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Xiao Y, Zhang Y, Yuan W, Wang C, Ge Y, Huang T, Gao J. Piezo2 Contributes to Traumatic Brain Injury by Activating the RhoA/ROCK1 Pathways. Mol Neurobiol 2024; 61:7419-7430. [PMID: 38388773 PMCID: PMC11415480 DOI: 10.1007/s12035-024-04058-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
Traumatic brain injury (TBI) can lead to short-term and long-term physical and cognitive impairments, which have significant impacts on patients, families, and society. Currently, treatment outcomes for this disease are often unsatisfactory, due at least in part to the fact that the molecular mechanisms underlying the development of TBI are largely unknown. Here, we observed significant upregulation of Piezo2, a key mechanosensitive ion channel protein, in the injured brain tissue of a mouse model of TBI induced by controlled cortical impact. Pharmacological inhibition and genetic knockdown of Piezo2 after TBI attenuated neuronal death, brain edema, brain tissue necrosis, and deficits in neural function and cognitive function. Mechanistically, the increase in Piezo2 expression contributed to TBI-induced neuronal death and subsequent production of TNF-α and IL-1β, likely through activation of the RhoA/ROCK1 pathways in the central nervous system. Our findings suggest that Piezo2 is a key player in and a potential therapeutic target for TBI.
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Affiliation(s)
- Yinggang Xiao
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China
| | - Yang Zhang
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China
| | - Wenjuan Yuan
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China
| | - Cunjin Wang
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China
| | - Yali Ge
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China
| | - Tianfeng Huang
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China.
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China.
| | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University/Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China.
- Yangzhou Key Laboratory of Anaesthesiology, Yangzhou, Jiangsu, China.
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Zhou H, Zhao Y, Zheng H, Chen C, Xie Z. Latent Trajectories of Cerebral Perfusion Pressure and Risk Prediction Models Among Patients with Traumatic Brain Injury: Based on an Interpretable Artificial Neural Network. World Neurosurg 2024:S1878-8750(24)01586-9. [PMID: 39278542 DOI: 10.1016/j.wneu.2024.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/18/2024]
Abstract
OBJECTIVE This study aimed to characterize long-term cerebral perfusion pressure (CPP) trajectory in traumatic brain injury (TBI) patients and construct an interpretable prediction model to assess the risk of unfavorable CPP evolution patterns. METHODS TBI patients with CPP records were identified from the Medical Information Mart for Intensive Care (MIMIC)-IV 2.1, eICU Collaborative Research Database (eICU-CRD) 2.0, and HiRID dataset 1.1.1. The research process consisted of 2 stages. First, group-based trajectory modeling (GBTM) was used to identify different CPP trajectories. Second, different artificial neural network (ANN) algorithms were used to predict the trajectories of CPP. RESULTS A total of 331 eligible patients' records from MIMIC-IV 2.1 and eICU-CRD 2.0 were used for trajectory analysis and model development. Additionally, 310 patients' data from HiRID were used for external validation. The GBTM identified 5 CPP trajectory groups, group 1 and group 5 were merged into class 1 based on unfavorable in-hospital mortality. The best 6 predictors were invasive systolic blood pressure coefficient of variation, venous blood chloride ion concentration, PaCO2, prothrombin time, CPP coefficient of variation, and mean CPP. Compared with other algorithms, Scaled Conjugate Gradient performed relatively better in identifying class 1. CONCLUSIONS This study identified 2 CPP trajectory groups associated with elevated risk and 3 with reduced risk. PaCO2 might be a strong predictor for the unfavorable CPP class. The ANN model achieved the primary goal of risk stratification, which is conducive to early intervention and individualized treatment.
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Affiliation(s)
- Hai Zhou
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yutong Zhao
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hui Zheng
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Changcun Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zongyi Xie
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
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Zoerle T, Beqiri E, Åkerlund CAI, Gao G, Heldt T, Hawryluk GWJ, Stocchetti N. Intracranial pressure monitoring in adult patients with traumatic brain injury: challenges and innovations. Lancet Neurol 2024; 23:938-950. [PMID: 39152029 DOI: 10.1016/s1474-4422(24)00235-7] [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: 07/08/2023] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 08/19/2024]
Abstract
Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Uniformed Services University, Cleveland, OH, USA
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Jha RM, Kochanek PM. Physiological trajectories after traumatic brain injury: markers or makers of disease? Lancet Neurol 2024; 23:7-9. [PMID: 37977158 PMCID: PMC11305088 DOI: 10.1016/s1474-4422(23)00428-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
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Åkerlund CAI, Holst A, Bhattacharyay S, Stocchetti N, Steyerberg E, Smielewski P, Menon DK, Ercole A, Nelson DW. Clinical descriptors of disease trajectories in patients with traumatic brain injury in the intensive care unit (CENTER-TBI): a multicentre observational cohort study. Lancet Neurol 2024; 23:71-80. [PMID: 37977157 DOI: 10.1016/s1474-4422(23)00358-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Patients with traumatic brain injury are a heterogeneous population, and the most severely injured individuals are often treated in an intensive care unit (ICU). The primary injury at impact, and the harmful secondary events that can occur during the first week of the ICU stay, will affect outcome in this vulnerable group of patients. We aimed to identify clinical variables that might distinguish disease trajectories among patients with traumatic brain injury admitted to the ICU. METHODS We used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study. We included patients aged 18 years or older with traumatic brain injury who were admitted to the ICU at one of the 65 CENTER-TBI participating centres, which range from large academic hospitals to small rural hospitals. For every patient, we obtained pre-injury data and injury features, clinical characteristics on admission, demographics, physiological parameters, laboratory features, brain biomarkers (ubiquitin carboxy-terminal hydrolase L1 [UCH-L1], S100 calcium-binding protein B [S100B], tau, neurofilament light [NFL], glial fibrillary acidic protein [GFAP], and neuron-specific enolase [NSE]), and information about intracranial pressure lowering treatments during the first 7 days of ICU stay. To identify clinical variables that might distinguish disease trajectories, we applied a novel clustering method to these data, which was based on a mixture of probabilistic graph models with a Markov chain extension. The relation of clusters to the extended Glasgow Outcome Scale (GOS-E) was investigated. FINDINGS Between Dec 19, 2014, and Dec 17, 2017, 4509 patients with traumatic brain injury were recruited into the CENTER-TBI core dataset, of whom 1728 were eligible for this analysis. Glucose variation (defined as the difference between daily maximum and minimum glucose concentrations) and brain biomarkers (S100B, NSE, NFL, tau, UCH-L1, and GFAP) were consistently found to be the main clinical descriptors of disease trajectories (ie, the leading variables contributing to the distinguishing clusters) in patients with traumatic brain injury in the ICU. The disease trajectory cluster to which a patient was assigned in a model was analysed as a predictor together with variables from the IMPACT model, and prediction of both mortality and unfavourable outcome (dichotomised GOS-E ≤4) was improved. INTERPRETATION First-day ICU admission data are not the only clinical descriptors of disease trajectories in patients with traumatic brain injury. By analysing temporal variables in our study, variation of glucose was identified as the most important clinical descriptor that might distinguish disease trajectories in the ICU, which should direct further research. Biomarkers of brain injury (S100B, NSE, NFL, tau, UCH-L1, and GFAP) were also top clinical descriptors over time, suggesting they might be important in future clinical practice. FUNDING European Union 7th Framework program, Hannelore Kohl Stiftung, OneMind, Integra LifeSciences Corporation, and NeuroTrauma Sciences.
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Affiliation(s)
- Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Anders Holst
- School of Electrical Engineering and Computer Science, KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Nino Stocchetti
- Department of Physiopathology and Transplant, Milan University, Milan, Italy; Fondazione IRCCS, Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | | | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden.
