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Fu S, Liu H, Wang G, Hu X, Wang S. Incidence, risk factors, and clinical outcomes of acute brain swelling associated with traumatic acute subdural hematoma: a retrospective study utilizing novel diagnostic criteria. Ther Adv Neurol Disord 2024; 17:17562864241242944. [PMID: 38638672 PMCID: PMC11025420 DOI: 10.1177/17562864241242944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/11/2024] [Indexed: 04/20/2024] Open
Abstract
Background Post-traumatic acute brain swelling (ABS) is a major cause of elevated intracranial pressure and thus mortality. The current definition of post-traumatic ABS has certain limitations, and there is limited information available regarding ABS associated with traumatic acute subdural hematoma (ASDH). Objectives To investigate the incidence, risk factors, and clinical outcomes of ABS associated with traumatic ASDH. Design Retrospective study. Methods Data for 161 patients diagnosed with traumatic ASDH were retrospectively collected. Novel computed tomography-based criteria were proposed for diagnosing ABS in patients with ASDH and determining its incidence. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of post-traumatic ABS. The Glasgow Outcome Scale (GOS) score, mortality, and functional prognosis of all patients at discharge and the proportion of intraoperative malignant brain bulge in surgical patients were taken as clinical outcome measures. Results A total of 45 (28%) patients experienced post-traumatic ABS, exhibiting significantly lower Glasgow Coma Scale scores on admission (p < 0.001). The incidence of hemispheric and whole-brain swelling was 8.1% and 19.9%, respectively. Risk factors independently associated with post-traumatic ABS were: (1) age [odds ratio (OR) = 0.917, p < 0.001]; (2) platelet to white blood cell ratio (PWR) (OR = 0.887, p = 0.012); and (3) traumatic subarachnoid hemorrhage (SAH) (OR = 4.346, p = 0.005). The ABS cohort had a lower GOS score [2 (1-3) versus 4 (3-5); p < 0.001], higher mortality (46.7% versus 6.9%; p < 0.001), and higher proportion of unfavorable functional prognosis (75.6% versus 34.5%; p < 0.001) upon discharge compared to the no ABS cohort, along with higher proportion of intraoperative malignant brain bulge (43.8% versus 0%; p < 0.001). Conclusion The incidence of ABS associated with ASDH is significantly high overall. Patients with ASDH who have young age, low PWR, and traumatic SAH are at an increased risk of developing post-traumatic ABS, and therefore of poor clinical outcomes.
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Affiliation(s)
- Shilong Fu
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, The First Hospital of Putian City, Putian, China
| | - Haibing Liu
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzhou, China
| | - Guofeng Wang
- Department of Neurosurgery, The First Hospital of Putian City, Putian, China
| | - Xiaofang Hu
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzhou, China
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University Fuzhou, Fujian 350025, China
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzhou, China
- Fujian Provincial Clinical Medical Research Center for Minimally Invasive Diagnosis and Treatment of Neurovascular Diseases, Fuzhou, China
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Paiva WS, Zippo E, Miranda C, Brasil S, Godoy DA, De Andrade AF, Neville I, Patriota GC, Domingues R, Teixeira MJ. Animal models for the study of intracranial hematomas (Review). Exp Ther Med 2022; 25:20. [PMID: 36561628 PMCID: PMC9748783 DOI: 10.3892/etm.2022.11719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Intracranial hematomas (ICH) are a frequent condition in neurosurgical and neurological practices, with several mechanisms of primary and secondary injury. Experimental research has been fundamental for the understanding of the pathophysiology implicated with ICH and the development of therapeutic interventions. To date, a variety of different animal approaches have been described that consider, for example, the ICH evolutive phase, molecular implications and hemodynamic changes. Therefore, choosing a test protocol should consider the scope of each particular study. The present review summarized investigational protocols in experimental research on the subject of ICH. With this subject, injection of autologous blood or bacterial collagenase, inflation of intracranial balloon and avulsion of cerebral vessels were the models identified. Rodents (mice) and swine were the most frequent species used. These different models allowed improvements on the understanding of intracranial hypertension establishment, neuroinflammation, immunology, brain hemodynamics and served to the development of therapeutic strategies.
