Early Systolic Dysfunction Following Traumatic Brain Injury: A Cohort Study

Risk factors and outcomes associated with systolic dysfunction following traumatic brain injury

Systolic dysfunction has been observed following isolated moderate-severe traumatic brain injury (Ims-TBI). However, early risk factors for the development of systolic dysfunction after Ims-TBI and their impact on the prognosis of patients with Ims-TBI have not been thoroughly investigated. A prospective observational study among patients aged 16 to 65 years without cardiac comorbidities who sustained Ims-TBI (Glasgow Coma Scale [GCS] score ≤12) was conducted. Systolic dysfunction was defined as left ventricular ejection fraction <50% or apparent regional wall motion abnormality assessed by transthoracic echocardiography within 24 hours after admission. The primary endpoint was the incidence of systolic dysfunction after Ims-TBI. The secondary endpoint was survival on discharge. Clinical data and outcomes were assessed within 24 hours after admission or during hospitalization. About 23 of 123 patients (18.7%) developed systolic dysfunction after Ims-TBI. Higher admission heart rate (odds ratios [ORs]: 1.05, 95% confidence interval [CI]: 1.02-1.08; P = .002), lower admission GCS score (OR: 0.77, 95% CI: 0.61-0.96; P = .022), and higher admission serum high-sensitivity cardiac troponin T (Hs-cTnT) (OR: 1.14, 95% CI: 1.06-1.22; P < .001) were independently associated with systolic dysfunction among patients with Ims-TBI. A combination of heart rate, GCS score, and serum Hs-cTnT level on admission improved the predictive performance for systolic dysfunction (area under curve = 0.85). Duration of mechanical ventilation, intensive care unit length of stay, and in-hospital mortality of patients with systolic dysfunction was higher than that of patients with normal systolic function (P < .05). Lower GCS (OR: 0.66, 95% CI: 0.45-0.82; P = .001), lower admission oxygen saturation (OR: 0.82, 95% CI: 0.69-0.98; P = .025), and the development of systolic dysfunction (OR: 4.85, 95% CI: 1.36-17.22; P = .015) were independent risk factors for in-hospital mortality in patients with Ims-TBI. Heart rate, GCS, and serum Hs-cTnT level on admission were independent early risk factors for systolic dysfunction in patients with Ims-TBI. The combination of these 3 parameters can better predict the occurrence of systolic dysfunction.

Traumatic Brain Injury and Traumatic Spinal Cord Injury

OBJECTIVE

This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury.

LATEST DEVELOPMENTS

Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated.

ESSENTIAL POINTS

Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.

Cardiac Injury After Traumatic Brain Injury: Clinical Consequences and Management

Traumatic brain injury (TBI) is a significant public health issue because of its increasing incidence and the substantial short-term and long-term burden it imposes. This burden includes high mortality rates, morbidity, and a significant impact on productivity and quality of life for survivors. During the management of TBI, extracranial complications commonly arise during the patient's stay in the intensive care unit. These complications can have an impact on both mortality and the neurological outcome of patients with TBI. Among these extracranial complications, cardiac injury is a relatively frequent occurrence, affecting approximately 25-35% of patients with TBI. The pathophysiology underlying cardiac injury in TBI involves the intricate interplay between the brain and the heart. Acute brain injury triggers a systemic inflammatory response and a surge of catecholamines, leading to the release of neurotransmitters and cytokines. These substances have detrimental effects on the brain and peripheral organs, creating a vicious cycle that exacerbates brain damage and cellular dysfunction. The most common manifestation of cardiac injury in TBI is corrected QT (QTc) prolongation and supraventricular arrhythmias, with a prevalence up to 5 to 10 times higher than in the general adult population. Other forms of cardiac injury, such as regional wall motion alteration, troponin elevation, myocardial stunning, or Takotsubo cardiomyopathy, have also been described. In this context, the use of β-blockers has shown potential benefits by intervening in this maladaptive process. β-blockers can limit the pathological effects on cardiac rhythm, blood circulation, and cerebral metabolism. They may also mitigate metabolic acidosis and potentially contribute to improved cerebral perfusion. However, further clinical studies are needed to elucidate the role of new therapeutic strategies in limiting cardiac dysfunction in patients with severe TBI.

Cardiac cycle timing and contractility following acute sport-related concussion

Cardiac sequelae following sport-related concussion are not well understood. This study describes changes in the cardiac cycle timing intervals and contractility parameters during the acute phase of concussion. Twelve athletes (21 ± 2 years, height = 182 ± 9 cm, mass = 86 ± 15 kg, BMI = 26 ± 3 kg/m2) were assessed within 5 days of sustaining a diagnosed concussion against their own pre-season baseline. A non-invasive cardiac sensor (LLA RecordisTM) was used to record the cardiac cycle parameters of the heart for 1 minute during supine rest. Cardiac cycle timing intervals (Isovolumic relaxation and contraction time, Mitral valve open to E wave, Rapid ejection period, Atrial systole to mitral valve closure, Systole, and Diastole) and contractile forces (Twist force and Atrial systole: AS) were compared. Systolic time significantly decreased during acute concussion (p = 0.034). Magnitude of AS significantly increased during acute concussion (p = 0.013). These results imply that concussion can result in altered systolic function.

Traumatic brain injury and risk of heart failure and coronary heart disease: A nationwide population-based cohort study

BACKGROUND

This study examined the long-term risks of heart failure (HF) and coronary heart disease (CHD) following traumatic brain injury (TBI), focusing on gender differences.

METHODS

Data from Taiwan's National Health Insurance Research Database included 29,570 TBI patients and 118,280 matched controls based on propensity scores.

