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Lau KW, Chen CT, Chen CC, Lin TC, Yeap MC, Hsieh PC, Chuang CC, Wang YC, Yang ST, Liu ZH. Clinical outcomes among patients with concurrent blunt cerebrovascular injury and traumatic intracranial hemorrhage. J Neurol Sci 2024; 466:123216. [PMID: 39255590 DOI: 10.1016/j.jns.2024.123216] [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: 04/01/2024] [Revised: 07/28/2024] [Accepted: 09/02/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) accounts for 1-3 % of patients with blunt trauma, which should be promptly diagnosed and managed due to risk of cerebral infarction and death. Antithrombotic therapy had been proven to reduce risk of stroke and mortality. However, due to concern of hematoma progression, treatment suggestion is still inconclusive for patients with concurrent traumatic intracranial hemorrhage. MATERIALS AND METHODS We performed a retrospective, observational study from 2002 to 2020 at a Level I trauma center, all patients with BCVI and concurrent traumatic intracranial hemorrhage were recruited. Patients' demographics, initial CT findings, severity of BCVI, treatment and outcomes were documented and analyzed to define possible risk factors of death and stroke. RESULTS Among all 57 patients, 49 (86.0 %) patients had injury at ICA, 6 (10.5 %) had VA injury, and 2 (3.5 %) suffered from both. Targeted treatments for BCVI were provided to 33 (57.9 %) patient, mostly endovascular intervention (78.8 %), antithrombotic treatment was given to 11 (19.3 %) patients. At 3-month follow-up, 17 (29.8 %) patients expired, and 18 (31.6 %) patients had cerebral infarction due to BCVI. We identified more severe initial CT findings (p = 0.016), higher head Abbreviated Injury Scale (p = 0.049) and initial life-threatening events (p = 0.047) as risk factors of death, and traumatic basal cistern subarachnoid hemorrhage(SAH) (p = 0.040) as single risk factor of cerebral infarction. CONCLUSIONS Around one-thirds of patients with concurrent BCVI and traumatic intracranial hemorrhage were death or suffered from cerebral infarction within 3 months, with severity of initial head injury and SAH at basal cistern as risk factors, respectively.
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Affiliation(s)
- Ka-Wei Lau
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Tzu-Chin Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Shun-Tai Yang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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Ernst G, Hughes K, Andrews B, Bauer A. Cerebral vasospasm in patients with traumatic subarachnoid hemorrhage, a possible point of intervention? J Clin Neurosci 2024; 125:106-109. [PMID: 38763077 DOI: 10.1016/j.jocn.2024.05.009] [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: 01/28/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE To determine the incidence of vasospasm in traumatic brain injury patients with traumatic subarachnoid hemorrhage. METHODS IRB approval was obtained for this retrospective chart review. An institutional trauma database was queried for adult patients with traumatic brain injury (TBI) and traumatic subarachnoid hemorrhage (tSAH) seen on CT head obtained within 20 days. The presence of vasospasm on CTA was determined by radiology report. Association between categorical background characteristics and intracranial vasospasm was assessed by the chi-square test and association between a continuous variables and intracranial vasospasm was assessed by a paired t-test. RESULTS 1142 patients with traumatic SAH were identified from the trauma database. 792 patients were excluded: 142 for age <18, 632 did not have CT angiography, and 18 had non-traumatic SAH. 350 patients were analyzed, of which 28 (8 %) had vasospasm. Traumatic vasospasm was associated with higher-grade TBI based on Cochran-Armitage trend test (p < 0.05). Vasospasm patients had longer length of stay in the ICU (mean days 13.64 vs 7.24, P < 0.001), and had a higher incidence of death (39.29 % vs 20.81 %), although this did not reach statistical significance. CONCLUSION Intracranial vasospasm, specifically in patients with tSAH, is associated with more severe TBI and longer stays in the ICU. Our incidence is smaller compared to other studies likely due to the retrospective nature and the infrequency of obtaining CT angiography after initial presentation. Prospective studies are warranted as the incidence is significant and may represent a point of intervention for TBI.
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Affiliation(s)
- Griffin Ernst
- University of Oklahoma Department of Neurosurgery, 1000 N Lincoln Blvd #4000, Oklahoma City, OK 73104, United States.
| | - Kendall Hughes
- University of Oklahoma Department of Neurosurgery, 1000 N Lincoln Blvd #4000, Oklahoma City, OK 73104, United States.
| | - Bethany Andrews
- University of Oklahoma Department of Neurosurgery, 1000 N Lincoln Blvd #4000, Oklahoma City, OK 73104, United States.
| | - Andrew Bauer
- University of Oklahoma Department of Neurosurgery, 1000 N Lincoln Blvd #4000, Oklahoma City, OK 73104, United States.
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Morishita M, Yamazaki T, Senoo M, Nishiya M. Cerebral Vasospasm After Burr Hole Evacuation of Chronic Subdural Hematoma. Cureus 2024; 16:e55140. [PMID: 38558741 PMCID: PMC10979758 DOI: 10.7759/cureus.55140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Cerebral vasospasm is a frequent complication of subarachnoid hemorrhage. We report a case of chronic subdural hematoma complicated by cerebral vasospasm after burr hole evacuation. A 74-year-old woman underwent burr hole evacuation of a chronic subdural hematoma. She developed left hemiparesis and disturbance of consciousness on postoperative day 3. Magnetic resonance imaging showed a right parietal infarct and decreased cerebral blood flow signal in the right middle cerebral artery territory. Digital subtraction angiography showed multiple segmental narrowings of the right middle cerebral artery. Her neurological symptoms recovered with conservative treatment. Follow-up angiography showed improvement in the arterial narrowing, which finally led to a diagnosis of cerebral vasospasm. Cerebral vasospasm can occur after burr hole evacuation of chronic subdural hematoma. Magnetic resonance angiography is useful for determining the cause of postoperative neurological worsening in chronic subdural hematoma patients.
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Affiliation(s)
- Masahiro Morishita
- Department of Neurosurgery, Hakodate Neurosurgical Hospital, Hokkaido, JPN
| | - Takaaki Yamazaki
- Department of Neurosurgery, Hakodate Neurosurgical Hospital, Hokkaido, JPN
| | - Makoto Senoo
- Department of Neurosurgery, Hakodate Neurosurgical Hospital, Hokkaido, JPN
| | - Mikio Nishiya
- Department of Neurosurgery, Hakodate Neurosurgical Hospital, Hokkaido, JPN
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Riordan K, Mamaril-Davis J, Aguilar-Salinas P, Dumont TM, Weinand ME. Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 232:107877. [PMID: 37441930 DOI: 10.1016/j.clineuro.2023.107877] [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: 04/06/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis. RESULTS Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively. CONCLUSIONS The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.
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Affiliation(s)
- Katherine Riordan
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - James Mamaril-Davis
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Martin E Weinand
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States.
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Yamada SM, Tomita Y, Takeda R, Nakane M. What is the impact of vasospasm on traumatic subarachnoid hemorrhage: Two cases of report. Trauma Case Rep 2021; 36:100543. [PMID: 34712767 PMCID: PMC8529170 DOI: 10.1016/j.tcr.2021.100543] [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] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Abstract
It is difficult to predict that vasospasm would occur in traumatic subarachnoid hemorrhage (SAH) patients. Younger age, a lower score of Glasgow coma scale (GCS≦8) on admission, and greater cisternal blood volume are considered to correlate with post-traumatic vasospasm. We present two cases of traumatic SAH with post-traumatic vasospasm; one was a 74-year-old man and the other was a 72-year-old woman. They were alert without any neurological deficits on admission, although the SAH was focally thick as if caused by an aneurysmal rupture. The thick SAH was still identified on follow-up CT performed in a few days. The patients demonstrated cognitive dysfunction at the 4th and 5th day of admission, respectively, and imaging studies revealed vasospasm at the artery in the thick SAH. After treatments, the vasospasm resolved and both patients recovered from the disorientation completely in three weeks. The authors considered that focally thick traumatic SAH with poor clearance is the most influential factor to post-traumatic vasospasm independent of age or a GCS score. A low GCS score in head trauma patients might be mainly associated with existence of brain contusion, intracerebral hemorrhage, epidural, or subdural hemorrhages, which are frequently associated with traumatic SAH. If the traumatic SAH is focally thick with poor clearance, it might be better to initiate prompt treatments for vasospasm within 3 days after trauma. The delay in treatments for vasospasm contributes to poor outcomes.
