Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

The Australian Traumatic Brain Injury Initiative: Systematic Review of Predictive Value of Biological Markers for People With Moderate-Severe Traumatic Brain Injury

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to co-design a data resource to predict outcomes for people with moderate-severe traumatic brain injury (TBI) across Australia. Fundamental to this resource is the data dictionary, which is an ontology of data items. Here, we report the systematic review and consensus process for inclusion of biological markers in the data dictionary. Standardized database searches were implemented from inception through April 2022. English-language studies evaluating association between a fluid, tissue, or imaging marker and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Records were screened using a prioritization algorithm and saturation threshold in Research Screener. Full-length records were then screened in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association, and high-value predictors were discussed in a consensus process. Searches retrieved 106,593 records; 1,417 full-length records were screened, resulting in 546 included records. Two hundred thirty-nine individual markers were extracted, evaluated against 101 outcomes. Forty-one markers were judged to be high-value predictors of 15 outcomes. Fluid markers retained following the consensus process included ubiquitin C-terminal hydrolase L1 (UCH-L1), S100, and glial fibrillary acidic protein (GFAP). Imaging markers included computed tomography (CT) scores (e.g., Marshall scores), pathological observations (e.g., hemorrhage, midline shift), and magnetic resonance imaging (MRI) classification (e.g., diffuse axonal injury). Clinical context and time of sampling of potential predictive indicators are important considerations for utility. This systematic review and consensus process has identified fluid and imaging biomarkers with high predictive value of clinical and long-term outcomes following moderate-severe TBI.

Late Blood Levels of Neurofilament Light Correlate With Outcome in Patients With Traumatic Brain Injury

Neurofilament light (NF-L) is an axonal protein that has shown promise as a traumatic brain injury (TBI) biomarker. Serum NF-L shows a rather slow rise after injury, peaking after 1-2 weeks, although some studies suggest that it may remain elevated for months after TBI. The aim of this study was to examine if plasma NF-L levels several months after the injury correlate with functional outcome in patients who have sustained TBIs of variable initial severity. In this prospective study of 178 patients with TBI and 40 orthopedic injury controls, we measured plasma NF-L levels in blood samples taken at the follow-up appointment on average 9 months after injury. Patients with TBI were divided into two groups (mild [mTBI] vs. moderate-to-severe [mo/sTBI]) according to the severity of injury assessed with the Glasgow Coma Scale upon admission. Recovery and functional outcome were assessed using the Extended Glasgow Outcome Scale (GOSE). Higher levels of NF-L at the follow-up correlated with worse outcome in patients with moderate-to-severe TBI (Spearman's rho = -0.18; p < 0.001). In addition, in computed tomography-positive mTBI group, the levels of NF-L were significantly lower in patients with GOSE 7-8 (median 18.14; interquartile range [IQR] 9.82, 32.15) when compared with patients with GOSE <7 (median 73.87; IQR 32.17, 110.54; p = 0.002). In patients with mTBI, late NF-L levels do not seem to provide clinical benefit for late-stage assessment, but in patients with initially mo/sTBI, persistently elevated NF-L levels are associated with worse outcome after TBI and may reflect ongoing brain injury.

Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury: An Intersociety Consensus Document

BACKGROUND

All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome.

METHODS

Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation.

RESULTS

The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions.

CONCLUSIONS

The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.

Predictive models for occurrence of expansive intracranial hematomas and surgical evacuation outcomes in traumatic brain injury patients in Uganda: A prospective cohort study

BACKGROUND

Hematoma expansion is a common manifestation of acute intracranial hemorrhage (ICH) which is associated with poor outcomes and functional status. Objective We determined the prevalence of expansive intracranial hematomas (EIH) and assessed the predictive model for EIH occurrence and surgical evacuation outcomes in patients with traumatic brain injury (TBI) in Uganda. Methods We recruited adult patients with TBI with intracranial hematomas in a prospective cohort study. Data analysis using logistic regression to identify relevant risk factors, assess the interactions between variables, and developing a predictive model for EIH occurrence and surgical evacuation outcomes in TBI patients was performed. The predictive accuracies of these algorithms were compared using the area under the receiver operating characteristic curve (AUC). A p-values of < 0.05 at a 95% Confidence interval (CI) was considered significant. Results A total of 324 study participants with intracranial hemorrhage were followed up for 6 months after surgery. About 59.3% (192/324) had expansive intracranial hemorrhage. The study participants with expansive intracranial hemorrhage had poor quality of life at both 3 and 6-months with p < 0.010 respectively. Among the 5 machine learning algorithms, the random forest performed the best in predicting EIH in both the training cohort (AUC = 0.833) and the validation cohort (AUC = 0.734). The top five features in the random forest algorithm-based model were subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma. Other models demonstrated good discrimination with AUC for intraoperative complication (0.675) and poor discrimination for mortality (0.366) after neurosurgical evacuation in TBI patients. Conclusion Expansive intracranial hemorrhage is common among patients with traumatic brain injury in Uganda. Early identification of patients with subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma, were crucial in predicting EIH and intraoperative complications.

Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury

Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.

Comparing Predictive Utility of Head Computed Tomography Scan-Based Scoring Systems for Traumatic Brain Injury: A Retrospective Study

This study compared the predictive utility of Marshall, Rotterdam, Stockholm, Helsinki, and NeuroImaging Radiological Interpretation System (NIRIS) scorings based on early non-contrast brain computed tomography (CT) scans in patients with traumatic brain injury (TBI). The area under a receiver operating characteristic curve (AUROC) was used to determine the predictive utility of scoring systems. Subgroup analyses were performed among patients with head AIS scores > 1. A total of 996 patients were included, of whom 786 (78.9%) were males. In-hospital mortality, ICU admission, neurosurgical intervention, and prolonged total hospital length of stay (THLOS) were recorded for 27 (2.7%), 207 (20.8%), 82 (8.2%), and 205 (20.6%) patients, respectively. For predicting in-hospital mortality, all scoring systems had AUROC point estimates above 0.9 and 0.75 among all included patients and patients with head AIS > 1, respectively, without any significant differences. The Marshall and NIRIS scoring systems had higher AUROCs for predicting ICU admission and neurosurgery than the other scoring systems. For predicting THLOS ≥ seven days, although the NIRIS and Marshall scoring systems seemed to have higher AUROC point estimates when all patients were analyzed, five scoring systems performed roughly the same in the head AIS > 1 subgroup.

Hyperosmolar therapies for neurological deterioration in mild and moderate traumatic brain injury: A scoping review

OBJECTIVE

To explore the available evidence on hyperosmolar therapies(HT) in mild and moderate traumatic brain injury(TBI) and to evaluate the effects on outcomes.A scoping review was conducted according to the Joanna Briggs Institute methodology. Inclusion criteria: (a)randomized controlled trials(RCTs), prospective and retrospective cohort studies and case-control studies; (b)all-ages mild and moderate TBIs; (c)HT administration; (d)functional outcomes recorded; (e)comparator group.

