Impact of a posttraumatic cerebral infarction on outcome in patients with TBI: the Italian multicenter cohort INCEPT study

Imaging Findings in Acute Traumatic Brain Injury: a National Institute of Neurological Disorders and Stroke Common Data Element-Based Pictorial Review and Analysis of Over 4000 Admission Brain Computed Tomography Scans from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

In 2010, the National Institute of Neurological Disorders and Stroke (NINDS) created a set of common data elements (CDEs) to help standardize the assessment and reporting of imaging findings in traumatic brain injury (TBI). However, as opposed to other standardized radiology reporting systems, a visual overview and data to support the proposed standardized lexicon are lacking. We used over 4000 admission computed tomography (CT) scans of patients with TBI from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study to develop an extensive pictorial overview of the NINDS TBI CDEs, with visual examples and background information on individual pathoanatomical lesion types, up to the level of supplemental and emerging information (e.g., location and estimated volumes). We documented the frequency of lesion occurrence, aiming to quantify the relative importance of different CDEs for characterizing TBI, and performed a critical appraisal of our experience with the intent to inform updating of the CDEs. In addition, we investigated the co-occurrence and clustering of lesion types and the distribution of six CT classification systems. The median age of the 4087 patients in our dataset was 50 years (interquartile range, 29-66; range, 0-96), including 238 patients under 18 years old (5.8%). Traumatic subarachnoid hemorrhage (45.3%), skull fractures (37.4%), contusions (31.3%), and acute subdural hematoma (28.9%) were the most frequently occurring CT findings in acute TBI. The ranking of these lesions was the same in patients with mild TBI (baseline Glasgow Coma Scale [GCS] score 13-15) compared with those with moderate-severe TBI (baseline GCS score 3-12), but the frequency of occurrence was up to three times higher in moderate-severe TBI. In most TBI patients with CT abnormalities, there was co-occurrence and clustering of different lesion types, with significant differences between mild and moderate-severe TBI patients. More specifically, lesion patterns were more complex in moderate-severe TBI patients, with more co-existing lesions and more frequent signs of mass effect. These patients also had higher and more heterogeneous CT score distributions, associated with worse predicted outcomes. The critical appraisal of the NINDS CDEs was highly positive, but revealed that full assessment can be time consuming, that some CDEs had very low frequencies, and identified a few redundancies and ambiguity in some definitions. Whilst primarily developed for research, implementation of CDE templates for use in clinical practice is advocated, but this will require development of an abbreviated version. In conclusion, with this study, we provide an educational resource for clinicians and researchers to help assess, characterize, and report the vast and complex spectrum of imaging findings in patients with TBI. Our data provides a comprehensive overview of the contemporary landscape of TBI imaging pathology in Europe, and the findings can serve as empirical evidence for updating the current NINDS radiologic CDEs to version 3.0.

Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury

BACKGROUND

Moderate-severe traumatic brain injury (msTBI) carries high morbidity and mortality worldwide. Accurate neuroprognostication is essential in guiding clinical decisions, including patient triage and transition to comfort measures. Here we provide recommendations regarding the reliability of major clinical predictors and prediction models commonly used in msTBI neuroprognostication, guiding clinicians in counseling surrogate decision-makers.

METHODS

Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we conducted a systematic narrative review of the most clinically relevant predictors and prediction models cited in the literature. The review involved framing specific population/intervention/comparator/outcome/timing/setting (PICOTS) questions and employing stringent full-text screening criteria to examine the literature, focusing on four GRADE criteria: quality of evidence, desirability of outcomes, values and preferences, and resource use. Moreover, good practice recommendations addressing the key principles of neuroprognostication were drafted.

RESULTS

After screening 8125 articles, 41 met our eligibility criteria. Ten clinical variables and nine grading scales were selected. Many articles varied in defining "poor" functional outcomes. For consistency, we treated "poor" as "unfavorable". Although many clinical variables are associated with poor outcome in msTBI, only the presence of bilateral pupillary nonreactivity on admission, conditional on accurate assessment without confounding from medications or injuries, was deemed moderately reliable for counseling surrogates regarding 6-month functional outcomes or in-hospital mortality. In terms of prediction models, the Corticosteroid Randomization After Significant Head Injury (CRASH)-basic, CRASH-CT (CRASH-basic extended by computed tomography features), International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-core, IMPACT-extended, and IMPACT-lab models were recommended as moderately reliable in predicting 14-day to 6-month mortality and functional outcomes at 6 months and beyond. When using "moderately reliable" predictors or prediction models, the clinician must acknowledge "substantial" uncertainty in the prognosis.

CONCLUSIONS

These guidelines provide recommendations to clinicians on the formal reliability of individual predictors and prediction models of poor outcome when counseling surrogates of patients with msTBI and suggest broad principles of neuroprognostication.

