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Mastandrea P, Mengozzi S, Bernardini S. Systematic review and meta-analysis of observational studies evaluating glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCHL1) as blood biomarkers of mild acute traumatic brain injury (mTBI) or sport-related concussion (SRC) in adult subjects. Diagnosis (Berl) 2024:dx-2024-0078. [PMID: 39167371 DOI: 10.1515/dx-2024-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/14/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Neurotrauma is the leading cause of death in individuals <45 years old. Many of the published articles on UCHL1 and GFAP lack rigorous methods and reporting. CONTENT Due to the high heterogeneity between studies, we evaluated blood GFAP and UCHL1 levels in the same subjects. We determined the biomarker congruence among areas under the ROC curves (AUCs), sensitivities, specificities, and laboratory values in ng/L to avoid spurious results. The definitive meta-analysis included 1,880 subjects in eight studies. The items with the highest risk of bias were as follows: cut-off not prespecified and case-control design not avoided. The AUC of GFAP was greater than the AUC of UCHL1, with a lower prediction interval (PI) limit of 50.1 % for GFAP and 37.3 % for UCHL1, and a significantly greater percentage of GFAP Sp. The PI of laboratory results for GFAP and UCHL1 were 0.517-7,518 ng/L (diseased), 1.2-255 ng/L (nondiseased), and 3-4,180 vs. 3.2-1,297 ng/L, respectively. SUMMARY Only the GFAP positive cut-off (255 ng/L) appears to be reliable. The negative COs appear unreliable. OUTLOOK GFAP needs better standardization. However, the AUCs of the phospho-Tau and phospho-Tau/Tau proteins resulted not significantly lower than AUC of GFAP, but this result needs further verifications.
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Affiliation(s)
- Paolo Mastandrea
- Department of Clinical Pathology, 90384 Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità San Giuseppe Moscati , Salerno, Italy
| | - Silvia Mengozzi
- U.O. Patologia Clinica, AUSL della Romagna, Laboratorio Unico, Cesena, Forli'-Cesena, Italy
| | - Sergio Bernardini
- Department of Experimental Medicine and Surgery, "Tor Vergata" University Hospital, Rome, Rome, Italy
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Oris C, Kahouadji S, Bouvier D, Sapin V. Blood Biomarkers for the Management of Mild Traumatic Brain Injury in Clinical Practice. Clin Chem 2024; 70:1023-1036. [PMID: 38656380 DOI: 10.1093/clinchem/hvae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/15/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Despite the use of validated guidelines in the management of mild traumatic brain injury (mTBI), processes to limit unnecessary brain scans are still not sufficient and need to be improved. The use of blood biomarkers represents a relevant adjunct to identify patients at risk for intracranial injury requiring computed tomography (CT) scan. CONTENT Biomarkers currently recommended in the management of mTBI in adults and children are discussed in this review. Protein S100 beta (S100B) is the best-documented blood biomarker due to its validation in large observational and interventional studies. Glial fibrillary acidic protein (GFAP) and ubiquitin carboxyterminal hydrolase L-1 (UCH-L1) have also recently demonstrated their usefulness in patients with mTBI. Preanalytical, analytical, and postanalytical performance are presented to aid in their interpretation in clinical practice. Finally, new perspectives on biomarkers and mTBI are discussed. SUMMARY In adults, the inclusion of S100B in Scandinavian and French guidelines has reduced the need for CT scans by at least 30%. S100B has significant potential as a diagnostic biomarker, but limitations include its rapid half-life, which requires blood collection within 3 h of trauma, and its lack of neurospecificity. In 2018, the FDA approved the use of combined determination of GFAP and UCH-L1 to aid in the assessment of mTBI. Since 2022, new French guidelines also recommend the determination of GFAP and UCH-L1 in order to target a larger number of patients (sampling within 12 h post-injury) and optimize the reduction of CT scans. In the future, new cut-offs related to age and promising new biomarkers are expected for both diagnostic and prognostic applications.
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Affiliation(s)
- Charlotte Oris
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
- CNRS, INSERM, iGReD, Clermont Auvergne University, Clermont-Ferrand, France
| | - Samy Kahouadji
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
- CNRS, INSERM, iGReD, Clermont Auvergne University, Clermont-Ferrand, France
| | - Damien Bouvier
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
- CNRS, INSERM, iGReD, Clermont Auvergne University, Clermont-Ferrand, France
| | - Vincent Sapin
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
- CNRS, INSERM, iGReD, Clermont Auvergne University, Clermont-Ferrand, France
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Aksoy HU, Yılmaz C, Orak SA, Ayça S, Polat M. Evaluation of GFAP, S100B, and UCHL-1 Levels in Children With Refractory Epilepsy. J Child Neurol 2024; 39:317-323. [PMID: 39155641 DOI: 10.1177/08830738241273339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
INTRODUCTION A number of biomarkers are used to evaluate the duration of the epileptic seizure and the interictal period following neuronal injury. Invasive diagnostic methods are increasingly being replaced by peripheral or minimally invasive biomarkers that give results faster and are more secure. PURPOSE We aimed to evaluate serum glial fibrillary acidic protein (GFAP), S100B, and ubiquitin C-terminal hydrolase (UCHL-1) levels in children with epilepsy. METHODS Our study included 3 groups: a nonrefractory epilepsy group, a refractory epilepsy group, and a control group. The GFAP, S100B, and UCHL-1 levels in serum samples collected 2-24 hours after the last seizure were analyzed using enzyme-linked immunosorbent assays. RESULTS A total of 69 children participated in the study, with 35 participants in the refractory epilepsy group, 18 in the nonrefractory epilepsy group, and 16 in the control group. The GFAP values in the refractory (25.4 ng/mL) and nonrefractory (26.1 ng/mL) epilepsy groups were found to be statistically significantly higher than those in the control group (17.9 ng/mL; P = .001). The S100B values were found to be significantly higher in the refractory epilepsy group (34.13 pg/mL) than in both the control group and the nonrefractory epilepsy group (28.05 pg/mL; P = .028). No significant differences were observed in the UCHL-1 levels between the 3 groups. CONCLUSIONS We conclude that the observed differences may be due to the increased expression of S100B and GFAP caused by increased and repetitive neuronal damage in refractory epilepsies compared with nonrefractory epilepsies.
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Affiliation(s)
- Halil Ural Aksoy
- Department of Pediatric Neurology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Celil Yılmaz
- Department of Pediatric Neurology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Sibgatullah Ali Orak
- Department of Pediatric Neurology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Senem Ayça
- Department of Pediatric Neurology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Muzaffer Polat
- Department of Pediatric Neurology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
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Lorton F, Lagares A, de la Cruz J, Méjan O, Pavlov V, Sapin V, Poca MA, Lehner M, Biberthaler P, Chauviré-Drouard A, Gras-Le-Guen C, Scherdel P. Performance of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) biomarkers in predicting CT scan results and neurological outcomes in children with traumatic brain injury (BRAINI-2 paediatric study): protocol of a European prospective multicentre study. BMJ Open 2024; 14:e083531. [PMID: 38754888 PMCID: PMC11097883 DOI: 10.1136/bmjopen-2023-083531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION In light of the burden of traumatic brain injury (TBI) in children and the excessive number of unnecessary CT scans still being performed, new strategies are needed to limit their use while minimising the risk of delayed diagnosis of intracranial lesions (ICLs). Identifying children at higher risk of poor outcomes would enable them to be better monitored. The use of the blood-based brain biomarkers glial fibrillar acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) could help clinicians in this decision. The overall aim of this study is to provide new knowledge regarding GFAP and UCH-L1 in order to improve TBI management in the paediatric population. METHODS AND ANALYSIS We will conduct a European, prospective, multicentre study, the BRAINI-2 paediatric study, in 20 centres in France, Spain and Switzerland with an inclusion period of 30 months for a total of 2880 children and adolescents included. To assess the performance of GFAP and UCH-L1 used separately and in combination to predict ICLs on CT scans (primary objective), 630 children less than 18 years of age with mild TBI, defined by a Glasgow Coma Scale score of 13-15 and with a CT scan will be recruited. To evaluate the potential of GFAP and UCH-L1 in predicting the prognosis after TBI (secondary objective), a further 1720 children with mild TBI but no CT scan as well as 130 children with moderate or severe TBI will be recruited. Finally, to establish age-specific reference values for GFAP and UCH-L1 (secondary objective), we will include 400 children and adolescents with no history of TBI. ETHICS AND DISSEMINATION This study has received ethics approval in all participating countries. Results from our study will be disseminated in international peer-reviewed journals. All procedures were developed in order to assure data protection and confidentiality. TRIAL REGISTRATION NUMBER NCT05413499.
