A systematic review of factors contributing to outcomes in patients with traumatic brain injury

Efficacy of Non-Invasive Brain Stimulation for Treating Depression in Patients with Traumatic Brain Injury: A Meta-Analysis and Meta-Regression of Randomized Controlled Trials

OBJECTIVE

This meta-analysis aimed to ascertain the efficacy of non-invasive brain stimulation (NIBS)-comprising repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS)-for depression in traumatic brain injury (TBI) patients.

METHODS

Comprehensive searches were conducted in PubMed, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials up to 28 January 2023. Random-effects models assessed the treatment effects, and heterogeneity was evaluated through I2 statistics and funnel plot inspection.

RESULTS

From 10 trials (234 participants; 8 rTMS, 2 tDCS), NIBS was found significantly more effective than sham in alleviating depressive symptoms (SMD: 0.588, 95% CI: 0.264-0.912; p < 0.001). rTMS, specifically, showed higher efficacy (SMD: 0.707, 95% CI: 0.306-1.108; p = 0.001) compared to sham, whereas tDCS outcomes were inconclusive (SMD: 0.271, 95% CI: -0.230 to 0.771; p = 0.289). Meta-regression found no correlation with the number of sessions, treatment intensity, or total dose. Notably, while post-treatment effects were significant, they diminished 1-2 months post intervention. Adverse events associated with NIBS were minimal, with no severe outcomes like seizures and suicide reported.

CONCLUSIONS

rTMS emerged as a potent short-term intervention for depression in TBI patients, while tDCS findings remained equivocal. The long-term efficacy of NIBS is yet to be established, warranting further studies. The low adverse event rate reaffirms NIBS's potential safety.

Low serum calcium is a novel predictor of unfavorable prognosis after traumatic brain injury

Background

Accurate and convenient serological markers for prognosis after traumatic brain injury (TBI) are still lacking. We aimed to explore the predictive value of serum calcium for prognosing outcomes within 6 months after TBI.

Methods

In this multicenter retrospective study, 1255 and 719 patients were included in development and validation cohorts, respectively, and their 6-month prognoses were recorded. Serum calcium was measured through routine blood tests within 24 h of hospital admission. Two multivariate predictive models with or without serum calcium for prognosis were developed. Receiver operating characteristics and calibration curves were applied to estimate their performance.

Results

The patients with lower serum calcium levels had a higher frequency of unfavorable 6-month prognosis than those without. Lower serum calcium level at admission was associated with an unfavorable 6-month prognosis in a wide spectrum of patients with TBI. Lower serum calcium level and our prognostic model including calcium performed well in predicting the 6-month unfavorable outcome. The calcium nomogram maintained excellent performance in discrimination and calibration in the external validation cohort.

Conclusions

Lower serum calcium level upon admission is an independent risk factor for an unfavorable 6-month prognosis after TBI. Integrating serum calcium into a multivariate predictive model improves the performance for predicting 6-month unfavorable outcomes.

Traumatic brain injury: Association between the Glasgow Coma Scale score and intensive care unit mortality

Background

Traumatic brain injury (TBI) prevalence in Botswana is high and this, coupled with a small population, may reduce productivity. There is no previous study in Botswana on the association between mortality from TBI and the Glasgow Coma Scale (GCS) score although global literature supports its existence.

Objectives

Our primary aim was to determine the association between the initial GCS score and the time to mortality of adults admitted with TBI at the Princess Marina Hospital, Gaborone, Botswana, between 2014 and 2019. Secondary aims were to assess the risk factors associated with time to mortality and to estimate the mortality rate from TBI.

Methods

This was a retrospective cohort design, medical record census conducted from 1 January 2014 to 31 December 2019.

Results

In total, 137 participants fulfilled the inclusion criteria, and the majority, 114 (83.2%), were male with a mean age of 34.5 years. The initial GCS score and time to mortality were associated (adjusted hazard ratio (aHR) 0.69; 95% confidence interval (CI) 0.508 - 0.947). Other factors associated with time to mortality included constricted pupil (aHR 0.12; 95% CI 0.044 - 0.344), temperature (aHR 0.82; 95% CI 0.727 - 0.929), and subdural haematoma (aHR 3.41; 95% CI 1.819 - 6.517). Most cases of TBI (74 (54%)) were due to road traffic accidents. The number of deaths was 48 (35% (95% CI 27.1% - 43.6%)), entirely due to severe TBI.

Conclusion

The study confirmed significant association between GCS and mortality. Males were mainly involved in TBI. These findings lack external validity because of the small sample size, and therefore a larger multicentre study is required for validation.

Contributions of the study

This study informs the relevant stakeholders in Botswana about sociodemographics, clinical characteristics, management and outcomes of patients admitted to the ICU with severe TBI on the backdrop of scarce ICU resources. It provides a basis for a larger study to inform its external validation.