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Affiliation(s)
- Wellingson Silva Paiva
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Emanuele Zippo
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Carolina Miranda
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Sérgio Brasil
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Correspondence to: Dr Sérgio Brasil, Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, 05403 São Paulo, Brazil
| | - Daniel Augustin Godoy
- Department of Intensive Care, Neurointensive Care Unit, Pasteur Hospital, 4700 Catamarca, Argentina
| | - Almir Ferreira De Andrade
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Iuri Neville
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | | | - Renan Domingues
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
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3
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Deshpande SJ, Velonjara J, Lujan S, Petroni G, Wang J, Patel KV, Boyle LN, Bell MJ, Vavilala MS. Provider perceptions of severe pediatric traumatic brain injury care priorities across hospitals in South America before and during the COVID-19 pandemic. PLoS One 2022; 17:e0275255. [PMID: 36174092 PMCID: PMC9522258 DOI: 10.1371/journal.pone.0275255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background
To understand provider perceptions of the COVID-19 pandemic on priorities of severe pediatric traumatic brain injury (TBI) care across hospitals in South America.
Methods
Site principal investigators (PIs) from 17 hospitals in South America enrolled in the PEGASUS-Argentina randomized controlled trial completed questionnaires regarding order of tasks performed in the care of a typical pediatric patient with severe TBI before (2019) and during (2021) the COVID-19 pandemic. Acute care processes were examined by quintiles to identify early, mid, and late actions and were categorized and compared. Associations of hospital volume and subspecialty resource availability with prioritization of key process actions were examined.
Finding
Site PIs from 15 and 16 hospitals completed the surveys in 2019 and 2021, respectively, including 14 who completed both. Action category order was stable between 2019 and 2021 and were ranked in priorities as: initial encounter, primary survey, interventions and invasive monitors, diagnostics, medications, staff communication, then disposition (in 2019) or nutrition (in 2021). There was variation in specific action order between hospitals at both timepoints, with only a few initial encounter and disposition actions limited to a single quintile. There was no reported association between hospital volume or subspecialty resource availability with prioritization of key process actions.
Interpretation
Despite novel healthcare challenges presented by the COVID-19 pandemic, providers in South America perceived maintaining standard severe pediatric TBI care consistent with BTF guidelines. There was large variability in specific action order between individual hospitals reported.
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Affiliation(s)
- Shyam J. Deshpande
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States of America
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
- Harborview Injury Prevention & Research Center, Seattle, WA, United States of America
| | - Julia Velonjara
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States of America
- Harborview Injury Prevention & Research Center, Seattle, WA, United States of America
- * E-mail:
| | - Silvia Lujan
- Centro de Informática e Investigación Clínica, Rosario, Argentina
| | - Gustavo Petroni
- Centro de Informática e Investigación Clínica, Rosario, Argentina
| | - Jin Wang
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
- Harborview Injury Prevention & Research Center, Seattle, WA, United States of America
| | - Kushang V. Patel
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States of America
- Harborview Injury Prevention & Research Center, Seattle, WA, United States of America
| | - Linda Ng Boyle
- Department of Industrial and System Engineering, University of Washington, Seattle, WA, United States of America
| | - Michael J. Bell
- Children’s National Hospital Critical Care Medicine, Washington, DC, United States of America
| | - Monica S. Vavilala
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States of America
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
- Harborview Injury Prevention & Research Center, Seattle, WA, United States of America
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4