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Affiliation(s)
- Fleur Lorton
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
| | - Alfonso Lagares
- Department of Neurosurgery,Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria imas12, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier de la Cruz
- Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria imas12, RICORS-SAMID, Madrid, Spain
| | - Odile Méjan
- Research and Development Immunoassay, bioMerieux SA, Marcy l'Etoile, France
| | | | - Vincent Sapin
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maria Antonia Poca
- Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit,Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Markus Lehner
- Department of Pediatric Surgery, Children's Hospital Lucerne, University of Lucerne, CH-6000 Lucerne, Switzerland
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Ismaningerstr 22, Technical University Munich, Munich, Germany
| | - Anne Chauviré-Drouard
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
| | - Christèle Gras-Le-Guen
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
| | - Pauline Scherdel
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
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Wickbom F, Calcagnile O, Marklund N, Undén J. Validation of the Scandinavian guidelines for minor and moderate head trauma in children: protocol for a pragmatic, prospective, observational, multicentre cohort study. BMJ Open 2024; 14:e078622. [PMID: 38569695 PMCID: PMC11146355 DOI: 10.1136/bmjopen-2023-078622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation. OBJECTIVE We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway. METHODS AND ANALYSIS This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value. ETHICS AND DISSEMINATION The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective. TRIAL REGISTRATION NUMBER NCT05964764.
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Affiliation(s)
- Fredrik Wickbom
- Department of Clinical Sciences, Malmö, Lund University Faculty of Medicine, Lund, Sweden
- Department of Operation and Intensive Care, Halland Hospital Halmstad, Region Halland, Halmstad, Sweden
| | - Olga Calcagnile
- Department of Paediatric Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences, Lund University, Lund University, Lund, Sweden
- Department of Neurosurgery, Skåne University Hospital Lund, Lund, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halland Hospital Halmstad, Region Halland, Halmstad, Sweden
- Lund University, Lund, Sweden
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Malhotra AK, Ide K, Salaheen Z, Mahood Q, Cunningham J, Hutchison J, Guerguerian AM. Acute Fluid Biomarkers for Diagnosis and Prognosis in Children with Mild Traumatic Brain Injury: A Systematic Review. Mol Diagn Ther 2024; 28:169-187. [PMID: 38133736 DOI: 10.1007/s40291-023-00685-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND OBJECTIVE Fluid biomarkers have the potential to improve the accuracy of diagnosis and prognosis in children with mild traumatic brain injury. Our primary objective was to assess the diagnostic and prognostic utility of acute blood and fluid biomarkers in children with mild traumatic brain injury. METHODS We performed a systematic review of the published literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Fluid biomarker studies assessing pediatric mild traumatic brain injury diagnosis or prognosis were included if blood or fluids were sampled within 24 h of injury. RESULTS Thirty-two studies involving 4743 patients were included comprising 25 diagnostic studies and ten prognostic studies with three studies assessing both diagnosis and prognosis. Sixteen of the 25 diagnostic studies reported the area under the receiver operating characteristic curve (AUC) for predicting abnormal computed tomography scans of the head; S100 calcium binding protein B (S100B, N = 6 studies, AUC range 0.67-1.00), glial fibrillary acidic protein (N = 5, AUC range 0.41-0.85), ubiquitin C-terminal hydrolase (N = 3, AUC 0.59 and 0.83), neuron specific enolase (N = 1, AUC 0.99), total tau (N = 1, AUC 0.65), and interleukin-6 (N = 1, AUC 0.61). In four of the ten prognostic studies, increased acute serum S100B levels, tumor necrosis factor-α, or interleukin-8 were associated with post-concussive symptoms or fatigue from 3 to 12 months post-injury. CONCLUSIONS The largest amount of evidence supported the potential use of S100B, glial fibrillary acidic protein, and UCH-L1, but there was mixed accuracy for diagnosis and prognostication for all biomarkers in pediatric mTBI.
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Affiliation(s)
- Armaan K Malhotra
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Kentaro Ide
- Department of Critical Care and Anesthesia, The National Center for Child Health and Development, Tokyo, Japan
| | - Zaid Salaheen
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Quenby Mahood
- Reference Library, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jessie Cunningham
- Reference Library, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jamie Hutchison
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Neuroscience and Mental Health Research Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Neuroscience and Mental Health Research Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Tsakiris C, Siempis T, Lianos GD, Vlachodimitropoulou L, Voulgaris S, Alexiou GA. Blood biomarkers: a new solution to the silent pandemic of traumatic brain injury. Biomark Med 2023; 17:783-785. [PMID: 38223950 DOI: 10.2217/bmm-2023-0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Affiliation(s)
- Charalampos Tsakiris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45110, Greece
| | - Timoleon Siempis
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45110, Greece
| | - Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina, Ioannina, 45110, Greece
| | | | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45110, Greece
| | - George A Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45110, Greece
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Iverson GL, Minkkinen M, Karr JE, Berghem K, Zetterberg H, Blennow K, Posti JP, Luoto TM. Examining four blood biomarkers for the detection of acute intracranial abnormalities following mild traumatic brain injury in older adults. Front Neurol 2022; 13:960741. [PMID: 36484020 PMCID: PMC9723459 DOI: 10.3389/fneur.2022.960741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/20/2022] [Indexed: 01/25/2023] Open
Abstract
Blood-based biomarkers have been increasingly studied for diagnostic and prognostic purposes in patients with mild traumatic brain injury (MTBI). Biomarker levels in blood have been shown to vary throughout age groups. Our aim was to study four blood biomarkers, glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neurofilament light (NF-L), and total tau (t-tau), in older adult patients with MTBI. The study sample was collected in the emergency department in Tampere University Hospital, Finland, between November 2015 and November 2016. All consecutive adult patients with head injury were eligible for inclusion. Serum samples were collected from the enrolled patients, which were frozen and later sent for biomarker analyses. Patients aged 60 years or older with MTBI, head computed tomography (CT) imaging, and available biomarker levels were eligible for this study. A total of 83 patients (mean age = 79.0, SD = 9.58, range = 60-100; 41.0% men) were included in the analysis. GFAP was the only biomarker to show statistically significant differentiation between patients with and without acute head CT abnormalities [U(83) = 280, p < 0.001, r = 0.44; area under the curve (AUC) = 0.79, 95% CI = 0.67-0.91]. The median UCH-L1 values were modestly greater in the abnormal head CT group vs. normal head CT group [U (83) = 492, p = 0.065, r = 0.20; AUC = 0.63, 95% CI = 0.49-0.77]. Older age was associated with biomarker levels in the normal head CT group, with the most prominent age associations being with NF-L (r = 0.56) and GFAP (r = 0.54). The results support the use of GFAP in detecting abnormal head CT findings in older adults with MTBIs. However, small sample sizes run the risk for producing non-replicable findings that may not generalize to the population and do not translate well to clinical use. Further studies should consider the potential effect of age on biomarker levels when establishing clinical cut-off values for detecting head CT abnormalities.