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Åkerlund C, Ercole A. Data-driven approaches to reveal the pathobiological heterogeneity in patients with traumatic brain injury. Intensive Care Med 2023; 49:1107-1109. [PMID: 37470833 PMCID: PMC10499679 DOI: 10.1007/s00134-023-07156-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Cecilia Åkerlund
- Section of Anaesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - Ari Ercole
- Division of Anaesthesia and Cambridge Centre for AI in Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
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Zoerle T, Birg T, Carbonara M, Smielewski P, Placek MM, Zanier ER, Åkerlund CAI, Ortolano F, Stocchetti N. Accuracy of Manual Intracranial Pressure Recording Compared to a Computerized High-Resolution System: A CENTER-TBI Analysis. Neurocrit Care 2023; 38:781-790. [PMID: 36922475 PMCID: PMC10241732 DOI: 10.1007/s12028-023-01697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/09/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Monitoring intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is crucial in the management of the patient with severe traumatic brain injury (TBI). In several institutions ICP and CPP are summarized hourly and entered manually on bedside charts; these data have been used in large observational and interventional trials. However, ICP and CPP may change rapidly and frequently, so data recorded in medical charts might underestimate actual ICP and CPP shifts. The aim of this study was to evaluate the accuracy of manual data annotation for proper capturing of ICP and CPP. For this aim, we (1) compared end-hour ICP and CPP values manually recorded (MR) with values recorded continuously by computerized high-resolution (HR) systems and (2) analyzed whether MR ICP and MR CPP are reliable indicators of the burden of intracranial hypertension and low CPP. METHODS One hundred patients were included. First, we compared the MR data with the values stored in the computerized system during the first 7 days after admission. For this point-to-point analysis, we calculated the difference between end-hour MR and HR ICP and CPP. Then we analyzed the burden of high ICP (> 20 mm Hg) and low CPP (< 60 mm Hg) measured by the computerized system, in which continuous data were stored, compared with the pressure-time dose based on end-hour measurements. RESULTS The mean difference between MR and HR end-hour values was 0.02 mm Hg for ICP (SD 3.86 mm Hg) and 1.54 mm Hg for CPP (SD 8.81 mm Hg). ICP > 20 mm Hg and CPP < 60 mm Hg were not detected by MR in 1.6% and 5.8% of synchronized measurements, respectively. Analysis of the pathological ICP and CPP throughout the recording, however, indicated that calculations based on manual recording seriously underestimated the ICP and CPP burden (in 42% and 28% of patients, respectively). CONCLUSIONS Manual entries fairly represent end-hour HR ICP and CPP. However, compared with a computerized system, they may prove inadequate, with a serious risk of underestimation of the ICP and CPP burden.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Tatiana Birg
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Elisa R Zanier
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Cascella M, Montomoli J, Bellini V, Vittori A, Biancuzzi H, Dal Mas F, Bignami EG. Crossing the AI Chasm in Neurocritical Care. COMPUTERS 2023; 12:83. [DOI: 10.3390/computers12040083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Despite the growing interest in possible applications of computer science and artificial intelligence (AI) in the field of neurocritical care (neuro-ICU), widespread clinical applications are still missing. In neuro-ICU, the collection and analysis in real time of large datasets can play a crucial role in advancing this medical field and improving personalized patient care. For example, AI algorithms can detect subtle changes in brain activity or vital signs, alerting clinicians to potentially life-threatening conditions and facilitating rapid intervention. Consequently, data-driven AI and predictive analytics can greatly enhance medical decision making, diagnosis, and treatment, ultimately leading to better outcomes for patients. Nevertheless, there is a significant disparity between the current capabilities of AI systems and the potential benefits and applications that could be achieved with more advanced AI technologies. This gap is usually indicated as the AI chasm. In this paper, the underlying causes of the AI chasm in neuro-ICU are analyzed, along with proposed recommendations for utilizing AI to attain a competitive edge, foster innovation, and enhance patient outcomes. To bridge the AI divide in neurocritical care, it is crucial to foster collaboration among researchers, clinicians, and policymakers, with a focus on specific use cases. Additionally, strategic investments in AI technology, education and training, and infrastructure are needed to unlock the potential of AI technology. Before implementing a technology in patient care, it is essential to conduct thorough studies and establish clinical validation in real-world environments to ensure its effectiveness and safety. Finally, the development of ethical and regulatory frameworks is mandatory to ensure the secure and efficient deployment of AI technology throughout the process.
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Affiliation(s)
- Marco Cascella
- Pain Unit and Research, Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80100 Napoli, Italy
| | - Jonathan Montomoli
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Romagna, 47923 Rimini, Italy
| | - Valentina Bellini
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù, IRCCS, 00165 Rome, Italy
| | - Helena Biancuzzi
- Department of Economics, Ca’ Foscari University, 30121 Venice, Italy
| | - Francesca Dal Mas
- Department of Management, Ca’ Foscari University, 30121 Venice, Italy
| | - Elena Giovanna Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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Godoy DA, Brasil S, Iaccarino C, Paiva W, Rubiano AM. The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management. Crit Care 2023; 27:137. [PMID: 37038236 PMCID: PMC10088257 DOI: 10.1186/s13054-023-04427-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023] Open
Abstract
For decades, one of the main targets in the management of severe acute brain injury (ABI) has been intracranial hypertension (IH) control. However, the determination of IH has suffered variations in its thresholds over time without clear evidence for it. Meanwhile, progress in the understanding of intracranial content (brain, blood and cerebrospinal fluid) dynamics and recent development in monitoring techniques suggest that targeting intracranial compliance (ICC) could be a more reliable approach rather than guiding actions by predetermined intracranial pressure values. It is known that ICC impairment forecasts IH, as intracranial volume may rapidly increase inside the skull, a closed bony box with derisory expansibility. Therefore, an intracranial compartmental syndrome (ICCS) can occur with deleterious brain effects, precipitating a reduction in brain perfusion, thereby inducing brain ischemia. The present perspective review aims to discuss the ICCS concept and suggest an integrative model for the combination of modern invasive and noninvasive techniques for IH and ICC assessment. The theory and logic suggest that the combination of multiple ancillary methods may enhance ICC impairment prediction, pointing proactive actions and improving patient outcomes.
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Affiliation(s)
| | - Sérgio Brasil
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil.
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University Modena and Reggio Emilia, Modena, Italy
- Department of Neurosurgery, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery, AUSLRE IRCCS, Reggio Emilia, Italy
| | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil
| | - Andres M Rubiano
- Universidad El Bosque. Bogotá, Bogotá, Colombia
- MEDITECH Foundation, Cali, Colombia
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Rakkar J, Azar J, Pelletier JH, Au AK, Bell MJ, Simon DW, Kochanek PM, Clark RSB, Horvat CM. Temporal Patterns in Brain Tissue and Systemic Oxygenation Associated with Mortality After Severe Traumatic Brain Injury in Children. Neurocrit Care 2023; 38:71-84. [PMID: 36171518 PMCID: PMC9957965 DOI: 10.1007/s12028-022-01602-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/30/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Brain tissue hypoxia is an independent risk factor for unfavorable outcomes in traumatic brain injury (TBI); however, systemic hyperoxemia encountered in the prevention and/or response to brain tissue hypoxia may also impact risk of mortality. We aimed to identify temporal patterns of partial pressure of oxygen in brain tissue (PbtO2), partial pressure of arterial oxygen (PaO2), and PbtO2/PaO2 ratio associated with mortality in children with severe TBI. METHODS Data were extracted from the electronic medical record of a quaternary care children's hospital with a level I trauma center for patients ≤ 18 years old with severe TBI and the presence of PbtO2 and/or intracranial pressure monitors. Temporal analyses were performed for the first 5 days of hospitalization by using locally estimated scatterplot smoothing for less than 1,000 observations and generalized additive models with integrated smoothness estimation for more than 1,000 observations. RESULTS A total of 138 intracranial pressure-monitored patients with TBI (median 5.0 [1.9-12.8] years; 65% boys; admission Glasgow Coma Scale score 4 [3-7]; mortality 18%), 71 with PbtO2 monitors and 67 without PbtO2 monitors were included. Distinct patterns in PbtO2, PaO2, and PbtO2/PaO2 were evident between survivors and nonsurvivors over the first 5 days of hospitalization. Time-series analyses showed lower PbtO2 values on day 1 and days 3-5 and lower PbtO2/PaO2 ratios on days 1, 2, and 5 among patients who died. Analysis of receiver operating characteristics curves using Youden's index identified a PbtO2 of 30 mm Hg and a PbtO2/PaO2 ratio of 0.12 as the cut points for discriminating between survivors and nonsurvivors. Univariate logistic regression identified PbtO2 < 30 mm Hg, hyperoxemia (PaO2 ≥ 300 mm Hg), and PbtO2/PaO2 ratio < 0.12 to be independently associated with mortality. CONCLUSIONS Lower PbtO2, higher PaO2, and lower PbtO2/PaO2 ratio, consistent with impaired oxygen diffusion into brain tissue, were associated with mortality in this cohort of children with severe TBI. These results corroborate our prior work that suggests targeting a higher PbtO2 threshold than recommended in current guidelines and highlight the potential use of the PbtO2/PaO2 ratio in the management of severe pediatric TBI.
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Affiliation(s)
- Jaskaran Rakkar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Azar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pediatric Critical Care, Geisinger Medical Center, Danville, PA, USA
| | - Jonathan H Pelletier
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alicia K Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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12
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Foote CW, Jarvis S, Doan XL, Guice J, Cruz B, Vanier C, Betancourt A, Bar-Or D, Palacio CH. Correlation between intracranial pressure monitoring for severe traumatic brain injury with hospital length of stay and discharge disposition: a retrospective observational cohort study. Patient Saf Surg 2022; 16:40. [PMID: 36581936 PMCID: PMC9801642 DOI: 10.1186/s13037-022-00350-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Intracranial pressure (ICP) monitoring is recommended for severe traumatic brain injuries (TBI) but some data suggests it may not improve outcomes. The objective was to investigate the effect of ICP monitoring among TBI. METHODS This retrospective observational cohort study (1/1/2015-6/1/2020) included severe TBI patients. Outcomes [discharge destination, length of stay (LOS)] were compared by ICP monitoring and were stratified by GCS (3 vs. 4-8), α < 0.05. RESULTS Of the123 patients who met inclusion criteria, 47% received ICP monitoring. There were baseline differences in the two groups characteristics, ICP monitored patients were younger (p = 0.02), had a subarachnoid hemorrhage less often (p = 0.04), and a subdural hematoma more often (p = 0.04) than those without ICP monitors. ICP monitored patients had a significantly longer median LOS (12 vs. 3, p < 0.01) than patients without monitoring. There was a trend towards more ICP monitored patients discharged home (40% vs. 23%, p = 0.06). Among patients with GCS = 3, ICP monitored patients had a longer LOS (p < 0.01) with no significant differences in discharge destinations. For those with a GCS of 4-8, ICP monitoring was associated with a longer LOS (p = 0.01), but fewer were discharged to a skilled nursing facility or long-term care (p = 0.01). CONCLUSIONS For TBI patients, ICP monitoring was associated with an increased LOS, with no significant differences in discharge destinations when compared to those without ICP monitoring. However, among only those with a GCS of 4-8, ICP monitoring was associated with a decreased proportion of patients discharged to a skilled nursing facility or long-term acute care .