The Value of Patient Registries to Advance Basic and Translational Research in the Area of Traumatic Brain Injury

The number of individuals affected by traumatic brain injury (TBI) is growing globally. TBIs may cause a range of physical, cognitive, and psychiatric deficits that can negatively impact employment, academic attainment, community independence, and interpersonal relationships. Although there has been a significant decrease in the number of injury related deaths over the past several decades, there has been no corresponding reduction in injury related disability over the same time period. We propose that patient registries with large, representative samples and rich multidimensional and longitudinal data have tremendous value in advancing basic and translational research and in capturing, characterizing, and predicting individual differences in deficit profile and outcomes. Patient registries, together with recent theoretical and methodological advances in analytic approaches and neuroscience, provide powerful tools for brain injury research and for leveraging the heterogeneity that has traditionally been cited as a barrier inhibiting progress in treatment research and clinical practice. We report on our experiences, and challenges, in developing and maintaining our own patient registry. We conclude by pointing to some future opportunities for discovery that are afforded by a registry model.

Biofluid Biomarkers in Traumatic Brain Injury: A Systematic Scoping Review

Emerging evidence suggests that biofluid-based biomarkers have diagnostic and prognostic potential in traumatic brain injuries (TBI). However, owing to the lack of a conceptual framework or comprehensive review, it is difficult to visualize the breadth of materials that might be available. We conducted a systematic scoping review to map and categorize the evidence regarding biofluid-based biochemical markers of TBI. A comprehensive search was undertaken in January 2019. Of 25,354 records identified through the literature search, 1036 original human studies were included. Five hundred forty biofluid biomarkers were extracted from included studies and classified into 19 distinct categories. Three categories of biomarkers including cytokines, coagulation tests, and nerve tissue proteins were investigated more than others and assessed in almost half of the studies (560, 515, and 502 from 1036 studies, respectively). S100 beta as the most common biomarker for TBI was tested in 21.2% of studies (220 articles). Cortisol was the only biomarker measured in blood, cerebrospinal fluid, urine, and saliva. The most common sampling time was at admission and within 24 h of injury. The included studies focused mainly on biomarkers from blood and central nervous system sources, the adult population, and severe and blunt injuries. The most common outcome measures used in studies were changes in biomarker concentration level, Glasgow coma scale, Glasgow outcome scale, brain computed tomography scan, and mortality rate. Biofluid biomarkers could be clinically helpful in the diagnosis and prognosis of TBI. However, there was no single definitive biomarker with accurate characteristics. The present categorization would be a road map to investigate the biomarkers of the brain injury cascade separately and detect the most representative biomarker of each category. Also, this comprehensive categorization could provide a guiding framework to design combined panels of multiple biomarkers.

Acceptable Blood Pressure Levels in the Prehospital Setting for Patients with Traumatic Brain Injury: A Multicenter Observational Study

BACKGROUND

Safe blood pressure levels in the prehospital setting for patients with traumatic brain injury (TBI) remain unclear. We aimed to investigate the association between prehospital blood pressure and the outcomes of patients with TBI to determine optimal threshold for hypotension that could be considered in the prehospital setting.

METHODS

Using data from the Japan Trauma Data Bank, we identified adult patients (aged ≥18 years) who experienced severe TBI (maximum head Abbreviated Injury Severity score ≥3) and were transported directly from the scene of the blunt trauma occurrence to the hospital, between 2004 and 2019. We excluded patients with prehospital systolic blood pressure (SBP) levels of <60 and ≥160 mm Hg. Using mixed effects logistic regression models, we investigated the association between prehospital SBP and in-hospital mortality, considering the hospital ID as a random effect variable. In addition, we also conducted a stratified analysis based on age (<60 vs. ≥60 years).

RESULTS

A total of 34,175 patients (16,114 aged <60 years and 18,061 aged ≥60 years) were eligible for the analyses. Plotting the adjusted odds ratios for in-hospital mortality as a function of SBP produced J-shaped curves. An SBP <110 mm Hg was significantly associated with in-hospital mortality, with an adjusted odds ratio of 1.52 (95% confidence interval: 1.39-1.65). Stratified analyses revealed that the threshold did not differ between the age groups.

CONCLUSIONS

An SBP <110 mm Hg in the prehospital setting is significantly associated with higher in-hospital mortality.

Health-related quality of life after 6 months post-injury on severe traumatic brain injury: A cohort study in two Malaysian hospitals

OBJECTIVE

Severe traumatic brain injury (TBI) survivors show physical and functional improvement but remain with the cognitive and psycho-social problem through our recovery. This study aims to measure the health-related quality of life of TBI survivors within 6 months post-injury.

METHOD

A cohort study was conducted where 33 severe TBI survivors recruited at two tertiary hospitals. The health-related quality of life was measured using the Quality of Life after Brain Injury (QOLIBRI) tool.

RESULTS

Participants mean age was 31.79 years old. The impaired range of health-related quality of life on 6 months post-injury seen, but an improvement occurs within 3-6 months post-injury.

CONCLUSIONS

Age and ventilation duration showed a moderate negative correlation in all domains and length of hospital stay showed a moderate negative correlation to social, daily life and self-domains. Nevertheless, small sample size and time constraint were the limitations of this study.

