[Guidelines for the management of severe traumatic brain injury. Part 3. Surgical management of severe traumatic brain injury (Options)]

[Surgical treatment of patients with skull defects and cerebrospinal fluid flow disorders after previous decompressive craniectomy]

Decompressive craniectomy (DC) is performed for refractory intracranial hypertension following severe traumatic brain injury, vascular and oncological diseases. This fact increases the number of patients with extensive and giant skull defects. Cerebrospinal fluid (CSF) flow disorders after DC are often accompanied by ventriculomegaly. However, only some patients with ventriculomegaly have hydrocephalus and require CSF bypass procedures. Differentiation of post-traumatic hydrocephalus requiring surgical treatment and atrophic dilation of ventricular system «ex vacuo» caused by brain injury is still an important issue. Skull sealing as a way to normalize CSF circulation and eliminate hydrocephalus is also an open question. Currently, there is no unified approach to patients with extensive and giant cranial defects combined with post-traumatic hydrocephalus. There is no unified algorithm for sequence of reconstructive and CSF bypass operations in these patients. Literature data on risks of infectious complications for different surgical strategies are controversial.

Predictive role of shock index in the early formation of cerebral infarction in patients with TBI and cerebral herniation

Background and purpose

Traumatic brain injury (TBI) with brain herniation predisposes to posttraumatic cerebral infarction (PTCI), which in turn seriously affects the prognosis of patients. At present, there is a lack of effective indicators that can accurately predict the occurrence of PTCI. We aimed to find possible risk factors for the development of PTCI by comparing the preoperative and postoperative clinical data of TBI patients with brain herniation.

Methods

The clinical data of 120 patients with craniocerebral trauma and brain herniation were retrospectively analyzed. Among them, 54 patients had cerebral infarction within 3–7 days after injury. The two groups of patients were compared through univariate and multivariate logistic regression analysis, and a classification tree model and a nomogram model were constructed. Finally, receiver operating characteristic curve analysis and decision curve analysis were conducted to analyze the clinical utility of the prediction model.

Results

Logistic regression analysis showed that factors like the Glasgow Coma Scale (GCS) score (P = 0.002), subarachnoid hemorrhage (SAH) (P = 0.005), aspiration pneumonia (P < 0.001), decompressive craniectomy (P < 0.05), intracranial pressure (ICP) monitoring (P = 0.006), the shock index (SI) (P < 0.001), the mean arterial pressure (MAP) (P = 0.005), and blood glucose (GLU) (P < 0.011) appeared to show a significant statistical correlation with the occurrence of infarction (P < 0.05), while age, sex, body temperature (T), D-dimer levels, and coagulation tests were not significantly correlated with PTCI after cerebral herniation. Combined with the above factors, Classification and Regression Tree was established, and the recognition accuracy rate reached 76.67%.

Conclusions

GCS score at admission, no decompressive craniectomy, no ICP monitoring, combined SAH, combined aspiration pneumonia, SI, MAP, and high GLU were risk factors for infarction, of which SI was the primary predictor of PTCI in TBI with an area under the curve of 0.775 (95% CI = 0.689–0.861). Further large-scale studies are needed to confirm these results.

Association between blood glucose levels and Glasgow Outcome Score in patients with traumatic brain injury: secondary analysis of a randomized trial

Background

Blood glucose levels that are too high or too low after traumatic brain injury (TBI) negatively affect patient prognosis. This study aimed to demonstrate the relationship between blood glucose levels and the Glasgow Outcome Score (GOS) in TBI patients.

Methods

This study was based on a randomized, dual-center, open-label clinical trial. A total of 208 patients who participated in the randomized controlled trial were followed up for 5 years. Information on the disease, laboratory examination, insulin therapy, and surgery for patients with TBI was collected as candidate variables according to clinical importance. Additionally, data on 5-year and 6-month GOS were collected as primary and secondary outcomes, respectively. For multivariate analysis, a generalized additive model (GAM) was used to investigate relationships between blood glucose levels and GOS. The results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs). We further applied a two- piecewise linear regression model to examine the threshold effect of blood glucose level and GOS.