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Affiliation(s)
- Christopher W. Foote
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA ,Valley Health Systems, Graduate Medical Education, 2075 East Flamingo Rd, Las Vegas, NV 89119 USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO 80113 USA
| | - Xuan-Lan Doan
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA ,Valley Health Systems, Graduate Medical Education, 2075 East Flamingo Rd, Las Vegas, NV 89119 USA
| | - Jordan Guice
- grid.416653.30000 0004 0450 5663Brooke Army Medical Center, 8551 Roger Brooke Dr, San Antonio, TX 78219 USA
| | - Bianca Cruz
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA
| | - Cheryl Vanier
- grid.430773.40000 0000 8530 6973Touro University, School of Medicine, 874 American Pacific Dr, Henderson, NV 89014 USA
| | - Alejandro Betancourt
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO 80113 USA
| | - Carlos H. Palacio
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA ,Valley Health Systems, Graduate Medical Education, 2075 East Flamingo Rd, Las Vegas, NV 89119 USA
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13
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Perizes EN, Chong G, Sanchez-Pinto LN. Derivation and Validation of Vasoactive Inotrope Score Trajectory Groups in Critically Ill Children With Shock. Pediatr Crit Care Med 2022; 23:1017-1026. [PMID: 36053068 PMCID: PMC9722555 DOI: 10.1097/pcc.0000000000003070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To determine whether there are clinically relevant and reproducible Vasoactive Inotrope Score (VIS) trajectories in children with shock during the acute phase of critical illness. DESIGN Retrospective, observational cohort study. SETTING Two tertiary, academic PICUs. PATIENTS Children (< 18 yr old) who required vasoactive infusions within 24 hours of admission to the PICU. Those admitted post cardiac surgery were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An hourly VIS was calculated for the first 72 hours after initiation of vasoactives. Group-based trajectory modeling (GBTM) was applied to a derivation set (75% of encounters) and compared with the trajectories in a validation set (25% of encounters) using the same variables. The primary outcome was in-hospital mortality, and the secondary outcome was multiple organ dysfunction syndrome (MODS) on day 7. A total of 1,828 patients met inclusion criteria, and 309 (16.9%) died. GBTM identified four subgroups that were reproducible in the validation set: "Mild, fast resolving shock" ( n = 853 [47%]; mortality 9%), "Moderate, slow resolving shock" ( n = 422 [23%]; mortality 15%), "Moderate, prolonged shock" ( n = 312 [17%]; mortality 21%), and "Severe, prolonged shock" ( n = 241 [13%]; mortality 40%). There was a significant difference in mortality, MODS on day 7, and suspected infection ( p < 0.001) across groups. The "Mild, fast resolving shock" and "Severe, prolonged shock" groups were identifiable within the first 24 hours. The "Moderate, slow resolving" and "Moderate, prolonged shock" groups were indistinguishable in the first 24 hours after initiation of vasoactives but differed in in-hospital mortality and MODS on day 7. Hydrocortisone administration was independently associated with poor outcomes in the "Mild, fast resolving shock" group. CONCLUSIONS We uncovered four distinct and reproducible VIS trajectory groups that were associated with different risk factors, response to therapy, and outcomes in children with shock. Characterizing VIS trajectory groups in the acute phase of critical illness may enable better prognostication and more targeted management.
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Affiliation(s)
- Elitsa N. Perizes
- Division of Critical Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Grace Chong
- Division of Critical Care, University of Chicago Medicine Comer Children’s Hospital, Chicago, IL
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - L. Nelson Sanchez-Pinto
- Division of Critical Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine (Health and Biomedical Informatics), Northwestern University Feinberg School of Medicine, Chicago, IL
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14
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Pease M, Arefan D, Barber J, Yuh E, Puccio A, Hochberger K, Nwachuku E, Roy S, Casillo S, Temkin N, Okonkwo DO, Wu S. Outcome Prediction in Patients with Severe Traumatic Brain Injury Using Deep Learning from Head CT Scans. Radiology 2022; 304:385-394. [PMID: 35471108 PMCID: PMC9340242 DOI: 10.1148/radiol.212181] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/29/2022] [Accepted: 02/23/2022] [Indexed: 12/23/2022]
Abstract
Background After severe traumatic brain injury (sTBI), physicians use long-term prognostication to guide acute clinical care yet struggle to predict outcomes in comatose patients. Purpose To develop and evaluate a prognostic model combining deep learning of head CT scans and clinical information to predict long-term outcomes after sTBI. Materials and Methods This was a retrospective analysis of two prospectively collected databases. The model-building set included 537 patients (mean age, 40 years ± 17 [SD]; 422 men) from one institution from November 2002 to December 2018. Transfer learning and curriculum learning were applied to a convolutional neural network using admission head CT to predict mortality and unfavorable outcomes (Glasgow Outcomes Scale scores 1-3) at 6 months. This was combined with clinical input for a holistic fusion model. The models were evaluated using an independent internal test set and an external cohort of 220 patients with sTBI (mean age, 39 years ± 17; 166 men) from 18 institutions in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study from February 2014 to April 2018. The models were compared with the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model and the predictions of three neurosurgeons. Area under the receiver operating characteristic curve (AUC) was used as the main model performance metric. Results The fusion model had higher AUCs than did the IMPACT model in the prediction of mortality (AUC, 0.92 [95% CI: 0.86, 0.97] vs 0.80 [95% CI: 0.71, 0.88]; P < .001) and unfavorable outcomes (AUC, 0.88 [95% CI: 0.82, 0.94] vs 0.82 [95% CI: 0.75, 0.90]; P = .04) on the internal data set. For external TRACK-TBI testing, there was no evidence of a significant difference in the performance of any models compared with the IMPACT model (AUC, 0.83; 95% CI: 0.77, 0.90) in the prediction of mortality. The Imaging model (AUC, 0.73; 95% CI: 0.66-0.81; P = .02) and the fusion model (AUC, 0.68; 95% CI: 0.60, 0.76; P = .02) underperformed as compared with the IMPACT model (AUC, 0.83; 95% CI: 0.77, 0.89) in the prediction of unfavorable outcomes. The fusion model outperformed the predictions of the neurosurgeons. Conclusion A deep learning model of head CT and clinical information can be used to predict 6-month outcomes after severe traumatic brain injury. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Haller in this issue.
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Affiliation(s)
| | | | - Jason Barber
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Esther Yuh
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Ava Puccio
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Kerri Hochberger
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Enyinna Nwachuku
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Souvik Roy
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Stephanie Casillo
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | - Nancy Temkin
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
| | | | | | - on behalf of TRACK-TBI Investigators
- From the Department of Neurosurgery, University of Pittsburgh Medical
Center, Pittsburgh, Pa (M.P., A.P., K.H., E.N., S.R., S.C., D.O.O.); Departments
of Radiology (D.A., S.W.), Biomedical Informatics (S.W.), and Bioengineering
(S.W.), and Intelligent Systems Program (S.W.), University of Pittsburgh, 3240
Craft Pl, Room 322, Pittsburgh, PA 15213; Department of Neurosurgery, University
of Washington, Seattle, Wash (J.B., N.T.); Department of Radiology, University
of California San Francisco, San Francisco, Calif (E.Y.)
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15
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Yang F, Peng C, Peng L, Wang P, Cheng C, Zuo W, Zhao L, Jin Z, Li W. Group-based trajectory modeling of intracranial pressure in patients with acute brain injury: Results from multi-center ICUs, 2008-2019. CNS Neurosci Ther 2022; 28:1218-1228. [PMID: 35611794 PMCID: PMC9253780 DOI: 10.1111/cns.13854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
Objective The objective of the study was to characterize the longitudinal, dynamic intracranial pressure (ICP) trajectory in acute brain injury (ABI) patients admitted to intensive care unit (ICU) and explore whether it added sights over traditional thresholds in predicting outcomes. Methods ABI patients with ICP monitoring were identified from two public databases named Medical Information Mart for the Intensive Care (MIMIC)‐IV and eICU Collaborative Research Database (eICU‐CRD). Group‐based trajectory modeling (GBTM) was employed to identify 4‐h ICP trajectories in days 0–5 post‐ICU admission. Then, logistic regression was used to compare clinical outcomes across distinct groups. To further validate previously reported thresholds, we created the receiver operating characteristic (ROC) curve in our dataset. Results A total of 810 eligible patients were ultimately enrolled in the study. GBTM analyses generated 6 distinct ICP trajectories, differing in the initial ICP, evolution pattern, and number/proportion of spikes >20/22 mmHg. Compared with patients in “the highest, declined then rose” trajectory, those belonging to the “lowest, stable,” “low, stable,” and “medium, stable” ICP trajectories were at lower risks of 30‐day mortality (odds ratio [OR] 0.04; 95% confidence interval [CI] 0.01, 0.21), (OR 0.04; 95% CI 0.01, 0.19), (OR 0.08; 95% CI 0.01, 0.42), respectively. ROC analysis demonstrated an unfavorable result, for example, 30‐day mortality in total cohort: an area under the curve (AUC): 0.528, sensitivity: 0.11, and specificity: 0.94. Conclusions This study identified three ICP trajectories associated with elevated risk, three with reduced risks for mortality during ICU hospitalization. Notably, a fixed ICP threshold should not be applied to all kinds of patients. GBTM, a granular method for describing ICP evolution and their association with clinical outcomes, may add to the current knowledge in intracranial hypertension treatment.