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Bell MJ, Rosario BL, Kochanek PM, Adelson PD, Morris KP, Au AK, Schober M, Butt W, Edwards RJ, Zimmerman J, Pineda J, Le TM, Dean N, Whalen MJ, Figaji A, Luther J, Beers SR, Gupta DK, Carpenter J, Buttram S, Wisniewski SR. Comparative Effectiveness of Diversion of Cerebrospinal Fluid for Children With Severe Traumatic Brain Injury. JAMA Netw Open 2022; 5:e2220969. [PMID: 35802371 PMCID: PMC9270700 DOI: 10.1001/jamanetworkopen.2022.20969] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Diversion of cerebrospinal fluid (CSF) has been used for decades as a treatment for children with severe traumatic brain injury (TBI) and is recommended by evidenced-based guidelines. However, these recommendations are based on limited studies. OBJECTIVE To determine whether CSF diversion is associated with improved Glasgow Outcome Score-Extended for Pediatrics (GOS-EP) and decreased intracranial pressure (ICP) in children with severe TBI. DESIGN, SETTING, AND PARTICIPANTS This observational comparative effectiveness study was performed at 51 clinical centers that routinely care for children with severe TBI in 8 countries (US, United Kingdom, Spain, the Netherlands, Australia, New Zealand, South Africa, and India) from February 2014 to September 2017, with follow-up at 6 months after injury (final follow-up, October 22, 2021). Children with severe TBI were included if they had Glasgow Coma Scale (GCS) scores of 8 or lower, had intracranial pressure (ICP) monitor placed on-site, and were aged younger than 18 years. Children were excluded if they were pregnant or an ICP monitor was not placed at the study site. Consecutive children were screened and enrolled, data regarding treatments were collected, and at discharge, consent was obtained for outcomes testing. Propensity matching for pretreatment characteristics was performed to develop matched pairs for primary analysis. Data analyses were completed on April 18, 2022. EXPOSURES Clinical care followed local standards, including the use of CSF diversion (or not), with patients stratified at the time of ICP monitor placement (CSF group vs no CSF group). MAIN OUTCOMES AND MEASURES The primary outcome was GOS-EP at 6 months, while ICP was considered as a secondary outcome. CSF vs no CSF was treated as an intention-to-treat analysis, and a sensitivity analysis was performed for children who received delayed CSF diversion. RESULTS A total of 1000 children with TBI were enrolled, including 314 who received CSF diversion (mean [SD] age, 7.18 [5.45] years; 208 [66.2%] boys) and 686 who did not (mean [SD] age, 7.79 [5.33] years; 437 [63.7%] boys). The propensity-matched analysis included 98 pairs. In propensity score-matched analyses, there was no difference between groups in GOS-EP (median [IQR] difference, 0 [-3 to 1]; P = .08), but there was a decrease in overall ICP in the CSF group (mean [SD] difference, 3.97 [0.12] mm Hg; P < .001). CONCLUSIONS AND RELEVANCE In this comparative effectiveness study, CSF diversion was not associated with improved outcome at 6 months after TBI, but a decrease in ICP was observed. Given the higher quality of evidence generated by this study, current evidence-based guidelines related to CSF diversion should be reconsidered.
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Affiliation(s)
- Michael J. Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Medical Center, Washington, District of Columbia
| | - Bedda L. Rosario
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
| | - Kevin P. Morris
- Division of Pediatric Critical Care, Birmingham Children’s Hospital NHS Foundation, Birmingham, United Kingdom
| | - Alicia K. Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michelle Schober
- Division of Pediatric Critical Care Medicine, University of Utah, Salt Lake City
| | - Warwick Butt
- Division of Pediatric Critical Care Medicine, The Royal Children’s Hospital, Melbourne, Australia
| | - Richard J. Edwards
- Division of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Harborview Medical Center, Seattle, Washington
| | - Jose Pineda
- Division of Pediatric Critical Care Medicine, St Louis Children’s Hospital, St Louis, Missouri
| | - Truc M. Le
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Nathan Dean
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Medical Center, Washington, District of Columbia
| | - Michael J. Whalen
- Division of Pediatric Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Anthony Figaji
- Department of Neurosurgery, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - James Luther
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Deepak K. Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sandra Buttram
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
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5
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Soares MS, Andrade AFD, Brasil S, DE-Lima-Oliveira M, Belon AR, Bor-Seng-Shu E, Nogueira RDC, Godoy DA, Paiva WS. Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:344-352. [PMID: 35195225 DOI: 10.1590/0004-282x-anp-2020-0591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. OBJECTIVE To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. METHODS An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. RESULTS Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. CONCLUSIONS These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.
