1
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Vreeburg RJG, Singh RD, van Erp IAM, Korhonen TK, Yue JK, Mee H, Timofeev I, Kolias A, Helmy A, Depreitere B, Moojen WA, Younsi A, Hutchinson P, Manley GT, Steyerberg EW, de Ruiter GCW, Maas AIR, Peul WC, van Dijck JTJM, den Boogert HF, Posti JP, van Essen TA. Early versus delayed cranioplasty after decompressive craniectomy in traumatic brain injury: a multicenter observational study within CENTER-TBI and Net-QuRe. J Neurosurg 2024:1-13. [PMID: 38669706 DOI: 10.3171/2024.1.jns232172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/26/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE The aim of this study was to compare the outcomes of early (≤ 90 days) and delayed (> 90 days) cranioplasty following decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). METHODS The authors analyzed participants enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and the Neurotraumatology Quality Registry (Net-QuRe) studies who were diagnosed with TBI and underwent DC and subsequent cranioplasty. These prospective, multicenter, observational cohort studies included 5091 patients enrolled from 2014 to 2020. The effect of cranioplasty timing on functional outcome was evaluated with multivariable ordinal regression and with propensity score matching (PSM) in a sensitivity analysis of functional outcome (Glasgow Outcome Scale-Extended [GOSE] score) and quality of life (Quality of Life After Brain Injury [QOLIBRI] instrument) at 12 months following DC. RESULTS Among 173 eligible patients, 73 (42%) underwent early cranioplasty and 100 (58%) underwent delayed cranioplasty. In the ordinal logistic regression and PSM, similar 12-month GOSE scores were found between the two groups (adjusted odds ratio [aOR] 0.87, 95% CI 0.61-1.21 and 0.88, 95% CI 0.48-1.65, respectively). In the ordinal logistic regression, early cranioplasty was associated with a higher risk for hydrocephalus than that with delayed cranioplasty (aOR 4.0, 95% CI 1.2-16). Postdischarge seizure rates (early cranioplasty: aOR 1.73, 95% CI 0.7-4.7) and QOLIBRI scores (β -1.9, 95% CI -9.1 to 9.6) were similar between the two groups. CONCLUSIONS Functional outcome and quality of life were similar between early and delayed cranioplasty in patients who had undergone DC for TBI. Neurosurgeons may consider performing cranioplasty during the index admission (early) to simplify the patient's chain of care and prevent readmission for cranioplasty but should be vigilant for an increased possibility of hydrocephalus. Clinical trial registration nos.: CENTER-TBI, NCT02210221 (clinicaltrials.gov); Net-QuRe, NTR6003 (trialsearch.who.int) and NL5761 (onderzoekmetmensen.nl).
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Affiliation(s)
- Rick J G Vreeburg
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Ranjit D Singh
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Inge A M van Erp
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Tommi K Korhonen
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- 3Neurocenter, Department of Neurosurgery and Research Unit of Clinical Neuroscience, Neurosurgery, Oulu University Hospital and University of Oulu, Finland
| | - John K Yue
- 4Department of Neurosurgery, University of California, San Francisco, California
| | - Harry Mee
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ivan Timofeev
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Angelos Kolias
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Adel Helmy
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Bart Depreitere
- 5Department of Neurosurgery, University Hospital Leuven, Belgium
| | - Wouter A Moojen
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Alexander Younsi
- 6Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Peter Hutchinson
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Geoffrey T Manley
- 4Department of Neurosurgery, University of California, San Francisco, California
| | - Ewout W Steyerberg
- 7Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Godard C W de Ruiter
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Andrew I R Maas
- 8Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- 9Department of Translational Neuroscience, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Wilco C Peul
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Jeroen T J M van Dijck
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hugo F den Boogert
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Jussi P Posti
- 10Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Finland; and
| | - Thomas A van Essen
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
- 11Department of Surgery, Division of Neurosurgey, QEII Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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2
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Yue JK, Lee YM, Sun X, van Essen TA, Elguindy MM, Belton PJ, Pisică D, Mikolic A, Deng H, Kanter JH, McCrea MA, Bodien YG, Satris GG, Wong JC, Ambati VS, Grandhi R, Puccio AM, Mukherjee P, Valadka AB, Tarapore PE, Huang MC, DiGiorgio AM, Markowitz AJ, Yuh EL, Okonkwo DO, Steyerberg EW, Lingsma HF, Menon DK, Maas AIR, Jain S, Manley GT. Performance of the IMPACT and CRASH prognostic models for traumatic brain injury in a contemporary multicenter cohort: a TRACK-TBI study. J Neurosurg 2024:1-13. [PMID: 38489823 PMCID: PMC11010725 DOI: 10.3171/2023.11.jns231425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/16/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization After Significant Head Injury (CRASH) prognostic models for mortality and outcome after traumatic brain injury (TBI) were developed using data from 1984 to 2004. This study examined IMPACT and CRASH model performances in a contemporary cohort of US patients. METHODS The prospective 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years 2014-2018) enrolled subjects aged ≥ 17 years who presented to level I trauma centers and received head CT within 24 hours of TBI. Data were extracted from the subjects who met the model criteria (for IMPACT, Glasgow Coma Scale [GCS] score 3-12 with 6-month Glasgow Outcome Scale-Extended [GOSE] data [n = 441]; for CRASH, GCS score 3-14 with 2-week mortality data and 6-month GOSE data [n = 831]). Analyses were conducted in the overall cohort and stratified on the basis of TBI severity (severe/moderate/mild TBI defined as GCS score 3-8/9-12/13-14), age (17-64 years or ≥ 65 years), and the 5 top enrolling sites. Unfavorable outcome was defined as GOSE score 1-4. Original IMPACT and CRASH model coefficients were applied, and model performances were assessed by calibration (intercept [< 0 indicated overprediction; > 0 indicated underprediction] and slope) and discrimination (c-statistic). RESULTS Overall, the IMPACT models overpredicted mortality (intercept -0.79 [95% CI -1.05 to -0.53], slope 1.37 [1.05-1.69]) and acceptably predicted unfavorable outcome (intercept 0.07 [-0.14 to 0.29], slope 1.19 [0.96-1.42]), with good discrimination (c-statistics 0.84 and 0.83, respectively). The CRASH models overpredicted mortality (intercept -1.06 [-1.36 to -0.75], slope 0.96 [0.79-1.14]) and unfavorable outcome (intercept -0.60 [-0.78 to -0.41], slope 1.20 [1.03-1.37]), with good discrimination (c-statistics 0.92 and 0.88, respectively). IMPACT overpredicted mortality and acceptably predicted unfavorable outcome in the severe and moderate TBI subgroups, with good discrimination (c-statistic ≥ 0.81). CRASH overpredicted mortality in the severe and moderate TBI subgroups and acceptably predicted mortality in the mild TBI subgroup, with good discrimination (c-statistic ≥ 0.86); unfavorable outcome was overpredicted in the severe and mild TBI subgroups with adequate discrimination (c-statistic ≥ 0.78), whereas calibration was nonlinear in the moderate TBI subgroup. In subjects ≥ 65 years of age, the models performed variably (IMPACT-mortality, intercept 0.28, slope 0.68, and c-statistic 0.68; CRASH-unfavorable outcome, intercept -0.97, slope 1.32, and c-statistic 0.88; nonlinear calibration for IMPACT-unfavorable outcome and CRASH-mortality). Model performance differences were observed across the top enrolling sites for mortality and unfavorable outcome. CONCLUSIONS The IMPACT and CRASH models adequately discriminated mortality and unfavorable outcome. Observed overestimations of mortality and unfavorable outcome underscore the need to update prognostic models to incorporate contemporary changes in TBI management and case-mix. Investigations to elucidate the relationships between increased survival, outcome, treatment intensity, and site-specific practices will be relevant to improve models in specific TBI subpopulations (e.g., older adults), which may benefit from the inclusion of blood-based biomarkers, neuroimaging features, and treatment data.
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Affiliation(s)
- John K Yue
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Young M Lee
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Xiaoying Sun
- 3Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, California
| | - Thomas A van Essen
- 4University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, Leiden, The Hague, The Netherlands
| | - Mahmoud M Elguindy
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Patrick J Belton
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Dana Pisică
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ana Mikolic
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- 6Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hansen Deng
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John H Kanter
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael A McCrea
- 8Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yelena G Bodien
- 9Department of Neurological Surgery, University of Utah Health Center, Salt Lake City, Utah
- 10Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Gabriela G Satris
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Justin C Wong
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Vardhaan S Ambati
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Ramesh Grandhi
- 11Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Ava M Puccio
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pratik Mukherjee
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 12Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Alex B Valadka
- 13Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Phiroz E Tarapore
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael C Huang
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Anthony M DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 14Institute of Health Policy Studies, University of California, San Francisco, California
| | - Amy J Markowitz
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Esther L Yuh
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 12Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - David O Okonkwo
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ewout W Steyerberg
- 15Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David K Menon
- 16Division of Anesthesia, Department of Medicine, University of Cambridge, United Kingdom; and
| | - Andrew I R Maas
- 17Department of Neurological Surgery, Antwerp University Hospital and University of Antwerp, Belgium
| | - Sonia Jain
- 3Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, California
| | - Geoffrey T Manley
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
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3
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Puccio AM, Yue JK, Korley FK, Okonkwo DO, Diaz-Arrastia R, Yuh EL, Ferguson AR, Mukherjee P, Wang KKW, Taylor SR, Deng H, Markowitz AJ, Sun X, Jain S, Manley GT. Diagnostic Utility of Glial Fibrillary Acidic Protein Beyond 12 Hours After Traumatic Brain Injury: A TRACK-TBI Study. J Neurotrauma 2024. [PMID: 38251868 DOI: 10.1089/neu.2023.0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
Blood levels of glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1) within 12h of suspected traumatic brain injury (TBI) have been approved by the Food and Drug administration to aid in determining the need for a brain computed tomography (CT) scan. The current study aimed to determine whether this context of use can be expanded beyond 12h post-TBI in patients presenting with Glasgow Coma Scale (GCS) 13-15. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled TBI participants aged ≥17 years who presented to a United States Level 1 trauma center and received a clinically indicated brain CT scan within 24h post-injury, a blood draw within 24h and at 14 days for biomarker analysis. Data from participants with emergency department arrival GCS 13-15 and biomarker values at days 1 and 14 were extracted for the primary analysis. A subgroup of hospitalized participants with serial biomarkers at days 1, 3, 5, and 14 were analyzed, including plasma GFAP and UCH-L1, and serum neuron-specific enolase (NSE) and S100 calcium-binding protein B (S100B). The primary analysis compared biomarker values dichotomized by head CT results (CT+/CT-). Area under receiver-operating characteristic curve (AUC) was used to determine diagnostic accuracy. The overall cohort included 1142 participants with initial GCS 13-15, with mean age 39.8 years, 65% male, and 73% Caucasian. The GFAP provided good discrimination in the overall cohort at days 1 (AUC = 0.82) and 14 (AUC = 0.72), and in the hospitalized subgroup at days 1 (AUC = 0.84), 3 (AUC = 0.88), 5 (AUC = 0.82), and 14 (AUC = 0.74). The UCH-L1, NSE, and S100B did not perform well (AUC = 0.51-0.57 across time points). This study demonstrates the utility of GFAP to aid in decision-making for diagnostic brain CT imaging beyond the 12h time frame in patients with TBI who have a GCS 13-15.
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Affiliation(s)
- Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Kevin K W Wang
- Center for Neurotrauma, Multiomics and Biomarkers, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Sabrina R Taylor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, San Diego, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, San Diego, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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4
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Yue JK, Yuh EL, Elguindy MM, Sun X, Van Essen TA, Deng H, Belton PJ, Satris GG, Wong JC, Valadka A, Korley FK, Robertson CS, McCrea M, Stein MB, Diaz-Arrastia R, Wang KKW, Temkin N, DiGiorgio AM, Tarapore PE, Huang MC, Markowitz A, Puccio AM, Mukherjee P, Okonkwo DO, Jain S, Manley GT. Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A TRACK-TBI Study. J Neurotrauma 2024. [PMID: 38450561 DOI: 10.1089/neu.2023.0253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 hours (h) of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants aged ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; 1 additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared to without (median: 630.6 pg/ml, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p=0.049), and were associated with axonal injury (no: median 226.7 pg/ml [109.6-435.1], yes: 828.6 pg/ml [204.0-1194.3], p=0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our modest sample size and await validation from larger studies.
