Traumatic Brain Injury (TBI) Detection: Past, Present, and Future

Impairment of inhibitory control due to repetitive subconcussions from indirect brain impacts: Evidence from event-related potentials and resting-state EEG complexity in parachuters

The present study aims to investigate the unknown relationship between inhibitory control and repetitive subconcussion induced by the indirect brain impacts. We enrolled 28 parachuters exposed to repetitive subconcussion (SC) and 27 matched health controls (HC). Parachuters who have completed at least 70 actual parachuting (71-112 times) and at least 1500 simulated platform jumps (1500-4500 times) were included in the SC group. The SC group had a reduced accuracy rate in both the Stroop congruent and incongruent conditions. Larger N2 and N450 amplitudes were elicited in the frontal regions of the SC group, which indicate compensatory adaptations to the deficit in conflict monitoring. The reduced frontal resting-state EEG complexity in full-band (1-40 Hz) may demonstrate the frontal structural damage following the indirect brain impacts of repetitive subconcussion. Pearson correlation analysis showed that in the SC group, the frontal beta-band sample entropy values are positively correlated with the accuracy rate of the Stroop incongruent condition, suggesting the frontal beta-band sample entropy values may serve as potential electrophysiological markers of impaired inhibitory control after indirectly repetitive brain impacts. This study provides the robust evidence that repetitive subconcussion resulting from indirect brain impacts may lead to impairment of inhibitory control.

Frailty Predicts in-Hospital Death in Traumatic Brain Injury Patients: A Retrospective Cohort Study

Background and Aim

Traumatic brain injury (TBI) is a severe public health problem in elderly patients, and frailty is associated with higher mortality rates in older patients. This study aims to assess the prognostic value of frailty in patients with TBI.

Methods

Clinical data from 348 TBI patients treated at Affiliated Kunshan Hospital of Jiangsu University and Kunshan Hospital of Traditional Chinese Medicine between December 2018 and December 2020 were retrospectively collected. Univariate and multivariate logistic regression analyses were used to determine risk factors affecting in-hospital mortality, and receiver operating characteristic (ROC) curves were plotted to assess the discriminatory power of the frailty index. Frailty was assessed using the FRAIL scale, where FRAIL stands for Fatigue, Resistance, Ambulation, Illness, and Loss of weight, with each item scored as 0 or 1.

Results

Using the FRIAL questionnaire, 122 patients had low frailty and 226 had high frailty. Multivariate logistic regression analysis showed that high frailty was a risk factor for in-hospital mortality in TBI patients (P<0.001, OR=2.012 [1.788-2.412]). The proportion of infections occurring in the two groups was statistically different (P=0.015), with severely infected TBI patients being more likely to develop complications. The ROC curve showed an area under the curve for the FRAIL score of 0.845 [0.752-0.938].

Conclusion

Frailty is an important risk factor for in-hospital mortality in elderly TBI patients, and more attention should be paid to patients with high levels of frailty. Clinicians should consider the degree of frailty when assessing TBI and making treatment decisions.

The application of mesenchymal stem cells in the treatment of traumatic brain injury: Mechanisms, results, and problems

Mesenchymal stem cells (MSCs) are multipotent stromal cells that can be derived from a wide variety of human tissues and organs. They can differentiate into a variety of cell types, including osteoblasts, adipocytes, and chondrocytes, and thus show great potential in regenerative medicine. Traumatic brain injury (TBI) is an organic injury to brain tissue with a high rate of disability and death caused by an external impact or concussive force acting directly or indirectly on the head. The current treatment of TBI mainly includes symptomatic, pharmacological, and rehabilitation treatment. Although some efficacy has been achieved, the definitive recovery effect on neural tissue is still limited. Recent studies have shown that MSC therapies are more effective than traditional treatment strategies due to their strong multi-directional differentiation potential, self-renewal capacity, and low immunogenicity and homing properties, thus MSCs are considered to play an important role and are an ideal cell for the treatment of injurious diseases, including TBI. In this paper, we systematically reviewed the role and mechanisms of MSCs and MSC-derived exosomes in the treatment of TBI, thereby providing new insights into the clinical applications of MSCs and MSC-derived exosomes in the treatment of central nervous system disorders.

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.

