underwent automated infrared pupillometry assessment every 4 h during the first 7 days after admission to compute NPi, with values ranging from 0 to 5 (with abnormal NPi being <3). The co-primary outcomes of the study were neurological outcome (assessed with the extended Glasgow Outcome Scale [GOSE]) and mortality at 6 months. We used logistic regression to model the association between NPi and poor neurological outcome (GOSE ≤4) at 6 months and Cox regression to model the relation of NPi with 6-month mortality. This study is registered with ClinicalTrials.gov, NCT04490005. FINDINGS Between Nov 1, 2020, and May 3, 2022, 514 patients (224 with traumatic brain injury, 139 with aneurysmal subarachnoid haemorrhage, and 151 with intracerebral haemorrhage) were enrolled. The median age of patients was 61 years (IQR 46-71), and the median Glasgow Coma Scale score on admission was 8 (5-11). 40 071 NPi measurements were taken (median 40 per patient [20-50]). The 6-month outcome was assessed in 497 (97%) patients, of whom 160 (32%) patients died, and 241 (47%) patients had at least one recording of abnormal NPi, which was associated with poor neurological outcome (for each 10% increase in the frequency of abnormal NPi, adjusted odds ratio 1·42 [95% CI 1·27-1·64]; p<0·0001) and in-hospital mortality (adjusted hazard ratio 5·58 [95% CI 3·92-7·95]; p<0·0001). INTERPRETATION NPi has clinically and statistically significant prognostic value for neurological outcome and mortality after acute brain injury. Simple, automatic, repeat automated pupillometry assessment could improve the continuous monitoring of disease progression and the dynamics of outcome prediction at the bedside. FUNDING NeurOptics.
Collapse
Affiliation(s)
- Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital and University of Lusanne, Lausanne, Switzerland; CHUV Directorate for Innovation and Clinical Research, CHUV-Lausanne University Hospital and University of Lusanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Brussels, Belgium
| | - Matteo Petrosino
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Aaron Blandino-Ortiz
- Department of Intensive Care Medicine, Ramón y Cajal University Hospital, Universidad de Alcalá, Madrid, Spain
| | - Pierre Bouzat
- Université Grenoble Alpes, Inserm U1216, Grenoble Institut Neurosciences, Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Grenoble, France
| | - Anselmo Caricato
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Randall M Chesnut
- Department of Neurological Surgery, and Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Anders C Feyling
- Department of Anaesthesia and Intensive Care, Oslo University Hospital Ullevål, Oslo, Norway
| | - Nawfel Ben-Hamouda
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital and University of Lusanne, Lausanne, Switzerland
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Julia Koehn
- Department of Neurology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Frank Rasulo
- Department of Neuroanesthesia and Neurocritical Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Francesca Elli
- Department of Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alessia Vargiolu
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Stefania Galimberti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| |
Collapse
|
12
|
Baggiani M, Graziano F, Rebora P, Robba C, Guglielmi A, Galimberti S, Giussani C, Suarez JI, Helbok R, Citerio G. Intracranial Pressure Monitoring Practice, Treatment, and Effect on Outcome in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 38:741-751. [PMID: 36471182 DOI: 10.1007/s12028-022-01651-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring and its management in aneurysmal subarachnoid hemorrhage (aSAH) is variable worldwide. The present study aimed to explore the practice of ICP monitoring, its variability across countries, and the association with 6-month outcomes in aSAH. METHODS This was a preplanned subanalysis of SYNAPSE-ICU, a multicenter, international, prospective, observational cohort study focused on patients diagnosed with aSAH. We evaluated the variability in ICP monitoring across countries through a logistic regression model adjusted for case-mix and considered countries as a random effect. The association between ICP probe insertion and 6-month mortality and a poor neurological outcome, defined as an Glasgow Outcome Score Extended ≤ 4, was assessed by using a propensity score approach. RESULTS A total of 423 patients with aSAH from 92 centers across 32 countries were included in this analysis. ICP monitoring was used in 295 (69.7%) patients. Significant between-country variability in ICP insertion was observed, with an incidence ranging between 4.7% and 79.9% (median odd ratio 3.04). The median duration of ICP monitoring was 12 days (first quartile [Q1] through third quartile [Q3] range 8-18), with an overall daily median ICP value of 14 mm Hg (Q1-Q3 10-19) and a median maximum value of 21 mm Hg (Q1-Q3 16-30). Patients monitored with ICP received more aggressive therapy treatments compared with non-monitored patients (therapy intensity level, TIL, score 10.33 [standard deviation 3.61] vs. 6.3 [standard deviation 4.19], p < 0.001). In more severe patients, ICP monitoring was significantly associated with better 6-month outcome (poor neurological outcome: odds ratio 0.14, 95% confidence interval 0.02-0.53, p = 0.0113; mortality: hazard ratio 0.25, 95% confidence interval 0.13-0.49, p < 0.0001). However, no significant effect was observed in patients with both reactive pupils. CONCLUSIONS Our cohort demonstrated high variability in ICP insertion practice among countries. A more aggressive treatment approach was applied in ICP-monitored patients. In patients with severe aSAH, ICP monitoring might reduce unfavorable outcomes and mortality at 6 months.
Collapse
Affiliation(s)
- Marta Baggiani
- Ospedale Maggiore della Carità di Novara, Università del Piemonte Orientale, Novara, Italy
| | - Francesca Graziano
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Paola Rebora
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Chiara Robba
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, Istituto Di Ricovero E Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Angelo Guglielmi
- Anaesthesia and Intensive Care Unit , Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Stefania Galimberti
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Carlo Giussani
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900, Monza, Italy
- Neurosurgery Unit, Neuroscience Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Giuseppe Citerio
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900, Monza, Italy.
- Neurointensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| |
Collapse
|
13
|
Menat S, Jacquens A, Mathon B, Bonnet B, Schotar E, Boch AL, Carpentier A, Puybasset L, Abdennour L, Degos V. Corticosteroid treatment for refractory intracranial hypertension: a rescue therapy in patients with severe traumatic brain injury with contusional lesions-a feedback. Acta Neurochir (Wien) 2023; 165:717-725. [PMID: 36808006 DOI: 10.1007/s00701-023-05507-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/21/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Refractory intracranial hypertension (rICH) is a severe complication among patients with severe traumatic brain injury (sTBI). Medical treatment may be insufficient, and in some cases, the only viable treatment option is decompressive hemicraniectomy. The assessment of a corticosteroid therapy against vasogenic edema secondary to severe brain injuries seems interesting to prevent this surgery in sTBI patients with rICH caused by contusional areas. METHODS This is a monocentric retrospective observational study including all consecutive sTBI patients with contusion injuries and a rICH requiring cerebrospinal fluid drainage with external ventricular drainage between November 2013 and January 2018. Patient inclusion criterium was a therapeutic index load (TIL; an indirect measure of TBI severity) > 7. Intracranial pressure (ICP) and TIL were assessed before and 48 h after corticosteroid therapy (CTC). Then, we divided the population into two groups according to the evolution of the TIL: responders and non-responders to corticosteroid therapy. RESULTS During the study period, 512 patients were hospitalized for sTBI, and among them, 44 (8.6%) with rICH were included. They received 240 mg per day [120 mg, 240 mg] of Solu-Medrol for 2 days [1; 3], 3 days after the sTBI. The average ICP in patients with rICH before the CTC bolus was 21 mmHg [19; 23]. After the CTC bolus, the ICP fell significantly to less than 15 mmHg (p < 0.0001) for at least 7 days. The TIL decreased significantly the day after the CTC bolus and until day 2. Among these 44 patients, 68% were included in the responder group (n = 30). DISCUSSION Short and systemic corticosteroid therapy in patients with refractory intracranial hypertension secondary to severe traumatic brain injury seems to be a potentially useful and efficient treatment for lowering intracranial pressure and decreasing the need for more invasive surgeries.