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Affiliation(s)
- Matheus Schmidt Soares
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Sérgio Brasil
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Marcelo DE-Lima-Oliveira
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Alessandro Rodrigo Belon
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edson Bor-Seng-Shu
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Daniel Agustin Godoy
- Hospital Carlos G. Malbrán, Sanatorio Pasteur, Unidad de Cuidados Intensivos, Catamarca, Argentina
| | - Wellingson Silva Paiva
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
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6
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Brasil S, Solla DJF, Nogueira RDC, Teixeira MJ, Malbouisson LMS, Paiva WDS. A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care. J Pers Med 2021; 11:1302. [PMID: 34945774 PMCID: PMC8707681 DOI: 10.3390/jpm11121302] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We validated a new noninvasive tool (B4C) to assess intracranial pressure waveform (ICPW) morphology in a set of neurocritical patients, correlating the data with ICPW obtained from invasive catheter monitoring. MATERIALS AND METHODS Patients undergoing invasive intracranial pressure (ICP) monitoring were consecutively evaluated using the B4C sensor. Ultrasound-guided manual internal jugular vein (IJV) compression was performed to elevate ICP from the baseline. ICP values, amplitudes, and time intervals (P2/P1 ratio and time-to-peak [TTP]) between the ICP and B4C waveform peaks were analyzed. RESULTS Among 41 patients, the main causes for ICP monitoring included traumatic brain injury, subarachnoid hemorrhage, and stroke. Bland-Altman's plot indicated agreement between the ICPW parameters obtained using both techniques. The strongest Pearson's correlation for P2/P1 and TTP was observed among patients with no cranial damage (r = 0.72 and 0.85, respectively) to the detriment of those who have undergone craniotomies or craniectomies. P2/P1 values of 1 were equivalent between the two techniques (area under the receiver operator curve [AUROC], 0.9) whereas B4C cut-off 1.2 was predictive of intracranial hypertension (AUROC 0.9, p < 000.1 for ICP > 20 mmHg). CONCLUSION B4C provided biometric amplitude ratios correlated with ICPW variation morphology and is useful for noninvasive critical care monitoring.
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Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | | | - Wellingson da Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
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Bussolin L, Falconi M, Leo MC, Parri N, DE Masi S, Rosati A, Cecchi C, Spacca B, Grandoni M, Bettiol A, Lucenteforte E, Lubrano R, Falsaperla R, Melosi F, Agostiniani R, Mangiantini F, Talamonti G, Calderini E, Mancino A, DE Luca M, Conti G, Petrini F. The management of pediatric severe traumatic brain injury: Italian Guidelines. Minerva Anestesiol 2021; 87:567-579. [PMID: 33432789 DOI: 10.23736/s0375-9393.20.14122-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of the work was to update the "Guidelines for the Management of Severe Traumatic Brain Injury" published in 2012, to reflect the new available evidence, and develop the Italian national guideline for the management of severe pediatric head injuries to reduce variation in practice and ensure optimal care to patients. EVIDENCE ACQUISITION MEDLINE and EMBASE were searched from January 2009 to October 2017. Inclusion criteria were English language, pediatric populations (0-18 years) or mixed populations (pediatric/adult) with available age subgroup analyses. The guideline development process was started by the Promoting Group that composed a multidisciplinary panel of experts, with the representatives of the Scientific Societies, the independent expert specialists and a representative of the Patient Associations. The panel selected the clinical questions, discussed the evidence and formulated the text of the recommendations. The documentarists of the University of Florence oversaw the bibliographic research strategy. A group of literature reviewers evaluated the selected literature and compiled the table of evidence for each clinical question. EVIDENCE SYNTHESIS The search strategies identified 4254 articles. We selected 3227 abstract (first screening) and, finally included 67 articles (second screening) to update the guideline. This Italian update includes 25 evidence-based recommendations and 5 research recommendations. CONCLUSIONS In recent years, progress has been made on the understanding of severe pediatric brain injury, as well as on that concerning all major traumatic pathology. This has led to a progressive improvement in the clinical outcome, although the quantity and quality of evidence remains particularly low.
