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Juskys R, Vilcinis R, Piliponis L, Tamasauskas A. Degree of basal cisterns compression predicting mortality and functional outcome after craniotomy and primary decompressive craniectomy in acute subdural hematoma population. Acta Neurochir (Wien) 2023; 165:4013-4020. [PMID: 37878128 DOI: 10.1007/s00701-023-05845-7] [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: 08/03/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES The compression of basal cisterns on CT is one of the signs of intracranial hypertension in TBI population. This study evaluates the relationship between the degree of basal cisterns effacement and outcomes in aSDH population. METHODS The study includes prospectively collected data from 290 patients who underwent osteoplastic craniotomy (OC) or primary decompressive craniectomy (pDC) for aSDH from 2016 to 2021. Univariate and multivariate regression analyses were performed to evaluate the association of baseline characteristics and extent of basal cisterns compression on pre-operative and post-operative CT scans with the outcomes at the time of discharge. Outcomes were dichotomized into mortality (and unfavourable (GOS 1-3 vs GOS 4-5). The degree of cisternal compression was evaluated using the cisternal effacement score of perimesencephalic and quadrigeminal cisternal components. Critical thresholds associated with the outcomes were calculated. RESULTS Age and pre-/post-operative degree of cisternal compression were the strongest independent predictors of intrahospital mortality in a whole sample and separately in OC and pDC subgroups. The unfavourable outcome was independently predicted by age, pre-/post-operative status of cisternal compression and initial GCS. Critical thresholds associated with the mortality and poor functional outcome were, respectively, age ≥ 70 (OR 3.14 [CI 95% 1.82-5.46], p < 0.001) and ≥ 67 (OR 3.87 [CI 95% 2.33-6.54], p < 0.001), pre-operative cisternal effacement score ≥ 9 (OR 6.39 [CI 95% 3.62-11.53], p < 0.001) and ≥ 7 (OR 4.93 [CI 95% 2.96-8.38], p < 0.001), post-operative cisternal effacement score ≥ 6 (OR 20.6 [CI 95% 10.08-45.10], p < 0.001) and ≥ 3 (OR 7.47 [CI 95% 3.87-15.73], p < 0.001) and initial GCS ≤ 8 (OR 0.24 [CI 95% 0.13-0.43], p < 0.001 and OR 0.12 [CI 95% 0.07-0.21], p < 0.001). CONCLUSIONS After adjusting for baseline characteristics, age and degree of cisternal compression remained the independent predictors of mortality, whereas unfavourable outcomes were associated with age, cisternal obliteration and GCS on presentation.
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Affiliation(s)
- R Juskys
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - R Vilcinis
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - L Piliponis
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - A Tamasauskas
- Neuroscience Institute, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Cunha L, Pereira E. Severe Traumatic Brain Injury and Ventriculoperitoneal Shunt Challenges: A Case Report. Cureus 2023; 15:e35828. [PMID: 37033578 PMCID: PMC10075335 DOI: 10.7759/cureus.35828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Traumatic brain injury (TBI) is an acquired damage to the brain caused by an external mechanical force and may result in temporary or long-term disability. It is a prevalent condition that highlights the need for increased awareness. Despite advances in the technology used to monitor and guide therapy, it is a difficult and complex disease process to manage. Elevated intracranial pressure (ICP), a complication of neurologic injury, is associated with increased mortality and worse outcomes. Decompressive craniectomy is effective in controlling ICP and is potentially lifesaving in patients who have failed medical therapy. As a long-term treatment, implanting a ventricular-peritoneal (VP) shunt is the typical neurosurgery method for treating hydrocephalus following TBI. Nevertheless, under certain circumstances, VP shunts fail and an interdisciplinary approach is essential to improve patients' outcomes. Herein, we present the case of a previously healthy young male patient who successfully underwent a surgical treatment following TBI. The aim of this case report is to share the knowledge gained at Centro Hospitalar Universitário do São João, in Portugal, regarding complications of VP shunts and how cranioplasty aided in the resolution of the problem.
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Rice AD, Hu C, Spaite DW, Barnhart BJ, Chikani V, Gaither JB, Denninghoff KR, Bradley GH, Howard JT, Keim SM, Bobrow BJ. Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury. Am J Emerg Med 2023; 65:95-103. [PMID: 36599179 DOI: 10.1016/j.ajem.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.
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Affiliation(s)
- Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America.
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ, United States of America
| | - Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Gail H Bradley
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ, United States of America
| | - Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, United States of America
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX, United States of America
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Scurfield AK, Wilson MD, Gurkoff G, Martin R, Shahlaie K. Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage. Neurocrit Care 2023; 38:149-157. [PMID: 36050537 PMCID: PMC9957945 DOI: 10.1007/s12028-022-01587-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome. METHODS In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model. RESULTS Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model. CONCLUSIONS This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.
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Affiliation(s)
- Abby K Scurfield
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, 830 Orange Street, New Haven, CT, 06511, USA
| | - Machelle D Wilson
- Division of Biostatistics, Department of Public Health Sciences, Davis Clinical and Translational Science Center, University of California, 2921 Stockton Blvd., Suite 1400, Sacramento, CA, 95817, USA
| | - Gene Gurkoff
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
| | - Ryan Martin
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
- Department of Neurology, University of California, 4860 Y Street, Suite 3740,, Davis, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA.
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Maye H, Waqar M, Colombo F, Lekka E. External validation of the GCS-Pupils Score as an outcome predictor after traumatic brain injury in adults: a single-center experience. Acta Neurochir (Wien) 2023; 165:289-297. [PMID: 36484865 DOI: 10.1007/s00701-022-05431-3] [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: 07/14/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The GCS-Pupils (GCS-P) score is a recently described scoring system to aid outcome prediction in patients with traumatic brain injury (TBI). The aim of this study was to provide the first external validation of the GCS-P score by identifying independent predictors of outcome in TBI patients. METHODS Review of prospective adult (≥ 16 years) TBI database at a tertiary neurosurgical center with a catchment population of 1.5 million over a 12-month period commencing October 2016. Multivariate logistic regression was used to identify predictors of discharge destination and 30-day mortality. RESULTS Three hundred and fifty-eight patients were included. The median age was 60 years with a male predominance of 64%. The median GCS-P was 14 (interquartile range 12-15) and the commonest GCS-P category was mild (13-15; 238/358, 66%). Discharge destination was home in 69% of patients and rehab services or equivalent in 31%. Multivariate analysis identified age (p = 0.01), CT findings of an acute subdural hematoma (p = 0.01) or diffuse axonal injury (p = 0.02), and a neurosurgical operation (p = 0.02) as independent predictors of discharge destination. The 30-day mortality rate was 11%. Within the category of severe TBI (GCS-P ≤ 8), GCS-P was able to identify patients with a very high likelihood of 30-day mortality (GCS-P ≤ 4; 16/31, 52%). Multivariate analysis revealed the Charlson comorbidity score (p = 0.01), GCS-P (p = 0.02), and traumatic subarachnoid hemorrhage (p = 0.05) as independent predictors of mortality. CONCLUSION The GCS-P is a useful predictor of 30-day mortality, although its usefulness for other clinical outcomes remains to be proven.
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Affiliation(s)
- Helen Maye
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Manchester, M6 8HD, UK.
| | - Mueez Waqar
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Manchester, M6 8HD, UK
| | - Francesca Colombo
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Manchester, M6 8HD, UK
| | - Elvira Lekka
- Department of Neurosurgery, Royal Preston Hospital, Preston, UK
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Salasky VR, Chang WTW. Neurotrauma Update. Emerg Med Clin North Am 2023; 41:19-33. [DOI: 10.1016/j.emc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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A Brief Review of Bolus Osmotherapy Use for Managing Severe Traumatic Brain Injuries in the Pre-Hospital and Emergency Department Settings. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2030035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Severe traumatic brain injury (TBI) management begins in the pre-hospital setting, but clinicians are left with limited options for stabilisation during retrieval due to time and space constraints, as well as a lack of access to monitoring equipment. Bolus osmotherapy with hypertonic substances is commonly utilised as a temporising measure for life-threatening brain herniation, but much contention persists around its use, largely stemming from a limited evidence base. Method: The authors conducted a brief review of hypertonic substance use in patients with TBI, with a particular focus on studies involving the pre-hospital and emergency department (ED) settings. We aimed to report pragmatic information useful for clinicians involved in the early management of this patient group. Results: We reviewed the literature around the pharmacology of bolus osmotherapy, commercially available agents, potential pitfalls, supporting evidence and guideline recommendations. We further reviewed what the ideal agent is, when it should be administered, dosing and treatment endpoints and/or whether it confers meaningful long-term outcome benefits. Conclusions: There is a limited evidence-based argument in support of the implementation of bolus osmotherapy in the pre-hospital or ED settings for patients who sustain a TBI. However, decades’ worth of positive clinician experiences with osmotherapy for TBI will likely continue to drive its on-going use. Choices regarding osmotherapy will likely continue to be led by local policies, individual patient characteristics and clinician preferences.
