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Taylor JD, Bailey M, Cooper DJ, French C, Menon DK, Nichol AD, Pisică D, Udy A, Volovici V, Higgins AM. Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma 2024; 41:1364-1374. [PMID: 38279804 DOI: 10.1089/neu.2023.0493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Traumatic brain injury (TBI) is a leading global cause of morbidity and mortality. Intracranial hypertension following moderate-to-severe TBI (m-sTBI) is a potentially modifiable secondary cerebral insult and one of the central therapeutic targets of contemporary neurocritical care. External ventricular drain (EVD) insertion is a common therapeutic intervention used to control intracranial hypertension and attenuate secondary brain injury. However, the optimal timing of EVD insertion in the setting of m-sTBI is uncertain and practice variation is widespread. Therefore, we aimed to assess if there is an association between timing of EVD placement and functional neurological outcome at 6 months post m-sTBI. We pooled individual patient data for all relevant harmonizable variables from the Erythropoietin in Traumatic Brain Injury (EPO-TBI) and Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomized control trials, and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Core Study version 3.0 and Australia-Europe NeuroTrauma Effectiveness Research in TBI (Oz-ENTER) prospective observational studies to create a combined dataset. The Glasgow Coma Scale (GCS) score was used to define TBI severity and we included all patients admitted to an intensive care unit with a GCS ≤12, who were 15 years or older and underwent EVD placement within 7 days of injury. We used hierarchical multi-variable logistic regression models to study the association between EVD insertion within 24 h of injury (early) compared with EVD insertion more than 24 h after injury (late) and 6-month functional neurological outcome measured using the Glasgow Outcome Score Extended (GOSE). In total, 2536 patients were assessed. Of these, 502 (20%) underwent early EVD insertion and 145 (6%) underwent late EVD insertion. Following adjustment for the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) score extended (Core + CT), sex, injury severity score, study and treatment site, patients receiving a late EVD had higher odds of death or severe disability (GOSE 1-4) at 6 months follow-up than those receiving an early EVD adjusted odds ratio; 95% confidence interval, 2.14; 1.22-3.76; p = 0.008. Our study suggests that in patients with m-sTBI where an EVD is needed, early (≤ 24 h post-injury) insertion may result in better long-term functional outcomes. This finding supports future prospective investigation in this area.
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Affiliation(s)
- Jonathon D Taylor
- Department of Critical Care Medicine, Auckland City Hospital, Grafton, Auckland, New Zealand
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
| | - Craig French
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
- Department of Intensive Care, University of Melbourne, Melbourne, Victoria, Australia
| | - David K Menon
- Division of Anesthesia, University of Cambridge, Addenbrooke's, Cambridge, United Kingdom
| | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
- University College Dublin Clinical Research Center, St. Vincent's University Hospital, Dublin, Ireland
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Zhu J, Shan Y, Li Y, Wu X, Gao G. Predicting the Severity and Discharge Prognosis of Traumatic Brain Injury Based on Intracranial Pressure Data Using Machine Learning Algorithms. World Neurosurg 2024; 185:e1348-e1360. [PMID: 38519020 DOI: 10.1016/j.wneu.2024.03.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE This study aimed to explore the potential of employing machine learning algorithms based on intracranial pressure (ICP), ICP-derived parameters, and their complexity to predict the severity and short-term prognosis of traumatic brain injury (TBI). METHODS A single-center prospectively collected cohort of neurosurgical intensive care unit admissions was analyzed. We extracted ICP-related data within the first 6 hours and processed them using complex algorithms. To indicate TBI severity and short-term prognosis, Glasgow Coma Scale score on the first postoperative day and Glasgow Outcome Scale-Extended score at discharge were used as binary outcome variables. A univariate logistic regression model was developed to predict TBI severity using only mean ICP values. Subsequently, 3 multivariate Random Forest (RF) models were constructed using different combinations of mean and complexity metrics of ICP-related data. To avoid overfitting, five-fold cross-validations were performed. Finally, the best-performing multivariate RF model was used to predict patients' discharge Glasgow Outcome Scale-Extended score. RESULTS The logistic regression model exhibited limited predictive ability with an area under the curve (AUC) of 0.558. Among multivariate models, the RF model, combining the mean and complexity metrics of ICP-related data, achieved the most robust ability with an AUC of 0.815. Finally, in terms of predicting discharge Glasgow Outcome Scale-Extended score, this model had a consistent performance with an AUC of 0.822. Cross-validation analysis confirmed the performance. CONCLUSIONS This study demonstrates the clinical utility of the RF model, which integrates the mean and complexity metrics of ICP data, in accurately predicting the TBI severity and short-term prognosis.
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Affiliation(s)
- Jun Zhu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchi Shan
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yihua Li
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Wu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Stein KY, Froese L, Sekhon M, Griesdale D, Thelin EP, Raj R, Tas J, Aries M, Gallagher C, Bernard F, Gomez A, Kramer AH, Zeiler FA. Intracranial Pressure-Derived Cerebrovascular Reactivity Indices and Their Critical Thresholds: A Canadian High Resolution-Traumatic Brain Injury Validation Study. J Neurotrauma 2024; 41:910-923. [PMID: 37861325 DOI: 10.1089/neu.2023.0374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
Current neurointensive care guidelines recommend intracranial pressure (ICP) and cerebral perfusion pressure (CPP) centered management for moderate-severe traumatic brain injury (TBI) because of their demonstrated associations with patient outcome. Cerebrovascular reactivity metrics, such as the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC index, have also demonstrated significant prognostic capabilities with regard to outcome. However, critical thresholds for cerebrovascular reactivity indices have only been identified in two studies conducted at the same center. In this study, we aim to determine the critical thresholds of these metrics by leveraging a unique multi-center database. The study included a total of 354 patients from the CAnadian High-Resolution TBI (CAHR-TBI) Research Collaborative. Based on 6-month Glasgow Outcome Scores, patients were dichotomized into alive versus dead and favorable versus unfavorable. Chi-square values were then computed for incrementally increasing values of each physiological parameter of interest against outcome. The values that generated the greatest chi-squares for each parameter were considered to be the thresholds with the greatest outcome discriminatory capacity. To confirm that the identified thresholds provide prognostic utility, univariate and multivariable logistical regression analyses were performed adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. Through the chi-square analysis, a lower limit CPP threshold of 60 mm Hg and ICP thresholds of 18 mm Hg and 22 mm Hg were identified for both survival and favorable outcome predictions. For the cerebrovascular reactivity metrics, different thresholds were identified for the two outcome dichotomizations. For survival prediction, thresholds of 0.35, 0.25, and 0 were identified for PRx, PAx, and RAC, respectively. For favorable outcome prediction, thresholds of 0.325, 0.20, and 0.05 were found. Univariate logistical regression analysis demonstrated that the time spent above/below thresholds were associated with outcome. Further, multivariable logistical regression analysis found that percent time above/below the identified thresholds added additional variance to the IMPACT core model for predicting both survival and favorable outcome. In this study, we were able to validate the results of the previous two works as well as to reaffirm the ICP and CPP guidelines from the Brain Trauma Foundation (BTF) and the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC).
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mypinder Sekhon
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andreas H Kramer
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Svedung Wettervik T, Hånell A, Lewén A, Enblad P. Should Patients with Traumatic Brain Injury with Significant Contusions be Treated with Different Neurointensive Care Targets? Neurocrit Care 2024:10.1007/s12028-024-01954-y. [PMID: 38506969 DOI: 10.1007/s12028-024-01954-y] [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: 09/01/2023] [Accepted: 02/01/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) with large contusions make up a specific TBI subtype. Because of the risk of brain edema worsening, elevated cerebral perfusion pressure (CPP) may be particularly dangerous. The pressure reactivity index (PRx) and optimal cerebral perfusion pressure (CPPopt) are new promising perfusion targets based on cerebral autoregulation, but they reflect the global brain state and may be less valid in patients with predominant focal lesions. In this study, we aimed to investigate if patients with TBI with significant contusions exhibited a different association between PRx, CPP, and CPPopt in relation to functional outcome compared to those with small/no contusions. METHODS This observational study included 385 patients with moderate to severe TBI treated at a neurointensive care unit in Uppsala, Sweden. The patients were classified into two groups: (1) significant contusions (> 10 mL) and (2) small/no contusions (but with extra-axial or diffuse injuries). The percentage of good monitoring time (%GMT) with intracranial pressure > 20 mm Hg; PRx > 0.30; CPP < 60 mm Hg, within 60-70 mm Hg, or > 70 mm Hg; and ΔCPPopt less than - 5 mm Hg, ± 5 mm Hg, or > 5 mm Hg was calculated. Outcome (Glasgow Outcome Scale-Extended) was assessed after 6 months. RESULTS Among the 120 (31%) patients with significant contusions, a lower %GMT with CPP between 60 and 70 mm Hg was independently associated with unfavorable outcome. The %GMTs with PRx and ΔCPPopt ± 5 mm Hg were not independently associated with outcome. Among the 265 (69%) patients with small/no contusions, a higher %GMT of PRx > 0.30 and a lower %GMT of ΔCPPopt ± 5 mm Hg were independently associated with unfavorable outcome. CONCLUSIONS In patients with TBI with significant contusions, CPP within 60-70 mm Hg may improve outcome. PRx and CPPopt, which reflect global cerebral pressure autoregulation, may be useful in patients with TBI without significant focal brain lesions but seem less valid for those with large contusions. However, this was an observational, hypothesis-generating study; our findings need to be validated in prospective studies before translating them into clinical practice.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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5
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Gomez A, Froese L, Griesdale D, Thelin EP, Raj R, van Iperenburg L, Tas J, Aries M, Stein KY, Gallagher C, Bernard F, Kramer AH, Zeiler FA. Prognostic value of near-infrared spectroscopy regional oxygen saturation and cerebrovascular reactivity index in acute traumatic neural injury: a CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Cohort Study. Crit Care 2024; 28:78. [PMID: 38486211 PMCID: PMC10938687 DOI: 10.1186/s13054-024-04859-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/02/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Near-infrared spectroscopy regional cerebral oxygen saturation (rSO2) has gained interest as a raw parameter and as a basis for measuring cerebrovascular reactivity (CVR) due to its noninvasive nature and high spatial resolution. However, the prognostic utility of these parameters has not yet been determined. This study aimed to identify threshold values of rSO2 and rSO2-based CVR at which outcomes worsened following traumatic brain injury (TBI). METHODS A retrospective multi-institutional cohort study was performed. The cohort included TBI patients treated in four adult intensive care units (ICU). The cerebral oxygen indices, COx (using rSO2 and cerebral perfusion pressure) as well as COx_a (using rSO2 and arterial blood pressure) were calculated for each patient. Grand mean thresholds along with exposure-based thresholds were determined utilizing sequential chi-squared analysis and univariate logistic regression, respectively. RESULTS In the cohort of 129 patients, there was no identifiable threshold for raw rSO2 at which outcomes were found to worsen. For both COx and COx_a, an optimal grand mean threshold value of 0.2 was identified for both survival and favorable outcomes, while percent time above - 0.05 was uniformly found to have the best discriminative value. CONCLUSIONS In this multi-institutional cohort study, raw rSO2was found to contain no significant prognostic information. However, rSO2-based indices of CVR, COx and COx_a, were found to have a uniform grand mean threshold of 0.2 and exposure-based threshold of - 0.05, above which clinical outcomes markedly worsened. This study lays the groundwork to transition to less invasive means of continuously measuring CVR.