RESULTS

The TBI cohort had higher incidences of CHD and HF (9.76 vs. 9.07 per 1000 person-years; 4.40 vs. 3.88 per 1000 person-years). Adjusted analyses showed a significantly higher risk of HF in the TBI group (adjusted hazard ratio = 1.08, 95% CI = 1.01-1.17, P = 0.031). The increased CHD risk in the TBI cohort became insignificant after adjustment. Subgroup analysis by gender revealed higher HF risk in men (aHR = 1.14, 95% CI = 1.03-1.25, P = 0.010) and higher CHD risk in women under 50 (aHR = 1.32, 95% CI = 1.15-1.52, P < 0.001). TBI patients without beta-blocker therapy may be at increased risk of HF.

CONCLUSION

Our results suggest that TBI increases the risk of HF and CHD in this nationwide cohort of Taiwanese citizens. Gender influences the risks differently, with men at higher HF risk and younger women at higher CHD risk. Beta-blockers have a neutral effect on HF and CHD risk.

Iron overload enhances TBI-induced cardiac dysfunction by promoting ferroptosis and cardiac inflammation

Previous studies have proved that cardiac dysfunction and myocardial damage can be found in TBI patients, but the underlying mechanisms of myocardial damage induced by TBI can't be illustrated. We want to investigate the function of ferroptosis in myocardial damage after TBI and determine if inhibiting iron overload might lessen myocardial injury after TBI due to the involvement of iron overload in the process of ferroptosis and inflammation. We detect the expression of ferroptosis-related proteins in cardiac tissue at different time points after TBI, indicating that TBI can cause ferroptosis in the heart in vivo. The echocardiography and myocardial enzymes results showed that ferroptosis can aggravate TBI-induced cardiac dysfunction. The result of DHE staining and 4-HNE expression showed that inhibition of ferroptosis can reduce ROS production and lipid peroxidation in myocardial tissue. In further experiments, DFO intervention was used to explore the effect of iron overload inhibition on myocardial ferroptosis after TBI, the production of ROS, expression of p38 MAPK and NF-κB was detected to explore the effect of iron overload on myocardial inflammation after TBI. The results above show that TBI can cause heart ferroptosis in vivo. Inhibition of iron overload can alleviate myocardial injury after TBI by reducing ferroptosis and inflammatory response induced by TBI.

Cardiovascular events in children with brain injury: A systematic review

BACKGROUND

Brain injury is a leading cause of morbidity and mortality in the pediatric population. Neurogenic stunned cardiomyopathy is a complication associated with several neurological conditions that can lead to worse outcomes. It presents as alterations in blood pressure, cardiac rhythm disturbances and the increase in cardiac injury biomarkers. This systematic review aims to assess the hemodynamic consequences of brain injury in the pediatric population to identify better management strategies and improve outcomes.

METHODS

An electronic literature search was performed in Pubmed, Scopus and WebOfScience, up until October 3rd, 2022. The selected articles underwent quality assessment using the National Heart, Lung and Blood Institute tools for cohort and case-control studies.

RESULTS

This systematic review includes thirteen articles on the effects of brain injury in arterial pressure, rhythm disturbances and biomarkers of myocardial injury. These studies showed the following key results: both hypotension and hypertension are associated with worse outcomes; brain injury could be related to longer QTc intervals; neurogenic stunned cardiomyopathy was a common found after brain injury.

CONCLUSION

This is the first systematic review to report cardiovascular abnormalities arising from brain injury in children. An early arterial pressure, electrocardiographic and echocardiographic evaluation, as well as the measure of serum biomarkers for myocardial injury, can be critical in identifying poor prognostic factors. Further research is required to understand the implications of our findings in clinical practice.

Predictive factors for cerebrocardiac syndrome in patients with severe traumatic brain injury: a retrospective cohort study

Background and objective

Cerebrocardiac syndrome (CCS) is a severe complication of severe traumatic brain injury (sTBI) that carries high mortality and disability rates. Early identification of CCS poses a significant clinical challenge. The main objective of this study was to investigate potential risk factors associated with the development of secondary CCS in patients with sTBI. It was hypothesized that elevated right heart Tei index (TI), lower Glasgow Coma Scale (GCS) scores, and elevated cardiac troponin-I (cTnI) levels would independently contribute to the occurrence of CCS in sTBI patients.

Methods

A retrospective cohort study was conducted to identify risk factors for CCS secondary to sTBI. One hundred and fifty-five patients were enrolled with sTBI admitted to the hospital between January 2016 and December 2020 and divided them into a CCS group (n = 75) and a non-CCS group (n = 80) based on the presence of CCS. This study involved the analysis and comparison of clinical data from two patient groups, encompassing demographic characteristics, peripheral oxygen saturation (SPO2), neuron-specific enolase (NSE), cardiac troponin-I (cTnI), N-terminal pro-brain natriuretic peptide (NT-proBNP), optic nerve sheath diameter (ONSD), cardiac ultrasound, acute physiology and chronic health evaluation (APACHE II) scores, and GCS scores and so on. Multivariate logistic regression was employed to identify independent risk factors for CCS, and receiver operating characteristic (ROC) curves were used to assess their predictive value for CCS secondary to sTBI.

Results

The study revealed that 48.4% of sTBI patients developed secondary CCS. In the multivariate analysis model 1 that does not include NT-proBNP and cTnI, ONSD (OR = 2.582, 95% CI: 1.054-6.327, P = 0.038), right heart Tei index (OR = 2.81, 95% CI: 1.288-6.129, P = 0.009), and GCS (OR = 0.212, 95% CI: 0.086-0.521, P = 0.001) were independent risk factors for secondary CCS in sTBI patients. In multivariate analysis model 2 that includes NT-proBNP and cTnI, cTnI (OR = 27.711, 95%CI: 3.086-248.795, P = 0.003), right heart Tei index (OR = 2.736, 95% CI: 1.056-7.091, P = 0.038), and GCS (OR = 0.147, 95% CI: 0.045-0.481, P = 0.002) were independent risk factors for secondary CCS in sTBI patients. The area under the ROC curve for ONSD, Tei index, GCS, and cTnI were 0.596, 0.613, 0.635, and 0.881, respectively. ONSD exhibited a positive predictive value (PPV) of 0.704 and a negative predictive value (NPV) of 0.634. The Tei index demonstrated a PPV of 0.624 and an NPV of 0.726, while GCS had a PPV of 0.644 and an NPV of 0.815. On the other hand, cTnI exhibited a significantly higher PPV of 0.936 and an NPV of 0.817. These findings indicate that the Tei index, GCS score, and cTnI possess certain predictive value for secondary CCS in patients with sTBI.