Early Experience With Artificial Intelligence Software to Detect Intracranial Occlusive Stroke in Trauma Patients

Objective Identifying ischemic stroke is a diagnostic challenge in the trauma subpopulation. We describe our early experience with artificial intelligence-assisted image analysis software for automatically identifying acute ischemic stroke in trauma patients.  Methods Patients were retrospectively screened for (i) admission to the trauma service at a level one trauma center between 2020 and 2022, (ii) radiologist-confirmed intracranial occlusion, (iii) occlusion identified on computed tomography angiography performed within 24 hours of admission, (iv) no intracranial hemorrhage, and (v) contemporaneous analysis with the large vessel occlusion (LVO) detection program. Baseline characteristics, stroke detection, response-activation, and outcome data were summarized.  Results Of 9893 trauma patients admitted, 88 (0.89%) patients had a cerebral stroke diagnosis, of which 10 patients (10/88; 11.4%) met inclusion criteria. Most patients were admitted following a fall (8/10; 80%). Six (6/10; 60.0%) patients had LVOs. The program correctly detected 83.3% (5/6) of patients, and these patients were triaged in less than one hour from arrival on average. The program did not falsely identify non-LVOs as LVOs for any patients. Conclusions Identifying adjunct tools to aid timely identification and treatment of ischemic stroke in trauma patients is necessary to increase the chances for meaningful neurological recovery. Our early experience exhibited potential for using automated software to aid occlusion identification and subsequent stroke team mobilization. Future studies in larger cohorts will expand upon these preliminary findings to establish the accuracy and clinical benefit of automated stroke detection tool integration for the trauma population.

Predictors of outcomes 3 to 12 months after traumatic brain injury: a systematic review and meta-analysis

The exact factors predicting outcomes following traumatic brain injury (TBI) remain elusive. In this systematic review and meta-analysis, we examined factors influencing outcomes in adult patients with TBI, from 3 months to 1 year after injury. A search of four electronic databases-PubMed, Scopus, Web of Science, and ScienceDirect-yielded 29 studies for review and 16 for meta-analysis, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. In patients with TBI of any severity, mean differences were observed in age (8.72 years; 95% confidence interval [CI], 4.77-12.66 years), lymphocyte count (-0.15 109/L; 95% CI, -0.18 to -0.11), glucose levels (1.20 mmol/L; 95% CI, 0.73-1.68), and haemoglobin levels (-0.91 g/dL; 95% CI, -1.49 to -0.33) between those with favourable and unfavourable outcomes. The prevalence rates of unfavourable outcomes were as follows: abnormal cisterns, 65.7%; intracranial pressure above 20 mmHg, 52.9%; midline shift of 5 mm or more, 63%; hypotension, 71%; hypoxia, 86.8%; blood transfusion, 70.3%; and mechanical ventilation, 90%. Several predictors were strongly associated with outcome. Specifically, age, lymphocyte count, glucose level, haemoglobin level, severity of TBI, pupillary reaction, and type of injury were identified as potential predictors of long-term outcomes.

Association Between Traumatic Brain Injury and Increased Risk of Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

To determine whether exposure to traumatic brain injury (TBI) is associated with increased risk of stroke in adults compared with referents not exposed to TBI, and to understand whether an association exists throughout the spectrum of injury severity, whether it differs between the acute and chronic phases after TBI, and whether the association is greater with hemorrhagic compared with ischemic stroke after TBI.

SETTING

A database search was conducted on January 22, 2021. Searches were run in MEDLINE (1946 to present), Embase (1988 to present), Evidence-Based Medicine Reviews (various dates), Scopus (1970 to present), and Web of Science (1975 to present).

DESIGN

Observational studies that quantified the association of stroke after TBI compared with referents without TBI were included. Three coauthors independently reviewed titles and abstracts to determine study eligibility. Study characteristics were extracted independently by 2 coauthors who followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and study quality was assessed independently by 2 coauthors who used the Newcastle-Ottawa Scale. Random-effects meta-analyses were performed.

MAIN MEASURES

The primary exposure was TBI of any severity, and the primary outcome was stroke of any kind. Subgroup analysis was performed to assess heterogeneity associated with severity of TBI, type of stroke, and time from TBI to stroke.

RESULTS

A total of 64 full-text articles were reviewed, and data were extracted from 8 cohort studies (N = 619 992 individuals exposed to TBI along with nonexposed referents). A significant overall association was found with TBI and stroke (hazard ratio, 2.06; 95% CI, 1.28-3.32). Significant subgroup differences were found with a smaller risk of ischemic stroke compared with stroke of all types (P < .001, I² = 93.9%).