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Affiliation(s)
- Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Logan Froese
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Levi van Iperenburg
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Kevin Y Stein
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Clare Gallagher
- Section of Neurosurgery, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Andreas H Kramer
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Centre on Aging, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Zhang Y, Qi X, Li W, Wan M, Ning X, Hu J. Research on the classification of early-stage brain edema by combining intrinsic optical signal imaging and laser speckle contrast imaging. JOURNAL OF BIOPHOTONICS 2024; 17:e202300394. [PMID: 38169143 DOI: 10.1002/jbio.202300394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/24/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
The early detection and pathological classification of brain edema are very important for symptomatic treatment. The dual-optical imaging system (DOIS) consists of intrinsic optical signal imaging (IOSI) and laser speckle contrast imaging (LSCI), which can acquire cerebral hemodynamic parameters of mice in real-time, including changes of oxygenated hemoglobin concentration ( Δ C HbO 2 ), deoxyhemoglobin concentration (ΔCHbR) and relative cerebral blood flow (rCBF) within the field of view. The slope sum of Δ C HbO 2 , ΔCHbR and rCBF was proposed to classify vasogenic edema (VE) and cytotoxic edema (CE). The slope sum values in the VE and CE group remain statistically different and the classification results provide higher accuracy of more than 93% for early brain edema detection. In conclusion, the differences of hemodynamic parameters between VE and CE in the early stage were revealed and the method helps in the classification of early brain edema.
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Affiliation(s)
- Yameng Zhang
- Nanjing University of Aeronautics and Astronautics, Nanjing, China
- Nanjing Institute of Technology, Nanjing, China
| | - Xinping Qi
- Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Weitao Li
- Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Min Wan
- Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Xue Ning
- Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Liu G, He M, Wu C, Lv P, Sun H, Wang H, Xin X, Liao H. Axonal injury mediated by neuronal p75NTR/TRAF6/JNK pathway contributes to cognitive impairment after repetitive mTBI. Exp Neurol 2024; 372:114618. [PMID: 38029807 DOI: 10.1016/j.expneurol.2023.114618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
Repetitive mild traumatic brain injury (rmTBI) is one of the leading causes of cognitive disorders. The impairment of axonal integrity induced by rmTBI is speculated to underlie the progression of cognitive dysfunction. However, few studies have uncovered the cellular mechanism regulating axonal impairment. In this study, we showed that after rmTBI, the activation of neuronal p75NTR signaling contributes to abnormal axonal morphology and impaired axonal transport, which further leads to cognitive dysfunction in mice. By neuron-specific knockdown of p75NTR or treatment with p75NTR inhibitor LM11A-31, we observed better recovery of axonal integrity and cognitive function after brain trauma. Further analysis revealed that p75NTR relies on its adaptor protein TRAF6 to activate downstream signaling via TAK1 and JNK. Overall, our results provide novel insight into the role of neuronal p75NTR in axonal injury and suggest that p75NTR may be a promising target for cognitive function recovery after rmTBI.
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Affiliation(s)
- Gang Liu
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing 210009, China
| | - Meijun He
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing 210009, China
| | - Chaoran Wu
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing 210009, China
| | - Pin Lv
- Department of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Hao Sun
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing 210009, China
| | - Heng Wang
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing 210009, China
| | - Xiaoyan Xin
- Department of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.
| | - Hong Liao
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing 210009, China; Chongqing Innovation Institute of China Pharmaceutical University, Chongqing 401135, China.
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8
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Gomez A, Froese L, Bergmann TJG, Sainbhi AS, Vakitbilir N, Islam A, Stein KY, Marquez I, Ibrahim Y, Zeiler FA. Non-Invasive Estimation of Intracranial Pressure-Derived Cerebrovascular Reactivity Using Near-Infrared Spectroscopy Sensor Technology in Acute Neural Injury: A Time-Series Analysis. SENSORS (BASEL, SWITZERLAND) 2024; 24:499. [PMID: 38257592 PMCID: PMC10818714 DOI: 10.3390/s24020499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024]
Abstract
The contemporary monitoring of cerebrovascular reactivity (CVR) relies on invasive intracranial pressure (ICP) monitoring which limits its application. Interest is shifting towards near-infrared spectroscopic regional cerebral oxygen saturation (rSO2)-based indices of CVR which are less invasive and have improved spatial resolution. This study aims to examine and model the relationship between ICP and rSO2-based indices of CVR. Through a retrospective cohort study of prospectively collected physiologic data in moderate to severe traumatic brain injury (TBI) patients, linear mixed effects modeling techniques, augmented with time-series analysis, were utilized to evaluate the ability of rSO2-based indices of CVR to model ICP-based indices. It was found that rSO2-based indices of CVR had a statistically significant linear relationship with ICP-based indices, even when the hierarchical and autocorrelative nature of the data was accounted for. This strengthens the body of literature indicating the validity of rSO2-based indices of CVR and potential greatly expands the scope of CVR monitoring.
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Affiliation(s)
- Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W2, Canada;
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
| | - Logan Froese
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
| | - Tobias J. G. Bergmann
- Department of Biosystems Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (T.J.G.B.); (I.M.)
| | - Amanjyot Singh Sainbhi
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
| | - Nuray Vakitbilir
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
| | - Abrar Islam
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
| | - Kevin Y. Stein
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
- Undergraduate Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
| | - Izabella Marquez
- Department of Biosystems Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (T.J.G.B.); (I.M.)
| | - Younis Ibrahim
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W2, Canada;
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada; (L.F.); (A.S.S.); (N.V.); (A.I.); (K.Y.S.); (Y.I.)
- Centre on Aging, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
- Department of Clinical Neurosciences, Karolinksa Institutet, 171 77 Stockholm, Sweden
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9
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Stein KY, Amenta F, Gomez A, Froese L, Sainbhi AS, Vakitbilir N, Marquez I, Zeiler FA. Associations between intracranial pressure thresholds and multimodal monitoring in acute traumatic neural injury: a scoping review. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05587-6. [PMID: 37067617 DOI: 10.1007/s00701-023-05587-6] [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: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Current moderate/severe traumatic brain injury (TBI) guidelines suggest the use of an intracranial pressure (ICP) treatment threshold of 20 mmHg or 22 mmHg. Over the past decade, the use of various cerebral physiology monitoring devices has been incorporated into neurocritical care practice and termed "multimodal monitoring." Such modalities include those that monitor systemic hemodynamics, systemic and brain oxygenation, cerebral blood flow (CBF), cerebral autoregulation, electrophysiology, and cerebral metabolism. Given that the relationship between ICP and outcomes is not yet entirely understood, a comprehensive review of the literature on the associations between ICP thresholds and multimodal monitoring is still needed. METHODS We conducted a scoping review of the literature for studies that present an objective statistical association between ICP above/below threshold and any multimodal monitoring variable. MEDLINE, BIOSIS, Cochrane library, EMBASE, Global Health, and SCOPUS were searched from inception to July 2022 for relevant articles. Full-length, peer-reviewed, original works with a sample size of ≥50 moderate-severe TBI patients were included in this study. RESULTS A total of 13 articles were deemed eligible for final inclusion. The included articles were significantly heterogenous in terms of their designs, demographics, and results, making it difficult to draw any definitive conclusions. No literature describing the association between guideline-based ICP thresholds and measures of brain electrophysiology, cerebral metabolism, or direct metrics of CBF was found. CONCLUSION There is currently little literature that presents objective statistical associations between ICP thresholds and multimodal monitoring physiology. However, overall, the literature indicates that having ICP above guideline based thresholds is associated with increased blood pressure, increased cardiac decoupling, reduced parenchymal brain oxygen tension, and impaired cerebral autoregulation, with no association with CBF velocity within the therapeutic range of ICP. There was insufficient literature to comment on other multimodal monitoring measures.
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Fiorella Amenta
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Izabella Marquez
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Centre on Aging, University of Manitoba, Winnipeg, Canada
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10
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Association between temporal patterns of baroreflex sensitivity after traumatic brain injury and prognosis: a preliminary study. Neurol Sci 2023; 44:1653-1663. [PMID: 36609622 PMCID: PMC10102132 DOI: 10.1007/s10072-022-06579-7] [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: 08/22/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) may lead to an increase in intracranial pressure (ICP) as well as impairment of cerebral vascular reactivity and the autonomic nervous system. This study aimed to investigate individual patterns of changes in baroreflex sensitivity (BRS) along with the assessment of pressure reactivity index (PRx) and ICP after TBI. MATERIALS AND METHODS Twenty-nine TBI patients with continuous arterial blood pressure (ABP) and ICP monitoring were included. BRS was calculated using the sequential cross-correlation method. PRx was estimated using slow-wave oscillations of ABP and ICP. Outcome was assessed using the Glasgow Outcome Scale. RESULTS Pooled data analysis of the lower breakpoint during the week that followed TBI revealed that BRS reached a minimum about 2 days after TBI. In patients with good outcome, there was a significant increase in BRS during the 7 days following TBI: rp = 0.21; p = 0.008 and the temporal changes in BRS showed either a "U-shaped" pattern or a gradual increase over time. The BRS value after 1.5 days was found to be a significant predictor of mortality (cut-off BRS = 1.8 ms/mm Hg; AUC = 0.83). In patients with poor outcome, ICP and PRx increased while BRS remained low. CONCLUSIONS We found an association between temporal patterns of BRS and prognosis in the early days following TBI. Further research in a larger cohort of patients is needed to confirm the weight of these preliminary observations for prediction of prognosis in TBI patients.