Nonsurviving Patients with Severe Traumatic Brain Injury Have Maintained High Serum sCD40L Levels

BACKGROUND

Soluble cluster of differentiation 40 ligand (sCD40L) is a member of the tumor necrosis factor family with proinflamatory and procoagulant effects. A previous study found higher serum sCD40L levels at day 1 of traumatic brain injury (TBI) in nonsurviving than surviving patients. Thus the objective of this study was to compare serum sCD40L levels during the first week of a severe TBI between surviving and nonsurviving patients and to determine whether it could be used as a mortality predictor biomarker.

METHODS

In this multicenter study severe TBI patients (with Glasgow Coma Scale score <9) with an Injury Severity Score in noncranial item <9 were included. Serum sCD40L concentrations at days 1, 4, and 8 of TBI were determined. We performed receiver operating characteristic analyses to determine the capacity of 30-day TBI mortality prediction by serum sCD40L levels at days 1, 4, and 8 of TBI.

RESULTS

We found that nonsurviving (n = 34) patients in comparison with surviving (n = 90) patients had higher sCD40L levels on days 1 (P < 0.001), 4 (P = 0.004), and 8 (P < 0.001) of TBI. We also found that the areas under curve of serum sCD40L concentrations at days 1, 4, and 8 of TBI to 30-day mortality prediction were 82% (P < 0.001), 72% (P = 0.01) and 83% (P < 0.001), respectively.

CONCLUSIONS

The existence of higher serum sCD40L levels in nonsurviving than surviving patients during the first week of TBI and fact that serum sCD40L levels during the first week of TBI can be used as a mortality predictor biomarker are the new findings of our study.

Enduring Neuroprotective Effect of Subacute Neural Stem Cell Transplantation After Penetrating TBI

Traumatic brain injury (TBI) is the largest cause of death and disability of persons under 45 years old, worldwide. Independent of the distribution, outcomes such as disability are associated with huge societal costs. The heterogeneity of TBI and its complicated biological response have helped clarify the limitations of current pharmacological approaches to TBI management. Five decades of effort have made some strides in reducing TBI mortality but little progress has been made to mitigate TBI-induced disability. Lessons learned from the failure of numerous randomized clinical trials and the inability to scale up results from single center clinical trials with neuroprotective agents led to the formation of organizations such as the Neurological Emergencies Treatment Trials (NETT) Network, and international collaborative comparative effectiveness research (CER) to re-orient TBI clinical research. With initiatives such as TRACK-TBI, generating rich and comprehensive human datasets with demographic, clinical, genomic, proteomic, imaging, and detailed outcome data across multiple time points has become the focus of the field in the United States (US). In addition, government institutions such as the US Department of Defense are investing in groups such as Operation Brain Trauma Therapy (OBTT), a multicenter, pre-clinical drug-screening consortium to address the barriers in translation. The consensus from such efforts including “The Lancet Neurology Commission” and current literature is that unmitigated cell death processes, incomplete debris clearance, aberrant neurotoxic immune, and glia cell response induce progressive tissue loss and spatiotemporal magnification of primary TBI. Our analysis suggests that the focus of neuroprotection research needs to shift from protecting dying and injured neurons at acute time points to modulating the aberrant glial response in sub-acute and chronic time points. One unexpected agent with neuroprotective properties that shows promise is transplantation of neural stem cells. In this review we present (i) a short survey of TBI epidemiology and summary of current care, (ii) findings of past neuroprotective clinical trials and possible reasons for failure based upon insights from human and preclinical TBI pathophysiology studies, including our group's inflammation-centered approach, (iii) the unmet need of TBI and unproven treatments and lastly, (iv) present evidence to support the rationale for sub-acute neural stem cell therapy to mediate enduring neuroprotection.

Blast-induced traumatic brain injury: the experience from a level I trauma center in southern Thailand

OBJECTIVE

In the ongoing conflict in southern Thailand, the improvised explosive device (IED) has been a common cause of blast-induced traumatic brain injury (bTBI). The authors investigated the particular characteristics of bTBI and the factors associated with its clinical outcome.

METHODS

A retrospective cohort study was conducted on all patients who had sustained bTBI between 2009 and 2017. Collected data included clinical characteristics, intracranial injuries, and outcomes. Factors analysis was conducted using a forest plot.

RESULTS

During the study period, 70 patients met the inclusion criteria. Fifty individuals (71.4%) were military personnel. One-third of the patients (32.9%) suffered moderate to severe bTBI, and the rate of intracerebral injuries on brain CT was 65.7%. Coup contusion was the most common finding, and primary blast injury was the most common mechanism of blast injury. Seventeen individuals had an unfavorable outcome (Glasgow Outcome Scale score 1–3), and the overall mortality rate for bTBI was 11.4%. In the univariate analysis, factors associated with an unfavorable outcome were preoperative coagulopathy, midline shift of the brain ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5–328.1) and coagulopathy (OR 28.7, 95% CI 4.5–180.3) were the only factors predicting a poor outcome of bTBI.

CONCLUSIONS

bTBIs range from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, in cases of bTBI, reversing an abnormal coagulogram is required as soon as possible to improve clinical outcomes. The management of brain shift needs further study.