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Affiliation(s)
- Fan Yang
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chi Peng
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Zhao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhichao Jin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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16
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Azad TD, Shah PP, Kim HB, Stevens RD. Endotypes and the Path to Precision in Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:259-266. [PMID: 35314969 DOI: 10.1007/s12028-022-01475-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/15/2022] [Indexed: 12/19/2022]
Abstract
Heterogeneity is recognized as a major barrier in efforts to improve the care and outcomes of patients with traumatic brain injury (TBI). Even within the narrower stratum of moderate and severe TBI, current management approaches do not capture the complexity of this condition characterized by manifold clinical, anatomical, and pathophysiologic features. One approach to heterogeneity may be to resolve undifferentiated TBI populations into endotypes, subclasses that are distinguished by shared biological characteristics. The endotype paradigm has been explored in a range of medical domains, including psychiatry, oncology, immunology, and pulmonology. In intensive care, endotypes are being investigated for syndromes such as sepsis and acute respiratory distress syndrome. This review provides an overview of the endotype paradigm as well as some of its methods and use cases. A conceptual framework is proposed for endotype research in moderate and severe TBI, together with a scientific road map for endotype discovery and validation in this population.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pavan P Shah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Han B Kim
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Phipps Suite 455, Baltimore, MD, 21287, USA
| | - Robert D Stevens
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Phipps Suite 455, Baltimore, MD, 21287, USA.
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17
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Godoy DA, Robba C, Paiva WS, Rabinstein AA. Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments. Neurocrit Care 2022; 36:302-316. [PMID: 34494211 PMCID: PMC8423073 DOI: 10.1007/s12028-021-01333-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022]
Abstract
Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.
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Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
- Intensive Care, Hospital Carlos Malbran, Catamarca, Argentina.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Investigational Research for Critical Care for Oncology and Neurosciences, Genoa, Italy
| | - Wellingson Silva Paiva
- Division of Neurological Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil
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18
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Jha RM, Rani A, Desai SM, Raikwar S, Mihaljevic S, Munoz-Casabella A, Kochanek PM, Catapano J, Winkler E, Citerio G, Hemphill JC, Kimberly WT, Narayan R, Sahuquillo J, Sheth KN, Simard JM. Sulfonylurea Receptor 1 in Central Nervous System Injury: An Updated Review. Int J Mol Sci 2021; 22:11899. [PMID: 34769328 PMCID: PMC8584331 DOI: 10.3390/ijms222111899] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/17/2022] Open
Abstract
Sulfonylurea receptor 1 (SUR1) is a member of the adenosine triphosphate (ATP)-binding cassette (ABC) protein superfamily, encoded by Abcc8, and is recognized as a key mediator of central nervous system (CNS) cellular swelling via the transient receptor potential melastatin 4 (TRPM4) channel. Discovered approximately 20 years ago, this channel is normally absent in the CNS but is transcriptionally upregulated after CNS injury. A comprehensive review on the pathophysiology and role of SUR1 in the CNS was published in 2012. Since then, the breadth and depth of understanding of the involvement of this channel in secondary injury has undergone exponential growth: SUR1-TRPM4 inhibition has been shown to decrease cerebral edema and hemorrhage progression in multiple preclinical models as well as in early clinical studies across a range of CNS diseases including ischemic stroke, traumatic brain injury, cardiac arrest, subarachnoid hemorrhage, spinal cord injury, intracerebral hemorrhage, multiple sclerosis, encephalitis, neuromalignancies, pain, liver failure, status epilepticus, retinopathies and HIV-associated neurocognitive disorder. Given these substantial developments, combined with the timeliness of ongoing clinical trials of SUR1 inhibition, now, another decade later, we review advances pertaining to SUR1-TRPM4 pathobiology in this spectrum of CNS disease-providing an overview of the journey from patch-clamp experiments to phase III trials.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Anupama Rani
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
| | - Sudhanshu Raikwar
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Sandra Mihaljevic
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Amanda Munoz-Casabella
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joshua Catapano
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Ethan Winkler
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy;
- Neurointensive Care Unit, Department of Neuroscience, San Gerardo Hospital, ASST—Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94143, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Raj Narayan
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY 11549, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain;
- Neurotraumatology and Neurosurgery Research Unit, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Department of Neurosurgery, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, School of Medicine, Yale University, New Haven, CT 06510, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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19
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Deng N, Xiao S, Zhong Y, Yao X. Effect of comprehensive nursing on prognosis and quality of life of coma patients after severe craniocerebral injury. Minerva Surg 2021; 77:82-84. [PMID: 34338463 DOI: 10.23736/s2724-5691.21.08946-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Na Deng
- Department of Neurosurgery, Pingxiang people's Hospital of Jiangxi Province, Pingxiang, China
| | - Shifei Xiao
- Department of Neurosurgery, Pingxiang people's Hospital of Jiangxi Province, Pingxiang, China
| | - Youyou Zhong
- Department of Neurosurgery, Pingxiang people's Hospital of Jiangxi Province, Pingxiang, China
| | - Xin Yao
- Department of Nursing, Pingxiang people's Hospital of Jiangxi Province, Pingxiang, China -
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20
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Jha RM, Zusman BE, Puccio AM, Okonkwo DO, Pease M, Desai SM, Leach M, Conley YP, Kochanek PM. Genetic Variants Associated With Intraparenchymal Hemorrhage Progression After Traumatic Brain Injury. JAMA Netw Open 2021; 4:e2116839. [PMID: 34309670 PMCID: PMC8314141 DOI: 10.1001/jamanetworkopen.2021.16839] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Intracerebral hemorrhage progression is associated with unfavorable outcome after traumatic brain injury (TBI). No effective treatments are currently available. This secondary injury process reflects an extreme form of vasogenic edema and blood-brain barrier breakdown. The sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) cation channel is a key underlying mechanism. A phase 2 trial of SUR1-TRPM4 inhibition in contusional TBI is ongoing, and a phase 3 trial is being designed. Targeted identification of patients at increased risk for hemorrhage progression may inform prognostication, trial design (including patient selection), and ultimately treatment response. OBJECTIVE To determine whether ABCC8 (SUR1) and TRPM4 genetic variability are associated with intraparenchymal hemorrhage (IPH) progression after severe TBI, based on the putative involvement of the SUR1-TRPM4 channel in this pathophysiology. DESIGN, SETTING, AND PARTICIPANTS In this genetic association study, DNA was extracted from 416 patients with severe TBI prospectively enrolled from a level I trauma academic medical center from May 9, 2002, to August 8, 2014. Forty ABCC8 and TRPM4 single-nucleotide variants (SNVs) were genotyped (multiplex, unbiased). Data were analyzed from January 7, 2020, to May 3, 2021. MAIN OUTCOMES AND MEASURES Primary analyses addressed IPH progression at 6, 24, and 120 hours in patients without acute craniectomy (n = 321). Multivariable regressions and receiver operating characteristic curves assessed SNV and haplotype associations with progression. Spatial modeling and functional predictions were determined using standard software. RESULTS Of the 321 patients included in the analysis (mean [SD] age, 37.0 [16.3] years; 247 [76.9%] male), IPH progression occurred in 102. Four ABCC8 SNVs were associated with markedly increased odds of progression (rs2237982 [odds ratio (OR), 2.60-3.80; 95% CI, 1.14-5.90 to 1.80-8.02; P = .02 to P < .001], rs2283261 [OR, 3.37-4.77; 95% CI, 1.07-10.77 to 1.89-12.07; P = .04 to P = .001], rs3819521 [OR, 2.96-3.92; 95% CI, 1.13-7.75 to 1.42-10.87; P = .03 to P = .009], and rs8192695 [OR, 3.06-4.95; 95% CI, 1.02-9.12 to 1.67-14.68]; P = .03-.004). These are brain-specific expression quantitative trait loci (eQTL) associated with increased ABCC8 messenger RNA levels. Regulatory annotations revealed promoter and enhancer marks and strong and/or active brain-tissue transcription, directionally consistent with increased progression. Three SNVs (rs2283261, rs2237982, and rs3819521) in this cohort have been associated with intracranial hypertension. Four TRPM4 SNVs were associated with decreased IPH progression (rs3760666 [OR, 0.40-0.49; 95% CI, 0.19-0.86 to 0.27-0.89; P = .02 to P = .009], rs1477363 [OR, 0.40-0.43; 95% CI, 0.18-0.88 to 0.23-0.81; P = .02 to P = .006], rs10410857 [OR, 0.36-0.41; 95% CI, 0.20-0.67 to 0.20-0.85; P = .02 to P = .001], and rs909010 [OR, 0.27-0.40; 95% CI, 0.12-0.62 to 0.16-0.58; P = .002 to P < .001]). Significant SNVs in both genes cluster downstream, flanking exons encoding the receptor site and SUR1-TRPM4 binding interface. Adding genetic variation to clinical models improved receiver operating characteristic curve performance from 0.6959 to 0.8030 (P = .003). CONCLUSIONS AND RELEVANCE In this genetic association study, 8 ABCC8 and TRPM4 SNVs were associated with IPH progression. Spatial clustering, brain-specific eQTL, and regulatory annotations suggest biological plausibility. These findings may have important implications for neurocritical care risk stratification, patient selection, and precision medicine, including an upcoming phase 3 trial design for SUR1-TRPM4 inhibition in severe TBI.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurobiology, Barrow Neurological Institute, Phoenix, Arizona
| | - Benjamin E. Zusman
- medical student at School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- now affiliated with Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ava M. Puccio
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Pease
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
| | - Matthew Leach
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yvette P. Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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21
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Jaffa MN, Jha RM, Elmer J, Kardon A, Podell JE, Zusman BE, Smith MC, Simard JM, Parikh GY, Armahizer MJ, Badjatia N, Morris NA. Pain Trajectories Following Subarachnoid Hemorrhage are Associated with Continued Opioid Use at Outpatient Follow-up. Neurocrit Care 2021; 35:806-814. [PMID: 34109554 PMCID: PMC8189709 DOI: 10.1007/s12028-021-01282-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is characterized by the worst headache of life and associated with long-term opioid use. Discrete pain trajectories predict chronic opioid use following other etiologies of acute pain, but it is unknown whether they exist following SAH. If discrete pain trajectories following SAH exist, it is uncertain whether they predict long-term opioid use. We sought to characterize pain trajectories after SAH and determine whether they are associated with persistent opioid use. METHODS We reviewed pain scores from patients admitted to a single tertiary care center for SAH from November 2015 to September 2019. Group-based trajectory modeling identified discrete pain trajectories during hospitalization. We compared outcomes across trajectory groups using χ2 and Kruskal-Wallis tests. Multivariable regression determined whether trajectory group membership was an independent predictor of long-term opioid use, defined as continued use at outpatient follow-up. RESULTS We identified five discrete pain trajectories among 305 patients. Group 1 remained pain free. Group 2 reported low scores with intermittent spikes and slight increase over time. Group 3 noted increasing pain severity through day 7 with mild improvement until day 14. Group 4 experienced maximum pain with steady decrement over time. Group 5 reported moderate pain with subtle improvement. In multivariable analysis, trajectory groups 3 (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5-8.3) and 5 (OR 8.0; 95% CI 3.1-21.1), history of depression (OR 3.6; 95% CI 1.3-10.0) and racial/ethnic minority (OR 2.3; 95% CI 1.3-4.1) were associated with continued opioid use at follow-up (median 62 days following admission, interquartile range 48-96). CONCLUSIONS Discrete pain trajectories following SAH exist. Recognition of pain trajectories may help identify those at risk for long-term opioid use.