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Stein KY, Froese L, Gomez A, Sainbhi AS, Batson C, Mathieu F, Zeiler FA. Association between cerebrovascular reactivity in adult traumatic brain injury and improvement in patient outcome over time: an exploratory analysis. Acta Neurochir (Wien) 2022; 164:3107-3118. [PMID: 36156746 DOI: 10.1007/s00701-022-05366-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Impaired cerebrovascular reactivity following moderate/severe traumatic brain injury (TBI) has emerged as a key potential driver of morbidity and mortality. However, the major contributions to the literature so far have been solely focused on single point measures of long-term outcome. Therefore, it remains unknown whether cerebrovascular reactivity impairment, during the acute phase of TBI, is associated with failure to improve in outcome across time. METHODS Cerebrovascular reactivity was measured using three intracranial pressure-based surrogate metrics. For each patient, % time spent above various literature-defined thresholds was calculated. Patients were dichotomized based on outcome transition into Improved vs Not Improved between 1 and 3 months, 3 and 6 months, and 1 and 6 months, based on the Glasgow Outcome Scale-Extended (GOSE). Univariate and multivariable logistic regression analyses were performed, adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. RESULTS Seventy-eight patients from the Winnipeg Acute TBI Database were included in this study. On univariate logistic regression analysis, higher % time with cerebrovascular reactivity metrics above clinically defined thresholds was associated with a lack of clinical improvement between 1 and 3 months and 1 and 6 months post injury (p < 0.05). These relationships held true on multivariable logistic regression analysis. CONCLUSION Our study demonstrates that impaired cerebrovascular reactivity, during the acute phase of TBI, is associated with failure to improve clinically over time. These preliminary findings highlight the significance that cerebrovascular reactivity monitoring carries in outcome recovery association in moderate/severe TBI.
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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12
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Froese L, Gomez A, Sainbhi AS, Batson C, Slack T, Stein KY, Mathieu F, Zeiler FA. Optimal bispectral index level of sedation and cerebral oximetry in traumatic brain injury: a non-invasive individualized approach in critical care? Intensive Care Med Exp 2022; 10:33. [PMID: 35962913 PMCID: PMC9375800 DOI: 10.1186/s40635-022-00460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Impaired cerebral autoregulation has been linked with worse outcomes, with literature suggesting that current therapy guidelines fail to significantly impact cerebrovascular reactivity. The cerebral oximetry index (COx_a) is a surrogate measure of cerebrovascular reactivity which can in theory be obtained non-invasively using regional brain tissue oxygen saturation and arterial blood pressure. The goal of this study was to assess the relationship between objectively measured depth of sedation through BIS and autoregulatory capacity measured through COx_a. Methods In a prospectively maintained observational study, we collected continuous regional brain tissue oxygen saturation, intracranial pressure, arterial blood pressure and BIS in traumatic brain injury patients. COx_a was obtained using the Pearson’s correlation between regional brain tissue oxygen saturation and arterial blood pressure and ranges from − 1 to 1 with higher values indicating impairment of cerebrovascular reactivity. Using BIS values and COx_a, a curve-fitting method was applied to determine the minimum value for the COx_a. The associated BIS value with the minimum COx_a is called BISopt. This BISopt was both visually and algorithmically determined, which were compared and assessed over the whole dataset. Results Of the 42 patients, we observed that most had a parabolic relationship between BIS and COx_a. This suggests a potential “optimal” depth of sedation where COx_a is the most intact. Furthermore, when comparing the BISopt algorithm with visual inspection of BISopt, we obtained similar results. Finally, BISopt % yield (determined algorithmically) appeared to be independent from any individual sedative or vasopressor agent, and there was agreement between BISopt found with COx_a and the pressure reactivity index (another surrogate for cerebrovascular reactivity). Conclusions This study suggests that COx_a is capable of detecting disruption in cerebrovascular reactivity which occurs with over-/under-sedation, utilizing a non-invasive measure of determination and assessment. This technique may carry implications for tailoring sedation in patients, focusing on individualized neuroprotection. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00460-9.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Trevor Slack
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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13
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Dynamic prediction of mortality after traumatic brain injury using a machine learning algorithm. NPJ Digit Med 2022; 5:96. [PMID: 35851612 PMCID: PMC9293936 DOI: 10.1038/s41746-022-00652-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 07/06/2022] [Indexed: 11/08/2022] Open
Abstract
Intensive care for patients with traumatic brain injury (TBI) aims to optimize intracranial pressure (ICP) and cerebral perfusion pressure (CPP). The transformation of ICP and CPP time-series data into a dynamic prediction model could aid clinicians to make more data-driven treatment decisions. We retrained and externally validated a machine learning model to dynamically predict the risk of mortality in patients with TBI. Retraining was done in 686 patients with 62,000 h of data and validation was done in two international cohorts including 638 patients with 60,000 h of data. The area under the receiver operating characteristic curve increased with time to 0.79 and 0.73 and the precision recall curve increased with time to 0.57 and 0.64 in the Swedish and American validation cohorts, respectively. The rate of false positives decreased to ≤2.5%. The algorithm provides dynamic mortality predictions during intensive care that improved with increasing data and may have a role as a clinical decision support tool.
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14
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Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
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Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
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15
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Froese L, Gomez A, Sainbhi AS, Slack T, Zeiler FA. Practical Considerations for Continuous Time-Domain Cerebrovascular Reactivity Indices in Traumatic Brain Injury: Do Scaling Errors in Parent Signals Matter? Front Neurol 2022; 13:857617. [PMID: 35386410 PMCID: PMC8978556 DOI: 10.3389/fneur.2022.857617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/17/2022] [Indexed: 12/02/2022] Open
Abstract
Literature pertaining to traumatic brain injury care involves the mediation and control of secondary brain injury mechanisms, chief among these is cerebral autoregulation. Cerebral autoregulation is frequently assessed through surrogate measures of cerebrovascular reactivity. An important aspect to acknowledge when calculating cerebrovascular reactivity indices is the linearity within two-parent bio-signals or variables. We highlighted the concept of linearity in raw parent bio-signals used for the calculation of the cerebrovascular reactivity index and what potential implications linearity carries for index derivation. Key of which is that the initial differencing or location of the pressure probes does not influence linear methods of cerebral reactivity calculations so long as the slow-wave vasogenic changes are being recorded.
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Affiliation(s)
- Logan Froese
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- *Correspondence: Logan Froese
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Amanjyot Singh Sainbhi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Trevor Slack
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A. Zeiler
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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16
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Continuous Determination of the Optimal Bispectral Index Value Based on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A Retrospective Observational Cohort Study of a Novel Individualized Sedation Target. Crit Care Explor 2022; 4:e0656. [PMID: 35265854 PMCID: PMC8901214 DOI: 10.1097/cce.0000000000000656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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17
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Huang Z, Yan L. Clinical efficacy and prognosis of standard large trauma craniotomy for patients with severe frontotemporal craniocerebral injury. Am J Transl Res 2022; 14:476-483. [PMID: 35173867 PMCID: PMC8829637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 12/05/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To observe the clinical efficacy, incidence of postoperative complications, and the quality of life in patients with severe craniocerebral injury undergoing standard large trauma craniotomy. METHODS Seventy-eight patients with severe craniocerebral injury who had been admitted to Hubei Hanchuan People's Hospital were selected retrospectively and assigned into an observation group and control group according to the treatment received, with 39 patients in each group. Patients in the control group were treated with conventional decompressive craniotomy and those in the observation group with standard large trauma craniotomy. The prognosis (GOS score), intracranial pressure before and after surgery, neurological functions (NIHSS score), cerebral hemodynamics (Vm, Vs, PI), quality of life (SF-36 score) and postoperative complications were compared. RESULTS The number of patients whose GOS scores were graded 5 was markedly higher in the observation group than that in the control group (P<0.05). The postoperative intracranial pressure and NIHSS scores in the observation group were lower than those in the control group (P<0.001). The postoperative Vm, Vs and PI were lower in the observation group than those in the control group, respectively (P<0.001). There was no statistical difference in the incidence of complications in the two groups (P>0.05). The SF-36 scores in the observation group were higher than those of the control group (P<0.01). CONCLUSION Standard large trauma craniotomy is effective in treating patients with severe frontotemporal craniocerebral injury. It decreases intracranial pressure, improves neurological function and quality of life and results in a good prognosis.