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Affiliation(s)
- Leonardo Bussolin
- Neuroanesthesiology, Intensive Care and Trauma Center, A. Meyer University Hospital, Florence, Italy
| | - Martina Falconi
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Maria C Leo
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Niccolò Parri
- Emergency Department and Trauma Center, A. Meyer University Hospital, Florence, Italy -
| | - Salvatore DE Masi
- Clinical Trial Office, A. Meyer University Hospital, Florence, Italy
| | - Anna Rosati
- Neurosciences Excellence Center, A. Meyer University Hospital, Florence, Italy
| | - Costanza Cecchi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy
| | - Barbara Spacca
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | - Manuela Grandoni
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | | | | | - Riccardo Lubrano
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics Unit, Pediatric Emergency Department, Neonatology and Neonatal Intensive Care, "Rodolico-San Marco" University Hospital, Catania, Italy
| | - Raffaele Falsaperla
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics and Neonatology Unit, Department of Maternal and Urological Sciences, Sapienza University, Latina, Rome, Italy
| | - Francesca Melosi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy.,Società Italiana di Neurosonologia ed Emodinamica Cerebrale (SINSEC), Bologna, Italy
| | | | | | | | - Edoardo Calderini
- Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Rome, Italy
| | - Aldo Mancino
- Società di Anestesia e Rianimazione Neonatale e Pediatrica Italiana (S.A.R.N.eP.I), Rome, Italy
| | - Marco DE Luca
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy
| | - Giorgio Conti
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy.,IRCCS A. Gemelli, Catholic University, Rome, Italy
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8
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Chau CYC, Mediratta S, McKie MA, Gregson B, Tulu S, Ercole A, Solla DJF, Paiva WS, Hutchinson PJ, Kolias AG. Optimal Timing of External Ventricular Drainage after Severe Traumatic Brain Injury: A Systematic Review. J Clin Med 2020; 9:E1996. [PMID: 32630454 PMCID: PMC7356750 DOI: 10.3390/jcm9061996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 12/26/2022] Open
Abstract
External ventricular drainage (EVD) may be used for therapeutic cerebrospinal fluid (CSF) drainage to control intracranial pressure (ICP) after traumatic brain injury (TBI). However, there is currently uncertainty regarding the optimal timing for EVD insertion. This study aims to compare patient outcomes for patients with early and late EVD insertion. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, MEDLINE/EMBASE/Scopus/Web of Science/Cochrane Central Register of Controlled Trials were searched for published literature involving at least 10 severe TBI (sTBI) patients from their inception date to December 2019. Outcomes assessed were mortality, functional outcome, ICP control, length of stay, therapy intensity level, and complications. Twenty-one studies comprising 4542 sTBI patients with an EVD were included; 19 of the studies included patients with an early EVD, and two studies had late EVD placements. The limited number of studies, small sample sizes, imbalance in baseline characteristics between the groups and poor methodological quality have limited the scope of our analysis. We present the descriptive statistics highlighting the current conflicting data and the overall lack of reliable research into the optimal timing of EVD. There is a clear need for high quality comparisons of early vs. late EVD insertion on patient outcomes in sTBI.