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Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Ruchira M Jha
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Kardon
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jamie E Podell
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Benjamin E Zusman
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Madeleine C Smith
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - J Marc Simard
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, MD, USA.,Department of Pathology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Department of Physiology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Gunjan Y Parikh
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Michael J Armahizer
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Nicholas A Morris
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA. .,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.
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22
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Yuan J, Botchway BOA, Zhang Y, Wang X, Liu X. Combined bioscaffold with stem cells and exosomes can improve traumatic brain injury. Stem Cell Rev Rep 2021; 16:323-334. [PMID: 31808037 DOI: 10.1007/s12015-019-09927-x] [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: 12/21/2022]
Abstract
The intricacy of the brain, along with the existence of blood brain barrier (BBB) does complicate the delivery of effective therapeutics through simple intravascular injection. Hence, an effective delivery mechanism of therapeutics in the event of either traumatic brain injury (TBI) or other brain injuries is needed. Stem cells can promote regeneration and repair injury. The usage of biomaterials and exosomes in transporting stem cells to target lesion sites has been suggested as a potential option. The combination of biomaterials with modified exosomes can help in transporting stem cells to injury sites, whiles also increasing their survival and promoting effective treatment. Herein, we review the current researches pertinent to biological scaffolds and exosomes in repairing TBI and present the current progress and new direction in the clinical setting. We begin with the role of bioscaffold in treating neuronal conditions, the effect of exosomes in injury, and conclude with the improvement of TBI via the employment of combined exosomes, bioscaffold and stem cells.
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Affiliation(s)
- Jiaying Yuan
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China
| | - Benson O A Botchway
- Institute of Neuroscience, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong Zhang
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China
| | - Xizhi Wang
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China
| | - Xuehong Liu
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China.
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23
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McCredie VA, Chavarría J, Baker AJ. How do we identify the crashing traumatic brain injury patient - the intensivist's view. Curr Opin Crit Care 2021; 27:320-327. [PMID: 33852501 PMCID: PMC8240643 DOI: 10.1097/mcc.0000000000000825] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Over 40% of patients with severe traumatic brain injury (TBI) show clinically significant neurological worsening within the acute admission period. This review addresses the importance of identifying the crashing TBI patient, the difficulties appreciating clinical neurological deterioration in the comatose patient and how neuromonitoring may provide continuous real-time ancillary information to detect physiologic worsening. RECENT FINDINGS The latest editions of the Brain Trauma Foundation's Guidelines omitted management algorithms for adult patients with severe TBI. Subsequently, three consensus-based management algorithms were published using a Delphi method approach to provide a bridge between the evidence-based guidelines and integration of the individual treatment modalities at the bedside. These consensus statements highlight the serious situation of critical deterioration requiring emergent evaluation and guidance on sedation holds to obtain a neurological examination while balancing the potential risks of inducing a stress response. SUMMARY One of the central tenets of neurocritical care is to detect the brain in trouble. The first and most fundamental neurological monitoring tool is the clinical exam. Ancillary neuromonitoring data may provide early physiologic biomarkers to help anticipate, prevent or halt secondary brain injury processes. Future research should seek to understand how data integration and visualization technologies may reduce the cognitive workload to improve timely detection of neurological deterioration.
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Affiliation(s)
- Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Toronto Western Hospital, University Health Network
- Krembil Research Institute, Toronto Western Hospital
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre
| | - Javier Chavarría
- Interdepartmental Division of Critical Care Medicine, University of Toronto
| | - Andrew J. Baker
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Department of Critical Care, St. Michael's Hospital Toronto, University of Toronto
- Department of Anesthesia, Keenan Research Centre for Biomedical Science, St. Michael's Hospital Toronto, University of Toronto, Toronto, Ontario, Canada
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24
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Eriksson J, Nelson D, Holst A, Hellgren E, Friman O, Oldner A. Temporal patterns of organ dysfunction after severe trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:165. [PMID: 33952314 PMCID: PMC8101241 DOI: 10.1186/s13054-021-03586-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/27/2021] [Indexed: 11/23/2022]
Abstract
Background Understanding temporal patterns of organ dysfunction (OD) may aid early recognition of complications after trauma and assist timing and modality of treatment strategies. Our aim was to analyse and characterise temporal patterns of OD in intensive care unit-admitted trauma patients.
Methods We used group-based trajectory modelling to identify temporal trajectories of OD after trauma. Modelling was based on the joint development of all six subdomains comprising the sequential organ failure assessment score measured daily during the first two weeks post trauma. Further, the time for trajectories to stabilise and transition to final group assignments were evaluated. Results Six-hundred and sixty patients were included in the final model. Median age was 40 years, and median ISS was 26 (IQR 17–38). We identified five distinct trajectories of OD. Group 1, mild OD (n = 300), median ISS of 20 (IQR 14–27), had an early resolution of OD and a low mortality. Group 2, moderate OD (n = 135), and group 3, severe OD (n = 87), were fairly similar in admission characteristics and initial OD but differed in subsequent OD trajectories, the latter experiencing an extended course and higher mortality. In group 3, 56% of the patients developed sepsis as compared with 19% in group 2. Group 4, extreme OD (n = 40), received most blood transfusions, had the highest proportion of shock at admission and a median ISS of 41 (IQR 29–50). They experienced significant and sustained OD affecting all organ systems and a 28-day mortality of 30%. Group 5, traumatic brain injury with OD (n = 98), had the highest mortality of 35% and the shortest time to death for non-survivors, median 3.5 (IQR 2.4–4.8) days. Groups 1 and 5 reached their final group assignment early, > 80% of the patients within 48 h. In contrast, groups 2 and 3 had a prolonged time to final group assignment. Conclusions We identified five distinct trajectories of OD after severe trauma during the first two weeks post-trauma. Our findings underline the heterogeneous course after trauma and describe some potentially important clinical insights that are suggested by the groupings and temporal trajectories. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03586-6.
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Affiliation(s)
- Jesper Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden. .,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - David Nelson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Anders Holst
- KTH, Royal Institute of Technology, Stockholm, Sweden.,RISE, Research Institutes of Sweden, Gothenburg, Sweden
| | - Elisabeth Hellgren
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
| | - Ola Friman
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
| | - Anders Oldner
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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25
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Godoy DA, Badenes R, Murillo-Cabezas F. Ten physiological commandments for severe head injury. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:280-292. [PMID: 34140125 DOI: 10.1016/j.redare.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 09/07/2020] [Indexed: 06/12/2023]
Abstract
Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina.
| | - R Badenes
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Universitat de València, Valencia, Spain; Instituto de Investigación Sanitaria de Valencia (INCLIVA), Valencia, Spain
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26
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How do we identify the crashing traumatic brain injury patient - the neurosurgeon's view. Curr Opin Crit Care 2021; 27:87-94. [PMID: 33395087 DOI: 10.1097/mcc.0000000000000799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view. RECENT FINDINGS In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected. SUMMARY Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.
