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Williams JR, Nieblas-Bedolla E, Feroze A, Young C, Temkin NR, Giacino JT, Okonkwo DO, Manley GT, Barber J, Durfy S, Markowitz AJ, Yu EL, Mukherjee P, Mac Donald CL. Prognostic Value of Hemorrhagic Brainstem Injury on Early Computed Tomography: A TRACK-TBI Study. Neurocrit Care 2021; 35:335-346. [PMID: 34309784 DOI: 10.1007/s12028-021-01263-8] [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: 01/07/2021] [Accepted: 04/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Traumatic brainstem injury has yet to be incorporated into widely used imaging classification systems for traumatic brain injury (TBI), and questions remain regarding prognostic implications for this TBI subgroup. To address this, retrospective data on patients from the multicenter prospective Transforming Research and Clinical Knowledge in TBI study were studied. METHODS Patients with brainstem and cerebrum injury (BSI+) were matched by age, sex, and admission Glasgow Coma Scale (GCS) score to patients with cerebrum injuries only. All patients had an interpretable head computed tomography (CT) scan from the first 48 hours after injury and a 6-month Glasgow Outcome Scale Extended (GOSE) score. CT scans were reviewed for brainstem lesions and, when present, characterized by location, size, and type (traumatic axonal injury, contusion, or Duret hemorrhage). Clinical, demographic, and outcome data were then compared between the two groups. RESULTS Mann-Whitney U-tests showed no significant difference in 6-month GOSE scores in patients with BSI+ (mean 2.7) compared with patients with similar but only cerebrum injuries (mean 3.9), although there is a trend (p = 0.10). However, subclassification by brainstem lesion type, traumatic axonal injury (mean 4.0) versus Duret hemorrhage or contusion (mean 1.4), did identify a proportion of BSI+ with significantly less favorable outcome (p = 0.002). The incorporation of brainstem lesion type (traumatic axonal injury vs. contusion/Duret), along with GCS into a multivariate logistic regression model of favorable outcome (GOSE score 4-8) did show a significant contribution to the prognostication of this brainstem injury subgroup (odds ratio 0.08, 95% confidence interval 0.00-0.67, p = 0.01). CONCLUSIONS These findings suggest two groups of patients with brainstem injuries may exist with divergent recovery potential after TBI. These data support the notion that newer CT imaging classification systems may augment traditional clinical measures, such as GCS in identifying those patients with TBI and brainstem injuries that stand a higher chance of favorable outcome.
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Affiliation(s)
- John R Williams
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA
| | | | - Abdullah Feroze
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA
| | - Christopher Young
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, 1001 Potrero Avenue, Bldg. 1 Rm 101, Box 0899, San Francisco, CA, 94143, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA
| | - Sharon Durfy
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, 1001 Potrero Avenue, Bldg. 1 Rm 101, Box 0899, San Francisco, CA, 94143, USA.
| | - Esther L Yu
- Department of Radiology, University of California, San Francisco, San Francisco, CA, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California, San Francisco, San Francisco, CA, USA
| | - Christine L Mac Donald
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359924, Seattle, WA, 98104, USA.
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Guo X, Ma L, Li H, Qi X, Wei Y, Duan Z, Xu J, Wang C, You C, Tian M. Brainstem iron overload and injury in a rat model of brainstem hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104956. [PMID: 32689646 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104956] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/27/2020] [Accepted: 05/11/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Brainstem hemorrhage (BSH) is the most devastating subtype of intracerebral hemorrhage (ICH) with the highest mortality ranging from 56 % to 61.2 %. However, there is no effective medical or surgical therapy to improve its outcomes in clinic to date due to lack of understanding of its injury mechanisms. Herein, we explored the brainstem iron overload and injury in a rat model of BSH. METHODS Neurological scores were examined on day 1, 3, and 7 after modeling, and mortality of the rats was recorded to draft a survival curve. Rats were monitored by MRI using T2 and susceptibility weighted imaging (SWI) before sacrifice for examination of histology and immunofluorescence on day 1, 3, and 7. RESULTS BSH rats had a high mortality of 56 % and demonstrated the severe neurological deficits mimicking the clinical conditions. SWI showed that the same increasing tendency in change of hypointense area with that in iron deposition by Perls staining from day 1 to 7. Expression of heme oxygenase 1 (HO-1) and generation of reactive oxygen species (ROS) had similar tendency and both peaked on day 3. Neuronal degeneration occurred and stayed elevated from day 1 to 7, while myelin sheath injury was initially observed on day 1 but without significant difference within 7 days. CONCLUSIONS The time courses of erythrocyte lysis, HO-1 expression, iron deposition and ROS generation are related to each other after BSH. Besides, brainstem injury including neuronal degeneration and myelin damage were observed and discussed.