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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 CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
| | - Saniya Mediratta
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK;
| | - Mikel A. McKie
- Medical Research Council Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge CB2 0SR, UK;
| | - Barbara Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne NE4 5PLE, UK;
| | - Selma Tulu
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK;
| | - Davi J. F. Solla
- Department of Neurology, Division of Neurosurgery, University of São Paulo, São Paulo 01246-903, Brazil; (D.J.F.S.); (W.S.P.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Wellingson S. Paiva
- Department of Neurology, Division of Neurosurgery, University of São Paulo, São Paulo 01246-903, Brazil; (D.J.F.S.); (W.S.P.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
- Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge CB2 0QQ, UK; (C.Y.C.C.); (S.T.); (P.J.H.)
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB2 0QQ, UK
- Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
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9
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Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, Davis-O'Reilly C, Hart EL, Bell MJ, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Vavilala MS, Wainwright MS. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 84:1169-1178. [PMID: 30822776 DOI: 10.1093/neuros/nyz051] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pe-diatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Nancy Carney
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - P David Adelson
- Deptartment of Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Erica L Hart
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Michael J Bell
- Department Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Susan L Bratton
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia's Children's Hospital, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Karin E Reuter-Rice
- School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina
| | - Monica S Vavilala
- Department of Anesthesiology & Pain Medicine, Department of Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, Washington
| | - Mark S Wainwright
- Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington
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10
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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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11
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med 2019; 20:280-289. [PMID: 30830016 DOI: 10.1097/pcc.0000000000001736] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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12
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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13
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Chen K, Dong J, Xia T, Zhang C, Zhao W, Xu Q, Cai X. Changes in cerebral hemodynamics in patients with posttraumatic diffuse brain swelling after external intraventricular drainage. Chin J Traumatol 2017; 18:90-4. [PMID: 26511300 DOI: 10.1016/j.cjtee.2015.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To investigate the changes of cerebral hemodynamics pre- and post-ventricular drainage in patients with posttraumatic acute diffuse brain swelling. METHODS Twenty-four cases of traumatic diffuse brain swelling were analyzed retrospectively. Patients in nonsurgical group were treated by medicine therapy. Patients in surgical group were treated by external ventricular drainage plus medicine therapy. The first CT perfusion scan was completed within 4-5 h after trauma and scanned again after 7 days. The changes of perfusion parameters in area-of-interest in two groups were analyzed and compared before and after treatment. RESULTS Compared with the nonsurgical group, the value of cerebral blood volume, cerebral blood flow and mean transit time in bilateral frontal temporoparietal grey matter, basal ganglia, cerebellum, and brain stem at pre- and post-therapy were increased significantly (p < 0.05) in surgical group, and consequently the prognosis of patients undergoing surgery was also better than that of nonsurgical group. CONCLUSION External ventricular drainage can improve cerebral perfusion and increase survival quality for the patients with posttraumatic acute diffuse brain swelling.
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Affiliation(s)
- Kefei Chen
- Department of Neurosurgery, Craniocerebral Trauma Cure Center of PLA, 101st Hospital of PLA, Wuxi 214044, China
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14
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de Andrade AF, Paiva WS, Neville IS, Noleto GS, Alves Junior A, Sandon LHD, Bor-Seng-Shu E, Amorim RL, Teixeira MJ. Monoblock external ventricular drainage system in the treatment of patients with acute hydrocephalus: a pilot study. Med Sci Monit 2014; 20:227-32. [PMID: 24509952 PMCID: PMC3933296 DOI: 10.12659/msm.890080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Infection is a major complication in patients undergoing external ventricular drainage (EVD). Our study aimed to evaluate the incidence of infection in a series with the monoblock EVD system. Material/Methods 46 patients treated with EVD at our emergency department were analyzed prospectively to research the incidence of infections with a new EVD system. Results The average rate of infection was 8.7%. When we stratified the patients according to the exclusive use of EVD without craniotomies, we identified a reduction in the overall incidence of ventriculitis from 8.7% to 2.3%. Age, etiology, and the presence of ventricular bleeding were not statistically significant risk factors. Conclusions Despite the small sample examined in this study, we believe that the monoblock system is a simple, inexpensive device that reduces accidental disconnection of the system.