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27
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Zusman BE, Kochanek PM, Bell MJ, Adelson PD, Wisniewski SR, Au AK, Clark RSB, Bayır H, Janesko-Feldman K, Jha RM. Cerebrospinal Fluid Sulfonylurea Receptor-1 is Associated with Intracranial Pressure and Outcome after Pediatric TBI: An Exploratory Analysis of the Cool Kids Trial. J Neurotrauma 2021; 38:1615-1619. [PMID: 33430695 DOI: 10.1089/neu.2020.7501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Sulfonylurea receptor-1 (SUR1) is recognized increasingly as a key contributor to cerebral edema, hemorrhage progression, and possibly neuronal death in multiple forms of acute brain injury. SUR1 inhibition may be protective and is actively undergoing evaluation in Phase-2/3 trials of traumatic brain injury (TBI) and stroke. In adult TBI, SUR1 expression is associated with intracranial hypertension and contusion expansion; its role in pediatric TBI remains unexplored. We tested 61 cerebrospinal fluid (CSF) samples from 16 pediatric patients with severe TBI enrolled in the multicenter Phase-3 randomized controlled "Cool Kids" trial and seven non-brain injured pediatric controls for SUR1 expression by enzyme-linked immunosorbent assay. Linear mixed models evaluated associations between mean SUR1 and intracranial pressure (ICP) over the first seven days and pediatric Glasgow Outcome Scale-Extended (GOS-E Peds) over the initial year after injury. SUR1 was undetectable in control CSF and increased versus control in nine of 16 patients with TBI. Mean SUR1 was not associated with age, sex, or therapeutic hypothermia. Each 1-point increase in initial Glasgow Coma Score was associated with a 1.68 ng/mL decrease in CSF SUR1. The CSF SUR1 was associated with increased ICP over seven days (b = 0.73, p = 0.004) and worse (higher) GOS-E Peds score (b = 0.24, p = 0.004). In this exploratory pediatric study, CSF SUR1 was undetectable in controls and variably elevated in severe TBI. Mean CSF SUR1 concentration was associated with ICP and outcome. These findings are distinct from our previous report in adults with severe TBI, where SUR1 was detected universally. SUR1 may be a viable therapeutic target in a subset of pediatric TBI, and further study is warranted.
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Affiliation(s)
- Benjamin E Zusman
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,UPMC Children's Hospital of Pittsburgh, UPMC, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | | | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Publich Health, Pittsburgh, Pennsylvania, USA
| | - Alicia K Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | - Hülya Bayır
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | - Keri Janesko-Feldman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | - Ruchira M Jha
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
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28
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Challenges and Opportunities in Multimodal Monitoring and Data Analytics in Traumatic Brain Injury. Curr Neurol Neurosci Rep 2021; 21:6. [PMID: 33527217 PMCID: PMC7850903 DOI: 10.1007/s11910-021-01098-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. RECENT FINDINGS Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
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29
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Stroh JN, Albers DJ, Bennett TD. Personalization and Pragmatism: Pediatric Intracranial Pressure and Cerebral Perfusion Pressure Treatment Thresholds. Pediatr Crit Care Med 2021; 22:213-216. [PMID: 33528196 PMCID: PMC7861119 DOI: 10.1097/pcc.0000000000002637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J N Stroh
- Department of Bioengineering, College of Engineering, Design, and Computing, Aurora, CO
| | - David J Albers
- Department of Bioengineering, College of Engineering, Design, and Computing, Aurora, CO
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Tellen D Bennett
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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30
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Godoy DA, Badenes R, Murillo-Cabezas F. Ten physiological commandments for severe head injury. ACTA ACUST UNITED AC 2021; 68:280-292. [PMID: 33487456 DOI: 10.1016/j.redar.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/17/2022]
Abstract
Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina.
| | - R Badenes
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España; Departamento de Cirugía, Universitat de València, Valencia, España; Instituto de Investigación Sanitaria de Valencia (INCLIVA), Valencia, España
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31
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Deng H, Zusman BE, Nwachuku EL, Yue JK, Chang YF, Conley YP, Okonkwo DO, Puccio AM. B-Cell Lymphoma 2 (Bcl-2) Gene Is Associated with Intracranial Hypertension after Severe Traumatic Brain Injury. J Neurotrauma 2021; 38:291-299. [PMID: 32515262 PMCID: PMC8182479 DOI: 10.1089/neu.2020.7028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Severe traumatic brain injury (TBI) activates the apoptotic cascade in neurons and glia as part of secondary cellular injury. B-cell lymphoma 2 (Bcl-2) gene encodes a pro-survival protein to suppress programmed cell death, and variation in this gene has potential to affect intracranial pressure (ICP). Participants were recruited from a single clinical center using a prospective observational study design. Inclusion criteria were: age 16-80 years; Glasgow Coma Scale (GCS) score 4-8; and at least 24 h of ICP monitoring treated between 2000-2014. Outcomes were mean ICP, spikes >20 and >25 mm Hg, edema, and surgical intervention. Odds ratios (OR), mean increases/decreases (B), and 95% confidence intervals (CIs) were reported. In 264 patients, average age was 39.2 years old and 78% of patients were male. Mean ICPs were 11.4 ± 0.4 mm Hg for patients with homozygous wild-type (AA), 12.8 ± 0.6 mm Hg for heterozygous (AG), and 14.3 ± 1.2 mm Hg for homozygous variant (GG; p = 0.023). Rs17759659 GG genotype was associated with more ICP spikes >20 mm Hg (p = 0.017) and >25 mm Hg (p = 0.048). Multi-variate analysis showed that GG relative to AA genotype had higher ICP (B = 2.7 mm Hg, 95% CI [0.5,4.9], p = 0.015), edema (OR = 2.5 [1.0, 6.0], p = 0.049) and need for decompression (OR = 3.7 [1.5-9.3], p = 0.004). In this prospective severe TBI cohort, Bcl-2 rs17759659 was associated with increased risk of intracranial hypertension, cerebral edema, and need for surgical intervention. The variant allele may impact programmed cell death of injured neurons, resulting in elevated ICP and post-traumatic secondary insults. Further risk stratification and targeted genotype-based therapies could improve outcomes after severe TBI.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin E. Zusman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Enyinna L. Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yvette P. Conley
- School of Nursing and Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Trofimov A, Dubrovin A, Martynov D, Agarkova D, Trofimova K, Zorkova A, Bragin DE. Microcirculatory Biomarkers of Secondary Cerebral Ischemia in Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:3-5. [PMID: 33839807 PMCID: PMC8086813 DOI: 10.1007/978-3-030-59436-7_1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM The purpose of this study was to study changes in cerebral microcirculation parameters in the development of secondary cerebral ischemia (SCI). METHODS A total of 202 patients with a Glasgow Coma Scale score ≤ 12 after experiencing a traumatic brain injury (TBI) were recruited for the study within 6 h of the injury. All patients were subjected to perfusion computed tomography. The cerebral blood flow velocity was recorded using transcranial Doppler ultrasound. The arterial blood pressure was measured noninvasively. The cerebrovascular resistance (CVR), cerebral arterial compliance (CAC), cerebrovascular time constant (CTC), and critical closing pressure (CCP) were measured using the neuromonitoring complex. All patients had unilateral foci of posttraumatic ischemia. Statistical analysis was performed using a paired Student's t test and factor analysis. RESULTS AND CONCLUSION The CVR and CCP were significantly increased in patients who developed SCI after TBI, whereas the CAC and CTC were significantly decreased (P < 0.05). Factor analyses revealed that the CVR, CAC, and CTC were significantly associated with development of posttraumatic ischemia (P < 0.05). The changes in the CVR and CCP in patients with TBI were significantly associated with SCI development (P < 0.05).
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Affiliation(s)
- Alex Trofimov
- Department of Neurosurgery, Privolzhsky Research Medical University, Nizhniy Novgorod, Russia.
| | - Antony Dubrovin
- Department of Neurosurgery, Privolzhsky Research Medical University, Nizhniy Novgorod, Russia
| | - Dmitry Martynov
- Department of Neurosurgery, Privolzhsky Research Medical University, Nizhniy Novgorod, Russia
| | - Darya Agarkova
- Department of Neurosurgery, Privolzhsky Research Medical University, Nizhniy Novgorod, Russia
| | - Ksenia Trofimova
- Department of Neurosurgery, Privolzhsky Research Medical University, Nizhniy Novgorod, Russia
| | - Ann Zorkova
- Department of Neurosurgery, Privolzhsky Research Medical University, Nizhniy Novgorod, Russia
| | - Denis E Bragin
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
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33
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Rivera EAT, Patel AK, Zeng-Treitler Q, Chamberlain JM, Bost JE, Heneghan JA, Morizono H, Pollack MM. Severity Trajectories of Pediatric Inpatients Using the Criticality Index. Pediatr Crit Care Med 2021; 22:e19-e32. [PMID: 32932405 PMCID: PMC7790848 DOI: 10.1097/pcc.0000000000002561] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To assess severity of illness trajectories described by the Criticality Index for survivors and deaths in five patient groups defined by the sequence of patient care in ICU and routine patient care locations. DESIGN The Criticality Index developed using a calibrated, deep neural network, measures severity of illness using physiology, therapies, and therapeutic intensity. Criticality Index values in sequential 6-hour time periods described severity trajectories. SETTING Hospitals with pediatric inpatient and ICU care. PATIENTS Pediatric patients never cared for in an ICU (n = 20,091), patients only cared for in the ICU (n = 2,096) and patients cared for in both ICU and non-ICU care locations (n = 17,023) from 2009 to 2016 Health Facts database (Cerner Corporation, Kansas City, MO). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Criticality Index values were consistent with clinical experience. The median (25-75th percentile) ICU Criticality Index values (0.878 [0.696-0.966]) were more than 80-fold higher than the non-ICU values (0.010 [0.002-0.099]). Non-ICU Criticality Index values for patients transferred to the ICU were 40-fold higher than those never transferred to the ICU (0.164 vs 0.004). The median for ICU deaths was higher than ICU survivors (0.983 vs 0.875) (p < 0.001). The severity trajectories for the five groups met expectations based on clinical experience. Survivors had increasing Criticality Index values in non-ICU locations prior to ICU admission, decreasing Criticality Index values in the ICU, and decreasing Criticality Index values until hospital discharge. Deaths had higher Criticality Index values than survivors, steeper increases prior to the ICU, and worsening values in the ICU. Deaths had a variable course, especially those who died in non-ICU care locations, consistent with deaths associated with both active therapies and withdrawals/limitations of care. CONCLUSIONS Severity trajectories measured by the Criticality Index showed strong validity, reflecting the expected clinical course for five diverse patient groups.