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Affiliation(s)
- John K Yue
- University of California, San Francisco, Neurological Surgery, 1001 Potrero Avenue, Bldg 1, Rm 101, San Francisco, California, United States, 94110
- San Francisco General Hospital, 36558, Brain and Spinal Injury Center, 1001 Potrero Avenue, Bldg 1, Rm 101, San Francisco, California, United States, 94110;
| | - Esther Lim Yuh
- University of California, San Francisco, Radiology and Biomedical Imaging, San Francisco, California, United States;
| | - Mahmoud M Elguindy
- University of California, San Francisco, Neurological Surgery, San Francisco, California, United States;
| | - Xiaoying Sun
- University of California San Diego, 8784, Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, California, United States;
| | - Thomas Arjan Van Essen
- LUMC, 4501, Neurosurgery, Albinusdreef 2, Leiden, Netherlands, 2300 RC
- Clinical Epidemiology, Albinusdreef 2, Netherlands;
| | - Hansen Deng
- University of Pittsburgh Medical Center, 6595, Neurological Surgery, Pittsburgh, Pennsylvania, United States;
| | - Patrick J Belton
- University of California, San Francisco, Neurological Surgery, San Francisco, California, United States;
| | - Gabriela G Satris
- University of California San Francisco, 8785, Neurosurgery, San Francisco, California, United States;
| | - Justin C Wong
- University of California, San Francisco, Neurological Surgery, San Francisco, California, United States;
| | - Alex Valadka
- The University of Texas Southwestern Medical Center, 12334, Department of Neurosurgery, Dallas, Texas, United States;
| | - Frederick Kofi Korley
- University of Michigan Health System, 21614, Emergency Medicine, 2800 Plymouth Road, North Campus Research Building, Building 26, Suite 333N, Ann Arbor, Michigan, United States, 48109;
| | - Claudia S Robertson
- Baylor College of Medicine, Neurosurgery, One Baylor Plaza, Houston, Texas, United States, 77030;
| | - Michael McCrea
- Medical College of Wisconsin, Neurosurgery, Hub for Collaborative Medicine, 8701 Watertown Plank Road, Milwaukee, Wisconsin, United States, 53226;
| | - Murray B Stein
- University of California, San Diego, Psychiatry, La Jolla, California, United States;
| | - Ramon Diaz-Arrastia
- University of Pennsylvania, 6572, Neurology, Penn Presbyterian Medical Center, 51 North 39th Street, Andrew Mutch Bldg., Room 409, Philadelphia, Pennsylvania, United States, 19104;
| | - Kevin K W Wang
- Morehouse School of Medicine, 1374, Neurobiology, Atlanta, Georgia, United States;
| | - Nancy Temkin
- University of Washington, Neurological Surgery, Box 359924, 325 9th Ave, Seattle, Washington, United States, 98104;
| | - Anthony Michael DiGiorgio
- University of California San Francisco, 8785, Neurological Surgery, 505 Parnassus Ave, San Francisco, San Francisco, California, United States, 94143;
| | - Phiroz E Tarapore
- University of California, San Francisco, Neurological Surgery, San Francisco, California, United States
- San Francisco General Hospital, Brain and Spinal Injury Center, San Francisco, California, United States;
| | - Michael C Huang
- University of California, San Francisco, Neurological Surgery, San Francisco, California, United States
- San Francisco General Hospital, 36558, Brain and Spinal Injury Center, San Francisco, California, United States;
| | - Amy Markowitz
- University of California, San Francisco, Neurological Surgery, San Francisco, California, United States;
| | - Ava M Puccio
- University of Pittsburgh Department of Neurological Surgery, 189496, B400-PUH, 200 Lothrop Street, Pittsburgh, Pennsylvania, United States, 15213-2536;
| | - Pratik Mukherjee
- University of California, San Francisco, Radiology and Biomedical Imaging, San Francisco, California, United States;
| | - David O Okonkwo
- University of Pittsburgh Medical Center, Neurosurgery, 200 Lothrop Street, Suite B-400, Pittsburgh, Pennsylvania, United States, 15213;
| | - Sonia Jain
- University of California San Diego, 8784, Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, California, United States;
| | - Geoffrey T Manley
- University of California San Francisco, Neurological Surgery, San Francisco, California, United States
- UCSF Weill Institute for Neurosciences, San Francisco, California, United States;
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5
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Roberts CJ, Barber J, Temkin NR, Dong A, Robertson CS, Valadka AB, Yue JK, Markowitz AJ, Manley GT, Nelson LD. Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery: A TRACK-TBI Study. JAMA Surg 2024; 159:248-259. [PMID: 38091011 PMCID: PMC10719833 DOI: 10.1001/jamasurg.2023.6374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/04/2023] [Indexed: 12/17/2023]
Abstract
Importance Traumatic brain injury (TBI) is associated with persistent functional and cognitive deficits, which may be susceptible to secondary insults. The implications of exposure to surgery and anesthesia after TBI warrant investigation, given that surgery has been associated with neurocognitive disorders. Objective To examine whether exposure to extracranial (EC) surgery and anesthesia is related to worse functional and cognitive outcomes after TBI. Design, Setting, and Participants This study was a retrospective, secondary analysis of data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective cohort study that assessed longitudinal outcomes of participants enrolled at 18 level I US trauma centers between February 1, 2014, and August 31, 2018. Participants were 17 years or older, presented within 24 hours of trauma, were admitted to an inpatient unit from the emergency department, had known Glasgow Coma Scale (GCS) and head computed tomography (CT) status, and did not undergo cranial surgery. This analysis was conducted between January 2, 2020, and August 8, 2023. Exposure Participants who underwent EC surgery during the index admission were compared with participants with no surgery in groups with a peripheral orthopedic injury or a TBI and were classified as having uncomplicated mild TBI (GCS score of 13-15 and negative CT results [CT- mTBI]), complicated mild TBI (GCS score of 13-15 and positive CT results [CT+ mTBI]), or moderate to severe TBI (GCS score of 3-12 [m/sTBI]). Main Outcomes and Measures The primary outcomes were functional limitations quantified by the Glasgow Outcome Scale-Extended for all injuries (GOSE-ALL) and brain injury (GOSE-TBI) and neurocognitive outcomes at 2 weeks and 6 months after injury. Results A total of 1835 participants (mean [SD] age, 42.2 [17.8] years; 1279 [70%] male; 299 Black, 1412 White, and 96 other) were analyzed, including 1349 nonsurgical participants and 486 participants undergoing EC surgery. The participants undergoing EC surgery across all TBI severities had significantly worse GOSE-ALL scores at 2 weeks and 6 months compared with their nonsurgical counterparts. At 6 months after injury, m/sTBI and CT+ mTBI participants who underwent EC surgery had significantly worse GOSE-TBI scores (B = -1.11 [95% CI, -1.53 to -0.68] in participants with m/sTBI and -0.39 [95% CI, -0.77 to -0.01] in participants with CT+ mTBI) and performed worse on the Trail Making Test Part B (B = 30.1 [95% CI, 11.9-48.2] in participants with m/sTBI and 26.3 [95% CI, 11.3-41.2] in participants with CT+ mTBI). Conclusions and Relevance This study found that exposure to EC surgery and anesthesia was associated with adverse functional outcomes and impaired executive function after TBI. This unfavorable association warrants further investigation of the potential mechanisms and clinical implications that could inform decisions regarding the timing of surgical interventions in patients after TBI.
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Affiliation(s)
- Christopher J. Roberts
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Athena Dong
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | | | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco
| | | | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, San Francisco, California
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
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Yue JK, Ramesh R, Krishnan N, Chyall L, Halabi C, Huang MC, Manley GT, Tarapore PE, DiGiorgio AM. Medicaid Insurance is a Predictor of Prolonged Hospital Length of Stay After Traumatic Brain Injury: A Stratified National Trauma Data Bank Cohort Analysis of 552 949 Patients. Neurosurgery 2024:00006123-990000000-01040. [PMID: 38305406 DOI: 10.1227/neu.0000000000002855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/17/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hospital length of stay (HLOS) is a metric of injury severity, resource utilization, and healthcare access. Recent evidence has shown an association between Medicaid insurance and increased HLOS after traumatic brain injury (TBI). This study aims to validate the association between Medicaid and prolonged HLOS after TBI using the National Trauma Data Bank. METHODS National Trauma Data Bank Trauma Quality Programs Participant Use Files (2003-2021) were queried for adult patients with TBI using traumatic intracranial injury ICD-9/ICD-10 codes. Patients with complete HLOS, age, sex, race, insurance payor, Glasgow Coma Scale, Injury Severity Score, and discharge disposition data were included (N = 552 949). Analyses were stratified by TBI severity using Glasgow Coma Scale. HLOS was coded into Tiers according to percentiles within TBI severity categories (Tier 1: 1-74th; 2: 75-84th; 3: 85-94th; 4: 95-99th). Multivariable logistic regressions evaluated associations between insurance payor and prolonged (Tier 4) HLOS, controlling for sociodemographic, Injury Severity Score, cranial surgery, and discharge disposition variables. Adjusted odds ratios (aOR) and 95% CI were reported. RESULTS HLOS Tiers consisted of 0-19, 20-27, 28-46, and ≥47 days (Tiers 1-4, respectively) in severe TBI (N = 103 081); 0-15, 16-21, 22-37, and ≥38 days in moderate TBI (N = 39 904); and 0-7, 8-10, 11-19, and ≥20 days in mild TBI (N = 409 964). Proportion of Medicaid patients increased with Tier ([Tier 1 vs Tier 4] severe: 16.0% vs 36.1%; moderate: 14.1% vs 31.6%; mild TBI: 10.2% vs 17.4%; all P < .001). On multivariable analyses, Medicaid was associated with prolonged HLOS (severe TBI: aOR = 2.35 [2.19-2.52]; moderate TBI: aOR = 2.30 [2.04-2.61]; mild TBI: aOR = 1.75 [1.67-1.83]; reference category: private/commercial). CONCLUSION This study supports Medicaid as an independent predictor of prolonged HLOS across TBI severity strata. Reasons may include different efficacies in care delivery and reimbursement, which require further investigation. Our findings support the development of discharge coordination pathways and policies for Medicaid patients with TBI.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Rithvik Ramesh
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Lawrence Chyall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Cathra Halabi
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Michael C Huang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Phiroz E Tarapore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
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Tritt A, Yue JK, Ferguson AR, Torres Espin A, Nelson LD, Yuh EL, Markowitz AJ, Manley GT, Bouchard KE. Data-driven distillation and precision prognosis in traumatic brain injury with interpretable machine learning. Sci Rep 2023; 13:21200. [PMID: 38040784 PMCID: PMC10692236 DOI: 10.1038/s41598-023-48054-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Abstract
Traumatic brain injury (TBI) affects how the brain functions in the short and long term. Resulting patient outcomes across physical, cognitive, and psychological domains are complex and often difficult to predict. Major challenges to developing personalized treatment for TBI include distilling large quantities of complex data and increasing the precision with which patient outcome prediction (prognoses) can be rendered. We developed and applied interpretable machine learning methods to TBI patient data. We show that complex data describing TBI patients' intake characteristics and outcome phenotypes can be distilled to smaller sets of clinically interpretable latent factors. We demonstrate that 19 clusters of TBI outcomes can be predicted from intake data, a ~ 6× improvement in precision over clinical standards. Finally, we show that 36% of the outcome variance across patients can be predicted. These results demonstrate the importance of interpretable machine learning applied to deeply characterized patients for data-driven distillation and precision prognosis.
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Affiliation(s)
- Andrew Tritt
- Applied Math and Computational Research Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - John K Yue
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Abel Torres Espin
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Geoffrey T Manley
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- Weill Neurohub, University of California San Francisco, San Francisco, CA, USA
- Weill Neurohub, University of California Berkeley, Berkeley, CA, USA
| | - Kristofer E Bouchard
- Weill Neurohub, University of California Berkeley, Berkeley, CA, USA.
- Scientific Data Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA.
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA.
- Helen Wills Neuroscience Institute and Redwood Center for Theoretical Neuroscience, University of California Berkeley, Berkeley, CA, USA.
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Shahrestani S, Brown NJ, Yue JK, Tan LA. Developing Mixed-effects Models to Optimize Prediction of Postoperative Outcomes in a Modern Sample of Over 450,000 Patients Undergoing Elective Cervical Spine Fusion Surgery. Clin Spine Surg 2023; 36:E536-E544. [PMID: 37651572 DOI: 10.1097/bsd.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
STUDY DESIGN A retrospective cohort. OBJECTIVE We utilize big data and modeling techniques to create optimized comorbidity indices for predicting postoperative outcomes following cervical spine fusion surgery. SUMMARY OF BACKGROUND DATA Cervical spine decompression and fusion surgery are commonly used to treat degenerative cervical spine pathologies. However, there is a paucity of high-quality data defining the optimal comorbidity indices specifically in patients undergoing cervical spine fusion surgery. METHODS Using data from 2016 to 2019, we queried the Nationwide Readmissions Database (NRD) to identify individuals who had received cervical spine fusion surgery. The Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining indicator was used to assess frailty. To measure the level of comorbidity, Elixhauser Comorbidity Index (ECI) scores were queried. Receiver operating characteristic curves were developed utilizing comorbidity indices as predictor variables for pertinent complications such as mortality, nonroutine discharge, top-quartile cost, top-quartile length of stay, and 1-year readmission. RESULTS A total of 453,717 patients were eligible. Nonroutine discharges occurred in 93,961 (20.7%) patients. The mean adjusted all-payer cost for the procedure was $22,573.14±18,274.86 (top quartile: $26,775.80) and the mean length of stay was 2.7±4.4 days (top quartile: 4.7 d). There were 703 (0.15%) mortalities and 58,254 (12.8%) readmissions within 1 year postoperatively. Models using frailty+ECI as primary predictors consistently outperformed the ECI-only model with statistically significant P -values for most of the complications assessed. Cost and mortality were the only outcomes for which this was not the case, as frailty outperformed both ECI and frailty+ECI in cost ( P <0.0001 for all) and frailty+ECI performed as well as ECI alone in mortality ( P =0.10). CONCLUSIONS Our data suggest that frailty+ECI may most accurately predict clinical outcomes in patients receiving cervical spine fusion surgery. These models may be used to identify high-risk populations and patients who may necessitate greater resource utilization following elective cervical spinal fusion.
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Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles
- Department of Medical Engineering, California Institute of Technology, Pasadena
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, Orange
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Lee A Tan
- Department of Neurological Surgery, University of California, San Francisco, CA
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Etemad LL, Yue JK, Barber J, Nelson LD, Bodien YG, Satris GG, Belton PJ, Madhok DY, Huie JR, Hamidi S, Tracey JX, Coskun BC, Wong JC, Yuh EL, Mukherjee P, Markowitz AJ, Huang MC, Tarapore PE, Robertson CS, Diaz-Arrastia R, Stein MB, Ferguson AR, Puccio AM, Okonkwo DO, Giacino JT, McCrea MA, Manley GT, Temkin NR, DiGiorgio AM. Longitudinal Recovery Following Repetitive Traumatic Brain Injury. JAMA Netw Open 2023; 6:e2335804. [PMID: 37751204 PMCID: PMC10523170 DOI: 10.1001/jamanetworkopen.2023.35804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023] Open
Abstract
Importance One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited. Objective To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years. Design, Setting, and Participants This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023. Exposures Postindex TBI(s). Main Outcomes and Measures Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs. Results Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains. Conclusions and Relevance In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.