Conclusions

The study provides valuable insights into the identification of independent risk factors for CCS secondary to sTBI. The findings highlight the significance of right heart Tei index, GCS score, and cTnI as potential predictive factors for CCS in sTBI patients. Further larger-scale studies are warranted to corroborate these findings and to provide robust evidence for the development of early intervention strategies aimed at reducing the incidence of CCS in this patient population.

Trajectories of interleukin 10 and heart fatty acid-binding protein levels in traumatic brain injury patients with or without extracranial injuries

Background

Interleukin 10 (IL-10) and heart fatty acid-binding protein (H-FABP) have gained interest as diagnostic biomarkers of traumatic brain injury (TBI), but factors affecting their blood levels in patients with moderate-to-severe TBI are largely unknown.

Objective

To investigate the trajectories of IL-10 and H-FABP between TBI patients with and without extracranial injuries (ECI); to investigate if there is a correlation between the levels of IL-10 and H-FABP with the levels of inflammation/infection markers C-reactive protein (CRP) and leukocytes; and to investigate if there is a correlation between the admission level of H-FABP with admission levels of cardiac injury markers, troponin (TnT), creatine kinase (CK), and creatine kinase MB isoenzyme mass (CK-MBm).

Materials and methods

The admission levels of IL-10, H-FABP, CRP, and leukocytes were measured within 24 h post-TBI and on days 1, 2, 3, and 7 after TBI. The admission levels of TnT, CK, and CK-MBm were measured within 24 h post-TBI.

Results

There was a significant difference in the concentration of H-FABP between TBI patients with and without ECI on day 0 (48.2 ± 20.5 and 12.4 ± 14.7 ng/ml, p = 0.02, respectively). There was no significant difference in the levels of IL-10 between these groups at any timepoints. There was a statistically significant positive correlation between IL-10 and CRP on days 2 (R = 0.43, p &lt; 0.01) and 7 (R = 0.46, p = 0.03) after injury, and a negative correlation between H-FABP and CRP on day 0 (R = -0.45, p = 0.01). The levels of IL-10 or H-FABP did not correlate with leukocyte counts at any timepoint. The admission levels of H-FABP correlated with CK (R = 0.70, p &lt; 0.001) and CK-MBm (R = 0.61, p &lt; 0.001), but not with TnT.

Conclusion

Inflammatory reactions during the early days after a TBI do not significantly confound the use of IL-10 and H-FABP as TBI biomarkers. Extracranial injuries and cardiac sources may influence the levels of H-FABP in patients with moderate-to-severe TBI.

Impact of Left Ventricular Systolic Function After Moderate-to-Severe Isolated Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Traumatic brain injury (TBI) can result in left ventricular dysfunction, which can lead to hypotension and secondary brain injuries. However, the association between left ventricular systolic dysfunction (LVSD) and in-hospital mortality in patients with moderate-to-severe isolated TBI is controversial. Therefore, we conducted a systematic review and meta-analysis to identify the prevalence of LVSD and evaluate whether LVSD following moderate-to-severe isolated TBI increases the in-hospital mortality. We searched PubMed, EMBASE, and the Cochrane Library database from January 1, 2010, through June 30, 2020. Meta-analysis was performed to determine the incidence of LVSD and related mortality in patients with moderate-to-severe isolated TBI. A systematic review identified 5 articles appropriate for meta-analysis. The total number of patients pooled was 256. LVSD was reported in 4 studies, of which the estimated incidence of patients with LVSD was 18.7% (95% confidence interval, 11.9-26.6). Five studies reported on in-hospital mortality, and the estimated in-hospital mortality was 14.1% (95% confidence interval, 5.3-25.6). Finally, 3 studies were eligible for analyzing the association of LVSD and in-hospital mortality. On meta-analysis, in-hospital mortality was significantly higher in patients with LVSD (risk ratio, 6.57; 95% confidence interval, 3.71-11.65; P < 0.001). In conclusion, LVSD after moderate-to-severe TBI is common and may be associated with worse in-hospital outcomes.

Risk Factors and Neurological Outcomes Associated With Circulatory Shock After Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study

BACKGROUND

Extracranial multisystem organ failure is a common sequela of severe traumatic brain injury (TBI). Risk factors for developing circulatory shock and long-term functional outcomes of this patient subset are poorly understood.

OBJECTIVE

To identify emergency department predictors of circulatory shock after moderate-severe TBI and examine long-term functional outcomes in patients with moderate-severe TBI who developed circulatory shock.

METHODS

We conducted a retrospective cohort study using the Transforming Clinical Research and Knowledge in TBI database for adult patients with moderate-severe TBI, defined as a Glasgow Coma Scale (GCS) score of <13 and stratified by the development of circulatory shock within 72 hours of hospital admission (Sequential Organ Failure Assessment score ≥2). Demographic and clinical data were assessed with descriptive statistics. A forward selection regression model examined risk factors for the development of circulatory shock. Functional outcomes were examined using multivariable regression models.

RESULTS

Of our moderate-severe TBI population (n = 407), 168 (41.2%) developed circulatory shock. Our predictive model suggested that race, computed tomography Rotterdam scores <3, GCS in the emergency department, and development of hypotension in the emergency department were associated with developing circulatory shock. Those who developed shock had less favorable 6-month functional outcomes measured by the 6-month GCS-Extended (odds ratio 0.36, P = .002) and 6-month Disability Rating Scale score (Diff. in means 3.86, P = .002) and a longer length of hospital stay (Diff. in means 11.0 days, P < .001).

