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Godoy DA, Rubiano AM, Aguilera S, Jibaja M, Videtta W, Rovegno M, Paranhos J, Paranhos E, de Amorim RLO, Castro Monteiro da Silva Filho R, Paiva W, Flecha J, Faleiro RM, Almanza D, Rodriguez E, Carrizosa J, Hawryluk GWJ, Rabinstein AA. Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization. Neurosurgery 2024:00006123-990000000-01104. [PMID: 38529956 DOI: 10.1227/neu.0000000000002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/30/2024] [Indexed: 03/27/2024] Open
Abstract
Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.
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Affiliation(s)
| | - Andres M Rubiano
- Universidad El Bosque, Bogota, Colombia
- MEDITECH Foundation, Cali, Colombia
| | - Sergio Aguilera
- Department Neurosurgery, Herminda Martín Hospital, Chillan, Chile
| | - Manuel Jibaja
- School of Medicine, San Francisco University, Quito, Ecuador
- Intensive Care Unit, Eugenio Espejo Hospital, Quito, Ecuador
| | - Walter Videtta
- Intensive Care Unit, Hospital Posadas, Buenos Aires, Argentina
| | - Maximiliano Rovegno
- Department Critical Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Paranhos
- Department of Neurosurgery and Critical Care, Santa Casa da Misericordia, Sao Joao del Rei, Minas Gerais, Brazil
| | - Eduardo Paranhos
- Intensive Care Unit, HEMORIO and Santa Barbara Hospitals, Rio de Janeiro, Brazil
| | | | | | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Sao Paulo, Brazil
| | - Jorge Flecha
- Intensive Care Unit, Trauma Hospital, Asuncion, Paraguay
- Social Security Institute Central Hospital, Asuncion, Paraguay
| | - Rodrigo Moreira Faleiro
- Department of Neurosurgery, João XXIII Hospital and Felício Rocho Hospital, Faculdade de Ciencias Médicas de MG, Belo Horizonte, Brazil
| | - David Almanza
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia
| | - Eliana Rodriguez
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia
| | - Jorge Carrizosa
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia
- Neurointensive Care Unit, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Neurological Institute, Akron, Ohio, USA
| | - Alejandro A Rabinstein
- Neurocritical Care and Hospital Neurology Division, Mayo Clinic, Rochester, Minnesota, USA
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Romagnoli S, Lobo FA, Picetti E, Rasulo FA, Robba C, Matta B. Non-invasive technology for brain monitoring: definition and meaning of the principal parameters for the International PRactice On TEChnology neuro-moniToring group (I-PROTECT). J Clin Monit Comput 2024:10.1007/s10877-024-01146-1. [PMID: 38512360 DOI: 10.1007/s10877-024-01146-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/26/2024] [Indexed: 03/23/2024]
Abstract
Technologies for monitoring organ function are rapidly advancing, aiding physicians in the care of patients in both operating rooms (ORs) and intensive care units (ICUs). Some of these emerging, minimally or non-invasive technologies focus on monitoring brain function and ensuring the integrity of its physiology. Generally, the central nervous system is the least monitored system compared to others, such as the respiratory, cardiovascular, and renal systems, even though it is a primary target in most therapeutic strategies. Frequently, the effects of sedatives, hypnotics, and analgesics are entirely unpredictable, especially in critically ill patients with multiple organ failure. This unpredictability exposes them to the risks of inadequate or excessive sedation/hypnosis, potentially leading to complications and long-term negative outcomes. The International PRactice On TEChnology neuro-moniToring group (I-PROTECT), comprised of experts from various fields of clinical neuromonitoring, presents this document with the aim of reviewing and standardizing the primary non-invasive tools for brain monitoring in anesthesia and intensive care practices. The focus is particularly on standardizing the nomenclature of different parameters generated by these tools. The document addresses processed electroencephalography, continuous/quantitative electroencephalography, brain oxygenation through near-infrared spectroscopy, transcranial Doppler, and automated pupillometry. The clinical utility of the key parameters available in each of these tools is summarized and explained. This comprehensive review was conducted by a panel of experts who deliberated on the included topics until a consensus was reached. Images and tables are utilized to clarify and enhance the understanding of the clinical significance of non-invasive neuromonitoring devices within these medical settings.