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Affiliation(s)
- Zhiqi Huang
- Department of Intensive Care Unit, Hubei Hanchuan People’s HospitalHanchuan 431600, Hubei Province, China
| | - Lijin Yan
- Department of Medical Examination Services, Hubei Hanchuan People’s HospitalHanchuan 431600, Hubei Province, China
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18
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Batson C, Stein KY, Gomez A, Sainbhi AS, Froese L, Alizadeh A, Mathieu F, Zeiler FA. Intracranial Pressure–Derived Cerebrovascular Reactivity Indices, Chronological Age, and Biological Sex in Traumatic Brain Injury: A Scoping Review. Neurotrauma Rep 2022; 3:44-56. [PMID: 35112107 PMCID: PMC8804238 DOI: 10.1089/neur.2021.0054] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
To date, there has been limited literature exploring the association between age and sex with cerebrovascular reactivity (CVR) in moderate/severe traumatic brain injury (TBI). Given the known link between age, sex, and cerebrovascular function, knowledge of the impacts on continuously assessed CVR is critical for the development of future therapeutics. We conducted a scoping review of the literature for studies that had a direct statistical interrogation of the relationship between age, sex, and continuous intracranial pressure (ICP)-based indices of CVR in moderate/severe TBI. The ICP-based indices researched included: pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC. MEDLINE, BIOSIS, EMBASE, SCOPUS, Global Health, and the Cochrane library were searched from inception to June 2021 for relevant articles. A total of 10 original studies fulfilled our inclusion criteria. Nine of the articles documented a correlation between advanced age and worse CVR, with eight using PRx (2192 total patients), three using PAx (978 total patients), and one using RAC (358 total patients), p < 0.05; R ranging from 0.17 to 0.495 for all indices across all studies. Three articles (1256 total patients) displayed a correlation between biological sex and PRx, with females trending towards higher PRx values (p < 0.05) in the limited available literature. However, no literature exists comparing PAx or RAC with biological sex. Findings showed that aging was associated with impaired CVR. We observed a trend between female sex and worse PRx values, but the literature was limited and statistical significance was borderline. The identified studies were few in number, carried significant population heterogeneity, and utilized grand averaging of large epochs of physiology during statistical comparisons with age and biological sex. Because of the heterogeneous nature of TBI populations and limited focus on the effects of age and sex on outcomes in TBI, it is challenging to highlight the differences between the indices and patient age groups and sex. The largest study showing an association between PRx and age was done by Zeiler and colleagues, where 165 patients were studied noting that patients with a mean PRx value above zero had a mean age above 51.4 years versus a mean age of 41.4 years for those with a mean PRx value below zero (p = 0.0007). The largest study showing an association between PRx and sex was done by Czosnyka and colleagues, where 469 patients were studied noting that for patients <50 years of age, PRx was worse in females (0.11 ± 0.047) compared to males (0.044 ± 0.031), p < 0.05. The findings from these 10 studies provide preliminary data, but are insufficient to definitively characterize the impact of age and sex on CVR in moderate/severe TBI. Future work in the field should focus on the impact of age and sex on multi-modal cerebral physiological monitoring.
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Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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19
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Batson C, Gomez A, Sainbhi AS, Froese L, Zeiler FA. Association of Age and Sex With Multi-Modal Cerebral Physiology in Adult Moderate/Severe Traumatic Brain Injury: A Narrative Overview and Future Avenues for Personalized Approaches. Front Pharmacol 2021; 12:676154. [PMID: 34899283 PMCID: PMC8652202 DOI: 10.3389/fphar.2021.676154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 10/22/2021] [Indexed: 12/30/2022] Open
Abstract
The impact of age and biological sex on outcome in moderate/severe traumatic brain injury (TBI) has been documented in large cohort studies, with advanced age and male sex linked to worse long-term outcomes. However, the association between age/biological sex and high-frequency continuous multi-modal monitoring (MMM) cerebral physiology is unclear, with only sparing reference made in guidelines and major literature in moderate/severe TBI. In this narrative review, we summarize some of the largest studies associating various high-frequency MMM parameters with age and biological sex in moderate/severe TBI. To start, we present this by highlighting the representative available literature on high-frequency data from Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Extracellular Brain Tissue Oxygenation (PbtO2), Regional Cerebral Oxygen Saturations (rSO2), Cerebral Blood Flow (CBF), Cerebral Blood Flow Velocity (CBFV), Cerebrovascular Reactivity (CVR), Cerebral Compensatory Reserve, common Cerebral Microdialysis (CMD) Analytes and their correlation to age and sex in moderate/severe TBI cohorts. Then we present current knowledge gaps in the literature, discuss biological implications of age and sex on cerebrovascular monitoring in TBI and some future avenues for bedside research into the cerebrovascular physiome after TBI.
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Affiliation(s)
- C Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - A Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - A S Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - L Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - F A Zeiler
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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20
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Svedung Wettervik T, Fahlström M, Enblad P, Lewén A. Cerebral Pressure Autoregulation in Brain Injury and Disorders-A Review on Monitoring, Management, and Future Directions. World Neurosurg 2021; 158:118-131. [PMID: 34775084 DOI: 10.1016/j.wneu.2021.11.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 12/14/2022]
Abstract
The role of cerebral pressure autoregulation (CPA) in brain injury and disorders has gained increased interest. The CPA is often disturbed as a consequence of acute brain injury, which contributes to further brain damage and worse outcome. Specifically, in severe traumatic brain injury, CPA disturbances predict worse clinical outcome and targeting an autoregulatory-oriented optimal cerebral perfusion pressure threshold may improve brain energy metabolism and clinical outcome. In aneurysmal subarachnoid hemorrhage, cerebral vasospasm in combination with distal autoregulatory disturbances precipitate delayed cerebral ischemia. The role of optimal cerebral perfusion pressure targets is less clear in aneurysmal subarachnoid hemorrhage, but high cerebral perfusion pressure targets are generally favorable in the vasospasm phase. In acute ischemia, autoregulatory disturbances may occur and autoregulatory-oriented blood pressure (optimal mean arterial pressure) management reduces the risk of hemorrhagic transformation, brain edema, and unfavorable outcome. In chronic occlusive disease such as moyamoya, the gradual reduction of the cerebral circulation leads to compensatory distal vasodilation and the residual CPA capacity predicts the risk for cerebral ischemia. In spontaneous intracerebral hemorrhage, the role of autoregulatory disturbances is less clear, but CPA disturbances correlate with worse clinical outcome. Also, in community-acquired bacterial meningitis, CPA dysfunction is frequent and correlates with worse clinical outcome, but autoregulatory management is yet to be evaluated. In this review, we discuss the role of CPA in different types of brain injury and disease, the strengths and limitations of the monitoring methods, the potentials of autoregulatory management, and future directions in the field.
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Affiliation(s)
| | - Markus Fahlström
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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21
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Batson C, Froese L, Gomez A, Sainbhi AS, Stein KY, Alizadeh A, Zeiler FA. Impact of Age and Biological Sex on Cerebrovascular Reactivity in Adult Moderate/Severe Traumatic Brain Injury: An Exploratory Analysis. Neurotrauma Rep 2021; 2:488-501. [PMID: 34901944 PMCID: PMC8655816 DOI: 10.1089/neur.2021.0039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Age and biological sex are two potential important modifiers of cerebrovascular reactivity post-traumatic brain injury (TBI) requiring close evaluation for potential subgroup responses. The goal of this study was to provide a preliminary exploratory analysis of the impact of age and biological sex on measures of cerebrovascular function in moderate/severe TBI. Forty-nine patients from the prospectively maintained TBI database at the University of Manitoba with archived high-frequency digital cerebral physiology were evaluated. Cerebrovascular reactivity indices were derived as follows: PRx (correlation between intracranial pressure [ICP] and mean arterial pressure [MAP]), PAx (correlation between pulse amplitude of ICP [AMP] and MAP), and RAC (correlation between AMP and cerebral perfusion pressure [CPP]). Time above clinically significant thresholds for each index was calculated over different periods of the acute intensive care unit stay. The association between PRx, PAx, and RAC measures with age was assessed using linear regression, and an age trichotomization scheme (<40, 40-60, >60) using Kruskal-Wallis testing. Similarly, association with biological sex was tested using Mann-Whitney U testing. Biological sex did not demonstrate an impact on any measures of cerebrovascular reactivity. Linear regression between age and PAx and RAC demonstrated a statistically significant positive linear relationship. Median PAx and RAC measures between trichotomized age categories demonstrated statistically significant increases with advancing age. The PRx failed to demonstrate any statistically significant relationship with age in this cohort, suggesting that in elderly patients with controlled ICP, PAx and RAC may be better metrics for detecting impaired cerebrovascular reactivity. Biological sex appears to not be associated with differences in cerebrovascular reactivity in this cohort. The PRx performed the worst in detecting impaired cerebrovascular reactivity in those with advanced age, where PAx and RAC appear to have excelled. Future work is required to validate these findings and explore the utility of different cerebrovascular reactivity indices.
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Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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22
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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23
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Marini CP, McNelis J, Petrone P. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Huie JR, Mondello S, Lindsell CJ, Antiga L, Yuh EL, Zanier ER, Masson S, Rosario BL, Ferguson AR. Biomarkers for Traumatic Brain Injury: Data Standards and Statistical Considerations. J Neurotrauma 2021; 38:2514-2529. [PMID: 32046588 PMCID: PMC8403188 DOI: 10.1089/neu.2019.6762] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Recent biomarker innovations hold potential for transforming diagnosis, prognostic modeling, and precision therapeutic targeting of traumatic brain injury (TBI). However, many biomarkers, including brain imaging, genomics, and proteomics, involve vast quantities of high-throughput and high-content data. Management, curation, analysis, and evidence synthesis of these data are not trivial tasks. In this review, we discuss data management concepts and statistical and data sharing strategies when dealing with biomarker data in the context of TBI research. We propose that application of biomarkers involves three distinct steps-discovery, evaluation, and evidence synthesis. First, complex/big data has to be reduced to useful data elements at the stage of biomarker discovery. Second, inferential statistical approaches must be applied to these biomarker data elements for assessment of biomarker clinical utility and validity. Last, synthesis of relevant research is required to support practice guidelines and enable health decisions informed by the highest quality, up-to-date evidence available. We focus our discussion around recent experiences from the International Traumatic Brain Injury Research (InTBIR) initiative, with a specific focus on four major clinical projects (Transforming Research and Clinical Knowledge in TBI, Collaborative European NeuroTrauma Effectiveness Research in TBI, Collaborative Research on Acute Traumatic Brain Injury in Intensive Care Medicine in Europe, and Approaches and Decisions in Acute Pediatric TBI Trial), which are currently enrolling subjects in North America and Europe. We discuss common data elements, data collection efforts, data-sharing opportunities, and challenges, as well as examine the statistical techniques required to realize successful adoption and use of biomarkers in the clinic as a foundation for precision medicine in TBI.