CONCLUSION

We report potential risk factors for circulatory shock after moderate-severe TBI. Our study suggests that developing circulatory shock after moderate-severe TBI is associated with poor long-term functional outcomes.

The prognostic value of cardiac troponin T in different age groups of traumatic brain injury patients

BACKGROUND

The cardiac dysfunction has been confirmed as a common non-neurological complication and associated with increased mortality in traumatic brain injury (TBI) patients. As a biological marker of cardiac injury, the cardiac troponin T (TnT) has been verified correlated with the outcome of some non-traumatic brain injury patients. However, the prognostic value of TnT in TBI patients has not been clearly illustrated. We designed this study to explore the association between TnT and the outcome of TBI patients in different age subgroups.

METHODS

Patients diagnosed with TBI in a prospective critical care database were eligible for this study. Univariate logistic regression analysis was firstly performed to explore the relationship between included variables and mortality. Then, the real effect of TnT on the outcome of different age subgroups was analyzed by multivariate logistic regression analysis adjusting the confounding effects of other significant risk factors. Finally, we draw receiver operating characteristic (ROC) curves to evaluate the prognostic value of TnT in different age groups of TBI patients.

RESULTS

520 patients were included in this study with a mortality rate of 20.2%. There were 112 (21.5%) non-elderly patients (age < 65) and 408 (78.5%) elderly patients (age ≥ 65). Non-survivors had a higher percentage of previous acute myocardial infarction (p = 0.019) and pupil no-reaction (p = 0.028; p = 0.011) than survivors. Survivors had higher GCS (p < 0.001) and lower TnT than non-survivors (p < 0.001). TnT was significantly associated with mortality in non-elderly patients (p = 0.031) but not in overall patients (p = 0.143) and elderly patients (p = 0.456) in multivariate logistic regression analysis. The AUC (area under the ROC curve) value of TnT in overall, non-elderly and elderly patients was 0.644, 0.693 and 0.632, respectively. Combining TnT with GCS increased the sensitivity of predicting the poor outcome in both non-elderly and elderly TBI patients.

CONCLUSION

The prognostic value of TnT differed between elderly and non-elderly TBI patients. Level of TnT was associated with mortality of non-elderly TBI patients but not elderly patients. Combining the TnT with GCS could increase the sensitivity of prognosis evaluation.

Left Ventricular Function in the Initial Period After Severe Traumatic Brain Injury in Swine

BACKGROUND

Cardiac dysfunction is common in the days after severe traumatic brain injury (TBI) and may contribute to hypotension episodes, leading to worse outcomes. Little is known about cardiac function in the minutes and hours immediately following TBI. By using fluid percussion TBI in a swine model, we aimed to characterize the immediate post injury cardiac function.

METHODS

Intubated, anesthetized immature (25.8 ± 1.5 kg) female swine were subjected to severe fluid percussion TBI (4.2 ± 0.2 atm). Beginning at 45 min, simulating hospital arrival, all animals were resuscitated with normal saline (NS), mannitol, and phenylephrine as needed to maintain a cerebral perfusion pressure more than 60 mm Hg and intracranial pressure (ICP) less than 20 mm Hg. Primary outcomes of cardiac function were cardiac output measured by thermodilution and transesophageal echo measurements of cardiac function recorded at prespecified time points and tested for trends over time using linear regression with spline at the time of resuscitation onset. Secondary outcomes included hemodynamic measurements, ICP, and cerebral perfusion pressure.

RESULTS

Eighteen animals were included. Post-TBI hemodynamic changes demonstrated an early decrease in mean arterial pressure and cerebral perfusion pressure with a corresponding increase in heart rate and ICP. Immediately after injury, there was a significant decrease in both left atrial area and tissue Doppler imaging e' of the LV lateral wall. In addition, there was a simultaneous increase in LV end diastolic diameter and increase in E/e' ratio of the lateral mitral annulus. All other transesophageal echo measurements demonstrated no significant changes throughout the duration of the experiment.

CONCLUSIONS

Traumatic brain injury is associated with cardiac dysfunction and increased mortality, however there is still a limited understanding of the hemodynamic and echocardiographic response associated with TBI. In this study we demonstrate the hemodynamic and echocardiographic changes in the early stages of TBI in swine. The authors hope that these results may help better understanding on the management of patients with severe head injury.

A prospective observational study of electrocardiographic and echocardiographic changes in traumatic brain injury - effect of surgical decompression

BACKGROUND

Traumatic brain injury (TBI) causes significant changes in myocardial function, which is represented by ECG and echocardiographic changes. We intended to study the effect of surgical decompression on these changes.

MATERIALS AND METHODS

We recruited adult TBI patients undergoing surgery within 48 h of injury. Preoperatively, the patient's demographic and clinical details were recorded. ECG and TTE were performed before surgery and 24 h later (first postoperative day [POD1]). ECG was analyzed for heart rate, PR, QRS, and QTc intervals, morphologic end-repolarization abnormalities (MERA), and ST-segment and T wave changes. TTE data included left ventricular ejection fraction (LVEF) and regional wall motion abnormalities (RWMA). Glasgow coma scale (GCS) at discharge was recorded. ECG and TTE changes before and after surgery were compared, and its association with discharge GCS was analyzed. Preoperative predictors of LV dysfunction were analyzed.

RESULTS

Of the 110 patients recruited, common ECG changes were prolonged QTc interval (42%) and MERA (47%). TTE showed poor LVEF (<50%) in 10% and RWMA in 10.8% of patients. Following surgery, both ECG and TTE changes improved. Preoperative LVEF <50% and/or RWMA were associated with a lower GCS score at discharge. Preoperative poor GCS motor score and prolonged QTc interval were independent predictors of LV dysfunction.

CONCLUSIONS

Poor LV function was associated with poor admission GCS and prolonged QTc interval. Patients with reduced LV function had lower GCS at discharge.

Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management

Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.