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Affiliation(s)
- Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and the Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, MA, United States,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, United States
| | - Mira Minkkinen
- Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Justin E. Karr
- Department of Psychology, University of Kentucky, Lexington, KY, United States
| | - Ksenia Berghem
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden,UK Dementia Research Institute at University College London, London, United Kingdom,Department of Neurodegenerative Disease, University College London Queen Square Institute of Neurology, London, United Kingdom,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, Hong Kong SAR, China
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jussi P. Posti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, Turku, Finland,Turku Brain Injury Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Teemu M. Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland,*Correspondence: Teemu M. Luoto
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Papa L, Rosenthal K, Cook L, Caire M, Thundiyil JG, Ladde JG, Garfinkel A, Braga CF, Tan CN, Ameli NJ, Lopez MA, Haeussler CA, Mendez Giordano D, Giordano PA, Ramirez J, Mittal MK, Zonfrillo MR. Concussion severity and functional outcome using biomarkers in children and youth involved in organized sports, recreational activities and non-sport related incidents. Brain Inj 2022; 36:939-947. [PMID: 35904331 DOI: 10.1080/02699052.2022.2106383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
This prospective multicenter study evaluated differences in concussion severity and functional outcome using glial and neuronal biomarkers glial Fibrillary Acidic (GFAP) and Ubiquitin C-terminal Hydrolase (UCH-L1) in children and youth involved in non-sport related trauma, organized sports, and recreational activities. Children and youth presenting to three Level 1 trauma centersfollowing blunt head trauma with a GCS 15 with a verified diagnosis of a concussion were enrolled within 6 hours of injury. Traumatic intracranial lesions on CT scan and functional outcome within 3 months of injury were evaluated. 131 children and youth with concussion were enrolled, 81 in the no sports group, 22 in the organized sports group and 28 in the recreational activities group. Median GFAP levels were 0.18, 0.07, and 0.39 ng/mL in the respective groups (p = 0.014). Median UCH-L1 levels were 0.18, 0.27, and 0.32 ng/mL respectively (p = 0.025). A CT scan of the head was performed in 110 (84%) patients. CT was positive in 5 (7%), 4 (27%), and 5 (20%) patients, respectively. The AUC for GFAP for detecting +CT was 0.84 (95%CI 0.75-0.93) and for UCH-L1 was 0.82 (95%CI 0.71-0.94). In those without CT lesions, elevations in UCH-L1 were significantly associated with unfavorable 3-month outcome. Concussions in the 3 groups were of similar severity and functional outcome. GFAP and UCH-L1 were both associated with severity of concussion and intracranial lesions, with the most elevated concentrations in recreational activities .
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | | | - Laura Cook
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Michael Caire
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Josef G Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Jay G Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Alec Garfinkel
- College of Medicine, California North state University, Elk Grove, California, USA
| | - Carolina F Braga
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Ciara N Tan
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Neema J Ameli
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Marco A Lopez
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Crystal A Haeussler
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Diego Mendez Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Philip A Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Jose Ramirez
- Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Manoj K Mittal
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark R Zonfrillo
- Department of Emergency Medicine, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
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Ubiquitin carboxyl-terminal esterase L1 is not elevated in the serum of concussed rugby players: an observational cross-sectional study. Sci Rep 2022; 12:12230. [PMID: 35851288 PMCID: PMC9293898 DOI: 10.1038/s41598-022-16447-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Concussion diagnosis is complicated by a lack of objective measures. Ubiquitin carboxyl-terminal esterase L1 (UCHL1) is a biomarker that has been shown to increase following traumatic brain injury but has not been investigated in concussed athletes on the sideline of athletic events. Therefore, this study was conducted to determine if UCHL1 can be used to aid in sideline concussion diagnosis. Blood was taken via standard venipuncture from a recreationally active control group, a group of rugby players prior to match play (pre-match), rugby players following match-play (match-control), and rugby players after suffering a sport-related concussion (SRC). UCHL1 was not significantly different among groups (p > 0.05) and was unable to distinguish between SRC and controls (AUROC < 0.400, p > 0.05). However, when sex-matched data were used, it was found that the female match-control group had a significantly higher serum UCHL1 concentration than the pre-match group (p = 0.041). Differences were also found in serum UCHL1 concentrations between male and female athletes in the match-control group (p = 0.007). This study does not provide evidence supporting the use of UCHL1 in sideline concussion diagnosis when blood is collected soon after concussion but does show differences in serum UCHL1 accumulation between males and females.
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11
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Podolak OE, Arbogast KB, Master CL, Sleet D, Grady MF. Pediatric Sports-Related Concussion: An Approach to Care. Am J Lifestyle Med 2022; 16:469-484. [PMID: 35860366 PMCID: PMC9290185 DOI: 10.1177/1559827620984995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/18/2020] [Accepted: 12/11/2020] [Indexed: 08/14/2023] Open
Abstract
Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.
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Affiliation(s)
- Olivia E. Podolak
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Sleet
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew F. Grady
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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12
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Nwafor DC, Brichacek AL, Foster CH, Lucke-Wold BP, Ali A, Colantonio MA, Brown CM, Qaiser R. Pediatric Traumatic Brain Injury: An Update on Preclinical Models, Clinical Biomarkers, and the Implications of Cerebrovascular Dysfunction. J Cent Nerv Syst Dis 2022; 14:11795735221098125. [PMID: 35620529 PMCID: PMC9127876 DOI: 10.1177/11795735221098125] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 04/14/2022] [Indexed: 11/15/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality. Recent studies suggest that children and adolescents have worse post-TBI outcomes and take longer to recover than adults. However, the pathophysiology and progression of TBI in the pediatric population are studied to a far lesser extent compared to the adult population. Common causes of TBI in children are falls, sports/recreation-related injuries, non-accidental trauma, and motor vehicle-related injuries. A fundamental understanding of TBI pathophysiology is crucial in preventing long-term brain injury sequelae. Animal models of TBI have played an essential role in addressing the knowledge gaps relating to pTBI pathophysiology. Moreover, a better understanding of clinical biomarkers is crucial to diagnose pTBI and accurately predict long-term outcomes. This review examines the current preclinical models of pTBI, the implications of pTBI on the brain’s vasculature, and clinical pTBI biomarkers. Finally, we conclude the review by speculating on the emerging role of the gut-brain axis in pTBI pathophysiology.