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Spaite DW, Hu C, Bobrow BJ, Barnhart B, Chikani V, Gaither JB, Denninghoff KR, Bradley GH, Rice AD, Howard JT, Keim SM. Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension. Ann Emerg Med 2022; 80:46-59. [PMID: 35339285 DOI: 10.1016/j.annemergmed.2022.01.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/17/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension. METHODS This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort. RESULTS Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort. CONCLUSION Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.
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Affiliation(s)
- Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ.
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ
| | - Vatsal Chikani
- Department of Health Services, Bureau of Emergency Medical Services, Phoenix, AZ
| | - Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
| | - Gail H Bradley
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ; Department of Health Services, Bureau of Emergency Medical Services, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
| | - Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, San Antonio, TX
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
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Left Ventricular Function in the Initial Period After Severe Traumatic Brain Injury in Swine. Neurocrit Care 2022; 37:200-208. [PMID: 35314968 DOI: 10.1007/s12028-022-01468-5] [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: 09/21/2021] [Accepted: 02/04/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cardiac dysfunction is common in the days after severe traumatic brain injury (TBI) and may contribute to hypotension episodes, leading to worse outcomes. Little is known about cardiac function in the minutes and hours immediately following TBI. By using fluid percussion TBI in a swine model, we aimed to characterize the immediate post injury cardiac function. METHODS Intubated, anesthetized immature (25.8 ± 1.5 kg) female swine were subjected to severe fluid percussion TBI (4.2 ± 0.2 atm). Beginning at 45 min, simulating hospital arrival, all animals were resuscitated with normal saline (NS), mannitol, and phenylephrine as needed to maintain a cerebral perfusion pressure more than 60 mm Hg and intracranial pressure (ICP) less than 20 mm Hg. Primary outcomes of cardiac function were cardiac output measured by thermodilution and transesophageal echo measurements of cardiac function recorded at prespecified time points and tested for trends over time using linear regression with spline at the time of resuscitation onset. Secondary outcomes included hemodynamic measurements, ICP, and cerebral perfusion pressure. RESULTS Eighteen animals were included. Post-TBI hemodynamic changes demonstrated an early decrease in mean arterial pressure and cerebral perfusion pressure with a corresponding increase in heart rate and ICP. Immediately after injury, there was a significant decrease in both left atrial area and tissue Doppler imaging e' of the LV lateral wall. In addition, there was a simultaneous increase in LV end diastolic diameter and increase in E/e' ratio of the lateral mitral annulus. All other transesophageal echo measurements demonstrated no significant changes throughout the duration of the experiment. CONCLUSIONS Traumatic brain injury is associated with cardiac dysfunction and increased mortality, however there is still a limited understanding of the hemodynamic and echocardiographic response associated with TBI. In this study we demonstrate the hemodynamic and echocardiographic changes in the early stages of TBI in swine. The authors hope that these results may help better understanding on the management of patients with severe head injury.
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Multisystem Trauma. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00036-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Assamadi M, Benantar L, Ait El Qadi A, Abou El Hassan T, Aniba K. [Epidemiological aspects and prognostic factors of severe traumatic brain injuries]. Neurochirurgie 2021; 67:571-578. [PMID: 33901522 DOI: 10.1016/j.neuchi.2021.04.005] [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: 03/16/2018] [Revised: 08/20/2019] [Accepted: 04/11/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the severity factors in severe traumatic brain injuries. METHODS A prospective descriptive study of severe head injuries admitted to the emergency department at Ibn Tofail Hospital at the University Hospital of Marrakech over a period of six months from May to October 2015. The following data was collected: circumstances, clinical, biology, radiology, treatment and evolution. RESULTS One hundred and nineteen patients with severe traumatic brain injury were collected (101 males, 84,9%). The mean age was 37,73±15,7 years. Road accidents were the most common cause representing 84%. The median Glasgow coma scale (GCS) was 7±3. We noted 36 cases (30,3%) of anisocoria, 32 cases (26,9%) of bilateral mydriasis and 72 cases (60,5%) of hypoxia. Cerebral contusions (66,1%) and meningeal hemorrhage (66,6%) were the most frequent lesions on CT. Forty-seven patients (42%) had stage VI Marshall lesions. Twenty-four patients (20.1%) required a neurosurgical intervention, 12 extradural hematoma evacuations and 10 craniocerebral wounds. Mortality was 64.7% (77 deaths), the main cause was neurological (64,9%). In the latter group, we observed more frequently an older age (P=0.00001), a management delay (P=0.011), a low initial GCS (P=0.000001), a bilateral nonreactive mydriasis (P=0.0001), a hypoxia (P=0.0002), a subarachnoid hemorrhage (P=0.008), a high Marshall score (P=0.017) and an anemia (P=0.046). CONCLUSION Head trauma is a public health problem. The victims are young, and the sequelae are frequently disabling. Several parameters are associated with a poorer prognosis including age, neurological state and the initial delay in management.
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Affiliation(s)
- M Assamadi
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - L Benantar
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - A Ait El Qadi
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - T Abou El Hassan
- Service d'accueil des urgences vitales, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - K Aniba
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
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Koo J, Lee J, Lee SH, Moon JH, Yang SY, Cho KT. Does the Size of Unilateral Decompressive Craniectomy Impact Clinical Outcomes in Patients with Intracranial Mass Effect after Severe Traumatic Brain Injury? Korean J Neurotrauma 2021; 17:3-14. [PMID: 33981638 PMCID: PMC8093026 DOI: 10.13004/kjnt.2021.17.e10] [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: 12/15/2020] [Revised: 02/20/2021] [Accepted: 03/18/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Decompressive craniectomy (DC) is one of the treatment modalities in severe traumatic brain injury (TBI), however, there was a lack of evidence for optimal craniectomy size. The authors aimed to investigate optimal DC size and analyze clinical outcome according to craniectomy size. Methods We retrospectively reviewed the medical data of 87 patients with a space occupying lesion following TBI who underwent unilateral DC. Craniectomy size was measured by anterior-posterior (AP) diameter and surface estimate (SE). Mortality, clinical outcome, and complications were collected and analyzed according to craniectomy size. Results Nineteen patients (21.8%) died and 35 patients (40.2%) had a favorable outcome at last follow-up (a mean duration, 30.3±39.4 months; range, 0.2-132.6 months). Receiver operating curve analyses identified AP diameter more than 12.5 cm (area under the curve [AUC]=0.740; p=0.002) and SE more than 98.0 cm2 (AUC=0.752; p=0.001) as cut-off values for survival, and AP diameter more than 13.4 cm (AUC=0.650; p=0.018) and SE more than 107.3 cm2 (AUC=0.685; p=0.003) for favorable outcome. Large craniectomy resulted in a significantly lower mortality rate and a higher rate of favorable outcome than small craniectomy (p=0.005 and p=0.014, respectively). However, procedure related bleeding occurred more frequently in the large craniectomy group (p=0.044). Conclusion Unilateral DC size is associated with clinical outcome of patients with a space occupying lesion following severe TBI. Large craniectomy is needed for survival and favorable outcome.
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Affiliation(s)
- Jinhwan Koo
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeongjun Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Su Hwan Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jung Hyeon Moon
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seung-Yeob Yang
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
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Bhardwaj A, Satapathy GC, Garg A, Chawla V, Jangra K. Incidence of Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury in a Tertiary Care ICU: A Retrospective Cohort Study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0040-1721553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) is an understudied complication of traumatic brain injury (TBI). PSH usually presents with transient rise in sympathetic outflow, leading to increased blood pressure, heart rate, temperature, respiratory rate, sweating, and posturing activity. We retrospectively analyzed the incidence of PSH in TBI using PSH-assessment measure (PSH-AM) scale.
Methods This single-center retrospective cohort study was conducted in traumatic head injury patients admitted in the intensive care unit from January 1, 2016 to December 31, 2019 in a tertiary care center. The data was collected from the hospital database after obtaining approval from the hospital ethics committee.
Results A total of 287 patients (18–65 years of age) were admitted to intensive care unit (ICU) with TBI out of which 227 patients were analyzed who had ICU stay for more than 14 days. PSH was diagnosed in 70 (30.8%) patients. Mean age of PSH positive patients was 40 ± 18 and 49 ± 11 years for PSH negative patients (p < 0.001). The age group between 40 and 50 years had a higher incidence of PSH. The age and Glasgow coma score (GCS) were significantly associated with the occurrence of PSH. The GCS score demonstrated good accuracy for predicting the occurrence of PSH with AUC 0.83, 95% CI of 0.775 to 0.886, and a p-value of 0.001.
Conclusion We observed that the incidence of PSH was 30.8% in the patients with TBI. Age and GCS were found to have a significant association for predicting the occurrence of PSH. The patients who developed PSH had a longer length of hospital stay in ICU.