An overview of mild traumatic brain injuries and emerging therapeutic targets

The majority of traumatic brain injuries (TBIs), approximately 90%, are classified as mild (mTBIs). Globally, an estimated 4 million injuries occur each year from concussions or mTBIs, highlighting their significance as a public health crisis. TBIs can lead to substantial long-term health consequences, including an increased risk of developing Alzheimer's Disease, Parkinson's Disease (PD), chronic traumatic encephalopathy (CTE), and nearly doubling one's risk of suicide. However, the current management of mTBIs in clinical practice and the available treatment options are limited. There exists an unmet need for effective therapy. This review addresses various aspects of mTBIs based on the most up-to-date literature review, with the goal of stimulating translational research to identify new therapeutic targets and improve our understanding of pathogenic mechanisms. First, we provide a summary of mTBI symptomatology and current diagnostic parameters such as the Glasgow Coma Scale (GCS) for classifying mTBIs or concussions, as well as the utility of alternative diagnostic parameters, including imaging techniques like MRI with diffusion tensor imaging (DTI) and serum biomarkers such as S100B, NSE, GFAP, UCH-L1, NFL, and t-tau. Our review highlights several pre-clinical concussion models employed in the study of mTBIs and the underlying cellular mechanisms involved in mTBI-related pathogenesis, including axonal damage, demyelination, inflammation, and oxidative stress. Finally, we examine a selection of new therapeutic targets currently under investigation in pre-clinical models. These targets may hold promise for clinical translation and address the pressing need for more effective treatments for mTBIs.

Biomaterials in Traumatic Brain Injury: Perspectives and Challenges

Traumatic brain injury (TBI) is a leading cause of mortality and long-term impairment globally. TBI has a dynamic pathology, encompassing a variety of metabolic and molecular events that occur in two phases: primary and secondary. A forceful external blow to the brain initiates the primary phase, followed by a secondary phase that involves the release of calcium ions (Ca2+) and the initiation of a cascade of inflammatory processes, including mitochondrial dysfunction, a rise in oxidative stress, activation of glial cells, and damage to the blood-brain barrier (BBB), resulting in paracellular leakage. Currently, there are no FDA-approved drugs for TBI, but existing approaches rely on delivering micro- and macromolecular treatments, which are constrained by the BBB, poor retention, off-target toxicity, and the complex pathology of TBI. Therefore, there is a demand for innovative and alternative therapeutics with effective delivery tactics for the diagnosis and treatment of TBI. Tissue engineering, which includes the use of biomaterials, is one such alternative approach. Biomaterials, such as hydrogels, including self-assembling peptides and electrospun nanofibers, can be used alone or in combination with neuronal stem cells to induce neurite outgrowth, the differentiation of human neural stem cells, and nerve gap bridging in TBI. This review examines the inclusion of biomaterials as potential treatments for TBI, including their types, synthesis, and mechanisms of action. This review also discusses the challenges faced by the use of biomaterials in TBI, including the development of biodegradable, biocompatible, and mechanically flexible biomaterials and, if combined with stem cells, the survival rate of the transplanted stem cells. A better understanding of the mechanisms and drawbacks of these novel therapeutic approaches will help to guide the design of future TBI therapies.

Effects of Virtual Reality Cognitive Training on Neuroplasticity: A Quasi-Randomized Clinical Trial in Patients with Stroke

Cognitive Rehabilitation (CR) is a therapeutic approach designed to improve cognitive functioning after a brain injury, including stroke. Two major categories of techniques, namely traditional and advanced (including virtual reality-VR), are widely used in CR for patients with various neurological disorders. More objective outcome measures are needed to better investigate cognitive recovery after a stroke. In the last ten years, the application of electroencephalography (EEG) as a non-invasive and portable neuroimaging method has been explored to extract the hallmarks of neuroplasticity induced by VR rehabilitation approaches, particularly within the chronic stroke population. The aim of this study is to investigate the neurophysiological effects of CR conducted in a virtual environment using the VRRS device. Thirty patients with moderate-to-severe ischemic stroke in the chronic phase (at least 6 months after the event), with a mean age of 58.13 (±8.33) for the experimental group and 57.33 (±11.06) for the control group, were enrolled. They were divided into two groups: an experimental group and a control group, receiving neurocognitive stimulation using VR and the same amount of conventional neurorehabilitation, respectively. To study neuroplasticity changes after the training, we focused on the power band spectra of theta, alpha, and beta EEG rhythms in both groups. We observed that when VR technology was employed to amplify the effects of treatments on cognitive recovery, significant EEG-related neural improvements were detected in the primary motor circuit in terms of power spectral density and time-frequency domains. Indeed, EEG analysis suggested that VR resulted in a significant increase in both the alpha band power in the occipital areas and the beta band power in the frontal areas, while no significant variations were observed in the theta band power. Our data suggest the potential effectiveness of a VR-based rehabilitation approach in promoting neuroplastic changes even in the chronic phase of ischemic stroke.

