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Godoy DA, Rubiano AM, Aguilera S, Jibaja M, Videtta W, Rovegno M, Paranhos J, Paranhos E, de Amorim RLO, Castro Monteiro da Silva Filho R, Paiva W, Flecha J, Faleiro RM, Almanza D, Rodriguez E, Carrizosa J, Hawryluk GWJ, Rabinstein AA. Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization. Neurosurgery 2024; 95:e57-e70. [PMID: 38529956 DOI: 10.1227/neu.0000000000002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/30/2024] [Indexed: 03/27/2024] Open
Abstract
Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.
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Affiliation(s)
| | - Andres M Rubiano
- Universidad El Bosque, Bogota , Colombia
- MEDITECH Foundation, Cali , Colombia
| | - Sergio Aguilera
- Department Neurosurgery, Herminda Martín Hospital, Chillan , Chile
| | - Manuel Jibaja
- School of Medicine, San Francisco University, Quito , Ecuador
- Intensive Care Unit, Eugenio Espejo Hospital, Quito , Ecuador
| | - Walter Videtta
- Intensive Care Unit, Hospital Posadas, Buenos Aires , Argentina
| | - Maximiliano Rovegno
- Department Critical Care, Pontificia Universidad Católica de Chile, Santiago , Chile
| | - Jorge Paranhos
- Department of Neurosurgery and Critical Care, Santa Casa da Misericordia, Sao Joao del Rei , Minas Gerais , Brazil
| | - Eduardo Paranhos
- Intensive Care Unit, HEMORIO and Santa Barbara Hospitals, Rio de Janeiro , Brazil
| | | | | | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Sao Paulo , Brazil
| | - Jorge Flecha
- Intensive Care Unit, Trauma Hospital, Asuncion , Paraguay
- Social Security Institute Central Hospital, Asuncion , Paraguay
| | - Rodrigo Moreira Faleiro
- Department of Neurosurgery, João XXIII Hospital and Felício Rocho Hospital, Faculdade de Ciencias Médicas de MG, Belo Horizonte , Brazil
| | - David Almanza
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá , Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
| | - Eliana Rodriguez
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá , Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
| | - Jorge Carrizosa
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
- Neurointensive Care Unit, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá , Colombia
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Neurological Institute, Akron , Ohio , USA
| | - Alejandro A Rabinstein
- Neurocritical Care and Hospital Neurology Division, Mayo Clinic, Rochester , Minnesota , USA
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Aries P, Ognard J, Cadieu A, Degos V, Huet O. Secondary Neurologic Deterioration After Moderate Traumatic Brain Injury: Development of a Multivariable Prediction Model and Proposition of a Simple Triage Score. Anesth Analg 2024; 138:171-179. [PMID: 37097898 PMCID: PMC10699506 DOI: 10.1213/ane.0000000000006460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Identifying patients at risk of secondary neurologic deterioration (SND) after moderate traumatic brain injury (moTBI) is a challenge, as such patients will need specific care. No simple scoring system has been evaluated to date. This study aimed to determine clinical and radiological factors associated with SND after moTBI and to propose a triage score. METHODS All adults admitted in our academic trauma center between January 2016 and January 2019 for moTBI (Glasgow Coma Scale [GCS] score, 9-13) were eligible. SND during the first week was defined either by a decrease in GCS score of >2 points from the admission GCS in the absence of pharmacologic sedation or by a deterioration in neurologic status associated with an intervention, such as mechanical ventilation, sedation, osmotherapy, transfer to the intensive care unit (ICU), or neurosurgical intervention (for intracranial mass lesions or depressed skull fracture). Clinical, biological, and radiological independent predictors of SND were identified by logistic regression (LR). An internal validation was performed using a bootstrap technique. A weighted score was defined based on beta (β) coefficients of the LR. RESULTS A total of 142 patients were included. Forty-six patients (32%) showed SND, and 14-day mortality rate was 18.4%. Independent variables associated with SND were age above 60 years (odds ratio [OR], 3.45 [95% confidence interval {CI}, 1.45-8.48]; P = .005), brain frontal contusion (OR, 3.22 [95% CI, 1.31-8.49]; P = .01), prehospital or admission arterial hypotension (OR, 4.86 [95% CI, 2.03-12.60]; P = .006), and a Marshall computed tomography (CT) score of 6 (OR, 3.25 [95% CI, 1.31-8.20]; P = .01). The SND score was defined with a range from 0 to 10. The score included the following variables: age >60 years (3 points), prehospital or admission arterial hypotension (3 points), frontal contusion (2 points), and Marshall CT score of 6 (2 points). The score was able to detect patients at risk of SND, with an area under the receiver operating characteristic curve (AUC) of 0.73 (95% CI, 0.65-0.82). A score of 3 had a sensitivity of 85%, a specificity of 50%, a VPN of 87%, and a VPP of 44 % to predict SND. CONCLUSIONS In this study, we demonstrate that moTBI patients have a significant risk of SND. A simple weighted score at hospital admission could be able to detect patients at risk of SND. The use of the score may enable optimization of care resources for these patients.
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Affiliation(s)
- Philippe Aries
- From the Department of Anesthesia and Surgical Intensive Care, Military Teaching Hospital “Clermont-Tonnerre”, Brest, France
- Military Teaching Hospital “Clermont-Tonnerre,” Brest, France
- French Military Health Service Academy, École du Val-de-Grâce, Paris, France
| | - Julien Ognard
- French Military Health Service Academy, École du Val-de-Grâce, Paris, France
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, Brest, France
- Laboratory of Medical Information Processing, LaTIM INSERM UMR 1101, Brest, France
| | - Amandine Cadieu
- From the Department of Anesthesia and Surgical Intensive Care, Military Teaching Hospital “Clermont-Tonnerre”, Brest, France
| | - Vincent Degos
- APHP, Department of Anesthesia, Critical Care and Peri-Operative Medicine, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
- Clinical Research Group ARPE, Sorbonne University, Paris, France
- INSERM UMR 1141, PROTECT, Paris, France
| | - Olivier Huet
- From the Department of Anesthesia and Surgical Intensive Care, Military Teaching Hospital “Clermont-Tonnerre”, Brest, France
- UFR de Medecine de Brest, Université de Bretagne Occidentale, Brest, France
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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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Yu H, Ande SR, Batoo D, Linton J, Shankar J. Prognostic Value of Initial Diagnostic Imaging Findings for Patient Outcomes in Adult Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Tomography 2023; 9:509-528. [PMID: 36961001 PMCID: PMC10037627 DOI: 10.3390/tomography9020042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION Termed the "silent epidemic," traumatic brain injury (TBI) is one of the greatest global contributors not only to post-traumatic death but also to post-traumatic long-term disability. This systematic review and meta-analysis aims to specifically evaluate the prognostic value of features on initial imaging completed within 24 h of arrival in adult patients with TBI. METHOD The authors followed the PRISMA 2020 checklist for systematic review and meta-analysis design and reporting. Comprehensive searches of the Medline and Embase databases were carried out. Two independent readers extracted the following demographic, clinical and imaging information using a predetermined data abstraction form. Statistics were performed using Revman 5.4.1 and R version 4.2.0. For pooled data in meta-analysis, forest plots for sensitivity and specificity were created to calculate the diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) curves were generated using a bivariate model, and diagnostic accuracy was determined using pooled sensitivity and specificity as well as the area under the receiver operator characteristic curve (AUC). RESULTS There were 10,733 patients over the 19 studies. Overall, most of the studies included had high levels of bias in multiple, particularly when it came to selection bias in patient sampling, bias in controlling for confounders, and reporting bias, such as in reporting missing data. Only subdural hematoma (SDH) and mortality in all TBI patients had both an AUC with 95% CI not crossing 0.5 and a DOR with 95% CI not crossing 1, at 0.593 (95% CI: 0.556-0.725) and 2.755 (95% CI: 1.474-5.148), respectively. CONCLUSION In meta-analysis, only SDH with mortality in all TBI patients had a moderate but significant association. Given the small number of studies, additional research focused on initial imaging, particularly for imaging modalities other than NECT, is required in order to confirm the findings of our meta-analysis and to further evaluate the association of imaging findings and outcome.
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Affiliation(s)
- Hang Yu
- Department of Radiology, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Sudharsana Rao Ande
- Department of Radiology, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Divjeet Batoo
- Department of Radiology, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Janice Linton
- Department of Radiology, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Jai Shankar
- Department of Radiology, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
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A Long Short-Term Memory Network Using Resting-State Electroencephalogram to Predict Outcomes Following Moderate Traumatic Brain Injury. COMPUTERS 2023. [DOI: 10.3390/computers12020045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Although traumatic brain injury (TBI) is a global public health issue, not all injuries necessitate additional hospitalisation. Thinking, memory, attention, personality, and movement can all be negatively impacted by TBI. However, only a small proportion of nonsevere TBIs necessitate prolonged observation. Clinicians would benefit from an electroencephalography (EEG)-based computational intelligence model for outcome prediction by having access to an evidence-based analysis that would allow them to securely discharge patients who are at minimal risk of TBI-related mortality. Despite the increasing popularity of EEG-based deep learning research to create predictive models with breakthrough performance, particularly in epilepsy prediction, its use in clinical decision making for the diagnosis and prognosis of TBI has not been as widely exploited. Therefore, utilising 60s segments of unprocessed resting-state EEG data as input, we suggest a long short-term memory (LSTM) network that can distinguish between improved and unimproved outcomes in moderate TBI patients. Complex feature extraction and selection are avoided in this architecture. The experimental results show that, with a classification accuracy of 87.50 ± 0.05%, the proposed prognostic model outperforms three related works. The results suggest that the proposed methodology is an efficient and reliable strategy to assist clinicians in creating an automated tool for predicting treatment outcomes from EEG signals.