RESULTS

From 4424 records, only 3 respected the inclusion criteria. In a retrospective cohort study of adult moderate TBIs, the Glasgow Coma Scale(GCS) remained the same at 48 hours in those treated with hypertonic saline(HTS) while it worsened in the non-treated. A trend toward increased pulmonary infections and length of stay was found. In an RCT of adult severe and moderate TBIs, moderate TBIs treated with HTS showed a trend toward better secondary outcomes than standard care alone, with similar odds of adverse effects. An RCT enrolling children with mild TBI found a significant improvement in concussive pain immediately after HTS administration and after 2-3 days. No adverse events occurred.

CONCLUSIONS

A gap in the literature about HTs' role in mild and moderate TBI was found. Some benefits may exist with limited side effects and further studies are desirable.

Manual lesion segmentations for traumatic brain injury characterization

Traumatic brain injury (TBI) often results in heterogenous lesions that can be visualized through various neuroimaging techniques, such as magnetic resonance imaging (MRI). However, injury burden varies greatly between patients and structural deformations often impact usability of available analytic algorithms. Therefore, it is difficult to segment lesions automatically and accurately in TBI cohorts. Mislabeled lesions will ultimately lead to inaccurate findings regarding imaging biomarkers. Therefore, manual segmentation is currently considered the gold standard as this produces more accurate masks than existing automated algorithms. These masks can provide important lesion phenotype data including location, volume, and intensity, among others. There has been a recent push to investigate the correlation between these characteristics and the onset of post traumatic epilepsy (PTE), a disabling consequence of TBI. One motivation of the Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx) is to identify reliable imaging biomarkers of PTE. Here, we report the protocol and importance of our manual segmentation process in patients with moderate-severe TBI enrolled in EpiBioS4Rx. Through these methods, we have generated a dataset of 127 validated lesion segmentation masks for TBI patients. These ground-truths can be used for robust PTE biomarker analyses, including optimization of multimodal MRI analysis via inclusion of lesioned tissue labels. Moreover, our protocol allows for analysis of the refinement process. Though tedious, the methods reported in this work are necessary to create reliable data for effective training of future machine-learning based lesion segmentation methods in TBI patients and subsequent PTE analyses.

Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

INTRODUCTION

Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization.

METHODS

Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported.

RESULTS

In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]).

CONCLUSIONS

Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Magnetic Resonance Imaging Findings in Infants with Severe Traumatic Brain Injury and Associations with Abusive Head Trauma

Young children with severe traumatic brain injury (TBI) have frequently been excluded from studies due to age and/or mechanism of injury. Magnetic resonance imaging (MRI) is now frequently being utilized to detect parenchymal injuries and early cerebral edema. We sought to assess MRI findings in infants with severe TBI, and to determine the association between specific MRI findings and mechanisms of injury, including abusive head trauma (AHT). MRI scans performed within the first 30 days after injury were collected and coded according to NIH/NINDS Common Data Elements (CDEs) for Neuroimaging in subjects age < 2 years old with severe TBI enrolled in the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial. Demographics and injury characteristics were analyzed. A total of 81 children were included from ADAPT sites with MRI scans. Median age was 0.77 years and 57% were male. Most common MRI finding was ischemia, present in 57/81 subjects (70%), in a median of 7 brain regions per subject. Contusion 46/81 (57%) and diffuse axonal injury (DAI) 36/81 (44.4%) subjects followed. Children were dichotomized based on likelihood of AHT with 43/81 subjects classified as AHT. Ischemia was found to be significantly associated with AHT (p = 0.001) and “inflicted” injury mechanism (p = 0.0003). In conclusion, the most common intracerebral injury seen on MRI of infants with severe TBI was ischemia, followed by contusion and DAI. Ischemia was associated with AHT, and ischemia affecting > 4 brain regions was predictive of AHT.

Prediction of Intraparenchymal Hemorrhage Progression and Neurologic Outcome in Traumatic Brain Injury Patients Using Radiomics Score and Clinical Parameters

(1) Background: Radiomics analysis of spontaneous intracerebral hemorrhages on computed tomography (CT) images has been proven effective in predicting hematoma expansion and poor neurologic outcome. In contrast, there is limited evidence on its predictive abilities for traumatic intraparenchymal hemorrhage (IPH). (2) Methods: A retrospective analysis of 107 traumatic IPH patients was conducted. Among them, 45 patients (42.1%) showed hemorrhagic progression of contusion (HPC) and 51 patients (47.7%) had poor neurological outcome. The IPH on the initial CT was manually segmented for radiomics analysis. After feature extraction, selection and repeatability evaluation, several machine learning algorithms were used to derive radiomics scores (R-scores) for the prediction of HPC and poor neurologic outcome. (3) Results: The AUCs for R-scores alone to predict HPC and poor neurologic outcome were 0.76 and 0.81, respectively. Clinical parameters were used to build comparison models. For HPC prediction, variables including age, multiple IPH, subdural hemorrhage, Injury Severity Score (ISS), international normalized ratio (INR) and IPH volume taken together yielded an AUC of 0.74, which was significantly (p = 0.022) increased to 0.83 after incorporation of the R-score in a combined model. For poor neurologic outcome prediction, clinical variables of age, Glasgow Coma Scale, ISS, INR and IPH volume showed high predictability with an AUC of 0.92, and further incorporation of the R-score did not improve the AUC. (4) Conclusion: The results suggest that radiomics analysis of IPH lesions on initial CT images has the potential to predict HPC and poor neurologic outcome in traumatic IPH patients. The clinical and R-score combined model further improves the performance of HPC prediction.

Usage of image registration and three-dimensional visualization tools on serial computed tomography for the analysis of patients with traumatic intraparenchymal hemorrhages

The aim of this study was to apply registration and three-dimensional (3D) display tools to assess the evolution of intraparenchymal hemorrhage (IPH) in patients with traumatic brain injury (TBI). We identified 109 TBI patients who had two computed tomography (CT) scans within 4 days retrospectively. The IPH was manually outlined. The registration was performed in 39 lesions from 29 patients with lesion volume < 1.5 cm on both baseline and follow-up CT. The center of mass (COM) of each lesion was calculated, and the distance between baseline and follow-up CT was used to evaluate the registration effect. The mean distances of COM before registration in the XYZ, XY, and YZ coordinates were 20.5 ± 10.2 mm, 17.8 ± 9.4 mm, and 15.9 ± 9.4 mm, respectively, which decreased significantly (p < 0.001) to 7.9 ± 4.9, 7.8 ± 5.0, and 6.1 ± 4.1 mm after registration. A 3D short video displaying the rendering view of all lesions in 34 randomly selected patients from baseline and follow-up scans were presented side-by-side for comparison. The detection rate of new IPH lesions increased in 3D videos (100%) as compared with axial CT slices (78.6-92.9%). A very high interrater agreement (k = 0.856) on perceiving IPH lesion progression upon viewing 3D video was noted, and the absolute volume increase was significantly higher (p < 0.001) for progressive lesions (median 7.36 cc) over non-progressive lesions (median 0.01 cc). Compared to patients with spontaneous hemorrhagic stroke, evaluation of multiple small traumatic hemorrhages in TBI is more challenging. The applied image analysis and visualization methods may provide helpful tools for comparing changes between serial CT scans.