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Affiliation(s)
- Leila L. Etemad
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Jason Barber
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Yelena G. Bodien
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California, San Francisco
| | - J. Russell Huie
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Sabah Hamidi
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Joye X. Tracey
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Bukre C. Coskun
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Justin C. Wong
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Amy J. Markowitz
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Michael C. Huang
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | | | | | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego
| | - Adam R. Ferguson
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joseph T. Giacino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Nancy R. Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Institute of Health Policy Studies, University of California, San Francisco
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10
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Yue JK, Krishnan N, Chyall L, Vega P, Hamidi S, Etemad LL, Tracey JX, Tarapore PE, Huang MC, Manley GT, DiGiorgio AM. Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury. Injury 2023; 54:110815. [PMID: 37268533 DOI: 10.1016/j.injury.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Hospital length of stay (HLOS) after traumatic brain injury (TBI) is a metric of injury severity, resource utilization, and access to services. This study aimed to evaluate socioeconomic and clinical factors associated with prolonged HLOS after TBI. METHODS Retrospective data from adult hospitalized patients diagnosed with acute TBI at a US Level 1 trauma center between August 1, 2019 - April 1, 2022 were extracted from the electronic health record. HLOS was stratified by Tier (1: 1-74th percentile; 2: 75-84th; 3: 85-94th; 4: 95-99th). Demographic, socioeconomic, injury severity, and level-of-care factors were compared by HLOS. Multivariable logistic regressions evaluated associations between socioeconomic and clinical variables and prolonged HLOS, using multivariable odds ratios (mOR) and [95% confidence intervals]. Estimated daily charges were calculated for a subset of medically-stable inpatients awaiting placement. Statistical significance was assessed at p < 0.05. RESULTS In 1443 patients, median HLOS was 4 days (interquartile range 2-8; range 0-145). HLOS Tiers were 0-7, 8-13, 14-27, and ≥28 days (Tiers 1-4, respectively). Patients with Tier 4 HLOS differed significantly from others, with increased Medicaid insurance (53.4% vs. 30.3-33.1%, p = 0.003), severe TBI (Glasgow Coma Scale 3-8: 38.4% vs. 8.7-18.2%, p < 0.001), younger age (mean 52.3-years vs. 61.1-63.7-years, p = 0.003), low socioeconomic status (53.4% vs. 32.0-33.9%, p = 0.003), and need for post-acute care (60.3% vs. 11.2-39.7%, p < 0.001). Independent factors associated with prolonged (Tier 4) HLOS were Medicaid (mOR = 1.99 [1.08-3.68], vs. Medicare/commercial), moderate and severe TBI (mOR = 3.48 [1.61-7.56]; mOR = 4.43 [2.18-8.99], respectively, vs. mild TBI), and need for post-acute placement (mOR = 10.68 [5.74-19.89], while age was protective (per-year mOR = 0.98 [0.97-0.99]). Estimated daily charges for a medically-stable inpatient was $17126. CONCLUSIONS Medicaid insurance, moderate/severe TBI, and need for post-acute care were independently associated with prolonged HLOS ≥28 days. Medically-stable inpatients awaiting placement accrue immense daily healthcare costs. At-risk patients should be identified early, receive care transitions resources, and be prioritized for discharge coordination pathways.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America.
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Lawrence Chyall
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Paloma Vega
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Sabah Hamidi
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Leila L Etemad
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Joye X Tracey
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Phiroz E Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America; Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
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van Essen TA, van Erp IA, Lingsma HF, Pisică D, Yue JK, Singh RD, van Dijck JT, Volovici V, Younsi A, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson PJ, Manley GT, Depreitere B, Steyerberg EW, Maas AI, de Ruiter GC, Peul WC. Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study. EClinicalMedicine 2023; 63:102161. [PMID: 37600483 PMCID: PMC10432786 DOI: 10.1016/j.eclinm.2023.102161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Background Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]). Interpretation We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
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Affiliation(s)
- Thomas A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - John K. Yue
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Ranjit D. Singh
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lianne D. Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Gerard M. Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J.A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Godard C.W. de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Schneider AL, Huie JR, Jain S, Sun X, Ferguson AR, Lynch C, Yue JK, Manley GT, Wang KK, Sandsmark DK, Campbell C, Diaz-Arrastia R. Associations of Microvascular Injury-Related Biomarkers With Traumatic Brain Injury Severity and Outcomes: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot Study. J Neurotrauma 2023; 40:1625-1637. [PMID: 37021339 PMCID: PMC10458378 DOI: 10.1089/neu.2022.0442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Traumatic brain injury (TBI) is characterized by heterogeneity in terms of injury severity, mechanism, outcome, and pathophysiology. A single biomarker alone is unlikely to capture the heterogeneity of even one injury subtype, necessitating the use of panels of biomarkers. Herein, we focus on traumatic cerebrovascular injury and investigate associations of a panel of 16 vascular injury-related biomarkers with indices of TBI severity and outcomes using data from 159 participants in the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) Pilot Study. Associations of individual biomarkers and clusters of biomarkers identified using non-linear principal components analysis with TBI severity and outcomes were assessed using logistic regression models and Spearman's correlations. As individual biomarkers, higher levels of thrombomodulin, angiopoietin (Ang)-2, von Willebrand factor, and P-selectin were associated with more severe injury; higher levels of Ang-1, Tie2, vascular endothelial growth factor (VEGF)-C, and basic fibroblast growth factor (bFGF) were associated with less severe injury (all p < 0.05 in age-adjusted models). After false discovery rate correction for multiple comparisons, higher levels of Ang-2 remained associated with more severe injury and higher levels of Ang-1, Tie2, and bFGF remained associated with less severe injury at a p < 0.05 level. In principal components analysis, principal component (PC)1, comprised of Ang1, bFGF, P-selectin, VEGF-C, VEGF-A, and Tie2, was associated with less severe injury (age-adjusted odds ratio [OR]: 0.63, 95% confidence interval [CI]: 0.44-0.88 for head computer tomography [CT] positive vs. negative) and PC2 (Ang-2, E-selectin, Flt-1, placental growth factor, thrombomodulin, and vascular cell adhesion protein 1) was associated with greater injury severity (age-adjusted OR: 2.29, 95% CI: 1.49-3.69 for Glasgow Coma Scale [GCS] 3-12 vs. 13-15 and age-adjusted OR 1.59, 95% CI: 1.11-2.32 for head CT positive vs. negative). Neither individual biomarkers nor PCs were associated with outcomes in adjusted models (all p > 0.05). In conclusion, in this trauma-center based population of acute TBI patients, biomarkers of microvascular injury were associated with TBI severity.
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Affiliation(s)
- Andrea L.C. Schneider
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - J. Russell Huie
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Adam R. Ferguson
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Cillian Lynch
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - John K. Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kevin K.W. Wang
- Program for Neurotrauma, Neuroproteomics, and Biomarker Research, Departments of Emergency Medicine, Psychiatry, and Chemistry, University of Florida, Gainesville, Florida, USA
| | - Danielle K. Sandsmark
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Ramon Diaz-Arrastia
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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13
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Deng H, Puccio DJ, Anand SK, Yue JK, Hudson JS, Legarreta AD, Wei Z, Okonkwo DO, Puccio AM, Nwachuku EL. Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients. Diagnostics (Basel) 2023; 13:2434. [PMID: 37510178 PMCID: PMC10378508 DOI: 10.3390/diagnostics13142434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David J Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Sharath K Anand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Enyinna L Nwachuku
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Yue JK, Krishnan N, Andrews JP, Semonche AM, Deng H, Aabedi AA, Wang AS, Caldwell DJ, Park C, Hirschhorn M, Ghoussaini KT, Oh T, Sun PP. Update on Pediatric Mild Traumatic Brain Injury in Rural and Underserved Regions: A Global Perspective. J Clin Med 2023; 12:jcm12093309. [PMID: 37176749 PMCID: PMC10179657 DOI: 10.3390/jcm12093309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Mild traumatic brain injury (MTBI) causes morbidity and disability worldwide. Pediatric patients are uniquely vulnerable due to developmental and psychosocial factors. Reduced healthcare access in rural/underserved communities impair management and outcome. A knowledge update relevant to current gaps in care is critically needed to develop targeted solutions. METHODS The National Library of Medicine PubMed database was queried using comprehensive search terms (("mild traumatic brain injury" or "concussion") and ("rural" or "low-income" or "underserved") and ("pediatric" or "child/children")) in the title, abstract, and Medical Subject Headings through December 2022. Fifteen articles on rural/underserved pediatric MTBI/concussion not covered in prior reviews were examined and organized into four topical categories: epidemiology, care practices, socioeconomic factors, and telehealth. RESULTS Incidences are higher for Individuals in rural regions, minorities, and those aged 0-4 years compared to their counterparts, and are increasing over time. Rural healthcare utilization rates generally exceed urban rates, and favor emergency departments (vs. primary care) for initial injury assessment. Management guidelines require customization to resource-constrained settings for implementation and adoption. Decreased community recognition of the seriousness of injury is a consensus challenge to care provision by clinicians. Low parental education and income were correlated with decreased MTBI knowledge and worse outcome. Telehealth protocols for triage/consultation and rehabilitation were feasible in improving care delivery to rural and remote settings. CONCLUSIONS Pediatric MTBI/concussion patients in rural/underserved regions experience increased risks of injury, geographic and financial healthcare barriers, and poorer outcomes. Globally, under-reporting of injury has hindered epidemiological understanding. Ongoing MTBI education should be implemented for rural caregivers, schools, and low-income populations to improve community awareness. Telehealth can improve care delivery across acuity settings, and warrants judicious inclusion in triage and treatment protocols.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Nishanth Krishnan
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - John P Andrews
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Alexa M Semonche
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Alexander A Aabedi
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Albert S Wang
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - David J Caldwell
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Christine Park
- Department of Neurosurgery, Duke University, Durham, NC 27708, USA
| | - Melessa Hirschhorn
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Kristen T Ghoussaini
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Taemin Oh
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Peter P Sun
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA
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Yue JK, Deng H. Traumatic Brain Injury: Contemporary Challenges and the Path to Progress. J Clin Med 2023; 12:jcm12093283. [PMID: 37176723 PMCID: PMC10179594 DOI: 10.3390/jcm12093283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide, and its incidence is increasing [...].
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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16
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Tantry EK, Yue JK, Krishnan N, Strelko O, Spiro E, Tarapore PE, Haddad AF, Huang MC, Manley GT, DiGiorgio AM. 402 Disparities in Traumatic Brain Injury Patients’ Length of Stay: An Analysis of NTDB Data. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Chalif E, Yue JK, Chillakuru Y, Badani A, Aghi MK. 177 International Authorship Trends in Academic Neurosurgery and Effect of Double-Blind Review. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Yue JK, Krishnan N, Wang AS, Chung JE, Etemad LL, Manley GT, Tarapore PE. A standardized postoperative bowel regimen protocol after spine surgery. Front Surg 2023; 10:1130223. [PMID: 37009608 PMCID: PMC10063852 DOI: 10.3389/fsurg.2023.1130223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/27/2023] [Indexed: 03/19/2023] Open
Abstract
ObjectivesSpine surgery is associated with early impairment of gastrointestinal motility, with postoperative ileus rates of 5–12%. A standardized postoperative medication regimen aimed at early restoration of bowel function can reduce morbidity and cost, and its study should be prioritized.MethodsA standardized postoperative bowel medication protocol was implemented for all elective spine surgeries performed by a single neurosurgeon from March 1, 2022 to June 30, 2022 at a metropolitan Veterans Affairs medical center. Daily bowel function was tracked and medications were advanced using the protocol. Clinical, surgical, and length of stay data are reported.ResultsAcross 20 consecutive surgeries in 19 patients, mean age was 68.9 years [standard deviation (SD) = 10; range 40–84]. Seventy-four percent reported preoperative constipation. Surgeries consisted of 45% fusion and 55% decompression; lumbar retroperitoneal approaches constituted 30% (10% anterior, 20% lateral). Two patients were discharged in good condition prior to bowel movement after meeting institutional discharge criteria; the other 18 cases all had return of bowel function by postoperative day (POD) 3 (mean = 1.8-days, SD = 0.7). There were no inpatient or 30-day complications. Mean discharge occurred 3.3-days post-surgery (SD = 1.5; range 1–6; home 95%, skilled nursing facility 5%). Estimated cumulative cost of the bowel regimen was $17 on POD 3.ConclusionsCareful monitoring of return of bowel function after elective spine surgery is important for preventing ileus, reducing healthcare cost, and ensuring quality. Our standardized postoperative bowel regimen was associated with return of bowel function within 3 days and low costs. These findings can be utilized in quality-of-care pathways.
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Affiliation(s)
- John K. Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Correspondence: John K. Yue
| | - Nishanth Krishnan
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Albert S. Wang
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Jason E. Chung
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Leila L. Etemad
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
| | - Phiroz E. Tarapore
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
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Yue JK, Krishnan N, Kanter JH, Deng H, Okonkwo DO, Puccio AM, Madhok DY, Belton PJ, Lindquist BE, Satris GG, Lee YM, Umbach G, Duhaime AC, Mukherjee P, Yuh EL, Valadka AB, DiGiorgio AM, Tarapore PE, Huang MC, Manley GT, Investigators TTRACKTBI. Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study. J Clin Med 2023; 12:2024. [PMID: 36902811 PMCID: PMC10004432 DOI: 10.3390/jcm12052024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization. METHODS Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported. RESULTS In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]). CONCLUSIONS Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.
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Affiliation(s)
- John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - John H. Kanter
- Section of Neurological Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Britta E. Lindquist
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA 94110, USA
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Young M. Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Gray Umbach
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Ann-Christine Duhaime
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA 94158, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael C. Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
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20
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Bodien YG, Barber J, Taylor SR, Boase K, Corrigan JD, Dikmen S, Gardner RC, Kramer JH, Levin H, Machamer J, McAllister T, Nelson LD, Ngwenya LB, Sherer M, Stein MB, Vassar M, Whyte J, Yue JK, Markowitz A, McCrea MA, Manley GT, Temkin N, Giacino JT. Feasibility and Utility of a Flexible Outcome Assessment Battery for Longitudinal Traumatic Brain Injury Research: A TRACK-TBI Study. J Neurotrauma 2023; 40:337-348. [PMID: 36097759 PMCID: PMC9902043 DOI: 10.1089/neu.2022.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The effects of traumatic brain injury (TBI) are difficult to measure in longitudinal cohort studies, because disparate pre-injury characteristics and injury mechanisms produce variable impairment profiles and recovery trajectories. In preparation for the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, which followed patients with injuries ranging from uncomplicated mild TBI to coma, we designed a multi-dimensional Flexible outcome Assessment Battery (FAB). The FAB relies on a decision-making algorithm that assigns participants to a Comprehensive (CAB) or Abbreviated Assessment Battery (AAB) and guides test selection across all phases of recovery. To assess feasibility of the FAB, we calculated the proportion of participants followed at 2 weeks (2w) and at 3, 6, and 12 months (3m, 6m, 12m) post-injury who completed the FAB and received valid scores. We evaluated utility of the FAB by examining differences in 6m and 12m Glasgow Outcome Scale-Extended (GOSE) scores between participant subgroups derived from the FAB-enabled versus traditional approach to outcome assessment applied at 2w. Among participants followed at 2w (n = 2094), 3m (n = 1871), 6m (n = 1736), and 12m (n = 1607) post-injury, 95-99% received valid completion scores on the FAB, in full or in part, either in person or by telephone. Level of function assessed by the FAB-enabled approach at 2w was associated with 6m and 12m GOSE scores (proportional odds p < 0.001). These findings suggest that the participant classification methodology afforded by the FAB may enable more effective data collection to improve detection of natural history changes and TBI treatment effects.