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Affiliation(s)
- Ajit Bhardwaj
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Ganesh C. Satapathy
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Arpit Garg
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Vikas Chawla
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Kiran Jangra
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Acceptable Blood Pressure Levels in the Prehospital Setting for Patients with Traumatic Brain Injury: A Multicenter Observational Study. World Neurosurg 2021; 149:e504-e511. [PMID: 33561555 DOI: 10.1016/j.wneu.2021.01.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Safe blood pressure levels in the prehospital setting for patients with traumatic brain injury (TBI) remain unclear. We aimed to investigate the association between prehospital blood pressure and the outcomes of patients with TBI to determine optimal threshold for hypotension that could be considered in the prehospital setting. METHODS Using data from the Japan Trauma Data Bank, we identified adult patients (aged ≥18 years) who experienced severe TBI (maximum head Abbreviated Injury Severity score ≥3) and were transported directly from the scene of the blunt trauma occurrence to the hospital, between 2004 and 2019. We excluded patients with prehospital systolic blood pressure (SBP) levels of <60 and ≥160 mm Hg. Using mixed effects logistic regression models, we investigated the association between prehospital SBP and in-hospital mortality, considering the hospital ID as a random effect variable. In addition, we also conducted a stratified analysis based on age (<60 vs. ≥60 years). RESULTS A total of 34,175 patients (16,114 aged <60 years and 18,061 aged ≥60 years) were eligible for the analyses. Plotting the adjusted odds ratios for in-hospital mortality as a function of SBP produced J-shaped curves. An SBP <110 mm Hg was significantly associated with in-hospital mortality, with an adjusted odds ratio of 1.52 (95% confidence interval: 1.39-1.65). Stratified analyses revealed that the threshold did not differ between the age groups. CONCLUSIONS An SBP <110 mm Hg in the prehospital setting is significantly associated with higher in-hospital mortality.
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Gaither JB, Spaite DW, Bobrow BJ, Keim SM, Barnhart BJ, Chikani V, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids). Ann Emerg Med 2021; 77:139-153. [PMID: 33187749 PMCID: PMC7855946 DOI: 10.1016/j.annemergmed.2020.09.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
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Affiliation(s)
- Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
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Hakim SM, Abdellatif AA, Ali MI, Ammar MA. Reliability of transcranial sonography for assessment of brain midline shift in adult neurocritical patients: a systematic review and meta-analysis. Minerva Anestesiol 2020; 87:467-475. [PMID: 33054015 DOI: 10.23736/s0375-9393.20.14624-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The aim of this systematic review and meta-analysis was to determine the reliability of transcranial sonography as an alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. EVIDENCE AQUISITION The PubMed, EMBASE, Cochrane Library, Scopus and Web of Science databases were searched. Original studies evaluating brain midline shift in adult neurocritical patients using both transcranial sonography and computed tomography were eligible. Primary outcome measure was concordance between both methods as quantified in terms of concordance correlation coefficient. Secondary outcome measure was limits of agreement, defined as mean difference between sonography and computed tomography plus and minus 1.96 standard deviations. EVIDENCE SYNTHESIS Twelve studies (574 patients, 689 examinations) were eligible. Ten studies (416 patients, 492 examinations) provided adequate data for evaluation of concordance. Pooling of effect sizes showed strong concordance between both methods (concordance correlation coefficient, 0.91; 95% CI, 0.87 to 0.94). Two missing studies were imputed and effect size was adjusted to 0.88 (95% CI, 0.81 to 0.93). Nine studies (442 patients, 571 examinations) provided adequate data for estimation of limits of agreement. Pooling of effect sizes showed a bias of -0.53 mm (95% limits of agreement, -1.22 to 0.16 mm). Four missing studies were imputed and bias was adjusted to -0.68 mm (95% limits of agreement, -1.31 to -0.04 mm). CONCLUSIONS Transcranial sonography may serve as reliable alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. Both methods have strong concordance with acceptably narrow limits of agreement.
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Affiliation(s)
- Sameh M Hakim
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt -
| | - Ayman A Abdellatif
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohammad I Ali
- Department of Intensive Care, King Abdulaziz Hospital, Al-Jouf, Saudi Arabia
| | - Mona A Ammar
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Harris L, Hill CS. Craniectomy size for subdural haematomas and the impact on brain shift and outcomes. Acta Neurochir (Wien) 2020; 162:2019-2027. [PMID: 32556813 DOI: 10.1007/s00701-020-04448-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported. METHOD A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement. RESULTS Thirty-six patients with mean age of 36.1 ± 12.5 (range 16-62) were included, with a median follow-up of 23.5 months (range 2.2-109.6). The median craniectomy size was 88.7 cm2 and the median subtemporal decompression was 15.0 mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R2 < 0.05). CONCLUSIONS This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.
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Affiliation(s)
- Lauren Harris
- Department of Neurosurgery, The Royal London Hospital, London, E1 1BB, UK.
| | - Ciaran Scott Hill
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, W1B 3GG, UK
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Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study. Brain Sci 2020; 10:brainsci10050269. [PMID: 32369967 PMCID: PMC7287871 DOI: 10.3390/brainsci10050269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 01/25/2023] Open
Abstract
A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.
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Bedry T, Tadele H. Pattern and Outcome of Pediatric Traumatic Brain Injury at Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: Observational Cross-Sectional Study. Emerg Med Int 2020; 2020:1965231. [PMID: 32399303 PMCID: PMC7204112 DOI: 10.1155/2020/1965231] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/26/2019] [Accepted: 12/13/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is the most common cause of death/disability in children. The Glasgow coma scale and other parameters are used for treatment/follow-up of TBI. Childhood TBI data are scarce from sub-Saharan Africa. The study aimed to determine the pattern and predictors of the TBI outcome in Southern Ethiopia. METHODS An observational cross-sectional study was conducted from September 2017 to September 2018 at Hawassa University Hospital. Structured questionnaires were used for data collection. Significant associations were declared at a P value of <0.05. RESULTS There were 4,258 emergency room (ER) visits during the study period, and TBI contributed to 317 (7.4%) cases. The mean age of study subjects was 7.66 ± 3.88 years. Boys, predominantly above 5 years of age, comprise 218 (68.8%) of the study subjects with a male to female ratio of 2.2 : 1. Pedestrian road traffic accidents (RTA), 120 (37.9%), and falls, 104 (32.8%), were the commonest causes of TBI. Mild, moderate, and severe TBI were documented in 231 (72.9%), 61 (19.2%), and 25 (7.9%) of cases, respectively. Most of the TBI cases presented within 24 hrs of injury, 258 (81.4%). Recovery with no neurologic deficit, 267 (84.2%); focal neurologic deficit, 30 (9.5%); depressed mentation, 10 (3.2%); and death, 10 (3.2%), were documented. Signs of increased intracranial pressure (ICP) at admission [AOR: 1.415 (95% CI: 1.4058-9.557)], severe TBI [AOR: 2.553 (95% CI: 1.965-4.524)], presence of hyperglycemia [AOR: 2.318 (95% CI: 1.873-7.874)], and presence of contusion, diffuse axonal injury (DAI), or intracranial bleeding on the head computed tomography (CT) scan [AOR: 2.45 (95% CI: 1.811-7.952)] predicted poor TBI outcome. CONCLUSION TBI contributed to 7.4% of pediatric ER visits. Pedestrian RTA and falls, early presentation (<24 hours of injury), and mild form of TBI among boys were the most common documented patterns. ICP, hyperglycemia, severe TBI, and presence of contusion, DAI, or intracranial bleeding on head CT predicted poor outcome. Strategies to ensure road safety and to prevent falls and animal-related injuries and TBI follow-up for ICP and glycemic controls are recommended.
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Affiliation(s)
- Tuji Bedry
- Department of Pediatrics and Child Health, College of Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Henok Tadele
- Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Quach N, Do J, Dirlikov B, Ehsanian R, Pasipanodya EC, Ali A, Duong T. The Prognosis of Axial vs. Extra-Axial Lesions on Functional Status After Traumatic Brain Injury. Front Neurol 2019; 10:1167. [PMID: 31736869 PMCID: PMC6838132 DOI: 10.3389/fneur.2019.01167] [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: 07/03/2019] [Accepted: 10/16/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Head computed tomography (CT) scans are widely used in acute head injury for medical triage and surgical decisions, yet there are contradictions on the prognostic value of different head CT classifications. The intra-axial (axial) lesion vs. extra-axial lesion is a well-known systemic classification but has not been applied into clinical practice since there is no evidence-based support for its prognostic value. Hypothesis: Axial injury is related to worse functional independence compared to extra-axial injury at admission to and discharge from acute rehabilitation hospitalization. Design: Observational retrospective study. Settings and participants: Data from 71 participants who were enrolled at an acute rehabilitation hospital in the Northern California Traumatic Brain Injury Model System of Care (NCTBIMS) between 2005 and 2018 were included in the analysis. Main outcome measure and statistical analysis: Results of non-contrast head CT within the first 7 days after injury were analyzed to determine those with axial vs. extra-axial lesions. Functional Independence Measure (FIM) total scores were compared between the axial vs. extra-axial groups at admission and discharge using parametric and non-parametric tests. Results: There were no statistically significant group differences in FIM total scores at rehabilitation admission and discharge between the axial group and extra-axial groups. Conclusion: In this cohort of patients there was no evidence to support the hypothesis that axial injury is related to worse functional independence compared to extra-axial injury at rehabilitation admission and discharge. Utilizing MRI findings or other outcome measures, such as the 10 meter ambulation test or cognitive tests, may provide better sensitivity to potential functional differences.