Idarucizumab for a traumatic head injury patient taking dabigatran

Background

Dabigatran is one of the four drugs currently used as a direct oral anticoagulant in Japan. Idarucizumab, which specifically targets dabigatran, was recently approved in Japan. We present a case of intracranial hemorrhage in a traumatic brain injury patient taking dabigatran who was treated by administering idarucizumab.

Case presentation

A 72-year-old man was injured in a traffic accident and was transferred to our emergency room. On arrival, his Glasgow Coma Scale score was 14 (eye, 3; verbal, 5; motor, 6), and his other vital signs were stable. Computed tomography (CT) imaging on arrival showed a small intracranial hematoma. A second CT 3 h later revealed expansion of the hematoma. We received information that he was taking dabigatran only after the second CT. Idarucizumab was then promptly administered, and emergency craniotomy for hematoma removal was performed. There was no tendency for bleeding during the operation, and blood transfusion was not required during the perioperative period. Although the patient underwent additional surgery for subdural effusion and hydrocephalus, his postoperative course was uneventful. He was transferred to a rehabilitation hospital on postoperative day 102.

Conclusion

We managed a patient taking dabigatran who suffered traumatic intracranial hemorrhage by administering idarucizumab preoperatively without the need for blood transfusion perioperatively. We suggest that idarucizumab could be a potent therapeutic bridge to definitive surgical management in such patients with traumatic brain injury who are taking dabigatran.

Characteristics of patients included and enrolled in studies on the prognostic value of serum biomarkers for prediction of postconcussion symptoms following a mild traumatic brain injury: a systematic review

OBJECTIVE

Mild traumatic brain injury (mTBI) has been insufficiently researched, and its definition remains elusive. Investigators are confronted by heterogeneity in patients, mechanism of injury and outcomes. Findings are thus often limited in generalisability and clinical application. Serum protein biomarkers are increasingly assessed to enhance prognostication of outcomes, but their translation into clinical practice has yet to be achieved. A systematic review was performed to describe the adult populations included and enrolled in studies that evaluated the prognostic value of protein biomarkers to predict postconcussion symptoms following an mTBI.

DATA SOURCES

Searches of MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, PsycBITE and PsycINFO up to October 2016.

DATA SELECTION AND EXTRACTION

Two reviewers independently screened for potentially eligible studies, extracted data and assessed the overall quality of evidence by outcome using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

A total of 23 298 citations were obtained from which 166 manuscripts were reviewed. Thirty-six cohort studies (2812 patients) having enrolled between 7 and 311 patients (median 89) fulfilled our inclusion criteria. Most studies excluded patients based on advanced age (n=10 (28%)), neurological disorders (n=20 (56%)), psychiatric disorders (n=17 (47%)), substance abuse disorders (n=13 (36%)) or previous traumatic brain injury (n=10 (28%)). Twenty-one studies (58%) used at least two of these exclusion criteria. The pooled mean age of included patients was 39.3 (SD 4.6) years old (34 studies). The criteria used to define a mTBI were inconsistent. The most frequently reported outcome was postconcussion syndrome using the Rivermead Post-Concussion Symptoms Questionnaire (n=18 (50%)) with follow-ups ranging from 7 days to 5 years after the mTBI.

CONCLUSIONS

Most studies have recruited samples that are not representative and generalisable to the mTBI population. These exclusion criteria limit the potential use and translation of promising serum protein biomarkers to predict postconcussion symptoms.

Traumatic brain injury and post-traumatic amnesia: a retrospective review of discharge outcomes

PRIMARY OBJECTIVE

To investigate if patients with traumatic brain injury, who are discharged to the community before emergence from post-traumatic amnesia (PTA), experience more adverse outcomes than those discharged after emergence from PTA.

RESEARCH DESIGN

A retrospective review of previously collected data and medical records.

METHODS AND PROCEDURES

Occurrences of adverse events including hospital readmissions, disengagement from follow-up services, non-compliance with discharge precautions, support system breakdown or undue carer strain at the post-discharge clinic review were recorded. The Glasgow Outcome Scale - Extended (GOS-E) and Supervision Rating Scale (SRS) were completed, retrospectively. Twenty-seven patients discharged to the community, prior to emergence from PTA, were compared to 20 patients discharged within seven days of emergence from PTA.

MAIN OUTCOMES AND RESULTS

Patients discharged prior to emergence from PTA did not experience an increase in adverse outcomes and showed a higher level of engagement in follow-up services (p = 0.015). There was no difference between groups in the improvements from discharge to clinic review on the GOS-E (p = 0.113) and SRS (p = 0.165).

CONCLUSIONS

Patients can be discharged prior to emergence from PTA, if all other discharge criteria have been met, without an increase in adverse outcomes.