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Affiliation(s)
- J. Russell Huie
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Esther L. Yuh
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Elisa R. Zanier
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Serge Masson
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Bedda L. Rosario
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Adam R. Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center (SFVAMC), San Francisco, California, USA
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25
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Gomez A, Froese L, Sainbhi AS, Batson C, Zeiler FA. Transcranial Doppler Based Cerebrovascular Reactivity Indices in Adult Traumatic Brain Injury: A Scoping Review of Associations With Patient Oriented Outcomes. Front Pharmacol 2021; 12:690921. [PMID: 34295251 PMCID: PMC8290494 DOI: 10.3389/fphar.2021.690921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/25/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Disruption in cerebrovascular reactivity following traumatic brain injury (TBI) is a known phenomenon that may hold prognostic value and clinical relevance. Ultimately, improved knowledge of this process and more robust means of continuous assessment may lead to advances in precision medicine following TBI. One such method is transcranial Doppler (TCD), which has been employed to evaluate cerebrovascular reactivity following injury utilizing a continuous time-series approach. Objective: The present study undertakes a scoping review of the literature on the association of continuous time-domain TCD based indices of cerebrovascular reactivity, with global functional outcomes, cerebral physiologic correlates, and imaging evidence of lesion change. Design: Multiple databases were searched from inception to November 2020 for articles relevant to the association of continuous time-domain TCD based indices of cerebrovascular reactivity with global functional outcomes, cerebral physiologic correlates, and imaging evidence of lesion change. Results: Thirty-six relevant articles were identified. There was significant evidence supporting an association with continuous time-domain TCD based indices and functional outcomes following TBI. Indices based on mean flow velocity, as measured by TCD, were most numerous while more recent studies point to systolic flow velocity-based indices encoding more prognostic utility. Physiologic parameters such as intracranial pressure, cerebral perfusion pressure, Carbon Dioxide (CO2) reactivity as well as more established indices of cerebrovascular reactivity have all been associated with these TCD based indices. The literature has been concentrated in a few centres and is further limited by the lack of multivariate analysis. Conclusions: This systematic scoping review of the literature identifies that there is a substantial body of evidence that cerebrovascular reactivity as measured by time-domain TCD based indices have prognostic utility following TBI. Indices based on mean flow velocities have the largest body of literature for their support. However, recent studies indicate that indices based on systolic flow velocities may contain the most prognostic utility and more closely follow more established measures of cerebrovascular reactivity. To a lesser extent, the literature supports some associations between these indices and cerebral physiologic parameters. These indices provide a more complete picture of the patient’s physiome following TBI and may ultimately lead to personalized and precise clinical care. Further validation in multi-institution studies is required before these indices can be widely adopted clinically.
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Affiliation(s)
- Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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26
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Sedation and cerebrovascular reactivity in traumatic brain injury: another potential avenue for personalized approaches in neurocritical care? Acta Neurochir (Wien) 2021; 163:1383-1389. [PMID: 33404872 DOI: 10.1007/s00701-020-04662-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Impaired cerebrovascular reactivity appears to be linked to worse global outcome in adult traumatic brain injury (TBI). Literature suggests that current treatments administered in TBI care, in the intensive care unit (ICU), fail to greatly impact recorded cerebrovascular reactivity measures. In particular, the impact of sedation on cerebrovascular reactivity in traumatic brain injury (TBI) remains unclear in vivo. The goal of this study was to preliminarily assess the relationship between objectively measured depth of sedation and cerebrovascular reactivity in TBI. METHODS Within, we describe a case series of 5 adult TBI patients with TBI, during which objective high-frequency physiology for sedation depth, using bispectral index (BIS), and both intracranial pressure (ICP) and arterial blood pressure (ABP) were recorded. Pressure reactivity index (PRx) and RAP (a metric of cerebral compensatory reserve) were derived. Relationships between cerebrovascular reactivity and compensatory reserve monitoring with BIS metrics were explored using descriptive plots. RESULTS A total of 5 cases in our prospectively maintained database with high-frequency physiology for ICP, ABP, and BIS. Through error bar plotting, it can be seen that each patient displays a parabolic relationship between BIS and PRx. This suggests a potential "optimal" depth of sedation where cerebrovascular reactivity is the most intact. CONCLUSIONS This small series highlights the potential impact of depth of sedation on cerebrovascular reactivity in TBI. It suggests that there may be an individual optimal depth of sedation, so as to optimize cerebrovascular reactivity. Further study of objective depth of sedation and its impact on cerebrovascular physiology in TBI is required.
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27
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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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28
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Scarboro M, McQuillan KA. Traumatic Brain Injury Update. AACN Adv Crit Care 2021; 32:29-50. [PMID: 33725106 DOI: 10.4037/aacnacc2021331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Traumatic brain injury is a devastating, life-changing event in most cases. After the primary brain insult, it is helpful to use evidence-based monitoring techniques to guide implementation of essential interventions to minimize secondary injury and thereby improve patient outcomes. An update on multimodal neuromonitoring is provided in this narrative review, with discussion of tools and techniques currently used in the treatment of patients with brain injury. Neuroprotective treatments, from the well-studied targeted temperature management to new potential therapeutics under investigation, such as glyburide, also are presented.
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Affiliation(s)
- Maureen Scarboro
- Maureen Scarboro is Acute Care Nurse Practitioner, Neurosurgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Karen A McQuillan
- Karen A. McQuillan is Lead Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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29
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Challenges and Opportunities in Multimodal Monitoring and Data Analytics in Traumatic Brain Injury. Curr Neurol Neurosci Rep 2021; 21:6. [PMID: 33527217 PMCID: PMC7850903 DOI: 10.1007/s11910-021-01098-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. RECENT FINDINGS Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
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30
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Kow CY, Harley B, Li C, Romo P, Gkolia P, Lu KY, Bell C, Jithoo R, Tee J, Cooper DJ, Rosenfeld JV, Lewis PM, Udy A, Hunn M. Escalating Mean Arterial Pressure in Severe Traumatic Brain Injury: A Prospective, Observational Study. J Neurotrauma 2021; 38:1995-2002. [PMID: 33280492 DOI: 10.1089/neu.2020.7289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To investigate cerebral autoregulatory status in patients with severe traumatic brain injury (TBI), guidelines now suggest active manipulation of mean arterial pressure (MAP). There is a paucity of data, however, describing the effect on intracranial pressure (ICP) when MAP is raised. Consecutive patients with TBI requiring ICP monitoring were enrolled from November 2019 to April 2020. The MAP and ICP were recorded continuously, and clinical annotations were made whenever intravenous vasopressors were commenced or adjusted to defend cerebral perfusion pressure (CPP) targets. A significant change in MAP burden was defined as MAP >100min.mm Hg over 15 min. The primary outcome was the change in ICP burden over the same 15-min period. Bedside and clinical parameters were then compared between these groups. Twenty-eight patients were enrolled, providing 212 clinical events, of which 60 were deemed significant. Over the first 15 min, 65% were associated with a net negative ICP burden. A greater reduction in ICP burden was observed with events occurring in patients without a history of hypotension at scene (p = 0.016), after three days post-injury (p = 0.0018), and where the pressure-reactivity index (PRx) was <0.25 (p = 0.0005) or the ICP amplitude to CPP correlation coefficient (RAC) was <-0.10 (p = 0.0036) at the initiation of vasopressor changes. The ICP burden in the first 15 min was highly correlated with the next 15-min period. In patients with severe TBI requiring ICP monitoring, increasing MAP to pursue a CPP target was followed by a net negative ICP burden in approximately two-thirds of events. These data suggest a MAP challenge may be a useful adjunct in managing intracranial hypertension.
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Affiliation(s)
- Chien Yew Kow
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Benjamin Harley
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Charles Li
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Phillip Romo
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Panagiota Gkolia
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Kuan-Ying Lu
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Catherine Bell
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Rondhir Jithoo
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jin Tee
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, and Monash University, Clayton, Victoria, Australia
| | - Philip M Lewis
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Electrical and Computer Systems Engineering, Monash University, Clayton, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Hunn
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
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31
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Guilfoyle MR, Helmy A, Donnelly J, Stovell MG, Timofeev I, Pickard JD, Czosnyka M, Smielewski P, Menon DK, Carpenter KLH, Hutchinson PJ. Characterising the dynamics of cerebral metabolic dysfunction following traumatic brain injury: A microdialysis study in 619 patients. PLoS One 2021; 16:e0260291. [PMID: 34914701 PMCID: PMC8675704 DOI: 10.1371/journal.pone.0260291] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability, particularly amongst young people. Current intensive care management of TBI patients is targeted at maintaining normal brain physiology and preventing secondary injury. Microdialysis is an invasive monitor that permits real-time assessment of derangements in cerebral metabolism and responses to treatment. We examined the prognostic value of microdialysis parameters, and the inter-relationships with other neuromonitoring modalities to identify interventions that improve metabolism. This was an analysis of prospective data in 619 adult TBI patients requiring intensive care treatment and invasive neuromonitoring at a tertiary UK neurosciences unit. Patients had continuous measurement of intracranial pressure (ICP), arterial blood pressure (ABP), brain tissue oxygenation (PbtO2), and cerebral metabolism and were managed according to a standardized therapeutic protocol. Microdialysate was assayed hourly for metabolites including glucose, pyruvate, and lactate. Cerebral perfusion pressure (CPP) and cerebral autoregulation (PRx) were derived from the ICP and ABP. Outcome was assessed with the Glasgow Outcome Score (GOS) at 6 months. Relationships between monitoring variables was examined with generalized additive mixed models (GAMM). Lactate/Pyruvate Ratio (LPR) over the first 3 to 7 days following injury was elevated amongst patients with poor outcome and was an independent predictor of ordinal GOS (p<0.05). Significant non-linear associations were observed between LPR and cerebral glucose, CPP, and PRx (p<0.001 to p<0.05). GAMM models suggested improved cerebral metabolism (i.e. reduced LPR with CPP >70mmHg, PRx <0.1, PbtO2 >18mmHg, and brain glucose >1mM. Deranged cerebral metabolism is an important determinant of patient outcome following TBI. Variations in cerebral perfusion, oxygenation and glucose supply are associated with changes in cerebral LPR and suggest therapeutic interventions to improve cerebral metabolism. Future prospective studies are required to determine the efficacy of these strategies.