Incidence and Clinical Impact of Myocardial Injury Following Traumatic Brain Injury: A Pilot TRACK-TBI Study

BACKGROUND

Traumatic brain injury (TBI) is a major global health problem. Little research has addressed extracranial organ dysfunction following TBI, particularly myocardial injury. Using a sensitive marker of myocardial injury-high sensitivity troponin (hsTn)-we examined the incidence of early myocardial injury following TBI and explored its association with neurological outcomes following moderate-severe TBI.

METHODS

We conducted a pilot cohort study of 133 adult (age above 17 y) subjects enrolled in the TRACK-TBI 18-center prospective cohort study. Descriptive statistics were used to examine the incidence of myocardial injury (defined as hsTn >99th percentile for a standardized reference population) across TBI severities, and to explore the association of myocardial injury with a 6-month extended Glasgow Outcome Score among patients with moderate-severe TBI.

RESULTS

The mean (SD) age of the participants was 44 (17) years, and 87 (65%) were male. Twenty-six patients (20%) developed myocardial injury following TBI; myocardial injury was present in 15% of mild TBI patients and 29% of moderate-severe TBI patients (P=0.13). Median (interquartile range) hsTn values were 3.8 ng/L (2.1, 9.0), 5.8 ng/L (4.5, 34.6), and 10.2 ng/L (3.0, 34.0) in mild, moderate, and severe TBI participants, respectively (P=0.04). Overall, 11% of participants with moderate-severe TBI and myocardial injury experienced a good outcome (6-mo extended Glasgow Outcome Score≥5) at 6 months, compared with 65% in the group that did not experience myocardial injury (P=0.01).

CONCLUSIONS

Myocardial injury is common following TBI, with a likely dose-response relationship with TBI severity. Early myocardial injury was associated with poor 6-month clinical outcomes following moderate-severe TBI.

Perioperative cardiovascular changes in patients with traumatic brain injury: A prospective observational study

Background:

Traumatic brain injury (TBI) is an acutely stressful condition. Stress and conglomeration of various factors predispose to the involvement of other organ systems. The stress response from TBI has been associated with cardiovascular complications reflecting as repolarization abnormalities on electrocardiogram (ECG) to systolic dysfunction on echocardiography. However, the perioperative cardiac functions in patients with TBI have not been evaluated.

Methods:

We conducted a prospective observational study in 60 consecutive adult patients of either sex between the age of 10 and 70 years with an isolated head injury who were taken up for decompressive craniectomy as per institutional protocol. ECG and transthoracic echocardiography was carried out preoperatively and then postoperatively within 24–48 h.

Results:

The mean age of our study population was 39 + 13 years with a median Glasgow coma score of 11. A majority (73%) of our patients suffered moderate TBI. Preoperatively, ECG changes were seen in 48.33% of patients. Postoperatively, ECG changes declined and were seen only in 13.33% of the total patients. Similarly, echocardiography demonstrated preoperative systolic dysfunction in 13.33% of the total study population. Later, it was found that systolic function significantly improved in all the patients after surgery.

Conclusion:

Cardiac dysfunction occurs frequently following TBI. Even patients with mild TBI had preoperative systolic dysfunction on echocardiography. Surgical intervention in the form of hematoma evacuation and decompression was associated with significant regression of both ECG and echocardiographic changes.

Changes in Subendocardial Viability Ratio in Traumatic Brain Injury Patients

Background: Traumatic brain injury (TBI) is often associated with cardiac dysfunction, which is a consequence of the brain-heart cross talk. The subendocardial viability ratio (SEVR) is an estimate of myocardial perfusion. The aim of this study was to analyze changes in the SEVR in patients with severe TBI without previous cardiac diseases. Methods: Adult patients treated for severe TBI with a Glasgow coma score <8 were studied. Pressure waveforms were obtained by a high-fidelity tonometer in the radial artery for SEVR calculation at five time points: immediately after admission to the intensive care unit and 24, 48, 72, and 96 h after admission. SEVRs and other clinically important parameters were analyzed in patients who survived and did not survive after 28 days of treatment, as well as in patients who underwent decompressive craniectomy (DC). Results: A total of 64 patients (16 females and 48 males) aged 18-64 years were included. Fifty patients survived and 14 died. DC was performed in 23 patients. SEVRs decreased 24 h after admission in nonsurvivors (p < 0.05) and after 48 h in survivors (p < 0.01) and its values were significantly lower in nonsurvivors than in survivors at 24, 72, and 96 h from admission (p < 0.05). The SEVR increased following DC (p < 0.05). Conclusions: A decreased SEVR is observed in TBI patients. Surgical decompression increases the SEVR, indicating improvement in coronary microvascular perfusion. The results of our study seem to confirm that brain injury affects myocardium function.

Systemic and local cardiac inflammation after experimental long bone fracture, traumatic brain injury and combined trauma in mice

Background

Trauma is the leading cause of death and disability worldwide, especially in the young population. Cardiac injuries are an independent predictor for a poor overall outcome after trauma. The aim of the present study was to analyze systemic inflammation as well as local cardiac inflammation after experimental limb-, neuro- and combined trauma in mice.

Methods

Male C57BL/6 mice received either a closed tibia fracture (Fx), isolated traumatic brain injury (TBI) or a combination of both (Fx ​+ ​TBI). Control animals underwent sham procedure. After 6 and 24 ​h, systemic levels of inflammatory mediators were analyzed, respectively. Locally, cardiac inflammation and cardiac structural alterations were investigated in left ventricular tissue of mice 6 and 24 ​h after trauma.