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Affiliation(s)
- Divine C. Nwafor
- Department of Neuroscience, West Virginia University School of Medicine, Morgantown, WV, USA
- West Virginia University School of Medicine, Morgantown, WV, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Allison L. Brichacek
- Department of Microbiology, Immunology, and Cell Biology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Chase H. Foster
- Department of Neurosurgery, George Washington University Hospital, Washington D.C., USA
| | | | - Ahsan Ali
- Department of Neuroscience, West Virginia University School of Medicine, Morgantown, WV, USA
| | | | - Candice M. Brown
- Department of Neuroscience, West Virginia University School of Medicine, Morgantown, WV, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Rabia Qaiser
- Department of Neurosurgery, Baylor Scott and White, Temple, TX, USA
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13
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Papa L, Ladde JG, O’Brien JF, Thundiyil JG, Tesar J, Leech S, Cassidy DD, Roa J, Hunter C, Miller S, Baker S, Parrish GA, Davison J, Van Dillen C, Ralls GA, Briscoe J, Falk JL, Weber K, Giordano PA. Evaluation of Glial and Neuronal Blood Biomarkers Compared With Clinical Decision Rules in Assessing the Need for Computed Tomography in Patients With Mild Traumatic Brain Injury. JAMA Netw Open 2022; 5:e221302. [PMID: 35285924 PMCID: PMC9907341 DOI: 10.1001/jamanetworkopen.2022.1302] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE In 2018, the combination of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) levels became the first US Food and Drug Administration-approved blood test to detect intracranial lesions after mild to moderate traumatic brain injury (MTBI). How this blood test compares with validated clinical decision rules remains unknown. OBJECTIVES To compare the performance of GFAP and UCH-L1 levels vs 3 validated clinical decision rules for detecting traumatic intracranial lesions on computed tomography (CT) in patients with MTBI and to evaluate combining biomarkers with clinical decision rules. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study from a level I trauma center enrolled adults with suspected MTBI presenting within 4 hours of injury. The clinical decision rules included the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study II (NEXUS II) criteria. Emergency physicians prospectively completed data forms for each clinical decision rule before the patients' CT scans. Blood samples for measuring GFAP and UCH-L1 levels were drawn, but laboratory personnel were blinded to clinical results. Of 2274 potential patients screened, 697 met eligibility criteria, 320 declined to participate, and 377 were enrolled. Data were collected from March 16, 2010, to March 5, 2014, and analyzed on August 11, 2021. MAIN OUTCOMES AND MEASURES The presence of acute traumatic intracranial lesions on head CT scan (positive CT finding). RESULTS Among enrolled patients, 349 (93%) had a CT scan performed and were included in the analysis. The mean (SD) age was 40 (16) years; 230 patients (66%) were men, 314 (90%) had a Glasgow Coma Scale score of 15, and 23 (7%) had positive CT findings. For the CCHR, sensitivity was 100% (95% CI, 82%-100%), specificity was 33% (95% CI, 28%-39%), and negative predictive value (NPV) was 100% (95% CI, 96%-100%). For the NOC, sensitivity was 100% (95% CI, 82%-100%), specificity was 16% (95% CI, 12%-20%), and NPV was 100% (95% CI, 91%-100%). For NEXUS II, sensitivity was 83% (95% CI, 60%-94%), specificity was 52% (95% CI, 47%-58%), and NPV was 98% (95% CI, 94%-99%). For GFAP and UCH-L1 levels combined with cutoffs at 67 and 189 pg/mL, respectively, sensitivity was 100% (95% CI, 82%-100%), specificity was 25% (95% CI, 20%-30%), and NPV was 100%; with cutoffs at 30 and 327 pg/mL, respectively, sensitivity was 91% (95% CI, 70%-98%), specificity was 20% (95% CI, 16%-24%), and NPV was 97%. The area under the receiver operating characteristic curve (AUROC) for GFAP alone was 0.83; for GFAP plus NEXUS II, 0.83; for GFAP plus NOC, 0.85; and for GFAP plus CCHR, 0.88. The AUROC for UCH-L1 alone was 0.72; for UCH-L1 plus NEXUS II, 0.77; for UCH-L1 plus NOC, 0.77; and for UCH-L1 plus CCHR, 0.79. The GFAP biomarker alone (without UCH-L1) contributed the most improvement to the clinical decision rules. CONCLUSIONS AND RELEVANCE In this cohort study, the CCHR, the NOC, and GFAP plus UCH-L1 biomarkers had equally high sensitivities, and the CCHR had the highest specificity. However, using different cutoff values reduced both sensitivity and specificity of GFAP plus UCH-L1. Use of GFAP significantly improved the performance of the clinical decision rules, independently of UCH-L1. Together, the CCHR and GFAP had the highest diagnostic performance.
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jay G. Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - John F. O’Brien
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Josef G. Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - James Tesar
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - David D. Cassidy
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jesus Roa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Christopher Hunter
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Susan Miller
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Sara Baker
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Gary A. Parrish
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Christine Van Dillen
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - George A. Ralls
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Joshua Briscoe
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jay L. Falk
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Kurt Weber
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Philip A. Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
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14
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Whitehouse DP, Vile AR, Adatia K, Herlekar R, Roy AS, Mondello S, Czeiter E, Amrein K, Büki A, Maas AIR, Menon DK, Newcombe VFJ. Blood Biomarkers and Structural Imaging Correlations Post-Traumatic Brain Injury: A Systematic Review. Neurosurgery 2022; 90:170-179. [PMID: 34995235 DOI: 10.1227/neu.0000000000001776] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Blood biomarkers are of increasing importance in the diagnosis and assessment of traumatic brain injury (TBI). However, the relationship between them and lesions seen on imaging remains unclear. OBJECTIVE To perform a systematic review of the relationship between blood biomarkers and intracranial lesion types, intracranial lesion injury patterns, volume/number of intracranial lesions, and imaging classification systems. METHODS We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, and Cumulative Index to Nursing and Allied Health Literature from inception to May 2021, and the references of included studies were also screened. Heterogeneity in study design, biomarker types, imaging modalities, and analyses inhibited quantitative analysis, with a qualitative synthesis presented. RESULTS Fifty-nine papers were included assessing one or more biomarker to imaging comparisons per paper: 30 assessed imaging classifications or injury patterns, 28 assessed lesion type, and 11 assessed lesion volume or number. Biomarker concentrations were associated with the burden of brain injury, as assessed by increasing intracranial lesion volume, increasing numbers of traumatic intracranial lesions, and positive correlations with imaging classification scores. There were inconsistent findings associating different biomarkers with specific imaging phenotypes including diffuse axonal injury, cerebral edema, and intracranial hemorrhage. CONCLUSION Blood-based biomarker concentrations after TBI are consistently demonstrated to correlate burden of intracranial disease. The relation with specific injury types is unclear suggesting a lack of diagnostic specificity and/or is the result of the complex and heterogeneous nature of TBI.
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Affiliation(s)
- Daniel P Whitehouse
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | | | - Krishma Adatia
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Rahul Herlekar
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Akangsha Sur Roy
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
- MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary
| | - Krisztina Amrein
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - András Büki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
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15
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Whitehouse DP, Monteiro M, Czeiter E, Vyvere TV, Valerio F, Ye Z, Amrein K, Kamnitsas K, Xu H, Yang Z, Verheyden J, Das T, Kornaropoulos EN, Steyerberg E, Maas AIR, Wang KKW, Büki A, Glocker B, Menon DK, Newcombe VFJ. Relationship of admission blood proteomic biomarkers levels to lesion type and lesion burden in traumatic brain injury: A CENTER-TBI study. EBioMedicine 2022; 75:103777. [PMID: 34959133 PMCID: PMC8718895 DOI: 10.1016/j.ebiom.2021.103777] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We aimed to understand the relationship between serum biomarker concentration and lesion type and volume found on computed tomography (CT) following all severities of TBI. METHODS Concentrations of six serum biomarkers (GFAP, NFL, NSE, S100B, t-tau and UCH-L1) were measured in samples obtained <24 hours post-injury from 2869 patients with all severities of TBI, enrolled in the CENTER-TBI prospective cohort study (NCT02210221). Imaging phenotypes were defined as intraparenchymal haemorrhage (IPH), oedema, subdural haematoma (SDH), extradural haematoma (EDH), traumatic subarachnoid haemorrhage (tSAH), diffuse axonal injury (DAI), and intraventricular haemorrhage (IVH). Multivariable polynomial regression was performed to examine the association between biomarker levels and both distinct lesion types and lesion volumes. Hierarchical clustering was used to explore imaging phenotypes; and principal component analysis and k-means clustering of acute biomarker concentrations to explore patterns of biomarker clustering. FINDINGS 2869 patient were included, 68% (n=1946) male with a median age of 49 years (range 2-96). All severities of TBI (mild, moderate and severe) were included for analysis with majority (n=1946, 68%) having a mild injury (GCS 13-15). Patients with severe diffuse injury (Marshall III/IV) showed significantly higher levels of all measured biomarkers, with the exception of NFL, than patients with focal mass lesions (Marshall grades V/VI). Patients with either DAI+IVH or SDH+IPH+tSAH, had significantly higher biomarker concentrations than patients with EDH. Higher biomarker concentrations were associated with greater volume of IPH (GFAP, S100B, t-tau;adj r2 range:0·48-0·49; p<0·05), oedema (GFAP, NFL, NSE, t-tau, UCH-L1;adj r2 range:0·44-0·44; p<0·01), IVH (S100B;adj r2 range:0.48-0.49; p<0.05), Unsupervised k-means biomarker clustering revealed two clusters explaining 83·9% of variance, with phenotyping characteristics related to clinical injury severity. INTERPRETATION Interpretation: Biomarker concentration within 24 hours of TBI is primarily related to severity of injury and intracranial disease burden, rather than pathoanatomical type of injury. FUNDING CENTER-TBI is funded by the European Union 7th Framework programme (EC grant 602150).