Collapse
Affiliation(s)
- Sophie Menat
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| | - Alice Jacquens
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France.
| | - Bertrand Mathon
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Baptiste Bonnet
- Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Eimad Schotar
- Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France.,Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Carpentier
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Louis Puybasset
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France.,Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Lamine Abdennour
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| |
Collapse
|
14
|
Robba C, Graziano F, Guglielmi A, Rebora P, Galimberti S, Taccone FS, Citerio G. Treatments for intracranial hypertension in acute brain-injured patients: grading, timing, and association with outcome. Data from the SYNAPSE-ICU study. Intensive Care Med 2023; 49:50-61. [PMID: 36622462 PMCID: PMC9852114 DOI: 10.1007/s00134-022-06937-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/08/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six months mortality and neurological outcome. METHODS A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. RESULTS 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p < 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p < 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p < 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p < 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p < 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. CONCLUSIONS During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six months mortality but not on neurological outcome.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Francesca Graziano
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Angelo Guglielmi
- Department of Clinical-Surgical Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Stefania Galimberti
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy. .,Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | | |
Collapse
|
15
|
Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Marquez I, Amenta F, Park K, Stein KY, Thelin EP, Zeiler FA. Cerebrovascular Reactivity Is Not Associated With Therapeutic Intensity in Adult Traumatic Brain Injury: A Validation Study. Neurotrauma Rep 2023; 4:307-317. [PMID: 37187506 PMCID: PMC10181802 DOI: 10.1089/neur.2023.0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Within traumatic brain injury (TBI) care, there is growing interest in pathophysiological markers as surrogates of disease severity, which may be used to improve and individualize care. Of these, assessment of cerebrovascular reactivity (CVR) has been extensively studied given that it is a consistent, independent factor associated with mortality and functional outcome. However, to date, the literature supports little-to-no impact of current guideline-supported therapeutic interventions on continuously measured CVR. Previous work in this area has suffered from a lack of validation studies, given the rarity of time-matched high-frequency cerebral physiology with serially recorded therapeutic interventions; thus, we undertook a validation study. Utilizing the Winnipeg Acute TBI database, we evaluated the association between daily treatment intensity levels, as measured through the therapeutic intensity level (TIL) scoring system, and continuous multi-modal-derived CVR measures. CVR measures included the intracranial pressure (ICP)-derived pressure reactivity index, pulse amplitude index, and RAC index (a correlation between the pulse amplitude of ICP and cerebral perfusion pressure), as well as the cerebral autoregulation measure of near-infrared spectroscopy-based cerebral oximetry index. These measures were also derived over a key threshold for each day and were compared to the daily total TIL measure. In summary, we could not observe any overall relationship between TIL and these CVR measures. This validates previous findings and represents only the second such analysis to date. This helps to confirm that CVR appears to remain independent of current therapeutic interventions and is a potential unique physiological target for critical care. Further work into the high-frequency relationship between critical care and CVR is required.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Address correspondence to: Logan Froese, BSc (Eng), Biomedical Engineering, Faculty of Engineering, University of Manitoba, 75 Chancellor's Circle, Winnipeg, Manitoba R3T 5V6, Canada;
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Izzy Marquez
- Undergraduate Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kangyun Park
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric P. Thelin
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Frederick A. Zeiler
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
16
|
Chen M, Wu H, Li Z, Ge S, Zhao L, Zhang X, Qu Y. Intracranial-Pressure-Monitoring-Assisted Management Associated with Favorable Outcomes in Moderate Traumatic Brain Injury Patients with a GCS of 9-11. J Clin Med 2022; 11:6661. [PMID: 36431137 PMCID: PMC9694446 DOI: 10.3390/jcm11226661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: With a mortality rate of 10−30%, a moderate traumatic brain injury (mTBI) is one of the most variable traumas. The indications for intracranial pressure (ICP) monitoring in patients with mTBI and the effects of ICP on patients’ outcomes are uncertain. The purpose of this study was to examine the indications of ICP monitoring (ICPm) and its effects on the long-term functional outcomes of mTBI patients. Methods: Patients with Glasgow Coma Scale (GCS) scores of 9−11 at Tangdu hospital, between January 2015 and December 2021, were enrolled and treated in this retrospective cohort study. We assessed practice variations in ICP interventions using the therapy intensity level (TIL). Six-month mortality and a Glasgow Outcome Scale Extended (GOS-E) score were the main outcomes. The secondary outcome was neurological deterioration (ND) events. The indication and the estimated impact of ICPm on the functional outcome were investigated by using binary regression analyses. Results: Of the 350 patients, 145 underwent ICP monitoring-assisted management, and the other 205 patients received a standard control based on imaging or clinical examinations. A GCS ≤ 10 (OR 1.751 (95% CI 1.216−3.023), p = 0.003), midline shift (mm) ≥ 2.5 (OR 3.916 (95% CI 2.076−7.386) p < 0.001), and SDH (OR 1.772 (95% CI 1.065−2.949) p = 0.028) were predictors of ICP. Patients who had ICPm (14/145 (9.7%)) had a decreased 6-month mortality rate compared to those who were not monitored (40/205 (19.5%), p = 0.011). ICPm was linked to both improved neurological outcomes at 6 months (OR 0.815 (95% CI 0.712−0.933), p = 0.003) and a lower ND rate (2 = 11.375, p = 0.010). A higher mean ICP (17.32 ± 3.52, t = −6.047, p < 0.001) and a more significant number of ICP > 15 mmHg (27 (9−45.5), Z = −5.406, p < 0.001) or ICP > 20 mmHg (5 (0−23), Z = −4.635, p < 0.001) 72 h after injury were associated with unfavorable outcomes. The best unfavorable GOS-E cutoff value of different ICP characteristics showed that the mean ICP was >15.8 mmHg (AUC 0.698; 95% CI, 0.606−0.789, p < 0.001), the number of ICP > 15 mmHg was >25.5 (AUC 0.681; 95% CI, 0.587−0.774, p < 0.001), and the number of ICP > 20 mmHg was >6 (AUC 0.660; 95% CI, 0.561−0.759, p < 0.001). The total TIL score during the first 72 h post-injury in the non-ICP group (9 (8, 11)) was lower than that of the ICP group (13 (9, 17), Z = −8.388, p < 0.001), and was associated with unfavorable outcomes. Conclusion: ICPm-assisted management was associated with better clinical outcomes six months after discharge and lower incidences of ND for seven days post-injury. A mean ICP > 15.8 mmHg, the number of ICP > 15 mmHg > 25.5, or the number of ICP > 20 mmHg > 6 implicate an unfavorable long-term prognosis after 72 h of an mTBI.