The Association Between Apolipoprotein E and Functional Outcome After Traumatic Brain Injury: A Meta-Analysis

Traumatic brain injury (TBI) is a leading cause of death and disability. Previous studies have investigated the association of apolipoprotein E (APOE) ε4 with functional outcome after TBI and reported inconsistent results.The purpose of this study was to perform a systematic literature search and conduct meta-analyses to examine whether APOE ε4 is associated with poorer functional outcome in patients with TBI.We performed a systematic literature search in PubMed, Cochrane Library, Embase, Google Scholar, and HuGE.The eligibility criteria of this study included the following: Patients had TBI; the studies reported APOE genotype data or provided odds ratios (ORs) and the corresponding 95% confidence intervals (CIs); the functional outcome was assessed using the Glasgow Outcome Scale (GOS) or the Glasgow Outcome Scale Extended (GOSE); and patients were followed for at least 3 months after TBI.In all meta-analyses, we used random-effects models to calculate the odds ratio as a measure of association. We examined the association of APOE ε4 with functional outcome at different time points after TBI.A total of 12 studies met the eligibility criteria and were included in the meta-analyses. We did not find a significant association between APOE ε4 and functional outcome at 6 (P = 0.23), 12 (P = 0.44), and 24 months (P = 0.85) after TBI. However, APOE ε4 was associated with an increased risk of unfavorable long-term (≥6 months) functional outcome after TBI (OR = 1.36, 95% CI: 1.07-1.74, P = 0.01).Limitations of this study include The sample size was limited; the initial severity of TBI varied within and across studies; we could not control for potential confounding factors, such as age at injury and sex; a meta-analysis of the genotype dosage effect was not feasible; and we could not examine the association with specific factors such as neurobehavioral or specific cognitive functions.Our meta-analysis indicates APOE ε4 is associated with the long-term functional outcome of patients with TBI. Future studies that control for confounding factors, with large sample sizes and more homogeneous initial TBI severity levels, are needed to validate the findings from this study.

Cognitive rehabilitation groups: A thematic analysis of feasibility and perceived benefits for clients with moderate to severe traumatic brain injury living in the Western Cape

Background

Traumatic brain injury (TBI) has a significant impact on the burden of care within the South African setting, impacting on the individual, the family, and the community as a whole. Often the consequences of TBI are permanent, resulting in numerous financial and emotional stressors.

Objective

This research focusses on the experience of outpatient cognitive rehabilitation groups for individuals who have suffered moderate to severe brain injuries within the South African setting.

Method

Participants with moderate to severe brain injury were required to attend five cognitive rehabilitation groups and engage in a semistructured interview. Qualitative data were examined via thematic analysis, to determine participants’ subjective experiences of group participation.

Results

There is a need within the South African setting for cognitive rehabilitation and support groups for individuals who have experienced a TBI. The benefits were notable for both the individuals attending and their support systems. In spite of the benefits there were notable limitations to attendance, including financial restrictions and transport limitations.

Conclusion

According to participants and their families, there is a scarcity of resources within the Western Cape for clients who have sustained a TBI. Despite limitations in capacity to attend there appears to be a need for structured outpatient cognitive rehabilitation programmes integrating the complex cognitive and emotional challenges faced by individuals with TBI and their families.

The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology

Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.

Gait and Glasgow Coma Scale scores can predict functional recovery in patients with traumatic brain injury

Fifty-one patients with mild (n = 14), moderate (n = 10) and severe traumatic brain injury (n = 27) received early rehabilitation. Level of consciousness was evaluated using the Glasgow Coma Score. Functional level was determined using the Glasgow Outcome Score, whilst mobility was evaluated using the Mobility Scale for Acute Stroke. Activities of daily living were assessed using the Barthel Index. Following Bobath neurodevelopmental therapy, the level of consciousness was significantly improved in patients with moderate and severe traumatic brain injury, but was not greatly influenced in patients with mild traumatic brain injury. Mobility and functional level were significantly improved in patients with mild, moderate and severe traumatic brain injury. Gait recovery was more obvious in patients with mild traumatic brain injury than in patients with moderate and severe traumatic brain injury. Activities of daily living showed an improvement but this was insignificant except for patients with severe traumatic brain injury. Nevertheless, complete recovery was not acquired at discharge. Multiple regression analysis showed that gait and Glasgow Coma Scale scores can be considered predictors of functional outcomes following traumatic brain injury.

The effect of environmental barriers on community integration for individuals with moderate to severe traumatic brain injury

OBJECTIVE

To describe environmental barriers endorsed by individuals with traumatic brain injury during the first 6 months after discharge and determine their effect on community integration.

DESIGN

Prospective longitudinal study with data collected at predischarge and at 1, 3, and 6 months postdischarge.

PARTICIPANTS

One hundred thirty-five individuals with a diagnosis of traumatic brain injury discharged from a large metropolitan hospital to a home/community environment.

MEASURES

Sydney Psychosocial Reintegration Scale; Craig Hospital Inventory of Environmental Factors; and Mayo-Portland Adaptability Inventory-4.

RESULTS

Multiple regression analyses indicated that environmental barriers arising during the transition from hospital to home had a negative association with community integration outcomes. Physical barriers were most commonly endorsed, but attitudinal barriers were significantly correlated with relationship changes.

CONCLUSION

Environmental barriers should be addressed in rehabilitation and considered in policy development for people with traumatic brain injury. Future research on the measurement of environmental barriers is recommended.