Association between serum calcium level and hemorrhagic progression in patients with traumatic intraparenchymal hemorrhage: Investigating the mediation and interaction effects of coagulopathy

In this study, we investigate the association of serum calcium with coagulopathy and hemorrhagic progression contusion (HPC) in patients with traumatic intraparenchymal hemorrhage (tIPH), and further explored the interaction and mediation effect between serum calcium as well as coagulopathy on HPC. Retrospective analyses of patients with tIPH admitted to the First Affiliated Hospital of Wenzhou Medical University between January 2016 to December 2019. The clinical data, coagulation parameters, and serum calcium levels were collected for further analysis. Multivariate logistic regression analysis was applied to identify the association of serum calcium level with coagulopathy and HPC. Causal mediation analysis (CMA) and additive interaction model were used to estimate the interaction and mediation effect between serum calcium as well as coagulopathy on HPC. Additionally, we repeated the analysis using corrected calcium. A total of 473 patients were included in this study. Of these, 54 (11.4%) patients had hypocalcemia at admission, 105 (22.2%) presented with coagulopathy, and 187 (39.5%) experienced HPC. Admission serum calcium level in patients presented with coagulopathy and HPC were 8.84 [IQR: 8.44-9.40] and 8.92 [IQR: 8.48-9.40] mg/dL respectively, which were significantly lower than that of patients without (9.10 [IQR: 8.68-9.88] and 9.12 [IQR: 8.72-9.89] mg/dL; all p < 0.001). Multivariate logistic regression analysis identified that hypocalcemia emerged as an independent risk factor for coagulopathy and HPC. However, no significant interaction was detected between hypocalcemia and coagulopathy. CMA showed that the mediator coagulopathy explained 24.4% (95% CI: 4.7-65.0%; p = 0.006) of the association between hypocalcemia and HPC. Moreover, comparable results were held using corrected calcium as well. Admission serum calcium level is associated with the HPC for patients with tIPH and this relationship is partially mediated by coagulopathy, but no significant interaction is detected. Further studies are needed to validate the findings and explore its mechanisms.

Predicting Neurological Deterioration after Moderate Traumatic Brain Injury: Development and Validation of a Prediction Model Based on Data Collected on Admission

Moderate traumatic brain injury (mTBI) is a heterogeneous entity that poorly defined in the literature. mTBI patients suffer from a high rate of neurological deterioration (ND), which is usually accompanied with poor prognosis and no definitive methods to predict. The purpose of this study is to develop and validate a prediction model that estimates the ND risk in mTBI patients using data collected on admission. Retrospectively collected 479 mTBI patients' data in our department were analyzed by logistic regression models. Bivariable logistic regression identified variables with a p-value<0.05. Multivariable logistic regression modeling with backward stepwise elimination was used to determine reduced parameters and establish a prediction model. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated. The prediction model was validated using 176 patients' data collected from another hospital. Eight independent prognostic factors were identified: hypertension, Marshall's scale (types III and IV), subdural hemorrhage (SDH), location of contusion (LOC) (frontal and temporal contusions), Injury Severity Score (ISS) >13, D-dimer level >11.4 mg/L, Glasgow Coma Scale (GCS) score ≤10, and platelet (PLT) count ≤152×109/L. A prediction model was established and was shown as a nomogram. Using bootstrapping, internal validation showed that the C-statistic of the prediction model was 0.881 (95% confidence interval (CI): 0.849-0.909). The results of external validation showed that the nomogram could predict ND with an area under the curve (AUC) of 0.827 (95% CI: 0763.-0.880). The present model, based on simple parameters collected on admission, can predict the risk of ND in mTBI patients accurately. The high discriminative ability indicates the potential of this model for classifying mTBI patients according to ND risk.

Distribution and volume analysis of early hemorrhagic contusions by MRI after traumatic brain injury: a preliminary report of the Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx)

Traumatic brain injury (TBI) can produce heterogeneous injury patterns including a variety of hemorrhagic and non-hemorrhagic lesions. The impact of lesion size, location, and interaction between total number and location of contusions may influence the occurrence of seizures after TBI. We report our methodologic approach to this question in this preliminary report of the Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx). We describe lesion identification and segmentation of hemorrhagic contusions by early posttraumatic magnetic resonance imaging (MRI). We describe the preliminary methods of manual lesion segmentation in an initial cohort of 32 TBI patients from the EpiBioS4Rx cohort and the preliminary association of hemorrhagic contusion and edema location and volume to seizure incidence.

Association between vasopressor use and mortality in patients with severe traumatic brain injury: a nationwide retrospective cohort study in Japan

Aim

Vasopressors are frequently incorporated into severe traumatic brain injury management algorithms. However, evidence regarding their clinical effectiveness is lacking. We undertook a nationwide retrospective cohort study to determine the association between vasopressor use and mortality in patients with severe traumatic brain injury.

Methods

Data were collected between January 2004 and December 2018 from the Japanese Trauma Data Bank, which includes data from 272 emergency hospitals in Japan. Adults aged 16 years and over with severe traumatic brain injury but without major extracranial injuries were examined. A severe traumatic brain injury was defined based on a Glasgow Coma Scale score of 3–8 on admission. Multivariable analysis and propensity score matching were carried out. Statistical significance was assessed using 95% confidence intervals.

Results

In total, 10,295 patients were eligible for analysis, with 654 included in the vasopressor group and 9,641 included in the nonvasopressor group. The proportion of deaths at hospital discharge was higher in the vasopressor group than in the nonvasopressor group (81.80% [535/654] versus 40.24% [3,880/9,641]). This finding was confirmed in a multivariable logistic regression analysis (adjusted odds ratio, 5.37; 95% confidence interval, 4.23–6.81). Among propensity score‐matched patients adjusted for severity, the proportion of deaths at hospital discharge remained higher in the vasopressor group than in the nonvasopressor group (81.87% [533/651] versus 56.22% [366/651]) (odds ratio, 3.52; 95% confidence interval, 2.73–4.53).

Conclusion

The study results suggest that vasopressor use in patients with severe isolated traumatic brain injury is associated with a higher mortality at hospital discharge.

How do we identify the crashing traumatic brain injury patient - the intensivist's view

PURPOSE OF REVIEW

Over 40% of patients with severe traumatic brain injury (TBI) show clinically significant neurological worsening within the acute admission period. This review addresses the importance of identifying the crashing TBI patient, the difficulties appreciating clinical neurological deterioration in the comatose patient and how neuromonitoring may provide continuous real-time ancillary information to detect physiologic worsening.