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Affiliation(s)
- Daniel P Whitehouse
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Department of Computing, Imperial College, London, UK
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Rét u. 2, H-7623 Pécs, Hungary; Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Ifjúság útja 20, H-7624 Pécs, Hungary; MTA-PTE Clinical Neuroscience MR Research Group; Pécs, Hungary
| | - Thijs Vande Vyvere
- Research and Development, Icometrix, Leuven, Belgium; Department of Radiology, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Fernanda Valerio
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Zheng Ye
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Krisztina Amrein
- Department of Neurosurgery, Medical School, University of Pécs, Rét u. 2, H-7623 Pécs, Hungary; Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Ifjúság útja 20, H-7624 Pécs, Hungary
| | | | - Haiyan Xu
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, McKnight Brain Institute, L4-100L 1149 South Newell Drive, Gainesville, FL 32611, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, McKnight Brain Institute, L4-100L 1149 South Newell Drive, Gainesville, FL 32611, USA
| | - Jan Verheyden
- Research and Development, Icometrix, Leuven, Belgium
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Ewout Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Wijlrijkstraat 10, 2650 Edegem, Belgium
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, McKnight Brain Institute, L4-100L 1149 South Newell Drive, Gainesville, FL 32611, USA; Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center (VAMC), 1601 SW, Archer Rd. Gainesville FL 32608, USA
| | - András Büki
- Department of Neurosurgery, Medical School, University of Pécs, Rét u. 2, H-7623 Pécs, Hungary; Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Ifjúság útja 20, H-7624 Pécs, Hungary
| | - Ben Glocker
- Biomedical Image Analysis Group, Department of Computing, Imperial College, London, UK
| | - David K Menon
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Virginia F J Newcombe
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK.
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16
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Wang KK, Munoz Pareja JC, Mondello S, Diaz-Arrastia R, Wellington C, Kenney K, Puccio AM, Hutchison J, McKinnon N, Okonkwo DO, Yang Z, Kobeissy F, Tyndall JA, Büki A, Czeiter E, Pareja Zabala MC, Gandham N, Berman R. Blood-based traumatic brain injury biomarkers - Clinical utilities and regulatory pathways in the United States, Europe and Canada. Expert Rev Mol Diagn 2021; 21:1303-1321. [PMID: 34783274 DOI: 10.1080/14737159.2021.2005583] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major global health issue, resulting in debilitating consequences to families, communities, and health-care systems. Prior research has found that biomarkers aid in the pathophysiological characterization and diagnosis of TBI. Significantly, the FDA has recently cleared both a bench-top assay and a rapid point-of-care assays of tandem biomarker (UCH-L1/GFAP)-based blood test to aid in the diagnosis mTBI patients. With the global necessity of TBI biomarkers research, several major consortium multicenter observational studies with biosample collection and biomarker analysis have been created in the USA, Europe, and Canada. As each geographical region regulates its data and findings, the International Initiative for Traumatic Brain Injury Research (InTBIR) was formed to facilitate data integration and dissemination across these consortia. AREAS COVERED This paper covers heavily investigated TBI biomarkers and emerging non-protein markers. Finally, we analyze the regulatory pathways for converting promising TBI biomarkers into approved in-vitro diagnostic tests in the United States, European Union, and Canada. EXPERT OPINION TBI biomarker research has significantly advanced in the last decade. The recent approval of an iSTAT point of care test to detect mild TBI has paved the way for future biomarker clearance and appropriate clinical use across the globe.
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Affiliation(s)
- Kevin K Wang
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.,Brain Rehabilitation Research Center (BRRC), Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Jennifer C Munoz Pareja
- Department of Pediatric Critical Care, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Canada
| | - Kimbra Kenney
- Department of Neurology, Uniformed Service University, Bethesda, Maryland, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jamie Hutchison
- The Hospital for Sick Children, Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole McKinnon
- The Hospital for Sick Children, Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.,Brain Rehabilitation Research Center (BRRC), Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Firas Kobeissy
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.,Brain Rehabilitation Research Center (BRRC), Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - J Adrian Tyndall
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Endre Czeiter
- Department of Neurosurgery, Pecs University, Pecs, Hungary
| | | | - Nithya Gandham
- Program for Neurotrauma, Neuroprotoemics & Biomarker Research, Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rebecca Berman
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
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17
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Traumatic brain injury biomarkers in pediatric patients: a systematic review. Neurosurg Rev 2021; 45:167-197. [PMID: 34170424 DOI: 10.1007/s10143-021-01588-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/23/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
Traumatic brain injury (TBI) is the main cause of pediatric trauma death and disability worldwide. Recent studies have sought to identify biomarkers of TBI for the purpose of assessing functional outcomes. The aim of this systematic review was to evaluate the utility of TBI biomarkers in the pediatric population by summarizing recent findings in the medical literature. A total of 303 articles were retrieved from our search. An initial screening to remove duplicate studies yielded 162 articles. After excluding all articles that did not meet the inclusion criteria, 56 studies were gathered. Among the 56 studies, 36 analyzed serum biomarkers; 11, neuroimaging biomarkers; and 9, cerebrospinal fluid (CSF) biomarkers. Most studies assessed biomarkers in the serum, reflecting the feasibility of obtaining blood samples compared to obtaining CSF or performing neuroimaging. S100B was the most studied serum biomarker in TBI, followed by SNE and UCH-L1, whereas in CSF analysis, there was no unanimity. Among the different neuroimaging techniques employed, diffusion tensor imaging (DTI) was the most common, seemingly holding diagnostic power in the pediatric TBI clinical setting. The number of cross-sectional studies was similar to the number of longitudinal studies. Our data suggest that S100B measurement has high sensitivity and great promise in diagnosing pediatric TBI, ideally when associated with head CT examination and clinical decision protocols. Further large-scale longitudinal studies addressing TBI biomarkers in children are required to establish more accurate diagnostic protocols and prognostic tools.
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18
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Alexiou GA, Lianos GD, Alexiou ES, Voulgaris S. Biomarkers to safely discharge head trauma patients in the COVID-19 pandemic era. Biomark Med 2021; 15:319-321. [PMID: 33666513 PMCID: PMC7958643 DOI: 10.2217/bmm-2021-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- George A Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | | | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
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19
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Elhady M, Youness ER, AbuShady MM, Nassar MS, Elaziz AA, Masoud MM, Foudaa FK, Elhamed WAA. Circulating glial fibrillary acidic protein and ubiquitin carboxy-terminal hydrolase-L1 as markers of neuronal damage in children with epileptic seizures. Childs Nerv Syst 2021; 37:879-884. [PMID: 33044615 DOI: 10.1007/s00381-020-04920-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Epilepsy is a common neurological disease that has a negative impact on physical, social, and cognitive function. Seizure-induced neuronal injury is one of the suggested mechanisms of epilepsy complications. We aimed to evaluate the circulating level of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) as markers of neuronal damage in children with epilepsy and its relation to epilepsy characteristics. STUDY DESIGN METHODS: This case control study included 30 children with epilepsy and 30 healthy children as a control group. Seizure severity was determined based on Chalfont score. Serum level of GFAP and UCH-L1were measured, and their associations with epilepsy characteristics were investigated. RESULTS Circulating levels of GFAP and UCH-L1 were significantly higher in children with epilepsy than in controls (17.440 ± 6.74 and 5.700 ± 1.64 vs 7.06 ± 3.30 and 1.81 ± 0.23, respectively) especially in those with generalized and active seizures. GFAP and UCH-L1 were significantly correlated to the severity of seizures in the previous 6 months. Elevated GFAP level was a predictor for active seizures (OR 1.841, 95%CI 1.043-3.250, P = 0.035). CONCLUSION Circulating GFAP and UCH-L1 expression is increased in children with epilepsy especially those with active seizures. SIGNIFICANCE GFAP and UCH-L 1may serve as peripheral biomarkers for neuronal damage in children with epilepsy that can be used to monitor disease progression and severity for early identification of those with drug-resistant epilepsy and those who are in need for epilepsy surgery.