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Affiliation(s)
- Nhung Quach
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States.,Beaumont Hospital-Trenton, Trenton, MI, United States
| | - Jacqueline Do
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Benjamin Dirlikov
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Reza Ehsanian
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States.,Department of Neurosurgery, Stanford University, Stanford, CA, United States.,Division of Physical Medicine and Rehabilitation, Department of Neurosurgery, The University of New Mexico, Albuquerque, NM, United States
| | - Elizabeth C Pasipanodya
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Arshad Ali
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Thao Duong
- Division of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, United States.,Department of Orthopedic Surgery, Stanford University, Stanford, CA, United States
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Spaite DW, Bobrow BJ, Keim SM, Barnhart B, Chikani V, Gaither JB, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg 2019; 154:e191152. [PMID: 31066879 PMCID: PMC6506902 DOI: 10.1001/jamasurg.2019.1152] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/03/2019] [Indexed: 12/27/2022]
Abstract
Importance Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures Primary: survival to hospital discharge; secondary: survival to hospital admission. Results Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02). Conclusions and Relevance Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration ClinicalTrials.gov identifier: NCT01339702.
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Affiliation(s)
- Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Khallaf M, Thabet AM, Ali M, Sharkawy E, Abdel-rehim S. The effect of dexmedetomidine versus propofol in traumatic brain injury: evaluation of some hemodynamic and intracranial pressure changes. EGYPTIAN JOURNAL OF NEUROSURGERY 2019. [DOI: 10.1186/s41984-019-0041-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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van Eijck MM, Sprengers MO, Oldenbeuving AW, de Vries J, Schoonman GG, Roks G. The use of the PSH-AM in patients with diffuse axonal injury and autonomic dysregulation: A cohort study and review. J Crit Care 2019; 49:110-117. [DOI: 10.1016/j.jcrc.2018.10.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 09/17/2018] [Accepted: 10/25/2018] [Indexed: 01/19/2023]
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Talari HR, Hamidian Y, Moussavi N, Fakharian E, Abedzadeh-Kalahroudi M, Akbari H, Taher EB. The Prognostic Value of Rotterdam Computed Tomography Score in Predicting Early Outcomes Among Children with Traumatic Brain Injury. World Neurosurg 2019; 125:e139-e145. [PMID: 30677579 DOI: 10.1016/j.wneu.2018.12.221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/28/2018] [Accepted: 12/29/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prediction of traumatic brain injury (TBI) among children is of great importance for accurate clinical decision making. OBJECTIVES This study aimed to determine the prognostic value of the Rotterdam scoring system in predicting early outcome among children with TBI. METHODS This study was conducted in 2017 on 506 children with brain injury in Kashan, Iran. A checklist was used to collect demographic and clinical characteristics of patients such as age, sex, mechanism of trauma, Glasgow Coma Scale (GCS) score, need for surgery, and brain injury outcome. Moreover, each participant's computed tomography scan was evaluated and scored using the Rotterdam system. Sensitivity, specificity, positive and negative predictive values, and the best cut-off score were calculated for the Rotterdam system. The relationships of the Rotterdam score with participants' characteristics were examined using the χ2 test, whereas the predictors of brain injury outcome were identified using the logistic regression analysis. RESULTS Pediatric death rate was 4.3%. Most deaths were among children who were male, aged <4, had developed brain injury owing to traffic accidents, had a GCS score of 3-8, suffered from compressed skull fracture and frontal lobe injury, had cerebral edema, and had a Rotterdam score of 5. The sensitivity and specificity of a Rotterdam score 3 were 86.4% and 97.9%, respectively. The logistic regression analysis indicated that only GCS and Rotterdam scores were significant predictors of brain injury outcome. CONCLUSIONS At a cut-off score of 3, the Rotterdam system can be used to predict TBI outcome among children with acceptable sensitivity and specificity.
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Affiliation(s)
- Hamid Reza Talari
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Yaser Hamidian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Nooshin Moussavi
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Esmail Fakharian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Masoumeh Abedzadeh-Kalahroudi
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran.
| | - Hossein Akbari
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Elaheh Baban Taher
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran; Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
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Amoo M, O'Halloran PJ, Leo AM, O'Loughlin A, Mahon P, Lim C. Outcomes of emergency neurosurgical intervention in neuro-critical care patients with traumatic brain injury at Cork University Hospital. Br J Neurosurg 2018; 32:585-589. [PMID: 30394116 DOI: 10.1080/02688697.2018.1522416] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Traumatic Brain Injury (TBI) is a major cause of death and disability; the leading cause of mortality and morbidity in previously healthy people aged under 40 in the United Kingdom (UK). There are currently little official Irish statistics regarding TBI or outcome measures following TBI, although it is estimated that over 2000 people per year sustain TBI in Ireland. We performed a retrospective cohort study of TBI patients who were managed in the intensive care unit (ICU) at CUH between July 2012 and December 2015. Demographic data were compiled by patients' charts reviews. Using the validated Glasgow outcome scale extended (GOS-E) outcome measure tool, we interviewed patients and/or their carers to measure functional outcomes. Descriptive statistical analyses were performed. Spearman's correlation analysis was used to assess association between different variables using IBM's Statistical Package for the Social Sciences (SPSS) 20. In the 42-month period, 102 patients were identified, mainly males (81%). 49% had severe TBI and 56% were referred from other hospitals. The mean age was 44.7 and a most of the patients were previously healthy, with 65% of patients having ASA I or II. Falls accounted for the majority of the TBI, especially amongst those aged over 50. The 30-day mortality was 25.5% and the mean length of hospital stay (LOS-H) was 33 days. 9.8% of the study population had a good recovery (GOS-E 8), while 7.8% had a GOS-E score of 3 (lower sever disability). Patients with Extra-Dural haemorrhage had better outcomes compared with those with SDH or multi-compartmental haemorrhages (p = 0.007). Older patients had a higher mortality, with the highest mortality (37.5%) among those over 50 years old (p = 0.009). TBI is associated with significant morbidity and mortality. Despite the young mean age and low ASA the mortality, morbidity and average LOS-H were significant, highlighting the health and socioeconomic burden of TBI.
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Affiliation(s)
- Michael Amoo
- a Department of Neurological Surgery , Cork University Hospital , Cork , Ireland
| | - Philip J O'Halloran
- a Department of Neurological Surgery , Cork University Hospital , Cork , Ireland
| | - Anne-Marie Leo
- b Department of Anaesthesia , Cork University Hospital , Cork Ireland
| | - Aoife O'Loughlin
- b Department of Anaesthesia , Cork University Hospital , Cork Ireland
| | - Padraig Mahon
- b Department of Anaesthesia , Cork University Hospital , Cork Ireland
| | - Chris Lim
- a Department of Neurological Surgery , Cork University Hospital , Cork , Ireland
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Zhu CS, Grandhi R, Patterson TT, Nicholson SE. A Review of Traumatic Brain Injury and the Gut Microbiome: Insights into Novel Mechanisms of Secondary Brain Injury and Promising Targets for Neuroprotection. Brain Sci 2018; 8:brainsci8060113. [PMID: 29921825 PMCID: PMC6025245 DOI: 10.3390/brainsci8060113] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/15/2018] [Accepted: 06/17/2018] [Indexed: 12/16/2022] Open
Abstract
The gut microbiome and its role in health and disease have recently been major focus areas of research. In this review, we summarize the different ways in which the gut microbiome interacts with the rest of the body, with focus areas on its relationships with immunity, the brain, and injury. The gut–brain axis, a communication network linking together the central and enteric nervous systems, represents a key bidirectional pathway with feed-forward and feedback mechanisms. The gut microbiota has a central role in this pathway and is significantly altered following injury, leading to a pro-inflammatory state within the central nervous system (CNS). Herein, we examine traumatic brain injury (TBI) in relation to this axis and explore potential interventions, which may serve as targets for improving clinical outcomes and preventing secondary brain injury.