Classification models for neurocognitive impairment in HIV infection based on demographic and clinical variables

Objective

We used demographic and clinical data to design practical classification models for prediction of neurocognitive impairment (NCI) in people with HIV infection.

Methods

The study population comprised 331 HIV-infected patients with available demographic, clinical, and neurocognitive data collected using a comprehensive battery of neuropsychological tests. Classification and regression trees (CART) were developed to obtain detailed and reliable models to predict NCI. Following a practical clinical approach, NCI was considered the main variable for study outcomes, and analyses were performed separately in treatment-naïve and treatment-experienced patients.

Results

The study sample comprised 52 treatment-naïve and 279 experienced patients. In the first group, the variables identified as better predictors of NCI were CD4 cell count and age (correct classification [CC]: 79.6%, 3 final nodes). In treatment-experienced patients, the variables most closely related to NCI were years of education, nadir CD4 cell count, central nervous system penetration-effectiveness score, age, employment status, and confounding comorbidities (CC: 82.1%, 7 final nodes). In patients with an undetectable viral load and no comorbidities, we obtained a fairly accurate model in which the main variables were nadir CD4 cell count, current CD4 cell count, time on current treatment, and past highest viral load (CC: 88%, 6 final nodes).

Conclusion

Practical classification models to predict NCI in HIV infection can be obtained using demographic and clinical variables. An approach based on CART analyses may facilitate screening for HIV-associated neurocognitive disorders and complement clinical information about risk and protective factors for NCI in HIV-infected patients.

Association between serum tissue inhibitor of matrix metalloproteinase-1 levels and mortality in patients with severe brain trauma injury

OBJECTIVE

Matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) play a role in neuroinflammation after brain trauma injury (TBI). Previous studies with small sample size have reported higher circulating MMP-2 and MMP-9 levels in patients with TBI, but no association between those levels and mortality. Thus, the aim of this study was to determine whether serum TIMP-1 and MMP-9 levels are associated with mortality in patients with severe TBI.

METHODS

This was a multicenter, observational and prospective study carried out in six Spanish Intensive Care Units. Patients with severe TBI defined as Glasgow Coma Scale (GCS) lower than 9 were included, while those with Injury Severity Score (ISS) in non-cranial aspects higher than 9 were excluded. Serum levels of TIMP-1, MMP-9 and tumor necrosis factor (TNF)-alpha, and plasma levels of tissue factor (TF) and plasminogen activator inhibitor (PAI)-1 plasma were measured in 100 patients with severe TBI at admission. Endpoint was 30-day mortality.

RESULTS

Non-surviving TBI patients (n = 27) showed higher serum TIMP-1 levels than survivor ones (n = 73). We did not find differences in MMP-9 serum levels. Logistic regression analysis showed that serum TIMP-1 levels were associated 30-day mortality (OR = 1.01; 95% CI = 1.001-1.013; P = 0.03). Survival analysis showed that patients with serum TIMP-1 higher than 220 ng/mL presented increased 30-day mortality than patients with lower levels (Chi-square = 5.50; P = 0.02). The area under the curve (AUC) for TIMP-1 as predictor of 30-day mortality was 0.73 (95% CI = 0.624-0.844; P<0.001). An association between TIMP-1 levels and APACHE-II score, TNF- alpha and TF was found.

CONCLUSIONS

The most relevant and new findings of our study, the largest series reporting data on TIMP-1 and MMP-9 levels in patients with severe TBI, were that serum TIMP-1 levels were associated with TBI mortality and could be used as a prognostic biomarker of mortality in TBI patients.

What is New and Innovative in Emergency Neurosurgery? Emerging Diagnostic Technologies Provide Better Care and Influence Outcome: A Specialist Review

The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life.

Introduction of the Uppsala Traumatic Brain Injury register for regular surveillance of patient characteristics and neurointensive care management including secondary insult quantification and clinical outcome

BACKGROUND

To improve neurointensive care (NIC) and outcome for traumatic brain injury (TBI) patients it is crucial to define and monitor indexes of the quality of patient care. With this purpose we established the web-based Uppsala TBI register in 2008. In this study we will describe and analyze the data collected during the first three years of this project.

METHODS

Data from the medical charts were organized in three columns containing: 1) Admission data; 2) Data from the NIC period including neurosurgery, type of monitoring, treatment, complications, neurological condition at discharge, and the amount of secondary insults; 3) Outcome six months after injury. Indexes of the quality of care implemented include: 1) Index of improvement; 2) Index of change; 3) The percentages of 'Talk and die' and 'Talk and deteriorate' patients.

RESULTS

Altogether 314 patients were included 2008-2010: 66 women and 248 men aged 0-86 years. Automatic reports showed that the proportion of patients improving during NIC varied between 80% and 60%. The percentage of deteriorated patients was less than 10%. The percentage of Talk and die/Talk and deteriorate cases was <1%. The mean Glasgow Coma Score (Motor) improved from 5.04 to 5.68 during the NIC unit stay. The occurrences of secondary insults were less than 5% of good monitoring time for intracranial pressure (ICP) >25 mmHg, cerebral perfusion pressure (CPP) <50 mmHg, and systolic blood pressure <100 mmHg. Favorable outcome was achieved by 64% of adults.