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Affiliation(s)
- Marwa Elhady
- Pediatric Department, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11735, Egypt.
| | - Eman R Youness
- Medical Biochemistry Department, National Research Centre, Cairo, Egypt
| | | | - Maysa S Nassar
- Child Health Department, National Research Centre, Cairo, Egypt
| | - Ali Abd Elaziz
- Child Health Department, National Research Centre, Cairo, Egypt
| | - Mahmoud M Masoud
- Medical Biochemistry Department, National Research Centre, Cairo, Egypt
| | - Fayez K Foudaa
- Medical Biochemistry Department, National Research Centre, Cairo, Egypt
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20
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Kawata K, Steinfeldt JA, Huibregtse ME, Nowak MK, Macy JT, Kercher K, Rettke DJ, Shin A, Chen Z, Ejima K, Newman SD, Cheng H. Association Between Proteomic Blood Biomarkers and DTI/NODDI Metrics in Adolescent Football Players: A Pilot Study. Front Neurol 2020; 11:581781. [PMID: 33304306 PMCID: PMC7701105 DOI: 10.3389/fneur.2020.581781] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022] Open
Abstract
While neuroimaging and blood biomarker have been two of the most active areas of research in the neurotrauma community, these fields rarely intersect to delineate subconcussive brain injury. The aim of the study was to examine the association between diffusion MRI techniques [diffusion tensor imaging (DTI) and neurite orientation/dispersion density imaging (NODDI)] and brain-injury blood biomarker levels [tau, neurofilament-light (NfL), glial-fibrillary-acidic-protein (GFAP)] in high-school football players at their baseline, aiming to detect cumulative neuronal damage from prior seasons. Twenty-five football players were enrolled in the study. MRI measures and blood samples were obtained during preseason data collection. The whole-brain, tract-based spatial statistics was conducted for six diffusion metrics: fractional anisotropy (FA), mean diffusivity (MD), axial/radial diffusivity (AD, RD), neurite density index (NDI), and orientation dispersion index (ODI). Five players were ineligible for MRIs, and three serum samples were excluded due to hemolysis, resulting in 17 completed set of diffusion metrics and blood biomarker levels for association analysis. Our permutation-based regression model revealed that serum tau levels were significantly associated with MD and NDI in various axonal tracts; specifically, elevated serum tau levels correlated to elevated MD (p = 0.0044) and reduced NDI (p = 0.016) in the corpus callosum and surrounding white matter tracts (e.g., longitudinal fasciculus). Additionally, there was a negative association between NfL and ODI in the focal area of the longitudinal fasciculus. Our data suggest that high school football players may develop axonal microstructural abnormality in the corpus callosum and surrounding white matter tracts, such as longitudinal fasciculus. A future study is warranted to determine the longitudinal multimodal relationship in response to repetitive exposure to sports-related head impacts.
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Affiliation(s)
- Keisuke Kawata
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
- Program in Neuroscience, College of Arts and Sciences, Indiana University, Bloomington, IN, United States
| | - Jesse A. Steinfeldt
- Department of Counseling and Educational Psychology, School of Education, Indiana University, Bloomington, IN, United States
| | - Megan E. Huibregtse
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Madeleine K. Nowak
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Jonathan T. Macy
- Department of Applied Health Science, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Kyle Kercher
- Department of Applied Health Science, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Devin J. Rettke
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Zhongxue Chen
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Keisuke Ejima
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Sharlene D. Newman
- Department of Psychological and Brain Sciences, College of Arts and Sciences, Indiana University, Bloomington, IN, United States
- Alabama Life Research Institute, University of Alabama, Tuscaloosa, AL, United States
| | - Hu Cheng
- Program in Neuroscience, College of Arts and Sciences, Indiana University, Bloomington, IN, United States
- Department of Psychological and Brain Sciences, College of Arts and Sciences, Indiana University, Bloomington, IN, United States
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21
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Mannix R, Levy R, Zemek R, Yeates KO, Arbogast K, Meehan WP, Leddy J, Master C, Mayer AR, Howell DR, Meier TB. Fluid Biomarkers of Pediatric Mild Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2020; 37:2029-2044. [DOI: 10.1089/neu.2019.6956] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Levy
- Medical College of Georgia, Augusta, Georgia, USA
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, and Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kristy Arbogast
- Division of Emergency Medicine, Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William P. Meehan
- Micheli Center for Sports Injury Prevention, Division of Sports Medicine and Department of Pediatrics Boston Children's Hospital, Boston, Massachusetts, USA
| | - John Leddy
- UBMD Department of Orthopedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York, USA
| | - Christina Master
- Sports Medicine and Performance Center, Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew R. Mayer
- Mind Research Network/LBERI and Departments of Psychology, Neurology, and Psychiatry, University of New Mexico, Albuquerque, New Mexico, USA
| | - David R. Howell
- Children's Hospital Colorado Sports Medicine Center and Department of Orthopedics University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Timothy B. Meier
- Departments of Neurosurgery, Cell Biology, Neurobiology and Anatomy, and Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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22
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Tschiffely AE, Statz JK, Edwards KA, Goforth C, Ahlers ST, Carr WS, Gill JM. Assessing a Blast-Related Biomarker in an Operational Community: Glial Fibrillary Acidic Protein in Experienced Breachers. J Neurotrauma 2020; 37:1091-1096. [PMID: 31642374 DOI: 10.1089/neu.2019.6512] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a risk for military personnel due to blast overpressures, which may result from a variety of sources, including artillery and improvised explosive devices. Much research has gone into the search for a biomarker to identify patients with a TBI. The FDA recently identified two proteins, glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1), as biomarkers to evaluate suspected brain injury. Our group previously observed changes in UCH-L1 in a military population exposed to repeated blast. In our current study we assessed GFAP protein levels in a military population exposed to repeated blast during a 2-week training protocol. We observed GFAP levels were reduced in the moderate blast cases on days 6 and 7 during the training. Specifically, moderate blast cases showed a 24.07% reduction from baseline on day 6 and a 29.61% reduction on day 7. Further, GFAP levels were negatively correlated with cumulative blast experienced during training and with duration of military service. We observed that repeated blast exposure at low levels may impact acute changes in GFAP. Additionally subacute cumulative blast exposure or duration of service was also a factor in influencing GFAP levels.