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Affiliation(s)
- Yelena G. Bodien
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Jason Barber
- University of Washington, Seattle, Washington, USA
| | - Sabrina R. Taylor
- University of California, San Francisco, San Francisco, California, USA
| | - Kim Boase
- University of Washington, Seattle, Washington, USA
| | | | | | - Raquel C. Gardner
- University of California, San Francisco, San Francisco, California, USA
| | - Joel H. Kramer
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Thomas McAllister
- University of Indiana School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Mark Sherer
- Baylor College of Medicine, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
| | - Murray B. Stein
- University of California San Diego, La Jolla, California, USA
| | - Mary Vassar
- University of California, San Francisco, San Francisco, California, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, USA
| | - John K. Yue
- University of California, San Francisco, San Francisco, California, USA
| | - Amy Markowitz
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Nancy Temkin
- University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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21
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Stein MB, Jain S, Parodi L, Choi KW, Maihofer AX, Nelson LD, Mukherjee P, Sun X, He F, Okonkwo DO, Giacino JT, Korley FK, Vassar MJ, Robertson CS, McCrea MA, Temkin N, Markowitz AJ, Diaz-Arrastia R, Rosand J, Manley GT, Duhaime AC, Ferguson AR, Gopinath S, Grandhi R, Madden C, Merchant R, Schnyer D, Taylor SR, Yue JK, Zafonte R. Polygenic risk for mental disorders as predictors of posttraumatic stress disorder after mild traumatic brain injury. Transl Psychiatry 2023; 13:24. [PMID: 36693822 PMCID: PMC9873804 DOI: 10.1038/s41398-023-02313-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Many patients with mild traumatic brain injury (mTBI) are at risk for mental health problems such as posttraumatic stress disorder (PTSD). The objective of this study was to determine whether the polygenic risk for PTSD (or for related mental health disorders or traits including major depressive disorder [MDD] and neuroticism [NEU]) was associated with an increased likelihood of PTSD in the aftermath of mTBI. We used data from individuals of European ancestry with mTBI enrolled in TRACK-TBI (n = 714), a prospective longitudinal study of level 1 trauma center patients. One hundred and sixteen mTBI patients (16.3%) had probable PTSD (PCL-5 score ≥33) at 6 months post-injury. We used summary statistics from recent GWAS studies of PTSD, MDD, and NEU to generate polygenic risk scores (PRS) for individuals in our sample. A multivariable model that included age, sex, pre-injury history of mental disorder, and cause of injury explained 7% of the variance in the PTSD outcome; the addition of the PTSD-PRS (and five ancestral principal components) significantly increased the variance explained to 11%. The adjusted odds of PTSD in the uppermost PTSD-PRS quintile was nearly four times higher (aOR = 3.71, 95% CI 1.80-7.65) than in the lowest PTSD-PRS quintile. There was no evidence of a statistically significant interaction between PTSD-PRS and prior history of mental disorder, indicating that PTSD-PRS had similar predictive utility among those with and without pre-injury psychiatric illness. When added to the model, neither MDD-PRS nor NEU-PRS were significantly associated with the PTSD outcome. These findings show that the risk for PTSD in the context of mTBI is, in part, genetically influenced. They also raise the possibility that an individual's PRS could be clinically actionable if used-possibly with other non-genetic predictors-to signal the need for enhanced follow-up and early intervention; this precision medicine approach needs to be prospectively studied.
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Affiliation(s)
- Murray B. Stein
- grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, La Jolla, CA USA ,grid.266100.30000 0001 2107 4242School of Public Health, University of California, San Diego, La Jolla, CA USA ,grid.410371.00000 0004 0419 2708VA San Diego Healthcare System, San Diego, CA USA
| | - Sonia Jain
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - Livia Parodi
- grid.32224.350000 0004 0386 9924Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA USA ,grid.32224.350000 0004 0386 9924McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA USA ,grid.66859.340000 0004 0546 1623Broad Institute of MIT and Harvard, Cambridge, MA USA
| | - Karmel W. Choi
- grid.66859.340000 0004 0546 1623Broad Institute of MIT and Harvard, Cambridge, MA USA ,grid.32224.350000 0004 0386 9924Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | - Adam X. Maihofer
- grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
| | - Lindsay D. Nelson
- grid.30760.320000 0001 2111 8460Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Pratik Mukherjee
- grid.266102.10000 0001 2297 6811Department of Radiology & Biomedical Imaging, UCSF, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Bioengineering & Therapeutic Sciences, UCSF, San Francisco, CA USA
| | - Xiaoying Sun
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - Feng He
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - David O. Okonkwo
- grid.412689.00000 0001 0650 7433Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Joseph T. Giacino
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.416228.b0000 0004 0451 8771Spaulding Rehabilitation Hospital, Charlestown, MA USA
| | - Frederick K. Korley
- grid.214458.e0000000086837370Department of Emergency Medicine, University of Michigan, Ann Arbor, MI USA
| | - Mary J. Vassar
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
| | - Claudia S. Robertson
- grid.39382.330000 0001 2160 926XDepartment of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Michael A. McCrea
- grid.30760.320000 0001 2111 8460Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Nancy Temkin
- grid.34477.330000000122986657Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA USA
| | - Amy J. Markowitz
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Ramon Diaz-Arrastia
- grid.25879.310000 0004 1936 8972Department of Neurology, University of Pennsylvania, Philadelphia, PA USA
| | - Jonathan Rosand
- grid.32224.350000 0004 0386 9924Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA USA ,grid.32224.350000 0004 0386 9924McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA USA ,grid.66859.340000 0004 0546 1623Broad Institute of MIT and Harvard, Cambridge, MA USA
| | - Geoffrey T. Manley
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
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22
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Yue JK, Kobeissy FH, Jain S, Sun X, Phelps RR, Korley FK, Gardner RC, Ferguson AR, Huie JR, Schneider AL, Yang Z, Xu H, Lynch CE, Deng H, Rabinowitz M, Vassar MJ, Taylor SR, Mukherjee P, Yuh EL, Markowitz AJ, Puccio AM, Okonkwo DO, Diaz-Arrastia R, Manley GT, Wang KK. Neuroinflammatory Biomarkers for Traumatic Brain Injury Diagnosis and Prognosis: A TRACK-TBI Pilot Study. Neurotrauma Rep 2023; 4:171-183. [PMID: 36974122 PMCID: PMC10039275 DOI: 10.1089/neur.2022.0060] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
The relationship between systemic inflammation and secondary injury in traumatic brain injury (TBI) is complex. We investigated associations between inflammatory markers and clinical confirmation of TBI diagnosis and prognosis. The prospective TRACK-TBI Pilot (Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot) study enrolled TBI patients triaged to head computed tomography (CT) and received blood draw within 24 h of injury. Healthy controls (HCs) and orthopedic controls (OCs) were included. Thirty-one inflammatory markers were analyzed from plasma. Area under the receiver operating characteristic curve (AUC) was used to evaluate discriminatory ability. AUC >0.7 was considered acceptable. Criteria included: TBI diagnosis (vs. OC/HC); moderate/severe vs. mild TBI (Glasgow Coma Scale; GCS); radiographic TBI (CT positive vs. CT negative); 3- and 6-month Glasgow Outcome Scale-Extended (GOSE) dichotomized to death/greater relative disability versus less relative disability (GOSE 1-4/5-8); and incomplete versus full recovery (GOSE <8/ = 8). One-hundred sixty TBI subjects, 28 OCs, and 18 HCs were included. Markers discriminating TBI/OC: HMGB-1 (AUC = 0.835), IL-1b (0.795), IL-16 (0.784), IL-7 (0.742), and TARC (0.731). Markers discriminating GCS 3-12/13-15: IL-6 (AUC = 0.747), CRP (0.726), IL-15 (0.720), and SAA (0.716). Markers discriminating CT positive/CT negative: SAA (AUC = 0.767), IL-6 (0.757), CRP (0.733), and IL-15 (0.724). At 3 months, IL-15 (AUC = 0.738) and IL-2 (0.705) discriminated GOSE 5-8/1-4. At 6 months, IL-15 discriminated GOSE 1-4/5-8 (AUC = 0.704) and GOSE <8/ = 8 (0.711); SAA discriminated GOSE 1-4/5-8 (0.704). We identified a profile of acute circulating inflammatory proteins with potential relevance for TBI diagnosis, severity differentiation, and prognosis. IL-15 and serum amyloid A are priority markers with acceptable discrimination across multiple diagnostic and outcome categories. Validation in larger prospective cohorts is needed. ClinicalTrials.gov Registration: NCT01565551.
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Affiliation(s)
- John K. Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Address correspondence to: John K. Yue, MD, Department of Neurosurgery, University of California, San Francisco, 1001 Potrero Avenue, Building 1, Room 101, San Francisco, CA 94143, USA.
| | - Firas H. Kobeissy
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
- Center for Neurotrauma, Multiomics and Biomarkers, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Sonia Jain
- Division of Biostatistics and Bioinformatics, Departments of Family Medicine and Public Health, University of California, San Diego, San Diego, California, USA
| | - Xiaoying Sun
- Division of Biostatistics and Bioinformatics, Departments of Family Medicine and Public Health, University of California, San Diego, San Diego, California, USA
| | - Ryan R.L. Phelps
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Frederick K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Raquel C. Gardner
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Adam R. Ferguson
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - J. Russell Huie
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrea L.C. Schneider
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zhihui Yang
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Haiyan Xu
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Cillian E. Lynch
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Miri Rabinowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary J. Vassar
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sabrina R. Taylor
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Amy J. Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ava M. Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Kevin K.W. Wang
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
- Center for Neurotrauma, Multiomics and Biomarkers, Morehouse School of Medicine, Atlanta, Georgia, USA
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23
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Gardner RC, Puccio AM, Korley FK, Wang KKW, Diaz-Arrastia R, Okonkwo DO, Puffer RC, Yuh EL, Yue JK, Sun X, Taylor SR, Mukherjee P, Jain S, Manley GT, Ferguson AR, Gaudette E, Shankar GC, Keene D, Madden C, Martin A, McCrea M, Merchant R, Mukherjee P, Ngwenya LB, Robertson C, Temkin N, Vassar M, Yue JK, Zafonte R. Effects of age and time since injury on traumatic brain injury blood biomarkers: a TRACK-TBI study. Brain Commun 2022; 5:fcac316. [PMID: 36642999 PMCID: PMC9832515 DOI: 10.1093/braincomms/fcac316] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/07/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
Older adults have the highest incidence of traumatic brain injury globally. Accurate blood-based biomarkers are needed to assist with diagnosis of patients across the spectrum of age and time post-injury. Several reports have suggested lower accuracy for blood-based biomarkers in older adults, and there is a paucity of data beyond day-1 post-injury. Our aims were to investigate age-related differences in diagnostic accuracy and 2-week evolution of four leading candidate blood-based traumatic brain injury biomarkers-plasma glial fibrillary acidic protein, ubiquitin carboxy-terminal hydrolase L1, S100 calcium binding protein B and neuron-specific enolase-among participants in the 18-site prospective cohort study Transforming Research And Clinical Knowledge in Traumatic Brain Injury. Day-1 biomarker data were available for 2602 participants including 2151 patients with traumatic brain injury, 242 orthopedic trauma controls and 209 healthy controls. Participants were stratified into 3 age categories (young: 17-39 years, middle-aged: 40-64 years, older: 65-90 years). We investigated age-stratified biomarker levels and biomarker discriminative abilities across three diagnostic groups: head CT-positive/negative; traumatic brain injury/orthopedic controls; and traumatic brain injury/healthy controls. The difference in day-1 glial fibrillary acidic protein, ubiquitin carboxy-terminal hydrolase L1 and neuron-specific enolase levels across most diagnostic groups was significantly smaller for older versus younger adults, resulting in a narrower range within which a traumatic brain injury diagnosis may be discriminated in older adults. Despite this, day-1 glial fibrillary acidic protein had good to excellent performance across all age-categories for discriminating all three diagnostic groups (area under the curve 0.84-0.96; lower limit of 95% confidence intervals all >0.78). Day-1 S100 calcium-binding protein B and ubiquitin carboxy-terminal hydrolase L1 showed good discrimination of CT-positive versus negative only among adults under age 40 years within 6 hours of injury. Longitudinal blood-based biomarker data were available for 522 hospitalized patients with traumatic brain injury and 24 hospitalized orthopaedic controls. Glial fibrillary acidic protein levels maintained good to excellent discrimination across diagnostic groups until day 3 post-injury irrespective of age, until day 5 post-injury among middle-aged or younger patients and until week 2 post-injury among young patients only. In conclusion, the blood-based glial fibrillary acidic protein assay tested here has good to excellent performance across all age-categories for discriminating key traumatic brain injury diagnostic groups to at least 3 days post-injury in this trauma centre cohort. The addition of a blood-based diagnostic to the evaluation of traumatic brain injury, including geriatric traumatic brain injury, has potential to streamline diagnosis.