CONCLUSIONS

TBI, regardless of injury severity, was associated with a higher risk of stroke. To improve secondary stroke prevention strategies, future studies should classify TBI severity and type of stroke more precisely and determine long-term risk.

Post-traumatic cerebral infarction caused by thrombus in the middle cerebral artery

A woman in her 80s was found unconscious after being hit by a car while crossing a road. After admission to hospitals, computed tomography (CT) scans revealed traumatic brain injury (TBI), and the patient was treated symptomatically. However, despite improvement of TBI in CT images, she died unexpectedly. Postmortem CT demonstrated cerebral infarction in the territory of the right middle cerebral artery (MCA). Histopathological examination revealed lumen-obstructing thrombosis and intimal injury upstream of the thrombosis in the right MCA. These findings suggested that the intimal injury in the MCA had led to thrombus formation, and thromboembolism in the region distal to the injury leading to post-traumatic cerebral infarction (PTCI). Both postmortem CT and autopsy were able to reveal the final condition of the deceased, which had not been fully anticipated by the clinicians who had treated her after the accident. The longitudinal antemortem to postmortem course revealed by multiple CT images and the histopathological examination provided crucial clues to the pathogenesis of PTCI in this case.

Association of Cytomegalovirus Infection with Lenticulostriate Stroke After Mild Head Trauma in Young Children

The development of lenticulostriate stroke following mild head trauma accounts for 3% of traumatic brain injuries in children. Nevertheless, the pathogenesis of infantile lenticulostriate stroke with lenticulostriate calcification is poorly understood. In this study, we explored the association of a recent viral infection with the development of infantile lenticulostriate stroke with lenticulostriate calcification following mild head trauma in children. We examined the records for 49 children (<36 months old) diagnosed with infantile stroke following mild head trauma at the First Hospital of Jilin University between January 2007 and August 2019. The demographic characteristics, clinical manifestations, and laboratory and imaging results were collected and analyzed. Antibodies against Epstein-Barr virus, herpes simplex virus, and cytomegalovirus in the patient sera were assessed. A total of 18 patients with lenticulostriate stroke and calcification were included in the Patient group (16.61 ± 10.57 months), and 14 patients without calcification were included in the Control group (13.07 ± 7.66 months). Imaging findings demonstrated the presence of lenticulostriate stroke in all patients. There were no significant differences in the demographic characteristics or clinical manifestations of stroke between both groups (P > .05). Similarly, no significant differences were observed in the Epstein-Barr virus and herpes simplex virus-1 antibody positivity in both groups. In contrast, cytomegalovirus antibody was significantly more abundant in the Patient group (P < .05). All patients were hospitalized for conservative treatment with favorable prognoses. Our results suggest that cytomegalovirus infection may be associated with the development of lenticulostriate strokes in pediatric patients following minor head injury.

Changes to the Major Trauma Pre-Hospital Emergency Medical System Network before and during the 2019 COVID-19 Pandemic

Objectives: During the coronavirus disease 2019 pandemic, emergency medical services (EMSs) were among the most affected; in fact, there were delays in rescue and changes in time-dependent disease networks. The aim of the study is to understand the impact of COVID-19 on the time-dependent trauma network in the Lombardy region. Methods: A retrospective analysis on major trauma was performed by analysing all records saved in the EmMa database from 1 January 2019 to 31 December 2019 and from 1 January 2020 to 31 December 2020. Age, gender, time to first emergency vehicle on scene and mission duration were collected. Results: In 2020, compared to 2019, there was a reduction in major trauma diagnoses in March and April, during the first lockdown, OR 0.59 (95% CI 0.49−0.70; p < 0.0001), and a reduction in road accidents and accidents at work, while injuries related to falls from height and violent events increased. There was no significant increase in the number of deaths in the prehospital setting, OR 1.09 (95% CI 0.73−1.30; p = 0.325). Conclusions: The COVID-19 pandemic has changed the epidemiology of major trauma, but in the Lombardy region there was no significant change in mortality in the out-of-hospital setting.

Inflammation and the role of infection: Complications and treatment options following neurotrauma

Traumatic brain injury can have devastating consequences for patients and extended hospital stays and recovery course. Recent data indicate that the initial insult causes profound changes to the immune system and leads to a pro-inflammatory state. This alteration in homeostasis predisposes patients to an increased risk of infection and underlying autoimmune conditions. Increased emphasis has been placed on understanding this process both in the clinical and preclinical literature. This review highlights the intrinsic inflammatory conditions that can occur within the initial hospital stay, discusses long-term immune consequences, highlights emerging treatment options, and delves into important pathways currently being investigated with preclinical models.