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Affiliation(s)
- Anna E Tschiffely
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland
| | - Jonathan K Statz
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland.,Henry M. Jackson Foundation, Bethesda, Maryland
| | - Katie A Edwards
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Carl Goforth
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stephen T Ahlers
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland
| | - Walter S Carr
- Department of Behavioral Biology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Jessica M Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland.,Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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23
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Hajiaghamemar M, Seidi M, Oeur RA, Margulies SS. Toward development of clinically translatable diagnostic and prognostic metrics of traumatic brain injury using animal models: A review and a look forward. Exp Neurol 2019; 318:101-123. [PMID: 31055005 PMCID: PMC6612432 DOI: 10.1016/j.expneurol.2019.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/11/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury is a leading cause of cognitive and behavioral deficits in children in the US each year. There is an increasing interest in both clinical and pre-clinical studies to discover biomarkers to accurately diagnose traumatic brain injury (TBI), predict its outcomes, and monitor its progression especially in the developing brain. In humans, the heterogeneity of TBI in terms of clinical presentation, injury causation, and mechanism has contributed to the many challenges associated with finding unifying diagnosis, treatment, and management practices. In addition, findings from adult human research may have little application to pediatric TBI, as age and maturation levels affect the injury biomechanics and neurophysiological consequences of injury. Animal models of TBI are vital to address the variability and heterogeneity of TBI seen in human by isolating the causation and mechanism of injury in reproducible manner. However, a gap between the pre-clinical findings and clinical applications remains in TBI research today. To take a step toward bridging this gap, we reviewed several potential TBI tools such as biofluid biomarkers, electroencephalography (EEG), actigraphy, eye responses, and balance that have been explored in both clinical and pre-clinical studies and have shown potential diagnostic, prognostic, or monitoring utility for TBI. Each of these tools measures specific deficits following TBI, is easily accessible, non/minimally invasive, and is potentially highly translatable between animals and human outcomes because they involve effort-independent and non-verbal tasks. Especially conspicuous is the fact that these biomarkers and techniques can be tailored for infants and toddlers. However, translation of preclinical outcomes to clinical applications of these tools necessitates addressing several challenges. Among the challenges are the heterogeneity of clinical TBI, age dependency of some of the biomarkers, different brain structure, life span, and possible variation between temporal profiles of biomarkers in human and animals. Conducting parallel clinical and pre-clinical research, in addition to the integration of findings across species from several pre-clinical models to generate a spectrum of TBI mechanisms and severities is a path toward overcoming some of these challenges. This effort is possible through large scale collaborative research and data sharing across multiple centers. In addition, TBI causes dynamic deficits in multiple domains, and thus, a panel of biomarkers combining these measures to consider different deficits is more promising than a single biomarker for TBI. In this review, each of these tools are presented along with the clinical and pre-clinical findings, advantages, challenges and prospects of translating the pre-clinical knowledge into the human clinical setting.
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Affiliation(s)
- Marzieh Hajiaghamemar
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
| | - Morteza Seidi
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - R Anna Oeur
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Susan S Margulies
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
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24
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Abstract
Over the past 2 decades, concussion care is increasingly in demand as research and media attention shed light on the importance of proper diagnosis and medical management to prevent complex, potentially disabling sequelae. The purpose of this review is to discuss the future of clinical concussion care across selected topics under the broad themes of diagnosis/assessment, intervention/treatment, and patient characteristics/presentations with the intent to direct clinicians' attention to important anticipated developments in the field. The current status of biomarkers, clinical settings, models of clinical concussion, return-to-activity, clinical subpopulations, treatment approaches, patient perceptions of injury, and social media are reviewed along with predictions for future developments.
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Affiliation(s)
- Aliyah R Snyder
- David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Christopher C Giza
- David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Pediatrics, David Geffen School of Medicine and UCLA Mattel Children's Hospital, University of California, Los Angeles, CA
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25
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Su YS, Schuster JM, Smith DH, Stein SC. Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury. J Neurotrauma 2019; 36:2083-2091. [PMID: 30547708 DOI: 10.1089/neu.2018.6020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.
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Affiliation(s)
- YouRong Sophie Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas H Smith
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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26
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Murray DM. Biomarkers in neonatal hypoxic-ischemic encephalopathy-Review of the literature to date and future directions for research. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:281-293. [PMID: 31324315 DOI: 10.1016/b978-0-444-64029-1.00013-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The widespread introduction of therapeutic hypothermia as a standard of care in hypoxic-ischemic encephalopathy (HIE) has brought increasing pressure on clinicians to make an early and accurate assessment of the degree of hypoxic injury (HI) that has occurred and the severity of the encephalopathy that will ensue. No single blood-based marker is currently robust enough to detect significant HI or predict outcome. However, research in the field has been active in the last 10 years and we know that HIE is associated with predictable alterations in the expression of a number of inflammatory proteins, neuron-specific proteins, metabolite pathways, and microRNA. These alterations evolve quickly over the first hours and days of life. Predictive power varies depending on the timing of measurement of the biomarker, the sample type, and the case mix of the cohort examined. Combining clinical data with biochemical measurements is currently the most likely path toward improved detection and prediction of outcome in neonatal HIE.
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Affiliation(s)
- Deirdre M Murray
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
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27
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Papa L, Zonfrillo MR, Welch RD, Lewis LM, Braga CF, Tan CN, Ameli NJ, Lopez MA, Haeussler CA, Mendez Giordano D, Giordano PA, Ramirez J, Mittal MK. Evaluating glial and neuronal blood biomarkers GFAP and UCH-L1 as gradients of brain injury in concussive, subconcussive and non-concussive trauma: a prospective cohort study. BMJ Paediatr Open 2019; 3:e000473. [PMID: 31531405 PMCID: PMC6721136 DOI: 10.1136/bmjpo-2019-000473] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/15/2019] [Accepted: 06/16/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To evaluate the ability of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) to detect concussion in children and adult trauma patients with a normal mental status and assess biomarker concentrations over time as gradients of injury in concussive and non-concussive head and body trauma. DESIGN Large prospective cohort study. SETTING Three level I trauma centres in the USA. PARTICIPANTS Paediatric and adult trauma patients of all ages, with and without head trauma, presenting with a normal mental status (Glasgow Coma Scale score of 15) within 4 hours of injury. Rigorous screening for concussive symptoms was conducted. Of 3462 trauma patients screened, 751 were enrolled and 712 had biomarker data. Repeated blood sampling was conducted at 4, 8, 12, 16, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168 and 180 hours postinjury in adults. MAIN OUTCOMES Detection of concussion and gradients of injury in children versus adults by comparing three groups of patients: (1) those with concussion; (2) those with head trauma without overt signs of concussion (non-concussive head trauma controls) and (3) those with peripheral (body) trauma without head trauma or concussion (non-concussive body trauma controls). RESULTS A total of 1904 samples from 712 trauma patients were analysed. Within 4 hours of injury, there were incremental increases in levels of both GFAP and UCH-L1 from non-concussive body trauma (lowest), to mild elevations in non-concussive head trauma, to highest levels in patients with concussion. In concussion patients, GFAP concentrations were significantly higher compared with body trauma controls (p<0.001) and with head trauma controls (p<0.001) in both children and adults, after controlling for multiple comparisons. However, for UCH-L1, there were no significant differences between concussion patients and head trauma controls (p=0.894) and between body trauma and head trauma controls in children. The AUC for initial GFAP levels to detect concussion was 0.80 (0.73-0.87) in children and 0.76 (0.71-0.80) in adults. This differed significantly from UCH-L1 with AUCs of 0.62 (0.53-0.72) in children and 0.69 (0.64-0.74) in adults. CONCLUSIONS In a cohort of trauma patients with normal mental status, GFAP outperformed UCH-L1 in detecting concussion in both children and adults. Blood levels of GFAP and UCH-L1 showed incremental elevations across three injury groups: from non-concussive body trauma, to non-concussive head trauma, to concussion. However, UCH-L1 was expressed at much higher levels than GFAP in those with non-concussive trauma, particularly in children. Elevations in both biomarkers in patients with non-concussive head trauma may be reflective of a subconcussive brain injury. This will require further study.