Results

Mice showed enhanced systemic inflammation after combined trauma, which was manifested by increased levels of KC, MCP-1 and G-CSF. Locally, mice exhibited increased expression of inflammatory cytokines (IL-1β, TNF) in heart tissue, which was probably mediated via toll-like receptor (TLR) signaling. Furthermore, mice demonstrated a redistribution of connexin 43 in cardiac tissue, which appeared predominantly after combined trauma. Besides inflammation and structural cardiac alterations, expression of glucose transporter 4 (GLUT4) mRNA was increased in the heart early after TBI and after combination of TBI and limb fracture, indicating a modification of energy metabolism. Early after combination of TBI and tibia fracture, nitrosative stress was increased, manifested by elevation of nitrotyrosine in cardiac tissue. Finally, mice showed a trend of increased systemic levels of cardiac troponin I and heart-fatty acid binding protein (HFABP) after combined trauma, which was associated with a significant decrease of troponin I and HFABP mRNA expression in cardiac tissue after TBI and combination of TBI and limb fracture.

Conclusion

Mice exhibited early cardiac alterations as well as alterations in cardiac glucose transporter expression, indicating a modification of energy metabolism, which might be linked to increased systemic- and local cardiac inflammation after limb-, neuro- and combined trauma. These cardiac alterations might predispose individuals for secondary cardiac damage after trauma that might compromise cardiac function after TBI and long bone fracture.

Translational potential statement

Injuries to the head and extremities frequently occur after severe trauma. In our study, we analyzed the effects of closed tibia fracture, isolated TBI, and the combination of both injuries with regard to the development of post-traumatic secondary cardiac injuries.

Association of Severe Acute Kidney Injury with Mortality and Healthcare Utilization Following Isolated Traumatic Brain Injury

BACKGROUND/OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of morbidity, mortality, and disability in the USA. While cardiopulmonary dysfunction can result in poor outcomes following severe TBI, the impact of acute kidney injury (AKI) is poorly understood. We examined the association of severe AKI with hospital mortality and healthcare utilization following isolate severe TBI.

METHODS

We conducted a retrospective cohort study using the National Trauma Data Bank from 2007 to 2014. We identified a cohort of adult patients with isolated severe TBI and described the incidence of severe AKI, corresponding to Acute Kidney Injury Network stage 3 disease or greater. We examined the association of severe AKI with the primary outcome of hospital mortality using multivariable logistic regression models. In secondary analyses, we examined the association of severe AKI with dialysis catheter placement, tracheostomy and gastrostomy utilization, and hospital length of stay.

RESULTS

There were 37,851 patients who experienced isolated severe TBI during the study period. Among these patients, 787 (2.1%) experienced severe (Stage 3 or greater) AKI. In multivariable models, the development of severe AKI in the hospital was associated with in-hospital mortality (OR 2.03, 95% CI 1.64-2.52), need for tracheostomy (OR 2.10, 95% CI 1.52-2.89), PEG tube placement (OR 1.88, 95% CI 1.45-2.45), and increased hospital length of stay (p < 0.001).

CONCLUSIONS

The overall incidence of severe AKI is relatively low (2.1%), but is associated with increased mortality and multiple markers of increased healthcare utilization following severe TBI.

Norepinephrine Leads to More Cardiopulmonary Toxicities than Epinephrine by Catecholamine Overdose in Rats

While catecholamines like epinephrine (E) and norepinephrine (NE) are commonly used in emergency medicine, limited studies have discussed the harm of exogenously induced catecholamine overdose. We investigated the possible toxic effects of excessive catecholamine administration on cardiopulmonary function and structure via continuous 6 h intravenous injection of E and/or NE in rats. Heart rate, echocardiography, and ventricular pressure were measured throughout administration. Cardiopulmonary structure was also assessed by examining heart and lung tissue. Consecutive catecholamine injections induced severe tachycardia. Echocardiography results showed NE caused worse dysfunction than E. Simultaneously, both E and NE led to higher expression of Troponin T and connexin43 in the whole ventricles, which increased further with E+NE administration. The NE and E+NE groups showed severe pulmonary edema while all catecholamine-administering groups demonstrated reduced expression of receptor for advanced glycation end products and increased connexin43 levels in lung tissue. The right ventricle was more vulnerable to catecholamine overdose than the left. Rats injected with NE had a lower survival rate than those injected with E within 6 h. Catecholamine overdose induces acute lung injuries and ventricular cardiomyopathy, and E+NE is associated with a more severe outcome. The similarities of the results between the NE and E+NE groups may indicate a predominant role of NE in determining the overall cardiopulmonary damage. The results provide important clinical insights into the pathogenesis of catecholamine storm.

Crosstalk between brain, lung and heart in critical care

Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.

Cardiac-cerebral-renal associations in pediatric traumatic brain injury: Preliminary findings

OBJECTIVE

The clinical epidemiology of organ outcomes in pediatric traumatic brain injury (TBI) has not been examined. We describe associated markers of cerebral, cardiac and renal injury after pediatric TBI.

DESIGN

Prospective observational study.

PATIENTS

Children 0-18 years who were hospitalized with TBI.

MEASUREMENTS

Measures of myocardial (at least one elevated plasma troponin [cTnI] ≥ 0.4 ng/ml) and multiorgan (hemodynamic variables, cerebral perfusion, and renal) function were examined within the first ten days of hospital admission and within 24 h of each other.

MAIN RESULTS

Data from 28 children who were 11[IQR 10.3] years, male (64.3%), with isolated TBI (67.9%), injury severity score (ISS) 25[10], and admission Glasgow coma score (GCS) 11[9] were examined. Overall, 50% (14 children) had elevated cTnI, including those with isolated TBI (57.9%; 11/19), polytrauma (33.3%; 3/9), mild TBI (57.1% 8/14), and severe TBI (42.9%; 6/11). Elevated cTnI occurred within the first six days of admission and across all age groups, in both sexes, and regardless of TBI lesion type, GCS, and ISS. Age-adjusted admission tachycardia was associated with cTnI elevation (AUC 0.82; p < 0.001). Reduced urine output occurred more commonly in patients with isolated TBI (27.3% elevated cTnI vs. 0% normal cTnI).

CONCLUSIONS

Myocardial injury commonly occurs during the first six days after pediatric TBI irrespective of injury severity, age, sex, TBI lesion type, or polytrauma. Age-adjusted tachycardia may be a clinical indicator of myocardial injury, and elevated troponin may be associated with cardio-cerebro-renal dysfunction.