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Affiliation(s)
- Almir Ferreira de Andrade
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gustavo Sousa Noleto
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Aderaldo Alves Junior
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz Henrique Dias Sandon
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Edson Bor-Seng-Shu
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Robson Luis Amorim
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
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15
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Zaninotto AL, de Paula Guirado VM, Baldivia B, Núñes MD, Amorim RLO, Teixeira MJ, de Lucia MCS, de Andrade AF, Paiva WS. Improvement of verbal fluency in patients with diffuse brain injury over time. Neuropsychiatr Dis Treat 2014; 10:1155-60. [PMID: 25028551 PMCID: PMC4077785 DOI: 10.2147/ndt.s62728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Diffuse axonal injury (DAI), a common cause of neurological sequelae in patients with traumatic brain injury (TBI), is considered one of the most prevalent forms of primary neuronal injury in patients with severe TBI. Cognitive deficits induced by DAI can persist over time, especially following moderate or severe injuries. The aim of the present study was to compare verbal fluency (VF) performance at 6 and 12 months after the trauma in a same group of patients with DAI. METHODS Eighteen patients with moderate to severe DAI and 17 healthy volunteers were enrolled. All DAI participants had sustained a TBI at least 6 months prior to the start of the study, were between 18 and 50 years of age, and had at least 4 years of education. The VF test was administered within an extensive neuropsychological test battery. We evaluated the same patients at 6 months (DAI1 group) and 12 months (DAI2 group) and compared the results of neuropsychological tests with a control group of healthy volunteers who were matched to patients for sex, age, and educational level. RESULTS In comparison to controls, the DAI1 group produced significantly fewer words. The DAI2 group produced significantly more semantic words than DAI1 (P<0.05) and demonstrated a trend towards the production of more clusters for letter A (P=0.09) and total words generated in a phonemic test (P=0.09). No significant differences were observed between DAI2 and the control group in the total number of words generated in phonetic FAS or semantic fluency scores. CONCLUSION The present findings may be useful in the construction of a management plan for long-term TBI rehabilitation that considers the trauma of each patient. Further, our results suggest the VF test is a suitable instrument for the assessment of cognitive difficulties following TBI.
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Affiliation(s)
- Ana Luiza Zaninotto
- Division of Psychology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Beatriz Baldivia
- Division of Psychology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Monica Domiano Núñes
- Division of Psychology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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16
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Posttraumatic refractory intracranial hypertension and brain herniation syndrome: cerebral hemodynamic assessment before decompressive craniectomy. BIOMED RESEARCH INTERNATIONAL 2013; 2013:750809. [PMID: 24377095 PMCID: PMC3860083 DOI: 10.1155/2013/750809] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/17/2013] [Indexed: 11/30/2022]
Abstract
Background. The pathophysiology of traumatic brain swelling remains little understood. An improved understanding of intracranial circulatory process related to brain herniation may have treatment implications. Objective. To investigate the cerebral hemodynamic changes associated with brain herniation syndrome due to traumatic brain swelling. Methods. Nineteen head-injured patients with evidence of refractory intracranial hypertension and transtentorial herniation were prospectively studied. Cerebral hemodynamic assessment by transcranial Doppler (TCD) ultrasonography was performed prior to decompressive craniectomy. Patients and their cerebral hemispheres were classified according to TCD-hemodynamic patterns, and the data correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury. Results. A wide variety of cerebral hemodynamic findings were observed. Ten patients (52.7%) presented with cerebral oligoemia, 3 patients (15.8%) with cerebral hyperemia, and 6 patients with nonspecific circulatory pattern. Circulatory disturbances were more frequently found in the side of maximal cerebral swelling than in the opposite side. Pulsatility index (PI) values suggested that ICP varied from acceptable to considerably high; patients with increased PI, indicating higher microvascular resistance. No correlation was found between cerebral hemodynamic findings and outcome. Conclusions. There is a marked heterogeneity of cerebral hemodynamic disturbances among patients with brain herniation syndrome.
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