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Affiliation(s)
- Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
| | - Ririko Takeda
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
| | - Makoto Nakane
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
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Prolonged Post-Traumatic Vasospasm Resulting in Delayed Cerebral Ischemia After Mild Traumatic Brain Injury. Neurocrit Care 2018; 29:512-518. [DOI: 10.1007/s12028-018-0542-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ball BZ, Pelargos PE, Christie C, Golshani K. Vasospasm in the setting of traumatic bilateral carotid-cavernous fistulas and its effect on treatment. Surg Neurol Int 2018; 9:7. [PMID: 29416904 PMCID: PMC5791513 DOI: 10.4103/sni.sni_190_17] [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: 05/25/2017] [Accepted: 10/10/2017] [Indexed: 11/09/2022] Open
Abstract
Background: Direct, Type A, cavernous-carotid fistulas (CCFs) are predominantly caused by head trauma, especially when basilar skull fractures are present. Transarterial endovascular treatment of direct CCFs is the preferred method of treatment. Bilateral CCFs are estimated to be present in 1–2% of the cases. The treatment of bilateral CCFs is difficult often requiring a combination of endovascular and open surgical approaches. Case Description: We present a case of traumatic bilateral CCFs presenting with vasospasm of the anterior circulation seen on the initial angiogram on day 1 and our treatment paradigm. Conclusion: This case illustrates the challenges in managing bilateral CCFs as well as the changes in collateral circulation because of cerebral vasospasm which affected our treatment paradigm.
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Affiliation(s)
- Benjamin Z Ball
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
| | - Panayiotis E Pelargos
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
| | - Catherine Christie
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
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Ogami K, Dofredo M, Moheet AM, Lahiri S. Early and Severe Symptomatic Cerebral Vasospasm After Mild Traumatic Brain Injury. World Neurosurg 2017; 101:813.e11-813.e14. [DOI: 10.1016/j.wneu.2017.03.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 03/08/2017] [Indexed: 11/30/2022]
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Wang F, Huang X, Wen L, Gong JB, Wang H, Li G, Zhan RY, Yang XF. Prognostic value of the Marshall computed tomography classification for traumatic subarachnoid hemorrhage. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0805.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: The Marshall computed tomography (CT) system for classification of traumatic brain injury (TBI) includes the most important independent prognostic variables except for traumatic subarachnoid hemorrhage (tSAH).
Objectives: To evaluate the prognostic effect of tSAH on different injury types based on the Marshall CT system.
Methods: We performed a retrospective study. All patients with severe closed head injury admitted from February 2011 to July 2012 were included. Their scans were classified into two groups: localized injury and diffuse injury using the Marshall classification. Outcomes were compared between patients with tSAH and those without tSAH among the two groups.
Results: Ninety-six patients were included in this study. Seventy-two (75%) were found to have tSAH, and outcomes significantly negatively correlated with tSAH in both localized injury and diffused injury groups.
Conclusions: tSAH had an important effect on the patients’ outcome. Although the Marshall classification includes important independent prognostic variables, tSAH should also be added.
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Affiliation(s)
- Fang Wang
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xin Huang
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Liang Wen
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jiang-biao Gong
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wang
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Gu Li
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Ren-ya Zhan
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiao-feng Yang
- Department of Neurosurgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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10
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Morris NA, Cool J, Merkler AE, Kamel H. Subarachnoid Hemorrhage and Long-Term Stroke Risk After Traumatic Brain Injury. Neurohospitalist 2016. [PMID: 28634501 DOI: 10.1177/1941874416675796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recent studies suggest that traumatic brain injury (TBI) is a risk factor for subsequent ischemic stroke, even years after the initial insult. The mechanisms of the association remain unclear. The presence of traumatic subarachnoid hemorrhage (tSAH) may mediate the effect of TBI on long-term stroke risk, as it has previously been linked to short-term vasospasm and delayed cerebral ischemia. METHODS Using administrative claims data, we conducted a retrospective cohort study of acute care hospitalizations. Patients discharged with a first-recorded diagnosis of tSAH were followed for a primary diagnosis of stroke. They were matched to patients with TBI but not tSAH. Cox proportional hazards modeling was used to assess the association between tSAH and stroke while adjusting for covariates. RESULTS We identified 40 908 patients with TBI (20 454 patients with tSAH) who were followed for a mean of 4.3 + 1.8 years. A total of 531 had an ischemic stroke after discharge. There was no significant difference in stroke risk between those with tSAH (1.79%; 95% confidence interval [CI] 1.54%-2.08%) versus without tSAH (2.12%; 95% CI 1.83%-2.44%). The same pattern was found in adjusted analyses even when the group was stratified by age-group or by proxies of TBI severity. CONCLUSIONS Our findings do not support a role of tSAH in mediating the association between TBI and protracted stroke risk. Further study is required to elucidate the mechanisms of long-term increased stroke risk after TBI.
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Affiliation(s)
- Nicholas A Morris
- Division of Critical Care Neurology, Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Joséphine Cool
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Alexander E Merkler
- Division of Critical Care Neurology, Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
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Glushakov AV, Arias RA, Tolosano E, Doré S. Age-Dependent Effects of Haptoglobin Deletion in Neurobehavioral and Anatomical Outcomes Following Traumatic Brain Injury. Front Mol Biosci 2016; 3:34. [PMID: 27486583 PMCID: PMC4949397 DOI: 10.3389/fmolb.2016.00034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/05/2016] [Indexed: 12/11/2022] Open
Abstract
Cerebral hemorrhages are common features of traumatic brain injury (TBI) and their presence is associated with chronic disabilities. Recent clinical and experimental evidence suggests that haptoglobin (Hp), an endogenous hemoglobin-binding protein most abundant in blood plasma, is involved in the intrinsic molecular defensive mechanism, though its role in TBI is poorly understood. The aim of this study was to investigate the effects of Hp deletion on the anatomical and behavioral outcomes in the controlled cortical impact model using wildtype (WT) C57BL/6 mice and genetically modified mice lacking the Hp gene (Hp(-∕-)) in two age cohorts [2-4 mo-old (young adult) and 7-8 mo-old (older adult)]. The data obtained suggest age-dependent significant effects on behavioral and anatomical TBI outcomes and recovery from injury. Moreover, in the adult cohort, neurological deficits in Hp(-∕-) mice at 24 h were significantly improved compared to WT, whereas there were no significant differences in brain pathology between these genotypes. In contrast, in the older adult cohort, Hp(-∕-) mice had significantly larger lesion volumes compared to WT, but neurological deficits were not significantly different. Immunohistochemistry for ionized calcium-binding adapter molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP) revealed significant differences in microglial and astrocytic reactivity between Hp(-∕-) and WT in selected brain regions of the adult but not the older adult-aged cohort. In conclusion, the data obtained in the study provide clarification on the age-dependent aspects of the intrinsic defensive mechanisms involving Hp that might be involved in complex pathways differentially affecting acute brain trauma outcomes.