Effect of New Nursing on Patients with Acute Cerebral Infarction

Objective. To explore the effect of the comfortable intervention-based nursing mode under the quality nursing intervention combined with Internet mobile health on the quality of life (QOL) and psychological status of patients with acute cerebral infarction (ACI). Methods. 90 ACI patients treated in our hospital (June 2019-June 2020) were chosen and equally split into the experimental group (EG) and control group (CG) according to the order of admission. CG received routine nursing, while EG received the comfortable intervention-based nursing mode under the quality nursing intervention combined with Internet mobile health to compare the clinical indexes between the two groups. Results. Compared with CG, EG after intervention achieved obviously higher SS-QOL, ESCA, and GCQ scores ( $P<0.001$ ), and lower MSSNS and NIHSS scores ( $P<0.001$ ). Conclusion. The application of the comfortable intervention-based nursing mode under the quality nursing intervention combined with Internet mobile health effectively improves QOL and alleviates the negative emotions of patients. Compared with routine nursing, this model has higher application value, and further research of the joint intervention will help build better a solution for patients.

Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma

INTRODUCTION

Hemorrhage in major trauma is life-threatening and the activation of the Massive Transfusion Protocol (MTP) was found to reduce the time to transfusion and mortality. The purpose was (i) to verify whether MTP activation identifies patients that require massive transfusions once admitted to the Emergency Department (ED), (ii) to establish whether pre-hospital MTP activation reduces the time to transfusion on arrival at the ED, (iii) to identify the variable that best predicts MTP activation.

MATERIALS AND METHODS

This is a retrospective, single-center study. The MTP was implemented at the end of 2012; it was activated for major trauma in pre-hospital setting on the basis on established criteria. Pre-hospital MTP activation aimed to make blood products available prior to the patients' arrival at the ED. The blood products are transfused when the patient arrives at the hospital.

RESULTS

The MTP was activated in pre-hospital setting in 219 patients. On arrival at the hospital, the Trauma Team Leader confirmed MTP activation in 146 (66.7%) patients. Patients with MTP criteria received a higher amount of blood products than the patients without MTP criteria, median 7 (IQR 2-13) units versus 2 (0-6) units, respectively (P < 0.001). At the same time, patients with a Shock Index ≥ 0.9 received more transfusions (5.5 [2-13] units) compared with patients characterized by a lower SI (2 [0-7.25] units, P = 0.009). 146 patients were transfused in the first hour of ED admission. Poisson's multiple regression shows that the SI is the variable that better predicted MTP activation compared to age, gender and the number of injured sites.

CONCLUSIONS

Pre-hospital MTP activation is useful to identify patients that require an urgent blood transfusion on arrival at the ED. Further analysis should be considered to evaluate the implementation of the Shock Index as a criterion to activate MTP.

Risk Factors for Cerebral Infarction After Moderate or Severe Traumatic Brain Injury

Purpose

Posttraumatic cerebral infarction (PTCI) is a common and relatively serious complication of traumatic brain injury (TBI) without a clear etiology. Evaluating risk factors in advance is particularly important to predict and avoid the occurrence of PTCI.

Patients and Methods

We retrospectively analyzed 297 patients with moderate to severe TBI admitted to the Department of Neurosurgery in our hospital from January 2019 to September 2020 and evaluated the effects of various factors such as age, sex, admission Glasgow Coma Scale (GCS), skull base fracture, subarachnoid hemorrhage (SAH), brain herniation, hypotensive shock, and decompressive craniectomy on the incidence of PTCI. We also performed a multivariate logistics regression analysis on the relevant factors identified and evaluated the diagnostic value of each risk factor in advance by receiver operating characteristic (ROC) analyses.

Results

Among the patients, 32 (10.77%) suffered PTCI. The incidence rates of PTCI in those with GCS scores of 3–8 and 9–12 were 15.87% (30/189) and 1.85% (2/108), respectively, while the rates were 18.84% (13/69), 15.03% (29/193), 18.57% (13/70), and 20.59% (14/68) in those with skull base fractures, traumatic SAH, brain herniation, and hypotensive shock, respectively, and 14.38% (23/160) in those who underwent decompressive craniectomy. These differences in PTCI incidence were statistically significant. However, the differences in PTCI incidence caused by patient age and sex were not statistically significant.

Conclusion

Low GCS score, skull base fractures, traumatic SAH, brain herniation, hypotensive shock, and decompressive craniectomy are risk factors for the occurrence of PTCI, while age and sex are not significantly correlated with the occurrence of PTCI.

Comorbidity in traumatic brain injury and functional outcomes: a systematic review

INTRODUCTION

Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.

EVIDENCE ACQUISITION

A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.

EVIDENCE SYNTHESIS

Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSIONS

Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).