Collapse
Affiliation(s)
| | | | | | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi’an 710038, China
| | | | | | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi’an 710038, China
| |
Collapse
|
17
|
Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
Collapse
Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
| |
Collapse
|
18
|
Volovici V, Pisică D, Gravesteijn BY, Dirven CMF, Steyerberg EW, Ercole A, Stocchetti N, Nelson D, Menon DK, Citerio G, van der Jagt M, Maas AIR, Haitsma IK, Lingsma HF, Åkerlund C, Amrein K, Andelic N, Andreassen L, Audibert G, Azouvi P, Azzolini ML, Bartels R, Beer R, Bellander BM, Benali H, Berardino M, Beretta L, Beqiri E, Blaabjerg M, Lund SB, Brorsson C, Buki A, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Lozano GC, Castaño-León AM, Cavallo S, Chevallard G, Chieregato A, Coburn M, Coles J, Cooper JD, Correia M, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, De Keyser V, Degos V, Corte FD, Boogert HD, Depreitere B, Dilvesi D, Dixit A, Dreier J, Dulière GL, Ezer E, Fabricius M, Foks K, Frisvold S, Furmanov A, Galanaud D, Gantner D, Ghuysen A, Giga L, Golubovic J, Gomez PA, Grossi F, Gupta D, Haitsma I, Helseth E, Hutchinson PJ, Jankowski S, Johnson F, Karan M, Kolias AG, Kondziella D, Koraropoulos E, Koskinen LO, Kovács N, Kowark A, Lagares A, Laureys S, Ledoux D, Lejeune A, Lightfoot R, Manara A, Martino C, Maréchal H, Mattern J, McMahon C, Menovsky T, Misset B, Muraleedharan V, Murray L, Negru A, Newcombe V, Nyirádi J, Ortolano F, Payen JF, Perlbarg V, Persona P, Piippo-Karjalainen A, Ples H, Pomposo I, Posti JP, Puybasset L, Radoi A, Ragauskas A, Raj R, Rhodes J, Richter S, Rocka S, Roe C, Roise O, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Sahuquillo J, Sandrød O, Sakowitz O, Sanchez-Porras R, Schirmer-Mikalsen K, Schou RF, Smielewski P, Sorinola A, Stamatakis E, Sundström N, Takala R, Tamás V, Tamosuitis T, Tenovuo O, Thomas M, Tibboel D, Tolias C, Trapani T, Tudora CM, Vajkoczy P, Vallance S, Valeinis E, Vámos Z, Van der Steen G, van Wijk RPJ, Vargiolu A, Vega E, Vik A, Vilcinis R, Vulekovic P, Williams G, Winzeck S, Wolf S, Younsi A, Zeiler FA, Ziverte A, Clusmann H, Voormolen D, van Dijck JTJM, van Essen TA. Comparative effectiveness of intracranial hypertension management guided by ventricular versus intraparenchymal pressure monitoring: a CENTER-TBI study. Acta Neurochir (Wien) 2022; 164:1693-1705. [PMID: 35648213 PMCID: PMC9233652 DOI: 10.1007/s00701-022-05257-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/11/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To compare outcomes between patients with primary external ventricular device (EVD)-driven treatment of intracranial hypertension and those with primary intraparenchymal monitor (IP)-driven treatment. METHODS The CENTER-TBI study is a prospective, multicenter, longitudinal observational cohort study that enrolled patients of all TBI severities from 62 participating centers (mainly level I trauma centers) across Europe between 2015 and 2017. Functional outcome was assessed at 6 months and a year. We used multivariable adjusted instrumental variable (IV) analysis with "center" as instrument and logistic regression with covariate adjustment to determine the effect estimate of EVD on 6-month functional outcome. RESULTS A total of 878 patients of all TBI severities with an indication for intracranial pressure (ICP) monitoring were included in the present study, of whom 739 (84%) patients had an IP monitor and 139 (16%) an EVD. Patients included were predominantly male (74% in the IP monitor and 76% in the EVD group), with a median age of 46 years in the IP group and 48 in the EVD group. Six-month GOS-E was similar between IP and EVD patients (adjusted odds ratio (aOR) and 95% confidence interval [CI] OR 0.74 and 95% CI [0.36-1.52], adjusted IV analysis). The length of intensive care unit stay was greater in the EVD group than in the IP group (adjusted rate ratio [95% CI] 1.70 [1.34-2.12], IV analysis). One hundred eighty-seven of the 739 patients in the IP group (25%) required an EVD due to refractory ICPs. CONCLUSION We found no major differences in outcomes of patients with TBI when comparing EVD-guided and IP monitor-guided ICP management. In our cohort, a quarter of patients that initially received an IP monitor required an EVD later for ICP control. The prevalence of complications was higher in the EVD group. PROTOCOL The core study is registered with ClinicalTrials.gov , number NCT02210221, and the Resource Identification Portal (RRID: SCR_015582).
Collapse
|
19
|
Dallagiacoma S, Robba C, Graziano F, Rebora P, Hemphill JC, Galimberti S, Citerio G. Intracranial Pressure Monitoring in Patients With Spontaneous Intracerebral Hemorrhage: Insights From the SYNAPSE-ICU Study. Neurology 2022; 99:e98-e108. [PMID: 35508390 DOI: 10.1212/wnl.0000000000200568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Uncertainties remain regarding the indications, management, and effect of intracranial pressure (ICP) monitoring and treatment on outcome in spontaneous intracranial hemorrhage (ICH) patients. METHODS Analysisof spontaneous ICH patients enrolled in the SYNAPSE-ICU study an international prospective observational study on the use of ICP monitoring. This study aimed to describe, in a large cohort of patients with spontaneous ICH admitted to ICU, the clinical practice of ICP monitoring, the occurrence of intracranial hypertension and its therapeutic management. We further assessed in-hospital mortality and the association between ICP monitoring and 6-months mortality and outcome by a propensity score approach with inverse probability weighting. RESULTS 587 ICH patients were included in this study; 281 (47.9%) received ICP monitoring. ICP-monitored patients, compared to non-monitored, were younger (61 vs 67 years, p<0.001), presented more frequently with both reactive pupils (67.2%, vs 55.2%, p=0.008), with better neurological status at admission (GCS≤ 8, 82.3% vs 88.8%, p=0.038) and received higher therapy intensity level during ICU stay. In 70.5% (170 out of 241) of ICP monitored patients the ICH score was equal to 3 or 4. Nearly half of monitored patients (46.6%) had at least one episode of ICP ≥ 20 mmHg during the first week. An intraventricular catheter (53.6%) was the most frequently used device and had fewer episodes of intracranial hypertension compared to the other monitoring devices (43.7% vs 64.9%, respectively). At weighted Cox regression model, ICP monitoring was associated with a significant reduction of 6-month mortality (Hazard Ratio, HR= 0.49 (95% Confidence Intervals CI=0.35-0.71, p=0.001), but not with neurological outcome (OR=0.83, 95%CI= 0.41-1.68, p=0.6077). CONCLUSIONS ICP monitoring in ICH was utilized mainly in moderately severe cases. ICP monitoring was associated with a reduction of in-hospital and 6-month mortality but did not improve 6-months functional outcomes. Further research and randomized controlled trials to generate higher-level medical evidence to support guidelines regarding ICP use and treatment in patients with ICH are needed.
Collapse
Affiliation(s)
- Stefania Dallagiacoma
- Neurology and Clinical Neurophysiology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Italy
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy. Department of Surgical Science and Diagnostic Integrated, University of Genoa, Italy
| | - Francesca Graziano
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | - Stefania Galimberti
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy .,Neurointensive Care Unit, Department Neuroscience, San Gerardo Hospital, ASST-Monza, Monza, Italy
| |
Collapse
|
20
|
Luz Teixeira T, Peluso L, Banco P, Njimi H, Abi-Khalil L, Chanchay Pillajo M, Schuind S, Creteur J, Bouzat P, Taccone FS. Early Pupillometry Assessment in Traumatic Brain Injury Patients: A Retrospective Study. Brain Sci 2021; 11:brainsci11121657. [PMID: 34942959 PMCID: PMC8699519 DOI: 10.3390/brainsci11121657] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether the early assessment of neurological pupil index (NPi) values derived from automated pupillometry could predict neurological outcome after traumatic brain injury (TBI). METHODS Retrospective observational study including adult (>18 years) TBI patients admitted from January 2018 to December 2020, with available NPi on admission. Abnormal NPi was considered if <3. Unfavorable neurological outcome (UO) at hospital discharge was considered for a Glasgow Outcome Scale of 1-3. RESULTS 100 patients were included over the study period (median age 48 (34-69) years and median GCS on admission 11 (6-15)); 49 (49%) patients had UO. On admission, 20 (20%) patients had an abnormal NPi (NPi < 3); median worst (i.e., from both eyes) NPi was 4.2 (3.2-4.5). Median worst and mean NPi on admission were significantly lower in the UO group than others (3.9 (1.7-4.4) vs. 4.4 (3.7-4.6); p = 0.005-4.0 (2.6-4.5) vs. 4.5 (3.9-4.7); p = 0.002, respectively). The ROC curve for the worst and mean NPi showed a moderate accuracy to predict UO (AUC 0.66 (0.56-0.77); p = 0.005 and 0.68 (0.57-0.78); p = 0.002). However, in a generalized linear model, the prognostic role of NPi on admission was limited. CONCLUSIONS Low NPi on admission has limited prognostic value in TBI.