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Affiliation(s)
- Mathew R. Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Joseph Donnelly
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Matthew G. Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - John D. Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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32
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Åkerlund CAI, Donnelly J, Zeiler FA, Helbok R, Holst A, Cabeleira M, Güiza F, Meyfroidt G, Czosnyka M, Smielewski P, Stocchetti N, Ercole A, Nelson DW. Impact of duration and magnitude of raised intracranial pressure on outcome after severe traumatic brain injury: A CENTER-TBI high-resolution group study. PLoS One 2020; 15:e0243427. [PMID: 33315872 PMCID: PMC7735618 DOI: 10.1371/journal.pone.0243427] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/21/2020] [Indexed: 12/19/2022] Open
Abstract
Magnitude of intracranial pressure (ICP) elevations and their duration have been associated with worse outcomes in patients with traumatic brain injuries (TBI), however published thresholds for injury vary and uncertainty about these levels has received relatively little attention. In this study, we have analyzed high-resolution ICP monitoring data in 227 adult patients in the CENTER-TBI dataset. Our aim was to identify thresholds of ICP intensity and duration associated with worse outcome, and to evaluate the uncertainty in any such thresholds. We present ICP intensity and duration plots to visualize the relationship between ICP events and outcome. We also introduced a novel bootstrap technique to evaluate uncertainty of the equipoise line. We found that an intensity threshold of 18 ± 4 mmHg (2 standard deviations) was associated with worse outcomes in this cohort. In contrast, the uncertainty in what duration is associated with harm was larger, and safe durations were found to be population dependent. The pressure and time dose (PTD) was also calculated as area under the curve above thresholds of ICP. A relationship between PTD and mortality could be established, as well as for unfavourable outcome. This relationship remained valid for mortality but not unfavourable outcome after adjusting for IMPACT core variables and maximum therapy intensity level. Importantly, during periods of impaired autoregulation (defined as pressure reactivity index (PRx)>0.3) ICP events were associated with worse outcomes for nearly all durations and ICP levels in this cohort and there was a stronger relationship between outcome and PTD. Whilst caution should be exercised in ascribing causation in observational analyses, these results suggest intracranial hypertension is poorly tolerated in the presence of impaired autoregulation. ICP level guidelines may need to be revised in the future taking into account cerebrovascular autoregulation status considered jointly with ICP levels.
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Affiliation(s)
- Cecilia AI Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
- * E-mail:
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Anders Holst
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Manuel Cabeleira
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Fabian Güiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technolology, Warszawa, Poland
| | - Peter Smielewski
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, and Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - David W. Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Froese L, Dian J, Batson C, Gomez A, Unger B, Zeiler FA. The impact of hypertonic saline on cerebrovascular reactivity and compensatory reserve in traumatic brain injury: an exploratory analysis. Acta Neurochir (Wien) 2020; 162:2683-2693. [PMID: 32959342 PMCID: PMC7505542 DOI: 10.1007/s00701-020-04579-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/07/2020] [Indexed: 01/17/2023]
Abstract
Background Intravenous hypertonic saline is utilized commonly in critical care for treatment of acute or refractory elevations of intracranial pressure (ICP) in traumatic brain injury (TBI) patients. Though there is a clear understanding of the general physiological effects of a hypertonic saline solution over long periods of time, smaller epoch effects of hypertonic saline (HTS) have not been thoroughly analyzed. The aim of this study was to perform a direct evaluation of the high-frequency response of HTS on the cerebrovascular physiological responses in TBI. Methods We retrospectively reviewed our prospectively maintained adult TBI database for those with archived high-frequency cerebral physiology and available HTS treatment information. We evaluated different epochs of physiology around HTS bolus dosing, comparing pre- with post-HTS. We assessed for changes in slow fluctuations in ICP, pulse amplitude of ICP (AMP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), cerebrovascular reactivity (as measured through pressure reactivity index (PRx)), and cerebral compensatory reserve (correlation (R) between AMP (A) and ICP (P)). Comparisons of mean measures and percentage time above clinically relevant thresholds for the physiological parameters were compared pre- and post-HTS using descriptive statistics and Mann-Whitney U testing. We assessed for subgroups of physiological responses using latent profile analysis (LPA). Results Fifteen patients underwent 69 distinct bolus infusions of hypertonic saline. Apart from the well-documented decrease in ICP, there was also a reduction in AMP. The analysis of cerebrovascular reactivity response to HTS solution had two main effects. For patients with grossly impaired cerebrovascular reactivity pre-HTS (PRx > + 0.30), HTS bolus led to improved reactivity. However, for those with intact cerebrovascular reactivity pre-HTS (PRx < 0), HTS bolus demonstrated a trend towards more impaired reactivity. This indicates that HTS has different impacts, dependent on pre-bolus cerebrovascular status. There was no significant change in metrics of cerebral compensatory reserve. LPA failed to demonstrate any subgroups of physiological responses to HTS administration. Conclusions The direct decrease in ICP and AMP confirms that a bolus dose of a HTS solution is an effective therapeutic agent for intracranial hypertension. However, in patients with intact autoregulation, hypertonic saline may impair cerebral hemodynamics. These findings regarding cerebrovascular reactivity remain preliminary and require further investigation. Electronic supplementary material The online version of this article (10.1007/s00701-020-04579-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Joshua Dian
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Carleen Batson
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Bertram Unger
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Zeiler FA, Ercole A, Cabeleira M, Stocchetti N, Hutchinson PJ, Smielewski P, Czosnyka M. Descriptive analysis of low versus elevated intracranial pressure on cerebral physiology in adult traumatic brain injury: a CENTER-TBI exploratory study. Acta Neurochir (Wien) 2020; 162:2695-2706. [PMID: 32886226 PMCID: PMC7550280 DOI: 10.1007/s00701-020-04485-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Background To date, the cerebral physiologic consequences of persistently elevated intracranial pressure (ICP) have been based on either low-resolution physiologic data or retrospective high-frequency data from single centers. The goal of this study was to provide a descriptive multi-center analysis of the cerebral physiologic consequences of ICP, comparing those with normal ICP to those with elevated ICP. Methods The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) High-Resolution Intensive Care Unit (HR-ICU) sub-study cohort was utilized. The first 3 days of physiologic recording were analyzed, evaluating and comparing those patients with mean ICP < 15 mmHg versus those with mean ICP > 20 mmHg. Various cerebral physiologic parameters were derived and evaluated, including ICP, brain tissue oxygen (PbtO2), cerebral perfusion pressure (CPP), pulse amplitude of ICP (AMP), cerebrovascular reactivity, and cerebral compensatory reserve. The percentage time and dose above/below thresholds were also assessed. Basic descriptive statistics were employed in comparing the two cohorts. Results 185 patients were included, with 157 displaying a mean ICP below 15 mmHg and 28 having a mean ICP above 20 mmHg. For admission demographics, only admission Marshall and Rotterdam CT scores were statistically different between groups (p = 0.017 and p = 0.030, respectively). The high ICP group displayed statistically worse CPP, PbtO2, cerebrovascular reactivity, and compensatory reserve. The high ICP group displayed worse 6-month mortality (p < 0.0001) and poor outcome (p = 0.014), based on the Extended Glasgow Outcome Score. Conclusions Low versus high ICP during the first 72 h after moderate/severe TBI is associated with significant disparities in CPP, AMP, cerebrovascular reactivity, cerebral compensatory reserve, and brain tissue oxygenation metrics. Such ICP extremes appear to be strongly related to 6-month patient outcomes, in keeping with previous literature. This work provides multi-center validation for previously described single-center retrospective results.
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Affiliation(s)
- Frederick A. Zeiler
- Department of Physical Medicine and Rehabilitation, University hospital Northern Norway, Tromsø, Norway
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden
- NeuroIntensive Care, Niguarda Hospital, Milan, Italy
- Department of Neurosurgery, Medical School, University of Pécs, Hungary and Neurotrauma Research Group, János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Ari Ercole
- Department of Physical Medicine and Rehabilitation, University hospital Northern Norway, Tromsø, Norway
| | - Manuel Cabeleira
- Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Nino Stocchetti
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy
| | | | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
- Department of Neurosurgery, Medical Faculty RWTH Aachen University, Aachen, Germany
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Price J, Sandbach DD, Ercole A, Wilson A, Barnard EBG. End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study. Emerg Med J 2020; 37:674-679. [PMID: 32928874 PMCID: PMC7588597 DOI: 10.1136/emermed-2019-209077] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 07/08/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0-4.5 kPa (30.0-33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO2-PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO2-PaCO2 gradient of TBI patients at hospital arrival. METHODS A retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% CI. ETCO2-PaCO2 gradient data were compared with a two-tailed, unpaired, t-test. RESULTS 107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and -0.2 (95% CI -0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2-PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg). CONCLUSION There is only moderate correlation of ETCO2 and PaCO2 at hospital arrival in patients with serious TBI. The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO2 measurement.
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Affiliation(s)
- James Price
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
| | - Daniel D Sandbach
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Ari Ercole
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Alastair Wilson
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department (Retired), Royal London Hospital, London, UK
| | - Ed Benjamin Graham Barnard
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
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High Arterial Glucose is Associated with Poor Pressure Autoregulation, High Cerebral Lactate/Pyruvate Ratio and Poor Outcome Following Traumatic Brain Injury. Neurocrit Care 2020; 31:526-533. [PMID: 31123993 PMCID: PMC6872512 DOI: 10.1007/s12028-019-00743-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Arterial hyperglycemia is associated with poor outcome in traumatic brain injury (TBI), but the pathophysiology is not completely understood. Previous preclinical and clinical studies have indicated that arterial glucose worsens pressure autoregulation. The aim of this study was to evaluate the relationship of arterial glucose to both pressure reactivity and cerebral energy metabolism. Method This retrospective study was based on 120 patients with severe TBI treated at the Uppsala University hospital, Sweden, 2008–2018. Data from cerebral microdialysis (glucose, pyruvate, and lactate), arterial glucose, and pressure reactivity index (PRx55-15) were analyzed the first 3 days post-injury. Results High arterial glucose was associated with poor outcome/Glasgow Outcome Scale-Extended at 6-month follow-up (r = − 0.201, p value = 0.004) and showed a positive correlation with both PRx55-15 (r = 0.308, p = 0.001) and cerebral lactate/pyruvate ratio (LPR) days 1–3 (r = 0. 244, p = 0.014). Cerebral lactate-to-pyruvate ratio and PRx55-15 had a positive association day 2 (r = 0.219, p = 0.048). Multivariate linear regression analysis showed that high arterial glucose predicted poor pressure autoregulation on days 1 and 2. Conclusions High arterial glucose was associated with poor outcome, poor pressure autoregulation, and cerebral energy metabolic disturbances. The latter two suggest a pathophysiological mechanism for the negative effect of arterial hyperglycemia, although further studies are needed to elucidate if the correlations are causal or confounded by other factors.