CONCLUSION

The Uppsala TBI register enables the routine monitoring of NIC quality indexes.

The provision of emotional support to the families of traumatic brain injury patients: perspectives of Finnish nurses

AIMS AND OBJECTIVES

To examine nursing staff's perceptions about how often they provide interventions of emotional support and the level of competence needed on neurosurgical wards to support traumatic brain injury patients' family members.

BACKGROUND

Traumatic brain injury in one individual affects the health of their whole family. Studying the emotional support provided by nursing staff is important because such support is crucial for the family members of a traumatic brain injury patient during the acute phase of treatment. Members of the nursing staff provide emotional support to family members by consoling them; this alleviates insecurity, anxiety, hopelessness and depression.

DESIGN

A structured self-reported questionnaire presented to 172 nurses working on neurosurgical wards. The response rate was 67% (n = 115).

METHODS

Descriptive statistics were used to determine how often nurses provided emotional support to the traumatic brain injury patients family members and one-way anova to examine the relationships between the background variables and the respondents' evaluations of how often they gave emotional support to brain injury patients' family members.

RESULTS

Thirty-seven percentage of nurses stated that they always took account of family members' individuality and 65% that they were always respectful. All registered nurses and staff members with long work experience (21 years or more) on a neurosurgical ward reported that they took family members' feelings of anger and guilt into consideration slightly more often than other nursing staff did. Most nurses considered these skills to represent basic competencies.

CONCLUSION

Further service training on dealing with difficult emotions of traumatic brain injury patients' family members could help nurses to face these situations. Both education and work experience affected the frequency at which nursing staff provided emotional support to traumatic brain injury patients' family members.

RELEVANCE TO CLINICAL PRACTICE

The results are relevant for example when planning specialised studies or in-service training for neuro-nurses, as well as when selecting the subjects to be addressed during the orientation of a new staff member. In addition, the results should help nursing staff to understand their role in the emotional support of family members.

Analysis of Intracranial Pressure

The monitoring of intracranial pressure (ICP) is an important tool in medicine for its ability to portray the brain’s compliance status. The bedside monitor displays the ICP waveform and intermittent mean values to guide physicians in the management of patients, particularly those having sustained a traumatic brain injury. Researchers in the fields of engineering and physics have investigated various mathematical analysis techniques applicable to the waveform in order to extract additional diagnostic and prognostic information, although they largely remain limited to research applications. The purpose of this review is to present the current techniques used to monitor and interpret ICP and explore the potential of using advanced mathematical techniques to provide information about system perturbations from states of homeostasis. We discuss the limits of each proposed technique and we propose that nonlinear analysis could be a reliable approach to describe ICP signals over time, with the fractal dimension as a potential predictive clinically meaningful biomarker. Our goal is to stimulate translational research that can move modern analysis of ICP using these techniques into widespread practical use, and to investigate to the clinical utility of a tool capable of simplifying multiple variables obtained from various sensors.

Traumatic brain injury-associated coagulopathy

Traumatic injury is a common cause of coagulopathy, primarily due to blood loss and hemodilution secondary to fluid resuscitation. Traumatic injury-associated coagulopathy often follows a course of transition from hyper- to hypocoagulable state exemplified in disseminated intravascular coagulation. The incidence of coagulopathy is significantly higher in patients with traumatic brain injury (TBI), especially those with penetrating trauma compared to injury to the trunk and limbs. This occurs despite the fact that patients with isolated TBI bleed less and receive restricted volume load of fluids. TBI-associated coagulopathy is extensively documented to associate with poor clinical outcomes, but its pathophysiology remains poorly understood. Studies in the past have shown that brain tissue is highly enriched in key procoagulant molecules. This review focuses on the biochemical and cellular characteristics of these molecules and pathways that could make brain uniquely procoagulant and prone to coagulopathy. Understanding this unique procoagulant environment will help to identify new therapeutic targets that could reverse a state of coagulopathy with minimal impacts on hemostasis, a critical requirement for neurosurgical treatments of TBI.

Alcohol use at time of injury and survival following traumatic brain injury: results from the National Trauma Data Bank

OBJECTIVE

Premised on biological evidence from animal research, recent clinical studies have, for the most part, concluded that elevated blood alcohol concentration levels are independently associated with higher survival or decreased mortality in patients with moderate to severe traumatic brain injury (TBI). This study aims to provide some counterevidence to this claim and to further future investigations.

METHOD

Incident data were drawn from the largest U.S. trauma registry, the National Trauma Data Bank, for emergency department admission years 2002-2006. TBI was identified according to the National Trauma Data Bank's definition using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes. To eliminate confounding, the exact matching method was used to match alcohol-positive with alcohol-negative incidents on sex, age, race/ethnicity, and facility. Logistic regression compared in-hospital mortality between 44,043 alcohol-positive and 59,817 matched alcohol-negative TBI incidents, with and without causes and intents of TBI and Injury Severity Score as covariates. A sensitivity analysis was performed within a subsample of isolated moderate to severe TBI incidents.