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Affiliation(s)
- Alexander V Glushakov
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine Gainesville, FL, USA
| | - Rodrigo A Arias
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine Gainesville, FL, USA
| | - Emanuela Tolosano
- Departments of Molecular Biotechnology and Health Sciences, University of Torino Torino, Italy
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of MedicineGainesville, FL, USA; Departments of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics and Neuroscience, University of Florida College of MedicineGainesville, FL, USA
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Huang KT, Abd-El-Barr MM, Dunn IF. Skull Fractures and Structural Brain Injuries. HEAD AND NECK INJURIES IN YOUNG ATHLETES 2016:85-103. [DOI: 10.1007/978-3-319-23549-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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13
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Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, Herscovitch P, Hinds SR, Manley GT, Pacifico A, Razumovsky A, Riley J, Salzer W, Shih R, Smirniotopoulos JG, Stocker D. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. J Neurotrauma 2015; 32:1693-721. [PMID: 26176603 PMCID: PMC4651019 DOI: 10.1089/neu.2013.3306] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The incidence of traumatic brain injury (TBI) in the United States was 3.5 million cases in 2009, according to the Centers for Disease Control and Prevention. It is a contributing factor in 30.5% of injury-related deaths among civilians. Additionally, since 2000, more than 260,000 service members were diagnosed with TBI, with the vast majority classified as mild or concussive (76%). The objective assessment of TBI via imaging is a critical research gap, both in the military and civilian communities. In 2011, the Department of Defense (DoD) prepared a congressional report summarizing the effectiveness of seven neuroimaging modalities (computed tomography [CT], magnetic resonance imaging [MRI], transcranial Doppler [TCD], positron emission tomography, single photon emission computed tomography, electrophysiologic techniques [magnetoencephalography and electroencephalography], and functional near-infrared spectroscopy) to assess the spectrum of TBI from concussion to coma. For this report, neuroimaging experts identified the most relevant peer-reviewed publications and assessed the quality of the literature for each of these imaging technique in the clinical and research settings. Although CT, MRI, and TCD were determined to be the most useful modalities in the clinical setting, no single imaging modality proved sufficient for all patients due to the heterogeneity of TBI. All imaging modalities reviewed demonstrated the potential to emerge as part of future clinical care. This paper describes and updates the results of the DoD report and also expands on the use of angiography in patients with TBI.
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Affiliation(s)
- Franck Amyot
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David B. Arciniegas
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Baylor College of Medicine, Houston, Texas
- Brain Injury Research, TIRR Memorial Hermann, Houston, Texas
| | | | - Kenneth C. Curley
- Combat Casualty Care Directorate (RAD2), U.S. Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Ramon Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Amir Gandjbakhche
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Peter Herscovitch
- Positron Emission Tomography Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Sidney R. Hinds
- Defense and Veterans Brain Injury Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Silver Spring, Maryland
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Anthony Pacifico
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | | | - Jason Riley
- Queens University, Kingston, Ontario, Canada
- ArcheOptix Inc., Picton, Ontario, Canada
| | - Wanda Salzer
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | - Robert Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - James G. Smirniotopoulos
- Department of Radiology, Neurology, and Biomedical Informatics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Derek Stocker
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Hochstadter E, Stewart TC, Alharfi IM, Ranger A, Fraser DD. Subarachnoid hemorrhage prevalence and its association with short-term outcome in pediatric severe traumatic brain injury. Neurocrit Care 2015; 21:505-13. [PMID: 24798696 DOI: 10.1007/s12028-014-9986-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is an independent prognostic indicator of outcome in adult severe traumatic brain injury (sTBI). There is a paucity of investigations on SAH in pediatric sTBI. The goal of this study was to determine in pediatric sTBI patients SAH prevalence, associated factors, and its relationship to short-term outcome. METHODS We retrospectively analyzed 171 sTBI patients (pre-sedation GCS ≤8 and head MAIS ≥4) who underwent CT head imaging within the first 24 h of hospital admission. Data were analyzed with both univariate and multivariate techniques. RESULTS SAH was found in 42 % of sTBI patients (n = 71/171), and it was more frequently associated with skull fractures, cerebral edema, diffuse axonal injury, contusion, and intraventricular hemorrhage (p < 0.05). Patients with SAH had higher Injury Severity Scores (p = 0.032) and a greater frequency of fixed pupil(s) on admission (p = 0.001). There were no significant differences in etiologies between sTBI patients with and without SAH. Worse disposition occurred in sTBI patients with SAH, including increased mortality (p = 0.009), increased episodes of central diabetes insipidus (p = 0.002), greater infection rates (p = 0.002), and fewer ventilator-free days (p = 0.001). In sTBI survivors, SAH was associated with increased lengths of stay (p < 0.001) and a higher level of care required on discharge (p = 0.004). Despite evidence that SAH is linked to poorer outcomes on univariate analyses, multivariate analysis failed to demonstrate an independent association between SAH and mortality (p = 0.969). CONCLUSION SAH was present in almost half of pediatric sTBI patients, and it was indicative of TBI severity and a higher level of care on discharge. SAH in pediatric patients was not independently associated with increased risk of mortality.
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15
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Wang QP, Ma JP, Zhou ZM, Yang M, You C. Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction. Int J Neurosci 2015; 126:707-12. [DOI: 10.3109/00207454.2015.1055357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Abstract
OBJECTIVE To gain a description of the prevalence and time course of vasospasm in children suffering moderate-to-severe traumatic brain injury. DESIGN A prospective, observational study was performed. Children with a diagnosis of traumatic brain injury, a Glasgow Coma Score less than or equal to 12, and abnormal head imaging were enrolled. Transcranial Doppler ultrasound was performed to identify and follow vasospasm. Diagnostic criteria included flow velocity elevation more than or equal to 2 sd above age and gender normal values for the middle cerebral and basilar arteries. Additional criteria required for vasospasm diagnosis in the middle cerebral artery was a ratio of flow in the middle cerebral artery to extracranial internal carotid artery more than or equal to 3. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixty-nine children were included. The prevalence of middle cerebral artery vasospasm in children with moderate traumatic brain injury (Glasgow Coma Score, 9-12) was 8.5% and was 33.5% in those with severe traumatic brain injury (Glasgow Coma Score, ≤ 8). The prevalence of basilar artery vasospasm in children with moderate traumatic brain injury was 3% and with severe traumatic brain injury was 21%. Mean time to onset of vasospasm was 4 days (± 2 d) in the middle cerebral arteries and 5 days (± 2.5 d) in the basilar artery. Mean duration of vasospasm in the middle cerebral artery was 2 days (± 2 d) and 1.5 days (± 1 d) in the basilar artery. Children in whom vasospasm developed were more likely to have been involved in motor vehicle accidents, had higher Injury Severity Scores, had fever at admission, and had lower Glasgow Coma Score scores. Good neurologic outcome (Glasgow Outcome Score Extended Pediatric version of ≥ 4) at 1 month from injury was seen in 76% of those with moderate traumatic brain injury without vasospasm and in 40% of those with vasospasm. In those with severe traumatic brain injury, good neurologic outcome was seen in 29% of those children without vasospasm and in 15% of those with vasospasm. CONCLUSIONS Vasospasm occurs in a sizeable number of children with moderate and severe traumatic brain injury. Children in whom vasospasm developed were more likely to have been involved in a motor vehicle accident, had higher Injury Severity Scores, had fever at admission, and had lower Glasgow Coma scores than in those whom vasospasm did not develop. Based on these findings, we recommend aggressive screening for posttraumatic vasospasm in these patients. Future studies should establish the relationship between vasospasm and long-term functional outcomes and should also evaluate potential preventative or therapeutic options for vasospasm in these children.
