Traumatic brain injury advancements

PGK1 Is Involved in the HIF-1 Signaling Pathway as a Hub Gene for Ferroptosis After Traumatic Brain Injury

The pathogenesis of ferroptosis in traumatic brain injury (TBI) is unclear; therefore, we aimed to identify key molecules associated with ferroptosis in TBI using bioinformatics analysis to determine its underlying mechanisms. GSE128543 dataset was downloaded from the Gene Expression Omnibus (GEO) database, and TBI-associated modules were obtained by weighted gene co-expression network analysis (WGCNA). We identified 60 differentially expressed genes (DEGs) by intersecting the modules with ferroptosis and glycolysis/gluconeogenesis gene libraries. The hypoxia-inducible factor-1 (HIF-1) signaling pathway was identified to be critical for ferroptosis post-TBI, and protein-protein interaction (PPI) network identified 20 hub genes, including phosphoglycerate kinase 1 (PGK1), ribosomal protein (RP) family, pyruvate kinase M1/2 (PKM), hypoxia-inducible factor 1α subunit (HIF-1α), and MYC genes. In this study, we further explored the role of PGK1, a gene involved in HIF-1 signaling pathway; however, its role and mechanism in TBI are still unclear. Moreover, we constructed a TBI mouse model and examined PGK1 and HIF-1α expression levels, and the results revealed their expressions increased after cortical injury in mice and they co-localized in the same cells. Furthermore, we examined the expressions of PGK1 in the cerebrospinal fluid of 20 clinical patients with different degrees of brain injuries within 48 h of surgery and examined the cognitive function of patients according to the Glasgow Coma Scale (GCS). The results revealed that PGK1 expression level was negatively correlated with the severity of the brain injury. These findings suggest that PGK1 may become a potential hub gene for ferroptosis via the HIF-1 signaling pathway, second to neurological injury after TBI, thereby affecting patient prognosis.

Multimodal evaluation of the effects of low-intensity ultrasound on cerebral blood flow after traumatic brain injury in mice

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide, and destruction of the cerebrovascular system is a major factor in the cascade of secondary injuries caused by TBI. Laser speckle imaging (LSCI)has high sensitivity in detecting cerebral blood flow. LSCI can visually show that transcranial focused ultrasound stimulation (tFUS) treatment stimulates angiogenesis and increases blood flow. To study the effect of tFUS on promoting angiogenesis in Controlled Cortical impact (CCI) model. tFUS was administered daily for 10 min and for 14 consecutive days after TBI. Cerebral blood flow was measured by LSCI at 1, 3, 7 and 14 days after trauma. Functional outcomes were assessed using LSCI and neurological severity score (NSS). After the last test, Nissl staining and vascular endothelial growth factor (VEGF) were used to assess neuropathology. TBI can cause the destruction of cerebrovascular system. Blood flow was significantly increased in TBI treated with tFUS. LSCI, behavioral and histological findings suggest that tFUS treatment can promote angiogenesis after TBI.

Innovative emergency strategies for patients with severe traumatic brain injury: An IoT-based resource integration

Severe traumatic brain injury patients are in critical condition, and rapid rescue is very important for prognosis. Currently, the resuscitation process is complex and it is difficult to get to the operating room quickly to target treatment. We present a new strategy based on the Internet of Things system to integrate complex first aid procedures for efficient and comprehensive rescuing of patients with severe traumatic brain injury. This system includes three modules: human sign monitoring equipment, emergency transport equipment, and a network diagnosis and treatment progress control center. The system not only supports the streamlining of rescue procedures but also transmits the patient's status and optimal treatment strategies in real-time by using an advanced Internet of Things system. After deploying the system in a hospital, we conducted a validation study to evaluate its feasibility and superiority in clinical use. The preliminary results of the study show that this system can significantly shorten the treatment time, which may help the prognosis of severe traumatic brain injury patients.

Extensive skull ossification after decompressive craniectomy in an elderly patient: A case report and literature review

RATIONALE

After severe traumatic brain injury, patients often present with signs of increased intracranial hypertension and partially require decompressive craniectomies. Artificial materials are usually required to repair skull defects and spontaneous skull ossification is rarely observed in adults.

PATIENT CONCERNS

This study reported a 64-year-old man was admitted to the hospital with a coma due to a traffic accident.

DIAGNOSIS

Emergency computed tomography (CT) examination upon admission showed a left temporo-occipital epidural hematoma with a cerebral hernia and skull fracture.

INTERVENTIONS

The patient underwent urgent craniotomy for hematoma removal and decompression under general anesthesia. The patient was discharged after 1 month of treatment.

OUTCOMES

The patient returned to the hospital for skull repair 145 days after the craniotomy. Pre-operative CT showed island skull regeneration in the skull defect area; therefore, skull repair was postponed after clinical evaluation. Regular follow-up is required. Twenty-three months after surgery, head CT showed that the new skull had completely covered the defect area.