Speckle Tracking Analysis of Left Ventricular Systolic Function Following Traumatic Brain Injury: A Pilot Prospective Observational Cohort Study

BACKGROUND

Systolic dysfunction and reduction in left ventricular ejection fraction (LVEF) has been documented after traumatic brain injury (TBI). Speckle tracking is an emerging technology for myocardial strain assessment which has been utilized to identify subclinical myocardial dysfunction, and is most commonly reported as global longitudinal strain (GLS). We examined myocardial strain and regional strain patterns following moderate-severe TBI.

MATERIALS AND METHODS

We conducted a prospective cohort study of moderate-severe TBI patients (Glasgow Coma Scale≤12) and age/sex-matched controls. Transthoracic echocardiography was performed within the first day and 1 week following TBI. Myocardial function was assessed using both GLS and LVEF, and impaired systolic function was defined as GLS >-16% or LVEF ≤50%. Regional strain patterns and individual strain trajectories were examined.

RESULTS

Thirty subjects were included, 15 patients with TBI and 15 age/sex-matched controls. Among patients with adequate echocardiographic windows, systolic dysfunction was observed in 2 (17%) patients using LVEF and 5 (38%) patients using GLS within the first day after TBI. Mean GLS was impaired in patients with TBI compared with controls (-16.4±3.8% vs. -20.7±1.8%, P=0.001). Regional myocardial examination revealed impaired strain primarily in the basal and mid-ventricular segments. There was no improvement in GLS from day 1 to day 7 (P=0.81).

CONCLUSIONS

Myocardial strain abnormalities are common and persist for at least 1 week following moderate-severe TBI. Speckle tracking may be useful for the early diagnosis and monitoring of systolic dysfunction following TBI.

Cerebral Perfusion Pressure Directed-Therapy Modulates Cardiac Dysfunction After Traumatic Brain Injury to Influence Cerebral Autoregulation in Pigs

BACKGROUND

Traumatic brain injury (TBI) is an important contributor to morbidity and mortality. Low cerebral perfusion pressure (CPP, mean arterial pressure [MAP] minus intracranial pressure) after TBI is associated with cerebral ischemia, impaired cerebral autoregulation, and poor outcomes. Normalization of CPP and limitation of cerebral autoregulation impairment is a key therapeutic goal. However, some vasoactive agents used to elevate MAP such as phenylephrine (Phe) improve outcome in females but not male piglets after TBI while dopamine (DA) does so in both sexes. Clinical evidence has implicated neurological injuries as a cause of cardiac dysfunction, and we recently described cardiac dysfunction after TBI. Cardiac dysfunction may, in turn, influence brain health. One mechanism of myocyte injury may involve catecholamine excess. We therefore tested the hypothesis that TBI caused cardiac dysfunction and catecholamine excess which may reciprocally be modulated by vasoactive agent choice to normalize CPP and prevent impairment of cerebral autoregulation after injury.

METHODS

TBI was produced in anesthetized pigs equipped with a closed cranial window, and Phe or DA administered to normalize CPP.

RESULTS

Plasma cardiac enzymes troponin and creatine kinase and catecholamines epinephrine and norepinephrine were elevated by TBI, such release potentiated by Phe in males but blocked in female piglets and blocked in both sexes after DA. Cerebral autoregulation was impaired after TBI, worsened by Phe in males but protected in females and males treated with DA. Papaverine-induced dilation was unchanged by fluid percussion brain injury, DA, and Phe.

CONCLUSIONS

These data indicate that pressor choice in elevation of CPP is important in limiting cardiac dysfunction and suggest that DA protects cerebral autoregulation in both sexes via reduction of cardiac biomarkers of injury and catecholamines released after TBI.

A pilot study evaluating a simple cardiac dysfunction score to predict complications and survival among critically-ill patients with traumatic brain injury

PURPOSE

To describe the frequency of cardiovascular complications and cardiac dysfunction in critically-ill patients with moderate-severe traumatic brain injury (msTBI) and cardiac factors associated with in-hospital survival.

METHODS

Retrospective analysis of a prospective cohort study at a single Level-1 trauma center with a dedicated neuro-trauma intensive care unit (ICU). Adult patients admitted to the ICU with msTBI were consecutively enrolled in the prospective OPTIMISM study between November 2009 and January 2017. Cardiac dysfunction was measured using a combination of EKG parameters, echocardiography abnormalities, and peak serum troponin-I levels during the index hospitalization. These items were combined into a cardiac dysfunction index (CDI), ranging from 0 to 3 points and modeled in a Cox regression analysis.

RESULTS

A total of 326 patients with msTBI were included. For every one-point increase in the CDI, the multivariable adjusted risk of dying during the patient's acute hospitalization more than doubled (adjusted HR 2.41; 95% CI 1.29-4.53).

CONCLUSION

Cardiac dysfunction was common in patients with msTBI and independently associated with more severe brain injury and a reduction in hospital survival in this population. Further research is needed to validate the CDI and create more precise scoring tools.

Early cardiovascular function and associated hemodynamics in adults with isolated moderate-severe traumatic brain injury: A pilot study

BACKGROUND

While cardiac dysfunction has been described following traumatic brain injury (TBI), its association with systemic and cerebral hemodynamics is not known. We examined the contemporaneous relationship between early cardiac function with systemic and cerebral hemodynamic parameters after moderate-severe TBI.

METHODS

Bedside transthoracic echocardiography (TTE) and transcranial Doppler (TCD) ultrasonography were performed within 24 h in patients > 18 years with isolated moderate-severe TBI. Systemic hemodynamic parameters were quantified using routine monitoring [heart rate and mean arterial pressures (MAP)] and calculation from echocardiographic data [stroke volume index (SVI), cardiac index (CI), and systemic vascular resistance index (SVRI)]. Systolic dysfunction was defined using TTE as global longitudinal strain (GLS) > -16%. Mean middle cerebral artery velocity (FVm) was the measure of cerebral hemodynamics and quantified using TCD.