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17
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Lasry O, Marcoux J. The use of intravenous Milrinone to treat cerebral vasospasm following traumatic subarachnoid hemorrhage. SPRINGERPLUS 2014; 3:633. [PMID: 25392803 PMCID: PMC4216821 DOI: 10.1186/2193-1801-3-633] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/07/2014] [Indexed: 11/29/2022]
Abstract
Introduction Traumatic subarachnoid hemorrhage (SAH) is a common intracranial lesion after traumatic brain injury (TBI). As in aneurysmal SAH, cerebral vasospasm is a common cause of secondary brain injury and is associated with the thickness of traumatic SAH. Unfortunately, there is limited literature on an effective treatment of this entity. The vasodilatory and inotropic agent, Milrinone, has been shown to be effective in treating vasospasm following aneurysmal SAH. The authors hypothesized that this agent could be useful and safe in treating vasospasm following tSAH. Case descriptions Case reports of 2 TBI cases from a level 1 trauma centre with tSAH and whom developed delayed ischemic neurological deficits (DINDs) are presented. Intravenous Milrinone treatment was provided to each patient following the “Montreal Neurological Hospital Protocol”. Discussion and evaluation Both patients had an improvement in their DINDs following the treatment protocol. There were no complications of treatment and the Glasgow Outcome Scores of the patients ranged from 4 to 5. Conclusion This is the first report of the use of intravenous Milrinone to treat cerebral vasospasm following traumatic SAH. This treatment option appeared to be safe and potentially useful at treating post-traumatic vasospasm. Prospective studies are necessary to establish Milrinone’s clinical effectiveness in treating this type of cerebral vasospasm.
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Affiliation(s)
- Oliver Lasry
- Department of Neurology and Neurosurgery, McGill University Health Centre, 1650 Cedar Ave., room L7-516, H3G 1A4 Montreal, QC Canada
| | - Judith Marcoux
- Department of Neurology and Neurosurgery, McGill University Health Centre, 1650 Cedar Ave., room L7-516, H3G 1A4 Montreal, QC Canada
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18
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Chong MY, Quak SM, Chong CT. Cerebral ischaemia in pituitary disorders--more common than previously thought: two case reports and literature review. Pituitary 2014; 17:171-9. [PMID: 23612931 DOI: 10.1007/s11102-013-0485-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vasospasm and consequent cerebral ischaemia in aneurysmal subarachnoid haemorrhage are well-described. The development of cerebral ischaemia following pituitary tumour surgery is under-appreciated, and can be attributed to mainly cerebral vasospasm or internal carotid artery compression. We report on two patients with pituitary tumours who developed delayed cerebral ischaemia after transsphenoidal and transcranial pituitary macroadenoma decompression. The patients had vasospasm of intracranial vessels demonstrable on magnetic resonance angiogram. One recovered neurologically following nimodipine and hypertensive-hypervolaemia therapy while the other developed fulminant cerebral infarction. We discuss the complex multi-factorial mechanisms of cerebral ischaemia in pituitary disorders, as well as the management strategies and their limitations.
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Affiliation(s)
- Margaret Yanfong Chong
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
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19
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The endothelium, a protagonist in the pathophysiology of critical illness: focus on cellular markers. BIOMED RESEARCH INTERNATIONAL 2014; 2014:985813. [PMID: 24800259 PMCID: PMC3988750 DOI: 10.1155/2014/985813] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/18/2014] [Accepted: 03/04/2014] [Indexed: 12/23/2022]
Abstract
The endotheliumis key in the pathophysiology of numerous diseases as a result of its precarious function in the regulation of tissue homeostasis. Therefore, its clinical evaluation providing diagnostic and prognostic markers, as well as its role as a therapeutic target, is the focus of intense research in patientswith severe illnesses. In the critically ill with sepsis and acute brain injury, the endothelium has a cardinal function in the development of organ failure and secondary ischemia, respectively. Cellular markers of endothelial function such as endothelial progenitor cells (EPC) and endothelialmicroparticles (EMP) are gaining interest as biomarkers due to their accessibility, although the lack of standardization of EPC and EMP detection remains a drawback for their routine clinical use. In this paper we will review data available on EPC, as a general marker of endothelial repair, and EMP as an equivalent of damage in critical illnesses, in particular sepsis and acute brain injury. Their determination has resulted in new insights into endothelial dysfunction in the critically ill. It remains speculative whether their determination might guide therapy in these devastating acute disorders in the near future.
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20
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Lee JJ, Segar DJ, Asaad WF. Comprehensive assessment of isolated traumatic subarachnoid hemorrhage. J Neurotrauma 2014; 31:595-609. [PMID: 24224706 DOI: 10.1089/neu.2013.3152] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Recent studies have shown that isolated traumatic subarachnoid hemorrhage (tSAH) in the setting of a high Glasgow Coma Scale (GCS) score (13-15) is a relatively less severe finding not likely to require operative neurosurgical intervention. This study sought to provide a more comprehensive assessment of isolated tSAH among patients with any GCS score, and to expand the analysis to examine the potential need for aggressive medical, endovascular, or open surgical interventions in these patients. By undertaking a retrospective review of all patients admitted to our trauma center from 2003-2012, we identified 661 patients with isolated tSAH. Only four patients (0.61%) underwent any sort of aggressive neurosurgical, medical, or endovascular intervention, regardless of GCS score. Most tSAH patients without additional systemic injury were discharged home (68%), including 53% of patients with a GCS score of 3-8. However, older patients were more likely to be discharged to a rehabilitation facility (p<0.01). There were six (1.7%) in-hospital deaths, and five patients of these patients were older than 80 years old. We conclude that isolated tSAH, regardless of admission GCS score, is a less severe intracranial injury that is highly unlikely to require aggressive operative, medical, or endovascular intervention, and is unlikely to be associated with major neurologic morbidity or mortality, except perhaps in elderly patients. Based upon our findings, we argue that impaired consciousness in the setting of isolated tSAH should strongly compel a consideration of non-traumatic factors in the etiology of the altered neurological status.
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Affiliation(s)
- Jonathan J Lee
- 1 Warren Alpert Medical School, Brown University , Providence, Rhode Island
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21
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Izzy S, Muehlschlegel S. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage and traumatic brain injury. Curr Treat Options Neurol 2013; 16:278. [PMID: 24347030 DOI: 10.1007/s11940-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OPINION STATEMENT Cerebral vasospasm (cVSP) consists of the vasoconstriction of large and small intracranial vessels which can lead to cerebral hypoperfusion, and in extreme cases, delayed ischemic deficits with stroke. While most commonly observed after aneurysmal subarachnoid hemorrhage (aSAH), cVSP can also occur after traumatic brain injury (TBI) as we have described in detail in this review. For the past decades, the research attention has focused on cVSP because of its association with delayed cerebral ischemia, which is the largest contributor of morbidity and mortality after aSAH. New discoveries in the cVSP pathophysiology involving multifactorial complex cascades and pathways pose new targets for therapeutic interventions in the prevention and treatment of cVSP. The goal of this review is to demonstrate the commonalities and differences in epidemiology and pathophysiology of both aSAH and TBI-associated cVSP, and highlight the more recently discovered pathways of cVSP. Finally, the latest cVSP surveillance methods and treatment options are illustrated.
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Affiliation(s)
- Saef Izzy
- Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
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22
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Armin SS, Colohan ART, Zhang JH. Traumatic subarachnoid hemorrhage: our current understanding and its evolution over the past half century. Neurol Res 2013; 28:445-52. [PMID: 16759448 DOI: 10.1179/016164106x115053] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Traumatic brain injury (TBI) is a common cause of morbidity and mortality in the US, especially among the young. Primary injury in TBI is preventable, whereas secondary injury is treatable. As a result, considerable research efforts have been focused on elucidating the pathophysiology of secondary injury and determining various prognosticators in the hopes of improving final outcome by minimizing secondary injury. One such variable, traumatic subarachnoid hemorrhage (tSAH), has been the focus of many discussions over the past half century as numerous clinical studies have shown tSAH to be associated with adverse outcome. Whether the relationship of tSAH with poorer outcome in TBI is merely an epiphenomenon or a result of direct cause and effect is unclear. Some investigators believe that tSAH is merely a marker of severer TBI, while others argue that it directly causes deleterious effects such as vasospasm and ischemia. At the present time, no proven treatment regimen aimed specifically at decreasing the detrimental effects of tSAH exists, although calcium channel blockers traditionally thought to target vasospasm have shown some promises. Given that tSAH may primarily be an early indicator of associated and evolving brain injury, vigilant diagnostic surveillance including serial head CT and prevention of secondary brain damage owing to hypotension, hypoxia and intracranial hypertension may be more cost-effective than attempting to treat potential adverse sequelae associated with tSAH.