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Affiliation(s)
- Raquel C Gardner
- Correspondence to: Raquel C. Gardner, MD Sheba Medical Center, Derech Sheba 2 Ramat Gan, Israel 52621 E-mail:
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kevin K W Wang
- Departments of Emergency Medicine, Psychiatry, and Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA,Brain Rehabilitation Research Center (BRRC), Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd., 32608, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Ross C Puffer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA,Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55901, USA
| | - Esther L Yuh
- Department of Radiology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Xiaoying Sun
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA 92161, USA
| | - Sabrina R Taylor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA 92161, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
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24
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Andrews JP, Wozny TA, Yue JK, Wang DD. Improved psychotic symptoms following resection of amygdalar low-grade glioma: illustrative case. J Neurosurg Case Lessons 2022; 4:CASE22362. [PMID: 36443957 PMCID: PMC9705519 DOI: 10.3171/case22362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epilepsy-associated psychoses are poorly understood, and management is focused on treating epilepsy. Chronic, interictal psychosis that persists despite seizure control is typically treated with antipsychotics. Whether resection of a mesial temporal lobe lesion may improve interictal psychotic symptoms that persist despite seizure control remains unknown. OBSERVATIONS In a 52-year-old man with well-controlled epilepsy and persistent comorbid psychosis, brain magnetic resonance imaging (MRI) revealed an infiltrative, intraaxial, T2 fluid-attenuated inversion recovery intense mass of the left amygdala. The patient received an amygdalectomy for oncological diagnosis and surgical treatment of a presumed low-grade glioma. Pathology was ganglioglioma, World Health Organization grade I. Postoperatively, the patient reported immediate resolution of auditory hallucinations. Patient has remained seizure-free on 2 antiepileptic drugs and no antipsychotic pharmacotherapy and reported lasting improvement in his psychotic symptoms. LESSONS This report discusses improvement of psychosis symptoms after resection of an amygdalar glioma, independent of seizure outcome. This case supports a role of the amygdala in psychopathology and suggests that low-grade gliomas of the limbic system may represent, at minimum, partially reversible etiology of psychotic symptoms.
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Affiliation(s)
- John P. Andrews
- Department of Neurosurgery, University of California San Francisco, San Francisco, California; and ,Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Thomas A. Wozny
- Department of Neurosurgery, University of California San Francisco, San Francisco, California; and ,Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - John K. Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California; and ,Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Doris D. Wang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California; and ,Department of Neurosurgery, San Francisco Veterans Affairs Medical Center, San Francisco, California
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Yue JK, Lee YM, Quintana D, Aabedi AA, Krishnan N, Wozny TA, Andrews JP, Huang MC. Paraparesis caused by intradural thoracic spinal granuloma secondary to organizing hematoma: illustrative case. J Neurosurg Case Lessons 2022; 4:CASE22432. [PMID: 36411545 PMCID: PMC9678799 DOI: 10.3171/case22432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Spinal granulomas form from infectious or noninfectious inflammatory processes and are rarely present intradurally. Intradural granulomas secondary to hematoma are unreported in the literature and present diagnostic and management challenges. OBSERVATIONS A 70-year-old man receiving aspirin presented with encephalopathy, subacute malaise, and right lower extremity weakness and was diagnosed with polysubstance withdrawal and refractory hypertension requiring extended treatment. Seven days after admission, he reported increased bilateral lower extremity (BLE) weakness. Magnetic resonance imaging showed T2-3 and T7-8 masses abutting the pia, with spinal cord compression at T2-3. He was transferred to the authors' institution, and work-up showed no vascular shunting or malignancy. He underwent T2-3 laminectomies for biopsy/resection. A firm, xanthochromic mass was resected en bloc. Pathology showed organizing hematoma without infection, vascular malformation, or malignancy. Subsequent coagulopathy work-up was unremarkable. His BLE strength significantly improved, and he declined resection of the inferior mass. He completed physical therapy and was cleared for placement in a skilled nursing facility. LESSONS Spinal granulomas can mimic vascular lesions and malignancy. The authors present the first report of paraparesis caused by intradural granuloma secondary to organizing hematoma, preceded by severe refractory hypertension. Tissue diagnosis is critical, and resection is curative. These findings can inform the vigilant clinician for expeditious treatment.
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Affiliation(s)
- John K. Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - Young M. Lee
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - Daniel Quintana
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - Alexander A. Aabedi
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - Nishanth Krishnan
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - Thomas A. Wozny
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - John P. Andrews
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
| | - Michael C. Huang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California; and ,Department of Neurosurgery, Veterans Affairs Medical Center, San Francisco, California
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Yue JK, Krishnan N, Chyall L, Haddad AF, Vega P, Caldwell DJ, Umbach G, Tantry E, Tarapore PE, Huang MC, Manley GT, DiGiorgio AM. Predictors of Extreme Hospital Length of Stay After Traumatic Brain Injury. World Neurosurg 2022; 167:e998-e1005. [PMID: 36058487 DOI: 10.1016/j.wneu.2022.08.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Hospital length of stay (HLOS) after traumatic brain injury (TBI) is an important metric of injury severity, resource utilization, and access to post-acute care services. Risk factors for protracted HLOS after TBI require further characterization. METHODS Data regarding adult inpatients admitted to a single U.S. level 1 trauma center with a diagnosis of acute TBI between August 1, 2019, and April 1, 2022, were extracted from the electronic health record. Patients with extreme HLOS (XHLOS, >99th percentile of institutional TBI HLOS) were compared with those without XHLOS. Socioeconomic status (SES), clinical/injury factors, and discharge disposition were analyzed. RESULTS In 1638 patients, the median HLOS was 3 days (interquartile range [IQR]: 2-8 days). XHLOS threshold was >70 days (N = 18; range: 72-146 days). XHLOS was associated with younger age (XHLOS/non-XHLOS: 50.4/59.6 years; P = 0.042) and greater proportions with severe TBI (55.6%/11.4%; P < 0.001), low SES (72.2%/31.4%; P < 0.001), and Medicaid insurance (77.8%/30.1%; P < 0.001). XHLOS patients were more likely to die in hospital (22.2%/8.1%) and discharge to post-acute facility (77.8%/16.3%; P < 0.001). No XHLOS patients were discharged to home. In XHLOS patients alive at discharge, medical stability was documented at median 39 days (IQR: 28-58 days) and were hospitalized for another 56 days (IQR: 26.5-78.5 days). CONCLUSIONS XHLOS patients were more likely to have severe injuries, low SES, and Medicaid. XHLOS is associated with in-hospital mortality and need for post-acute placement. XHLOS patients often demonstrated medical stability long before placement, underscoring complex relationships between SES, health insurance, and outcome. These findings have important implications for quality improvement and resource utilization at acute care hospitals and await validation from larger trials.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.
| | - Nishanth Krishnan
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Lawrence Chyall
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Alexander F Haddad
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Paloma Vega
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - David J Caldwell
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Gray Umbach
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Evelyne Tantry
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Phiroz E Tarapore
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Michael C Huang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Anthony M DiGiorgio
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Deng H, Nwachuku EL, Wilkins TE, Yue JK, Fetzick A, Chang YF, Beers SR, Okonkwo DO, Puccio AM. Time to Follow Commands in Severe Traumatic Brain Injury Survivors With Favorable Recovery at 2 Years. Neurosurgery 2022; 91:633-640. [PMID: 35833650 PMCID: PMC10553145 DOI: 10.1227/neu.0000000000002087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The recovery of severe traumatic brain injury (TBI) survivors with long-term favorable outlook is understudied. Time to follow commands varies widely in this patient population but has important clinical implications. OBJECTIVE To (1) evaluate time to follow commands in severe patients with TBI with favorable outcomes, (2) characterize their trajectory of recovery, and (3) identify predictors associated with delayed cognitive improvement. METHODS Participants were recruited prospectively at a Level I trauma center through the Brain Trauma Research Center from 2003 to 2018. Inclusion criteria were age 16 to 80 years, Glasgow Coma Scale score ≤8 and motor score <6, and Glasgow Outcome Scale-Extended measure ≥4 at 2 years postinjury. RESULTS In 580 patients, there were 229 (39.5%) deaths and 140 (24.1%) patients had favorable outcomes at 2 years. The mean age was 33.7 ± 14.5 years, median Glasgow Coma Scale was 7 (IQR 6-7), and median Injury Severity Score was 30 (IQR 26-38). The mean time to follow commands was 12.7 ± 11.8 days. On multivariable linear regression, the presence of diffuse axonal injury (B = 9.2 days [4.8, 13.7], P < .0001) or intraventricular hemorrhage (B = 6.4 days [0.5, 12.3], P < .035) was associated with longer time before following commands and patients who developed nosocomial infections (B = 6.5 days [1.6-11.4], P < .01). CONCLUSION In severe TBI survivors with favorable outcomes, time to follow commands varied widely. Most patients began to follow commands within 2 weeks. Evidence of diffuse axonal injury, intraventricular hemorrhage, and infections can delay cognitive improvement in the acute period. Patients make considerable recovery up to 2 years after their injury.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Enyinna L. Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tiffany E. Wilkins
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Anita Fetzick
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sue R. Beers
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Korley FK, Jain S, Sun X, Puccio AM, Yue JK, Gardner RC, Wang KKW, Okonkwo DO, Yuh EL, Mukherjee P, Nelson LD, Taylor SR, Markowitz AJ, Diaz-Arrastia R, Manley GT. Prognostic value of day-of-injury plasma GFAP and UCH-L1 concentrations for predicting functional recovery after traumatic brain injury in patients from the US TRACK-TBI cohort: an observational cohort study. Lancet Neurol 2022; 21:803-813. [PMID: 35963263 PMCID: PMC9462598 DOI: 10.1016/s1474-4422(22)00256-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/26/2022] [Accepted: 05/30/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The prognostic value of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) as day-of-injury predictors of functional outcome after traumatic brain injury is not well understood. GFAP is a protein found in glial cells and UCH-L1 is found in neurons, and these biomarkers have been cleared to aid in decision making regarding whether brain CT should be performed after traumatic brain injury. We aimed to quantify their prognostic accuracy and investigate whether these biomarkers contribute novel prognostic information to existing clinical models. METHODS We enrolled patients from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) observational cohort study. TRACK-TBI includes patients 17 years and older who are evaluated for TBI at 18 US level 1 trauma centres. All patients receive head CT at evaluation, have adequate visual acuity and hearing preinjury, and are fluent in either English or Spanish. In our analysis, we included participants aged 17-90 years who had day-of-injury plasma samples for measurement of GFAP and UCH-L1 and completed 6-month assessments for outcome due to traumatic brain injury with the Glasgow Outcome Scale-Extended (GOSE-TBI). Biomarkers were analysed as continuous variables and in quintiles. This study is registered with ClinicalTrials.gov, NCT02119182. FINDINGS We enrolled 2552 patients from Feb 26, 2014, to Aug 8, 2018. Of the 1696 participants with brain injury and data available at baseline and at 6 months who were included in the analysis, 120 (7·1%) died (GOSE-TBI=1), 235 (13·9%) had an unfavourable outcome (ie, GOSE-TBI ≤4), 1135 (66·9%) had incomplete recovery (ie, GOSE-TBI <8), and 561 (33·1%) recovered fully (ie, GOSE-TBI=8). The area under the curve (AUC) of GFAP for predicting death at 6 months in all patients was 0·87 (95% CI 0·83-0·91), for unfavourable outcome was 0·86 (0·83-0·89), and for incomplete recovery was 0·62 (0·59-0·64). The corresponding AUCs for UCH-L1 were 0·89 (95% CI 0·86-0·92) for predicting death, 0·86 (0·84-0·89) for unfavourable outcome, and 0·61 (0·59-0·64) for incomplete recovery at 6 months. AUCs were higher for participants with traumatic brain injury and Glasgow Coma Scale (GCS) score of 3-12 than for those with GCS score of 13-15. Among participants with GCS score of 3-12 (n=353), adding GFAP and UCH-L1 (alone or combined) to each of the three International Mission for Prognosis and Analysis of Clinical Trials in traumatic brain injury models significantly increased their AUCs for predicting death (AUC range 0·90-0·94) and unfavourable outcome (AUC range 0·83-0·89). However, among participants with GCS score of 13-15 (n=1297), adding GFAP and UCH-L1 to the UPFRONT study model modestly increased the AUC for predicting incomplete recovery (AUC range 0·69-0·69, p=0·025). INTERPRETATION In addition to their known diagnostic value, day-of-injury GFAP and UCH-L1 plasma concentrations have good to excellent prognostic value for predicting death and unfavourable outcome, but not for predicting incomplete recovery at 6 months. These biomarkers contribute the most prognostic information for participants presenting with a GCS score of 3-12. FUNDING US National Institutes of Health, National Institute of Neurologic Disorders and Stroke, US Department of Defense, One Mind, US Army Medical Research and Development Command.
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Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California at San Diego, La Jolla, CA, USA
| | - Xiaoying Sun
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California at San Diego, La Jolla, CA, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Raquel C Gardner
- Department of Neurology, Memory and Aging Center, University of California at San Francisco, San Francisco, CA, USA; Weill Institute for Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics and Biomarkers Research, Department of Emergency Medicine, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Esther L Yuh
- Department of Radiology, University of California at San Francisco, San Francisco, CA, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California at San Francisco, San Francisco, CA, USA
| | - Lindsay D Nelson
- Department of Neurosurgery and Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Traumatic Brain Injury Clinical Research Center, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA, USA
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30
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Yue JK, Haddad AF, Wang AS, Caldwell DJ, Umbach G, Digiorgio AM, Tarapore PE, Huang MC, Manley GT. Evacuation of a multi-loculated acute-on-chronic subdural hematoma using tandem bedside subdural evacuation port systems. Trauma Case Rep 2022; 40:100668. [PMID: 35794957 PMCID: PMC9251328 DOI: 10.1016/j.tcr.2022.100668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background Purpose Findings Conclusions
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Affiliation(s)
- John K. Yue
- Corresponding author at: Department of Neurological Surgery, University of California, San Francisco, 1001 Potrero Avenue, Bldg 1, Rm 101, San Francisco, CA 94143, United States of America.