RESULTS

Alcohol use at the time of injury was found to be significantly associated with an increased risk for TBI. Including varied causes and intents of TBI and Injury Severity Score as potential confounders in the regression model explained away the statistical significance of the seemingly protective effect of alcohol against TBI mortality for all TBIs and for isolated moderate to severe TBIs.

CONCLUSIONS

The null finding shows that the purported reduction in TBI mortality attributed to positive blood alcohol likely is attributable to residual confounding. Accordingly, the risk of TBI associated with alcohol use should not be overlooked.

[Prognostic factors in severe traumatic brain injury]

OBJECTIVE

To describe the factors associated to mortality of patients with severe traumatic brain injury (TBI).

DESIGN

A retrospective observational study was made of patients with severe TBI covering the period between 1 January 2007 and 31 December 2010.

SETTING

Virgen de la Vega Hospital, Salamanca (Spain).

PATIENTS

All patients hospitalized during the consecutive study period.

MAIN VARIABLES OF INTEREST

The dependent variable has been the death rate, while the independent variables were divided into two groups: epidemiological and clinical.

RESULTS

The mean patient age was the 50.84 years; 75.5% were males. The average score on the Glasgow Coma Scale (GCS) was 5.09, and the average Injury Severity Score (ISS) was 30.8. Higher mortality was observed in older patients with a higher ISS score. A total of 68.1% of the patients in which intracranial pressure (ICP) was monitored showed intracranial hypertension (ICH). The mortality rate in patients with severe TBI was 36.8%, and was associated mainly to a lower GCS score, the existence of hyperglycemia, coagulopathy, hypoxemia, the presence of mydriasis and shock. The independent mortality indicators in patients with severe TBI were the existence of mydriasis (OR: 32.75), the GCS score (OR: 2.65) and hyperglycemia (OR: 6.08).

CONCLUSIONS

The existence of mydriasis, the GCS score and hyperglycemia should be taken into account as prognostic factors in TBI patients.

Injury severity scoring systems: a review of application to practice

AIM

This study reviews the historical development of injury severity scoring systems and their application to clinical practice.

BACKGROUND

A variety of injury severity scoring systems have been developed and applied since more than four decades. It is increasingly important for nurses to be familiar with these scoring systems, their strengths and weaknesses, and their applications to nursing practice.

DESIGN

Systematic literature review.

METHODS

The injury severity scoring systems developed from the 1970s to 2011 were identified via electronic database searches, footnote chasing and contact with clinical experts. The most frequently used scoring systems in the literature were classified according to the criteria used in each scoring system.

CONCLUSIONS

All injury severity scoring systems are valuable but have certain problems. A universal scoring system applicable for various purposes appears difficult to achieve. However, the understanding and proper use of scoring systems will allow us to perform critical evaluations and continual refinement of trauma management.

RELEVANCE TO CLINICAL PRACTICE

As nurses and researchers, it is critical that we should know the application of these injury severity scoring systems to ensure their quality and appropriate utilization.

Post-traumatic hypoxia exacerbates neurological deficit, neuroinflammation and cerebral metabolism in rats with diffuse traumatic brain injury

Background

The combination of diffuse brain injury with a hypoxic insult is associated with poor outcomes in patients with traumatic brain injury. In this study, we investigated the impact of post-traumatic hypoxia in amplifying secondary brain damage using a rat model of diffuse traumatic axonal injury (TAI). Rats were examined for behavioral and sensorimotor deficits, increased brain production of inflammatory cytokines, formation of cerebral edema, changes in brain metabolism and enlargement of the lateral ventricles.

Methods

Adult male Sprague-Dawley rats were subjected to diffuse TAI using the Marmarou impact-acceleration model. Subsequently, rats underwent a 30-minute period of hypoxic (12% O₂/88% N₂) or normoxic (22% O₂/78% N₂) ventilation. Hypoxia-only and sham surgery groups (without TAI) received 30 minutes of hypoxic or normoxic ventilation, respectively. The parameters examined included: 1) behavioural and sensorimotor deficit using the Rotarod, beam walk and adhesive tape removal tests, and voluntary open field exploration behavior; 2) formation of cerebral edema by the wet-dry tissue weight ratio method; 3) enlargement of the lateral ventricles; 4) production of inflammatory cytokines; and 5) real-time brain metabolite changes as assessed by microdialysis technique.

Results

TAI rats showed significant deficits in sensorimotor function, and developed substantial edema and ventricular enlargement when compared to shams. The additional hypoxic insult significantly exacerbated behavioural deficits and the cortical production of the pro-inflammatory cytokines IL-6, IL-1β and TNF but did not further enhance edema. TAI and particularly TAI+Hx rats experienced a substantial metabolic depression with respect to glucose, lactate, and glutamate levels.

Conclusion

Altogether, aggravated behavioural deficits observed in rats with diffuse TAI combined with hypoxia may be induced by enhanced neuroinflammation, and a prolonged period of metabolic dysfunction.