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Affiliation(s)
- Caroline S Zhu
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
| | - Ramesh Grandhi
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
- Department of Neurosurgery, The University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
- Department of Neurosurgery, The University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Thomas Tyler Patterson
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
| | - Susannah E Nicholson
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
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Samuel S, Lee M, Brown RJ, Choi HA, Baguley IJ. Incidence of paroxysmal sympathetic hyperactivity following traumatic brain injury using assessment tools. Brain Inj 2018; 32:1115-1121. [PMID: 29856656 DOI: 10.1080/02699052.2018.1482002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, Texas, USA
| | - Monica Lee
- Department of Pharmacy, Houston Methodist West Hospital, USA
| | - Robert J Brown
- Department of Neurosurgery and Neurology, The University of Texas Medical School at Houston, USA
| | - Huimahn A. Choi
- Department of Neurosurgery and Neurology, The University of Texas Medical School at Houston, USA
| | - Ian J Baguley
- Western Medical School, The University of Sydney, NSW, Australia
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Para RA, Sarmast AH, Shah MA, Mir TA, Mir AW, Sidiq S, Lone AQ, Ramzan AU. Our Experience with Management and Outcome of Isolated Traumatic Brain Injury Patients Admitted in Intensive Care Unit. J Emerg Trauma Shock 2018; 11:288-292. [PMID: 30568372 PMCID: PMC6262657 DOI: 10.4103/jets.jets_34_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Traumatic brain injury (TBI) is a major cause of death and disability throughout the world. Commonly used predictors of outcome both individually or in combination include age, Glasgow Coma Scale score, pupillary reactivity, early hypoxia, and hypotension. Most of the studies previously done to examine risk factors for mortality in severe TBI were done in the setting of polytrauma. Aims and Objectives The aim and objective of this study was to do an in-depth analysis of various factors associated with the management and outcome of patients with isolated TBI admitted in an Intensive Care Unit (ICU). Materials and Methods A total of seventy adult patients who were admitted to Intensive Critical Care Unit (ICU) with isolated TBI were selected during a 12-month period from January 2016 to December 2016. This is a prospective analytical study and parameters studied included age, sex, cause of admission classified by type of trauma, premorbid functional status, acute and chronic comorbidities, brain noncontrast computed tomography scan data, Glasgow Coma Scale (GCS), hemodynamic status, respiratory status, and mechanical ventilation, blood gases, serum electrolytes, serum glucose, hemoglobin, leukocyte and platelet counts, renal function, and urinary output. Results The study population consisted of 46 (65.7%) males and 24 (34.2%) females. The mean age was 35.5 years (range, 18-65 years). The most common mode of trauma was road traffic accident (43.6%) followed by fall from height (35.7%). Statistically insignificant relationship (P < 0.05) was seen with sex and mode of injury among survivors and nonsurvivors; however, 61.9% of patients with age ≥40 years died (P < 0.005). Among clinical parameters at admission to ICU, low GCS, hypotension (mean arterial pressure ≤80 mmHg), hypoxia (pO2 ≤60 mmHg, spO2 ≤90 mmHg), and nonreacting pupils were significantly associated with increased mortality (P < 0.05). Conclusion Isolated TBI still continues to have a good amount of morbidity and mortality which perhaps can be reduced by strict adherence to guidelines of management.
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Affiliation(s)
- Reyaz Ahmed Para
- Department of Critical Care Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arif Hussain Sarmast
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mohammad Akbar Shah
- Department of Critical Care Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Toufeeq Ahmad Mir
- Department of Critical Care Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Waheed Mir
- Department of Critical Care Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Suhail Sidiq
- Department of Critical Care Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Qayoom Lone
- Department of Critical Care Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Altaf Umer Ramzan
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Bansal M, Sinha VD, Bansal J. Diagnostic and Prognostic Capability of Newer Magnetic Resonance Imaging Brain Sequences in Diffuse Axonal Injury Patient. Asian J Neurosurg 2018; 13:348-356. [PMID: 29682033 PMCID: PMC5898104 DOI: 10.4103/ajns.ajns_229_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives: Diffuse axonal injury is one of the major causes of unconsciousness, profound neurologic deficits and persistent vegetative state after head trauma. In recent years, MR imaging has been gaining popularity as an adjunctive imaging method in patients with DAI. Our study aims to assess the relative diagnostic and prognostic capability of various MRI sequences. Patients and Methods: Retrospective observational study done in 1 year duration on 30 DAI patients. Clinical assessment done with GCS at admission and GOS at 6 month. MRI Brain FLAIR, DWI, T2*GRE AND SWI sequences taken. DAI grade were evaluated for different MRI sequences. Prognosis was correlated to total number of lesion/locations and DAI grade of patients. Statistical analysis was done using SPSS Statistical software (ver.20.0.0) and XL-Stat and ANOVA one way test, post hoc test (Turkey test) and Chi square test. Result: We studied 30 male patients, mean age 32.57±8.72 ranges. The commonest mode of injury is RTA-80%, fall-16% followed by assault-3.33%. Out of 30 patients, 17 patients (56.67%) had GCS <=8, 13 patients (43.33%) had GCS between 9 and 12 and no patient had a GCS score between 13 and 15. The mean GCS score was 8.47±1.50. At a 6 month follow up, out of a total of 30 patients, 2 patients (6.66%) expired (GOS-1), 3 patients (10%) remained in persistent vegetative state (GOS-2), 11 patients (36.67%) and 10 patients (33.33%) were found to be severely (GOS-3) and moderately (GOS-4) disabled respectively and 4 patients (13.33%) showed good recovery (GOS-5). Mean GOS is 3.37+/-1.06. Newer imaging -SWI able to detects lesion better (diagnosis of DAI) as compared to other older sequences like FLAIR,DWI,T2*GRE. But no statistically significant found between total number of lesion/locations to the outcome and also newer imaging do not change the grade of DAI patients. Conclusion: Although advanced imaging in head injury, SWI helps in diagnosing the diffuse axonal injury more efficiently than other imaging sequences, but it is the grade of patients at admission that predicts the outcome best.
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Affiliation(s)
- Mayank Bansal
- Department of Neurosurgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Virendra Deo Sinha
- Department of Neurosurgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Juhi Bansal
- Department of Radiology, SMS Medical College, Jaipur, Rajasthan, India
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Oh H, Lee K, Shin S, Seo W. Temporal Patterns and Influential Factors of Blood Glucose Levels During the First 10-Day Critical Period After Brain Injury. Clin Nurs Res 2017; 28:744-761. [PMID: 29254374 DOI: 10.1177/1054773817749725] [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: 11/17/2022]
Abstract
This study was conducted to document temporal patterns of blood glucose level changes during the first 10-day critical period and to identify factors that influence stress-induced hyperglycemia development in brain injury patients. The medical records of 190 brain injury patients were retrospectively reviewed. Blood glucose levels in the poor recovery group were significantly higher than in the good recovery group, particularly during the first 72 hr (158-172 mg/dl). The poor recovery group showed persistent, fluctuating hyperglycemia, whereas the good recovery group exhibited hyperglycemic peaks during the first 3 days that subsequently reduced linearly to normal. Gender, preexisting hypertension, disease severity at admission, total calorie intake, and steroid use were found to influence stress-induced hyperglycemia development significantly. In conclusion, close monitoring and adjustment are required to maintain safe blood glucose levels and the development of protocols for safe glycemic management is essential to improve critical care in brain injury patients.
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Affiliation(s)
- HyunSoo Oh
- 1 Inha University, Incheon, Republic of Korea
| | - KangIm Lee
- 1 Inha University, Incheon, Republic of Korea
| | | | - WhaSook Seo
- 1 Inha University, Incheon, Republic of Korea
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Bonow RH, Barber J, Temkin NR, Videtta W, Rondina C, Petroni G, Lujan S, Alanis V, La Fuente G, Lavadenz A, Merida R, Jibaja M, Gonzáles L, Falcao A, Romero R, Dikmen S, Pridgeon J, Chesnut RM. The Outcome of Severe Traumatic Brain Injury in Latin America. World Neurosurg 2017; 111:e82-e90. [PMID: 29229352 DOI: 10.1016/j.wneu.2017.11.171] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries. METHODS This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection. RESULTS A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5-8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23-1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17-2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57-0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination. CONCLUSIONS Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | | | - Gustavo Petroni
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- University Hospital San Juan De Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Antonio Falcao
- Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - James Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Spaite DW, Hu C, Bobrow BJ, Chikani V, Barnhart B, Gaither JB, Denninghoff KR, Adelson PD, Keim SM, Viscusi C, Mullins T, Rice AD, Sherrill D. Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality. Ann Emerg Med 2017; 70:522-530.e1. [PMID: 28559036 PMCID: PMC5614805 DOI: 10.1016/j.annemergmed.2017.03.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury. The association of traumatic brain injury mortality with the depth or duration of out-of-hospital hypotension is unknown. We evaluated the relationship between the depth and duration of out-of-hospital hypotension and mortality in major traumatic brain injury. METHODS We evaluated adults and older children with moderate or severe traumatic brain injury in the preimplementation cohort of Arizona's statewide Excellence in Prehospital Injury Care study. We used logistic regression to determine the association between the depth-duration dose of hypotension (depth of systolic blood pressure <90 mm Hg integrated over duration [minutes] of hypotension) and odds of inhospital death, controlling for significant confounders. RESULTS There were 7,521 traumatic brain injury cases included (70.6% male patients; median age 40 years [interquartile range 24 to 58]). Mortality was 7.8% (95% confidence interval [CI] 7.2% to 8.5%) among the 6,982 patients without hypotension (systolic blood pressure ≥90 mm Hg) and 33.4% (95% CI 29.4% to 37.6%) among the 539 hypotensive patients (systolic blood pressure <90 mm Hg). Mortality was higher with increased hypotension dose: 0.01 to 14.99 mm Hg-minutes 16.3%; 15 to 49.99 mm Hg-minutes 28.1%; 50 to 141.99 mm Hg-minutes 38.8%; and greater than or equal to 142 mm Hg-minutes 50.4%. Log2 (the logarithm in base 2) of hypotension dose was associated with traumatic brain injury mortality (adjusted odds ratio 1.19 [95% CI 1.14 to 1.25] per 2-fold increase of dose). CONCLUSION In this study, the depth and duration of out-of-hospital hypotension were associated with increased traumatic brain injury mortality. Assessments linking out-of-hospital blood pressure with traumatic brain injury outcomes should consider both depth and duration of hypotension.