Results

A total of 182 patients were included in the final analysis. Multivariate GAM analysis revealed that a bell-shaped relationship existed between average blood glucose level and 5-year GOS score or 6-month GOS score. The inflection points of the average blood glucose level were 8.81 (95% CI: 7.43–9.48) mmol/L considering 5-year GOS as the outcome and were 8.88 (95% CI 7.43−9.74) mmol/L considering 6-month GOS score as the outcome. The same analysis revealed that there was also a bell relationship between average blood glucose levels and the favorable outcome group (GOS score ≥ 4) at 5 years or 6 months.

Conclusion

In a population of patients with traumatic brain injury, blood glucose levels were associated with the GOS. There was also a threshold effect between blood glucose levels and the GOS. A blood glucose level that is either too high or too low conveys a poor prognosis.

Trial registration

ClinicalTrials.gov NCT02161055. Registered on 11 June 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06005-5.

[Clinical and MRI predictors of coma duration, intensive care and outcome of traumatic brain injury]

OBJECTIVE

This research is aimed to study the clinical and MRI predictors of coma duration, the intensity of critical care, and outcome of traumatic brain injury (TBI).

MATERIAL AND METHODS

The data from 309 patients with TBI of varying severity were included in the analysis, of whom 257 (86.7%) were treated in the intensive care unit (ICU), including 196 (63.4%) patients admitted in a comatose state lasting longer than 1 day. All patients underwent brain MRI within 21 days after the injury. MRI findings were classified according to MRI grading scale of brain damage level and localization proposed previously.

RESULTS

The proposed MRI grading significantly correlated with the Glasgow coma (GCS, r=-0.67; p<0.0001) and Glasgow outcome (0.69; p<0.001) scores in the entire group. In a subgroup of comatose patients (GCS<9) it correlated with coma duration (r=0.52; p<0.0001). Spearman correlation analysis showed a significant relationship between the MRI classification and a number of parameters: ICU length of stay (r=0.62; p<0.0001), the duration of artificial ventilation (r=0.47; p<0.0001), the rate of artificial ventilation, sedatives, analgesics, mannitol, hypertonic saline and vasopressors usage (p<0.01). These data confirm the relationship between higher grades of MRI classification (deep brain damage) and the need for the escalation of intensive care main components.

CONCLUSION

Our results support the hypothesis that the levels and localization of brain damage, estimated by the proposed MRI grading scale, might be predictors of coma duration, intensity and duration of intensive care, and TBI outcomes. A prognosis based on clinical and neuroimaging data comparison can be valuable for planning and efficient use of the hospital beds and ICU resources, for optimizing the patient flow and timing of patient transfer to neurorehabilitation facilities.

The value of anti-epileptic therapy as a prophylactic factor for seizures in the management of moderate traumatic brain injury

AIM

The value of anti-epileptic therapy in the prophylaxis of post-traumatic seizures.

PATIENTS & METHODS

All patients received a standard anti-epileptic drug (AED) and were divided into two groups: Group A -with early AED and Group B -with late AED.

RESULTS

Patients (871/1062) met the inclusion criteria. Multivariate analysis demonstrated that computer tomography findings, headache and prior history of brain head injury were independent risk factors of seizures. Only late post-traumatic seizures (LPTS) was significantly associated with AED (p < 0.05).

CONCLUSION

Early treatment with AED seems to not affect the incidence of lPTS. In addition, an AED with a mean time of initiation of 7.5 days from the moderate traumatic brain injury occurrence could reduce the lPTS incidence.

Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP])

Background  Traumatic brain injury (TBI) is a global public health problem. In Colombia, it is estimated that 70% of deaths from violence and 90% of deaths from road traffic accidents are TBI related. In the year 2014, the Ministry of Health of Colombia funded the development of a clinical practice guideline (CPG) for the diagnosis and treatment of adult patients with severe TBI. A critical barrier to the widespread implementation was identified-that is, the lack of a specific protocol that spans various levels of resources and complexity across the four treatment phases. The objective of this article is to present the process and recommendations for the management of patients with TBI in various resource environments, across the treatment phases of prehospital care, emergency department (ED), surgery, and intensive care unit. Methods  Using the Delphi methodology, a consensus of 20 experts in emergency medicine, neurosurgery, prehospital care, and intensive care nationwide developed recommendations based on 13 questions for the management of patients with TBI in Colombia. Discussion  It is estimated that 80% of the global population live in developing economies where access to resources required for optimum treatment is limited. There is limitation for applications of CPGs recommendations in areas where there is low availability or absence of resources for integral care. Development of mixed methods consensus, including evidence review and expertise points of good clinical practices can fill gaps in application of CPGs. BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol) is intended to be a practical handbook for care providers to use to treat TBI patients with whatever resources are available. Results  Stratification of recommendations for interventions according to the availability of the resources on different stages of integral care is a proposed method for filling gaps in actual evidence, to organize a better strategy for interventions in different real-life scenarios. We develop 10 algorithms of management for building TBI protocols based on expert consensus to articulate treatment options in prehospital care, EDs, neurological surgery, and intensive care, independent of the level of availability of resources for care.

Penetrating transorbital injury by a coloring pencil in a 3-year-old child: A case report

A transorbital penetrating injury by a foreign body is an extremely rare type of injury, and its severity is often difficult to estimate by examination of the superficial wound alone. Thus, such injuries are challenging for neurosurgeons to investigate and manage. We herein present a peculiar case involving a 3-year-old girl with a penetrating transorbital skull-base injury caused by a coloring pencil and discuss the anatomical location of the foreign body, radiological examination findings, diagnosis, and treatment strategy. The pencil was completely removed by manual extraction. Follow-up investigations confirmed a good outcome. Multidisciplinary cooperation, radiological examination, correct diagnosis, timely treatment, and detailed follow-up studies are necessary to manage penetrating transorbital skull-base injuries caused by foreign bodies. The orbital walls are very thin in children, and the orbital roof and superior orbital fissure are often penetrated by foreign bodies in cases such as that described herein. The anatomical location of the foreign body influences the clinical management strategy.

Mortality And Morbidity of Severe Traumatic Brain Injuries; A Pediatric Intensive Care Unit Experience Over 15 Years

Objective

To determine the mortality, morbidity, types of intracranial hemorrhages, and factors associated with length of stay (LOS) associated with accidental traumatic brain injury (TBI) at a pediatric intensive care unit (PICU) of a regional trauma center in an Asian city.

Methods

This study is a retrospective review of types of head injury, mortality and morbidity demographics of patients admitted to a PICU with TBI. All patients with accidental TBI were included, namely road traffic injury (RTI) and fall, and their demographics compared. Non-accidental injuries (NAI) were excluded.

Results

95 children (78% males) were admitted to a PICU with RTI or falls from 2002 to 2017. They accounted for 3.7% of PICU admissions. Comparing with falls, victims of RTI were older (p<0.001) and more likely to suffer from skull fracture (p=0.017). There were 4 deaths with falls (6.8%) but none with RTI. Subarachnoid hemorrhages, extradural hemorrhages, the use of mechanical ventilation, inotropes and neurological supports were associated with longer LOS in PICU in these injuries (p<0.001).

Conclusion

A longer PICU LOS is associated with extradural and subarachnoid hemorrhages, usage of inotropes, mechanical ventilation and neurological supports in falls and RTI. Three-quarters of victims are males. Preventive health education should be especially directed to boys to reduce severe TBI in this Asian city.