RECENT FINDINGS

The latest editions of the Brain Trauma Foundation's Guidelines omitted management algorithms for adult patients with severe TBI. Subsequently, three consensus-based management algorithms were published using a Delphi method approach to provide a bridge between the evidence-based guidelines and integration of the individual treatment modalities at the bedside. These consensus statements highlight the serious situation of critical deterioration requiring emergent evaluation and guidance on sedation holds to obtain a neurological examination while balancing the potential risks of inducing a stress response.

SUMMARY

One of the central tenets of neurocritical care is to detect the brain in trouble. The first and most fundamental neurological monitoring tool is the clinical exam. Ancillary neuromonitoring data may provide early physiologic biomarkers to help anticipate, prevent or halt secondary brain injury processes. Future research should seek to understand how data integration and visualization technologies may reduce the cognitive workload to improve timely detection of neurological deterioration.

How do we identify the crashing traumatic brain injury patient - the neurosurgeon's view

PURPOSE OF REVIEW

To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view.

RECENT FINDINGS

In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected.

SUMMARY

Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.

Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome

Secondary injuries remain an important cause of the morbidity and mortality associated with traumatic brain injury (TBI). Progression of cerebral contusions occurs in up to 75% of patients with TBI, and this contributes to subsequent clinical deterioration and requirement for surgical intervention. Despite this, the role of early clinical and radiological factors in predicting contusion progression remains relatively poorly defined due to studies investigating progression of all types of hemorrhagic injuries as a combined cohort. In this review, we summarize data from recent studies on factors which predict contusion progression, and the effect of contusion progression on clinical outcomes.

Bloodletting Puncture at Hand Twelve Jing-Well Points Relieves Brain Edema after Severe Traumatic Brain Injury in Rats via Inhibiting MAPK Signaling Pathway

OBJECTIVE

To investigate whether blood-brain barrier (BBB) served a key role in the edema-relief effect of bloodletting puncture at hand twelve Jing-well points (HTWP) in traumatic brain injury (TBI) and the potential molecular signaling pathways.

METHODS

Adult male Sprague-Dawley rats were assigned to the sham-operated (sham), TBI, and bloodletting puncture (bloodletting) groups (n=24 per group) using a randomized number table. The TBI model rats were induced by cortical contusion and then bloodletting puncture were performed at HTWP twice a day for 2 days. The neurological function and cerebral edema were evaluated by modified neurological severity score (mNSS), cerebral water content, magnetic resonance imaging and hematoxylin and eosin staining. Cerebral blood flow was measured by laser speckles. The protein levels of aquaporin 4 (AQP4), matrix metalloproteinases 9 (MMP9) and mitogen-activated protein kinase pathway (MAPK) signaling were detected by immunofluorescence staining and Western blot.

RESULTS

Compared with TBI group, bloodletting puncture improved neurological function at 24 and 48 h, alleviated cerebral edema at 48 h, and reduced the permeability of BBB induced by TBI (all P<0.05). The AQP4 and MMP9 which would disrupt the integrity of BBB were downregulated by bloodletting puncture (P<0.05 or P<0.01). In addition, the extracellular signal-regulated kinase (ERK) and p38 signaling pathways were inhibited by bloodletting puncture (P<0.05).

CONCLUSIONS

Bloodletting puncture at HTWP might play a significant role in protecting BBB through regulating the expressions of MMP9 and AQP4 as well as corresponding regulatory upstream ERK and p38 signaling pathways. Therefore, bloodletting puncture at HTWP may be a promising therapeutic strategy for TBI-induced cerebral edema.

Combination Therapy Using Prothrombin Complex Concentrate and Vitamin K in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Prevents Progressive Hemorrhagic Injury: A Historically Controlled Study

Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00-0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.

Intracranial Pressure and Intracranial Elastance Monitoring in Neurocritical Care

Patients with acute brain injuries tend to be physiologically unstable and at risk of rapid and potentially life-threatening decompensation due to shifts in intracranial compartment volumes and consequent intracranial hypertension. Invasive intracranial pressure (ICP) monitoring therefore remains a cornerstone of modern neurocritical care, despite the attendant risks of infection and damage to brain tissue arising from the surgical placement of a catheter or pressure transducer into the cerebrospinal fluid or brain tissue compartments. In addition to ICP monitoring, tracking of the intracranial capacity to buffer shifts in compartment volumes would help in the assessment of patient state, inform clinical decision making, and guide therapeutic interventions. We review the anatomy, physiology, and current technology relevant to clinical management of patients with acute brain injury and outline unmet clinical needs to advance patient monitoring in neurocritical care.

Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis

OBJECTIVE

Traumatic intracerebral hemorrhage (TICH) represents approximately 13%-48% of the lesions after a traumatic brain injury (TBI), and hemorrhagic progression (HP) occurs in 38%-63% of cases. In previous studies, decompressive craniectomy (DC) has been characterized as a risk factor in the HP of TICH; however, few studies have focused exclusively on this relationship. The object of the present study was to analyze the relationship between DC and the growth of TICH and to reveal any correlation with the size of the craniectomy, degree of cerebral parenchymal herniation (CPH), or volumetric expansion of the TICH.

METHODS

The authors retrospectively analyzed the records of 497 adult patients who had been consecutively admitted after suffering a severe or moderate closed TBI. An inclusion criterion was presentation with one or more TICHs on the initial or control CT. Demographic, clinical, radiological, and treatment variables were assessed for associations.

RESULTS

Two hundred three patients presenting with 401 individual TICHs met the selection criteria. TICH growth was observed in 281 cases (70.1%). Eighty-two cases (20.4%) underwent craniectomy without TICH evacuation. In the craniectomy group, HP was observed in 71 cases (86.6%); in the noncraniectomy group (319 cases), HP occurred in 210 cases (65.8%). The difference in the incidence of HP between the two groups was statistically significant (OR 3.41, p < 0.01). The mean area of the craniectomy was 104.94 ± 27.5 cm2, and the mean CPH distance through the craniectomy was 17.85 ± 11.1 mm. The mean increase in the TICH volume was greater in the groups with a craniectomy area > 115 cm2 and CPH > 25 mm (16.12 and 14.47 cm3, respectively, p = 0.01 and 0.02). After calculating the propensity score (PS), the authors followed three statistical methods-matching, stratification, and inverse probability treatment weighting (IPTW)-thereby obtaining an adequate balance of the covariates. A statistically significant relationship was found between HP and craniectomy (OR 2.77, p = 0.004). This correlation was confirmed with the three methodologies based on the PS with odds greater than 2.

CONCLUSIONS

DC is a risk factor for the growth of TICH, and there is also an association between the size of the DC and the magnitude of the volume increase in the TICH.

A system of radiological criteria for grading and prognosticating temporal lobe contusions

INTRODUCTION

Temporal contusions are common in patients with head injuries and require close monitoring due to the propensity of these patients to deteriorate rapidly and fatally. This study attempts to introduce a radiological grading system for temporal lobe contusions and analyse its prognostic value so as to better identify patients at risk of deterioration.