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Is there a weekend effect on mortality rate and outcome for moderate and severe traumatic brain injury? A population-based, observational cohort study. BRAIN & SPINE 2022; 2:101699. [PMID: 36506297 PMCID: PMC9729811 DOI: 10.1016/j.bas.2022.101699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/17/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Purpose The aim of the study was to analyse patient and injury characteristics and the effects of weekend admissions on mortality rate and outcome after moderate and severe traumatic brain injuries. Methods This is an observational cohort study based on data from a prospectively maintained regional trauma registry in South Western Norway. Patients with moderate and severe traumatic brain injury admitted between January 1st, 2004 and December 31st, 2019 were included in this study. Results During the study period 688 patients were included in the study with similar distribution between moderate (n = 318) and severe (n = 370) traumatic brain injury. Mortality rate was 46% in severe and 13% in moderate traumatic brain injury. Two hundred and thirty-one (34%) patients were admitted during weekends. Patients admitted during weekends were significantly younger (median age (IQR) 32.0 (25.5-67.0) vs 47.0 (20.0-55.0), p < 0.001). Pre-injury ASA 1 was significantly more common in patients admitted during weekends (n = 146, 64%, p = 0.001) while ASA 3 showed significance during weekdays compared to weekends (n = 101, 22%, p = 0.013). On binominal logistic regression analysis mortality rate was significantly higher with older age (OR 1.03, 95% CI for OR 1.02-1.04, p < 0.001) and increasing TBI severity (OR 7.08, 95% CI for OR 4.67-10.73, p < 0.001). Conclusions Mortality rate and poor clinical outcome remain high in severe traumatic brain injury. While a higher number of patients are admitted during the weekend, mortality rate does not differ from weekday admissions.
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Chen M, Wu H, Li Z, Ge S, Zhao L, Zhang X, Qu Y. Intracranial-Pressure-Monitoring-Assisted Management Associated with Favorable Outcomes in Moderate Traumatic Brain Injury Patients with a GCS of 9-11. J Clin Med 2022; 11:6661. [PMID: 36431137 PMCID: PMC9694446 DOI: 10.3390/jcm11226661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: With a mortality rate of 10−30%, a moderate traumatic brain injury (mTBI) is one of the most variable traumas. The indications for intracranial pressure (ICP) monitoring in patients with mTBI and the effects of ICP on patients’ outcomes are uncertain. The purpose of this study was to examine the indications of ICP monitoring (ICPm) and its effects on the long-term functional outcomes of mTBI patients. Methods: Patients with Glasgow Coma Scale (GCS) scores of 9−11 at Tangdu hospital, between January 2015 and December 2021, were enrolled and treated in this retrospective cohort study. We assessed practice variations in ICP interventions using the therapy intensity level (TIL). Six-month mortality and a Glasgow Outcome Scale Extended (GOS-E) score were the main outcomes. The secondary outcome was neurological deterioration (ND) events. The indication and the estimated impact of ICPm on the functional outcome were investigated by using binary regression analyses. Results: Of the 350 patients, 145 underwent ICP monitoring-assisted management, and the other 205 patients received a standard control based on imaging or clinical examinations. A GCS ≤ 10 (OR 1.751 (95% CI 1.216−3.023), p = 0.003), midline shift (mm) ≥ 2.5 (OR 3.916 (95% CI 2.076−7.386) p < 0.001), and SDH (OR 1.772 (95% CI 1.065−2.949) p = 0.028) were predictors of ICP. Patients who had ICPm (14/145 (9.7%)) had a decreased 6-month mortality rate compared to those who were not monitored (40/205 (19.5%), p = 0.011). ICPm was linked to both improved neurological outcomes at 6 months (OR 0.815 (95% CI 0.712−0.933), p = 0.003) and a lower ND rate (2 = 11.375, p = 0.010). A higher mean ICP (17.32 ± 3.52, t = −6.047, p < 0.001) and a more significant number of ICP > 15 mmHg (27 (9−45.5), Z = −5.406, p < 0.001) or ICP > 20 mmHg (5 (0−23), Z = −4.635, p < 0.001) 72 h after injury were associated with unfavorable outcomes. The best unfavorable GOS-E cutoff value of different ICP characteristics showed that the mean ICP was >15.8 mmHg (AUC 0.698; 95% CI, 0.606−0.789, p < 0.001), the number of ICP > 15 mmHg was >25.5 (AUC 0.681; 95% CI, 0.587−0.774, p < 0.001), and the number of ICP > 20 mmHg was >6 (AUC 0.660; 95% CI, 0.561−0.759, p < 0.001). The total TIL score during the first 72 h post-injury in the non-ICP group (9 (8, 11)) was lower than that of the ICP group (13 (9, 17), Z = −8.388, p < 0.001), and was associated with unfavorable outcomes. Conclusion: ICPm-assisted management was associated with better clinical outcomes six months after discharge and lower incidences of ND for seven days post-injury. A mean ICP > 15.8 mmHg, the number of ICP > 15 mmHg > 25.5, or the number of ICP > 20 mmHg > 6 implicate an unfavorable long-term prognosis after 72 h of an mTBI.
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Affiliation(s)
| | | | | | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi’an 710038, China
| | | | | | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi’an 710038, China
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Wang LC, Wei WY, Ho PC. Short-Term Cortical Electrical Stimulation during the Acute Stage of Traumatic Brain Injury Improves Functional Recovery. Biomedicines 2022; 10:biomedicines10081965. [PMID: 36009512 PMCID: PMC9405844 DOI: 10.3390/biomedicines10081965] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Functional restoration is an important issue in the treatment of traumatic brain injury (TBI). Various electrical stimulation devices and protocols have been applied in preclinical studies and have shown therapeutic potential for brain trauma. Short-term invasive cortical electrical stimulation during the acute stage of TBI might be a feasible adjuvant therapy for patients with moderate-to-severe brain injury receiving neurosurgical treatment in the intensive care unit. However, the therapeutic effects of short-term multisession cortical electrical stimulation for brain trauma are not clear. This study explored the therapeutic effects of acute-stage short-term cortical electrical stimulation on TBI. We conducted seven sessions of one-hour cortical electrical stimulation from day 0 to day 6 in rats after brain trauma by controlled cortical impact and then evaluated the functional outcome and histopathological changes. Our data showed that short-term cortical electrical stimulation improved motor coordination, short-term memory, and learning ability and attenuated neurological severity after brain trauma. Lesion volume, apoptosis, and gliosis after brain trauma were reduced, and trauma-induced neurogenesis in the hippocampus for the innate neural reparative response was increased. Our study demonstrated that short-term cortical electrical stimulation applied in the acute stage of traumatic brain injury is a potential adjuvant therapy to improve the recovery of neurological deficits.
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Affiliation(s)
- Liang-Chao Wang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5284)
| | - Wei-Yen Wei
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Pei-Chuan Ho
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
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Godoy DA, Seifi A, Chi G, Paredes Saravia L, Rabinstein AA. Intracranial Pressure Monitoring in Moderate Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:514-522. [PMID: 35610529 DOI: 10.1007/s12028-022-01533-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/03/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The principal aim of this study was to determine the prevalence of intracranial pressure (ICP) monitoring and intracranial hypertension (IHT) in patients treated for moderate traumatic brain injury (TBI). A secondary objective was to assess factors associated with ICP monitoring. METHODS We conducted a systematic review of the literature to identify studies that assessed ICP monitoring in moderate TBI. The meta-analysis was performed by using a random-effects model. RESULTS A total of 13 studies comprising 116,714 patients were pooled to estimate the overall prevalence of ICP monitoring and IHT (one episode or more of ICP > 20 mm Hg) after moderate TBI. The prevalence rate for ICP monitoring was 18.3% (95% confidence interval 8.1-36.1%), whereas the proportion of IHT was 44% (95% confidence interval 33.8-54.7%). Three studies were pooled to estimate the prevalence of ICP monitoring according to Glasgow Coma Scale (GCS) (≤ 10 vs. > 10). ICP monitoring was performed in 32.2% of patients with GCS ≤ 10 versus 15.2% of patients with GCS > 10 (p = 0.59). Both subgroups were highly heterogeneous. We found no other variables associated with ICP monitoring or IHT. CONCLUSIONS The prevalence of ICP monitoring in moderate TBI is low, but the prevalence of IHT is high among patients undergoing ICP monitoring. Current literature is limited in size and quality and does not identify factors associated with ICP monitoring or IHT. Further research is needed to guide the optimal use of ICP monitoring in moderate TBI.