[Modern diagnostics and treatment of posttraumatic hydrocephalus]

One of the frequent consequences of severe traumatic brain injury is posttraumatic hydrocephalus that not only hampers the processes of consciousness recovery, rehabilitation, and social adaptation of patients but also is the cause of disability. Pathological processes underlying the clinical picture of posttraumatic hydrocephalus and the relationship between CSF circulation disorders and structural changes in the brain substance have not been adequately studied. Of particular importance are patients in the chronic vegetative or minimally conscious state, recovery from which is blocked by posttraumatic hydrocephalus. The question of reversibility of impaired consciousness depending on the disease duration has remained open. High risks of purulent-inflammatory complications of shunting surgery are especially important in patients with chronic infection foci (tracheostomy, gastrostomy, epicystostomy, prolonged bladder catheterization, pressure ulcers, etc.), but their actual effect on the shunting outcomes has not been revealed. Posttraumatic hydrocephalus remains a topical neurosurgical problem requiring clarification of its diagnostic criteria, differentiation from atrophy-related ventriculomegaly, and comprehensive development of pathogenetic and therapeutic aspects.

[Autoregulation of cerebral blood flow in severe diffuse axonal brain injury: the role of neuroanatomical factors]

Autoregulation of cerebral blood flow (ACBF) is a system of mechanisms for maintaining stable adequate perfusion of the brain despite changes in systemic arterial pressure. In recent years, new data on the numerous metabolic and systemic mechanisms of cerebral blood flow regulation have been obtained, but the role of neurogenic regulation has not yet been fully understood and, therefore, not considered in clinical practice.

AIM

The study aim was to assess the effect of anatomical injuries to deep brain structures on the extent and duration of ACBF abnormalities in a model of severe diffuse axonal injury (DAI).

RESULTS

The study demonstrated that brain injury in the projection of a dopaminergic structure (substantia nigra) and a cholinergic structure (nucleus basalis of Meynert region) was more common in patients with impaired ACBF and was associated with a longer duration of the impairment.

CONCLUSION

The obtained data may indicate the presence of central (neurogenic) pathways of cerebral vessel tone regulation; traumatic injury of the pathways leads to a more severe and prolonged period of impaired ACBF. Probably, injury to these regulatory structures in some patients has an indirect effect on the course of intracranial hypertension. Further experimental and clinical studies in this direction are needed to elucidate all elements of neurogenic regulation of cerebral vessel tone and ACBF mechanisms.

The value of the identification of predisposing factors for post-traumatic amnesia in management of mild traumatic brain injury

OBJECT

To identify the risk factors for post-traumatic amnesia (PTA) and to document the incidence of PTA after mild traumatic brain injuries.

METHODS

This was a prospective study, affecting mild TBI (mTBI) (Glasgow Coma Scale 14-15) cases attending to the Emergency Department between January 2009 and April 2012 (40 months duration). Patients were divided into two groups (Group A: without PTA, and Group B: with PTA, and they were assessed according to the risk factors.

RESULTS

A total of 1762 patients (males: 1002, 56.8%) were meeting study inclusion criteria [Group A: n = 1678 (83.8%), Group B: n = 84 (4.2%)]. Age, CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs, and skull base fractures), anticoagulation therapy and seizures were independent factors of PTA. There was no statistically significant correlation between PTA and sex, convexity fractures, stroke event, mechanism of mTBI (fall +/or beating), hypertension, coronary heart disease, chronic smokers and diabetes (p > 0.005).

CONCLUSION

CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs and skull base fractures), age, seizures and anticoagulation/antiplatelet therapy, were independent factors of PTA and could be used as predictive factors after mTBI.

[Penetrating orbitocranial injury: a review of the literature and a case report of injury by a watercolor brush in a 3-year-old child]

We present a rare case of orbitocranial penetrating injury by a watercolor brush in a 3-year-old child. Injuries of this localization can affect important orbital structures (eyeball, blood vessels, nerves, muscles) and cause severe intracranial damages. In some cases, diagnosis of these injuries in children may be difficult due to the lack of marked clinical manifestations. The presented clinical case illustrates the approaches for choosing methods for diagnosis of injury in childhood and subsequent treatment options.