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Affiliation(s)
- Sean S Armin
- Division of Neurosurgery, Loma Linda University Medical Center, CA 92354, USA
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23
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Cerebral vasospasm in traumatic brain injury. Neurol Res Int 2013; 2013:415813. [PMID: 23862062 PMCID: PMC3703898 DOI: 10.1155/2013/415813] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 06/04/2013] [Indexed: 01/13/2023] Open
Abstract
Vasospasm following traumatic brain injury (TBI) may dramatically affect the neurological and functional recovery of a vulnerable patient population. While the reported incidence of traumatic vasospasm ranges from 19%–68%, the true incidence remains unknown due to variability in protocols for its detection. Only 3.9%–16.6% of patients exhibit clinical deficits. Compared to vasospasm resulting from aneurysmal SAH (aSAH), the onset occurs earlier and the duration is shorter. Overall, the clinical course tends to be milder, although extreme cases may occur. Traumatic vasospasm can occur in the absence of subarachnoid hemorrhage. Surveillance transcranial Doppler ultrasonography (TCD) has been utilized to monitor for radiographic vasospasm following TBI. However, effective treatment modalities remain limited. Hypertension and hypervolemia, the mainstays of treatment of vasospasm associated with aSAH, must be used judiciously in TBI patients, and calcium-channel blockers have offered mixed clinical results. Currently, the paucity of large prospective cohort studies and level-one data limits the ability to form evidence-based recommendations regarding the diagnosis and management of vasospasm associated with TBI.
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24
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Early mortality predictor of severe traumatic brain injury: A single center study of prognostic variables based on admission characteristics. INDIAN JOURNAL OF NEUROTRAUMA 2013. [DOI: 10.1016/j.ijnt.2013.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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25
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Maas MB, Nemeth AJ, Rosenberg NF, Kosteva AR, Guth JC, Liotta EM, Prabhakaran S, Naidech AM. Subarachnoid Extension of Primary Intracerebral Hemorrhage is Associated With Poor Outcomes. Stroke 2013; 44:653-7. [DOI: 10.1161/strokeaha.112.674341] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Extension of hemorrhage into the subarachnoid space is observed in primary intracerebral hemorrhage (ICH), yet the phenomenon has undergone limited study and is of unknown significance. The objective of this study is to evaluate the incidence, characteristics, and clinical consequences of subarachnoid hemorrhage extension (SAHE) in ICH on functional outcomes.
Methods—
Patients with primary ICH were enrolled into a prospective registry between December 2006 and June 2012. Patients were managed and serial neuroimaging was obtained per a structured protocol. Presence of any subarachnoid blood on imaging was identified as SAHE by expert reviewers blinded to outcomes. Regression models were developed to test whether the occurrence of SAHE was an independent predictor of functional outcomes as measured with the modified Rankin Scale.
Results—
Of 234 patients with ICH, 93 (39.7%) had SAHE. Interrater agreement for SAHE was excellent (kappa=0.991). SAHE was associated with lobar hemorrhage location (65% of SAHE vs 19% of non-SAHE cases;
P
<0.001) and larger hematoma volumes (median 23.8 vs 6.7;
P
<0.001). Fever (69.9% vs 51.1%;
P
=0.005) and seizures (8.6% vs 2.8%;
P
=0.07) were more common in patients with SAHE. SAHE was a predictor of death by day 14 (odds ratio, 4.45; 95% confidence interval, 1.88–10.53;
P
=0.001) and of higher (worse) modified Rankin Scale scores at 28 days (odds ratio, 1.76 per mRS point; 95% confidence interval, 1.01–3.05;
P
=0.012) after adjustment for ICH score.
Conclusions—
SAHE is associated with worse modified Rankin Scale independent of traditional ICH severity measures. Underlying mechanisms and potential treatments of SAHE require further study.
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Affiliation(s)
- Matthew B. Maas
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - Alexander J. Nemeth
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - Neil F. Rosenberg
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - Adam R. Kosteva
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - James C. Guth
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - Eric M. Liotta
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - Shyam Prabhakaran
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
| | - Andrew M. Naidech
- From the Departments of Neurology (M.B.M., N.F.R., A.R.K., J.C.G., E.M.L., S.K.P, A.M.N.) and Radiology (A.J.N.), Northwestern University, Chicago, IL
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26
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Multiple symptomatic traumatic cerebral vasospasm treated by percutaneous transluminal angioplasty. J Trauma Acute Care Surg 2012; 72:E116. [PMID: 22491587 DOI: 10.1097/ta.0b013e31823b5b90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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27
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Fung C, Z'Graggen WJ, Beck J, Gralla J, Jakob SM, Schucht P, Raabe A. Traumatic subarachnoid hemorrhage, basal ganglia hematoma and ischemic stroke caused by a torn lenticulostriate artery. Acta Neurochir (Wien) 2012; 154:59-62. [PMID: 21976234 DOI: 10.1007/s00701-011-1162-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 09/02/2011] [Indexed: 11/28/2022]
Abstract
Subarachnoid hemorrhage (SAH), basal ganglia hematoma (BGH) and ischemic stroke are common diseases with diverging therapies. The simultaneous occurrence of these diseases is rare and complicates the therapy. We report the case of a 30-year-old man with a ruptured lenticulostriate artery after traumatic brain injury that caused the combination of SAH, BGH and ischemic stroke and subsequent cerebral vasospasm. This rupture mimicked the pathophysiology and imaging appearance of aneurysmal SAH. The site of rupture was not secured by any treatment; however, hyperdynamic therapy and percutaneous transluminal angioplasty were feasible in this setting to prevent additional delayed neurological deficit.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Bern University Hospital, Susan Wieting, Switzerland
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28
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Shahlaie K, Keachie K, Hutchins IM, Rudisill N, Madden LK, Smith KA, Ko KA, Latchaw RE, Muizelaar JP. Risk factors for posttraumatic vasospasm. J Neurosurg 2011; 115:602-11. [PMID: 21663415 DOI: 10.3171/2011.5.jns101667] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT Posttraumatic vasospasm (PTV) is an underrecognized cause of ischemic damage after severe traumatic brain injury (TBI) that independently predicts poor outcome. There are, however, no guidelines for PTV screening and management, partly due to limited understanding of its pathogenesis and risk factors. METHODS A database review of 46 consecutive cases of severe TBI in pediatric and adult patients was conducted to identify risk factors for the development of PTV. Univariate analysis was performed to identify potential risk factors for PTV, which were subsequently analyzed using a multivariate logistic regression model to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Fever on admission was an independent risk factor for development of PTV (OR 22.2, 95% CI 1.9-256.8), and patients with hypothermia on admission did not develop clinically significant vasospasm during their hospital stay. The presence of small parenchymal contusions was also an independent risk factor for PTV (OR 7.8, 95% CI 0.9-69.5), whereas the presence of subarachnoid hemorrhage or other patterns of intracranial injury were not. Other variables, such as age, sex, ethnicity, degree of TBI severity, or admission laboratory values, were not independent predictors for the development of clinically significant PTV. CONCLUSIONS Independent risk factors for PTV include parenchymal contusions and fever. These results suggest that diffuse mechanical injury and activation of inflammatory pathways may be underlying mechanisms for the development of PTV, and that a subset of patients with these risk factors may be an appropriate population for aggressive screening. Further studies are needed to determine if treatments targeting fever and inflammation may be effective in reducing the incidence of vasospasm following severe TBI.