METHODS

The study was conducted as a cross-sectional observational study from April 2011-March 2017 on 42 patients with temporal lobe contusion. Each patients was graded according to the proposed system from a minimum of four to a maximum of 13 and then further grouped in three grades - grade 1 (score = 4), grade 2 (score 5-7) and grade 3 (score > 7) - and their clinical course was closely observed.

RESULTS

The minimum and maximum scores observed were four and 11 respectively. The proposed grading system has statistically significant correlation to the Glasgow Coma Scale (p-value < 0.05). All patients in grade 1 (17) could be managed conservatively, while all those in grade 3 (five) needed immediate surgical intervention. Of 20 patients in grade 2, 11 had a score of 5-6 and did not require surgery, whereas nine patients had a score of seven and of these eight required delayed surgical intervention. This correlation was statistically significant (p-value < 0.05).

CONCLUSION

The proposed temporal lobe contusion grading system is a good radiological tool to predict the clinical course of patients and thereby identify patients at higher risk of delayed deterioration.

Role of Sulfonylurea Receptor 1 and Glibenclamide in Traumatic Brain Injury: A Review of the Evidence

Cerebral edema and contusion expansion are major determinants of morbidity and mortality after TBI. Current treatment options are reactive, suboptimal and associated with significant side effects. First discovered in models of focal cerebral ischemia, there is increasing evidence that the sulfonylurea receptor 1 (SUR1)-Transient receptor potential melastatin 4 (TRPM4) channel plays a key role in these critical secondary injury processes after TBI. Targeted SUR1-TRPM4 channel inhibition with glibenclamide has been shown to reduce edema and progression of hemorrhage, particularly in preclinical models of contusional TBI. Results from small clinical trials evaluating glibenclamide in TBI have been encouraging. A Phase-2 study evaluating the safety and efficacy of intravenous glibenclamide (BIIB093) in brain contusion is actively enrolling subjects. In this comprehensive narrative review, we summarize the molecular basis of SUR1-TRPM4 related pathology and discuss TBI-specific expression patterns, biomarker potential, genetic variation, preclinical experiments, and clinical studies evaluating the utility of treatment with glibenclamide in this disease.

Radiological Parameters to Predict Hemorrhagic Progression of Traumatic Contusional Brain Injury

Introduction

Traumatic intracerebral contusion is a frequent factor culminating in death and disability, and its progression relates to unfavorable outcome. We evaluated the radiological factors associated with hemorrhagic progression of contusions (HPC).

Materials and Methods

Two hundred and forty-six patients were enrolled in this prospective cohort over a period of 1 year. Contusion volume was quantified using the "ABC/2" technique, whereas progression was considered as >30% increase in the initial volume. Univariate and multivariate statistics were used to examine the correlation between the risk factors of interest and HPC.

Results

HPC was seen in 110 (44.7%) patients. Binary logistic regression showed in the final adjusted model that multiplicity (relative risk [RR]: 2.24, 95% confidence limit [CL]: 1.00-5.48), bilateral lesions (RR: 2.99, 95% CL: 1.08-8.25), initial volume of contusion (RR: 4.96, 95% CL: 1.87-13.13), frontal location (RR: 1.42, 95% CL: 1.08-3.56), and presence of concomitant intracranial hematoma (extradural-RR: 3.90, 95% CL: 1.51-10.01, subdural-RR: 2.91, 95% CL: 1.26-6.69, and subarachnoid-RR: 2.27, 95% CL: 1.01-5.80) were significantly associated with HPC. The overall mortality was 18.7% and was almost equal among patients with and without HPC. Mortality was significantly associated with Glasgow Coma Scale on admission (adjusted RR: 12.386, 95% CL: 4.789-32.035) and presence of comorbid conditions (adjusted RR: 0.313, 95% CL: 0.114-0.860).

Conclusion

Initial computed tomography scan is a good predictor of high-risk group for HPC.

Kir6.2, the Pore-Forming Subunit of ATP-Sensitive K+ Channels, Is Overexpressed in Human Posttraumatic Brain Contusions

Brain contusions (BCs) are one of the most frequent lesions in patients with moderate and severe traumatic brain injury (TBI). BCs increase their volume due to peri-lesional edema formation and/or hemorrhagic transformation. This may have deleterious consequences and its mechanisms are still poorly understood. We previously identified de novo upregulation sulfonylurea receptor (SUR) 1, the regulatory subunit of adenosine triphosphate (ATP)-sensitive potassium (KATP) channels and other channels, in human BCs. Our aim here was to study the expression of the pore-forming subunit of KATP, Kir6.2, in human BCs, and identify its localization in different cell types. Protein levels of Kir6.2 were detected by western blot (WB) from 33 contusion specimens obtained from 32 TBI patients aged 14-74 years. The evaluation of Kir6.2 expression in different cell types was performed by immunofluorescence in 29 contusion samples obtained from 28 patients with a median age of 42 years. Control samples were obtained from limited brain resections performed to access extra-axial skull base tumors or intraventricular lesions. Contusion specimens showed an increase of Kir6.2 expression in comparison with controls. Regarding cellular location of Kir6.2, there was no expression of this channel subunit in blood vessels, either in control samples or in contusions. The expression of Kir6.2 in neurons and microglia was also analyzed, but the observed differences were not statistically significant. However, a significant increase of Kir6.2 was found in glial fibrillary acidic protein (GFAP)-positive cells in contusion specimens. Our data suggest that further research on SUR1-regulated ionic channels may lead to a better understanding of key mechanisms involved in the pathogenesis of BCs, and may identify novel targeted therapeutic strategies.

A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis?

PURPOSE OF REVIEW

Standard clinical protocols for treating cerebral edema and intracranial hypertension after severe TBI have remained remarkably similar over decades. Cerebral edema and intracranial hypertension are treated interchangeably when in fact intracranial pressure (ICP) is a proxy for cerebral edema but also other processes such as extent of mass lesions, hydrocephalus, or cerebral blood volume. A complex interplay of multiple molecular mechanisms results in cerebral edema after severe TBI, and these are not measured or targeted by current clinically available tools. Addressing these underpinnings may be key to preventing or treating cerebral edema and improving outcome after severe TBI.

RECENT FINDINGS

This review begins by outlining basic principles underlying the relationship between edema and ICP including the Monro-Kellie doctrine and concepts of intracranial compliance/elastance. There is a subsequent brief discussion of current guidelines for ICP monitoring/management. We then focus most of the review on an evolving precision medicine approach towards cerebral edema and intracranial hypertension after TBI. Personalization of invasive neuromonitoring parameters including ICP waveform analysis, pulse amplitude, pressure reactivity, and longitudinal trajectories are presented. This is followed by a discussion of cerebral edema subtypes (continuum of ionic/cytotoxic/vasogenic edema and progressive secondary hemorrhage). Mechanisms of potential molecular contributors to cerebral edema after TBI are reviewed. For each target, we present findings from preclinical models, and evaluate their clinical utility as biomarkers and therapeutic targets for cerebral edema reduction. This selection represents promising candidates with evidence from different research groups, overlap/inter-relatedness with other pathways, and clinical/translational potential. We outline an evolving precision medicine and translational approach towards cerebral edema and intracranial hypertension after severe TBI.