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Affiliation(s)
- Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ.
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; College of Public Health, University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ; Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ
| | - Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, University of Arizona, Phoenix, AZ
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - Duane Sherrill
- College of Public Health, University of Arizona, Tucson, AZ
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Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol 2017; 16:721-729. [PMID: 28816118 DOI: 10.1016/s1474-4422(17)30259-4] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/28/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
A substantial minority of patients who survive an acquired brain injury develop a state of sympathetic hyperactivity that can persist for weeks or months, consisting of periodic episodes of increased heart rate and blood pressure, sweating, hyperthermia, and motor posturing, often in response to external stimuli. The unifying term for the syndrome-paroxysmal sympathetic hyperactivity (PSH)-and clear diagnostic criteria defined by expert consensus were only recently established. PSH has predominantly been described after traumatic brain injury (TBI), in which it is associated with worse outcomes. The pathophysiology of the condition is not completely understood, although most researchers consider it to be a disconnection syndrome with paroxysms driven by a loss of inhibitory control over excitatory autonomic centres. Although therapeutic strategies to alleviate sympathetic outbursts have been proposed, their effects on PSH are inconsistent between patients and their influence on outcome is unknown. Combinations of drugs are frequently used and are chosen on the basis of local custom, rather than on objective evidence. New rigorous tools for diagnosis could allow better characterisation of PSH to enable stratification of patients for future therapeutic trials.
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Affiliation(s)
- Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK.
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Gaither JB, Chikani V, Stolz U, Viscusi C, Denninghoff K, Barnhart B, Mullins T, Rice AD, Mhayamaguru M, Smith JJ, Keim SM, Bobrow BJ, Spaite DW. Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes. PREHOSP EMERG CARE 2017; 21:575-582. [PMID: 28481163 DOI: 10.1080/10903127.2017.1308609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. METHODS This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. RESULTS 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. CONCLUSION In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.
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Turgeon AF, Lauzier F, Zarychanski R, Fergusson DA, Léger C, McIntyre LA, Bernard F, Rigamonti A, Burns K, Griesdale DE, Green R, Scales DC, Meade MO, Savard M, Shemilt M, Paquet J, Gariépy JL, Lavoie A, Reddy K, Jichici D, Pagliarello G, Zygun D, Moore L. Prognostication in critically ill patients with severe traumatic brain injury: the TBI-Prognosis multicentre feasibility study. BMJ Open 2017; 7:e013779. [PMID: 28416497 PMCID: PMC5775467 DOI: 10.1136/bmjopen-2016-013779] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Severe traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury. DESIGN A prospective cohort study. SETTING 9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12 months following injury. OUTCOMES The compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up. RESULTS We successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45 years (IQR 29.0-60.0), a median Injury Severity Score of 38 (IQR 25-50) and a Glasgow Coma Scale of 6 (IQR 3-7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6 months and 2 were at 12 months. CONCLUSIONS In this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.
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Affiliation(s)
- Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Critical Care and of Haematology and Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Unit, Center for Transfusion and Critical Care Research, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Caroline Léger
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Lauralyn A McIntyre
- Clinical Epidemiology Unit, Center for Transfusion and Critical Care Research, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Francis Bernard
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Andrea Rigamonti
- Interdepartmental Division of Critical Care Medicine, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karen Burns
- Interdepartmental Division of Critical Care Medicine, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Green
- Department of Critical Care Medicine, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maureen O Meade
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Martin Savard
- Department of Medicine, Division of Neurology, Université Laval, Québec, Québec, Canada
| | - Michèle Shemilt
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Jérôme Paquet
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec, Québec, Canada
- Department Radiology and Nuclear Medicine, Université Laval, Québec, Québec, Canada
| | - Jean-Luc Gariépy
- Department Radiology and Nuclear Medicine, Université Laval, Québec, Québec, Canada
| | - André Lavoie
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Kesh Reddy
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Draga Jichici
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Giuseppe Pagliarello
- Department of Critical Care Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David Zygun
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Preventive and Social Medicine, Université Laval, Québec, Québec, Canada
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Peng Y, Zhu H, Chen H, Zhu Z, Zhou H, Zhang S, Gao L, Shi L, Li X, Luo Z. Dexmedetomidine attenuates acute paroxysmal sympathetic hyperactivity. Oncotarget 2017; 8:69012-69019. [PMID: 28978176 PMCID: PMC5620316 DOI: 10.18632/oncotarget.16920] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/20/2017] [Indexed: 12/18/2022] Open
Abstract
We evaluated the curative effect of dexmedetomidine on paroxysmal sympathetic hyperactivity (PSH) in a retrospective study of 72 PSH patients after neurosurgery. Our results showed that dexmedetomidine was superior to propofol for treatment of PSH with respect to: average time needed to reduce paroxysmal hypertension (PH) to <140/90 mmHg (29.03±8.86 vs. 42.0±14.77 min), average remission time of PH (3.97±1.73 vs. 5.65±1.51 min), PH remission rate (61.22±10.8% vs. 41.52±14.15%), PH duration (9.31±2.66 vs. 13.05±4.19 days), average time for body temperature to return to normal (10.62±4.14 vs. 15.31±4.58 days), average time for heartrate to return to normal (11.34±3.90 vs. 15.72±4.10 days), and average time of respiratory rate below 25 breaths per minute (BPM) (7.00±1.74 vs. 15.32±5.87 days). Multiple logistic regression analyses showed that dexmedetomidine did not protect against the recurrence of PSH. Age and Glasgow Coma Score were the main factors predicting PSH recurrence. There was no difference in Glasgow Outcome Score (GOS) between the two groups during the 6 months of postoperative follow-up (p>0.05). These data suggest dexmedetomidine effectively controls an acute attack of PSH, but it does not improve the long-term prognosis of patients compared with propofol.
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Affiliation(s)
- Yuan Peng
- Department of Intensive Care Unit and Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou 215300, P. R. China
| | - Haifeng Zhu
- Department of Neurosurgery and Medical Oncology, Jiangsu Funing People's Hospital, Funing 224400, P. R. China
| | - Haodong Chen
- Department of Neurosurgery, Liuhe Hospital Affiliated to Medical College of Yangzhou University, Nanjing 211500, P. R. China
| | - Zijin Zhu
- Department of Neurosurgery, Anhui Province Wangjiang Hospital, Anhui 246200, P. R. China
| | - Huahai Zhou
- Department of Neurosurgery, Sihong County People's Hospital, Suqian 223900, P. R. China
| | - Shuguang Zhang
- Department of Intensive Care Unit and Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou 215300, P. R. China
| | - Lili Gao
- Department of Neurosurgery and Medical Oncology, Jiangsu Funing People's Hospital, Funing 224400, P. R. China
| | - Lei Shi
- Department of Intensive Care Unit and Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou 215300, P. R. China
| | - Xiaoliang Li
- Department of Intensive Care Unit and Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou 215300, P. R. China
| | - Zhengxiang Luo
- Department of Neurosurgery, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210029, P. R. China
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Spaite DW, Hu C, Bobrow BJ, Chikani V, Sherrill D, Barnhart B, Gaither JB, Denninghoff KR, Viscusi C, Mullins T, Adelson PD. Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold. JAMA Surg 2017; 152:360-368. [PMID: 27926759 PMCID: PMC5637731 DOI: 10.1001/jamasurg.2016.4686] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. OBJECTIVE To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. DESIGN, SETTING, AND PARTICIPANTS Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. MAIN OUTCOMES AND MEASURES The main outcome measure was in-hospital mortality. RESULTS Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range. CONCLUSIONS AND RELEVANCE We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.