Collapse
Affiliation(s)
- Thomas Luz Teixeira
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Pierluigi Banco
- Department of Anesthesiology and Intensive Care, University of Grenobles, 38400 Grenobles, France; (P.B.); (P.B.)
| | - Hassane Njimi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Layal Abi-Khalil
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Mélanie Chanchay Pillajo
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Sophie Schuind
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
| | - Jacques Creteur
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care, University of Grenobles, 38400 Grenobles, France; (P.B.); (P.B.)
- Grenoble Institute Neurosciences, University of Grenoble Alpes, 38700 Grenoble, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
- Correspondence: ; Tel.: +32-25555587
| |
Collapse
|
21
|
van Erp IAM, van Essen TA, Fluiter K, van Zwet E, van Vliet P, Baas F, Haitsma I, Verbaan D, Coert B, de Ruiter GCW, Moojen WA, van der Jagt M, Peul WC. Safety and efficacy of C1-inhibitor in traumatic brain injury (CIAO@TBI): study protocol for a randomized, placebo-controlled, multi-center trial. Trials 2021; 22:874. [PMID: 34863258 PMCID: PMC8642972 DOI: 10.1186/s13063-021-05833-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/15/2021] [Indexed: 01/21/2023] Open
Abstract
Background Traumatic brain injury (TBI) is a major cause of death and disability across all ages. After the primary impact, the pathophysiologic process of secondary brain injury consists of a neuroinflammation response that critically leads to irreversible brain damage in the first days after the trauma. A key catalyst in this inflammatory process is the complement system. Inhibiting the complement system could therefore be a therapeutic target in TBI. Objective To study the safety and efficacy of C1-inhibitor (C1-INH) compared to placebo in patients with TBI. By temporarily blocking the complement system, we hypothesize a decrease in the posttraumatic neuroinflammatory response resulting in a less unfavorable clinical outcome for TBI patients. Methods CIAO@TBI is a multicenter, randomized, blinded, phase II placebo-controlled trial. Adult TBI patients with GCS < 13 requiring intracranial pressure (ICP) monitoring will be randomized, using block randomization, within 12 h after trauma to one dose 6000 IU C1-INH or placebo. A total of 106 patients will be included, and follow-up will occur up to 12 months. The primary endpoints are (1) Therapy Intensity Level (TIL) Scale, (2) Glasgow Outcome Scale-Extended (GOSE) at 6 months, and (3) complication rate during hospitalization. Outcomes will be determined by a trial nurse blinded for the treatment allocation. Analyses will be conducted in an intention-to-treat analysis. Discussion We expect that C1-INH administration will be safe and potentially effective to improve clinical outcomes by reducing neuroinflammation in TBI patients. Trial registration ClinicalTrials.gov NCT04489160. Registered on 27 July 2020. EudraCT 2020-000140-58 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05833-1.
Collapse
Affiliation(s)
- Inge A M van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, Hague, The Netherlands.
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, Hague, The Netherlands
| | - Kees Fluiter
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik van Zwet
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter van Vliet
- Department of Intensive Care, Haaglanden Medical Center, The Hague, The Netherlands
| | - Frank Baas
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Bert Coert
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Godard C W de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, Hague, The Netherlands
| | - Wouter A Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, Hague, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, Hague, The Netherlands
| |
Collapse
|
22
|
Tas J, Beqiri E, van Kaam RC, Czosnyka M, Donnelly J, Haeren RH, van der Horst ICC, Hutchinson PJ, van Kuijk SMJ, Liberti AL, Menon DK, Hoedemaekers CWE, Depreitere B, Smielewski P, Meyfroidt G, Ercole A, Aries MJH. Targeting Autoregulation-Guided Cerebral Perfusion Pressure after Traumatic Brain Injury (COGiTATE): A Feasibility Randomized Controlled Clinical Trial. J Neurotrauma 2021; 38:2790-2800. [PMID: 34407385 DOI: 10.1089/neu.2021.0197] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Managing traumatic brain injury (TBI) patients with a cerebral perfusion pressure (CPP) near to the cerebral autoregulation (CA)-guided "optimal" CPP (CPPopt) value is associated with improved outcome and might be useful to individualize care, but has never been prospectively evaluated. This study evaluated the feasibility and safety of CA-guided CPP management in TBI patients requiring intracranial pressure monitoring and therapy (TBIicp patients). The CPPopt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) parallel two-arm feasibility trial took place in four tertiary centers. TBIicp patients were randomized to either the Brain Trauma Foundation (BTF) guideline CPP target range (control group) or to the individualized CA-guided CPP targets (intervention group). CPP targets were guided by six times daily software-based alerts for up to 5 days. The primary feasibility end-point was the percentage of time with CPP concordant (±5 mm Hg) with the set CPP targets. The main secondary safety end-point was an increase in therapeutic intensity level (TIL) between the control and intervention group. Twenty-eight patients were randomized to the control and 32 patients to the intervention group. CPP in the intervention group was in the target range for 46.5% (interquartile range, 41.2-58) of the monitored time, significantly higher than the feasibility target specified in the published protocol (36%; p < 0.001). There were no significant differences between groups for TIL or for other safety end-points. Conclusively, targeting an individual and dynamic CA-guided CPP is feasible and safe in TBIicp patients. This encourages a prospective trial powered for clinical outcomes.
Collapse
Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ruud C van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Roel H Haeren
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Neurosurgery, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Analisa L Liberti
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Anaesthesia and Intensive Care, San Carlo Borromeo Hospital, Milan, Italy
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | | | - Bart Depreitere
- Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Marcel J H Aries
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
23
|
Robba C, Graziano F, Rebora P, Elli F, Giussani C, Oddo M, Meyfroidt G, Helbok R, Taccone FS, Prisco L, Vincent JL, Suarez JI, Stocchetti N, Citerio G. Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study. Lancet Neurol 2021; 20:548-558. [PMID: 34146513 DOI: 10.1016/s1474-4422(21)00138-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients' outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. METHODS We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. FINDINGS Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39-69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8-4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26-0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26-0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7-12]) than in those who were not monitored (5 [3-8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91-0·98; p=0·0011). INTERPRETATION The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results. FUNDING University of Milano-Bicocca and the European Society of Intensive Care Medicine.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Francesca Graziano
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Elli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Carlo Giussani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neurosurgery, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale di Monza, Monza, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals, Leuven, Belgium
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lara Prisco
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals Trust, Oxford, UK
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplant, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neurointensive Care Unit, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale di Monza, Monza, Italy.
| | | |
Collapse
|
24
|
Semi-automated Computed Tomography Volumetry as a Proxy for Intracranial Pressure in Patients with Severe Traumatic Brain Injury: Clinical Feasibility Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839810 DOI: 10.1007/978-3-030-59436-7_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is associated with high mortality due to intracranial pressure (ICP). Whether computed tomography (CT) scanning of the brain within the first 24 h is indicative of intracranial hypertension is largely unknown. We assessed the feasibility of semi-automated CT segmentation in comparison with invasive ICP measurements. RELEVANCE CT volumetry of the brain might provide ICP data when invasive monitoring is not possible or is undesirable. METHODS We identified 33 patients with TBI who received a CT scan at admission and ICP monitoring within 24 h. Semi-automated segmentation of CT images in Matlab yielded cerebrospinal fluid (CSF) and intracranial volume (ICV) data. The ratio CSF/ICV × 100 (expressed as a percentage) was used as a proxy for ICP. The association between invasive ICP and the CSF/ICV ratio was evaluated using a simple linear regression model and a mono-exponential function derived from previous research in animals. RESULTS ICP is moderately but significantly associated with the CSF/ICV ratio (r = -0.44, p = 0.01). The mono-exponential function provided a better fit of the relationship between ICP and the CSF/ICV ratio than the linear model. CONCLUSION Our feasibility TBI data show that cross-sectional volumetric CT measures are associated with ICP. This non-invasive method can be used in future studies to monitor patients who are not candidates for invasive monitoring or to evaluate therapy effects objectively.