RESULTS

Among 15 patients [mean age 43 ± 13 years, GCS 5 ± 3, 73% male], 15 TTE and 15 TCD exams were performed simultaneously. Five (33%) patients had systolic dysfunction, with significantly worse GLS (median [IQR] -12.1% [-14.1, -12] vs. -19.1% [-19.9, -17.7], p = 0.004). Median (IQR) MAP was 97 (89, 107) mmHg, SVI (29.0 [20.5, 31.0] mL m^-2), and CI (2.83 [2.05, 3.10] L/min m^-2) were low to normal, while SVRI (2704 dyne sec/cm⁵ m^-2 [2210, 4084]) was normal to high. None of the patients had abnormal TCDs. Higher GLS (reduced systolic function) was associated with lower SVI (r² = 0.274, p = 0.03) but not other parameters.

CONCLUSION

Systemic hemodynamic parameters were consistent with an early catecholamine-excess state. While reduced systolic function was associated with lower SVI, there was no relationship with reduced cerebral perfusion, possibly due to normal MAP.

Risk Factors for Recurrent Hematoma After Surgery for Acute Traumatic Subdural Hematoma

OBJECTIVE

The development of postcraniotomy hematoma (PCH) after surgery for acute traumatic subdural hematoma (aSDH) has been associated with an increased risk of a poor outcome. The risk factors contributing to PCH remain poorly understood. Our aim was to study the potential risk factors for PCH in a consecutive series of surgically evacuated patients with aSDH.

METHODS

A total of 132 patients with aSDH treated at Turku University Hospital (Turku, Finland) from 2008 to 2012 were enrolled in the present retrospective cohort study. The demographic, clinical, laboratory, and imaging data were collected from the medical records. A comprehensive analysis of the data using 6 different univariate methods, including machine learning and multivariate analyses, was conducted to identify the factors related to PCH.

RESULTS

The incidence of PCH after primary surgery for traumatic aSDH was 10.6%. The patients experiencing PCH were younger (P = 0.04). No difference was found in the use of anticoagulant or antiplatelet medication for the patients with and without PCH. Multivariate analyses identified alcohol inebriation at the time of injury (odds ratio [OR], 12.67; P = 0.041) and hypocapnia (OR, 26.09; P = 0.003) as independent risk factors for PCH. The patients with PCH had had hyponatremia (OR, 0.08; P = 0.018) less often, and their maximal systolic blood pressure was lower (OR, 0.94; P = 0.009). The area under the curve for the multivariate model was 0.96 (P = 0.049), with a Youden index of 0.88.

CONCLUSIONS

The results suggest that alcohol inebriation at the time of injury and hypocapnia during hospitalization are risk factors for the development of PCH.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Cardiac Dysfunction in Adult Patients with Traumatic Brain Injury: A Prospective Cohort Study

BACKGROUND

There are limited data regarding the development of myocardial dysfunction after a traumatic brain injury (TBI). We investigated incidence, risk factors, and prognostic importance of cardiac dysfunction in adult patients admitted to the intensive care unit (ICU) after a moderate to severe TBI.

METHODS

Prospective observational study of consecutive patients admitted to neuro-trauma ICU with moderate to severe TBI from August 2014 to June 2015.

RESULTS

A total of 46 patients were included. Patients' mean (±SD) age was 44.7 (±20.7) years and mean Glasgow Coma Scale value was 5.6 (±3). Motor vehicle accident was the most common mechanism of TBI, with subdural and subarachnoid hemorrhages as the most common pathologies. Cardiac dysfunction developed in 6 of 46 (13%) patients. Patients with cardiac dysfunction had higher prevalence of diabetes mellitus (50% vs. 10%, P = 0.03) and higher proportion of electrocardiogram abnormalities (83% vs. 27%, P = 0.02) compared to the patients without cardiac dysfunction. Mean Glasgow Coma Scale scores were not significantly different between patients who developed cardiac dysfunction from those who did not (5.5 vs. 5.6, P = 0.95). Requirement for vasopressor support (33.3% vs. 40%, P = 1.0) and median ventilator days (5.2 vs. 4.7, P = 0.9) were similar between patients with and without cardiac dysfunction. There were no significant differences in hospital lengths of stay (12.3 vs. 13.8 days, P = 0.34) and hospital mortality (33% vs. 17.5%, P = 0.58) between the two groups.

CONCLUSIONS

Cardiac dysfunction occurs in patients after moderate to severe TBI, with mild to moderate reduction in left ventricular ejection fraction. Patients who developed cardiac dysfunction after TBI had a higher prevalence of diabetes mellitus and higher proportion of abnormalities in electrocardiograms. Development of cardiac dysfunction was not associated with adverse clinical outcomes.

Neuroanesthesiology Update

We provide a synopsis of innovative research, recurring themes, and novel experimental findings pertinent to the care of neurosurgical patients and critically ill patients with neurological diseases. We cover the following broad topics: general neurosurgery, spine surgery, stroke, traumatic brain injury, monitoring, and anesthetic neurotoxicity.

Brain-Heart Interactions in Traumatic Brain Injury

The cardiovascular manifestations associated with nontraumatic head disorders are commonly known. Similar manifestations have been reported in patients with traumatic brain injury (TBI); however, the underlying mechanisms and impact on the patient's clinical outcomes are not well explored. The neurocardiac axis theory and neurogenic stunned myocardium phenomenon could partly explain the brain-heart link and interactions and can thus pave the way to a better understanding and management of TBI. Several observational retrospective studies have shown a promising role for beta-adrenergic blockers in patients with TBI in reducing the overall TBI-related mortality. However, several questions remain to be answered in clinical randomized-controlled trials, including population selection, beta blocker type, dosage, timing, and duration of therapy, while maintaining the optimal mean arterial pressure and cerebral perfusion pressure in patients with TBI.