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | | | - Robert D Welch
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lawrence M Lewis
- Division of Emergency Medicine, Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Carolina F Braga
- Department of Family Medicine and Community Health, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Ciara N Tan
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Neema J Ameli
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Marco A Lopez
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Crystal A Haeussler
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Diego Mendez Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Philip A Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Jose Ramirez
- Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Manoj K Mittal
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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28
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Fiandaca MS, Mapstone M, Mahmoodi A, Gross T, Macciardi F, Cheema AK, Merchant-Borna K, Bazarian J, Federoff HJ. Plasma metabolomic biomarkers accurately classify acute mild traumatic brain injury from controls. PLoS One 2018; 13:e0195318. [PMID: 29677216 PMCID: PMC5909890 DOI: 10.1371/journal.pone.0195318] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/20/2018] [Indexed: 12/20/2022] Open
Abstract
Past and recent attempts at devising objective biomarkers for traumatic brain injury (TBI) in both blood and cerebrospinal fluid have focused on abundance measures of time-dependent proteins. Similar independent determinants would be most welcome in diagnosing the most common form of TBI, mild TBI (mTBI), which remains difficult to define and confirm based solely on clinical criteria. There are currently no consensus diagnostic measures that objectively define individuals as having sustained an acute mTBI. Plasma metabolomic analyses have recently evolved to offer an alternative to proteomic analyses, offering an orthogonal diagnostic measure to what is currently available. The purpose of this study was to determine whether a developed set of metabolomic biomarkers is able to objectively classify college athletes sustaining mTBI from non-injured teammates, within 6 hours of trauma and whether such a biomarker panel could be effectively applied to an independent cohort of TBI and control subjects. A 6-metabolite panel was developed from biomarkers that had their identities confirmed using tandem mass spectrometry (MS/MS) in our Athlete cohort. These biomarkers were defined at ≤6 hours following mTBI and objectively classified mTBI athletes from teammate controls, and provided similar classification of these groups at the 2, 3, and 7 days post-mTBI. The same 6-metabolite panel, when applied to a separate, independent cohort provided statistically similar results despite major differences between the two cohorts. Our confirmed plasma biomarker panel objectively classifies acute mTBI cases from controls within 6 hours of injury in our two independent cohorts. While encouraged by our initial results, we expect future studies to expand on these initial observations.
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Affiliation(s)
- Massimo S. Fiandaca
- Translational Laboratory and Biorepository, Department of Neurology, University of California Irvine, Irvine, CA United States of America
- Department of Neurological Surgery, University of California Irvine, Irvine, CA United States of America
- Department of Anatomy & Neurobiology, University of California Irvine, Irvine, CA United States of America
| | - Mark Mapstone
- Translational Laboratory and Biorepository, Department of Neurology, University of California Irvine, Irvine, CA United States of America
| | - Amin Mahmoodi
- Translational Laboratory and Biorepository, Department of Neurology, University of California Irvine, Irvine, CA United States of America
| | - Thomas Gross
- Translational Laboratory and Biorepository, Department of Neurology, University of California Irvine, Irvine, CA United States of America
| | - Fabio Macciardi
- Translational Laboratory and Biorepository, Department of Neurology, University of California Irvine, Irvine, CA United States of America
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine, CA United States of America
| | - Amrita K. Cheema
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States of America
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University Medical Center, Washington, DC, United States of America
| | - Kian Merchant-Borna
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America
| | - Jeffrey Bazarian
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America
| | - Howard J. Federoff
- Translational Laboratory and Biorepository, Department of Neurology, University of California Irvine, Irvine, CA United States of America
- * E-mail:
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29
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Kawata K, Mitsuhashi M, Aldret R. A Preliminary Report on Brain-Derived Extracellular Vesicle as Novel Blood Biomarkers for Sport-Related Concussions. Front Neurol 2018; 9:239. [PMID: 29706930 PMCID: PMC5906531 DOI: 10.3389/fneur.2018.00239] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
The purpose of the study was to test the utility of unique panel of blood biomarkers as a means to reflect one’s recovery process after sport-related neurotrauma. We established a panel of biomarkers that reacted positive with CD81 (extracellular vesicle marker) and various neuron- and glia-specific antigens [e.g., neurofilament light polypeptide (NF-L), tau, synaptosome-associated protein 25 (SNAP25), glial fibrillary acidic protein, and myelin basic protein]. We first evaluated test–retest reliabilities of brain-derived exosome markers, followed by an application of these markers in eight professional ice hockey players to detect cumulative neuronal burden from a single ice hockey season. During the season, two players were diagnosed with concussions by team physician based on an exhibition of symptoms as well as abnormality in balance and ocular motor testing. One player reached symptom-free status 7 days after the concussion, while the other player required 36 days for symptoms to completely resolve. Blood samples and clinical assessments including balance error scoring system and near point of convergence throughout recovery process were obtained. Biomarkers indicative of axonal damage, neuronal inflammation, and glial activation showed excellent test–retest reliabilities (intraclass correlation coefficient: 0.713–0.998, p’s < 0.01). There was a statistically significant increase in the NF-L marker at post-season follow-up compared to pre-season baseline (Z = −2.100, P = 0.036); however the statistical significance did not withstand Bonferroni correction for multiple comparisons. In concussion cases, neuronal and microglia markers notably increased after concussions, with the unique expression patterns being similar to that of concussion recovery process. These longitudinal data coupled with excellent test–retest reliabilities of novel array of blood biomarkers potentially reflect the damage in neural cell structures and metabolic crisis due to concussion. However, future studies with larger sample size and appropriate control groups to evaluate sensitivity and specificity of these markers are needed. This preliminary case report suggests the potential utility of multimodal blood biomarkers for concussion prognosis and recovery assessment.
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Affiliation(s)
- Keisuke Kawata
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | | | - Randy Aldret
- School of Kinesiology, University of Louisiana at Lafayette, Lafayette, LA, United States
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Blood biomarkers in paediatric mild traumatic brain injury: a systematic review. Neurosci Biobehav Rev 2018; 87:206-217. [DOI: 10.1016/j.neubiorev.2018.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/09/2018] [Accepted: 02/09/2018] [Indexed: 12/15/2022]
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Ramezani F, Bahrami-Amiri A, Babahajian A, Shahsavari Nia K, Yousefifard M. Ubiquitin C-Terminal Hydrolase-L1 (UCH-L1) in Prediction of Computed Tomography Findings in Traumatic Brain Injury; a Meta-Analysis. EMERGENCY (TEHRAN, IRAN) 2018; 6:e62. [PMID: 30788389 PMCID: PMC6368936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Ubiquitin C-terminal hydrolase-L1 (UCH-L1) is one of the promising candidates, with an acceptable diagnostic value for predicting head computed tomography (CT) scan findings. However, there has been a controversy between studies and still, there is no general overview on this. Therefore, the current systematic review and meta-analysis attempted to estimate the value of UCH-L1 in predicting intracranial lesions in traumatic brain injury. METHODS Two independent reviewers screened records from the search of four databases Medline, Embase, Scopus and Web of Science. The data were analyzed in the STATA 14.0 statistical program and the findings were reported as a standardized mean difference (SMD), summary receiver performance characteristics curve (SROC), sensitivity, specificity, and diagnostic odds ratio with 95% confidence interval (95% CI). RESULTS Finally, the data of 13 articles were entered into the meta-analysis. The mean serum level of UCH-L1 was significantly higher in patients with CT-positive than in TBI patients with CT negative (SMD = 1.67, 95% CI: 1.12 to 2.23, I2 = 98.1%; p <0.0001). The area under the SROC curve for UCH-L1 in the prediction of intracranial lesions after mild TBI was 0.83 (95% CI: 0.80 to 0.86). Sensitivity, specificity and diagnostic odds ratio of serum UCH-L1 was 0.97 (95% CI: 0.92 to 0.99), 0.40 (95% CI: 0.30 to 0.51) and 19.37 (95% CI: 7.25 to 51.75), respectively. When the analysis was limited to assessing the serum level of UCH-L1 within the first 6 hours after mild TBI, its sensitivity and specificity increased to 0.99 (95% CI: 0.94 to 1.0) and 0.44 (95% CI: 0.38 to 0.052), respectively. In addition, the diagnostic odds ratio of 6-hour serum level of UCH-L1 in the prediction of intracranial lesions was 680.87 (95% CI: 50.50 to 9197.97). CONCLUSION Moderate level of evidence suggests that serum/plasma levels of UCH-L1 have good value in prediction of head CT findings. It was also found that evaluation of serum/plasma level of UCH-L1 within the first 6 hours following TBI would increase its predictive value. However, there is a controversy about the best cutoffs of the UCH-L1.
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Affiliation(s)
- Fatemeh Ramezani
- Physiology Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Bahrami-Amiri
- Occupational Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Asrin Babahajian
- Liver and Digestive Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - kavous Shahsavari Nia
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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