Collapse
|
25
|
Tas J, Beqiri E, van Kaam CR, Ercole A, Bellen G, Bruyninckx D, Cabeleira M, Czosnyka M, Depreitere B, Donnelly J, Fedriga M, Hutchinson PJ, Menon D, Meyfroidt G, Liberti A, Outtrim JG, Robba C, Hoedemaekers CWE, Smielewski P, Aries MJ. An Update on the COGiTATE Phase II Study: Feasibility and Safety of Targeting an Optimal Cerebral Perfusion Pressure as a Patient-Tailored Therapy in Severe Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:143-147. [PMID: 33839835 DOI: 10.1007/978-3-030-59436-7_29] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Monitoring of cerebral autoregulation (CA) in patients with a traumatic brain injury (TBI) can provide an individual 'optimal' cerebral perfusion pressure (CPP) target (CPPopt) at which CA is best preserved. This potentially offers an individualized precision medicine approach. Retrospective data suggest that deviation of CPP from CPPopt is associated with poor outcomes. We are prospectively assessing the feasibility and safety of this approach in the COGiTATE [CPPopt Guided Therapy: Assessment of Target Effectiveness] study. Its primary objective is to demonstrate the feasibility of individualizing CPP at CPPopt in TBI patients. The secondary objectives are to investigate the safety and physiological effects of this strategy. METHODS The COGiTATE study has included patients in four European hospitals in Cambridge, Leuven, Nijmegen, and Maastricht (coordinating centre). Patients with severe TBI requiring intracranial pressure (ICP)-directed therapy are allocated into one of two groups. In the intervention group, CPPopt is calculated using a published (modified) algorithm. In the control group, the CPP target recommended in the Brain Trauma Foundation guidelines (CPP 60-70 mmHg) is used. RESULTS Patient recruitment started in February 2018 and will continue until 60 patients have been studied. Fifty-one patients (85% of the intended total) have been recruited in October 2019. The first results are expected early 2021. CONCLUSION This prospective evaluation of the feasibility, safety and physiological implications of autoregulation-guided CPP management is providing evidence that will be useful in the design of a future phase III study in severe TBI patients.
Collapse
Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - C R van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ari Ercole
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Gert Bellen
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - D Bruyninckx
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marta Fedriga
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - D Menon
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Cellular and Molecular Medicine, Catholic University Leuven, University Hospital, Leuven, Belgium
| | - Annalisa Liberti
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J G Outtrim
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - C Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - C W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marcel J Aries
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
26
|
Roquilly A, Moyer JD, Huet O, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Jeantrelle C, Vermeersch V, Gaillard T, Cinotti R, Demeure dit Latte D, Mahe PJ, Vourc’h M, Martin FP, Chopin A, Lerebourg C, Flet L, Chiffoleau A, Feuillet F, Asehnoune K. Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial. JAMA 2021; 325:2056-2066. [PMID: 34032829 PMCID: PMC8150692 DOI: 10.1001/jama.2021.5561] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Fluid therapy is an important component of care for patients with traumatic brain injury, but whether it modulates clinical outcomes remains unclear. OBJECTIVE To determine whether continuous infusion of hypertonic saline solution improves neurological outcome at 6 months in patients with traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial conducted in 9 intensive care units in France, including 370 patients with moderate to severe traumatic brain injury who were recruited from October 2017 to August 2019. Follow-up was completed in February 2020. INTERVENTIONS Adult patients with moderate to severe traumatic brain injury were randomly assigned to receive continuous infusion of 20% hypertonic saline solution plus standard care (n = 185) or standard care alone (controls; n = 185). The 20% hypertonic saline solution was administered for 48 hours or longer if patients remained at risk of intracranial hypertension. MAIN OUTCOMES AND MEASURES The primary outcome was Extended Glasgow Outcome Scale (GOS-E) score (range, 1-8, with lower scores indicating worse functional outcome) at 6 months, obtained centrally by blinded assessors and analyzed with ordinal logistic regression adjusted for prespecified prognostic factors (with a common odds ratio [OR] >1.0 favoring intervention). There were 12 secondary outcomes measured at multiple time points, including development of intracranial hypertension and 6-month mortality. RESULTS Among 370 patients who were randomized (median age, 44 [interquartile range, 27-59] years; 77 [20.2%] women), 359 (97%) completed the trial. The adjusted common OR for the GOS-E score at 6 months was 1.02 (95% CI, 0.71-1.47; P = .92). Of the 12 secondary outcomes, 10 were not significantly different. Intracranial hypertension developed in 62 (33.7%) patients in the intervention group and 66 (36.3%) patients in the control group (absolute difference, -2.6% [95% CI, -12.3% to 7.2%]; OR, 0.80 [95% CI, 0.51-1.26]). There was no significant difference in 6-month mortality (29 [15.9%] in the intervention group vs 37 [20.8%] in the control group; absolute difference, -4.9% [95% CI, -12.8% to 3.1%]; hazard ratio, 0.79 [95% CI, 0.48-1.28]). CONCLUSIONS AND RELEVANCE Among patients with moderate to severe traumatic brain injury, treatment with continuous infusion of 20% hypertonic saline compared with standard care did not result in a significantly better neurological status at 6 months. However, confidence intervals for the findings were wide, and the study may have had limited power to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03143751.
Collapse
Affiliation(s)
- Antoine Roquilly
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Jean Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Olivier Huet
- CHU de Brest, Anesthesia and Intensive Care Unit, Brest, France
| | | | - Benjamin Cohen
- CHU de Tours, Anesthesia and Intensive Care Unit, Tours, France
| | | | - Kevin Chalard
- CHU de Montpellier, Anesthesia and Intensive Care Unit, Montpellier, France
| | - Philippe Seguin
- CHU de Rennes, Anesthesia and Intensive Care Unit, Rennes, France
| | - Caroline Jeantrelle
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | | | - Thomas Gaillard
- CHU d’Angers, Anesthesia and Intensive Care Unit, Angers, France
| | - Raphael Cinotti
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Dominique Demeure dit Latte
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Pierre Joachim Mahe
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Mickael Vourc’h
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Florian Pierre Martin
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Alice Chopin
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Celine Lerebourg
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Laurent Flet
- CHU de Nantes, Service de pharmacie, Hôtel Dieu, Nantes, France
| | - Anne Chiffoleau
- DRCI, Departement promotion, cellule vigilances, CHU Nantes, Nantes, France
| | - Fanny Feuillet
- DRCI, Plateforme de Méthodologie et de Biostatistique, CHU Nantes, Nantes, France
- Université de Nantes, Université de Tours, INSERM, SPHERE U1246, Nantes, France
| | - Karim Asehnoune
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| |
Collapse
|
27
|
Sedation and cerebrovascular reactivity in traumatic brain injury: another potential avenue for personalized approaches in neurocritical care? Acta Neurochir (Wien) 2021; 163:1383-1389. [PMID: 33404872 DOI: 10.1007/s00701-020-04662-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Impaired cerebrovascular reactivity appears to be linked to worse global outcome in adult traumatic brain injury (TBI). Literature suggests that current treatments administered in TBI care, in the intensive care unit (ICU), fail to greatly impact recorded cerebrovascular reactivity measures. In particular, the impact of sedation on cerebrovascular reactivity in traumatic brain injury (TBI) remains unclear in vivo. The goal of this study was to preliminarily assess the relationship between objectively measured depth of sedation and cerebrovascular reactivity in TBI. METHODS Within, we describe a case series of 5 adult TBI patients with TBI, during which objective high-frequency physiology for sedation depth, using bispectral index (BIS), and both intracranial pressure (ICP) and arterial blood pressure (ABP) were recorded. Pressure reactivity index (PRx) and RAP (a metric of cerebral compensatory reserve) were derived. Relationships between cerebrovascular reactivity and compensatory reserve monitoring with BIS metrics were explored using descriptive plots. RESULTS A total of 5 cases in our prospectively maintained database with high-frequency physiology for ICP, ABP, and BIS. Through error bar plotting, it can be seen that each patient displays a parabolic relationship between BIS and PRx. This suggests a potential "optimal" depth of sedation where cerebrovascular reactivity is the most intact. CONCLUSIONS This small series highlights the potential impact of depth of sedation on cerebrovascular reactivity in TBI. It suggests that there may be an individual optimal depth of sedation, so as to optimize cerebrovascular reactivity. Further study of objective depth of sedation and its impact on cerebrovascular physiology in TBI is required.