Pathophysiology and treatment of cerebral edema in traumatic brain injury

Cerebral edema (CE) and resultant intracranial hypertension are associated with unfavorable prognosis in traumatic brain injury (TBI). CE is a leading cause of in-hospital mortality, occurring in >60% of patients with mass lesions, and ∼15% of those with normal initial computed tomography scans. After treatment of mass lesions in severe TBI, an important focus of acute neurocritical care is evaluating and managing the secondary injury process of CE and resultant intracranial hypertension. This review focuses on a contemporary understanding of various pathophysiologic pathways contributing to CE, with a subsequent description of potential targeted therapies. There is a discussion of identified cellular/cytotoxic contributors to CE, as well as mechanisms that influence blood-brain-barrier (BBB) disruption/vasogenic edema, with the caveat that this distinction may be somewhat artificial since molecular processes contributing to these pathways are interrelated. While an exhaustive discussion of all pathways with putative contributions to CE is beyond the scope of this review, the roles of some key contributors are highlighted, and references are provided for further details. Potential future molecular targets for treating CE are presented based on pathophysiologic mechanisms. We thus aim to provide a translational synopsis of present and future strategies targeting CE after TBI in the context of a paradigm shift towards precision medicine. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Derivation of a Predictive Score for Hemorrhagic Progression of Cerebral Contusions in Moderate and Severe Traumatic Brain Injury

BACKGROUNDS

After traumatic brain injury (TBI), hemorrhagic progression of contusions (HPCs) occurs frequently. However, there is no established predictive score to identify high-risk patients for HPC.

METHODS

Consecutive patients who were hospitalized (2008-2013) with non-penetrating moderate or severe TBI were studied. The primary outcome was HPC, defined by both a relative increase in contusion volume by ≥30 % and an absolute increase by ≥10 mL on serial imaging. Logistic regression models were created to identify independent risk factors for HPC. The HPC Score was then derived based on the final model.

RESULTS

Among a total of 286 eligible patients, 61 (21 %) patients developed HPC. On univariate analyses, HPC was associated with older age, higher initial blood pressure, antiplatelet medications, anticoagulants, subarachnoid hemorrhage (SAH) subdural hematoma (SDH), skull fracture, frontal contusion, larger contusion volume, and shorter interval from injury to initial CT. In the final model, SAH (OR 6.33, 95 % CI, 1.80-22.23), SDH (OR 3.46, 95 % CI, 1.39-8.63), and skull fracture (OR 2.67, 95 % CI, 1.28-5.58) were associated with HPC. Based on these factors, the HPC Score was derived (SAH = 2 points, SDH = 1 point, and skull fracture = 1 point). This score had an area under the receiver operating curve of 0.77. Patients with a score of 0-2 had a 4.0 % incidence of HPC, while patients with a score of 3-4 had a 34.6 % incidence of HPC.

CONCLUSIONS

A simple HPC Score was developed for early risk stratification of HPC in patients with moderate or severe TBI.

The Neurological Wake-up Test-A Role in Neurocritical Care Monitoring of Traumatic Brain Injury Patients?

The most fundamental clinical monitoring tool in traumatic brain injury (TBI) patients is the repeated clinical examination. In the severe TBI patient treated by continuous sedation in a neurocritical care (NCC) unit, sedation interruption is required to enable a clinical evaluation (named the neurological wake-up test; NWT) assessing the level of consciousness, pupillary diameter and reactivity to light, and presence of focal neurological deficits. There is a basic conflict regarding the NWT in the NCC setting; can the clinical information obtained by the NWT justify the risk of inducing a stress response in a severe TBI patient? Furthermore, in the presence of advanced multimodal monitoring and neuroimaging, is the NWT necessary to identify important clinical alterations? In studies of severe TBI patients, the NWT was consistently shown to induce a stress reaction including brief increases in intracranial pressure (ICP) and changes in cerebral perfusion pressure (CPP). However, it has not been established whether these short-lived ICP and CPP changes are detrimental to the injured brain. Daily interruption of sedation is associated with a reduced ventilator time, shorter hospital stay and reduced mortality in many studies of general intensive care unit patients, although such clinical benefits have not been firmly established in TBI. To date, there is no consensus on the use of the NWT among NCC units and systematic studies are scarce. Thus, additional studies evaluating the role of the NWT in clinical decision-making are needed. Multimodal NCC monitoring may be an adjunct in assessing in which TBI patients the NWT can be safely performed. At present, the NWT remains the golden standard for clinical monitoring and detection of neurological changes in NCC and could be considered in TBI patients with stable baseline ICP and CPP readings. The focus of the present review is an overview of the existing literature on the role of the NWT as a clinical monitoring tool for severe TBI patients.

Effects of Deferoxamine Mesylate on Hematoma and Perihematoma Edema after Traumatic Intracerebral Hemorrhage

Deferoxamine mesylate can cross the blood-brain barrier and reduce iron accumulation in nervous tissue; moreover, it has a variety of neuroprotective functions in addition to complexing with iron ions. Such iron chelators are expected to become a new treatment option for intracerebral hemorrhage. This study evaluated the effects of deferoxamine mesylate on hematoma and edema absorption after traumatic intracerebral hemorrhage (TICH), and it provides clinical evidence for TICH treatment with deferoxamine mesylate. Patients with isolated TICH, confirmed by head computed tomography, were enrolled prospectively from January 2013 to December 2016. Patients were divided non-randomly into an experimental or control group as decided by the attending neurosurgeon. Patients in the experimental group received intravenous deferoxamine mesylate (20 mg/kg daily) from the day of admission for 5 consecutive days. We evaluated the impact of deferoxamine mesylate on the change in edema volume and the absorption of hematoma volume using a propensity score-matched analysis. In total, 190 patients were included. After matching, 94 patients were included in the final analysis (47 per group); no variable differed significantly between the two groups. The hematoma volume on the 7th day in the control group was higher than that at the same time-point in the experimental group (9.4 ± 7.2 vs. 5.2 ± 4.8 mL; p = 0.001). There was no difference in hematoma volume on Day 1 (12.6 ± 7.8 vs. 12.8 ± 6.4 mL; p = 0.896), Day 3 (12.4 ± 7.4 vs. 11.4 ± 4.9 mL; p = 0.442), and Day 14 (3.2 ± 3.0 vs. 2.5 ± 2.6 mL; p = 0.215) between the groups. The absorption of hematoma volume between the 1st and 3rd days and the 1st and 7th days in the experimental group was higher than that during the same periods in the control group. The edema volumes on the 3rd, 7th, and 14th days in the control group were higher than those at the same time-points in the experimental group. There was no difference in edema volume on the 1st day. The changes in edema volume between the 1st and 3rd days, the 1st and 7th days, and the 1st and 14th days in the control group were higher than those during the same periods in the experimental group. Deferoxamine mesylate may accelerate hematoma absorption and inhibit edema after TICH; however, further investigation is required to reach definitive conclusions.