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da Silva Bento P, Santiago AD, Vendrame Saes LS, Erbs Pessoa JL, Ockner Silva TL, Schirmer J, de Aguiar Roza B. Loss of Potential Donors Due to Hemodynamic Maintenance. Transplant Proc 2020; 52:1226-1230. [PMID: 32192745 DOI: 10.1016/j.transproceed.2020.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Statistics indicate low utilization of potential donors, where only about one-third are converted into actual donors. In this context, it is plausible to argue that many potential donors are not hemodynamically stable for harvesting multiple organs since the procedures for maintaining parameters of stability may not be a priority in all critical care units in the country. Thus, it is necessary to identify losses of potential donors due to hemodynamic maintenance since reversing this situation enable minimizing mortality on waiting lists. METHODS This was a retrospective quantitative study, based on information sent to Notification, Organ Procurement, and Distribution Centers by reporting hospitals in the state of São Paulo, using the Death Information Form regarding the specifics of each death registered in their intensive care units and emergency rooms. RESULTS Hemodynamic instability contributed to a loss of 537 potential donors, corresponding to 61.9% of failures to obtain potentially transplantable organs. CONCLUSION Of the 33,175 cases of death reported, 867 fulfilled the criteria to be possible and potential donors (ie, patients diagnosed with brain death). Among these cases, 38.1% fulfilled Criterion 3 (ie, they were hemodynamically stable and in ideal organ donation condition). Therefore, this study concludes that losses due to maintenance occurred in 537 brain dead patients. This finding highlights the importance of investing in the development of competencies of professionals who work in critical care units to increase the number of multiple organ and tissue donors and reduce waiting lists.
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Affiliation(s)
| | - Alessandra Duarte Santiago
- Intra-Hospital Commission of Organ and Tissue Donation for Transplant, Hospital São Paulo, São Paulo, Brazil
| | | | | | | | - Janine Schirmer
- Clinical and Surgical Nursing Department, Paulista Nursing School, Federal University of São Paulo, São Paulo, Brazil
| | - Bartira de Aguiar Roza
- Clinical and Surgical Nursing Department, Paulista Nursing School, Federal University of São Paulo, São Paulo, Brazil
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Kundu B, Awad AW, Park MS, Grandhi R, Enniss T, Hawryluk GWJ. Characterization of Focal Brain Tissue Water Measurements in Human Traumatic Brain Injury. World Neurosurg 2019; 135:e271-e285. [PMID: 31805402 DOI: 10.1016/j.wneu.2019.11.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cerebral edema is a major cause of morbidity in patients with severe traumatic brain injury (TBI). Intraparenchymal thermal conductivity-based probes that measure local cerebral blood flow can measure percent brain tissue water (%BTW) content, but such measures have been insufficiently characterized in patients with TBI. METHODS We retrospectively reviewed physiologic data from patients with severe TBI treated at our institution (2014-2016) who underwent cerebral blood flow monitoring. RESULTS Sixteen patients underwent focal %BTW measurements at a 15-minute sampling rate. %BTW measurements showed characteristic temporal profiles, with a mean time to peak of 3.7 ± 1.7 days. The mean minimum and maximum %BTWs were 71.0 ± 3.9% and 82.7 ± 7.4%, respectively (overall mean %BTW, 77.0 ± 2.9%). Intracranial pressure (ICP) values of 22 mm Hg (the current treatment threshold for patients with trauma) corresponded to 75.8 ± 5.4 %BTW. Repeated measures correlation showed that %BTW is negatively correlated with serum sodium concentration (r = -0.3; P < 0.001) and weakly positively correlated with ICP (r = 0.08; P = 0.01) and regional cerebral blood flow (r = 0.06; P < 0.001). These effects were consistent in a multivariable model including time from injury. In the best model, time was modeled as a quadratic term because the %BTW followed a parabolic trajectory. CONCLUSIONS %BTW may be a clinically useful, real-time measurement of cerebral edema in patients with TBI. It is closely associated with the serum sodium concentration and follows a characteristic temporal course with characteristic trajectory and stability over time.
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Affiliation(s)
- Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Al-Wala Awad
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Toby Enniss
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA; Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada.
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Raj R, Luostarinen T, Pursiainen E, Posti JP, Takala RSK, Bendel S, Konttila T, Korja M. Machine learning-based dynamic mortality prediction after traumatic brain injury. Sci Rep 2019; 9:17672. [PMID: 31776366 PMCID: PMC6881446 DOI: 10.1038/s41598-019-53889-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 11/07/2019] [Indexed: 12/21/2022] Open
Abstract
Our aim was to create simple and largely scalable machine learning-based algorithms that could predict mortality in a real-time fashion during intensive care after traumatic brain injury. We performed an observational multicenter study including adult TBI patients that were monitored for intracranial pressure (ICP) for at least 24 h in three ICUs. We used machine learning-based logistic regression modeling to create two algorithms (based on ICP, mean arterial pressure [MAP], cerebral perfusion pressure [CPP] and Glasgow Coma Scale [GCS]) to predict 30-day mortality. We used a stratified cross-validation technique for internal validation. Of 472 included patients, 92 patients (19%) died within 30 days. Following cross-validation, the ICP-MAP-CPP algorithm's area under the receiver operating characteristic curve (AUC) increased from 0.67 (95% confidence interval [CI] 0.60-0.74) on day 1 to 0.81 (95% CI 0.75-0.87) on day 5. The ICP-MAP-CPP-GCS algorithm's AUC increased from 0.72 (95% CI 0.64-0.78) on day 1 to 0.84 (95% CI 0.78-0.90) on day 5. Algorithm misclassification was seen among patients undergoing decompressive craniectomy. In conclusion, we present a new concept of dynamic prognostication for patients with TBI treated in the ICU. Our simple algorithms, based on only three and four main variables, discriminated between survivors and non-survivors with accuracies up to 81% and 84%. These open-sourced simple algorithms can likely be further developed, also in low and middle-income countries.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland.
| | - Teemu Luostarinen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland
| | - Eetu Pursiainen
- Data Scientist, Analytics and AI Development Services, HUS IT Management, Helsinki University Hospital, Haartmaninkatu 4, PB 340, 00029 HUS, Helsinki, Finland
| | - Jussi P Posti
- Division of Clinical Neurosciences, Department of Neurosurgery, and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Hämeentie 11, 20521, Turku, Finland
| | - Riikka S K Takala
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Hämeentie 11, 20521, Turku, Finland
| | - Stepani Bendel
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Teijo Konttila
- Data Scientist, Analytics and AI Development Services, HUS IT Management, Helsinki University Hospital, Haartmaninkatu 4, PB 340, 00029 HUS, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland
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Chau CYC, Craven CL, Rubiano AM, Adams H, Tülü S, Czosnyka M, Servadei F, Ercole A, Hutchinson PJ, Kolias AG. The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury. J Clin Med 2019; 8:E1422. [PMID: 31509945 PMCID: PMC6780113 DOI: 10.3390/jcm8091422] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.
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Affiliation(s)
- Charlene Y C Chau
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N3BG, UK
| | - Andres M Rubiano
- Neurosciences Institute, INUB-MEDITECH Research Group, El Bosque University, 113033 Bogotá, Colombia
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Selma Tülü
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, 20090 Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK.
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Mencser Z, Kopniczky Z, Kis D, Barzo P. Slit Ventricle as a Neurosurgical Emergency: Case Report and Review of Literature. World Neurosurg 2019; 130:493-498. [PMID: 31295607 DOI: 10.1016/j.wneu.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/30/2019] [Accepted: 07/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Symptomatic slit ventricle is one of the most challenging complications of shunt surgery in children. Clinical signs and symptoms may appear with a wide range of intracranial pressure (ICP) values. We report the case of a 10-year-old girl, who did not present the classic clinical features of extremely elevated ICP, which was proven by multiple invasive ICP recordings, performed during shunt revisions. CASE DESCRIPTION At the age of 6 months, the patient presented squeal for many hours, accompanied with sunset eyes, bulging anterior fontanel, and dilated ventricles of all 4 ventricles on computed tomography scan. Acute ventriculoperitoneal shunt insertion was performed with adjustable valve. During the following 9 years, she was regularly seen and medically treated for intermittent headache, with nausea and vomiting. From 9 years of age, she was hospitalized for severe (10/10 on the visual analog scale), unbearable headache, agitation, and screaming on multiple occasions. Altogether, we had to revise the shunt system 5 times throughout 1 year. Radiologic imaging always showed narrow ventricles. Ophthalmologic examination of the fundus never revealed signs of raised ICP. Perioperative monitoring of the ICP with intraparenchymal sensor showed unexpected high values of 40-45 mm Hg. However, repetitive shunt revisions were successful only temporarily because the symptoms always returned. Only bilateral shunting of the ventricular system was able to eliminate the symptoms permanently. CONCLUSIONS Images of slit ventricle can be associated either with low or extremely high ICP needing urgent surgical consideration, including ICP monitoring. Bilateral shunt insertion can be effective treatment for slit ventricle syndrome.
