Efficacy of Simultaneous Administration of Nimodipine, Progesterone, and Magnesium Sulfate in Patients with Severe Traumatic Brain Injury: A Randomized Controlled Trial

Electrolyte Imbalance and Neurologic Injury

Neurologic injury continues to be a debilitating worldwide disease with high morbidity and mortality. The systemic sequelae of a neural insult often lead to prolonged hospital stays and challenging nutritional demands that contribute to poorer prognoses. Clinical management of a given condition should prioritize preserving the homeostatic parameters disrupted by inflammatory response cascades following the primary insult. This focused review examines the reciprocal relationship between electrolyte disturbance and neurologic injury. A prolonged electrolyte imbalance can significantly impact morbidity and mortality in neurologic injuries. A detailed overview of the major electrolytes and their physiologic, iatrogenic, and therapeutic implications are included. The pathophysiology of how dysnatremias, dyskalemias, dyscalcemias, and dysmagnesemias occur and the symptoms they can induce are described. The manifestations in relation to traumatic brain injury, status epilepticus, and acute ischemic stroke are addressed. Each type of injury and the strength of its association with a disruption in either sodium, potassium, calcium, or magnesium is examined. The value of supplementation and replacement is highlighted with an emphasis on the importance of early recognition in this patient population. This review also looks at the current challenges associated with correcting imbalances in the setting of different injuries, including the relevant indications and precautions for some of the available therapeutic interventions. Based on the findings of this review, there may be a need for more distinct clinical guidelines on managing different electrolyte imbalances depending on the specified neurologic injury. Additional research and statistical data on individual associations between insult and imbalance are needed to support this potential future call for context-based protocols.

Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis

BACKGROUND

Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV.

METHODS

A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis.

RESULTS

Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively.

CONCLUSIONS

The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.

Pharmacological components with neuroprotective effects in the management of traumatic brain injury: evidence from network meta-analysis

BACKGROUND

Neuroprotective drugs have been used to prevent secondary brain injury in patients with traumatic brain injury; however, the optimal medication remains questionable. We performed a Bayesian network meta-analysis to evaluate the safety and efficacy of different medications with known neuroprotective properties in this group of patients.

METHODS

Several databases were searched to identify any eligible trials comparing pharmacological components with confirmed neuroprotective mechanisms. Bayesian network meta-analysis was performed to combine direct and indirect evidence. The surface under the cumulative ranking curve was obtained to determine the ranking probability of the treatment agents for each outcome. The primary outcome was all-cause mortality.

RESULTS

A total of 23 trials comprising 4,325 participants were identified. The pooled relative risk (RR) showed administration of erythropoietin (RR: 0.68; 95% CrI: 0.50-0.93) and propranolol (RR: 0.43; 95% CrI: 0.20-0.85) decreased all-cause mortality compared with placebo. We also found erythropoietin (RR: 1.55; 95% CrI: 1.03-2.35), propranolol (RR: 1.52; 95% CrI: 1.05-2.20), and progesterone (RR: 1.47; 95% CrI: 1.03-2.10) showed better efficacy in functional recovery.

CONCLUSION

Overall, erythropoietin and propranolol were associated with reduced mortality in adults with traumatic brain injury. These treatment agents were also associated with improved functional outcomes.

The Effect of Remifentanil, MgSO4, or Remifentanil-MgSO4 as Neuroprotectors on BDNF, MAC, and Caspase-3 Levels in Wistar Rats with Traumatic Brain Injury

BACKGROUND: Traumatic brain injury (TBI) can lead to cell death and neurologic dysfunction. Meanwhile, Remifentanyl is an opioid with potent analgesia, while magnesium sulfate (MgSO4) has antinociceptive properties that can prevent hemodynamic instability during laryngoscopy. AIM: This study aims to examine the effect of remifentanil, MgSO4 and their combination on BDNF, MAC, and Caspase-3 levels in Wistar rat models with TBI. METHODOLOGY: An experimental study was conducted on 30 male Wistar rats which were randomly divided into five groups. The control group (G1) received normal saline, the induced group (G2) received normal saline after TBI induction using the modified Feeney method, and the treated group (G3, G4, and G5) received remifentanil, MgSO4, and their combination after TBI induction. The rats’ brain tissues were analyzed for BDNF, MAC, and Caspase-3 levels using ELISA. The data were analyzed statistically with ANOVA followed by post hoc Multiple Comparison Test (p < 0.05). RESULTS: Treatment with remifentanil, MgSO4 or the combination of both in TBI subjects reduced MAC and Caspase-3 but increased the BDNF level. The post hoc multiple comparisons showed significant differences in all groups except groups 3 and 5 in terms of MAC (p = 0.190) and Caspase-3 (p = 0.999). The combination of remifentanil-MgSO4 increased BDNF levels significantly. CONCLUSION: The administration of remifentanil, MgSO4 , or their combination can serve as a neuroprotector in Wistar rat models with TBI by lowering MAC and Caspase-3 as well as increasing BDNF levels.