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Affiliation(s)
- Daniel Agustin Godoy
- Critical Care Department, Neurointensive Care Unit, Sanatorio Pasteur, Chacabuco 675 , 4700, Catamarca, Argentina.
| | - Ali Seifi
- Department of Neurosurgery, Division of Neurocritical Care, University of Texas Health Science Center at San Antonio, School of Medicine, San Antonio, TX, USA
| | - Gerald Chi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Alejandro A Rabinstein
- Department of Neurology, Neuroscience Intensive Care Unit, Mayo Clinic, Rochester, MN, USA
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Jeon JP, Kim S, Kim TY, Han SW, Lim SH, Youn DH, Kim BJ, Hong EP, Park CH, Kim JT, Ahn JH, Rhim JK, Park JJ, Kim HC, Kang SH. Association Between Copeptin and Six-Month Neurologic Outcomes in Patients With Moderate Traumatic Brain Injury. Front Neurol 2022; 12:749110. [PMID: 35547639 PMCID: PMC9081440 DOI: 10.3389/fneur.2021.749110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background Copeptin has been reported as a predictive biomarker for the prognosis after traumatic brain injury (TBI). However, most of them were in patients with severe TBI and limited value in predicting outcomes in patients with moderate TBI defined as Glasgow Coma Scale (GCS) score from 9 to 12. We aimed to investigate the predictive value of copeptin in assessing the neurologic outcome following moderate TBI. Methods Patients were prospectively enrolled between May 2017 and November 2020. We consecutively measured plasma copeptin within 24 h after trauma, days 3, 5, and 7 using ELISA. The primary outcome was to correlate plasma copeptin levels with poor neurologic outcome at 6 months after moderate TBI. The secondary outcome was to compare the prognostic accuracy of copeptin and C-reactive protein (CRP) in assessing the outcome of patient. Results A total of 70 patients were included for the final analysis. The results showed that 29 patients (41.4%) experienced a poor neurologic outcome at 6 months. Multivariable logistic regression analysis revealed that increased copeptin (odds ration [OR] = 1.020, 95% CI: 1.005–1.036), GCS score of 9 or 10 (OR = 4.507, 95% CI: 1.266–16.047), and significant abnormal findings on CT (OR = 4.770; 95% CI: 1.133–20.076) were independent risk factors for poor outcomes. Consecutive plasma copeptin levels were significantly different according to outcomes (p < 0.001). Copeptin on day 7 exhibited better prognostic performance than CRP with an area under receiver operating characteristic curve (AUROC) difference of 0.179 (95% CI: 0.032–0.325) in predicting 6-month poor outcomes. Conclusion Plasma copeptin level can be a useful marker in predicting 6-month outcomes in patients with moderate TBI.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Seonghyeon Kim
- Department of Orthopaedic Surgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Tae Yeon Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sung Woo Han
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Seung Hyuk Lim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Dong Hyuk Youn
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Eun Pyo Hong
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Chan Hum Park
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jong-Tae Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, South Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk Medical Center, Seoul, South Korea
| | - Heung Cheol Kim
- Department of Radioilogy, Hallym University College of Medicine, Chuncheon, South Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
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11
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Chen M, Li Z, Yan Z, Ge S, Zhang Y, Yang H, Zhao L, Liu L, Zhang X, Cai Y, Qu Y. Predicting Neurological Deterioration after Moderate Traumatic Brain Injury: Development and Validation of a Prediction Model Based on Data Collected on Admission. J Neurotrauma 2022; 39:371-378. [PMID: 35018830 DOI: 10.1089/neu.2021.0360] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Moderate traumatic brain injury (mTBI) is a heterogeneous entity that poorly defined in the literature. mTBI patients suffer from a high rate of neurological deterioration (ND), which is usually accompanied with poor prognosis and no definitive methods to predict. The purpose of this study is to develop and validate a prediction model that estimates the ND risk in mTBI patients using data collected on admission. Retrospectively collected 479 mTBI patients' data in our department were analyzed by logistic regression models. Bivariable logistic regression identified variables with a p-value<0.05. Multivariable logistic regression modeling with backward stepwise elimination was used to determine reduced parameters and establish a prediction model. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated. The prediction model was validated using 176 patients' data collected from another hospital. Eight independent prognostic factors were identified: hypertension, Marshall's scale (types III and IV), subdural hemorrhage (SDH), location of contusion (LOC) (frontal and temporal contusions), Injury Severity Score (ISS) >13, D-dimer level >11.4 mg/L, Glasgow Coma Scale (GCS) score ≤10, and platelet (PLT) count ≤152×109/L. A prediction model was established and was shown as a nomogram. Using bootstrapping, internal validation showed that the C-statistic of the prediction model was 0.881 (95% confidence interval (CI): 0.849-0.909). The results of external validation showed that the nomogram could predict ND with an area under the curve (AUC) of 0.827 (95% CI: 0763.-0.880). The present model, based on simple parameters collected on admission, can predict the risk of ND in mTBI patients accurately. The high discriminative ability indicates the potential of this model for classifying mTBI patients according to ND risk.
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Affiliation(s)
- Mingsheng Chen
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Zhihong Li
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Zhifeng Yan
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Shunnan Ge
- Tangdu Hospital Fourth Military Medical University, 56697, Department of Neurosurgery, Xi'an, Shaan Xi, China;
| | - Yongbing Zhang
- Department of Neurosurgery, Yan'an People's Hospital, yan'an, Shaanxi, China;
| | - Haigui Yang
- Department of Neurosurgery, Yan'an People's Hospital, yan'an, Shaanxi, China;
| | - Lanfu Zhao
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Lingyu Liu
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Xingye Zhang
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Yaning Cai
- Air Force Medical University Tangdu Hospital Department of Neurosurgery, 571816, Xi'an, Shaanxi, China;
| | - Yan Qu
- Tangdu Hospital Fourth Military Medical University, 56697, Department of Neurosurgery, Xi'an, Shaan Xi, China.,Tangdu Hospital Fourth Military Medical University, 56697, Neurosurgery Dpartment, Xi'an, China;
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Potentially Severe (Moderate) Traumatic Brain Injury: A New Categorization Proposal. Crit Care Med 2021; 48:1851-1854. [PMID: 32804788 DOI: 10.1097/ccm.0000000000004575] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Kokkinou M, Kyprianou TC, Kyriakides E, Constantinidou F. A population study on the epidemiology and outcome of brain injuries in intensive care. NeuroRehabilitation 2021; 47:143-152. [PMID: 32741786 DOI: 10.3233/nre-203111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Traumatic Brain Injury (TBI) is characterized by a highly heterogenous profile in terms of pathophysiology, clinical presentation and outcome. OBJECTIVE This is the first population study investigating the epidemiology and outcomes of moderate-to-severe TBI in Cyprus. Patients treated in the Intensive Care Unit (ICU) of Nicosia General Hospital, the only Level 1 Trauma Centre in the country, were recruited between January 2013 and December 2016. METHODS This was an observational cohort study, using longitudinal methods and six-month follow-up. Patients (N = 203) diagnosed with TBI were classified by the Glasgow Coma Scale at the Emergency Department as moderate or severe. RESULTS Compared to international multicentre studies, the current cohort demonstrates a different case mix that includes older age, more motor vehicle collisions and lower mortality rates. There was a significantly higher proportion of injured males. Females were significantly older than males. There were no sex differences in the type, severity or place of injury. Sex did not yield differences in mortality or outcomes or on injury indices predicting outcomes. In contrast, older age was a predictor of higher mortality rates and worse outcomes. CONCLUSION Trends as described in the study emphasize the importance of continuous evaluation of TBI epidemiology and outcome in different countries.
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Affiliation(s)
- M Kokkinou
- Registered Clinical Psychologist & Doctoral Candidate, Department of Psychology & Center for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus
| | - T C Kyprianou
- Associate Professor at St George, University of London, Medical Program at the University of Nicosia Medical School, Nicosia, Cyprus
| | - E Kyriakides
- ICU Clinical Informatics Administrator, Nicosia General Hospital, Nicosia, Cyprus
| | - F Constantinidou
- Professor of Language Disorders and Clinical Neuropsychology, Department of Psychology & Director of the Centre for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus
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Koyama H, Yagi K, Hara K, Matsubara S, Tao Y, Uno M. Combination Therapy Using Prothrombin Complex Concentrate and Vitamin K in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Prevents Progressive Hemorrhagic Injury: A Historically Controlled Study. Neurol Med Chir (Tokyo) 2020; 61:47-54. [PMID: 33208582 PMCID: PMC7812312 DOI: 10.2176/nmc.oa.2020-0252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00-0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.
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Affiliation(s)
- Hiroshi Koyama
- Department of Neurosurgery, Kawasaki Medical School.,Department of Neurosurgery, Tokushima University Hospital
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
| | - Keijiro Hara
- Department of Neurosurgery, Kawasaki Medical School
| | | | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
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15
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Baldon IV, Amorim AC, Santana LM, Solla DJ, Kolias A, Hutchinson P, Paiva WS, Rosa-Júnior M. The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis. PLoS One 2020; 15:e0235561. [PMID: 32634141 PMCID: PMC7340282 DOI: 10.1371/journal.pone.0235561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/17/2020] [Indexed: 01/14/2023] Open
Abstract
Background The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI). Purpose To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality. Data sources The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies. Study selection A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria. Data analysis All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04). Data synthesis This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality. Limitations Only four articles were selected. Conclusions The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.