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Affiliation(s)
- Zoltan Mencser
- Department of Neurosurgery, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary.
| | - Zsolt Kopniczky
- Department of Neurosurgery, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary; Department of Neurotraumatology, Péterfy Hospital - National Institute of Traumatology, Budapest, Hungary
| | - David Kis
- Department of Neurosurgery, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Pal Barzo
- Department of Neurosurgery, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
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Zeiler FA, Ercole A, Cabeleira M, Beqiri E, Zoerle T, Carbonara M, Stocchetti N, Menon DK, Smielewski P, Czosnyka M. Compensatory-reserve-weighted intracranial pressure versus intracranial pressure for outcome association in adult traumatic brain injury: a CENTER-TBI validation study. Acta Neurochir (Wien) 2019; 161:1275-1284. [PMID: 31053909 PMCID: PMC6581920 DOI: 10.1007/s00701-019-03915-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/13/2019] [Indexed: 12/16/2022]
Abstract
Background Compensatory-reserve-weighted intracranial pressure (wICP) has recently been suggested as a supplementary measure of intracranial pressure (ICP) in adult traumatic brain injury (TBI), with a single-center study suggesting an association with mortality at 6 months. No multi-center studies exist to validate this relationship. The goal was to compare wICP to ICP for association with outcome in a multi-center TBI cohort. Methods Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived ICP and wICP (calculated as wICP = (1 − RAP) × ICP; where RAP is the compensatory reserve index derived from the moving correlation between pulse amplitude of ICP and ICP). Various univariate logistic regression models were created comparing ICP and wICP to dichotomized outcome at 6 to 12 months, based on Glasgow Outcome Score—Extended (GOSE) (alive/dead—GOSE ≥ 2/GOSE = 1; favorable/unfavorable—GOSE 5 to 8/GOSE 1 to 4, respectively). Models were compared using area under the receiver operating curves (AUC) and p values. Results wICP displayed higher AUC compared to ICP on univariate regression for alive/dead outcome compared to mean ICP (AUC 0.712, 95% CI 0.615–0.810, p = 0.0002, and AUC 0.642, 95% CI 0.538–746, p < 0.0001, respectively; no significant difference on Delong’s test), and for favorable/unfavorable outcome (AUC 0.627, 95% CI 0.548–0.705, p = 0.015, and AUC 0.495, 95% CI 0.413–0.577, p = 0.059; significantly different using Delong’s test p = 0.002), with lower wICP values associated with improved outcomes (p < 0.05 for both). These relationships on univariate analysis held true even when comparing the wICP models with those containing both ICP and RAP integrated area under the curve over time (p < 0.05 for all via Delong’s test). Conclusions Compensatory-reserve-weighted ICP displays superior outcome association for both alive/dead and favorable/unfavorable dichotomized outcomes in adult TBI, through univariate analysis. Lower wICP is associated with better global outcomes. The results of this study provide multi-center validation of those seen in a previous single-center study. Electronic supplementary material The online version of this article (10.1007/s00701-019-03915-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Tommaso Zoerle
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Marco Carbonara
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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Patient-specific ICP Epidemiologic Thresholds in Adult Traumatic Brain Injury: A CENTER-TBI Validation Study. J Neurosurg Anesthesiol 2019; 33:28-38. [PMID: 31219937 DOI: 10.1097/ana.0000000000000616] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patient-specific epidemiologic intracranial pressure (ICP) thresholds in adult traumatic brain injury (TBI) have emerged, using the relationship between pressure reactivity index (PRx) and ICP, displaying stronger association with outcome over existing guideline thresholds. The goal of this study was to explore this relationship in a multi-center cohort in order to confirm the previous finding. METHODS Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit cohort, we derived individualized epidemiologic ICP thresholds for each patient using the relationship between PRx and ICP. Mean hourly dose of ICP was calculated for every patient for the following thresholds: 20, 22 mm Hg and the patient's individual ICP threshold. Univariate logistic regression models were created comparing mean hourly dose of ICP above thresholds to dichotomized outcome at 6 to 12 months, based on Glasgow Outcome Score-Extended (GOSE) (alive/dead-GOSE≥2/GOSE=1; favorable/unfavorable-GOSE 5 to 8/GOSE 1 to 4, respectively). RESULTS Individual thresholds were identified in 65.3% of patients (n=128), in keeping with previous results (23.0±11.8 mm Hg [interquartile range: 14.9 to 29.8 mm Hg]). Mean hourly dose of ICP above individual threshold provides superior discrimination (area under the receiver operating curve [AUC]=0.678, P=0.029) over mean hourly dose above 20 mm Hg (AUC=0.509, P=0.03) or above 22 mm Hg (AUC=0.492, P=0.035) on univariate analysis for alive/dead outcome at 6 to 12 months. The AUC for mean hourly dose above individual threshold trends to higher values for favorable/unfavorable outcome, but fails to reach statistical significance (AUC=0.610, P=0.060). This was maintained when controlling for baseline admission characteristics. CONCLUSIONS Mean hourly dose of ICP above individual epidemiologic ICP threshold has stronger associations with mortality compared with the dose above Brain Trauma Foundation defined thresholds of 20 or 22 mm Hg, confirming prior findings. Further studies on patient-specific epidemiologic ICP thresholds are required.
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Svedung Wettervik T, Howells T, Enblad P, Lewén A. Temporal Neurophysiological Dynamics in Traumatic Brain Injury: Role of Pressure Reactivity and Optimal Cerebral Perfusion Pressure for Predicting Outcome. J Neurotrauma 2019; 36:1818-1827. [DOI: 10.1089/neu.2018.6157] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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Maggio MG, Maresca G, De Luca R, Stagnitti MC, Porcari B, Ferrera MC, Galletti F, Casella C, Manuli A, Calabrò RS. The Growing Use of Virtual Reality in Cognitive Rehabilitation: Fact, Fake or Vision? A Scoping Review. J Natl Med Assoc 2019; 111:457-463. [PMID: 30739728 DOI: 10.1016/j.jnma.2019.01.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This review aims to evaluate the role of Virtual Reality (VR) in cognitive rehabilitation of different neurological diseases, and the accessibility to healthcare systems providing this type of treatment. METHOD OF RESEARCH Studies performed between 2003 and 2017 and fulfilling the selected criteria were found on PubMed, Scopus, Cochrane and Web of Sciences databases. The search combined the terms VR rehabilitation with different neurological disease. RESULTS Our findings showed that neurological patients performed significant improvement in many cognitive domains (executive and visual-spatial abilities; speech, attention and memory skills) following the use of VR training. CONCLUSIONS This review supports the idea that rehabilitation through new VR tools could positively affect neurological patients' outcomes, by boosting motivation and participation so to get a better response to treatment. In particular, VR can be used to enhance the effects of conventional therapies, promoting longer training sessions and a reduction in overall hospitalization time.
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Affiliation(s)
| | | | | | | | - Bruno Porcari
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
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Chen S, Gallagher MJ, Hogg F, Papadopoulos MC, Saadoun S. Visibility Graph Analysis of Intraspinal Pressure Signal Predicts Functional Outcome in Spinal Cord Injured Patients. J Neurotrauma 2018; 35:2947-2956. [DOI: 10.1089/neu.2018.5775] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Suliang Chen
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
| | - Mathew J. Gallagher
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
| | - Florence Hogg
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
| | | | - Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
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Clinical outcomes following early versus late pharmacologic thromboprophylaxis in patients with traumatic intracranial hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2018; 43:861-872. [DOI: 10.1007/s10143-018-1045-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/26/2018] [Accepted: 10/23/2018] [Indexed: 12/23/2022]
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Latella D, Maggio MG, De Luca R, Maresca G, Piazzitta D, Sciarrone F, Carioti L, Manuli A, Bramanti P, Calabro RS. Changes in sexual functioning following traumatic brain injury: An overview on a neglected issue. J Clin Neurosci 2018; 58:1-6. [PMID: 30314923 DOI: 10.1016/j.jocn.2018.09.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/27/2018] [Indexed: 12/28/2022]
Abstract
Traumatic brain injury (TBI) is any damage to the skull and/or the brain and its frameworks due to an external force. Following TBI, patients may report cognitive, physiological and psychosocial changes with a devastating impact on important aspects of the patient's life, such as sexual functioning. Although sexual dysfunction (SD) occurs at a significantly greater frequency in individuals with TBI, it is not commonly assessed in the clinical setting and little information is available on this crucial aspect of patients' quality of life. As the number of people with TBI is on the rise, there is a need for better management of TBI problems, including SD, by providing information to patients and their caregivers to achieve sexual health, with a consequent increase in their quality of life. Discussing and treating sexual problems in TBI patients enters the framework of a holistic approach. The purpose of this narrative review is provide clinicians with information concerning changes in sexual functioning and relationships in individuals with TBI, for a better management of patient's functional outcomes and quality of life.
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Affiliation(s)
| | | | | | | | | | | | - Luigi Carioti
- IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
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Protein biomarkers of epileptogenicity after traumatic brain injury. Neurobiol Dis 2018; 123:59-68. [PMID: 30030023 DOI: 10.1016/j.nbd.2018.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/10/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022] Open
Abstract
Traumatic brain injury (TBI) is a major risk factor for acquired epilepsy. Post-traumatic epilepsy (PTE) develops over time in up to 50% of patients with severe TBI. PTE is mostly unresponsive to traditional anti-seizure treatments suggesting distinct, injury-induced pathomechanisms in the development of this condition. Moderate and severe TBIs cause significant tissue damage, bleeding, neuron and glia death, as well as axonal, vascular, and metabolic abnormalities. These changes trigger a complex biological response aimed at curtailing the physical damage and restoring homeostasis and functionality. Although a positive correlation exists between the type and severity of TBI and PTE, there is only an incomplete understanding of the time-dependent sequelae of TBI pathobiologies and their role in epileptogenesis. Determining the temporal profile of protein biomarkers in the blood (serum or plasma) and cerebrospinal fluid (CSF) can help to identify pathobiologies underlying the development of PTE, high-risk individuals, and disease modifying therapies. Here we review the pathobiological sequelae of TBI in the context of blood- and CSF-based protein biomarkers, their potential role in epileptogenesis, and discuss future directions aimed at improving the diagnosis and treatment of PTE.
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50
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Li L, Ma X, Pandey S, Deng X, Chen S, Cui D, Gao L. The Most-Cited Works in Severe Traumatic Brain Injury: A Bibliometric Analysis of the 100 Most-Cited Articles. World Neurosurg 2018; 113:e82-e87. [DOI: 10.1016/j.wneu.2018.01.164] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/20/2018] [Accepted: 01/22/2018] [Indexed: 01/24/2023]
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