Quantitative Electroencephalography Objectivity and Reliability in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review

Background. Persons with a history of traumatic brain injury (TBI) may exhibit short- and long-term cognitive deficits as well as psychiatric symptoms. These symptoms often reflect functional anomalies in the brain that are not detected by standard neuroimaging. In this context, quantitative electroencephalography (qEEG) is more suitable to evaluate non-normative activity in a wide range of clinical settings. Method. We searched the literature using the "Medline" and "Web of Science" online databases. The search was concluded on February 23, 2023, and revised on July 12, 2023. It returned 134 results from Medline and 4 from Web of Science. We then applied the PRISMA method, which led to the selection of 31 articles, the most recent one published in March 2023. Results. The qEEG method can detect functional anomalies in the brain occurring immediately after and even years after injury, revealing in most cases abnormal power variability and increases in slow (delta and theta) versus decreases in fast (alpha, beta, and gamma) frequency activity. Moreover, other findings show that reduced beta coherence between frontoparietal regions is associated with slower processing speed in patients with recent mild TBI (mTBI). More recently, machine learning (ML) research has developed highly reliable models and algorithms for the detection of TBI, some of which are already integrated into commercial qEEG equipment. Conclusion. Accumulating evidence indicates that the qEEG method may improve the diagnosis and management of TBI, in many cases revealing long-term functional anomalies in the brain or even neuroanatomical insults that are not revealed by standard neuroimaging. While FDA clearance has been obtained only for some of the commercially available equipment, the qEEG method allows for systematic, cost-effective, non-invasive, and reliable investigations at emergency departments. Importantly, the automated implementation of intelligent algorithms based on multimodally acquired, clinically relevant measures may play a key role in increasing diagnosis reliability.

HBOT has a better cognitive outcome than NBH for patients with mild traumatic brain injury: A randomized controlled clinical trial

BACKGROUND

Normobaric hyperoxia (NBH) and hyperbaric oxygen therapy (HBOT) are effective treatment plan for traumatic brain injury (TBI). The aim of this study was to compare cognitive outcome after mild TBI between NBH and HBOT so as to provide a more suitable treatment strategy for patients with mild TBI.

METHODS

A prospective research was conducted between October 2017 and March 2023, enrolling patients with mild TBI (Glasgow coma scale score: 13-15 points) within 24 hours of injury in Cangzhou Central Hospital. Patients were randomized into 3 groups: group control (C), group NBH and group HBOT. The patients in HBOT group received hyperbaric oxygen therapy in high pressure oxygen chamber and patients in NBH group received hyperbaric oxygen therapy. at 0 minute before NBH or HBOT (T1), 0 minute after NBH or HBOT (T2) and 30 days after NBH or HBOT (T3), level of S100β, NSE, GFAP, HIF-1α, and MDA were determined by ELISA. At the same time, the detection was performed for MoCA and MMSE scores, along with rSO2.

RESULTS

The results showed both NBH and HBOT could improve the score of MoCA and MMSE, as well as the decrease the level of S100β, NSE, GFAP, HIF-1α, MDA, and rSO2 compared with group C. Furthermore, the patients in group HBOT have higher score of MoCA and MMSE and lower level of S100β, NSE, GFAP, HIF-1α, MDA, and rSO2.

CONCLUSION

Both NBH and HBOT can effectively improve cognitive outcome for patients with mild TBI by improving cerebral hypoxia and alleviating brain injury, while HBOT exert better effect than NBH.

AI-Based Decision Support System for Traumatic Brain Injury: A Survey

Traumatic brain injury (TBI) is one of the major causes of disability and mortality worldwide. Rapid and precise clinical assessment and decision-making are essential to improve the outcome and the resulting complications. Due to the size and complexity of the data analyzed in TBI cases, computer-aided data processing, analysis, and decision support systems could play an important role. However, developing such systems is challenging due to the heterogeneity of symptoms, varying data quality caused by different spatio-temporal resolutions, and the inherent noise associated with image and signal acquisition. The purpose of this article is to review current advances in developing artificial intelligence-based decision support systems for the diagnosis, severity assessment, and long-term prognosis of TBI complications.

Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist's Point of View

INTRODUCTION

Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.