Collapse
|
28
|
Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A. Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 2021; 25:78. [PMID: 33622371 PMCID: PMC7901510 DOI: 10.1186/s13054-020-03370-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs). METHODS We studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP. RESULTS 313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0-2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome. CONCLUSION Substantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies. TAKE HOME MESSAGE Substantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments. TRIAL REGISTRATION The core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
Collapse
Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| |
Collapse
|
29
|
Lenstra JJ, Kuznecova-Keppel Hesselink L, la Bastide-van Gemert S, Jacobs B, Nijsten MWN, van der Horst ICC, van der Naalt J. The Association of Early Electrocardiographic Abnormalities With Brain Injury Severity and Outcome in Severe Traumatic Brain Injury. Front Neurol 2021; 11:597737. [PMID: 33488498 PMCID: PMC7819976 DOI: 10.3389/fneur.2020.597737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/09/2020] [Indexed: 12/22/2022] Open
Abstract
The aim of this study was to evaluate the frequency of electrocardiographic (ECG) abnormalities in the acute phase of severe traumatic brain injury (TBI) and the association with brain injury severity and outcome. In contrast to neurovascular diseases, sparse information is available on this issue. Data of adult patients with severe TBI admitted to the Intensive Care Unit (ICU) for intracranial pressure monitoring of a level-1 trauma center from 2002 till 2018 were analyzed. Patients with a cardiac history were excluded. An ECG recording was obtained within 24 h after ICU admission. Admission brain computerized tomography (CT)-scans were categorized by Marshall-criteria (diffuse vs. mass lesions) and for location of traumatic lesions. CT-characteristics and maximum Therapy Intensity Level (TILmax) were used as indicators for brain injury severity. We analyzed data of 198 patients, mean (SD) age of 40 ± 19 years, median GCS score 3 [interquartile range (IQR) 3–6], and 105 patients (53%) had thoracic injury. In-hospital mortality was 30%, with sudden death by cardiac arrest in four patients. The incidence of ECG abnormalities was 88% comprising ventricular repolarization disorders (57%) mostly with ST-segment abnormalities, conduction disorders (45%) mostly with QTc-prolongation, and arrhythmias (38%) mostly of supraventricular origin. More cardiac arrhythmias were observed with increased grading of diffuse brain injury (p = 0.042) or in patients treated with hyperosmolar therapy (TILmax) (65%, p = 0.022). No association was found between ECG abnormalities and location of brain lesions nor with thoracic injury. Multivariate analysis with baseline outcome predictors showed that cardiac arrhythmias were not independently associated with in-hospital mortality (p = 0.097). Only hypotension (p = 0.029) and diffuse brain injury (p = 0.017) were associated with in-hospital mortality. In conclusion, a high incidence of ECG abnormalities was observed in patients with severe TBI in the acute phase after injury. No association between ECG abnormalities and location of brain lesions or presence of thoracic injury was present. Cardiac arrhythmias were indicative for brain injury severity but not independently associated with in-hospital mortality. Therefore, our findings likely suggest that ECG abnormalities should be considered as cardiac mimicry representing the secondary effect of traumatic brain injury allowing for a more rationale use of neuroprotective measures.
Collapse
Affiliation(s)
- Jelmer-Joost Lenstra
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Sacha la Bastide-van Gemert
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | | | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| |
Collapse
|
30
|
Agrawal D, Raghavendran K, Zhao L, Rajajee V. A Prospective Study of Optic Nerve Ultrasound for the Detection of Elevated Intracranial Pressure in Severe Traumatic Brain Injury. Crit Care Med 2020; 48:e1278-e1285. [PMID: 33048902 PMCID: PMC7708401 DOI: 10.1097/ccm.0000000000004689] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intracranial pressure monitoring plays a critical role in the management of severe traumatic brain injury. Our objective was to evaluate the accuracy of optic nerve sheath diameter as a noninvasive screening test for the detection of elevated intracranial pressure and prediction of intracranial pressure treatment intensity. DESIGN Prospective, blinded study of diagnostic accuracy. SETTING Neurotrauma ICU. SUBJECTS Consecutive patients with severe traumatic brain injury. INTERVENTIONS Optic nerve ultrasound was performed daily and optic nerve ultrasound measured at the point-of-care as well as remotely by an expert blinded to all patient details. Optic disc elevation was also measured. The index test was the highest remote-expert optic nerve ultrasound for the admission. The reference standard was the concurrent invasive intracranial pressure, with test-positivity set at intracranial pressure greater than 22 mm Hg. A priori the minimally acceptable sensitivity threshold was 90% with corresponding specificity 60%. We also evaluated the ability of optic nerve ultrasound to predict a therapeutic intensity level greater than 10. MEASUREMENTS AND MAIN RESULTS One hundred twenty patients were enrolled. The intraclass correlation coefficient between point of care and expert optic nerve sheath diameter after enrollment of 50 subjects was poor at 0.16 (-0.08 to 0.41) but improved to 0.87 (0.81-0.92) for the remaining subjects after remedial training. The area under the curve of the receiver operating characteristic curve of the highest expert-measured optic nerve sheath diameter to detect intracranial pressure greater than 22 mm Hg was 0.81 (0.73-0.87); area under the curve for prediction of therapeutic intensity level greater than 10 was 0.51 (0.42-0.60). Optic nerve sheath diameter greater than 0.72 demonstrated sensitivity 82% (48-98%) and specificity 79% (70-86%) for intracranial pressure greater than 22 mm Hg. The area under the curve of highest measured optic disc elevation to detect intracranial pressure greater than 22 mm Hg was 0.84 (0.76-0.90). Optic disc elevation greater than 0.04 cm attained sensitivity 90% (56-100%) and specificity 71% (61-79%). CONCLUSIONS While optic nerve sheath diameter demonstrated a modest, statistically significant correlation with intracranial pressure, a predetermined level of diagnostic accuracy to justify routine clinical use as a screening test was not achieved. Measurement of optic disc elevation appears promising for the detection of elevated intracranial pressure, however, verification from larger studies is necessary.