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Affiliation(s)
- Isabella Vargas Baldon
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Andre Candeas Amorim
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Larissa Marques Santana
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Davi J. Solla
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Angelos Kolias
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s, Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Peter Hutchinson
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s, Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Wellingson S. Paiva
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Marcos Rosa-Júnior
- Department of Neuroradiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
- * E-mail:
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16
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Assessment of intracranial pressure monitoring in patients with moderate traumatic brain injury: A retrospective cohort study. Clin Neurol Neurosurg 2020; 189:105538. [DOI: 10.1016/j.clineuro.2019.105538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 11/17/2022]
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17
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Grahf DC, Binz SI, Belle T, Jayaprakash N. Watching the Brain: an Overview of Neuromonitoring Systems and Their Utility in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00208-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Rau CS, Wu SC, Hsu SY, Liu HT, Huang CY, Hsieh TM, Chou SE, Su WT, Liu YW, Hsieh CH. Concurrent Types of Intracranial Hemorrhage are Associated with a Higher Mortality Rate in Adult Patients with Traumatic Subarachnoid Hemorrhage: A Cross-Sectional Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16234787. [PMID: 31795322 PMCID: PMC6926691 DOI: 10.3390/ijerph16234787] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/30/2022]
Abstract
Traumatic subarachnoid hemorrhage (SAH) is the second most frequent intracranial hemorrhage and a common radiologic finding in computed tomography. This study aimed to estimate the risk of mortality in adult trauma patients with traumatic SAH concurrent with other types of intracranial hemorrhage, such as subdural hematoma (SDH), epidural hematoma (EDH), and intracerebral hemorrhage (ICH), compared to the risk in patients with isolated traumatic SAH. We searched our hospital’s trauma database from 1 January, 2009 to 31 December, 2018 to identify hospitalized adult patients ≥20 years old who presented with a trauma abbreviated injury scale (AIS) of ≥3 in the head region. Polytrauma patients with an AIS of ≥3 in any other region of the body were excluded. A total of 1856 patients who had SAH were allocated into four exclusive groups: (Group I) isolated traumatic SAH, n = 788; (Group II) SAH and one diagnosis, n = 509; (Group III) SAH and two diagnoses, n = 493; and (Group IV) SAH and three diagnoses, n = 66. One, two, and three diagnoses indicated occurrences of one, two, or three other types of intracranial hemorrhage (SDH, EDH, or ICH). The adjusted odds ratio with a 95% confidence interval (CI) of the level of mortality was calculated with logistic regression, controlling for sex, age, and pre-existing comorbidities. Patients with isolated traumatic SAH had a lower rate of mortality (1.8%) compared to the other three groups (Group II: 7.9%, Group III: 12.4%, and Group IV: 27.3%, all p < 0.001). When controlling for sex, age, and pre-existing comorbidities, we found that Group II, Group III, and Group IV patients had a 4.0 (95% CI 2.4–6.5), 8.9 (95% CI 4.8–16.5), and 21.1 (95% CI 9.4–47.7) times higher adjusted odds ratio for mortality, respectively, than the patients with isolated traumatic SAH. In this study, we demonstrated that compared to patients with isolated traumatic SAH, traumatic SAH patients with concurrent types of intracranial hemorrhage have a higher adjusted odds ratio for mortality.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan;
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Hang-Tsung Liu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Ting-Min Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Yueh-Wei Liu
- Department of General Gurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan
- Correspondence: (Y.-W.L.); (C.-H.H.); Tel.: +886-7-345-4746 (C.-H.H.)
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan
- Correspondence: (Y.-W.L.); (C.-H.H.); Tel.: +886-7-345-4746 (C.-H.H.)
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Servadei F, Spaggiari R, Tropeano MP. Editorial. Perceive the differences, differentiate the perceptions: why should we be interested in TBI management in Tanzania? Neurosurg Focus 2019; 47:E7. [DOI: 10.3171/2019.8.focus19682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
OBJECTIVES To characterize admission patterns, treatments, and outcomes among patients with moderate traumatic brain injury. DESIGN Retrospective cohort study. SETTING National Trauma Data Bank. PATIENTS Adults (age > 18 yr) with moderate traumatic brain injury (International Classification of Diseases, Ninth revision codes and admission Glasgow Coma Scale score of 9-13) in the National Trauma Data Bank between 2007 and 2014. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Demographics, mechanism of injury, hospital course, and facility characteristics were examined. Admission characteristics associated with discharge outcomes were analyzed using multivariable Poisson regression models. Of 114,066 patients, most were white (62%), male (69%), and had median admission Glasgow Coma Scale score of 12 (interquartile range, 10-13). Seventy-seven percent had isolated traumatic brain injury. Concussion, which accounted for 25% of moderate traumatic brain injury, was the most frequent traumatic brain injury diagnosis. Fourteen percent received mechanical ventilation, and 66% were admitted to ICU. Over 50% received care at a community hospital. Seven percent died, and 32% had a poor outcome, including those with Glasgow Coma Scale score of 13. Compared with patients 18-44 years, patients 45-64 years were twice as likely (adjusted relative risk, 1.97; 95% CI, 1.92-2.02) and patients over 80 years were five times as likely (adjusted relative risk, 4.66; 95% CI, 4.55-4.76) to have a poor outcome. Patients with a poor discharge outcome were more likely to have had hypotension at admission (adjusted relative risk, 1.10; 95% CI, 1.06-1.14), lower admission Glasgow Coma Scale (adjusted relative risk, 1.37; 95% CI, 1.34-1.40), higher Injury Severity Score (adjusted relative risk, 2.97; 95% CI, 2.86-3.09), and polytrauma (adjusted relative risk, 1.05; 95% CI, 1.02-1.07), compared with those without poor discharge outcomes. CONCLUSIONS Many patients with moderate traumatic brain injury deteriorate, require neurocritical care, and experience poor outcomes. Optimization of care and outcomes for this vulnerable group of patients are urgently needed.
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Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, Agrawal A, Adeleye AO, Shrime MG, Rubiano AM, Rosenfeld JV, Park KB. Estimating the global incidence of traumatic brain injury. J Neurosurg 2019; 130:1080-1097. [PMID: 29701556 DOI: 10.3171/2017.10.jns17352] [Citation(s) in RCA: 1183] [Impact Index Per Article: 236.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 10/18/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups. METHODS Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group. RESULTS Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs. CONCLUSIONS Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 2Department of Neurological Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center
| | - Abbas Rattani
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 3Meharry Medical College, School of Medicine, Nashville, Tennessee
| | | | - Ronnie E Baticulon
- 5University of the Philippines College of Medicine, Philippine General Hospital, Manila, Philippines
| | - Ya-Ching Hung
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
| | - Maria Punchak
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 6David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amit Agrawal
- 7Department of Neurosurgery, Narayana Medical College, Nellore, Andhra Pradesh, India
| | - Amos O Adeleye
- 8Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan
- 9Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Mark G Shrime
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 10Office of Global Surgery and Health, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Andrés M Rubiano
- 11Neurosciences Institute, Neurosurgery Service, El Bosque University, El Bosque Clinic, MEDITECH-INUB Research Group, Bogotá, Colombia
| | - Jeffrey V Rosenfeld
- 12Department of Neurosurgery, Alfred Hospital
- 13Department of Surgery, Monash University, Melbourne, Australia; and
- 14Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kee B Park
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
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Su YS, Schuster JM, Smith DH, Stein SC. Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury. J Neurotrauma 2019; 36:2083-2091. [PMID: 30547708 DOI: 10.1089/neu.2018.6020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.
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Affiliation(s)
- YouRong Sophie Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas H Smith
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Dalle Ore CL, Rennert RC, Schupper AJ, Gabel BC, Gonda D, Peterson B, Marshall LF, Levy M, Meltzer HS. The identification of a subgroup of children with traumatic subarachnoid hemorrhage at low risk of neuroworsening. J Neurosurg Pediatr 2018; 22:559-566. [PMID: 30095347 DOI: 10.3171/2018.5.peds18140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/21/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVEPediatric traumatic subarachnoid hemorrhage (tSAH) often results in intensive care unit (ICU) admission, the performance of additional diagnostic studies, and ICU-level therapeutic interventions to identify and prevent episodes of neuroworsening.METHODSData prospectively collected in an institutionally specific trauma registry between 2006 and 2015 were supplemented with a retrospective chart review of children admitted with isolated traumatic subarachnoid hemorrhage (tSAH) and an admission Glasgow Coma Scale (GCS) score of 13-15. Risk of blunt cerebrovascular injury (BCVI) was calculated using the BCVI clinical prediction score.RESULTSThree hundred seventeen of 10,395 pediatric trauma patients were admitted with tSAH. Of the 317 patients with tSAH, 51 children (16%, 23 female, 28 male) were identified with isolated tSAH without midline shift on neuroimaging and a GCS score of 13-15 at presentation. The median patient age was 4 years (range 18 days to 15 years). Seven had modified Fisher grade 3 tSAH; the remainder had grade 1 tSAH. Twenty-six patients (51%) had associated skull fractures; 4 involved the petrous temporal bone and 1 the carotid canal. Thirty-nine (76.5%) were admitted to the ICU and 12 (23.5%) to the surgical ward. Four had an elevated BCVI score. Eight underwent CT angiography; no vascular injuries were identified. Nine patients received an imaging-associated general anesthetic. Five received hypertonic saline in the ICU. Patients with a modified Fisher grade 1 tSAH had a significantly shorter ICU stay as compared to modified Fisher grade 3 tSAH (1.1 vs 2.5 days, p = 0.029). Neuroworsening was not observed in any child.CONCLUSIONSChildren with isolated tSAH without midline shift and a GCS score of 13-15 at presentation appear to have minimal risk of neuroworsening despite the findings in some children of skull fractures, elevated modified Fisher grade, and elevated BCVI score. In this subgroup of children with tSAH, routine ICU-level care and additional diagnostic imaging may not be necessary for all patients. Children with modified Fisher grade 1 tSAH may be particularly unlikely to require ICU-level admission. Benefits to identifying a subgroup of children at low risk of neuroworsening include improvement in healthcare efficiency as well as decreased utilization of unnecessary and potentially morbid interventions, including exposure to ionizing radiation and general anesthesia.