Severe traumatic brain injury: targeted management in the intensive care unit

Severe traumatic brain injury (TBI) is currently managed in the intensive care unit with a combined medical-surgical approach. Treatment aims to prevent additional brain damage and to optimise conditions for brain recovery. TBI is typically considered and treated as one pathological entity, although in fact it is a syndrome comprising a range of lesions that can require different therapies and physiological goals. Owing to advances in monitoring and imaging, there is now the potential to identify specific mechanisms of brain damage and to better target treatment to individuals or subsets of patients. Targeted treatment is especially relevant for elderly people-who now represent an increasing proportion of patients with TBI-as preinjury comorbidities and their therapies demand tailored management strategies. Progress in monitoring and in understanding pathophysiological mechanisms of TBI could change current management in the intensive care unit, enabling targeted interventions that could ultimately improve outcomes.

Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma

OBJECTIVE

Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score.

METHODS

Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome.

RESULTS

Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels.

CONCLUSIONS

The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

Brain contusion as the main risk factor of memory or emotional complaints in chronic complicated mild traumatic brain injury

OBJECTIVE

To investigate the risk factors for memory or emotional complaints in patients with complicated mild traumatic brain injury (mTBI).

METHODS

Retrospective analysis of medical records was conducted by physicians in a teaching hospital in Southern Taiwan, and complicated mTBI had been identified by means of computed tomography. Psychological complaints, including problems with memory and emotions, were collected by structured telephone interviews, 10-15 minutes long, and were held with subjects who agreed to participate in our study. Among 327 patients who were injured for more than two years, 190 agreed to join this study (mean age: 41.6 years; male: 60.5%; stably employed: 50.0%). We used demographic data and neurological factors to predict memory or emotional complaints without muscle power or response speed (MEMR) complaints.

RESULTS

Only the presence or absence of cerebral contusions predicted memory or emotional complaints without MEMR complaints in different employed status, and the odds ratio was 4.82-13.50 times higher for those with cerebral contusions than for those without.

CONCLUSIONS

Cerebral contusions were the primary risk factor for MEMR complaints in chronic complicated mTBI. Early preventive psychological intervention might be necessary for patients with complicated mTBI and cerebral contusions.

Early Brain Edema is a Predictor of In-Hospital Mortality in Traumatic Brain Injury

BACKGROUND

Identifying patients who may progress to a poor clinical outcome will encourage earlier appropriate therapeutic interventions. Brain edema may contribute to secondary injury in traumatic brain injury (TBI) and thus, may be a useful prognostic indicator.

OBJECTIVE

We determined whether the presence of brain edema on the initial computed tomography (CT) scan of TBI patients would predict poor in-hospital outcome.

METHODS

We performed a retrospective review of all trauma patients with nonpenetrating head trauma at a Level I Trauma Center. International Classification of Diseases, Ninth Revision codes indicated the presence of brain edema and we evaluated the validity of this pragmatic assessment quantitatively in a random subset of patients. In-hospital mortality was the primary outcome variable. Univariate analysis and logistic regression identified predictors of mortality in all TBI patients and those with mild TBI.

RESULTS

Over 7200 patients were included in the study, including 6225 with mild TBI. Measurements of gray and white matter CT density verified radiological assessments of brain edema. Patients with documented brain edema had a mortality rate over 10 times that of the entire study population. With logistic regression accounting for Injury Severity Score, Glasgow Coma Scale score, other CT findings, and clinical variables, brain edema predicted an eightfold greater mortality rate in all patients (odds ratio 8.0, 95% confidence interval 4.6-14.0) and fivefold greater mortality rate for mild TBI patients (odds ratio 4.9, 95% confidence interval 2.0-11.7).

CONCLUSIONS

Brain edema is an independent prognostic variable across all categories of TBI severity. By alerting emergency physicians to patients with poor predicted clinical outcomes, this finding will drive better resource allocation, earlier intervention, and reduced patient mortality.

Clinical efficacy of three dimensional conformal radiotherapy for malignant digestive system tumors

AIM: To evaluate the clinical effects of three dimensional conformal radiotherapy for malignant tumors of the digestive system.

METHODS: From January 2012 to January 2014, 84 patients with liver metastases of malignant tumors at our hospital were studied. The patients were randomly divided into an observation group and a control group, with 42 cases in each group. The control group was treated by hepatic arterial chemoembolization, and the observation group was treated by three dimensional conformal radiotherapy. The efficacy was analyzed and compared between the two groups.

RESULTS: The effective rate in the observation group was 69.0%, significantly better than that of the control group (40.5%, P < 0.05). The incidence of adverse reactions was significantly lower in the observation group than in the control group (P < 0.05). The number of cases with complete relief in the observation group was significantly higher than that in the control group (P < 0.05), although there was no significant difference in the number of cases with partial relief. The observation group was significantly better than the control group in terms of quality of life and 1-year survival rate (P < 0.05).

CONCLUSION: Three dimensional conformal radiotherapy for liver metastases of digestive system malignant tumors can not only improve the clinical efficacy, but also reduce the rate of adverse reactions and significantly improve the quality of life of patients.

Contrecoup Traumatic Intracerebral Hemorrhage: A Geometric Study of the Impact Site and Association with Hemorrhagic Progression

Traumatic intracerebral hemorrhage (TICH) represents 13-48% of the lesions after a traumatic brain injury (TBI). The frequency of TICH-hemorrhagic progression (TICH-HP) is estimated to be approximately 38-63%. The relationship between the impact site and TICH location has been described in many autopsy-based series. This association, however, has not been consistently demonstrated since the introduction of computed tomography (CT) for studying TBI. This study aimed to determine the association between the impact site and TICH location in patients with moderate and severe TBI. We also analyzed the associations between the TICH location, the impact site, the production mechanism (coup or contrecoup), and hemorrhagic progression. We retrospectively analyzed the records of 408 patients after a moderate or severe TBI between January 2010 and November 2014. We identified 177 patients with a total of 369 TICHs. We found a statistically significant association between frontal TICHs and impact sites located on the anterior area of the head (OR 5.8, p < 0.001). The temporal TICH location was significantly associated with impact sites located on the posterior head area (OR 4.9, p < 0.001). Anterior and lateral TICHs were associated with impact sites located at less than 90 degrees (coup) (OR 1.64, p = 0.03) and more than 90 degrees (contrecoup), respectively. Factors independently associated with TICH-HP obtained through logistic regression included an initial volume of <1 cc, cisternal compression, falls, acute subdural hematoma, multiple TICHs, and contrecoup TICHs. We demonstrated a significant association between the TICH location and impact site. The contrecoup represents a risk factor independently associated with hemorrhagic progression.