LESSON

We collected other 11 similar cases of spontaneous human skull regeneration in a literature search to analyze the possible factors impacting skull regeneration. The analysis of the cases indicated that maintaining the integrity of the periosteum, dura, and blood vessels during craniotomy may play an important role in skull regeneration. Skull regeneration predominantly occurs in young patients with rapid growth and development; therefore, an appropriate postponement of the cranioplasty time under close monitoring could be considered for young patients with skull defects.

Dexmedetomidine inhibits the PSD95-NMDA receptor interaction to promote functional recovery following traumatic brain injury

The present study examined the effects of dexmedetomidine (Dex) on cognitive and motor recovery in mice following traumatic brain injury (TBI). TBI induces synaptic damage, which leads to motor dysfunction and cognitive decline. Although Dex is known to induce neuroprotection, its role following TBI remains unknown. In the present study, male C57BL/6 mice (8 weeks old; n=72) were subjected to cortical impact injury to generate a TBI mice model. Mice were divided into four groups: TBI, sham, TBI + vehicle, and TBI + Dex. Mice in the TBI + vehicle and TBI + Dex groups received intraperitoneal injections of saline (n=18) and 100 µg/kg Dex (n=18), respectively, at 1 and 12 h following surgery. At 24 h post-injury, 10 animals from each group were sacrificed, and brain tissue was isolated for Fluoro-Jade B staining and RNA and protein extraction. At 72 h post-TBI, motor function was evaluated. Furthermore, cognitive impairment was assessed between day 14 and 19 using the Morris water maze. The results demonstrated that the mRNA and protein expression of post-synaptic density 95 (PSD95) was reduced post-TBI. In addition, neuronal degeneration was evaluated using FJB staining, where PSD95 formed a complex with the N-methyl-D-aspartic acid (NMDA) receptor subunit (NR2B) and neuronal nitric oxide synthase (nNOS) inducing neuronal death post-TBI. Treatment with Dex efficiently decreased the PSD95-NR2B-nNOS interaction, which reduced the TBI-induced neuronal death. Furthermore, Dex treatment contributed to the enhanced cognitive and motor recovery following TBI. The results from the present study reported a potential mechanistic action of Dex treatment post-TBI, which may be associated with the inhibition of PSD95-NMDA interaction.

Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents

BACKGROUND

With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients.

METHODS

We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed.

RESULTS

A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion.

CONCLUSIONS

The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients.

LEVEL OF EVIDENCE

Level III prognostic.

Effect of auricular electroacupuncture combined with body acupuncture in improving the consciousness of patients after traumatic brain injury: Study protocol for a randomized controlled trial

BACKGROUND

Traumatic brain injury (TBI) has become a major cause of morbidity and mortality both in China and abroad. Disorders of consciousness following severe TBI is a common refractory complication, resulting in difficult rehabilitation and poor life quality. However, effective therapeutic approaches remain limited. Although acupuncture has been widely applied in the treatment of neurological disorders in China, its efficacy and safety for consciousness recovery remain to be elucidated.

METHODS

Here, we conduct a study design and protocol of a randomized, blinded, controlled study to evaluate the efficacy and safety of electroacupuncture at auricular acupoints "heart" and "brainstem" combined with body acupuncture in the consciousness recovery of patients with TBI. A total of 80 patients with initial Glasgow coma scale score between 3 and 8 points will be recruited in the trial and randomized into intervention (combined application of auricular electroacupuncture and body acupuncture) group or control (conventional treatment) group. Patients in the intervention group will receive electroacupuncture at bilateral auricular acupoints "heart" and "brainstem" (4 points in total) combined with body acupuncture in addition to conventional treatment while patients in the control group will receive conventional treatment alone for 8 weeks. The primary outcomes are changes of Glasgow coma scale score and mismatch negativity of event-related brain potentials at baseline after 4 weeks after the final treatment and 4 weeks after the final treatment. The secondary outcome measures will be changes of Barthel and FuglMeyer scores at baseline after 4 weeks after the final treatment and 4 weeks after the final treatment. The safety will also be assessed by monitoring the incidence of adverse events and changes in vital signs during the study.

DISCUSSION

Results from this trial will significantly support the application of auricular acupuncture and body acupuncture in the consciousness recovery of patients with severe TBI. If found to be effective and safe, auricular acupuncture combined with body acupuncture will be a valuable complementary option for comatose patients with TBI.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1800020245. Registered on 21 December 2018.