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Yue JK, Phelps RRL, Hemmerle DP, Upadhyayula PS, Winkler EA, Deng H, Chang D, Vassar M, Taylor S, Schnyer D, Lingsma HF, Puccio A, Yuh E, Mukherjee P, Huang MC, Ngwenya LB, Valadka AB, Markowitz A, Okonkwo DO, Manley GT. 182 Predictors of Six-Month Inability to Return to Work in Previously Employed Subjects After Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Yue JK, Kobeissy F, Yang Z, Xu H, Deng H, Han K, Puccio A, Sun X, Rabinowitz M, Markowitz A, Okonkwo DO, Diaz-Arrastia R, Manley GT, Wang K. 322 Neuroinflammatory Biomarkers for Traumatic Brain Injury Diagnosis and Prognosis: Results From the TRACK-TBI Pilot Study. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Deng H, Nwachuku E, Wilkins T, Yue JK, Fetzick AL, Chang YF, Beers S, Okonkwo DO, Puccio A. 489 Time to Following Commands and Favorable Recovery After Severe Traumatic Brain Injury. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Yue JK, Chang D, Han KJ, Wang AS, Oh T, Sun PP. Management of migrating intracranial bullet fragments in a 13-year-old female after firearm brain injury: technical and surgical nuances. Brain Inj 2022; 36:432-439. [PMID: 35099341 DOI: 10.1080/02699052.2022.2034185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION We present the challenges and nuances of management in a rare case of multiple migrating intracranial fragments after pediatric gunshot wound to the head (GSWH). CASE PRESENTATION A 13-year-old girl suffered left parietal GSWH, with new neurologic decline 3 days after initial debridement. Serial imaging showed the largest intracranial fragments had migrated into the left trigone, and descended further with head of bed (HOB) elevation. HOB was iteratively decreased, with concurrent intracranial pressure monitoring. After extubation, with an alert and stable neurologic exam, HOB was decreased to -15 degrees, allowing gravity-assisted migration of the fragments to an anatomically favorable position within the left occipital horn. The patient underwent occipital craniotomy for fragment retrieval on hospital day 27. Two large and >20 smaller fragments were retrieved using neuronavigation and intraoperative ultrasound. Forensics showed these to be .45 caliber handgun bullet fragments. The patient recovered well after 2-months of intensive inpatient rehabilitation. DISCUSSION During new neurologic decline after GSWH, bullet migration must be considered and serial cranial imaging is requisite. Surgical retrieval of deep fragments requires judicious planning to minimize further injury. Tightly controlled HOB adjustments with gravity assistance for repositioning of fragments may have utility in optimizing anatomic favorability prior to surgery.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kasey J Han
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Albert S Wang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Peter P Sun
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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35
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Deng H, Luy DD, Abou-Al-Shaar H, Yue JK, Zinn PO, Puccio AM, Okonkwo DO. Critical care for concomitant severe traumatic brain injury and acute spinal cord injury in the polytrauma patient: illustrative case. Journal of Neurosurgery: Case Lessons 2022; 3:CASE21521. [PMID: 36130580 PMCID: PMC9379735 DOI: 10.3171/case21521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
The occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. Clinicians face challenges from a decision-making and rehabilitative perspective. Management is complex and understudied. Treatment should be systematic beginning at the scene, focusing on airway resuscitation and hemodynamic stabilization, immobilization, and timely transport. Early operative interventions should be provided, followed by minimizing secondary pathophysiology. The authors present a case to delineate decision-making in the treatment of combined cranial and spinal trauma.
OBSERVATIONS
A 19-year-old man presented as a level I trauma patient after falling 30 feet as the result of scaffolding collapse. The patient was unresponsive and was intubated; he had an initial Glasgow Coma Scale score of 4. Computed tomography revealed multicompartmental bleeding and herniation, for which supra- and infratentorial decompressive craniectomies were performed. The patient also suffered from thoracic SCI that resulted in complete paraplegia. Multimodality monitoring was used. After stabilization and lengthy rehabilitation, the patient obtained significant functional improvement.
LESSONS
The approach to initial management of concomitant head and spine trauma is to establish intracranial stability followed by intraspinal stability. Patients can make considerable recovery, particularly younger patients, who are more likely to benefit from early aggressive interventions and medical treatment.
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Affiliation(s)
| | | | | | - John K. Yue
- Brain Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | - Ava M. Puccio
- Department of Neurological Surgery and
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - David O. Okonkwo
- Department of Neurological Surgery and
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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36
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Yue JK, Chang D, Caton MT, Haddad AF, Dalle Ore CL, Wozny TA, Oh T, Wang AS, Tonetti DA, Auguste KI, Sun PP, Cooke DL, Hetts SW, Abla AA, Gupta N, Roland JL. The Hybrid Operative Suite with Intraoperative Biplane Rotational Angiography in Pediatric Cerebrovascular Neurosurgery: Utility and Lessons Learned. Pediatr Neurosurg 2022; 57:245-259. [PMID: 35508115 DOI: 10.1159/000524875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/26/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The benefits of performing open and endovascular procedures in a hybrid neuroangiography surgical suite include confirmation of treatment results and reduction in number of procedures, leading to improved efficiency of care. Combined procedural suites are infrequently used in pediatric facilities due to technical and logistical limitations. We report the safety, utility, and lessons learned from a single-institution experience using a hybrid suite equipped with biplane rotational digital subtraction angiography and pan-surgical capabilities. METHODS We conducted a retrospective review of consecutive cases performed at our institution that utilized the hybrid neuroangiography surgical suite from February 2020 to August 2021. Demographics, surgical metrics, and imaging results were collected from the electronic medical record. Outcomes, interventions, and nuances for optimizing preoperative/intraoperative setup and postoperative care were presented. RESULTS Eighteen procedures were performed in 17 patients (mean age 13.4 years, range 6-19). Cases included 14 arteriovenous malformations (AVM; 85.7% ruptured), one dural arteriovenous fistula, one mycotic aneurysm, and one hemangioblastoma. The average operative time was 416 min (range 321-745). There were no intraoperative or postoperative complications. All patients were alive at follow-up (range 0.1-14.7 months). Five patients had anticipated postoperative deficits arising from their hemorrhage, and 12 returned to baseline neurological status. Four illustrative cases demonstrating specific, unique applications of the hybrid angiography suite are presented. CONCLUSION The hybrid neuroangiography surgical suite is a safe option for pediatric cerebrovascular pathologies requiring combined surgical and endovascular intervention. Hybrid cases can be completed within the same anesthesia session and reduce the need for return to the operating room for resection or surveillance angiography. High-quality intraoperative angiography enables diagnostic confirmation under a single procedure, mitigating risk of morbidity and accelerating recovery. Effective multidisciplinary planning enables preoperative angiograms to be completed to inform the operative plan immediately prior to definitive resection.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael Travis Caton
- Department of Neurointerventional Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Albert S Wang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kurtis I Auguste
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Peter P Sun
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Neurointerventional Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Neurointerventional Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Jarod L Roland
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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37
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Burke J, Gugger J, Ding K, Kim JA, Foreman B, Yue JK, Puccio AM, Yuh EL, Sun X, Rabinowitz M, Vassar MJ, Taylor SR, Winkler EA, Deng H, McCrea M, Stein MB, Robertson CS, Levin HS, Dikmen S, Temkin NR, Barber J, Giacino JT, Mukherjee P, Wang KKW, Okonkwo DO, Markowitz AJ, Jain S, Lowenstein D, Manley GT, Diaz-Arrastia R. Association of Posttraumatic Epilepsy With 1-Year Outcomes After Traumatic Brain Injury. JAMA Netw Open 2021; 4:e2140191. [PMID: 34964854 PMCID: PMC8717106 DOI: 10.1001/jamanetworkopen.2021.40191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Posttraumatic epilepsy (PTE) is a recognized sequela of traumatic brain injury (TBI), but the long-term outcomes associated with PTE independent of injury severity are not precisely known. OBJECTIVE To determine the incidence, risk factors, and association with functional outcomes and self-reported somatic, cognitive, and psychological concerns of self-reported PTE in a large, prospectively collected TBI cohort. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective cohort study was conducted as part of the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study and identified patients presenting with TBI to 1 of 18 participating level 1 US trauma centers from February 2014 to July 2018. Patients with TBI, extracranial orthopedic injuries (orthopedic controls), and individuals without reported injuries (eg, friends and family of participants; hereafter friend controls) were prospectively followed for 12 months. Data were analyzed from January 2020 to April 2021. EXPOSURE Demographic, imaging, and clinical information was collected according to TBI Common Data Elements. Incidence of self-reported PTE was assessed using the National Institute of Neurological Disorders and Stroke Epilepsy Screening Questionnaire (NINDS-ESQ). MAIN OUTCOMES AND MEASURES Primary outcomes included Glasgow Outcome Scale Extended, Rivermead Cognitive Metric (RCM; derived from the Rivermead Post Concussion Symptoms Questionnaire), and the Brief Symptom Inventory-18 (BSI). RESULTS Of 3296 participants identified as part of the study, 3044 met inclusion criteria, and 1885 participants (mean [SD] age, 41.3 [17.1] years; 1241 [65.8%] men and 644 [34.2%] women) had follow-up information at 12 months, including 1493 patients with TBI; 182 orthopedic controls, 210 uninjured friend controls; 41 patients with TBI (2.8%) and no controls had positive screening results for PTE. Compared with a negative screening result for PTE, having a positive screening result for PTE was associated with presenting Glasgow Coma Scale score (8.1 [4.8] vs.13.5 [3.3]; P < .001) as well as with anomalous acute head imaging findings (risk ratio, 6.42 [95% CI, 2.71-15.22]). After controlling for age, initial Glasgow Coma Scale score, and imaging findings, compared with patients with TBI and without PTE, patients with TBI and with positive PTE screening results had significantly lower Glasgow Outcome Scale Extended scores (mean [SD], 6.1 [1.7] vs 4.7 [1.5]; P < .001), higher BSI scores (mean [SD], 50.2 [10.7] vs 58.6 [10.8]; P = .02), and higher RCM scores (mean [SD], 3.1 [2.6] vs 5.3 [1.9]; P = .002) at 12 months. CONCLUSIONS AND RELEVANCE In this cohort study, the incidence of self-reported PTE after TBI was found to be 2.8% and was independently associated with unfavorable outcomes. These findings highlight the need for effective antiepileptogenic therapies after TBI.
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Affiliation(s)
- John Burke
- Department of Neurosurgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - James Gugger
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Kan Ding
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| | - Jennifer A. Kim
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - John K. Yue
- Department of Neurosurgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Ava M. Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- Department of Radiology, University of California. San Francisco
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California, San Diego
| | - Miri Rabinowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary J. Vassar
- Department of Neurosurgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Sabrina R. Taylor
- Department of Neurosurgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Ethan A. Winkler
- Department of Neurosurgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Murray B. Stein
- Department of Psychiatry and Public Health, University of California, San Diego
| | - Claudia S. Robertson
- Departments of Neurosurgery and Critical Care, Baylor College of Medicine, Houston, Texas
| | - Harvey S. Levin
- Departments of Neurosurgery and Neurology, Baylor College of Medicine, Houston, Texas
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Nancy R. Temkin
- Department of Neurosurgery, University of Washington, Seattle
- Departments of Biostatistics, University of Washington, Seattle
| | - Jason Barber
- Departments of Biostatistics, University of Washington, Seattle
| | - Joseph T. Giacino
- Rehabilitation Neuropsychology, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- Department of Radiology, University of California. San Francisco
| | - Kevin K. W. Wang
- Department of Psychiatry and Neurosciences, McKnight Brain Institute, University of Florida, Gainesville
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California, San Diego
| | | | - Geoffrey T. Manley
- Department of Neurosurgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
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Deng H, Goldschmidt E, Nwachuku E, Yue JK, Angriman F, Wei Z, Agarwal N, Puccio AM, Okonkwo DO. Hydrocephalus and Cerebrospinal Fluid Analysis Following Severe Traumatic Brain Injury: Evaluation of a Prospective Cohort. Neurol Int 2021; 13:527-534. [PMID: 34698266 PMCID: PMC8544497 DOI: 10.3390/neurolint13040052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
The development of hydrocephalus after severe traumatic brain injury (TBI) is an under-recognized healthcare phenomenon and can increase morbidity. The current study aims to characterize post-traumatic hydrocephalus (PTH) in a large cohort. Patients were prospectively enrolled age 16-80 years old with Glasgow Coma Scale (GCS) score ≤8. Demographics, GCS, Injury Severity Score (ISS), surgery, and cerebrospinal fluid (CSF) were analyzed. Outcomes were shunt failure and Glasgow Outcome Scale (GOS) at 6 and 12-months. Statistical significance was assessed at p < 0.05. In 402 patients, mean age was 38.0 ± 16.7 years and 315 (78.4%) were male. Forty (10.0%) patients developed PTH, with predominant injuries being subdural hemorrhage (36.4%) and diffuse axonal injury (36.4%). Decompressive hemicraniectomy (DHC) was associated with hydrocephalus (OR 3.62, 95% CI (1.62-8.07), p < 0.01). Eighteen (4.5%) patients had shunt failure and proximal obstruction was most common. Differences in baseline CSF cell count were associated with increased shunt failure. PTH was not associated with worse outcomes at 6 (p = 0.55) or 12 (p = 0.47) months. Hydrocephalus is a frequent sequela in 10.0% of patients, particularly after DHC. Shunt placement and revision procedures are common after severe TBI, within the first 4 months of injury and necessitates early recognition by the clinician.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA;
| | - Enyinna Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - John K. Yue
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON M4N 3M5, Canada; (J.K.Y.); (F.A.)
| | - Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON M4N 3M5, Canada; (J.K.Y.); (F.A.)