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Affiliation(s)
- Cecilia L Dalle Ore
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
| | - Robert C Rennert
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
| | - Alexander J Schupper
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
| | - Brandon C Gabel
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
| | - David Gonda
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
- Divisions of2Neurosurgery and
| | - Bradley Peterson
- 3Pediatric Critical Care, Rady Children's Hospital, San Diego, California
| | - Lawrence F Marshall
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
| | - Michael Levy
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
- Divisions of2Neurosurgery and
| | - Hal S Meltzer
- 1Department of Neurosurgery, University of California San Diego School of Medicine; and
- Divisions of2Neurosurgery and
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Moderate Traumatic Brain Injury: Clinical Characteristics and a Prognostic Model of 12-Month Outcome. World Neurosurg 2018; 114:e1199-e1210. [PMID: 29614364 DOI: 10.1016/j.wneu.2018.03.176] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with moderate traumatic brain injury (TBI) often are studied together with patients with severe TBI, even though the expected outcome of the former is better. Therefore, we aimed to describe patient characteristics and 12-month outcomes, and to develop a prognostic model based on admission data, specifically for patients with moderate TBI. METHODS Patients with Glasgow Coma Scale scores of 9-13 and age ≥16 years were prospectively enrolled in 2 level I trauma centers in Europe. Glasgow Outcome Scale Extended (GOSE) score was assessed at 12 months. A prognostic model predicting moderate disability or worse (GOSE score ≤6), as opposed to a good recovery, was fitted by penalized regression. Model performance was evaluated by area under the curve of the receiver operating characteristics curves. RESULTS Of the 395 enrolled patients, 81% had intracranial lesions on head computed tomography, and 71% were admitted to an intensive care unit. At 12 months, 44% were moderately disabled or worse (GOSE score ≤6), whereas 8% were severely disabled and 6% died (GOSE score ≤4). Older age, lower Glasgow Coma Scale score, no day-of-injury alcohol intoxication, presence of a subdural hematoma, occurrence of hypoxia and/or hypotension, and preinjury disability were significant predictors of GOSE score ≤6 (area under the curve = 0.80). CONCLUSIONS Patients with moderate TBI exhibit characteristics of significant brain injury. Although few patients died or experienced severe disability, 44% did not experience good recovery, indicating that follow-up is needed. The model is a first step in development of prognostic models for moderate TBI that are valid across centers.
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Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
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Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
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Rau CS, Wu SC, Chien PC, Kuo PJ, Chen YC, Hsieh HY, Hsieh CH. Prediction of Mortality in Patients with Isolated Traumatic Subarachnoid Hemorrhage Using a Decision Tree Classifier: A Retrospective Analysis Based on a Trauma Registry System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14111420. [PMID: 29165330 PMCID: PMC5708059 DOI: 10.3390/ijerph14111420] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 11/24/2022]
Abstract
Background: In contrast to patients with traumatic subarachnoid hemorrhage (tSAH) in the presence of other types of intracranial hemorrhage, the prognosis of patients with isolated tSAH is good. The incidence of mortality in these patients ranges from 0–2.5%. However, few data or predictive models are available for the identification of patients with a high mortality risk. In this study, we aimed to construct a model for mortality prediction using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry, in a Level 1 trauma center. Methods: Five hundred and forty-five patients with isolated tSAH, including 533 patients who survived and 12 who died, between January 2009 and December 2016, were allocated to training (n = 377) or test (n = 168) sets. Using the data on demographics and injury characteristics, as well as laboratory data of the patients, classification and regression tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: In this established DT model, three nodes (head Abbreviated Injury Scale (AIS) score ≤4, creatinine (Cr) <1.4 mg/dL, and age <76 years) were identified as important determinative variables in the prediction of mortality. Of the patients with isolated tSAH, 60% of those with a head AIS >4 died, as did the 57% of those with an AIS score ≤4, but Cr ≥1.4 and age ≥76 years. All patients who did not meet the above-mentioned criteria survived. With all the variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 90.9% and specificity of 98.1%) and 97.7% (sensitivity of 100% and specificity of 97.7%), for the training set and test set, respectively. Conclusions: The study established a DT model with three nodes (head AIS score ≤4, Cr <1.4, and age <76 years) to predict fatal outcomes in patients with isolated tSAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Pao-Jen Kuo
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Yi-Chun Chen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
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Sandsmark DK, Elliott JE, Lim MM. Sleep-Wake Disturbances After Traumatic Brain Injury: Synthesis of Human and Animal Studies. Sleep 2017; 40:3074241. [PMID: 28329120 PMCID: PMC6251652 DOI: 10.1093/sleep/zsx044] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 12/23/2022] Open
Abstract
Sleep-wake disturbances following traumatic brain injury (TBI) are increasingly recognized as a serious consequence following injury and as a barrier to recovery. Injury-induced sleep-wake disturbances can persist for years, often impairing quality of life. Recently, there has been a nearly exponential increase in the number of primary research articles published on the pathophysiology and mechanisms underlying sleep-wake disturbances after TBI, both in animal models and in humans, including in the pediatric population. In this review, we summarize over 200 articles on the topic, most of which were identified objectively using reproducible online search terms in PubMed. Although these studies differ in terms of methodology and detailed outcomes; overall, recent research describes a common phenotype of excessive daytime sleepiness, nighttime sleep fragmentation, insomnia, and electroencephalography spectral changes after TBI. Given the heterogeneity of the human disease phenotype, rigorous translation of animal models to the human condition is critical to our understanding of the mechanisms and of the temporal course of sleep-wake disturbances after injury. Arguably, this is most effectively accomplished when animal and human studies are performed by the same or collaborating research programs. Given the number of symptoms associated with TBI that are intimately related to, or directly stem from sleep dysfunction, sleep-wake disorders represent an important area in which mechanistic-based therapies may substantially impact recovery after TBI.
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Affiliation(s)
| | - Jonathan E Elliott
- VA Portland Health Care System, Portland, OR
- Department of Neurology, Oregon Health & Science University, Portland, OR
| | - Miranda M Lim
- VA Portland Health Care System, Portland, OR
- Department of Neurology, Oregon Health & Science University, Portland, OR
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR; Department of Behavioral Neuroscience, Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR
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Kamal VK, Agrawal D, Pandey RM. Epidemiology, clinical characteristics and outcomes of traumatic brain injury: Evidences from integrated level 1 trauma center in India. J Neurosci Rural Pract 2016; 7:515-525. [PMID: 27695230 PMCID: PMC5006462 DOI: 10.4103/0976-3147.188637] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a leading cause of mortality, morbidity, disability, and socioeconomic losses in the Indian subcontinent. However, for policymaking and research, there is a lack of reliable and larger data in our settings. AIMS AND OBJECTIVES To evaluate and describe the epidemiological, clinical characteristics, and outcomes of patients with TBI in a Level 1 Trauma Center in India. MATERIALS AND METHODS In this retrospective study, all patients with moderate or severe TBI, based on emergency department Glasgow Coma Scale, admitted to neurosurgery Intensive Care Unit (ICU) during May 2010-July 2012 were evaluated to provide detailed information on TBI-related variables and outcomes using descriptive statistics. RESULTS Among the 1527 patients with moderate or severe TBI patients with mean age 32.15 ± 16.76 years (range: 1-90) and male:female ratio 6.5:1, 1281 (83.89%) had severe TBI. The majority of cases took place in the age group of 21-40 years (50.24%) with the most common mode of injury as road traffic accidents (RTAs) (64.96%). Surgical intervention (craniotomy) was done in 49.12% of patients. About 34.58% (n = 528) patients died in hospital, and 67.21% (n = 701) had unfavorable outcome at 6 months. CONCLUSIONS This is the first study of its kind from the Indian subcontinent that gives data on the admission characteristics, mortality, and 6 months outcome of such patients. Most of the injuries occurred due to RTAs, more common among the economic productive age groups and mostly in males with a high rate of mortality and unfavorable outcome.
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Affiliation(s)
- Vineet Kumar Kamal
- Department of Biostatistics, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Yang LY, Greig NH, Huang YN, Hsieh TH, Tweedie D, Yu QS, Hoffer BJ, Luo Y, Kao YC, Wang JY. Post-traumatic administration of the p53 inactivator pifithrin-α oxygen analogue reduces hippocampal neuronal loss and improves cognitive deficits after experimental traumatic brain injury. Neurobiol Dis 2016; 96:216-226. [PMID: 27553877 DOI: 10.1016/j.nbd.2016.08.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/04/2016] [Accepted: 08/18/2016] [Indexed: 01/08/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Neuronal apoptosis in the hippocampus has been detected after TBI. The hippocampal dysfunction may result in cognitive deficits in learning, memory, and spatial information processing. Our previous studies demonstrated that a p53 inhibitor, pifithrin-α oxygen analogue (PFT-α (O)), significantly reduced cortical cell death, which is substantial following controlled cortical impact (CCI) TBI, and improved neurological functional outcomes via anti-apoptotic mechanisms. In the present study, we examined the effect of PFT-α (O) on CCI TBI-induced hippocampal cellular pathophysiology in light of this brain region's role in memory. To investigate whether p53-dependent apoptosis plays a role in hippocampal neuronal loss and associated cognitive deficits and to define underlying mechanisms, SD rats were subjected to experimental CCI TBI followed by the administration of PFT-α or PFT-α (O) (2mg/kg, i.v.) or vehicle at 5h after TBI. Magnetic resonance imaging (MRI) scans were acquired at 24h and 7days post-injury to assess evolving structural hippocampal damage. Fluoro-Jade C was used to stain hippocampal sub-regions, including CA1 and dentate gyrus (DG), for cellular degeneration. Neurological functions, including motor and recognition memory, were assessed by behavioral tests at 7days post injury. p53, p53 upregulated modulator of apoptosis (PUMA), 4-hydroxynonenal (4-HNE), cyclooxygenase-IV (COX IV), annexin V and NeuN were visualized by double immunofluorescence staining with cell-specific markers. Levels of mRNA encoding for caspase-3, p53, PUMA, Bcl-2, Bcl-2-associated X protein (BAX) and superoxide dismutase (SOD) were measured by RT-qPCR. Our results showed that post-injury administration of PFT-α and, particularly, PFT-α (O) at 5h dramatically reduced injury volumes in the ipsilateral hippocampus, improved motor outcomes, and ameliorated cognitive deficits at 7days after TBI, as evaluated by novel object recognition and open-field test. PFT-α and especially PFT-α (O) significantly reduced the number of FJC-positive cells in hippocampus CA1 and DG subregions, versus vehicle treatment, and significantly decreased caspase-3 and PUMA mRNA expression. PFT-α (O), but not PFT-α, treatment significantly lowered p53 and elevated SOD2 mRNA expression. Double immunofluorescence staining demonstrated that PFT-α (O) treatment decreased p53, annexin V and 4-HNE positive neurons in the hippocampal CA1 region. Furthermore, PUMA co-localization with the mitochondrial maker COX IV, and the upregulation of PUMA were inhibited by PFT-α (O) after TBI. Our data suggest that PFT-α and especially PFT-α (O) significantly reduce hippocampal neuronal degeneration, and ameliorate neurological and cognitive deficits in vivo via antiapoptotic and antioxidative properties.