Hypertonic saline maintains coagulofibrinolytic homeostasis following moderate‑to‑severe traumatic brain injury by regulating monocyte phenotype via expression of lncRNAs

Traumatic brain injury (TBI) is the most common cause of death and permanent disability in people aged <45, and is associated with secondary brain injury and bleed progression, resulting in increased morbidity and mortality. TBI may also induce innate host defense responses characterized by activation of resident microglia and astrocytes, brain microvascular endothelial cells and peripheral blood monocytes. In the present study, 34 patients with moderate‑to‑severe traumatic brain injury were randomly divided into two groups, including a 7.5% hypertonic saline (HS) treatment group (4 ml/kg) and 3% HS treatment group (4 ml/kg). The results demonstrated that treatment with 7.5% HS decreased the intracranial pressure and improved coagulofibrinolytic homeostasis. Analysis of the monocyte subsets revealed significant reduction in the proportion of cluster of differentiation (CD)14++CD16+ circulating inflammatory monocytes in the 7.5% HS group. In addition, 7.5% HS treatment downregulated the expression of long non‑coding (lnc) RNA2448‑11 and lncRNA1403 in the peripheral blood mononuclear cells of patients with TBI. Using reverse transcription‑quantitative polymerase chain reaction, it was determined that 7.5% HS regulated the expression of tumor necrosis factor‑α, interleukin‑1β, transforming growth factor‑β and thrombomodulin, which are the target genes of lncRNA2448‑11 and lncRNA1403. These results indicated that 7.5% HS improved the intracranial pressure and coagulofibrinolytic homeostasis by modulating the phenotype of monocytes through lncRNA2448‑11 and lncRNA1403. These findings provided evidence that initial resuscitation with HS imparts functional changes to inflammatory cells following TBI, thereby reducing potential neuroinflammatory events associated with secondary brain injury.

Decompressive craniectomy versus craniotomy only for intracranial hemorrhage evacuation: A propensity matched study

BACKGROUND

Decompressive craniectomy (DC) is often performed in conjunction with evacuation of intracranial hemorrhage (ICH) to control intracranial pressure (ICP) in patients with a traumatic brain injury (TBI). The efficacy of DC in lowering ICP is well established; however, its effect on clinical outcomes remains controversial. The aim of our study is to assess outcomes in TBI patients undergoing DC versus craniotomy only (CO) for the evacuation of ICH.

METHODS

We performed a 5-year retrospective analysis of TBI patients with ICH who underwent craniotomy or craniectomy for traumatic ICH. Patients were divided into two groups, those who underwent CO and those who underwent DC. Propensity scoring matched patients in a 1:2 ratio for demographics, admission Glasgow Coma Scale (GCS) score, severity of injury, type and size of ICH, and anticoagulant use. Outcome measures included mortality, adverse discharge disposition (skilled nursing facility), discharge GCS and Glasgow Outcome Scale scores, and complications.

RESULTS

We reviewed 1,831 patients with TBI, of which 155 underwent craniotomy and/or craniectomy. After propensity score matching, we included 99 of those patients in our study (DC, 33; CO, 66). Matched groups were similar in age (p = 0.68), admission GCS score (p = 0.50), Injury Severity Score (p = 0.70), head Abbreviated Injury Scale score (p = 0.32), and intracranial bleeding characteristics. Overall, 26.3% (n = 26) of the patients died and 62.6% (n = 62) were discharged to Rehab/skilled nursing facility. There was no difference in the mortality rate (27.3% vs. 25.0%; p = 0.99), adverse discharge disposition (45% vs. 33%; p = 0.66), GCS score (p = 0.53), and Glasgow Outcome Scale (p = 0.80) at discharge between the DC and the CO groups. However, patients in DC group had higher complication rates and ventilator days.

CONCLUSION

This study showed no significant difference in clinical outcomes for patients undergoing evacuation of ICH regardless of the procedure performed. DC did not appear to be superior to craniotomy alone for the treatment of acute ICH.

LEVEL OF EVIDENCE

Therapeutic, level III.

Abnormalities in Dynamic Brain Activity Caused by Mild Traumatic Brain Injury Are Partially Rescued by the Cannabinoid Type-2 Receptor Inverse Agonist SMM-189

Mild traumatic brain injury (mTBI) can cause severe long-term cognitive and emotional deficits, including impaired memory, depression, and persevering fear, but the neuropathological basis of these deficits is uncertain. As medial prefrontal cortex (mPFC) and hippocampus play important roles in memory and emotion, we used multi-site, multi-electrode recordings of oscillatory neuronal activity in local field potentials (LFPs) in awake, head-fixed mice to determine if the functioning of these regions was abnormal after mTBI, using a closed-skull focal cranial blast model. We evaluated mPFC, hippocampus CA1, and primary somatosensory/visual cortical areas (S1/V1). Although mTBI did not alter the power of oscillations, it did cause increased coherence of θ (4-10 Hz) and β (10-30 Hz) oscillations within mPFC and S1/V1, reduced CA1 sharp-wave ripple (SWR)-evoked LFP activity in mPFC, downshifted SWR frequencies in CA1, and enhanced θ-γ phase-amplitude coupling (PAC) within mPFC. These abnormalities might be linked to the impaired memory, depression, and persevering fear seen after mTBI. Treatment with the cannabinoid type-2 (CB2) receptor inverse agonist SMM-189 has been shown to mitigate functional deficits and neuronal injury after mTBI in mice. We found that SMM-189 also reversed most of the observed neurophysiological abnormalities. This neurophysiological rescue is likely to stem from the previously reported reduction in neuron loss and/or the preservation of neuronal function and connectivity resulting from SMM-189 treatment, which appears to stem from the biasing of microglia from the proinflammatory M1 state to the prohealing M2 state by SMM-189.