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Affiliation(s)
| | - Anita K Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Qing Zeng-Treitler
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E Bost
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Julia A Heneghan
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Hiroki Morizono
- Children's National Research Institute, Associate Research Professor of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
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Jha RM, Mondello S, Bramlett HM, Dixon CE, Shear DA, Dietrich WD, Wang KKW, Yang Z, Hayes RL, Poloyac SM, Empey PE, Lafrenaye AD, Yan HQ, Carlson SW, Povlishock JT, Gilsdorf JS, Kochanek PM. Glibenclamide Treatment in Traumatic Brain Injury: Operation Brain Trauma Therapy. J Neurotrauma 2020; 38:628-645. [PMID: 33203303 DOI: 10.1089/neu.2020.7421] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Glibenclamide (GLY) is the sixth drug tested by the Operation Brain Trauma Therapy (OBTT) consortium based on substantial pre-clinical evidence of benefit in traumatic brain injury (TBI). Adult Sprague-Dawley rats underwent fluid percussion injury (FPI; n = 45), controlled cortical impact (CCI; n = 30), or penetrating ballistic-like brain injury (PBBI; n = 36). Efficacy of GLY treatment (10-μg/kg intraperitoneal loading dose at 10 min post-injury, followed by a continuous 7-day subcutaneous infusion [0.2 μg/h]) on motor, cognitive, neuropathological, and biomarker outcomes was assessed across models. GLY improved motor outcome versus vehicle in FPI (cylinder task, p < 0.05) and CCI (beam balance, p < 0.05; beam walk, p < 0.05). In FPI, GLY did not benefit any other outcome, whereas in CCI, it reduced 21-day lesion volume versus vehicle (p < 0.05). On Morris water maze testing in CCI, GLY worsened performance on hidden platform latency testing versus sham (p < 0.05), but not versus TBI vehicle. In PBBI, GLY did not improve any outcome. Blood levels of glial fibrillary acidic protein and ubiquitin carboxyl terminal hydrolase-1 at 24 h did not show significant treatment-induced changes. In summary, GLY showed the greatest benefit in CCI, with positive effects on motor and neuropathological outcomes. GLY is the second-highest-scoring agent overall tested by OBTT and the only drug to reduce lesion volume after CCI. Our findings suggest that leveraging the use of a TBI model-based phenotype to guide treatment (i.e., GLY in contusion) might represent a strategic choice to accelerate drug development in clinical trials and, ultimately, achieve precision medicine in TBI.
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Affiliation(s)
- Ruchira M Jha
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Neurology, Neurobiology, and Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - C Edward Dixon
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - W Dalton Dietrich
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Ronald L Hayes
- Center for Innovative Research, Center for Proteomics and Biomarkers Research, Banyan Biomarkers, Inc., Alachua, Florida, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Audrey D Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hong Q Yan
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W Carlson
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John T Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Janice S Gilsdorf
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Pediatrics, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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35
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Kochanek PM, Jackson TC, Jha RM, Clark RS, Okonkwo DO, Bayır H, Poloyac SM, Wagner AK, Empey PE, Conley YP, Bell MJ, Kline AE, Bondi CO, Simon DW, Carlson SW, Puccio AM, Horvat CM, Au AK, Elmer J, Treble-Barna A, Ikonomovic MD, Shutter LA, Taylor DL, Stern AM, Graham SH, Kagan VE, Jackson EK, Wisniewski SR, Dixon CE. Paths to Successful Translation of New Therapies for Severe Traumatic Brain Injury in the Golden Age of Traumatic Brain Injury Research: A Pittsburgh Vision. J Neurotrauma 2020; 37:2353-2371. [PMID: 30520681 PMCID: PMC7698994 DOI: 10.1089/neu.2018.6203] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
New neuroprotective therapies for severe traumatic brain injury (TBI) have not translated from pre-clinical to clinical success. Numerous explanations have been suggested in both the pre-clinical and clinical arenas. Coverage of TBI in the lay press has reinvigorated interest, creating a golden age of TBI research with innovative strategies to circumvent roadblocks. We discuss the need for more robust therapies. We present concepts for traditional and novel approaches to defining therapeutic targets. We review lessons learned from the ongoing work of the pre-clinical drug and biomarker screening consortium Operation Brain Trauma Therapy and suggest ways to further enhance pre-clinical consortia. Biomarkers have emerged that empower choice and assessment of target engagement by candidate therapies. Drug combinations may be needed, and it may require moving beyond conventional drug therapies. Precision medicine may also link the right therapy to the right patient, including new approaches to TBI classification beyond the Glasgow Coma Scale or anatomical phenotyping-incorporating new genetic and physiologic approaches. Therapeutic breakthroughs may also come from alternative approaches in clinical investigation (comparative effectiveness, adaptive trial design, use of the electronic medical record, and big data). The full continuum of care must also be represented in translational studies, given the important clinical role of pre-hospital events, extracerebral insults in the intensive care unit, and rehabilitation. TBI research from concussion to coma can cross-pollinate and further advancement of new therapies. Misconceptions can stifle/misdirect TBI research and deserve special attention. Finally, we synthesize an approach to deliver therapeutic breakthroughs in this golden age of TBI research.
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Affiliation(s)
- Patrick M. Kochanek
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Travis C. Jackson
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ruchira M. Jha
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Hülya Bayır
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samuel M. Poloyac
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Amy K. Wagner
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Philip E. Empey
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Yvette P. Conley
- Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Michael J. Bell
- Department of Critical Care Medicine, Children's National Medical Center, Washington, DC, USA
| | - Anthony E. Kline
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Corina O. Bondi
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dennis W. Simon
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W. Carlson
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Christopher M. Horvat
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alicia K. Au
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Amery Treble-Barna
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Milos D. Ikonomovic
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lori A. Shutter
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - D. Lansing Taylor
- University of Pittsburgh Drug Discovery Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew M. Stern
- Drug Discovery Institute, Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven H. Graham
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerian E. Kagan
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Edwin K. Jackson
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stephen R. Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - C. Edward Dixon
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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36
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Lazaridis C, Goldenberg FD. Intracranial Pressure in Traumatic Brain Injury: From Thresholds to Heuristics. Crit Care Med 2020; 48:1210-1213. [PMID: 32697493 DOI: 10.1097/ccm.0000000000004383] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, IL
- Division of Neurocritical Care, Department of Surgery (Neurosurgery), University of Chicago Medical Center, Chicago, IL
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, IL
- Division of Neurocritical Care, Department of Surgery (Neurosurgery), University of Chicago Medical Center, Chicago, IL
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37
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA.
| | - Ruchira M Jha
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA
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Intracranial Pressure Threshold Heuristics in Traumatic Brain Injury: One, None, Many! Neurocrit Care 2020; 32:672-676. [DOI: 10.1007/s12028-020-00940-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Iqbal O'Meara AM, Sequeira J, Miller Ferguson N. Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature. Front Neurol 2020; 11:118. [PMID: 32153494 PMCID: PMC7044347 DOI: 10.3389/fneur.2020.00118] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Abstract
Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.
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Affiliation(s)
- A M Iqbal O'Meara
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Jake Sequeira
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
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Hüser M, Kündig A, Karlen W, De Luca V, Jaggi M. Forecasting intracranial hypertension using multi-scale waveform metrics. Physiol Meas 2020; 41:014001. [PMID: 31851948 DOI: 10.1088/1361-6579/ab6360] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Acute intracranial hypertension is an important risk factor of secondary brain damage after traumatic brain injury. Hypertensive episodes are often diagnosed reactively, leading to late detection and lost time for intervention planning. A pro-active approach that predicts critical events several hours ahead of time could assist in directing attention to patients at risk. APPROACH We developed a prediction framework that forecasts onsets of acute intracranial hypertension in the next 8 h. It jointly uses cerebral auto-regulation indices, spectral energies and morphological pulse metrics to describe the neurological state of the patient. One-minute base windows were compressed by computing signal metrics, and then stored in a multi-scale history, from which physiological features were derived. MAIN RESULTS Our model predicted events up to 8 h in advance with an alarm recall rate of 90% at a precision of 30% in the MIMIC-III waveform database, improving upon two baselines from the literature. We found that features derived from high-frequency waveforms substantially improved the prediction performance over simple statistical summaries of low-frequency time series, and each of the three feature classes contributed to the performance gain. The inclusion of long-term history up to 8 h was especially important. SIGNIFICANCE Our results highlight the importance of information contained in high-frequency waveforms in the neurological intensive care unit. They could motivate future studies on pre-hypertensive patterns and the design of new alarm algorithms for critical events in the injured brain.