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Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis School of Medicine, Sacramento, California 95817, USA.
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Bell RS, Ecker RD, Severson MA, Wanebo JE, Crandall B, Armonda RA. The evolution of the treatment of traumatic cerebrovascular injury during wartime. Neurosurg Focus 2010; 28:E5. [PMID: 20568945 DOI: 10.3171/2010.2.focus1025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.
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Affiliation(s)
- Randy S Bell
- Department of Neurosurgery, National Naval Medical Center, Bethesda, Maryland 20889, USA.
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30
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Pradilla G, Chaichana KL, Hoang S, Huang J, Tamargo RJ. Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:365-79. [PMID: 20380976 DOI: 10.1016/j.nec.2009.10.008] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Morbidity and mortality of patients with aneurysmal subarachnoid hemorrhage (aSAH) is significantly related to the development of chronic cerebral vasospasm. Despite extensive clinical and experimental research, the pathophysiology of the events that result in delayed arterial spasm is not fully understood. A review of the published literature on cerebral vasospasm that included but was not limited to all PubMed citations from 1951 to the present was performed. The findings suggest that leukocyte-endothelial cell interactions play a significant role in the pathophysiology of cerebral vasospasm and explain the clinical variability and time course of the disease. Experimental therapeutic targeting of the inflammatory response when timed correctly can prevent vasospasm, and supplementation of endothelial relaxation by nitric oxide-related therapies and other approaches could result in reversal of the arterial narrowing and improved outcomes in patients with aSAH.
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Affiliation(s)
- Gustavo Pradilla
- Division of Cerebrovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Meyer Building 8-181, 600 North Wolfe Street, Baltimore, MD 21287, USA
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31
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Zacharia BE, Hickman ZL, Grobelny BT, DeRosa P, Kotchetkov I, Ducruet AF, Connolly ES. Epidemiology of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:221-33. [PMID: 20380965 DOI: 10.1016/j.nec.2009.10.002] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a form of hemorrhagic stroke that affects up to 30,000 individuals per year in the United States. The incidence of aSAH has been shown to be associated with numerous nonmodifiable (age, gender, ethnicity, family history, aneurysm location, size) and modifiable (hypertension, body mass index, tobacco and illicit drug use) risk factors. Although early repair of ruptured aneurysms and aggressive postoperative management has improved overall outcomes, it remains a devastating disease, with mortality approaching 50% and less than 60% of survivors returning to functional independence. As treatment modalities change and the percentage of minority and elderly populations increase, it is critical to maintain an up-to-date understanding of the epidemiology of SAH.
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Affiliation(s)
- Brad E Zacharia
- Department of Neurological Surgery, Columbia University Medical Center, 630 West 168th Street, P&S Building 5-454, New York, NY 10032, USA
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CT and MR imaging of primary cerebrovascular complications in pediatric head trauma. Emerg Radiol 2010; 17:309-15. [DOI: 10.1007/s10140-010-0860-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
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Chaichana KL, Pradilla G, Huang J, Tamargo RJ. Role of inflammation (leukocyte-endothelial cell interactions) in vasospasm after subarachnoid hemorrhage. World Neurosurg 2009; 73:22-41. [PMID: 20452866 DOI: 10.1016/j.surneu.2009.05.027] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2008] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed vasospasm is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). This phenomenon was first described more than 50 years ago, but only recently has the role of inflammation in this condition become better understood. METHODS The literature was reviewed for studies on delayed vasospasm and inflammation. RESULTS There is increasing evidence that inflammation and, more specifically, leukocyte-endothelial cell interactions play a critical role in the pathogenesis of vasospasm after aSAH, as well as in other conditions including meningitis and traumatic brain injury. Although earlier clinical observations and indirect experimental evidence suggested an association between inflammation and chronic vasospasm, recently direct molecular evidence demonstrates the central role of leukocyte-endothelial cell interactions in the development of chronic vasospasm. This evidence shows in both clinical and experimental studies that cell adhesion molecules (CAMs) are up-regulated in the perivasospasm period. Moreover, the use of monoclonal antibodies against these CAMs, as well as drugs that decrease the expression of CAMs, decreases vasospasm in experimental studies. It also appears that certain individuals are genetically predisposed to a severe inflammatory response after aSAH based on their haptoglobin genotype, which in turn predisposes them to develop clinically symptomatic vasospasm. CONCLUSION Based on this evidence, leukocyte-endothelial cell interactions appear to be the root cause of chronic vasospasm. This hypothesis predicts many surprising features of vasospasm and explains apparently unrelated phenomena observed in aSAH patients. Therapies aimed at preventing inflammation may prevent and/or reverse arterial narrowing in patients with aSAH and result in improved outcomes.
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Affiliation(s)
- Kaisorn L Chaichana
- Division of Cerebrovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Cansever T, Canbolat A, Kırış T, Sencer A, Civelek E, Karasu A. Effects of arterial and venous wall homogenates, arterial and venous blood, and different combinations to the cerebral vasospasm in an experimental model. ACTA ACUST UNITED AC 2009; 71:573-9; discussion 579. [DOI: 10.1016/j.surneu.2008.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 02/24/2008] [Indexed: 11/25/2022]
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Abstract
Raised intracranial pressure (ICP) is a life threatening condition that is common to many neurological and non-neurological illnesses. Unless recognized and treated early it may cause secondary brain injury due to reduced cerebral perfusion pressure (CPP), and progress to brain herniation and death. Management of raised ICP includes care of airway, ventilation and oxygenation, adequate sedation and analgesia, neutral neck position, head end elevation by 20 degrees-30 degrees, and short-term hyperventilation (to achieve PCO(2) 32-35 mm Hg) and hyperosmolar therapy (mannitol or hypertonic saline) in critically raised ICP. Barbiturate coma, moderate hypothermia and surgical decompression may be helpful in refractory cases. Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome. Emerging evidence suggests that cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies.
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Shahlaie K, Boggan JE, Latchaw RE, Ji C, Muizelaar JP. Posttraumatic vasospasm detected by continuous brain tissue oxygen monitoring: treatment with intraarterial verapamil and balloon angioplasty. Neurocrit Care 2008; 10:61-9. [PMID: 18807219 DOI: 10.1007/s12028-008-9138-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 08/14/2008] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Posttraumatic vasospasm (PTV) is a relatively common event following traumatic brain injury (TBI) that has been strongly correlated with worse neurological outcome in many studies. However, vasospasm continues to be an under-recognized source of secondary injury following TBI, and currently published guidelines do not address screening or management strategies for PTV. Brain tissue oxygen (P(bt)O(2)) monitoring probes allow for continuous screening for cerebral hypoxia following TBI, but their use as a monitor for PTV has not been previously described. METHODS Case report and literature review. RESULTS We present a case of PTV identified by persistent low P(bt)O(2) despite aggressive medical therapy. Computed tomography and digital subtraction angiography confirmed severe cerebral arterial vasospasm involving both anterior and posterior circulations. The patient was successfully treated with serial intraarterial therapy including balloon angioplasty and verapamil infusion. CONCLUSION Posttraumatic vasospasm should be included in the differential diagnosis of cerebral hypoxia (e.g., low P(bt)O(2)) following TBI. Management strategies for PTV may include early, aggressive intraarterial therapies including drug infusion and balloon angioplasty.