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Affiliation(s)
- Ling-Yu Yang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Nigel H Greig
- Drug Design & Development Section, Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Ya-Ni Huang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Hsin Sheng Junior College of Medical Care and Management, Taoyuan, Taiwan
| | - Tsung-Hsun Hsieh
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Neural Regenerative Medicine, Taipei Medical University, Taipei, Taiwan
| | - David Tweedie
- Drug Design & Development Section, Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Qian-Sheng Yu
- Drug Design & Development Section, Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Barry J Hoffer
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yu Luo
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yu-Chieh Kao
- Translational Imaging Research Center and Department of Radiology, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jia-Yi Wang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Lund SB, Gjeilo KH, Moen KG, Schirmer-Mikalsen K, Skandsen T, Vik A. Moderate traumatic brain injury, acute phase course and deviations in physiological variables: an observational study. Scand J Trauma Resusc Emerg Med 2016; 24:77. [PMID: 27216804 PMCID: PMC4878035 DOI: 10.1186/s13049-016-0269-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 05/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with moderate traumatic brain injury (TBI) are a heterogeneous group with great variability in clinical course. Guidelines for monitoring and level of care in the acute phase are lacking. The main aim of this observational study was to describe injury severity and the acute phase course during the first three days post-injury in a cohort of patients with moderate TBI. Deviations from defined parameters in selected physiological variables were also studied, based on guidelines for severe TBI during the same period. METHODS During a 5-year period (2004-2009), 119 patients ≥16 years (median age 47 years, range 16-92) with moderate TBI according to the Head Injury Severity Scale were admitted to a Norwegian level 1 trauma centre. Injury-related and acute phase data were collected prospectively. Deviations in six physiological variables were collected retrospectively. RESULTS Eighty-six percent of the patients had intracranial pathology on CT scan and 61 % had extracranial injuries. Eighty-four percent of all patients were admitted to intensive care units (ICUs) the first day, and 51 % stayed in ICUs ≥3 days. Patients staying in ICUs ≥3 days had lower median Glasgow Coma Scale score; 12 (range 9-15) versus 13 (range 9-15, P = 0.003) and more often extracranial injuries (77 % versus 42 %, P = 0.001) than patients staying in ICU 0-2 days. Most patients staying in ICUs ≥3 days had at least one episode of hypotension (53 %), hypoxia (57 %), hyperthermia (59 %), anaemia (56 %) and hyperglycaemia (65 %), and the proportion of anaemia related to number of measurements was high (33 %). CONCLUSION Most of the moderate TBI patients stayed in an ICU the first day, and half of them stayed in ICUs ≥3 days due to not only intracranial, but also extracranial injuries. Deviations in physiological variables were often seen in this latter group of patients. Lack of guidelines for patients with moderate TBI may leave these deviations uncorrected. We propose that in future research of moderate TBI, patients might be differentiated with regard to their need for monitoring and level of care the first few days post-injury. This could contribute to improvement of acute phase management.
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Affiliation(s)
- Stine B Lund
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway.
- Department of Nursing Science, Faculty of Health and Social Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Kari H Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kent G Moen
- Department of Medical Imaging, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
| | - Kari Schirmer-Mikalsen
- Department of Anaesthesia and Intensive care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Toril Skandsen
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
| | - Anne Vik
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
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Godoy DA, Rubiano A, Rabinstein AA, Bullock R, Sahuquillo J. Moderate Traumatic Brain Injury: The Grey Zone of Neurotrauma. Neurocrit Care 2016; 25:306-19. [DOI: 10.1007/s12028-016-0253-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Ibrahim S, Hu W, Wang X, Gao X, He C, Chen J. Traumatic Brain Injury Causes Aberrant Migration of Adult-Born Neurons in the Hippocampus. Sci Rep 2016; 6:21793. [PMID: 26898165 PMCID: PMC4761898 DOI: 10.1038/srep21793] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/01/2016] [Indexed: 01/30/2023] Open
Abstract
Traumatic brain injury (TBI) promotes neural stem/progenitor cell (NSC) proliferation in an attempt to initiate innate repair mechanisms. However, all immature neurons in the CNS are required to migrate from their birthplace to their final destination to develop into functional neurons. Here we assessed the destination of adult-born neurons following TBI. We found that a large percentage of immature neurons migrated past their normal stopping site at the inner granular cell layer (GCL), and became misplaced in the outer GCL of the hippocampal dentate gyrus. The aberrant migration of adult-born neurons in the hippocampus occurred 48 hours after TBI, and lasted for 8 weeks, resulting in a great number of newly generated neurons misplaced in the outer GCL in the hippocampus. Those misplaced neurons were able to become mature and differentiate into granular neurons, but located ectopically in the outer GCL with reduced dendritic complexity after TBI. The adult-born neurons at the misplaced position may make wrong connections with inappropriate nearby targets in the pre-existing neural network. These results suggest that although stimulation of endogenous NSCs following TBI might offer new avenues for cell-based therapy, additional intervention is required to further enhance successful neurogenesis for repairing the damaged brain.
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Affiliation(s)
- Sara Ibrahim
- Spinal Cord and Brain Injury Research Group, Department of Neurosurgery, Stark Neuroscience Research Institute, Indianapolis, Indiana, United States of America
| | - Weipeng Hu
- Department of Neurosurgery, 2nd Affiliated Hospital, Fujian Medical University, Quanzhou, 362000, China
| | - Xiaoting Wang
- Spinal Cord and Brain Injury Research Group, Department of Neurosurgery, Stark Neuroscience Research Institute, Indianapolis, Indiana, United States of America
| | - Xiang Gao
- Spinal Cord and Brain Injury Research Group, Department of Neurosurgery, Stark Neuroscience Research Institute, Indianapolis, Indiana, United States of America
| | - Chunyan He
- School of Biomedical Sciences, Huaqiao University, Quanzhou, 362000, China
| | - Jinhui Chen
- Spinal Cord and Brain Injury Research Group, Department of Neurosurgery, Stark Neuroscience Research Institute, Indianapolis, Indiana, United States of America
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Rosa M, da Rocha AJ, Maia ACM, Saade N, Veiga JCE, Romero JM. Contusion Contrast Extravasation Depicted on Multidetector Computed Tomography Angiography Predicts Growth and Mortality in Traumatic Brain Contusion. J Neurotrauma 2015. [PMID: 26214242 DOI: 10.1089/neu.2015.4062] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) is the main cause of death in trauma victims and causes high rates of disability and neurological sequelae. Approximately 38-65% of traumatic brain contusions (TBC) demonstrate hemorrhagic expansion on serial computed tomography (CT) scans. Thus far, however, no single variable can accurately predict the hemorrhage expansion of a TBC. Our purpose was to evaluate contrast extravasation (CE) as a predictor of expansion, mortality, and poor outcome in TBC in a Brazilian cohort. After Institutional Review Board approval, we used multidetector CT angiography (MDCTA) to study 121 consecutive patients (106 men, 87.6%) with ages varying from 10 to 85 years. Informed consent was obtained from all subjects. The clinical and imaging findings were correlated with the findings on the initial MDCTA using either the Fisher exact test or Student t test and a multivariate logistic regression model. Of the persons who presented CE in TBC, 21.8% died (in-hospital mortality), whereas in the absence of this sign, the mortality rate was 7.6% (p = 0.014). In addition, expansion of the hemorrhagic component of the TBC was detected in 61.1% of the CE-positive patients, whereas expansion was only observed in 10% of the CE-negative patients (p < 0.001). Poor outcome was observed in 24.2% of the patients in the CE-negative group, but in the presence of CE, 72.7% evolved with poor outcome (p < 0.001). The CE was a strong independent predictor of expansion, poor outcome, and increased risk of in-hospital mortality in our series of patients with TBC.