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Affiliation(s)
- Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- College of Public Health, University of Arizona, Tucson, Arizona
| | - Bentley J. Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, Arizona
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Vatsal Chikani
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Duane Sherrill
- College of Public Health, University of Arizona, Tucson, Arizona
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
| | - Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix, Arizona
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, Arizona
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Tang Q, Lei J, Gao G, Feng J, Mao Q, Jiang J. Prevalence of persistent vegetative state in patients with severe traumatic brain injury and its trend during the past four decades: A meta-analysis. NeuroRehabilitation 2017; 40:23-31. [DOI: 10.3233/nre-161387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Traumatic brain injury (TBI) is a physical insult (a bump, jolt, or blow) to the brain that results in temporary or permanent impairment of normal brain function. TBI describes a heterogeneous group of disorders. The resulting secondary injury, namely brain swelling and its sequelae, is the reason why patients with these vastly different initial insults are homogenously treated. Much of the evidence for the management of TBI is poor or conflicting, and thus definitive guidelines are largely unavailable for clinicians at this time. A substantial portion of this article focuses on discussing the controversies in the management of TBI.
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Affiliation(s)
- Sayuri Jinadasa
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - M Dustin Boone
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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Pressure to Progress: Severe Traumatic Brain Injury and Slow Recovery in the Current Health Care Environment. AUSTRALIAN JOURNAL OF REHABILITATION COUNSELLING 2017. [DOI: 10.1017/s1323892200000661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This paper discusses issues arising from a study of referral from acute care following traumatic brain injury (TBI) in Queensland, in which aged care facilities were relied upon for the discharge of those with slow recovery after severe TBI. The discussion considers: (1) recovery following severe TBI; (2) the current policy context; (3) approaches to care beyond acute care; and (4) implications for policy and practice. In the current health care environment, with increasing pressure on scarce resources, it is critical that practitioners advocate for the dignity and care of people who sustain severe TBI and who are slow to recover.
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Tang Q, Wu X, Weng W, Li H, Feng J, Mao Q, Gao G, Jiang J. The preventive effect of dexmedetomidine on paroxysmal sympathetic hyperactivity in severe traumatic brain injury patients who have undergone surgery: a retrospective study. PeerJ 2017; 5:e2986. [PMID: 28229021 PMCID: PMC5314954 DOI: 10.7717/peerj.2986] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 01/12/2017] [Indexed: 11/20/2022] Open
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) results and aggravates in secondary brain injury, which seriously affects the prognosis of severe traumatic brain injury patients. Although several studies have focused on the treatment of PSH, few have concentrated on its prevention. Methods Ninety post-operation (post-op) severe traumatic brain injury (sTBI) patients admitted from October 2014 to April 2016 were chosen to participate in this study. Fifty of the post-op sTBI patients were sedated with dexmedetomidine and were referred as the “dexmedetomidine group” (admitted from May 2015 to April 2016). The other 40 patients (admitted from October 2014 to May 2015) received other sedations and were referred as the “control group.” The two groups were then compared based on their PSH scores and the scores and ratios of those patients who met the criteria of “probable,” “possible” and “unlikely” using the PSH assessment measure (PSH-AM) designed by Baguley et al. (2014). The durations of the neurosurgery intensive care unit (NICU) and hospital stays and the Glasgow outcome scale (GOS) values for the two groups were also compared to evaluate the therapeutic effects and the patients’ prognosis. Results The overall PSH score for the dexmedetomidine group was 5.26 ± 4.66, compared with 8.58 ± 8.09 for the control group. The difference between the two groups’ PSH scores was significant (P = 0.017). The score of the patients who met the criterion of “probable” was 18.33 ± 1.53 in the dexmedetomidine group and 22.63 ± 2.97 in the control group, and the difference was statistically significant (P = 0.045). The ratio of patients who were classified as “unlikely” between the two groups was statistically significant (P = 0.028); that is, 42 (84%) in the dexmedetomidine group and 25 (62.5%) in the control group. The differences in NICU, hospital stays and GOS values between the two groups were not significant. Conclusion Dexmedetomidine has a preventive effect on PSH in sTBI patients who have undergone surgery.
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Affiliation(s)
- Qilin Tang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Xiang Wu
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Weiji Weng
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Hongpeng Li
- Department of Neurosurgery, Rizhao City Hospital of Traditional Chinese Medicine , Rizhao , Shandong Province , China
| | - Junfeng Feng
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Qing Mao
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Guoyi Gao
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyao Jiang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
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Spaite DW, Hu C, Bobrow BJ, Chikani V, Barnhart B, Gaither JB, Denninghoff KR, Adelson PD, Keim SM, Viscusi C, Mullins T, Sherrill D. The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury. Ann Emerg Med 2017; 69:62-72. [PMID: 27692683 PMCID: PMC5173421 DOI: 10.1016/j.annemergmed.2016.08.007] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/30/2016] [Accepted: 08/01/2016] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination. METHODS All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out-of-hospital oxygen saturation ≤10%, and out-of-hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center. RESULTS Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death. CONCLUSION In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.
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Affiliation(s)
- Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ.
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; College of Public Health, the University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ; Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ
| | - Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, the University of Arizona, Phoenix, AZ
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ
| | - Duane Sherrill
- College of Public Health, the University of Arizona, Tucson, AZ
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Stawicki SP, Wojda TR, Nuschke JD, Mubang RN, Cipolla J, Hoff WS, Hoey BA, Thomas PG, Sweeney J, Ackerman D, Hosey J, Falowski S. Prognostication of traumatic brain injury outcomes in older trauma patients: A novel risk assessment tool based on initial cranial CT findings. Int J Crit Illn Inj Sci 2017; 7:23-31. [PMID: 28382256 PMCID: PMC5364765 DOI: 10.4103/ijciis.ijciis_2_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction: Advanced age has been traditionally associated with worse traumatic brain injury (TBI) outcomes. Although prompt neurosurgical intervention (NSI, craniotomy or craniectomy) may be life-saving in the older trauma patient, it does not guarantee survival and/or return to preinjury functional status. The aim of this study was to determine whether a simple score, based entirely on the initial cranial computed tomography (CCT) is predictive of the need for NSI and key outcome measures (e.g., morbidity and mortality) in the older (age 45+ years) TBI patient subset. We hypothesized that increasing number of categorical CCT findings is independently associated with NSI, morbidity, and mortality in older patients with severe TBI. Methods: After IRB approval, a retrospective study of patients 45 years and older was performed using our Regional Level 1 Trauma Center registry data between June 2003 and December 2013. Collected variables included patient demographics, Injury Severity Score (ISS), Abbreviated Injury Scale Head (AISh), brain injury characteristics on CCT, Glasgow Coma Scale (GCS), Intensive Care Unit (ICU) and hospital length of stay (LOS), all-cause morbidity and mortality, functional independence scores, as well as discharge disposition. A novel CCT scoring tool (CCTST, scored from 1 to 8+) was devised, with one point given for each of the following findings: subdural hematoma, epidural hematoma, subarachnoid blood, intraventricular blood, cerebral contusion/intraparenchymal blood, skull fracture, pneumocephalus, brain edema/herniation, midline shift, and external (skin/face) trauma. Descriptive statistics and univariate analyses were conducted with 30-day mortality, in-hospital morbidity, and need for NSI as primary end-points. Secondary end-points included the length of stay in the ICU (ICULOS), step-down unit (SDLOS), and the hospital (HLOS) as well as patient functional outcomes, and postdischarge destination. Factors associated with the need for NSI were determined using matched NSI (n = 310) and non-NSI (n = 310) groups. All other analyses examined the combined patient sample (n = 620). Variables achieving a significance level of P < 0.20 were included in the logistic regression. Receiver operating characteristic curves, with corresponding area under the curve (AUC) determinations, were also analyzed. Statistical significance was set at α = 0.05. Data are presented as percentages, mean ± standard deviation, or adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs). Results: A total of 620 patients were analyzed, including 310 patients who underwent NSI and 310 age- and ISS-matched non-NSI controls. Average patient age was 72.8 ± 13.4 years (64.1% male, 99% blunt trauma, mean ISS 25.1 ± 8.68, and mean AISh/GCS of 4.63/10.9). CCTST was the only variable independently associated with NSI (AOR 1.23, 95% CI 1.06–1.42) and was inversely proportional to initial GCS and functional outcome scores on discharge. Increasing CCTST was associated with greater mortality, morbidity, HLOS, SDLOS, ICULOS, and ventilator days. On multivariate analysis, factors independently associated with mortality included AISh (AOR 2.70, 95% CI 1.21–6.00), initial GCS (AOR 1.14, 1.07–1.22), and CCTST (AOR 1.31, 1.09–1.58). Variables independently associated with in-hospital morbidity included CCTST (AOR 1.16, 1.02–1.34), GCS (AOR 1.05, 1.01–1.09), and NSI (AOR 2.62, 1.69–4.06). Multivariate models incorporating factors independently associated with each respective outcome displayed good overall predictive characteristics for mortality (AUC 0.787) and in-hospital morbidity (AUC 0.651). Finally, modified CCTST demonstrated good overall predictive ability for NSI (AUC 0.755). Conclusion: This study found that the number of discrete findings on CCT is independently associated with major TBI outcome measures, including 30-day mortality, in-hospital morbidity, and NSI. Of note, multivariate models with best predictive characteristics incorporate both CCTST and GCS. CCTST is easy to calculate, and this preliminary investigation of its predictive utility in older patients with TBI warrants further validation, focusing on exploring prognostic synergies between CCTST, GCS, and AISh. If independently confirmed to be predictive of clinical outcomes and the need for NSI, the approach described herein could lead to a shift in both operative and nonoperative management of patients with TBI.