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Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
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Abstract
Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
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Affiliation(s)
- Leonardo Rangel-Castillo
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Claudia S. Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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Tian HL, Xu T, Hu J, Cui YH, Chen H, Zhou LF. Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage. ACTA ACUST UNITED AC 2008; 69:241-6; discussion 246. [PMID: 17707493 DOI: 10.1016/j.surneu.2007.02.032] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Accepted: 02/13/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Posttraumatic hydrocephalus is a common complication of head injury. However, hydrocephalus after tSAH has seldom been addressed. We present this clinical study to determine the incidence of hydrocephalus and analyze the risk factors for developing hydrocephalus in patients with tSAH. METHODS A consecutive series of 301 patients with tSAH were retrospectively reviewed to determine the effects of the admission GCS score, age, sex, decompressive craniectomy, intraventricular hemorrhage, and features of tSAH (according to the initial computerized tomography scans) on the development of hydrocephalus. Risk factors for hydrocephalus were evaluated by using logistic regression analysis. RESULTS Of the 301 patients, hydrocephalus was observed in 36 (11.96%). Increasing age (P< .05), intraventricular hemorrhage (P< .05), and thickness (P< .01) or distribution (P< .05) of tSAH were significantly associated with the development of hydrocephalus. No relationship was found between hydrocephalus and sex, admission GCS score, location of tSAH, or decompressive craniectomy. CONCLUSION Hydrocephalus frequently occurs in patients with tSAH. Increasing age, low GCS score on admission, intraventricular hemorrhage, and severe SAH could be risk factors for facilitating the development of hydrocephalus.
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Affiliation(s)
- Heng-Li Tian
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Armin SS, Colohan ART, Zhang JH. Vasospasm in traumatic brain injury. ACTA NEUROCHIRURGICA SUPPLEMENT 2008. [DOI: 10.1007/978-3-211-75718-5_88] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Affiliation(s)
- Michael E Kelly
- Department of Neurosurgery, Stanford University, Stanford, CA 94305-5327, USA
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Smith JS, Chang EF, Rosenthal G, Meeker M, von Koch C, Manley GT, Holland MC. The role of early follow-up computed tomography imaging in the management of traumatic brain injury patients with intracranial hemorrhage. ACTA ACUST UNITED AC 2007; 63:75-82. [PMID: 17622872 DOI: 10.1097/01.ta.0000245991.42871.87] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether routine follow-up computed tomography (CT) for patients with head injury, in the absence of clinical indications, alters patient management. METHODS Nonpenetrating head injury patients admitted to San Francisco General Hospital during an 18-month period were reviewed. Patients not surgically treated at presentation and with a routine follow-up head CT within 24 hours were included. Surgical and nonsurgical interventions after repeat CT were assessed. Clinical and imaging parameters were correlated with progressive hemorrhagic injury (PHI) and with delayed development of surgical lesions. RESULTS PHI was identified in 49 (42%) of 116 patients. None of these patients required a nonoperative intervention in response to the PHI. Six of these patients developed a neurologic change concurrent with routine follow-up imaging and required operative intervention. Thus, no patient underwent an intervention in response to a worsening head CT in the absence of clinical findings. Of the six patients who developed a surgical lesion, two had increased intracranial pressure, one had a change in pupillary examination, three had worsening mental status, and one had change in the motor examination. Univariate risk factors for development of a delayed surgical lesion included 5 to 10 mm of midline shift (p = 0.001), basal cistern effacement (p = 0.01), and higher Marshall score (p = 0.01) on initial CT imaging. CONCLUSIONS Although PHI is common with head injury, delayed interventions in the absence of clinical indicators are uncommon. Our data suggest that early follow-up CT imaging in the setting of head trauma is not routinely indicated. We suggest that assessment, based on the severity of findings on initial brain imaging and serial clinical examinations, should guide the need for follow-up imaging in the setting of head trauma.
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Affiliation(s)
- Justin S Smith
- Department of Neurological Surgery, UCSF Brain and Spinal Injury Center, San Francisco General Hospital and University of California, San Francisco School of Medicine, San Francisco, California 94143-0112, USA.
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Abstract
Effective treatment of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. medical management of increased intracranial pressure should include sedation and paralysis, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
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Affiliation(s)
- Leonardo Rangel-Castillo
- Research Assistant, Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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Kohta M, Minami H, Tanaka K, Kuwamura K, Kondoh T, Kohmura E. Delayed onset massive oedema and deterioration in traumatic brain injury. J Clin Neurosci 2007; 14:167-70. [PMID: 17161292 DOI: 10.1016/j.jocn.2006.01.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Accepted: 01/10/2006] [Indexed: 11/17/2022]
Abstract
A 52-year-old man fell from standing and a computed tomography (CT) scan revealed traumatic intracerebral haematoma and subarachnoid haemorrhage in the temporal cortex. He was treated without surgery and discharged. On day 30 after the accident, he had no neurological deficit. On day 37 he complained of headache and urinary incontinence, and on day 39 he was hospitalized due to progressive neurological deterioration (reduced conciousness, dilated pupils, and left hemiplegia). A CT scan revealed a diffuse low-density in the right cerebral hemisphere with marked midline shift. Emergency decompressive craniectomy and right temporal lobectomy were performed. Angiography after surgery revealed moderate vasospasm in the right middle and anterior cerebral arteries. The patient remained severely disabled. Delayed onset neurological deterioration can be caused by brain oedema and vasospasm after traumatic brain injury, despite an intervening period of improvement.
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Affiliation(s)
- Masaaki Kohta
- Department of Neurosurgery, Awaji Hospital, Sumoto, Japan
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Yanagawa Y, Sakamoto T, Okada Y. Persistent intracranial hypertension treated by hypothermic therapy after severe head injury might induce late-phase cerebral vasospasm. ACTA ACUST UNITED AC 2007; 62:287-91; discussion 291. [PMID: 17297314 DOI: 10.1097/01.ta.0000223023.98182.d9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vasospasm caused by intracranial hypertension in head injury remains controversial. METHODS Between 1996 and 2004, we prospectively and consecutively performed conventional cerebral angiography for six patients with head injuries who showed persistent intracranial hypertension (over 20 mm Hg for longer than 5 days) despite performing various treatments for intracranial hypertension. RESULTS All subjects had a minor hemorrhage at admission, classified as Fisher group 2. Five of the six patients had angiographically confirmed vasospasm, and one of them later developed a cerebral infarction. Four of the five subjects who exhibited cerebral vasospasm had undergone hypothermic therapy to control the intracranial hypertension. CONCLUSION Our results suggest that persistent intracranial hypertension that is treated by hypothermic therapy may be related to late phase cerebral vasospasm.
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Affiliation(s)
- Youichi Yanagawa
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan.
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Armonda RA, Bell RS, Vo AH, Ling G, DeGraba TJ, Crandall B, Ecklund J, Campbell WW. Wartime traumatic cerebral vasospasm: recent review of combat casualties. Neurosurgery 2007; 59:1215-25; discussion 1225. [PMID: 17277684 DOI: 10.1227/01.neu.0000249190.46033.94] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Blast-related neurotrauma is associated with the severest casualties from Operation Iraqi Freedom (OIF). A consequence of this is cerebral vasospasm. This study evaluated all inpatient neurosurgical consults related to battle injury from OIF. METHODS Evaluation of all admissions from OIF from April 2003 to October 2005 was performed on patients with neurotrauma and a diagnostic cerebral angiogram. Differences between patients with and without vasospasm and predictors of vasospasm were analyzed. RESULTS Fifty-seven out of 119 neurosurgical consults were evaluated. Of these, 47.4% had traumatic vasospasm; 86.7% of patients without vasospasm and 80.8% of patients with vasospasm sustained blast trauma. Average spasm duration was 14.3 days, with a range of up to 30 days. Vasospasm was associated with the presence of pseudoaneurysm (P = 0.05), hemorrhage (P = 0.03), the number of lobes injured (P = 0.012), and mortality (P = 0.029). Those with vasospasm fared worse than those without (P = 0.002). The number of lobes injured and the presence of pseudoaneurysm were significant predictors of vasospasm (P = 0.016 and 0.02, respectively). There was a significant quadratic trend towards neurological improvement for those receiving aggressive open surgical treatment (P = 0.002). In the vasospasm group, angioplasty with microballoon significantly lowered middle cerebral artery and basilar blood-flow velocities(P = 0.046 and 0.026, respectively). CONCLUSION Traumatic vasospasm occurred in a substantial number of patients with severe neurotrauma, and clinical outcomes were worse for those with this condition. However, aggressive open surgical and endovascular treatment strategies may have improved outcome. This was the first study to analyze the effects of blast-related injury on the cerebral vasculature.