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Affiliation(s)
- Marcos Rosa
- 1 Section of Neuroradiology , Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil .,2 Section of Radiology, Federal University of Espírito Santo , Vitória ES, Brazil
| | - Antônio José da Rocha
- 1 Section of Neuroradiology , Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil
| | | | - Nelson Saade
- 3 Division of Neurosurgery , Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil
| | | | - Javier M Romero
- 4 Division of Neuroradiology, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
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Buki A, Kovacs N, Czeiter E, Schmid K, Berger RP, Kobeissy F, Italiano D, Hayes RL, Tortella FC, Mezosi E, Schwarcz A, Toth A, Nemes O, Mondello S. Minor and repetitive head injury. Adv Tech Stand Neurosurg 2015; 42:147-92. [PMID: 25411149 DOI: 10.1007/978-3-319-09066-5_8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in the young, active population and expected to be the third leading cause of death in the whole world until 2020. The disease is frequently referred to as the silent epidemic, and many authors highlight the "unmet medical need" associated with TBI.The term traumatically evoked brain injury covers a heterogeneous group ranging from mild/minor/minimal to severe/non-salvageable damages. Severe TBI has long been recognized to be a major socioeconomical health-care issue as saving young lives and sometimes entirely restituting health with a timely intervention can indeed be extremely cost efficient.Recently it has been recognized that mild or minor TBI should be considered similarly important because of the magnitude of the patient population affected. Other reasons behind this recognition are the association of mild head injury with transient cognitive disturbances as well as long-term sequelae primarily linked to repeat (sport-related) injuries.The incidence of TBI in developed countries can be as high as 2-300/100,000 inhabitants; however, if we consider the injury pyramid, it turns out that severe and moderate TBI represents only 25-30 % of all cases, while the overwhelming majority of TBI cases consists of mild head injury. On top of that, or at the base of the pyramid, are the cases that never show up at the ER - the unreported injuries.Special attention is turned to mild TBI as in recent military conflicts it is recognized as "signature injury."This chapter aims to summarize the most important features of mild and repetitive traumatic brain injury providing definitions, stratifications, and triage options while also focusing on contemporary knowledge gathered by imaging and biomarker research.Mild traumatic brain injury is an enigmatic lesion; the classification, significance, and its consequences are all far less defined and explored than in more severe forms of brain injury.Understanding the pathobiology and pathomechanisms may aid a more targeted approach in triage as well as selection of cases with possible late complications while also identifying the target patient population where preventive measures and therapeutic tools should be applied in an attempt to avoid secondary brain injury and late complications.
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Affiliation(s)
- Andras Buki
- MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary,
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Abstract
PURPOSE OF REVIEW To present the practical aspects of transcranial Doppler (TCD) and provide evidence supporting its use for the management of traumatic brain injury (TBI) patients. RECENT FINDINGS TCD measures systolic, mean, and diastolic cerebral blood flow (CBF) velocities and calculates the pulsatility index from basal intracranial arteries. These variables reflect the brain circulation, provided there is control of potential confounding factors. TCD can be useful in patients with severe TBI to detect low CBF, for example, during intracranial hypertension, and to assess cerebral autoregulation. In the emergency room, TCD might complement brain computed tomography (CT) scan and clinical examination to screen patients at risk for further neurological deterioration after mild-to-moderate TBI. SUMMARY The diagnostic value of TCD should be incorporated into other findings from multimodal brain monitoring and CT scan to optimize the bedside management of patients with TBI and help guide the choice of appropriate therapies.
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Traumatic subarachnoid hemorrhage due to motor vehicle crash versus fall from height: a 4-year epidemiologic study. World Neurosurg 2014; 82:e639-44. [PMID: 24947116 DOI: 10.1016/j.wneu.2014.06.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 02/10/2014] [Accepted: 06/11/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage (TSAH). Although TSAH after trauma is associated with poor prognoses, the impact of mechanism of injury (MOI) and the pathophysiology remains unknown. We hypothesized that outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based on the MOI. METHODS Data were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012. All patients presented with head trauma and TSAH were included. Patient data included age, gender, nationality, mechanism of injury, injury severity score (ISS), types of head injuries, and associated injuries. Ventilator days, intensive care unit length of stay, pneumonia, and mortality were also studied. RESULTS A total of 1665 patients with TBI were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were male patients and 86% were expatriates. MVC (53%) and FFH (35%) were the major mechanisms of injury. The overall mean ISS and head abbreviated injury score were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in MVC group sustained severe TSAH, had significantly greater head abbreviated injury score (3.5 ± 0.9 vs. 3.2 ± 0.9; P = 0.009) and ISS (21.6 ± 10.6 vs. 15.9 ± 9.5; P = 0.001), and lower scene Glasgow coma scale (10.8 ± 4.8 vs. 13.2 ± 3.4; P = 0.001) compared with the FFH group. In addition, the MVC group sustained more intraventricular hemorrhage (4.7 vs. 0.7; P = 0.001) and diffuse axonal injury (4.2 vs. 2.9; P = 0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; P = 0.008) was higher in the FFH group. Lower extremities (14% vs. 4.3%; P = 0.004) injury was mainly associated with the MVC group. The overall mortality was 19 % among patients with TSAH. The mortality rate was higher in the MVC group when compared with the FFH group (24% vs. 10%; P = 0.001). In both groups, ISS and Glasgow coma scale at the scene were independent predictors of mortality. CONCLUSIONS Patients with TSAH have a higher mortality rate. In this population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the incidence and severity of TBI in Qatar.
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Iaccarino C, Schiavi P, Picetti E, Goldoni M, Cerasti D, Caspani M, Servadei F. Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg 2014; 120:908-18. [PMID: 24506250 DOI: 10.3171/2013.12.jns131090] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Traumatic parenchymal mass lesions are common sequelae of traumatic brain injuries (TBIs). They occur in up to 8.2% of all TBI cases and 13%-35% of severe TBI cases, and they account for up to 20% of surgical intracranial lesions. Controversy exists concerning the association between radiological and clinical evolution of brain contusions. The aim of this study was to identify predictors of unfavorable outcome, analyze the evolution of brain contusions, and evaluate specific indications for surgery. METHODS In a retrospective, multicenter study, patients with brain contusions were identified in separate patient cohorts from 11 hospitals over a 4-year period (2008-2011). Data on clinical parameters and course of the contusion were collected. Radiological parameters were registered by using CT images taken at the time of hospital admission and at subsequent follow-up times. Patients who underwent surgical procedures were identified. Outcomes were evaluated 6 months after trauma by using the Glasgow Outcome Scale-Extended. RESULTS Multivariate analysis revealed the following reliable predictors of unfavorable outcome: 1) increased patient age, 2) lower Glasgow Coma Scale score at first evaluation, 3) clinical deterioration in the first hours after trauma, and 4) onset or increase of midline shift on follow-up CT images. Further multivariate analysis identified the following as statistically significant predictors of clinical deterioration during the first hours after trauma: 1) onset of or increase in midline shift on follow-up CT images (p < 0.001) and 2) increased effacement of basal cisterns on follow-up CT images (p < 0.001). CONCLUSIONS In TBI patients with cerebral contusion, the onset of clinical deterioration is predictably associated with the onset or increase of midline shift and worsened status of basal cisterns but not with hematoma or edema volume increase. A combination of clinical deterioration and increased midline shift/basal cistern compression is the most reasonable indicator for surgery.
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Affiliation(s)
- Corrado Iaccarino
- Arcispedale Santa Maria Nuova-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia; and Neurosurgery-Neurotraumatology Unit
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Wuthisuthimethawee P, Saeheng S, Oearsakul T. Serum cleaved tau protein and traumatic mild head injury: a preliminary study in the Thai population. Eur J Trauma Emerg Surg 2013; 39:293-6. [PMID: 26815235 DOI: 10.1007/s00068-013-0263-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 02/04/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the correlation between serum cleaved tau protein and traumatic mild head injury (MHI) (GCS 13-15). METHODS A prospective observational study was conducted. Blood specimens from 12 healthy persons and 44 adult patients with traumatic MHI were collected in the emergency department to measure the cleaved tau protein level using a Human Tau phosphoSerine 396 ELISA kit. A brain computed tomography (CT) scan was done in all patients. The serum cleaved tau protein level was considered positive at a cut-off point of 0.1 pg/ml. An intracranial lesion was defined as any abnormality detected by brain CT scan. RESULTS The mean age of the traumatic MHI patients was 34.9 ± 15.6 years (range 15-74). The median GCS was 15. The median time from injury to arrival at the emergency department was 30 min. There were 11 intracranial lesions detected by brain CT scan (25.0 %). Serum cleaved tau protein was not detected in either healthy or traumatic MHI patients. CONCLUSION As it was uncorrelated with traumatic MHI, serum cleaved tau protein proved to be an unreliable biomarker to use in the early detection of and decision-making for traumatic MHI patients at the emergency department.
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Affiliation(s)
- P Wuthisuthimethawee
- Department of Emergency Medicine, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - S Saeheng
- Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - T Oearsakul
- Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Letourneau-Guillon L, Huynh T, Jakobovic R, Milwid R, Symons SP, Aviv RI. Traumatic intracranial hematomas: prognostic value of contrast extravasation. AJNR Am J Neuroradiol 2012; 34:773-9. [PMID: 23079406 DOI: 10.3174/ajnr.a3309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Contrast extravasation within spontaneous intracranial hemorrhage is a well-described predictor of hematoma growth, poor clinical outcome, and mortality. The purpose of this study was to assess the prognostic value of contrast extravasation in acute traumatic intracranial hematomas. MATERIALS AND METHODS In our institution, CTA (including PCCT) is the primary screening technique for cervical vascular injuries. Sixty consecutive patients with at least 1 acute intracranial hematoma (ICH, subdural hematoma, and/or epidural hematoma) meeting predefined size criteria, with CTA/PCCT performed within 24 hours of admission and follow-up CT within 72 hours of admission, were retrospectively evaluated for CE by 2 observers. The predictive value of CE for a composite outcome (hematoma expansion, need for hematoma evacuation, in-hospital mortality) was evaluated on a per-patient basis. Interobserver agreement for CE and the association between baseline variables and outcome were also examined. Different patterns of extravasation were evaluated on a per-lesion basis, with outcomes including hematoma expansion and evacuation. RESULTS CE was present in 30 (50%) patients with almost perfect interobserver agreement (κ=0.87; 95% CI, 0.74-0.99). The per-patient multivariate analysis showed independent association of midline shift (P=.020), Glasgow Coma Scale score≤8 (P=.024), and CE (P=.017), with poor outcome and demonstrated a trend toward poor outcome prediction for age 65 years or older (P=.050). In the per-lesion analysis, only extravasation identified on CTA (active and contained extravasation) was associated with hematoma expansion and evacuation. CONCLUSIONS Contrast extravasation within intracranial hematomas predicts poor in-hospital outcome in the setting of acute traumatic intracranial injuries.