A Retrospective Analysis of Randomized Controlled Trials on Traumatic Brain Injury: Evaluation of CONSORT Item Adherence

Traumatic brain injury (TBI) contributes to death and disability, resulting in an enormous individual and socio-economic challenges. Despite huge efforts, there are still controversies on treatment strategies and early outcome estimation. We evaluate current randomized controlled trials (RCTs) on TBI according to their fulfillment of the CONSORT (Consolidated Statement of Reporting Trials) statement’s criteria as a marker of transparency and the quality of study planning and realization. A PubMed search for RCTs on TBI (January 2014–December 2019) was carried out. After screening of the abstracts (n = 1.926), the suitable full text manuscripts (n = 72) were assessed for the fulfillment of the CONSORT criteria. The mean ratio of consort statement fulfillment was 59% (±13%), 31% of the included studies (n = 22) complied with less than 50% of the CONSORT criteria. Citation frequency was moderately related to ratio of CONSORT item fulfillment (r = 0.4877; p < 0.0001) and citation frequency per year (r = 0.5249; p < 0.0001). The ratio of CONSORT criteria fulfillment was associated with the impact factor of the publishing journal (r = 0.6428; p < 0.0001). Essential data for study interpretation, such as sample size determination (item 7a), participant flow (item 13a) as well as losses and exclusions (item 13b), were only reported in 53%, 60% and 63%, respectively. Reporting and methodological aspects in RCTs on TBI still may be improved. Thus, the interpretation of study results may be hampered due to methodological weaknesses.

Nutraceutical induction and mimicry of heme oxygenase activity as a strategy for controlling excitotoxicity in brain trauma and ischemic stroke: focus on oxidative stress

Introduction: Ischemic stroke and traumatic brain injury are leading causes of acute mortality, and in the longer run, major causes of significant mental and physical impairment. Most of the brain neuronal cell death in the minutes and hours following an ischemic stroke or brain trauma is mediated by the process of excitotoxicity, in which sustained elevations of extracellular glutamate, reflecting a failure of ATP-dependent mechanism which sequester glutamate in neurons and astrocytes, drive excessive activation of NMDA receptors. Areas covered: A literature search was undertaken to clarify the molecular mechanisms whereby excessive NMDA activation leads to excitotoxic neuronal death, and to determine what safe nutraceutical agents might have practical potential for rescuing at-risk neurons by intervening in these mechanisms. Expert opinion: Activation of both NADPH oxidase and neuronal nitric oxide synthase in the microenvironment of activated NMDA receptors drives production of superoxide and highly toxic peroxynitrite. This leads to excessive activation of PARP and p38 MAP kinase, mitochondrial dysfunction, and subsequent neuronal death. Heme oxygenase-1 (HO-1) induction offers protection via inhibition of NADPH oxidase and promotion of cGMP generation. Phase 2-inductive nutraceuticals can induce HO-1, and other nutraceuticals can mimic the effects of its products biliverdin and carbon monoxide.

Drug Repurposing in Neurological Disorders: Implications for Neurotherapy in Traumatic Brain Injury

Traumatic brain injury (TBI) remains a significant leading cause of death and disability among adults and children globally. To date, there are no Food and Drug Administration-approved drugs that can substantially attenuate the sequelae of TBI. The innumerable challenges faced by the conventional de novo discovery of new pharmacological agents led to the emergence of alternative paradigm, which is drug repurposing. Repurposing of existing drugs with well-characterized mechanisms of action and human safety profiles is believed to be a promising strategy for novel drug use. Compared to the conventional discovery pathways, drug repurposing is less costly, relatively rapid, and poses minimal risk of the adverse outcomes to study on participants. In recent years, drug repurposing has covered a wide range of neurodegenerative diseases and neurological disorders including brain injury. This review highlights the advances in drug repurposing and presents some of the promising candidate drugs for potential TBI treatment along with their possible mechanisms of neuroprotection. Edaravone, glyburide, ceftriaxone, levetiracetam, and progesterone have been selected due to their potential role as putative TBI neurotherapeutic agents. These drugs are Food and Drug Administration-approved for purposes other than brain injuries; however, preclinical and clinical studies have shown their efficacy in ameliorating the various detrimental outcomes of TBI.