Collapse
Affiliation(s)
- Deepak Agrawal
- Department of Neurosurgery, JPN Apex Trauma Centre and Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | | | - Lili Zhao
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
- Department of Neurology, University of Michigan, Ann Arbor, MI
| |
Collapse
|
31
|
Froese L, Dian J, Gomez A, Unger B, Zeiler FA. The cerebrovascular response to norepinephrine: A scoping systematic review of the animal and human literature. Pharmacol Res Perspect 2020; 8:e00655. [PMID: 32965778 PMCID: PMC7510331 DOI: 10.1002/prp2.655] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Intravenous norepinephrine (NE) is utilized commonly in critical care for cardiovascular support. NE's impact on cerebrovasculature is unclear and may carry important implications during states of critical neurological illness. The aim of the study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of NE. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019 was performed. All manuscripts pertaining to the administration of NE, in which the impact on CBF/cerebral vasculature was recorded, were included. We identified 62 animal studies and 26 human studies. Overall, there was a trend to a direct vasoconstriction effect of NE on the cerebral vasculature, with conflicting studies having demonstrated both increases and decreases in regional CBF (rCBF) or global CBF. Healthy animals and those undergoing cardiopulmonary resuscitation demonstrated a dose-dependent increase in CBF with NE administration. However, animal models and human patients with acquired brain injury had varied responses in CBF to NE administration. The animal models indicate an increase in cerebral vasoconstriction with NE administration through the alpha receptors in vessels. Global and rCBF during the injection of NE displays a wide variation depending on treatment and model/patient.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
| | - Joshua Dian
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Alwyn Gomez
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Bertram Unger
- Section of Critical CareDepartment of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Frederick A. Zeiler
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Centre on AgingUniversity of ManitobaWinnipegCanada
- Division of AnaesthesiaDepartment of MedicineAddenbrooke’s HospitalUniversity of CambridgeCambridgeUK
| |
Collapse
|
32
|
Froese L, Dian J, Gomez A, Unger B, Zeiler FA. Cerebrovascular Response to Phenylephrine in Traumatic Brain Injury: A Scoping Systematic Review of the Human and Animal Literature. Neurotrauma Rep 2020; 1:46-62. [PMID: 34223530 PMCID: PMC8240891 DOI: 10.1089/neur.2020.0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous phenylephrine (PE) is utilized commonly in critical care for cardiovascular support. Its impact on the cerebrovasculature is unclear and its use may have important implications during states of critical neurological illness. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of PE in traumatic brain injury (TBI), evaluating both animal models and human studies. We searched MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to January 2020. We identified 12 studies with various animal models and 4 studies in humans with varying TBI pathology. There was a trend toward a consistent increase in mean arterial pressure (MAP) by the injection of PE systemically, and by proxy, an increase of the cerebral perfusion pressure (CPP). There was a consistent constriction of cerebral vessels by PE reported in the small number of studies documenting such a response. However, the heterogeneity of the literature on the CBF/cerebral blood volume (CBV) response makes the strength of the conclusions on PE limited. Studies were heterogeneous in design and had significant limitations, with most failing to adjust for confounding factors in cerebrovascular/CBF response. This review highlights the significant knowledge gap on the cerebrovascular/CBF effects of PE administration in TBI, calling for further study on the impact of PE on the cerebrovasculature both in vivo and in experimental settings.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Dian
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bertram Unger
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Center on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| |
Collapse
|
33
|
Chau CYC, Mediratta S, McKie MA, Gregson B, Tulu S, Ercole A, Solla DJF, Paiva WS, Hutchinson PJ, Kolias AG. Optimal Timing of External Ventricular Drainage after Severe Traumatic Brain Injury: A Systematic Review. J Clin Med 2020; 9:E1996. [PMID: 32630454 PMCID: PMC7356750 DOI: 10.3390/jcm9061996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 12/26/2022] Open
Abstract
External ventricular drainage (EVD) may be used for therapeutic cerebrospinal fluid (CSF) drainage to control intracranial pressure (ICP) after traumatic brain injury (TBI). However, there is currently uncertainty regarding the optimal timing for EVD insertion. This study aims to compare patient outcomes for patients with early and late EVD insertion. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, MEDLINE/EMBASE/Scopus/Web of Science/Cochrane Central Register of Controlled Trials were searched for published literature involving at least 10 severe TBI (sTBI) patients from their inception date to December 2019. Outcomes assessed were mortality, functional outcome, ICP control, length of stay, therapy intensity level, and complications. Twenty-one studies comprising 4542 sTBI patients with an EVD were included; 19 of the studies included patients with an early EVD, and two studies had late EVD placements. The limited number of studies, small sample sizes, imbalance in baseline characteristics between the groups and poor methodological quality have limited the scope of our analysis. We present the descriptive statistics highlighting the current conflicting data and the overall lack of reliable research into the optimal timing of EVD. There is a clear need for high quality comparisons of early vs. late EVD insertion on patient outcomes in sTBI.
Collapse
Affiliation(s)
- Charlene Y. C. Chau
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
| | - Saniya Mediratta
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK;
| | - Mikel A. McKie
- Medical Research Council Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge CB2 0SR, UK;
| | - Barbara Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne NE4 5PLE, UK;
| | - Selma Tulu
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK;
| | - Davi J. F. Solla
- Department of Neurology, Division of Neurosurgery, University of São Paulo, São Paulo 01246-903, Brazil; (D.J.F.S.); (W.S.P.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Wellingson S. Paiva
- Department of Neurology, Division of Neurosurgery, University of São Paulo, São Paulo 01246-903, Brazil; (D.J.F.S.); (W.S.P.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
- Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
- Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| |
Collapse
|
34
|
Cederberg D, Hansson HA, Visse E, Siesjö P. Antisecretory Factor May Reduce ICP in Severe TBI-A Case Series. Front Neurol 2020; 11:95. [PMID: 32210902 PMCID: PMC7067821 DOI: 10.3389/fneur.2020.00095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 01/27/2020] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI) constitutes a global epidemic. Overall outcome is poor, with mortality ranging from 10 to 70% and significant long-term morbidity. Several experimental reports have claimed effect on traumatic edema, but all clinical trials have failed. Antisecretory factor, an endogenous protein, is commercially available as Salovum®, which is classified as a medical food by the European Union and has been proven effective in experimental trauma models. It has, however, previously not been tested in humans with severe TBI. We hereby report a case series of five adult patients with severe TBI, treated with Salovum. The objective of the intervention was to evaluate safety and, if possible, its effect on intracranial pressure and outcome. Patients received 1 g Salovum per kilo of body weight divided into six doses per 24 h. Each dose was administered through the nasogastric tube. Patients were scheduled for 5 days of treatment with Salovum. Intracranial pressure was controlled in all patients. In three of five patients, intracranial pressure could be controlled with Salovum and deep sedation (no barbiturates), except during periods of gastroparesis. Five of five patients had a favorable short-term outcome, and four of five patients had a favorable long-term outcome. No toxicity was observed. We conclude that at least three of the five treated patients experienced an effect of Salovum with signs of reduction of intracranial pressure and signs of clinical benefit. In order to validate the potential of antisecretory factor in TBI, a prospective, randomized, double-blind, placebo-controlled trial with Salovum has been initiated. Primary outcome for the trial is 30-day mortality; secondary outcomes are treatment intensity level, intracranial pressure, and number of days at the neurointensive care unit.
Collapse
Affiliation(s)
- David Cederberg
- Department of Neurosurgery, Skane University Hospital, Lund, Sweden
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Edward Visse
- Department of Neurosurgery, Skane University Hospital, Lund, Sweden
| | - Peter Siesjö
- Department of Neurosurgery, Skane University Hospital, Lund, Sweden
| |
Collapse
|
35
|
Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis. Intensive Care Med 2020; 46:995-1004. [PMID: 32100061 PMCID: PMC7210239 DOI: 10.1007/s00134-020-05965-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/09/2020] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers. METHODS This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. RESULTS A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01). CONCLUSIONS Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.