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Affiliation(s)
- Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Edoardo Picetti, Parma University Hospital, Parma, Italy
| | - Frank A Rasulo
- Neuroanesthesia and Neurocritical Care Unit, Spedali Civili University affiliated hospital of Brescia, Brescia, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Università di Genova, Genova, Italy
| | - Basil Matta
- Consultant in Anaesthesia, Trauma and Critical Care, Cambridge University Hospitals, Cambridge, England
- Assistant Professor - University of Cambridge, Cambridge, England
- Global Senior Medical Director - Masimo International Irvine, Irvine, CA, United States
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Kshirsagar SJ, Pande AH, Naik SV, Yadav A, Sakhala RM, Salve SM, Nuhaimah A, Desai P. Bedside ultrasonographic evaluation of optic nerve sheath diameter for monitoring of intracranial pressure in traumatic brain injury patients: a cross sectional study in level II trauma care center in India. Acute Crit Care 2024; 39:155-161. [PMID: 38476068 PMCID: PMC11002624 DOI: 10.4266/acc.2023.01172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Optic nerve sheath diameter (ONSD) is an emerging non-invasive, easily accessible, and possibly useful measurement for evaluating changes in intracranial pressure (ICP). The utilization of bedside ultrasonography (USG) to measure ONSD has garnered increased attention due to its portability, real-time capability, and lack of ionizing radiation. The primary aim of the study was to assess whether bedside USG-guided ONSD measurement can reliably predict increased ICP in traumatic brain injury (TBI) patients. METHODS A total of 95 patients admitted to the trauma intensive care unit was included in this cross sectional study. Patient brain computed tomography (CT) scans and Glasgow Coma Scale (GCS) scores were assessed at the time of admission. Bedside USG-guided binocular ONSD was measured and the mean ONSD was noted. Microsoft Excel was used for statistical analysis. RESULTS Patients with low GCS had higher mean ONSD values (6.4±1.0 mm). A highly significant association was found among the GCS, CT results, and ONSD measurements (P<0.001). Compared to CT scans, the bedside USG ONSD had 86.42% sensitivity and 64.29% specificity for detecting elevated ICP. The positive predictive value of ONSD to identify elevated ICP was 93.33%, and its negative predictive value was 45.00%. ONSD measurement accuracy was 83.16%. CONCLUSIONS Increased ICP can be accurately predicted by bedside USG measurement of ONSD and can be a valuable adjunctive tool in the management of TBI patients.
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Affiliation(s)
- Sujit J. Kshirsagar
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Anandkumar H. Pande
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Sanyogita V. Naik
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Alok Yadav
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Ruchira M. Sakhala
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Sangharsh M. Salve
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Aysath Nuhaimah
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Priyanka Desai
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
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Maramattom BV, Abraham M, Sundararajan A. Assessment of Midline Shift in Postdecompressive Craniectomy Patients in Neurocritical Care: Comparison between Transcranial Ultrasonography and Computerized Tomography. Neurol India 2023; 71:1167-1171. [PMID: 38174452 DOI: 10.4103/0028-3886.391386] [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] [Indexed: 01/05/2024]
Abstract
Background Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation. Aims and Objectives To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient. Materials and Methods Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS. Results A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement. Conclusion Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients.
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Affiliation(s)
- Boby V Maramattom
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Abraham
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
| | - Ananthram Sundararajan
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
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Liang Y, Duan Y, Xing C, Jin J, Yan L, Liu X, Wang J. Clinical Value of TCCD for Evaluating the Prognosis of Patients with Severe Traumatic Brain Injury After Large Decompressive Craniectomy: A Retrospective Study. Adv Ther 2022; 39:4556-4567. [PMID: 35934765 DOI: 10.1007/s12325-022-02251-w] [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: 04/23/2022] [Accepted: 06/29/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION It is challenging to assess the prognosis of patients with severe traumatic brain injury (sTBI) after large decompressive craniectomy (DC). The aim of this study was to evaluate the clinical value of transcranial color-coded duplex sonography (TCCD) for assessing the prognosis of sTBI patients 6 months after large DC. METHODS This was a retrospective observational study that consecutively enrolled 84 patients with sTBI who were followed up for prognosis until 6 months after large DC. The primary endpoint was the Glasgow Outcome Score (GOS). According to the GOS, patients were divided into an unfavorable prognosis group (GOS 1-3, n = 47) and a favorable prognosis group (GOS 4-5, n = 37). RESULTS Significant between-group differences were found in age and hemodynamic parameters (systolic peak blood flow velocity, end-diastolic blood flow velocity, mean blood flow velocity, pulsatility index and resistance index) of the middle cerebral artery detected by TCCD (P < 0.05 for all). Subsequently, ridge regression was used to build a prognostic model for patients with large DC. Based on the cerebral hemodynamic parameters measured by TCCD and age, the mean (± standard deviation) area under the curve of the prognostic model in patients with sTBI after large DC was 0.76 ± 0.22. The sensitivity and specificity were 82.08% and 74.17%, respectively. CONCLUSIONS The cerebral hemodynamic parameters detected by TCCD, combined with age, may be used to predict the outcomes of patients with sTBI at 6 months after large DC. As a noninvasive method, TCCD has the potential to assess the prognosis of these patients. TRIAL REGISTRATION ChiCTR: ChiCTR1800019758. Registered 27 November 2018-retrospectively registered ( http://www.chictr.org.cn/index.aspx ).
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Affiliation(s)
- Yuan Liang
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yunyou Duan
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Changyang Xing
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jinglan Jin
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Lingjuan Yan
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xi Liu
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jia Wang
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China.
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