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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McCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, Dikmen S, Stein M, Bodien YG, Boase K, Taylor SR, Vassar M, Mukherjee P, Robertson C, Diaz-Arrastia R, Okonkwo DO, Markowitz AJ, Manley GT, Adeoye O, Badjatia N, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Goldman D, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Toga A, Valadka A, Wang K, Yue JK, Yuh E, Zafonte R. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol 2021; 78:982-992. [PMID: 34228047 DOI: 10.1001/jamaneurol.2021.2043] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Moderate to severe traumatic brain injury (msTBI) is a major cause of death and disability in the US and worldwide. Few studies have enabled prospective, longitudinal outcome data collection from the acute to chronic phases of recovery after msTBI. Objective To prospectively assess outcomes in major areas of life function at 2 weeks and 3, 6, and 12 months after msTBI. Design, Setting, and Participants This cohort study, as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, was conducted at 18 level 1 trauma centers in the US from February 2014 to August 2018 and prospectively assessed longitudinal outcomes, with follow-up to 12 months postinjury. Participants were patients with msTBI (Glasgow Coma Scale scores 3-12) extracted from a larger group of patients with mild, moderate, or severe TBI who were enrolled in TRACK-TBI. Data analysis took place from October 2019 to April 2021. Exposures Moderate or severe TBI. Main Outcomes and Measures The Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) were used to assess global functional status 2 weeks and 3, 6, and 12 months postinjury. Scores on the GOSE were dichotomized to determine favorable (scores 4-8) vs unfavorable (scores 1-3) outcomes. Neurocognitive testing and patient reported outcomes at 12 months postinjury were analyzed. Results A total of 484 eligible patients were included from the 2679 individuals in the TRACK-TBI study. Participants with severe TBI (n = 362; 283 men [78.2%]; median [interquartile range] age, 35.5 [25-53] years) and moderate TBI (n = 122; 98 men [80.3%]; median [interquartile range] age, 38 [25-53] years) were comparable on demographic and premorbid variables. At 2 weeks postinjury, 36 of 290 participants with severe TBI (12.4%) and 38 of 93 participants with moderate TBI (41%) had favorable outcomes (GOSE scores 4-8); 301 of 322 in the severe TBI group (93.5%) and 81 of 103 in the moderate TBI group (78.6%) had moderate disability or worse on the DRS (total score ≥4). By 12 months postinjury, 142 of 271 with severe TBI (52.4%) and 54 of 72 with moderate TBI (75%) achieved favorable outcomes. Nearly 1 in 5 participants with severe TBI (52 of 270 [19.3%]) and 1 in 3 with moderate TBI (23 of 71 [32%]) reported no disability (DRS score 0) at 12 months. Among participants in a vegetative state at 2 weeks, 62 of 79 (78%) regained consciousness and 14 of 56 with available data (25%) regained orientation by 12 months. Conclusions and Relevance In this study, patients with msTBI frequently demonstrated major functional gains, including recovery of independence, between 2 weeks and 12 months postinjury. Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.
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Affiliation(s)
- Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Harvey S Levin
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Sureyya Dikmen
- Department of Neurological Surgery, University of Washington, Seattle
| | - Murray Stein
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle
| | - Sabrina R Taylor
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Mary Vassar
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Pratik Mukherjee
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Claudia Robertson
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | - David O Okonkwo
- Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amy J Markowitz
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Geoffrey T Manley
- Neurological Surgery, University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sonia Jain
- University of California, San Diego, La Jolla
| | | | | | - Joel Kramer
- University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | - Amber Nolan
- University of California, San Francisco, San Francisco
| | - Eva Palacios
- University of California, San Francisco, San Francisco
| | - Daniel Perl
- Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Arthur Toga
- University of Southern California, Los Angeles
| | | | | | - John K Yue
- University of California, San Francisco, San Francisco
| | - Esther Yuh
- University of California, San Francisco, San Francisco
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Phelps RR, Yue JK, Tsolinas RE, Deng H, Rios J, Upadhyayula PS, Dalle Ore CL, Lee YM, Suen CG, Burke JF, Winkler EA, Dhall SS. Elderly traumatic central cord syndrome in the United States: a review of management and outcomes. J Neurosurg Sci 2021; 65:442-449. [PMID: 34114428 DOI: 10.23736/s0390-5616.21.05078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION As the incidence of elderly spinal cord injury rises, improved understanding of risk profiles and outcomes is needed. This review summarizes clinical characteristics, management, and outcomes specific to the elderly (≥65-years) with acute traumatic central cord syndrome in the United States. EVIDENCE AQUISITION Literature review of the PubMed, Embase, and CINAHL databases (01/2007-03/2020) regarding elderly subjects with acute traumatic central cord syndrome. EVIDENCE SYNTHESIS Nine studies met inclusion criteria. Acute traumatic central cord syndrome was more common among married (50%), Caucasian (22-71%) males (63-86%) with an annual income <40,999 U.S. dollars (30%). Mechanisms consisted predominantly of traumatic falls (32-55%) and motor vehicle collisions (15-34%), with admission American Spinal Injury Association Impairment Scale grades D (25-79%) and C (21-51%). Mortality was 2-3%. American Spinal Injury Association Impairment Scale motor score, maximum canal compromise, and extent of parenchymal damage were predictors of one-year recovery. Greater comorbidities (heart failure, weight loss, coagulopathy, diabetes), lower income (<51,000 U.S. dollars), and age ≥80 were predictors of mortality. A substantial cohort underwent surgery (40-45%). Elderly patients were less likely to receive surgical intervention, and surgery timing had variable effects on recovery. CONCLUSIONS Elderly patients with acute traumatic central cord syndrome are uniquely at risk due to cumulative comorbidities, protracted recovery times, and unclear effects of surgical timing on outcomes. Prospective research should focus on validating age-specific risk factors, formalizing surgical indications, and delineating the impact of time to surgery on acute and long-term outcomes for this condition.
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Affiliation(s)
- Ryan R Phelps
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | | | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Rios
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Pavan S Upadhyayula
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA.,Department of Neurological Surgery, Columbia University Hospital, New York, NY, USA
| | - Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Young M Lee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Catherine G Suen
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - John F Burke
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, CA, USA -
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Winkler EA, Lee A, Yue JK, Raygor KP, Rutledge WC, Rubio RR, Josephson SA, Berger MS, Raper DMS, Abla AA. Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era. Acta Neurochir (Wien) 2021; 163:1527-1540. [PMID: 33694012 PMCID: PMC8053658 DOI: 10.1007/s00701-021-04803-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
Background Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. Methods Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. Results Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome. Conclusions Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Anthony Lee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Roberto R Rubio
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - S Andrew Josephson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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42
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Tsolinas RE, Burke JF, DiGiorgio AM, Thomas LH, Duong-Fernandez X, Harris MH, Yue JK, Winkler EA, Suen CG, Pascual LU, Ferguson AR, Huie JR, Pan JZ, Hemmerle DD, Singh V, Torres-Espin A, Omondi C, Kyritsis N, Haefeli J, Weinstein PR, de Almeida Neto CA, Kuo YH, Taggard D, Talbott JF, Whetstone WD, Manley GT, Bresnahan JC, Beattie MS, Dhall SS. Transforming Research and Clinical Knowledge in Spinal Cord Injury (TRACK-SCI): an overview of initial enrollment and demographics. Neurosurg Focus 2021; 48:E6. [PMID: 32357323 DOI: 10.3171/2020.2.focus191030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/14/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Traumatic spinal cord injury (SCI) is a dreaded condition that can lead to paralysis and severe disability. With few treatment options available for patients who have suffered from SCI, it is important to develop prospective databases to standardize data collection in order to develop new therapeutic approaches and guidelines. Here, the authors present an overview of their multicenter, prospective, observational patient registry, Transforming Research and Clinical Knowledge in SCI (TRACK-SCI). METHODS Data were collected using the National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs). Highly granular clinical information, in addition to standardized imaging, biospecimen, and follow-up data, were included in the registry. Surgical approaches were determined by the surgeon treating each patient; however, they were carefully documented and compared within and across study sites. Follow-up visits were scheduled for 6 and 12 months after injury. RESULTS One hundred sixty patients were enrolled in the TRACK-SCI study. In this overview, basic clinical, imaging, neurological severity, and follow-up data on these patients are presented. Overall, 78.8% of the patients were determined to be surgical candidates and underwent spinal decompression and/or stabilization. Follow-up rates to date at 6 and 12 months are 45% and 36.3%, respectively. Overall resources required for clinical research coordination are also discussed. CONCLUSIONS The authors established the feasibility of SCI CDE implementation in a multicenter, prospective observational study. Through the application of standardized SCI CDEs and expansion of future multicenter collaborations, they hope to advance SCI research and improve treatment.
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Affiliation(s)
- Rachel E Tsolinas
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of
| | - John F Burke
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Anthony M DiGiorgio
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Leigh H Thomas
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Xuan Duong-Fernandez
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Mark H Harris
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - John K Yue
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Ethan A Winkler
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Catherine G Suen
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Lisa U Pascual
- 4Orthopaedic Surgery and Orthopedic Trauma Institute, Zuckerberg San Francisco General Hospital.,5Orthopedic Surgery
| | - Adam R Ferguson
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience.,6San Francisco Veterans Affairs Healthcare System
| | - J Russell Huie
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Jonathan Z Pan
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,7Anesthesia and Perioperative Care
| | - Debra D Hemmerle
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Vineeta Singh
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,3Weill Institutes for Neuroscience.,8Neurology, and
| | - Abel Torres-Espin
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Cleopa Omondi
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Nikos Kyritsis
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Jenny Haefeli
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Philip R Weinstein
- 2Neurological Surgery.,3Weill Institutes for Neuroscience.,9Institute for Neurodegenerative Diseases, Spine Center, University of California San Francisco
| | - Carlos A de Almeida Neto
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Yu-Hung Kuo
- 12Department of Neurological Surgery, University of California San Francisco-Fresno, Fresno, California
| | - Derek Taggard
- 12Department of Neurological Surgery, University of California San Francisco-Fresno, Fresno, California
| | - Jason F Talbott
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,10Department of Radiology and Biomedical Imaging, Zuckerberg San Francisco General Hospital, San Francisco; and
| | | | - Geoffrey T Manley
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
| | - Jacqueline C Bresnahan
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Michael S Beattie
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery.,3Weill Institutes for Neuroscience
| | - Sanjay S Dhall
- 1Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital; Departments of.,2Neurological Surgery
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Yue JK, Oh T, Han KJ, Chang D, Sun PP. A Case of Torticollis in an 8-Month-Old Infant Caused by Posterior Fossa Arachnoid Cyst: An Important Entity for Differential Diagnosis. Pediatr Rep 2021; 13:197-202. [PMID: 33921315 PMCID: PMC8167635 DOI: 10.3390/pediatric13020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/23/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022] Open
Abstract
Torticollis is a clinical diagnosis with heterogeneous causes. We present an unusual case of acquired torticollis in an 8-month-old female infant with a large cerebellopontine angle arachnoid cyst. Symptoms resolved after surgical fenestration. Non-traumatic acquired or new-onset torticollis requires brain imaging, and posterior fossa lesions are an important entity in the differential for pediatric clinicians.
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Affiliation(s)
- John K. Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA; (T.O.); (K.J.H.); (D.C.); (P.P.S.)
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA
- Correspondence:
| | - Taemin Oh
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA; (T.O.); (K.J.H.); (D.C.); (P.P.S.)
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA
| | - Kasey J. Han
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA; (T.O.); (K.J.H.); (D.C.); (P.P.S.)
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA
| | - Diana Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA; (T.O.); (K.J.H.); (D.C.); (P.P.S.)
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA
| | - Peter P. Sun
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA; (T.O.); (K.J.H.); (D.C.); (P.P.S.)
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94122, USA
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Korley FK, Datwyler SA, Jain S, Sun X, Beligere G, Chandran R, Marino JA, McQuiston B, Zhang H, Caudle KL, Wang KKW, Puccio AM, Okonkwo DO, Yue JK, Taylor SR, Markowitz A, Manley GT, Diaz-Arrastia R. Comparison of GFAP and UCH-L1 Measurements from Two Prototype Assays: The Abbott i-STAT and ARCHITECT Assays. Neurotrauma Rep 2021; 2:193-199. [PMID: 33937911 PMCID: PMC8086519 DOI: 10.1089/neur.2020.0037] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) may aid in the evaluation of traumatic brain injury (TBI). The objective of this analysis was to compare GFAP and UCH-L1 values measured using a handheld device compared with a core laboratory platform. We analyzed plasma samples from patients with TBI and healthy controls enrolled in the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) cohort study. GFAP and UCH-L1 were measured twice in each subject using prototype assays, first with the Abbott i-STAT™ handheld device, and second with the Abbott ARCHITECT® platform. We then quantified the agreement in biomarker values obtained using these two methods. GFAP and UCH-L1 were measured twice in 570 and 572 samples, respectively. GFAP values measured by the ARCHITECT platform (median 143.3 [interquartile range (IQR): 19.8–925.8] pg/mL) were higher than values measured by the i-STAT (median 116.0 [IQR: 9.2–856.5] pg/mL). GFAP values from the two platforms were strongly correlated (p = 0.985). Similarly, UCH-L1 values measured by the ARCHITECT platform (median 163.9 [IQR: 82.5–412.4] pg/mL) were higher than values measured by the i-STAT (median 122.5 [IQR: 63.0–297.3] pg/mL). UCH-L1 values from the two platforms were strongly correlated (p = 0.933). Passing-Bablok regression equations were developed to estimate the relationship between the two platforms, specifically to predict i-STAT values from the ARCHITECT platform. GFAP and UCH-L1 values measured using the prototype assays on the Abbott i-STAT and ARCHITECT platforms are strongly correlated and values from either platform may be converted to the other.