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Affiliation(s)
- Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Thomas R Wojda
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - John D Nuschke
- Bethlehem Campus, Temple University School of Medicine, Bethlehem, Pennsylvania, USA
| | - Ronnie N Mubang
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - James Cipolla
- Level I Regional Trauma Center, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - William S Hoff
- Level I Regional Trauma Center, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Brian A Hoey
- Level I Regional Trauma Center, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Peter G Thomas
- Level I Regional Trauma Center, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Joan Sweeney
- Neurology Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Daniel Ackerman
- Neurology Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jonathan Hosey
- Neurology Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Steven Falowski
- Neurosurgery Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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Saade N, Veiga JCE, Cannoni LF, Haddad L, Araújo JLV. Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury. Rev Col Bras Cir 2016; 41:256-62. [PMID: 25295986 DOI: 10.1590/0100-69912014004006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 10/22/2013] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to determine predictive factors for prognosis of decompressive craniectomy in patients with severe traumatic brain injury (TBI), describing epidemiological findings and the major complications of this procedure. METHODS we conducted a retrospective study based on analysis of clinical and neurological outcome, using the extended Glasgow outcome in 56 consecutive patients diagnosed with severe TBI scale treated in the emergency department from February 2004 to July 2012. The variables assessed were age, mechanism of injury, presence of pupillary changes, Glasgow coma scale (GCS) score on admission, CT scan findings (volume, type and association of intracranial lesions, deviation from the midline structures and classification in the scale of Marshall and Rotterdam). RESULTS we observed that 96.4% of patients underwent unilateral decompressive craniectomy (DC) with expansion duraplasty, and the remainder to bilateral DC, 53.6% of cases being on the right 42.9% on the left, and 3.6% bilaterally, with predominance of the fourth decade of life and males (83.9%). Complications were described as transcalvarial herniation (17.9%), increased volume of brain contusions (16.1%) higroma (16.1%), hydrocephalus (10.7%), swelling of the contralateral lesions (5.3%) and CSF leak (3.6%). CONCLUSION among the factors studied, only the presence of mydriasis with absence of pupillary reflex, scoring 4 and 5 in the Glasgow Coma Scale, association of intracranial lesions and diversion of midline structures (DML) exceeding 15 mm correlated statistically as predictors of poor prognosis.
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Affiliation(s)
- Nelson Saade
- Department of Neurosurgery, Faculty of Medical Sciences, Irmandade da Santa Casa de Misericórdia de São Paulo
| | - José Carlos Esteves Veiga
- Department of Neurosurgery, Faculty of Medical Sciences, Irmandade da Santa Casa de Misericórdia de São Paulo
| | - Luiz Fernando Cannoni
- Department of Neurosurgery, Faculty of Medical Sciences, Irmandade da Santa Casa de Misericórdia de São Paulo
| | - Luciano Haddad
- Department of Neurosurgery, Faculty of Medical Sciences, Irmandade da Santa Casa de Misericórdia de São Paulo
| | - João Luiz Vitorino Araújo
- Department of Neurosurgery, Faculty of Medical Sciences, Irmandade da Santa Casa de Misericórdia de São Paulo
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McMillan T, Wilson L, Ponsford J, Levin H, Teasdale G, Bond M. The Glasgow Outcome Scale - 40 years of application and refinement. Nat Rev Neurol 2016; 12:477-85. [PMID: 27418377 DOI: 10.1038/nrneurol.2016.89] [Citation(s) in RCA: 193] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The Glasgow Outcome Scale (GOS) was first published in 1975 by Bryan Jennett and Michael Bond. With over 4,000 citations to the original paper, it is the most highly cited outcome measure in studies of brain injury and the second most-cited paper in clinical neurosurgery. The original GOS and the subsequently developed extended GOS (GOSE) are recommended by several national bodies as the outcome measure for major trauma and for head injury. The enduring appeal of the GOS is linked to its simplicity, short administration time, reliability and validity, stability, flexibility of administration (face-to-face, over the telephone and by post), cost-free availability and ease of access. These benefits apply to other derivatives of the scale, including the Glasgow Outcome at Discharge Scale (GODS) and the GOS paediatric revision. The GOS was devised to provide an overview of outcome and to focus on social recovery. Since the initial development of the GOS, there has been an increasing focus on the multidimensional nature of outcome after head injury. This Review charts the development of the GOS, its refinement and usage over the past 40 years, and considers its current and future roles in developing an understanding of brain injury.
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Affiliation(s)
- Tom McMillan
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 8RZ, UK
| | - Lindsay Wilson
- Department of Psychology, University of Stirling, Stirling FK9 4LA, UK
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Victoria 3800, Australia
| | - Harvey Levin
- Department of Physical Medicine &Rehabilitation, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030, USA
| | - Graham Teasdale
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 8RZ, UK
| | - Michael Bond
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 8RZ, UK
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Nelson CG, Elta T, Bannister J, Dzandu J, Mangram A, Zach V. Severe Traumatic Brain Injury: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:186-91. [PMID: 27005826 PMCID: PMC4807741 DOI: 10.12659/ajcr.897116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Male, 28 Final Diagnosis: Closed head injury Symptoms: Bilateral mydriasis • coma Medication: — Clinical Procedure: Ventriculostomy and hemicraniectomy Specialty: Neurology
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Affiliation(s)
- Clinton G Nelson
- Department of Trauma Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, USA
| | - Tara Elta
- Department of Neurocritical Care, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, USA
| | - Jeanette Bannister
- Department of Neurocritical Care, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, USA
| | - James Dzandu
- Department of Trauma Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, USA
| | - Alicia Mangram
- Department of Trauma Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, USA
| | - Victor Zach
- Department of Neurocritical Care, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, USA
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Abstract
Traumatic brain injury (TBI) is a significant public-health concern. TBI is defined as an acute brain injury resulting from mechanical energy to the head from external physical forces. Some of the leading causes of TBI include falls, assaults, motor vehicle or traffic accidents, and sport-related concussion. Two of the most common identified risk factors are sex (males are nearly three times more likely to suffer a TBI than females); and a bimodal age pattern (persons 65 years and older, and children under 14 years old). It is estimated that approximately 1.5-2 million Americans suffer from TBI annually. TBIs account for around 1.4 million emergency room visits, 275 000 hospital admissions, and 52 000 deaths in the USA each year. TBI contributes to approximately 30% of all deaths in the USA annually. In Australia, it is estimated that approximately 338 700 individuals (1.9% of the population) suffer from a disability related to TBI. Of these, 160 200 were severely or profoundly affected by acquired brain injury, requiring daily support. In the UK, TBI accounted for 3.4% of all emergency department attendances annually. An overall rate of 453 per 100 000 was found for all TBI severities, of which 40 per 100 000 (10.9%) were moderate to severe. TBI often results in residual symptoms that affect an individual's cognition, movement, sensation, and/or emotional functioning. Recovery and rehabilitation from TBI may require considerable resources and may take years. Some individuals never fully recover, and some require lifetime ongoing care and support. TBI has an enormous social and financial cost, with estimates of the annual financial burden associated with TBI ranging between 9 and 10 billion US dollars.
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Affiliation(s)
- A J Gardner
- Hunter New England Local Health District Sports Concussion Program; Priority Research Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
| | - R Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital; MassGeneral Hospital for Children Sport Concussion Program and Red Sox Foundation and Massachusetts General Hospital Home Base Program, Brigham and Women's Hospital, Boston, MA, USA
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Steppacher I, Kaps M, Kissler J. Against the odds: a case study of recovery from coma after devastating prognosis. Ann Clin Transl Neurol 2015; 3:61-5. [PMID: 26783551 PMCID: PMC4704482 DOI: 10.1002/acn3.269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/30/2015] [Accepted: 11/02/2015] [Indexed: 11/14/2022] Open
Abstract
To demonstrate the possibility for hidden rehabilitation potential even following most severe brain injury and the uncertainty of current prognosis factors for coma and unresponsive wakefulness syndrome, we detail the rehabilitation of J. W., after coma from traumatic brain injury. Originally, with many negative prognosis factors and several medical complications, prognosis was devastating. But, with continuing treatment, J. W. improved to a high level of independence in everyday life. This shows the need for rehabilitation research to further specify the “prognostic power” of various combinations of prognosis factors, so that practitioners can come to accurate single‐case recommendations when both positive and negative predictors are present.
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Affiliation(s)
- Inga Steppacher
- Department for Psychology University of Bielefeld Bielefeld Germany
| | - Michael Kaps
- Kliniken Schmieder Lurija Institut Allensbach Germany
| | - Johanna Kissler
- Department for Psychology University of Bielefeld Bielefeld Germany
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