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Affiliation(s)
- L Letourneau-Guillon
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Moderate traumatic brain injury triggers rapid necrotic death of immature neurons in the hippocampus. J Neuropathol Exp Neurol 2012; 71:348-59. [PMID: 22437344 DOI: 10.1097/nen.0b013e31824ea078] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Traumatic brain injury (TBI) causes cell death predominantly in the cerebral cortex, but there is additional secondary cell death in the hippocampus. We previously found that most of the dying cells in the mouse hippocampus are newborn immature granular neurons in a mouse model of lateral controlled cortical impact (CCI) injury with a moderate level of impact. It is not known how long this selective cell death in the hippocampal dentate gyrus lasts, and how it is induced. Using Fluoro-Jade B and immunohistochemistry, we show that most of the neuron death in the hippocampus occurs within 24 hours after TBI and that cell death continues at low level for at least another 2 weeks in this lateral CCI model. Most of the dying immature granular neurons did not exhibit morphologic characteristics of apoptosis, and only a small subpopulation of the dying cells was positive for apoptotic markers. In contrast, most of the dying cells coexpressed the receptor-interacting protein 1, a marker of necrosis, suggesting that immature neurons mainly died of necrosis. These results indicate that moderate TBI mainly triggers rapid necrotic death of immature neurons in the hippocampus in a mouse CCI model.
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Kurland D, Hong C, Aarabi B, Gerzanich V, Simard JM. Hemorrhagic progression of a contusion after traumatic brain injury: a review. J Neurotrauma 2011; 29:19-31. [PMID: 21988198 DOI: 10.1089/neu.2011.2122] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The magnitude of damage to cerebral tissues following head trauma is determined by the primary injury, caused by the kinetic energy delivered at the time of impact, plus numerous secondary injury responses that almost inevitably worsen the primary injury. When head trauma results in a cerebral contusion, the hemorrhagic lesion often progresses during the first several hours after impact, either expanding or developing new, non-contiguous hemorrhagic lesions, a phenomenon termed hemorrhagic progression of a contusion (HPC). Because a hemorrhagic contusion marks tissues with essentially total unrecoverable loss of function, and because blood is one of the most toxic substances to which the brain can be exposed, HPC is one of the most severe types of secondary injury encountered following traumatic brain injury (TBI). Historically, HPC has been attributed to continued bleeding of microvessels fractured at the time of primary injury. This concept has given rise to the notion that continued bleeding might be due to overt or latent coagulopathy, prompting attempts to normalize coagulation with agents such as recombinant factor VIIa. Recently, a novel mechanism was postulated to account for HPC that involves delayed, progressive microvascular failure initiated by the impact. Here we review the topic of HPC, we examine data relevant to the concept of a coagulopathy, and we detail emerging data elucidating the mechanism of progressive microvascular failure that predisposes to HPC after head trauma.
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Affiliation(s)
- David Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA
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Bouzat P, Francony G, Declety P, Genty C, Kaddour A, Bessou P, Brun J, Jacquot C, Chabardes S, Bosson JL, Payen JF. Transcranial Doppler to screen on admission patients with mild to moderate traumatic brain injury. Neurosurgery 2011; 68:1603-9; discussion 1609-10. [PMID: 21311381 DOI: 10.1227/neu.0b013e31820cd43e] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Detecting patients at risk for secondary neurological deterioration (SND) after mild to moderate traumatic brain injury is challenging. OBJECTIVE To assess the diagnostic accuracy of transcranial Doppler (TCD) on admission in screening these patients. METHODS This prospective, observational cohort study enrolled 98 traumatic brain injury patients with an initial Glasgow Coma Scale score of 9 to 15 whose initial computed tomography (CT) scan showed either absent or mild lesions according to the Trauma Coma Data Bank (TCDB) classification, ie, TCDB I and TCDB II, respectively. TCD measurements of the 2 middle cerebral arteries were obtained on admission under stable conditions in all patients. Neurological outcome was reassessed on day 7. RESULTS Of the 98 patients, 21 showed SND, ie, a decrease of ≥ 2 points from the initial Glasgow Coma Scale or requiring any treatment for neurological deterioration. Diastolic cerebral blood flow velocities and pulsatility index measurements were different between patients with SND and patients with no SND. Using receiver-operating characteristic analysis, we found the best threshold limits to be 25 cm/s (sensitivity, 92%; specificity, 76%; area under curve, 0.93) for diastolic cerebral blood flow velocity and 1.25 (sensitivity, 90%; specificity, 91%; area under curve, 0.95) for pulsatility index. According to a recursive-partitioning analysis, TCDB classification and TCD measurements were the most discriminative among variables to detect patients at risk for SND. CONCLUSION In patients with no severe brain lesions on CT after mild to moderate traumatic brain injury, TCD on admission, in complement with brain CT scan, could accurately screen patients at risk for SND.
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Affiliation(s)
- Pierre Bouzat
- Department of Anesthesia and Critical Care, Albert Michallon Hospital, Grenoble, France
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Andriessen TMJC, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, Steyerberg EW, Vos PE. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma 2011; 28:2019-31. [PMID: 21787177 DOI: 10.1089/neu.2011.2034] [Citation(s) in RCA: 183] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Changes in the demographics, approach, and treatment of traumatic brain injury (TBI) patients require regular evaluation of epidemiological profiles, injury severity classification, and outcomes. This prospective multicenter study provides detailed information on TBI-related variables of 508 moderate-to-severe TBI patients. Variability in epidemiology and outcome is examined by comparing our cohort with previous multicenter studies. Additionally, the relation between outcome and injury severity classification assessed at different time points is studied. Based on the emergency department Glasgow Coma Scale (GCS), 339 patients were classified as having severe and 129 as having moderate TBI. In 15%, the diagnosis differed when the accident scene GCS was used for classification. In-hospital mortality was higher if severe TBI was diagnosed at both time points (44%) compared to moderate TBI at one or both time points (7-15%, p<0.001). Furthermore, 14% changed diagnosis when a threshold (≥6 h) for impaired consciousness was used as a criterion for severe TBI: In-hospital mortality was<5% when impaired consciousness lasted for<6 h. This suggests that combining multiple clinical assessments and using a threshold for impaired consciousness may improve the classification of injury severity and prediction of outcome. Compared to earlier multicenter studies, our cohort demonstrates a different case mix that includes a higher age (mean=47.3 years), more diffuse (Traumatic Coma Databank [TCDB] I-II) injuries (58%), and more major extracranial injuries (40%), with relatively high 6 month mortality rates for both severe (46%) and moderate (21%) TBI. Our results confirm that TBI epidemiology and injury patterns have changed in recent years whereas case fatality rates remain high.
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Wong GKC, Yeung JHH, Graham CA, Zhu XL, Rainer TH, Poon WS. Neurological outcome in patients with traumatic brain injury and its relationship with computed tomography patterns of traumatic subarachnoid hemorrhage. J Neurosurg 2011; 114:1510-5. [DOI: 10.3171/2011.1.jns101102] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Traumatic subarachnoid hemorrhage (SAH) is a poor prognostic factor for traumatic brain injury. The authors aimed to further investigate neurological outcome among head injury patients by examining the prognostic values of CT patterns of traumatic SAH, in particular, the thickness and distribution.
Methods
The study was conducted using a database in a regional trauma center in Hong Kong. Data had been prospectively collected in consecutive trauma patients between January 2006 and December 2008. Patients included in the study had significant head injury (as defined by a head Abbreviated Injury Scale [AIS] score of 2 or more) with traumatic SAH according to admission CT.
Results
Over the 36-month period, 661 patients with significant head injury were admitted to the Prince of Wales Hospital in Hong Kong. Two hundred fourteen patients (32%) had traumatic SAH on admission CT. The mortality rate was significantly greater and a 6-month unfavorable outcome was significantly more frequent in patients with traumatic SAH. Multivariate analysis showed that the maximum thickness (mm) of traumatic SAH was independently associated with neurological outcome (OR 0.8, 95% CI 0.7–0.9) and death (OR 1.3, 95% CI 1.2–1.5) but not with the extent or location of hemorrhage.
Conclusions
Maximum thickness of traumatic SAH was a strong independent prognostic factor for death and clinical outcome. Anatomical distribution per se did not affect clinical outcome.
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Affiliation(s)
| | - Janice H. H. Yeung
- 2Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Colin A. Graham
- 2Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | | | - Timothy H. Rainer
- 2Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Khan S, Khan N, Masood S, Rana AQ. Evolution of traumatic intracerebral hemorrhage captured with CT imaging: report of a case and the role of serial CT scans. Emerg Radiol 2010; 17:493-6. [PMID: 20645118 DOI: 10.1007/s10140-010-0891-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 06/29/2010] [Indexed: 11/25/2022]
Abstract
Delayed enlargement of a traumatic cerebral contusion can occur subsequent to an initial CT scan, and this can lead to neurological deterioration, brain herniation, and death. Herein, we describe the case of a 76-year-old male who experienced an intracerebral hemorrhage subsequent to a fall and whose injury worsened over time. We summarize the current recommendations in the literature for when to initiate follow-up imaging in patients with traumatic head injury, the risk factors for progression, and the role of close clinical monitoring and serial imaging in managing such patients. Finally, we illustrate how these recommendations were applied in our case.
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Affiliation(s)
- Sofia Khan
- Undergraduate Medical Education, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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