The value of intraoperative intracranial pressure monitoring for predicting re-operation using salvage decompressive craniectomy after craniotomy in patients with traumatic mass lesions

BACKGROUND

The risk factors of predicting the need for postoperative decompressive craniectomy due to intracranial hypertension after primary craniotomy remain unclear. This study aimed to investigate the value of intraoperative intracranial pressure (ICP) monitoring in predicting re-operation using salvage decompressive craniectomy (SDC).

METHODS

From January 2008 to October 2014, we retrospectively reviewed 284 patients with severe traumatic brain injury (STBI) who underwent craniotomy for mass lesion evacuation without intraoperative brain swelling. Intraoperative ICP was documented at the time of initial craniotomy and then again after the dura was sutured. SDC was used when postoperative ICP was continually higher than 25 mmHg for 1 h without a downward trend. Univariate and multivariate analyses were applied to both initial demographic and radiographic features to identify risk factors of SDC requirement.

RESULTS

Of 284, 41 (14.4%) patients who underwent SDC had a higher Initial ICP than those who didn't (38.1 ± 9.2 vs. 29.3 ± 8.1 mmHg, P < 0.001), but there was no difference in ICP after the dura was sutured. The factors which have significant effects on SDC are higher initial ICP [odds ratio (OR): 1.100, 95% confidence interval (CI): 1.052-1.151, P < 0.001], older age (OR: 1.039, 95% CI: 1.002-1.077, P = 0.039), combined lesions (OR: 3.329, 95% CI: 1.199-9.244, P = 0.021) and early hypotension (OR: 2.524, 95% CI: 1.107-5.756, P = 0.028). The area under the curve of multivariate regression model was 0.771.

CONCLUSIONS

The incidence of re-operation using SDC after craniotomy was 14.4%. The independent risk factors of SDC requirement are initial ICP, age, early hypotension and combined lesions.

Acute outcomes of isolated cerebral contusions in children with Glasgow Coma Scale scores of 14 to 15 after blunt head trauma

BACKGROUND

Little data exist to guide the management of children with cerebral contusions after minor blunt head trauma. We therefore aimed to determine the risk of acute adverse outcomes in children with minor blunt head trauma who had cerebral contusions and no other traumatic brain injuries on computed tomography (i.e., isolated cerebral contusions).

METHODS

We conducted a secondary analysis of a public use data set originating from a prospective cohort study performed in 25 PECARN (Pediatric Emergency Care Applied Research Network) emergency departments of children younger than 18 years with blunt head trauma resulting from nontrivial injury mechanisms and with Glasgow Coma Scale (GCS) scores of 14 or 15. In this analysis, we included only children with isolated cerebral contusions. We defined a normal mental status as a GCS score of 15 and no other signs of abnormal mental status. Acute adverse outcomes included intubation longer than 24 hours because of the head trauma, neurosurgery, or death from the head injury.

RESULTS

Of 14,983 children with GCS scores of 14 or 15 who received cranial computed tomography scans in the parent study, 152 (1.0%; 95% confidence interval, 0.8-1.2%) had cerebral contusions, of which 54 (35.8%) of 151 with available data were isolated. The median age of those with isolated cerebral contusions was 9 years (interquartile range, 1-13); 31 (57.4%) had a normal mental status. Of 36 patients with available data on isolated cerebral contusion size, 34 (94.4%) were described as small. 43 (79.6%) of 54 patients with isolated cerebral contusions were hospitalized, including 16 (29.6%) of 54 to an intensive care unit. No patients with isolated cerebral contusions died, were intubated longer than 24 hours for head trauma, or required neurosurgery (95% confidence interval for all outcomes, 0-6.6%).

CONCLUSION

Children with small isolated cerebral contusions after minor blunt head trauma are unlikely to require further acute intervention, including neurosurgery, suggesting that neither intensive care unit admission nor prolonged hospitalization is generally required.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

Sulfonylurea Receptor 1 in Humans with Post-Traumatic Brain Contusions

Post-traumatic brain contusions (PTBCs) are traditionally considered primary injuries and can increase in size, generate perilesional edema, cause mass effect, induce neurological deterioration, and cause death. Most patients experience a progressive increase in pericontusional edema, and nearly half, an increase in the hemorrhagic component itself. The underlying molecular pathophysiology of contusion-induced brain edema and hemorrhagic progression remains poorly understood. The aim of this study was to investigate sulfonylurea 1/transient receptor potential melastatin 4 (SUR1-TRPM4) ion channel SUR1 expression in various cell types (neurons, astrocytes, endothelial cells, microglia, macrophages, and neutrophils) of human brain contusions and whether SUR1 up-regulation was related to time postinjury. Double immunolabeling of SUR1 and cell-type- specific proteins was performed in 26 specimens from traumatic brain injury patients whose lesions were surgically evacuated. Three samples from limited brain resections performed for accessing extra-axial skull-base tumors or intraventricular lesions were controls. We found SUR1 was significantly overexpresed in all cell types and was especially prominent in neurons and endothelial cells (ECs). The temporal pattern depended on cell type: 1) In neurons, SUR1 increased within 48 h of injury and stabilized thereafter; 2) in ECs, there was no trend; 3) in glial cells and microglia/macrophages, a moderate increase was observed over time; and 4) in neutrophils, it decreased with time. Our results suggest that up-regulation of SUR1 in humans point to this channel as one of the important molecular players in the pathophysiology of PTBCs. Our findings reveal opportunities to act therapeutically on the mechanisms of growth of traumatic contusions and therefore reduce the number of patients with neurological deterioration and poor neurological outcomes.

Traumatic Intracerebral Hemorrhage: Risk Factors Associated with Progression

The increase in the volume of a traumatic intracerebral hemorrhage (TICH) is a widely studied phenomenon that has a direct impact on the prognosis of patients. The objective of this study was to identify the risk factors associated with the progression of TICH. We retrospectively analyzed the records of 1970 adult patients >15 years of age who were consecutively admitted after sustaining a closed severe traumatic brain injury (TBI) between January 1987 and November 2013 at a single center. Beginning in 2007, patients with moderate TBIs were also included. A total of 782 patients exhibited one or more TICH on the initial CT scan, and met the selection criteria. The main outcome variable was the presence or absence of progression of the TICH. Univariate and multivariate statistical analyses were performed. Factors independently associated with the growth of TICH obtained through logistic regression included the following: an initial volume <5 cc (odds ratio [OR] 2.42, p<0.001), cisternal compression (OR 1.95, p<0.001), decompressive craniectomy (OR 2.18, p<0.001), age (mean 37.67 vs. 42.95 years; OR 1.01, p<0.001), falls as mechanism of trauma (OR 1.72, p=0.001), multiple TICHs (OR 1.56, p=0.007), and hypoxia (OR 1.56, p=0.02). TICH progression occurred with a frequency of 63% in our study. We showed that there was a correlation between TICH growth and some variables, such as multiple TICHs, a lower initial volume, acute subdural hematoma, cisternal compression, older patient age, hypoxia, falls, and decompressive craniectomy.

Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference

BACKGROUND

Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI.

METHODS

A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants. The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.