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van Erp IAM, van Essen TA, Lingsma H, Pisica D, Singh RD, van Dijck JTJM, Volovici V, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson P, Depreitere B, Steyerberg EW, Maas AIR, de Ruiter GCW, Peul WC. Early surgery versus conservative treatment in patients with traumatic intracerebral hematoma: a CENTER-TBI study. Acta Neurochir (Wien) 2023; 165:3217-3227. [PMID: 37747570 PMCID: PMC10624744 DOI: 10.1007/s00701-023-05797-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Evidence regarding the effect of surgery in traumatic intracerebral hematoma (t-ICH) is limited and relies on the STITCH(Trauma) trial. This study is aimed at comparing the effectiveness of early surgery to conservative treatment in patients with a t-ICH. METHODS In a prospective cohort, we included patients with a large t-ICH (< 48 h of injury). Primary outcome was the Glasgow Outcome Scale Extended (GOSE) at 6 months, analyzed with multivariable proportional odds logistic regression. Subgroups included injury severity and isolated vs. non-isolated t-ICH. RESULTS A total of 367 patients with a large t-ICH were included, of whom 160 received early surgery and 207 received conservative treatment. Patients receiving early surgery were younger (median age 54 vs. 58 years) and more severely injured (median Glasgow Coma Scale 7 vs. 10) compared to those treated conservatively. In the overall cohort, early surgery was not associated with better functional outcome (adjusted odds ratio (AOR) 1.1, (95% CI, 0.6-1.7)) compared to conservative treatment. Early surgery was associated with better outcome for patients with moderate TBI and isolated t-ICH (AOR 1.5 (95% CI, 1.1-2.0); P value for interaction 0.71, and AOR 1.8 (95% CI, 1.3-2.5); P value for interaction 0.004). Conversely, in mild TBI and those with a smaller t-ICH (< 33 cc), conservative treatment was associated with better outcome (AOR 0.6 (95% CI, 0.4-0.9); P value for interaction 0.71, and AOR 0.8 (95% CI, 0.5-1.0); P value for interaction 0.32). CONCLUSIONS Early surgery in t-ICH might benefit those with moderate TBI and isolated t-ICH, comparable with results of the STITCH(Trauma) trial.
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Affiliation(s)
- Inge A M van Erp
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands.
| | - Thomas A van Essen
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Hester Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Dana Pisica
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Ranjit D Singh
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Jeroen T J M van Dijck
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Victor Volovici
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Lianne D Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Gerard M Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W Steyerberg
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre and Haaglanden Medical Centre, Leiden and The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Antwerp, Belgium
| | - Godard C W de Ruiter
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
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Yue JK, Krishnan N, Kanter JH, Deng H, Okonkwo DO, Puccio AM, Madhok DY, Belton PJ, Lindquist BE, Satris GG, Lee YM, Umbach G, Duhaime AC, Mukherjee P, Yuh EL, Valadka AB, DiGiorgio AM, Tarapore PE, Huang MC, Manley GT, Investigators TTRACKTBI. Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study. J Clin Med 2023; 12:2024. [PMID: 36902811 PMCID: PMC10004432 DOI: 10.3390/jcm12052024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization. METHODS Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported. RESULTS In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]). CONCLUSIONS Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.
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Affiliation(s)
- John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - John H. Kanter
- Section of Neurological Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Britta E. Lindquist
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA 94110, USA
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Young M. Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Gray Umbach
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Ann-Christine Duhaime
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA 94158, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael C. Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
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Milej D, Rajaram A, Suwalski M, Morrison LB, Shoemaker LN, St. Lawrence K. Assessing the relationship between the cerebral metabolic rate of oxygen and the oxidation state of cytochrome-c-oxidase. NEUROPHOTONICS 2022; 9:035001. [PMID: 35874144 PMCID: PMC9298853 DOI: 10.1117/1.nph.9.3.035001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/22/2022] [Indexed: 05/07/2023]
Abstract
Significance: Hyperspectral near-infrared spectroscopy (hsNIRS) combined with diffuse correlation spectroscopy (DCS) provides a noninvasive approach for monitoring cerebral blood flow (CBF), the cerebral metabolic rate of oxygen ( CMRO 2 ) and the oxidation state of cytochrome-c-oxidase (oxCCO). CMRO 2 is calculated by combining tissue oxygen saturation ( S t O 2 ) with CBF, whereas oxCCO can be measured directly by hsNIRS. Although both reflect oxygen metabolism, a direct comparison has yet to be studied. Aim: We aim to investigate the relationship between CMRO 2 and oxCCO during periods of restricted oxygen delivery and lower metabolic demand. Approach: A hybrid hsNIRS/DCS system was used to measure hemodynamic and metabolic responses in piglets exposed to cerebral ischemia and anesthetic-induced reductions in brain activity. Results: Although a linear relationship was observed between CMRO 2 and oxCCO during ischemia, both exhibited a nonlinear relationship with respect to CBF. In contrast, linear correlation was sufficient to characterize the relationships between CMRO 2 and CBF and between the two metabolic markers during reduced metabolic demand. Conclusions: The observed relationship between CMRO 2 and oxCCO during periods of restricted oxygen delivery and lower metabolic demand indicates that the two metabolic markers are strongly correlated.
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Affiliation(s)
- Daniel Milej
- Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
- Western University, Department of Medical Biophysics, London, Ontario, Canada
- Address all correspondence to Daniel Milej,
| | - Ajay Rajaram
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Marianne Suwalski
- Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
- Western University, Department of Medical Biophysics, London, Ontario, Canada
| | - Laura B. Morrison
- Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
| | - Leena N. Shoemaker
- Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
- Western University, Department of Medical Biophysics, London, Ontario, Canada
- Western University, Department of Kinesiology, London, Ontario, Canada
| | - Keith St. Lawrence
- Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
- Western University, Department of Medical Biophysics, London, Ontario, Canada
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