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Affiliation(s)
- Xi Guo
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Lu Ma
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Hao Li
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Xin Qi
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yang Wei
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Zhongxin Duan
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jiake Xu
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Chengwei Wang
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Integrated Traditional and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Chao You
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Meng Tian
- Neurosurgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China.
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Wei J, Shen Z, Wang H, Zhao Q, Ji R, Wang B, Xin Y, Jiang X. Research progress on mechanism and dosimetry of brainstem injury induced by intensity-modulated radiotherapy, proton therapy, and heavy ion radiotherapy. Eur Radiol 2020; 30:5011-20. [PMID: 32318844 DOI: 10.1007/s00330-020-06843-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
Abstract
Radiotherapy (RT) is an effective method for treating head and neck cancer (HNC). However, RT may cause side effects during and after treatment. Radiation-induced brainstem injury (BSI) is often neglected due to its low incidence and short survival time and because it is indistinguishable from intracranial tumor progression. It is currently believed that the possible mechanism of radiation-induced BSI includes increased expression of vascular endothelial growth factor and damage of vascular endothelial cells, neurons, and glial cells as well as an inflammatory response and oxidative stress. At present, it is still difficult to avoid BSI even with several advanced RT techniques. Intensity-modulated radiotherapy (IMRT) is the most commonly used therapeutic technique in the field of RT. Compared with early conformal therapy, it has greatly reduced the injury to normal tissues. Proton beam radiotherapy (PBT) and heavy ion radiotherapy (HIT) have good dose distribution due to the presence of a Bragg peak, which not only results in better control of the tumor but also minimizes the dose to the surrounding normal tissues. There are many clinical studies on BSI caused by IMRT, PBT, and HIT. In this paper, we review the mechanism, dosimetry, and other aspects of BSI caused by IMRT, PBT, and HIT.Key Points• Enhanced MRI imaging can better detect radiation-induced BSI early.• This article summarized the dose constraints of brainstem toxicity in clinical studies using different techniques including IMRT, PBT, and HIT and recommended better dose constraints pattern to clinicians.• The latest pathological mechanism of radiation-induced BSI and the corresponding advanced treatment methods will be discussed.
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Fu Q, Qi Z, Yang R, Cheng K, Yang Y, Xie P. Brainstem injury associated with supratentorial lesions is revealed by electronystagmography of the cold caloric reflex test. Am J Transl Res 2017; 9:2119-2131. [PMID: 28559965 PMCID: PMC5446497] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
To explore the brainstem injury associated with supratentorial lesions, we conducted analysis of ICP levels and detected ENG parameters by using the cold caloric reflex test and histopathological examinations of the brainstem. Rat model of intracerebral hemorrhage was well-established in the study of supratentorial lesions of varying severities (n=210). Intracerebral pressure monitoring and electronystagmography of the cold caloric reflex test were simultaneously performed in animals. Apoptotic, immunohistochemical, and histopathological changes in different segments of the brainstem were investigated at various time intervals. Electronystagmography parameters were analyzed by cold caloric reflex test. The result showed that the increase of intracerebral pressure was correlated with lesion severity including elevating levels and rostral-caudal progression of neuronal apoptosis, demyelination, N-methyl-D-aspartate cell receptor down-regulation (r=0.815), and histopathological changes. Mutiple discrimination analysis of electronystagmography parameters presented a diagnostic accuracy rate of 79.5% in localizing brainstem injury. In conclusion, our data demonstrated that electronystagmography monitoring along with the cold caloric reflex test performed a favorable effect on the estimation of brainstem injury in ICH rat model, which provided a potential bedside diagnostic tool to assess and predict the progress of supratentorial lesion patient in future.
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Affiliation(s)
- Qizhi Fu
- Department of Neurology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and TechnologyLuoyang, China
| | - Zhiguo Qi
- Department of Neurology, The First Affiliated Hospital of Jiamusi UniversityJiamusi, China
| | - Ruirui Yang
- Department of Neurology, The Shandong Provincial HospitalJinan, China
| | - Ke Cheng
- Institute of Neuroscience, Chongqing Medical UniversityChongqing, China
| | - Yongtao Yang
- Institute of Neuroscience, Chongqing Medical UniversityChongqing, China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical UniversityChongqing, China
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Abstract
The vertebral arteries are rarely injured in penetrating neck trauma due to their deep location in the foramen transversarium. These injuries in isolation are not associated with neurological deficits or ischemic changes on radiology as the collaterals are usually sufficient. We report a case of fatal unilateral vertebral artery stab injury leading to bilateral cerebellar and brainstem infarction. The carotid Doppler ruled out the presence of any carotid artery injury. Life-threatening injuries are possible in the presence of hypoplastic contralateral vertebral artery or inadequate flow from the anterior circulation not making up for the deficit. This emphasizes that thorough evaluation and timely management of suspected injuries to even a single vertebral artery should be undertaken.
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Affiliation(s)
- Avijit Sarkari
- Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj K Singh
- Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok K Mahapatra
- Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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