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Affiliation(s)
- Matthias Hüser
- Biomedical Informatics Group, Institute of Machine Learning, Department of Computer Science, ETH Zürich, 8092 Zürich, Switzerland
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Jha RM, Bell J, Citerio G, Hemphill JC, Kimberly WT, Narayan RK, Sahuquillo J, Sheth KN, Simard JM. Role of Sulfonylurea Receptor 1 and Glibenclamide in Traumatic Brain Injury: A Review of the Evidence. Int J Mol Sci 2020; 21:E409. [PMID: 31936452 PMCID: PMC7013742 DOI: 10.3390/ijms21020409] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 02/07/2023] Open
Abstract
Cerebral edema and contusion expansion are major determinants of morbidity and mortality after TBI. Current treatment options are reactive, suboptimal and associated with significant side effects. First discovered in models of focal cerebral ischemia, there is increasing evidence that the sulfonylurea receptor 1 (SUR1)-Transient receptor potential melastatin 4 (TRPM4) channel plays a key role in these critical secondary injury processes after TBI. Targeted SUR1-TRPM4 channel inhibition with glibenclamide has been shown to reduce edema and progression of hemorrhage, particularly in preclinical models of contusional TBI. Results from small clinical trials evaluating glibenclamide in TBI have been encouraging. A Phase-2 study evaluating the safety and efficacy of intravenous glibenclamide (BIIB093) in brain contusion is actively enrolling subjects. In this comprehensive narrative review, we summarize the molecular basis of SUR1-TRPM4 related pathology and discuss TBI-specific expression patterns, biomarker potential, genetic variation, preclinical experiments, and clinical studies evaluating the utility of treatment with glibenclamide in this disease.
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Affiliation(s)
- Ruchira M. Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15201, USA
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20121 Milan, Italy;
- Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94110, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02108, USA;
| | - Raj K. Narayan
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d′Hebron Research Institute (VHIR), 08001 Barcelona, Spain;
- Department of Neurosurgery, Universitat Autònoma de Barcelona (UAB), 08001 Barcelona, Spain
- Department of Neurosurgery, Vall d′Hebron University Hospital, 08001 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT 06501, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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The authors reply. Pediatr Crit Care Med 2019; 20:1105-1107. [PMID: 31688689 DOI: 10.1097/pcc.0000000000002095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Using Intracranial Pressure Trajectories for Outcome Prediction in Traumatic Brain Injury: Are Summary Measures Still Valid in the Era of Precision-Based Medicine? Crit Care Med 2019; 46:1876-1878. [PMID: 30312235 DOI: 10.1097/ccm.0000000000003397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Prescott HC. Identifying Sepsis Subtypes from Routine Clinical Data. Am J Respir Crit Care Med 2019; 200:272-273. [PMID: 30848936 PMCID: PMC6680309 DOI: 10.1164/rccm.201903-0532ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hallie C Prescott
- 1Department of Internal MedicineUniversity of MichiganAnn Arbor, Michiganand
- 2Veterans Affairs Center for Clinical Management ResearchHealth Services Research & Development Center of InnovationAnn Arbor, Michigan
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Jha RM, Desai SM, Zusman BE, Koleck TA, Puccio AM, Okonkwo DO, Park SY, Shutter LA, Kochanek PM, Conley YP. Downstream TRPM4 Polymorphisms Are Associated with Intracranial Hypertension and Statistically Interact with ABCC8 Polymorphisms in a Prospective Cohort of Severe Traumatic Brain Injury. J Neurotrauma 2019; 36:1804-1817. [PMID: 30484364 PMCID: PMC6551973 DOI: 10.1089/neu.2018.6124] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Sulfonylurea-receptor-1(SUR1) and its associated transient-receptor-potential cation channel subfamily-M (TRPM4) channel are key contributors to cerebral edema and intracranial hypertension in traumatic brain injury (TBI) and other neurological disorders. Channel inhibition by glyburide is clinically promising. ABCC8 (encoding SUR1) single-nucleotide polymorphisms (SNPs) are reported as predictors of raised intracranial pressure (ICP). This project evaluated whether TRPM4 SNPs predicted ICP and TBI outcome. DNA was extracted from 435 consecutively enrolled severe TBI patients. Without a priori selection, all 11 TRPM4 SNPs available on the multiplex platform (Illumina:Human-Core-Exome v1.0) were genotyped spanning the 25 exon gene. A total of 385 patients were analyzed after quality control. Outcomes included ICP and 6 month Glasgow Outcome Scale (GOS) score. Proxy SNPs, spatial modeling, and functional predictions were determined using established software programs. rs8104571 (intron-20) and rs150391806 (exon-24) were predictors of ICP. rs8104571 heterozygotes predicted higher average ICP (β = 10.3 mm Hg, p = 0.00000029), peak ICP (β = 19.6 mm Hg, p = 0.0007), and proportion ICP >25 mm Hg (β = 0.16 p = 0.004). rs150391806 heterozygotes had higher mean (β = 7.2 mm Hg, p = 0.042) and peak (β = 28.9 mm Hg, p = 0.0015) ICPs. rs8104571, rs150391806, and 34 associated proxy SNPs in linkage-disequilibrium clustered downstream. This region encodes TRPM4's channel pore and a region postulated to juxtapose SUR1 sequences encoded by an ABCC8 DNA segment containing previously identified relevant SNPs. There was an interaction effect on ICP between rs8104571 and a cluster of predictive ABCC8 SNPs (rs2237982, rs2283261, rs11024286). Although not significant in univariable or a basic multivariable model, in an expanded model additionally accounting for injury pattern, computed tomographic (CT) appearance, and intracranial hypertension, heterozygous rs8104571 was associated with favorable 6 month GOS (odds ratio [OR] = 16.7, p = 0.007951). This trend persisted in a survivor-only subcohort (OR = 20.67, p = 0.0168). In this cohort, two TRPM4 SNPs predicted increased ICP with large effect sizes. Both clustered downstream, spanning a region encoding the channel pore and interacting with SUR1. If validated, this may guide risk stratification and eventually inform treatment-responder classification for SUR1-TRPM4 inhibition in TBI. Larger studies are warranted.
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Affiliation(s)
- Ruchira M. Jha
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shashvat M. Desai
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Benjamin E. Zusman
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Ava M. Puccio
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Seo-Young Park
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lori A. Shutter
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Anesthesia, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yvette P. Conley
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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Jha RM, Kochanek PM. A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis? Curr Neurol Neurosci Rep 2018; 18:105. [PMID: 30406315 PMCID: PMC6589108 DOI: 10.1007/s11910-018-0912-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Standard clinical protocols for treating cerebral edema and intracranial hypertension after severe TBI have remained remarkably similar over decades. Cerebral edema and intracranial hypertension are treated interchangeably when in fact intracranial pressure (ICP) is a proxy for cerebral edema but also other processes such as extent of mass lesions, hydrocephalus, or cerebral blood volume. A complex interplay of multiple molecular mechanisms results in cerebral edema after severe TBI, and these are not measured or targeted by current clinically available tools. Addressing these underpinnings may be key to preventing or treating cerebral edema and improving outcome after severe TBI. RECENT FINDINGS This review begins by outlining basic principles underlying the relationship between edema and ICP including the Monro-Kellie doctrine and concepts of intracranial compliance/elastance. There is a subsequent brief discussion of current guidelines for ICP monitoring/management. We then focus most of the review on an evolving precision medicine approach towards cerebral edema and intracranial hypertension after TBI. Personalization of invasive neuromonitoring parameters including ICP waveform analysis, pulse amplitude, pressure reactivity, and longitudinal trajectories are presented. This is followed by a discussion of cerebral edema subtypes (continuum of ionic/cytotoxic/vasogenic edema and progressive secondary hemorrhage). Mechanisms of potential molecular contributors to cerebral edema after TBI are reviewed. For each target, we present findings from preclinical models, and evaluate their clinical utility as biomarkers and therapeutic targets for cerebral edema reduction. This selection represents promising candidates with evidence from different research groups, overlap/inter-relatedness with other pathways, and clinical/translational potential. We outline an evolving precision medicine and translational approach towards cerebral edema and intracranial hypertension after severe TBI.
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Affiliation(s)
- Ruchira M Jha
- Department of Critical Care Medicine, Room 646A, Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA.
- Safar Center for Resuscitation Research John G. Rangos Research Center, 6th Floor; 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Room 646A, Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA
- Safar Center for Resuscitation Research John G. Rangos Research Center, 6th Floor; 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh John G. Rangos Research Center, 6th Floor 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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Pathophysiology and treatment of cerebral edema in traumatic brain injury. Neuropharmacology 2018; 145:230-246. [PMID: 30086289 DOI: 10.1016/j.neuropharm.2018.08.004] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/24/2018] [Accepted: 08/03/2018] [Indexed: 12/30/2022]
Abstract
Cerebral edema (CE) and resultant intracranial hypertension are associated with unfavorable prognosis in traumatic brain injury (TBI). CE is a leading cause of in-hospital mortality, occurring in >60% of patients with mass lesions, and ∼15% of those with normal initial computed tomography scans. After treatment of mass lesions in severe TBI, an important focus of acute neurocritical care is evaluating and managing the secondary injury process of CE and resultant intracranial hypertension. This review focuses on a contemporary understanding of various pathophysiologic pathways contributing to CE, with a subsequent description of potential targeted therapies. There is a discussion of identified cellular/cytotoxic contributors to CE, as well as mechanisms that influence blood-brain-barrier (BBB) disruption/vasogenic edema, with the caveat that this distinction may be somewhat artificial since molecular processes contributing to these pathways are interrelated. While an exhaustive discussion of all pathways with putative contributions to CE is beyond the scope of this review, the roles of some key contributors are highlighted, and references are provided for further details. Potential future molecular targets for treating CE are presented based on pathophysiologic mechanisms. We thus aim to provide a translational synopsis of present and future strategies targeting CE after TBI in the context of a paradigm shift towards precision medicine. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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