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Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Sonia Jain
- Herbert Wertheim School of Public Health, University of California, San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Herbert Wertheim School of Public Health, University of California, San Diego, La Jolla, California, USA
| | | | | | | | | | | | - Krista L Caudle
- U.S. Army Medical Materiel Development Activity (USAMMDA), Warfighter Brain Health Project Management Office (WBH PMO), Fort Detrick, Maryland, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics & Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, Gainesville, Florida, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Amy Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Traumatic Brain Injury Clinical Research Center, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
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45
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Yue JK, Phelps RR, Hemmerle DD, Upadhyayula PS, Winkler EA, Deng H, Chang D, Vassar MJ, Taylor SR, Schnyer DM, Lingsma HF, Puccio AM, Yuh EL, Mukherjee P, Huang MC, Ngwenya LB, Valadka AB, Markowitz AJ, Okonkwo DO, Manley GT. Predictors of six-month inability to return to work in previously employed subjects after mild traumatic brain injury: A TRACK-TBI pilot study. J Concussion 2021; 5. [PMID: 34046212 PMCID: PMC8153496 DOI: 10.1177/20597002211007271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction: Return to work (RTW) is an important milestone of mild traumatic brain injury (mTBI) recovery. The objective of this study was to evaluate whether baseline clinical variables, three-month RTW, and three-month postconcussional symptoms (PCS) were associated with six-month RTW after mTBI. Methods: Adult subjects from the prospective multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot study with mTBI (Glasgow Coma Scale 13–15) who were employed at baseline, with completed three-and six-month RTW status, and three-month Acute Concussion Evaluation (ACE), were extracted. Univariate and multivariable analyses were performed for six-month RTW, with focus on baseline employment, three-month RTW, and three-month ACE domains (physical, cognitive, sleep, and/or emotional postconcussional symptoms (PCS)). Odds ratios (OR) and 95% confidence intervals [CI] were reported. Significance was assessed at p < 0.05. Results: In 152 patients aged 40.7 ± 15.0years, 72% were employed full-time at baseline. Three- and six-month RTW were 77.6% and 78.9%, respectively. At three months, 59.2%, 47.4%, 46.1% and 31.6% scored positive for ACE physical, cognitive, sleep, and emotional PCS domains, respectively. Three-month RTW predicted six-month RTW (OR = 19.80, 95% CI [7.61–51.52]). On univariate analysis, scoring positive in any three-month ACE domain predicted inability for six-month RTW (OR = 0.10–0.11). On multivariable analysis, emotional symptoms predicted inability to six-month RTW (OR = 0.19 [0.04–0.85]). Subjects who scored positive in all four ACE domains were more likely to be unable to RTW at six months (4 domains: 58.3%, vs. 0-to-3 domains: 9.5%; multivariable OR = 0.09 [0.02–0.33]). Conclusions: Three-month post-injury is an important time point at which RTW status and PCS should be assessed, as both are prognostic markers for six-month RTW. Clinicians should be particularly vigilant of patients who present with emotional symptoms, and patients with symptoms across multiple PCS categories, as these patients are at further risk of inability to RTW and may benefit from targeted evaluation and support.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ryan Rl Phelps
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Debra D Hemmerle
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Pavan S Upadhyayula
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Mary J Vassar
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Sabrina R Taylor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - David M Schnyer
- Department of Psychology, University of Texas, Austin, TX, USA
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ava M Puccio
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Laura B Ngwenya
- Department of Neurological Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Alex B Valadka
- Department of Neurological Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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Xu LB, Yue JK, Korley F, Puccio AM, Yuh EL, Sun X, Rabinowitz M, Vassar MJ, Taylor SR, Winkler EA, Puffer RC, Deng H, McCrea M, Stein MB, Robertson CS, Levin HS, Dikmen S, Temkin NR, Giacino JT, Mukherjee P, Wang KK, Okonkwo DO, Markowitz AJ, Jain S, Manley GT, Diaz-Arrastia R. High-Sensitivity C-Reactive Protein is a Prognostic Biomarker of Six-Month Disability after Traumatic Brain Injury: Results from the TRACK-TBI Study. J Neurotrauma 2021; 38:918-927. [PMID: 33161875 PMCID: PMC7987360 DOI: 10.1089/neu.2020.7177] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Systemic inflammation impacts outcome after traumatic brain injury (TBI), but most TBI biomarker studies have focused on brain-specific proteins. C-reactive protein (CRP) is a widely used biomarker of inflammation with potential as a prognostic biomarker after TBI. The Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study prospectively enrolled TBI patients within 24 h of injury, as well as orthopedic injury and uninjured controls; biospecimens were collected at enrollment. A subset of hospitalized participants had blood collected on day 3, day 5, and 2 weeks. High-sensitivity CRP (hsCRP) and glial fibrillary acidic protein (GFAP) were measured. Receiver operating characteristic analysis was used to evaluate the prognostic ability of hsCRP for 6-month outcome, using the Glasgow Outcome Scale-Extended (GOSE). We included 1206 TBI subjects, 122 orthopedic trauma controls (OTCs), and 209 healthy controls (HCs). Longitudinal biomarker sampling was performed in 254 hospitalized TBI subjects and 19 OTCs. hsCRP rose between days 1 and 5 for TBI and OTC subjects, and fell by 2 weeks, but remained elevated compared with HCs (p < 0.001). Longitudinally, hsCRP was significantly higher in the first 2 weeks for subjects with death/severe disability (GOSE <5) compared with those with moderate disability/good recovery (GOSE ≥5); AUC was highest at 2 weeks (AUC = 0.892). Combining hsCRP and GFAP at 2 weeks produced AUC = 0.939 for prediction of disability. Serum hsCRP measured within 2 weeks of TBI is a prognostic biomarker for disability 6 months later. hsCRP may have utility as a biomarker of target engagement for anti-inflammatory therapies.
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Affiliation(s)
- Linda B. Xu
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John K. Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Frederick Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ava M. Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Esther L. Yuh
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Miri Rabinowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary J. Vassar
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sabrina R. Taylor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ethan A. Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ross C. Puffer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Murray B. Stein
- Department of Psychiatry and Family Medicine, University of California San Diego, San Diego, California, USA
| | - Claudia S. Robertson
- Department of Neurosurgery and Critical Care, Baylor College of Medicine, Houston, Texas, USA
| | - Harvey S. Levin
- Department of Neurosurgery and Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Nancy R. Temkin
- Department of Neurosurgery and Biostatistics, University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Kevin K.W. Wang
- Department of Psychiatry and Neurosciences, McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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47
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Levin HS, Temkin NR, Barber J, Nelson LD, Robertson C, Brennan J, Stein MB, Yue JK, Giacino JT, McCrea MA, Diaz-Arrastia R, Mukherjee P, Okonkwo DO, Boase K, Markowitz AJ, Bodien Y, Taylor S, Vassar MJ, Manley GT. Association of Sex and Age With Mild Traumatic Brain Injury-Related Symptoms: A TRACK-TBI Study. JAMA Netw Open 2021; 4:e213046. [PMID: 33822070 PMCID: PMC8025125 DOI: 10.1001/jamanetworkopen.2021.3046] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Knowledge of differences in mild traumatic brain injury (mTBI) recovery by sex and age may inform individualized treatment of these patients. OBJECTIVE To identify sex-related differences in symptom recovery from mTBI; secondarily, to explore age differences within women, who demonstrate poorer outcomes after TBI. DESIGN, SETTING, AND PARTICIPANTS The prospective cohort study Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) recruited 2000 patients with mTBI from February 26, 2014, to July 3, 2018, and 299 patients with orthopedic trauma (who served as controls) from January 26, 2016, to July 27, 2018. Patients were recruited from 18 level I trauma centers and followed up for 12 months. Data were analyzed from August 19, 2020, to March 3, 2021. EXPOSURES Patients with mTBI (defined by a Glasgow Coma Scale score of 13-15) triaged to head computed tomography in 24 hours or less; patients with orthopedic trauma served as controls. MAIN OUTCOMES AND MEASURES Measured outcomes included (1) the Rivermead Post Concussion Symptoms Questionnaire (RPQ), a 16-item self-report scale that assesses postconcussion symptom severity over the past 7 days relative to preinjury; (2) the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), a 20-item test that measures the severity of posttraumatic stress disorder symptoms; (3) the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale that measures depression based on symptom frequency over the past 2 weeks; and (4) the Brief Symptom Inventory-18 (BSI-18), an 18-item scale of psychological distress (split into Depression and Anxiety subscales). RESULTS A total of 2000 patients with mTBI (1331 men [67%; mean (SD) age, 41.0 (17.3) years; 1026 White (78%)] and 669 women [33%; mean (SD) age, 43.0 (18.5) years; 505 (76%) White]). After adjustment of multiple comparisons, significant TBI × sex interactions were observed for cognitive symptoms (B = 0.76; 5% false discovery rate-corrected P = .02) and somatic RPQ symptoms (B = 0.80; 5% false discovery rate-corrected P = .02), with worse symptoms in women with mTBI than men, but no sex difference in symptoms in control patients with orthopedic trauma. Within the female patients evaluated, there was a significant TBI × age interaction for somatic RPQ symptoms, which were worse in female patients with mTBI aged 35 to 49 years compared with those aged 17 to 34 years (B = 1.65; P = .02) or older than 50 years (B = 1.66; P = .02). CONCLUSIONS AND RELEVANCE This study found that women were more vulnerable than men to persistent mTBI-related cognitive and somatic symptoms, whereas no sex difference in symptom burden was seen after orthopedic injury. Postconcussion symptoms were also worse in women aged 35 to 49 years than in younger and older women, but further investigation is needed to corroborate these findings and to identify the mechanisms involved. Results suggest that individualized clinical management of mTBI should consider sex and age, as some women are especially predisposed to chronic postconcussion symptoms even 12 months after injury.
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Affiliation(s)
- Harvey S. Levin
- Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | | | | | | | | | - Joseph T. Giacino
- Spaulding Rehabilitation Center, Boston, Massachusetts
- Massachusetts General Hospital, Boston
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | | | | | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle
| | | | - Yelena Bodien
- Spaulding Rehabilitation Center, Boston, Massachusetts
- Massachusetts General Hospital, Boston
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48
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Yue JK, Phelps RRL, Chandra A, Winkler EA, Manley GT, Berger MS. Sideline Concussion Assessment: The Current State of the Art. Neurosurgery 2021; 87:466-475. [PMID: 32126135 DOI: 10.1093/neuros/nyaa022] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 12/15/2019] [Indexed: 02/03/2023] Open
Abstract
More than 200 million American adults and children participate in organized physical activity. Growing awareness has highlighted that concussion, especially when repeated, may be associated with prolonged neurological, cognitive, and/or neuropsychiatric sequelae. Objective diagnosis of concussion remains challenging. Although some concussion symptoms may be apparent even to nonmedical observers, diagnosis and removal from play for evaluation depend on validated assessment tools and trained, vigilant healthcare personnel. Over the past 2 decades, sideline concussion measures have undergone significant revision and augmentation to become more comprehensive batteries in order to detect a wide spectrum of symptomatology, eg, neurocognitive function, postconcussive symptoms, gait/balance, and saccadic eye movements. This review summarizes the current state-of-the-art concussion evaluation instruments, ranging from the Sports Concussion Assessment Tool (SCAT) and tools that may enhance concussion detection, to near-term blood-based biomarkers and emerging technology (eg, head impact sensors, vestibulo-ocular/eye-tracking, and mobile applications). Special focus is directed at feasibility, utility, generalizability, and challenges to implementation of each measure on-field and on the sidelines. This review finds that few instruments beyond the SCAT provide guidance for removal from play, and establishing thresholds for concussion detection and removal from play in qualification/validation of future instruments is of high importance. Integration of emerging sideline concussion evaluation tools should be supported by resources and education to athletes, caregivers, athletic staff, and medical professionals for standardized administration as well as triage, referral, and prevention strategies. It should be noted that concussion evaluation instruments are used to assist the clinician in sideline diagnosis, and no single test can diagnose concussion as a standalone investigation.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ryan R L Phelps
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ankush Chandra
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California
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49
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Deng H, Zusman BE, Nwachuku EL, Yue JK, Chang YF, Conley YP, Okonkwo DO, Puccio AM. B-Cell Lymphoma 2 (Bcl-2) Gene Is Associated with Intracranial Hypertension after Severe Traumatic Brain Injury. J Neurotrauma 2021; 38:291-299. [PMID: 32515262 PMCID: PMC8182479 DOI: 10.1089/neu.2020.7028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Severe traumatic brain injury (TBI) activates the apoptotic cascade in neurons and glia as part of secondary cellular injury. B-cell lymphoma 2 (Bcl-2) gene encodes a pro-survival protein to suppress programmed cell death, and variation in this gene has potential to affect intracranial pressure (ICP). Participants were recruited from a single clinical center using a prospective observational study design. Inclusion criteria were: age 16-80 years; Glasgow Coma Scale (GCS) score 4-8; and at least 24 h of ICP monitoring treated between 2000-2014. Outcomes were mean ICP, spikes >20 and >25 mm Hg, edema, and surgical intervention. Odds ratios (OR), mean increases/decreases (B), and 95% confidence intervals (CIs) were reported. In 264 patients, average age was 39.2 years old and 78% of patients were male. Mean ICPs were 11.4 ± 0.4 mm Hg for patients with homozygous wild-type (AA), 12.8 ± 0.6 mm Hg for heterozygous (AG), and 14.3 ± 1.2 mm Hg for homozygous variant (GG; p = 0.023). Rs17759659 GG genotype was associated with more ICP spikes >20 mm Hg (p = 0.017) and >25 mm Hg (p = 0.048). Multi-variate analysis showed that GG relative to AA genotype had higher ICP (B = 2.7 mm Hg, 95% CI [0.5,4.9], p = 0.015), edema (OR = 2.5 [1.0, 6.0], p = 0.049) and need for decompression (OR = 3.7 [1.5-9.3], p = 0.004). In this prospective severe TBI cohort, Bcl-2 rs17759659 was associated with increased risk of intracranial hypertension, cerebral edema, and need for surgical intervention. The variant allele may impact programmed cell death of injured neurons, resulting in elevated ICP and post-traumatic secondary insults. Further risk stratification and targeted genotype-based therapies could improve outcomes after severe TBI.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin E. Zusman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Enyinna L. Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yvette P. Conley
- School of Nursing and Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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50
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Yue JK, Chang D, Oh T, Winkler EA, Lu AY, Hetts SW, Young EP, Reddy AT, Fox CK, Abla AA, Roland JL. Multiple Tumor-Associated Intracranial Aneurysms Adjacent to a Suprasellar Germ Cell Tumor: Case Report and Review of Literature. Pediatr Neurosurg 2021; 56:482-491. [PMID: 34320494 DOI: 10.1159/000517890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/14/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Tumor-associated intracranial aneurysms are rare and not well understood. CASE PRESENTATION We describe a 4-year-old female with multiple intracranial aneurysms intimately associated with a suprasellar germ cell tumor (GCT). We provide the clinical history, medical, and surgical treatment course, as well as a comprehensive and concise synthesis of the literature on tumor-associated aneurysms. DISCUSSION We discuss mechanisms for aneurysm formation with relevance to the current case, including cellular and paracrine signaling pertinent to suprasellar GCTs and possible molecular pathways involved. We review the complex multidisciplinary treatment required for complex tumor and cerebrovascular interactions.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alex Y Lu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Interventional Neuroradiology, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth P Young
- Department of Pediatric Hematology/Oncology, University of California San Francisco, San Francisco, California, USA
| | - Alyssa T Reddy
- Department of Pediatric Hematology/Oncology, University of California San Francisco, San Francisco, California, USA
| | - Christine K Fox
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jarod L Roland
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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