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Affiliation(s)
- Rocco A Armonda
- Department of Neurosurgery, National Naval Medical Center, Bethesda, Maryland 20814, USA.
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Gallia GL, Tamargo RJ. Leukocyte-endothelial cell interactions in chronic vasospasm after subarachnoid hemorrhage. Neurol Res 2007; 28:750-8. [PMID: 17164038 DOI: 10.1179/016164106x152025] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Leukocyte-endothelial cell interactions appear to be the root cause of chronic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). Early clinical observations and indirect experimental evidence suggested an association between inflammation and chronic vasospasm. Early clinical observations in patients with post-hemorrhagic vasospasm included pyrexia, leukocytosis and the presence of circulating immune complexes. Inflammatory infiltrates and increased levels of immunoglobulins and complement fractions within spastic cerebral arteries also provided early evidence for an inflammatory mechanism underlying chronic vasospasm. Early indirect experimental evidence included the ability to reproduce chronic vasospasm with the introduction of inflammatory agents into the subarachnoid space and the inhibition of vasospasm with anti-inflammatory agents. Currently, however, there is an increasing body of direct molecular evidence that demonstrates the pivotal role of leukocyte-endothelial cell interactions in the development of chronic vasospasm. Cell adhesion molecules such as intercellular adhesion molecule-1 (ICAM-1), lymphocyte function-associated antigen-1 (LFA-1), macrophage antigen-1 (Mac-1) and endothelial (E)-selectin mediate interactions between circulating leukocytes and cerebral endothelium. Following aSAH, ICAM-1 is up-regulated in cerebral endothelial cells and along with other cell adhesion molecules, can be detected in the serum and cerebrospinal fluid (CSF) of patients with post-hemorrhagic vasospasm. Monoclonal antibody blocking experiments have demonstrated that the prevention of leukocyte extravasation into the subarachnoid space prevents chronic vasospasm. Similarly, drugs like ibuprofen, which prevent ICAM-1 up-regulation and transendothelial cell migration of leukocytes, prevent vasospasm. In this review, we highlight early observations that suggested an association between inflammation and post-hemorrhagic vasospasm, detail the role of leukocyte-endothelial cell interactions in the development of chronic vasospasm and discuss therapeutic implications of an inflammatory etiology of post-hemorrhagic cerebral vasospasm.
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Affiliation(s)
- Gary L Gallia
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Oertel M, Boscardin WJ, Obrist WD, Glenn TC, McArthur DL, Gravori T, Lee JH, Martin NA. Posttraumatic vasospasm: the epidemiology, severity, and time course of an underestimated phenomenon: a prospective study performed in 299 patients. J Neurosurg 2005; 103:812-24. [PMID: 16304984 DOI: 10.3171/jns.2005.103.5.0812] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this prospective study was to evaluate the cumulative incidence, duration, and time course of cerebral vasospasm after traumatic brain injury (TBI) in a cohort of 299 patients. METHODS Transcranial Doppler (TCD) ultrasonography studies of blood flow velocity in the middle cerebral and basilar arteries (VMCA and VBA, respectively) were performed at regular intervals during the first 2 weeks posttrauma in association with 133Xe cerebral blood flow (CBF) measurements. According to current definitions of vasospasm, five different criteria were used to classify the patients: A (VMCA > 120 cm/second); B (VMCA > 120 cm/second and a Lindegaard ratio [LR] > 3); C (spasm index [SI] in the anterior circulation > 3.4); D (VBA > 90 cm/second); and E (SI in the posterior circulation > 2.5). Criteria C and E were considered to represent hemodynamically significant vasospasm. Mixed-effects spline models were used to analyze the data of multiple measurements with an inconsistent sampling rate. Overall 45.2% of the patients demonstrated at least one criterion for vasospasm. The patients in whom vasospasm developed were significantly younger and had lower Glasgow Coma Scale scores on admission. The normalized cumulative incidences were 36.9 and 36.2% for patients with Criteria A and B, respectively. Hemodynamically significant vasospasm in the anterior circulation (Criterion C) was found in 44.6% of the patients, whereas vasospasm in the BA-Criterion D or E-was found in only 19 and 22.5% of the patients, respectively. The most common day of onset for Criteria A, B, D, and E was postinjury Day 2. The highest risk of developing hemodynamically significant vasospasm in the anterior circulation was found on Day 3. The daily prevalence of vasospasm in patients in the intensive care unit was 30% from postinjury Day 2 to Day 13. Vasospasm resolved after a duration of 5 days in 50% of the patients with Criterion A or B and after a period of 3.5 days in 50% of those patients with Criterion D or E. Hemodynamically significant vasospasm in the anterior circulation resolved after 2.5 days in 50% of the patients. The time course of that vasospasm was primarily determined by a decrease in CBF. CONCLUSIONS The incidence of vasospasm after TBI is similar to that following aneurysmal subarachnoid hemorrhage. Because vasospasm is a significant event in a high proportion of patients after severe head injury, close TCD and CBF monitoring is recommended for the treatment of such patients.
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Affiliation(s)
- Matthias Oertel
- Department of Biostatistics, Brain Injury Research Center, David Geffen School of Medicine, University of California at Los Angeles, California 90095-7039, USA
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Maeda T, Lee SM, Hovda DA. Restoration of Cerebral Vasoreactivity by an L-Type Calcium Channel Blocker following Fluid Percussion Brain Injury. J Neurotrauma 2005; 22:763-71. [PMID: 16004579 DOI: 10.1089/neu.2005.22.763] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) results in significant acute reductions in regional cerebral blood flow (rCBF). However, the mechanisms by which TBI impairs CBF and cerebral vascular reactivity have remained elusive. In the present study, the effect of verapamil, an L-type calcium (Ca(2+)) channel blocker, on post-traumatic vascular reactivity was evaluated following a lateral fluid percussion injury (FPI) in rats. rCBF was measured by [(14)C]-iodoantipyrine autoradiography 1 h after FPI. Following FPI, significant rCBF reductions were documented in all examined cortical areas. These reductions were the most prominent (72.0%) at the primary injury site. Intravenous infusion of verapamil (VE; 200 microg/kg/min), and norepinephrine (NE; 20 microg/mL/min) to maintain normal blood pressure, increased rCBF by 141.5% at the primary injury site when compared to untreated, FPinjured animals. Under stimulated conditions, both the ipsilateral and contralateral hemispheres failed to show any increases in rCBF at 1 h following FPI. In direct contrast, following VE+NE treatment all cortical areas measured showed near normal vascular reactivity to direct cortical stimulation (normal reactivity = 45% increase in rCBF vs. 47% increase in FPI+VE+NE cases). These findings suggest that the majority of post-traumatic hemodynamic depressions are closely related to mechanisms involving vasoconstriction. Furthermore, Ca(2+) may play a causative role in this vasoconstriction and the loss of vasoreactivity.
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Affiliation(s)
- Takeshi Maeda
- Brain Injury Research Center, Department of Surgery/Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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