Collapse
|
36
|
Beqiri E, Smielewski P, Robba C, Czosnyka M, Cabeleira MT, Tas J, Donnelly J, Outtrim JG, Hutchinson P, Menon D, Meyfroidt G, Depreitere B, Aries MJ, Ercole A. Feasibility of individualised severe traumatic brain injury management using an automated assessment of optimal cerebral perfusion pressure: the COGiTATE phase II study protocol. BMJ Open 2019; 9:e030727. [PMID: 31542757 PMCID: PMC6756360 DOI: 10.1136/bmjopen-2019-030727] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Individualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines. METHODS AND ANALYSIS CPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intracranial pressure monitoring are randomised within the first 24 hours of admission in neurocritical care unit. For the control arm, the CPP target is the Brain Trauma Foundation guidelines target (60-70 mm Hg); for the intervention group an automated CPP target is provided as the CPP at which the patient's cerebrovascular reactivity is best preserved (CPPopt). For a maximum of 5 days, attending clinicians review the CPP target 4-hourly. The main hypothesis of COGiTATE are: (1) in the intervention group the percentage of the monitored time with measured CPP within a range of 5 mm Hg above or below CPPopt will reach 36%; (2) the difference in between groups in daily therapy intensity level score will be lower or equal to 3. ETHICS AND DISSEMINATION Ethical approval has been obtained for each participating centre. The results will be presented at international scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02982122.
Collapse
Affiliation(s)
- Erta Beqiri
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
- Physiology and Transplantation, University of Milan, Milano, Italy
| | | | - Chiara Robba
- Anaesthesia and Intensive Care,Policlinico San Martino, IRCCS for Oncology and Neuroscience, University of Genoa, Genova, Italy
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | - Jeanette Tas
- Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | | | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Intensieve geneeskunde, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Bart Depreitere
- Intensieve geneeskunde, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Marcel J Aries
- Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| |
Collapse
|
37
|
Zeiler FA, Ercole A, Beqiri E, Cabeleira M, Aries M, Zoerle T, Carbonara M, Stocchetti N, Smielewski P, Czosnyka M, Menon DK. Cerebrovascular reactivity is not associated with therapeutic intensity in adult traumatic brain injury: a CENTER-TBI analysis. Acta Neurochir (Wien) 2019; 161:1955-1964. [PMID: 31240583 PMCID: PMC6704258 DOI: 10.1007/s00701-019-03980-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/11/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Impaired cerebrovascular reactivity in adult traumatic brain injury (TBI) is known to be associated with poor outcome. However, there has yet to be an analysis of the association between the comprehensively assessed intracranial hypertension therapeutic intensity level (TIL) and cerebrovascular reactivity. METHODS Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived pressure reactivity index (PRx) as the moving correlation coefficient between slow-wave in ICP and mean arterial pressure, updated every minute. Mean daily PRx, and daily % time above PRx of 0 were calculated for the first 7 days of injury and ICU stay. This data was linked with the daily TIL-Intermediate scores, including total and individual treatment sub-scores. Daily mean PRx variable values were compared for each TIL treatment score via mean, standard deviation, and the Mann U test (Bonferroni correction for multiple comparisons). General fixed effects and mixed effects models for total TIL versus PRx were created to display the relation between TIL and cerebrovascular reactivity. RESULTS A total of 249 patients with 1230 ICU days of high frequency physiology matched with daily TIL, were assessed. Total TIL was unrelated to daily PRx. Most TIL sub-scores failed to display a significant relationship with the PRx variables. Mild hyperventilation (p < 0.0001), mild hypothermia (p = 0.0001), high levels of sedation for ICP control (p = 0.0001), and use vasopressors for CPP management (p < 0.0001) were found to be associated with only a modest decrease in mean daily PRx or % time with PRx above 0. CONCLUSIONS Cerebrovascular reactivity remains relatively independent of intracranial hypertension therapeutic intensity, suggesting inadequacy of current TBI therapies in modulating impaired autoregulation. These findings support the need for investigation into the molecular mechanisms involved, or individualized physiologic targets (ICP, CPP, or Co2) in order to treat dysautoregulation actively.
Collapse
Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tommaso Zoerle
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| |
Collapse
|
38
|
Discovery and validation of temporal patterns involved in human brain ketometabolism in cerebral microdialysis fluids of traumatic brain injury patients. EBioMedicine 2019; 44:607-617. [PMID: 31202815 PMCID: PMC6606955 DOI: 10.1016/j.ebiom.2019.05.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 12/24/2022] Open
Abstract
Background Traumatic brain injury (TBI) is recognized as a metabolic disease, characterized by acute cerebral glucose hypo-metabolism. Adaptive metabolic responses to TBI involve the utilization of alternative energy substrates, such as ketone bodies. Cerebral microdialysis (CMD) has evolved as an accurate technique allowing continuous sampling of brain extracellular fluid and assessment of regional cerebral metabolism. We present the successful application of a combined hypothesis- and data-driven metabolomics approach using repeated CMD sampling obtained routinely at patient bedside. Investigating two patient cohorts (n = 26 and n = 12), we identified clinically relevant metabolic patterns at the acute post-TBI critical care phase. Methods Clinical and CMD metabolomics data were integrated and analysed using in silico and data modelling approaches. We used both unsupervised and supervised multivariate analysis techniques to investigate structures within the time series and associations with patient outcome. Findings The multivariate metabolite time series exhibited two characteristic brain metabolic states that were attributed to changes in key metabolites: valine, 4-methyl-2-oxovaleric acid (4-MOV), isobeta-hydroxybutyrate (iso-bHB), tyrosyine, and 2-ketoisovaleric acid (2-KIV). These identified cerebral metabolic states differed significantly with respect to standard clinical values. We validated our findings in a second cohort using a classification model trained on the cerebral metabolic states. We demonstrated that short-term (therapeutic intensity level (TIL)) and mid-term patient outcome (6-month Glasgow Outcome Score (GOS)) can be predicted from the time series characteristics. Interpretation We identified two specific cerebral metabolic patterns that are closely linked to ketometabolism and were associated with both TIL and GOS. Our findings support the view that advanced metabolomics approaches combined with CMD may be applied in real-time to predict short-term treatment intensity and long-term patient outcome.
Collapse
|
39
|
Intracranial pressure management in patients with traumatic brain injury: an update. Curr Opin Crit Care 2018; 23:110-114. [PMID: 28157822 DOI: 10.1097/mcc.0000000000000393] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Intracranial pressure (ICP) monitoring and treatment is central in the management of traumatic brain injury. Despite 4 decades of clinical use, several aspects remain controversial, including the indications for ICP and treatment options. RECENT FINDINGS Two major trials tested surgical decompression and mild hypothermia as treatments for high ICP. Both were rigorous, randomized, multicenter studies, with different designs. Decompression was tested for ICP refractory to conventional treatment, whereas hypothermia was offered as an alternative to conventional medical therapy. Decompression reduced mortality, but at the expense of more disability. The hypothermia trial was stopped because of a worse outcome in the treated arm. Indications for ICP monitoring have been reviewed and new international guidelines issued. New contributions published in 2016 have dealt with computerized analysis for predicting ICP crises; noninvasive or innovative methods for measuring ICP; reassessment of standard therapeutic interventions, such as hypertonic solutions and the level of intensity of ICP therapy. SUMMARY Aggressive strategies for ICP control, like surgical decompression or hypothermia, carefully tested, have controversial effects on outcome. Several articles have made worthwhile contributions to important clinical issues, but with no real breakthroughs.
Collapse
|
40
|
|
41
|
Cnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, Nelson D, Ercole A, Stocchetti N, Citerio G, Peul WC, Maas AIR, Menon D, Steyerberg EW, Lingsma HF. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:233. [PMID: 28874206 PMCID: PMC5586023 DOI: 10.1186/s13054-017-1816-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/10/2017] [Indexed: 11/23/2022]
Abstract
Background No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI. Methods A 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Results The survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%). Conclusions Substantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1816-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
| | - Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | |
Collapse
|